The Good Doctor (2017) s04e17 Episode Script
Letting Go
1
Don't put any food down the sink.
Garbage disposal's broken.
- I'll call the landlord.
- All right.
He took a week to call the plumber when we lost the hot water, but I guess this doesn't matter as much.
We'll just use the regular trash.
Yes.
10% to 15% of known pregnancies end in miscarriage.
This wasn't unusual.
No.
You're right.
We're not the only people to go through this.
The best thing to do is to just get back to normal.
Hmm.
I'm glad you're going back into work.
Couple more days of rest, and I'll be doing that, too.
Are you sure you're all right? "All right" is stretching it, but yeah.
We just need some time.
How you feeling? All right.
How's Lea doing? She thinks we need time.
I agree.
Hey, Shaun.
How are you feeling? All right.
And Lea thinks we need time.
Well, I didn't expect to see you here.
You have a few days leave.
I thought you'd be home.
I prefer to work.
Well, we respect your judgment.
Bon appetit.
Gastric reflux causing projectile vomiting.
I'm clearing your schedule for the next How many days? Oh.
Well, that is up to my lovely and talented doctors.
Welcome to St.
Bonaventure, Senator Clark.
Oh, please.
Marian.
Oh, Marian, I am a huge supporter.
You had my vote in the presidential primaries.
Thank you, Dr.
Browne.
- Oh, Claire.
- Claire.
If only there'd been another couple million like you.
Yeah.
It's okay.
Nothing wrong with a balanced ticket.
I was in my hotel this morning, going over my speech, when this started happening to my face.
Whole left side went rogue, blinking and twitching like crazy.
Has it happened before? This was the third time.
Fortunately, all in private.
Needless to say, I had to cancel my appearance.
Can I see that again? Oh.
I'm sorry.
I just deleted it.
The only thing worse than people seeing my twitchy face in person is them seeing my twitchy face on a hacked video.
Mm.
So, how do we go about deleting it from my body? It's a hemi-facial spasm.
We should do an MRI to rule out the more serious possible causes.
Which are? Aneurysm, MS, possibly a brain tumor.
What are the less serious causes? Stress, exhaustion, too much coffee.
Well, that's my job description.
Which can be treated with Botox injections and Ativan.
Ah.
Sold.
We still need to do the MRI.
Do both.
Oh.
As Claire knows, I always have to control the agenda.
Hi.
Artie Hill.
I have mild heart failure.
I'm Dr.
Park.
How do you know you have mild heart failure? I'm tired, and I've been having palpitations.
We'll run tests, but if it makes you feel better, a lot of people have palpitations, and it doesn't usually mean heart failure.
Yeah, but I was just talking to my doctor on the phone, and he told me I have heart failure.
The doctor who did my bypass.
Your bypass? He told me I should go to the nearest emergency room.
I was in the park, looking at the cherry trees, and I started feeling funny, so I called When was this bypass? - Um - A month ago.
Paul Nakano.
I performed his surgery at San Jose General.
Mr.
Hill, I hope you took a taxi, as I asked you to.
It was only three blocks.
If you don't mind, I'd like to get a 12-lead EKG, cardiac CT, and bloodwork.
Ordinarily, I'd be thinking about volume overload as the cause But in this case, sodium and B.
U.
N.
are normal.
The next thing I'd look at is a post-op myocardial infarction.
But in this case, the troponins are normal.
So you know what I'm thinking? Yes.
You did your job too damn well.
The heart's been so strengthened from the bypass that it's revealed a weakness in the valve.
It can't handle the pump pressure.
Hmm.
Dr.
Nakano was my Chief of Surgery when I was a resident.
Hmm.
So, when do you want to open him up? I'm hoping never.
Have either of you ever done a transcatheter aortic valve replacement? I've read about it.
It's minimally invasive and way preferable to opening up the patient for the second time in a month.
Well, I look forward to learning from you again.
Hmm.
Oh.
Excuse me! Sir? Person in the hall? Oh, sorry.
Hello.
I am Dr.
Shaun Murphy.
I am a surgeon.
Uh, I-I can't find my socks.
And I can't find the button to call someone.
Ah.
Now, why would they put it there? You can't even see it.
What about the socks? I have mild heart failure.
I was in the park, looking at the cherry trees Cherry trees aren't in bloom at this time of year.
Well, I can still look at them, though.
They don't disappear just because the blossoms fall.
Mm.
I can get you socks from the pre-op supplies area.
Ah, yes.
I remember those crappy socks they give you.
I'll take 'em.
Why do you guys keep it so cold in here? My feet are freezing.
It's beautiful to look at if you're inside and don't have to go anywhere.
And you might not want to go anywhere if you don't Take care of Arthur.
But he lost his silly head and shot Br Every night, we have three clients a week who think I'm waiting tables We'll use a pigtail catheter to place the guide wire, then run a delivery catheter through an 18 French sheath to ferry the new valve through the femoral artery to the heart.
Then we inflate a balloon that expands the new valve and installs it right inside his current one.
That would kill him.
He has cold feet.
Who are you? I'm Dr.
Shaun Murphy.
He's one of my residents.
Oh.
Artie has cold feet? He's afraid of the procedure? No, I think Dr.
Murphy means it literally.
The patient has cold feet.
Is his body temperature dropping? No, his core body temperature is stable at 98.
5.
He rarely has cold feet.
I got him socks.
You're gonna need to draw some dotted lines here for me.
Okay.
Cold feet means impaired circulation, which means constricted blood flow from the heart, which means a damaged vessel.
If we try to push the new valve through the damaged area, it will rip open, killing him.
"Damaged vessel"? Yes.
You make a mistake during the bypass, most likely a tear in the aorta.
I didn't make a mistake.
Mm, you caused an aortic dissection.
Shaun, this man has more cardiac experience than everyone in this room times ten.
A lot of people have cold feet.
My wife has cold feet.
Everyone has cold feet in a hospital.
Yes.
We should perform an angio on Mr.
Hill.
That will show the aortic dissection.
This man recently underwent an open heart surgery.
He's gonna have valve replacement.
We don't need to load him up with yet another procedure when there was no mistake.
Studies show that old people are less likely to admit mistakes because they are less aware when they've made one.
Okay, Dr.
Murphy, you've told us your thoughts on this case.
It's my understanding that you have a few days of leave.
I suggest you take them.
I prefer to continue working.
Then do it somewhere else.
You Will kill him.
You think my surgeon is wrong? Yes.
And you're, like, a-a real doctor, right? I am a real doctor.
No offense, but best heart guy around versus the guy who happened to be passing my room when I needed socks.
Why shouldn't I let Dr.
Nakano do what he thinks I need? If anything goes wrong, he can fix it.
It could be difficult.
The tip of the catheter would be likely to rupture your weakened aorta, ripping it open and causing you to hemorrhage into your chest and bleed out in a matter of minutes.
If you survived, you'd have severe anoxic brain damage.
But it's unlikely you'd survive.
Go home.
Is Mr.
Hill requesting the angio? He's not just requesting.
He's demanding.
This is why you take a leave of absence when you need one.
You're not thinking clearly or you never would have pulled a stunt like this.
I prefer to stay at work.
I could assist with E.
R.
consults.
Dr.
Murphy, because I'm being professional, you may not understand how angry I am right now.
Will you do what Mr.
Hill wants? What you want, you mean? Yes, we'll do it.
You've forced our hand.
Good.
I would have fired him.
Honey, when Freya brings you a dead rat, she's offering you a gift.
I know.
I waited until she was gone so she wouldn't see me toss it away.
Wish you were here.
You could strike the right balance between enthusiasm and discouragement.
Oh.
Honey, I gotta go.
My doctors are here.
You sure everything is okay there? Absolutely.
These shots are working like a charm.
- Love you! - Love you.
Mwah.
The shots are not doing the job.
What else do you have for me? I had another episode.
It was shorter, but still there.
The MRI shows a branch off the basilar artery that's compressing the facial nerve.
Unfortunately, you have a "tortuous" artery.
Where it should be straight, it bends and twists.
Bad news is, it'd be a nightmare to try and address this surgically.
Good news Is, other than some twitching, which is minimized by the Botox, it's not causing any other problems.
Exactly.
Aside from the complete destruction of all I want to achieve in life.
Melodramatic, yet true.
These episodes keep happening, eventually one of them will get caught on video.
Ten minutes later, it'll be all over social media.
My opponents will mock me relentlessly.
I think a lot of people would have sympathy for you.
We don't vote for people we feel sympathy for.
We want strong leaders.
We want the symbol more than the reality.
Please help me.
Unfortunately, there's nothing we can do.
We'll see what we can come up with.
Last night I came out I was so damn manic I don't even know Where I went wrong But I went wrong And it's times like these That I swear to God Oh, that my mother can't See me and if she did I don't know how I would keep it together I don't know How I would keep it Shaun? You shouldn't be here.
Andrews is pissed at you, with good reason.
There's no need to make him any more angry.
That's why I'm hiding.
I couldn't wait in the lounge because the walls are glass and people could see me.
"Wait"? What are you waiting for? When they see that I was right, they'll let me come back.
I want to be prepared.
I'm reading about options in aortic dissection.
- Shaun, no.
- Yes.
Once they do the angio, they'll see the evidence.
Dr.
Andrews won't be angry anymore.
They did the angio.
Mm.
Oh.
No.
No, they They couldn't.
They did it.
I was there.
You were wrong.
But - Cold feet - It was a focused angio.
I saw the ascending aorta and the aortic root.
There was no sign of dissection.
They're giving the patient a chance to rest before scheduling the TAVR.
We all make mistakes.
But I think you should leave the building while you're still forgivable.
- Lea.
- Yeah.
How are you? I'm good.
It happened to me, too.
Twice.
We could bypass the basilar artery.
A 25% mortality rate, sure.
How about stereotactic radiosurgery? No, she wouldn't like it.
It takes months to see any kind of improvement.
It's interesting.
The fact that you like this person makes you willing to make really stupid decisions that could kill her.
We could meet in the middle.
Tortuous or not, the main basilar isn't causing the spasms.
So we leave it alone and just sling up the branch of the artery that's applying the pressure.
Nice.
I have two predictions to make.
One, she'll come up with a rationalization to justify not telling her husband about this surgery, and two, you'll come up with a rationalization to justify forgiving her for that.
You wouldn't have fired him.
He's dealing with some personal issues, and I remember you giving me some slack once when I screwed up.
Well, you were facing a challenging surgery, and your girlfriend, who I never liked, by the way, dumped you, so You knew about the dumping? Oh, yeah.
I just didn't know why.
She wanted a commitment.
Said I didn't love her enough.
And I told her I loved her, but I didn't have time to get into it because I had an esophagus to reconstruct.
Why did you help me? I mean, why me and not Penzer? He was always number one in our class.
I was always second.
Where's Penzer now? What, you think I've been following the guy's career for the past 20 years? He's at the NIH, making policy.
That's Penzer.
Great mind, great hands, but I knew he'd never be a surgeon.
He didn't love it enough.
- I can wait.
- Oh, this can, too.
Just letting the phone get to 10%, then I'll run the gauntlet of well-wishers and head out.
Yeah.
I'm one of them.
When my grandma died, I remember a whole relay of the mothers of the church bringing food to the house.
They all loved my grandma.
The older ladies got their best hats and gloves out for the service.
Pastor made a special prayer at the gravesite.
We all told stories about her.
There were rituals.
We said goodbye to the past.
You're saying goodbye to the future.
I'm sorry for your loss.
And how soon could I get out of here? If all goes well, a day, maybe two at most.
Oh.
You hear that, Cal? Rebooking for Thursday.
There was an "if" there.
That's strange.
I heard a "when.
" Now, I will be appointing Cal as my healthcare surrogate while I'm under.
Mm, uh, most people appoint their spouse.
Or at least notify them.
He'll just try to talk me out of this.
Because he loves me.
Whereas Cal is using me to find a better position, but knows exactly what I want.
So Let's fix my broken brain.
I got your text.
I'm a good diagnostician.
Of course you are.
Sit down.
You You want to sit? No.
I accounted for every symptom.
I listened to the patient's history.
Someone's feet were cold.
Okay? Uh, just Sometimes that means something.
Sometimes it doesn't.
This time, it didn't.
S-So what? What are you still doing here, Shaun? Wh Do you not want to go home? You gotta go home.
You suffered a loss.
You gotta You gotta deal with it.
You gotta face it.
Mm.
Why do I have to "face it"? What does that mean? It happened.
Yeah.
It did happen.
It happened, okay? Go home and be with Lea.
Oh, Claire.
I'm happy to see you.
Uh, it seems the reporters have discovered I'm here, so poor Cal has gone off to craft a believable explanation.
So, what's something a person might be hospitalized for that says "I'm an unstoppable force"? You want me to provide you with a good lie? Yeah.
But you must be scared.
I'm terrified.
You know, when I'm scared, I think about Evvie Sinclair.
You were the commencement speaker at my high school graduation.
Oh.
I was a bit of a mess back then.
I had no idea what I was gonna do with my life or what I could do with my life.
And you told us about Evvie Sinclair, born with Turner Syndrome, small in stature, facial abnormalities, speech impairment.
But she just had a desperate need to learn.
And against her parents' wishes, she started high school.
And And I just remember thinking If Evvie can go through those doors and walk down those halls I went home that day, and I applied to 11 colleges.
So, I am a doctor Because of you.
And Evvie.
Mm.
That was a great story.
Rickie Demarest.
He was my campaign manager before Cal.
He made up some lovely stuff.
You're back early.
Dr.
Andrews sent me home, and Dr.
Glassman thinks we should talk.
Dr.
Glassman is not a counselor.
He's a neurosurgeon.
And a sometimes annoying person.
I'm gonna make some tea.
Oh.
It's your mother.
- No, no, no, no, no.
- Hello.
Hi, Shaun.
How are you? I'm Well.
Lea Can't talk to you now.
Oh, you're both home.
I wanted to ask about strollers.
The one Lea likes, I read a review that said the front wheel keeps coming off.
I'm sure she won't listen, so I'm gonna send a link.
You should read it, too.
Yes.
Thank you.
You don't want your little girl pitching headfirst onto the sidewalk.
Oh, no.
No.
We wouldn't.
Just hang up.
Just Okay.
I should go.
And now that we know it's a girl, I was wondering I already bought a onesie with little dinosaurs on it.
Unbelievably cute.
Mm.
Cute.
Yes.
Okay, that sounds good.
I am due at the hospital.
Just a quick question.
Since it's not a boy, the dinosaurs will have to go.
- I'm - What would be nice for a girl? I don't I don't know.
There's one with ballet shoes.
That's stupid.
Why would you have to change it? A girl would like dinosaurs just as much as a boy.
Dinosaurs are fascinating.
You need to shut up.
Um Shaun? As you all know, Senator Clark is a very competitive person.
She tore her meniscus while charging the net to return a drop shot.
For the record, it was match point, which she won.
She underwent I wonder if he negotiates employment contracts.
And thanks to the terrific doctors here at St.
Bonaventure, she will be back fighting for you before you know it.
Senator Clark wanted to thank all Oh, did you hear that? We're terrific.
You must be.
You repaired her meniscus through her head.
It's no one's business why she's here.
And there's the rationalization I've been waiting for.
If this was someone you didn't like, these character flaws would reveal some deep problem worthy of your eternal judgment, but since You're head of department.
I'm sure you've had to spin things sometimes.
"Spin things"? Sure.
Lie? No.
Just one more example of how Senator Clark has been able And that was an example of both.
Marian isn't waking up.
And to that end, she's already making calls and sending e-mails.
Oh.
And texts.
She just told me to wrap it up.
I yelled at your mother.
Yeah.
I misdiagnosed a patient.
That's why they sent me home.
I'm not behaving normally.
Neither am I.
But maybe this is normal for where we're at.
Dr.
Glassman talked about "facing my loss," but I don't know what that means, and even if we could face it, won't we just hurt ourselves for no reason? I don't know.
I don't think grief has an actual solution.
It has to.
I can't stay this way.
Claire told me about this support group.
I'm not sure we can just force ourselves past this.
The cold feet are not a coincidence.
If they do the TAVR procedure, they'll kill the patient.
For a different reason.
The guide wire's in place.
I'm preparing to deliver the valve.
Okay, you You have to stop.
If that valve goes through - Get out of here, Murphy.
- No.
If that valve goes through, he'll die.
- Call Security.
- I thought it was an aortic dissection, but I was wrong.
The cold feet are from a coarctation No.
No.
No, no.
It's too close.
You're too close.
Stop! Stop! Stop, please! Stop! B.
P.
's spiking.
200 over 100.
Heart rate's up.
He's gonna stroke.
Give him nitro and cardene! I'm pulling out.
B.
P.
's dropping.
He's starting to stabilize.
Okay.
Dr.
Murphy? Go on.
Dr.
Nakano did not make a mistake in the bypass.
He did everything right.
But Mr.
Hill has a congenital narrowing of the abdominal aorta.
He's had that coarctation for year, but never knew because his body compensated for the poor circulation by raising his blood pressure, which caused his heart to deteriorate, requiring a bypass.
The stronger, repaired heart put pressure on the valve, and his blood pressure dropped.
No more compensation.
His feet got cold.
And I could get the guide wire up there, but the valve delivery system would be too big to fit through the coarctation without damaging the vessel.
Yes.
We'll have to open him up.
And the valve will have to be replaced directly Through surgery.
I hope you'll join us for that.
How's Cal gonna spin this? Her latest tennis match went into extra sets? Slinged branch looks good, no conflict with the seventh nerve, no bleeds, no strokes.
The basilar is dilated.
And compressing her brain stem.
She's stopped breathing.
We need to intubate.
Get the airway cart.
Tell them she's gonna be at the conference.
And if they keep asking, tell them the Senator believes anyone not ready to commit on climate change action is on the wrong side of history.
Just never use that phrase more than once a month.
He has to run.
The sling procedure went fine, but the basilar artery was less stable than we hoped.
It's gotten even more dilated and is causing progressive neurological deficits.
We have no choice but to bypass the artery.
The last surgery was dangerous.
This one way more so.
What do you need me to sign? We should inform her husband.
There is a one in four chance that she could die.
If I told Pete that, he'd be at the airport in half an hour, and everyone would know that Marian is in this hospital for something this serious.
She has a brain aneurysm.
That doesn't make her weak.
Even worse.
It makes her mortal.
Her husband has a right to be here.
A moral right.
To destroy her career.
Which is what I'm protecting her from.
This is just a game to you, isn't it? Yeah.
The game they make you play before you can do anything real.
Valve placed.
Leaflets mobile.
New valve is perfectly seated in the annulus.
No regurgitation, flow in both coronary arteries.
I'm about to close up.
Looks like we've got a paravalvular leak.
We need to go back and fix this.
Irrigate and check the image.
No leak.
Slight excess from the washing jets in the mechanical valve.
Normal finding.
Wow.
You're very good.
I think he knows that.
Still nice to hear.
Closing up now.
Two-oh Vicryl suture.
Retracting temporal lobe and cerebellum Very carefully.
Vascular anatomy is fully exposed, avoiding the tortuous area.
Radial artery graft length looks to be a perfect fit.
Anastomosing with 9-0 Prolene.
Temporal lobe's swelling.
B.
P.
and heart rate are plummeting.
Drop her CO2, full propofol burst suppression.
Widen the craniotomy.
With the cerebellum herniating outward? We do that, she may never walk normally again.
If she didn't want a twitch Drill.
Open the arachnoid plane and release CSF collections.
Reduce the pressure from the inside.
For her, it's worth the risk.
Arachnoid dissector.
There was a patient admitted this morning I think you should see.
You thinking of Mrs.
Cavanaugh? That's a good idea, Dr.
Park.
We'd welcome another take as to whether she's a good candidate for inserting an ICD.
I'll consult just on that question, if you'd like me to.
But I won't join in the O.
R.
I'm quitting surgery.
I don't understand.
When did you decide Fifteen minutes ago.
I nearly closed up without doing a final antibiotic lavage.
But you didn't.
Nurse Barker prompted you with the syringe.
It was a tiny error.
There was no contamination of the field.
Many surgeons don't even do a final lavage.
I always told myself once I started making tiny errors, I'd stop before I made a big one.
Paul, we almost lost a patient today.
You were still rattled.
Thank you, Marcus.
But I made this plan years ago, because I knew that when the time came, I'd look for reasons why whatever I did wrong was tiny, minor, didn't count.
That's when I made the rule.
Everything counts.
Dr.
Murphy, it was nice sewing with you.
You gave us a scare.
But all good now.
You're mad at me.
About little Evvie.
Well, Evvie inspired me.
I took strength from her for years.
Now it's all fiction.
Fictional lives can save real lives.
Four years ago, I used that story on the Senate floor.
I got my bill passed by one vote.
That lie helped millions of people with disabilities.
I'm really proud of that lie.
I'm heading out to have a drink with Dr.
Nakano.
Are you going to try to talk him out of leaving surgery? No.
I'm going because no one's meant to shoulder loss alone.
And I'm the one who should be with him tonight.
Why? Because we love the same thing.
And he knows no one would understand what he's lost more than I would.
I have been thinking About all the people you've helped, including me.
And about not Sharing the danger you were in with your husband.
Probably not sharing a lot of other things.
And it struck me that Being in a marriage like that must be lonely.
You can't trust him to lie.
So you end up sharing more of yourself with a guy like Cal, who is a hired gun and who's gonna end up working for somebody else two years from now.
The fact that Pete and I don't talk shop doesn't make our marriage less than wonderful.
Another lie? Hey, hey! How 'bout those Devils, huh? But before I go all fan girl about last night's game, let's talk about the upcoming climate change conference.
I have to tell you guys a story about a little boy who lives on the Outer Banks of South Carolina, whose home is about to be washed away I could get another mug, or I could wash these.
It's a tough decision.
Mm.
I should probably tell you, I didn't get to calling the landlord.
And maybe ten minutes ago, I saw a couple fruit flies near the drain, so So Yeah.
Now it's my fault if we're If we get bugs.
Garbage disposal's broken.
- I'll call the landlord.
- All right.
He took a week to call the plumber when we lost the hot water, but I guess this doesn't matter as much.
We'll just use the regular trash.
Yes.
10% to 15% of known pregnancies end in miscarriage.
This wasn't unusual.
No.
You're right.
We're not the only people to go through this.
The best thing to do is to just get back to normal.
Hmm.
I'm glad you're going back into work.
Couple more days of rest, and I'll be doing that, too.
Are you sure you're all right? "All right" is stretching it, but yeah.
We just need some time.
How you feeling? All right.
How's Lea doing? She thinks we need time.
I agree.
Hey, Shaun.
How are you feeling? All right.
And Lea thinks we need time.
Well, I didn't expect to see you here.
You have a few days leave.
I thought you'd be home.
I prefer to work.
Well, we respect your judgment.
Bon appetit.
Gastric reflux causing projectile vomiting.
I'm clearing your schedule for the next How many days? Oh.
Well, that is up to my lovely and talented doctors.
Welcome to St.
Bonaventure, Senator Clark.
Oh, please.
Marian.
Oh, Marian, I am a huge supporter.
You had my vote in the presidential primaries.
Thank you, Dr.
Browne.
- Oh, Claire.
- Claire.
If only there'd been another couple million like you.
Yeah.
It's okay.
Nothing wrong with a balanced ticket.
I was in my hotel this morning, going over my speech, when this started happening to my face.
Whole left side went rogue, blinking and twitching like crazy.
Has it happened before? This was the third time.
Fortunately, all in private.
Needless to say, I had to cancel my appearance.
Can I see that again? Oh.
I'm sorry.
I just deleted it.
The only thing worse than people seeing my twitchy face in person is them seeing my twitchy face on a hacked video.
Mm.
So, how do we go about deleting it from my body? It's a hemi-facial spasm.
We should do an MRI to rule out the more serious possible causes.
Which are? Aneurysm, MS, possibly a brain tumor.
What are the less serious causes? Stress, exhaustion, too much coffee.
Well, that's my job description.
Which can be treated with Botox injections and Ativan.
Ah.
Sold.
We still need to do the MRI.
Do both.
Oh.
As Claire knows, I always have to control the agenda.
Hi.
Artie Hill.
I have mild heart failure.
I'm Dr.
Park.
How do you know you have mild heart failure? I'm tired, and I've been having palpitations.
We'll run tests, but if it makes you feel better, a lot of people have palpitations, and it doesn't usually mean heart failure.
Yeah, but I was just talking to my doctor on the phone, and he told me I have heart failure.
The doctor who did my bypass.
Your bypass? He told me I should go to the nearest emergency room.
I was in the park, looking at the cherry trees, and I started feeling funny, so I called When was this bypass? - Um - A month ago.
Paul Nakano.
I performed his surgery at San Jose General.
Mr.
Hill, I hope you took a taxi, as I asked you to.
It was only three blocks.
If you don't mind, I'd like to get a 12-lead EKG, cardiac CT, and bloodwork.
Ordinarily, I'd be thinking about volume overload as the cause But in this case, sodium and B.
U.
N.
are normal.
The next thing I'd look at is a post-op myocardial infarction.
But in this case, the troponins are normal.
So you know what I'm thinking? Yes.
You did your job too damn well.
The heart's been so strengthened from the bypass that it's revealed a weakness in the valve.
It can't handle the pump pressure.
Hmm.
Dr.
Nakano was my Chief of Surgery when I was a resident.
Hmm.
So, when do you want to open him up? I'm hoping never.
Have either of you ever done a transcatheter aortic valve replacement? I've read about it.
It's minimally invasive and way preferable to opening up the patient for the second time in a month.
Well, I look forward to learning from you again.
Hmm.
Oh.
Excuse me! Sir? Person in the hall? Oh, sorry.
Hello.
I am Dr.
Shaun Murphy.
I am a surgeon.
Uh, I-I can't find my socks.
And I can't find the button to call someone.
Ah.
Now, why would they put it there? You can't even see it.
What about the socks? I have mild heart failure.
I was in the park, looking at the cherry trees Cherry trees aren't in bloom at this time of year.
Well, I can still look at them, though.
They don't disappear just because the blossoms fall.
Mm.
I can get you socks from the pre-op supplies area.
Ah, yes.
I remember those crappy socks they give you.
I'll take 'em.
Why do you guys keep it so cold in here? My feet are freezing.
It's beautiful to look at if you're inside and don't have to go anywhere.
And you might not want to go anywhere if you don't Take care of Arthur.
But he lost his silly head and shot Br Every night, we have three clients a week who think I'm waiting tables We'll use a pigtail catheter to place the guide wire, then run a delivery catheter through an 18 French sheath to ferry the new valve through the femoral artery to the heart.
Then we inflate a balloon that expands the new valve and installs it right inside his current one.
That would kill him.
He has cold feet.
Who are you? I'm Dr.
Shaun Murphy.
He's one of my residents.
Oh.
Artie has cold feet? He's afraid of the procedure? No, I think Dr.
Murphy means it literally.
The patient has cold feet.
Is his body temperature dropping? No, his core body temperature is stable at 98.
5.
He rarely has cold feet.
I got him socks.
You're gonna need to draw some dotted lines here for me.
Okay.
Cold feet means impaired circulation, which means constricted blood flow from the heart, which means a damaged vessel.
If we try to push the new valve through the damaged area, it will rip open, killing him.
"Damaged vessel"? Yes.
You make a mistake during the bypass, most likely a tear in the aorta.
I didn't make a mistake.
Mm, you caused an aortic dissection.
Shaun, this man has more cardiac experience than everyone in this room times ten.
A lot of people have cold feet.
My wife has cold feet.
Everyone has cold feet in a hospital.
Yes.
We should perform an angio on Mr.
Hill.
That will show the aortic dissection.
This man recently underwent an open heart surgery.
He's gonna have valve replacement.
We don't need to load him up with yet another procedure when there was no mistake.
Studies show that old people are less likely to admit mistakes because they are less aware when they've made one.
Okay, Dr.
Murphy, you've told us your thoughts on this case.
It's my understanding that you have a few days of leave.
I suggest you take them.
I prefer to continue working.
Then do it somewhere else.
You Will kill him.
You think my surgeon is wrong? Yes.
And you're, like, a-a real doctor, right? I am a real doctor.
No offense, but best heart guy around versus the guy who happened to be passing my room when I needed socks.
Why shouldn't I let Dr.
Nakano do what he thinks I need? If anything goes wrong, he can fix it.
It could be difficult.
The tip of the catheter would be likely to rupture your weakened aorta, ripping it open and causing you to hemorrhage into your chest and bleed out in a matter of minutes.
If you survived, you'd have severe anoxic brain damage.
But it's unlikely you'd survive.
Go home.
Is Mr.
Hill requesting the angio? He's not just requesting.
He's demanding.
This is why you take a leave of absence when you need one.
You're not thinking clearly or you never would have pulled a stunt like this.
I prefer to stay at work.
I could assist with E.
R.
consults.
Dr.
Murphy, because I'm being professional, you may not understand how angry I am right now.
Will you do what Mr.
Hill wants? What you want, you mean? Yes, we'll do it.
You've forced our hand.
Good.
I would have fired him.
Honey, when Freya brings you a dead rat, she's offering you a gift.
I know.
I waited until she was gone so she wouldn't see me toss it away.
Wish you were here.
You could strike the right balance between enthusiasm and discouragement.
Oh.
Honey, I gotta go.
My doctors are here.
You sure everything is okay there? Absolutely.
These shots are working like a charm.
- Love you! - Love you.
Mwah.
The shots are not doing the job.
What else do you have for me? I had another episode.
It was shorter, but still there.
The MRI shows a branch off the basilar artery that's compressing the facial nerve.
Unfortunately, you have a "tortuous" artery.
Where it should be straight, it bends and twists.
Bad news is, it'd be a nightmare to try and address this surgically.
Good news Is, other than some twitching, which is minimized by the Botox, it's not causing any other problems.
Exactly.
Aside from the complete destruction of all I want to achieve in life.
Melodramatic, yet true.
These episodes keep happening, eventually one of them will get caught on video.
Ten minutes later, it'll be all over social media.
My opponents will mock me relentlessly.
I think a lot of people would have sympathy for you.
We don't vote for people we feel sympathy for.
We want strong leaders.
We want the symbol more than the reality.
Please help me.
Unfortunately, there's nothing we can do.
We'll see what we can come up with.
Last night I came out I was so damn manic I don't even know Where I went wrong But I went wrong And it's times like these That I swear to God Oh, that my mother can't See me and if she did I don't know how I would keep it together I don't know How I would keep it Shaun? You shouldn't be here.
Andrews is pissed at you, with good reason.
There's no need to make him any more angry.
That's why I'm hiding.
I couldn't wait in the lounge because the walls are glass and people could see me.
"Wait"? What are you waiting for? When they see that I was right, they'll let me come back.
I want to be prepared.
I'm reading about options in aortic dissection.
- Shaun, no.
- Yes.
Once they do the angio, they'll see the evidence.
Dr.
Andrews won't be angry anymore.
They did the angio.
Mm.
Oh.
No.
No, they They couldn't.
They did it.
I was there.
You were wrong.
But - Cold feet - It was a focused angio.
I saw the ascending aorta and the aortic root.
There was no sign of dissection.
They're giving the patient a chance to rest before scheduling the TAVR.
We all make mistakes.
But I think you should leave the building while you're still forgivable.
- Lea.
- Yeah.
How are you? I'm good.
It happened to me, too.
Twice.
We could bypass the basilar artery.
A 25% mortality rate, sure.
How about stereotactic radiosurgery? No, she wouldn't like it.
It takes months to see any kind of improvement.
It's interesting.
The fact that you like this person makes you willing to make really stupid decisions that could kill her.
We could meet in the middle.
Tortuous or not, the main basilar isn't causing the spasms.
So we leave it alone and just sling up the branch of the artery that's applying the pressure.
Nice.
I have two predictions to make.
One, she'll come up with a rationalization to justify not telling her husband about this surgery, and two, you'll come up with a rationalization to justify forgiving her for that.
You wouldn't have fired him.
He's dealing with some personal issues, and I remember you giving me some slack once when I screwed up.
Well, you were facing a challenging surgery, and your girlfriend, who I never liked, by the way, dumped you, so You knew about the dumping? Oh, yeah.
I just didn't know why.
She wanted a commitment.
Said I didn't love her enough.
And I told her I loved her, but I didn't have time to get into it because I had an esophagus to reconstruct.
Why did you help me? I mean, why me and not Penzer? He was always number one in our class.
I was always second.
Where's Penzer now? What, you think I've been following the guy's career for the past 20 years? He's at the NIH, making policy.
That's Penzer.
Great mind, great hands, but I knew he'd never be a surgeon.
He didn't love it enough.
- I can wait.
- Oh, this can, too.
Just letting the phone get to 10%, then I'll run the gauntlet of well-wishers and head out.
Yeah.
I'm one of them.
When my grandma died, I remember a whole relay of the mothers of the church bringing food to the house.
They all loved my grandma.
The older ladies got their best hats and gloves out for the service.
Pastor made a special prayer at the gravesite.
We all told stories about her.
There were rituals.
We said goodbye to the past.
You're saying goodbye to the future.
I'm sorry for your loss.
And how soon could I get out of here? If all goes well, a day, maybe two at most.
Oh.
You hear that, Cal? Rebooking for Thursday.
There was an "if" there.
That's strange.
I heard a "when.
" Now, I will be appointing Cal as my healthcare surrogate while I'm under.
Mm, uh, most people appoint their spouse.
Or at least notify them.
He'll just try to talk me out of this.
Because he loves me.
Whereas Cal is using me to find a better position, but knows exactly what I want.
So Let's fix my broken brain.
I got your text.
I'm a good diagnostician.
Of course you are.
Sit down.
You You want to sit? No.
I accounted for every symptom.
I listened to the patient's history.
Someone's feet were cold.
Okay? Uh, just Sometimes that means something.
Sometimes it doesn't.
This time, it didn't.
S-So what? What are you still doing here, Shaun? Wh Do you not want to go home? You gotta go home.
You suffered a loss.
You gotta You gotta deal with it.
You gotta face it.
Mm.
Why do I have to "face it"? What does that mean? It happened.
Yeah.
It did happen.
It happened, okay? Go home and be with Lea.
Oh, Claire.
I'm happy to see you.
Uh, it seems the reporters have discovered I'm here, so poor Cal has gone off to craft a believable explanation.
So, what's something a person might be hospitalized for that says "I'm an unstoppable force"? You want me to provide you with a good lie? Yeah.
But you must be scared.
I'm terrified.
You know, when I'm scared, I think about Evvie Sinclair.
You were the commencement speaker at my high school graduation.
Oh.
I was a bit of a mess back then.
I had no idea what I was gonna do with my life or what I could do with my life.
And you told us about Evvie Sinclair, born with Turner Syndrome, small in stature, facial abnormalities, speech impairment.
But she just had a desperate need to learn.
And against her parents' wishes, she started high school.
And And I just remember thinking If Evvie can go through those doors and walk down those halls I went home that day, and I applied to 11 colleges.
So, I am a doctor Because of you.
And Evvie.
Mm.
That was a great story.
Rickie Demarest.
He was my campaign manager before Cal.
He made up some lovely stuff.
You're back early.
Dr.
Andrews sent me home, and Dr.
Glassman thinks we should talk.
Dr.
Glassman is not a counselor.
He's a neurosurgeon.
And a sometimes annoying person.
I'm gonna make some tea.
Oh.
It's your mother.
- No, no, no, no, no.
- Hello.
Hi, Shaun.
How are you? I'm Well.
Lea Can't talk to you now.
Oh, you're both home.
I wanted to ask about strollers.
The one Lea likes, I read a review that said the front wheel keeps coming off.
I'm sure she won't listen, so I'm gonna send a link.
You should read it, too.
Yes.
Thank you.
You don't want your little girl pitching headfirst onto the sidewalk.
Oh, no.
No.
We wouldn't.
Just hang up.
Just Okay.
I should go.
And now that we know it's a girl, I was wondering I already bought a onesie with little dinosaurs on it.
Unbelievably cute.
Mm.
Cute.
Yes.
Okay, that sounds good.
I am due at the hospital.
Just a quick question.
Since it's not a boy, the dinosaurs will have to go.
- I'm - What would be nice for a girl? I don't I don't know.
There's one with ballet shoes.
That's stupid.
Why would you have to change it? A girl would like dinosaurs just as much as a boy.
Dinosaurs are fascinating.
You need to shut up.
Um Shaun? As you all know, Senator Clark is a very competitive person.
She tore her meniscus while charging the net to return a drop shot.
For the record, it was match point, which she won.
She underwent I wonder if he negotiates employment contracts.
And thanks to the terrific doctors here at St.
Bonaventure, she will be back fighting for you before you know it.
Senator Clark wanted to thank all Oh, did you hear that? We're terrific.
You must be.
You repaired her meniscus through her head.
It's no one's business why she's here.
And there's the rationalization I've been waiting for.
If this was someone you didn't like, these character flaws would reveal some deep problem worthy of your eternal judgment, but since You're head of department.
I'm sure you've had to spin things sometimes.
"Spin things"? Sure.
Lie? No.
Just one more example of how Senator Clark has been able And that was an example of both.
Marian isn't waking up.
And to that end, she's already making calls and sending e-mails.
Oh.
And texts.
She just told me to wrap it up.
I yelled at your mother.
Yeah.
I misdiagnosed a patient.
That's why they sent me home.
I'm not behaving normally.
Neither am I.
But maybe this is normal for where we're at.
Dr.
Glassman talked about "facing my loss," but I don't know what that means, and even if we could face it, won't we just hurt ourselves for no reason? I don't know.
I don't think grief has an actual solution.
It has to.
I can't stay this way.
Claire told me about this support group.
I'm not sure we can just force ourselves past this.
The cold feet are not a coincidence.
If they do the TAVR procedure, they'll kill the patient.
For a different reason.
The guide wire's in place.
I'm preparing to deliver the valve.
Okay, you You have to stop.
If that valve goes through - Get out of here, Murphy.
- No.
If that valve goes through, he'll die.
- Call Security.
- I thought it was an aortic dissection, but I was wrong.
The cold feet are from a coarctation No.
No.
No, no.
It's too close.
You're too close.
Stop! Stop! Stop, please! Stop! B.
P.
's spiking.
200 over 100.
Heart rate's up.
He's gonna stroke.
Give him nitro and cardene! I'm pulling out.
B.
P.
's dropping.
He's starting to stabilize.
Okay.
Dr.
Murphy? Go on.
Dr.
Nakano did not make a mistake in the bypass.
He did everything right.
But Mr.
Hill has a congenital narrowing of the abdominal aorta.
He's had that coarctation for year, but never knew because his body compensated for the poor circulation by raising his blood pressure, which caused his heart to deteriorate, requiring a bypass.
The stronger, repaired heart put pressure on the valve, and his blood pressure dropped.
No more compensation.
His feet got cold.
And I could get the guide wire up there, but the valve delivery system would be too big to fit through the coarctation without damaging the vessel.
Yes.
We'll have to open him up.
And the valve will have to be replaced directly Through surgery.
I hope you'll join us for that.
How's Cal gonna spin this? Her latest tennis match went into extra sets? Slinged branch looks good, no conflict with the seventh nerve, no bleeds, no strokes.
The basilar is dilated.
And compressing her brain stem.
She's stopped breathing.
We need to intubate.
Get the airway cart.
Tell them she's gonna be at the conference.
And if they keep asking, tell them the Senator believes anyone not ready to commit on climate change action is on the wrong side of history.
Just never use that phrase more than once a month.
He has to run.
The sling procedure went fine, but the basilar artery was less stable than we hoped.
It's gotten even more dilated and is causing progressive neurological deficits.
We have no choice but to bypass the artery.
The last surgery was dangerous.
This one way more so.
What do you need me to sign? We should inform her husband.
There is a one in four chance that she could die.
If I told Pete that, he'd be at the airport in half an hour, and everyone would know that Marian is in this hospital for something this serious.
She has a brain aneurysm.
That doesn't make her weak.
Even worse.
It makes her mortal.
Her husband has a right to be here.
A moral right.
To destroy her career.
Which is what I'm protecting her from.
This is just a game to you, isn't it? Yeah.
The game they make you play before you can do anything real.
Valve placed.
Leaflets mobile.
New valve is perfectly seated in the annulus.
No regurgitation, flow in both coronary arteries.
I'm about to close up.
Looks like we've got a paravalvular leak.
We need to go back and fix this.
Irrigate and check the image.
No leak.
Slight excess from the washing jets in the mechanical valve.
Normal finding.
Wow.
You're very good.
I think he knows that.
Still nice to hear.
Closing up now.
Two-oh Vicryl suture.
Retracting temporal lobe and cerebellum Very carefully.
Vascular anatomy is fully exposed, avoiding the tortuous area.
Radial artery graft length looks to be a perfect fit.
Anastomosing with 9-0 Prolene.
Temporal lobe's swelling.
B.
P.
and heart rate are plummeting.
Drop her CO2, full propofol burst suppression.
Widen the craniotomy.
With the cerebellum herniating outward? We do that, she may never walk normally again.
If she didn't want a twitch Drill.
Open the arachnoid plane and release CSF collections.
Reduce the pressure from the inside.
For her, it's worth the risk.
Arachnoid dissector.
There was a patient admitted this morning I think you should see.
You thinking of Mrs.
Cavanaugh? That's a good idea, Dr.
Park.
We'd welcome another take as to whether she's a good candidate for inserting an ICD.
I'll consult just on that question, if you'd like me to.
But I won't join in the O.
R.
I'm quitting surgery.
I don't understand.
When did you decide Fifteen minutes ago.
I nearly closed up without doing a final antibiotic lavage.
But you didn't.
Nurse Barker prompted you with the syringe.
It was a tiny error.
There was no contamination of the field.
Many surgeons don't even do a final lavage.
I always told myself once I started making tiny errors, I'd stop before I made a big one.
Paul, we almost lost a patient today.
You were still rattled.
Thank you, Marcus.
But I made this plan years ago, because I knew that when the time came, I'd look for reasons why whatever I did wrong was tiny, minor, didn't count.
That's when I made the rule.
Everything counts.
Dr.
Murphy, it was nice sewing with you.
You gave us a scare.
But all good now.
You're mad at me.
About little Evvie.
Well, Evvie inspired me.
I took strength from her for years.
Now it's all fiction.
Fictional lives can save real lives.
Four years ago, I used that story on the Senate floor.
I got my bill passed by one vote.
That lie helped millions of people with disabilities.
I'm really proud of that lie.
I'm heading out to have a drink with Dr.
Nakano.
Are you going to try to talk him out of leaving surgery? No.
I'm going because no one's meant to shoulder loss alone.
And I'm the one who should be with him tonight.
Why? Because we love the same thing.
And he knows no one would understand what he's lost more than I would.
I have been thinking About all the people you've helped, including me.
And about not Sharing the danger you were in with your husband.
Probably not sharing a lot of other things.
And it struck me that Being in a marriage like that must be lonely.
You can't trust him to lie.
So you end up sharing more of yourself with a guy like Cal, who is a hired gun and who's gonna end up working for somebody else two years from now.
The fact that Pete and I don't talk shop doesn't make our marriage less than wonderful.
Another lie? Hey, hey! How 'bout those Devils, huh? But before I go all fan girl about last night's game, let's talk about the upcoming climate change conference.
I have to tell you guys a story about a little boy who lives on the Outer Banks of South Carolina, whose home is about to be washed away I could get another mug, or I could wash these.
It's a tough decision.
Mm.
I should probably tell you, I didn't get to calling the landlord.
And maybe ten minutes ago, I saw a couple fruit flies near the drain, so So Yeah.
Now it's my fault if we're If we get bugs.