ER s11e13 Episode Script
Middleman
E.
R.
Previously on E.
R.
Yes, I believe the drug ruined her kidney.
You're alleging potential slander that could cost the hospital millions in support.
Abby, he's all yours today.
- Who? - Hey.
- Nothing's gonna happen.
- Why is that? - You're my student.
- Welcome, roomie.
God, I'm gonna regret this.
If we wanna make our patients happier, we need to teach our residents - to connect with them better.
- You might wanna start with Pratt.
- I'm not an intern, okay? - So stop acting like one.
E.
R.
11x13 "MIDDLEMAN" No more hot water.
Sorry about that.
I should have warned you.
- Building needs a bigger water heater.
- God, I'm freezing.
Let me see what I can do about that.
Come on in here.
How about we call in sick? I'm arguing a motion today.
It's my first time in front of this judge.
Well, let's just try to hook up after my shift, then.
I can't.
I'm going to a friend's birthday dinner at Dandelion.
Dandelion.
- Pretty swank.
- Yeah.
We're splurging.
It's girls' night out.
She's turning 30.
Well, you know, after today, I'm on nights for a week, so Yeah.
Don't worry.
I'll make it up to you.
Greg I- I like you.
I really do.
But I just don't think there's a future.
What? I'm looking for a guy who's a little further along in his life.
You're a student.
You live like a student.
I'm not a student.
I'm a Resident.
Listen, Greg, you're great.
But I'm looking for a guy I can get serious with.
An adult.
Hamster bite, itchy eyes.
For Abby, twisted ankle.
Med students, how do you know when to order a film? - Ottawa rules? - Which are? Point tenderness over the lateral or medial malleolus.
What else? Interns, help him out.
- Inability to walk on the scene.
- Or take four steps in the ER.
- Hey, man.
- Vomiting diabetic for you.
Saved the best for you.
Vertigo times six hours.
- Morning.
- This board's a mess.
Sam, the diabetic in Exam 3 needs a D-stick, Chem-7, and an IV.
How will you learn to put in a line with somebody else doing it? - Aren't IV's a nurses' thing? - If you're R2 or below - do your own.
- I can get an IV into a scalp vein.
Good.
Keep your skills up then.
Man has a point.
Today, everybody does their own lines.
I will take this.
I need the practice.
I'm moving on to Surgery.
Why make up arbitrary rules if it's gonna slow us? - Because I can.
- You woke on the wrong side - of the waterbed this morning.
- Yeah, me.
Oh, you have a waterbed? I can't make this schedule.
We don't have enough Attendings.
Hire a few part-timers.
We can barely afford to pay the doctors we already have.
Call CT.
Vertigo guy's gonna need a head with contrast.
- You need an Attending to sign off.
- What? - Residents can't order CT's.
- Since when? We have to cut down on unnecessary CT's - or we have to buy another scanner.
- Well, this is a necessary scan.
You were in there two seconds.
You do a neuro exam? - There could be a cerebellar mass.
- Or an inner-ear infection.
Do the exam and we'll see about your CT.
I've been ordering my own scans since I've been here.
What's that about? - It's about me making the rules.
- Oh, come on.
That's stupid.
Come on, man.
Back me up.
It's her ER.
Sorry, Pratt.
It sucks to be you.
Mr.
Turner, I'm Dr.
Pratt.
How can I help? - Where are my pain meds? - What seems to be the problem? What do you think? I am in pain.
I need pain meds.
Now.
Mr.
Turner, I can't help you until you tell me- Vicodin, morphine, go! Oh, Pratt, you gotta help me.
I've been stuck with a homeless woman named Rocky who says she knows you.
A frequent flyer with a positive review of systems.
Complaints: headache times two years tingling feet, cough, insomnia, intractable emesis, pruritus- - Am I supposed to work this up? - She comes in for company.
Knows what to say to guarantee she'll be here hours.
I can't spend any more time in there.
Her breath is killing me.
Call Social Work.
Have them hold her hand.
Half an hour with Wendall, she'll be cured.
Half hour with Wendall, I'd be cured, know what I mean? Pratt, I'm applying for a Robert Wood Johnson grant to look at the effects of Prevnar on occult bacteremia.
Good luck with that.
Hey, do we have a handout for the local rehab programs? We need to pull charts on kids under 2 who've had a septic workup and record the demographic data on these.
- We? - Fill out my chart review I'll put your name on the paper.
Not into research, don't care about publishing.
You'll be out looking for a job in a couple years staring at a blank page where articles should be listed.
When they hire the guy from Harvard who's got a five-page CV and published three books during his Residency you'll look back and wish you'd stepped up.
Actually, I'm writing something right now.
It's about the abuse of power by Attendings in a county hospital system.
I need these back in a week.
I use the ABCD mnemonic: Airway, bones, cardiac, diaphragm.
And then you look at the lung fields.
Is the problem that I'm a student? Or that I'm your student? Looking for infiltrates, opacity, vascularity, pneumothorax.
- I'm just trying to isolate the issue here.
- We've covered this.
- I'm your supervisor.
- Temporarily.
Your evaluation form is sitting in my box right now.
Okay, 72-year-old female with nausea.
Are you gonna let some false sense of hierarchy get in the way of this? One more word, and I'll flunk you.
Hi, Mrs.
McDow.
Feeling a little queasy? - A little.
- Chest bothering you? I think I'm having heart pangs.
Ever had anything like this before? Sometimes, when I'm walking Ferdinand.
He's a mutt, and I love him.
Pulse is racing.
My husband brought him home from the pound just a few months before he passed away.
I'm sorry to hear that.
What's your plan? O2, aspirin, nitropatch, morphine, Lopressor.
Okay, we'll get you some medication.
That should help with pain.
My student here is going to get you an EKG and check out your heart.
- You're the boss.
- Yes, she is.
Okay.
Say: He's only been at this school a month, already missed five days.
You can close now.
You have a sore throat? How about a stuffy nose? He's quiet.
Said he didn't feel well enough to go to school.
Okay.
Wanna open your ears for me, young man? How long has he had ear tubes? I'm not sure.
He's my husband's kid.
Been living in Detroit with his mom till a month ago.
Mom's doing six months for selling meth.
He had nowhere else to go.
Work.
- What's this? - How'd you do that? Does it hurt? No.
- Culture you asked for.
- Thanks.
Thomas, how'd you get that scratch? Hey, it's okay.
You can tell me what happened.
I don't remember.
Oh, Jane.
I'm applying for a Pharmyxia educational grant.
- Okay.
- I need to give them a current inventory of textbooks and computers.
It'd be a perfect job for a medical student.
- Really? - Yeah.
Take stock of all computers, educational CD's, textbooks anything used for educational purposes, and record them on these.
You poaching my student? Attending scut comes before intern scut.
Sorry.
I missed so much work, I got fired.
So then I'm home sulking all the time, and my boyfriend bailed.
Chronic pain can put a strain on relationships.
- Have you considered-? - Counseling? We've been down that road.
Ms.
Slattery, here's your note for work.
I've signed your discharge.
- You are all set.
- I don't know why I bother.
There are pain clinics, support groups- You people always give the same useless advice.
Therapy, support groups.
I've tried that.
I've tried everything.
Nothing helps.
I told you I didn't need Social Work.
- Hang in there.
We're all done here.
- Good luck.
- What was that about? - It's back pain.
You heard her.
You called me to see a patient who doesn't want my help? She needed someone to complain to, I needed to do work.
- I'm not a babysitter.
- Need you to talk to a kid in Exam 3.
Has a gash on his chest - won't tell me how it got there.
- See? A real consult.
- Thirty-seven-year-old GSW to chest.
- You ready? - Just get started.
- We should go together.
- His name's Thomas.
- Tachy at 114, BP, 135/80, sats, 92 - on a high-flow mask.
- Mr.
Lysander, I'm Dr.
Kovac.
Ly- Lysander's my first name.
Lysander Martin.
- Interesting name.
- It's from Shakespeare.
My mom wanted to name me after a romantic hero.
- Okay.
- She got it wrong.
- One, two, three.
- Decreased breath sounds on the right.
- Always wanted to ride in an ambulance.
- He needs a tube.
Got the Trauma page.
Hi.
I'm Dr.
Dubenko, Trauma surgeon.
So many doctors.
You all here for me? Thirty-seven-year-old with single GSW to the chest.
Lysander Martin was shot.
Lysander Martin was gunned down.
- I don't believe it.
- This guy's a talker.
- No kidding.
- Wound looks through and through.
I don't even feel the pain.
Is that like the endorphins or something? Hello, doctors.
He's decreased on the right, needs a chest tube.
- Is this Lysander Martin? - Yeah.
Need to put that mask on.
What's that for? He's being charged with assault.
Nobody's gonna be mad at you.
- Right? - Of course not.
All done.
You can talk to us, you know? It's okay.
You're safe here.
I was climbing a fence at school.
I slipped on the top.
So you got this cut from a fence? It's the wire kind with the sharp things sticking out.
I didn't wanna say because I ripped my shirt.
It was Casey's.
- Great, Thomas.
- It's okay.
I don't care.
I'd like a couple minutes with Thomas alone if that's all right.
It's just a scratch.
Is that absolutely necessary? They'll kill me at work if I don't show up.
You can't go until his rapid strep's back.
Cardiac unit.
Excuse me.
I'll be right back.
She's got right bundle branch.
That's pretty common.
I have that too.
I also have an aberrant reentrant conductance pathway.
- That explains a lot.
- Yeah.
My EKG's kind of wild.
I assume you want another 12-lead? Yes.
Thank you.
There are a few findings on your EKG that are consistent with ischemia which means that your heart muscle isn't getting enough blood.
- That can't be good.
- We'll- We'll check another EKG.
We'll see if they've progressed.
Thank you, dear.
And I'll be back.
Abby, I'm asking all Residents to keep a tally of time spent on paper charting.
You switching to an automated system? If we get the money.
Keep track of start and stop times on your documentation.
Could you ask the house staff to fill out forms, and collect surveys when you're done? Thank you.
What's the time survey about? I'm applying for an informatics grant from Genadon.
Genadon Pharmaceuticals? Yes.
Why? Residents should be treating patients not doing free research for drug companies.
Maybe they'd be able to if someone hadn't spilled their guts on television.
- I was right.
- You know, the makers of Zarictal give this hospital over $50,000 in educational grants.
That's money for computers, conferences, support staff.
I can't count on that now.
Gonna go to another drug company? Can't we be more creative than that? The county health system's bleeding.
Unrestricted grants from pharmaceutical companies pay.
There's no such thing as unrestricted grants from pharmaceutical companies.
The fact that we rely on that money is a serious conflict of interest.
Yeah.
And I never thought I'd be kissing corporate ass when I went to school.
Welcome to adulthood.
- We owe our patients.
- To keep our doors open.
- It compromises independence.
- Know what? Most of us had to make compromises to get through med school and Residency.
That's probably a foreign concept to someone who's never had to worry about money in their life.
It must be nice.
Little pressure here.
- And I'm in.
- Sats up to 98.
Nice, Pratt.
Morrison's looks good.
No fluid.
You haven't told us how you got shot, Mr.
Martin.
Lysander, please.
Call me Lysander.
Midsummer Night's Dream.
Spends the play being pushed around by Puck.
Puck is evil.
- O silk.
- Why are you looking in the abdomen? - Injury's in the chest.
- Bullet could have ricocheted.
- Nipples to navel, no man's land.
- I've always hated those ER truisms.
Wounds are aligned, bullet went through man needs a chest tube.
Leave it at that.
- It's done.
- Good.
Oxygen, pain control, ICU next.
- Do I need an operation? - No.
It's not clear yet.
How can you be so sure without looking? - Want to scan the belly? - Yeah.
Call them down.
Why do ER docs radiate the hell out of people instead of trusting your own clinical judgment? I trust my clinical judgment, and I want a CT.
- CT.
That's a cat scan, right? - Yeah.
Scanner's down.
Could be a couple of hours.
- Good.
- If the bullet nicked the bowel he doesn't have hours.
Needs an ex-lap.
Let the surgeons decide who needs the surgery.
- Are these guys fighting over me? - Come on, Kovac.
Let it go.
He's my patient.
Okay.
Vitals Q hour, chest tube to suction, morphine, PRN.
There.
He's admitted to the Trauma service.
Board him until the bed's ready.
Okay? Now he's my patient.
You can go.
Two small coffees.
I hate when they don't leave room for the milk.
If we missed that intestinal injury, he will get septic and die.
Why does Dubenko think he can act like that to the ER staff? Hubris? I love that word.
- And one more sugar, please.
- Sure.
- He doesn't get to you? - Dr.
Hair? I think he's kind of cute.
What? Surgery and ER have these battles in every hospital I've ever worked in.
It's not personal.
Surgeons have to believe they're better and smarter than everyone else.
It's a defense mechanism to make up for their terrible lifestyle.
- The guy needs an ex-lap.
- It's a pissing match, Luka.
Let it go.
Come on.
You're taller and sexier.
And you already got the girl.
- This isn't about ego.
- Oh, it's not? Nineteen-year-old.
Arrow to abdomen.
- It hurts! - What's your name? - His name's Dan.
- Airway's fine, tachy to 130.
- BP, 99/50.
Four of MS.
- Need a little help.
- I need more of that stuff.
- Hang in there.
We're gonna fix you up.
- What happened? - They made me balance an apple on my head while they took shots.
- Who did? - The DKE brothers.
I'm a pledge.
It's a hazing stunt? Said the arrow had a plastic tip, couldn't hurt me.
They were wrong.
We actually didn't think he'd let us do it.
God, I'm glad I'm not a guy.
All right, here's your note for school.
- Thank you.
- No more climbing fences till you're double digits, okay? Keep the wound dry until it's scabbed over.
- Thank you, doctor.
- Anytime.
- Can you hold on? - We really need to go.
No, I- Just one minute.
I wasn't done.
I asked you to find out what happened.
You did.
If you call me to consult wait for my assessment before releasing him.
Your assessment was that the injury was consistent with the story.
- What's the problem? - I haven't completed my evaluation.
- I can't sign off until I interview him.
- I don't need you to sign off.
I got a 16-year-old girl with abdominal pain.
Can you do the sexual history? She'd rather talk to a woman.
I am sick and tired of you all using Social Work as a crutch when your patient smells bad or you don't wanna spend time with them.
Actually, she smells kind of good.
Thanks.
You should page me before you discharge.
Which is it? We're calling you too often or not enough? If I don't leave now, I may lose my job.
Don't worry about it.
You're all set.
When are you gonna take this thing out? It's not safe doing it here.
We'll do it up in the OR.
Dubenko's on his way.
He's got no veins.
- I'm not having luck either.
- On the feet? Set up for a central line.
Ray, let's tube him.
- All right.
- Sterile sixes to Jane.
Jake said you were cool like that.
- Like what? - Letting med students do procedures.
- That's how he sold me on the switch.
- What switch? - Anyone reached my mom? - We're working on it.
He's swapping his remaining shifts with me so he can do nights with Neela supervising.
We'll put a breathing tube down your throat for the OR.
When you wake up, this thing will be out, and you'll be all fixed up, okay? - Eighteen gauge in dorsal arch.
- Twenty etomidate, 100 of sux.
He wants to get a sense of how other interns do things.
Oh, systolic's down to 62.
Abby, why don't you go next door and get the rapid infuser.
Flush the line with saline.
I'll be back.
- Etomidate is in.
- Okay, suction.
We hardly ever do DPL's anymore.
- Yeah.
Because CT makes us lazy.
- It's archaic.
DPL has a higher sensitivity with occult intra-abdominal injury.
Dubenko doesn't want us near this guy.
Well, it's safe, it's faster, and it's indicated in penetrating thoracic injury.
- Lower thoracic injury.
- Is there always this much debate? - Only with the really important stuff.
- Cool.
- I'm stealing your rapid infuser.
- Send Jane in.
She should see this.
Okay, we're gonna put a small catheter into your belly.
We're gonna run a liter of saline in and out.
If the fluid comes back clear, you're good.
If there's any blood, you're gonna need the OR.
- Makes sense to me.
- He's not our patient.
Dubenko's gonna freak out.
- Hey.
- Hey.
The kid with the arrow in his belly went up to the OR.
That's good.
I was never in a fraternity.
Boy - What? - I said I was never in a- Look, I'm sorry.
Maybe sometimes I'm not the best team player.
I have so many balls in the air.
I'm sorry I took it out on you.
It was a lot easier being a Resident.
Attendings made tough calls, protected us from all that administrative crap.
Didn't seem like that at the time.
Students wanna be Residents.
Residents wanna be Attendings.
Yup.
And Attendings just wanna be left alone.
I'm not doing any more consults down here today.
- Why? Who's covering? - No one.
The ER's blacklisted.
What? They all brag about the ER's multidisciplinary approach but doctors only listen to other doctors.
- What happened? - Have the Residents call a candy striper if they need somebody to keep their patients company today.
Okay, grasp the fascia with the towel clips and pull up.
- Are you a student? - No.
She is.
Now just pop the angiocath through to the peritoneal cavity and aspirate as you go.
Want me to hold the clamps while you do that? No.
I've got it.
- How long have you been a doctor? - Three years.
I'm in.
- Nothing back.
- I've worked at the same place for the last 14.
Extend with the scalpel and thread in your tubing.
Dr.
Kovac, urosepsis guy is coding.
Morris is in there alone.
Okay.
Dump in a warm liter of saline and let gravity pull it back out.
It takes about 20 minutes.
- And if Dubenko sees this? - Call me.
- You want me to go with him? - Yeah.
He seems like a cool boss.
He's one of them.
I have a bunch.
I've had the same one for the whole time.
Jack Meegly.
He's a year younger than I am, and he's made me call him Mr.
Meegly.
Sounds like a jerk.
Last night, I had my crew rearrange this display so that the cell phones were separated from the CD's.
This morning, he came by, and he made me change it all back.
I don't have the authority to change the displays in my own damn department.
It sucks to be the middleman.
For the last 14 years, I've been working holidays and covering his ass while he cheats on his wife with the girls in Cosmetics.
Two hundred cc's in.
Today, I had enough.
I went to the firearms section I took a gun out of the case I grabbed some bullets, I went into Meegly's office, and I fired into the air.
You're kidding.
I didn't wanna hurt him.
I was just mad.
That explains the handcuffs and your friend outside.
So, what happened next? He was calm.
He grabbed the gun out of my hands.
And then he He shot you? Story of my life.
Damn.
Thought I had it bad.
Sorry for the delay, Mr.
Martin.
ICU should have a bed in- Well, Dr.
Pratt, what are you doing? - A DPL.
- Yeah, I see.
Well, why stop there? Get sterile, Pratt.
- We're going in.
- What? - Scrub up, you assist.
- He's not serious.
You guys are so sure he needs an ex-lap, let's open him up right here.
Let's go.
I'm not really getting surgery, am I? Oh, no.
I was just making a point.
Where's Kovac? - Sam's out looking for him.
- Quick, friendly tip of advice.
Next time you're caught between a surgeon and anyone else - listen to the surgeon.
- How about this time? He's gotta finish what he started.
Gravity's gonna pull the fluid into the bag.
If it's red, we know you're bleeding.
ER docs convince yourselves of the worst possible diagnosis then radiate, bleed and bludgeon to prove you're right.
Dr.
Kovac is always on us to avoid unnecessary tests.
So obsessed with the dramatic save that you fail to develop any finesse.
- Finesse? - Sledgehammers and carpet-bombing where discretion and restraint are required.
He wouldn't push a procedure if he didn't think we'd find something.
Kovac has you doing a procedure on somebody's patient- You have something to say, say it to me, not my Resident.
You and I should discuss it in the hallway.
- No, we can discuss it right here.
- Very well.
My patient is fully aware that you and your Resident ignored my instructions and proceeded with this test.
- It's okay.
- After years of taking care of the cases that you guys blow off, I've learned to develop intuition.
Your intuitive approach is very sweet, but I practice evidence-based medicine.
Okay? Let's look at the evidence, shall we? - It's pink.
Does that mean I'm bleeding? - No.
May I? Last vitals.
Seventy-two, 18, 114/66.
Note, I am reading this through the fluid.
- How does that correlate to cell count? - Ten thousand RBC's, tops.
- Is that bad? - It's nothing.
Tablespoon of blood.
- Probably from Dr.
Pratt's incision.
- You don't know that.
Should we get another doctor? Like a tiebreaker or something? - Maybe break the tie? - Look, if he was bleeding we'd be looking at tomato juice, not pink lemonade.
He could have a small tear that's intermittently oozing.
I'm getting very tired of this game.
And since I can't trust you to stay away from my patient I'm going to go and find him a bed myself.
He's not mad at me, is he? A blocked blood vessel deprived your heart of oxygen which caused the abnormal rhythm.
That's why you passed out.
The cardiologist will thread a catheter through your groin into your heart and unblock the vessel.
- Will it hurt? - No.
You'll be sedated.
Curtain B is open.
Is there any family you'd like us to call for you? My- My son lives in Seattle.
Got any friends who could come be with you? No.
It's just me and my dog now.
I'll tell you what, Gertie.
My shift is almost over, and I love the cath lab.
I'm gonna come hang out with you while they do your procedure.
You wanna stay with me? Listen, I'll be quiet.
I'm not gonna bug you.
Privacy, please.
I need to do my assessment.
That was nice of you.
I wasn't lying.
I really do like the cath lab.
Hey, listen you did a great job on your rotation.
I probably should've mentioned that sooner.
- Thank you.
- And I want you to know Just let me know if you need any help down the line.
- Sure.
- And I think it's good that you switched to have some shifts with Neela.
She's very smart.
And I- I- It's good to have variety.
Abby, I was wondering about something.
Yeah? Do you think Gertie's blockage is in the circumflex or the LAD? You know, the next time you decide to start a turf war with Dubenko do me a favor, leave me out of it.
This isn't about power, it's about the patient.
But he's seen hundreds of GSW's.
What makes you so sure you're right? If you have a strong gut feeling about something, you have to listen to it.
- Come on, we were wrong.
- We don't know that yet.
Made us look like fools.
- Is that what you're worried about? - What? Nothing will get a doctor into bigger trouble than the fear of looking stupid.
Trust me.
So you're on nights for the rest of the rotation? Yeah.
- I guess this is it.
I'm on days.
- It's too bad.
- Okay, bye.
- Bye.
Abby, I'm sure Neela's a good doctor but that's not why I switched shifts.
- No? - No.
I switched shifts so that after today, I would no longer be your student.
So tonight, I want you to fill out that evaluation seal the envelope and turn it in.
Because tomorrow night - you and me, we're going out.
- No, we're not.
- Yes, we are.
- No, we're not.
- Yeah.
- No, we're not.
You ever think about Surgery? You seem the type.
No.
A month in the Death Star's enough for me.
- Death Star? - Surgical ICU.
Pratt, excessive yawning a sign of something? Yeah.
Sleepiness.
Well, Lysander doesn't seem sleepy.
He seems kind of wired.
- He's yawning? - Yeah, a lot.
Detective Burowski's been waiting two hours.
Can we go in? Not yet.
Call Dubenko.
- Are you the mom? - Teacher's aide.
He's in after-school daycare.
Found him like this.
- Rounds of epi? - Three.
No pulse.
- Carter.
Full arrest on a schoolyard.
- Injuries to the head, chest, abdomen.
- Okay.
Trauma 2.
- Somebody page Wendall.
- Why? - She and Pratt saw this kid today.
- What are you doing? - Just give me a minute, you'll see.
- You okay like that? - Well, I'm sliding a little bit.
- Maybe this will help.
- Can I make a call? - Sure.
What's the number? -555-0198.
Thanks.
What is this, Medieval Torture Day in the ER? Nurse noticed frequent yawning in an alert patient.
- You got 30 seconds.
- Could be a sign - of diaphragmatic injury.
- You're kidding me.
- It's a theory.
- Hard to prove but wouldn't necessarily show up on the DPL.
- You've reached Jack and Sally's house.
- Machine.
I've got a bed for him in the ICU upstairs, okay? Hi, Sally? It's Lysander from Electronics.
Methylene blue in the abdomen should seep through the diaphragmatic tear.
And come out of the chest tube.
I've been shot, and I'm hanging upside down with a tube in my belly and a vacuum cleaner in my chest.
- And in case I don't make it- - You're gonna make it.
I just wanted to let you know that your husband cheats on you and that I love you.
Meegly's wife, well, she works in Appliances.
I met her when she was just a trainee.
Okay.
I want my patient upstairs now.
Blue.
Sam, Chuny's at the blood bank.
We need a nurse in here.
- Coming.
- Okay.
- Hold compressions.
- What can I do? You can work on access.
My God, it's Thomas.
The kid with the chest lac.
- Still P.
E.
A.
Rate, 66.
- All right, resume.
Hematoma, right parietal area.
Ecchymosis and swelling to the right mandible and bilateral maxillae.
- What the hell? - Can't get a pressure.
Who did this? - Found him on the schoolyard.
- Is his mother here? Brother? Bruising and edema to bilateral thighs.
How did this happen? Isn't it funny how you can be so completely sure of a diagnosis then find out you were totally wrong? You should write up the case, Dr.
Pratt.
Think you'll do the surgery laparoscopically or are you gonna go open? Don't know yet.
We'll have to run the bowel.
Think the bullet may have been bouncing around the abdomen? - Know what? It's possible.
- And Dr.
Kovac was right.
Good night, Dr.
Pratt.
Thank you.
I think this has been the best day of my life.
- Hey, Chuny, what's going on in there? - Abused kid.
You don't wanna know.
- You guys need an extra set of hands? - It's Thomas.
- Oh, man! - Hanging the first unit.
- Switch out.
You look tired.
- Just started.
- I should have finished my interview.
- P.
E.
A.
at the scene.
There was a sock shoved down his throat.
How many meds you give him? - Too many.
- How much volume? - Third liter's going in.
- I blew it.
- Wendall - Pace him.
He's oozing from his IV sites.
It's DIC.
Go for cryo and FFP.
No, Pratt.
Anybody got an ETA on the family? Another epi, another atropine, and let's treat the DIC.
Come on, he's a kid, man.
I'm not stopping yet.
- Atropine's in.
- Pratt, you want me to switch in? - Central access.
- It won't change.
Throw in a femoral.
He's got two large-bore IV's with good flow.
- What's the time? - It's 43 minutes.
The family's here.
Why don't you see if they're ready to come in? - How is he? - This is Thomas' dad.
His injuries are very severe.
Do you wanna see him? Sometimes it helps to see how hard the doctors are working.
Casey, go back and sit down.
I don't think he needs to see this.
I wanna be with him.
- I saw them.
- Who? I saw them pull Thomas behind the swings after school today.
Who did you see? They had a thing about his clothes.
I gave him my shirt yesterday, but they still wouldn't leave him alone.
Did they cut him? I tried to get Thomas to tell you.
But they said they'd kill him if he said anything.
He was scared.
Everyone's scared of them.
Casey, tell me who they are.
I promise you'll be safe.
I still have to be in school with them every day.
Who? There's four of them.
They're sixth graders.
- PH is 6.
8.
- Amp of bicarb.
Hold compressions.
Okay, that's it.
Six twenty-five.
Please He's still got a rhythm.
A non-perfusing rhythm with a rate of 28.
We haven't even tried transcutaneous pacing.
Forty-eight minutes of cerebral hypoxia.
- How much fluid did you give him? - Three liters of NS, four of O-neg.
Ten rounds of epi and atropine.
Greg.
No.
He's fixed and dilated, with a pH that's not compatible with life.
Mr.
Bryson, Mrs.
Bryson, I am very sorry.
- Hey.
- Hi.
I was about to put this in your box.
Med-student evaluation.
How's it going with him? He's thorough.
He's got a good fund of knowledge.
That's not what I meant.
And I'm sorry, I didn't get to those time surveys today.
We're so screwed at this point another day doesn't matter.
What's going on? Is Carter's press conference that big a deal? If Keating-Ward pulls funding, others will follow suit.
Drug companies don't wanna associate with a department that overreacts during a post-marketing surveillance.
Well, Admin somehow always finds money to keep us open.
I could lose my job.
Why? You didn't personally run County Health into the ground.
No, but my tenure's up for review, and I'm way short.
They made you department head.
I think you've proved your worth.
The committee's only concern is how much money I bring in.
- That sucks.
- I have to bring in $100,000 a year - to even be in the ballpark.
- There's a quota? We're being pimped out by the university.
You don't bring in the cash, you're out.
Pharmaceutical grants are an easy way to raise a bunch of money fast.
I can't lose my job.
I have Chuck and Cosmo now.
I just talked to the OR.
Lysander had a three-centimeter diaphragmatic laceration.
- Okay.
- You saved his life.
We all miss things, Pratt.
The social worker saw this kid too.
I pulled rank on her.
Attending trumps Resident, Resident trumps intern.
We all trump the social worker.
It's a great system.
Most of the time it works.
- How do you stand it? - What? The responsibility.
- Busy shift? - Oh, the usual.
What about you? What did you do? Tried to sleep, couldn't.
Watched bad TV, ate cereal.
I hate working nights.
Okay, bring it on.
Torticollis in 2 waiting for Benadryl to kick in.
And tinea capitis has a scrip for griseo, but he needs to see an Attending.
- That's it? - I'm out of here.
Anyone wanna go to Ike Ryan's? Luka's working.
Alex is at a sleepover.
I need a drink.
- No, thanks.
I'm exhausted.
- I'm in.
Dr.
Lewis, the inventory of teaching materials you asked for.
Thank you, Jane.
You're the only person who actually did what I asked.
Textbooks and journals are in the front.
Computer stuff is in the back.
Come on out with us.
I'll buy you a drink.
I can't.
There is something you can do for me though.
- Shoot.
- Write me a recommendation? - Okay.
- Way to work it, Jane.
Ray, you coming out with us? Oh, I never drink with Attendings.
It gets too weird.
- The plumber came, the shower's fixed.
- Oh, hallelujah.
I love you.
You owe me 80 bucks.
Ready to sign out? Please don't give me the speech about how we win some and we lose some.
I wasn't going to.
I didn't complete my assessment.
I didn't do my job.
What do you think would have happened-? Please, don't.
Don't what? Try to cheer me up.
I should have saved that kid.
- Can I help you, sir? - No, actually, I'm looking for someone.
What's the name of the party? Really.
I'm good.
Thanks.
- Oh, God! - Oh, no, that's awful.
Hi.
I'm sorry, ladies, I didn't mean to interrupt.
This will take a minute.
Greg? I went to work thinking about what you said.
- What are you doing here? - And I just need to tell you something.
The work that I do, it's as real and as serious as it gets.
Now, I don't know how you define an adult but I assure you, I'm all grown up.
Look, I'm sorry.
I didn't mean to offend you.
I don't know what you're looking for, but I hope you find it.
Good luck.
Abby.
What are you doing here? - Big problem.
- What? You never signed off on my ABG or IV placement.
So you staked out my apartment so I could sign your book? All student-teacher relations have to be wrapped up by tomorrow.
That is very important.
I see.
Sign it.
- How do you know where I live? - Residency office.
They just gave out my address just like that? You could have been anybody.
It's disturbing, really.
They even gave me your phone number too.
Well, I guess they thought you looked like a nice boy.
- I'm not that nice.
- Maybe I should change my number.
Good idea.
Okay.
Well, congratulations, Jake.
Your ER rotation is officially over.
R.
Previously on E.
R.
Yes, I believe the drug ruined her kidney.
You're alleging potential slander that could cost the hospital millions in support.
Abby, he's all yours today.
- Who? - Hey.
- Nothing's gonna happen.
- Why is that? - You're my student.
- Welcome, roomie.
God, I'm gonna regret this.
If we wanna make our patients happier, we need to teach our residents - to connect with them better.
- You might wanna start with Pratt.
- I'm not an intern, okay? - So stop acting like one.
E.
R.
11x13 "MIDDLEMAN" No more hot water.
Sorry about that.
I should have warned you.
- Building needs a bigger water heater.
- God, I'm freezing.
Let me see what I can do about that.
Come on in here.
How about we call in sick? I'm arguing a motion today.
It's my first time in front of this judge.
Well, let's just try to hook up after my shift, then.
I can't.
I'm going to a friend's birthday dinner at Dandelion.
Dandelion.
- Pretty swank.
- Yeah.
We're splurging.
It's girls' night out.
She's turning 30.
Well, you know, after today, I'm on nights for a week, so Yeah.
Don't worry.
I'll make it up to you.
Greg I- I like you.
I really do.
But I just don't think there's a future.
What? I'm looking for a guy who's a little further along in his life.
You're a student.
You live like a student.
I'm not a student.
I'm a Resident.
Listen, Greg, you're great.
But I'm looking for a guy I can get serious with.
An adult.
Hamster bite, itchy eyes.
For Abby, twisted ankle.
Med students, how do you know when to order a film? - Ottawa rules? - Which are? Point tenderness over the lateral or medial malleolus.
What else? Interns, help him out.
- Inability to walk on the scene.
- Or take four steps in the ER.
- Hey, man.
- Vomiting diabetic for you.
Saved the best for you.
Vertigo times six hours.
- Morning.
- This board's a mess.
Sam, the diabetic in Exam 3 needs a D-stick, Chem-7, and an IV.
How will you learn to put in a line with somebody else doing it? - Aren't IV's a nurses' thing? - If you're R2 or below - do your own.
- I can get an IV into a scalp vein.
Good.
Keep your skills up then.
Man has a point.
Today, everybody does their own lines.
I will take this.
I need the practice.
I'm moving on to Surgery.
Why make up arbitrary rules if it's gonna slow us? - Because I can.
- You woke on the wrong side - of the waterbed this morning.
- Yeah, me.
Oh, you have a waterbed? I can't make this schedule.
We don't have enough Attendings.
Hire a few part-timers.
We can barely afford to pay the doctors we already have.
Call CT.
Vertigo guy's gonna need a head with contrast.
- You need an Attending to sign off.
- What? - Residents can't order CT's.
- Since when? We have to cut down on unnecessary CT's - or we have to buy another scanner.
- Well, this is a necessary scan.
You were in there two seconds.
You do a neuro exam? - There could be a cerebellar mass.
- Or an inner-ear infection.
Do the exam and we'll see about your CT.
I've been ordering my own scans since I've been here.
What's that about? - It's about me making the rules.
- Oh, come on.
That's stupid.
Come on, man.
Back me up.
It's her ER.
Sorry, Pratt.
It sucks to be you.
Mr.
Turner, I'm Dr.
Pratt.
How can I help? - Where are my pain meds? - What seems to be the problem? What do you think? I am in pain.
I need pain meds.
Now.
Mr.
Turner, I can't help you until you tell me- Vicodin, morphine, go! Oh, Pratt, you gotta help me.
I've been stuck with a homeless woman named Rocky who says she knows you.
A frequent flyer with a positive review of systems.
Complaints: headache times two years tingling feet, cough, insomnia, intractable emesis, pruritus- - Am I supposed to work this up? - She comes in for company.
Knows what to say to guarantee she'll be here hours.
I can't spend any more time in there.
Her breath is killing me.
Call Social Work.
Have them hold her hand.
Half an hour with Wendall, she'll be cured.
Half hour with Wendall, I'd be cured, know what I mean? Pratt, I'm applying for a Robert Wood Johnson grant to look at the effects of Prevnar on occult bacteremia.
Good luck with that.
Hey, do we have a handout for the local rehab programs? We need to pull charts on kids under 2 who've had a septic workup and record the demographic data on these.
- We? - Fill out my chart review I'll put your name on the paper.
Not into research, don't care about publishing.
You'll be out looking for a job in a couple years staring at a blank page where articles should be listed.
When they hire the guy from Harvard who's got a five-page CV and published three books during his Residency you'll look back and wish you'd stepped up.
Actually, I'm writing something right now.
It's about the abuse of power by Attendings in a county hospital system.
I need these back in a week.
I use the ABCD mnemonic: Airway, bones, cardiac, diaphragm.
And then you look at the lung fields.
Is the problem that I'm a student? Or that I'm your student? Looking for infiltrates, opacity, vascularity, pneumothorax.
- I'm just trying to isolate the issue here.
- We've covered this.
- I'm your supervisor.
- Temporarily.
Your evaluation form is sitting in my box right now.
Okay, 72-year-old female with nausea.
Are you gonna let some false sense of hierarchy get in the way of this? One more word, and I'll flunk you.
Hi, Mrs.
McDow.
Feeling a little queasy? - A little.
- Chest bothering you? I think I'm having heart pangs.
Ever had anything like this before? Sometimes, when I'm walking Ferdinand.
He's a mutt, and I love him.
Pulse is racing.
My husband brought him home from the pound just a few months before he passed away.
I'm sorry to hear that.
What's your plan? O2, aspirin, nitropatch, morphine, Lopressor.
Okay, we'll get you some medication.
That should help with pain.
My student here is going to get you an EKG and check out your heart.
- You're the boss.
- Yes, she is.
Okay.
Say: He's only been at this school a month, already missed five days.
You can close now.
You have a sore throat? How about a stuffy nose? He's quiet.
Said he didn't feel well enough to go to school.
Okay.
Wanna open your ears for me, young man? How long has he had ear tubes? I'm not sure.
He's my husband's kid.
Been living in Detroit with his mom till a month ago.
Mom's doing six months for selling meth.
He had nowhere else to go.
Work.
- What's this? - How'd you do that? Does it hurt? No.
- Culture you asked for.
- Thanks.
Thomas, how'd you get that scratch? Hey, it's okay.
You can tell me what happened.
I don't remember.
Oh, Jane.
I'm applying for a Pharmyxia educational grant.
- Okay.
- I need to give them a current inventory of textbooks and computers.
It'd be a perfect job for a medical student.
- Really? - Yeah.
Take stock of all computers, educational CD's, textbooks anything used for educational purposes, and record them on these.
You poaching my student? Attending scut comes before intern scut.
Sorry.
I missed so much work, I got fired.
So then I'm home sulking all the time, and my boyfriend bailed.
Chronic pain can put a strain on relationships.
- Have you considered-? - Counseling? We've been down that road.
Ms.
Slattery, here's your note for work.
I've signed your discharge.
- You are all set.
- I don't know why I bother.
There are pain clinics, support groups- You people always give the same useless advice.
Therapy, support groups.
I've tried that.
I've tried everything.
Nothing helps.
I told you I didn't need Social Work.
- Hang in there.
We're all done here.
- Good luck.
- What was that about? - It's back pain.
You heard her.
You called me to see a patient who doesn't want my help? She needed someone to complain to, I needed to do work.
- I'm not a babysitter.
- Need you to talk to a kid in Exam 3.
Has a gash on his chest - won't tell me how it got there.
- See? A real consult.
- Thirty-seven-year-old GSW to chest.
- You ready? - Just get started.
- We should go together.
- His name's Thomas.
- Tachy at 114, BP, 135/80, sats, 92 - on a high-flow mask.
- Mr.
Lysander, I'm Dr.
Kovac.
Ly- Lysander's my first name.
Lysander Martin.
- Interesting name.
- It's from Shakespeare.
My mom wanted to name me after a romantic hero.
- Okay.
- She got it wrong.
- One, two, three.
- Decreased breath sounds on the right.
- Always wanted to ride in an ambulance.
- He needs a tube.
Got the Trauma page.
Hi.
I'm Dr.
Dubenko, Trauma surgeon.
So many doctors.
You all here for me? Thirty-seven-year-old with single GSW to the chest.
Lysander Martin was shot.
Lysander Martin was gunned down.
- I don't believe it.
- This guy's a talker.
- No kidding.
- Wound looks through and through.
I don't even feel the pain.
Is that like the endorphins or something? Hello, doctors.
He's decreased on the right, needs a chest tube.
- Is this Lysander Martin? - Yeah.
Need to put that mask on.
What's that for? He's being charged with assault.
Nobody's gonna be mad at you.
- Right? - Of course not.
All done.
You can talk to us, you know? It's okay.
You're safe here.
I was climbing a fence at school.
I slipped on the top.
So you got this cut from a fence? It's the wire kind with the sharp things sticking out.
I didn't wanna say because I ripped my shirt.
It was Casey's.
- Great, Thomas.
- It's okay.
I don't care.
I'd like a couple minutes with Thomas alone if that's all right.
It's just a scratch.
Is that absolutely necessary? They'll kill me at work if I don't show up.
You can't go until his rapid strep's back.
Cardiac unit.
Excuse me.
I'll be right back.
She's got right bundle branch.
That's pretty common.
I have that too.
I also have an aberrant reentrant conductance pathway.
- That explains a lot.
- Yeah.
My EKG's kind of wild.
I assume you want another 12-lead? Yes.
Thank you.
There are a few findings on your EKG that are consistent with ischemia which means that your heart muscle isn't getting enough blood.
- That can't be good.
- We'll- We'll check another EKG.
We'll see if they've progressed.
Thank you, dear.
And I'll be back.
Abby, I'm asking all Residents to keep a tally of time spent on paper charting.
You switching to an automated system? If we get the money.
Keep track of start and stop times on your documentation.
Could you ask the house staff to fill out forms, and collect surveys when you're done? Thank you.
What's the time survey about? I'm applying for an informatics grant from Genadon.
Genadon Pharmaceuticals? Yes.
Why? Residents should be treating patients not doing free research for drug companies.
Maybe they'd be able to if someone hadn't spilled their guts on television.
- I was right.
- You know, the makers of Zarictal give this hospital over $50,000 in educational grants.
That's money for computers, conferences, support staff.
I can't count on that now.
Gonna go to another drug company? Can't we be more creative than that? The county health system's bleeding.
Unrestricted grants from pharmaceutical companies pay.
There's no such thing as unrestricted grants from pharmaceutical companies.
The fact that we rely on that money is a serious conflict of interest.
Yeah.
And I never thought I'd be kissing corporate ass when I went to school.
Welcome to adulthood.
- We owe our patients.
- To keep our doors open.
- It compromises independence.
- Know what? Most of us had to make compromises to get through med school and Residency.
That's probably a foreign concept to someone who's never had to worry about money in their life.
It must be nice.
Little pressure here.
- And I'm in.
- Sats up to 98.
Nice, Pratt.
Morrison's looks good.
No fluid.
You haven't told us how you got shot, Mr.
Martin.
Lysander, please.
Call me Lysander.
Midsummer Night's Dream.
Spends the play being pushed around by Puck.
Puck is evil.
- O silk.
- Why are you looking in the abdomen? - Injury's in the chest.
- Bullet could have ricocheted.
- Nipples to navel, no man's land.
- I've always hated those ER truisms.
Wounds are aligned, bullet went through man needs a chest tube.
Leave it at that.
- It's done.
- Good.
Oxygen, pain control, ICU next.
- Do I need an operation? - No.
It's not clear yet.
How can you be so sure without looking? - Want to scan the belly? - Yeah.
Call them down.
Why do ER docs radiate the hell out of people instead of trusting your own clinical judgment? I trust my clinical judgment, and I want a CT.
- CT.
That's a cat scan, right? - Yeah.
Scanner's down.
Could be a couple of hours.
- Good.
- If the bullet nicked the bowel he doesn't have hours.
Needs an ex-lap.
Let the surgeons decide who needs the surgery.
- Are these guys fighting over me? - Come on, Kovac.
Let it go.
He's my patient.
Okay.
Vitals Q hour, chest tube to suction, morphine, PRN.
There.
He's admitted to the Trauma service.
Board him until the bed's ready.
Okay? Now he's my patient.
You can go.
Two small coffees.
I hate when they don't leave room for the milk.
If we missed that intestinal injury, he will get septic and die.
Why does Dubenko think he can act like that to the ER staff? Hubris? I love that word.
- And one more sugar, please.
- Sure.
- He doesn't get to you? - Dr.
Hair? I think he's kind of cute.
What? Surgery and ER have these battles in every hospital I've ever worked in.
It's not personal.
Surgeons have to believe they're better and smarter than everyone else.
It's a defense mechanism to make up for their terrible lifestyle.
- The guy needs an ex-lap.
- It's a pissing match, Luka.
Let it go.
Come on.
You're taller and sexier.
And you already got the girl.
- This isn't about ego.
- Oh, it's not? Nineteen-year-old.
Arrow to abdomen.
- It hurts! - What's your name? - His name's Dan.
- Airway's fine, tachy to 130.
- BP, 99/50.
Four of MS.
- Need a little help.
- I need more of that stuff.
- Hang in there.
We're gonna fix you up.
- What happened? - They made me balance an apple on my head while they took shots.
- Who did? - The DKE brothers.
I'm a pledge.
It's a hazing stunt? Said the arrow had a plastic tip, couldn't hurt me.
They were wrong.
We actually didn't think he'd let us do it.
God, I'm glad I'm not a guy.
All right, here's your note for school.
- Thank you.
- No more climbing fences till you're double digits, okay? Keep the wound dry until it's scabbed over.
- Thank you, doctor.
- Anytime.
- Can you hold on? - We really need to go.
No, I- Just one minute.
I wasn't done.
I asked you to find out what happened.
You did.
If you call me to consult wait for my assessment before releasing him.
Your assessment was that the injury was consistent with the story.
- What's the problem? - I haven't completed my evaluation.
- I can't sign off until I interview him.
- I don't need you to sign off.
I got a 16-year-old girl with abdominal pain.
Can you do the sexual history? She'd rather talk to a woman.
I am sick and tired of you all using Social Work as a crutch when your patient smells bad or you don't wanna spend time with them.
Actually, she smells kind of good.
Thanks.
You should page me before you discharge.
Which is it? We're calling you too often or not enough? If I don't leave now, I may lose my job.
Don't worry about it.
You're all set.
When are you gonna take this thing out? It's not safe doing it here.
We'll do it up in the OR.
Dubenko's on his way.
He's got no veins.
- I'm not having luck either.
- On the feet? Set up for a central line.
Ray, let's tube him.
- All right.
- Sterile sixes to Jane.
Jake said you were cool like that.
- Like what? - Letting med students do procedures.
- That's how he sold me on the switch.
- What switch? - Anyone reached my mom? - We're working on it.
He's swapping his remaining shifts with me so he can do nights with Neela supervising.
We'll put a breathing tube down your throat for the OR.
When you wake up, this thing will be out, and you'll be all fixed up, okay? - Eighteen gauge in dorsal arch.
- Twenty etomidate, 100 of sux.
He wants to get a sense of how other interns do things.
Oh, systolic's down to 62.
Abby, why don't you go next door and get the rapid infuser.
Flush the line with saline.
I'll be back.
- Etomidate is in.
- Okay, suction.
We hardly ever do DPL's anymore.
- Yeah.
Because CT makes us lazy.
- It's archaic.
DPL has a higher sensitivity with occult intra-abdominal injury.
Dubenko doesn't want us near this guy.
Well, it's safe, it's faster, and it's indicated in penetrating thoracic injury.
- Lower thoracic injury.
- Is there always this much debate? - Only with the really important stuff.
- Cool.
- I'm stealing your rapid infuser.
- Send Jane in.
She should see this.
Okay, we're gonna put a small catheter into your belly.
We're gonna run a liter of saline in and out.
If the fluid comes back clear, you're good.
If there's any blood, you're gonna need the OR.
- Makes sense to me.
- He's not our patient.
Dubenko's gonna freak out.
- Hey.
- Hey.
The kid with the arrow in his belly went up to the OR.
That's good.
I was never in a fraternity.
Boy - What? - I said I was never in a- Look, I'm sorry.
Maybe sometimes I'm not the best team player.
I have so many balls in the air.
I'm sorry I took it out on you.
It was a lot easier being a Resident.
Attendings made tough calls, protected us from all that administrative crap.
Didn't seem like that at the time.
Students wanna be Residents.
Residents wanna be Attendings.
Yup.
And Attendings just wanna be left alone.
I'm not doing any more consults down here today.
- Why? Who's covering? - No one.
The ER's blacklisted.
What? They all brag about the ER's multidisciplinary approach but doctors only listen to other doctors.
- What happened? - Have the Residents call a candy striper if they need somebody to keep their patients company today.
Okay, grasp the fascia with the towel clips and pull up.
- Are you a student? - No.
She is.
Now just pop the angiocath through to the peritoneal cavity and aspirate as you go.
Want me to hold the clamps while you do that? No.
I've got it.
- How long have you been a doctor? - Three years.
I'm in.
- Nothing back.
- I've worked at the same place for the last 14.
Extend with the scalpel and thread in your tubing.
Dr.
Kovac, urosepsis guy is coding.
Morris is in there alone.
Okay.
Dump in a warm liter of saline and let gravity pull it back out.
It takes about 20 minutes.
- And if Dubenko sees this? - Call me.
- You want me to go with him? - Yeah.
He seems like a cool boss.
He's one of them.
I have a bunch.
I've had the same one for the whole time.
Jack Meegly.
He's a year younger than I am, and he's made me call him Mr.
Meegly.
Sounds like a jerk.
Last night, I had my crew rearrange this display so that the cell phones were separated from the CD's.
This morning, he came by, and he made me change it all back.
I don't have the authority to change the displays in my own damn department.
It sucks to be the middleman.
For the last 14 years, I've been working holidays and covering his ass while he cheats on his wife with the girls in Cosmetics.
Two hundred cc's in.
Today, I had enough.
I went to the firearms section I took a gun out of the case I grabbed some bullets, I went into Meegly's office, and I fired into the air.
You're kidding.
I didn't wanna hurt him.
I was just mad.
That explains the handcuffs and your friend outside.
So, what happened next? He was calm.
He grabbed the gun out of my hands.
And then he He shot you? Story of my life.
Damn.
Thought I had it bad.
Sorry for the delay, Mr.
Martin.
ICU should have a bed in- Well, Dr.
Pratt, what are you doing? - A DPL.
- Yeah, I see.
Well, why stop there? Get sterile, Pratt.
- We're going in.
- What? - Scrub up, you assist.
- He's not serious.
You guys are so sure he needs an ex-lap, let's open him up right here.
Let's go.
I'm not really getting surgery, am I? Oh, no.
I was just making a point.
Where's Kovac? - Sam's out looking for him.
- Quick, friendly tip of advice.
Next time you're caught between a surgeon and anyone else - listen to the surgeon.
- How about this time? He's gotta finish what he started.
Gravity's gonna pull the fluid into the bag.
If it's red, we know you're bleeding.
ER docs convince yourselves of the worst possible diagnosis then radiate, bleed and bludgeon to prove you're right.
Dr.
Kovac is always on us to avoid unnecessary tests.
So obsessed with the dramatic save that you fail to develop any finesse.
- Finesse? - Sledgehammers and carpet-bombing where discretion and restraint are required.
He wouldn't push a procedure if he didn't think we'd find something.
Kovac has you doing a procedure on somebody's patient- You have something to say, say it to me, not my Resident.
You and I should discuss it in the hallway.
- No, we can discuss it right here.
- Very well.
My patient is fully aware that you and your Resident ignored my instructions and proceeded with this test.
- It's okay.
- After years of taking care of the cases that you guys blow off, I've learned to develop intuition.
Your intuitive approach is very sweet, but I practice evidence-based medicine.
Okay? Let's look at the evidence, shall we? - It's pink.
Does that mean I'm bleeding? - No.
May I? Last vitals.
Seventy-two, 18, 114/66.
Note, I am reading this through the fluid.
- How does that correlate to cell count? - Ten thousand RBC's, tops.
- Is that bad? - It's nothing.
Tablespoon of blood.
- Probably from Dr.
Pratt's incision.
- You don't know that.
Should we get another doctor? Like a tiebreaker or something? - Maybe break the tie? - Look, if he was bleeding we'd be looking at tomato juice, not pink lemonade.
He could have a small tear that's intermittently oozing.
I'm getting very tired of this game.
And since I can't trust you to stay away from my patient I'm going to go and find him a bed myself.
He's not mad at me, is he? A blocked blood vessel deprived your heart of oxygen which caused the abnormal rhythm.
That's why you passed out.
The cardiologist will thread a catheter through your groin into your heart and unblock the vessel.
- Will it hurt? - No.
You'll be sedated.
Curtain B is open.
Is there any family you'd like us to call for you? My- My son lives in Seattle.
Got any friends who could come be with you? No.
It's just me and my dog now.
I'll tell you what, Gertie.
My shift is almost over, and I love the cath lab.
I'm gonna come hang out with you while they do your procedure.
You wanna stay with me? Listen, I'll be quiet.
I'm not gonna bug you.
Privacy, please.
I need to do my assessment.
That was nice of you.
I wasn't lying.
I really do like the cath lab.
Hey, listen you did a great job on your rotation.
I probably should've mentioned that sooner.
- Thank you.
- And I want you to know Just let me know if you need any help down the line.
- Sure.
- And I think it's good that you switched to have some shifts with Neela.
She's very smart.
And I- I- It's good to have variety.
Abby, I was wondering about something.
Yeah? Do you think Gertie's blockage is in the circumflex or the LAD? You know, the next time you decide to start a turf war with Dubenko do me a favor, leave me out of it.
This isn't about power, it's about the patient.
But he's seen hundreds of GSW's.
What makes you so sure you're right? If you have a strong gut feeling about something, you have to listen to it.
- Come on, we were wrong.
- We don't know that yet.
Made us look like fools.
- Is that what you're worried about? - What? Nothing will get a doctor into bigger trouble than the fear of looking stupid.
Trust me.
So you're on nights for the rest of the rotation? Yeah.
- I guess this is it.
I'm on days.
- It's too bad.
- Okay, bye.
- Bye.
Abby, I'm sure Neela's a good doctor but that's not why I switched shifts.
- No? - No.
I switched shifts so that after today, I would no longer be your student.
So tonight, I want you to fill out that evaluation seal the envelope and turn it in.
Because tomorrow night - you and me, we're going out.
- No, we're not.
- Yes, we are.
- No, we're not.
- Yeah.
- No, we're not.
You ever think about Surgery? You seem the type.
No.
A month in the Death Star's enough for me.
- Death Star? - Surgical ICU.
Pratt, excessive yawning a sign of something? Yeah.
Sleepiness.
Well, Lysander doesn't seem sleepy.
He seems kind of wired.
- He's yawning? - Yeah, a lot.
Detective Burowski's been waiting two hours.
Can we go in? Not yet.
Call Dubenko.
- Are you the mom? - Teacher's aide.
He's in after-school daycare.
Found him like this.
- Rounds of epi? - Three.
No pulse.
- Carter.
Full arrest on a schoolyard.
- Injuries to the head, chest, abdomen.
- Okay.
Trauma 2.
- Somebody page Wendall.
- Why? - She and Pratt saw this kid today.
- What are you doing? - Just give me a minute, you'll see.
- You okay like that? - Well, I'm sliding a little bit.
- Maybe this will help.
- Can I make a call? - Sure.
What's the number? -555-0198.
Thanks.
What is this, Medieval Torture Day in the ER? Nurse noticed frequent yawning in an alert patient.
- You got 30 seconds.
- Could be a sign - of diaphragmatic injury.
- You're kidding me.
- It's a theory.
- Hard to prove but wouldn't necessarily show up on the DPL.
- You've reached Jack and Sally's house.
- Machine.
I've got a bed for him in the ICU upstairs, okay? Hi, Sally? It's Lysander from Electronics.
Methylene blue in the abdomen should seep through the diaphragmatic tear.
And come out of the chest tube.
I've been shot, and I'm hanging upside down with a tube in my belly and a vacuum cleaner in my chest.
- And in case I don't make it- - You're gonna make it.
I just wanted to let you know that your husband cheats on you and that I love you.
Meegly's wife, well, she works in Appliances.
I met her when she was just a trainee.
Okay.
I want my patient upstairs now.
Blue.
Sam, Chuny's at the blood bank.
We need a nurse in here.
- Coming.
- Okay.
- Hold compressions.
- What can I do? You can work on access.
My God, it's Thomas.
The kid with the chest lac.
- Still P.
E.
A.
Rate, 66.
- All right, resume.
Hematoma, right parietal area.
Ecchymosis and swelling to the right mandible and bilateral maxillae.
- What the hell? - Can't get a pressure.
Who did this? - Found him on the schoolyard.
- Is his mother here? Brother? Bruising and edema to bilateral thighs.
How did this happen? Isn't it funny how you can be so completely sure of a diagnosis then find out you were totally wrong? You should write up the case, Dr.
Pratt.
Think you'll do the surgery laparoscopically or are you gonna go open? Don't know yet.
We'll have to run the bowel.
Think the bullet may have been bouncing around the abdomen? - Know what? It's possible.
- And Dr.
Kovac was right.
Good night, Dr.
Pratt.
Thank you.
I think this has been the best day of my life.
- Hey, Chuny, what's going on in there? - Abused kid.
You don't wanna know.
- You guys need an extra set of hands? - It's Thomas.
- Oh, man! - Hanging the first unit.
- Switch out.
You look tired.
- Just started.
- I should have finished my interview.
- P.
E.
A.
at the scene.
There was a sock shoved down his throat.
How many meds you give him? - Too many.
- How much volume? - Third liter's going in.
- I blew it.
- Wendall - Pace him.
He's oozing from his IV sites.
It's DIC.
Go for cryo and FFP.
No, Pratt.
Anybody got an ETA on the family? Another epi, another atropine, and let's treat the DIC.
Come on, he's a kid, man.
I'm not stopping yet.
- Atropine's in.
- Pratt, you want me to switch in? - Central access.
- It won't change.
Throw in a femoral.
He's got two large-bore IV's with good flow.
- What's the time? - It's 43 minutes.
The family's here.
Why don't you see if they're ready to come in? - How is he? - This is Thomas' dad.
His injuries are very severe.
Do you wanna see him? Sometimes it helps to see how hard the doctors are working.
Casey, go back and sit down.
I don't think he needs to see this.
I wanna be with him.
- I saw them.
- Who? I saw them pull Thomas behind the swings after school today.
Who did you see? They had a thing about his clothes.
I gave him my shirt yesterday, but they still wouldn't leave him alone.
Did they cut him? I tried to get Thomas to tell you.
But they said they'd kill him if he said anything.
He was scared.
Everyone's scared of them.
Casey, tell me who they are.
I promise you'll be safe.
I still have to be in school with them every day.
Who? There's four of them.
They're sixth graders.
- PH is 6.
8.
- Amp of bicarb.
Hold compressions.
Okay, that's it.
Six twenty-five.
Please He's still got a rhythm.
A non-perfusing rhythm with a rate of 28.
We haven't even tried transcutaneous pacing.
Forty-eight minutes of cerebral hypoxia.
- How much fluid did you give him? - Three liters of NS, four of O-neg.
Ten rounds of epi and atropine.
Greg.
No.
He's fixed and dilated, with a pH that's not compatible with life.
Mr.
Bryson, Mrs.
Bryson, I am very sorry.
- Hey.
- Hi.
I was about to put this in your box.
Med-student evaluation.
How's it going with him? He's thorough.
He's got a good fund of knowledge.
That's not what I meant.
And I'm sorry, I didn't get to those time surveys today.
We're so screwed at this point another day doesn't matter.
What's going on? Is Carter's press conference that big a deal? If Keating-Ward pulls funding, others will follow suit.
Drug companies don't wanna associate with a department that overreacts during a post-marketing surveillance.
Well, Admin somehow always finds money to keep us open.
I could lose my job.
Why? You didn't personally run County Health into the ground.
No, but my tenure's up for review, and I'm way short.
They made you department head.
I think you've proved your worth.
The committee's only concern is how much money I bring in.
- That sucks.
- I have to bring in $100,000 a year - to even be in the ballpark.
- There's a quota? We're being pimped out by the university.
You don't bring in the cash, you're out.
Pharmaceutical grants are an easy way to raise a bunch of money fast.
I can't lose my job.
I have Chuck and Cosmo now.
I just talked to the OR.
Lysander had a three-centimeter diaphragmatic laceration.
- Okay.
- You saved his life.
We all miss things, Pratt.
The social worker saw this kid too.
I pulled rank on her.
Attending trumps Resident, Resident trumps intern.
We all trump the social worker.
It's a great system.
Most of the time it works.
- How do you stand it? - What? The responsibility.
- Busy shift? - Oh, the usual.
What about you? What did you do? Tried to sleep, couldn't.
Watched bad TV, ate cereal.
I hate working nights.
Okay, bring it on.
Torticollis in 2 waiting for Benadryl to kick in.
And tinea capitis has a scrip for griseo, but he needs to see an Attending.
- That's it? - I'm out of here.
Anyone wanna go to Ike Ryan's? Luka's working.
Alex is at a sleepover.
I need a drink.
- No, thanks.
I'm exhausted.
- I'm in.
Dr.
Lewis, the inventory of teaching materials you asked for.
Thank you, Jane.
You're the only person who actually did what I asked.
Textbooks and journals are in the front.
Computer stuff is in the back.
Come on out with us.
I'll buy you a drink.
I can't.
There is something you can do for me though.
- Shoot.
- Write me a recommendation? - Okay.
- Way to work it, Jane.
Ray, you coming out with us? Oh, I never drink with Attendings.
It gets too weird.
- The plumber came, the shower's fixed.
- Oh, hallelujah.
I love you.
You owe me 80 bucks.
Ready to sign out? Please don't give me the speech about how we win some and we lose some.
I wasn't going to.
I didn't complete my assessment.
I didn't do my job.
What do you think would have happened-? Please, don't.
Don't what? Try to cheer me up.
I should have saved that kid.
- Can I help you, sir? - No, actually, I'm looking for someone.
What's the name of the party? Really.
I'm good.
Thanks.
- Oh, God! - Oh, no, that's awful.
Hi.
I'm sorry, ladies, I didn't mean to interrupt.
This will take a minute.
Greg? I went to work thinking about what you said.
- What are you doing here? - And I just need to tell you something.
The work that I do, it's as real and as serious as it gets.
Now, I don't know how you define an adult but I assure you, I'm all grown up.
Look, I'm sorry.
I didn't mean to offend you.
I don't know what you're looking for, but I hope you find it.
Good luck.
Abby.
What are you doing here? - Big problem.
- What? You never signed off on my ABG or IV placement.
So you staked out my apartment so I could sign your book? All student-teacher relations have to be wrapped up by tomorrow.
That is very important.
I see.
Sign it.
- How do you know where I live? - Residency office.
They just gave out my address just like that? You could have been anybody.
It's disturbing, really.
They even gave me your phone number too.
Well, I guess they thought you looked like a nice boy.
- I'm not that nice.
- Maybe I should change my number.
Good idea.
Okay.
Well, congratulations, Jake.
Your ER rotation is officially over.