The Good Doctor (2017–…): Season 3, Episode 12 - Mutations - full transcript

Shaun, Morgan, and Audrey treat a 25-yo runner with severe swelling, but when things worsen, Shaun enlists Carly. Meanwhile, Alex, Claire, and Neil treat two 16-yo cancer patients who are dating. Shaun and Carly also work on intimacy.

Those are yours.

We bought them together.

Because you "found the pattern soothing."

I'm gonna miss you, Shaun.

I love Carly.

And that's great.

I am so happy for you.

Now you can hang the toilet paper
incorrectly anytime you want.

And Carly and I can go back

to the way things were before our fight.

Well, sometimes couples need
a little time to recover.

We won't.

Carly asked for you to move out.

You are moving out.

How many kidneys do I need
in my body to attend prom?


Even if the surgery removes my kidney,

it'll be laparoscopic,

so my inpatient time
will be seven days, tops.

And then three more days of rest at home.

I can take my girlfriend to prom, right?

That's not a purely medical decision.

I have to draw some blood.

What are the chances
Dr. Melendez might be able

to remove the tumor
but spare Ryan's kidney?

Well, the MRI will let us know

how much the chemo shrunk the tumor,

but you shouldn't count on it.

One chili burger,
extra mustard, extra pickles.

Hi. Morning, Mr. Cooper.

I'm not sure he can have
that with his surgery...

Oh, he's fine until about 6:30 tonight.

I know you.

Angie... Valens.

I helped put in your chemo port.

I owe you a big thank-you.

We met in chemo.

They should put us in a public
service announcement or something.

Yeah... "I lost a tumor and gained
a boyfriend. Thanks, chemo."

James McDougall?

That's who we're here for, too.

All of you can head over to Bay 4.

Guy saw me six months ago
for a stress fracture.

He's a lunatic ultra-marathoner.

I just hope he didn't go too
hard too soon and break it again.

He didn't break it again.

Your GP was right to start
you on ketoprofen for the swelling,

but clearly, it isn't working.

That's why Drs. Murphy and Reznick

are going to block off some
of your lymphatic channels.

It should reduce production.

The more pressing concern is why.

Have you ever had surgery
on your lymph nodes?

What about cancer or radiation treatment?

No. Physically, I've always been healthy.


I was diagnosed with Persistent
Depressive Disorder when I was 16.

That's why you got to get me
back out on the road, Doc.

Are antidepressants
not effective for you?

I mean, they help.

But running really is key.

Saved my marriage and... And my life.

Lymphedema can be caused by an infection.

He doesn't have a fever.

Ketoprofen can suppress fevers.

Let's get some cultures

and start him on broad-spec antibiotics.

As requested, your restock on enemas.

Nice cover.

How've you been feeling?

The methotrexate is working great.

No pain, no redness.

Stiffness, flu-like symptoms?

No. All good.

How long are you planning to hide out

doing RA exams and clipping
diabetics' toenails?

Dizziness, headaches, nausea?

I... Sometimes I'm a little
queasy after I eat.

You had to love neurosurgery.

How about we try to get you a medication

that doesn't irritate your stomach?

No. My hands feel great.
That's all I care about.

You used to open up skulls and
poke around people's brains.

There's no way this fulfills you.

I enjoy it.

Or, rather, I usually enjoy it.

I'll let you get back to it.

Maybe someone out there needs an enema.

Got a measurement on the Wilms tumor?

Mm, not quite there yet.

You mentioned 7 centimeters as our limit

to doing this laparoscopically.

What if we pushed it to 7.2?

Would speed up recovery.

By a few days.

Forget I brought it up.

Ryan wanting to take
his girlfriend to prom

should not factor into our surgical plan.

Is he nuts about her?

Ohh. Crazy, head over heels in love.

They both are.


I wouldn't mind being
an idiot like that again.

Though, I'm not sure
I ever felt that way,

totally happy.

So therapy's going well?

No metastasis in the lungs.

Look at that.

Your tumor is gone.


How's that possible?

The chemotherapy worked
better than we expected.

Wait, like, no tumor? Zero?

- No need for surgery whatsoever?
- That is right.

These are discharge forms.

Both of my kidneys
are taking you to prom!

Aah! Hell, yeah, we are!


- Angie!
- She's having a seizure!

2 milligrams of lorazepam
and portable oxygen, stat.

Let's get that under her head.

His lungs are filled with fluid.

I need a chest X-ray
and a bedside ultrasound.

And page Dr. Reznick.

Imaging has confirmed

a reoccurrence of your brain tumor.

What stage?


The best approach is
surgery, a wide resection of the tumor,

followed by radiation and chemo
to encourage full remission.

Sounds like a fun couple months.

Full recovery will probably
take closer to eight.

We can get through this, baby,
just like last time.

W-When will the surgery be?

We need to do some additional imaging,

and I'd like to consult a colleague

about the best surgical approach.

That'll take a few days.

Take your time.



Now that Ryan can go, I have to go.


This is your health we're talking about.

Mom, please.

I just want to do this one
thing like a normal kid.

Can you tell her it's okay?

We can't.

Until we remove your tumor,

you're at risk of
potentially fatal seizures.

After you're recovered,

you and Ryan can get all dressed up,

and we'll go have dinner
at the Grandview. Okay?

Prom sucks.

My buddy had a fake ID.

I got so drunk in the limo
that I passed out

and never made it into the dance.

Maybe that wasn't everybody's experience.

I was prom king. My date was queen.

I had the dress, I had the date,

I had the mom who got arrested.

Spent the night picking
her up from the drunk tank.

Did you see Park while you were there?

Go to scheduling, get Angie's
surgery set for Friday

with the best neurosurgery OR nurses.

Let's go see Glassman.

Now I'm identifying

the submillimeter lymphatic vessels.

I need an 11-0 micro suture
and a 70 micron needle.

Instead of harvesting nodes to this area,

could we redirect lymphatics
away from his lymph system?

We could.

If you identify an appropriate vessel,

you can make the connection.

We're clearly not
dealing with an infection.

There must be a blockage
somewhere in his lymph system.

Most likely cancer.

His CBC didn't show any abnormal cells.

Lymphoma doesn't always show up.

We need to run cytology
on his lymphatic fluid.

It's either gonna be nasty or very nasty,

depending upon how it attaches
to the thalamus and fornix.

Which no imaging or testing
can possibly determine.

So, our options are?

Between an endoscopic approach
or an open anterior one.

That is correct.

I'd run a stereotactic MRI
with fiducials and DTI

to gauge how close the white
matter tracts actually are.

You should scrub in.

Another doctor can cover the clinic.

I haven't been in an OR in over a year,

and then, as a patient.

I'm not asking you to cut.

But it'd be a huge value
to have you there.

I appreciate that.

I'll consider it.

Hello. We need to run cytology
on this lymphatic fluid.

I would be happy to.

Lea moved out this morning.

- Thank you.
- You're welcome.

Can you come over tonight?

Uh, that probably won't work...

Or we could go to your apartment?

I can't.

Lea said that it might take time

for us to recover from our fight.

But I told her that we were okay.

We are.

I made plans tonight.

To hang out with a friend
who just got fired.

But I would love to come over
tomorrow night.


I'll put a rush on this test, too.

Your lymphovenous
anastomosis technique...

I was impressed.

It's a little early in the morning

to be sucking up, Reznick.

Not for me.
I like to get a jump on things.

I'm fascinated by the way
you use plastic procedures,

like microsurgery,
in other surgical specialties.

I thought it might make an
interesting topic for a paper.

Want to write it with me?


Let's talk and eat.

That's not breakfast.

I'm buying.

What publications do you want to target?

Last time, Angie had
bad post-op vomiting.

- Of course. I'll make note of it...
- Excuse me.

She's asleep. She needs her rest.

I'll wait out here until she's awake.

Ryan, your immune system is weak.

It would be so easy for you to
pick up a bug and pass it to Angie.

I haven't been around
anyone but my dad. I swear.

He could wear a mask.

After Angie's surgery,
we'll see about arranging a visit.

Please tell her Ryan came by.

I'm sorry if I overstepped.

I'd like to change Angie's status

to "No visitors" on her chart.


Please take Mr. McDougall to his room.

I'll be there in a moment.

Is that James McDougall?

- And the woman with him?
- His wife.

Is it cancer?

No... Worse.

His lymphedema is caused
by a genetic mutation.

If you don't find a
medication he responds to,

he'll drown from the inside.

The mutation is on James' ARAF gene...

It makes an enzyme called kinase,

which can cause cells to overproliferate.

It's a genetic condition.

What set it off now?

Probably the stress fracture.

Sent his immune system into overdrive,

which fired up his lymphatic system.

What treatment protocol
targets this mutation?

An MEK inhibitor.

The problem is, which one?

There are 41 possibilities,
each with different side effects.

Good luck.

Well, I was hoping you could stay.

Okay. Sure.

We need you to stay completely still.

Not a problem.

You okay?

Ryan totally bailed.

He hasn't come back to see me.

If you tell her that her mom
said he couldn't visit,

she'll be pissed at her mom.

How's that gonna help?

He's probably busy catching up in school.

We had a pact.

As long as we were together,
cancer wasn't gonna beat us.

He broke it.

Cancer wins.

Do you mind finishing?

Imaging finished?

Not quite.

Mrs. Valens, Angie would
really like to see Ryan.

I know you're concerned about infection,

but there is minimal risk.

Actually... Actually, none,
if they do a video chat.

Interesting idea.

I'll think about it.

Angie's depressed.

And studies have shown that
that can have a negative impact

on her surgical outcome.

Ryan doesn't always improve Angie's mood.

A couple of weeks ago,
they had some silly fight,

and she cried for days.

Thank you for letting me know.

I'm gonna do my best to cheer her up.

She's a 16-year-old.

She wants her boyfriend.


And how smart were you when you were 16?

Well, what about Selumetinib?

It's shown promising results
on related conditions.

And a high occurrence of liver disease.

Binimetinib is similar,
but has fewer complications.

Any objections?

Let's start James on that.

This is exciting, working together.

It is.

Although, I'm used to samples
and slides instead of patients.

Patients can be difficult.

But you will be fine.

Do you need something?

I was curious how James was
responding to the Binimetinib.

His urine output is up,

which suggests the lymphatic fluid...

And his potassium is a little low.

Can you... give him this?

I wasn't really...


I'm Dr. Lever.

The tumor's abutting
and possibly infiltrating

the white matter tracts of her fornix.

We'll likely have to remove a section.

That'll affect her ability
to form memories.

With a lot of neuropsych rehab,

she may be able to compensate
with other pathways.

Studies have shown that positive
attitudes lead to positive outcomes.

You're worried about her attitude?

She's worried about young love.

I'm worried about what Angie
is facing after surgery.

Physical therapy, cognitive therapy,

one challenge after another.

And what she wants is so simple.

You want to make a sad kid happy?

I guess I do.

Which isn't my job, and I need to stop

getting sucked into
people's personal issues.

Is there a way to do that
without antagonizing the mother?


Then make her happy.

We've never gotten this far before.


We haven't.

And you're okay?

I am very okay.




Did... I do something wrong?

No, I'm sorry. It's me.

You said we were okay.

I thought we were.

I-I want us to be.

You have no reason to still be mad.

I'm not mad.

I'm... I'm just...

It's Morgan.

The medication caused James
an upper GI bleed.

Have you localized
the source of the bleeding?

Working on it.

Seems to be coming from
the antrum of the stomach.

We stopped the Binimetinib.

On top of causing this, it hadn't
done much to curtail the swelling.

Where's Dr. Lever?

There's the ulcerative lesion. Cautery.


They're used in medical research

because of their quick maturation,

and 84% of genes associated
with human disease

have a zebrafish equivalent.

You think we should do
a transgenic expression

of James' ARAF mutation
into the zebrafish genome.

Translation for those of us

without a genetics textbook handy?

We make mini-Jameses, as zebrafish,

all with the same disorder.

Then we test every conceivable
drug on those fish.

How long before we can start testing?

If we implant the embryos now,

probably by late afternoon tomorrow.

Get going.

Shaun, go with her.
You have Path experience.

I understand no means no.

If you don't want to have sex,

I accept that.

But I am very confused.

So am I.

I thought I was fine u-until I...

I told Lea to move out, like you wanted.

You said that things were okay.

They aren't. How do I make them okay?

I can't tell you, because I don't know.

When I was in chemo,

the nurses used to force
that stuff down my throat,

so I know you're not drinking
it because of the taste.

It's fast, easy nutrition.

That and you don't end up puking
your guts out in the bathroom.

I was president of this
hospital for over 10 years.

I made a few friends,
including Jack the janitor...

Talks a lot, A's fan, horrible gossip.

If the methotrexate is making you sick,

we should try another medication.

How can you guarantee
that you're not gonna throw up

in the middle of your next surgery?

It won't happen.

Because it only happens
if I eat solid food.

And I stopped.

At least at work.

That is a lot of fish tanks.

Forty. So we can test all of
the possible medications for...

Are you throwing a party?

Hope so.

How are you doing, Shaun?

Since your father passed away?

I don't think about him very much.

My mom... died recently.

I-I don't know if you knew that.

She pops into my head all the time.

Not always the nicest thoughts.

It's okay not to love them.

They didn't make us who we are.

Has your mom gone home?

There is one more thing
we have to deal with tonight.

Come on.

How many more sets of imaging
can you possibly do?

One of these is your prom dress.

I like the pink, but I think
you'd look gorgeous in both.

Hurry up and choose.

Your date'll be here soon.

All the medications are in.

Which means more waiting
to see which medicine works.

It's hard to be patient.

Do you think the fish control
how they react to the meds?


It's just how their bodies respond.

That's how I felt last night.

I thought I was ready
for us to be together,

but my body had a different response.

I can't turn that response off

any more than these fish can control

how their mutation reacts
to the medication.

Was our mutation

me going to Wyoming with Lea?

Do you think we can find
our right medication?

♪ For me ♪

♪ Darling, just dive right in ♪

♪ Follow my lead ♪

♪ I found a girl ♪

♪ Beautiful and sweet ♪

You look amazing.

♪ I never knew you were
the someone waiting for me

So do you.

♪ 'Cause we were just kids
when we fell in love

♪ Not knowing what it was ♪

♪ I will not give you up this time ♪

♪ Darling, just kiss me slow ♪

♪ Your heart is all I own ♪

♪ And in your eyes, you're holding mine ♪

♪ Baby, I'm ♪

♪ Dancing in the dark ♪

♪ With you between my arms ♪

♪ Barefoot on the grass ♪

♪ Listening to our favorite song ♪

♪ When you said you looked a mess ♪

♪ I whispered underneath my breath ♪

Looks like you might be feeling

a little idiotic happiness right now.


Maybe a touch.

♪ No, no ♪

Dance with a prom king?


♪ You look perfect tonight ♪

He's tachycardic.

We were talking,
and then he just stopped.

We need to do a pericardial tap.

Call the cath lab.
Tell them we're coming.

No time. We're doing it here.

James, the pain in your chest

is from too much fluid around your heart.

We're gonna put a tube
into your chest to drain it.

Call Shaun and Carly.
Tell them we're running out of time.

♪ ...will be loving you till we're 70 ♪

♪ And, baby, my heart could
still fall as hard at 23 ♪

♪ And I'm thinking about how ♪

♪ People fall in love
in mysterious ways ♪

I brought Angie's Bearfeet Bear.

It always makes her feel like sh...

It's... prom.

Ryan has been wearing his mask all night.

♪ And I just want to tell you I am ♪

♪ So, honey, now ♪

♪ Take me into your loving arms ♪

Don't let her stay up too late.

♪ Kiss me under the light
of a thousand stars ♪

♪ Place your hand on my beating heart ♪

Morgan called. James isn't doing well.

Cross SL-327 off the list.

I see one...

No, two tumors.


This is my stop.

I'll see you after.

I love you.

I love you, too, Mom.

Don't worry. Okay?

I got this.

I know you do.



What if I wake up and
don't remember Ryan at all?


You'll have the chance to fall
in love with him all over again.



We're down to five potential options.

I don't need five potential.
I need one actual.

There are two that best curb...

Choose one.

We should try Refametinib.

It caused abnormal cell growth.

Trametinib is safer.

Which doesn't mean it's safe.

Nothing's safe.

Which do you want us to do?


That's the one.

Saline in.

Advancing scope
toward the third ventricle.

Claire, hold gentle pressure on the tumor

while I cut off its blood supply.

We've got some significant bleeding.

Adjust the scope and suction.

Look higher.

Septal vein... There's your bleeder.

Cauterize away.

Micro dissector.

The tumor's immobile.

I can't resect it without
injuring the nerve tracts.

She'd be comatose.

Try sharp dissection.

- I can't get a plane.
- How bad?

It's completely invaded her thalamus.

Thin it out with a suction aspirator.

It's too adherent.

If I keep going, I'm gonna kill her.

Any ideas?

Tell ICU Angie will be coming
sooner than we planned.

Let's close her up.

What's next?

Another round of radiation, chemo?

Her carcinoma is

unlikely to respond to those therapies.

No. We have to try.

Angie will want to fight.

She's seizing.

Give me lorazepam and Dilantin, stat.

Phenobarb and propofol on deck.

You're crying.



I found James on Facebook.

He and Marjorie want to go to Costa Rica.

Their dog is a three-legged
rescue named Tripod.

He's not a slide. He's a person.

He's a good person.

And he might die.

This is why I like to stay in the lab.


Is a very dumb thing to say.

If you had stayed in the lab,

James would probably be dead already.

Your plan with the
zebrafish gave him a chance.

It was a beautiful, perfect idea,

from a beautiful, almost perfect person.

Your earlobes are lopsided.

I'm so sorry.

We couldn't save her.

Ms. Valens?

Nice call on the zebrafish.

About our paper, let's meet weekly.

I'm thinking lunch every
Tuesday in the cafeteria.


I heard about Melendez's patient.


You were right.

I should probably try
another medication for my RA.

I need solid food.

Claire? Wait up.

You okay?

Fine. I'm just tired.

You did an amazing thing for Angie.

You gave her mother a memory
that she will have forever.

Well, it won't make up
for the daughter she lost.

You're angry.

I'm not. I am sad.

- Who are you angry at?
- I'm not.

Are you angry at me and Glassman

because we couldn't save her?

- No!
- At Angie?

No, you can't be mad
at someone for dying!

That's not true. You know that.

She was sick.

And she was trying to get better.

She failed and left you alone.

After you'd spent a lifetime
trying to take care of her.

You have every reason
to be mad at your mother.

I hate feeling this way.

My whole life, I've been angry at her,

and now it will never change.

I don't know how to stop.

Therapy will help.

Time will help.

There is one other thing
that's worked for me.

Did we fix our mutation?

That the best you got?