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00:14Robby.
00:14Yep.
00:16Cellulitis on the dorsum of the foot, now spreading up the leg.
00:20Hello, I'm Dr. Robby.
00:21I wonder if I take a look?
00:23How long do you think this is going to take?
00:25I took an early lunch break.
00:27I don't know that you're going to make it back to work today.
00:31Erathema and Worm's halfway up her knee.
00:33When did you see her, Donnie?
00:34He didn't, I did.
00:36When?
00:37About four hours ago, I gave her a dose of Keflex, told her to come back if things got worse.
00:40Things have definitely gotten worse.
00:43Data, what's open?
00:43Trauma 2.
00:44Jessie, can you get her starting Trauma 2 with some Banco and Blood Cultures piece?
00:47Got it, boss.
00:48You coming with?
00:49Suit yourself.
00:51Santos, you want in on Trauma 2?
00:54Uh, too much starting, too little time.
00:5762-year-old male presents with chief complaint of left lower back pain.
01:02Consider the diagnosis of Jesus Christ.
01:05I'm charting.
01:06Sorry.
01:09Did I do something wrong?
01:11Besides interrupting me, probably.
01:12Then I apologize.
01:14I know that second year of residency can be stressful, so if there's anything I can do to help you,
01:21like stop talking?
01:22That's a great idea.
01:23Yeah.
01:25Consider the diagnosis of aortic aneurysm or dissection.
01:29Got a new one for you in 13.
01:31I'm 20 charts behind.
01:35Crying me a river, old lady with bad abdominal pain.
01:37Somebody's got to see her.
01:38Dana, please do me as holiday.
01:40Holiday weekend.
01:41Westbridge is down in our waiting room.
01:42One's on overdrive.
01:43I'm sorry, but your charting's going to have to wait until after you're shipped.
01:48Ogilvy, Dr. Santos needs you to pick up a new patient in 13.
01:53Yes, ma'am.
01:54I'm on it.
01:56Try it while you supervise.
01:58Best I can do.
01:59I'm not going to pay for money.
02:01And that's just trying to help him.
02:03Setting up a GoFundMe, that's what our generation does.
02:06That's how they support each other.
02:08Doctor, tell him.
02:09Your wife's right.
02:10Staying here is going to cost more than we can afford.
02:12Look, I'm feeling better.
02:14I'll just leave.
02:16Mr. Diaz, even if your blood sugar is back to normal, we have to continue with the insulin drip
02:21until we clear the ketones from your bloodstream.
02:23Otherwise, you could experience electrolyte disorders, heart and kidney problems.
02:26Your health is what matters.
02:30I'll make you a deal.
02:32You agree to stay on the insulin drip, and I'll go find our case manager to discuss cost-cutting options
02:36for your stay.
02:37Deal.
02:38And I'm sitting here making sure he doesn't move.
02:40You should go look for Anna.
02:42Mm-hmm.
02:43I can find her.
02:44BRB.
02:47Hang in, Vanko.
02:49What Vanko?
02:50A really strong antibiotic to kill skin germs.
02:53Need a hand?
02:53Uh, no.
02:55We got this.
02:55I'll just observe.
02:57Pretend I'm not even here.
02:58Uh, let's send off a CBC, blood cultures, and CMP.
03:02And also a lactic acid, CRP, and calcitonin.
03:05She's not febrile, not tachycardic, no evidence of SIRS.
03:09Yep.
03:10What SIRS?
03:11Systemic inflammatory response syndrome.
03:15Sorry.
03:15An exaggerated defense response.
03:17Sorry, a what?
03:18Sometimes the human body can have an overreaction to an infection, so we're going to monitor you and make sure
03:23that this does not progress.
03:27It's my boss.
03:28Sorry.
03:29I have to take this or he's going to fire me.
03:32Hello?
03:34Uh, no.
03:35I'm still at the hospital.
03:37I'm being seen right now.
03:39Ow.
03:40They just stuck me with a needle.
03:43Um, I don't know.
03:45You want to talk to them?
03:48They're kind of busy right now.
03:51I know who you are.
03:52Second IV's in.
03:54Well, I'm not overreacting.
03:55My body's overreacting.
03:58Please, please don't fire me.
04:00I...
04:00This is Dr. Michael Rabinovich.
04:02I am the chief of emergency medicine at PTMC.
04:05If you fire her, she will sue you, and I will testify on her behalf.
04:10Okay.
04:12Don't worry about it.
04:13We got you.
04:19Do you know how long Jackson's going to be asleep?
04:21So, there's no exact timeline that the sedatives we gave him, but he should be awake soon.
04:26Have you spoken to your parents yet?
04:27Yeah, they're on their way back from Columbus.
04:29Maybe you should take some time for yourself before they arrive.
04:32Um, yeah, a cafeteria's right down the hall.
04:34Decent grilled cheese.
04:35Stay away from the tuna.
04:36Thanks, but I'm not hungry.
04:39You know, I just can't believe that a campus security guard tased my brother.
04:43Aren't they supposed to be helping students and protect them, not shoot at them?
04:46You have every right to be upset, and you should absolutely pursue accountability.
04:51But right now, we are taking care of your brother, and you should really take care of yourself.
04:56I have your number.
04:57I'll text you as soon as Jackson's LP results get back, or if he wakes up.
05:02Okay.
05:04Okay, thank you.
05:05Of course.
05:09Uh, hypoactive bowel sounds, soft with moderate tenderness in the left lower quadrant.
05:14Uh, Mrs. Randolph, do you take Percocet every day?
05:17No.
05:18Huh.
05:19And what about your water intake?
05:20Pause.
05:21Mrs. Randolph, you said you don't take Percocet every day, but when was the last time you took some?
05:26Uh, maybe three or four times last week.
05:30Yeah.
05:30Assisted living, had a ballroom dance competition, and I tweaked my back.
05:35Mm-hmm.
05:36Any further questions, Ogilvy?
05:38Uh, when was your last bowel movement?
05:43I don't know.
05:44Sometime last week.
05:46I've been stopped up for at least five or six days.
05:49Mm-hmm.
05:50Painkillers can cause constipation.
05:52I know.
05:53That's why they put me on a stool softener, and then they tried an enema.
05:58And no movement?
05:59Sip.
05:59And then they gave me this horrible drink.
06:03Magcitrate.
06:04Yeah.
06:06Magcitrate.
06:08Maybe puke.
06:09All right, what's next, Ogilvy?
06:11Let's get you an x-ray and see how we can help you, Mrs. Randolph.
06:17Differential?
06:18Uh, probable stool impaction, but with her history of cholecystectomy, it could be small bowel obstruction.
06:23Or worse.
06:25Sigmoid volvulus?
06:27But that's a surgical emergency.
06:29Wouldn't you have tons of pain?
06:31Not always, especially when you're in your 80s.
06:40I am getting concerned.
06:42This is a millimeter past the line.
06:44Or my line was sloppy.
06:45Any increase in pain?
06:46Oh.
06:47Okay, sorry.
06:48Let's try fluoromorphine.
06:49White counts only 10,000.
06:51It'd be over 12 for SIRS.
06:53There are other criteria.
06:55She's still afebrile.
06:56Did you ask about past history of MRSA?
06:57Not specifically, but she's never been hospitalized.
06:59Are you evidence of an immunocompromised state?
07:01No, she's healthy.
07:02Steroid use.
07:02Never.
07:03Maximum heart rate's only 89.
07:05Is that okay?
07:06That's good.
07:07Very good.
07:08Stay with her.
07:09Monitor her closely.
07:10If there's any change in her condition, you can't find me.
07:12I mean, any change.
07:17Roxy Hamler, 42, home hospice patient with a history of lung cancer.
07:21New onset tonic-clonic seizure with right lower leg pain.
07:24She hid it on the coffee table.
07:28Initially non-verbal, now coming around.
07:30That's normal after a seizure.
07:31Hi, I'm Dr. El-Hashimi.
07:32Do you need a hand?
07:33Nope, we got it.
07:34She hid her hand?
07:35No.
07:35I was there.
07:36I caught her.
07:37No IV?
07:37Couldn't get one in.
07:38Give her four of I and Berset for the seizure.
07:4025 of Fent for the pain.
07:42See number two?
07:43Drama one.
07:44This way?
07:44Haven't seen you guys in a hot minute.
07:47Pick up from SCI Jones Forge.
07:50You're supposed to go to Westbridge.
07:51We got it diverted to you.
07:52Yeah, you and everybody else.
07:54Princess, I need you to pivot to Central 9.
07:55Got it.
07:56Gus Varney, 54, victim of assault with diffuse blunt trauma.
08:00He's got bruising to the face, the right chest, 10-centimeter laceration to the left arm.
08:03VPs 136 over 84, pulse 102, good stats, 95 on Romare.
08:07How you feeling there, Mr. Varney?
08:09Fucking hurts.
08:10Where?
08:11Everywhere.
08:12I am Dr. Robbie.
08:13This is Dr. El-Hashimi.
08:14We'll get you something for the pain.
08:15I've got a progressing cellulitis.
08:17Go, I'm good.
08:19Gus, do you know who hurt you?
08:21One of the fine, upstanding citizens of cell block 6.
08:24It's a deep lack in the through the muscle fascia.
08:27Can we get the cuffs off once he settles?
08:29Not a chance.
08:30Orange jumpsuit, he's cuffed for a reason.
08:31Let's go.
08:44Okay, everyone, on my count.
08:47One, two...
08:49Hold on.
08:54Go.
08:55One, two, three.
08:58Eat fast.
08:59Whitaker, primary assessment.
09:01On it.
09:07Oh, weird bruise.
09:08Did he fall on something?
09:10Footprint.
09:10Got stomped.
09:11Jesus.
09:14Is that necessary?
09:16Afraid so.
09:17Oh.
09:18Airways patent.
09:21Good lung sliding on the left.
09:24Sorry.
09:25Good on the right, too.
09:26How are the lungs?
09:27Good breath sounds.
09:29No crepitus.
09:30No fusion.
09:31Pulse ox 97, BP 118 over 78, heart rate 112.
09:35Tachycardic from the pain.
09:36Start with four of morphine, repeat PR.
09:37On it.
09:38Okay.
09:39Swollen mandible.
09:41Open your mouth for me, Gus.
09:43Little wider.
09:44Can't.
09:45Whitaker, you know the tongue blade exam?
09:47Yeah.
09:47It's a great test for a mandible fracture.
09:50Gus, bite down hard on this for me.
09:55Sorry, Gus.
09:56Positive test.
09:58No free fluid in the belly.
10:00Any idea how long this will take?
10:01Too soon to tell.
10:02Whitaker, your assessment?
10:03Fractured left mandible, multiple rib fractures.
10:07Complex forearm lack.
10:09Okay, log roll to the left, then pan scan.
10:11Where were you when Mr. Varney got assaulted?
10:13I just move him.
10:13I don't get to know him.
10:14CT's ready for us.
10:16Cycling the BP.
10:17Okay, this redness is now a centimeter over that line,
10:20and this might be a bullet forming.
10:22Vanko takes a little time to work.
10:23Vital signs are still stable.
10:25122 over 78.
10:26I got it.
10:28How are you feeling, Debbie?
10:31I'm feeling a little warm.
10:32That can happen with Vanko.
10:34Thanks, man.
10:36Lactic acid, 4.2.
10:38Uh, okay.
10:40What's wrong?
10:41That can be a sign of a more serious infection,
10:43but the good news is we know what to do.
10:45Jesse, two liters of LR wide open?
10:48This is severe substance.
10:50I know, but at 7 a.m.
10:51it was a simple cellulitis.
10:52Anyone want to give her her Keflex?
10:53We could add carbapenem or zoosin
10:55and broaden our antibiotic coverage.
10:56Thanks for coming.
10:57I got it.
10:58Thanks.
10:59Jesse, one gram meropenem,
11:01900 milligrams,
11:02Clinda and Paige Dr. Garcia, please.
11:04What's going on?
11:05We're adding new antibiotics.
11:07It's serious.
11:08We want to get ahead of it
11:09and make sure it doesn't become serious.
11:13What else can I do?
11:14I think you've done enough.
11:15You can go.
11:20All good in there?
11:21Code sepsis.
11:22Stable for the moment.
11:24How about you?
11:25Perfect vitals.
11:26E-FAS negative.
11:26Off to CT.
11:27Good.
11:28Keep me posted.
11:30Ditto.
11:35How's it going?
11:36Great.
11:37If you ignore the hot mess in chairs.
11:39Any update on our little baby Jane Doe?
11:41Security's reviewing the CCTV
11:42from last night and this morning.
11:46You two kissing Mike up yet?
11:47I think someone needs to smoke a cigarette.
11:49I'm trying to quit.
11:50Why don't you quit when I'm on my trip?
11:52Everyone's glad to have you back.
11:54Well, not everyone.
11:57Hey, you winning on this betting board?
12:00Look, all you got to do is pick why Westbridge went down,
12:03how many of their patients we're going to get,
12:04and when they'll be back in action.
12:06Hey, already up to $500.
12:09Oh.
12:10I got a pass.
12:11Still catching up on rehab bills.
12:13Respect.
12:17All right.
12:18What's the ruse on me changing my bet?
12:20And only if you double down.
12:24Cinco.
12:28You watch too many movies, man.
12:32Considered the diagnosis of aortic aneurysm or dissection,
12:36but the point of care ultrasound was negative.
12:38Don't want that good luck, granny.
12:40Ordered an acute abdominal series to rule out
12:42obstruction still waiting on the x-ray.
12:44Then you're free to treat our latest and greatest in SAS 16.
12:47Oh, come on, D.
12:48It's like every time I get a moment to chart,
12:50I barely get a sentence out before I get interrupted.
12:54Sucks to be you, but trust me,
12:55it sucks worse for the poor gal in 16.
12:58I'm beginning to think you enjoy your drinking.
13:00Burks to the job.
13:03Wumblebee, let's go.
13:07Hold out your hand, Louie.
13:11A little shaky.
13:13I'm no surprise.
13:14I've been here since 4 a.m.
13:16We can get you something, then.
13:17Oh, I can take care of myself
13:18if you cut me loose right now.
13:21Let's get Louie 50 milligrams of Librium.
13:23I'll put it in the order.
13:27I will get it from the PDFs.
13:33I'm already assigned as Louie's treating physician,
13:35just to make sense that I put it in.
13:38Yeah, yeah, yeah, of course.
13:45Uh, any changes with our septic waitress?
13:48Not yet.
13:48Wait, if you have a sept, I...
13:50I don't.
13:50The point-of-care ultrasound was negative for both.
13:54I considered the diagnosis of Cotacquina syndrome.
13:56You wrote the great American novel?
13:58Um, charting and supervising.
14:01It's Dana's idea.
14:02Who is the lucky patient?
14:04An unhoused woman with a bad cough.
14:06Ogilvy's all over it.
14:07Okay.
14:12Okay, deep breath in.
14:14Blow it out real hard.
14:16You haven't heard enough already?
14:18I need to check for wheezing with forced exhalation.
14:25Cough is killing me.
14:27You smoke, Mrs. Yardley?
14:29Yeah, but I haven't been able to for a couple of days
14:31because of this cough.
14:32You ever consider quitting?
14:34You ever consider minding your own business?
14:42Well, the good news is that your test from earlier
14:44came back negative for both COVID and influenza,
14:46but I'm going to order a chest x-ray
14:47so that we can see what's really going on in those lungs.
14:49You got time to let us do that?
14:52Where the fuck else you think I gotta be?
14:56Yeah, we're in three grams of cap room for ten minutes.
14:59That'll prevent another seizure.
15:02Nobody can ever get an IV in her.
15:04Yeah, midline cath is the way to go
15:06when your veins are shot.
15:07Tacking to 114, BP 94 over 70,
15:11sat 91 on two liters.
15:13Cool.
15:14Is it possible to get her a blanket and some socks?
15:18Can do.
15:20When was she diagnosed?
15:22Seven years ago.
15:24Reset did a lobe.
15:27Four cycles of platinum chemo gave us a couple good years,
15:30but then it spread to the bones.
15:32Has she had radiation therapy?
15:34They shrunk down the mats, but they're still there.
15:37That's why you're at hospice at home.
15:39Yeah.
15:39I'm sorry.
15:41Me too.
15:45I'm sorry.
15:46You have kids?
15:48Two boys.
15:50Fifteen and nine.
15:52My son's 12.
15:54Goes fast.
15:56Too fast.
15:58Swelling and bruising over the distal tibia?
16:01Uh, uh, 50 of fentanyl.
16:04What's this?
16:04All except for 100.
16:06What do you usually take for a pain?
16:10Uh, MS-contin, 30 milligrams twice a day,
16:14oxycodone for breakthrough,
16:15and sublingual lactic for, um,
16:18when it gets really bad.
16:20That's a lot.
16:21You handle pain meds?
16:23Sometimes.
16:25All the time.
16:26A hospice nurse comes by a few times a week,
16:29but I was alone when she had the seizure.
16:32They told us that it could happen,
16:34but she couldn't breathe.
16:38911.
16:39I'm so sorry.
16:42I'm sorry.
16:44I'm sorry.
16:55Due to your family income,
16:57you make too much to be eligible
16:59for either Penny or the hospital's charity care.
17:02But we can't afford health care premiums.
17:05It's unfortunately very common
17:07for people to fall between the cracks.
17:09It's an imperfect system.
17:11Can PTMC help with the cost in any way?
17:14We can offer financial assistance.
17:16You'd pay the same that Medicare or Medicaid would pay.
17:19How much is that?
17:20You pay 60%.
17:21We cover 40%.
17:26Uh-huh.
17:29Where have you been?
17:31How are you doing?
17:32I'm sorry, Minita.
17:33You were being thoughtful.
17:35I just blew up.
17:37Well, Ms. Noel was just telling us
17:39that the hospital is going to give us a big discount.
17:41We can knock 40% off your final bill.
17:44That's great.
17:45Mm-hmm.
17:46I stay here for a few days.
17:47My bill could be over $100,000, right?
17:51Yes, unfortunately.
17:53It could end up being lower
17:55depending on your level of needed care.
17:57Or higher.
18:00So we would still have to pay $60,000,
18:04which we don't have.
18:05He has to stay here to get better, right?
18:08Yes.
18:08No.
18:10Excuse me?
18:11I mean, not necessarily.
18:14Couldn't we just admit him to med-surg instead of ICU?
18:16Wouldn't that be a lot cheaper?
18:18Med-surg won't accept him with an insulin drip.
18:20They're usually true,
18:21but let me talk to the chargers upstairs,
18:25and I'll see what she says.
18:30Food poisoning in the whole jazz skin to leave.
18:32Wants to take her kids to the water park.
18:34Those places are cesspools.
18:37Be tuned to the choir.
18:38If she's feeling fine on his own friend,
18:39she's good to go.
18:40All right.
18:41Louie's in South 15.
18:42Meds are coming down.
18:43Another couple hours to monitor,
18:44and then he can brew.
18:45Straight to the liquor store.
18:46Don't pass a go.
18:47What about that clamshell case that went up?
18:49What do you think?
18:50Out of surgery, in recovery, still sedated.
18:52Good.
18:53Keep me posted on that.
18:54I'd love to.
18:57Three times in one day,
18:59to what do we owe the pleasure?
19:00I came down for a consult,
19:02and to persuade Ahmad to start a new bedding board.
19:05Why is the Westbridge board full already?
19:07I was going to ask him to start one about you
19:08and your midlife crisis trip.
19:10I give up four weeks.
19:13Seven tops.
19:15Gee, you have little faith.
19:16Not about faith, just facts.
19:20Based on my experience,
19:21you're a seven-week-age kind of guy.
19:24Hey, Robbie,
19:24a med student's got a pickleball player
19:26in the North Hall,
19:27a possible Achilles rupture,
19:28asking for your opinion.
19:29Thank you, Perla.
19:30Somebody down here has a little faith in me.
19:35You know what motorcycle mic sabbatical's really about?
19:38I never try to guess what's going on in that head of his.
19:41Three months being on the open road by himself.
19:44The man can't stand to be alone
19:45for more than a few hours,
19:46and he sleeps with the TV on in his bedroom.
19:49I really don't think I needed to know that.
19:54Maybe he's looking for something now.
19:56We're trying to outrun some old ghosts.
19:59I hope he finds what he's looking for.
20:03The man deserves some peace.
20:05Amen.
20:05I consider the diagnosis of caudaquina syndrome,
20:09but the motor and sensory exam were both intact in the...
20:13Our unhoused coffer has pneumonia.
20:14I'm cursed.
20:15Fucking cursed.
20:17Fuck.
20:20That is a cavitary lesion in the right upper lobe.
20:24Active TB.
20:25What's next?
20:27Uh, AFB stand to confirm.
20:29Move her to a negative airflow room.
20:30Start her own meds.
20:31Call infection control and public health,
20:34and now you get to sign in as a patient
20:36and get your blood drawn for a quantifier in gold.
20:38It's too soon to be positive.
20:40Yeah, but you were exposed.
20:41You need a baseline test,
20:43and then again in eight weeks to see if you convert.
20:46And if I do?
20:48Then meds every day for three or four months
20:50with regular blood tests to check for toxicity.
20:53Jesus.
20:54All right, let Dana know what's up,
20:55and for the love of God, mask up when you move her.
21:07Dr. Langdon.
21:08Hey, man. Alex.
21:10Let's take a look.
21:14Ah.
21:16Is it bad?
21:17It's not good.
21:19Sorry, your chart says you were burned with dry ice?
21:21What happened?
21:22My jack-off, brother.
21:23Does he not like you?
21:25I asked him to do it,
21:26just not like this exactly.
21:28What? Why?
21:29He was going to brand me like I branded him.
21:32Brand? Like cattle?
21:34Instead of hot branding,
21:35you stick the iron in dry ice,
21:37let it get super cold,
21:38and then you put it on your skin.
21:40Cool, huh?
21:41I don't know.
21:43Let's get some lead on this.
21:44I'll get some snips to debride.
21:48You good?
21:49Uh, yeah.
21:50Yeah, good.
21:52You sure?
21:53Doesn't seem like Robbie's all that happy I'm back.
21:57Well, he's not going to be here,
21:59and I'm happy you're back.
22:01Thanks.
22:07Head of neck CT is negative except for mandible fracture.
22:12Let's get him off the board.
22:14Roll him right side out.
22:15Hey, we're going to need the cuffs off.
22:20Ready?
22:20And one, two, three.
22:23Ah, gentle.
22:23Ah!
22:25Dr. King, how are the chest and belly?
22:26Uh, we have three anterior rib fractures
22:29and a small pulmonary contusion.
22:32Not too bad.
22:33When do pulmonary contusions peak?
22:35After a few hours.
22:36And do we always admit for a three rib fracture?
22:38Uh, in the elderly, yes,
22:39but not if a patient can manage the pain
22:41and doesn't need supplemental oxygen.
22:42Good.
22:44Okay, he's really hurting here.
22:45You think you could set us up
22:46with a serratus anterior field block?
22:48No problem.
22:49Oh, uh, as long as that's okay with Dr. Al-Hashimi.
22:52If the patient consents.
22:54Mr. Varney, we want to give you a shot
22:57to numb your broken ribs so you can breathe easier.
23:00Okay, get Mr. Varney prepped and draped.
23:02Dr. Mohan, you're in charge.
23:03Let's identify the landmarks.
23:05Cuffs?
23:08Yeah, you can just leave him off, man.
23:09He's clearly not moving on his own.
23:11Listen, we follow protocol for his safety and yours.
23:19Do you need to get that?
23:21Nope, it's my mom.
23:23Ignore it, just ignore it.
23:26Amen, sister.
23:27Forum is numb, we can irrigate.
23:28If I ignore a problem for long enough,
23:30it just goes away, right?
23:32I wish I could ignore my deposition.
23:34That you can't ignore, but you'll be fine.
23:38What's up with you, Whitaker?
23:39Trouble in rooming land?
23:40No, not really.
23:42I think I overstepped with Dr. Langdon earlier.
23:45Oh.
23:47He was trying to prescribe the patient benzos,
23:50and I told Langdon that it'd be better if I did it.
23:53Oof.
23:53Only because I was already the assigned physician.
23:56But yeah, now I feel like an asshole.
23:58Langdon's fine.
23:59He went to rehab, he's working the steps,
24:02and hopefully it's all behind him.
24:06Place the needle in plane, superficial to the serratus anterior,
24:10between it and the latissimus dorsi.
24:12Mm-hmm.
24:13You can see the fluid dissect and diffuse.
24:16Dr. Mohan, we need you.
24:17We've got two more rigs from Westbridge pulling up right now.
24:21Go.
24:21We got this.
24:22Thanks.
24:23How are we doing in here?
24:25Uh, spiked attempt to 102, gave Tylenol.
24:29Check out her leg.
24:31That is a definite bullet.
24:33Did surgery come down yet?
24:34Not yet.
24:35I need surgery.
24:36Page up again.
24:37Surgery would be a last resort.
24:39We would like them to come down and check out your leg
24:42in case we need to remove this infected skin.
24:44I thought it was just a little swelling
24:46because I'm on my feet all day.
24:49CP's down to 85 over 40.
24:50How much LR is it?
24:52Full bolus.
24:52You know the leader.
24:53Let's start levofed titrate to a man with 65.
24:56Can someone please tell me what's going on?
24:58Postdoc's down to 89.
24:59100% non-rebreather.
25:01Sometimes an infection can cause your blood pressure to drop
25:04and lower the amount of oxygen in your blood.
25:06Am I going to be okay?
25:08We're doing everything that we can to make sure that you are.
25:10Jessie?
25:14What's up?
25:15Be ready to intubate if you need to.
25:17You want me to call Langdon?
25:18No, I will be right back and you can call surgery
25:20and tell them to get their heads out of their asses
25:21and get down here.
25:32Did you bring Langdon back here?
25:33No, Al Hashimi did.
25:34You banished him to Scott Purgatory.
25:36He did everything you would have done with that cellulitis patient.
25:38If you think he missed something, tell him.
25:40Well, we're probably going to need to intubate.
25:42We're definitely going to need an ICU bed.
25:43What happened?
25:45She is in septic shock on pressers.
25:47Open shoulder dislocation is back.
25:49Westbridge shut down all their ORs,
25:50so they told us to bring him back here.
25:52Are you joking?
25:52This ain't the Radisson.
25:54Not my problem.
25:54Where should we park him?
25:55Grab a wall.
25:56On the well, call ortho.
25:57Call the OR and tell him we got a patient back
25:59that needs surgery and admission.
26:00Hey, so sorry about this ambulance tour
26:03of Allegheny County, Mr. Billings,
26:05but we got you from here, I promise.
26:06Yeah, I'm starving.
26:07Is there any way I can get something to eat?
26:09Sorry, not before surgery.
26:11Can I have a visitor?
26:12Sure.
26:13Any word from Gloria about what's going on at Westbridge?
26:15Radio silence from the Ivory Tower
26:17and the charge nurse over there isn't responded.
26:19Must be bad.
26:20I wonder if it's something that security needs to know about.
26:22I keep you posted.
26:23Hey, you're kind of buds with Gloria.
26:25Did she say anything to you about what's happening at Westbridge?
26:27No, you?
26:28Nope.
26:29How are your patients?
26:31Our prisoner, Gus, has stable injuries
26:33and our law student in Central 10 is awake,
26:35normal LP, and awaiting a psych consult.
26:38Good.
26:38The quicker we can treat him, street him,
26:40move him up the food chain, the better.
26:42Question.
26:44Why are you treating me like one of your residents?
26:48I'm not.
26:49As the attending, I'd like to know the status
26:51of all the patients and doctors in the ED
26:53in case I need to jump in quickly.
26:55Makes sense.
26:56Now your turn.
26:59What?
27:00As your fellow attending in our ED,
27:02it only makes sense for me to know the status
27:04of all the patients and all the doctors
27:06in case I need to jump in on a moment's notice.
27:10Touche.
27:13You have a non-displaced fracture, distal tibia,
27:16so if you look at the bone here, it's pretty well aligned.
27:18Sorry, hi.
27:20Hi, I was in the shower
27:21and I came as soon as I got Paul's message.
27:24Lena?
27:24Hi.
27:25What happened?
27:27I had a seizure.
27:29You load her with Capra?
27:30Uh, yeah.
27:31Yeah, she's back to baseline mental status.
27:33I'm sorry I'm confused.
27:35Aren't you off duty?
27:36I'm Roxy's death doula.
27:39Her what?
27:40I help advocate for people like Roxy
27:43to make their transition to death
27:44a more peaceful process.
27:46It's like a birth doula, but for the end of life.
27:48She's been a real lifesaver for our family.
27:52My husband cracking jokes while I'm dying.
27:55See why I married him?
27:57Whatever you have to say about my condition,
27:58you can share with Lena, too.
28:01Um, we were just explaining that Roxy
28:02has a pathological fracture through a metastatic lesion.
28:05Can you fix that?
28:07The bones are well aligned,
28:08so she won't need surgery.
28:10The treatment is immobilization and a long way.
28:12Ah.
28:14Maybe we up her pain.
28:16Uh, yeah, sure.
28:17We could do that.
28:19The bones should heal in about six weeks.
28:21If I live that long.
28:25You still know I'm here?
28:27Yeah, yeah, bro.
28:28Great.
28:30You think it's gonna leave a scar?
28:32I don't think it.
28:33I know it.
28:37Holy shit.
28:37What the fuck are you doing here?
28:40I'm sorry, who are you?
28:41Concerned brother.
28:42That looks not too bad.
28:44You good in me?
28:46Yeah, it's nasty.
28:47Thanks to you.
28:49Wait, you did this?
28:50Oh, yeah.
28:50You want to see the video?
28:53Yes.
28:54Definitely.
28:55It's you.
28:58All right.
28:59All right, I'm getting close.
29:01Brothers unite!
29:02Oh!
29:04Dude.
29:05Why in the world would you ask to have that done to you?
29:08He was trying to brand me with our family crest.
29:13Your family crest is the Penguins logo?
29:16We were gonna be bonded for life.
29:17You already are.
29:18With DNA.
29:19Yeah.
29:20I love you, man.
29:22I'm real sorry.
29:23It's okay.
29:24Doc said it's gonna take some time, but it'll heal okay.
29:28Awesome.
29:29So maybe we can try again in a couple of months, or...
29:31No!
29:34Okay.
29:37Yellow on the end title?
29:39Sorry.
29:39Got it backed up.
29:40Sounds a little wet.
29:41Someone asked for a surgical console?
29:42Yeah, it's because of all the fluid.
29:43Here are the lines for now.
29:44And setting 50% title volume 500 AC 12?
29:47Yep.
29:47That's perfect.
29:48Surgery here.
29:49Hello?
29:49Hey!
29:50It's about time.
29:50Where's Garcia?
29:51Stuck in the R.
29:52She sent me down.
29:53What you got?
29:53Septic shock.
29:54Respiratory failure.
29:55Impossible necrotizing fasciitis.
29:56She needs to go to the R.
29:57ASAP.
29:58The infection was isolated at the dorsum of the foot five hours ago, but now we're almost
30:02to the knee with bullet crevice and edema.
30:03Yeah.
30:04You seen neck fascia before?
30:05In a textbook.
30:06I was a med student two weeks ago.
30:10I've got to show this to Dr. Garcia.
30:12Okay.
30:12Jesus Christ.
30:13Go get anybody else from your service down here.
30:15Shamsie, Miller, Walsh.
30:16I don't know any of those people, but...
30:17Don't take this personally.
30:17I just need a fucking grown-up down here.
30:21Nice job on the sub-Qs.
30:23Really took the tension off the wound.
30:25Thanks.
30:25I can help with the skin layer.
30:28Forehands are faster than two.
30:32Whoa.
30:33Whoa.
30:34That just tore right through the skin.
30:36May need to take bigger bites farther away from the wound edges.
30:39Yeah.
30:41Skin seems pretty fragile.
30:46Ah.
30:49Oh.
30:50Yeah, this is not working.
30:52He has the skin strength of an 80-year-old.
30:54Put down steristrips with benzoin, not across the wound, but along each wound edge, both sides.
30:59It'll hold the sutures.
31:01Yeah.
31:02What say you, Dr. Robbie?
31:04Great.
31:05MacGyver move.
31:06Go for it.
31:09Does Dr. MacGyver work here?
31:13I don't know.
31:15The patient's symptoms are consistent with lumbar radiculopathy at L4, L5, most likely due to disc herniation.
31:22Coughing patient admitted to isolation for verified medication administration and started on right therapy.
31:26Yeah, why do I even bother?
31:28Just fail me now.
31:29Okay.
31:30Get in touch with a social worker.
31:31They're going to want to do contact tracing and help her figure out transitional housing for when she's discharged.
31:36Got it.
31:37And make sure infection control responded.
31:39The people in the waiting room could have been exposed.
31:41Those they need to be notified and tested.
31:44Okay.
31:48Relax.
31:49You can take the mask off.
31:49You don't have TB.
31:51At least not yet.
31:54Oh, great.
31:57This is fucked up.
32:00How are you so calm?
32:02Expected job hazard.
32:03You can get used to it.
32:04Yeah, no thanks.
32:0670% of doctors in training at urban hospitals get exposed to TB and wind up on meds.
32:11Jesus.
32:12Mm-hmm.
32:13I don't teach you that in med school.
32:16Mrs. Randolph's back.
32:18Pulled up her x-ray.
32:20Okay.
32:21No volvulus, no air fluid levels.
32:23What do you think of this?
32:26Fecal material?
32:28A shit ton.
32:30Sorry, I had to be said.
32:31So what, she needs an enema?
32:33No, tried and failed, remember?
32:35Yeah.
32:35Time to dig in.
32:37How are we going to do that?
32:39Oh, there is no we in disimpaction.
32:47I haven't done one before.
32:50Shouldn't I observe first?
32:53I know just the guy to teach you.
33:04I spoke to the charge nurse in medsurg.
33:07They can take Orlando today.
33:09Yes, that was wonderful.
33:10They know he's on an insulin drip.
33:12They know and they can change to a squid protocol.
33:15Squid?
33:15Sub-Q insulin and DKA.
33:17So no IV drip.
33:19Just shots of short-acting insulin every four hours PRN.
33:22The medsurg nurses have time to check a glucose every hour?
33:25They say so.
33:26And five days on medsurg is going to cut your hospital bill down by two-thirds.
33:32Okay, um, so what's that going to cost?
33:36I can't give you an exact amount, but roughly $35,000.
33:39So after about 40%, I'll still have to pay, what, like, $20,000?
33:44The hospital can work out a payment plan.
33:46Orlando, we'll be okay.
33:48We'll figure it out.
33:50I'll take on extra shifts at the coffee shop.
33:52We got you, Dad.
33:55Let's give you some private time with your family.
33:58Thanks.
34:01Sorry.
34:03I was worried he might bail.
34:04My pleasure.
34:05The real thanks goes to the newbie here for thinking outside the box.
34:11Sorry I doubted your medsurg pitch.
34:14Ah, no sweat.
34:15How'd you think of that?
34:17Uh, my family had to think of a lot of creative ways to help manage her grandma.
34:23Leukemia.
34:24System doesn't work for you, you gotta work the system.
34:28She survived?
34:30For a while, until she didn't.
34:32She died before my freshman year of college.
34:35Sorry.
34:37Her death taught me a lot.
34:40Mainly that I don't want to be around people dying.
34:44I got her in that right there.
34:46Like, are you out of here soon?
34:47Yeah.
34:47Oh, I think so.
34:49Okay.
34:49Hi.
34:52Uh, morphine PCA looks ready to go.
34:55This should do the trick.
34:57Uh, do you notice a difference?
34:59Better.
35:00Oh, great.
35:01Great.
35:02How does this thing work?
35:04There's a baseline rate of morphine, and if you're having pain, you can push this button,
35:08you'll get some extra.
35:10And you can push for another dose every ten minutes if needed.
35:12Your very own morphine butler.
35:14Mm-hmm.
35:17Amazing.
35:18She can go home with this?
35:20Uh, yeah.
35:21Though you'll need more equipment for the house now that she can't bear weight on her leg.
35:26Okay, like, what?
35:28Uh, a wheelchair to go to the bathroom, a shower chair, uh, wall bars if you don't already
35:33have them, and a hospital bed could be helpful, too.
35:37How do we get all that?
35:39You don't.
35:40I do.
35:40I will get everything so that the two of you can get out of here and back to the kids
35:44at home.
35:54Nice of you to join us, Huckleberry.
35:55What do you need?
35:56Some help with a disimpaction.
36:00That is a med student procedure.
36:02Oh, you know the old adage, see one, do one, teach one.
36:06Say hello to teaching young Ogilvy here.
36:10Okay.
36:11Double glove, Ogilvy.
36:13All right.
36:13Mrs. Randolph, we're going to need to manually unblock your rectum so that you can get your
36:18bowels moving again.
36:19I know.
36:20Here we go.
36:22Mrs. Randolph, I would like you to relax like you're having a bowel movement.
36:28Nice and deep.
36:32Okay.
36:34Curve the finger like an ice cream scoop.
36:39And bring it out.
36:42You're up, Ogilvy.
36:48Some more pressure, Mrs. Randolph?
36:51I'm ready.
36:59And here I thought you were in a quick study.
37:03You're gone.
37:05Mrs. Randolph, in order to prevent this from happening again, I think you need a better
37:09stool softener.
37:10You can try Miralax, just a tablespoon with a big glass of water every morning should do
37:15the trick.
37:15Okay.
37:18Oh.
37:20Sorry.
37:21Passing gas is good, means we're making progress.
37:24Does that mean that I can stop?
37:26No.
37:26Nope.
37:27Keep going.
37:32Ogilvy, you might want to...
37:41Much better.
37:44Maps holding on levophed.
37:46One mic per kg per minute.
37:48Give me a favor, give me some 4x4s and some betadine.
37:50Sorry, we're getting killed with transfers from Westbridge, mesenteric ischemia, perforated
37:55bowel.
37:55Got a hot one here.
37:56Yeah.
37:57Possible nexash?
37:59Possible.
38:00Need CT with contrast to confirm.
38:01This is spreading like wildfire.
38:02By the time you get your CT, it's going to be up to her way.
38:04She's going to need a hemicorporectomy.
38:05She needs a CT scan.
38:06How about a stainless steel scan?
38:09For Christ's sake.
38:11Rabinovich.
38:12Robby, what the fuck are you doing?
38:15Oh, God, I think it might be...
38:17That's called dirty dishwater exudate without purulence.
38:19There's a gray appearance to the fascia, and in the OR you'll see easy separation in
38:23the tissue planes.
38:24When do you start your sabbatical?
38:25Tomorrow.
38:25Not a moment too soon.
38:27Thanks for coming down.
38:32I'm catching up on my charting as fast as I can.
38:35Why don't you give my generative AI app a try?
38:38It's 30% more efficient, and providers report increased job satisfaction.
38:42And you'll rarely have to stay over time to complete charts.
38:45Yeah?
38:47Okay.
38:48Yeah, I'm usually here at least a couple hours after every shift trying to catch up, so...
38:52Sure, AI will make doctors more efficient, but hospitals will expect us to treat more patients
38:57without any extra pay, of course, all the while eliminating staff positions for attending
39:01and residence.
39:02Oh, Dr. Robby, I am not an advocate for erasing my own profession, but I am advocating for getting
39:08to spend more time with my son.
39:10Nothing can replace family.
39:13What's the status of your septic patient?
39:15Neck fascia.
39:16Surgery's taking her up.
39:17Think they'll be able to save her leg?
39:20Right now, I'm just hoping they can save her life.
39:22Hey, uh, how's all going to be doing?
39:24Uh, a little TB exposure, a touch of asplosion.
39:28All in all, pretty good day so far.
39:30This is a game.
39:31Hey, you know what?
39:32I was going to let you miss Peter and Aubrey's epic 4th of July party.
39:35Come on now, hey.
39:38Brotson bro, you are the man.
39:40Appreciate the bromance over here, but no food, because you might go into surgery.
39:44No beer, because we're a goddamn hospital.
39:51Starting your sabbatical early?
39:52I know somebody who could really use a drink right now.
39:54In the hospital?
39:56As a parting gift.
40:03How's it looking?
40:04Good.
40:05The stereostrips did the trick.
40:07CT is ready.
40:08We already scanned him.
40:09The head and neck want thin cuts and a 3D reconstruction of the mandible before they decide if Mr. Varney
40:15needs surgery.
40:16Had they even come down to examine him in person?
40:18No, they must be backed up.
40:19Or there's a July 4th sale at the BMW dealership.
40:23Labs are back.
40:24Albumin's low, total protein's low.
40:26He also has megaloblastic anemia.
40:28Malnutrition.
40:29Probably jail cuisine.
40:30Whitaker, what labs should we add?
40:31B12, folate, iron levels.
40:34Good.
40:35We're going to run some more tests, Mr. Varney.
40:37Hang in there.
40:43I have to pee.
40:45Oh.
40:45There's no pure wick here, but here you go, hon.
40:48I'll help you get on.
40:49No, no, no bedpan.
40:51I can walk to the bathroom.
40:52I just need a little help.
40:53Are you sure?
40:54Hey, babe.
40:55Oh, we got this, Mr. Hemel.
40:56You'll have to bring your IV and portable oxygen.
41:00Please?
41:02I'll grab a wheelchair.
41:04Let's try to suit you up and dangle your legs.
41:06Okay.
41:11One, two, three.
41:19This is not a good idea.
41:21I don't think we're going to need this.
41:23Hey, Paul.
41:24Paul, why don't you come grab a cup of coffee with me?
41:27I'm still zonked for my all-nighter,
41:29and I want to go over some delivery instructions with you.
41:32Uh, sure.
41:36You okay?
41:37Mm-hmm.
41:38Yeah, it's okay.
41:39Okay.
41:40Okay.
41:41Okay.
41:47Bedpan it is.
41:56You lose your pole socks again, bud?
42:04Louie.
42:05Louie!
42:07He kept pulling off his pole socks.
42:10It's on.
42:10It's at 71.
42:11Louie, wake up!
42:14I'm going to get the carotid.
42:16I got the airway.
42:16Hey, Carla!
42:17Crash cart intubation tray, please!
42:26I don't know.
42:53I don't know.
43:34I don't know.
43:50I don't know.
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