Chicago Med (2015) s03e03 Episode Script
Trust Your Gut
1 Then why don't you check the drawer next to the pantry? I'm sorry, Robin, but I I don't know where they are.
I'll tell you what, I'll get another set made on my way home.
[clears throat.]
[sighs.]
Look, babe, I really have to go.
Yeah, sure, that's fine.
Okay, I love you too.
Bye-bye.
My apologies.
Everything okay? Yeah, Robin just couldn't find her keys.
Rough morning? Perhaps I should take over the pre-op? That will not be necessary.
Shall we? Please.
Just a heads-up: the board is gonna push you for more growth.
The bottom line has them concerned.
When hasn't it? Can set my watch over their money worries.
I'll be fine.
It's different this time.
C-Suite feels we can better recognize how medicine and business are one and the same.
Ah, let me guess: scale back on outreach, combine responsibilities, outsource? So basically, sacrifice patient care? I won't do that, Peter.
Well, Sharon, you have to do something, because the ED is hemorrhaging cash, and if the bleeding doesn't stop, it's not going to be good for anybody.
- Mm.
- Need I remind you Randall Memorial closed their ED? Dr.
Halstead, Doris, you're with me.
- Copy that.
- Barry? - [heavy breathing.]
- Alex Mayer, 23.
Slash and stab.
Large diagonal lacerations of the abdomen.
He's a little tachy.
GCS 15.
Get it out! You're going Baghdad.
Get it out! The weapon still in? I don't know.
Wasn't even a call.
We were a few blocks away, I saw him on the street, bleeding, loaded him in the ambo and rolled.
- I can feel it inside me! - Whoa, whoa! Alex, keep your hands down.
I got you, Dr.
Halstead.
Let's transfer.
On my count.
One, two, three! [screams.]
[groans.]
Two of Versed to calm him down.
Thank you, boys.
[sobbing.]
- How's that Versed coming? - On it, Doctor.
Gaping diagonal incision of the right upper quad.
Evidence of evisceration? No, I can see the base.
Abdomen's still intact.
Just a flesh wound.
It's really clean, though.
Wash it out and stitch it up.
Irrigation.
Sir, you're a lucky man.
Whoever knifed you didn't do any serious damage.
[suspenseful music.]
Look at this.
Betadine's smeared all over the abdomen.
The skin was prepped before the cut.
I'm telling you, that incision is precise.
Back-alley surgery gone wrong? Alex, what happened? I was desperate.
Dr.
Halstead, his hand, under the blood.
More Betadine.
So he doused his own hands.
Alex, did you cut into yourself? I had to! I had to get it out! Get what out? The person living inside me! - [gasps.]
- Oh, I'm sorry.
Are you all right? I was just trying to say "hi.
" Um, it's Edith Lake.
Your insulin patient? The woman who slashed my tires? Oh, the woman you think slashed your tires.
Who else? I saw her yesterday, across the street from my apartment.
You really think it was her? Looked like her.
Next.
Dr.
Latham, this is Ray Preston, 53.
Fell short of breath while jogging.
I was only two miles in.
I'm always good for five before I start to get tired.
Ray lives in Galena.
It's about 3 1/2 hours west of Chicago.
His cardiologist performed an EKG, stress test, and cardiac cath.
Told me to skip the community hospital and come straight here.
Dr.
Rhodes, I know we're getting pretty close to show time here, but are you absolutely sure I need this surgery? I'm positive.
But I'm not in any pain.
I know, that's the danger.
Severe three-vessel disease, complicated by Heavy calcification and extremely poor targets.
CABG is still doable, but it will be more challenging than normal.
Indeed.
You're a lucky man, Mr.
Preston.
Keeping fit bought you the time to notice something was wrong.
Yeah.
Well, Dr.
Rhodes said people with arteries as damaged as mine usually just drop dead.
He's absolutely right.
Not to worry, Ray.
We'll take great care of you.
To streamline costs, Dr.
Stohl and I are implementing a system to track supplies to know exactly what we've used.
Everything will be barcoded and logged into Pyxis.
It will operate by finger scan, like we do for medications.
That's easy enough for minor treatments, but what about emergencies? Not a lot of time to stop down and scan your prints during a trauma.
A tech will take note of what was used in the moment and then scan after the fact.
"In the moment.
" They'll follow us into the trauma bay? Between nurses and equipment, we're already tight on space.
Another body We'll find the room because we have to.
Not to worry, Miss Goodwin.
All right, uh, let's get back to work.
Thank you for your time.
Doctors, one more thing before you go, while I have you here, charting.
When I was in Attending, it was pen, paper, and long-form.
Today, it's it's tablets and shorthand.
I get it tech saves time but details get lost in translation, so please be explicit in procedure notes.
Okay? Document everything.
If you do it, write it down.
Okay? [dramatic music.]
I clean up nice, don't I? I haven't noticed.
I saw that.
Why don't you believe me? I'm not crazy.
Something lives inside of me, right here.
I hear you.
I understand.
Then get it out! [sobs.]
I feel it all the time! Alex we're gonna help you, I promise.
Sedative? No, no, no.
Wait, wait, wait.
I'm sorry, I'm sorry.
I'm telling you the truth.
I can feel it inside of me.
Please.
[breathes fearfully.]
[breathing slows.]
Please What'd you give him? Five of Versed.
Hm.
Two probably would have sufficed.
He put hands on you.
I was being cautious.
So what are you thinking? Schizophrenia.
Yeah, that was my initial thought, but now I'm not so sure.
Seriously? His, uh, paranoia that there's something living inside him, and his attempt to remove it is literally a textbook definition of a somatic delusional disorder.
I'm stuck on the level of premeditation.
You know, sterilization with Betadine, the clean incision, doing it near a hospital All that kind of forethought it's just not consistent with schizophrenic psychosis.
So he's a germophobe with a steady hand.
It doesn't mean he's not schizophrenic.
Mm, could be true, too.
So, um start him on anti-psychotics and reassess when his mind's clear? I'm just not there yet.
My gut tells me it's chemical.
You know, like maybe a methamphetamine overdose.
Before we go any further, let's run a tox screen, see if he's just high.
What's with you? You look half-dead.
Yeah, these 90-hour weeks are killing a brother.
Law says you can't do more than 80.
[laughs.]
When Dr.
Stohl asks you to volunteer, you don't say "no.
" Game is rigged.
All part of being a big-shot doc.
Big shot, right.
Big shot, living off of ramen and cheeseburgers.
What? Yeah, that's all I got time for.
You are getting a steady paycheck now.
Sign up for one of those meal delivery services.
You're gonna need the fuel.
That's not a bad idea.
Hey, um do you mind setting it up for me? What? You you always know what I like.
Sure.
Thank you.
Thank you, thank you.
I'ma try to get some Zs before the troll hawks me for more rounds.
Don't give me that look.
Mm-hmm.
Okay.
Thank you, Helen.
Bye.
Good news: Helen's gonna watch Owen tonight.
Watch as in all night? - Mm-hmm.
- Yes.
[giggles.]
Just one thing I ask.
Anything.
That you shave.
You don't like the sandpaper feel, huh? Uh-huh.
You ask a lot Mm.
But okay.
- Thank you.
- Yeah.
Proximal anastomosis is complete.
That looks good.
Let's move on to the base.
Do you have a suitable landing spot? Yeah.
Lighter calcification in this area.
Potts, please.
I'd go more distal.
Vessel's bigger.
You'll get a cleaner target.
This area of vessel is perfect.
If you say so.
8-0 Prolene.
The artery could probably handle the 7-0.
I prefer the 8-0.
Just thought the larger stitch might be easier for you to work with.
I don't understand the debate.
The difference between vessel location, and now suture choice, is negligible.
Good point, Dr.
Latham.
Dr.
Rhodes, you're lead surgeon.
I'm only assisting.
I defer to your preference.
Thank you, Doctor.
Now, how about from here on out, we keep the background noise to a minimum? [tense music.]
[alarm beeps.]
Myra Adams, 20.
Passed out in her bathroom washing her face.
Struck her head as she fell.
Chamber two.
GCS 6.
BP 128 over 60, heart rate 102 Her brother Eric's a step behind.
- Total wreck.
- Hey, uh, what's what's wrong with her? She's tensing up.
Decorticate posturing.
- Can you hear me? - Excuse us.
Can you tell me your name? Responds to pain.
All right, we're gonna transfer on my count.
One, two, three.
Uh, she was complaining about her stomach last night.
I-I told her it was, like, uh, something that she ate.
It's okay.
Please give the doctor some room to examine her.
Okay.
Clear breath sounds bilaterally.
CBC, CMP, coags, and u-tox.
Nat, belly's soft.
All right, nasal airway and a head CT.
And while we're there, let's scan her C spine and belly, okay? We're on it.
All right, let's move her.
Look, I-I should have brought her in last night.
Uh, why why is this happening to her? Look, we're gonna do everything we can to help your sister, okay? She's lucky you found her when you did.
I-I gotta, uh, call my parents.
Sure.
This level of posturing Has to be some sort of brain injury.
Yeah.
Thank you.
Uh, we're looking for our daughter, Myra Adams.
Our son called.
Is she all right? Come with me, please.
Dr.
Manning, Dr.
Choi.
These are Myra's parents.
What happened? We talked to her two days ago.
She was fine.
Myra? Myra, honey! Oh, please, I'd like to see her.
Yes, of course, please.
- Honey.
- What's going on? I don't know.
You poor baby.
Myra? Honey? We're here.
What's wrong with her? We don't know yet.
She collapsed in the bathroom and hasn't regained consciousness.
We don't think it's a brain injury.
Myra's CT scans were clear.
Last month, her friends brought her in to the ED.
Could that have something to do with this? Honey, that doctor said she was just dehydrated.
She, uh, got an IV.
She was, uh she was fine.
We checked her chart.
Back then, Myra's tox screen and blood work was normal, except she was slightly anemic.
Same as now.
She vegetarian? Vegan.
As long as I can remember.
Never liked meat.
[chuckles.]
Well, that would explain the anemia.
Is there anything else you can tell us? Uh, she, um What? No, it's just, uh, it was finals week, so she wasn't really, like, eating, or sleeping much at all.
She always worked so hard.
I tell her all the time, she needs to rest.
How do you know all that? I've been staying with her.
[scoffs.]
Since when? - [wheezing.]
- [machine beeping.]
Myra? She's tachycardic and tachypneic.
That means her heart is racing and she's having trouble breathing.
We need to intubate her.
Please let the doctors help her, okay? - My baby, no, oh, God.
- Please, okay? Let's get an EEG and LP, an antibiotics and antiviral, just in case.
Gram of Ceftriaxone, 500 milligrams Acyclovir.
Why is it happening? Why? [dramatic music.]
And lift.
I still would've landed the grafts more distal, but your way worked, too.
I'll take that as a "nice job.
" Didn't know my approval meant so much to you.
Always on, aren't you? "Always on.
" What does that mean? Nothing.
It's just, um steel sharpening steel.
Hmm, can't say I'm any more enlightened.
[heart monitor beeps rapidly.]
BP's falling.
We're in to the 80s.
Anterior lateral ST elevations.
Damn it.
Cardiac ischemia.
One of your grafts must have went down.
All right, get him back on the table.
I'll go back in to fix the graft.
No, we've already broken down the room.
By the time we re-prep, we'll have lost too much time.
IR's a better option.
What about the hybrid room? I have it booked for a stenotic dialysis arm graft.
I'll bump it and cath Ray.
If I can't fix the issue noninvasively, room's already prepped for us to re-open him up.
Dr.
Rhodes? [dramatic music.]
It's a good idea.
Okay, let's go.
Myra's lumbar puncture was negative.
There's no infection.
However, her EEG was positive for seizures.
We've put her on Ativan, but unfortunately, they haven't subsided.
Myra's always been so healthy.
I just don't understand.
But the Ativan, it'll work, right? Well, we're gonna do an MRI to get a closer look at her brain, see if there's something that the CT didn't pick up.
- Oh, my God.
- What what's happening? She's posturing again.
I'm afraid whatever's going on in her brain is getting worse.
Her pupils are sluggish.
Bolus another five milligrams of Ativan on top of the drip and get her up to MRI, quickly.
Hey, can I can I go with her? Sure.
No, no.
Eric, you stay with us.
I'm gonna order an echo, check for heart vegetations.
You're thinking sepsis, but her white blood cell count was totally normal.
Everything was normal the last time she was here, too, but she's back, even worse than before.
Ethan, these two ED visits could be totally unrelated.
No, I think they missed something last time.
Missed what? I don't know.
[sighs.]
Don't beat yourself up, Connor.
Grafts fail, often in patients with far less calcification than Ray.
Doesn't make any sense.
I checked every graft before I closed.
They were solid.
They still are.
Good flow through all repaired vessels.
One, two, three.
The problem is here.
Clot of the left anterior descending artery.
Likely a bad reaction to the protamine administered during anesthesia.
Recommendations on how to proceed? Treat noninvasively with heparin.
Thin the blood, let his heart clear the clot out on its own.
Too conservative.
Clot's already stopped up the vessel.
The LAD is the widow-maker.
If it's down much longer, Ray's not coming back.
We've got to suck it out.
I agree with Dr.
Bekker.
Thrombo-aspiration, though the riskier procedure, ensures complete removal of the blockage.
Excuse me, Dr.
Rhodes.
Alex's tox screen's negative for methamphetamine.
Negative for all drugs, in fact he's clean.
Yeah, I saw the report.
So now can we start him on a course of anti-psychotics? I'm just still not convinced it's schizophrenia.
How? He's presented with more than enough evidence of a thought disorder to warrant the diagnosis.
Yeah, but even so, before today, I mean, his medical record's clean.
History doesn't track with schizophrenia.
Or meth addiction.
He doesn't fit the profile of a user, either.
Just 'cause he's clean today, doesn't mean he's free of the drug.
So that's what the fan is for? White noise, Dr.
Charles? Really? Yes, really.
White noise has been proven to trigger auditory hallucinations in meth users.
How long have you been waiting for something to happen? [sighs.]
Hm, seven or eight minutes.
How long does it usually take? Two or three.
Probably not meth.
Go ahead, start anti-psychotics.
Two of Haldol Dr.
Charles [dramatic music.]
Oh, my God.
Alex get his hand, get his hand! I needed it gone.
Just see wait! Help! We need some help in here! [breathing rapidly.]
What happened? He used a pen to pop the stitches and chisel through his abdominal wall.
- Clearly.
- All right, no time to re-pack.
Got to scoop and move.
Saline.
Okay, call OR.
Tell them we're coming immediately.
Let's go! Okay, go, go, go! Hmm, sweet potato or quinoa? Noah's menu.
Why don't you feed yourself before the next wave of orders coming down? You've been ripping and running all day.
Exactly why I need to get this done now.
- Dr.
Manning? - Yes.
We think we know what might have caused this.
Eric.
Myra got sick while he was staying with her.
We never wanted him around our daughter.
He's a bad influence.
He never applied himself.
He's the opposite of Myra.
No job, hangs out with a bunch of deadbeats.
We kicked him out because he was stealing from us.
He takes drugs.
I'm sorry.
I'm I'm not following.
He probably slipped her something.
A drug of some sort.
There's no evidence of that.
Well, are you sure? Because if you knew what it was I understand that this is a very difficult time, but the best thing we can do right now is wait for the MRI to come back, and I promise, as soon as we hear anything, you will be the first to know.
Okay? - [scoffs.]
- All right.
[scoffs.]
They're blaming Eric for this? How is this his fault? They're desperate, looking for answers, and we don't know the whole story.
Family dynamics can be complicated.
Doesn't matter.
It's family.
It's blood.
Time like this, they should be banding together, not ostracizing one of their own.
I'd expect you to say that.
This again? Really? [scoffs.]
Here we go.
[somber music.]
You've got a soft spot for family, sometimes at your own expense.
Planning meals for Noah when you're slammed at work, for example.
Helping my brother when he's exhausted.
That's a bad thing in your eyes? The day I turned 18, it was sink-or-swim.
Noah's a grown man, April.
You're not doing him any favors by constantly picking up his slack.
Some point, we've all got to learn to go it alone.
I'd expect you to say that.
[sighs.]
All right, think we're there.
Vacuuming.
Got it.
Ah, blood flow's good.
BP's holding.
Nice job.
Thanks.
Look, I know I have a tendency to step on toes, Not personal.
I just want to Win? [heart monitor beeping rapidly.]
What happened? Artery ruptured.
Blood is pouring into his chest.
Blood flow was blocked, and now it's out of control.
All right, help me stent the leak - before he arrests.
- Where's the rupture? - Distal LAD.
- Are you kidding? That's not even where the clot was.
It's an entirely different section of vessel.
[dramatic music.]
Murphy's Law.
How's he doing? A few more feet to go, but no perforations to the bowel.
I was just standing there.
Meanwhile, he was ripping himself open with a pen? Wait.
The extra Versed.
It completely tranqed him out.
But if I hadn't given it to him, who knows? I mean, Alex was intent on harming himself.
He could have attacked one of us.
What the hell? There's something embedded deep in his left gutter, next to the colon.
What is it? I have no idea.
Did you see this? Myra's MRI.
Global edema in the brain.
Two hours ago, there was no sign of swelling.
Echo was clean, too.
It's not sepsis.
Or encephalitis, meningitis, HSV, CMV.
We need to brainstorm zebras.
Paraneoplastic syndrome? Usually presents with a fever, but there could be cancer cells in her spinal fluid.
Or another autoimmune, lupus, sarcoid, some kind of tumor What about FilmArray PCR tests? I'll draw paraneoplastic and autoimmune panels.
Have a lab put a rush on 'em.
I'll talk to hem-onc, get bone and PET scans.
Okay.
Myra's mom says she's been busting her ass for this fellowship in New Zealand.
She got it.
She's just starting her life.
We keep testing till we find out what's wrong.
Yeah.
Dr.
Halstead, I've been reviewing the write-up of our self-surgery patient, Alex.
Not bad, but I think some small additions to the chart are in order.
Additions? Perhaps "elaborations" is the better word.
Regarding the initial intake, you noted, "Wound lavaged and closed.
" I was there.
It was a little more than that.
I think we should say, "Wound lavaged "and irrigated with chlorhexidine and two liters of normal saline," okay? "Six-inch lacerations repaired in two layers "with 60 interrupted 2-0 nylon sutures.
" You don't think that's overdoing it a little bit? Absolutely not.
This is exactly what we did.
So you'll adjust? - Yes? - Yes.
Residence charts, too.
Yes.
Good man.
The art of charting.
The one thing I didn't learn in residency.
I'll look them over.
Thanks.
I don't understand.
What are you what are you saying? We did what's called a nuclear blood flow study and it showed no circulation to her brain.
Well, there must be some other test you can run.
They've all been negative.
Something else you can do.
I'm sorry.
There isn't.
[cries.]
We've done everything we can, but unfortunately, your daughter is brain-dead.
[pants.]
No [sobbing.]
No Okay.
- Our little girl - I'm so sorry No, no, no, no, no.
She's gonna wake up.
She's gonna be fine.
Myra? Myra My baby.
Myra.
She's gone, sweetie.
Your little girl's gone.
[somber music.]
We'll give you some time with her.
No Our baby [cries.]
Oh, baby [cries.]
Excuse me.
Mr.
Adams.
Our daughter was always doing things for other people.
She told us if anything ever happened to her, she, uh wanted to donate her organs.
Of course.
We'll get that started.
We want her life to have meant something.
We understand.
[breathes raggedly.]
Thank you.
Of course.
You're high.
Look at you! You're high.
Your sister's dead and you're high! Wait, Myra's, uh de? She's dead? Ah This is your fault, isn't it? You did this.
See? I told you he is no good.
He is a drug addict.
What did you give her? Nothing.
We told you.
Myra's tox screen was negative.
You worthless piece of.
- Oh.
- Whoa.
Get out.
[dramatic music.]
Get out! He's moving in the wrong direction.
He'll turn around.
Your optimism is enchanting.
Reality, though: between the clot, then the bleed, his heart is dying.
We should push for a transplant.
We're only a few hours post-op.
We are miles away from that discussion.
Normally, yes, but a hit-and-run just died in surgery.
His heart is an HLA match.
You already tested for compatibility? Ray's not even on the list.
Anything that could go wrong with Ray has.
We fix one thing, something else breaks.
A heart has fallen into our laps.
Let's use it and steal a win.
Is that our priority? You want his death on your record? Dr.
Bekker, you may have elbowed your way onto Ray's case, but he's still my patient.
Transplant's not an option.
Then you're just wasting time, because the balloon pump he's on won't hold.
He'll max out on pressors but he'll still need to go on VA-ECMO.
Then it gets invasive: a procedure for a temporary LVAD.
When that's not enough, a bigger procedure for a permanent one.
You're going to put Ray through months of physical and emotional strain, only to get back to exactly where we are right now.
Ray's arteries were bad, not his heart.
Now that the vessels are repaired, it will compensate for the clot and the bleed.
It'll heal.
No, it won't.
And when I'm right, I'll make sure the blame is on you, not me.
[tense music.]
Wow.
I guess there was something living inside Alex.
I'm still not exactly sure what I'm looking at.
Is it a tumor? Possibly.
Or it could be a fetus in fetu: a twin that her absorbed in utero.
Either way, it's not a result of schizophrenia or meth.
How about that? That's gotta be so rare.
To say the least.
It's very cool.
Hm.
But how did he know, not only that there was something inside him, but exactly where it was? Beats me.
And after all the advances we've made, splicing the genome, reprogramming viruses, mapping the brain in this case, you know, just completely trumped by human instinct.
Everything I've learned about human nature, I still can't see things coming.
He scared you? There's risk in our work.
I guess I realized a long time ago, you you choose to see the threat or the opportunity.
[solemn music.]
[distant siren wailing.]
Hey, Eric.
Hey, uh, listen, the last thing that I need right now is a lecture.
Hey, I'm here for me as much as I am for you.
What happened back there sometimes, when people are grieving, they lash out.
Yeah, no, that's that's how my folks always are.
Man, they think I'm, uh I'm worthless.
I don't know.
May maybe I am, but they think I want to be like this, and and I really don't.
Uh, you know, My-Myra she was the only one who ever, like like, really, like like, saw me.
You know? Yeah.
And now it's [sighs.]
What do you want, Eric? I want to get clean.
You know, I wanna, like, wake up and just feel clear.
Okay.
We'll set you up with a social worker, get you in a program.
[laughs.]
Wha seriously? Yeah.
You'll get the support you need, but it's up to you to come through.
Why are you doing this for me? I guess I'm seeing that there's a difference between a crutch and a helping hand.
Thank you.
Yeah.
[laughs.]
Let's get you something to eat first, huh? Help you come down.
No, no, I had a burger earlier.
Uh, it made me, like, feel really sick.
It's why I I had to get high.
You know, not to not to feel it.
Maybe food poisoning? Uh, no, I just I just felt crappy, like I always do.
Always, or just after eating? Hey.
Oh, you again.
Yeah, last guy only had a hangnail.
Brought him in anyway.
Okay.
Crew's meeting at Molly's tonight.
Come and hang? This sudden flirting what is it? Have you seen you? You're still a catch.
I always have been.
You should've thought about that before you cheated.
I'm not the same guy anymore.
Hm.
Barry up to something? I'm not sure.
Yeah, right.
This round two? Too much baggage.
Mm-hmm.
Make him work for it.
Mm.
[chuckles.]
Can I help you with something? No, I'm just giving today's charts a once-over.
Ugh, well, you better settle in.
Some of them are a few chapters long.
Stohl's five-minute knee aspiration reads like "War and Peace.
" Hey, Nat, I was speaking with Eric The drugs he's self-medicating.
Since he was a kid, he's gotten sick after eating protein.
Myra was a vegan avoided protein.
You're thinking that's what made her sick, too? Last month, when Myra was feeling confused, she was fasting while studying.
Ketosis.
Her body was starving, so it started digesting muscle as fuel, which released protein into her blood.
Okay, well, that explains what made her sick last month, but what about today? The fellowship.
She probably wasn't eating again.
I think this is OTC a metabolic disorder fits.
You were right.
The visits were connected.
- Yeah.
- Wait.
Did they transplant the liver yet? It's still up in the OR.
They can't use it.
[suspenseful music.]
If Myra had OTC, she couldn't break down nitrogen.
So it built up in her body as ammonia and finally put her in a coma.
And if the liver gets transplanted Same thing will happen to the recipient.
Is the transplant finished? No, the last surgery ran late.
They moved the transplant to OR 3.
Come on.
Okay - Stop! - What the hell? Liver might not be good.
The biopsy was clean.
It's a genetic defect.
It wouldn't show up on the biopsy.
I got my patient wide open, Choi.
You transplant that liver, he could be dead within hours.
We need time to test the donor's blood, see if she had OTC.
I'll pack and hold, but the donor's liver's only got four hours till it's shot, so move it.
A metabolic disorder caused her death? The precise term is "ornithine transcarbamylase deficiency," or OTC.
You see, Myra's liver was missing a vital enzyme that helps break down protein.
Something as simple as eating a burger could cause toxic levels of ammonia to build up in her blood and attack her nervous system.
- But Myra was a vegan.
- Yeah.
Which is how she was able to avoid symptoms for so long, but when she pushed herself, and didn't eat finals, the fellowship her body started breaking down muscle, which released protein into her blood.
So, you mean, she'd be alive right now if she'd just eaten? [solemn music.]
If this disease is genetic, that means one of us gave it to her.
Yes, um, it is passed through the X chromosome, from mother to child, but OTC sufferers exhibit totally normal liver function.
That's why all of Myra's tests came back clean.
We were only able to diagnose her once Eric explained his lethargy and sickness after eating.
We believe he has the defect as well, and he's been self-medicating with drugs.
Wha? Oh Eric is this true? I'm so sorry.
Oh, son Forgive us? Will you forgive us? We're so sorry.
Oh, Eric.
[crying.]
So, how's our patient? Heading for ECMO? Actually, no.
Uh, BP's risen and is holding, vitals have stabilized as well, so I'm going to remove the balloon pump and give his heart back its full load.
What do you want, an "I was wrong"? I'm not holding my breath.
Ah, I see our patient is making a turn for the better.
For a moment, there was concern the damage was irreparable.
A transplant option presented itself, but upon discussing the visual assessment of the heart during surgery, the decision was made to give it more time to come back on its own.
It was a risk, but it appears we made the right choice.
Indeed.
Nice work, doctors.
Thank you.
You and Dr.
Bekker your successes suggest a good pairing, but your exchanges often convey the opposite.
What's peculiar is Dr.
Bekker seems to enjoy this discordance.
Do you? Maybe I do.
You okay? We turned this hospital upside-down chasing zebras, but a simple ammonia test would've given us everything we needed to know.
There's no way you could've known.
Silver lining: the liver transplant was stopped before it was too late, and thanks to you, Eric's getting the help he needs.
I may coddle my family, but seems I'm not the only one with a soft spot.
Yes, yes, yes.
Wonderful, Dr.
Halstead.
Above and beyond.
Excellent medicine, and your writing for the ED.
It's been a good day.
We're gonna turn this place around.
He more happy about the work, or the bill? So I guess the rumors are true.
This morning's board meeting was basically an edict to shake the old money tree? Ah, nothing that hasn't come down the pipe before.
I'm handling it.
And these itemized charts that Stohl's championing? I mean, detail equals charges, right? Basically a menu for Billing to pad the invoices? Well, I've looked at every chart coming out of the ED today.
Each one has been accurate to the services provided.
Well, I should hope he's not committing fraud.
I mean, the fact that you even had to check Look, Sharon.
You set the tone, so if you're okay with it, well, then, it must The numbers are clear.
If I don't improve the bottom line, the board will start slashing.
Do you want to see the ED closed, or contracted out? Because that's what'll happen.
No, of course not, but I also don't wanna see the bottom line dictating patient care.
Well, let me tell you something.
Psych is the biggest money-loser in the ED.
You, Daniel, are a major part of our problem, so don't get on the soapbox with me.
You seen Natalie? She's in the doctor's lounge.
Oh, she told me that you had a hot date planned tonight.
Uh-huh, and I'm even gonna shave.
No.
The things we do for love [chuckles.]
[laughs softly.]
[somber music.]
Hey.
Day like today mm.
Tell me about it.
You make a really nice pillow.
Your hot date? Nice.
Hi.
Dirty Martini.
Extra olives.
You remember the important things.
Wasn't sure you'd show.
Well, don't get ahead of yourself.
You say that you've changed.
We'll see.
Thank you.
[phone buzzing.]
April, I'll be there in ten minutes.
Okay.
I'll tell you what, I'll get another set made on my way home.
[clears throat.]
[sighs.]
Look, babe, I really have to go.
Yeah, sure, that's fine.
Okay, I love you too.
Bye-bye.
My apologies.
Everything okay? Yeah, Robin just couldn't find her keys.
Rough morning? Perhaps I should take over the pre-op? That will not be necessary.
Shall we? Please.
Just a heads-up: the board is gonna push you for more growth.
The bottom line has them concerned.
When hasn't it? Can set my watch over their money worries.
I'll be fine.
It's different this time.
C-Suite feels we can better recognize how medicine and business are one and the same.
Ah, let me guess: scale back on outreach, combine responsibilities, outsource? So basically, sacrifice patient care? I won't do that, Peter.
Well, Sharon, you have to do something, because the ED is hemorrhaging cash, and if the bleeding doesn't stop, it's not going to be good for anybody.
- Mm.
- Need I remind you Randall Memorial closed their ED? Dr.
Halstead, Doris, you're with me.
- Copy that.
- Barry? - [heavy breathing.]
- Alex Mayer, 23.
Slash and stab.
Large diagonal lacerations of the abdomen.
He's a little tachy.
GCS 15.
Get it out! You're going Baghdad.
Get it out! The weapon still in? I don't know.
Wasn't even a call.
We were a few blocks away, I saw him on the street, bleeding, loaded him in the ambo and rolled.
- I can feel it inside me! - Whoa, whoa! Alex, keep your hands down.
I got you, Dr.
Halstead.
Let's transfer.
On my count.
One, two, three! [screams.]
[groans.]
Two of Versed to calm him down.
Thank you, boys.
[sobbing.]
- How's that Versed coming? - On it, Doctor.
Gaping diagonal incision of the right upper quad.
Evidence of evisceration? No, I can see the base.
Abdomen's still intact.
Just a flesh wound.
It's really clean, though.
Wash it out and stitch it up.
Irrigation.
Sir, you're a lucky man.
Whoever knifed you didn't do any serious damage.
[suspenseful music.]
Look at this.
Betadine's smeared all over the abdomen.
The skin was prepped before the cut.
I'm telling you, that incision is precise.
Back-alley surgery gone wrong? Alex, what happened? I was desperate.
Dr.
Halstead, his hand, under the blood.
More Betadine.
So he doused his own hands.
Alex, did you cut into yourself? I had to! I had to get it out! Get what out? The person living inside me! - [gasps.]
- Oh, I'm sorry.
Are you all right? I was just trying to say "hi.
" Um, it's Edith Lake.
Your insulin patient? The woman who slashed my tires? Oh, the woman you think slashed your tires.
Who else? I saw her yesterday, across the street from my apartment.
You really think it was her? Looked like her.
Next.
Dr.
Latham, this is Ray Preston, 53.
Fell short of breath while jogging.
I was only two miles in.
I'm always good for five before I start to get tired.
Ray lives in Galena.
It's about 3 1/2 hours west of Chicago.
His cardiologist performed an EKG, stress test, and cardiac cath.
Told me to skip the community hospital and come straight here.
Dr.
Rhodes, I know we're getting pretty close to show time here, but are you absolutely sure I need this surgery? I'm positive.
But I'm not in any pain.
I know, that's the danger.
Severe three-vessel disease, complicated by Heavy calcification and extremely poor targets.
CABG is still doable, but it will be more challenging than normal.
Indeed.
You're a lucky man, Mr.
Preston.
Keeping fit bought you the time to notice something was wrong.
Yeah.
Well, Dr.
Rhodes said people with arteries as damaged as mine usually just drop dead.
He's absolutely right.
Not to worry, Ray.
We'll take great care of you.
To streamline costs, Dr.
Stohl and I are implementing a system to track supplies to know exactly what we've used.
Everything will be barcoded and logged into Pyxis.
It will operate by finger scan, like we do for medications.
That's easy enough for minor treatments, but what about emergencies? Not a lot of time to stop down and scan your prints during a trauma.
A tech will take note of what was used in the moment and then scan after the fact.
"In the moment.
" They'll follow us into the trauma bay? Between nurses and equipment, we're already tight on space.
Another body We'll find the room because we have to.
Not to worry, Miss Goodwin.
All right, uh, let's get back to work.
Thank you for your time.
Doctors, one more thing before you go, while I have you here, charting.
When I was in Attending, it was pen, paper, and long-form.
Today, it's it's tablets and shorthand.
I get it tech saves time but details get lost in translation, so please be explicit in procedure notes.
Okay? Document everything.
If you do it, write it down.
Okay? [dramatic music.]
I clean up nice, don't I? I haven't noticed.
I saw that.
Why don't you believe me? I'm not crazy.
Something lives inside of me, right here.
I hear you.
I understand.
Then get it out! [sobs.]
I feel it all the time! Alex we're gonna help you, I promise.
Sedative? No, no, no.
Wait, wait, wait.
I'm sorry, I'm sorry.
I'm telling you the truth.
I can feel it inside of me.
Please.
[breathes fearfully.]
[breathing slows.]
Please What'd you give him? Five of Versed.
Hm.
Two probably would have sufficed.
He put hands on you.
I was being cautious.
So what are you thinking? Schizophrenia.
Yeah, that was my initial thought, but now I'm not so sure.
Seriously? His, uh, paranoia that there's something living inside him, and his attempt to remove it is literally a textbook definition of a somatic delusional disorder.
I'm stuck on the level of premeditation.
You know, sterilization with Betadine, the clean incision, doing it near a hospital All that kind of forethought it's just not consistent with schizophrenic psychosis.
So he's a germophobe with a steady hand.
It doesn't mean he's not schizophrenic.
Mm, could be true, too.
So, um start him on anti-psychotics and reassess when his mind's clear? I'm just not there yet.
My gut tells me it's chemical.
You know, like maybe a methamphetamine overdose.
Before we go any further, let's run a tox screen, see if he's just high.
What's with you? You look half-dead.
Yeah, these 90-hour weeks are killing a brother.
Law says you can't do more than 80.
[laughs.]
When Dr.
Stohl asks you to volunteer, you don't say "no.
" Game is rigged.
All part of being a big-shot doc.
Big shot, right.
Big shot, living off of ramen and cheeseburgers.
What? Yeah, that's all I got time for.
You are getting a steady paycheck now.
Sign up for one of those meal delivery services.
You're gonna need the fuel.
That's not a bad idea.
Hey, um do you mind setting it up for me? What? You you always know what I like.
Sure.
Thank you.
Thank you, thank you.
I'ma try to get some Zs before the troll hawks me for more rounds.
Don't give me that look.
Mm-hmm.
Okay.
Thank you, Helen.
Bye.
Good news: Helen's gonna watch Owen tonight.
Watch as in all night? - Mm-hmm.
- Yes.
[giggles.]
Just one thing I ask.
Anything.
That you shave.
You don't like the sandpaper feel, huh? Uh-huh.
You ask a lot Mm.
But okay.
- Thank you.
- Yeah.
Proximal anastomosis is complete.
That looks good.
Let's move on to the base.
Do you have a suitable landing spot? Yeah.
Lighter calcification in this area.
Potts, please.
I'd go more distal.
Vessel's bigger.
You'll get a cleaner target.
This area of vessel is perfect.
If you say so.
8-0 Prolene.
The artery could probably handle the 7-0.
I prefer the 8-0.
Just thought the larger stitch might be easier for you to work with.
I don't understand the debate.
The difference between vessel location, and now suture choice, is negligible.
Good point, Dr.
Latham.
Dr.
Rhodes, you're lead surgeon.
I'm only assisting.
I defer to your preference.
Thank you, Doctor.
Now, how about from here on out, we keep the background noise to a minimum? [tense music.]
[alarm beeps.]
Myra Adams, 20.
Passed out in her bathroom washing her face.
Struck her head as she fell.
Chamber two.
GCS 6.
BP 128 over 60, heart rate 102 Her brother Eric's a step behind.
- Total wreck.
- Hey, uh, what's what's wrong with her? She's tensing up.
Decorticate posturing.
- Can you hear me? - Excuse us.
Can you tell me your name? Responds to pain.
All right, we're gonna transfer on my count.
One, two, three.
Uh, she was complaining about her stomach last night.
I-I told her it was, like, uh, something that she ate.
It's okay.
Please give the doctor some room to examine her.
Okay.
Clear breath sounds bilaterally.
CBC, CMP, coags, and u-tox.
Nat, belly's soft.
All right, nasal airway and a head CT.
And while we're there, let's scan her C spine and belly, okay? We're on it.
All right, let's move her.
Look, I-I should have brought her in last night.
Uh, why why is this happening to her? Look, we're gonna do everything we can to help your sister, okay? She's lucky you found her when you did.
I-I gotta, uh, call my parents.
Sure.
This level of posturing Has to be some sort of brain injury.
Yeah.
Thank you.
Uh, we're looking for our daughter, Myra Adams.
Our son called.
Is she all right? Come with me, please.
Dr.
Manning, Dr.
Choi.
These are Myra's parents.
What happened? We talked to her two days ago.
She was fine.
Myra? Myra, honey! Oh, please, I'd like to see her.
Yes, of course, please.
- Honey.
- What's going on? I don't know.
You poor baby.
Myra? Honey? We're here.
What's wrong with her? We don't know yet.
She collapsed in the bathroom and hasn't regained consciousness.
We don't think it's a brain injury.
Myra's CT scans were clear.
Last month, her friends brought her in to the ED.
Could that have something to do with this? Honey, that doctor said she was just dehydrated.
She, uh, got an IV.
She was, uh she was fine.
We checked her chart.
Back then, Myra's tox screen and blood work was normal, except she was slightly anemic.
Same as now.
She vegetarian? Vegan.
As long as I can remember.
Never liked meat.
[chuckles.]
Well, that would explain the anemia.
Is there anything else you can tell us? Uh, she, um What? No, it's just, uh, it was finals week, so she wasn't really, like, eating, or sleeping much at all.
She always worked so hard.
I tell her all the time, she needs to rest.
How do you know all that? I've been staying with her.
[scoffs.]
Since when? - [wheezing.]
- [machine beeping.]
Myra? She's tachycardic and tachypneic.
That means her heart is racing and she's having trouble breathing.
We need to intubate her.
Please let the doctors help her, okay? - My baby, no, oh, God.
- Please, okay? Let's get an EEG and LP, an antibiotics and antiviral, just in case.
Gram of Ceftriaxone, 500 milligrams Acyclovir.
Why is it happening? Why? [dramatic music.]
And lift.
I still would've landed the grafts more distal, but your way worked, too.
I'll take that as a "nice job.
" Didn't know my approval meant so much to you.
Always on, aren't you? "Always on.
" What does that mean? Nothing.
It's just, um steel sharpening steel.
Hmm, can't say I'm any more enlightened.
[heart monitor beeps rapidly.]
BP's falling.
We're in to the 80s.
Anterior lateral ST elevations.
Damn it.
Cardiac ischemia.
One of your grafts must have went down.
All right, get him back on the table.
I'll go back in to fix the graft.
No, we've already broken down the room.
By the time we re-prep, we'll have lost too much time.
IR's a better option.
What about the hybrid room? I have it booked for a stenotic dialysis arm graft.
I'll bump it and cath Ray.
If I can't fix the issue noninvasively, room's already prepped for us to re-open him up.
Dr.
Rhodes? [dramatic music.]
It's a good idea.
Okay, let's go.
Myra's lumbar puncture was negative.
There's no infection.
However, her EEG was positive for seizures.
We've put her on Ativan, but unfortunately, they haven't subsided.
Myra's always been so healthy.
I just don't understand.
But the Ativan, it'll work, right? Well, we're gonna do an MRI to get a closer look at her brain, see if there's something that the CT didn't pick up.
- Oh, my God.
- What what's happening? She's posturing again.
I'm afraid whatever's going on in her brain is getting worse.
Her pupils are sluggish.
Bolus another five milligrams of Ativan on top of the drip and get her up to MRI, quickly.
Hey, can I can I go with her? Sure.
No, no.
Eric, you stay with us.
I'm gonna order an echo, check for heart vegetations.
You're thinking sepsis, but her white blood cell count was totally normal.
Everything was normal the last time she was here, too, but she's back, even worse than before.
Ethan, these two ED visits could be totally unrelated.
No, I think they missed something last time.
Missed what? I don't know.
[sighs.]
Don't beat yourself up, Connor.
Grafts fail, often in patients with far less calcification than Ray.
Doesn't make any sense.
I checked every graft before I closed.
They were solid.
They still are.
Good flow through all repaired vessels.
One, two, three.
The problem is here.
Clot of the left anterior descending artery.
Likely a bad reaction to the protamine administered during anesthesia.
Recommendations on how to proceed? Treat noninvasively with heparin.
Thin the blood, let his heart clear the clot out on its own.
Too conservative.
Clot's already stopped up the vessel.
The LAD is the widow-maker.
If it's down much longer, Ray's not coming back.
We've got to suck it out.
I agree with Dr.
Bekker.
Thrombo-aspiration, though the riskier procedure, ensures complete removal of the blockage.
Excuse me, Dr.
Rhodes.
Alex's tox screen's negative for methamphetamine.
Negative for all drugs, in fact he's clean.
Yeah, I saw the report.
So now can we start him on a course of anti-psychotics? I'm just still not convinced it's schizophrenia.
How? He's presented with more than enough evidence of a thought disorder to warrant the diagnosis.
Yeah, but even so, before today, I mean, his medical record's clean.
History doesn't track with schizophrenia.
Or meth addiction.
He doesn't fit the profile of a user, either.
Just 'cause he's clean today, doesn't mean he's free of the drug.
So that's what the fan is for? White noise, Dr.
Charles? Really? Yes, really.
White noise has been proven to trigger auditory hallucinations in meth users.
How long have you been waiting for something to happen? [sighs.]
Hm, seven or eight minutes.
How long does it usually take? Two or three.
Probably not meth.
Go ahead, start anti-psychotics.
Two of Haldol Dr.
Charles [dramatic music.]
Oh, my God.
Alex get his hand, get his hand! I needed it gone.
Just see wait! Help! We need some help in here! [breathing rapidly.]
What happened? He used a pen to pop the stitches and chisel through his abdominal wall.
- Clearly.
- All right, no time to re-pack.
Got to scoop and move.
Saline.
Okay, call OR.
Tell them we're coming immediately.
Let's go! Okay, go, go, go! Hmm, sweet potato or quinoa? Noah's menu.
Why don't you feed yourself before the next wave of orders coming down? You've been ripping and running all day.
Exactly why I need to get this done now.
- Dr.
Manning? - Yes.
We think we know what might have caused this.
Eric.
Myra got sick while he was staying with her.
We never wanted him around our daughter.
He's a bad influence.
He never applied himself.
He's the opposite of Myra.
No job, hangs out with a bunch of deadbeats.
We kicked him out because he was stealing from us.
He takes drugs.
I'm sorry.
I'm I'm not following.
He probably slipped her something.
A drug of some sort.
There's no evidence of that.
Well, are you sure? Because if you knew what it was I understand that this is a very difficult time, but the best thing we can do right now is wait for the MRI to come back, and I promise, as soon as we hear anything, you will be the first to know.
Okay? - [scoffs.]
- All right.
[scoffs.]
They're blaming Eric for this? How is this his fault? They're desperate, looking for answers, and we don't know the whole story.
Family dynamics can be complicated.
Doesn't matter.
It's family.
It's blood.
Time like this, they should be banding together, not ostracizing one of their own.
I'd expect you to say that.
This again? Really? [scoffs.]
Here we go.
[somber music.]
You've got a soft spot for family, sometimes at your own expense.
Planning meals for Noah when you're slammed at work, for example.
Helping my brother when he's exhausted.
That's a bad thing in your eyes? The day I turned 18, it was sink-or-swim.
Noah's a grown man, April.
You're not doing him any favors by constantly picking up his slack.
Some point, we've all got to learn to go it alone.
I'd expect you to say that.
[sighs.]
All right, think we're there.
Vacuuming.
Got it.
Ah, blood flow's good.
BP's holding.
Nice job.
Thanks.
Look, I know I have a tendency to step on toes, Not personal.
I just want to Win? [heart monitor beeping rapidly.]
What happened? Artery ruptured.
Blood is pouring into his chest.
Blood flow was blocked, and now it's out of control.
All right, help me stent the leak - before he arrests.
- Where's the rupture? - Distal LAD.
- Are you kidding? That's not even where the clot was.
It's an entirely different section of vessel.
[dramatic music.]
Murphy's Law.
How's he doing? A few more feet to go, but no perforations to the bowel.
I was just standing there.
Meanwhile, he was ripping himself open with a pen? Wait.
The extra Versed.
It completely tranqed him out.
But if I hadn't given it to him, who knows? I mean, Alex was intent on harming himself.
He could have attacked one of us.
What the hell? There's something embedded deep in his left gutter, next to the colon.
What is it? I have no idea.
Did you see this? Myra's MRI.
Global edema in the brain.
Two hours ago, there was no sign of swelling.
Echo was clean, too.
It's not sepsis.
Or encephalitis, meningitis, HSV, CMV.
We need to brainstorm zebras.
Paraneoplastic syndrome? Usually presents with a fever, but there could be cancer cells in her spinal fluid.
Or another autoimmune, lupus, sarcoid, some kind of tumor What about FilmArray PCR tests? I'll draw paraneoplastic and autoimmune panels.
Have a lab put a rush on 'em.
I'll talk to hem-onc, get bone and PET scans.
Okay.
Myra's mom says she's been busting her ass for this fellowship in New Zealand.
She got it.
She's just starting her life.
We keep testing till we find out what's wrong.
Yeah.
Dr.
Halstead, I've been reviewing the write-up of our self-surgery patient, Alex.
Not bad, but I think some small additions to the chart are in order.
Additions? Perhaps "elaborations" is the better word.
Regarding the initial intake, you noted, "Wound lavaged and closed.
" I was there.
It was a little more than that.
I think we should say, "Wound lavaged "and irrigated with chlorhexidine and two liters of normal saline," okay? "Six-inch lacerations repaired in two layers "with 60 interrupted 2-0 nylon sutures.
" You don't think that's overdoing it a little bit? Absolutely not.
This is exactly what we did.
So you'll adjust? - Yes? - Yes.
Residence charts, too.
Yes.
Good man.
The art of charting.
The one thing I didn't learn in residency.
I'll look them over.
Thanks.
I don't understand.
What are you what are you saying? We did what's called a nuclear blood flow study and it showed no circulation to her brain.
Well, there must be some other test you can run.
They've all been negative.
Something else you can do.
I'm sorry.
There isn't.
[cries.]
We've done everything we can, but unfortunately, your daughter is brain-dead.
[pants.]
No [sobbing.]
No Okay.
- Our little girl - I'm so sorry No, no, no, no, no.
She's gonna wake up.
She's gonna be fine.
Myra? Myra My baby.
Myra.
She's gone, sweetie.
Your little girl's gone.
[somber music.]
We'll give you some time with her.
No Our baby [cries.]
Oh, baby [cries.]
Excuse me.
Mr.
Adams.
Our daughter was always doing things for other people.
She told us if anything ever happened to her, she, uh wanted to donate her organs.
Of course.
We'll get that started.
We want her life to have meant something.
We understand.
[breathes raggedly.]
Thank you.
Of course.
You're high.
Look at you! You're high.
Your sister's dead and you're high! Wait, Myra's, uh de? She's dead? Ah This is your fault, isn't it? You did this.
See? I told you he is no good.
He is a drug addict.
What did you give her? Nothing.
We told you.
Myra's tox screen was negative.
You worthless piece of.
- Oh.
- Whoa.
Get out.
[dramatic music.]
Get out! He's moving in the wrong direction.
He'll turn around.
Your optimism is enchanting.
Reality, though: between the clot, then the bleed, his heart is dying.
We should push for a transplant.
We're only a few hours post-op.
We are miles away from that discussion.
Normally, yes, but a hit-and-run just died in surgery.
His heart is an HLA match.
You already tested for compatibility? Ray's not even on the list.
Anything that could go wrong with Ray has.
We fix one thing, something else breaks.
A heart has fallen into our laps.
Let's use it and steal a win.
Is that our priority? You want his death on your record? Dr.
Bekker, you may have elbowed your way onto Ray's case, but he's still my patient.
Transplant's not an option.
Then you're just wasting time, because the balloon pump he's on won't hold.
He'll max out on pressors but he'll still need to go on VA-ECMO.
Then it gets invasive: a procedure for a temporary LVAD.
When that's not enough, a bigger procedure for a permanent one.
You're going to put Ray through months of physical and emotional strain, only to get back to exactly where we are right now.
Ray's arteries were bad, not his heart.
Now that the vessels are repaired, it will compensate for the clot and the bleed.
It'll heal.
No, it won't.
And when I'm right, I'll make sure the blame is on you, not me.
[tense music.]
Wow.
I guess there was something living inside Alex.
I'm still not exactly sure what I'm looking at.
Is it a tumor? Possibly.
Or it could be a fetus in fetu: a twin that her absorbed in utero.
Either way, it's not a result of schizophrenia or meth.
How about that? That's gotta be so rare.
To say the least.
It's very cool.
Hm.
But how did he know, not only that there was something inside him, but exactly where it was? Beats me.
And after all the advances we've made, splicing the genome, reprogramming viruses, mapping the brain in this case, you know, just completely trumped by human instinct.
Everything I've learned about human nature, I still can't see things coming.
He scared you? There's risk in our work.
I guess I realized a long time ago, you you choose to see the threat or the opportunity.
[solemn music.]
[distant siren wailing.]
Hey, Eric.
Hey, uh, listen, the last thing that I need right now is a lecture.
Hey, I'm here for me as much as I am for you.
What happened back there sometimes, when people are grieving, they lash out.
Yeah, no, that's that's how my folks always are.
Man, they think I'm, uh I'm worthless.
I don't know.
May maybe I am, but they think I want to be like this, and and I really don't.
Uh, you know, My-Myra she was the only one who ever, like like, really, like like, saw me.
You know? Yeah.
And now it's [sighs.]
What do you want, Eric? I want to get clean.
You know, I wanna, like, wake up and just feel clear.
Okay.
We'll set you up with a social worker, get you in a program.
[laughs.]
Wha seriously? Yeah.
You'll get the support you need, but it's up to you to come through.
Why are you doing this for me? I guess I'm seeing that there's a difference between a crutch and a helping hand.
Thank you.
Yeah.
[laughs.]
Let's get you something to eat first, huh? Help you come down.
No, no, I had a burger earlier.
Uh, it made me, like, feel really sick.
It's why I I had to get high.
You know, not to not to feel it.
Maybe food poisoning? Uh, no, I just I just felt crappy, like I always do.
Always, or just after eating? Hey.
Oh, you again.
Yeah, last guy only had a hangnail.
Brought him in anyway.
Okay.
Crew's meeting at Molly's tonight.
Come and hang? This sudden flirting what is it? Have you seen you? You're still a catch.
I always have been.
You should've thought about that before you cheated.
I'm not the same guy anymore.
Hm.
Barry up to something? I'm not sure.
Yeah, right.
This round two? Too much baggage.
Mm-hmm.
Make him work for it.
Mm.
[chuckles.]
Can I help you with something? No, I'm just giving today's charts a once-over.
Ugh, well, you better settle in.
Some of them are a few chapters long.
Stohl's five-minute knee aspiration reads like "War and Peace.
" Hey, Nat, I was speaking with Eric The drugs he's self-medicating.
Since he was a kid, he's gotten sick after eating protein.
Myra was a vegan avoided protein.
You're thinking that's what made her sick, too? Last month, when Myra was feeling confused, she was fasting while studying.
Ketosis.
Her body was starving, so it started digesting muscle as fuel, which released protein into her blood.
Okay, well, that explains what made her sick last month, but what about today? The fellowship.
She probably wasn't eating again.
I think this is OTC a metabolic disorder fits.
You were right.
The visits were connected.
- Yeah.
- Wait.
Did they transplant the liver yet? It's still up in the OR.
They can't use it.
[suspenseful music.]
If Myra had OTC, she couldn't break down nitrogen.
So it built up in her body as ammonia and finally put her in a coma.
And if the liver gets transplanted Same thing will happen to the recipient.
Is the transplant finished? No, the last surgery ran late.
They moved the transplant to OR 3.
Come on.
Okay - Stop! - What the hell? Liver might not be good.
The biopsy was clean.
It's a genetic defect.
It wouldn't show up on the biopsy.
I got my patient wide open, Choi.
You transplant that liver, he could be dead within hours.
We need time to test the donor's blood, see if she had OTC.
I'll pack and hold, but the donor's liver's only got four hours till it's shot, so move it.
A metabolic disorder caused her death? The precise term is "ornithine transcarbamylase deficiency," or OTC.
You see, Myra's liver was missing a vital enzyme that helps break down protein.
Something as simple as eating a burger could cause toxic levels of ammonia to build up in her blood and attack her nervous system.
- But Myra was a vegan.
- Yeah.
Which is how she was able to avoid symptoms for so long, but when she pushed herself, and didn't eat finals, the fellowship her body started breaking down muscle, which released protein into her blood.
So, you mean, she'd be alive right now if she'd just eaten? [solemn music.]
If this disease is genetic, that means one of us gave it to her.
Yes, um, it is passed through the X chromosome, from mother to child, but OTC sufferers exhibit totally normal liver function.
That's why all of Myra's tests came back clean.
We were only able to diagnose her once Eric explained his lethargy and sickness after eating.
We believe he has the defect as well, and he's been self-medicating with drugs.
Wha? Oh Eric is this true? I'm so sorry.
Oh, son Forgive us? Will you forgive us? We're so sorry.
Oh, Eric.
[crying.]
So, how's our patient? Heading for ECMO? Actually, no.
Uh, BP's risen and is holding, vitals have stabilized as well, so I'm going to remove the balloon pump and give his heart back its full load.
What do you want, an "I was wrong"? I'm not holding my breath.
Ah, I see our patient is making a turn for the better.
For a moment, there was concern the damage was irreparable.
A transplant option presented itself, but upon discussing the visual assessment of the heart during surgery, the decision was made to give it more time to come back on its own.
It was a risk, but it appears we made the right choice.
Indeed.
Nice work, doctors.
Thank you.
You and Dr.
Bekker your successes suggest a good pairing, but your exchanges often convey the opposite.
What's peculiar is Dr.
Bekker seems to enjoy this discordance.
Do you? Maybe I do.
You okay? We turned this hospital upside-down chasing zebras, but a simple ammonia test would've given us everything we needed to know.
There's no way you could've known.
Silver lining: the liver transplant was stopped before it was too late, and thanks to you, Eric's getting the help he needs.
I may coddle my family, but seems I'm not the only one with a soft spot.
Yes, yes, yes.
Wonderful, Dr.
Halstead.
Above and beyond.
Excellent medicine, and your writing for the ED.
It's been a good day.
We're gonna turn this place around.
He more happy about the work, or the bill? So I guess the rumors are true.
This morning's board meeting was basically an edict to shake the old money tree? Ah, nothing that hasn't come down the pipe before.
I'm handling it.
And these itemized charts that Stohl's championing? I mean, detail equals charges, right? Basically a menu for Billing to pad the invoices? Well, I've looked at every chart coming out of the ED today.
Each one has been accurate to the services provided.
Well, I should hope he's not committing fraud.
I mean, the fact that you even had to check Look, Sharon.
You set the tone, so if you're okay with it, well, then, it must The numbers are clear.
If I don't improve the bottom line, the board will start slashing.
Do you want to see the ED closed, or contracted out? Because that's what'll happen.
No, of course not, but I also don't wanna see the bottom line dictating patient care.
Well, let me tell you something.
Psych is the biggest money-loser in the ED.
You, Daniel, are a major part of our problem, so don't get on the soapbox with me.
You seen Natalie? She's in the doctor's lounge.
Oh, she told me that you had a hot date planned tonight.
Uh-huh, and I'm even gonna shave.
No.
The things we do for love [chuckles.]
[laughs softly.]
[somber music.]
Hey.
Day like today mm.
Tell me about it.
You make a really nice pillow.
Your hot date? Nice.
Hi.
Dirty Martini.
Extra olives.
You remember the important things.
Wasn't sure you'd show.
Well, don't get ahead of yourself.
You say that you've changed.
We'll see.
Thank you.
[phone buzzing.]
April, I'll be there in ten minutes.
Okay.