The Good Doctor (2017) s04e12 Episode Script

1 I couldn't sleep.
We should start taking your blood pressure every day.
This is very sweet and responsible.
Yes, I am going to try to be extra responsible now.
Yeah.
W-We We have to talk about what we want to do.
I love you.
I want a child.
So I want this child.
I love you, too.
And I do want kids, but it's complicated.
Is this the right time in my career? In our relationship? Am I too young? Can we afford this? Am I willing to make this commitment right now? We can start depositing money into a shared account for expenses, and I can talk to Dr.
Glassman about hiring you an assistant to help with your workload Shaun, just slow down.
I-I don't need you to answer these questions now.
I just need to think.
To figure out what to do.
And you do, too.
Dr.
Chambers, I'd like you to meet a few of our residents.
This is Doctor I know that I'm old, but I can still read name tags.
Dr.
Chambers, you started experiencing aches in your right hand a month ago? Then tremors, weakness, spasms.
Had to drop out in the middle of a bowel resection last Friday.
I sent you a video of the surgery.
Given your symptoms, it seems that carpal tunnel Oh, it "seems.
" [CHUCKLING.]
Well, then, problem solved.
I'll be on my way.
Sir, can I just say that the documentary on your work in Haiti changed my life.
It's the reason why I went into If you want to suck up to me, call me "doctor," not "sir.
" And this is a hospital, not Coachella.
If you can't wear something appropriate, at least try something that fits.
[SIGHS.]
[PAPER RUSTLES.]
Rule out autoimmune disorders, hypothyroidism, diabetes, amyloidosis, MS, and multiple myeloma.
Then we'll get back to carpal tunnel.
Alright.
If you have any other questions or concerns, please don't hesitate Twelve.
First, I prefer blankets not made of sandpaper.
Second, dim these damn lights.
This isn't some San Fernando Valley porn shoot.
THIRD SHAUN: If you made a list, you don't need to tell us.
He's had the pain for nine months now.
ASHER: And it's on both sides? Mm-hmm.
Sometimes his forehead, other times his cheeks, his nose.
And it's persisting through very high doses of hydrocodone.
Yeah, obviously, the drugs don't work.
It's why I'm here.
ANA: Oscar.
It's a fair question.
Look, I'm sorry.
Okay, I've been to six doctors now.
I can't work.
I mean, I-I c I can't even kiss my wife.
I can hardly smile.
I'm just gonna lightly brush your cheek.
[GROANS.]
Okay.
[BREATHING HEAVILY.]
Please help me.
I've been on the phone for like an hour with the cable company Lea's pregnant.
You want to have Yes.
Wow.
[CHUCKLES.]
I'm glad you're happy.
Um, do you have any concerns? Yes.
Sleep deprivation.
But I have started looking into an affordable night nurse.
Well, there's gonna be some bigger issues.
I mean, this is a [LAUGHS.]
This is a gigantic moment for anyone, especially Especially for you.
You mean because of my ASD? Yeah, because of your ASD.
Because of your family.
Your job.
I mean [CHUCKLES.]
A million things.
I don't want to tell you what what to I mean, I don't even know what I Having a child changes everything.
[WHIRRING.]
ASHER: Nasal cavity's clear.
There's no abscess, facial tumor, or sinusitis.
It could be acoustic neuroma.
Without any hearing loss? Let's do an MRI to check.
We've run eight negative tests already.
We don't need a ninth.
We do the tests till we know what he has.
It's fibromyalgia.
So, your diagnosis for his pain is "pain that no one can explain"? - Well done.
- Some pain's unavoidable.
When I was competing in Tae Kwon Do, they taught us to adjust our relationship to it, learn to tolerate it.
It can make you stronger.
Wow.
That statement has the absolute ideal ratio of heartlessness, humble-bragging, and machismo.
Bravo.
Seriously? You're pleased with that? "Machismo," Spanish, "bravo"'s Italian.
And "humble-bragging" 's 2011.
We can do better, don't you think? Maybe we're not finding anything because it's psychological? Some kind of conversion disorder? You do the MRI.
I'll talk to the wife.
Negative for endocrine issues.
He's got a history of moderate carotid stenosis.
If enough plaque builds up, starves the brain of oxygen, maybe could cause the hand problems.
If it got that bad, we'd have already seen signs of a stroke.
ENRIQUE: Anyone else annoyed that we're wasting all these resources to confirm what's clearly carpal tunnel? He may be a jerk, but he's a great doctor.
If Silas Chambers has a medical opinion, we better check it out.
I didn't think he was a jerk.
Dr.
Andrews and Dr.
Lim also criticize us and have particular demands.
Yeah.
They want us to improve.
How do you know Dr.
Chambers doesn't? He did improve Enrique.
Not kidding.
You look snazzy.
I know what Dr.
Chambers has.
We're having trouble finding a physical basis for your husband's pain.
And you defended me when I asked him about painkillers earlier.
A few years ago, Oscar was on a job site.
Working crazy hours.
He was exhausted.
He shot himself with a With a nail gun.
Right through his palm.
We didn't have insurance, so we went to this clinic, and, um Opioids? Really bad.
Took a year for him to kick.
Now, um he's taking more pills than ever.
Whenever I talk to him about getting help, he just gets mad.
I, uh I had to move out last week.
I'm only here because he asked me to.
I think he's faking.
[SIGHS.]
You threw 113 sutures in your last day of surgery.
In at least half, I detected a very subtle tremor.
Congratulations on discovering a symptom I told you about.
It occurs during the part of your stitch when the wrist is straight, not when it's bent.
That is not carpal tunnel.
It is musician's dystonia.
My wrist flexes on every suture.
You're talking about a difference of milliseconds.
Yes, he is.
Your condition was probably caused by your repetitive technique.
Even Dr.
Andrews throws sutures in varied ways.
You never do.
This kind of obsessive behavior is common for those with autism.
So, I can refer What did you just say? I'm not autistic.
ANDREWS: Dr.
Murphy didn't mean any offense.
He himself is on the spectrum.
Oh, is he? I thought his robotic voice and hand clasping were just charming affectations.
Do you really think I am anything like him? - I'm not saying that - I am.
You're extremely organized.
You hardly make eye contact.
And given your problems with food, blankets, and lighting, plus the fact you wear headphones even in surgery, you clearly have sensory issues.
I'm organized.
Would you rather I show up in the O.
R.
and just wing it? I have good taste in food and music.
Now that's a mental disorder? And as for eye contact Okay.
I didn't come here for a psych consult.
It was just an observation about a possible reason for the behavior that led to your hand symptoms, which is what we should be talking about.
Physical therapy is the recommended course for dystonia.
I'm not wasting months on a treatment that won't work.
I want an MRI-guided ultrasound ablation of the VO nucleus of the thalamus.
You want to jump to brain surgery? I would jump right to amputating a toe if it got me my career back.
ANDREWS: What were you thinking? You just supported me.
Yes, because part of my job is not yelling at residents in front of patients.
What you did is equivalent to looking at a fuzzy MRI and blurting out a patient has cancer.
Cancer can kill you.
Neither diagnosis is one a patient is excited to hear.
Prep him for the ablation.
And do not talk to him again about autism.
He's seen six doctors in the last month, gotten three opioid prescriptions, and he had a previous opioid problem.
It's textbook drug-seeking.
It's also textbook "a bunch of dingbats missing a trigeminal neuralgia diagnosis.
" Mm, his wife agrees with me.
She knows him.
Would explain why yours left you.
Snap.
Except my wife didn't leave me, so neither a good point, nor even a clever one.
FIESTA imaging would take hours to set up, cost the patient serious money, and still come out negative.
Because it's textbook drug-seeking.
We have other patients who need us.
I'm sending the discharge order.
Hey.
[LEA RETCHING.]
I hate poop.
Like, what if I suck at changing diapers? Maybe we should start with the bigger issues and work our way down.
This isn't at the top of my list, but since you are a doctor Shaun's ASD Is it? Inheritable? Probably.
But it's unclear how much.
So, even that.
W-What am I supposed to do with that? Think it through.
Let's say you have a little baby Shaun.
Like tiny, honest, brilliant guy who adores me Mini button-down, teeny blue eyes And me? A mom? I mean, I'm not saying my life would be worse, but it would just be so different from what I was planning.
Not that I was really planning, but I am enjoying just being.
And so what if you wait? I just want to make sure I'm making the right decision.
Mm-hmm.
[SIGHS.]
I guess you'll never really know.
I had to make a lot of hard choices about my mom.
And I still wake up wondering which of them went the wrong way.
But you still gotta choose.
[WHIRRING.]
No abnormal signal in the mid pons.
So, are you and Dr.
Park like this at home, too? When I let him out of his cage for meals, yes.
[DOOR OPENS.]
Hey, we're almost [SIGHS.]
Oh, come on.
Did you not get the text I didn't send about this? Don't bother asking for consults if you're gonna Wait.
What's that on the right superior cerebellar artery? An abnormal loop causing compression.
He has trigeminal neuralgia.
The pain's real.
CLAIRE: We have good visualization of the target area.
ANDREWS: Connect the ultrasound to the stereotactic frame.
SHAUN: Ablation won't work.
ENRIQUE: You changed your mind? You don't think he has dystonia? He does, but it's a symptom.
His vertebral artery takes an aberrant course.
It is pressing against his spinal cord.
He needs vascular surgery or he'll die.
It's a disorder of the nerve that carries sensation from the face to the brain.
And it's one of the most painful conditions that exists.
And very hard to diagnose.
Thank God Dr.
Park approved all those tests.
[SIGHS.]
Y-You were in agony.
And I I told him I thought you were lying.
You thought I was lying? You thought I was just being an addict.
And still you came here with me.
Sat at my side.
We'd like to do a microvascular decompression.
We'd go in through the back of your skull and put in a Teflon patch to cushion the affected nerve.
You're You're cutting into his brain? It's relatively safe.
And other options are unlikely to relieve the pain.
Look, I-I'll do it.
Uh, thank you so much.
CLAIRE: We want to run a vertebral artery BTO.
If you tolerate it, then we would sacrifice the Sacrifice the vessel with onyx embolization.
We recognize you might not love this proposal.
The one in which my hand weakness remains, destroying my career? Did you consider vertebral-to-vertebral artery bypass with physical removal of the aberrant artery? Mm, that would carry a very high risk for a stroke or bleed.
It would fix the dystonia and let me get back to work.
With your history of carotid stenosis, it would be a coin flip whether you survive.
I can live with those numbers.
Or, for that matter, die with them.
LIM: Corridor to the trigeminal nerve origin is open.
PARK: I freed up the offending vessel.
Teflon sponge.
The sponge is too big.
It'll compress the brain stem.
I have at least 4 millimeters of room.
You have half that.
Yes, you have a better view 50 feet away.
LIM: How long have they been like this? - ASHER: A while.
- It's getting worse, though.
MORGAN: Sorry, Park, you're right.
Just like you were when you decided to discharge the sick guy.
Wow, you invented sarcasm.
Really impressive.
Hey, look at me, I'm using it, too.
LIM: Park, you missed the diagnosis.
Reznick, you ignored protocol.
How about you both show some humility and shut up? Sorry.
Teflon's placed.
What if we used the saphenous vein for the bypass? Not enough flow.
He'll stroke out.
Carotid to distal vert, then? Stenosis is too severe.
Dude's loaded.
He's at retirement age.
He could teach, travel, screw around all day.
Why is he demanding that we do this? When you dedicate your life to something that gives you meaning, it starts to define you.
His decision may be irrational, but I get it.
I don't think it is irrational.
Dr.
Chambers has no friends, no children, no family, no outside interests.
If he can't be a surgeon, he'll have nothing.
I think our best bet is a radial graft.
Highest flow I can think of.
Any other ideas? Okay.
We go with the radial graft.
I'm impressed.
I was actually starting to wonder if I was losing my touch.
But then I had a dark afternoon of the soul and suddenly I knew it Those were totally solid burns.
Maybe not A+, but A-, B+ at the worst.
So it hit me your plan was to throw me off my game, make me doubt myself I'm attracted to you.
I've been fighting this stupid feeling, trying to find reasons to not feel.
Are you kidding me? [CHUCKLES.]
Yes.
Your jokes were lame.
And that's how you screw with someone.
No.
You're not that good of a liar.
I-I can't have a roommate who has feelings for me.
Since when can't you take a joke? Since my roommate hit on me.
You have to move out.
As soon as possible.
We've decided to use your radial artery for the graft.
We've scheduled an O.
R.
for tomorrow morning.
- Good call.
- I agree.
You should risk your life for this surgery.
Are you being facetious? No.
[SIGHS.]
It just boggles the mind.
You can't understand what anyone means.
You can't express yourself like an adult.
You're a child playing dress-up.
And everyone here just plays along.
Let's go, Shaun.
Y-You're agitated.
I'm fine.
You are rubbing your mug.
People with ASD often have comfort objects for when they become agitated.
I can order you Propranolol.
You're gonna give me the Ruseckas-Freedman ASD Diagnostic Questionnaire, and that's gonna shut your damn mouth.
Okay, the "Rafad-Q" is just a tool.
An official diagnosis needs to come from a psychiatrist.
Well, since I might be dead tomorrow, this is your next-best option.
I'll get the test.
Why can't you treat people with just an ounce of respect? Respect has to be earned, not doled out like candy.
No, that's just an excuse people like you use to justify your garbage behavior.
That's just an excuse people like you use to avoid facing reality.
No one was respectful to me when I was a resident.
They were dismissive and cruel.
But it lit a fire and it made me the man I am today.
The man that you came into my room idolizing.
Not anymore.
I'm devastated.
Surgeons deal in human lives, not childish fantasies.
If you want to succeed, you're gonna have to be a lot more like me.
Everything okay? - Yep.
- Surgery went very smoothly.
No pain right now.
Want to take it for a test drive? [BREATHES DEEPLY.]
[SHUDDERS.]
It's worse.
Collateral circulation is not ideal.
How are we gonna harvest the artery? What's going on? How much am I gonna have to change who I am to be a surgeon? Ah, to be great Or even good at anything, we have to compromise.
I used to get too emotionally involved in my work, with patients, everyone.
And I had to learn to distance myself.
Yeah, you've really grown cold and heartless.
I have changed.
We all end up changing.
You just got to try and make it a good change.
I don't want to change.
I want to change what's around me.
Oh, I'll figure it out.
[CHUCKLES.]
I'm sure you will.
Hey, you're the guy who makes living in a van look cool.
[CHUCKLES.]
So, uh, the circulation The right side looks like it has better length.
Yeah.
Better collateral, too.
[FOOTSTEPS APPROACHING.]
Given the poor outcome, we can't recommend further surgery right now.
We suggest six months of pain medication and referrals to neurology and pain management specialists.
W-What surgery aren't you recommending? A DREZ lesioning.
We'd cut the signal from the trigeminal nerve to the sensory areas of your brain.
But there's a real possibility of paralysis on one side of your body.
I want the surgery.
ANA: Baby, I'll help you manage the pain.
I-I'll move back in.
I'll take care of you.
You know how I treated you before.
I'm only gonna get worse.
I would never leave you again.
That's what scares me.
I'd start cutting you down, being cruel, and you'd just put up with it.
[SIGHS.]
I won't let that happen.
[CLICKS TONGUE.]
We'll prep an O.
R.
"I frequently point out other people's mistakes.
" Duh.
That's a yes.
"People tell me I overthink things.
" Only people who underthink things.
But, fine, another yes.
"I sometimes speak in an abnormal tone.
" Who thinks they speak in an abnormal tone? Just mark no.
How many more of these? None.
Your answers are fully congruent with someone on the spectrum.
No.
You keyed it wrong.
No, look.
No, I Or something.
- Here.
Look, I didn't.
- No, give it to me.
- No, I - Oh! Don't! [MUG SHATTERS.]
You idiot! S-Stupid, careless I-I stepped back Get out of my room.
- Get out! - Okay.
[BREATHING HEAVILY.]
LIM: Make sure we're not impacting normal spinal cord pathways.
ASHER: Somatosensories are at baseline.
PARK: BP's steady.
[ALARM SOUNDING.]
Leg and arm SSEPs at 50% decreased amplitude.
Check the cord above and below for hematoma or bony compression.
Cord's fine.
Push IV fluids and start pressors.
So, what is it? I don't know.
[ALARM SOUNDING.]
LIM: Any issues with motor potentials? ASHER: Unilateral amplitude down 70%.
PARK: We're about to get total neurological collapse.
MORGAN: It's a clot from a small branch artery.
We checked the spinal blood vessels The outside.
But the electrode could have injured a sulcal artery.
We need to follow the DREZ pathway inward and search for a small clot.
Start at the site of last ablation with the electrode.
It's gotta be deep.
This'll be easier if she's in here.
Scrub in, Dr.
Reznick.
CLAIRE: We're setting up the neuromonitoring for Silas' surgery.
He's angry with me.
Silas? He's angry with everyone.
Dr.
Andrews said to stop talking to him about ASD.
But I brought it up anyway, gave him a test, his mug broke, and I don't know what to do now.
I don't know what to feel.
And Lea Lea told me about the pregnancy.
Okay.
[EXHALES SHAKILY.]
Is this hard for me because I'm dealing with both things at once? I think both things are related.
What if my child has no friends? What if they're picked on? This is not small-town Wyoming.
The world has changed, Shaun.
I haven't changed.
How can I know what they're feeling? How can I comfort them? How can I be a good father? Remember when we first met? Right over there? You were mad at me.
Yeah.
But you were right about the patient.
And you were stubborn.
And crazy smart.
And you are still all of those things.
But if you were still just that guy that I met running through those doors, we would not be sitting here right now.
You have changed.
You've adapted.
You've grown.
Do you know how hard that is? Most people don't even try.
And you are going to grow into a great father.
Whenever it happens.
MORGAN: Slowly go perpendicular at the angle of our ablation electrode.
[ALARM SOUNDING.]
Still not seeing the clot.
ASHER: Amplitude loss at 80%.
Maybe it's not a clot.
Maybe it's something higher up, in the brain.
PARK: No.
You were right the first time.
Maybe it's hiding behind some ultrasound-impervious segment.
Cut the dentate ligament.
It'll get more lateral access.
LIM: Completely section the ligament.
I see it.
Removing the clot.
[ALARM STOPS, MONITOR BEEPS.]
ASHER: Amplitude returning to normal baseline.
Let me know if you need me.
LIM: We're good.
Thank you.
Hey.
We did good together.
We did.
You still have to move out, though.
Tonight.
On my first day here, Dr.
Melendez said I would never do anything besides suction.
But later, he let me make my first surgical incision.
He became my friend.
I miss him.
Are you in the right room? Did somebody tell you I needed pointless stories? I used to think being a doctor was all I needed to make me happy.
It did make me happy.
But I realized I wanted more.
And that I could have more.
I changed.
You can change, too.
But not if you're dead from this surgery.
I've made up my mind.
Please leave.
My brother Steve, he gave me a plastic scalpel before he died.
It broke.
I was very sad.
I asked you to leave.
When I fixed my scalpel, it made me feel better.
I was 9 years old when my father died.
I loved drinking hot chocolate with him in the morning.
He'd bring me a mug after every business trip.
He understood me.
My mother didn't.
Nobody did.
I tried fitting in, but I got frustrated.
So I gave up.
On relationships.
On friends.
On all but the one thing I was good at.
And now, Dr.
Murphy, I'm too old.
I've made too many enemies.
Too many mistakes.
People tolerate me because I save lives.
Without that why would anyone ever care about me? I care.
[MONITOR BEEPING.]
That smells good.
Bland.
Mm, pasta with olive oil.
Kinda puke-proof.
Have you thought any more about Yes.
I made a list.
I guess I've learned from you.
What's the first thing yours says? That I think I would be a good father but that I can't know for sure.
You'd make a great dad.
It's on my list.
You were right.
It is very complicated.
But I do know I want you to be happy, Lea.
I have so many reasons to do this.
And so many doubts.
I'm just scared, Shaun.
But if we are both having doubts, then maybe now isn't the right time.
Okay.
[SIGHS.]
Mm.
I see that my hemoglobin's stable and my white count is fine.
Yeah.
We just wrote your discharge orders.
This is a referral for an ASD specialist.
I can look into that on my own.
Thank you, Dr.
Murphy.
And thank you, Dr.
Guerin.
Welcome back.
Mm.
Did it work? Let's find out.
[SIGHS.]
Mm.
[BREATHES DEEPLY.]
Your hand's cold.
[CHUCKLES.]
I'm transferring out.
Last year, I applied to a program at Johns Hopkins.
They train doctors to travel the world, help out needy areas.
They'll let me enroll late.
Sounds like a good place for you.
Thanks for always being a great boss.
And a great friend.
Can't have been that great, sneaking out like this.
Uh, actually, for the first time I can remember, it felt hard to say goodbye.
You're always doing so much for other people.
Please don't forget to do something for yourself every now and then.
Were you messing with me or not? If I was, would you let me stay? Yes.
I wasn't messing with you.
Then I guess it's good we're not roommates anymore.
'Cause I couldn't do this.
This is a one-time thing.
Unless I change my mind.
So consider that an incentive.
We get by on love and faith We get by with a smile on our face We get by with help from our kin We get by through thick and through thin We get by We get by No matter what happens, I'll be there for you We get by Was just the other day I heard from my old friend Lea Dilallo? She was going through changes Once again Matters of the head Matters of the heart May be too early to tell But it's never too late to start She called your name.
We get by We get by I spent all day reminding myself of all the reasons why this was a good idea.
We get by But now that it's actually happening, it doesn't make me feel any better.
It just makes me feel really sad.
Day by day Maybe it's not the right time, but will it ever be? If you don't have yours You sure got mine We get by We get by day by day I We get by feel the same.
In our own way We get by Are we really doing this? We get by - No matter how it happens - We I'll be there for you are having a baby.
We get by We get by Mm.
We get by Yes.
No matter how long I'll be waiting here for you [BOTH LAUGH.]
We get by - No matter what happens - Yeah? Okay.
Okay.
I'll be there for you