02x17 - Monday Mourning

[bunniefuu]

Lunch, one o'clock?

12:30.

Oh, yeah, right.

Hey.

Morning.

Hey.

Morning, Dr.

Halstead.

Good morning.

Yeah, yeah, yeah.

Wait.

Dr.

Wheeler, you got one in 3.

Be there in a minute.

Okay.

Morning, Jeff.

Hey, man.

[wind blowing]

This is obviously a tremendous shock.

Dr.

Wheeler was one of us.

And the burden of processing all that has happened will be a long and...

and difficult one, so there would be no judgment on anyone who would prefer not to be here today.

At times like this, talking about anything, even the weather, never hurt anyone, so my colleague Dr.

Richardson has made herself available all day.

She'll be up in her office if anybody wants to stop by.

Okay?

All right, thank you.

Ms.

Goodwin, in my experience, the key to maintaining morale in times like this is to keep things running smoothly.

Of course.

Okay if I take Dr.

Reese to fill in for the day?

Dr.

Charles?

Sure.

Thank you.

Maggie, waiting room's full.

Let's keep 'em moving.

Trying, Dr.

Choi.

What have we got?

Kid who fell in the river about five minutes out, Good Samaritan right behind.

Bunch of runny noses and earaches, and abdominal pain in 6.

Dr.

Manning, you're on the kid.

Clarke and Sexton, stand by to assist.

Reese, you're on deck.

Everyone else, take a room.

Let's go.

Don't worry.

We'll get through this.

Hi.

I'm Dr.

Choi.

Heard you're having some belly pain.

Yeah.

It's not a big deal.

He fell down the stairs.

Really?

How'd that happen?

Aah!

It was nothing.

He was carrying a pretty heavy box of books.

We're packing up to move next week.

And everyone thinks reading's good for you.

Might have a broken rib.

I'd like to get some scans and make sure there's nothing else going on, but it doesn't look too serious.

I'll be back to check on you in a little bit.

Um...

Is there anything else?

No.

It's...

It's just...

he's been a little clumsy lately.

But that's normal, right?

Tripping over his feet?

He's just growing into his body.

It's probably nothing, but since we got some time, I'll run some blood to rule out any infections or toxicities just to be sure.

Thank you.

Need any help?

We got it.

Mags, put him in Baghdad?

Already on it, Dr.

Choi.

Dustin Banks, eight years old.

Fell through the ice into the river.

15 minutes before he was pulled out.

Heart's in Brady-arrest.

Core temp 27 degrees Celsius.

Cold and dead, Sexton?

What do you think?

Uh, that he's not dead until he's warm and dead?

You just won the first shift of compressions.

All right.

On my count.

One, two, three.

April, I need to intubate.

50 of sux, 10 of etomidate.

On it.

Can he hear me?

Dustin!

Whoa, whoa, whoa, whoa.

The doctor will be with you as soon as she can, okay?

Jim Kessler, 58.

Had a STEMI after jumping in the river to save the kid.

Aspirin and nitro in the field.

Sinus rhythm now 120/80.

Mr.

Kessler, I'm Dr.

Reese.

Can you hear me?

Sure can.

Great.

On the count of three, let's move him.

One, two, three.

Meds are in.

Maggie, get an ECMO unit.

Pneumonia season.

Every single one's in use upstairs.

He's not gonna wake up till he's 95 degrees.

What about bypass?

They're both in surgery.

We can get one down here in about 90 minutes.

Then we're gonna have to keep his heart b*ating until we get it.

Compressions for 90 minutes?

In five-minute shifts.

And we'll warm him the best we can with a left lung lavage.

Jeff, we need two 32-french chest tubes.

April, get a warmer and all the saline in the hospital.

Let's go.

Left lung lavage?

Sure it'll work?

We're gonna try.

Dr.

Manning, this is David Banks, Dustin's father.

Is he gonna be okay?

It's too soon to tell.

The benefit of hypothermia is it preserves brain function.

But if we don't warm him fast enough, the cold will eventually overwhelm his body, so we're gonna circulate warm saline through his chest cavity until we can put him on bypass, okay?

Okay, the warmer's on its way, but for this amount of saline, Central Supply needs a doctor's order.

Okay.

I promise you we are gonna do everything that we can.

Your EKG shows ST elevations.

Definitely a heart att*ck.

Ever had any heart problems before?

Little chest pain here and there.

My doc's got me on some pills.

Okay, well, he should've told you not to jump in a frozen river.

The shock is probably what tipped you over the edge.

Everybody's a Monday morning quarterback.

I don't know what that means, but I do know that we need to assess the extent of your coronary artery disease, so I want to send you up to the cath lab.

Long as there's some hot cocoa in it for me, you got a deal.

All right.

I'll check back in with you soon.

Activate the STEMI protocol.

And uh, call Dr.

Rhodes for a consult.

You got it.

He got off lucky.

He could've gone into cold shock, v-fib, coagulopathy.

What a great but crazy thing to do.

He probably didn't even think about it.

Just saw a kid in trouble and reacted.

Thank you.

Hey, Nat.

Hey, Jay.

It's a tough day, huh?

Yeah.

Just hang in there.

Thank you.

All right.

All Kevin's scans show are a broken rib and a pretty good bruise on his kidney, so I agree with Dr.

Choi.

There's no neurologic reason he fell.

He simply slipped.

I'd like nephrology to get a look just to be safe, but then he should be okay to leave.

So, he'll be all right to drive across country next week?

Mom.

Shh.

Let the doctor talk.

Might be a little uncomfortable, but he'll be fine.

Thank you for all your help.

You got it.

My advice: bring some pillows.

Lead levels and Lyme titers?

Pretty aggressive workup for a kid who just slipped and fell.

Nothing wrong with covering our bases.

Hey, Maggie?

Mm-hmm?

How's the resuscitation going?

Getting 20 people from 5 different departments to work seamlessly together...

What could go wrong?

Mm.

Well, you keep me updated.

Yeah.

Let me ask you: did Dr.

Wheeler have any interpersonal issues with anyone on staff?

I mean, I don't know.

I don't think so.

But he was making some pretty big mistakes lately.

Yeah, and it was getting worse after the drinking incident.

Mm-hmm.

Was there anything that, um, might have been weighing on him?

I mean, you can tell that he was losing his confidence.

Hm.

Um, okay, then.

I'll let you get back to work.

All right.

I'm sorry.

Can I help you?

I was told to ask for you.

Okay.

I'm Dr.

Wheeler's father.

I need help!

Can somebody help me?

What happened?

I don't know.

He...

he can't move.

Kevin, squeeze my fingers.

Just...

wait, wait.

Can you feel my hand?

All right, let's get him to CT, now.

What?

What's happening?

I think your son's having a stroke.

Oh, my God, Kevin, no.

So, the episodes that he's been having recently could've been TIAs.

They may have been coming for some time.

Well, it's possible.

But the CT looks negative.

It is.

However, there can be a delay before an embolic stroke shows up on the scan.

Exactly.

Which is why we need an MRI.

Right.

An MRI?

That'll take an hour.

His stroke could be evolving right before our eyes.

If it is a stroke.

His left side's completely paralyzed...

What else could it be?

I don't know.

That's why I want an MRI.

Every minute we wait to break up the clot in his brain increases the odds of his paralysis becoming permanent.

He needs tPA.

Whoa, well, he's also got a bruised kidney.

TPA could cause a massive hemorrhage.

We cannot risk that until we know for sure what we're treating.

You've still got more than a two-hour window for tPA.

I can get him in and out of the MRI in 40 minutes.

Good.

Do it.

I'm sorry about your resident.

He wasn't my resident.

Yeah.

Thanks.

Yeah, it's awful.

I mean, residency...

Who doesn't consider doing it?

Still, you never think anybody actually will.

You thought about su1c1de?

Of course.

Didn't you?

No.

Huh.

That's unusual.

You have moderate three-vessel disease.

But given the fact that you've already had a cardiac event, it is my recommendation that we do a coronary artery bypass graft.

This is pretty major surgery, right?

It is, but you are an excellent candidate.

So I'd like to give your heart a day to rest, and then we can get you on the schedule for tomorrow.

[takes deep breath]

If you say so, let's do it.

Great.

By the way, it's a pleasure to meet you.

I hear that you are quite the hero.

[chuckles]

No.

Just lucky I happened to be there.

Well, either way, thank you.

H-how did you know he needed help?

What do you mean?

He was drowning.

No.

I understand.

But what went through your head the moment before you jumped in?

Was it...

was it an actual decision, or was it more like an instinct kicking in?

I don't know.

We should let you get your rest.

Dr.

Reese will be back when we have a room ready for you upstairs.

Dr.

Reese?

Dr.

Reese, are you okay?

What?

Yeah.

I'm fine.

Yeah, everything's fine.

I'm gonna go check on the room.

Where is he?

My son, Dustin.

Where...

Mrs.

Banks?

Hi.

I'm Dr.

Manning.

Your son is right here.

But let me just explain to you what's going on first, okay?

Cheryl, I don't know what happened.

I was right..

This is your fault!

You are a terrible father.

Mrs.

Banks, please, let me just explain to you what's going on, okay?

Hey.

How come you're getting a snack?

It's time for lunch.

I'm sorry.

We've been slammed.

I got to get back.

Okay.

But you could've texted and saved me the drive across town.

I told you I haven't had a second.

You had time to get a snack, though.

Fine.

You win.

That's a great answer.

I'm sorry my dying patient inconvenienced you.

Come on, April.

What do you want me to say?

That's just how you justify everything...

your work.

Now you're gonna start in on my work?

Nah.

I'm going.

Rather eat by myself anyway.

You ever seen this before?

A resident ending it like this?

Unfortunately, I have.

Yeah.

Several times.

You know that 400 doctors take their own lives every year, right?

Most of any profession.

I don't have a lot of evidence to back this up, but I got a strong hunch it's got something to do with taking people who have a powerful desire to help and throwing them into a game where the odds are just stacked against them.

I mean, this I do know: situations like this, it's never just one thing.

It's always a complex set of circumstances, and, um, you know, trying to figure it out, trying to assign blame...

It's pretty pointless.

Hey, thanks for getting him a bed so fast.

[takes deep breath]

Tough day, huh?

You and Dr.

Wheeler were friends?

No.

I hardly knew him.

He came to me...

twice...

asking about pills, about therapy.

And that wasn't really what he was asking for.

He was asking for help.

I don't know why he came to me, but he did, and now he's dead.

What kind of terrible psychiatrist am I gonna be?

You can't jump in and save everyone, Reese.

It's just not possible.

It's not that I didn't jump in to save him.

I didn't even see that he was drowning.

Dr.

Rhodes, better come here.

[wheezing, gasping]

BP's dropping, ST segments are elevated.

[groaning, gasping]

He's barely got a pulse.

He's in cardiogenic shock.

It must be another MI.

We're gonna balloon-pump him.

Bolus heparin, start dopamine, dobutamine.

Get him on high-flow O2.

Got it.

I'll tell the cath lab we're coming.

There's no time.

We're gonna do it here.

We're...

How will we know if we're in the right place?

If he bleeds out, we'll know we punctured the iliac.

If he stops breathing, then we perforated into the mediastinum.

But if we don't get his blood pressure back up right now, none of that's gonna matter anyways.

[groaning, gasping]

Hang in there, Jim.

Let me know when you see it.

Almost there.

Got it.

Almost there, Jim.

I got you.

All right, turn it on.

Come on, come on, come on, come on...

Pressure's coming up.

70/35.

80/40.

Okay.

Get him ready to go upstairs.

Still no improvement.

He's always been so healthy.

What could cause a stroke in a 15-year-old?

Not much.

And he's negative for the usual suspects, so if his MRI is positive, we'll have to start looking for less common causes.

I'm not gonna have to stay overnight, am I?

Kevin, not now.

Dr.

Halstead, Dr.

Choi?

Excuse us.

MRI?

Yeah.

Still no evidence of a stroke.

This can't be right.

Well, it may not be.

It says it's a poor study due to patient movement.

So it's inconclusive.

Tell MRI we're sending him back up for a repeat scan.

Are you kidding?

If this is a stroke, we're running out of time.

Doesn't his affect strike you as weird?

So little concern?

He's a confused teenager who's probably also in shock.

Well, I don't like it.

It doesn't add up.

And we should figure it out after we treat what may soon become permanent paralysis.

I'm not gonna risk a massive hemorrhage and a transfusion for no reason.

He's going back to MRI.

Hey.

Hey.

I just spoke with CCU.

Mr.

Kessler's pressure still isn't coming up.

Okay.

We'll give it a few more minutes, and if it doesn't improve, I'll have to operate.

Okay.

Wheeler came to me, too, Reese, when we had that pile-up in the blizzard, and the pregnant woman almost bled out.

He took it hard.

I had the chance to reassure him, but I didn't.

All right.

I appreciate that you're trying to make me feel better, but it doesn't.

I'm gonna go check on Mr.

Kessler.

Whoa!

Whoa, whoa, whoa.

Noah.

Sorry.

Sorry, sorry, sorry.

Let me...

Let me help you.

Hey, um, I saw you and Tate getting a little edgy.

Are you okay?

I'm fine.

Yeah?

Okay, good.

I just don't want you to, you know...

What?

Screw things up?

What?

No, no.

I just want you to be happy...

with a guy...

who was a all-pro wide receiver three times.

Three times, right?

Okay, everybody, the bypass machine just opened up.

We need to get him upstairs now.

So you'll be able to warm him up?

Much faster, yes.

And it hasn't been too long, right?

He might still be okay?

We won't know about his neurological function until he wakes up, but this is definitely a step in the right direction.

[sighs]

Thank you, Dr.

Manning.

Of course.

I can't tell you how much we both appreciate this.

He's ready to go.

Okay.

Let's do it.

Hold on.

Ms.

Goodwin?

They need the bypass machine upstairs for an emergency case.

What do you mean, an emergency?

It's for Mr.

Kessler, the man who saved your son.

They need to operate on him immediately.

But it was promised to us!

We've been waiting for it.

Plus that man would want Dustin to have it.

There can't be a bigger emergency than this.

My son is dying.

Are you just gonna stand there and do nothing?

Mrs.

Banks, Dustin still has options, other ways of continuing to warm.

Mr.

Kessler does not.

Without surgery, he will die.

My son is going to die.

Tell her.

Put him back on the monitors.

Wait.

Wait!

Are you giving up?

No.

But Ms.

Goodwin is right.

We can try peritoneal lavage to speed things up.

You are his doctor.

You're supposed to fight for your patients.

My son is only eight years old.

What kind of a monster are you?

Mrs.

Banks.

Mrs.

Banks, I am truly, truly sorry.

April, set up for the lavage.

On it.

The waiting room's backed up again, Maggie.

I'm doing my best, Dr.

Choi.

We need to do better.

Too many people losing focus today.

It's dangerous.

Is that right?

That patient in there, Kevin, 15-year-old with hemi-paresis, but his attending is fixated on his mood rather than his symptoms.

What do you mean?

He seems a little detached.

But he's just a kid trying to play it cool.

So now we're wasting valuable time ordering scan after scan when we should be treating him.

Well, I mean, surely this attending gave you his reasons, right?

He did.

But I think the incident this morning is clouding his judgment.

I'm not sure he should be working today.

Really?

Dr.

Charles, we're in the business of saving lives, and the moment people lose confidence in their leader, the fight is lost.

We've already had one casualty today.

I won't have another.

Kevin, how are you?

I'm Dr.

Charles.

Hey.

I understand you're having a little trouble with your left side.

Oh, yeah.

Yeah.

How you doing with that?

I know it can be a little scary.

It's not that big a deal.

Excuse me, Dr.

Charles, this patient's schedule for an MRI.

Yes.

Okay.

Well, um, nice to meet you.

Yeah.

Metz and DeBakeys.

Let's get him cannulated for bypass, and get me a sheet of woven patch.

Woven patch?

I thought we were doing a three-vessel CABG.

Change of plans.

This isn't an MI.

Page Dr.

Reese.

Tell her I need her now.

3.0?

How's he doing?

Still only 89 degrees.

Look, I know Dr.

Wheeler had a difficult time here.

Did he ever talk to you about it?

No.

Was there anyone he might have talked to?

A confidant?

Honestly, I have no idea.

Okay.

Uh, Ms.

Goodwin?

Yes?

I spent eight months working alongside someone who was in so much pain that he took his own life, and I never even noticed.

Am I a monster?

No, Dr.

Manning.

No, you're not.

Excuse me.

I'm looking for my friend.

Is this the visitors entrance?

Uh, for the ED, yeah.

Has he been admitted yet?

I don't know.

He said he can't move his arm or leg.

It sounds really bad.

His name wouldn't be Kevin, by any chance, would it?

Yeah, it is.

Huh.

Tell me: is your buddy, like, a real cool customer?

You know, like a James Dean type?

Who's James Dean?

What I mean is, um, is he the kind of guy that doesn't really get too worked up about stuff?

Kevin?

You're kidding.

They're making him move to California.

Of course he's worked up.

He's got to move?

Yeah.

They're just dragging him away.

Huh.

You're gonna miss him, huh?

Yeah.

Sorry...

tell me your name.

I'm Dr.

Charles.

Emmett.

Emmett.

Nice to meet you.

Um, I think that there might be a chance that we could help your friend.

Could we go see him together?

Yeah.

Okay.

Dr.

Rhodes, why did you bring me here?

I can't assist on a bypass graft.

We're not doing a bypass graft.

What?

But I...

Look.

A ventricular septal defect?

From necrosis.

Lack of blood flow from his heart att*ck at the river caused a small patch of muscle to die.

That's impossible to find.

How did you even know to look?

You see this discoloration?

Uh-huh.

I missed this once.

Guy d*ed before we even got him off the table.

I know that you feel like you let Wheeler down, like you missed the signs of him needing help.

As doctors, all we can do is learn from that and try not to miss them again.

Maggie, when's Kevin Roth getting back from MRI?

Didn't you get Dr.

Choi's message?

He took your patient to interventional radiology.

What?

Do not administer that tPA!

Dr.

Choi, now.

The hell are you doing?

His window's nearly closed.

I had no choice.

No, you don't have a choice.

I'm your attending.

And you're not willing to do what the patient needs.

So, you're 100% sure of the correct clinical course?

Because to me, this is not a clear-cut case.

Doesn't mean we can avoid making the hard decisions.

Even if those decisions might k*ll him?

Gentlemen, if we could take a b*at, this young man might help us shed some light on the situation.

Hey, man.

Emmett, what are you doing here?

I was worried.

You were worried about me?

Yeah, man.

Your text said you couldn't move.

I didn't know if you were dying or paralyzed.

I just came as fast as I could.

Oh, Mr.

Wheeler, I'm sorry.

I'll give you some time.

Why did he do it?

Even if he was having trouble, why?

I don't know.

Did you ever see Jason do that trick where you'd pull a card out of the deck and it turns out it's in his pocket?

Yeah.

When he was a kid.

Yeah.

I saw him do it once up on the pediatric oncology ward.

I guess he used to go up there a couple times a week to do magic for the kids.

And oh, man, did they love it.

He did this thing where he would pull a lemon out of his ear, and then out of one of the kids' ears, and then out of another, and they'd be rolling on the ground.

[laughs]

Just ten minutes in their day where they didn't have to think about whatever terrible illness they had.

I didn't know your son very well.

And I've seen a lot of doctors come through here.

He would've been a good one.

[sniffling]

Thank you.

Yeah.

We had no idea.

It seems like he's been harboring thoughts and feelings that he wasn't comfortable expressing, and his body found a way to express them for him.

So he wasn't actually paralyzed?

No.

But he was experiencing real symptoms.

It's why we call it a conversion disorder.

It's the physical manifestation of a psychological desire.

Desire?

Sounds like you're saying he wanted to be paralyzed.

I'm saying he didn't want to move.

And his subconscious decided that having a serious medical condition might be a good way to accomplish that.

That sounds crazy.

Crazy, no.

Complicated, sure.

But if you think about it as a whole, an understandable response to what must have seemed like an impossible situation.

I mean, having to leave somebody that he couldn't tell you about, somebody for whom he had very strong feelings.

But if he was so upset, why didn't he seem to care about being paralyzed?

Compartmentalization is just part of the condition.

But trust me: your son cares.

I mean, he cares a great deal.

Just to be safe, we'd like to observe him in the hospital overnight.

Then probably a good idea for the three of you to sit down and have a talk.

They're getting a room for him upstairs.

I'll let you know when it's ready.

Thank you.

Damn.

The funny thing about feelings: you know, we think that if we push them down hard enough, that they'll disappear.

Never quite works out that way.

I could've k*lled him.

Yeah, well, you didn't.

Cheryl?

Cheryl, I was watching him every second, and then Ben called about this thing, and I had to look it up on my phone.

And I know you never take your eyes off the kids for a minute, and I'm always working, and you're a far better parent than I am.

I'm sorry.

I don't know what else to tell you.

I'm just so sorry.

I'm tagging you out.

There's a couch in the lounge that's free.

I'll grab you in 20.

Thanks.

There's something else I have to do.

[sighs]

Hey.

Hey.

Listen, I'm sorry about earlier, going off on you like that.

Okay.

But...

But what?

I know that you blame me for the miscarriage.

April...

No.

Admit it.

No matter how many times you're told that my working had nothing to do with it, you just...

you won't let it go.

But it's bigger than that.

You would've had me quit my job a year ago, before I was even pregnant.

You want a different kind of woman.

I want you.

I love you.

I just imagined a different kind of life.

[stifled sob]

[sighs]

I know.

I hope you find everything you want.

You too.

You too.

Amazing what the mind can do, isn't it?

Mm.

Keeps me employed.

That's for sure.

You know, Wheeler...

Maybe what happened wasn't my fault, but I didn't help.

Hey, join the club.

Look, not for nothing, helping people is just...

Just about the hardest job there is.

You've been doing it...

what?

25, 30...

several years?

What...

what's the secret?

Well, I'm still looking for that, but if I had to guess, I'd say it had something to do with, you know, just keep showing up, keep doing your job, put one foot in front of the other, 'cause when you start to get all tangled up in here, you know, that's when, I mean, it can just paralyze you.

Yeah.

Still, it's gonna be a while before I can sleep again.

Dr.

Halstead?

I think we're lucky to have you here.

You keep up the good work.

Hey.

I think he's waking up.

Hey, buddy.

Dustin!

He's trying to breath.

Hang on, Dustin.

We're gonna take this tube out, okay?

Hang in there, buddy.

We're right here, buddy, okay?

We'll take this out.

Dustin?

Can you hear us, buddy?

Hey.

There we go.

[coughs]

All right, sweetheart.

Dustin!

Bilateral breath sounds are present.

Pupils are equal and reactive to light.

Hey, Dustin, if you can hear me, can you tell me who this is?

Mom?

Oh, my God.

Let's d/c the lung lavage, but keep the peritoneal going until he's 98 degrees, okay?

Got it.

We're gonna need to observe him for a few days, but this is a very good sign.

Dr.

Manning?

Yes?

I'm sorry about what I said earlier.

Thank you.

Thank you for everything that you've done.

I'm just happy we were able to save your boy.

[sobs]

How about that?

I guess every now and then we get lucky.

Yeah.

How'd it go with Dr.

Richardson?

She stay busy?

Uh, nobody showed.

Nobody?

Yeah, but that's...

you know, it takes time.

Trust me.

People are dealing in their own way.

When I took this job, Daniel, I wanted to create an environment where we would never lose someone.

Everyone would look out for each other.

I thought I did.

But then today I found out there was a very troubled young man in our midst, and not a single person knew him.

I failed.

Sharon, come on.

No, no.

You...

you got to wonder about all the ones who don't jump off the ledge...

What's going through their heads, how this job is affecting them.

[sighs]

I worry about these people, Daniel.

I worry about them.

I know you do.

I know you do.

I wish I could protect them.

He's right here, Ethan.

I'm so sorry.

They won't need me in the ED tomorrow, so I'll be back on your service.

Thank you.

Thanks.

I'll see you tomorrow.

Everybody comes to you, don't they?

With all their pain?

And you just have to absorb it.

How are you doing today?

It was awful.

It's just awful.