The Good Doctor (2017) s04e09 Episode Script
Irresponsible Salad Bar Practices
1
Your primary doctor is right.
The mass is on the smaller side.
We'll confirm with the new images, but it should be manageable with medication.
No surgery needed.
Well, my fiance will be so relieved.
He's been worried I'll look like Frankenstein in all our photos.
Also that I might die.
When's the big day? June.
You've been dealing with wedding planning on top of a pituitary tumor? You deserve a medal.
Our medical record system, on the other hand, it has you listed as female.
Probably because of the Pap smears.
Software clearly needs a trans update.
Deep breath.
I'll fix it so everything is correct going forward.
Please confirm your gender and pronouns.
Male, he/him/his.
Thanks for asking.
We're the ones with the messed-up software.
Your scans from this morning were just uploaded.
In less than two weeks, the tumor's doubled in size.
You're just too good to be true I can't take my eyes off of you You'd be like heaven to touch 34-year-old female, Zara Norton.
Tachycardic and delirious.
Dr.
Guerin, update vitals.
Dr.
Wolke, draw blood for CBC and electrolytes.
Oh, pretty baby Now that I've found you, stay Pupils are dilated, but reactive.
Ms.
Norton, smells like you've had some marijuana? Mmm-mmm.
I just unloaded a shipment at the dispensary.
Test for THC and a full tox screen.
I am a peddler.
Not a user Run it.
BP's elevated, 180 over 115.
That could explain the delirium.
Ooh, that sound high.
Better take my meds.
See, I never miss a Oh, no.
Oh, no, that's not it.
BP's climbing, 210 over 120.
Enalaprilat, 1.
25 milligrams, IV.
Ms.
Norton, do you remember the name of your medication? You can call me Zara.
See? It say right here on the Okay, forget about the meds.
She is not taking any.
This is untreated chronic hypertension.
What if you're wrong? What if she's on a loop diuretic for her pressure? This could cause renal failure.
She's heading into hypertensive crisis.
What if we try an angiotensin receptor blocker? No drug interaction.
Angiotensin receptor blockers work too slowly.
I'm giving her the ACE inhibitor.
BP's going down.
Nice call.
Latest budget report.
Yeah, the PDF's sitting in my inbox.
I'm trying to ignore it.
And thus A sit-down visit? Just checking in, see how you're doing.
Okay.
You? Me? I'm recovering from the year, like everybody else.
Pandemic, the surge.
You were here for every minute of every day.
It must have taken a toll.
It comes with the territory.
You're not, uh, stressed or distracted? I'm tired.
Okay.
Well, maybe you should take some time off.
No.
But thank you.
I'm fine.
You don't seem fine.
Are there issues with my work performance? No, you do great work.
Then I'm not sure why we're having this conversation.
Because I'm worried about you.
Because other people are worried about you.
There's no shame in struggling a little bit.
You know, what would be weird is if you didn't struggle at all.
If you need to see someone, the hospital will cover the cost.
Great.
You'll pay my bills.
And the damage to my reputation, who takes care of that? I don't think that seeing a therapist will affect your career.
Says the white guy.
Okay.
Privacy protections are there for a reason.
No one needs to know.
Thank you for checking in.
- How you feeling? - Good.
Be better when I understand what landed me up in here.
You had an acute hypertensive crisis.
Oh, I know my blood pressure's high.
I'm already on medication for it.
You probably wanna know what it is.
There's no medication.
We need to do an echocardiogram to make sure your heart wasn't damaged in the crisis.
Fine by me.
Here's 10% discount on any purchase over $50 or more at Z & B Naturals.
I'm Z.
B is my partner Bill.
You're surrounded by pot all day, every day, but you never touch the stuff? How? Why? It's just never been my thing.
Ah.
The name always trips me up.
Chlorthalidone.
That's for hypertension.
Yeah, bottle seems pretty full.
How long have you been on this? About six months.
Just refilled it.
Take it every day.
Smile.
Head tilt.
Now he smiles.
Burst of laughter.
Yeah.
Rio Gutierrez, 29, pituitary mass went from manageable with meds to likely surgery.
So, talking to the new radiology resident, huh? I wanted Dr.
D'Souza's opinion on an intriguing set of scans.
She is very talented.
You're crushing on her.
N No.
I am not.
I love Lea.
Well, those two things aren't mutually exclusive.
Mr.
Gutierrez's blood has high levels of prolactin.
Prolactin is produced in the pituitary gland.
The tumor could be secreting it.
Or the tumor could be reacting to the high levels of hormones being produced elsewhere in the body.
The patient is a transgender man.
Do an ultrasound.
Advance the probe until you see the cardiac chamber.
Maybe Zara has secondary hypertension due to renal vascular disease.
She doesn't.
Her creatinine is 1.
2.
Her GFR is in normal range.
Well, that would make it unlikely, but not impossible.
It'd also explain why her prescribed hypertension meds weren't working and why she got better when you gave her that ACE inhibitor.
Mmm.
Simpler explanation, she's not taking her meds.
Valve looks normal.
Should I move on to the two-chamber view? Yeah.
We have no reason to think that she's lying.
She seems to be telling the truth about her pot usage.
No THC in her blood or urine.
She couldn't possibly be lying about something else.
The left ventricle is thickened, which is consistent with untreated hypertension.
Heart rate's climbing.
Cardiac output is dropping.
Stroke volume as well.
She's in cardiogenic shock.
Would you mind if I did an ultrasound on your abdomen? For a brain tumor? This is my fiance, Eli Simpson.
When I heard about the new scans, I kind of stormed the castle.
My hero.
Your prolactin levels are very high, which might be caused by the tumor, unless another condition raised your prolactin, encouraging more growth.
What condition boosts prolactin? Do you think I'm pregnant? He can't be.
He's on testosterone.
Except for a few weeks last month.
I forgot to take my shot before our trip.
But there's no way that You're pregnant.
You went into cardiogenic shock because your heart wasn't pumping adequately.
We did a minor procedure and installed an Impella pump, but it's a short-term solution.
I do feel a little out of breath.
But that might be just 'cause of you, Dr.
Andrews.
Ms.
Norton, I'm a married man and your doctor.
You have a rare condition.
Certain parts of your heart muscle have become abnormally thick.
So, this wall in between the chambers, that's the septum.
That's a normal one.
This is what yours looks like.
Oh, wow.
It's gonna require surgery.
We're gonna run a few more tests to determine the best approach.
Wait.
You gonna be my surgeon, Dr.
Andrews? I sure will.
And y'all two gonna be with him? Yeah.
My lucky day.
Three doctors of color taking care of me.
Doctors who won't talk down to me.
Not exactly what I'm used to.
You guys know what I mean.
My mother made me wear a suit and tie whenever we went to the pediatrician.
Put on your Sunday best just to get on the scale and touch your toes.
Yeah.
Made me so mad, I wound up becoming a doctor.
The testing confirmed your tumor is a hormone-producing prolactinoma.
And the pregnancy is about six weeks along.
Do you consider yourself gay? - I don't think that's - Yes.
Because I am gay.
But you have vaginal intercourse with your fiance.
- That is how he got pregnant - Dr.
Murphy, that's enough.
- I I just want - I think you should leave.
I'm sorry.
That was completely inappropriate.
Our treatment plan for your tumor depends on your plan for your pregnancy.
So We've talked about kids, but I always figured that was way down the road.
And not this way.
I always assumed we'd adopt.
I'd have go off T, and stay off.
If Rio doesn't continue the pregnancy, then what happens? Your hormone levels would drop quickly, which would cause the tumor to shrink.
After that, we'd use medication, possibly a minor surgery.
I'd like to terminate the pregnancy.
I looked over all of Zara's labs.
All signs point to her taking her hypertension medicine regularly.
Her MRIs show significant ventricular septal thickness, bad turbulence jet flow.
There's myocardial edema, too.
The ACE inhibitors were a bad call.
Which eventually sent our patient into cardiogenic shock.
Why'd you ignore what she was telling us? I made a medical diagnosis based on pattern processing that we're taught in med school, which involves considering, you know, race, education, occupation, BMI.
Always sounded like profiling to me.
Yes, we have the rain, but more impressively, the wind.
That rain's going to be coming in sideways.
Just take a look at how the wind increases as we progress throughout the day.
So, this afternoon, we're talking about 50-mile-per-hour gusts possible.
Sorry for crashing.
Radiology doesn't have a TV.
You like The Weather Channel? I find it soothing.
Would you like to join me? And we have more intense rainfall coming through, and that's going to also lead to some flood potential.
All of us are going to get into the action.
You got the mountains.
Would you mind if I lowered the volume by four output levels? Oh.
That would be perfect.
All the areas around here in Northern California, Modesto, Stockton, Sacramento.
The northern part of San Francisco I find the reflection on the screen so distracting.
So do I.
Could I do this? Nurse paged me.
Is something wrong? I've changed my mind.
I want to keep the baby.
Since you are continuing the pregnancy, we'll need to surgically remove the prolactinoma.
So, you'll cut into his brain? Our safest option is to go in through the nasal cavity in what's known as a transsphenoidal surgery, TSS for short.
It's less invasive than our other option.
That still sounds dangerous.
I've made up my mind.
Do I get any say in this? I'm all for us having a family, but I'm not ready to No one's ever ready for kids.
Yesterday, you said that you never considered getting pregnant, and now you're willing to risk your life for it.
When I was about seven, I had this one refuge.
I'd hang a quilt over a couple chairs and hide out with my two buds, Foxie the Fox and Fuzz the Lion, and I'd imagine, I was the dad.
And they were my twin little guys, fraternal, obviously.
We were a family.
When I transitioned, I put that dream aside.
At least, as far as them coming from me.
But now Whether we planned it or not, this is our baby.
How soon can you do the surgery? I'll order an image-guidance MRI to get things started.
Based on the cardiac MRI and catheterization, there are two treatment options.
Myectomy, basically open heart surgery, and alcohol septal ablation, where we use the alcohol to kill targeted sections of the heart muscle.
Well, what would you recommend? The surgery is more invasive, tougher recovery, but better efficacy long-term.
The ablation is less dangerous, but you're more likely to need further medical interventions.
Now, you call that a recommendation? There are pros and cons to both.
Uh, you'll need to weigh them.
I'll give you some time.
You always want to take care of people, Dr.
Browne? Pretty much.
Me, too.
Oh.
Well, you run a marijuana dispensary.
It's not all about getting people high.
No, maybe not, but I'm guessing most of your clientele My Great-Aunt Lucy had pancreatic cancer.
A year, she hung on.
In agony.
Marijuana was the only thing that helped her eat or sleep.
Doctors didn't give her anything for the pain? They suggested ibuprofen.
Now, you know doctors are 22% less likely to give pain meds to Black patients than to white patients with the same symptoms.
My point is, you and I, we're a lot alike.
We're both strong, Black women finding our way in the world, but one of us knows more about medicine than the other.
So, I'd like to know, what would you do in my situation? The open myectomy is a bigger risk but offers more long-term benefits.
I've made my decision.
I'm with you, Dr.
Browne.
Book the myectomy.
Here's the Rio Gutierrez imaging for your upcoming TSS.
Set that on the table, please.
I, um I noted the tumor's suprasellar expansion and surrounding edema and splaying of circle of Willis.
That is very helpful.
Bye, Dr.
Murphy.
You're safe, Shaun.
She's gone.
Not really.
Dr.
D'Souza is still in my brain.
I don't like it.
We kissed.
- When? - What? I have so many thoughts about her, and I have so many questions I want to ask Rio.
Wouldn't he get more pleasure for Questions you're not supposed to ask him.
The kiss, Shaun.
When did you kiss? Last night.
In my dream.
If I can't ask questions, how do I understand? My My brain My My brain isn't behaving the way I want it to.
How do I make it stop? You're attracted to Dr.
D'Souza.
Why does that bother you? When I was with Carly and had feelings for Lea, it meant I was supposed to be with Lea.
What if this means I'm supposed to be with Dr.
D'Souza? No.
You've loved Lea for years.
This is just attraction.
But shouldn't loving Lea make it go away? Relationships would be a lot easier if it worked that way.
You're feeling guilty.
I say take Lea out for a nice dinner, something special.
And tell her about my crush.
I need to let Lea know.
- No, definitely not.
- No, you do not.
I want to get your thoughts on the suprasellar extension of the tumor - for this TSS.
- You remember Sarah Pepper? Runs nephrology at S.
F.
Regional? Always wears a shawl? So, during the staff meeting last week, she fell apart.
Screaming, crying in front of the whole department.
Totally nuts.
Rough day at the office.
Wonder how you'd approach and resect without getting a CSF leak.
Yeah.
Place a lumbar drain, then infuse saline and do Valsalva maneuver.
Okay.
Apparently, Pepper's meltdown was so over the top, the hospital forced her to take a leave.
- How long? - Unspecified.
She's always been a little crazy.
Last I checked, eccentric and emotional didn't qualify as crazy.
Thanks for taking a look.
I read that cisgender people often reduce transgender people to their genitalia, and that that is offensive.
Did I do that to you and Rio? Yes.
I'm sorry.
Rio will be going into surgery soon.
He's been asking for you.
You haven't been answering your phone.
Thanks for letting me know.
He is very confusing to me, too.
Rio has worked so hard, he had a bilateral subcutaneous mastectomy and takes hormone replacement therapy, but now he is choosing the most female act.
It's not female if Rio's doing it.
Y Yes.
And he must have dealt with a lot of prejudice during his transition.
I dealt with prejudice.
My brother helped me.
Does he have a brother? His family doesn't talk to him.
And now Rio is having brain surgery.
He is very brave.
You can stay here.
I have a patient, Zara Norton.
We, uh We diagnosed her with HOCM.
I saw the file.
Dr.
Guerin expressed some concerns about my initial handling of the case in the ER.
He thinks I stereotyped her, based on her race.
Do you think you did? She was crashing.
I had to make a call.
I didn't have a lot to go on.
Glassman came to see me this morning.
Someone told him I'm unstable and need help.
Any idea where he heard that? I asked for help.
You can, too.
You're a resident.
No one cares if you need help.
I got this job in part because my main competition, a man, backed me.
The second anyone thinks I can't handle this No one is gonna think that They will if you keep telling them I'm a mess.
You have PTSD.
You shouldn't be ashamed.
Says the women who just profiled a Black female patient.
You judged her, just like people will judge me and whisper that I've always been a little intense, so no wonder I was asked to step down.
Nobody needs to know.
Exactly.
You tell me that it doesn't matter.
You tell me everyone will understand, and then you tell me to keep it to myself.
Should I be ashamed, or shouldn't I be? All right, Ms.
Norton, time to head to pre-op.
What's in the bag, handsome? I like to know what goes into my body.
Uh, cefazolin.
It's a prophylactic antibiotic we give before surgeries.
Makes sense.
Hey, what was the med y'all gave me when I first got here to the ER? Enalaprilat.
It's an ACE inhibitor.
Isn't that for hypertension? Mmm-hmm.
But I thought I already told y'all I was on meds for my blood pressure.
You did.
So, you figured I needed more? Or did you not believe me? I'm sorry.
You must be scared.
You shouldn't have to be scared alone.
I love you.
I love you, too.
Eli.
I can't see you.
I'm right here, babe.
Can you follow this with your eyes? It keeps disappearing.
You've lost peripheral vision.
The tumor is impinging on the optic fibers.
We can't perform the TSS surgery.
With the tumor's continued growth, the best remaining option is the open pterional craniotomy.
But it is higher risk with a lengthier recovery.
All of which is on top of the potential for gender dysphoria during pregnancy.
Is that still a concern? I think back to before I started taking T, how terrible that felt.
The thought of feeling that all over again We could go back to the original plan.
You mean terminate the pregnancy? The tumor should shrink on its own.
After everything you've done to get where you are in your life, it's scary to think about doing something that would put that at risk.
This is my next step.
I'm ready to take it, even if I'm scared.
You have to take risks sometimes, Dr.
Lim.
Thank you.
Shouldn't you be prepping Zara for surgery? It's canceled.
She wants to be transferred to a different hospital.
One where she won't be "racially profiled into heart failure.
" Shaun, you okay? I am having thoughts I don't want to have.
Both Park and Jordan say I shouldn't tell you.
But you're going to, aren't you? Yes, I am.
I have a work crush.
Also, my patient is a pregnant trans man Okay, one at a time, Shaun.
About this crush? Her name is Dr.
Cintia D'Souza.
She is a second-year radiology resident.
Last night, I dreamed we were in the Residents' Lounge, watching The Weather Channel, and then we started kissing Okay, I got it.
Are you mad? Park and Jordan were right.
I shouldn't have told you.
No.
I'm not mad.
A little surprised, but that's okay.
I'm still attracted to other guys sometimes.
N No.
No.
What? Who? - It doesn't matter.
- Who? There Okay, there is this one physical therapist N No.
No.
No.
What if we're attracted to other people because there is something wrong with our relationship? You're not planning on kissing Dr.
D'Souza in real life? No.
Or working late with her, doing some X-rays alone, where you might end up leaning over the same light box.
We don't use light boxes anymore.
And I don't plan to work late with her.
Then I don't think either of us has anything to be worried about.
I have to go prep for a pterional craniotomy.
I'm Dr.
Glassman, president of the hospital.
Unless you're here to drive me to S.
F.
Regional, you can head right back on out.
I apologize for your experience in the emergency room.
That's mighty white of you.
I don't recommend that you transfer to S.
F.
Regional, or any other hospital, for that matter.
I'm sure they got the same fancy equipment, same shiny sets of diplomas y'all got here, and maybe a few less racist doctors.
Well, apparently, that doesn't seem to be the case.
I pulled data on comparable hospitals within 100 miles, did numbers on surgical outcomes and patient satisfaction, aggregated by race.
Apparently, we're doing well, comparatively.
Your argument is that your hospital may be racially biased, but it's less racially biased than these other hospitals? Yeah.
Pretty much.
Stay at St.
Bonaventure, the president of the hospital will monitor your care every step of the way.
For whatever it's worth, I don't think you can do better than that.
She's gonna stay, on one condition.
That you're off the team.
Dr.
Park, please open Sylvian fissure.
Arachnoid knife and Rhoton dissector.
Tumor is visible.
What makes someone a man? I thought it was just the chromosomes, but that must not be it, which makes things confusing and difficult, and I know Rio was uncomfortable when he Life is uncomfortable.
It hits you with tough situations and you muscle through them.
I see a tiny bleed in the circular sinus.
Pack it with Floseal.
Someone give me an update.
We got a drop in end tidal CO2 and oxygen sat.
See any evidence of exposed air cells? No.
But waxing bone edges just to be safe.
But the tumor thinned the sellar floor and sphenoid wall.
Making it permeable to oxygen.
It's an air embolism.
BP's dropping.
Dr.
Lim, what should we do? Saline gauze, tilt the table to eliminate the negative air pressure gradient, and place a central line.
This will stop the air leak and allow us to access the air bubble.
Inserting Bunegin air-aspirating cath.
You are 2 centimeters from the superior vena cava.
Aspirate the right atrium until you don't see any more air bubbles.
Nice save, Dr.
Lim.
Let's get this tumor out.
Make your transverse aortotomy with Potts scissors, Dr.
Wolke.
Extending the muscular incision down to the mid-ventricle.
There's the myectomy site.
There's the aberrant muscle bundle.
Get her off bypass, see how she does.
How's the cardiac output? Reduced and insufficient.
Low output could mean we need to further reduce the septum.
Unless it means that we reduced it too much.
Damaged the cardiac electrical conductors that control the heart rate.
She's having third-degree heart block.
Enrique's right.
We took too much muscle.
Put her back on bypass.
We could augment the wall with a bovine patch.
Still wouldn't insulate the electrical system.
She'd still be at risk of complete heart block and cardiac arrest.
We could insert a dual chamber pacer.
She won't need the conduction system in the wall of her heart to control her heart rate.
Let's go! How was the craniotomy? It went well.
The patient is in recovery.
Your text said you have good news.
And by good news, I mean bad news for Dr.
D'Souza.
Plenty of great stuff to crush a crush.
First observation, she smells like cinnamon.
Mmm.
Which is more puzzling than irritating.
Actually kind of nice.
Which is obviously not helpful.
Oh, okay.
She does this weird self-grooming gesture where she tucks her hair behind her ear.
And then sorta massages her ear.
Also n not helpful.
Okay.
I'm sorry.
I'm sorry.
Mmm-hmm.
Okay.
At the salad bar, she used the cucumber tongs to reach for the cucumbers, and then the tomatoes.
And the olives.
And the pickles.
- Ugh.
- Mmm.
Mmm-hmm.
Hey.
Hey.
I can see all of you.
How'd How'd we do? Great.
We got all of the mass, vision is restored.
You have every reason to expect a full recovery and a healthy pregnancy.
We're gonna be dads.
Are you ready? I've never been a pregnant man before.
You'll always be the best man that I've ever known.
Came to see how you were doing.
Dr.
Andrews told me you was the one who figured out how to save me.
Still don't change what went down earlier, though.
When I got to med school, people took one look at me and they thought they knew exactly who I was.
Black girl on financial aid.
She must not be that smart.
She must have gotten a lot of breaks.
She'll probably need a lot more.
And I worked I worked so hard to prove them wrong, that I wasn't who they thought I was, that I deserved to be there, that I that I fit in.
When you came into the ER, loud and messy, I saw I saw everything I have tried hard not to be.
And I think it made me angry.
And I'm ashamed of that.
And I'm really sorry.
I used to be that way.
But I got tired of working that hard to make white people comfortable.
You two heading out for the night? We sure are.
How did the craniotomy go, Shaun? Did you guys get all the prolactinoma? Yes.
Is that cafeteria salad? Are there pickles in there? Did you want some? You know, I'm good.
Thank you.
Shaun, did you - No, thank you.
- Mmm-hmm.
It does help to focus on her irresponsible salad bar practices and dietary preferences.
I've got a ton of strategies to manage discomfort.
So do I.
- Hey.
- Hey.
To replenish your supply, and a peace offering.
I wasn't aware we were at war.
Well, seemed like my gossip about Pepper kind of landed wrong.
Bad day.
Sorry to crash the party.
Dr.
Glassman wanted me to show this to you two.
I asked Lea to run some numbers on various metrics by race, and the results are not great, especially when it comes to pain management.
We are under-treating African-American and Latinx patients by a considerable margin.
I think I need a little of that peace offering.
Help yourself.
- Anyone else? - No.
Thank you.
Uh me, neither.
I Started taking sertraline.
For PTSD.
Sorry to hear that.
You doing okay? Not really.
But I'm working on it.
Okay.
Dr.
Browne, good work.
Thank you.
I apologized to Zara.
She pointed out I spent med school trying to make white people comfortable.
I mean, she's right.
It wasn't just med school.
Exhausting, isn't it? But we had to do it, right? To be here? I tried tut in my code but nothing happens Get out of the way The cyber attack is trying to convince me to pay an exorbitant amount of money They've given 24 hours.
If I'm wrong, all the imaging machines in the entire hospital will self-destruct.
I'm never 100% sure the surgery is going to cure the patient but I still do the surgery.
Get into new episode of THE GOOD DOCTOR
The mass is on the smaller side.
We'll confirm with the new images, but it should be manageable with medication.
No surgery needed.
Well, my fiance will be so relieved.
He's been worried I'll look like Frankenstein in all our photos.
Also that I might die.
When's the big day? June.
You've been dealing with wedding planning on top of a pituitary tumor? You deserve a medal.
Our medical record system, on the other hand, it has you listed as female.
Probably because of the Pap smears.
Software clearly needs a trans update.
Deep breath.
I'll fix it so everything is correct going forward.
Please confirm your gender and pronouns.
Male, he/him/his.
Thanks for asking.
We're the ones with the messed-up software.
Your scans from this morning were just uploaded.
In less than two weeks, the tumor's doubled in size.
You're just too good to be true I can't take my eyes off of you You'd be like heaven to touch 34-year-old female, Zara Norton.
Tachycardic and delirious.
Dr.
Guerin, update vitals.
Dr.
Wolke, draw blood for CBC and electrolytes.
Oh, pretty baby Now that I've found you, stay Pupils are dilated, but reactive.
Ms.
Norton, smells like you've had some marijuana? Mmm-mmm.
I just unloaded a shipment at the dispensary.
Test for THC and a full tox screen.
I am a peddler.
Not a user Run it.
BP's elevated, 180 over 115.
That could explain the delirium.
Ooh, that sound high.
Better take my meds.
See, I never miss a Oh, no.
Oh, no, that's not it.
BP's climbing, 210 over 120.
Enalaprilat, 1.
25 milligrams, IV.
Ms.
Norton, do you remember the name of your medication? You can call me Zara.
See? It say right here on the Okay, forget about the meds.
She is not taking any.
This is untreated chronic hypertension.
What if you're wrong? What if she's on a loop diuretic for her pressure? This could cause renal failure.
She's heading into hypertensive crisis.
What if we try an angiotensin receptor blocker? No drug interaction.
Angiotensin receptor blockers work too slowly.
I'm giving her the ACE inhibitor.
BP's going down.
Nice call.
Latest budget report.
Yeah, the PDF's sitting in my inbox.
I'm trying to ignore it.
And thus A sit-down visit? Just checking in, see how you're doing.
Okay.
You? Me? I'm recovering from the year, like everybody else.
Pandemic, the surge.
You were here for every minute of every day.
It must have taken a toll.
It comes with the territory.
You're not, uh, stressed or distracted? I'm tired.
Okay.
Well, maybe you should take some time off.
No.
But thank you.
I'm fine.
You don't seem fine.
Are there issues with my work performance? No, you do great work.
Then I'm not sure why we're having this conversation.
Because I'm worried about you.
Because other people are worried about you.
There's no shame in struggling a little bit.
You know, what would be weird is if you didn't struggle at all.
If you need to see someone, the hospital will cover the cost.
Great.
You'll pay my bills.
And the damage to my reputation, who takes care of that? I don't think that seeing a therapist will affect your career.
Says the white guy.
Okay.
Privacy protections are there for a reason.
No one needs to know.
Thank you for checking in.
- How you feeling? - Good.
Be better when I understand what landed me up in here.
You had an acute hypertensive crisis.
Oh, I know my blood pressure's high.
I'm already on medication for it.
You probably wanna know what it is.
There's no medication.
We need to do an echocardiogram to make sure your heart wasn't damaged in the crisis.
Fine by me.
Here's 10% discount on any purchase over $50 or more at Z & B Naturals.
I'm Z.
B is my partner Bill.
You're surrounded by pot all day, every day, but you never touch the stuff? How? Why? It's just never been my thing.
Ah.
The name always trips me up.
Chlorthalidone.
That's for hypertension.
Yeah, bottle seems pretty full.
How long have you been on this? About six months.
Just refilled it.
Take it every day.
Smile.
Head tilt.
Now he smiles.
Burst of laughter.
Yeah.
Rio Gutierrez, 29, pituitary mass went from manageable with meds to likely surgery.
So, talking to the new radiology resident, huh? I wanted Dr.
D'Souza's opinion on an intriguing set of scans.
She is very talented.
You're crushing on her.
N No.
I am not.
I love Lea.
Well, those two things aren't mutually exclusive.
Mr.
Gutierrez's blood has high levels of prolactin.
Prolactin is produced in the pituitary gland.
The tumor could be secreting it.
Or the tumor could be reacting to the high levels of hormones being produced elsewhere in the body.
The patient is a transgender man.
Do an ultrasound.
Advance the probe until you see the cardiac chamber.
Maybe Zara has secondary hypertension due to renal vascular disease.
She doesn't.
Her creatinine is 1.
2.
Her GFR is in normal range.
Well, that would make it unlikely, but not impossible.
It'd also explain why her prescribed hypertension meds weren't working and why she got better when you gave her that ACE inhibitor.
Mmm.
Simpler explanation, she's not taking her meds.
Valve looks normal.
Should I move on to the two-chamber view? Yeah.
We have no reason to think that she's lying.
She seems to be telling the truth about her pot usage.
No THC in her blood or urine.
She couldn't possibly be lying about something else.
The left ventricle is thickened, which is consistent with untreated hypertension.
Heart rate's climbing.
Cardiac output is dropping.
Stroke volume as well.
She's in cardiogenic shock.
Would you mind if I did an ultrasound on your abdomen? For a brain tumor? This is my fiance, Eli Simpson.
When I heard about the new scans, I kind of stormed the castle.
My hero.
Your prolactin levels are very high, which might be caused by the tumor, unless another condition raised your prolactin, encouraging more growth.
What condition boosts prolactin? Do you think I'm pregnant? He can't be.
He's on testosterone.
Except for a few weeks last month.
I forgot to take my shot before our trip.
But there's no way that You're pregnant.
You went into cardiogenic shock because your heart wasn't pumping adequately.
We did a minor procedure and installed an Impella pump, but it's a short-term solution.
I do feel a little out of breath.
But that might be just 'cause of you, Dr.
Andrews.
Ms.
Norton, I'm a married man and your doctor.
You have a rare condition.
Certain parts of your heart muscle have become abnormally thick.
So, this wall in between the chambers, that's the septum.
That's a normal one.
This is what yours looks like.
Oh, wow.
It's gonna require surgery.
We're gonna run a few more tests to determine the best approach.
Wait.
You gonna be my surgeon, Dr.
Andrews? I sure will.
And y'all two gonna be with him? Yeah.
My lucky day.
Three doctors of color taking care of me.
Doctors who won't talk down to me.
Not exactly what I'm used to.
You guys know what I mean.
My mother made me wear a suit and tie whenever we went to the pediatrician.
Put on your Sunday best just to get on the scale and touch your toes.
Yeah.
Made me so mad, I wound up becoming a doctor.
The testing confirmed your tumor is a hormone-producing prolactinoma.
And the pregnancy is about six weeks along.
Do you consider yourself gay? - I don't think that's - Yes.
Because I am gay.
But you have vaginal intercourse with your fiance.
- That is how he got pregnant - Dr.
Murphy, that's enough.
- I I just want - I think you should leave.
I'm sorry.
That was completely inappropriate.
Our treatment plan for your tumor depends on your plan for your pregnancy.
So We've talked about kids, but I always figured that was way down the road.
And not this way.
I always assumed we'd adopt.
I'd have go off T, and stay off.
If Rio doesn't continue the pregnancy, then what happens? Your hormone levels would drop quickly, which would cause the tumor to shrink.
After that, we'd use medication, possibly a minor surgery.
I'd like to terminate the pregnancy.
I looked over all of Zara's labs.
All signs point to her taking her hypertension medicine regularly.
Her MRIs show significant ventricular septal thickness, bad turbulence jet flow.
There's myocardial edema, too.
The ACE inhibitors were a bad call.
Which eventually sent our patient into cardiogenic shock.
Why'd you ignore what she was telling us? I made a medical diagnosis based on pattern processing that we're taught in med school, which involves considering, you know, race, education, occupation, BMI.
Always sounded like profiling to me.
Yes, we have the rain, but more impressively, the wind.
That rain's going to be coming in sideways.
Just take a look at how the wind increases as we progress throughout the day.
So, this afternoon, we're talking about 50-mile-per-hour gusts possible.
Sorry for crashing.
Radiology doesn't have a TV.
You like The Weather Channel? I find it soothing.
Would you like to join me? And we have more intense rainfall coming through, and that's going to also lead to some flood potential.
All of us are going to get into the action.
You got the mountains.
Would you mind if I lowered the volume by four output levels? Oh.
That would be perfect.
All the areas around here in Northern California, Modesto, Stockton, Sacramento.
The northern part of San Francisco I find the reflection on the screen so distracting.
So do I.
Could I do this? Nurse paged me.
Is something wrong? I've changed my mind.
I want to keep the baby.
Since you are continuing the pregnancy, we'll need to surgically remove the prolactinoma.
So, you'll cut into his brain? Our safest option is to go in through the nasal cavity in what's known as a transsphenoidal surgery, TSS for short.
It's less invasive than our other option.
That still sounds dangerous.
I've made up my mind.
Do I get any say in this? I'm all for us having a family, but I'm not ready to No one's ever ready for kids.
Yesterday, you said that you never considered getting pregnant, and now you're willing to risk your life for it.
When I was about seven, I had this one refuge.
I'd hang a quilt over a couple chairs and hide out with my two buds, Foxie the Fox and Fuzz the Lion, and I'd imagine, I was the dad.
And they were my twin little guys, fraternal, obviously.
We were a family.
When I transitioned, I put that dream aside.
At least, as far as them coming from me.
But now Whether we planned it or not, this is our baby.
How soon can you do the surgery? I'll order an image-guidance MRI to get things started.
Based on the cardiac MRI and catheterization, there are two treatment options.
Myectomy, basically open heart surgery, and alcohol septal ablation, where we use the alcohol to kill targeted sections of the heart muscle.
Well, what would you recommend? The surgery is more invasive, tougher recovery, but better efficacy long-term.
The ablation is less dangerous, but you're more likely to need further medical interventions.
Now, you call that a recommendation? There are pros and cons to both.
Uh, you'll need to weigh them.
I'll give you some time.
You always want to take care of people, Dr.
Browne? Pretty much.
Me, too.
Oh.
Well, you run a marijuana dispensary.
It's not all about getting people high.
No, maybe not, but I'm guessing most of your clientele My Great-Aunt Lucy had pancreatic cancer.
A year, she hung on.
In agony.
Marijuana was the only thing that helped her eat or sleep.
Doctors didn't give her anything for the pain? They suggested ibuprofen.
Now, you know doctors are 22% less likely to give pain meds to Black patients than to white patients with the same symptoms.
My point is, you and I, we're a lot alike.
We're both strong, Black women finding our way in the world, but one of us knows more about medicine than the other.
So, I'd like to know, what would you do in my situation? The open myectomy is a bigger risk but offers more long-term benefits.
I've made my decision.
I'm with you, Dr.
Browne.
Book the myectomy.
Here's the Rio Gutierrez imaging for your upcoming TSS.
Set that on the table, please.
I, um I noted the tumor's suprasellar expansion and surrounding edema and splaying of circle of Willis.
That is very helpful.
Bye, Dr.
Murphy.
You're safe, Shaun.
She's gone.
Not really.
Dr.
D'Souza is still in my brain.
I don't like it.
We kissed.
- When? - What? I have so many thoughts about her, and I have so many questions I want to ask Rio.
Wouldn't he get more pleasure for Questions you're not supposed to ask him.
The kiss, Shaun.
When did you kiss? Last night.
In my dream.
If I can't ask questions, how do I understand? My My brain My My brain isn't behaving the way I want it to.
How do I make it stop? You're attracted to Dr.
D'Souza.
Why does that bother you? When I was with Carly and had feelings for Lea, it meant I was supposed to be with Lea.
What if this means I'm supposed to be with Dr.
D'Souza? No.
You've loved Lea for years.
This is just attraction.
But shouldn't loving Lea make it go away? Relationships would be a lot easier if it worked that way.
You're feeling guilty.
I say take Lea out for a nice dinner, something special.
And tell her about my crush.
I need to let Lea know.
- No, definitely not.
- No, you do not.
I want to get your thoughts on the suprasellar extension of the tumor - for this TSS.
- You remember Sarah Pepper? Runs nephrology at S.
F.
Regional? Always wears a shawl? So, during the staff meeting last week, she fell apart.
Screaming, crying in front of the whole department.
Totally nuts.
Rough day at the office.
Wonder how you'd approach and resect without getting a CSF leak.
Yeah.
Place a lumbar drain, then infuse saline and do Valsalva maneuver.
Okay.
Apparently, Pepper's meltdown was so over the top, the hospital forced her to take a leave.
- How long? - Unspecified.
She's always been a little crazy.
Last I checked, eccentric and emotional didn't qualify as crazy.
Thanks for taking a look.
I read that cisgender people often reduce transgender people to their genitalia, and that that is offensive.
Did I do that to you and Rio? Yes.
I'm sorry.
Rio will be going into surgery soon.
He's been asking for you.
You haven't been answering your phone.
Thanks for letting me know.
He is very confusing to me, too.
Rio has worked so hard, he had a bilateral subcutaneous mastectomy and takes hormone replacement therapy, but now he is choosing the most female act.
It's not female if Rio's doing it.
Y Yes.
And he must have dealt with a lot of prejudice during his transition.
I dealt with prejudice.
My brother helped me.
Does he have a brother? His family doesn't talk to him.
And now Rio is having brain surgery.
He is very brave.
You can stay here.
I have a patient, Zara Norton.
We, uh We diagnosed her with HOCM.
I saw the file.
Dr.
Guerin expressed some concerns about my initial handling of the case in the ER.
He thinks I stereotyped her, based on her race.
Do you think you did? She was crashing.
I had to make a call.
I didn't have a lot to go on.
Glassman came to see me this morning.
Someone told him I'm unstable and need help.
Any idea where he heard that? I asked for help.
You can, too.
You're a resident.
No one cares if you need help.
I got this job in part because my main competition, a man, backed me.
The second anyone thinks I can't handle this No one is gonna think that They will if you keep telling them I'm a mess.
You have PTSD.
You shouldn't be ashamed.
Says the women who just profiled a Black female patient.
You judged her, just like people will judge me and whisper that I've always been a little intense, so no wonder I was asked to step down.
Nobody needs to know.
Exactly.
You tell me that it doesn't matter.
You tell me everyone will understand, and then you tell me to keep it to myself.
Should I be ashamed, or shouldn't I be? All right, Ms.
Norton, time to head to pre-op.
What's in the bag, handsome? I like to know what goes into my body.
Uh, cefazolin.
It's a prophylactic antibiotic we give before surgeries.
Makes sense.
Hey, what was the med y'all gave me when I first got here to the ER? Enalaprilat.
It's an ACE inhibitor.
Isn't that for hypertension? Mmm-hmm.
But I thought I already told y'all I was on meds for my blood pressure.
You did.
So, you figured I needed more? Or did you not believe me? I'm sorry.
You must be scared.
You shouldn't have to be scared alone.
I love you.
I love you, too.
Eli.
I can't see you.
I'm right here, babe.
Can you follow this with your eyes? It keeps disappearing.
You've lost peripheral vision.
The tumor is impinging on the optic fibers.
We can't perform the TSS surgery.
With the tumor's continued growth, the best remaining option is the open pterional craniotomy.
But it is higher risk with a lengthier recovery.
All of which is on top of the potential for gender dysphoria during pregnancy.
Is that still a concern? I think back to before I started taking T, how terrible that felt.
The thought of feeling that all over again We could go back to the original plan.
You mean terminate the pregnancy? The tumor should shrink on its own.
After everything you've done to get where you are in your life, it's scary to think about doing something that would put that at risk.
This is my next step.
I'm ready to take it, even if I'm scared.
You have to take risks sometimes, Dr.
Lim.
Thank you.
Shouldn't you be prepping Zara for surgery? It's canceled.
She wants to be transferred to a different hospital.
One where she won't be "racially profiled into heart failure.
" Shaun, you okay? I am having thoughts I don't want to have.
Both Park and Jordan say I shouldn't tell you.
But you're going to, aren't you? Yes, I am.
I have a work crush.
Also, my patient is a pregnant trans man Okay, one at a time, Shaun.
About this crush? Her name is Dr.
Cintia D'Souza.
She is a second-year radiology resident.
Last night, I dreamed we were in the Residents' Lounge, watching The Weather Channel, and then we started kissing Okay, I got it.
Are you mad? Park and Jordan were right.
I shouldn't have told you.
No.
I'm not mad.
A little surprised, but that's okay.
I'm still attracted to other guys sometimes.
N No.
No.
What? Who? - It doesn't matter.
- Who? There Okay, there is this one physical therapist N No.
No.
No.
What if we're attracted to other people because there is something wrong with our relationship? You're not planning on kissing Dr.
D'Souza in real life? No.
Or working late with her, doing some X-rays alone, where you might end up leaning over the same light box.
We don't use light boxes anymore.
And I don't plan to work late with her.
Then I don't think either of us has anything to be worried about.
I have to go prep for a pterional craniotomy.
I'm Dr.
Glassman, president of the hospital.
Unless you're here to drive me to S.
F.
Regional, you can head right back on out.
I apologize for your experience in the emergency room.
That's mighty white of you.
I don't recommend that you transfer to S.
F.
Regional, or any other hospital, for that matter.
I'm sure they got the same fancy equipment, same shiny sets of diplomas y'all got here, and maybe a few less racist doctors.
Well, apparently, that doesn't seem to be the case.
I pulled data on comparable hospitals within 100 miles, did numbers on surgical outcomes and patient satisfaction, aggregated by race.
Apparently, we're doing well, comparatively.
Your argument is that your hospital may be racially biased, but it's less racially biased than these other hospitals? Yeah.
Pretty much.
Stay at St.
Bonaventure, the president of the hospital will monitor your care every step of the way.
For whatever it's worth, I don't think you can do better than that.
She's gonna stay, on one condition.
That you're off the team.
Dr.
Park, please open Sylvian fissure.
Arachnoid knife and Rhoton dissector.
Tumor is visible.
What makes someone a man? I thought it was just the chromosomes, but that must not be it, which makes things confusing and difficult, and I know Rio was uncomfortable when he Life is uncomfortable.
It hits you with tough situations and you muscle through them.
I see a tiny bleed in the circular sinus.
Pack it with Floseal.
Someone give me an update.
We got a drop in end tidal CO2 and oxygen sat.
See any evidence of exposed air cells? No.
But waxing bone edges just to be safe.
But the tumor thinned the sellar floor and sphenoid wall.
Making it permeable to oxygen.
It's an air embolism.
BP's dropping.
Dr.
Lim, what should we do? Saline gauze, tilt the table to eliminate the negative air pressure gradient, and place a central line.
This will stop the air leak and allow us to access the air bubble.
Inserting Bunegin air-aspirating cath.
You are 2 centimeters from the superior vena cava.
Aspirate the right atrium until you don't see any more air bubbles.
Nice save, Dr.
Lim.
Let's get this tumor out.
Make your transverse aortotomy with Potts scissors, Dr.
Wolke.
Extending the muscular incision down to the mid-ventricle.
There's the myectomy site.
There's the aberrant muscle bundle.
Get her off bypass, see how she does.
How's the cardiac output? Reduced and insufficient.
Low output could mean we need to further reduce the septum.
Unless it means that we reduced it too much.
Damaged the cardiac electrical conductors that control the heart rate.
She's having third-degree heart block.
Enrique's right.
We took too much muscle.
Put her back on bypass.
We could augment the wall with a bovine patch.
Still wouldn't insulate the electrical system.
She'd still be at risk of complete heart block and cardiac arrest.
We could insert a dual chamber pacer.
She won't need the conduction system in the wall of her heart to control her heart rate.
Let's go! How was the craniotomy? It went well.
The patient is in recovery.
Your text said you have good news.
And by good news, I mean bad news for Dr.
D'Souza.
Plenty of great stuff to crush a crush.
First observation, she smells like cinnamon.
Mmm.
Which is more puzzling than irritating.
Actually kind of nice.
Which is obviously not helpful.
Oh, okay.
She does this weird self-grooming gesture where she tucks her hair behind her ear.
And then sorta massages her ear.
Also n not helpful.
Okay.
I'm sorry.
I'm sorry.
Mmm-hmm.
Okay.
At the salad bar, she used the cucumber tongs to reach for the cucumbers, and then the tomatoes.
And the olives.
And the pickles.
- Ugh.
- Mmm.
Mmm-hmm.
Hey.
Hey.
I can see all of you.
How'd How'd we do? Great.
We got all of the mass, vision is restored.
You have every reason to expect a full recovery and a healthy pregnancy.
We're gonna be dads.
Are you ready? I've never been a pregnant man before.
You'll always be the best man that I've ever known.
Came to see how you were doing.
Dr.
Andrews told me you was the one who figured out how to save me.
Still don't change what went down earlier, though.
When I got to med school, people took one look at me and they thought they knew exactly who I was.
Black girl on financial aid.
She must not be that smart.
She must have gotten a lot of breaks.
She'll probably need a lot more.
And I worked I worked so hard to prove them wrong, that I wasn't who they thought I was, that I deserved to be there, that I that I fit in.
When you came into the ER, loud and messy, I saw I saw everything I have tried hard not to be.
And I think it made me angry.
And I'm ashamed of that.
And I'm really sorry.
I used to be that way.
But I got tired of working that hard to make white people comfortable.
You two heading out for the night? We sure are.
How did the craniotomy go, Shaun? Did you guys get all the prolactinoma? Yes.
Is that cafeteria salad? Are there pickles in there? Did you want some? You know, I'm good.
Thank you.
Shaun, did you - No, thank you.
- Mmm-hmm.
It does help to focus on her irresponsible salad bar practices and dietary preferences.
I've got a ton of strategies to manage discomfort.
So do I.
- Hey.
- Hey.
To replenish your supply, and a peace offering.
I wasn't aware we were at war.
Well, seemed like my gossip about Pepper kind of landed wrong.
Bad day.
Sorry to crash the party.
Dr.
Glassman wanted me to show this to you two.
I asked Lea to run some numbers on various metrics by race, and the results are not great, especially when it comes to pain management.
We are under-treating African-American and Latinx patients by a considerable margin.
I think I need a little of that peace offering.
Help yourself.
- Anyone else? - No.
Thank you.
Uh me, neither.
I Started taking sertraline.
For PTSD.
Sorry to hear that.
You doing okay? Not really.
But I'm working on it.
Okay.
Dr.
Browne, good work.
Thank you.
I apologized to Zara.
She pointed out I spent med school trying to make white people comfortable.
I mean, she's right.
It wasn't just med school.
Exhausting, isn't it? But we had to do it, right? To be here? I tried tut in my code but nothing happens Get out of the way The cyber attack is trying to convince me to pay an exorbitant amount of money They've given 24 hours.
If I'm wrong, all the imaging machines in the entire hospital will self-destruct.
I'm never 100% sure the surgery is going to cure the patient but I still do the surgery.
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