Chicago Med (2015) s02e18 Episode Script

Lesson Learned

1 Whoa, whoa, whoa, we're live.
Naima? 22-year-old male, gunshot wound to the abdomen.
GCS 15.
- Dr.
Choi, GSW! - On it! - BP, 100 over 50.
- Oh, wait a second.
Wait a sec.
- Get this one up to surgery.
- All right, let's go.
- [groaning, coughing] - Okay, here we go.
- Dr.
Choi, you're good? - Good.
All right, Monique Seven treatment rooms on the East side, four trauma bays on the West.
Bays three and four combine to treat gunshot wounds, a place affectionately known as Baghdad.
4,000 shootings in Chicago.
- Some days, we get - [yells] A dozen.
[yelling] Drug dispensers are in the North and South end of the E.
D, extra gurneys, isolations suites in the ambulance bay.
Uh, Band-Aid, wound dressings, gauze, and extra weaponry are in the supply closet next to the elevator, which brings us right here to the command center.
- Deer in the headlights.
- Mm-hmm.
- Nursling? - Monique Lawson.
She's got her Pediatric Advanced Life Support certification, and is doing her E.
check-off skills training with yours truly.
Be careful, she bites.
Monique, Doris, move.
I hardly slept last night.
[laughs] I couldn't stop thinking.
I mean, so many people coming in, horrible injuries.
And this isn't even a busy day.
I just hope I'm up to it.
Quick, nurses' credo? Uh, cure sometimes, treat often, comfort always.
Don't kill your patient all: Because that's the doctor's job.
- I heard that.
- [laughs] Maggie, what you got for me? Alzheimer's patient, here from long-term care facility.
Hypotensive and high fever in Treatment 2.
Any family? Advanced directives? No, surrogate just passed away, and no one else was designated, so it's going to be our call.
Okay, and you need to be initiating catheter duty.
Patient in Treatment 6.
Have a stab at her.
Wait, we need to page Will.
What is it? This is Bella Rowan Dr.
She was Will's teacher, his mentor.
Lungs are wet.
Does this hurt, Dr.
Rowan? [laboring exhale] - Oh - Okay, all right, all right.
Who are you? I'm Dr.
Oh I'm gonna help Dr.
Manning here take care of you.
- Is that all right? - Oh, good.
- Okay.
- Gotta go.
- Why is that? - Mm, miss my bus.
Oh, where are you going? What? [coughing] Okay, okay, okay - [moans] - Tell you what, Dr.
Rowan [moaning] We promise to do our best, to get you out of here so you can catch that bus.
- How's that sound? - Good.
- Good.
- Good.
[labored breathing] All right.
I'll be back to check on you in a few minutes.
I'm pretty sure she's got aspiration pneumonia.
- Yeah.
- You start antibiotics? Vanc and Zosyn, plus Levophed to maintain her pressure.
Metabolic panel, urine analysis, and blood cultures are all pending.
She's obviously been sick for days.
Why did they wait so long to bring her in? I'm sorry, Will.
Halstead, I came as soon as I heard.
I was an O.
nurse under Dr.
Rowan when I was starting out.
How is she? Not good, and we're playing catchup.
All right, let's put in a central line and get a chest X-Ray, and I wanna keep close tabs on her volume status.
Please, keep me updated every 20 minutes.
Of course.
Hey, we went to Joe's last night.
My sister loves stone crab.
It was nice.
I mean, there were a lot of years when Claire wasn't speaking to me.
Eh, I'm sure she had very good reason.
Well, she can tell you all about it herself.
- What do you mean? - She wants to meet you.
She wants to have you over for dinner.
By meet, you mean grill? Make sure I'm worthy of a Rhodes? No, that's more my father.
Claire's not like that.
She's happy if I'm happy, and I'm happy.
I'm not sure if I'm ready to, uh, meet the family.
Morning, Dr.
- Robin - Leah.
Bardovi, are you ready for your first coarctation repair? I've been studying cases all week.
Course there's nothing like watching the maestro.
[chuckles] I will catch you at lunch, Maestro.
We'll continue this conversation later.
Let's go.
Patient's 13.
Pretty late to get a coarctation diagnosis.
Uh, his dad's an oil worker.
He did a stint in Nigeria.
Nobody there caught it.
Knock, knock? - Dr.
- Mitch, how are you doing? This is Dr.
She's gonna be assisting me in the surgery.
Brandon, how are we doing this morning, bud? We are both looking forward to getting on the other side of this thing.
Ain't that right, buddy? Uh, yeah, sure.
Hey, are you guys gonna have to saw me open to do this? Yes.
Yes, we are.
[chuckles] I'm not scared.
I'm just wondering if Halloran's gonna have a cool scar after the battle of Madigan.
- Halloran? - It's a character in some dumb online game that he plays.
Dad, it's not a game.
It's fan fiction.
I published a chapter today, and my followers are gonna wanna know what happens to Halloran after he slays the High Locust.
That's you.
All right, then.
Well, I am honored.
And yes, Halloran's gonna have a pretty gnarly battle scar.
Well, at least one of us isn't nervous.
So, coarctation repair.
It sounds complicated, but it's actually a relatively simple procedure.
Uh, I'm gonna make an incision in Brandon's left chest.
We'll place him on partial bypass, and then resect, or cut out, the narrowed portion of his aorta, and place a graft.
Now I know all this is a lot, but any questions, feel free.
Uh, yeah, I was doing some research online, and it seems that, uh, Brandon's chicken legs and his puny size are because of his condition? I mean, any chance that that'll change? Uh, obviously, Brandon's health is our primary concern, uh, but yes, he may grow at a more rapid rate once the blood flow issue is corrected.
[exhales] Okay.
All right, Brandon, see ya on the battle field.
Reese? You didn't answer your page.
Oh, sorry.
I I was just Uh When Jason Wheeler jumped, do you think he was scared? Was I mean, was was he at peace? Right before he stepped off, was there a moment of regret? I just I just can't stop thinking about him.
But see, I I don't want to, and then I feel guilty, because I don't.
The thing about suicide, it's never really a lone act.
It tends to leave a lot of victims in its wake.
I'd be lying if I said I'd been sleeping too well recently.
But, um but you and I We've got work to do.
Excuse me.
Sean Adams, formal Naval aviator, now flies for a private charter company.
And he was doing his pre-flight check and felt faint.
Co-pilot brought him in.
Says it's not the first time.
Now I checked Mr.
Adams out.
Can't find anything wrong.
Probably just dehydrated and overworked.
Says he feels fine and wants to go.
So, um so why are we here? Charter company wants a psych evaluation.
Co-pilot says he's also been acting different.
Doesn't go out with the boys anymore, naps a lot, seems to be low energy.
Sounds like depression.
- Possibly.
- In any case, the company won't let him fly till you sign off.
Why don't we have a little chat? Thanks.
Code blue! Unresponsive two-year-old.
Quick, what do we do first? Check pulse, start compressions.
- There is no pulse.
- Compressions at what rate? - 150 beats per minute.
- Good.
You got a team behind you.
What's next? I tell them to start bagging.
Pulse check.
Okay, but there's still no pulse.
Patient's dying.
What now? Use the paddles to do a quick look.
Shows v-fib.
She's coding, so? Need to shock at 4 joules per kilo? Well, move then.
You're losing her.
Charge to 28 joules.
I'm shocking the patient.
You just killed me.
- I did? - Mm-hmm.
You forgot to yell "clear" before shocking.
Just one of those minor details.
Let's take it from the top.
Come on.
It just seems like everyone's overreacting.
But you can see their point of view.
I mean, people put their lives in your hands.
And I'm fine.
I've answered your question.
I know what today is.
I know where I am.
Aside from lack of energy, your co-pilot says that at times you seem mildly confused.
I have no idea what he's talking about.
[stammers, laughs] Maybe he's the one that's confused.
Adams, I imagine there's a lot of pressure at your job.
I used to land F-14s on an aircraft carrier.
That's pressure.
Have you ever had thoughts of hurting yourself? What? No.
Let's see here.
Are you on any medication? You mean do I take anything that might affect my performance? No.
I take a statin, like 10 million other Americans.
And no, I don't drink, if that's your next question.
All right, Mr.
Adams, well, thank you for your time.
Getting, um, a little ahead of yourself.
Don't you think? Well, he is exhibiting signs of depression, and there is a high rate of suicide among pilots.
Reese, trust me, I understand what's on your mind, but suicidality should not necessarily be a default diagnosis.
So what do you think? I think that Mr.
Adams is linear, lucid.
I mean, he's certainly not confused.
Are you gonna sign off on him? Well, I didn't say that.
I mean, I thought he was a little defensive around the medication issue.
Well, the man has to prove himself to keep his job.
That would make me defensive.
And you know what, that could be all there is to it.
But look, he's a pilot.
Let's just take the extra step.
You know, run a tox screen, make sure he's clean.
To your point, depressives often self-medicate, so I'm not ruling out the diagnosis.
Rowan's LFTs are high, her creatinine's through the roof.
Kidneys are struggling.
White cell count's high too.
Multiple organ failure and pending respiratory failure.
- We need to intubate her.
- What at her age? - Nurse! - No, mm, Will you know what this means.
She might never get off.
What if we bridge her with BiPAP? That'll take the stress off the lungs, until the infection cools.
We'd still wind up intubating her, - and we'd have lost time.
- Dr.
Halstead there's a Mr.
Sherwood here from the nursing home.
He wants to know how Dr.
Rowan is doing.
I'll be happy to tell him.
Sherwood, is it? You mind telling me how you and your staff let a textbook case of aspiration pneumonia go unattended? I-I don't think that happened.
You don't? Then then how was she allowed to aspirate in the first place? - Dr.
Halstead - 'cause I I visited her every month.
I knew she had trouble swallowing.
Your staff knew she had trouble swallowing.
Okay, I-I promise you I'll look into this.
- I'm sure you will.
- Oh, you better.
I mean, that she that Dr.
Rowan should come to this, all because you denied her the most basic hey! Dr.
Halstead Thank you, Mr.
Will They're criminals.
I mean, we should call IDPH, have their license revoked.
You've all achieved something very special today.
Now you're physicians, doctors.
In a few months, you'll begin your residencies, caring for people in need.
If you take one thing away from me today, let it be this.
Treat the patient, not the disease.
- Brought you some Vitner's.
- Ah - Triple cheese.
[chuckles] - Thanks.
Rowan? I'm really sorry, Will.
- I know how hard it'll be - No.
No, if we can get her temp down and her sats up, I think we'll be over the hump.
I just remember when my grandma got sick, how tough it was for my mom.
The options, decisions [chuckles] Seeing my grandma so ill.
It was awful.
Yeah, I hear what you're saying.
But, Nina, she can beat this.
Rowan gave me so much.
Getting her through this, it's the least I can do.
Enter the patient's first and last name, select an urgency level, pick your labs, and then hit submit.
- Excuse me - Yep.
I'm looking for my husband, Sean Adams.
He's in Treatment 4.
I'll page his doctor.
Thank you.
How's it look? Systolic's still 50 higher in the arms, but that's not uncommon right after surgery.
It should come down in the next 24 hours or so.
It looks like Halloran slayed the High Locust after all.
Hey, um, so how much longer before he's up and running around? Uh, well, over the next few months, you should see an increase in energy and some improvement in muscle development.
Oh, thanks.
I can't tell ya.
I've been dreaming about the day I could get out in the yard and toss a football with my son, like my dad did with me.
Well, hopefully that'll happen.
Right now, why don't you just let him get some rest? See, Mr.
Adams, as part of our evaluation, we run a toxicology screen, and I'm happy to say that yours was normal.
I told you I don't take drugs.
However, we did find something else.
- Profound anemia.
- Anemia? It could explain your feeling faint.
Okay, I-I guess I gotta eat more steak.
[chuckles] It's actually more serious than that.
We need to transfuse you with several units of blood right away.
We also need to find out what's causing it, so I'd like to admit you for a battery of scans and tests.
Uh-uh, I've got my own doctor.
I'll make an appointment with him.
Adams, we don't want you to leave in this condition.
- You're not well.
- I feel fine.
Sean, are you sure about that? Yes, and a car ride home and sleeping in my own bed isn't gonna hurt me.
That may not be true.
I-I emphatically recommend that you take Dr.
Choi's advice.
As far as the psych evaluation goes, am I in the clear? Well, not listening to your physician isn't the greatest sign to me.
Well, you're not the only psychiatrist in Chicago.
I'll get a referral from my primary.
- Sean - Viv, we're going.
Hand me my clothes.
Please get me whatever paperwork I need to sign, so I can get out of here.
I'll be back shortly.
Something's just not right with him.
- I agree.
- But is it physical or mental? Your guess is as good as mine.
Unfortunately, we have no grounds to hold him.
I'll get the paperwork ready.
Okay, so your patient is in SVT.
What do you do? Um, cardiovert at 7 joules.
So she's back in sinus rhythm.
What now? - Check her vitals - Mm-hmm.
Establish IV access, provide fluids if her BP drops below 75 systolic.
And? The adenosine? You got a dose? Um Adenosine is scratched out.
Calculate then.
Your patient's gonna revert back to SVT.
- Come on.
- Um It's a life and death situation here.
5 milligrams of adenosine.
Dum, dum, duh-dum Dum, dum, dum, dum, dum, dum, dum It's 0.
65, not 6.
Oh [sighs] I'm sorry.
[sighs] - What happened? - He can't feel his left arm.
All right, left BP is 80 over 30.
Check the right.
Sat's at 70.
Hey, Brandon, can you squeeze my hand? [gasps] No.
No, I can't.
- Okay.
- Right arm's 150 over 100.
What's what's going on? All right, legs are cold.
We need a CT angio now! Got it! - Dad? - What is happening? Brandon's not getting blood to his left arm, but I need a picture of it to see.
It's possible that the graft we put in has become occluded.
Occlud occluded? What does that mean? The first surgery may not have worked.
So you have to do it again? It may be more complicated than that.
She's in v-fib! Paddles.
Start compressions.
- Will, I'll break her ribs.
- Charge to 200 joules.
Star compressions now! Are you sure? I - Out of my way.
- No, Will.
[valve hissing] - Are we charged? - 200 joules.
Holding the CPR.
One milligram of epi, charge to 200 again.
- 200.
- All right, clear.
Pulse is good.
Halstead decided to intubate.
You know, this woman is the reason I stayed in nursing.
My first year as an O.
nurse, I actually thought about quitting.
- You? - Oh, I had a rough time.
[chuckles] There was this, um, surgery I scrubbed on.
I think it was a vascular case.
The resident asked for a ten blade scalpel.
It slipped out of my hand, dropped in the incision.
- Oh, my God.
- It didn't hurt the patient, but that resident reamed me out.
Rowan stepped in, called him out, said everyone in the O.
deserved civility.
Bella Rowan.
Wonderful woman.
Extraordinary teacher.
Sean? Sean, oh, my God.
Oh, my God.
Uh, help, someone! Help my husband, please.
Okay, hey, I need a gurney here.
Whoa! Mr.
Adams, can you hear me? - What's wrong with him? - Unresponsive, has a pulse.
Let's get him in a room.
Bring it over here.
[whimpers] Let's transfer on my count.
Ready, one, two, three.
- [grunts] - [whimpers] - Here we go.
- All right, he's not breathing.
Get a laryngoscope and a 7.
5 ET tube.
- Sean! - Trauma 1 to prep.
He's totally flaccid.
Don't need drugs.
Monique, you start the IV.
Sean - Okay, you stand right here.
- Okay.
He's got a massive upper GI bleed.
His stomach's filling with blood.
I'm in.
April, listen to his lungs.
Good breath sounds bilaterally.
All right, hang two units of blood - and get another four ready.
- What's going on? - Why why is this happening? - I don't know, but we're gonna find out.
- [valve hissing] - Hang saline.
- Saline's up.
- All right, stay on it.
Got your page.
Rowan's latest labs.
I am so sorry.
She's in acute renal failure.
Hyperkalemic and still acidotic.
All right, we'll start her on low flow dialysis.
It should correct her electrolytes and PH.
Will I won't stand by and let her die.
Tell April to call renal.
[sighs] Graft occlusion is a possible outcome of any vascular surgery.
It's nobody's fault.
Okay, so there are two options, right? - We could either - Just let me handle this, okay? Mitch, a moment? Uh What is it? So the CT revealed that the graft I placed in Brandon's chest kinked, causing re-coarctation, or essentially a, uh A narrowing of his aorta.
Like before? I'm sorry.
So so what? We're just back at square one? Yes, but this time, things are more complicated.
Now I can repair the graft by placing a stent, and we would do that in the cath lab.
But the stent will cover the opening of his left subclavian artery.
That will cut off circulation to his left arm, meaning Brandon will lose that arm.
- Lose his arm? - Mm-hmm.
Uh, no.
No [stammers] he can't.
He can't.
It there must be something else you can do.
I'm sorry, but no.
I'm afraid this is our only viable option.
Oh, God.
Hey, look, Mitch, why don't you go be with your son, okay? We'll take him up to surgery soon.
I'm very sorry.
[sighs] Pardon me, Dr.
I know you must've had a very good reason, but you didn't present the other option, the carotid subclavian bypass.
Wouldn't that preserve Brandon's arm? Dr.
Bardovi, 20 to 30% of young patients will stroke out and possibly die when you clamp their carotid.
It's too big of a risk.
Okay, but still- It's too big of a risk.
What was that all about? Look, this boy's father I know the type.
I grew up with one.
He wants his son to be something he isn't.
He'll choose the bypass.
It's too dangerous.
But it's his decision, not yours.
I already opened Brandon up once.
I'm not gonna do it again.
I'm not gonna risk this boy's life just to save his arm.
[sighs] Huge gastric ulcer.
That's where all the blood was coming from.
Were you able to stop the bleeding? Yeah, GI cauterized it, but that's not the headline.
Sean's endoscopy shows chronic caustic esophageal erosions.
And his chest X-Ray - Pneumonitis.
- Yeah.
This is a pattern suggestive of ingesting some sort of hydrocarbon.
Isn't that in cleaning products? And lighter fluid, motor oil, gasoline.
Extremely toxic, so we must be talking about low doses over a long period of time.
So I was right.
We should be concerned he's suicidal.
Why assume he's doing this to himself? Well, what, you think someone's poisoning him? I don't know.
It's possible.
I had a case where a wife was slipping something into her husband's food.
So you think it's his wife? You know, hydrocarbons are extremely noxious, - so he would've smelled it.
- Not necessarily.
They're all over any aircraft hanger.
With constant exposure, he could be nose blind.
I don't know.
Suicide? Attempted murder? I think it might be something else altogether.
I just checked in on Dr.
I heard you ordered dialysis.
She's in renal failure.
That's the appropriate treatment.
I understand the medicine, doctor.
- Even if you dialyze her - I am.
Even if you dialyze her, she's unlikely to come off the vent.
That means she'll be bedridden.
Eventually, she'll need a tracheostomy.
You've already broken her ribs.
Now she'll have bed sores, a feeding tube.
Shouldn't quality of life be a consideration? I mean, remember that ballplayer I told you about? He was a pitcher with one arm.
He was one of the best.
All right, so, you know, be strong.
We can do this.
I mean, the important thing is that you're gonna be alive.
And healthy.
We'll figure out the rest, okay? Together.
- Mitch - Yeah.
Guys, if you can hold on for a second.
- Have a word with you? - Okay, buddy.
So, I've been thinking about Brandon's case, and there is something else we can try.
- [device whirs] - Wrong angle.
You need to go in perpendicular, or you'll stay in the cortex.
[device whirring] You're too shallow.
You need to keep on drilling until you hub the needle.
Not like that.
Who taught her how to do an IO? An orangutan? Okay.
She'll get there.
We've all gone through this.
Just take it slowly.
Go ahead.
[device whirs] There you go.
White board says carotid subclavian bypass.
It's just, I thought I presented both options to the patient's father.
As I suspected, he chose the carotid subclavian bypass.
And you're gonna do a great job, Dr.
You're an exceptional surgeon, and it is an honor to be Dr.
Bardovi, you don't have to do that.
You're a fine surgeon, and trust me, I'm a less than perfect teacher.
Adams, can I ask you, um You ever find yourself doing something that you know you shouldn't, but you just can't stop? I have no idea what you're talking about.
[chuckles] My wife would say that I I watch too much football.
[chuckles] Can I tell you my dirty little secret? I went through this phase where I would come home every night, cut my nails every night, like down to the quick.
Hm, couldn't stop.
On some level, I must've been satisfying some urge, but my hands were bleeding.
[stammers] It wasn't good.
And the point of this? The point is that I understand compulsive behavior.
You know, it's not rational.
You can't explain it.
You just you just do it.
Yeah, but eventually, like with me, your fingers bleed, or something similar.
And it just starts to To cost you too much, and you wanna stop.
I mean, you realize that it's interfering with your life, and you you just really, really wanna stop.
Sean, I think you have a compulsion, and you're tired, and you're also getting scared.
I mean, who wouldn't be scared? All that all that blood? All that vomiting? Yes.
I'm tired.
Adams, we think you're ingesting something very harmful.
Can you tell us what it is? Mr.
Adams, please, we can help you.
I'm sorry? Say again? I drank gasoline.
Is my husband crazy? Why would anyone drink gasoline? I know it's very difficult to fathom, but I'm quite sure that your husband is suffering from a psychiatric disorder known as Pica, which involves the compulsive consumption of non-nutritive, and sometimes even hazardous, substances.
For some, it's paint chips.
For others, dirt.
For your husband, it's gasoline.
Why? There's no unified theory as to the cause.
All we know is that it manifests itself as a compulsion, an irresistible urge, against one's conscious wishes.
[sighs] Can he stop? Probably not on his own, but if he'll allow us, we can help him.
We'll do whatever it takes to get him healthy.
Before we discuss the course of psychotherapy, I'd like to talk to you and your husband about repairing the physical damage.
- Of course.
- Thanks.
He could've killed himself.
Sometimes we get a win, right? Sometimes we get a win.
If you take one thing away from me today, let it be this: treat the patient, not the disease.
You haven't started.
Just finished the line.
Why? You were right.
We shouldn't do this.
What changed your mind? Treat the patient, not the disease.
Our patient wouldn't have wanted this.
April, 10 milligrams of morphine, and hang a drip, please.
Rowan I'm going to extubate you.
I promise you won't feel any pain.
I'll let you two be alone with her now.
[coughing] Okay, going to start the carotid anastomosis.
Everybody get ready.
We're going to clamp the left carotid.
Carla, tell me if you see any change on the EEG.
Peripheral cross clamp times two? - Carotid is cross-clamped.
- Brain waves look good.
Okay, eleven blade, followed by 5-0 prolene.
Let's sew this graft in quickly.
Brain waves flattening on the right.
He's impending infarct.
We only have four minutes of hypoxia before deficits occur.
Do we unclamp him? We can still call this off and take him to the cath lab.
It's safer.
Rhodes No.
This kid's not losing his arm.
Coming around the front wall now.
Left side brain's 50, right side's 70.
Bardovi, follow me.
Eyes on the field.
Rhodes, you need to get those clamps off.
Thank you, Marty, I'm almost there.
Left side's 30, right side's 50.
Okay, done.
Coming off cross clamp.
Cross clamps are off.
I've reestablished flow.
EEG is normalizing.
You have a good wave pattern.
He's good.
Nice work, Dr.
Okay, everyone, let's get set up for the stent.
- Good night.
- Good night.
How could you do this to us? - Uh, excuse me? - My husband told me.
He'll lose his pilot's license.
We'll lose everything.
I'm very sorry.
Uh, I had no choice.
I am legally obligated to report him.
It's his life.
I called the FAA.
I had to.
Every time he gets on a plane, he puts his own life and the lives of all of his passengers at risk.
I know this wasn't, um, necessarily the win that you were looking for, but at least we saved a man's life.
See you in the morning? I heard the surgery went well.
Yeah, thankfully.
[chuckles] Yeah, don't worry, I won't tell anyone.
- Tell 'em what? - Mm, that you were scared.
Oh, that's what you think, huh? Yeah.
[sighs] Man, you're definitely a Charles.
- You're very perceptive.
- Hm.
I was after that first time.
I was I was afraid.
I was afraid I was gonna lose him.
[soft exhale] I have fears of my own, you know.
- Cholera? Typhus? - [chuckles] Yeah.
And relationships.
[chuckles] There are a lot of pitfalls in dating a surgeon.
It's crazy hours, stress of the job Great case, Dr.
Very impressive.
And thanks for the vote of confidence.
Fawning women falling at your feet.
Yeah, I don't know if I can compete with all of that.
[laughs] You don't have to compete.
I'm all in.
So your sister [both laugh] Let's see, is she a red or white wine drinker? Mm, white.
Not Chardonnay.
Uh, Sauvignon Blanc.
- Will? - [sniffles] Hey.
I'm I'm so sorry for your loss.