Next time, maybe inform the department chair
before the shit hits the fan.
I was on my way to tell you.
Make sure you get everything you need.
OK, let's do this.
IT called me up because
I've trained in cyberattack prevention and response.
Then you can tell everybody what to do.
No, thank you.
Best if it comes from the department chair.
Oh, you think?
All right, everybody, circle up.
What the fuck?
We may have had a cyberattack.
No, we shut down to prevent a cyberattack.
OK, everybody, settle down. Listen up.
As you can see, we're doing a little
redecorating in the central work area.
Our hospital computers are at risk for a cyberattack,
so we are going old school, analog.
- For how long? - Great question.
Our IT department has shut everything down
to give them time to bolster our cyber defenses.
I believe the question was, for how long?
Uh, hard to say.
Could be up to 24 hours.
Jesus Christ.
So first order of business,
we need to replicate the electronic patient boards
on these dry-erase boards.
So please, somebody tell me
they got a photo of the boards.
Uh, yeah, yeah, yeah.
Right here. OK.
Oh, uh...
It's a little blurry.
No, more than a little blurry.
- Sorry. - Oh, my God.
- I remember. - Great.
If everybody else can remember their patient names
and their room numbers, that would be awesome.
No, I mean I can remember all of it.
All of what?
Names, doctors, room numbers.
I kind of have a photographic memory.
Seriously? The whole board?
Central 12, Harlow Graham, headache,
- abdominal pain, ASL only. - Oh, shit.
I have an interpreter waiting for me.
- Go. - OK, for patient privacy,
all chief complaints will be abbreviated.
So HA for headache,
AP for abdominal pain, and so forth.
Central 10, Jackson Davis, new-onset psychosis.
Javadi, psych admission.
Greek letter psi for psych.
Pedes is Baby Jane Doe, fever, Dr. Mohan,
awaiting admission orders.
Nurses need to convert to a zone defense--
north, central, south, trauma.
Where's Dana?
In with a sexual assault case.
She can't leave until the exam is finished.
Yeah, it could be a while.
Princess has charge nurse experience.
- Not really. - That's a great idea.
Princess it is.
You can make the nursing assignments.
- Next. - Central 9,
Roxie Hamler, end-stage lung cancer.
Sorry, do we have to stand here while
- she recites the whole board? - No.
In fact, go check on your patients
and then please come back here.
Thank you.
How many hours a day are you on your laptop?
At least eight hours.
I work from home.
And are you at a desk all day?
No, no.
I will either sit on the sofa,
or sometimes I'll be in bed,
kind of sitting up with the computer on my lap,
that kind of thing.
So you're always looking down at the screen?
- Yeah. - OK.
I'm going to check the muscles in your neck.
- Ooh! - Ooh!
Ow, that hurts.
All right. Well, I think we can help.
Come on over.
OK, gather up.
Listen up, everybody. This is our chart rack.
So as you can see, each slot and clipboard
has a room number on it.
When you pick up a new patient,
you grab a fresh chart from the T-system.
Pick your chart by chief complaint.
Use the cartoon to find it.
Why are there two bodies?
Trauma on the left, medical on the right.
So head injury, you go left.
Headache, go right.
Are those fish swimming in seaweed?
No.
That is bees and grass.
That's the section for insect bites,
skin rash, allergies.
OK, let's say, for example,
Dr. Al-Hashimi has a new patient with belly pain.
For the history, circle the positives,
like vomiting and diarrhea.
Backslash the negative, such as recent travel,
sick contacts, fever.
For physical exam, checkmark normals on the left,
and circle any abnormal findings on the right.
Questions?
Is your generative AI program
still gonna be working?
Not for a while.
And ditch your SpectraLink phones.
Those are voice over internet.
PTMC Emergency.
Go ahead, Medic Command.
That is how we will hear about incoming runs.
Thanks.
Two minutes out with abdominal pain and fever.
OK, has everybody got that so far?
How do we write orders?
Physician order form in triplicate.
Labs, X-rays, IV fluid, medication.
Will the labs still be able to run blood tests?
Yes.
Are the CT scanners still working?
Yes, but the results will come back
on paper from the radiologist.
This is the dark ages.
So if you have orders with labs or X-rays,
they go into the clerk file here.
They will sign them off.
They will add a downtime slip on them,
make sure they go to the correct department.
I'm sorry, who are the clerks?
- You're looking at them. - At your service.
Larry and Antoine are filling in
- until more help arrives. - We got this.
After the clerk orders, chart gets moved
to the nursing order rack here for IVs,
medications, procedures.
Medications are locked up in the PDS.
The PDS is getting unlocked by a clinical pharmacist,
- Dr. Megan Nordt. - We've got your back.
This is a lot.
Any questions? Yes.
Uh, no.
What's up with the third rack?
When your patient is ready to be discharged,
chart goes here.
This lets everybody know
we're about to have an open bed.
Or that your tuna melt is up.
Jesse?
- What is that? - What is that?
That is a fax machine.
They still make those?
This is our lifeline to labs and X-rays.
When the results come back, they will fax to us,
and the clerks will put them on the charts.
- Yes? - If you say so.
Incoming.
OK, Dr. McKay, Dr. Whitaker, Ogilvie, you're with me.
The rest of you, build your clipboards.
Howard Knox, 52, abdominal pain and fever.
152 over 90, tachy at 120.
- Couldn't get an IV. - I wonder why.
Hello, sir. My name is Dr. Robby.
- Howard. - This is a teaching hospital.
I'll be supervising Doctors McKay and Dr. Whitaker
- and student Dr. Ogilvie. - Hey.
- Hello. - How are you feeling?
- Not so great. - OK.
- Princess, what's free? - Trauma 1.
Perlah?
All right, orders for Mylanta and bupivacaine, Central 12.
Wrong spot, Dr. Santos.
And you need a sticker.
Put it in the nursing orders rack.
And meet me over at PDS.
How much does this suck?
I didn't think today could get any worse.
This is how we rolled when I was a resident.
Was that in the 1900s?
Yeah, when charts were written by candlelight.
Hey, today will be an adventure.
Think of it like "Back to the Future."
Or possibly "Titanic."
Here is your antacid.
Cheers.
And I marked the trigger point
that is bringing out your headache,
and a shot of local anesthetic in that area
could really help.
Yeah, let's do it.
All right.
You are going to feel a little pinprick
and some burning.
OK.
Oh, ow, ow, that really hurts.
Temp 101.4, tachy at 128, pulse ox 92 on 2 liters.
When did the pain start?
It's been on and off for about a week.
- And where do you feel it? - All over.
It started on the left, and now there's some on the right.
How about that fever?
Since last night.
I was burning up.
Then I had chills pretty bad.
I can't find a vein here.
We'll try for a midline.
Let us know if this hurts.
- Ah, ah. - Sorry.
- And on this side? - Yeah, yeah!
Sorry, sir.
Guarding with no rigidity.
For pain, 100 of fent IM?
Plan, Dr. Whitaker?
Blood cultures, lactate, Zosyn.
We're gonna need a CT to figure out what's going on.
Ah-ah.
- Yeah, it's not gonna work. - Yep.
Write neatly. Penmanship counts.
Howard, for the scan, we're gonna have
to lay you flat on your back.
Can you do that?
I could ten years ago,
but now it's too hard to breathe.
If we can't lay you flat,
then we're gonna have to put a tube in your windpipe
to help you breathe-- are you OK with that?
Intubation with rapid sequence induction?
No, we can't lay him down.
The tube will go in your nose
while you're awake, sir.
- Well... - Right.
Does it hurt?
You'll be numbed up completely.
You won't feel any discomfort.
Do you happen to know your weight?
A little over 400.
When was the last time you checked?
It's been a while.
Is it possible that you might be over 450?
Possibly.
Perlah, let's call for the Hoyer.
So we're gonna place the tube and get you ready for the scan.
Is this something serious?
Well, it's hard to tell without a CT.
You could just need antibiotics,
or you could require an operation.
If surgery is necessary,
then your weight could make things
- a little bit more complicated. - I know.
- I'm sorry. - Not to worry.
We're gonna take very good care of you.
Team.
OK.
Pain medication for you, OK?
Let's try for a midline,
basilic vein with ultrasound guidance.
Can ultrasound check for an appy?
He's a little too large for an ultrasound.
Plus, our CT can only handle 450 pounds.
And so if he's over that, we send him to the zoo?
He's right there.
I--I heard that there's a large animal CT at the zoo.
Presby's CT can handle 650.
Yeah, if Presby's still up and running.
Wh...
That--that's not a jinx. It's--
Have any of you ever done an awake naso-tracheal?
OK.
Perlah, can you also ask
Dr. Al-Hashimi to come in?
I'm gonna need an assist.
Yep. You got it.
Ah, sorry. Signed.
Hall bed F, George Francis, shortness of breath,
Dr. Mohan, awaiting D-dimer.
Wow. She's still going?
Yeah. Remarkable, really.
Dr. Al, Robby's asking for you.
Uh, OK.
In Trauma if you need me, Princess.
Got it.
Who's supposed to run the downtime slips
to X-ray and lab?
Uh, the charge nurse?
Don't look at me.
My plate's full!
Uh, parents of Roxie Hamler?
Central 9.
Oh, I got it, Donnie.
Hi, I'm Victoria Javadi,
one of the student doctors here.
I've been assisting with Roxie's care.
Oh, thank you so much.
- I'm Lloyd. - Cora.
It's nice to meet you.
She broke her leg?
Um, yeah.
There's a fracture down by the ankle.
She's in a boot now, so there's not quite so much pain.
But I'll take you. She's just in 9.
The hospital Wi-Fi isn't working.
Oh, it'll be down for a while.
Sorry.
Mom broke her leg, Grandpa.
We heard.
How are you, honey?
You've got this, kiddo.
Yeah.
How long will she stay in the ER?
Oh, until a bed opens up upstairs.
Could be a while.
You know, it's getting pretty crowded in here.
Maybe we should take Tucker and Shane out for ice cream.
- Yes, please. - No, no. I'm OK.
Maybe your mom would like some time to rest.
Yeah. Go.
Can she have ice cream?
She can have anything she wants.
Come on, let's go.
Bye, Mom.
Ice cream, ice cream.
Yep.
Listen up.
This is Oxymetazoline.
This will open up the passage.
What medication do you take?
Uh, Lisinopril and Metformin.
Ozempic? Wegovy?
No. Kind of expensive.
I'm going to squirt some numbing gel in your nose.
If it drips back in your throat, that's OK.
Here, in case you need it.
Do you smoke?
Alcohol?
- Never. - Do you exercise?
Moving from the bedroom to the kitchen.
No, I'd walk more,
but I need a bench to rest on every block.
What about water aerobics?
Let's focus on helping Mr. Knox.
Agreed.
It took me 25 years to get this way.
Car crash, burn unit,
four leg surgeries over ten years.
Laid me up so much, I lost my job.
I need to numb the back of your tongue.
This is gonna taste pretty bad.
Is there anyone you'd like us to call?
No.
Any family?
Mm. My parents passed.
I'm single.
Go figure.
Siblings?
Sister in Arizona.
We don't talk much.
Now that we've numbed up the back of your tongue,
we can anesthetize a bit deeper.
Um, sorry to interrupt.
I have a middle-aged woman
with sudden onset blindness.
- I can go. - OK.
Will you see if Abbot's still around?
- Yeah. - Thank you.
What's your sister's name?
Lauren Milford.
Where in Arizona?
Flagstaff, I think.
Just gonna go over your tongue
and numb your vocal cords.
Ah.
Ah...
How many fingers?
I don't see any fingers.
And now?
I can see a little bit of light.
Um, Brooke, you've met Dr. King.
This is Dr. Al-Hashimi.
- Nice to meet you. - And her wife, Wendy.
- Hello. - Hello.
OK if we discuss your symptoms?
As long as I can correct you if you get anything wrong.
Trust me, she will.
One hour of sudden, painless vision loss in the left eye.
No history of hypercoagulable state
or vascular disease.
Could you look straight ahead, please?
Could be a central retinal artery occlusion.
In English, please?
A little blood clot can block the artery
at the back of the eye and decrease your vision.
Sometimes it's called an eye stroke.
Stroke?
Like she could be paralyzed?
No, this would be limited to the eye.
Is it permanent?
First, we have to make the diagnosis.
Retinal exam?
Hard to get a good look.
We need the FOP.
The what?
Oh, Princess.
We need patient stickers on each of these order sheets,
or the pharmacy won't know who to give meds to.
We're on it.
Princess, smartphone fundoscope?
Equipment corridor, eye cart.
- Thanks. - You seem a little confused.
How do I figure out which new patient to pick up?
Top of the board.
They're listed in the order they arrive.
You erase the first one, then put
your initials in the MD box.
OK. Thanks.
- Caleb. - Michael.
Are you managing this chaos OK?
Well, it's all pretty easy when you're a short-timer.
Any more comatose patients for me to have a chat with?
I'm kidding.
OK.
Victoria, this is Nicole Steadman.
I run the parent support group
for the psychiatric service.
Yeah. Nicole's daughter was diagnosed
sophomore year in college.
You think Jackson's parents might have a chat with her?
We can certainly ask.
Now we can see the whole retina
without dilating the pupil.
You're looking in the wrong eye.
Oh, we start with the good eye for comparison.
Oh.
Retina looks great.
Now for the bad eye?
Eyes wide open.
How's it look?
Extremely pale, no blood flow.
Digital massage, 10 seconds on, 5 seconds off.
Order non-contrast head CT.
Come in.
Hi.
Heard your patient took off.
She's taking a little break.
How long are you gonna wait?
You know about the cyber shutdown thing?
Yeah.
Wish I could help, but I gotta stay here
till all the evidence is collected, so...
It's a hot mess out there.
This whole day is.
Sorry. I was just leaving.
You OK?
I'm good.
I'm glad to hear it.
You get something to eat?
No.
Let's keep going.
OK.
Yeah.
Why don't we keep one in the ER?
Because our intubated patients are usually sedated.
Right.
Maybe you could ease up
with your comments about his weight.
I was just wondering how he got so big
and how we could help.
We can help by finding out what's wrong with him
and treating him with respect.
How's your belly now?
Second pain shot helped.
OK. There's more if you need it.
Diminished bowel sounds.
VidaTalk from the ICU.
Great.
Howard, we need to open up that passageway now
so we can pass the tube.
I'm gonna start with my pinky.
Slowly, over a few minutes, I'm gonna go deeper,
all the way to the back of my knuckle.
Once the tube's through your vocal cords,
you won't be able to talk.
But this is a communication device.
Swipe through the screen for anything you want to say.
Hit the icon, and it talks to us.
I would like some pain medicine.
My pain is a nine.
Can I get it to order a pizza?
There's cell service in the ambulance bay.
I found his sister's new number, left a voicemail.
OK, I'm gonna start.
You ready?
Not really.
Go ahead.
Robby, over here.
Here we go. Head back.
You thinking it's surgical?
I'm hoping for a non-perfed appy.
- Can you do it with a scope? - Possibly,
but he could be treated with antibiotics alone.
And if he needs surgery?
With his size, an emergency open laparotomy,
death rate's close to 50%.
OK, one step at a time.
Let's keep trying his sister every 15 minutes.
She'll get it.
Half the downtime slips are blank.
What are you talking about?
Here and here.
Larry, are you using a felt tip pen?
Maybe.
It's not going through for the copies.
Ballpoint pen only.
OK.
Digby still MIA?
Is that the homeless guy?
We need the bed if he eloped.
- What do you need? - An attending.
- Or a senior resident? - Nope, I'm good.
- Dr. Al-Hashimi, can I present? - Yes.
32-year-old deaf woman with myofascial headache.
Ibuprofen caused gastritis and epigastric pain,
and she vasovagalled, but now pain-free
after Mylanta and a trigger point injection.
Excellent. That can take care of the pain
- for several months. - Yeah.
It shouldn't recur if she keeps her screen at eye level.
There was a delay
in getting an ASL interpreter.
And I almost gave up and ordered
an unnecessary brain and abdominal CT.
Good thing you didn't.
Dr. Al-Hashimi, for you.
Nice job on the trigger point.
Yeah, I know.
How's the T-system going?
- Quick and easy. - Yeah.
On these MDMs, don't just circle your diagnosis.
Also put a backslash through all the ones
that you've ruled out.
No problem.
Thank you very much.
Princess, bump Central 13 to the front of the CT line.
What do you got?
Sudden onset blindness patient
has central retinal artery occlusion.
I just spoke to an ophthalmologist
at the VA, principal investigator
for thrombolytics in cases like this.
Not exactly standard of care.
Kind of risky.
We'll do informed consent.
It's our best shot at saving some of her vision.
Your patient, your call.
I'm not gonna be around long enough for any complications.
I'll be taking two swabs from the vagina,
two swabs from the cervix.
Let me know if you feel any discomfort.
OK.
Each swab gets labeled-- first vaginal, second vaginal.
Smear a slide with both, and let it air dry.
Same for the cervix?
Yeah.
No slide needed.
How you doing, Ilana?
Hanging in there.
OK.
Almost done.
All these samples go in the vaginal contact envelope.
- I can help with that. - No.
It's gotta be me.
I'm gonna pull this out.
OK.
All good here.
Legs can come down.
Are we done?
One last thing.
Four more swabs inside your mouth.
Didn't you do that already?
This one's different-- inside your cheek for your DNA,
not for his.
So it could be bipolar or schizophrenia?
Those are the two most likely possibilities.
How do they know which it is?
Based on response to medicine,
but also with therapy and observation on the ward.
They'll monitor his mood and interactions with others.
Is there a blood test or a brain scan
that will tell us for sure?
Unfortunately not.
When properly medicated, people with bipolar disorder
can have successful careers.
So we hope for bipolar?
You can hope for your son's happiness.
With early treatment, 20% of people
with schizophrenia have a complete recovery.
So 80% don't?
This is a new version of Jackson.
How old was your daughter?
20.
Studying architecture at Georgetown.
Schizophrenia.
I'm sorry.
Oh, she's good.
Living at home, working as a cashier at Giant Eagle.
Employee of the Month.
We still have struggles,
but there's also laughter and love.
Good to go.
How'd that feel?
Very weird.
There's no pain. Just weird.
OK, the next step is, we're gonna take this tube
and pass it through your nose,
stopping at the back of your tongue.
Best not to talk for that.
Tube's soaking in warm water to make it more flexible.
Do you wanna try it?
What day and time is it?
4th of July, 2:31 p.m.
When is my tube coming out?
We have to put it in first.
I know.
Just practicing.
Sounds like you're an expert already.
Before I can't talk,
I just wanna say
thank you for everything.
You're very welcome.
Here we go.
STI prevention.
One shot treats gonorrhea,
then pills for chlamydia and trichomonas.
Thank you.
We also have morning-after contraception.
She has an IUD.
Over 99% effective, not 100%.
We still offer.
I'll pass.
For HIV, we got PEP, Post-Exposure Prophylaxis.
28 days.
The sooner you start, the more effective.
Emma, I'm pretty sure they could use
an extra set of hands out there.
It's nice to meet you, Ilana.
You're a very brave woman.
Yeah.
She's a good nurse.
She's still learning, but she will be.
After this, we're done?
Yeah.
I'm glad you were here today.
Me too.
We have a decision to make.
Studies have shown that some vision
can be restored with a clot-busting medication.
So give it.
But there are possible risks.
For eye stroke, only 17% get better without any treatment.
- Only 17%? - Yes.
But with the medicine, another 20% can improve.
But there can be complications.
2% of patients who receive the medication get worse,
and 1% have severe disability or death.
Honey, this one has to be your call.
No, it's our call.
What would you do without me?
I'd figure out how to get by.
And I'd probably cry for two years solid.
Two years? That's all?
I want the medication.
OK.
OK, we need your full name to make a chart.
Jackie Liddell.
And you are?
Her friend Jaquie.
- You have the same name? - No, no.
She's Jackie with a C-K. I'm Jaquie with a Q.
You can call me CK.
Oh.
Best not to talk, CK, OK?
- Just chill. - Chill?
- Q, I bit off half my tongue! - What?
She said, I bit off half my tongue.
You can understand that?
Oh, you should hear her when she's had
two pitchers of margaritas, fucked up and slurring.
Ooh, you are such an idiot!
Princess, what's open?
South 15's clean.
Deep tongue laceration.
I can jump on this.
Robby and Al-Hashimi are both with critical patients.
Hello.
I'm Dr. Langdon.
I'll be supervising your care.
Jesus, CK, your doctor's fucking hot.
Tube's at 14 centimeters, just above the airway.
OK, Howard, I'm going to start.
If you want me to stop, you just put your hand up, OK?
Blue mark tells me I'm in the tube.
Looks like he cleared it.
If he inhales, we should see chords.
OK, deep breath for me, Howard.
- OK. - Beautiful.
Chords are sensitive, so we spray lidocaine
- in the scope. - OK.
1 cc going in now.
And we'll just give that a second to work.
How you doing, Howard?
Once the tube's in, you'll have to breathe
through your nose.
OK, Howard, hold still.
I am now going in past your vocal cords
until we see the carina.
Ogilvie.
Uh, there.
Right and left mainstem.
And the tube slides in.
And then the scope comes out.
Great.
OK, inflate the balloon.
Deep breath through your nose.
Amazing.
You good?
Great end-tidal waveform.
Does he need a vent?
He's breathing on his own,
but a little CPAP wouldn't hurt.
Starting at 5, titrate to 10.
OK, that went really well, Howard.
Now we're going to check your weight.
So the nurse examiner is supposed
to lock up the rape kit in this fridge,
where it stays until it gets turned over to law enforcement.
It's called preserving the chain of evidence.
Are you fucking kidding me?
Is there a problem?
Jesus Christ.
Police are supposed to pick up the rape kits within 72 hours.
This one I did two weeks ago.
God damn it.
So how exactly did this happen?
We were in between pubs taking a selfie.
Very nice.
Until she jerked her head up.
Ooh.
Ouch.
OK, topical epi did the trick.
- No more bleeding. - Sweet.
I can go home now?
I don't think so.
It looks like the Grand Canyon across the back of your tongue.
We need to put in some stitches.
I don't want stitches.
Oh. Listen to the doctor.
Don't tell me what to do.
This is all your fault.
- No, it's not. - Uh, yes, it is.
- Uh, Princess. - No, it's not.
Princess, hey, why don't you show Q
where she can wait while we patch up her friend?
Of course.
OK, this is a numbing shot for the tip.
The tip?
That's not where I bit it.
One step at a time.
That's 20 migs of TNK.
In at 14:39.
Feeling anything?
Not yet.
Could take an hour or two.
We're going to move you to another room
for better monitoring.
Dr. King.
I'd like you to stay with her.
Why?
In case there are complications.
You'll be there to respond quickly
to a blown pupil, a seizure, altered mental status.
Or I could catch up on my charts.
And my deposition's coming up.
Think of this as a great way to steal some quiet time
and get mentally prepared.
Jesse, Mel's with you.
Oh, excuse me, Dr. Mohan.
Excuse me.
Dr. Mohan.
Uh, in a minute, George.
I've got this.
Thank you.
Oh, uh, I, um--
D-dimer is back normal.
Oh.
I'm ready to go.
Are you feeling better?
I--I really wasn't short of breath this time.
Then why'd you come in?
When I found out about the blood clot in my leg,
I just kept thinking it's gonna go to my lung and kill me.
We've talked before about how the Eliquis would prevent that.
I know.
Well, I finally took your advice.
I got out of the house, and I joined
the Frick Park Lawn Bowling Club.
Wonderful.
Yeah.
I mean, you're right, you know?
We all need a community.
You're gonna do what?
In order to fix your tongue,
we need to move it forward to access the laceration.
You're just gonna feel some pulling, OK?
I guess so.
Go for it.
What size suture is that?
O-silk, the biggest one we got.
As soon as I cut the needle, you're on traction, Joy.
Oh.
That is pretty deep.
And now we can numb up the cut.
It's best to start with--
Proximal side first so she doesn't
feel the distal injection.
Give it ten minutes.
I'll be back for the repair.
I got a rape kit sitting here for two weeks
that was supposed to be picked up within 72 hours.
I don't care!
Get someone over here now! No.
You expect us to treat your officers
as soon as they come in,
you get a detective to pick these kits up ASAP.
I gotta go.
- Dana-- - Hey, Dana.
South 19 got their head CT before we went down.
No results yet.
All right, I'll send a reminder.
- Hey, Dana. - Dana.
Hang on.
What's up?
We put in an order for more pain meds for Roxie.
All right, so put it in the nursing racks.
Oh, I did, a long time ago.
All right. I'll bump it to the front.
Thank you.
Uh, what's that noise?
UFO landed.
Aliens are invading.
Hey, Dana.
Chem 7's not back on Trauma 2 yet.
Let me see the chart.
Oh, Jesus.
I bet your Chem 7 rec went to Radiology.
Larry, Antoine.
You put labs and chest X-ray on the same downtime form.
You need two slips--one for labs, one for radiology.
- Got it. - Won't happen again.
I'll run it down myself.
Use the iStat at bedside.
They won't take him to CT without a creatinine.
Oh, perfect.
Nice to have you back.
Thrilled to be here.
You trying to text?
I am just composing.
I'm gonna send it from the bay.
My mechanic friend, Duke, never showed up.
I thought he was coming in this morning.
That was the plan.
I guess he got busy.
What if he's a no-show?
Tell me what he needs.
I'll pass it on to the night shift.
That won't be necessary.
Oh, Princess.
Ask and you shall receive.
Normal head CT.
Thanks. I'll get him discharged.
How's your day going?
I think I'm getting writer's cramp.
You with the big guy?
Yeah. It's sad.
Bad car accident, multiple operations, tons of stress.
Lidocaine shot to a sensitive area.
I got a binge-drinking party girl with a tongue lac.
Mm.
Sounds like she needs some help.
In more ways than one.
How's, uh--how's your first shift back going?
One day at a time.
First year sober is the hardest.
That's what they keep telling me.
I'm nine years and counting.
Oh.
Special delivery for my guy.
If you, um--if you need anything, call me.
Thanks.
Where are you going?
Blisters in North 3.
That's where I'm going.
Did you sign up for the patient?
I pulled the chart from the rack.
You're supposed to sign up on the dry-erase board.
You're supposed to have a clipboard for the patient.
I thought the nurses had that.
Whatever.
Hi.
I'm Student Doctor Ogilvie.
And this is--wow.
That is some rash.
- Yeah. Tell me about it. - Student Doctor Javadi.
- When did this start? - Last night.
And have you been on any hikes recently
around poison ivy?
Nope. Haven't left the house.
What about new medications, lotions, soaps,
detergents, even?
I don't take medicine.
Nothing new with all that other stuff.
Uh-huh. And where did this start?
Everywhere, all at once.
Just a lot of pain, really itchy.
What is it?
I'm not sure yet.
Um, be back in a second.
Can't--will you--
What are you thinking?
I have no idea.
Agreed.
Bullous pemphigoid?
Autoimmune severe pruritis?
Yeah, but not as deadly as pemphigus vulgaris.
Untreated, the death rate is over 90%.
We need to check for pustules,
mucous membrane involvement--
And the Nikolsky sign.
Here you go.
What?
For your progress note.
Did I hear we're making progress?
Oh, um, it's just what we call it
when we write down things to describe a clinical course.
Any changes?
Not so far.
It's time for the next neuro check.
Excuse me, Dr. King, do you have a minute?
Um, no.
I'm observing a patient right now.
60 seconds tops.
I'll check pupils.
We're good here.
Hey.
I just finished my deposition.
Oh, should I go up now?
Yeah. Just wait until you get a call.
OK.
Well, I'd ask how it went,
but we're not supposed to discuss the case.
This isn't a discussion.
It's a monologue, so shut up and listen.
The malpractice case is frivolous.
The mother of the measles kid claims
we caused intellectual decline
by performing a spinal tap.
But the tap was perfect with no complications.
Her son presented with altered mental status
due to low oxygen from measles pneumonia.
Any change in intellect was due to hypoxic brain injury.
It had nothing to do with your spinal tap.
End of monologue.
We never discussed the case.
I gotta get some sleep.
Thanks, I guess.
OK, are you ready to lay down?
I got your head.
Nice and slow.
One, two, three.
OK.
How's that feel?
Lifting up now.
Keep going.
And... that ought to do it right about there.
215?
Oh, that's in kilos.
OK, team.
It's not that much over 450.
No, we can't risk breaking our CT on a holiday weekend.
Would the medics take him while he's intubated?
If I go along for the ride, I could still get a nap in
before my night shift.
474.
Our CT can't handle your weight,
but we're gonna take you over to Presbyterian Hospital.
Road trip.
I'll keep you company the whole time.
Sorry for all this trouble.
It's OK.
This is what we do.
So sub Q starts deep.
You want to bury the knot.
Yeah, I've done these before.
Joy, how do we cut the ends?
Short. Slide to the knot.
Turn 45 degrees.
Excellent.
Um, Dr. Langdon, we have a case.
It'll have to wait.
It could be urgent.
Find Robby or Al-Hashimi.
This girl is wasted.
Drunk as a skunk.
Should we check her blood alcohol level?
No, it won't change what we do.
She can go home when she has a steady gait.
I already sent one off.
Joy, do you want to guess her blood alcohol?
Why would I want to do that?
I don't know. 'Cause it's fun.
When will you have a bed?
I'm not sure she needs a bed.
She's a febrile infant.
Who is clearly over a month old and looks amazing.
Every marker is normal. She has a cold virus.
Infants with rhinovirus can still have
a serious bacterial infection.
Not this one.
We send kids like this home all the time.
Except this one doesn't have a home or a parent.
All right.
I can't put a kid with a virus in the nursery,
and I can't waste a private room on a healthy baby.
Then what do you propose?
CYF can place her in emergency foster care
by tomorrow morning.
You want to leave her down here overnight?
Seems to be the standard of care these days.
Have your attending give me a call.
Will do.
I can't believe this.
Let CYF know it's very urgent.
Got it.
This is turning into quite the day.
You know, I've been thinking
about applying for a fellowship.
I thought you had a job lined up in New Jersey.
I did, to be close to my mom.
But she sold her house to travel the world
with her new boyfriend.
So what's the point of New Jersey?
Yeah, good question.
Which fellowship?
I've narrowed it down to ultrasound, toxicology,
and sports medicine.
Those are very disparate fields
leading to very different careers.
I know.
I'm a little undecided.
Do you have research experience?
I was a part of a study on racial disparities
in health care until the White House
cut the funding last year.
Yeah. You are not alone.
Have you considered a geriatrics fellowship?
I have not.
I've seen your skills with the elderly,
and there are a lot of openings.
It might be your best shot.
Think about it.
Last stitch.
You want me to cut?
I got it.
It looks good.
OK. Let's pull the traction suture.
With pleasure.
OK, Jackie.
- Jackie. - Stop it.
Stop.
All done.
All done with what?
Sewing up your tongue.
What happened to my tongue?
You bit it.
Ha.
No, I didn't.
That is called a blackout.
How much did you drink?
A couple Bloody Marys.
Only a couple?
I don't know. Maybe more.
It's a holiday, a pub crawl.
Do you usually have a couple cocktails every day?
Only on weekends.
How about during the week?
Nothing much.
Just wine with dinner or a few beers.
Maybe we should recommend rehab?
Yeah.
We could try.
Ready to roll.
How are you feeling?
My pain is a two.
We got meds if you need them.
Scan will be quicker than the ride to Presby.
We'll keep trying to reach your sister.
- You guys are the best. - See you later.
Can I put a new patient in T1?
Uh, no, I kind of want to leave one trauma room open.
Why don't you double up the north if you have to?
Mr. Digby?
- It's just Digby. - Right.
We've been looking all over. Where you been?
With Louie.
You've been in there for an hour?
He was my friend.
- I had a lot to say. - Hmm.
Well, let's get you back to your bed.
Louie got his wings.
- Dr. Robby. - Dr. Robby.
We picked up a patient together.
Teamwork!
It's a concerning bullous rash.
We might need a biopsy for pemphigus vulgaris.
It's phytophotodermatitis.
- What? - I asked.
He was making three gallons of margaritas for a party,
squeezing fresh limes out in the sun.
Let's go take a peek.
I don't need to see it again.
How's it going out there?
Standing room only.
If I call the fire department, will they clear
- that waiting room? - I wish.
What's up?
12 patients need med refills.
Shouldn't they see their doctors?
With the Medicaid cuts, we are their doctor.
No, I can't e-prescribe to their pharmacies.
So get out your pen. Go old school.
Dana, on what?
Nordt, you got the security pads?
Sure do.
Just need a patient sticker.
- Any other questions? - Yeah.
What would have happened if you weren't here today?
You'd all be curled up in the fetal position,
crying like babies.
Were you wearing flip-flops?
I was.
- What is it? - Phytophotodermatitis.
Otherwise known as margarita burn.
For some people, limes plus sunshine
can cause a horrible rash.
This is all because of limes?
Have you ever squeezed limes outside in the sun before?
I don't think so.
You will feel better after a day of steroid pills.
But once these heal, you gotta wear sunscreen.
Because these blisters can turn into dark scars
and stay a while if you don't.
I'll be right back with your aftercare instructions.
- Hey, Robby. - Yep.
My, uh-- my hospice patient Roxie
is still in a ton of pain.
Where are we with the morphine?
10 milligrams an hour.
OK, you can bolus another 2 and go up to 12.
I will let Princess know.
12 an hour is a lot.
Yeah, on top of the MS Contin,
she could stop breathing.
Are you familiar with the doctrine of double effect?
- Not really. - No.
It is an ethical principle in palliative care.
We treat pain.
And if, in doing so, there's a negative side effect,
we accept it.
Even if the negative side effect is death?
In some cases, that could be the best outcome.
Maybe the nurse has it.
Emma. Emma, where does--
Maybe the fax ran out of paper?
No, there is enough paper. I don't know what's wrong.
- Could be in another room. - We should call IT.
You want me to check every room?
How are we gonna get through this mess?
I was about to ask you.
Ask the pharmacist.
She can't leave the PDS.
Nothing's getting done here.