ER s02e13 Episode Script
It's Not Easy Being Greene
E.
R.
Previously on E.
R.
I have never seen such a chain of errors on judgement.
But I did what you said.
In a case where the injuries were inflamatory like, leaving a newborn motherless Mr O'Brian.
He's Carl's newly anointed.
The heir apparent.
It's been the best and hardest work I've ever done.
Good.
That's music to my ears.
You're a candidate for chief resident next year.
But is just that now is not a very good time.
There is never a good time.
The truth is mommy and daddy aren't gonna live together anymore.
"It's Not Easy Being Greene" - I love it when those endorphins kick in.
- You're not on today, are you? I thought I'd drop by, ease up your workload a little bit.
After I take a shower.
- It's his day off? - That's dedication.
Dedication? Man, that's sad.
Don't move, Mrs.
Zarian.
It's a little bit of glass, and it's almost free.
Susan, were your ears burning? David Morgenstern and I were just talking about you.
He feels you're the top contender for Chief Resident next year.
Oh, thanks.
This year's field was pretty disappointing but we found your work to be consistently solid.
Now, I know you're concerned about taking time away from the baby but that doesn't have to be the case.
Keep the bevel facing out.
By applying time-management techniques you can work more efficiently reduce on-the-job stress and get home at a reasonable hour.
Mrs.
Zarian I've got a book on the subject, if you're interested.
No pressure.
I just wanna let you know how we're thinking.
- Son of a bitch! - What? They cut me back to three shifts a week.
- They're cutting back on nurses? - Nurse managers because of our outrageous salaries.
I still need $12,000 worth of work on my house! They bumped me up to six shifts a week.
So much for my weekend.
- I know a way to make some quick cash.
- Talk to me.
I joined this guy Alvin's investment club.
Put up a $2000 membership fee and in a week to 10 days, you collect 10 to $20,000.
- From? - The fees of the new people who join.
- It's called a pyramid scam, it's illegal.
- Well, that's not what Alvin says.
Trust me, if you're not in early, you lose your shirt.
When did you get in? - Hey.
- Hey, yourself.
All right, let's see what we got here.
- Where'd you learn to do sub-q sutures? - From your med student.
- I obviously taught him well, didn't I? - Benton.
- See you later.
- Listen, I should warn you: You might want to invest in a new suit and some luggage.
You're going to Paris to present our clamp-and-run study to the institute.
- Are you serious? - Oui.
Simon did an analysis of our result.
Our P-value was.
06.
We're one successful outcome away from statistical significance.
- We can publish? - Soon.
One more aneurysm and our numbers will blind the most dubious skeptics.
After that, we head to D.
C.
to play dog-and-pony for the FDA.
Now, Simon doesn't fly, so he stays here which makes you the next choice for Clamp-and-Run Ambassador to Europe.
I don't know what to say.
I'm honored.
It's good practice for the future.
You've gotta find another patient soon because the Norwegians are doing a similar study.
And, Peter, we cannot let the Vikings pillage our thunder.
- Malik, you seen Carter? - He called and said he'd be late.
He should be coming any minute.
No, wait! Wait! Wait! Yeah! Oh, God! John! Oh, God! Oh, God! Oh, baby.
I think we broke my record.
Yeah.
- Oh, John.
- What? Your control is phenomenal.
- Yeah? - Yeah.
Yeah.
Thank you.
You know, you may find this hard to believe, but that wasn't always the case.
- No? - It's hard to believe, it's true though.
But I found if I could distract myself and think about mundane things then I could delay the inevitable.
Well, what kind of things do you think about? Let's see.
Sometimes I take a mental inventory of the machines in the O.
R.
Thora-Seal, ventilators, auto-infusers.
And then, as the degree of difficulty increases, I run the procedures.
Appendectomies, thyroidectomies, bowel resections.
- Yuck! - What? While we're making love, you're thinking about bowel resections.
Given your earlier testimonial this is a case of the ends justifying the means.
- What? Get out! - I'm kidding.
I'm just kidding.
So last night I get a letter from Jen's lawyer politely informing me that she's suing me for full custody of Rachel.
- Oh, no.
- Yeah, it seems I've been a distant and absent father.
This after commuting from Milwaukee for half a year.
Well, it sounds like a lot of lawyer B.
S.
I can't imagine she'd actually go through with it.
- I was climbing the walls all night.
- Well, that's why you're here.
- Tiny prick.
- I beg your pardon? I need a TB test too.
So I hear Morgenstern has really turned up the pressure on you becoming Chief Resident.
Yeah, it's a good opportunity, but can I do it and not work killer hours? You know how well I managed to balance work and family.
- Guess that answers that.
- You'll be able to work it out.
Take your paperwork home, hours won't be that bad.
- You have to cut Weaver some slack.
- What do you mean? You go out of your way to avoid her.
And if she's gonna be training you you're gonna have to work together hand in hand.
Oh, there's an image.
- Why are you here on your day off? - I went for a jog and ended up here.
- Figured I might as well save some lives.
- One other good reason not to exercise.
five-minute grand mal seizure.
I'll take it.
Start a chart.
On his day off? - The orders should've been in already.
- I forgot.
- I thought you wanted a Residency.
- I do.
Keep forgetting, you'll be in North Dakota.
We got 300 applications.
- When do the interviews start? - They already have.
Vucelich needs one more aneurysm for his study.
Abdominal pains, chest pains, traumas, call me.
How often do you get dizzy spells, Mrs.
Henry? Oh, I get three or four a day.
Usually when I'm working in the shed.
- You garden this time of year? - I'm a vermiculturist.
- I raise earthworms.
- Really? Big ones from Belgium.
Finest castings in the world.
- And by castings you mean? - Worm dung.
Black gold.
It's the best fertilizer money can buy.
It fixes the nitrogen in the soil.
- And you sell the stuff? - I sell the worms.
Your blood pressure's a little high.
- So it pays well? - Six figures.
Has he had a seizure before? No, he's a health nut.
He runs every day.
We're gonna have to get a CAT scan of his head to pinpoint the cause.
Alan.
Alan? - When's he gonna come back? - It takes a little time to recover.
- Well, how long? - Usually about 30 minutes.
Multifocal PVCs.
What? His heart rhythm's a little off.
Probably oxygen deprivation from the seizure.
- Has he had a murmur before? - No.
Well, it's probably nothing serious.
Let's get an echo of his heart after the CT, just to be safe.
Lidocaine bolus, 100 milligrams, then start a drip.
No, Carter.
John Carter.
I thought maybe you were trying to get in touch with me to set up an interview for the Residency.
No, huh? Well, I'm available at any- Okay, great- Right.
I hear Vucelich doubled his finder's fee - for an aneurysm.
- Could be.
I made 1000 bucks.
Patient with a history of ulcers, says the pain's different this time.
- Rigid belly? - Hard to tell.
He's so fat.
But see the calcifications on the descending aorta? - No, where? - Here.
It's too lateral.
Probably just schmutz on his lungs.
- I shouldn't call Vucelich? - If you wanna get yelled at.
Harper, I need you to get this guy to CT.
Coming.
Can you return this x-ray to his room? - Which room? - Six.
Hey, you done with that? Wow, that's a mother of an aneurysm.
- How can you tell? - Calcification on the descending aorta.
Yeah.
Yeah.
We're gonna run the CAT scan on his head to rule out lesions that could've caused the seizure.
What's wrong? He's in V-tach.
Let's get him to Trauma.
- Haleh? - I'm here.
- What's wrong with him? - His heart rhythm's worse.
You sure he hasn't taken medication? Any non-prescription drugs? - No, never! - We're gonna get this under control.
Can someone take Mrs.
Wimbur to the waiting room? - But I just wanna- - It's okay.
- Another 50 of lidocaine, IV push.
- Heart's racing, 200.
- Rhythm is all over the place.
- Looks like Torsade de Pointes.
All right, Harper.
Let's get lytes and the tox screen.
And see if we got any records on this guy.
Anything that can give us a clue.
Lido's on board.
- What's your gut say, Haleh? - Low potassium.
- Lydia? - Cocaine.
His wife says he's tox-free.
We'll know soon enough.
Heart rate's up to 210.
Let's try and cardiovert.
Paddles.
Start him at 100.
- Hands off! - Clear.
- Faint pulse.
- There we go.
Nice rhythm.
- He's moved his head.
- His rate's down to 160.
- One-eighty.
Here we go again.
- All right, lidocaine's not working.
Let's try bretylium, 500 IV push.
Prep a transvenous pacemaker.
Charge 200.
Hands off! What makes you think there's an aneurysm? The calcium plaque on the descending aorta.
While you saved his life, you made the Norwegian surgeons very unhappy.
- Good work.
- Thank you.
- Where's the patient? - Room 6.
To Room 6.
Hey, way to go, Carter.
Labs are back.
Lytes are normal, tox screen's negative.
We were both wrong.
- What the hell's wrong with this guy? - Rate's up to 220.
- Faint pulse.
- All right, pacer's in.
Let's overdrive him to 230.
Maximum gain.
- See if I can grab hold of this rhythm.
- You've got capture.
Lovely.
Let's take him down slowly.
- Two-ten.
- Two hundred.
One-eighty.
- He's jumping back up.
- Lost capture.
Let's start CPR.
Add Pronestyl, Paddles, set them at 360.
- What time is it? -0845.
Mark that time.
- Hands off.
Clear.
- Clear.
- Wide-complex tachycardia.
- Still no pulse.
- Time? -9:05.
- How long has he been down? - Twenty minutes.
Tried the pacer, he went into V-fib.
Shocked him 15-20 times.
He keeps running these chaotic rhythms.
- Could he be hypocalcemic? - No, lytes are fine.
- Cocaine? - Tox screen's negative.
- Acidotic? - Good question.
Let's get another gas.
- How much Pronestyl? - That makes 900.
- Time? -0922.
- Another hundred of Pronestyl.
- Got your blood gases here: PH 7.
24, PO-2's 110.
- He's still in fib.
- He's going down.
- The anti-arrhythmics? - Still got a few more.
- Stand by with the amiodarone.
- Charging up to 360.
- Back up.
Clear! - Clear.
- Time? -0932.
- Still no pulse.
- Try magnesium sulfate.
- Clear.
- Clear.
- Time? -9:41.
- High dose epi, five mgs.
Clear.
- Hit of epi in.
- Time? -9:45.
- Clear! - Clear.
- Clear! - Clear.
Time of death 9:55.
Why? There was an electrical disturbance in your husband's heart that caused it to beat in an irregular way.
I wish I could tell you what caused it to happen but the truth is, I don't know.
Well, that's not good enough.
I mean, we came in here, and his heart was okay.
You said it wasn't anything serious, so somebody must have screwed up! - How did you let this happen? - Mrs.
Wimbur.
What did you do to him?! Hello, Alvin.
Well, do you have his new number? - So, Kerry- - One second.
Yes, Susan? I've been thinking about your invitation and I would like to throw my hat in for Chief Resident.
I'm glad.
I look forward to showing you the ropes.
Me too.
Nobody's signed up for the gallbladder in 2 yet.
I've got it.
- How long does a CAT scan take? - Hopefully, not more than an hour but sometimes there's a wait.
I'm a little concerned about my worms in the truck.
- You brought them with you? - Just one bin.
I was making a delivery when the dizziness hit.
- Do you think someone'll steal them? - No, they're locked up.
You don't leave $5000 worth of worms unsecured, but they could freeze.
Listen, if I gave you my keys, could you bring them in out of the cold? - We can't have animals in the hospital.
- Oh, there's no danger.
Worms are the only disease-free organisms on Earth.
It's a fact.
- I really shouldn't.
- Please, they're my worms.
- All right.
- Thank you.
And could you feed them, please? - What do they eat? - Table scraps, as long as it's vegetarian.
Nothing too greasy because fat doesn't sit well with worms.
Mrs.
D'Angelo, I see you've been with us before.
- Gallstones flaring up again? - They're killing me.
I can't sleep, I can't eat.
And every three weeks, I end up back here.
Pain pills didn't help? I took twice as much.
Didn't do anything.
- Yeah, you shouldn't do that.
- Please, doctor get a surgeon to take these damn stones out.
It's been going on like this for six months now.
Okay.
Sorry.
Okay.
I'll get an ultrasound.
Unless your condition is life-threatening any surgery would be considered elective, and unfortunately - There's an 18-month waiting list.
- Yeah, I'm afraid so.
- My neighbor got hers out the next day.
- Does she have private insurance? Is it my fault I'm on Medicaid? Okay, we'll start with the ultrasound and see what we have.
Thank you.
His name is Alan Wimbur.
You guys just picked him up.
I was hoping you could do the autopsy today.
- Hey, Jerry, where's the ultrasound? - You've got me.
Let me know, because I'd like to observe.
Autopsy? I wanna find out what happened to his heart.
You should go home.
His wife accused me of killing him.
She's probably gonna sue.
People get upset and feel they need to blame someone.
I heard a murmur on exam.
Before getting an echo, I wanted to get a CT.
Yeah, guy comes in with a seizure, first thing you want is a CT.
Thanks, I was just checking.
Dr.
Greene? Dr.
Morgenstern's office just called.
He'd like to see you upstairs.
Word travels fast.
- You're making excellent time, Peter.
- Suction! Let Carter suction.
It's his reward for hunting down an aneurysm like a hound.
I feel privileged for the opportunity.
- Well, now, that's what I call suction.
- Thank you, thank you.
- MacGruder, is this patient warm? - Shoot, shoot, shoot! - MacGruder! - Temp is 106.
- He has malignant hypothermia.
- Is he reacting to anesthesia? Give him dantrolene, get ice packs, cooling blankets.
If we don't get his temp down, he's gonna have scrambled eggs for brains.
Who took this patient's history? He was intolerant to fluoroethane.
Damn it! I lay out a banquet and you crap all over my table! - He never had an operation.
- Cooling blankets! Well, lift him up, get him under.
Peter, come on over here.
Evert the cortex.
Log-roll him over.
Suction, Peter.
Tie that off, Peter.
- He never had an operation before? - No.
Well, you're right, there was no way of knowing.
My apologies.
Metz! Metz! Are you free for lunch? - Susan? - Yeah.
Medical records sent down the chart on your gallstone lady.
- Thanks.
- I took a peek.
- I know she's been on cefoxitin.
- Yeah.
Cefotaxime has better biliary penetration.
I know it's hard memorizing all the antibiotics out there - but it's well worth the time.
- Right.
- Who's the ultrasound for? - Same lady.
Didn't she have one last month? She's complaining of more pain.
I wanna rule out obstruction and cholangitis.
Remember Charcot's triad.
Cholangitis is indicated by pain, fever and jaundice of which she has only one.
You can rule her out without the expense of an ultrasound.
If you're gonna be Chief, you gotta watch the bottom line.
Mark.
I don't believe you've met Kathy Snyder, one of the hospital attorneys.
- Hello.
- Hello.
Is this about this cardiac arrest who died this morning? - I haven't heard anything.
Have you? - No.
Kathy wanted to talk about the O'Brien lawsuit.
- You get a court date? - We've worked out a settlement.
- I'm not sure I want to settle.
- The hospital is sure.
It's a good thing.
Mr.
O'Brien gets compensated, and you can put this behind you.
If I settle, this will follow me my entire career.
Every time I apply for a staff job or insurance If we took it to trail, we could lose 2 million easily.
You wanna lug that around your entire career? I've been over this a thousand times.
I didn't do anything wrong.
It was a very complicated delivery.
I did as good a job as any emergency physician could have.
Other emergency physicians would and have disagreed with you.
A pregnant woman comes in with preeclampsia and for whatever reason, you didn't pick up on it.
Her condition was masked by urinary infection! I don't want to argue the details with you, Mark.
You make thousands of diagnoses a year, 99 percent of them are right on.
- You made a mistake, as we all do.
- I don't accept that.
- Mark, please- - This is about my reputation as a doctor.
I'm not gonna settle.
Take my name off of it.
You can't separate yourself from the suit.
Well, I'll hire my own lawyer, and I'll fight it myself.
- That's a lot of worms.
- Hey, big fella.
- Woman makes a fortune selling these.
- To whom? Landscapers, farmers.
Could be a great sideline.
- You're kidding, right? - No.
This could pay for the hole in my roof.
- I took the spoiled food from the fridge.
- Veggie? - That's what you asked for.
- They don't like grease.
How do they feel about yogurt? I don't hear any complaining.
Eat up, little worms.
John! - Hi.
- Told you it was an aneurysm.
- You were right.
- Did Vucelich know who I was? Didn't you tell him about me? - That I found it? - I meant to.
I mean, I should have.
The whole thing happened really fast.
I was gonna say something, and they just assumed that What are you doing in here? The hospital decided to settle the O'Brien suit.
Isn't that good news? Morgenstern thinks I'm at fault for not picking up the preeclampsia.
- That's not fair.
He wasn't even there.
- You were there.
It was as complicated a case as I've ever seen.
You did everything you could.
You think I should have caught the preeclampsia? It was a difficult diagnosis.
Anyone could have missed it.
If you were called up on the witness stand and asked: "Did Greene screw up? " What would you say? I'm sorry, Mark.
Come on, dude.
Be bold.
We start our own investment club.
We collect right off the bat.
- No, thanks, man.
- What's to lose? - What'd you lose? Two grand? - Alvin's gonna come through.
Can you find out why the worm lady isn't back from CT? She had palpitations, so they're doing a cardiac workup.
Call me when she comes down.
Jerry, medical records copy a chart for me? - Yeah, O'Brien, right? - Yeah, thanks.
Hey! What happened to those worms in Radiology? - They're doing a consult.
- No, those earthworms.
I put a bucket of earthworms in there.
They're gone.
Well, I didn't take them.
Ray, I'm Dr.
Ross.
I understand you've been having some headaches and missing school.
- Yeah, they're pretty bad.
- Okay.
- Where in your head does it hurt? - Here.
- How long you been having these? - About a month.
- How often? - All the time, I guess.
- Do you feel dizzy? - Yeah.
Okay, pull like that.
- Play sports? - J.
V.
football, middle linebacker.
I was a running back.
We used to hate you guys.
Squeeze my hand.
- You ever get headaches playing sports? - No.
No.
Okay.
We're gonna get you a CAT scan.
You know what that is? No? It's when we take a picture of your brain.
We wanna make sure it's still in there.
All right.
I'll be back in a minute.
Dr.
Vucelich, Dr.
Benton.
I'm sorry to say Tradition holds they serve olives and walnuts with the drink.
Dr.
Vucelich, Dr.
Benton, I'm sorry to interrupt you.
I misled you both earlier.
The finder's fee for the aneurysm should go to Harper Tracy.
She's a third-year student.
She caught it.
Taking credit for a colleague's work is a very dangerous precedent, Mr.
Carter.
I can assure you that it will never happen again.
Well, your reassurance rings hollow just now.
One has to wonder if this is a momentary lapse of integrity or a fundamental flaw in your character.
Well, time will tell.
In any event, the patient's secondary condition means he's not an appropriate candidate for the study so there will be no finder's fee.
- Is there anything else? - No.
Strange boy.
- The patient is being excluded? - What's that? Oh, yes.
It seems that he has a history of, excuse me, neurological problems which exceed the parameters of the protocol, so What were we talking about, Peter? Oh, I remember.
George Cinq.
Walnuts, olives.
Actually, I was an habitué of this bistro, called "L'Ami Louis," and there was - Mrs.
D'Angelo.
Feeling any better? - No.
Are you going to do that test? I consulted with another doctor, and we feel the ultrasound is unnecessary.
- You don't have any new symptoms.
- You're not even gonna check? Given that you don't have a fever or any other symptoms there's no way I can justify the expense.
The expense.
I see.
I can take it from here.
I know the routine.
The nurse gives me a few pills that don't work, and I'm pushed out the door.
I checked with the elective surgery waiting list and they can get you in by the end of the year.
It's February 1 st.
- Help! - What happened? They were out by the trash.
Must've been there an hour.
Get some blankets, heat up some saline, we'll do a warm-water lavage.
- The lamps they use on newborns.
- Great idea.
Go up to OB, see if they'll lend us some.
- All right.
Oh, damn it! - The lid's frozen.
Oh, God! All right.
Rib spreader, rib spreader.
- What are you doing? - I'm gonna knock it loose.
- What do you got? - Hypothermia, earthworms.
- Five grand worth.
- Earthworms? Yeah.
They're Belgian.
They don't take kindly to cold.
Got it, got it! - Oh, no! - It's frozen solid.
Well, maybe they're still alive underneath.
Surgical mallet, reflex hammer.
Thanks.
All right.
All right.
Oh, no.
What am I gonna tell Mrs.
Henry? Good news, buddy.
Your brain's right were it should be.
- All right.
Let's talk about school.
- Why? Well, because school can cause stress, and stress can cause headaches.
Do you have any trouble with your classes or students or teachers - or anything like that? - No.
All right, what about your girlfriend? - Which one? - There's a problem right there.
- How many girlfriends do you have? - A few.
I don't know.
All right.
You're not doing drugs, are you? - Smoking pot? - No.
- No? - No.
- You okay? - Yeah, I'm fine.
What's the matter? I can't.
I can't.
What? - There's something wrong with me.
- Okay.
All guys who are your age, they think that there's something wrong with them.
No.
- I'm different.
- How are you different? The girls at school I I don't feel anything when I'm around them.
I think I'm gay.
I know I am.
I mean, what am I supposed to tell my dad, my brothers? I'm just sick of being this fake person.
Haleh, will you call Psych? See if we can get a Resident down to look at the kid in 1.
Preferably someone from adolescent medicine.
- What's the problem? - Kid thinks he's gay.
Needs somebody to talk to.
I'm going to lunch.
I'll check the charts.
Try and make yourself useful.
Okay.
Hey, good catch this morning on the aneurysm.
Harper, Carter, give me a hand.
- What happened? - She collapsed.
Acute shortness of breath, chest pain.
- Pulse is high.
- Carter, start on an oxygen mask.
- Harper, what do we order? - EKG, chest film, blood gas - Chem-7, CBC, cardiac enzymes.
- And? - Myoglobin.
- Myoglobin.
- Do it.
- She has neck-vein distention.
- Temp's 101.
- Susan? - Chief complaint? - Shortness of breath, chest pain.
- She has a history of renal failure.
- What's the differential? - Susan? - Harper? Acute MI, pulmonary embolism, pneumonia - pericarditis, congestive heart failure.
- Pleural effusion.
Pleural effusion.
Stop that! - Prompting from the peanut gallery? - Let's get a gas cooking.
Get an EKG, let's see how her heart's doing.
After you.
Hell of a way to spend your day off.
Yeah.
Wish I never would have come in.
Believe me.
What's that? Jody O'Brien? It's the first time I looked at that since the big day.
She had two high BPs, proteinuria.
I missed a preeclampsia.
If I hadn't, she'd be alive.
- Could've happened to any of us.
- It's not supposed to happen to me.
- Well, you are arrogant.
- Arrogant? It's like there's you and the Pope.
You guys are infallible.
- Then, of course, there's the rest of us.
- Yeah? Well, after today, the Pope's on his own.
Good.
I think I might have killed that guy this morning.
Mark.
Hey, Mark! When I first checked his heart, I heard a murmur.
He must've had a congenital defect.
That guy crashed 10 minutes after he got in there.
There's nothing you could have done.
Yeah, yeah.
Yes, there is.
Could've gotten an echo, and then I could've gotten him to the O.
R.
You're holding yourself to a ridiculous standard, Mark.
- I gotta get to an autopsy.
- It's your day off.
Go home! Low-voltage EKG.
- BP's falling.
- She's decompensating.
- Where's that blood gas? - I'll check.
- You got it? - These numbers don't make sense.
- What? - You hit a vein instead of an artery.
- Is that the blood gas? - Yeah, no.
I mean yeah.
- But I tapped a vein instead of an artery.
- No, I tapped a vein.
Whoever did it, do it again and do it right.
Carter, you do it.
- Non-specific ST changes.
- Where are we? Susan? I don't know where you are - I'm at pericardial effusion.
- Or pump failure, or an embolism.
- Let's get an echo! - Positive Ewart's sign.
Pressure's down, 50/30.
Pericardiocentesis tray! Shouldn't you confirm your diagnosis before sticking a needle in her heart? - I've made my diagnosis.
- Alligator clamp is on the needle.
The diagnostic gold standard is an echocardiogram.
You wait while Tech comes down.
I'll see if there's any fluid around her heart.
Okay.
I'm in.
- Anything yet? - No, not yet.
- Here it comes.
- What do you know? Looks cloudy.
I wonder if it's transudate or exudate fluid.
Anyone know the gold standard to differentiate the two? Kerry? Measure LDH to protein.
What's the LDH ratio to identify exudate fluid? - I'd have to look it up.
- It's.
5 to 1.
- Greene? - Yeah.
You guys should come here more often, brush up on your gross anatomy.
- You guys find anything conclusive? - Why, what are you looking for? - Something wrong with the heart.
- Think you missed something? - Possibly.
- Well, you came at just the right time.
Size and shape normal.
Okay.
Who wants to section this? Bill? I think it's your turn.
Martin, will you hand him a knife? Doug.
It's been an hour, and Psych still hasn't come down for that boy.
- All right, I'll call them.
- Why don't you talk to him yourself? Because there's nothing physically wrong with him, and I have four other patients.
Is it because the kid's gay? - What? - You heard me.
If you mean, is it because that boy's particular problems fall out of my frame of reference or my area of expertise then the answer is yes.
If you mean, is it because I'm homophobic then the answer is no.
Okay? No congenital or valvular anomalies.
Endocardium normal.
Myocardium of normal thickness and color.
Blood vessels at base, normal.
Coronary ostia are in the usual anatomical position.
Arteries show no sign of plaque.
He's normal.
- No sign of anything congenital? - Were you here a second ago? What was the cause of death? Typical ER thinking.
Gotta be cause and effect.
See, down here we operate on a slightly different gestalt.
Sometimes there are answers, but many times, mystery.
It's not very satisfying.
You think you're a scientist? You want explanations, hard answers, algorithms of care? That's dog crap.
Medicine's an art.
And art is ambiguous.
All right.
Preliminary results: Idiopathic dysrhythmia.
No known cause of death.
- Nurse? - Hi, how are you feeling? Oh, tired.
They gave me a million-dollar workup and couldn't find anything wrong.
I just want to take my worms and go home.
I have some bad news for you.
Your worms were mistaken for trash and put outside in the snow.
- No.
- By the time I found out they were already frozen solid.
We brought them in.
We tried to warm them with blankets and water.
We used all our capabilities.
But we couldn't get them back.
I'm very sorry.
Can I see them? - What's that? - Vucelich's study protocol.
"Parameters for exclusionary status.
" Are you excluding someone? - Vucelich did.
- Anyone I know? The guy we worked on today.
He went bad.
He ever drop people who do well? Why are you reading this now? Has he dropped someone before this? Mrs.
Rubadoux.
He's not- I mean Vucelich wouldn't drop bad outcomes just to pretty-up his numbers, would he? I don't know.
I don't need you to hide my mistakes.
If I screw up, let me deal with it.
- You're right.
- Don't lie on my behalf.
- I won't.
- It's insulting.
I got it, okay? I gave you the credit.
What do you want? - What is with you today? - Sorry, this Residency thing.
My chances of getting in here are about 1 in 50.
I don't even have an interview set up yet.
I'm gonna end up in North Dakota.
- Damn it.
- What? I forgot Dr.
Benton's TPN orders.
None of his post-ops are getting their IVs.
- Susan? - One second.
Yes, Kerry? According to The Washington Manual, the determinative LDH ratio isn't .
5 to 1, it's .
6.
Oh, you got me again.
If you're gonna be Chief, get your facts straight.
You know, if being Chief means having you breathing down my back to hell with it.
I don't want you as my mentor.
Just stay out of my way.
That's the first time I've ever seen you act like a Chief Resident.
Maybe Morgenstern was right.
Where are you going? I was coming to talk to you.
I was telling my dad how good I'm feeling.
It was taking a long time.
The nurse said the CAT scan, it was okay? - Yeah, it's normal.
- No tumors, or- I hate to tell you - what's been going through my head.
- He's fine.
Thank God.
It could be migraines.
Yes, it could also be stress-related, something I wanted to talk to Ray about, if I could- I know what it is.
It's that damn trig.
Every time I have one of those quizzes, I get headaches.
- You're kidding.
- No, I do.
- Could that be what it is? - It could.
Because if that's it, I mean, I know the prescription.
Applying the seat of your pants to the chair.
Yeah.
Button your coat.
I'm sorry about this.
I spent the whole damn day waiting.
It's okay.
Listen, Ray, if you wanna talk about this or anything else at all - you just call me here, okay? - Sure.
Well, I thought she was still at Beth Israel doing whatever it is she does.
Oh, right, right.
- He's on the phone.
Be off in a minute.
- I don't need him anyway.
I just wanna get the records on a patient.
- Which one? - Rubadoux, Sylvie.
I believe she was dropped.
Claire, could you come here? I can't find my pocket schedule.
Help yourself.
Yeah, my life is unraveling as we speak.
What jacket did you wear to the lecture? Claire, let's be serious.
How can I possibly know? Why don't you just find my schedule like I asked you to? Who's that? Who's been asking? No, tell me.
Kemper's been asking? Well, you can tell Kemper that I am centimeters away.
With any luck, I'll be in the New England Journal next month - Damn, man.
Where'd you get all that? - Alvin came through.
- No guts, no glory.
- You've gotta be kidding me.
- Life ain't fair.
- Are you gonna report that to the IRS? I assume that's a rhetorical question.
Well, I'm gonna make my fortune the old-fashioned legal way.
- Delivering Chinese food? - No, raising earthworms.
- I got a dozen in there.
- I thought they froze to death.
No, most of them moved into the middle of the bin for warmth and survived.
You took that lady's worms.
No, she gave me enough to start my own colony.
It's my ticket out of here.
Come on, guys, let's go home.
Good night.
- Good night.
- Bye.
- Didn't mean to scare you.
- No, you didn't.
I finished your discharge summaries, called in your orders and I rounded the patients upstairs.
Can I go home? - Bye, Carter.
- I'm sorry about what happened earlier.
Good night.
- Carter? - Yeah? - Were the TPN orders called in on time? - Yeah.
No.
I screwed up again.
They were 45 minutes late.
I know.
I called the pharmacy.
- So are we sworn enemies forever? - No.
Denial's a funny thing.
It keeps you from asking the scary questions.
Which ones? The ones I've been asking myself all day today.
Am I dangerous? Should I be practicing medicine? We all ask those questions.
And the answers are "no" and "yes.
" In that order.
I hope so.
I lost my family for this job.
You're wallowing.
Yes, I am wallowing.
The first good wallow I've had in a while, so don't ruin it.
Well, I'm gonna drive home.
You want a ride? No.
I jogged in, I'm gonna jog out.
- Hey, you wanna hear something funny? - Definitely.
You know that guy who died this morning? It wasn't my fault.
I did everything right, and he died anyway.
- So, what's the lesson in that? - Can't win.
Oh, man.
You are wallowing.
- Good night.
- Night.
- Susan? - Yeah? Did anybody think it was odd, my coming in today? No.
I was just checking.
- Night.
- Good night.
R.
Previously on E.
R.
I have never seen such a chain of errors on judgement.
But I did what you said.
In a case where the injuries were inflamatory like, leaving a newborn motherless Mr O'Brian.
He's Carl's newly anointed.
The heir apparent.
It's been the best and hardest work I've ever done.
Good.
That's music to my ears.
You're a candidate for chief resident next year.
But is just that now is not a very good time.
There is never a good time.
The truth is mommy and daddy aren't gonna live together anymore.
"It's Not Easy Being Greene" - I love it when those endorphins kick in.
- You're not on today, are you? I thought I'd drop by, ease up your workload a little bit.
After I take a shower.
- It's his day off? - That's dedication.
Dedication? Man, that's sad.
Don't move, Mrs.
Zarian.
It's a little bit of glass, and it's almost free.
Susan, were your ears burning? David Morgenstern and I were just talking about you.
He feels you're the top contender for Chief Resident next year.
Oh, thanks.
This year's field was pretty disappointing but we found your work to be consistently solid.
Now, I know you're concerned about taking time away from the baby but that doesn't have to be the case.
Keep the bevel facing out.
By applying time-management techniques you can work more efficiently reduce on-the-job stress and get home at a reasonable hour.
Mrs.
Zarian I've got a book on the subject, if you're interested.
No pressure.
I just wanna let you know how we're thinking.
- Son of a bitch! - What? They cut me back to three shifts a week.
- They're cutting back on nurses? - Nurse managers because of our outrageous salaries.
I still need $12,000 worth of work on my house! They bumped me up to six shifts a week.
So much for my weekend.
- I know a way to make some quick cash.
- Talk to me.
I joined this guy Alvin's investment club.
Put up a $2000 membership fee and in a week to 10 days, you collect 10 to $20,000.
- From? - The fees of the new people who join.
- It's called a pyramid scam, it's illegal.
- Well, that's not what Alvin says.
Trust me, if you're not in early, you lose your shirt.
When did you get in? - Hey.
- Hey, yourself.
All right, let's see what we got here.
- Where'd you learn to do sub-q sutures? - From your med student.
- I obviously taught him well, didn't I? - Benton.
- See you later.
- Listen, I should warn you: You might want to invest in a new suit and some luggage.
You're going to Paris to present our clamp-and-run study to the institute.
- Are you serious? - Oui.
Simon did an analysis of our result.
Our P-value was.
06.
We're one successful outcome away from statistical significance.
- We can publish? - Soon.
One more aneurysm and our numbers will blind the most dubious skeptics.
After that, we head to D.
C.
to play dog-and-pony for the FDA.
Now, Simon doesn't fly, so he stays here which makes you the next choice for Clamp-and-Run Ambassador to Europe.
I don't know what to say.
I'm honored.
It's good practice for the future.
You've gotta find another patient soon because the Norwegians are doing a similar study.
And, Peter, we cannot let the Vikings pillage our thunder.
- Malik, you seen Carter? - He called and said he'd be late.
He should be coming any minute.
No, wait! Wait! Wait! Yeah! Oh, God! John! Oh, God! Oh, God! Oh, baby.
I think we broke my record.
Yeah.
- Oh, John.
- What? Your control is phenomenal.
- Yeah? - Yeah.
Yeah.
Thank you.
You know, you may find this hard to believe, but that wasn't always the case.
- No? - It's hard to believe, it's true though.
But I found if I could distract myself and think about mundane things then I could delay the inevitable.
Well, what kind of things do you think about? Let's see.
Sometimes I take a mental inventory of the machines in the O.
R.
Thora-Seal, ventilators, auto-infusers.
And then, as the degree of difficulty increases, I run the procedures.
Appendectomies, thyroidectomies, bowel resections.
- Yuck! - What? While we're making love, you're thinking about bowel resections.
Given your earlier testimonial this is a case of the ends justifying the means.
- What? Get out! - I'm kidding.
I'm just kidding.
So last night I get a letter from Jen's lawyer politely informing me that she's suing me for full custody of Rachel.
- Oh, no.
- Yeah, it seems I've been a distant and absent father.
This after commuting from Milwaukee for half a year.
Well, it sounds like a lot of lawyer B.
S.
I can't imagine she'd actually go through with it.
- I was climbing the walls all night.
- Well, that's why you're here.
- Tiny prick.
- I beg your pardon? I need a TB test too.
So I hear Morgenstern has really turned up the pressure on you becoming Chief Resident.
Yeah, it's a good opportunity, but can I do it and not work killer hours? You know how well I managed to balance work and family.
- Guess that answers that.
- You'll be able to work it out.
Take your paperwork home, hours won't be that bad.
- You have to cut Weaver some slack.
- What do you mean? You go out of your way to avoid her.
And if she's gonna be training you you're gonna have to work together hand in hand.
Oh, there's an image.
- Why are you here on your day off? - I went for a jog and ended up here.
- Figured I might as well save some lives.
- One other good reason not to exercise.
five-minute grand mal seizure.
I'll take it.
Start a chart.
On his day off? - The orders should've been in already.
- I forgot.
- I thought you wanted a Residency.
- I do.
Keep forgetting, you'll be in North Dakota.
We got 300 applications.
- When do the interviews start? - They already have.
Vucelich needs one more aneurysm for his study.
Abdominal pains, chest pains, traumas, call me.
How often do you get dizzy spells, Mrs.
Henry? Oh, I get three or four a day.
Usually when I'm working in the shed.
- You garden this time of year? - I'm a vermiculturist.
- I raise earthworms.
- Really? Big ones from Belgium.
Finest castings in the world.
- And by castings you mean? - Worm dung.
Black gold.
It's the best fertilizer money can buy.
It fixes the nitrogen in the soil.
- And you sell the stuff? - I sell the worms.
Your blood pressure's a little high.
- So it pays well? - Six figures.
Has he had a seizure before? No, he's a health nut.
He runs every day.
We're gonna have to get a CAT scan of his head to pinpoint the cause.
Alan.
Alan? - When's he gonna come back? - It takes a little time to recover.
- Well, how long? - Usually about 30 minutes.
Multifocal PVCs.
What? His heart rhythm's a little off.
Probably oxygen deprivation from the seizure.
- Has he had a murmur before? - No.
Well, it's probably nothing serious.
Let's get an echo of his heart after the CT, just to be safe.
Lidocaine bolus, 100 milligrams, then start a drip.
No, Carter.
John Carter.
I thought maybe you were trying to get in touch with me to set up an interview for the Residency.
No, huh? Well, I'm available at any- Okay, great- Right.
I hear Vucelich doubled his finder's fee - for an aneurysm.
- Could be.
I made 1000 bucks.
Patient with a history of ulcers, says the pain's different this time.
- Rigid belly? - Hard to tell.
He's so fat.
But see the calcifications on the descending aorta? - No, where? - Here.
It's too lateral.
Probably just schmutz on his lungs.
- I shouldn't call Vucelich? - If you wanna get yelled at.
Harper, I need you to get this guy to CT.
Coming.
Can you return this x-ray to his room? - Which room? - Six.
Hey, you done with that? Wow, that's a mother of an aneurysm.
- How can you tell? - Calcification on the descending aorta.
Yeah.
Yeah.
We're gonna run the CAT scan on his head to rule out lesions that could've caused the seizure.
What's wrong? He's in V-tach.
Let's get him to Trauma.
- Haleh? - I'm here.
- What's wrong with him? - His heart rhythm's worse.
You sure he hasn't taken medication? Any non-prescription drugs? - No, never! - We're gonna get this under control.
Can someone take Mrs.
Wimbur to the waiting room? - But I just wanna- - It's okay.
- Another 50 of lidocaine, IV push.
- Heart's racing, 200.
- Rhythm is all over the place.
- Looks like Torsade de Pointes.
All right, Harper.
Let's get lytes and the tox screen.
And see if we got any records on this guy.
Anything that can give us a clue.
Lido's on board.
- What's your gut say, Haleh? - Low potassium.
- Lydia? - Cocaine.
His wife says he's tox-free.
We'll know soon enough.
Heart rate's up to 210.
Let's try and cardiovert.
Paddles.
Start him at 100.
- Hands off! - Clear.
- Faint pulse.
- There we go.
Nice rhythm.
- He's moved his head.
- His rate's down to 160.
- One-eighty.
Here we go again.
- All right, lidocaine's not working.
Let's try bretylium, 500 IV push.
Prep a transvenous pacemaker.
Charge 200.
Hands off! What makes you think there's an aneurysm? The calcium plaque on the descending aorta.
While you saved his life, you made the Norwegian surgeons very unhappy.
- Good work.
- Thank you.
- Where's the patient? - Room 6.
To Room 6.
Hey, way to go, Carter.
Labs are back.
Lytes are normal, tox screen's negative.
We were both wrong.
- What the hell's wrong with this guy? - Rate's up to 220.
- Faint pulse.
- All right, pacer's in.
Let's overdrive him to 230.
Maximum gain.
- See if I can grab hold of this rhythm.
- You've got capture.
Lovely.
Let's take him down slowly.
- Two-ten.
- Two hundred.
One-eighty.
- He's jumping back up.
- Lost capture.
Let's start CPR.
Add Pronestyl, Paddles, set them at 360.
- What time is it? -0845.
Mark that time.
- Hands off.
Clear.
- Clear.
- Wide-complex tachycardia.
- Still no pulse.
- Time? -9:05.
- How long has he been down? - Twenty minutes.
Tried the pacer, he went into V-fib.
Shocked him 15-20 times.
He keeps running these chaotic rhythms.
- Could he be hypocalcemic? - No, lytes are fine.
- Cocaine? - Tox screen's negative.
- Acidotic? - Good question.
Let's get another gas.
- How much Pronestyl? - That makes 900.
- Time? -0922.
- Another hundred of Pronestyl.
- Got your blood gases here: PH 7.
24, PO-2's 110.
- He's still in fib.
- He's going down.
- The anti-arrhythmics? - Still got a few more.
- Stand by with the amiodarone.
- Charging up to 360.
- Back up.
Clear! - Clear.
- Time? -0932.
- Still no pulse.
- Try magnesium sulfate.
- Clear.
- Clear.
- Time? -9:41.
- High dose epi, five mgs.
Clear.
- Hit of epi in.
- Time? -9:45.
- Clear! - Clear.
- Clear! - Clear.
Time of death 9:55.
Why? There was an electrical disturbance in your husband's heart that caused it to beat in an irregular way.
I wish I could tell you what caused it to happen but the truth is, I don't know.
Well, that's not good enough.
I mean, we came in here, and his heart was okay.
You said it wasn't anything serious, so somebody must have screwed up! - How did you let this happen? - Mrs.
Wimbur.
What did you do to him?! Hello, Alvin.
Well, do you have his new number? - So, Kerry- - One second.
Yes, Susan? I've been thinking about your invitation and I would like to throw my hat in for Chief Resident.
I'm glad.
I look forward to showing you the ropes.
Me too.
Nobody's signed up for the gallbladder in 2 yet.
I've got it.
- How long does a CAT scan take? - Hopefully, not more than an hour but sometimes there's a wait.
I'm a little concerned about my worms in the truck.
- You brought them with you? - Just one bin.
I was making a delivery when the dizziness hit.
- Do you think someone'll steal them? - No, they're locked up.
You don't leave $5000 worth of worms unsecured, but they could freeze.
Listen, if I gave you my keys, could you bring them in out of the cold? - We can't have animals in the hospital.
- Oh, there's no danger.
Worms are the only disease-free organisms on Earth.
It's a fact.
- I really shouldn't.
- Please, they're my worms.
- All right.
- Thank you.
And could you feed them, please? - What do they eat? - Table scraps, as long as it's vegetarian.
Nothing too greasy because fat doesn't sit well with worms.
Mrs.
D'Angelo, I see you've been with us before.
- Gallstones flaring up again? - They're killing me.
I can't sleep, I can't eat.
And every three weeks, I end up back here.
Pain pills didn't help? I took twice as much.
Didn't do anything.
- Yeah, you shouldn't do that.
- Please, doctor get a surgeon to take these damn stones out.
It's been going on like this for six months now.
Okay.
Sorry.
Okay.
I'll get an ultrasound.
Unless your condition is life-threatening any surgery would be considered elective, and unfortunately - There's an 18-month waiting list.
- Yeah, I'm afraid so.
- My neighbor got hers out the next day.
- Does she have private insurance? Is it my fault I'm on Medicaid? Okay, we'll start with the ultrasound and see what we have.
Thank you.
His name is Alan Wimbur.
You guys just picked him up.
I was hoping you could do the autopsy today.
- Hey, Jerry, where's the ultrasound? - You've got me.
Let me know, because I'd like to observe.
Autopsy? I wanna find out what happened to his heart.
You should go home.
His wife accused me of killing him.
She's probably gonna sue.
People get upset and feel they need to blame someone.
I heard a murmur on exam.
Before getting an echo, I wanted to get a CT.
Yeah, guy comes in with a seizure, first thing you want is a CT.
Thanks, I was just checking.
Dr.
Greene? Dr.
Morgenstern's office just called.
He'd like to see you upstairs.
Word travels fast.
- You're making excellent time, Peter.
- Suction! Let Carter suction.
It's his reward for hunting down an aneurysm like a hound.
I feel privileged for the opportunity.
- Well, now, that's what I call suction.
- Thank you, thank you.
- MacGruder, is this patient warm? - Shoot, shoot, shoot! - MacGruder! - Temp is 106.
- He has malignant hypothermia.
- Is he reacting to anesthesia? Give him dantrolene, get ice packs, cooling blankets.
If we don't get his temp down, he's gonna have scrambled eggs for brains.
Who took this patient's history? He was intolerant to fluoroethane.
Damn it! I lay out a banquet and you crap all over my table! - He never had an operation.
- Cooling blankets! Well, lift him up, get him under.
Peter, come on over here.
Evert the cortex.
Log-roll him over.
Suction, Peter.
Tie that off, Peter.
- He never had an operation before? - No.
Well, you're right, there was no way of knowing.
My apologies.
Metz! Metz! Are you free for lunch? - Susan? - Yeah.
Medical records sent down the chart on your gallstone lady.
- Thanks.
- I took a peek.
- I know she's been on cefoxitin.
- Yeah.
Cefotaxime has better biliary penetration.
I know it's hard memorizing all the antibiotics out there - but it's well worth the time.
- Right.
- Who's the ultrasound for? - Same lady.
Didn't she have one last month? She's complaining of more pain.
I wanna rule out obstruction and cholangitis.
Remember Charcot's triad.
Cholangitis is indicated by pain, fever and jaundice of which she has only one.
You can rule her out without the expense of an ultrasound.
If you're gonna be Chief, you gotta watch the bottom line.
Mark.
I don't believe you've met Kathy Snyder, one of the hospital attorneys.
- Hello.
- Hello.
Is this about this cardiac arrest who died this morning? - I haven't heard anything.
Have you? - No.
Kathy wanted to talk about the O'Brien lawsuit.
- You get a court date? - We've worked out a settlement.
- I'm not sure I want to settle.
- The hospital is sure.
It's a good thing.
Mr.
O'Brien gets compensated, and you can put this behind you.
If I settle, this will follow me my entire career.
Every time I apply for a staff job or insurance If we took it to trail, we could lose 2 million easily.
You wanna lug that around your entire career? I've been over this a thousand times.
I didn't do anything wrong.
It was a very complicated delivery.
I did as good a job as any emergency physician could have.
Other emergency physicians would and have disagreed with you.
A pregnant woman comes in with preeclampsia and for whatever reason, you didn't pick up on it.
Her condition was masked by urinary infection! I don't want to argue the details with you, Mark.
You make thousands of diagnoses a year, 99 percent of them are right on.
- You made a mistake, as we all do.
- I don't accept that.
- Mark, please- - This is about my reputation as a doctor.
I'm not gonna settle.
Take my name off of it.
You can't separate yourself from the suit.
Well, I'll hire my own lawyer, and I'll fight it myself.
- That's a lot of worms.
- Hey, big fella.
- Woman makes a fortune selling these.
- To whom? Landscapers, farmers.
Could be a great sideline.
- You're kidding, right? - No.
This could pay for the hole in my roof.
- I took the spoiled food from the fridge.
- Veggie? - That's what you asked for.
- They don't like grease.
How do they feel about yogurt? I don't hear any complaining.
Eat up, little worms.
John! - Hi.
- Told you it was an aneurysm.
- You were right.
- Did Vucelich know who I was? Didn't you tell him about me? - That I found it? - I meant to.
I mean, I should have.
The whole thing happened really fast.
I was gonna say something, and they just assumed that What are you doing in here? The hospital decided to settle the O'Brien suit.
Isn't that good news? Morgenstern thinks I'm at fault for not picking up the preeclampsia.
- That's not fair.
He wasn't even there.
- You were there.
It was as complicated a case as I've ever seen.
You did everything you could.
You think I should have caught the preeclampsia? It was a difficult diagnosis.
Anyone could have missed it.
If you were called up on the witness stand and asked: "Did Greene screw up? " What would you say? I'm sorry, Mark.
Come on, dude.
Be bold.
We start our own investment club.
We collect right off the bat.
- No, thanks, man.
- What's to lose? - What'd you lose? Two grand? - Alvin's gonna come through.
Can you find out why the worm lady isn't back from CT? She had palpitations, so they're doing a cardiac workup.
Call me when she comes down.
Jerry, medical records copy a chart for me? - Yeah, O'Brien, right? - Yeah, thanks.
Hey! What happened to those worms in Radiology? - They're doing a consult.
- No, those earthworms.
I put a bucket of earthworms in there.
They're gone.
Well, I didn't take them.
Ray, I'm Dr.
Ross.
I understand you've been having some headaches and missing school.
- Yeah, they're pretty bad.
- Okay.
- Where in your head does it hurt? - Here.
- How long you been having these? - About a month.
- How often? - All the time, I guess.
- Do you feel dizzy? - Yeah.
Okay, pull like that.
- Play sports? - J.
V.
football, middle linebacker.
I was a running back.
We used to hate you guys.
Squeeze my hand.
- You ever get headaches playing sports? - No.
No.
Okay.
We're gonna get you a CAT scan.
You know what that is? No? It's when we take a picture of your brain.
We wanna make sure it's still in there.
All right.
I'll be back in a minute.
Dr.
Vucelich, Dr.
Benton.
I'm sorry to say Tradition holds they serve olives and walnuts with the drink.
Dr.
Vucelich, Dr.
Benton, I'm sorry to interrupt you.
I misled you both earlier.
The finder's fee for the aneurysm should go to Harper Tracy.
She's a third-year student.
She caught it.
Taking credit for a colleague's work is a very dangerous precedent, Mr.
Carter.
I can assure you that it will never happen again.
Well, your reassurance rings hollow just now.
One has to wonder if this is a momentary lapse of integrity or a fundamental flaw in your character.
Well, time will tell.
In any event, the patient's secondary condition means he's not an appropriate candidate for the study so there will be no finder's fee.
- Is there anything else? - No.
Strange boy.
- The patient is being excluded? - What's that? Oh, yes.
It seems that he has a history of, excuse me, neurological problems which exceed the parameters of the protocol, so What were we talking about, Peter? Oh, I remember.
George Cinq.
Walnuts, olives.
Actually, I was an habitué of this bistro, called "L'Ami Louis," and there was - Mrs.
D'Angelo.
Feeling any better? - No.
Are you going to do that test? I consulted with another doctor, and we feel the ultrasound is unnecessary.
- You don't have any new symptoms.
- You're not even gonna check? Given that you don't have a fever or any other symptoms there's no way I can justify the expense.
The expense.
I see.
I can take it from here.
I know the routine.
The nurse gives me a few pills that don't work, and I'm pushed out the door.
I checked with the elective surgery waiting list and they can get you in by the end of the year.
It's February 1 st.
- Help! - What happened? They were out by the trash.
Must've been there an hour.
Get some blankets, heat up some saline, we'll do a warm-water lavage.
- The lamps they use on newborns.
- Great idea.
Go up to OB, see if they'll lend us some.
- All right.
Oh, damn it! - The lid's frozen.
Oh, God! All right.
Rib spreader, rib spreader.
- What are you doing? - I'm gonna knock it loose.
- What do you got? - Hypothermia, earthworms.
- Five grand worth.
- Earthworms? Yeah.
They're Belgian.
They don't take kindly to cold.
Got it, got it! - Oh, no! - It's frozen solid.
Well, maybe they're still alive underneath.
Surgical mallet, reflex hammer.
Thanks.
All right.
All right.
Oh, no.
What am I gonna tell Mrs.
Henry? Good news, buddy.
Your brain's right were it should be.
- All right.
Let's talk about school.
- Why? Well, because school can cause stress, and stress can cause headaches.
Do you have any trouble with your classes or students or teachers - or anything like that? - No.
All right, what about your girlfriend? - Which one? - There's a problem right there.
- How many girlfriends do you have? - A few.
I don't know.
All right.
You're not doing drugs, are you? - Smoking pot? - No.
- No? - No.
- You okay? - Yeah, I'm fine.
What's the matter? I can't.
I can't.
What? - There's something wrong with me.
- Okay.
All guys who are your age, they think that there's something wrong with them.
No.
- I'm different.
- How are you different? The girls at school I I don't feel anything when I'm around them.
I think I'm gay.
I know I am.
I mean, what am I supposed to tell my dad, my brothers? I'm just sick of being this fake person.
Haleh, will you call Psych? See if we can get a Resident down to look at the kid in 1.
Preferably someone from adolescent medicine.
- What's the problem? - Kid thinks he's gay.
Needs somebody to talk to.
I'm going to lunch.
I'll check the charts.
Try and make yourself useful.
Okay.
Hey, good catch this morning on the aneurysm.
Harper, Carter, give me a hand.
- What happened? - She collapsed.
Acute shortness of breath, chest pain.
- Pulse is high.
- Carter, start on an oxygen mask.
- Harper, what do we order? - EKG, chest film, blood gas - Chem-7, CBC, cardiac enzymes.
- And? - Myoglobin.
- Myoglobin.
- Do it.
- She has neck-vein distention.
- Temp's 101.
- Susan? - Chief complaint? - Shortness of breath, chest pain.
- She has a history of renal failure.
- What's the differential? - Susan? - Harper? Acute MI, pulmonary embolism, pneumonia - pericarditis, congestive heart failure.
- Pleural effusion.
Pleural effusion.
Stop that! - Prompting from the peanut gallery? - Let's get a gas cooking.
Get an EKG, let's see how her heart's doing.
After you.
Hell of a way to spend your day off.
Yeah.
Wish I never would have come in.
Believe me.
What's that? Jody O'Brien? It's the first time I looked at that since the big day.
She had two high BPs, proteinuria.
I missed a preeclampsia.
If I hadn't, she'd be alive.
- Could've happened to any of us.
- It's not supposed to happen to me.
- Well, you are arrogant.
- Arrogant? It's like there's you and the Pope.
You guys are infallible.
- Then, of course, there's the rest of us.
- Yeah? Well, after today, the Pope's on his own.
Good.
I think I might have killed that guy this morning.
Mark.
Hey, Mark! When I first checked his heart, I heard a murmur.
He must've had a congenital defect.
That guy crashed 10 minutes after he got in there.
There's nothing you could have done.
Yeah, yeah.
Yes, there is.
Could've gotten an echo, and then I could've gotten him to the O.
R.
You're holding yourself to a ridiculous standard, Mark.
- I gotta get to an autopsy.
- It's your day off.
Go home! Low-voltage EKG.
- BP's falling.
- She's decompensating.
- Where's that blood gas? - I'll check.
- You got it? - These numbers don't make sense.
- What? - You hit a vein instead of an artery.
- Is that the blood gas? - Yeah, no.
I mean yeah.
- But I tapped a vein instead of an artery.
- No, I tapped a vein.
Whoever did it, do it again and do it right.
Carter, you do it.
- Non-specific ST changes.
- Where are we? Susan? I don't know where you are - I'm at pericardial effusion.
- Or pump failure, or an embolism.
- Let's get an echo! - Positive Ewart's sign.
Pressure's down, 50/30.
Pericardiocentesis tray! Shouldn't you confirm your diagnosis before sticking a needle in her heart? - I've made my diagnosis.
- Alligator clamp is on the needle.
The diagnostic gold standard is an echocardiogram.
You wait while Tech comes down.
I'll see if there's any fluid around her heart.
Okay.
I'm in.
- Anything yet? - No, not yet.
- Here it comes.
- What do you know? Looks cloudy.
I wonder if it's transudate or exudate fluid.
Anyone know the gold standard to differentiate the two? Kerry? Measure LDH to protein.
What's the LDH ratio to identify exudate fluid? - I'd have to look it up.
- It's.
5 to 1.
- Greene? - Yeah.
You guys should come here more often, brush up on your gross anatomy.
- You guys find anything conclusive? - Why, what are you looking for? - Something wrong with the heart.
- Think you missed something? - Possibly.
- Well, you came at just the right time.
Size and shape normal.
Okay.
Who wants to section this? Bill? I think it's your turn.
Martin, will you hand him a knife? Doug.
It's been an hour, and Psych still hasn't come down for that boy.
- All right, I'll call them.
- Why don't you talk to him yourself? Because there's nothing physically wrong with him, and I have four other patients.
Is it because the kid's gay? - What? - You heard me.
If you mean, is it because that boy's particular problems fall out of my frame of reference or my area of expertise then the answer is yes.
If you mean, is it because I'm homophobic then the answer is no.
Okay? No congenital or valvular anomalies.
Endocardium normal.
Myocardium of normal thickness and color.
Blood vessels at base, normal.
Coronary ostia are in the usual anatomical position.
Arteries show no sign of plaque.
He's normal.
- No sign of anything congenital? - Were you here a second ago? What was the cause of death? Typical ER thinking.
Gotta be cause and effect.
See, down here we operate on a slightly different gestalt.
Sometimes there are answers, but many times, mystery.
It's not very satisfying.
You think you're a scientist? You want explanations, hard answers, algorithms of care? That's dog crap.
Medicine's an art.
And art is ambiguous.
All right.
Preliminary results: Idiopathic dysrhythmia.
No known cause of death.
- Nurse? - Hi, how are you feeling? Oh, tired.
They gave me a million-dollar workup and couldn't find anything wrong.
I just want to take my worms and go home.
I have some bad news for you.
Your worms were mistaken for trash and put outside in the snow.
- No.
- By the time I found out they were already frozen solid.
We brought them in.
We tried to warm them with blankets and water.
We used all our capabilities.
But we couldn't get them back.
I'm very sorry.
Can I see them? - What's that? - Vucelich's study protocol.
"Parameters for exclusionary status.
" Are you excluding someone? - Vucelich did.
- Anyone I know? The guy we worked on today.
He went bad.
He ever drop people who do well? Why are you reading this now? Has he dropped someone before this? Mrs.
Rubadoux.
He's not- I mean Vucelich wouldn't drop bad outcomes just to pretty-up his numbers, would he? I don't know.
I don't need you to hide my mistakes.
If I screw up, let me deal with it.
- You're right.
- Don't lie on my behalf.
- I won't.
- It's insulting.
I got it, okay? I gave you the credit.
What do you want? - What is with you today? - Sorry, this Residency thing.
My chances of getting in here are about 1 in 50.
I don't even have an interview set up yet.
I'm gonna end up in North Dakota.
- Damn it.
- What? I forgot Dr.
Benton's TPN orders.
None of his post-ops are getting their IVs.
- Susan? - One second.
Yes, Kerry? According to The Washington Manual, the determinative LDH ratio isn't .
5 to 1, it's .
6.
Oh, you got me again.
If you're gonna be Chief, get your facts straight.
You know, if being Chief means having you breathing down my back to hell with it.
I don't want you as my mentor.
Just stay out of my way.
That's the first time I've ever seen you act like a Chief Resident.
Maybe Morgenstern was right.
Where are you going? I was coming to talk to you.
I was telling my dad how good I'm feeling.
It was taking a long time.
The nurse said the CAT scan, it was okay? - Yeah, it's normal.
- No tumors, or- I hate to tell you - what's been going through my head.
- He's fine.
Thank God.
It could be migraines.
Yes, it could also be stress-related, something I wanted to talk to Ray about, if I could- I know what it is.
It's that damn trig.
Every time I have one of those quizzes, I get headaches.
- You're kidding.
- No, I do.
- Could that be what it is? - It could.
Because if that's it, I mean, I know the prescription.
Applying the seat of your pants to the chair.
Yeah.
Button your coat.
I'm sorry about this.
I spent the whole damn day waiting.
It's okay.
Listen, Ray, if you wanna talk about this or anything else at all - you just call me here, okay? - Sure.
Well, I thought she was still at Beth Israel doing whatever it is she does.
Oh, right, right.
- He's on the phone.
Be off in a minute.
- I don't need him anyway.
I just wanna get the records on a patient.
- Which one? - Rubadoux, Sylvie.
I believe she was dropped.
Claire, could you come here? I can't find my pocket schedule.
Help yourself.
Yeah, my life is unraveling as we speak.
What jacket did you wear to the lecture? Claire, let's be serious.
How can I possibly know? Why don't you just find my schedule like I asked you to? Who's that? Who's been asking? No, tell me.
Kemper's been asking? Well, you can tell Kemper that I am centimeters away.
With any luck, I'll be in the New England Journal next month - Damn, man.
Where'd you get all that? - Alvin came through.
- No guts, no glory.
- You've gotta be kidding me.
- Life ain't fair.
- Are you gonna report that to the IRS? I assume that's a rhetorical question.
Well, I'm gonna make my fortune the old-fashioned legal way.
- Delivering Chinese food? - No, raising earthworms.
- I got a dozen in there.
- I thought they froze to death.
No, most of them moved into the middle of the bin for warmth and survived.
You took that lady's worms.
No, she gave me enough to start my own colony.
It's my ticket out of here.
Come on, guys, let's go home.
Good night.
- Good night.
- Bye.
- Didn't mean to scare you.
- No, you didn't.
I finished your discharge summaries, called in your orders and I rounded the patients upstairs.
Can I go home? - Bye, Carter.
- I'm sorry about what happened earlier.
Good night.
- Carter? - Yeah? - Were the TPN orders called in on time? - Yeah.
No.
I screwed up again.
They were 45 minutes late.
I know.
I called the pharmacy.
- So are we sworn enemies forever? - No.
Denial's a funny thing.
It keeps you from asking the scary questions.
Which ones? The ones I've been asking myself all day today.
Am I dangerous? Should I be practicing medicine? We all ask those questions.
And the answers are "no" and "yes.
" In that order.
I hope so.
I lost my family for this job.
You're wallowing.
Yes, I am wallowing.
The first good wallow I've had in a while, so don't ruin it.
Well, I'm gonna drive home.
You want a ride? No.
I jogged in, I'm gonna jog out.
- Hey, you wanna hear something funny? - Definitely.
You know that guy who died this morning? It wasn't my fault.
I did everything right, and he died anyway.
- So, what's the lesson in that? - Can't win.
Oh, man.
You are wallowing.
- Good night.
- Night.
- Susan? - Yeah? Did anybody think it was odd, my coming in today? No.
I was just checking.
- Night.
- Good night.