ER s03e06 Episode Script
Fear of Flying
Previously on ER I like kids.
Fear of flying cannot be conquered.
Mom got her real-estate license at 40.
I helped with her homework.
I can help you with yours if you want.
You're probably too tired after your trip to dance.
- Kind of, but - So maybe later.
Do you know what you're doing or not? If you have to keep confirming, you don't know what you're doing.
I worked just as hard as everyone else.
You have to work twice as hard, stay twice as late to be twice as good.
Oh, God! The flight rotation was the highlight of my residency.
I'll be thousands of feet in the air in something shaped like a potato.
Well, actually, it's only hundreds of feet.
Oh, God! Don't they have ambulances in this sticks? They don't have a trauma center in Boone County.
If it's bad, we go.
- How far? - Fifty, 60 miles.
Head up.
Didn't you know this was a requirement of your residency? All right, deep breath.
Let it out slowly.
Okay.
My knees won't move! Come on.
Stay low.
- Dee McManus, Susan Lewis.
- Hi.
First flight? The sum of the angles of a triangle equals 180 degrees, right? - Hey, Carol.
- Hi, Doug.
- Hi.
- Doug Ross, this is William Litman.
- William is my lab partner.
- No kidding? How's it going? I have an intuitive 19th-century Euclidean mind.
It's actually crippling to the understanding of the geometric - I'm flunking out.
- What are you working on? String theory.
The multi-dimensional curvature of time and space.
The Riemannian manifold is "M" dimensional space that locally looks like "N" dimensional space when "M" is less than "N.
" Susan, take a look.
It's beautiful.
- What are you doing? - Hyperventilating.
Leave me alone.
You should really check out this view.
It helps you set your gyroscope.
- What was that? - The pilot.
He was just adjusting the rotor pitch.
Absolutely normal.
Right.
Normal.
There it is.
Oh, man! We're first on scene.
We're gonna need the O-neg and blood Y's.
There's a field near 5:00.
Oh, God! Stay low and watch the tail rotors.
We've got five victims.
Hay truck and a van hit head-on.
Two ejected and three are trapped.
- Where is the fire response? - Two engines and an ambulance en route.
- ETA? - Thirty minutes.
Triage first.
Susan, you check the car.
It's all right, sweetie.
Please get us out of this car! Yes, I'm still holding for authorization.
Hello? Dallas by three, you think? ER.
Hold on.
ICU's got no beds till 1999, and they're sending us two vents.
Way to go, Mr.
Gomez! Chuny, we need more IVAC's in 3.
Patric Brazil, metastatic prostate cancer.
Cough, fever, two months progressive weakness.
Gave 300 cc's of saline.
He's a no-code.
I've been Mr.
B's caretaker for 22 years.
He wants to be cryogenically preserved when he deanimates.
- He wants to what? - Be put on ice when he croaks.
He's been waiting eight years to join Mrs.
B in their suspension capsule.
His wife's been frozen for eight years? It was their 50th anniversary present to each other.
They want to be preserved so that they could come back in the future.
Just like those dinosaurs in that movie.
Isn't it romantic? Let's hang a dobutamine drip.
Start at 10 mcg per kilo - Watch the IV.
- Settle down, Mr.
Sotcheck.
Rescue 1-16 for you to rule out MI.
- We're swamped.
- Who's covering Haleh's vacation? The last nurse who floated down here hid in the bathroom.
- Sterling from Med-Surg West.
- Rhonda Sterling? - Yeah, what's wrong with her? - She's a floor nurse.
- I'm not babysitting her.
- Me neither.
The fire's out! - What's your name? - Gail.
She's only 10 days old.
- Is she all right? - She's moving and crying.
- I'm Dr.
Lewis.
What's your name? - Zach.
- Gail, does your neck hurt? - Is he all right? Get a C-collar on her.
Sir? Sir, can you hear me? It's brain matter.
The guy's a goner.
Get him on oxygen.
Where, Zach? Your neck? Does this hurt? David? Where's my husband? Gail, where are you hurt? My right leg and my side.
David.
Please! - Dr.
Greene's working on him.
- My husband is a doctor.
He has to check on the children.
- He's a pediatrician.
- Go, I'll stand by.
Okay, I'm gonna go check on your husband.
The trucker's gone.
I need you here.
He's still moving.
He's pulseless with massive head trauma.
I've got a tension hemopneumo that we can save.
Needle him, left side.
He's decompressing.
Thirty-two French.
This guy's a pediatrician.
- Really? - His family's in the van.
Wife and newborn baby girl.
Wife's stable.
There's a boy about 8 years old.
Number four-two facial fracture.
I'm worried about his airway.
I'm in.
Hook it up to the Foley bag.
He's hemorrhaging.
Grab two units O-neg out of the cooler.
I'll start a line.
- What about my husband? - Gail, we're getting you out.
Yeah, I'm still holding.
Do you like Green Bay minus seven over Washington? - Excuse me.
- Hang on one second.
Please don't tell! Mommy! Where do you want him? Curtain Area 3.
End of the hall.
Don't tell her! - Carol Hathaway? - Carol.
I was pulled off my ward and assigned down here.
What patient do you want me to take? Actually, we share our patients here.
Let me show you.
Here are the patients that are waiting to be seen.
Nursing orders are flagged and put over here, so when you're I'll take Mr.
Washington.
Where is Curtain Area 3? - There.
- Thank you.
- Secure his head.
- We need to start a second line.
Dr.
Lewis! The boy's stopped breathing.
Go! Watch his C-spine! Keep in-line traction.
You're in the way.
Too much blood.
I need suction.
- Another 6.
0.
- That was it.
Okay, 5.
5.
Mark, I need your help.
Get him on the chopper.
We're taking care of him, Gail.
Please don't let him die! - I can't see.
Turn it up.
- It is up.
There's better control in the chopper.
Ready? One, two, three.
- Doctor, I need you to start this IV.
- Okay.
Go on, I'll check it out.
- What's up? - She needs an IV.
Usually we try a few times before we call a doc.
Up in Med-Surg we call the doctor when we miss.
I'll do it.
Mrs.
Fesmire needs - Where's the potassium? - In the Med Room under "P.
" I can see the vocal cords.
I'm in.
- I'll be right back.
- Susan! All right, Fred, fire it up.
Susan! - How much longer? - 20 or 30 minutes.
Gail, we're taking your son and your husband to County General Hospital.
- Are they all right? - They need to go to a trauma center.
- How will I know what's happening? - I will get word to you, Gail.
- Please! - I promise.
- Are you okay? - Yeah.
- It's Dr.
Greene from the whirlybird.
- Where's Mrs.
Fesmire's potassium? I'm on break.
I'm getting to her.
This is County General on Beta-two.
Go ahead.
We're incoming on Air-vac One with two major traumas.
Grab Lydia and Chuny.
Tell them to clear the trauma rooms.
- Go ahead, Air-Vac One.
- I'm gonna need a vent Goodbye, Mr.
B.
You will keep him cold until they come for him, won't you? So that he could be with his wife.
- Please? - Sure.
Should I clean out the fridge? The dad's got a hemopneumo and a head trauma.
airway.
He's getting shocky.
- Good job, Susan.
- What? I said good job.
Draw up meds.
Watch that IV.
Fluids wide open.
Let's get a cross-table, CBC, type and cross for four units Draw up a saline-flush crash cart.
- Where is the saline? - Pulse 160, thready - He's waking up.
- Hey, Zach.
That tube in your throat is helping you breathe.
- Set up for lavage.
- Want a gas? Got it.
You bet.
Chuny, give me a hand right here.
Okay, we got a bloody tap.
Page Benton.
See if the dad will sign a consent form for an ex-lap.
- Put that O-neg on the rapid infuser.
- Is he conscious? He's responding to pain.
Dr.
Herlihy, open your eyes.
Somebody needs to sign his son's surgical consent.
BP's low, 70 palp.
Pulse ox is only 85.
Ask Jerry to track down the number of the hospital in Boone County where they're taking the mother and the baby.
Do the heart sounds seem distant to you? Tamponade? - Hang in there, Zach.
- Hold him still.
- He's gotta be sedated.
- Give him Versed, one milligram IV.
Where is it? It's clotted.
I need that saline.
- Another liter.
- Let's go! Zach, I'm gonna give you something to help you sleep, okay? Hold him.
What was that? Did it hurt? Are you sure that's saline? - Oh, my God! That's potassium.
- How much went in? - About a quarter cc.
- Insulin and glucose.
- Where is it? - Second drawer.
Hold on.
It's probably not enough to stop his heart.
I think we're gonna be okay.
- What do you got? - 7-year-old TC.
Airway compromised at the scene.
Peritoneal lavage was positive.
- BP's crashing, 60 palp.
- Pericardiocentesis tray.
- Go ahead.
- I'll drop the central line.
Hook an alligator clip to an EKG lead.
Use V-1.
Not mine.
It's the patient's.
He's a doctor.
It might be his office.
Why don't you dial the number? Jerry called Dwight Hospital.
The baby and wife haven't arrived.
- Are they on their way? - I don't know.
- What do we have? - Blunt abdominal trauma.
Hypotensive intraperitoneal hemorrhage confirmed by lavage.
Facial trauma intubated in the field with an RSI.
H&H is 11, 32.
Type and cross four, 650 cc's of saline.
We're set onboard.
- Way to go, Carter! - Let's take him up.
Where are his parents? Second unit's in.
So you got his partner to take calls? Okay, we'll let you know.
Forty cc's non-clotting blood, out.
Dr.
Herlihy, you've been in an accident.
You're in the ER.
BP's back up, 120 over 80.
I'm worried about an intracranial bleed.
- The nurse goes with him.
- Am I on call? You're a patient.
You were involved in traffic accident.
Your son, Zach, has just been taken up to surgery.
- Surgery? - He was injured in the accident.
What accident? Get a rush on that head CT.
Zach, everything's gonna be okay.
- We could've killed that boy.
- I got confused.
- You have no business working the ER.
- You think I don't know that? I want you to restock supplies for the rest of the day.
This is Carol Hathaway in the ER.
Clear a CT room, please.
Where's the number for chopper dispatch? Mark, can I run something past you? A guy died, and I don't know what to do about his cryogenics request.
He and his wife bought a tank so they could be frozen when they died.
- Where is his wife now? - In the tank.
I have an number for a cryogenics company in California.
Yeah, still holding.
- What? - Nothing.
Page me as soon as you know.
The helicopter's standing by.
We may have to get the wife and baby.
- Okay, DeBakey.
- 5.
0 Prolene on a Castroviejo.
- Retract caudally.
- Retractor.
Splenic vein's repaired.
What about this pancreas? I'd resect rather than do a subtotal pancreatectomy.
I agree.
Metz.
How would you repair after resection? Interrupted horizontal mattresses and a figure eight in the pancreatic duct.
- 3.
0 silk on a needle driver.
- Anything else to do? Irrigate.
Run the bowel under control.
Insert a Jackson-Pratt drain through a separate stab wound.
And use cautery instead of a scalpel to minimize bleeding.
- Then close.
- Do exactly what you just described.
All right, cut the suture three millimeters, no longer.
Irrigate.
Normal saline.
Make sure it's warm.
Park her in the hall till we can clear an exam room.
- Have you seen Susan? - She got paged to chopper duty.
- What's up? - I need ice, lots of ice.
California Cryonics said to put him on ice until their local rep arrives.
They better hurry.
Dr.
Lewis! - Susan, are you all right? - Yeah, I want to bring them in.
- I'll go.
- No, I'm fine.
Really? You can stay here with Herlihy.
Dr.
Lewis.
We gotta go.
May I? See your orders? John, take these to ICU and make sure they're carried out as meticulously as written.
Peter, care to join me in a sarcoma resection? - Yeah, I'd love to.
- Good.
Gant can cover any trauma calls.
Scrub in, in 45 minutes.
Don't you just love her? - Where's Zach? Where's my husband? - Your husband was unconscious.
He woke up confused and disoriented.
He has a head injury? What about my son? - He's in surgery.
- Don't worry.
They're in good hands.
Move! Does this hurt? BP's okay, 115 over 65.
Let's get a C-spine.
H&H, type and cross for four.
- Good set of lungs on her.
- Respiratory rate's kind of high.
- Who knows with all that crying? - It's 60, pulse 160.
Abdomen's distended.
She's been taking in a lot of air.
Get a baby Gram, CBC and a gas.
Darling, are you hurt or just mad at the world? - What'll it be? - Do you believe in reincarnation? Next life I'm coming back as Cindy Crawford.
A deceased patient wants to be cryogenically preserved.
We gotta freeze a dead guy.
You got any ice? - Neck looks okay.
- CT was normal.
Dad's still altered, they're doing an MRI.
- Why did they take Megan away? - She's just next door.
- Zach's out of surgery.
- He's gonna be all right? He's in ICU.
I'll check on him as soon as I can.
Oh, God! I need my husband.
Please.
Where is David? - Her abdomen's kind of firm.
- She swallowed a lot of air.
- What shall we do? - What is it, Gant? Her abdomen's persistently distended.
She keeps crying.
Her resps are high.
The BP, the pulses and color are okay.
- Why didn't you drop an NG? - We considered it - In such a small baby? - Do it off the rectal thermometer.
You didn't do a full surgical evaluation of the patient, Dr.
Gant.
It's positive for blood.
Prep a cutdown tray.
Type and cross for two units and page Keaton.
- Where's her mother? - Trauma 1.
Dr.
Ross and I thought it was an equivocal exam.
If you don't know what you're doing, call someone who does.
Hi, I'm Dr.
Benton.
Your daughter has internal injuries that's gonna require an operation.
She's only 10 days old.
It's okay.
Dr.
Keaton will be with her.
And she's the best pediatric surgeon in Chicago.
We need your consent for an exploratory laparotomy.
Where's my husband? I want him to sign for it.
Her husband's a pediatrician.
He can't do it right now.
He handles all the family medical decisions.
- You can do this, Gail.
- But I don't know.
Your baby needs it.
Okay.
Cutdown tray.
Use a volutrol.
We may have to transfuse.
Gant was on track.
I talked him out of it.
Hang D5, 40 normal.
- What do you think, Peter? - She has an acute abdomen.
Hi, pretty girl.
- Vitals? - BP's 80 over 40, pulse 160.
Resps 65, temp's 101.
4.
- Oh, what blue, blue eyes! - 92 room air.
Teacup, that's too low.
Let's get her on O-2, four liters by mask.
Did you appreciate the periumbilical redness? - The abdomen's a little tight.
- No, I missed it.
Well, it's easy to miss.
- Why a cutdown? - No veins.
Twenty-two angio.
This was a nice pickup, Peter.
Thank you.
Ah, yes.
There we go.
I couldn't see or feel a vein.
It's just a matter of knowing where it is.
Let's get her a cross-table lateral and check for free air.
- Any thoughts on antibiotics? - Since you don't need anaerobic coverage on newborns, I'd go with amp and gent.
Dennis, since you did the trauma assessment, why don't you scrub in? Peter, let's go talk to Mom.
Good girl.
There you go, Mr.
Brazil.
Shrimp cocktail time.
Hubert Skinner, California Cryonics.
Mr.
Brazil.
- You got some kind of I.
D.
? - It's all there.
Give him I'll pack him up, and we'll be on our way.
- Is he a doctor? - I don't think so.
What do we do? The heparin can't hurt, him being dead and all.
In the newborn, I use a transverse abdominal incision.
The rectus is thin so there's less pain post-op.
We're using a respirator, so atelectasis isn't an issue.
Zap that little bleeder.
- Cautery.
- Fifteen blade.
If there's a perforation we should get a gush of air when I nick the peritoneum.
- There it is.
- She's easier to ventilate.
Dennis, why do we want to keep bleeding to a minimum? Transfusions are dangerous.
You can't type and cross-match blood because of the fetal hemoglobin.
There it is.
Perfed jejunum.
You're teaching your interns well.
He's in and out.
MRI was normal.
Dr.
Herlihy, do you remember my name? - Where's my wife and kids? - I'm Mark Greene.
Your family was involved in a traffic accident.
Your wife's in the ER, with a tib-fib fracture.
Zach had facial trauma and hemoperitoneum.
He's out of surgery in ICU.
- Was it his spleen? - No.
Pancreatic injury.
What about Megan? Megan just went up to rule out intestinal perforation.
Why? What happened to her? She was in the accident with you.
What accident? Do you know my name? No.
Should I? It's okay.
Gently.
To repair it, we use a 4.
0 silk, interrupted Hufnagel.
Field looks dry.
You don't need a two-layer in anastomosis.
Cautery alone gives you hemostasis.
Let's irrigate.
Warm saline, please.
Zach's abdomen is distending.
- Any changes in his vitals or pulse? - I think he's bleeding.
Damn! Peter, do you think you're ready to finish alone? - Yeah.
- Nothing fancy.
Just close.
All right, people.
Let's go.
Thank you.
One more.
His abdomen is more distended.
- Has he regained consciousness? - No.
Four-by-eight.
Thank you.
- All right.
Completely dry.
- What's that? Looks like a little fiber and debris on the liver surface.
- Should I call Dr.
Keaton? - No.
I'll clean it out.
Okay, got it.
Let's close the peritoneum first.
3.
0 Vicryl.
Now, retract medially.
Cut.
Good.
- There's a little blood.
- Where? Oozing from the liver where you just touched it.
I'll put a little pressure on it.
Use suction.
Gently, okay? Damn it! - It's still oozing.
- I'm not closing while it's bleeding.
I'll put a stitch in for hemostasis.
Retract caudally.
Come on, Gant.
Retractor.
- Is Anesthesia standing by? - I called them.
- He is distended.
Vitals? - Stable.
BP 90 over 60.
Pulse is 96.
Pulse ox is 99 percent.
Should I clear an O.
R.
? Hang on.
Disconnect the NG from the wall.
Sometimes you get an erosive gastritis.
Hook it back up.
Clots can block the NG causing acute dilatation.
Irrigate it out and crisis resolved.
It's just experience, doctor.
- She's still bleeding! - I can see that.
I'll put a gelfoam on the bleeding site.
You apply pressure.
Come on.
- Do you want me to get Dr.
Keaton? - No.
More suction.
I'm gonna oversew.
Heart rate's starting to fluctuate.
Give me a bolus of normal saline, 40 cc's.
The liver's so fragile, my stitch cut right through.
I'm gonna take a bigger bite.
Retract this way.
You need to get this baby off the table.
All right, bag her faster, damn it! - I'm getting Keaton.
- No! Go! Go! Do you think it'll help her to see her husband like this? Megan's in surgery.
Zach's in ICU.
Your husband got out of X-ray.
- He's okay? - His tests are normal, but there's still memory loss.
Could it be permanent? You can see these things in a concussion.
- But it might be? - We just have to wait and see.
- Blood loss? - A hundred cc's.
One third of her volume.
What did you do to her liver? I was trying to peel away some fiber and debris.
Move.
- 2.
0 chromic on an S-H.
- It started to ooze.
Clear.
There's no way to control the bleeding.
Peter, handle the suction.
Dennis, retract distally.
Cautery.
Crank it up to 18.
Pulse and BP are destabilizing.
We have to transfuse with unwashed O-neg.
She's bradying down.
Rate's 80.
muscles and staples for the skin.
David? Oh, my God! David.
- What happened? - Didn't you tell him? - We did.
Many times.
- Zach's condition is stabilized.
Zach? - What about Megan? - Dr.
Benton's closing right now.
That's wonderful news.
Was there a truck? Yeah.
Yeah, there was a truck.
- What were you thinking? - There was debris.
- I only told you to close.
- In my judgment I didn't ask for your judgment! Perry, Dennis, set up a vent.
F-I O-2 at 100 percent.
Stand by with dopamine - Does that say chicken belt? - Conjunctivitis.
I hate chart QA.
- What? - Nothing.
Thanks for helping me in the chopper.
No problem.
Things can get pressured in here.
It just isn't a place for someone who is inexperienced.
I can't have you work here again.
Zach? Oh, God! - Can I touch him? - Sure.
Zach, honey, it's Mommy.
I'm gonna stay right here until you wake up.
- What about Megan? - No one from Surgery's talked to you? - I'll go find out what's going on.
- Thank you.
- Why hasn't anyone talked to her? - I don't know.
Benton was closing over an hour ago.
- Blood gas has improved.
- Not by much.
Could you excuse us, Kit? Dennis? Thank you.
I should never have left you unsupervised.
There are nuances in neonatal surgery.
The liver's more friable.
I wanted a clean field before I closed.
It seemed appropriate.
What's at issue here is that you ignored my specific instructions.
I followed standard operative procedures.
I've done it a dozen times in other patients.
This is not an "other" patient.
This is an infant! Outside now.
You don't know anything about pediatric surgery.
Are you unwilling to learn from your mistakes? Does it say not to stitch a liver? You didn't know what you were doing.
You should've called me! Why did I find three stitches in there? Because you arrogantly and blindly think you have all the answers.
If that baby dies, it'll be my responsibility but it'll be your fault.
- Dr.
Keaton, she's crashing.
Pulse ox is 86.
Heart rate's down to 45.
Decreased breath sounds on the right.
Sounds like a pneumothorax.
Chest x-ray.
Don't need it.
Increase transillumination on the right side.
- Chest-tube tray.
- This is no longer a teaching case.
- She's gonna need a repeat ABG.
- Pulse is up to 72.
- Dynamap's not registering a BP.
- Get ready with Thermo-Seal.
She's arresting.
Heart rate's down to 20.
Let's start CPR.
Epi one to ten thousand point four.
Atropine.
08 milligrams.
How's the blood gas? PH 7.
3.
PO-245.
PCO-230 on 100 percent oxygen.
We have to put her on an ECMO bypass.
Kit, call the tech.
Get two units O-neg to prime the system.
- Do we bring her back up to the O.
R.
? - No, we'll bring the O.
R.
To her.
Dr.
Greene? Dr.
Herlihy? - What time is it? - Eight o'clock.
P.
M.
? Where's my family? Your wife's upstairs.
Both the kids had laparotomies.
A bed opened up for you in ICU.
How'd they do? Your son's out of surgery.
I don't know about your daughter.
- How do I find out about my daughter? - I'll check on her.
- Thank you, Dr.
Greene.
- Mark.
Mark.
Pedes O.
R.
Called.
His daughter decompensated in surgery.
- She's still flatline.
- Repeat.
04 of epi.
Go ahead, Kit.
How long has she been down? Twenty-two minutes.
- Is the ECMO circuit primed? - Yes.
Good.
I'm ready.
Venous connection first.
Arterial.
Turn it on.
- We've got a heartbeat and a pulse.
- Faint.
She's pinking up.
Let's get a repeat gas.
We need to anti-coagulate her.
Heparin, 150 units IV.
Start drip at 10 units an hour.
- How come we anti-coagulate her? - We have to, or her blood will clot.
- Won't she bleed out? - We have to hope that she doesn't.
I'll dictate an operative report.
Meet me in Pedes ICU in five minutes.
We gotta tell the parents.
Peter, how'd it go? - How's the baby? - Not good.
Dr.
Benton You didn't sign the code sheet.
Hey, we're all human.
We all make mistakes.
Any other words of wisdom, Gant? You're a real prick, you know that? Mrs.
Herlihy, this is Dr.
Keaton.
She operated on both Zach and Megan.
Mrs.
Herlihy Megan had a perforated intestine from the accident.
When we operated to repair it, there were complications.
- What are you saying? - She's in the NICU on a device that helps her heart and lungs oxygenate her blood.
There was bleeding during the operation, and she went into shock.
Then her lung collapsed, and finally, her heart stopped.
We got it started again by putting her on a bypass machine.
Is she gonna die? She's in extremely critical condition.
It's It is a possibility.
The Lord is my shepherd, I shall not want.
He makes me lie down in green pastures.
He The Lord is my shepherd, I shall not want.
He makes me lie down in green pastures.
He's Dr.
Benton? I can't remember the words.
Fear of flying cannot be conquered.
Mom got her real-estate license at 40.
I helped with her homework.
I can help you with yours if you want.
You're probably too tired after your trip to dance.
- Kind of, but - So maybe later.
Do you know what you're doing or not? If you have to keep confirming, you don't know what you're doing.
I worked just as hard as everyone else.
You have to work twice as hard, stay twice as late to be twice as good.
Oh, God! The flight rotation was the highlight of my residency.
I'll be thousands of feet in the air in something shaped like a potato.
Well, actually, it's only hundreds of feet.
Oh, God! Don't they have ambulances in this sticks? They don't have a trauma center in Boone County.
If it's bad, we go.
- How far? - Fifty, 60 miles.
Head up.
Didn't you know this was a requirement of your residency? All right, deep breath.
Let it out slowly.
Okay.
My knees won't move! Come on.
Stay low.
- Dee McManus, Susan Lewis.
- Hi.
First flight? The sum of the angles of a triangle equals 180 degrees, right? - Hey, Carol.
- Hi, Doug.
- Hi.
- Doug Ross, this is William Litman.
- William is my lab partner.
- No kidding? How's it going? I have an intuitive 19th-century Euclidean mind.
It's actually crippling to the understanding of the geometric - I'm flunking out.
- What are you working on? String theory.
The multi-dimensional curvature of time and space.
The Riemannian manifold is "M" dimensional space that locally looks like "N" dimensional space when "M" is less than "N.
" Susan, take a look.
It's beautiful.
- What are you doing? - Hyperventilating.
Leave me alone.
You should really check out this view.
It helps you set your gyroscope.
- What was that? - The pilot.
He was just adjusting the rotor pitch.
Absolutely normal.
Right.
Normal.
There it is.
Oh, man! We're first on scene.
We're gonna need the O-neg and blood Y's.
There's a field near 5:00.
Oh, God! Stay low and watch the tail rotors.
We've got five victims.
Hay truck and a van hit head-on.
Two ejected and three are trapped.
- Where is the fire response? - Two engines and an ambulance en route.
- ETA? - Thirty minutes.
Triage first.
Susan, you check the car.
It's all right, sweetie.
Please get us out of this car! Yes, I'm still holding for authorization.
Hello? Dallas by three, you think? ER.
Hold on.
ICU's got no beds till 1999, and they're sending us two vents.
Way to go, Mr.
Gomez! Chuny, we need more IVAC's in 3.
Patric Brazil, metastatic prostate cancer.
Cough, fever, two months progressive weakness.
Gave 300 cc's of saline.
He's a no-code.
I've been Mr.
B's caretaker for 22 years.
He wants to be cryogenically preserved when he deanimates.
- He wants to what? - Be put on ice when he croaks.
He's been waiting eight years to join Mrs.
B in their suspension capsule.
His wife's been frozen for eight years? It was their 50th anniversary present to each other.
They want to be preserved so that they could come back in the future.
Just like those dinosaurs in that movie.
Isn't it romantic? Let's hang a dobutamine drip.
Start at 10 mcg per kilo - Watch the IV.
- Settle down, Mr.
Sotcheck.
Rescue 1-16 for you to rule out MI.
- We're swamped.
- Who's covering Haleh's vacation? The last nurse who floated down here hid in the bathroom.
- Sterling from Med-Surg West.
- Rhonda Sterling? - Yeah, what's wrong with her? - She's a floor nurse.
- I'm not babysitting her.
- Me neither.
The fire's out! - What's your name? - Gail.
She's only 10 days old.
- Is she all right? - She's moving and crying.
- I'm Dr.
Lewis.
What's your name? - Zach.
- Gail, does your neck hurt? - Is he all right? Get a C-collar on her.
Sir? Sir, can you hear me? It's brain matter.
The guy's a goner.
Get him on oxygen.
Where, Zach? Your neck? Does this hurt? David? Where's my husband? Gail, where are you hurt? My right leg and my side.
David.
Please! - Dr.
Greene's working on him.
- My husband is a doctor.
He has to check on the children.
- He's a pediatrician.
- Go, I'll stand by.
Okay, I'm gonna go check on your husband.
The trucker's gone.
I need you here.
He's still moving.
He's pulseless with massive head trauma.
I've got a tension hemopneumo that we can save.
Needle him, left side.
He's decompressing.
Thirty-two French.
This guy's a pediatrician.
- Really? - His family's in the van.
Wife and newborn baby girl.
Wife's stable.
There's a boy about 8 years old.
Number four-two facial fracture.
I'm worried about his airway.
I'm in.
Hook it up to the Foley bag.
He's hemorrhaging.
Grab two units O-neg out of the cooler.
I'll start a line.
- What about my husband? - Gail, we're getting you out.
Yeah, I'm still holding.
Do you like Green Bay minus seven over Washington? - Excuse me.
- Hang on one second.
Please don't tell! Mommy! Where do you want him? Curtain Area 3.
End of the hall.
Don't tell her! - Carol Hathaway? - Carol.
I was pulled off my ward and assigned down here.
What patient do you want me to take? Actually, we share our patients here.
Let me show you.
Here are the patients that are waiting to be seen.
Nursing orders are flagged and put over here, so when you're I'll take Mr.
Washington.
Where is Curtain Area 3? - There.
- Thank you.
- Secure his head.
- We need to start a second line.
Dr.
Lewis! The boy's stopped breathing.
Go! Watch his C-spine! Keep in-line traction.
You're in the way.
Too much blood.
I need suction.
- Another 6.
0.
- That was it.
Okay, 5.
5.
Mark, I need your help.
Get him on the chopper.
We're taking care of him, Gail.
Please don't let him die! - I can't see.
Turn it up.
- It is up.
There's better control in the chopper.
Ready? One, two, three.
- Doctor, I need you to start this IV.
- Okay.
Go on, I'll check it out.
- What's up? - She needs an IV.
Usually we try a few times before we call a doc.
Up in Med-Surg we call the doctor when we miss.
I'll do it.
Mrs.
Fesmire needs - Where's the potassium? - In the Med Room under "P.
" I can see the vocal cords.
I'm in.
- I'll be right back.
- Susan! All right, Fred, fire it up.
Susan! - How much longer? - 20 or 30 minutes.
Gail, we're taking your son and your husband to County General Hospital.
- Are they all right? - They need to go to a trauma center.
- How will I know what's happening? - I will get word to you, Gail.
- Please! - I promise.
- Are you okay? - Yeah.
- It's Dr.
Greene from the whirlybird.
- Where's Mrs.
Fesmire's potassium? I'm on break.
I'm getting to her.
This is County General on Beta-two.
Go ahead.
We're incoming on Air-vac One with two major traumas.
Grab Lydia and Chuny.
Tell them to clear the trauma rooms.
- Go ahead, Air-Vac One.
- I'm gonna need a vent Goodbye, Mr.
B.
You will keep him cold until they come for him, won't you? So that he could be with his wife.
- Please? - Sure.
Should I clean out the fridge? The dad's got a hemopneumo and a head trauma.
airway.
He's getting shocky.
- Good job, Susan.
- What? I said good job.
Draw up meds.
Watch that IV.
Fluids wide open.
Let's get a cross-table, CBC, type and cross for four units Draw up a saline-flush crash cart.
- Where is the saline? - Pulse 160, thready - He's waking up.
- Hey, Zach.
That tube in your throat is helping you breathe.
- Set up for lavage.
- Want a gas? Got it.
You bet.
Chuny, give me a hand right here.
Okay, we got a bloody tap.
Page Benton.
See if the dad will sign a consent form for an ex-lap.
- Put that O-neg on the rapid infuser.
- Is he conscious? He's responding to pain.
Dr.
Herlihy, open your eyes.
Somebody needs to sign his son's surgical consent.
BP's low, 70 palp.
Pulse ox is only 85.
Ask Jerry to track down the number of the hospital in Boone County where they're taking the mother and the baby.
Do the heart sounds seem distant to you? Tamponade? - Hang in there, Zach.
- Hold him still.
- He's gotta be sedated.
- Give him Versed, one milligram IV.
Where is it? It's clotted.
I need that saline.
- Another liter.
- Let's go! Zach, I'm gonna give you something to help you sleep, okay? Hold him.
What was that? Did it hurt? Are you sure that's saline? - Oh, my God! That's potassium.
- How much went in? - About a quarter cc.
- Insulin and glucose.
- Where is it? - Second drawer.
Hold on.
It's probably not enough to stop his heart.
I think we're gonna be okay.
- What do you got? - 7-year-old TC.
Airway compromised at the scene.
Peritoneal lavage was positive.
- BP's crashing, 60 palp.
- Pericardiocentesis tray.
- Go ahead.
- I'll drop the central line.
Hook an alligator clip to an EKG lead.
Use V-1.
Not mine.
It's the patient's.
He's a doctor.
It might be his office.
Why don't you dial the number? Jerry called Dwight Hospital.
The baby and wife haven't arrived.
- Are they on their way? - I don't know.
- What do we have? - Blunt abdominal trauma.
Hypotensive intraperitoneal hemorrhage confirmed by lavage.
Facial trauma intubated in the field with an RSI.
H&H is 11, 32.
Type and cross four, 650 cc's of saline.
We're set onboard.
- Way to go, Carter! - Let's take him up.
Where are his parents? Second unit's in.
So you got his partner to take calls? Okay, we'll let you know.
Forty cc's non-clotting blood, out.
Dr.
Herlihy, you've been in an accident.
You're in the ER.
BP's back up, 120 over 80.
I'm worried about an intracranial bleed.
- The nurse goes with him.
- Am I on call? You're a patient.
You were involved in traffic accident.
Your son, Zach, has just been taken up to surgery.
- Surgery? - He was injured in the accident.
What accident? Get a rush on that head CT.
Zach, everything's gonna be okay.
- We could've killed that boy.
- I got confused.
- You have no business working the ER.
- You think I don't know that? I want you to restock supplies for the rest of the day.
This is Carol Hathaway in the ER.
Clear a CT room, please.
Where's the number for chopper dispatch? Mark, can I run something past you? A guy died, and I don't know what to do about his cryogenics request.
He and his wife bought a tank so they could be frozen when they died.
- Where is his wife now? - In the tank.
I have an number for a cryogenics company in California.
Yeah, still holding.
- What? - Nothing.
Page me as soon as you know.
The helicopter's standing by.
We may have to get the wife and baby.
- Okay, DeBakey.
- 5.
0 Prolene on a Castroviejo.
- Retract caudally.
- Retractor.
Splenic vein's repaired.
What about this pancreas? I'd resect rather than do a subtotal pancreatectomy.
I agree.
Metz.
How would you repair after resection? Interrupted horizontal mattresses and a figure eight in the pancreatic duct.
- 3.
0 silk on a needle driver.
- Anything else to do? Irrigate.
Run the bowel under control.
Insert a Jackson-Pratt drain through a separate stab wound.
And use cautery instead of a scalpel to minimize bleeding.
- Then close.
- Do exactly what you just described.
All right, cut the suture three millimeters, no longer.
Irrigate.
Normal saline.
Make sure it's warm.
Park her in the hall till we can clear an exam room.
- Have you seen Susan? - She got paged to chopper duty.
- What's up? - I need ice, lots of ice.
California Cryonics said to put him on ice until their local rep arrives.
They better hurry.
Dr.
Lewis! - Susan, are you all right? - Yeah, I want to bring them in.
- I'll go.
- No, I'm fine.
Really? You can stay here with Herlihy.
Dr.
Lewis.
We gotta go.
May I? See your orders? John, take these to ICU and make sure they're carried out as meticulously as written.
Peter, care to join me in a sarcoma resection? - Yeah, I'd love to.
- Good.
Gant can cover any trauma calls.
Scrub in, in 45 minutes.
Don't you just love her? - Where's Zach? Where's my husband? - Your husband was unconscious.
He woke up confused and disoriented.
He has a head injury? What about my son? - He's in surgery.
- Don't worry.
They're in good hands.
Move! Does this hurt? BP's okay, 115 over 65.
Let's get a C-spine.
H&H, type and cross for four.
- Good set of lungs on her.
- Respiratory rate's kind of high.
- Who knows with all that crying? - It's 60, pulse 160.
Abdomen's distended.
She's been taking in a lot of air.
Get a baby Gram, CBC and a gas.
Darling, are you hurt or just mad at the world? - What'll it be? - Do you believe in reincarnation? Next life I'm coming back as Cindy Crawford.
A deceased patient wants to be cryogenically preserved.
We gotta freeze a dead guy.
You got any ice? - Neck looks okay.
- CT was normal.
Dad's still altered, they're doing an MRI.
- Why did they take Megan away? - She's just next door.
- Zach's out of surgery.
- He's gonna be all right? He's in ICU.
I'll check on him as soon as I can.
Oh, God! I need my husband.
Please.
Where is David? - Her abdomen's kind of firm.
- She swallowed a lot of air.
- What shall we do? - What is it, Gant? Her abdomen's persistently distended.
She keeps crying.
Her resps are high.
The BP, the pulses and color are okay.
- Why didn't you drop an NG? - We considered it - In such a small baby? - Do it off the rectal thermometer.
You didn't do a full surgical evaluation of the patient, Dr.
Gant.
It's positive for blood.
Prep a cutdown tray.
Type and cross for two units and page Keaton.
- Where's her mother? - Trauma 1.
Dr.
Ross and I thought it was an equivocal exam.
If you don't know what you're doing, call someone who does.
Hi, I'm Dr.
Benton.
Your daughter has internal injuries that's gonna require an operation.
She's only 10 days old.
It's okay.
Dr.
Keaton will be with her.
And she's the best pediatric surgeon in Chicago.
We need your consent for an exploratory laparotomy.
Where's my husband? I want him to sign for it.
Her husband's a pediatrician.
He can't do it right now.
He handles all the family medical decisions.
- You can do this, Gail.
- But I don't know.
Your baby needs it.
Okay.
Cutdown tray.
Use a volutrol.
We may have to transfuse.
Gant was on track.
I talked him out of it.
Hang D5, 40 normal.
- What do you think, Peter? - She has an acute abdomen.
Hi, pretty girl.
- Vitals? - BP's 80 over 40, pulse 160.
Resps 65, temp's 101.
4.
- Oh, what blue, blue eyes! - 92 room air.
Teacup, that's too low.
Let's get her on O-2, four liters by mask.
Did you appreciate the periumbilical redness? - The abdomen's a little tight.
- No, I missed it.
Well, it's easy to miss.
- Why a cutdown? - No veins.
Twenty-two angio.
This was a nice pickup, Peter.
Thank you.
Ah, yes.
There we go.
I couldn't see or feel a vein.
It's just a matter of knowing where it is.
Let's get her a cross-table lateral and check for free air.
- Any thoughts on antibiotics? - Since you don't need anaerobic coverage on newborns, I'd go with amp and gent.
Dennis, since you did the trauma assessment, why don't you scrub in? Peter, let's go talk to Mom.
Good girl.
There you go, Mr.
Brazil.
Shrimp cocktail time.
Hubert Skinner, California Cryonics.
Mr.
Brazil.
- You got some kind of I.
D.
? - It's all there.
Give him I'll pack him up, and we'll be on our way.
- Is he a doctor? - I don't think so.
What do we do? The heparin can't hurt, him being dead and all.
In the newborn, I use a transverse abdominal incision.
The rectus is thin so there's less pain post-op.
We're using a respirator, so atelectasis isn't an issue.
Zap that little bleeder.
- Cautery.
- Fifteen blade.
If there's a perforation we should get a gush of air when I nick the peritoneum.
- There it is.
- She's easier to ventilate.
Dennis, why do we want to keep bleeding to a minimum? Transfusions are dangerous.
You can't type and cross-match blood because of the fetal hemoglobin.
There it is.
Perfed jejunum.
You're teaching your interns well.
He's in and out.
MRI was normal.
Dr.
Herlihy, do you remember my name? - Where's my wife and kids? - I'm Mark Greene.
Your family was involved in a traffic accident.
Your wife's in the ER, with a tib-fib fracture.
Zach had facial trauma and hemoperitoneum.
He's out of surgery in ICU.
- Was it his spleen? - No.
Pancreatic injury.
What about Megan? Megan just went up to rule out intestinal perforation.
Why? What happened to her? She was in the accident with you.
What accident? Do you know my name? No.
Should I? It's okay.
Gently.
To repair it, we use a 4.
0 silk, interrupted Hufnagel.
Field looks dry.
You don't need a two-layer in anastomosis.
Cautery alone gives you hemostasis.
Let's irrigate.
Warm saline, please.
Zach's abdomen is distending.
- Any changes in his vitals or pulse? - I think he's bleeding.
Damn! Peter, do you think you're ready to finish alone? - Yeah.
- Nothing fancy.
Just close.
All right, people.
Let's go.
Thank you.
One more.
His abdomen is more distended.
- Has he regained consciousness? - No.
Four-by-eight.
Thank you.
- All right.
Completely dry.
- What's that? Looks like a little fiber and debris on the liver surface.
- Should I call Dr.
Keaton? - No.
I'll clean it out.
Okay, got it.
Let's close the peritoneum first.
3.
0 Vicryl.
Now, retract medially.
Cut.
Good.
- There's a little blood.
- Where? Oozing from the liver where you just touched it.
I'll put a little pressure on it.
Use suction.
Gently, okay? Damn it! - It's still oozing.
- I'm not closing while it's bleeding.
I'll put a stitch in for hemostasis.
Retract caudally.
Come on, Gant.
Retractor.
- Is Anesthesia standing by? - I called them.
- He is distended.
Vitals? - Stable.
BP 90 over 60.
Pulse is 96.
Pulse ox is 99 percent.
Should I clear an O.
R.
? Hang on.
Disconnect the NG from the wall.
Sometimes you get an erosive gastritis.
Hook it back up.
Clots can block the NG causing acute dilatation.
Irrigate it out and crisis resolved.
It's just experience, doctor.
- She's still bleeding! - I can see that.
I'll put a gelfoam on the bleeding site.
You apply pressure.
Come on.
- Do you want me to get Dr.
Keaton? - No.
More suction.
I'm gonna oversew.
Heart rate's starting to fluctuate.
Give me a bolus of normal saline, 40 cc's.
The liver's so fragile, my stitch cut right through.
I'm gonna take a bigger bite.
Retract this way.
You need to get this baby off the table.
All right, bag her faster, damn it! - I'm getting Keaton.
- No! Go! Go! Do you think it'll help her to see her husband like this? Megan's in surgery.
Zach's in ICU.
Your husband got out of X-ray.
- He's okay? - His tests are normal, but there's still memory loss.
Could it be permanent? You can see these things in a concussion.
- But it might be? - We just have to wait and see.
- Blood loss? - A hundred cc's.
One third of her volume.
What did you do to her liver? I was trying to peel away some fiber and debris.
Move.
- 2.
0 chromic on an S-H.
- It started to ooze.
Clear.
There's no way to control the bleeding.
Peter, handle the suction.
Dennis, retract distally.
Cautery.
Crank it up to 18.
Pulse and BP are destabilizing.
We have to transfuse with unwashed O-neg.
She's bradying down.
Rate's 80.
muscles and staples for the skin.
David? Oh, my God! David.
- What happened? - Didn't you tell him? - We did.
Many times.
- Zach's condition is stabilized.
Zach? - What about Megan? - Dr.
Benton's closing right now.
That's wonderful news.
Was there a truck? Yeah.
Yeah, there was a truck.
- What were you thinking? - There was debris.
- I only told you to close.
- In my judgment I didn't ask for your judgment! Perry, Dennis, set up a vent.
F-I O-2 at 100 percent.
Stand by with dopamine - Does that say chicken belt? - Conjunctivitis.
I hate chart QA.
- What? - Nothing.
Thanks for helping me in the chopper.
No problem.
Things can get pressured in here.
It just isn't a place for someone who is inexperienced.
I can't have you work here again.
Zach? Oh, God! - Can I touch him? - Sure.
Zach, honey, it's Mommy.
I'm gonna stay right here until you wake up.
- What about Megan? - No one from Surgery's talked to you? - I'll go find out what's going on.
- Thank you.
- Why hasn't anyone talked to her? - I don't know.
Benton was closing over an hour ago.
- Blood gas has improved.
- Not by much.
Could you excuse us, Kit? Dennis? Thank you.
I should never have left you unsupervised.
There are nuances in neonatal surgery.
The liver's more friable.
I wanted a clean field before I closed.
It seemed appropriate.
What's at issue here is that you ignored my specific instructions.
I followed standard operative procedures.
I've done it a dozen times in other patients.
This is not an "other" patient.
This is an infant! Outside now.
You don't know anything about pediatric surgery.
Are you unwilling to learn from your mistakes? Does it say not to stitch a liver? You didn't know what you were doing.
You should've called me! Why did I find three stitches in there? Because you arrogantly and blindly think you have all the answers.
If that baby dies, it'll be my responsibility but it'll be your fault.
- Dr.
Keaton, she's crashing.
Pulse ox is 86.
Heart rate's down to 45.
Decreased breath sounds on the right.
Sounds like a pneumothorax.
Chest x-ray.
Don't need it.
Increase transillumination on the right side.
- Chest-tube tray.
- This is no longer a teaching case.
- She's gonna need a repeat ABG.
- Pulse is up to 72.
- Dynamap's not registering a BP.
- Get ready with Thermo-Seal.
She's arresting.
Heart rate's down to 20.
Let's start CPR.
Epi one to ten thousand point four.
Atropine.
08 milligrams.
How's the blood gas? PH 7.
3.
PO-245.
PCO-230 on 100 percent oxygen.
We have to put her on an ECMO bypass.
Kit, call the tech.
Get two units O-neg to prime the system.
- Do we bring her back up to the O.
R.
? - No, we'll bring the O.
R.
To her.
Dr.
Greene? Dr.
Herlihy? - What time is it? - Eight o'clock.
P.
M.
? Where's my family? Your wife's upstairs.
Both the kids had laparotomies.
A bed opened up for you in ICU.
How'd they do? Your son's out of surgery.
I don't know about your daughter.
- How do I find out about my daughter? - I'll check on her.
- Thank you, Dr.
Greene.
- Mark.
Mark.
Pedes O.
R.
Called.
His daughter decompensated in surgery.
- She's still flatline.
- Repeat.
04 of epi.
Go ahead, Kit.
How long has she been down? Twenty-two minutes.
- Is the ECMO circuit primed? - Yes.
Good.
I'm ready.
Venous connection first.
Arterial.
Turn it on.
- We've got a heartbeat and a pulse.
- Faint.
She's pinking up.
Let's get a repeat gas.
We need to anti-coagulate her.
Heparin, 150 units IV.
Start drip at 10 units an hour.
- How come we anti-coagulate her? - We have to, or her blood will clot.
- Won't she bleed out? - We have to hope that she doesn't.
I'll dictate an operative report.
Meet me in Pedes ICU in five minutes.
We gotta tell the parents.
Peter, how'd it go? - How's the baby? - Not good.
Dr.
Benton You didn't sign the code sheet.
Hey, we're all human.
We all make mistakes.
Any other words of wisdom, Gant? You're a real prick, you know that? Mrs.
Herlihy, this is Dr.
Keaton.
She operated on both Zach and Megan.
Mrs.
Herlihy Megan had a perforated intestine from the accident.
When we operated to repair it, there were complications.
- What are you saying? - She's in the NICU on a device that helps her heart and lungs oxygenate her blood.
There was bleeding during the operation, and she went into shock.
Then her lung collapsed, and finally, her heart stopped.
We got it started again by putting her on a bypass machine.
Is she gonna die? She's in extremely critical condition.
It's It is a possibility.
The Lord is my shepherd, I shall not want.
He makes me lie down in green pastures.
He The Lord is my shepherd, I shall not want.
He makes me lie down in green pastures.
He's Dr.
Benton? I can't remember the words.