Chicago Med (2015–…): Season 7, Episode 5 - Change Is a Tough Pill to Swallow - full transcript
.
- With the suggestion
from Dr. Cooper
I could've sabotaged
Archer's CVP monitor
so that the Vas-COM
could save the day.
And I came close to doing it.
- If this ever gets
to be too much for you,
I'll put a stop
to the whole thing.
- I'll take it from here.
- I assumed I'd perform
the surgery.
- You're free to watch.
- Best by the powers that be.
- I'm sorry.
I made a fool of myself
with Dr. Marcel.
I'm crushing on my advisor.
- How long
you been doing this?
- 35 years.
- How?
- You got to hang on
to those good days.
You got to hang on
to those wins.
- Really, Dad?
- What? It's fine.
- It's a red zone.
It's for emergencies only.
No--
- See?
Now, it's an emergency.
Oh, you know what?
I wanna check this out.
New PDT system.
I can check all
of my units in real time.
- But, look,
can I check it out later?
I really do have to go.
I'm late.
- Everything okay here?
- Oh, yeah, we all good.
Just a little ride-along.
Letting a civilian see
what a real job looks like.
- Yeah, thanks.
- Yeah.
Am I embarrassing you?
- I'll see you later.
[siren beeps]
Come on, Dad.
- [laughs]
[siren beeps]
Okay, I'm gone.
- [laughs]
- Hey, what's up?
- Do you remember
how when we were
in physical exam class,
when we did breast exams,
they would tell us
to make small talk
with the patient actors?
- Yeah, to help
put them at ease.
- Yeah and there was
that one guy, Mandelbrot.
Super awkward.
Caught hell for asking
one of them what
she was doing that weekend.
- Oh.
- He is a panelist
at the next summit
for female physicians.
[laughs]
- Wait, that wasn't Mandelbrot.
It was Richardson.
- No, pretty sure
it was Mandelbrot.
- No, it was Richardson.
- You haven't changed a bit.
Always got to one-up me.
- I'm not trying to one-up you.
- Two shots for Dr. Hammer.
Three for Dr. Halstead.
- [laughs] Thank you.
Have a good day.
- You too. Thanks, Carly.
- Morning.
- Good morning.
Dr. Halstead, how are things
with Dr. Cooper?
- Uh, pretty well, I think.
- Oh, yeah?
- I mean, he hasn't said
anything otherwise.
- Good morning,
Ms. Goodwin, Will.
- Matt.
- Just the man
I was looking for.
I want to tell you about
the conference
coming up in a few weeks.
- National Critical Care
Society annual meeting.
- It's here in Chicago.
You should go.
Vasik's gonna be
a platinum sponsor.
They're gonna have
a corner booth.
It's gonna be
the perfect chance
for you to meet
some of the upper-level execs.
Oh, do you think that you could
spare him for the day?
- It's always good
when our doctors
broaden their expertise.
- I'll be there.
- Okay, great.
I'll get you the details.
Um, Ms. Goodwin.
- This might be good.
And maybe I can get them to
offer me a deal like Cooper's.
[phone buzzes]
- Geez, I got to get this, but,
uh, you're on the right track.
- Thank you, La'Shawn.
Morning, Alim.
Hey.
- Hey.
- What time did you get in?
- Uh, I don't know.
Like, around four.
- Why so early?
- Always try to get
a leg up on the day.
- Two hours before your shift?
- Well, if I'm meeting
with my patients earlier,
then I can read up
on their conditions.
That way, I'm running rounds,
I'll have all the answers.
Plus, if I'm here
a little early,
I can study for my boards.
- Sleep ever a factor
in this equation?
- Life of an intern.
What can I tell ya?
- Dr. Marcel.
- Yeah.
- Treatment three incoming.
[bell beeping]
- What do we got?
- Avery Quinn,
28-year-old female.
Pedestrian versus auto.
BP 80/45.
Heart rate 114, satting at 88.
- Okay, Avery, I'm Dr. Marcel.
We're gonna take
good care of you, okay?
- It hurts so much.
- Trigger the MTP,
give her 50 of fentanyl.
Here we go, guys.
Transfer on my count.
One, two, three.
- [groans]
- There it is.
All right, let's roll her.
You're okay, we got you.
The board...
- [groans]
- All right, we're good.
Avery, can you put
your arms by your side for me?
You're gonna feel
a little bit of pressure, okay?
- [groans]
- O2 sats down to 82.
- Avery, Avery.
Avery...she's out.
We need to intubate.
20 of etomidate, 100 of sux.
Get a CBC, CMP,
type and cross four units.
Let's get a fastscan
and have them prep OR 12.
- No, she's going to OR seven.
- Excuse me?
- Yeah, I'll take it from here.
And let's add
a coag panel and LFTs.
- Dr. Blake,
I think you're mistaken.
This is a trauma,
not a transplant surgery.
- Yeah, I can see that.
She's got free fluid,
and she's in shock.
Her liver's ruptured
but repairable.
We got to get her up now.
- I'm in. Bag her.
All do respect, Dr. Blake,
you're a transplant surgeon.
I got this.
- Thank you, Dr. Marcel,
but I'll be
taking over the case now.
- I'm sorry,
I can't let you do that.
This is my patient.
- And I understand that,
but she's also my daughter.
Now, I'm gonna need you
to move.
Let's go.
[dramatic music]
- You got a transplant patient?
- No, I don't.
But we have a problem.
♪
.
- Hey, Alex, I'm Dr. Scott.
- I'm Susan.
This is Todd.
And this is Ry--Ryan, come on.
- Hey, Ryan, can I get
a couple of those?
- Ryan, enough with the gloves,
okay?
- Thanks. [laughs]
Alex, says here that you
got hit in the head
with a Nerf gun.
- Yeah.
- Oof, I bet that hurt.
The thing is, you're supposed
to get hit with the foam dart,
not the actual gun.
[chuckles]
- Stop it.
- It was an accident.
The boys were playing.
- Mom, it wasn't a Nerf gun.
- Okay.
I--I didn't even see it happen.
I--okay.
- Ryan.
- Mom---mom.
- Hey, just a minute.
- Mom--
- They were down in
the basement and--
- It wasn't a Nerf gun.
- Ryan, okay.
- Hey, hey, hey, Ryan.
What's up, buddy?
Talk to me.
- It was an Ultra Blaster.
- Oh, yeah?
Triple action
with the slam-fire?
- Uh-huh.
- Sweet. Yeah.
- "I'm sorry, Doctor"?
Todd, you want to take him
for a walk to the truck?
Give him his meds.
Okay, go with Dad. Go.
- Oh, man.
Tough day, huh, bro?
- He has ADHD.
- Yeah, we have him
on Adderall,
but we keep upping the dose,
and some days
are just a little tough.
- [whispers] I know.
It's okay.
What about you?
How you doing?
- [whispers] I'm fine.
- You sure?
Okay then.
For now, we're gonna keep
applying pressure
and get you all stitched up.
Shouldn't be too long.
Hey, Mags, I need somebody
to throw stitches in six.
- I'm on it.
- You already have
two patients up.
You sure you have time?
- Don't worry.
I got it.
- [sighs]
- Rough morning, huh?
- Yeah.
It's a tricky family dynamic.
I'm treating
a 10-year-old named Alex.
His brother has ADHD.
Seems like
it's pretty tough on them.
- Yeah.
- Takes up a lot
of the family's energy.
- Oh, yeah.
Parents so focused
on--on the kid with the illness
that they see right through
the other one.
Yeah, unfortunately
not at all uncommon.
There's even a name for it.
It's called--it's called
glass child syndrome.
- Oh, that sounds like
exactly what's happening.
- Yeah, happy to provide you
with a couple referrals
for a therapist
for the--for the kid
if you think the parents'll
be open to it.
- I think that'd be great.
Thanks.
[phone buzzes]
- Oh.
Dr. Choi,
I've been bugging him
for an update on his rehab.
I better take this.
- Go ahead, man, and tell him
I look forward to meeting.
- Will do.
- I understand
this must be hard for you,
but that's the very reason
I can't let you go in there.
- I appreciate your concern,
but I'm fine.
- Dr. Blake.
- Ms. Goodwin.
- You know very well
it's against hospital policy
to operate on a family member.
- I am perfectly qualified
to perform this surgery.
- Pamela, you are
a transplant surgeon.
- Dr. Archer and I
see these cases every day.
- And I make more money
for this hospital
than any other doctor here.
- That is not the point.
Dr. Archer is
a top trauma surgeon.
He will do an excellent job.
- I will,
and if you're so inclined,
I'd be happy
to have you observe.
♪
- Ryan.
- Ryan--
can you sit still
for just one minute?
- [sighs] I'm gonna go
get some air.
- Yeah.
- Will, can I get
your opinion on something?
- Sure.
What's going on?
- I've got a 71-year-old woman
who's hypotensive
and tachycardic.
Passed out this morning
at home.
No medical history
other than asthma.
She could use
some cardiac monitoring,
and I know that
you're big on the Vas-COM.
- Well, I mean, there are
a number
of good cardiac output
monitors.
But the Vas-COM
is a terrific device.
You mind if I, uh,
have a look at her?
See if she's a good candidate?
- Yeah, yeah, sure.
- Eleanor, Ron,
this is Dr. Halstead.
- Hi.
- He's just going to ask you
a few questions.
- Nice to meet you.
- You have to help her.
Ellie, tell him,
you've never been sick
a day in your life.
- Ron--
- No, no, that's good to hear.
You mind if I?
- Mm-hm.
- Make a fist.
And release.
- [sighs]
- Good.
Does she have
any sensitivities or allergies?
Recent injuries,
meds that would interfere
with an arterial line?
- Just seasonal allergies.
- Okay. Eleanor, do you
ever have any trouble
when you get your blood drawn?
- I don't think so.
- What about leg swelling?
Long car rides, trips?
- No, not that I can remember.
- That's good.
All right, it was nice
to meet you.
I'll have a chat
with Dr. Hammer.
We'll be right back.
- What do you think?
She look good for the Vas-COM?
- Uh, maybe.
She was
a little vague in her answers.
- But she definitely
should have
her cardiac output monitored?
- Dr. Hammer,
if you're interested,
I could give you copies
of the Vas-COM's FDA-approved
usage criteria?
- You know, that--that
won't be necessary.
I think Eleanor would be
a great candidate.
- Okay, good.
I'll get it set up.
- Dr. Scott.
- Alex?
- Dr. Taylor.
- Buddy? What?
Alex.
- Bud...
- Excuse me.
- Honey, honey?
What--what's happening?
- He's having a seizure.
Give him 12 liters of O2
and .five of Ativan.
- Wait, seizure?
Why is he having a seizure?
- I'm not sure yet.
[whispers]
Come on.
Come on, come on,
come on, come on.
♪
Hey, Alex, you with me?
- Uh-huh.
- [whispers] Okay.
♪
We're gonna figure this out
as soon as we can.
Dr. Taylor.
♪
- Hi, hi, okay.
It's okay.
- Has that cut been bleeding
like that the whole time?
- I tried holding pressure,
but it didn't work.
And if I would've tried
to stitch too soon,
he would've got a hematoma.
- He could have
a bleeding disorder.
Did you order coags?
- Um, well, no. I--
- Get a coag panel, Maggie.
And let CT know
we're on our way.
- Wait, do you think he
could have a subdural hematoma?
- Yes, and if he does have
a bleeding disorder,
then the trauma
from getting hit in the head
could've caused
a bleed in the skull,
which means he could herniate
at any moment.
All right, now.
Let's go.
♪
- [whispering]
Oh, my God.
.
- Okay, ready to release
the pringle.
- Hold on, I didn't get
a good look at the duodenum.
- It's clear.
- Okay.
- All right, pulling back
on the lap.
[heart monitor beeping]
Looks good.
- What's her pH and temp?
- 7.34 and 36.9.
- All right, looks like
you're good to close.
- Uh, actually, we're just
gonna pack and leave her open.
- No, her bleeding's
under control.
Packing her isn't necessary.
- I disagree.
She's got a grade four
liver laceration.
The risk of re-bleeding
is too high.
- She's a healthy 28-year-old.
Leaving her open puts her
at increased risk
for infection, coagulopathy,
hypothermia, and acidosis.
- Dr. Blake, I--
- Close her up, doctor.
- I understand your concerns.
- No, no, point well taken.
I see the merit
in what Dr. Blake is saying.
- Dr. Archer--
- All right, hold off
on the lap.
I need Celox, Gelfoam,
and get an O Max
and suture for Dr. Marcel.
- Dr. Archer, you--
- Dr. Marcel.
♪
[knocking]
- Mr. and Mrs. Miller,
I'm Dr. Charles.
I had been consulting
with--with Dr. Scott
on Alex's case.
- Psychiatry?
- Head injury.
You know, can't be too careful.
Anyway, Dr. Scott wanted me
to let you know that
Alex's scans are almost ready.
And in the meantime,
is there anything
I can get you?
A bottle of water?
- Thank you, but we're fine.
- Yeah.
[cell phone buzzes]
Oh, sorry.
This is work.
Um, don't forget
to text my parents.
Excuse me.
- Oh, okay. Yep.
- Ryan? Is it Ryan?
How about you, buddy?
Can I get you something?
- Do you mind if I...
- No, not at all.
- Okay, I'll be right back.
- Not at all.
- Would you, uh,
like a sandwich or something?
No? Bag of chips?
Soda?
Anything at all?
- No!
You interrupted me.
- Oh, I'm sorry.
I, uh, I--I didn't mean to.
- Now I have to start
all over again.
- Oh, you were counting.
Huh?
Okay, well, I'm--again,
I'm very sorry.
You--you get back to that.
All right?
- Mr. and Mrs. Miller, we just
got Alex's test results back.
Alex is stable right now,
but the scan did confirm that
he is bleeding into his brain.
And the intracranial pressure
is great enough
that he needs
immediate surgical evacuation.
- Oh, my God.
- Wait, wait, wait.
How'd this happen?
- Well, his test results
came back positive
for a bleeding disorder called
Von Willebrand disease.
So the impact from a small toy
could've caused a bleed
that his body
just wasn't able to stop.
- I--I know this is a lot,
but Dr. Abrams
will be doing the surgery,
and he's our very best.
The procedure
shouldn't be that long.
I'll be here for status updates
or if you have any questions.
- And if we have your consent,
we could get started
right away.
- Sure.
- Yeah, of course.
Whatever you need.
- Okay.
So why don't I take you
somewhere
that's more comfortable
to wait?
- Um, Ryan.
Hey, buddy.
Come on, buddy.
We're gonna take
a little walk, all right?
♪
[all talking briefly]
- Hey, I saw
Eleanor's oxygenation
and cardiac output are down.
Have you gotten her labs
back yet?
- Yeah; they don't show much.
Mild infiltrates
on her chest X-ray
and some eosinophilia.
Still don't know
what's going on.
- I'm a little concerned.
One of her fingers and two
of her toes are going cold.
- Oh, could just be
a vasospasm.
- That could be, but--
look, the major drawback
to any arterial line,
including the Vas-COM,
is the potential
for thrombus formation.
So I think we should
pull it out.
- Pull it out?
I mean, thromboembolization
in arterial lines
is extremely rare,
and it almost never occurs
this quickly.
- I understand.
I just think we should err
on the side of safety.
What?
- Is something going on?
It's getting us great numbers.
Keeping Eleanor's meds titrated
and her pressure
and heart rate optimized.
Without it, we'd just be
shooting in the dark.
- I know.
I just want to make sure
we're using it appropriately.
- I think we are.
Let's just give it
a little more time.
[uneasy music]
♪
- Dr. Archer.
- Yeah.
- What the hell
happened back there?
- What?
- Giving in to Dr. Blake
like that.
- The surgery was a success,
and if you'll excuse me,
I have an ED to run.
- Hold on, Dean.
You know,
with that kind of injury,
keeping her open
is the right thing to do.
- Dr. Blake's reasoning
was medically sound.
I mean, I could argue it
either way.
- Oh, come on!
- Crockett...
hospital politics
is a lot like the military.
You put in your time.
You do as your told.
And eventually you can rise up
to become a Dr. Blake, too.
♪
- Hey, buddy.
This is my friend, Dr. Charles.
- Hey, Alex.
- We just came to check in
on you before your surgery,
see if you had any questions.
- Is this gonna hurt?
- No, no.
They're gonna give you
some medicine.
It's gonna put you
right to sleep.
You won't feel a thing.
- Even when they open my head?
- Next thing you know,
you're just gonna
wake up in recovery.
We promise.
- Okay.
- Anything else on your mind?
- No.
It's just,
when they look inside my head,
will they see my secrets?
- Uh, I don't think so.
But if there is something
on your mind,
a lot of kids tell me that
it's just better to get it out.
- This wasn't Ryan's fault.
- Oh, don't worry about that.
Ryan's not in any trouble.
- No, I made him do it.
I made fun of him,
and I know if I did it enough,
then he'd get really mad
and hit me.
- Yeah?
Why would you want him
to hit you?
- Because...
- Because?
If you got hurt, maybe
Mom and Dad pay
a little more attention to you?
- It was stupid.
I shouldn't have done it.
- Hey, it's okay.
Let's get you taken care of.
All right?
- Alex, it's gonna be okay,
buddy.
You're gonna be fine.
We'll see you in a bit.
- [sighs] Man, listen,
I deal with a lot of sick kids,
but what do you do for this?
- So... kid with ADHD,
control issues, right?
Random outbursts.
- True.
- Yeah, but Alex knew he could
only get Ryan to lash out
if he backed him into a corner.
That's not random.
- So, what are we looking at
if this isn't ADHD?
- I think maybe
an anxiety disorder.
- Oh, another misdiagnosis.
Second in a week.
- And if I'm right,
that misdiagnosis
is causing this family
a lot of problems.
[alarm beeping]
- You have to come quick.
Something's wrong with Ellie.
[dramatic music]
[monitor beeping]
- Eleanor, can you hear me?
- Yeah.
- Okay.
- Squeeze my hand.
♪
- What's happening?
Why's she like this?
- She had a TIA,
a mini-stroke.
Start her on aspirin
and clopidogrel
and call for an MRI
of her head.
- A stroke?
What--what? Why?
- 'Cause she's forming thrombi.
They're blood clots
in her vessels, and one's
travelled to her brain.
- Oh, my God.
♪
- Get a suture kit.
We have to pull the Vas out.
- I'll call Dr. Hammer.
Excuse me, Mr. Halt.
She's up in radiology.
- No, no, no.
Every minute that passes
increases her risk
of a major stroke.
We have to pull it right now.
♪
.
- Hey, you okay?
- No.
I screwed everything up today.
- I saw Alex's notes.
Von Willebrand disease?
You couldn't have known.
- I could've ordered
those labs earlier.
- But it doesn't matter.
The outcome still
would've been the same.
Look, you're always gonna wish
that you could've done
something earlier.
It's part
of being a good doctor.
- Alex is in surgery, Maggie.
He's bleeding into his brain.
- Which isn't your fault.
♪
- You pulled
my patient's Vas-COM?
- She had a TIA.
The Vas-COM was
most likely the source.
- You don't know that.
Could've been lupus,
endocarditis, even leukemia.
And now we have no way
to monitor her.
- She could've had
another stroke at any minute.
What--what was
I supposed to do?
- She's my patient, Will.
You at least
should've asked me.
- By the time
you got down here--
I'm not taking that chance.
- No, you were afraid
that I would disagree
and that I'd stop you.
- No.
- It's the same old Will
from med school,
always thinking
that you know better.
- Stevie, that's not
what this was about.
- You tell yourself that.
♪
- Hi.
I don't know if you remember me
from this morning.
I'm the surgeon on your case,
Dr. Marcel.
How you feeling?
- Like I got hit by a car.
- Well, you did
just have major surgery,
but, uh, it went well,
and I imagine you will feel
a little better each day.
- Here you go.
Dr. Blake said to go slow.
- Thanks, Dina.
- Ice chips.
My mom is in love with them.
Frankly, I think they're
just as much
an aspiration risk as liquids.
- Aspiration risk?
What, are you
a--you a doctor, too?
- Made it halfway through
a third year of med school.
- Oh, okay.
- Realized I was doing it
for my mom, not for me.
- Oh.
- I'm assuming
you've met her by now?
- Made her acquaintance, yeah.
- She try to scrub in?
- How'd you guess?
- [groans]
I know my mom.
- [laughs]
- She didn't talk to me
for six months
after I quit med school.
- Wow, that's rough.
- No.
The day I took control
of my life?
Best move I ever made.
- Anyway, I should
let you get some rest.
Um, enjoy your ice chips,
and I'll check back later.
So wait, what did you
end up doing after med school?
- A malpractice lawyer.
- Medical?
Your mom must be very proud.
- [laughs]
- Mr. and Mrs. Miller,
I have an update for you.
- Be right back, buddy.
- So, look, they're--they're
just finishing up
in surgery now.
All indications are that
the procedure was a success.
And Alex is doing great.
- Oh, my God, really?
Thank you so much.
Listen, Dr. Scott and I
talked to Alex
before the procedure today.
And I understand that you have
a lot on your plate right now,
but I--I also think
it's important that I share
this conversation with you.
both: Okay.
- So--so what
he told us is that
he provoked Ryan
into this outburst today.
He feels terrible.
I think he is looking
for some attention.
But where Ryan's concerned--
what this means to me
is that it wasn't
an impulsive outburst.
It wasn't--it wasn't random.
And that and a couple other
things I've observed today
are leading me to believe
it's very possible
that--that your son has
been misdiagnosed with ADHD
and that we were
probably looking
at some kind
of anxiety disorder instead.
- Wait, what are you
talking about?
Look at him.
He can't sit still.
- But Mr. Miller,
it's--it's the counting, right?
The tapping.
I think that
he's self-soothing
to help him cope
with these feelings of anxiety.
And when that stops working,
I think he feels
backed into a corner,
and then you have
a fight-or-flight situation.
- Well, what
about the Adderall?
His doctor said
that would help.
- If he actually had ADHD,
it would be working.
But it's not, right?
I think that in Ryan's case,
it's actually working
against him
and serving to only intensify
these feelings of anxiety
to the point
where they're often,
frankly, unbearable.
- Dr. Charles,
man, look I--I--
we appreciate everything
you're doing.
Really, but please,
our son's in surgery.
- I am sorry.
This is just not an ideal time
to have this conversation.
But I just wouldn't
be doing my job
if I didn't tell you
how important I think
it would be to reassess Ryan
and make sure that you are
looking at the right diagnosis
for him, for his brother,
for all of you,
for your whole family.
- No, Dr. Charles, it's just--
it's just been a long day.
- Listen, I am going
to check back with you
when Alex wakes up, okay?
- Yeah, yeah.
- Okay.
- I should've consulted you
before pulling the Vas-COM.
It wasn't my place.
I'm sorry.
And besides, you were right.
She's getting worse and
still having embolic events.
So it wasn't
the Vas-COM after all.
- Clearly,
but I've gone through
every clotting disorder,
and none of it fits.
- Is it possible
we're looking at this wrong?
That she doesn't even have
a clotting disorder?
- Of course.
It's just so little to go on.
I mean, history of asthma,
eosinophils,
and left-sided
lung infiltrates.
- Left?
I thought
they were on the right.
- Seriously, Will?
- No, no, wait.
The X-ray from this morning
had them on the left.
But look...
The one from this afternoon
shows they moved to the right.
- Migratory infiltrates.
Could this be vasculitis?
Churg-Strauss?
- I mean maybe.
She could've moved
from the asthmatic stage
into the vascular stage today.
- It's a long shot,
but it's possible.
- If we're right,
her organs could start
to shut down at any moment.
- I'll start her on prednisone
and azathioprine
and set her up
for a diagnostic lung biopsy.
- Dr. Hammer, Dr. Halstead,
you need to come.
Eleanor's getting worse.
.
- I don't like
these QRS complexes.
- Eleanor, do you feel any pain
in your chest or arm?
- It feels tight.
- Oh, God, Ellie.
- Why don't you come here?
[beeping]
- She's going into v-tach.
- I'll get the paddles.
- No, no, Ellie.
- Wait.
If this is Churg-Strauss,
this could be a tamponade.
We need to aspirate the fluid.
- I know, but if we're wrong,
we won't have time
to cardiovert.
- I think we're right
about this.
- I do, too.
18 gauge on a syringe.
- 18 gauge.
[beeping]
- Ron, there's fluid
around Eleanor's heart.
They need to drain it.
[beeping]
- Nothing.
Got it.
- Sinus rhythm.
- Eleanor, can you hear me?
- Uh-huh.
- Oh, thank God.
- Call IR.
Tell them we're coming up
for a drain and a lung biopsy.
- You got it.
- Good job.
- Hey. How you feeling?
- Okay.
- Good.
Surgery went well.
In fact, the neurosurgeon said
that you had
the best-looking brain
he's seen in quite a while.
- Yeah?
- Yeah.
Told your parents,
but they weren't surprised.
Said they always knew
you had a great brain.
- They said that?
- Yeah, they did.
You know, Alex,
kids with great brains--
they don't always get
the most attention,
but... people notice.
- What's going on?
- O2 sats are 91.
BP's down to 83/50.
- Drains are full.
- [groans]
- Belly's firm.
Okay, etomidate and sux,
then transduce
to a bladder pressure.
Let's go.
Hey, Avery, look at me.
You're re-bleeding
into your abdomen.
I need to intubate and take you
back to the OR, okay?
- [groans]
- What happened?
- Abdominal compartment
syndrome.
We're going back to the OR.
- No, no need.
You can use a cordis catheter
and decompress here.
- There's too much blood.
We don't have enough time.
I'm in. Bag her.
- And if you open her up,
there'll be too much swelling,
and you'll never
be able to close.
- Get the cordis.
- Dr. Marcel,
bladder pressure's 35.
[beeping]
- It's too high.
We need to open her up
to release the pressure.
Get me a 10 blade.
- Dr. Marcel,
I already told you--
- Back off, Dr. Blake.
Here we go. Ready?
[beeping]
♪
- Sats are up to 96
and BP's 112/83.
She's stable.
- All right,
get her up to the OR.
♪
- Make sure
you get her swelling down.
♪
You're gonna need to close
her up as soon as possible.
♪
- How is Alex?
- Um, his surgery just ended.
He's doing really well.
- Alex probably hates me.
I want to tell him
I'm really, really sorry.
- You'll be able
to see him soon.
And then you can tell him.
- Can I see him now?
- I'm not supposed to let you
until he's in his room.
- Please?
- Okay, maybe we could
just take a quick peek.
If it's okay with your parents.
- Mom, can I go
with the doctor?
- Yeah, honey.
- Okey doke, let's go.
So he's still a little sleepy,
so we're just gonna give him
a quick wave hi, okay?
- That's not Alex.
- It's okay.
He's just
a little bandaged from surgery.
- I didn't do that.
- No, of course you didn't.
- I didn't mean to.
No, I'm sorry.
I'm sorry.
- Hey, hey, Ryan,
Ryan, Ryan, it's okay.
Listen to me. Listen to me.
Ryan, look,
you didn't do anything wrong.
- Stop it.
- Ryan!
Ryan! Ryan!
♪
I'm so sorry.
This is all my fault.
- The security camera
picked him up.
We're okay.
- Still, I just
can't apologize enough.
Maybe I should talk
to his parents or--
- You know what?
I think it's probably better
if I handle this.
Listen, Vanessa,
not your fault.
Okay?
You were trying to help.
♪
- Ryan, your brother
just had surgery.
That's why he looks like that.
He's gonna be fine, buddy.
Now, can you please come out?
- Please, Ryan?
♪
- Mind if I give it a try?
- Yes.
- Hey, Ryan.
You know what?
I don't think that you wanted
to hurt your brother today.
I think the only reason
you threw that toy today
was because you didn't know
what else to do.
- I got so mad.
- 'Cause those feelings,
they just...
They just keep building
and building.
- Uh-huh.
I can't stop them.
And I'm always
getting in trouble.
- What if I told you
that I didn't think that
that was your fault?
- That's not what people say.
They're always telling me
to reset.
- Well, you know what?
I don't think it's your fault.
Not only that, you know
those--those feeling you get?
I get them, too.
- You do?
- Oh, yeah.
Everybody does.
And one of the things that
really helps me when I get them
is, actually,
to talk about them.
You know, there's
this weird magic when you--
when you get them out.
They just--they just don't
seem to bother you as much.
- Really?
- Yeah.
And I guarantee you,
whatever feeling you're having
there are people in your life--
they want to hear about it.
I mean, your mom and dad...
They would really want
to hear about them.
- They would?
- Of course we would, honey.
- And you won't think
that I'm bad?
- Ryan,
we never think you're bad.
♪
- I got you.
♪
- You really don't think
this is ADHD?
- I don't think it is.
- So this Adderall
isn't helping?
- I think it's
actually making it worse.
♪
.
- Hey, I just saw
Eleanor's biopsy results.
Churg-Strauss.
- Hey, maybe we work well
together after all.
- Maybe we do.
I'll see you tomorrow.
- See you tomorrow.
Oh, I made a few calls.
It was definitely Mandelbrot.
[laughter]
Bye.
- Bye.
- Will, I just met Eleanor.
Churg-Strauss,
one in a million.
- Yeah.
- Though I did see you had
to pull her Vas-COM.
- Yeah, I hated to do it.
Uh, but she
was throwing emboli,
had some
cold fingers and toes--
- Hey, hey, Will, you
absolutely did the right thing.
The last thing we need
is for the Vas-COM
to be used inappropriately
and then it gets a bad rap.
- That--that's what I thought,
too.
- Now that she's stable,
however, it did seem
medically warranted to get
her on better monitoring again,
so I just put in
another Vas-COM.
♪
- Okay.
- Anyway, I'm glad you're
coming to the conference.
- Yeah, same here.
- Hey, maybe, um,
if you get there early.
we could have a drink?
- Sure.
♪
- [groans]
So what do you think?
- What do I think?
Um, I think that they have made
a crucial breakthrough.
And now they got
some work to do.
- Yeah, you know,
it's something--
how easy it is,
even in a loving family,
to feel so unseen.
- Huh?
- I guess I didn't always
appreciate how good I had it.
♪
- Your numbers look good.
And your drains are clear.
- [groans]
- So, if you get thirsty,
you can just ask the nurses
for some ice chips.
- Ice chips.
- [laughs]
- Finally going to
get some sleep?
- Boards aren't going to study
for themselves.
- Believe me,
a nap wouldn't hurt.
Anyway, I'm going to run
this boy's Adderall
over to the pharmacy,
then I'm out of here.
- All right, well, um,
see you tomorrow.
- Hey, Vanessa,
I know how tough
internship can be.
But everyone here already sees
what a good doctor you are.
- Thanks, Maggie.
- Yeah.
- Hey, Mike.
- Hey, Phil.
♪
- Hey, Dad.
- Hey, Dylan,
what are you doing here?
- Oh, you know, stopping by.
- Okay.
- Italian beef?
- Is that Al's?
Oh, come on.
It's been a long time.
- I know.
Ever since you
used to bring them
to me every day
at medical school.
- [laughs]
Really, that was just so
I could get one, too.
- [laughs]
Here you go.
- Thank you.
Mmm, mmm, mmm.
- Yeah.
You know, um,
just wanted to say
thank you, Dad.
- For what?
Bringing you sandwiches?
- No, no.
For everything.
♪
- Okay, you know what, boy?
How many times
I got to tell you
you got to ask for
extra giardiniera over there?
♪
[phone dings]
- Dr. Marcel, this is Enid,
from Dr. Blake's service.
Dr. Blake has
a kidney transplant
that she would
like you to scrub in on.
Uh, please be here
in half an hour.
- [sighs]
♪
[clears throat]
♪
[wolf howls]
- With the suggestion
from Dr. Cooper
I could've sabotaged
Archer's CVP monitor
so that the Vas-COM
could save the day.
And I came close to doing it.
- If this ever gets
to be too much for you,
I'll put a stop
to the whole thing.
- I'll take it from here.
- I assumed I'd perform
the surgery.
- You're free to watch.
- Best by the powers that be.
- I'm sorry.
I made a fool of myself
with Dr. Marcel.
I'm crushing on my advisor.
- How long
you been doing this?
- 35 years.
- How?
- You got to hang on
to those good days.
You got to hang on
to those wins.
- Really, Dad?
- What? It's fine.
- It's a red zone.
It's for emergencies only.
No--
- See?
Now, it's an emergency.
Oh, you know what?
I wanna check this out.
New PDT system.
I can check all
of my units in real time.
- But, look,
can I check it out later?
I really do have to go.
I'm late.
- Everything okay here?
- Oh, yeah, we all good.
Just a little ride-along.
Letting a civilian see
what a real job looks like.
- Yeah, thanks.
- Yeah.
Am I embarrassing you?
- I'll see you later.
[siren beeps]
Come on, Dad.
- [laughs]
[siren beeps]
Okay, I'm gone.
- [laughs]
- Hey, what's up?
- Do you remember
how when we were
in physical exam class,
when we did breast exams,
they would tell us
to make small talk
with the patient actors?
- Yeah, to help
put them at ease.
- Yeah and there was
that one guy, Mandelbrot.
Super awkward.
Caught hell for asking
one of them what
she was doing that weekend.
- Oh.
- He is a panelist
at the next summit
for female physicians.
[laughs]
- Wait, that wasn't Mandelbrot.
It was Richardson.
- No, pretty sure
it was Mandelbrot.
- No, it was Richardson.
- You haven't changed a bit.
Always got to one-up me.
- I'm not trying to one-up you.
- Two shots for Dr. Hammer.
Three for Dr. Halstead.
- [laughs] Thank you.
Have a good day.
- You too. Thanks, Carly.
- Morning.
- Good morning.
Dr. Halstead, how are things
with Dr. Cooper?
- Uh, pretty well, I think.
- Oh, yeah?
- I mean, he hasn't said
anything otherwise.
- Good morning,
Ms. Goodwin, Will.
- Matt.
- Just the man
I was looking for.
I want to tell you about
the conference
coming up in a few weeks.
- National Critical Care
Society annual meeting.
- It's here in Chicago.
You should go.
Vasik's gonna be
a platinum sponsor.
They're gonna have
a corner booth.
It's gonna be
the perfect chance
for you to meet
some of the upper-level execs.
Oh, do you think that you could
spare him for the day?
- It's always good
when our doctors
broaden their expertise.
- I'll be there.
- Okay, great.
I'll get you the details.
Um, Ms. Goodwin.
- This might be good.
And maybe I can get them to
offer me a deal like Cooper's.
[phone buzzes]
- Geez, I got to get this, but,
uh, you're on the right track.
- Thank you, La'Shawn.
Morning, Alim.
Hey.
- Hey.
- What time did you get in?
- Uh, I don't know.
Like, around four.
- Why so early?
- Always try to get
a leg up on the day.
- Two hours before your shift?
- Well, if I'm meeting
with my patients earlier,
then I can read up
on their conditions.
That way, I'm running rounds,
I'll have all the answers.
Plus, if I'm here
a little early,
I can study for my boards.
- Sleep ever a factor
in this equation?
- Life of an intern.
What can I tell ya?
- Dr. Marcel.
- Yeah.
- Treatment three incoming.
[bell beeping]
- What do we got?
- Avery Quinn,
28-year-old female.
Pedestrian versus auto.
BP 80/45.
Heart rate 114, satting at 88.
- Okay, Avery, I'm Dr. Marcel.
We're gonna take
good care of you, okay?
- It hurts so much.
- Trigger the MTP,
give her 50 of fentanyl.
Here we go, guys.
Transfer on my count.
One, two, three.
- [groans]
- There it is.
All right, let's roll her.
You're okay, we got you.
The board...
- [groans]
- All right, we're good.
Avery, can you put
your arms by your side for me?
You're gonna feel
a little bit of pressure, okay?
- [groans]
- O2 sats down to 82.
- Avery, Avery.
Avery...she's out.
We need to intubate.
20 of etomidate, 100 of sux.
Get a CBC, CMP,
type and cross four units.
Let's get a fastscan
and have them prep OR 12.
- No, she's going to OR seven.
- Excuse me?
- Yeah, I'll take it from here.
And let's add
a coag panel and LFTs.
- Dr. Blake,
I think you're mistaken.
This is a trauma,
not a transplant surgery.
- Yeah, I can see that.
She's got free fluid,
and she's in shock.
Her liver's ruptured
but repairable.
We got to get her up now.
- I'm in. Bag her.
All do respect, Dr. Blake,
you're a transplant surgeon.
I got this.
- Thank you, Dr. Marcel,
but I'll be
taking over the case now.
- I'm sorry,
I can't let you do that.
This is my patient.
- And I understand that,
but she's also my daughter.
Now, I'm gonna need you
to move.
Let's go.
[dramatic music]
- You got a transplant patient?
- No, I don't.
But we have a problem.
♪
.
- Hey, Alex, I'm Dr. Scott.
- I'm Susan.
This is Todd.
And this is Ry--Ryan, come on.
- Hey, Ryan, can I get
a couple of those?
- Ryan, enough with the gloves,
okay?
- Thanks. [laughs]
Alex, says here that you
got hit in the head
with a Nerf gun.
- Yeah.
- Oof, I bet that hurt.
The thing is, you're supposed
to get hit with the foam dart,
not the actual gun.
[chuckles]
- Stop it.
- It was an accident.
The boys were playing.
- Mom, it wasn't a Nerf gun.
- Okay.
I--I didn't even see it happen.
I--okay.
- Ryan.
- Mom---mom.
- Hey, just a minute.
- Mom--
- They were down in
the basement and--
- It wasn't a Nerf gun.
- Ryan, okay.
- Hey, hey, hey, Ryan.
What's up, buddy?
Talk to me.
- It was an Ultra Blaster.
- Oh, yeah?
Triple action
with the slam-fire?
- Uh-huh.
- Sweet. Yeah.
- "I'm sorry, Doctor"?
Todd, you want to take him
for a walk to the truck?
Give him his meds.
Okay, go with Dad. Go.
- Oh, man.
Tough day, huh, bro?
- He has ADHD.
- Yeah, we have him
on Adderall,
but we keep upping the dose,
and some days
are just a little tough.
- [whispers] I know.
It's okay.
What about you?
How you doing?
- [whispers] I'm fine.
- You sure?
Okay then.
For now, we're gonna keep
applying pressure
and get you all stitched up.
Shouldn't be too long.
Hey, Mags, I need somebody
to throw stitches in six.
- I'm on it.
- You already have
two patients up.
You sure you have time?
- Don't worry.
I got it.
- [sighs]
- Rough morning, huh?
- Yeah.
It's a tricky family dynamic.
I'm treating
a 10-year-old named Alex.
His brother has ADHD.
Seems like
it's pretty tough on them.
- Yeah.
- Takes up a lot
of the family's energy.
- Oh, yeah.
Parents so focused
on--on the kid with the illness
that they see right through
the other one.
Yeah, unfortunately
not at all uncommon.
There's even a name for it.
It's called--it's called
glass child syndrome.
- Oh, that sounds like
exactly what's happening.
- Yeah, happy to provide you
with a couple referrals
for a therapist
for the--for the kid
if you think the parents'll
be open to it.
- I think that'd be great.
Thanks.
[phone buzzes]
- Oh.
Dr. Choi,
I've been bugging him
for an update on his rehab.
I better take this.
- Go ahead, man, and tell him
I look forward to meeting.
- Will do.
- I understand
this must be hard for you,
but that's the very reason
I can't let you go in there.
- I appreciate your concern,
but I'm fine.
- Dr. Blake.
- Ms. Goodwin.
- You know very well
it's against hospital policy
to operate on a family member.
- I am perfectly qualified
to perform this surgery.
- Pamela, you are
a transplant surgeon.
- Dr. Archer and I
see these cases every day.
- And I make more money
for this hospital
than any other doctor here.
- That is not the point.
Dr. Archer is
a top trauma surgeon.
He will do an excellent job.
- I will,
and if you're so inclined,
I'd be happy
to have you observe.
♪
- Ryan.
- Ryan--
can you sit still
for just one minute?
- [sighs] I'm gonna go
get some air.
- Yeah.
- Will, can I get
your opinion on something?
- Sure.
What's going on?
- I've got a 71-year-old woman
who's hypotensive
and tachycardic.
Passed out this morning
at home.
No medical history
other than asthma.
She could use
some cardiac monitoring,
and I know that
you're big on the Vas-COM.
- Well, I mean, there are
a number
of good cardiac output
monitors.
But the Vas-COM
is a terrific device.
You mind if I, uh,
have a look at her?
See if she's a good candidate?
- Yeah, yeah, sure.
- Eleanor, Ron,
this is Dr. Halstead.
- Hi.
- He's just going to ask you
a few questions.
- Nice to meet you.
- You have to help her.
Ellie, tell him,
you've never been sick
a day in your life.
- Ron--
- No, no, that's good to hear.
You mind if I?
- Mm-hm.
- Make a fist.
And release.
- [sighs]
- Good.
Does she have
any sensitivities or allergies?
Recent injuries,
meds that would interfere
with an arterial line?
- Just seasonal allergies.
- Okay. Eleanor, do you
ever have any trouble
when you get your blood drawn?
- I don't think so.
- What about leg swelling?
Long car rides, trips?
- No, not that I can remember.
- That's good.
All right, it was nice
to meet you.
I'll have a chat
with Dr. Hammer.
We'll be right back.
- What do you think?
She look good for the Vas-COM?
- Uh, maybe.
She was
a little vague in her answers.
- But she definitely
should have
her cardiac output monitored?
- Dr. Hammer,
if you're interested,
I could give you copies
of the Vas-COM's FDA-approved
usage criteria?
- You know, that--that
won't be necessary.
I think Eleanor would be
a great candidate.
- Okay, good.
I'll get it set up.
- Dr. Scott.
- Alex?
- Dr. Taylor.
- Buddy? What?
Alex.
- Bud...
- Excuse me.
- Honey, honey?
What--what's happening?
- He's having a seizure.
Give him 12 liters of O2
and .five of Ativan.
- Wait, seizure?
Why is he having a seizure?
- I'm not sure yet.
[whispers]
Come on.
Come on, come on,
come on, come on.
♪
Hey, Alex, you with me?
- Uh-huh.
- [whispers] Okay.
♪
We're gonna figure this out
as soon as we can.
Dr. Taylor.
♪
- Hi, hi, okay.
It's okay.
- Has that cut been bleeding
like that the whole time?
- I tried holding pressure,
but it didn't work.
And if I would've tried
to stitch too soon,
he would've got a hematoma.
- He could have
a bleeding disorder.
Did you order coags?
- Um, well, no. I--
- Get a coag panel, Maggie.
And let CT know
we're on our way.
- Wait, do you think he
could have a subdural hematoma?
- Yes, and if he does have
a bleeding disorder,
then the trauma
from getting hit in the head
could've caused
a bleed in the skull,
which means he could herniate
at any moment.
All right, now.
Let's go.
♪
- [whispering]
Oh, my God.
.
- Okay, ready to release
the pringle.
- Hold on, I didn't get
a good look at the duodenum.
- It's clear.
- Okay.
- All right, pulling back
on the lap.
[heart monitor beeping]
Looks good.
- What's her pH and temp?
- 7.34 and 36.9.
- All right, looks like
you're good to close.
- Uh, actually, we're just
gonna pack and leave her open.
- No, her bleeding's
under control.
Packing her isn't necessary.
- I disagree.
She's got a grade four
liver laceration.
The risk of re-bleeding
is too high.
- She's a healthy 28-year-old.
Leaving her open puts her
at increased risk
for infection, coagulopathy,
hypothermia, and acidosis.
- Dr. Blake, I--
- Close her up, doctor.
- I understand your concerns.
- No, no, point well taken.
I see the merit
in what Dr. Blake is saying.
- Dr. Archer--
- All right, hold off
on the lap.
I need Celox, Gelfoam,
and get an O Max
and suture for Dr. Marcel.
- Dr. Archer, you--
- Dr. Marcel.
♪
[knocking]
- Mr. and Mrs. Miller,
I'm Dr. Charles.
I had been consulting
with--with Dr. Scott
on Alex's case.
- Psychiatry?
- Head injury.
You know, can't be too careful.
Anyway, Dr. Scott wanted me
to let you know that
Alex's scans are almost ready.
And in the meantime,
is there anything
I can get you?
A bottle of water?
- Thank you, but we're fine.
- Yeah.
[cell phone buzzes]
Oh, sorry.
This is work.
Um, don't forget
to text my parents.
Excuse me.
- Oh, okay. Yep.
- Ryan? Is it Ryan?
How about you, buddy?
Can I get you something?
- Do you mind if I...
- No, not at all.
- Okay, I'll be right back.
- Not at all.
- Would you, uh,
like a sandwich or something?
No? Bag of chips?
Soda?
Anything at all?
- No!
You interrupted me.
- Oh, I'm sorry.
I, uh, I--I didn't mean to.
- Now I have to start
all over again.
- Oh, you were counting.
Huh?
Okay, well, I'm--again,
I'm very sorry.
You--you get back to that.
All right?
- Mr. and Mrs. Miller, we just
got Alex's test results back.
Alex is stable right now,
but the scan did confirm that
he is bleeding into his brain.
And the intracranial pressure
is great enough
that he needs
immediate surgical evacuation.
- Oh, my God.
- Wait, wait, wait.
How'd this happen?
- Well, his test results
came back positive
for a bleeding disorder called
Von Willebrand disease.
So the impact from a small toy
could've caused a bleed
that his body
just wasn't able to stop.
- I--I know this is a lot,
but Dr. Abrams
will be doing the surgery,
and he's our very best.
The procedure
shouldn't be that long.
I'll be here for status updates
or if you have any questions.
- And if we have your consent,
we could get started
right away.
- Sure.
- Yeah, of course.
Whatever you need.
- Okay.
So why don't I take you
somewhere
that's more comfortable
to wait?
- Um, Ryan.
Hey, buddy.
Come on, buddy.
We're gonna take
a little walk, all right?
♪
[all talking briefly]
- Hey, I saw
Eleanor's oxygenation
and cardiac output are down.
Have you gotten her labs
back yet?
- Yeah; they don't show much.
Mild infiltrates
on her chest X-ray
and some eosinophilia.
Still don't know
what's going on.
- I'm a little concerned.
One of her fingers and two
of her toes are going cold.
- Oh, could just be
a vasospasm.
- That could be, but--
look, the major drawback
to any arterial line,
including the Vas-COM,
is the potential
for thrombus formation.
So I think we should
pull it out.
- Pull it out?
I mean, thromboembolization
in arterial lines
is extremely rare,
and it almost never occurs
this quickly.
- I understand.
I just think we should err
on the side of safety.
What?
- Is something going on?
It's getting us great numbers.
Keeping Eleanor's meds titrated
and her pressure
and heart rate optimized.
Without it, we'd just be
shooting in the dark.
- I know.
I just want to make sure
we're using it appropriately.
- I think we are.
Let's just give it
a little more time.
[uneasy music]
♪
- Dr. Archer.
- Yeah.
- What the hell
happened back there?
- What?
- Giving in to Dr. Blake
like that.
- The surgery was a success,
and if you'll excuse me,
I have an ED to run.
- Hold on, Dean.
You know,
with that kind of injury,
keeping her open
is the right thing to do.
- Dr. Blake's reasoning
was medically sound.
I mean, I could argue it
either way.
- Oh, come on!
- Crockett...
hospital politics
is a lot like the military.
You put in your time.
You do as your told.
And eventually you can rise up
to become a Dr. Blake, too.
♪
- Hey, buddy.
This is my friend, Dr. Charles.
- Hey, Alex.
- We just came to check in
on you before your surgery,
see if you had any questions.
- Is this gonna hurt?
- No, no.
They're gonna give you
some medicine.
It's gonna put you
right to sleep.
You won't feel a thing.
- Even when they open my head?
- Next thing you know,
you're just gonna
wake up in recovery.
We promise.
- Okay.
- Anything else on your mind?
- No.
It's just,
when they look inside my head,
will they see my secrets?
- Uh, I don't think so.
But if there is something
on your mind,
a lot of kids tell me that
it's just better to get it out.
- This wasn't Ryan's fault.
- Oh, don't worry about that.
Ryan's not in any trouble.
- No, I made him do it.
I made fun of him,
and I know if I did it enough,
then he'd get really mad
and hit me.
- Yeah?
Why would you want him
to hit you?
- Because...
- Because?
If you got hurt, maybe
Mom and Dad pay
a little more attention to you?
- It was stupid.
I shouldn't have done it.
- Hey, it's okay.
Let's get you taken care of.
All right?
- Alex, it's gonna be okay,
buddy.
You're gonna be fine.
We'll see you in a bit.
- [sighs] Man, listen,
I deal with a lot of sick kids,
but what do you do for this?
- So... kid with ADHD,
control issues, right?
Random outbursts.
- True.
- Yeah, but Alex knew he could
only get Ryan to lash out
if he backed him into a corner.
That's not random.
- So, what are we looking at
if this isn't ADHD?
- I think maybe
an anxiety disorder.
- Oh, another misdiagnosis.
Second in a week.
- And if I'm right,
that misdiagnosis
is causing this family
a lot of problems.
[alarm beeping]
- You have to come quick.
Something's wrong with Ellie.
[dramatic music]
[monitor beeping]
- Eleanor, can you hear me?
- Yeah.
- Okay.
- Squeeze my hand.
♪
- What's happening?
Why's she like this?
- She had a TIA,
a mini-stroke.
Start her on aspirin
and clopidogrel
and call for an MRI
of her head.
- A stroke?
What--what? Why?
- 'Cause she's forming thrombi.
They're blood clots
in her vessels, and one's
travelled to her brain.
- Oh, my God.
♪
- Get a suture kit.
We have to pull the Vas out.
- I'll call Dr. Hammer.
Excuse me, Mr. Halt.
She's up in radiology.
- No, no, no.
Every minute that passes
increases her risk
of a major stroke.
We have to pull it right now.
♪
.
- Hey, you okay?
- No.
I screwed everything up today.
- I saw Alex's notes.
Von Willebrand disease?
You couldn't have known.
- I could've ordered
those labs earlier.
- But it doesn't matter.
The outcome still
would've been the same.
Look, you're always gonna wish
that you could've done
something earlier.
It's part
of being a good doctor.
- Alex is in surgery, Maggie.
He's bleeding into his brain.
- Which isn't your fault.
♪
- You pulled
my patient's Vas-COM?
- She had a TIA.
The Vas-COM was
most likely the source.
- You don't know that.
Could've been lupus,
endocarditis, even leukemia.
And now we have no way
to monitor her.
- She could've had
another stroke at any minute.
What--what was
I supposed to do?
- She's my patient, Will.
You at least
should've asked me.
- By the time
you got down here--
I'm not taking that chance.
- No, you were afraid
that I would disagree
and that I'd stop you.
- No.
- It's the same old Will
from med school,
always thinking
that you know better.
- Stevie, that's not
what this was about.
- You tell yourself that.
♪
- Hi.
I don't know if you remember me
from this morning.
I'm the surgeon on your case,
Dr. Marcel.
How you feeling?
- Like I got hit by a car.
- Well, you did
just have major surgery,
but, uh, it went well,
and I imagine you will feel
a little better each day.
- Here you go.
Dr. Blake said to go slow.
- Thanks, Dina.
- Ice chips.
My mom is in love with them.
Frankly, I think they're
just as much
an aspiration risk as liquids.
- Aspiration risk?
What, are you
a--you a doctor, too?
- Made it halfway through
a third year of med school.
- Oh, okay.
- Realized I was doing it
for my mom, not for me.
- Oh.
- I'm assuming
you've met her by now?
- Made her acquaintance, yeah.
- She try to scrub in?
- How'd you guess?
- [groans]
I know my mom.
- [laughs]
- She didn't talk to me
for six months
after I quit med school.
- Wow, that's rough.
- No.
The day I took control
of my life?
Best move I ever made.
- Anyway, I should
let you get some rest.
Um, enjoy your ice chips,
and I'll check back later.
So wait, what did you
end up doing after med school?
- A malpractice lawyer.
- Medical?
Your mom must be very proud.
- [laughs]
- Mr. and Mrs. Miller,
I have an update for you.
- Be right back, buddy.
- So, look, they're--they're
just finishing up
in surgery now.
All indications are that
the procedure was a success.
And Alex is doing great.
- Oh, my God, really?
Thank you so much.
Listen, Dr. Scott and I
talked to Alex
before the procedure today.
And I understand that you have
a lot on your plate right now,
but I--I also think
it's important that I share
this conversation with you.
both: Okay.
- So--so what
he told us is that
he provoked Ryan
into this outburst today.
He feels terrible.
I think he is looking
for some attention.
But where Ryan's concerned--
what this means to me
is that it wasn't
an impulsive outburst.
It wasn't--it wasn't random.
And that and a couple other
things I've observed today
are leading me to believe
it's very possible
that--that your son has
been misdiagnosed with ADHD
and that we were
probably looking
at some kind
of anxiety disorder instead.
- Wait, what are you
talking about?
Look at him.
He can't sit still.
- But Mr. Miller,
it's--it's the counting, right?
The tapping.
I think that
he's self-soothing
to help him cope
with these feelings of anxiety.
And when that stops working,
I think he feels
backed into a corner,
and then you have
a fight-or-flight situation.
- Well, what
about the Adderall?
His doctor said
that would help.
- If he actually had ADHD,
it would be working.
But it's not, right?
I think that in Ryan's case,
it's actually working
against him
and serving to only intensify
these feelings of anxiety
to the point
where they're often,
frankly, unbearable.
- Dr. Charles,
man, look I--I--
we appreciate everything
you're doing.
Really, but please,
our son's in surgery.
- I am sorry.
This is just not an ideal time
to have this conversation.
But I just wouldn't
be doing my job
if I didn't tell you
how important I think
it would be to reassess Ryan
and make sure that you are
looking at the right diagnosis
for him, for his brother,
for all of you,
for your whole family.
- No, Dr. Charles, it's just--
it's just been a long day.
- Listen, I am going
to check back with you
when Alex wakes up, okay?
- Yeah, yeah.
- Okay.
- I should've consulted you
before pulling the Vas-COM.
It wasn't my place.
I'm sorry.
And besides, you were right.
She's getting worse and
still having embolic events.
So it wasn't
the Vas-COM after all.
- Clearly,
but I've gone through
every clotting disorder,
and none of it fits.
- Is it possible
we're looking at this wrong?
That she doesn't even have
a clotting disorder?
- Of course.
It's just so little to go on.
I mean, history of asthma,
eosinophils,
and left-sided
lung infiltrates.
- Left?
I thought
they were on the right.
- Seriously, Will?
- No, no, wait.
The X-ray from this morning
had them on the left.
But look...
The one from this afternoon
shows they moved to the right.
- Migratory infiltrates.
Could this be vasculitis?
Churg-Strauss?
- I mean maybe.
She could've moved
from the asthmatic stage
into the vascular stage today.
- It's a long shot,
but it's possible.
- If we're right,
her organs could start
to shut down at any moment.
- I'll start her on prednisone
and azathioprine
and set her up
for a diagnostic lung biopsy.
- Dr. Hammer, Dr. Halstead,
you need to come.
Eleanor's getting worse.
.
- I don't like
these QRS complexes.
- Eleanor, do you feel any pain
in your chest or arm?
- It feels tight.
- Oh, God, Ellie.
- Why don't you come here?
[beeping]
- She's going into v-tach.
- I'll get the paddles.
- No, no, Ellie.
- Wait.
If this is Churg-Strauss,
this could be a tamponade.
We need to aspirate the fluid.
- I know, but if we're wrong,
we won't have time
to cardiovert.
- I think we're right
about this.
- I do, too.
18 gauge on a syringe.
- 18 gauge.
[beeping]
- Ron, there's fluid
around Eleanor's heart.
They need to drain it.
[beeping]
- Nothing.
Got it.
- Sinus rhythm.
- Eleanor, can you hear me?
- Uh-huh.
- Oh, thank God.
- Call IR.
Tell them we're coming up
for a drain and a lung biopsy.
- You got it.
- Good job.
- Hey. How you feeling?
- Okay.
- Good.
Surgery went well.
In fact, the neurosurgeon said
that you had
the best-looking brain
he's seen in quite a while.
- Yeah?
- Yeah.
Told your parents,
but they weren't surprised.
Said they always knew
you had a great brain.
- They said that?
- Yeah, they did.
You know, Alex,
kids with great brains--
they don't always get
the most attention,
but... people notice.
- What's going on?
- O2 sats are 91.
BP's down to 83/50.
- Drains are full.
- [groans]
- Belly's firm.
Okay, etomidate and sux,
then transduce
to a bladder pressure.
Let's go.
Hey, Avery, look at me.
You're re-bleeding
into your abdomen.
I need to intubate and take you
back to the OR, okay?
- [groans]
- What happened?
- Abdominal compartment
syndrome.
We're going back to the OR.
- No, no need.
You can use a cordis catheter
and decompress here.
- There's too much blood.
We don't have enough time.
I'm in. Bag her.
- And if you open her up,
there'll be too much swelling,
and you'll never
be able to close.
- Get the cordis.
- Dr. Marcel,
bladder pressure's 35.
[beeping]
- It's too high.
We need to open her up
to release the pressure.
Get me a 10 blade.
- Dr. Marcel,
I already told you--
- Back off, Dr. Blake.
Here we go. Ready?
[beeping]
♪
- Sats are up to 96
and BP's 112/83.
She's stable.
- All right,
get her up to the OR.
♪
- Make sure
you get her swelling down.
♪
You're gonna need to close
her up as soon as possible.
♪
- How is Alex?
- Um, his surgery just ended.
He's doing really well.
- Alex probably hates me.
I want to tell him
I'm really, really sorry.
- You'll be able
to see him soon.
And then you can tell him.
- Can I see him now?
- I'm not supposed to let you
until he's in his room.
- Please?
- Okay, maybe we could
just take a quick peek.
If it's okay with your parents.
- Mom, can I go
with the doctor?
- Yeah, honey.
- Okey doke, let's go.
So he's still a little sleepy,
so we're just gonna give him
a quick wave hi, okay?
- That's not Alex.
- It's okay.
He's just
a little bandaged from surgery.
- I didn't do that.
- No, of course you didn't.
- I didn't mean to.
No, I'm sorry.
I'm sorry.
- Hey, hey, Ryan,
Ryan, Ryan, it's okay.
Listen to me. Listen to me.
Ryan, look,
you didn't do anything wrong.
- Stop it.
- Ryan!
Ryan! Ryan!
♪
I'm so sorry.
This is all my fault.
- The security camera
picked him up.
We're okay.
- Still, I just
can't apologize enough.
Maybe I should talk
to his parents or--
- You know what?
I think it's probably better
if I handle this.
Listen, Vanessa,
not your fault.
Okay?
You were trying to help.
♪
- Ryan, your brother
just had surgery.
That's why he looks like that.
He's gonna be fine, buddy.
Now, can you please come out?
- Please, Ryan?
♪
- Mind if I give it a try?
- Yes.
- Hey, Ryan.
You know what?
I don't think that you wanted
to hurt your brother today.
I think the only reason
you threw that toy today
was because you didn't know
what else to do.
- I got so mad.
- 'Cause those feelings,
they just...
They just keep building
and building.
- Uh-huh.
I can't stop them.
And I'm always
getting in trouble.
- What if I told you
that I didn't think that
that was your fault?
- That's not what people say.
They're always telling me
to reset.
- Well, you know what?
I don't think it's your fault.
Not only that, you know
those--those feeling you get?
I get them, too.
- You do?
- Oh, yeah.
Everybody does.
And one of the things that
really helps me when I get them
is, actually,
to talk about them.
You know, there's
this weird magic when you--
when you get them out.
They just--they just don't
seem to bother you as much.
- Really?
- Yeah.
And I guarantee you,
whatever feeling you're having
there are people in your life--
they want to hear about it.
I mean, your mom and dad...
They would really want
to hear about them.
- They would?
- Of course we would, honey.
- And you won't think
that I'm bad?
- Ryan,
we never think you're bad.
♪
- I got you.
♪
- You really don't think
this is ADHD?
- I don't think it is.
- So this Adderall
isn't helping?
- I think it's
actually making it worse.
♪
.
- Hey, I just saw
Eleanor's biopsy results.
Churg-Strauss.
- Hey, maybe we work well
together after all.
- Maybe we do.
I'll see you tomorrow.
- See you tomorrow.
Oh, I made a few calls.
It was definitely Mandelbrot.
[laughter]
Bye.
- Bye.
- Will, I just met Eleanor.
Churg-Strauss,
one in a million.
- Yeah.
- Though I did see you had
to pull her Vas-COM.
- Yeah, I hated to do it.
Uh, but she
was throwing emboli,
had some
cold fingers and toes--
- Hey, hey, Will, you
absolutely did the right thing.
The last thing we need
is for the Vas-COM
to be used inappropriately
and then it gets a bad rap.
- That--that's what I thought,
too.
- Now that she's stable,
however, it did seem
medically warranted to get
her on better monitoring again,
so I just put in
another Vas-COM.
♪
- Okay.
- Anyway, I'm glad you're
coming to the conference.
- Yeah, same here.
- Hey, maybe, um,
if you get there early.
we could have a drink?
- Sure.
♪
- [groans]
So what do you think?
- What do I think?
Um, I think that they have made
a crucial breakthrough.
And now they got
some work to do.
- Yeah, you know,
it's something--
how easy it is,
even in a loving family,
to feel so unseen.
- Huh?
- I guess I didn't always
appreciate how good I had it.
♪
- Your numbers look good.
And your drains are clear.
- [groans]
- So, if you get thirsty,
you can just ask the nurses
for some ice chips.
- Ice chips.
- [laughs]
- Finally going to
get some sleep?
- Boards aren't going to study
for themselves.
- Believe me,
a nap wouldn't hurt.
Anyway, I'm going to run
this boy's Adderall
over to the pharmacy,
then I'm out of here.
- All right, well, um,
see you tomorrow.
- Hey, Vanessa,
I know how tough
internship can be.
But everyone here already sees
what a good doctor you are.
- Thanks, Maggie.
- Yeah.
- Hey, Mike.
- Hey, Phil.
♪
- Hey, Dad.
- Hey, Dylan,
what are you doing here?
- Oh, you know, stopping by.
- Okay.
- Italian beef?
- Is that Al's?
Oh, come on.
It's been a long time.
- I know.
Ever since you
used to bring them
to me every day
at medical school.
- [laughs]
Really, that was just so
I could get one, too.
- [laughs]
Here you go.
- Thank you.
Mmm, mmm, mmm.
- Yeah.
You know, um,
just wanted to say
thank you, Dad.
- For what?
Bringing you sandwiches?
- No, no.
For everything.
♪
- Okay, you know what, boy?
How many times
I got to tell you
you got to ask for
extra giardiniera over there?
♪
[phone dings]
- Dr. Marcel, this is Enid,
from Dr. Blake's service.
Dr. Blake has
a kidney transplant
that she would
like you to scrub in on.
Uh, please be here
in half an hour.
- [sighs]
♪
[clears throat]
♪
[wolf howls]