ER s12e13 Episode Script
Body and Soul
E.
R.
E.
R.
12x13 "BODY AND SOUL" You can't be out here.
Sir? Sir, it's not safe, sir.
Sir, you can't be here.
Sir? They found some guy wandering and disoriented.
- Just what we need, another lost soul.
- You can never have enough.
Nate Lennox, 54, medic alert bracelet says he has ALS.
Paralyzed and unresponsive.
He rolled out on to the ice at Prospect Rink.
Was somebody with him? I called the number on the bracelet, left a message.
Mr.
Lennox, can you hear me? - How'd he get out of the house? - Good question.
Do you think he was abandoned? Somebody's taking care of him.
He's got clean clothes, had a shave this morning.
Pulse ox is only 89.
Let's get him on five liters by a mask.
Okay.
- I'm gonna need some lifting help.
- Let's leave him in the chair for now.
If we lay him down, it might compress his lungs, might make things worse.
Okay, crackles bilaterally.
CBC, chem panel and a portable chest.
Let's call for his old medical records.
Whoa, hey, hey.
- Hey, did you hit the joystick? - No.
Okay, sats are up to 92.
Have RT induce a sputum for a Gram's stain and culture.
Whoa, hey.
- Don't do that.
- I didn't touch it.
Is there a short or something? I think the computer has an eye sensor that's controlling the chair.
- I think he wants to get out of here.
- Probably altered from too low oxygen.
Yeah, well, I'm gonna disconnect the battery.
Hang on.
Need a hand? ALS with pneumonia.
Could use a Hep-Lock.
What's his name? Nate Lennox.
I've seen him before, a while back.
No help.
Don't.
- He did that with his eyes? - Looks like a speech-synthesizer program.
It's okay now, sir.
We're gonna take care of you.
Want out.
Please, let me out.
Please, let me out.
Okay, sir, we're gonna sit you forward now.
Sats are still borderline.
I'm not sure how aggressive we need to be with this guy.
Is he a DNR? If I were like that, I sure as hell would be.
Mr.
Lennox, your oxygen levels are falling.
Do you understand? We need to know your wishes about resuscitation.
Okay.
- Home.
- Does that mean - you don't want heroic measures? - Home.
If you stop breathing, do you want us to use a machine, a ventilator? Hungry.
Food.
Do you have a living will? An advanced directive? - Drugstore.
- I don't think we're getting through.
Do you know where you are? I have amyotrophic lateral sclerosis.
Also known as Lou Gehrig's disease.
It is a progressive degenerative neurologic disorder that has weakened my muscles.
All of my senses are intact.
- My mind is clear.
- Not today, it isn't.
Got his old records.
We need the name of his neurologist.
Maybe he'll know what to do with this.
You want me to up his oxygen? I'm gonna say let's go with BiPAP.
It'll buy us time without having to intubate.
I knew he looked familiar.
- What? - He should already be on BiPAP.
Neela and I treated him a year ago.
He came in for shortness of breath.
Every time you have a thought every time you take a breath every time you move a muscle every time you take a crap you should thank your ATP.
AT- ATP.
Oxidative phosphorylation The bedpan may distort things a little.
Oh, boy.
The kids at school are gonna make fun of me.
- It's too tight? - No, it's fine.
It's like an oven in here.
I'm sorry, they're working on the a.
c.
So hot.
The BiPAP increases your tidal volume.
Your neurologist says it'll give you more energy and a longer survival.
That's great news.
Sam, labs were hemolyzed on your heat-stroke guy.
- I'll be right back.
- I'll wait here.
Ha.
I should have another listen.
Where did you go to med school? Uh, right here.
I was a biochemistry major at Yale, so I placed out of your class.
Yale? Oh.
I worked in Sandra Hamilton's lab - senior year.
- Yeah, I know it.
We were in awe of your work on anti-sense RNA.
I cited your studies in my paper on gene inactivation in Trypanosoma brucei.
You published as an undergraduate? Second author.
Impressive.
So, what are you doing here in this cesspool? Are you just here for the big bucks? What is it gonna be? Orthopedics? Plastic surgery? Neither.
I can't stand surgeons.
They're arrogant workaholics who can't relate to people unless they're asleep.
Sorry, Nate, the car overheated and I had to take the el.
What happened? - I'm fine.
- He had some shortness of breath.
- I'm Dr.
Rasgotra.
- Oh, Fran Bevens.
Did you reach Dr.
Ames? - He's already been down.
- Okay.
He's consulting a speech pathologist.
- Good.
- Not good.
I don't need it.
It's getting hard to understand what you're saying.
Maybe they should start listening better.
Hello, Fran.
Jared, it's good to see you.
Ready to start? - I'm trying to contain my enthusiasm.
- How long are you guys gonna be? - Half an hour.
- Fifteen minutes.
We'll be back with your aftercare instructions.
You think about what you're doing.
You may realize you don't belong here.
- Where does he think you belong? - At Jumbo Mart.
He misses my slushies.
Please be kind.
Hey, severe sunburn.
Dispo if the pain is down with Toradol and aloe.
- Not too bad.
- Soft rule out going to tele.
- Excellent.
- And this guy's with his PMD.
- So there's nothing for you to do.
- Lennox? Is that Nate Lennox? The biochemistry professor.
- No, wait, I've got one more.
- Yeah, I'll figure it out.
Nate.
You like my new look? Well, not a lot of people could pull that off.
- Good to see you, Abby.
- Hi, Fran.
What you doing? Playing "Medal of Honor.
" I just killed a couple of Nazis.
His facial muscles are weakening.
He needs to practice with assisted speech.
Hey, I've got a great idea.
Well, we can wait on speech therapy for the time being.
But I gotta tell you, Nate, you're just putting off the inevitable.
- You need to start wearing this.
- Why? Because it has your diagnosis on it, and your name and your phone number.
We're lucky you were in class today.
Otherwise, who knows what might have happened.
Okay, okay.
How about this thing? Do I have to wear it all the time? Well, we'll start with bedtime use.
You'll get the benefits of eight hours a night while you're asleep.
I keep waking up and something else is gone.
- Thank God for the bracelet.
- Is that comfortable? Nate.
Nate.
He was speaking with the computer when he first came in.
We can't get an IV in him.
He always needs a central line.
He was at an ice rink? Yeah, any idea why? I don't know.
It was like any other day.
I got up, I shaved him, bathed him.
Fed him breakfast and then transferred him to the chair.
He was watching television, so I went to take a quick nap.
How did he get outside? Well, he can open the front door with his computer.
Ray, ready to present? Dr.
Kovac? - Fran Bevens.
- Hello.
Hello, sir.
You saw him a few years ago.
Right, middle and lower lobe infiltrates.
He's altered, borderline oxygenation, even with BiPAP.
Can we have a word? Yes, of course.
We need to make a decision about intubating and ventilation.
You think he can get over the pneumonia? He could, or he could be intubated in the ICU, going downhill for four weeks.
He hasn't got a lot of reserve.
There's no guarantee he'll get better.
This may be the natural endpoint of his disease.
So maybe it's time to focus on keeping him comfortable.
Fran, I just heard you were here.
Thank you for coming by.
- I've taken care of him before.
He decided to go out by himself.
Why did you do that, Nate? - In motion.
- What's in motion? Free.
- Pulse ox is down to 82.
- Yeah, what are you doing? His lungs are full of junk, his sats down, he needs to be intubated.
We've been just discussing about how best to proceed.
Well, helping him breathe would be a good way to start.
I don't think that he'd want that, Abby.
- Abby - Yankauer.
We haven't come to a consensus.
- I'm not comfortable with this.
- I'm not intubating.
Large mucous plug at the cords.
- Okay, that should help.
- Temporarily.
Sats are coming up.
This will give us time to treat him with oxygen and antibiotics until he's alert enough to tell us what he wants.
Dr.
Lennox? Nate.
Nate, talk to us.
Around and into the subclavian.
- Fluoro off.
Okay, that's as far as we go.
- Ceftriaxone's ready.
How'd he do? - Well, we're starting the IV antibiotics.
- When did he last eat? - I fed him this morning.
He needs some calories.
- How are you doing? - You're in the hospital, Nate.
Nate? You remember when we talked about putting in a trach if you had trouble breathing? You said you wanted to keep going until they found a stem-cell cure.
Why don't we just let him rest? Snowmobile versus tree.
Morris needs some help.
- 500 of azithro after the Rocephin.
- Got it.
Okay, we all need to agree on this.
You told me you wanted a trach.
That was a long time ago, Abby.
His biggest fear now is that he'll end up on life-support aware of everything, but with no way to communicate.
He was communicating a half-hour ago.
That could have been random eye movements.
- Four hundred cc's of Jevity? - Yep.
So if we do the trach?.
He's out of here in a day.
He can go home with a portable ventilator.
You'd have to learn how to suction and troubleshoot the vent.
But we can get you some help.
I know you're tired.
- He's the one who's tired.
- Fran I'm with him every day, Abby.
I know.
Looks like we got a clogged G-tube here.
- Do you flush it with water? - Yes, after every feeding.
He needs nutritional support to fight off infection.
- It won't go.
- Do you know when the tube was put in? - No, I- - G-tube placed in May, 2002.
He came in after a choking spell.
Each May, the graduating medical students - vote for teacher of the year- - I love the fresh flowers.
They must think it'll make up for cutting back on my teaching.
but rather a scientist, whose dynamism- May I have a glass of wine? Thanks very much.
made a strong impression and stayed with the students throughout their training.
- It gives me great pleasure to present - Nate, what is it? - the 2002 Teacher of the Year Award - Nate, Nate.
to Dr.
Nathan Lennox.
Well, his chest x-ray is negative for aspiration.
- You got lucky, Nate.
- Yeah.
I'm the luckiest man on the face of the Earth.
It's time for a feeding tube.
No, it's not.
Well, your chewing and swallowing muscles are getting pretty weak.
Fran will have to cut my meat smaller - won't she? - Takes him an hour to eat a meal.
- He's lost 10 pounds.
- More like 5.
The rest is water weight.
Weight loss accelerates the progression of ALS.
The extra calories from the tube feeding will mean increased strength more energy and longer survival.
- I'll think about it.
- Romano around? In the O.
R.
with a pneumonectomy, but I'll see about getting you on the schedule.
I said, I'll think about it.
Well, we'll save you a spot.
We can always cancel.
- Good night.
- I'll walk out with you, Donald.
- I'll be right back.
- Good night, been great.
- Tell them to send the trophy to my mom.
- Trophy? I won the potato-sack race at the County retreat.
Is Abby Lockhart around? - No, not tonight.
- It's pretty quiet around here.
Well, sometimes it's slow.
It's not just that.
What, are you cutting back on staff or something? Well, one of our Attendings died.
Mark Greene.
A lot of people took off to go to his memorial.
Chen wants you in Exam 3 with the belly-pain guy.
It's a slam-dunk diverticulitis.
I called Medicine.
- All she has to do is co-sign my chart.
- I'll let you tell her that yourself.
- What year of residency are you in? - First.
I'm an intern.
Ho-ho! Pretty cocky for an intern, aren't you? Huh? - You're either real smart or really insecure.
- If I were you, I'd put my money - on the first one.
- Of course, all the great minds wanna work in the County ER.
Actually, this is just temporary.
I'm planning on moving over to Northwestern soon.
- Congratulations.
You got in, huh? - Well, not yet, but believe me, I will.
Pre-op instructions for the G-tube.
Okay, cool.
This is gonna show you everything you need to know about the procedure.
Where to show up, what to eat the night before, what to wear Are you okay? Look, I know it's hard, but- This isn't me.
It's the disease.
Okay.
The nerve deterioration leads to pseudobulbar affect.
His emotions can be very exaggerated.
- Yeah, I see.
- Okay.
It's called emotional incontinence.
It sucks.
You get a little upset about something, and next thing, you're crying like a baby.
There has to be some sort of medicine for that.
He won't take them.
Side effects are too much.
And it's the BDNF.
I've been injecting nerve growth factor twice a day for a year.
The stuff turns ALS mice into Olympic athletes.
- But human trials, worthless.
- Results haven't panned out in humans.
- I'm sorry to hear that.
- And now Fran has to pour - Ensure in my stomach tube all day.
- It's no big deal.
Come on.
- Shh.
Come on, calm down.
- I didn't wanna be a burden on anyone.
Shh.
Come on.
Come on.
- Should this be hurting him? - Maybe just a little.
Okay, G-tube is in.
Balloon is up.
Check the pump.
I think he's waking up a little bit.
- Go ahead and set up for PFT's.
- Flow is looking good.
- Thank you.
- Mm-hm.
All right, we need to test his lung function.
Nate, I'm gonna put this in your mouth and Sam's gonna pinch your nose.
Here we go.
Easy.
All right.
Easy, yeah.
Okay.
All right, deep breath in.
And blow it out, blow it out, blow it out.
- Great.
- Forced vital capacity is 32 percent of normal.
- That's the amount of air he can move- - I know.
Okay.
Nate? Nate, your lung capacity has deteriorated.
The best way to help your breathing is for us to put in a trach.
You're gonna need assisted ventilation.
Do you want us to do it? I'm not sure you'll recover without it.
The trach is the best chance you have of clearing up your pneumonia.
Nate.
Okay.
Okay.
- Call Surgery, he consented.
- I'm okay.
- Abby, I don't think that's what he meant.
- What? He said, "Okay.
" He said, "I'm okay" after that, which could mean, leave him alone.
- It's not exactly informed consent.
- Nate.
You want the trach, don't you? - You know, you all heard what he said.
- At a vital capacity of 30 percent some ALS patients enter into hospice care.
- It means they have six months to live.
- His FVC is low because of pneumonia.
- Clear that, lung function will be back.
- Best-case scenario.
He expressed his wishes in advance.
Now he's too sick, can't give reliable consent.
- How's his PO2? - I wanna do a trach.
- We have a consent issue.
- I explained the procedure to the patient.
I asked if he wanted it.
He said, "Okay," on his computer.
- He did? - He also said, "I'm okay," after that.
I don't think that he understood.
He was alert and looking at me the entire time.
He understood.
I really don't think that this is what he wants.
Fran has a durable power of attorney.
- Thank you.
- It's your call.
You know, with all due respect, I'm sorry, but Nate expressed his wishes and I think we have to go with that.
Well, if there's a chance that he asked for the procedure I'm not sure that he did.
- I think we have to do it.
- Dr.
Kovac- Ray, I need you next door to help me with a central line.
Let's go.
- I'd like to page Dr.
Ames.
- I'll try to find him.
And call Dubenko.
Put in the trach and RT to set up a vent.
Between first and second tracheal ring.
Close your eyes if you're having any pain.
Doesn't look like he's feeling anything.
- Aspirate air, confirm you're in.
- Guidewire.
So you're in surgery now, Neela? I'm just doing an elective.
Things change, right? Certainly do.
Eleven French dilator.
Balloon's good to go.
I hope he's okay with this.
Well, it doesn't wanna pass.
A little more muscle.
You doing all right, Nate? Okay, remove the dilator, slide the trach tube in.
Mm.
Bit of oozing here.
Direct pressure should take care of that.
A little bleeding can be normal.
- Tachy at 130.
- I'll open up his fluids.
Is he okay? He could be sensitive to the blood loss.
Let's take another look.
- Oh, my God.
- Pressure again, 10 blade.
- What are you doing? - Converting to an open procedure.
- We need deep hemostasis.
- Two units of packed cells.
- Blood transfusion? - Just a precaution.
Call for type specific.
Sam, see if his antibody screen's in the old chart.
- Abby, grab a Yankauer.
- What's happening? - A minor complication.
- Doesn't look minor.
- Suction on high.
- Shouldn't have let you do this.
- Mosquito clamp.
- Antibody screens negative.
- He's in pain.
Give him medication.
- Four of morphine.
- No morphine.
- Had a bad reaction in 2001 - when he came with a broken wrist.
- The transgene will be suppressed.
Use two fluorescent reporters with different spectra.
- Why two? - One for our transfected cells.
And one for translational fusion with the target gene.
- That's- That's brilliant.
- Well, it's simple.
I don't know if it's brill- Four morphine.
- Get to work on the plasmid DNA vectors.
- Right now? I don't want Gregorio beating us to the Nobel Prize.
Right.
- You're not supposed to take the stairs.
- They were servicing the elevators.
- Wait for the next one.
All right.
- We were late.
- I've canceled your morning classes.
- Don't be ridiculous.
Why'd you do that? I couldn't reach Baker.
He's the only one- - Baker doesn't decide- - What did he say? He thinks it's time to start using a wheelchair.
You've got to be kidding.
Weakness in your legs is progressing to the point that it's not safe.
- Next time, you could break your hip.
- They have power wheelchairs.
Motorized scooters.
You'll still be very independent.
Until my battery goes dead.
You won't be losing something.
You'll be conserving energy so you can do more things.
You're trying to turn me into an invalid.
People with degenerative diseases do best when they have- What? Hope? Do you read the paper? Bush just banned federal funding for embryonic stem-cell research.
I am trying to hold on to hope, doctor.
But nobody's cooperating these days.
Well, Dr.
Ames has some papers on mobility assist devices- I don't want them.
- I'll go pick them up.
Thank you.
- Not for me.
Not for me.
So Fran drives you to all your doctor visits? Mostly, she just drives me crazy.
- Ow, ow.
- How long have you been together? We're not together.
- She works for me.
- Oh.
For some time now? Fifteen years.
She was right out of college.
I needed an assistant who was on the ball.
She was ridiculously overqualified.
The thing that really surprised me was that she stayed after that first year.
She could have gone to law school, to business school.
- But I have to say, she stuck with me.
- She knows you pretty well.
And that's why I assumed you guys- No, no, no.
There was a point a million years ago when it almost happened.
But then I came to my senses.
You married? Then you understand.
Who has time for family when you're devoted to your work? Well, some people try for a balance.
Maybe if you're an ER doc.
But if you're trying to push back the frontiers of science, it's 24/7.
Right.
It's not bad to be married to your career.
My career's a good companion.
Never nags me.
- Whoa.
- You okay? Side effect of the morphine.
It's good to know.
This will make you feel better.
Two of Versed.
- That should settle him down.
- Sats, 89.
- Maybe we've done enough.
If you can't? - We need to find the source.
May have to open his chest, but we'll find it.
- Damn it.
- It's a detour, we can get back on track.
You don't know that.
If you'd like, I can take you to the family room.
- No.
- Okay.
Stay, hold his hand, talk with him.
- Vascular clamp and pickups.
- Frazier tip suction.
- Nate, I am so sorry.
- Careful, careful.
Whoa, whoa, whoa.
Right there.
Deep to the manubrium.
I think you've got it.
- My, oh, my.
- What? Poked through innominate vein.
Never seen anything like that.
Very unusual anatomy.
Well, when they made Nate, they broke the mold.
Sats are coming up.
BP, 120/75.
- Okay, we're out of the woods.
- Good.
Trach's in, vent tubing.
You gave us a little scare there.
- Okay.
- Let me help.
You're not gonna be needing this anymore.
Nate.
Dr.
Lennox, open your eyes.
Could just be because of the sedative.
There might be some damage.
The blood loss may have deprived the brain of oxygen.
Pass the tubing all the way and cover the suction port with your thumb.
Then pull out slowly.
It's making him cough.
That's good.
It'll help clear the secretions.
That's all there is to it.
How often? Maybe two, three times a day.
More, if he sounds junky.
We're gonna get you some help at home.
I don't think so.
You know how many caregivers he's made me get rid of? It's just easier if I do it myself.
Sometimes you need a break.
Well, I'm fine.
I've cut back to 12 hours a day.
We have night aides, you know.
I mean, if there's a problem, they still come and wake me up.
It's hard for me to see someone not giving him the best care, so Nate.
Hey, Nate.
Okay, you let us know when you're ready to talk.
Can I take him home? - In a couple days.
- How about tonight? I think that after everything he's been through we should probably keep an eye on him.
I know, but I promised him that I would keep him at home.
- It's what he wants.
- He'll do better in the hospital.
Yeah.
But I promised him.
- How long have you been with him? - Oh, 21 years.
It's hard for me to believe sometimes.
It started out as just a job, you know.
But after a while There was this one time I traveled with him to Boston.
It was September of '99.
It's beautiful there in the fall.
He was giving a paper at a molecular-biology symposium.
I was still prepping his slides and his handouts five minutes before the talk.
We worked so hard, he added a couple of days to the trip.
We went up to Cape Cod.
Hotel was right on the beach.
He took me sailing.
It was one of those times in life where you think everything is just falling into place.
Well, a couple of weeks later - he got the diagnosis.
- I saw the neurologist today.
- Everything okay? Good.
- Blood tests are normal.
No periventricular lesions on the MRI.
- So it's not MS.
- Great.
- Although, I was kind of hoping for MS.
- What? The EMG showed denervation of the muscles of the right hand.
I have motor neuron disease, Fran.
- I have ALS.
- Oh, my God.
Average life expectancy is 4 years, but 5 percent of patients progress, then plateau.
There's some guy in his 60s who's still playing golf 40 years into the disease.
They're starting me on a new drug called Riluzole.
It's very promising at slowing the progression of the degeneration.
There are going to be challenges, but I'm hopeful about the new research.
And they' re setting me up with a multidisciplinary support team.
Physical and occupational therapists, nutritionists, speech pathologists - respiratory therapists.
- I can help too.
Well, I'm still gonna need an assistant obviously, of course.
Now more than ever.
That's not what I meant.
I have to put all my energy into fighting this disease.
He didn't wanna start something, only to have it taken away.
- He was afraid it would be too painful.
- For you or for him? - For both of us.
- Hello.
Hey, good to see you're back.
My neck.
- They did a trach.
- To treat your pneumonia.
- Really? - Yes, your oxygen levels are up.
Your tidal volume's improved.
You're more alert.
I'll never wear a turtleneck again.
- You still want an ICU bed? - No.
- I'll get a tele bed.
- Thank you.
We're admitting you for antibiotics and respiratory therapy.
No trach.
I thought you would have wanted this.
Appreciate it.
It saved your life, Nate.
I understand.
You know, you can live for a long time with this.
My facial muscles are getting weaker.
Once I lose my eye movements, I'll be locked in.
I'll be seeing, hearing, and feeling my surroundings but I'll be unable to communicate my needs and wishes.
I don't want to get to that point.
This infection that you have is a temporary setback.
Once you get rid of that, you're gonna be right back to where you were.
- I'm going downhill.
- Well, maybe more slowly with good oxygenation and ventilation.
Had enough.
No, in a couple of days, you're gonna have a lot more energy- He's made up his mind.
Take out trach.
I can't.
Fine.
Then home.
Poker.
He wants me to invite some of his friends over for poker.
His friends can visit him in the hospital.
Beer.
We've got beer.
Well, you're in no condition to go home, Nate.
I'm not comfortable with this.
I am.
Why don't we wait in the lobby? No.
Outside.
I'm not sure that the van is here yet.
- Fresh air.
- You know, it's cold out there.
Oh, no.
I might catch pneumonia.
Well, I'm sending a respiratory therapist home to assist you.
- Don't bother.
- You know, it's to help Fran.
Tonight, we turn off the vent.
Go to sleep.
Won't wake up.
Miss Bevens, I got those papers for you to sign.
I'll be quick.
I know the way out.
Well, it's hospital policy.
Somebody has to accompany you to the van.
You forgot your coat.
You have a treatable condition.
I'm just asking for two days in the hospital.
Two.
- Can't.
- Why not? I don't want to be a soul trapped in a corpse.
- Well, you're not there yet.
- Close.
Wait.
Just wait a minute.
Wait, wait.
- What happened to fighting this disease? - Too tired.
Once we treat the pneumonia, you're gonna feel better.
You can even plateau.
Look at Stephen Hawking, he's had this disease for 40 years.
I'm not Stephen Hawking.
You're still advising students, writing books.
You published the lead article in Cell two months ago.
Just please, wait.
Wait.
If you recover from this, you could hang on until there's a cure.
If I don't recover? Then I'll be there.
To make sure you're comfortable, take you off the vent, and let you go.
I bet you 10 bucks you can get through this.
Ten bucks? All you have to do is go back into the hospital.
I'm impressed.
You've become a pretty persuasive doctor.
Well, I'm not so sure I'd be here if it weren't for you.
The air you breathe, all the food you eat it all leads to the production of one incredible molecule: ATP.
Adenosine triphosphate.
The end result of oxidative phosphorylation.
This is the force of life.
Seventy-three hundred kilocalories per mole.
Pure unadulterated energy.
What are you doing right now? Taking notes, crossing your legs coughing, digesting your food listening to your voice mail while your professor is lecturing.
Every action of the human body, every single thing it means to be alive is powered by ATP.
How much do you weigh? - One fifty-five.
- Stand up.
Stand up.
Every day, the human body uses 180 pounds of ATP.
Yes, yes.
More than you weigh.
And yet, and yet, this body only has half a pound of ATP.
- What's going on? - You recycle it? Yes.
Yes, you do.
Thank you.
Bravo, thank you.
A-plus.
You recycle it.
Otherwise, you would burn off your ATP in five minutes.
The human body recycles it If you were a car, you would get Now, electron transport jams protons into the intermembrane space of the mitochondria.
ATP synthase is, in fact, a rotary engine.
The flow of protons spins the shaft.
That sucks in ADP and blows out fresh ATP filled with the energy it takes to fuel the human body, the human mind and, yes, yes, the human spirit.
Okay, we're done.
Thank you very much.
Tomorrow- Thank you.
Tomorrow, chapter 19, Lehninger.
Electron Transport in Detail.
Thank you.
Thank you.
- Dr.
Lennox.
Do you have a minute? - Yeah? - And you are? - Abby Lockhart.
I'm a first year.
I need your signature to drop this class.
You wanna quit biochemistry? I failed the midterm, and I'm not feeling very optimistic about the final.
- It's a required course.
- Maybe I'll try again next year.
Tough to do.
Second-year curriculum is pretty busy.
I'm thinking about maybe taking a year off to reconsider my options.
Wow, I'm surprised.
So you don't wanna be a doctor? I d- I want- I'm trying.
I just- It's a lot.
With biochemistry, and physiology, and microbiology, anatomy.
- It's just a lot, it's a lot to memorize.
- There's your problem.
Rote memorization is the path to failure.
Um, do you like sports? - Do you ice skate? - Not, really.
No.
Do you dance? Everybody likes to dance.
I took ballet when I was a kid, yes.
Did you like it? Yes.
I was the sugarplum fairy in The Nutcracker, third from the left.
Excellent.
Do you wanna learn? Stop memorizing and think conceptually.
Biochemistry is the dance of life.
Ballet is its central dogma.
Adenine holds hands with thymine, cytosine with guanine.
When they let go, a line of gypsy dancers breaks free to look for new partners, and messenger RNA is created.
Oh, I'm sorry.
I'm sorry.
I'm not usually so clumsy.
See? Um, yeah.
Can you sign my form? My office hours begin at 1 p.
m.
on Tuesdays.
- Show up.
- You're gonna tutor me? Think of it as dance lessons.
After three weeks, I guarantee that you'll pass with flying colors.
In fact, I will bet you 10 bucks.
That's is a very generous offer, I just- I just- I know that you can do this.
I wish I had your confidence.
You will.
Don't give up.
If nothing else, I will teach you how to fight.
I'll see you Tuesday.
Thank you.
R.
E.
R.
12x13 "BODY AND SOUL" You can't be out here.
Sir? Sir, it's not safe, sir.
Sir, you can't be here.
Sir? They found some guy wandering and disoriented.
- Just what we need, another lost soul.
- You can never have enough.
Nate Lennox, 54, medic alert bracelet says he has ALS.
Paralyzed and unresponsive.
He rolled out on to the ice at Prospect Rink.
Was somebody with him? I called the number on the bracelet, left a message.
Mr.
Lennox, can you hear me? - How'd he get out of the house? - Good question.
Do you think he was abandoned? Somebody's taking care of him.
He's got clean clothes, had a shave this morning.
Pulse ox is only 89.
Let's get him on five liters by a mask.
Okay.
- I'm gonna need some lifting help.
- Let's leave him in the chair for now.
If we lay him down, it might compress his lungs, might make things worse.
Okay, crackles bilaterally.
CBC, chem panel and a portable chest.
Let's call for his old medical records.
Whoa, hey, hey.
- Hey, did you hit the joystick? - No.
Okay, sats are up to 92.
Have RT induce a sputum for a Gram's stain and culture.
Whoa, hey.
- Don't do that.
- I didn't touch it.
Is there a short or something? I think the computer has an eye sensor that's controlling the chair.
- I think he wants to get out of here.
- Probably altered from too low oxygen.
Yeah, well, I'm gonna disconnect the battery.
Hang on.
Need a hand? ALS with pneumonia.
Could use a Hep-Lock.
What's his name? Nate Lennox.
I've seen him before, a while back.
No help.
Don't.
- He did that with his eyes? - Looks like a speech-synthesizer program.
It's okay now, sir.
We're gonna take care of you.
Want out.
Please, let me out.
Please, let me out.
Okay, sir, we're gonna sit you forward now.
Sats are still borderline.
I'm not sure how aggressive we need to be with this guy.
Is he a DNR? If I were like that, I sure as hell would be.
Mr.
Lennox, your oxygen levels are falling.
Do you understand? We need to know your wishes about resuscitation.
Okay.
- Home.
- Does that mean - you don't want heroic measures? - Home.
If you stop breathing, do you want us to use a machine, a ventilator? Hungry.
Food.
Do you have a living will? An advanced directive? - Drugstore.
- I don't think we're getting through.
Do you know where you are? I have amyotrophic lateral sclerosis.
Also known as Lou Gehrig's disease.
It is a progressive degenerative neurologic disorder that has weakened my muscles.
All of my senses are intact.
- My mind is clear.
- Not today, it isn't.
Got his old records.
We need the name of his neurologist.
Maybe he'll know what to do with this.
You want me to up his oxygen? I'm gonna say let's go with BiPAP.
It'll buy us time without having to intubate.
I knew he looked familiar.
- What? - He should already be on BiPAP.
Neela and I treated him a year ago.
He came in for shortness of breath.
Every time you have a thought every time you take a breath every time you move a muscle every time you take a crap you should thank your ATP.
AT- ATP.
Oxidative phosphorylation The bedpan may distort things a little.
Oh, boy.
The kids at school are gonna make fun of me.
- It's too tight? - No, it's fine.
It's like an oven in here.
I'm sorry, they're working on the a.
c.
So hot.
The BiPAP increases your tidal volume.
Your neurologist says it'll give you more energy and a longer survival.
That's great news.
Sam, labs were hemolyzed on your heat-stroke guy.
- I'll be right back.
- I'll wait here.
Ha.
I should have another listen.
Where did you go to med school? Uh, right here.
I was a biochemistry major at Yale, so I placed out of your class.
Yale? Oh.
I worked in Sandra Hamilton's lab - senior year.
- Yeah, I know it.
We were in awe of your work on anti-sense RNA.
I cited your studies in my paper on gene inactivation in Trypanosoma brucei.
You published as an undergraduate? Second author.
Impressive.
So, what are you doing here in this cesspool? Are you just here for the big bucks? What is it gonna be? Orthopedics? Plastic surgery? Neither.
I can't stand surgeons.
They're arrogant workaholics who can't relate to people unless they're asleep.
Sorry, Nate, the car overheated and I had to take the el.
What happened? - I'm fine.
- He had some shortness of breath.
- I'm Dr.
Rasgotra.
- Oh, Fran Bevens.
Did you reach Dr.
Ames? - He's already been down.
- Okay.
He's consulting a speech pathologist.
- Good.
- Not good.
I don't need it.
It's getting hard to understand what you're saying.
Maybe they should start listening better.
Hello, Fran.
Jared, it's good to see you.
Ready to start? - I'm trying to contain my enthusiasm.
- How long are you guys gonna be? - Half an hour.
- Fifteen minutes.
We'll be back with your aftercare instructions.
You think about what you're doing.
You may realize you don't belong here.
- Where does he think you belong? - At Jumbo Mart.
He misses my slushies.
Please be kind.
Hey, severe sunburn.
Dispo if the pain is down with Toradol and aloe.
- Not too bad.
- Soft rule out going to tele.
- Excellent.
- And this guy's with his PMD.
- So there's nothing for you to do.
- Lennox? Is that Nate Lennox? The biochemistry professor.
- No, wait, I've got one more.
- Yeah, I'll figure it out.
Nate.
You like my new look? Well, not a lot of people could pull that off.
- Good to see you, Abby.
- Hi, Fran.
What you doing? Playing "Medal of Honor.
" I just killed a couple of Nazis.
His facial muscles are weakening.
He needs to practice with assisted speech.
Hey, I've got a great idea.
Well, we can wait on speech therapy for the time being.
But I gotta tell you, Nate, you're just putting off the inevitable.
- You need to start wearing this.
- Why? Because it has your diagnosis on it, and your name and your phone number.
We're lucky you were in class today.
Otherwise, who knows what might have happened.
Okay, okay.
How about this thing? Do I have to wear it all the time? Well, we'll start with bedtime use.
You'll get the benefits of eight hours a night while you're asleep.
I keep waking up and something else is gone.
- Thank God for the bracelet.
- Is that comfortable? Nate.
Nate.
He was speaking with the computer when he first came in.
We can't get an IV in him.
He always needs a central line.
He was at an ice rink? Yeah, any idea why? I don't know.
It was like any other day.
I got up, I shaved him, bathed him.
Fed him breakfast and then transferred him to the chair.
He was watching television, so I went to take a quick nap.
How did he get outside? Well, he can open the front door with his computer.
Ray, ready to present? Dr.
Kovac? - Fran Bevens.
- Hello.
Hello, sir.
You saw him a few years ago.
Right, middle and lower lobe infiltrates.
He's altered, borderline oxygenation, even with BiPAP.
Can we have a word? Yes, of course.
We need to make a decision about intubating and ventilation.
You think he can get over the pneumonia? He could, or he could be intubated in the ICU, going downhill for four weeks.
He hasn't got a lot of reserve.
There's no guarantee he'll get better.
This may be the natural endpoint of his disease.
So maybe it's time to focus on keeping him comfortable.
Fran, I just heard you were here.
Thank you for coming by.
- I've taken care of him before.
He decided to go out by himself.
Why did you do that, Nate? - In motion.
- What's in motion? Free.
- Pulse ox is down to 82.
- Yeah, what are you doing? His lungs are full of junk, his sats down, he needs to be intubated.
We've been just discussing about how best to proceed.
Well, helping him breathe would be a good way to start.
I don't think that he'd want that, Abby.
- Abby - Yankauer.
We haven't come to a consensus.
- I'm not comfortable with this.
- I'm not intubating.
Large mucous plug at the cords.
- Okay, that should help.
- Temporarily.
Sats are coming up.
This will give us time to treat him with oxygen and antibiotics until he's alert enough to tell us what he wants.
Dr.
Lennox? Nate.
Nate, talk to us.
Around and into the subclavian.
- Fluoro off.
Okay, that's as far as we go.
- Ceftriaxone's ready.
How'd he do? - Well, we're starting the IV antibiotics.
- When did he last eat? - I fed him this morning.
He needs some calories.
- How are you doing? - You're in the hospital, Nate.
Nate? You remember when we talked about putting in a trach if you had trouble breathing? You said you wanted to keep going until they found a stem-cell cure.
Why don't we just let him rest? Snowmobile versus tree.
Morris needs some help.
- 500 of azithro after the Rocephin.
- Got it.
Okay, we all need to agree on this.
You told me you wanted a trach.
That was a long time ago, Abby.
His biggest fear now is that he'll end up on life-support aware of everything, but with no way to communicate.
He was communicating a half-hour ago.
That could have been random eye movements.
- Four hundred cc's of Jevity? - Yep.
So if we do the trach?.
He's out of here in a day.
He can go home with a portable ventilator.
You'd have to learn how to suction and troubleshoot the vent.
But we can get you some help.
I know you're tired.
- He's the one who's tired.
- Fran I'm with him every day, Abby.
I know.
Looks like we got a clogged G-tube here.
- Do you flush it with water? - Yes, after every feeding.
He needs nutritional support to fight off infection.
- It won't go.
- Do you know when the tube was put in? - No, I- - G-tube placed in May, 2002.
He came in after a choking spell.
Each May, the graduating medical students - vote for teacher of the year- - I love the fresh flowers.
They must think it'll make up for cutting back on my teaching.
but rather a scientist, whose dynamism- May I have a glass of wine? Thanks very much.
made a strong impression and stayed with the students throughout their training.
- It gives me great pleasure to present - Nate, what is it? - the 2002 Teacher of the Year Award - Nate, Nate.
to Dr.
Nathan Lennox.
Well, his chest x-ray is negative for aspiration.
- You got lucky, Nate.
- Yeah.
I'm the luckiest man on the face of the Earth.
It's time for a feeding tube.
No, it's not.
Well, your chewing and swallowing muscles are getting pretty weak.
Fran will have to cut my meat smaller - won't she? - Takes him an hour to eat a meal.
- He's lost 10 pounds.
- More like 5.
The rest is water weight.
Weight loss accelerates the progression of ALS.
The extra calories from the tube feeding will mean increased strength more energy and longer survival.
- I'll think about it.
- Romano around? In the O.
R.
with a pneumonectomy, but I'll see about getting you on the schedule.
I said, I'll think about it.
Well, we'll save you a spot.
We can always cancel.
- Good night.
- I'll walk out with you, Donald.
- I'll be right back.
- Good night, been great.
- Tell them to send the trophy to my mom.
- Trophy? I won the potato-sack race at the County retreat.
Is Abby Lockhart around? - No, not tonight.
- It's pretty quiet around here.
Well, sometimes it's slow.
It's not just that.
What, are you cutting back on staff or something? Well, one of our Attendings died.
Mark Greene.
A lot of people took off to go to his memorial.
Chen wants you in Exam 3 with the belly-pain guy.
It's a slam-dunk diverticulitis.
I called Medicine.
- All she has to do is co-sign my chart.
- I'll let you tell her that yourself.
- What year of residency are you in? - First.
I'm an intern.
Ho-ho! Pretty cocky for an intern, aren't you? Huh? - You're either real smart or really insecure.
- If I were you, I'd put my money - on the first one.
- Of course, all the great minds wanna work in the County ER.
Actually, this is just temporary.
I'm planning on moving over to Northwestern soon.
- Congratulations.
You got in, huh? - Well, not yet, but believe me, I will.
Pre-op instructions for the G-tube.
Okay, cool.
This is gonna show you everything you need to know about the procedure.
Where to show up, what to eat the night before, what to wear Are you okay? Look, I know it's hard, but- This isn't me.
It's the disease.
Okay.
The nerve deterioration leads to pseudobulbar affect.
His emotions can be very exaggerated.
- Yeah, I see.
- Okay.
It's called emotional incontinence.
It sucks.
You get a little upset about something, and next thing, you're crying like a baby.
There has to be some sort of medicine for that.
He won't take them.
Side effects are too much.
And it's the BDNF.
I've been injecting nerve growth factor twice a day for a year.
The stuff turns ALS mice into Olympic athletes.
- But human trials, worthless.
- Results haven't panned out in humans.
- I'm sorry to hear that.
- And now Fran has to pour - Ensure in my stomach tube all day.
- It's no big deal.
Come on.
- Shh.
Come on, calm down.
- I didn't wanna be a burden on anyone.
Shh.
Come on.
Come on.
- Should this be hurting him? - Maybe just a little.
Okay, G-tube is in.
Balloon is up.
Check the pump.
I think he's waking up a little bit.
- Go ahead and set up for PFT's.
- Flow is looking good.
- Thank you.
- Mm-hm.
All right, we need to test his lung function.
Nate, I'm gonna put this in your mouth and Sam's gonna pinch your nose.
Here we go.
Easy.
All right.
Easy, yeah.
Okay.
All right, deep breath in.
And blow it out, blow it out, blow it out.
- Great.
- Forced vital capacity is 32 percent of normal.
- That's the amount of air he can move- - I know.
Okay.
Nate? Nate, your lung capacity has deteriorated.
The best way to help your breathing is for us to put in a trach.
You're gonna need assisted ventilation.
Do you want us to do it? I'm not sure you'll recover without it.
The trach is the best chance you have of clearing up your pneumonia.
Nate.
Okay.
Okay.
- Call Surgery, he consented.
- I'm okay.
- Abby, I don't think that's what he meant.
- What? He said, "Okay.
" He said, "I'm okay" after that, which could mean, leave him alone.
- It's not exactly informed consent.
- Nate.
You want the trach, don't you? - You know, you all heard what he said.
- At a vital capacity of 30 percent some ALS patients enter into hospice care.
- It means they have six months to live.
- His FVC is low because of pneumonia.
- Clear that, lung function will be back.
- Best-case scenario.
He expressed his wishes in advance.
Now he's too sick, can't give reliable consent.
- How's his PO2? - I wanna do a trach.
- We have a consent issue.
- I explained the procedure to the patient.
I asked if he wanted it.
He said, "Okay," on his computer.
- He did? - He also said, "I'm okay," after that.
I don't think that he understood.
He was alert and looking at me the entire time.
He understood.
I really don't think that this is what he wants.
Fran has a durable power of attorney.
- Thank you.
- It's your call.
You know, with all due respect, I'm sorry, but Nate expressed his wishes and I think we have to go with that.
Well, if there's a chance that he asked for the procedure I'm not sure that he did.
- I think we have to do it.
- Dr.
Kovac- Ray, I need you next door to help me with a central line.
Let's go.
- I'd like to page Dr.
Ames.
- I'll try to find him.
And call Dubenko.
Put in the trach and RT to set up a vent.
Between first and second tracheal ring.
Close your eyes if you're having any pain.
Doesn't look like he's feeling anything.
- Aspirate air, confirm you're in.
- Guidewire.
So you're in surgery now, Neela? I'm just doing an elective.
Things change, right? Certainly do.
Eleven French dilator.
Balloon's good to go.
I hope he's okay with this.
Well, it doesn't wanna pass.
A little more muscle.
You doing all right, Nate? Okay, remove the dilator, slide the trach tube in.
Mm.
Bit of oozing here.
Direct pressure should take care of that.
A little bleeding can be normal.
- Tachy at 130.
- I'll open up his fluids.
Is he okay? He could be sensitive to the blood loss.
Let's take another look.
- Oh, my God.
- Pressure again, 10 blade.
- What are you doing? - Converting to an open procedure.
- We need deep hemostasis.
- Two units of packed cells.
- Blood transfusion? - Just a precaution.
Call for type specific.
Sam, see if his antibody screen's in the old chart.
- Abby, grab a Yankauer.
- What's happening? - A minor complication.
- Doesn't look minor.
- Suction on high.
- Shouldn't have let you do this.
- Mosquito clamp.
- Antibody screens negative.
- He's in pain.
Give him medication.
- Four of morphine.
- No morphine.
- Had a bad reaction in 2001 - when he came with a broken wrist.
- The transgene will be suppressed.
Use two fluorescent reporters with different spectra.
- Why two? - One for our transfected cells.
And one for translational fusion with the target gene.
- That's- That's brilliant.
- Well, it's simple.
I don't know if it's brill- Four morphine.
- Get to work on the plasmid DNA vectors.
- Right now? I don't want Gregorio beating us to the Nobel Prize.
Right.
- You're not supposed to take the stairs.
- They were servicing the elevators.
- Wait for the next one.
All right.
- We were late.
- I've canceled your morning classes.
- Don't be ridiculous.
Why'd you do that? I couldn't reach Baker.
He's the only one- - Baker doesn't decide- - What did he say? He thinks it's time to start using a wheelchair.
You've got to be kidding.
Weakness in your legs is progressing to the point that it's not safe.
- Next time, you could break your hip.
- They have power wheelchairs.
Motorized scooters.
You'll still be very independent.
Until my battery goes dead.
You won't be losing something.
You'll be conserving energy so you can do more things.
You're trying to turn me into an invalid.
People with degenerative diseases do best when they have- What? Hope? Do you read the paper? Bush just banned federal funding for embryonic stem-cell research.
I am trying to hold on to hope, doctor.
But nobody's cooperating these days.
Well, Dr.
Ames has some papers on mobility assist devices- I don't want them.
- I'll go pick them up.
Thank you.
- Not for me.
Not for me.
So Fran drives you to all your doctor visits? Mostly, she just drives me crazy.
- Ow, ow.
- How long have you been together? We're not together.
- She works for me.
- Oh.
For some time now? Fifteen years.
She was right out of college.
I needed an assistant who was on the ball.
She was ridiculously overqualified.
The thing that really surprised me was that she stayed after that first year.
She could have gone to law school, to business school.
- But I have to say, she stuck with me.
- She knows you pretty well.
And that's why I assumed you guys- No, no, no.
There was a point a million years ago when it almost happened.
But then I came to my senses.
You married? Then you understand.
Who has time for family when you're devoted to your work? Well, some people try for a balance.
Maybe if you're an ER doc.
But if you're trying to push back the frontiers of science, it's 24/7.
Right.
It's not bad to be married to your career.
My career's a good companion.
Never nags me.
- Whoa.
- You okay? Side effect of the morphine.
It's good to know.
This will make you feel better.
Two of Versed.
- That should settle him down.
- Sats, 89.
- Maybe we've done enough.
If you can't? - We need to find the source.
May have to open his chest, but we'll find it.
- Damn it.
- It's a detour, we can get back on track.
You don't know that.
If you'd like, I can take you to the family room.
- No.
- Okay.
Stay, hold his hand, talk with him.
- Vascular clamp and pickups.
- Frazier tip suction.
- Nate, I am so sorry.
- Careful, careful.
Whoa, whoa, whoa.
Right there.
Deep to the manubrium.
I think you've got it.
- My, oh, my.
- What? Poked through innominate vein.
Never seen anything like that.
Very unusual anatomy.
Well, when they made Nate, they broke the mold.
Sats are coming up.
BP, 120/75.
- Okay, we're out of the woods.
- Good.
Trach's in, vent tubing.
You gave us a little scare there.
- Okay.
- Let me help.
You're not gonna be needing this anymore.
Nate.
Dr.
Lennox, open your eyes.
Could just be because of the sedative.
There might be some damage.
The blood loss may have deprived the brain of oxygen.
Pass the tubing all the way and cover the suction port with your thumb.
Then pull out slowly.
It's making him cough.
That's good.
It'll help clear the secretions.
That's all there is to it.
How often? Maybe two, three times a day.
More, if he sounds junky.
We're gonna get you some help at home.
I don't think so.
You know how many caregivers he's made me get rid of? It's just easier if I do it myself.
Sometimes you need a break.
Well, I'm fine.
I've cut back to 12 hours a day.
We have night aides, you know.
I mean, if there's a problem, they still come and wake me up.
It's hard for me to see someone not giving him the best care, so Nate.
Hey, Nate.
Okay, you let us know when you're ready to talk.
Can I take him home? - In a couple days.
- How about tonight? I think that after everything he's been through we should probably keep an eye on him.
I know, but I promised him that I would keep him at home.
- It's what he wants.
- He'll do better in the hospital.
Yeah.
But I promised him.
- How long have you been with him? - Oh, 21 years.
It's hard for me to believe sometimes.
It started out as just a job, you know.
But after a while There was this one time I traveled with him to Boston.
It was September of '99.
It's beautiful there in the fall.
He was giving a paper at a molecular-biology symposium.
I was still prepping his slides and his handouts five minutes before the talk.
We worked so hard, he added a couple of days to the trip.
We went up to Cape Cod.
Hotel was right on the beach.
He took me sailing.
It was one of those times in life where you think everything is just falling into place.
Well, a couple of weeks later - he got the diagnosis.
- I saw the neurologist today.
- Everything okay? Good.
- Blood tests are normal.
No periventricular lesions on the MRI.
- So it's not MS.
- Great.
- Although, I was kind of hoping for MS.
- What? The EMG showed denervation of the muscles of the right hand.
I have motor neuron disease, Fran.
- I have ALS.
- Oh, my God.
Average life expectancy is 4 years, but 5 percent of patients progress, then plateau.
There's some guy in his 60s who's still playing golf 40 years into the disease.
They're starting me on a new drug called Riluzole.
It's very promising at slowing the progression of the degeneration.
There are going to be challenges, but I'm hopeful about the new research.
And they' re setting me up with a multidisciplinary support team.
Physical and occupational therapists, nutritionists, speech pathologists - respiratory therapists.
- I can help too.
Well, I'm still gonna need an assistant obviously, of course.
Now more than ever.
That's not what I meant.
I have to put all my energy into fighting this disease.
He didn't wanna start something, only to have it taken away.
- He was afraid it would be too painful.
- For you or for him? - For both of us.
- Hello.
Hey, good to see you're back.
My neck.
- They did a trach.
- To treat your pneumonia.
- Really? - Yes, your oxygen levels are up.
Your tidal volume's improved.
You're more alert.
I'll never wear a turtleneck again.
- You still want an ICU bed? - No.
- I'll get a tele bed.
- Thank you.
We're admitting you for antibiotics and respiratory therapy.
No trach.
I thought you would have wanted this.
Appreciate it.
It saved your life, Nate.
I understand.
You know, you can live for a long time with this.
My facial muscles are getting weaker.
Once I lose my eye movements, I'll be locked in.
I'll be seeing, hearing, and feeling my surroundings but I'll be unable to communicate my needs and wishes.
I don't want to get to that point.
This infection that you have is a temporary setback.
Once you get rid of that, you're gonna be right back to where you were.
- I'm going downhill.
- Well, maybe more slowly with good oxygenation and ventilation.
Had enough.
No, in a couple of days, you're gonna have a lot more energy- He's made up his mind.
Take out trach.
I can't.
Fine.
Then home.
Poker.
He wants me to invite some of his friends over for poker.
His friends can visit him in the hospital.
Beer.
We've got beer.
Well, you're in no condition to go home, Nate.
I'm not comfortable with this.
I am.
Why don't we wait in the lobby? No.
Outside.
I'm not sure that the van is here yet.
- Fresh air.
- You know, it's cold out there.
Oh, no.
I might catch pneumonia.
Well, I'm sending a respiratory therapist home to assist you.
- Don't bother.
- You know, it's to help Fran.
Tonight, we turn off the vent.
Go to sleep.
Won't wake up.
Miss Bevens, I got those papers for you to sign.
I'll be quick.
I know the way out.
Well, it's hospital policy.
Somebody has to accompany you to the van.
You forgot your coat.
You have a treatable condition.
I'm just asking for two days in the hospital.
Two.
- Can't.
- Why not? I don't want to be a soul trapped in a corpse.
- Well, you're not there yet.
- Close.
Wait.
Just wait a minute.
Wait, wait.
- What happened to fighting this disease? - Too tired.
Once we treat the pneumonia, you're gonna feel better.
You can even plateau.
Look at Stephen Hawking, he's had this disease for 40 years.
I'm not Stephen Hawking.
You're still advising students, writing books.
You published the lead article in Cell two months ago.
Just please, wait.
Wait.
If you recover from this, you could hang on until there's a cure.
If I don't recover? Then I'll be there.
To make sure you're comfortable, take you off the vent, and let you go.
I bet you 10 bucks you can get through this.
Ten bucks? All you have to do is go back into the hospital.
I'm impressed.
You've become a pretty persuasive doctor.
Well, I'm not so sure I'd be here if it weren't for you.
The air you breathe, all the food you eat it all leads to the production of one incredible molecule: ATP.
Adenosine triphosphate.
The end result of oxidative phosphorylation.
This is the force of life.
Seventy-three hundred kilocalories per mole.
Pure unadulterated energy.
What are you doing right now? Taking notes, crossing your legs coughing, digesting your food listening to your voice mail while your professor is lecturing.
Every action of the human body, every single thing it means to be alive is powered by ATP.
How much do you weigh? - One fifty-five.
- Stand up.
Stand up.
Every day, the human body uses 180 pounds of ATP.
Yes, yes.
More than you weigh.
And yet, and yet, this body only has half a pound of ATP.
- What's going on? - You recycle it? Yes.
Yes, you do.
Thank you.
Bravo, thank you.
A-plus.
You recycle it.
Otherwise, you would burn off your ATP in five minutes.
The human body recycles it If you were a car, you would get Now, electron transport jams protons into the intermembrane space of the mitochondria.
ATP synthase is, in fact, a rotary engine.
The flow of protons spins the shaft.
That sucks in ADP and blows out fresh ATP filled with the energy it takes to fuel the human body, the human mind and, yes, yes, the human spirit.
Okay, we're done.
Thank you very much.
Tomorrow- Thank you.
Tomorrow, chapter 19, Lehninger.
Electron Transport in Detail.
Thank you.
Thank you.
- Dr.
Lennox.
Do you have a minute? - Yeah? - And you are? - Abby Lockhart.
I'm a first year.
I need your signature to drop this class.
You wanna quit biochemistry? I failed the midterm, and I'm not feeling very optimistic about the final.
- It's a required course.
- Maybe I'll try again next year.
Tough to do.
Second-year curriculum is pretty busy.
I'm thinking about maybe taking a year off to reconsider my options.
Wow, I'm surprised.
So you don't wanna be a doctor? I d- I want- I'm trying.
I just- It's a lot.
With biochemistry, and physiology, and microbiology, anatomy.
- It's just a lot, it's a lot to memorize.
- There's your problem.
Rote memorization is the path to failure.
Um, do you like sports? - Do you ice skate? - Not, really.
No.
Do you dance? Everybody likes to dance.
I took ballet when I was a kid, yes.
Did you like it? Yes.
I was the sugarplum fairy in The Nutcracker, third from the left.
Excellent.
Do you wanna learn? Stop memorizing and think conceptually.
Biochemistry is the dance of life.
Ballet is its central dogma.
Adenine holds hands with thymine, cytosine with guanine.
When they let go, a line of gypsy dancers breaks free to look for new partners, and messenger RNA is created.
Oh, I'm sorry.
I'm sorry.
I'm not usually so clumsy.
See? Um, yeah.
Can you sign my form? My office hours begin at 1 p.
m.
on Tuesdays.
- Show up.
- You're gonna tutor me? Think of it as dance lessons.
After three weeks, I guarantee that you'll pass with flying colors.
In fact, I will bet you 10 bucks.
That's is a very generous offer, I just- I just- I know that you can do this.
I wish I had your confidence.
You will.
Don't give up.
If nothing else, I will teach you how to fight.
I'll see you Tuesday.
Thank you.