02x02 - Middle Ground

(BIRDS CHIRPING)

You're here early.

Trouble sleeping?

No.

Just wanted to get out of my apartment and to work.

We work you plenty hard enough.

Go home.

Making sure you're rested is also part of the job.

I understand.

What should I tell a patient if they don't think they're sick but I think they have pancreatic cancer?

You think one of our patients has pancreatic cancer?

(BURPS)

Seventeen.

He's burped times in minutes.

It's a frequent symptom of pancreatic cancer.

Shaun, it's acid reflux.

He's also jaundiced.

No, he isn't.

Paul's skin is definitely not the same color it was six months ago.

- Paul?

- I looked at his mouth when he was telling me about his daughter.

- She just...

- Walk with me.

(QUIETLY)

Say nothing.

Hey, Shaun.

(NORMAL VOICE)

Do a CVC, CMP, amylase, lipase, CA- levels, and CT abdomen, pelvis pancreatic protocol, and do not tell him why.

You want me to lie?

I don't want you to tell the truth.

The discoloration, if there is any, is very minor.

I don't want you scaring the crap out of the man over nothing.

Excellent.

I've been practicing lying.

I lied to you before when I said I just wanted to get out of my apartment and to work.

Take Claire.

Hello.

I'm Dr. Lim.

How can I help you today...

Asha?

I want plastic surgery.

Sweetheart, this is the Emergency Room.

If you want, I can make an appointment for you...

Well, you do vaginal rejuvenation, right?

Yes...

On much older, much vainer women, generally after having many children.

I don't know what the boys have told you...

Examine me.

Please.

Please take off your underwear.

(SOMBER MUSIC PLAYS)

Were you in an accident?

No.

Can you help me?

- Did your father do this to you?

- No.

- Please just...

- Did your mother...

- I need to know who did this to you.

- No, you don't!

It doesn't matter who...

(INHALES DEEPLY)

When I was years old...

I was...

Tied down, and I was circumcised.

(VOICE BREAKING)

Please.

I'm hideous.

Will you help me?

Yes.

Why do you need to confirm a diagnosis of acid reflux?

Because we're doctors.

It's what we do.

We just like to be sure of everything.

There are a few remote possibilities...

I've got this!

Are you familiar with the hospital employee manual section , subsection C, triple I?

- No.

- Good.

- Good?

- Yes.

It requires that all employees shall be subject to, and I quote, "Any and all possible necessary tests "to confirm any and all diagnoses, "no matter how mundane, the cost of which tests "shall be borne by the hospital," end quote.

The Board wants to make sure that no one is exposed to patients if there is any chance that they have any communicable condition.

I had the flu last week.

Why didn't anybody do anything for me then?

- It's a new policy.

- You might have pancreatic cancer.

What?

What'd he say?

Female genital mutilation is the ritual cutting or removal of some, or all, of the external female genitalia.

Over million victims worldwide.

It is almost universally practiced in a number of African and Asian countries.

Where was she born?

Wisconsin.

(EXHALES DEEPLY)

Yeah, it's way more common here than you think.

- What religion is she?

- I didn't ask.

This isn't about religion.

No legit religious organization endorses this stuff.

We're gonna do the labiaplasty first thing in the morning.

The damage done to her nerves is not going to get undone, nor is the psych damage, but at least she'll look like other girls.

We should be able to have her out of here by : in the evening.

Outpatient?

Why the hurry?

So her mother will simply think she's in school, then out studying with her friends.

She loves her parents and doesn't want to tell them that she's rejecting one of their cultural traditions.

They won't stay in the dark for long, since we're legally obligated to report them.

That "cultural tradition" also fits - the definition of abuse.

- And they'll also find out when we ask for their permission to do this surgery.

She's a minor.

Her ID says she's .

Yes, her fake ID says she's .

Her number starts with an "H," which means she was born in the ' s.

Also, the photo background is green instead of blue.

- Also six other things.

- (SIGHS)

Maybe we can get Legal to get a court order...

If I believe that ID is real, then I am entitled to perform this surgery without seeking consent of anyone other than the patient.

And, as legally required within hours, I will report the evidence of abuse under the name and address listed on that ID.

If the investigation of that report doesn't begin until the girl is long gone and happens to lead nowhere because the name wasn't real, that's no fault of mine.

Are you sure you want to risk your medical license to protect an abusive mother?

If we do this by the book, we never see that girl again and no one gets help.

If we do this by the book, maybe the cops lock the parents up.

We shine a light on this thing, her community gets scared, and maybe the next girl doesn't need our help.

Or maybe the testimony of the girl about what happened to her when she was doesn't help the cops at all.

Maybe the parents just take their daughter home, and maybe we scare the next girl into not even asking for help.

I'm doing the surgery to this girl under this name tomorrow morning at : a.m.

I can't believe people ever lie.

There are so many questions people might ask you, but if you tell the truth, you already know the answers.

And, also, it's wrong.

But sometimes, you shouldn't tell the whole truth?

No.

Of course not.

Because that lets you be honorable and tell the truth and be a good person, but at the same time, you get to completely deceive the person.

- No, I don't think that...

- Lea came back.

Wow, Shaun, that's great.

She's staying with me until she finds her own place.

You must be so excited.

Yes.

You're not excited?

I said, "Yes." Paul has one year to live.

He has pancreatic cancer.

Stage III.

There are no metastatic lesions, but there are - local nodes involved.

- And there's partial encasement of the superior mesenteric artery.

That puts it past the point where we can cure with local resection.

We could do Whipple surgery.

That's not advised for stage III pancreatic cancer.

Not quite.

It's not advised for stage IV.

For stage III, it's discretionary.

- (BOOK THUDS)

- In my discretion, he's better off with semi-comfortable months, rather than running the risk of dying on the table tomorrow.

If he doesn't die on the table, he could have many years.

CLAIRE: It isn't our call to make.

I'll talk to Paul, advise him of the parameters, let him make his own decision.

No.

Shaun should do it.

Claire can do it.

Yes, she can, which is why you should do it.

This is a teaching hospital.

Andrews is right...

Being a surgeon isn't just about cutting.

Would it be okay if we spoke someplace more quiet?

You need someplace quiet to tell me I have acid reflux?

I think we should be someplace quiet because people sometimes get very upset when they find out they probably only have less than a year to live.

Okay, uh...

Can I call my family?

They should probably hear what you have to say, too.

I'd rather just talk to...

Of course you can.

DR. LIM: I'll elevate it with a -inch Ambler tissue hook.

You separate the underlying tissue with iris forceps.

DR. REZNICK: I got it.

Tenotomy scissors.

I think we're actually a little ahead of schedule.

Might be able to get her home in time to do her homework.

Back to the bosom of her loving family.

We'd remove as much of the cancer as possible by removing the head of the pancreas and other attached organs, but then, we'd have to reconstruct the anatomy.

The easiest way to do that is to bring up a loop of jejunum...

Shaun.

Sorry.

The jejunum is part of the small intestine between the duodenum and ileum.

It's complicated, very dangerous surgery.

And even if it's successful, post-operative complications are frequent and serious.

And recovery can be very painful.

But if it works, he's better?

He'll be healthy?

He would still need chemotherapy and a lifetime of monitoring.

But hopefully, a long lifetime.

Let's do it, Dad.

What do you say?

What should I do?

It's your decision.

All we can do is present you with the facts.

Yeah, here are the facts, Dad...

The surgery may kill you.

Not doing the surgery will kill you.

Can you give us a few minutes?

Of course.

(LIQUID POURS)

It was very nice of Dr.

Andrews to give you an office, even though, you're on medical leave.

Yeah, he is a prince.

Who's your surgeon going to be?

I haven't d...

I haven't decided yet.

You should definitely go with Dr.

Joshua Atkinson at Stanford Medical Center.

His mortality index is . .

It's too low.

Not enough of his patients are dying?

No, Shaun, sometimes patients die.

Doesn't matter how good the doctor is.

But when your mortality rate is as low as Atkinson's, it means you're turning away patients.

You turn away patients, it means you lack confidence.

You lack confidence, I don't want you inside my head.

And I'd like to be able to dress myself when I'm all done.

Shaun, what are you doing here?

You showed up at work early this morning.

Go home.

Get some rest.

I won't rest if I go home.

The surgery went great.

Once everything's healed, I think you'll be very happy with the results.

- What time is it?

- Not quite : .

We just need you to pee, and...

I need to go home.

And you will...

very soon.

(EXHALES SHARPLY)

- It hurts.

- I told you it would.

We did a lot of cutting and scraping.

You had a lot of scar tissue.

It hurts a lot.

We'll give you some Tylenol, and you can tell your mother you're cramping.

(GRUNTS)

Ow!

(BREATHING HEAVILY)

Hang ketamine...

micrograms per kilogram per hour.

Why does it hurt this much?

I don't know.

But you're not going home.

Ow!

She's heavily sedated.

What did we do to her?

What if this is good news?

I know you haven't been a doctor all that long, but pain is rarely a sign of good news.

It is if you're talking about a part of the body you thought was dead.

What if this means there's still viable nerve endings in there?

What if this means we can actually reconstruct her clitoris and that it's capable of sensation?

Maybe.

All we know for sure is she's not gonna be home anywhere near : , which means we're about to have a missing child on our hands.

We have to bring Andrews up to speed.

I did a bad job of telling you that you're dying.

Is there a good way?

I can't figure out when I'm supposed to lie, when I'm supposed to tell part of the truth.

And it doesn't really matter, because I can't figure out how to do it anyway.

You did fine with me.

You never need to lie.

Lies don't protect you from the truth.

I don't like your haircut.

(CHUCKLES)

Okay.

Maybe sometimes, when the truth can't help someone...

...you should definitely just lie.

Do you think praying will help you reach a decision?

I've already reached a decision.

I'm praying to help me find comfort with that decision.

My family wants the surgery.

And what do you want?

I want what my family wants.

I love them.

But they love you, too, right?

Don't they want what you want?

Long ago, I made a decision to be there for them no matter what.

And if the last choice I make in my life is consistent with that, I'm comfortable with that.

(DOOR OPENS, CLOSES)

- (PAPER SHUFFLING)

- I'm surprised by you.

I, arguably, made errors in judgment, but it was all in an effort to help a patient.

Yes, and that would make sense if you thought you'd never have another patient ever again.

And if there wasn't currently an opening for Chief of Surgery.

I didn't know that was on the table.

See, that's the difference between you and Melendez.

I have no doubt that as soon as I got this promotion, Melendez had done the math and reacted accordingly.

But I suspect that even if you had done the math, it wouldn't have changed how you handled this patient.

I don't view that as a weakness.

I'll handle the administrative fallout.

You...

...notify the parents immediately.

I can't.

We don't know the girl's real name, and we have to keep her sedated, so there's no way we can track...

She's a teenager.

She's got a phone.

Next time it rings, answer it.

(KEYS CLACKING)

(DOOR OPENS, CLOSES)

- You feel the mesenteric artery pulsing?

- SHAUN: Yes.

You shouldn't.

You're too close to the vein.

Great.

Dr.

Browne, pass a penrose drain through.

Bovie.

(MONITOR BEEPING)

(ELECTRICITY CRACKLING FAINTLY)

Suction.

(SUCTION WHIRRING)

Got it all.

I see leaking pancreatic fluid.

DR.

MELENDEZ: That'll eat holes in everything it touches.

Our duct tie didn't hold.

Suction.

Needle driver.

DR.

BLAIZ: Excellent.

You have approved a scrub nurse and a circulating nurse and seven other personnel.

Everyone and everything is covered, except for an actual surgeon.

Yeah.

I think we may have to postpone.

Have you notified your tumor to stop growing in the interim?

I think any possible damage from a delay may be more than offset by having somebody competent digging around in my brain.

"Competent"?

- What's wrong with Sanders?

- % mortality rate.

- Taylor?

- I don't like the way he's planning on dealing with a carotid tear.

- That's nowhere near your tumor.

- It's the principle.

- Unger?

- He doesn't like me.

- No one likes you.

- No!

You don't like me.

He doesn't like me.

That's two.

Just pick a name.

I don't care who.

I don't care if they're a doctor.

Just pick a name.

Because in hours, you're either getting your surgery or you're getting a new oncologist.

ZANE: (IN AFRICAN ACCENT)

She's in pain.

That's why she's asleep right now, because of what you did to her?

What I did to her I believe revealed that what you did to her didn't do as much damage as we initially feared.

We want to do a second surgery...

How can you stop her pain?

It's called clitoral reconstruction.

The nerves of her clitoris are exposed.

We can sheath them using...

(IN AFRICAN ACCENT)

Our daughter wants this?

Asha wants to be like other girls.

She wants to be able to...

Mara told you that?

That's our daughter's name.

Not Asha.

You don't know her at all.

We need to do this surgery to relieve her pain.

No.

There must be another way.

We want a second opinion.

Not at this hospital.

How soon can our daughter be moved?

Excuse me, Dr.

Lim.

I am Ellen Vahtra from Child Protective Services.

Until I complete my review, I'm afraid you're not going to be moving your daughter anywhere.

How did it go?

Is Dad okay?

No, I'm good.

There were complications, but we found solutions.

It went very well.

We got it all.

(ALL CRYING)

Oh, my...

There's still...

I don't think I did that well.

They're too happy.

Post-surgical complications are still a major concern that they...

Let them enjoy the good news.

Is deceiving someone in a way that makes them happy better than deceiving someone in a way that makes them sad?

Shaun.

I think there's someone here to see you.

Hey.

I had some time, so I thought you might want to have some lunch with me?

I do not have time.

♪ ♪

What's wrong?

What did she do?

Shaun.

Sha...

You don't want to talk to Lea.

I don't understand.

(INHALES SHARPLY)

I don't understand.

I don't understand!

You're not being fair to her or yourself.

- She's always been nice to you.

- No, she hasn't.

She's your friend.

Whatever's happened, you have to talk to her about it.

Be honest about what you're feeling...

I can't be.

- Of course you can.

- I don't know...

I don't know how I feel!

I can't be honest if I don't know how I feel!

Our -year-old daughter is lying in a hospital bed unconscious to protect her from overwhelming pain because of what this place did to her without our permission.

And you are investigating us?

Your daughter is suffering because you butchered her when she was years old.

Dr.

Lim, please refrain from unsubstantiated allegations.

Either they're the butchers or they're protecting the butchers.

If you didn't do it, tell us who did.

It was an aunt and a grandmother from Kenya.

They were watching Mara while we were on vacation.

Well, you must've been horrified.

Did you take her to a doctor?

That girl's s*x organs were covered with scar tissue.

She had no medical attention to treat any of her wounds.

ZANE: She was fine.

She was happy, laughing.

It's not that big a deal.

I was cut.

My mother was cut.

Her mother was cut.

It is a rite of passage connecting our women to their ancestors.

She will not find a husband in our culture if she's...

So she'll find someone else.

It's not that big a deal.

These parents forfeited the right to make any calls about their daughter a long time ago.

Our daughter is an honor student, taking three AP classes in her junior year, went on a mission to Haiti to build a school.

We have raised her well.

She is a good person.

We're proud of her.

I'm sure she is a good person.

But you are not gonna convince me that what happened to Mara when she was years old is anything short of an abomination.

But that's not the issue today.

The issue is, how do we best help this girl now?

The clitoral reconstruction should protect the exposed nerve.

ZANE: "Should"?

That is the surgery that, in my medical opinion, is called for.

But it's not the only option?

We could oblate the peripheral nerves and remove the remaining clitoral tissue.

And is that surgery safer or more dangerous?

It's simpler, but that's not the only factor here.

It's the only factor to us.

We want to know that our daughter won't spend the rest of her life in pain.

Please.

For a moment, can we think about something other than Mara's pain?

Can we think about her pleasure?

We have a chance to give her a healthy, meaningful s*x life.

That is what she came here looking for.

Wake her up.

She's in pain, and she's already told me what she wanted.

Yesterday, she was requesting cosmetic surgery.

Today, you're asking her to risk a lifetime of pain for a chance at pleasure.

From everything I've heard, she's mature enough to make the call herself, even if it means suffering for a few minutes to do so.

Dr.Unger has a mortality index that is not too high and not too low.

It's not gonna be Unger.

You have not eliminated Dr.

Ko.

Not yet.

I may have to go out of state to find a neurosurgeon.

Plus, I may have to find myself a new oncologist.

You've used Dr.

Ko many times.

Did you think she might kill your patients?

No.

Do you think you're better than them?

Yes, a little.

That was a joke.

You don't want to talk about this.

No, I don't want to talk about this, Shaun.

That, in fact, is the point of the alcohol.

Okay, I understand.

Good.

Why can't we talk about it?

Because it's upsetting.

Is that why you're stalling?

Because you're afraid of dying?

I'm not afraid of dying.

Really?

Why not?

You should be.

Dying is terrible.

Yes, dying is terrible.

But there are worse things.

What's worse than dying?


Not dying.

That doesn't make sense.

Makes sense to me.

That doesn't make sense.

That's the middle ground, Shaun.

Brain surgeries have a tendency to end in the middle ground.

Brain surgeries can be considered a success even when the patient ends up compromised.

He can't walk.

He can't talk.

His hand can't stop shaking.

I've been terrible at a lot of things in my life, but I am damn smart.

(VOICE BREAKING)

And I am a damn good surgeon.

And if I can't be those things, then I don't know who I'd be.

You'd be my friend.

Well, thank you, Shaun.

(CELLPHONE VIBRATING)

(VIBRATING STOPS)

I have to go.

My patient just crashed.

It's not enough.

Is it?

No.

I'm sorry it isn't.

♪ ♪

(WEAKLY)

Mom.

Dad.

We're here.

We love you.

We just don't understand why you would turn your back.

Uh...

VAHTRA: Hello, Mara.

I'm Ellen Vahtra.

I'm a social worker.

Your parents know what happened, and Dr.

Lim gave you a nerve block.

It hurts.

It still hurts.

I understand that, and we are going to try to get you back to sleep as quickly as possible.

But something happened during your surgery, and we need you to make a decision about what is done next.

We believe that, despite what was done to you as a child, the reason you're in so much pain because you still have functioning nerves in your clitoris, nerves that had been covered with scar tissue.

I'd like to repair that.

We can make you physiologically complete.

But there's no guarantee that it would work.

I'm confident.

There is a safer choice.

(INHALES DEEPLY)

We could...

remove your entire clitoris.

This is your choice.

You will be protected no matter what.

Take it out.

Mara, we can make you whole...

I made a mistake.

Take it out.

She's on medication.

She's in pain...

Dr. Lim, please let her go back to sleep.

And prepare to operate to remove the damaged tissue.

(SNIFFLES)

Hang fresh, frozen plasma, too.

Looks like he's going into DIC.

Give me another hemostat.

SHAUN: BP's over .

We should have warned the family.

Can't see anything in here.

There's too much blood.

- More suction.

- I think you got the hepatic artery.

The warning wouldn't have made any difference.

SHAUN: The bleeding is not slowing down.

We need to send the aorta to the celiac.

- I need to see it to clamp it.

- They would have been prepared.

A-line systolic's .

He's bottoming out.

No, they wouldn't.

You two, shut up and pack his abdomen with laps while I sort through this mess.

I won't do it.

Can we appeal this?

Do you know?

I've spoken with our legal department.

Unless we can prove the social worker was biased, we are stuck with this ruling.

Well, then you're also stuck with "I won't do it." You're a good doctor.

This hospital will miss you.

You're gonna fire me because I won't butcher a teenage girl?

Of course I am.

This hospital will face lawsuits, suspensions, perhaps criminal charges, and this little girl will still get the surgery you hate.

Could Dr. Lim at least talk to Mara again?

You want to wake her up again in pain?

Every woman deserves the right to make decisions about her sexuality without her parents hanging over her.

Okay.

♪ ♪

(GRUNTS SOFTLY)

When I was years old, my father caught me with a boy.

I mean, we weren't doing it, but my top was off and Well, it doesn't matter.

My father hit me.

I still have a small scar.

Our relationship was never the same.

(GROANS SOFTLY)

But that's what growing up is.

Not everyone gets called a slut.

Not everyone gets butchered.

But everyone becomes a man or a woman and stops being a child.

I want to take a piece of tissue from inside your cheek and I want to graft it to your clitoris.

We can make you feel...

love.

I can't turn my back on my family, on my traditions.

Traditions connect us to the past.

What about the future?

Please.

No.

I'm in pain.

(INHALES SHARPLY)

♪ ♪

DR.MELENDEZ: Cross-clamping his aorta.

SHAUN: He's in ventricular fibrillation.

(MONITORS BEEPING RAPIDLY)

CLAIRE: Starting chest compressions.

Okay.

Everybody clear.

(PADDLES WHINE)

(THUMP)

Prep the cheek, as well.

She's taking the graft?

The paperwork doesn't say...

She consented verbally.

We didn't want to keep her awake any longer than absolutely necessary.

I wanted to help her as much as you...

When she wanted help.

- But if she doesn't want this...

- She wants this.

Dr. Lim just told us.

Prep the cheek.

(FLATLINE)

(MONITOR TURNS OFF)

I'll tell the family.

DR.

MELENDEZ: No.

Claire, you do it.

This isn't the time for learning.

(DOOR SLIDES)

- I'm sorry.

- (WHIMPERS)

Paul died during surgery.

He had a gastroduodenal artery rupture.

It's a common complication of a Whipple surgery, especially when someone's cancer was...

As advanced as his was.

We...

did everything we could for as long as we could.

He didn't suffer.

(SOLEMN MUSIC PLAYS)

You did this to him.

Dad didn't want this.

You saw that look on his face.

He was scared.

In my experience, it does no good to dwell...

(SHAKILY)

Of course he was scared.

That doesn't mean...

He just wanted to live his last few months.

LORI: Stop it.

Nobody made your father do anything.

He knew the risks.

(VOICE BREAKING)

It's your fault, too, Mom.

All of us.

He would do anything for us.

We killed our father.

(WOMEN CRYING)

It's not true.

(CRYING STOPS)

Paul wanted this surgery.

He told me he wanted this surgery.

♪ ♪

(ALL CRYING)

♪ ♪

Was that true?

Paul told me...

When the truth can't help someone, we should lie.

Mom?

(EXHALES DEEPLY)

How are you?

Does anything hurt?

Not much.

I'm better.

Looks like she's doing well.

Thank you, Doctor.

There should still be some discomfort at the surgical site.

A nurse will bring you some...

Sorry.

A nurse will bring you some Tylenol, which should really be all you need.

Thank you.

You're gonna be great.

(SIGHS)

(CEREAL POURING, BOX SHAKING)

You're here.

Yes.

I live here.

You know that.

Well, I was starting to doubt it the last couple of days.

You come home after I'm asleep.

You leave before I can even get up.

Wow.

Thank you.

Please take this.

No, this is yours, Shaun.

I gave it to you to remember me by.

It hurt.

I didn't want to tell you the truth because I didn't know it, but I have to tell you the truth because it will help.

Every night, I would come home, and I would look at that baseball, and I would think of you.

The baseball was here, but you weren't.

That's sweet.

No, it isn't.

It hurt.

You hurt me.

Okay, Shaun, you know...

You went away, and it hurt, and it kept hurting, and now you're back.

If you stay, you will go away again, and it will hurt again.

So I want you to go back to Hershey.

I know you don't mean that, and I know...

Please go back to Hershey or anywhere other than here!

♪ ♪

(DOOR OPENS, CLOSES)

♪ ♪

Feeling okay?

Yeah, sure, superduper.

I want to thank you for your trust.

I'll do my best to deserve it.

Well, that's all I can ask.

You know the drill.