|Transcripts - Forever Dreaming
|01x16 - Disorder
|Page 1 of 1|
|Author:||bunniefuu [ 05/04/16 20:55 ]|
|Post subject:||01x16 - Disorder|
And easy on the CrossFit for a while, okay?
Just cleared Treatment 3. Just got to turn it over.
Man, we're up again already?
Looks like it.
What's going on?
Who are they?
Yeah, they're doing a surprise site survey.
The Joint Commission.
They rate the performance standards of hospitals and certify them.
So far, JCAHO's reports have been positive.
So let's keep it that way.
Stick to protocols and with big smiles.
Dr. Choi, we're gonna need some of your Navy-inspired discipline today.
Sorry, I'm with the paramedics today.
Resident ride along.
And discipline, that a nice way of saying I'm a tight ass?
Oh, yes. Tight.
I didn't say that.
And, uh, getting those docs in line, isn't that? the chief resident's job anyway?
Wonderful, the guy enforcing the rules is the one who's always breaking them.
Good luck with that.
Code One team to the ED.
What do we got?
58-year-old male. "Peeds" versus auto.
GCS 12. Vitals stable.
Gross deformity to the left upper arm.
Right in here.
He's complaining of chest and back pains.
Mr. Clay, can you hear me?
Mr. Clay? On my count.
One, two, three.
Central line and a CVC catheter.
Breath sounds clear bilaterally.
Tenderness in the left chest and thoracic spine. What happened here?
He's walking with his wife on Michigan Avenue.
Suddenly flips out, starts wailing on her.
A couple of Samaritans jumped in to help out.
He takes off right into traffic.
Score one for, uh, karma.
12-lead EKGs, chest X-rays, CT of the chest, abdomen, and pelvis, with recons of the TLS spine.
Leave me... no.
Leave me alone. I'm fine.
Laura Clay. 55-year-old female.
I need to get to my husband.
Whoa, whoa, whoa. Ma'am, ma'am, ma'am.
Heart rate's tachycardic.
This is all my fault.
Look, I blocked my fall with my hand, not my C spine.
I'm neurologically intact.
Technical. Are you a doctor?
Yes, yes, I am.
Honey, I'm here.
Ma'am, stay right there.
I'm right here.
There are too many of them! [crying]
I'm here, my love!
2... I need restraints. 2 of Versed and 5 of Haldol.
There are too many of th...
No, not Haldol!
Quetiapine. He's not abusive.
He has Lewy Body Dementia.
Wait, scratch the Haldol. 25 of quetiapine.
It's all right, my love.
What the hell's Lewy Body?
Debilitating form of dementia.
Alzheimer's meets Parkinson's.
He took a pretty good whack.
He's got a chest bruise, left first rib fracture, proximal humerus fracture.
How are his labs?
It's all good.
Calcium was elevated.
I suspect he'll develop a kidney stone down the road, but it's likely he's had a few before.
Prior heart surgery?
Says it was a quadruple bypass.
Had it done at Northwestern five years ago.
He remembers the details?
Yeah, he's lucid.
Somewhat. All right, EKG is normal, but because of the prior heart surgery, I'm gonna repeat it every few hours.
He's all yours.
Mr. Clay, I'm Dr. Charles. How are you feeling?
My wife, Laura, where is she?
She's being treated right now, but will be in shortly.
I hurt her again, didn't I? [breathing heavily]
This isn't the life she deserves.
Damn, you got the online thing down, huh?
There was a time.
Yeah, what's her name?
Easy. She's taken.
Vicki. Doctor at the VA.
There are so many female paramedics who are gonna be sorry to hear you're off the market.
Couple guys, too.
Well, you let 'em down easy for me.
You sure you gonna be okay back here?
'Cause we can just throw Desmond in the back.
Eh, I'm fine.
Ambo's like the Humvee. You sit where there's room.
Comfort's not a factor.
This day's gonna go by quick then.
Ambo 61, 40-year-old male down in his home.
222 Bromley Avenue.
Some kind of lower extremity insult.
He's in severe pain, possibly trapped.
Copy Main. Ambo 61 responding.
All right, we're on!
It doesn't make any sense.
I've had Boomer since he was a puppy.
He's super loyal. I leave the room for a second, he's looking for me.
I had a dog like that.
He might nip a little, but this was a full-on attack.
In my experience, dogs can be unpredictable.
Even really friendly ones.
Sometimes if a dog's in pain, though, he...
We were playing tug of war, like we always do.
Dog bites shouldn't be stitched.
They need to stay open so the wound doesn't become infected.
Also, I'm gonna give you a tetanus shot and an antibiotic.
Boomer's healthy. He's had all his shots.
It's just a precaution.
[indistinct radio chatter]
Paul's in trouble down there.
Did you call 911?
Yes, I'm his neighbor.
It's the paramedics.
Ooh, that's ripe.
Man, look at this. He's a hoarder.
What do you think?
You good going in there?
Uh, get the truck company here.
Tell 'em they're gonna have to help dig us out, and grab me a second radio.
And, uh, I'm gonna try and go in through the back door.
You got it.
Third squad caught a high-rise fire.
Dispatch is pulling a truck from up north to help us out.
It'll be a while before they get here.
In the beginning, I wanted to think it would pass.
Any wife would, but I'm also a neurologist, and I couldn't ignore his symptoms.
Oh, so you diagnosed the Lewy Body Dementia?
Yes, but I got second and third opinions, and they both agreed it was LBD, and that was about four years ago.
Four years, really?
You know, Nathan expressed deep regret to me about the pain that he's caused you.
That kind of insight is rare for somebody who's been battling LBD for that long.
Well, my husband was an engineer, and his brain is wired to solve problems.
Last year, I retired early.
I wanted to devote more time to his cognitive therapy.
Hmm, well, it's been working.
There's moments when he's lucid.
But more and more, it's this.
Mrs. Clay, Nathan's latest EKG is still normal.
I want to do another one in a few hours, but if it is good too, I'll discharge him.
Thank you, doctor.
I know that it would be better and safer for the both of us if Nathan went to a care facility, but if I do that, then it's over.
And I'm not ready to give up our Sundays listening to opera.
I know it's hard to imagine, but my Nathan is still in there.
Last week he made me dinner, Florentine lasagna.
He can still cook?
Well, meals take longer to prepare than they used to, but... he does it for me.
He's fighting just as hard as I am.
Everything's gonna be okay.
How you doing, Ethan?
Fine, as long as I breathe through my mouth.
Is it as tight in there as I think it is?
Are you claustrophobic?
Didn't used to be.
I mean, and Tate totally snores, but I don't mind.
Oh, he does this thing where he shoots his dirty boxers into the hamper like a buzzer beater.
Anyway, it's cute.
Oh, my God.
You're in love.
Whoa, whoa, whoa, whoa. What's that?
Used gloves go in the bio bin, not the trash.
Okay, those were actually clean though.
They were on the floor.
Probably just got stuck to the pair that came out before them.
Unless you're certain, it's bio.
Come on, Maggie. You know the protocol.
I've also been through this circus about a dozen times.
JCAHO days are about patient care, not about a pair of latex gloves.
Look, I'm already in the doghouse with Goodwin.
If there's any chance of getting out, I want it.
So by the book... by the book.
By the book.
Okay honey, eight across.
It's five letters and the clue is rental agreement, and the first letter is L.
I'm thinking the second is E.
Good. Good, honey.
All right, next one.
We're gonna do 23 down.
The clue is collects...
With an S.
I don't know.
His blood pressure tanked.
All right, bag and hang a liter bolus.
SATS are dropping.
Grab the bag and hook it up to the O2.
All right, 20 of etomidate. 100 of sux.
Let's bring in the FAST scan.
April, give me some pressure.
And I'm in.
Here you go.
Heart rate 110.
All right, belly's clean.
Poor wall motion of the LV and a small effusion.
He's bleeding internally?
Mrs. Clay, please, right over here.
SATS are back up.
It's not gonna matter if he goes into cardiac arrest.
CT of the heart and great vessels.
Let's get him ready to go.
If we may?
The blunt trauma from the car accident displaced one of Nathan's bypass grafts.
His aorta is leaking blood.
Right now it's just a slow drip.
It hasn't ruptured yet.
So there's still an opportunity to operate, repair the suture line, and plug the hole?
Your husband's prior heart bypass surgery significantly increases the difficulty of the operation.
His odds of surviving the procedure plummet.
So if surgery isn't a viable option, what is?
Given the circumstances, we feel the safest choice is to make Nathan comfortable.
We can't be certain.
A day, a week, maybe a few months until the aneurysm ruptures.
We're very sorry.
Help. I can't move.
I'm coming, Paul.
Don't touch that!
What was that?
Ethan, what happened?
Got bit by the lid of a tin can.
Truck company is almost here.
They're going to clear a path to get the stretcher through.
Hold on, Paul!
Oh, thank God.
I haven't been able to pee in over 16 hours.
I thought I was gonna explode.
Brachytherapy for prostate cancer?
Two days ago.
My urologist said it was the way to go.
Who's your urologist?
I'll call and tell them you've experienced a blockage.
Dr. Mason, over at Advocate South.
Uh, contact info's, uh, in my phone in my pants pocket.
Oh, whoa, whoa, whoa, whoa, whoa, whoa.
Just a little spill. I got it.
Okay, hold on.
I'll call environmental services and have them send a janitor.
It's just pee.
I've cleaned it a thousand times.
Yeah, but not with JCAHO and Robocop Halstead on the prowl.
By the book, remember?
I think the seed came out. It's radioactive, right?
Oh, it did.
Okay, I'll call Urology instead.
Cath lab for a cardio angiogram?
Should give a better view of Nathan's pseudo-aneurysm and hopefully help me estimate a timeline for his wife.
You mind grabbing me an MRI of his head while you're up there?
His injuries don't necessitate it.
It's not for him. It's for me.
Uh, Dr. Charles.
Dr. Rhodes, his awareness and gross motor skills are just too strong for somebody who's been battling LBD as long as he has.
No amount of cognitive therapy in the world is gonna outthink this disease to the degree that he appears to be.
Laura and two other neurologists have all agreed on the Lewy Body diagnosis.
You think they're wrong?
I don't know what to think.
That's why I need the scan.
I need the wife's consent.
Hasn't she been through enough?
I'm just trying to spare her some false hope here.
JCAHO day isn't exactly the time to be sneaking in unauthorized tests.
I don't know what to tell you.
What've we got?
Hey, guys, start clearing out!
[indistinct radio chatter]
Don't touch that.
There's a second person.
I'm hearing another victim.
Ethan, the neighbors seem sure it's only Paul in there.
Don't touch that!
There's someone else here.
Dr. Perrington, got a hemoptysis patient.
Chest X-ray says it's a COPD, but I think he needs a bronch.
You want to take a quick look?
The esteemed Dr. Halstead needs my help with a patient.
Look, I, uh... I'm sorry about what happened the other day.
You want a consult, page my resident.
Okay, no redness, no inflammation.
So I can go?
The nurses are working on your discharge paperwork right now.
Your wound should heal in about seven days or so.
Until then, irrigate them and keep them covered.
You all right? Oh, just itchy and a little sweaty.
Mind if I take a look?
Could be an allergic reaction to the antibiotics.
You do feel warm though.
I'll get a temp.
[phone vibrates and chimes]
Oh, my sister checking in.
I left Boomer with her.
She's not a dog person either.
I get the impression they're not for you.
I've treated a lot of dog wounds, especially on kids.
It's 99.4. Was normal at intake.
CBC and CMP?
I'm not out of here, am I?
Itching and fever, even a low one, could be more than an allergic reaction.
Someone will be with you shortly.
Paul, is there anyone else in the house?
No, no, it's just me.
You've got to hurry!
Ethan, what happened?
Are you okay?
[plane flying overhead]
What's all this?
Well, it's pretty clear an attending job at Med isn't gonna happen.
You don't know that.
Just being realistic.
Perrington's on the hiring committee.
She hates me.
Not to mention Goodwin.
But really, Miami, Will?
I've seen you sunburn walking from the ED to your car.
Hey, got to go where the jobs are.
No coffee. JCAHO day.
I don't understand.
There should be atrophy, heavy degeneration, tangled cells in the white matter.
When was this taken?
About an hour ago.
I'm sorry. I had a hunch.
I rushed it. I really should have...
That is a healthy brain.
There's no disease. This means that...
Nathan doesn't have Lewy Body Dementia.
He has the symptoms.
Keeps getting worse. Practically a textbook case.
Take a look at this cross section we took during the MRI.
Notice the adenoma, benign tumor, in the parathyroid gland.
So you think this is all hormonal irregularity?
Elevated parathyroid hormone is consistent with increased calcium and cognitive impairment. Nathan has both.
Yes, but he also has hallucinations, physical aggression. You don't see that in patients with hyperparathyroidism.
That's where his recent bypass surgery makes him unique, okay?
The beta blocker he's been taking ever since causes increased levels of violent behavior in a select amount of patients.
Oh, my God.
A hormonal imbalance with a medication side effect.
Why didn't I see that?
The clues were right in front of me.
Because they mimic the symptoms of Lewy Body Dementia to a T, and four years ago that adenoma would have been so small no scan could have caught it.
Look, I'm just telling you that presented with the same evidence, I would have done exactly the same thing, reached exactly the same diagnosis.
Anybody would have.
And if I had caught the PTH four years ago, Nathan doesn't run into traffic, doesn't get hit by a car.
Today never happens.
He's dying and it's entirely my fault.
Don't touch that!
Help. Please, please anybody!
I need help!
Ethan, talk to me.
Ethan, do you copy?
Living room's clear.
Help me, please.
Paul, I'm Dr. Choi.
Okay, your heart's racing. When's the last time you had any fluids?
My leg, burned it. Yeah.
I see that.
Don't touch that.
How did this happen?
I was cooking.
I tripped and spilled a frying pan, grease.
This didn't just happen.
This burn is thick, leathery.
24 hours old?
Why didn't you seek help sooner?
I didn't want anybody to see how I live.
Okay, I'm here now.
Gonna take care of you.
Yep, doesn't happen often, but it can get expelled in the urine.
So, um, how radioactive is it?
To us, harmless.
Still, don't touch it with your bare hands.
So you're not gonna dispose of it?
Not on JCAHO day.
Call the radiation safety officer.
Here we go.
I get it.
You didn't do Nathan's bypass surgery.
You don't know what you're walking into.
I can get you every angio he had.
You will know exactly where the surgeon placed every suture.
The bigger issues are the adhesions and scar tissue that have formed over the last five years.
We can expose a healthy heart in 10 or 15 minutes.
After a quadruple bypass surgery, it could take hours.
An infinite number of complications can arise.
When I decided to make Nathan comfortable, I believed he had a neurological death sentence.
Now it's a whole new world.
The dementia can be reversed.
I understand, but the fact that he doesn't have LBD doesn't make the surgery any easier.
Nathan's odds of dying in that operating room are just as high as they ever were.
It's still my recommendation to not operate.
I'll do the surgery.
Thank you for giving us a second chance.
Difficult is not impossible.
Brett, how close are you?
Ugh, Ethan, finally.
I'm fine, but Paul's got a serious third degree burn that needs to be released in the ED. ETA?
I think we're almost to the kitchen.
We need more room for the gear.
Don't touch that! Get away, get away.
Who was that?
The other person I heard, a parrot.
Look, you still have the hallway to deal with and Paul's foot's still swelling.
No pulse in the instep or ankle.
All right, uh, we're coming as fast as we can.
[exhales] But not fast enough?
Okay, Paul, here's the deal.
Your skin's so burned, blood can't get in or out of your foot. I'm gonna cut into your leg on both sides of the burn to release the pressure.
I wait any longer, you're gonna lose your foot.
But... is it gonna hurt?
Already pushed morphine in your IV.
But I'll feel it?
Focus on me, not my hands.
It'll be over before you know it.
Deep breath. [inhales]
Then exhale. [exhales]
Keep breathing, Paul. Keep breathing.
Big breath. [inhales]
Bigger exhale. [exhales]
Good job, Paul.
A high white cell count, what does that mean?
You probably have an infection.
Have you felt sick recently?
No, not really.
I mean, every now and then my throat aches a little.
It doesn't really bother me though.
Hmm, the lymph nodes are swollen, consistent with an upper respiratory infection.
Let's get a rapid strep test.
What kind of dog is Boomer?
Boxer bulldog mix.
When I went to the shelter, all the dogs swarmed me, but Boomer hung back.
Not because he was shy.
It was a move so he'd stand out.
He was playing me.
I'm gonna swab the back of your throat.
I'll get this to the lab.
I'm doing what I think is right.
Nathan's mental impairment is due to a pea-sized tumor that is easily removable.
A 45-minute operation will cure him.
But first, he has to survive this monumentally difficult surgery.
I'm sorry, you can't bring your dog into the hospital.
It's my sister's dog.
She's somewhere in the back not answering her texts.
Only service dogs in the ED.
Oh, is this Boomer?
How'd you know?
I've been taking care of Tara.
She said he was a boxer bulldog mix.
I thought it was only gonna be one or two hours.
It's been five. Is she okay?
She spiked a low fever.
We're testing for strep.
That's nothing. Okay, good.
Look, I have to go to work.
There's no pets allowed in my building.
He barks one time and I can get evicted.
I'm sorry, there's nowhere else to take him.
Um, no, no, no. I can't take this...
It all happened really fast.
What do I do?
Get him out of here. Now.
But where do I take...
Reese, I don't care where.
Hey, look at this guy.
Yeah, Earl, this is Boomer.
Could you watch him for a minute?
But don't get too close because...
Oh, come on, fella.
Come on, guy. Let's go.
Come on, big boy.
When I'm out, the city will condemn my home, won't they?
Fresh start, I guess.
Get away. Don't touch that.
Don't touch that.
There they are. Ethan.
Hey, you okay?
For a second there, it sounded like...
Little hairy for a while, that's all.
Escharotomy in the field.
Damn, nice job.
One across. Six letters.
Bread, milk, eggs.
All right, guys.
[indistinct radio chatter]
Got it, clear.
Lift him up.
Don't touch that.
Dr. Manning, uh, Tara's rapid strep came back negative.
Okay, so we're back at square one.
You know what, let's run a, uh...
[snarling] Easy! Easy.
I'm sorry. I am so sorry.
Hey, Earl, what's going on?
I don't know what happened.
Twenty people petted this dog, and this patient is the only one he barked at.
Come on, boy. Come on.
Come on, Boomer. Come on, come on, Boomer.
Let's run an infused CT chest and abdomen on Tara.
Oh, I've heard stories.
Snakes in the grass.
Bypass grafts are buried in the scar tissue, tough to see.
Soften your grip... an... and go slow.
I see it.
Proximal pseudo-aneurysm of the LAD bypass graft.
Let's cannulate and get him on the pump so we can do the repair.
No, I don't need the pump.
It just needs a single repair stitch.
I can do it on the beating heart.
EKG's ischemic. STs elevation.
He's bleeding. 8-0 suture to me.
I've got the better angle.
I pushed for the surgery. I can't lose him.
I'll get you better exposure.
Going to put a second stitch in now.
Don't back-wall the graft.
Bleeding has stopped and EKG's improving.
We're out of the woods.
I want to check his other bypass grafts.
Something goes wrong in the future, no surgeon's gonna open his chest a third time.
I have cancer?
The next step is a biopsy to determine exactly which kind.
But I'm only 26.
I go to the gym every day.
I don't smoke.
It's not fair.
But I don't feel sick.
Well, that's because it was caught early.
You have time to get way ahead of this.
The lymph nodes are around here, aren't they?
Boomer's been nipping at me for a month.
Always right there.
Do you think he knew?
It seems some dogs can smell cancers, even in the very early stages.
Yeah, he wasn't attacking you.
He was trying to protect you.
Maggie, what's going on with Treatment 4?
We don't have the space for this...
I know, I know. It's been all day.
Dr. Halstead, environmental services hasn't shown up yet.
I can't even get an estimate as to when they will.
[sighs] I'll go see them in person.
I'll drag someone down here if I have to.
Knock some heads.
I need that room back.
How's he doing?
How are you doing?
As a neurologist, Lewy Body Dementia was my worst nightmare.
I'd seen so many cases, and I'm wondering if it influenced my diagnosis.
Medicine, you know.
Practiced by human beings, no less.
Four years we could have been doing CTs, but I had an answer, so there was no reason to continue radiating his brain.
I robbed Nathan of his mind.
I imprisoned him.
I drained our savings.
Squandered our time together, time that we can never get back.
How am I gonna tell him what I've done?
He's never gonna forgive me.
Your husband's gonna forgive you, Laura.
I want you to trust me on that.
Your struggle, if I may, is figuring out how you're gonna forgive yourself.
Vitals are stable.
EKG looks good.
Cleveland Clinic has an axiom.
Emergency surgery on a healthy heart?
Redo surgery for a repaired heart?
Emergency surgery for a repaired heart?
No, because overwhelmingly, those patients die on the table.
I couldn't do nothing.
I suspect it was ego more than altruism.
Great surgeons know the balance.
You're confident, not arrogant.
I like that, Dr. Rhodes.
Nice job today.
You're good. You're good.
Don't come from above.
Come from the front so he can see you, and hold out the back of your hand first.
Come on, buddy.
Did you ever hear that origin story about dogs?
In Eden, humans and animals got along, even spoke the same language, but when Adam and Eve sinned and God drove them out, a great chasm opened up between people and animals.
And as the chasm grew wider, at the very last moment, a dog leaped across it to be with us.
[car trunk opening]
That's a great story.
[knocks on door] Come in.
Ms. Goodwin, can I talk to you for a moment?
Quickly, I'm on the homestretch with JCAHO, and I don't want to let up now.
I know my voice isn't official, but I'd like to put in a good word for Will regarding the open ED attending position.
It'd be a shame to lose him.
He's a great doctor.
He cares about this hospital.
Just a few weeks ago you asked to be taken off his shifts.
We don't always see eye to eye, but his heart is in the right place.
Well, Dr. Manning, I'm glad your opinion of Dr. Halstead has changed.
Dr. Halstead, environmental services are on their way?
Turns out, every department in the hospital's calling ES to handle things they normally take care of themselves.
Be tomorrow before a janitor shows up.
There. The room is yours again.
I won't tell if you won't.
Huh, guess that means I get to clean this up now the way I wanted to eight hours ago.
You know, toss me a pair.
You know, the kind that, uh, stick to yours when you pull 'em out.
You want in?
We've come this far.
And they call you Robocop.
Reese, come with me.
Yeah, I've seen that look.
Look, we all know how important JCAHO site visits are.
Yet, despite what I said about the rules, my team ordered tests on the sly, brought a dog into the ED, and handled radioactive material.
Sharon, you have every right to be upset.
Really. But we can't really be ignoring the, uh, the second law of thermodynamics here.
Now, can we?
Well, systems do tend to degenerate into ever more disordered versions of themselves, right?
I mean, look around you.
All we're doing here, all day long, is battle the universe's desire to fall apart.
Yeah, should've seen the house I was in today.
I'm just saying, I love rules.
We all do, but in bringing order to disorder, every now and then a couple gonna get bent.
Nice try, Daniel.
But the good news is JCAHO didn't catch any of you, so we keep our top rating.
I'll see you all tomorrow.
Second law of thermodynamics.
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