ER s12e01 Episode Script

Cañon City

E.
R.
Previously on E.
R.
Got a letter from your dad.
Steve keeps telling him that he's got some new job in Colorado.
Sam, you've got to tell Alex the truth.
Alex! It's all gonna be okay.
E.
R.
12x01 "CAÑON CITY" - He's 12.
- When's the last time you saw him? Around 8:30.
So four and a half hours ago? Friends, relatives, anyone he might be with? We've been calling and driving around.
There's nothing.
- Any fights, school problems? - We had an argument.
I went upstairs to take a shower and get ready for bed and about an hour later, Visa called for an authorization on my card.
He'd gone to the bus station and tried to buy a ticket.
- Ticket to where? - Colorado.
- Why Colorado? - His dad is there.
What about his home situation? Is it stable? Drugs? Violence? Alex has a good home.
What about Dad, you let him know Alex might be on his way or calling? He's not that easy to get ahold of.
Why's that? He's in prison.
Alex doesn't know that his dad is in jail.
He's been asking me if he can go live with him- I'm sorry, shouldn't we be calling Amtrak or the airlines? No, they won't board a minor without parental consent.
- You got a recent photo? - This happens all the time.
Nine times out of 10, they're back home in 24 hours or less.
Alex doesn't have 24 hours.
He's diabetic.
He could be in a coma by this time tomorrow if he doesn't get his insulin.
- Sam.
Sam.
- We gotta go by Shelley's - Union Station, the park- - Sam, the car's He likes Navy Pier, maybe he went over there.
And then we'll circle back to the school, and the arcade on Lincoln- - We should be at home when he calls.
- We'll check Denny's and McDonald's.
Open the door.
- Sam, he's not- - Please, open the door.
Sam, when he calls, he'll call home.
They said we should be there.
He knows how to monitor his carbs, stay hydrated.
He's too smart.
He's stubborn and resourceful and smart.
He's not coming back.
Oh.
The day shift.
- There is a God.
- Ew.
- Hard night? - Okay.
Everybody's here.
Good.
It's 8:02.
Time for rounds.
Curtain Number 1.
- Wait.
Ray, you're on.
- Huh? You're an R-2 now, R-2s run the board.
Okay.
Well- Okay.
Curtain 1, foreign body in the eye.
Sanding his boat without eye gear.
Shard of glass under the lid.
- Corneal abrasion? - Didn't get a chance to check.
Okay.
Jane, he's yours.
Fluorescein, slit-lamp exam, home.
Curtain 3, we have an altered 19-year-old.
Drank a gallon of antifreeze.
Responding to fomepizole, waiting on psych and an ICU bed.
- Great.
Moving on.
- Whoa.
Good teaching case.
Yeah.
Take a minute and tell us all about fomepizole.
Well, it's pretty new.
Yeah? What does it do? Lowers the ethylene glycol level? Tell them how.
Increases renal excretion.
- Anyone else? - Does it inhibit alcohol dehydrogenase? I think it might prevent formation of acidic metabolites.
Get it in early and you avoid dialysis.
I'm gonna read about this and make a handout.
R-2s have to do the reading before rounds.
- How? I just got here.
- Get here early.
Teaching should be spontaneous, off-the-cuff.
Excuse me.
Is there somewhere private I can go breastfeed? We've been here three hours.
My kid needs to eat.
Yeah, yeah, there's a family room down the hallway.
Mom, I'm starving.
All the way on your left.
- How old is that kid? - He's gotta be 6.
That is a little freaky.
Sam? Hey.
- What? - It's okay.
- Did they call? - No.
It's his picture on the TV.
- How long was I asleep for? - About an hour.
All right, we gotta start calling everybody again.
We already called everybody.
They're gonna call us if- Sam.
Hi, Debbie.
Yeah.
Nope.
No, huh? Okay.
Yeah, yeah.
As soon as- Of course.
- As soon as I hear anything.
- Hi, yes.
This is Luka Kovac again.
- Hello.
- What is it? - Altered traffic collision.
- GCS, eight.
Systolic's 100.
Let's bag her.
- What's your plan, Ray? - All right.
Intubation, FAST exam and a head CT.
- Okay.
I'll be in Curtain 2.
- Dr.
Lewis? - Call me if you need me.
- I guess she trusts you.
Yeah, 20 of etomidate, 100 of sux.
Portable C-spine and chest to follow.
- Get that SonoSite ready.
Come here.
- Mind if I intubate? Might wanna observe one first.
Why do we use etomidate? - We need a sedative with a paralytic.
- No, I know that.
But isn't it true that ketamine causes less respiratory depression? Maybe.
Well, does it have a more favorable hemodynamic profile? If you're concerned about interabdominal hemorrhaging, then it- Jane, we use etomidate because it's a good drug.
- Okay, let me take a look.
- Sats up to 92.
All right, pull the handle at 45 degrees and never rock back against the teeth.
Shouldn't you give a dose of Pavulon? - Sometimes we do, yeah.
- Is sux okay in crush injuries? - Uh-huh.
Cricoid pressure.
- What about hyperkalemia? Look, never seen it happen.
The 8-0, it won't pull through.
All right.
We need a smaller tube.
Bag her.
Is sux okay in burn patients? More observation and less conversation.
We tube her and then we can chat, okay? - Seven and a half.
- Okay.
Thank you.
Sergeant Parker wouldn't tell us what this was about.
We haven't found your son yet.
Twelve thousand fliers went out.
Precincts, hospitals, state police.
We notified the folks in Colorado and we're getting some play on local television.
Please, have a seat.
We canvassed the airline ticket counters, Union Station, buses.
Nobody recognized your son.
Hey.
Thanks for coming back down.
Still nothing from Alex? No, no.
You know, I'm sorry.
Why didn't you tell us this over the phone? Why did you want us to come down here? We got a report of an unidentified diabetic kid in a coma.
It matches your son's general description.
- Where is he? - In all likelihood, it's not him.
We're waiting for them to fax a photo, but the- They're still working on him at the hospital.
- Where is he? - Iowa.
Davenport, Iowa.
- It's 200 miles.
- I'll drive.
They'll know if it's him or not before we get there.
- If it's him, we'll be closer.
- If not, we'll be farther away.
I can't just sit at the house waiting for someone to call to tell me they've found Alex in a ditch somewhere or a Dumpster.
I can't! Okay? I can't.
Tell Dubenko the second HemoCue was 12.
1.
- Going to the O.
R.
? - FAST was positive, needs an ex-lap.
- How'd it go, Haleh? - It was a little rough.
Do you wanna give Dr.
Barnett some feedback? There wasn't much teaching.
You seemed distracted by questions from the interns.
- Well, they wouldn't shut up.
- Ray.
His frustration prevented the team from working together.
There was tension in the room.
Could have caused a delay in diagnosing a splenic lac.
- Oh, please.
- Thank you, Haleh.
Thank you.
Thanks.
What was that about? Improving your skills.
Making you a better teacher, a better leader.
Since when do nurses evaluate the Residents? Haleh's been here longer.
She knows.
I needed to treat this patient.
You also need to create a positive learning climate.
Are you torturing all the R-2s, or is it just me? Ray.
Resolving TIA? Go.
We must have missed it.
They said it's over a mile from the interstate.
We've only gone- Ah! That's it.
Hello? Anybody here? Excuse me.
There's a button.
Over there.
Hold your horses, I'm coming.
Hi, you have a boy in DKA? Security guard found him down behind Penney's at the mall, didn't have any ID.
His blood sugar was 764, pH 7.
10, GCS eight.
Ketones were positive at one to 64.
He's on IV saline, insulin and potassium.
He just started opening his eyes on command.
You just missed Dr.
Hahn.
He went home to get his digital camera so we could send a picture to Chicago.
No.
No, it wasn't him.
Right.
Thanks.
- Anything? - No, not yet.
God! Damn it, Alex! Erica's fine to stay at the apartment till we get back.
He's not coming home, Luka.
You have the keys? Where are we going? Colorado.
- No infiltrate.
- Like I said, fever without source.
- Everything okay? - Well, he doesn't have pneumonia.
- Urine? - All clear.
- Rapid strep? - No clinical indication.
Okay.
Mason, can you open up your mouth for me? - I don't like that.
- Come on, you're a big boy.
I already did it.
Okay.
Real quick, huh? Ah.
- A little bigger.
- Uh.
- Any rash? - No.
He looks good.
Can you remove his pajamas for me? - Dr.
Babinski had him in a gown.
- I don't wanna take off my clothes again.
Look, I'm sorry, but it's important.
Okay? You said we can go home.
- I want to go home.
- Mason.
- Mason.
- Okay.
- I want to go home now! Mason, come on.
- Ray? - Two seconds.
- No! - Excuse me.
Be right back.
- No! - Come on, Mason.
- No! - Come on, Mason.
One more time.
How's it going in there? Just looking for a fever source.
Babinski said there wasn't one.
You know how it is with interns.
You gotta check up on them.
But not for 20 minutes.
The interns are doctors.
You have to trust their skills.
But they were students last week, don't know what they're doing.
You're micromanaging every case.
That's not good.
We were caught up.
We've got six to be seen and 20 in the rack.
And that's my fault? I liked you better when you were the closer.
Still no service.
We're about 30 miles from Omaha, so we'll probably get service soon.
- Where in Colorado? - Huh? Where's Steve? Cañon City.
- Where's that? - In the mountains somewhere, I think.
Never been.
What? Colorado.
Always wanted to go.
I hear it's beautiful.
Yeah.
What were you and Alex fighting about? Last night, before he left? The usual.
Me? Us.
I should have just told him the truth.
- Well, he knew we were having trouble.
- No.
The truth about his father.
After the Attending leaves you alone in Trauma, you'll be critiqued by a nurse.
That's weird.
Even if the patient's crashing, make nice with the newbies or you'll be dinged.
Ray, can I give another four of morphine to McKenzie? - You think he needs it? - No, I just want him to stop breathing.
Fine.
You're responsible for everything the intern does but question the history, they get testy on you.
- Sounds like you had a great day.
- Yeah.
You ready, Neela? Tonight's all about you and me.
- And me.
Teddy Marsh, new intern.
- Hello.
First shift.
An overnight.
Awesome.
This is Neela.
She's the R-2.
She's in charge.
Your mission, clear that board by morning.
I'm so screwed.
Antifreeze overdose has been here all night waiting on ICU.
Let's step it up.
The day shift wants to get out of here.
Fomepizole's an alcohol dehydrogenase inhibitor.
You'll be fine.
- What? - Neela, you're running rounds.
Let's start.
It's about nine hours to Denver.
I think we can make it by dawn.
- You try to sleep.
I'll drive.
- No, I'm okay.
No, no.
I'm awake.
I'm not sure I will be in the next four hours.
Shoot.
My cell-phone battery's almost dead.
I should have brought my charger.
Hey, Luka.
Thank you.
The calculated osmolality is approximated by multiplying the sodium concentration by two and adding glucose divided by 18 and the BUN, over 2.
8.
Anyone have the numbers handy? That's okay.
We'll make some up.
Let's say he's measured- What does this have to do with a fractured rib? Absolutely nothing.
- I have a date.
- Go.
We could be here all night.
- Thank you.
- Divided by 2.
8.
Twenty minutes and we're only on the second patient.
Stay focused on the clinically relevant teaching points.
It is.
There's an osmolar gap.
- Interns need to know what that means.
- Not right now.
Stab wound.
Need some help here.
Neela, take it with Marsh.
Pratt, Morris, finish running the board.
- Ready? - My first trauma as a doc.
All right.
Single stab to the right chest, agonal resps, sats 84 on 15 liters.
All right, Trauma 1, let's go.
Now enter the thoracic cavity through the intercostal.
Okay.
I felt a pop.
Okay, insert finger, feel lung tissue, pass the tube on a curved clamp.
Pretty cool.
My first night, my first chest tube.
The key is to avoid the neurovascular bundle at the inferior margin of the rib.
The tube won't pass.
All right, let me try.
I can't find the tract.
Sometimes you need to check again with a finger.
There is no tract.
Did you enter the thoracic cavity? I thought I did.
Did you feel lung tissue? It was warm and soft.
Lung tissue expands and contracts with ventilation.
Right.
Now we're into the pleura.
I'm sorry.
I thought I was in.
- I'll do better next time.
- How you doing? Finishing up a chest tube.
Can you start a central line? I got a cue ball versus cheek to sew up.
Trauma patient takes priority.
0-silk.
Pulse is 98, BP is stable, what's the big deal? My guy needs a three-layer closure on a complex stellate facial lac.
- That could take two hours.
- Yeah.
Let Plastics do it.
Someone needs to keep an eye on the board.
Don't worry.
I told the nurses to send off labs and x-rays on everyone.
- Morris! - Looks like everything's under control.
- Is that a vertical mattress? - No, it's horizontal.
What are you doing? Bugs.
It's difficult to see.
Where are we? We passed Grand Island about an hour ago.
We should get to a phone, call Chicago.
Okay.
What time is it? One-thirty.
I was dreaming about Alex.
He was 2 or 3.
And I needed a bathing suit so I was looking through the racks at some department store.
And when I looked back, Alex was gone.
He just vanished.
I guess you don't have to be Freud to figure that one out.
I lost my son at the ocean.
Daniella didn't want me to take him, but I insisted.
I was mad that she didn't trust me, so We had a big fight, and she let us go.
What happened? It was a very hot day, so everyone had come to the beach.
You have beaches in Croatia? Beautiful beaches.
Miles of them.
Anyway, so we found about an inch of sand that wasn't already taken, and we went down to the water.
He wanted to build a sand castle so I went back up to pick up his little shovel and bucket.
And when I came back, he was gone.
I looked everywhere ran up and down the beach to the shops by the road, into the water.
I couldn't find him.
How long was he missing? Two hours.
Where was he? Some boy had a dog.
The police found him wandering.
He knew his name, so they called our house and Daniella answered.
When I got home, he was sitting in a bathtub with his sister having a wonderful time.
I went to the kitchen and I cried by the sink, with the water running.
What was his name? Marco.
Alex is gonna be all right, Sam.
We're gonna find him and he's gonna be all right.
It's 3 a.
m.
Shouldn't this be slowing down by now? You've got a dark cloud, Neela.
Always have.
Twelve more out there triaging as we speak.
Neurosurg is coming to see the subdural, he'll need a unit bed.
I'm gonna lie down for a couple hours.
Cool? We've got three intubated patients and a full board.
You are more than capable of managing whatever comes in.
What? That's the fun of being the big R-2.
You get to be queen of the night shift.
Don't wanna be.
I wanna get the board cleared before day shift comes.
Can I get a copy of your schedule? I'm trying to avoid nights that you're on.
Are you going to bed and leaving me alone with this mess? - You're not alone.
You have him.
- Busy? I wanna present my guy.
Wake me only if it's really, really important.
- He's going to bed? - Yup.
It's you and me against the world.
Chuny had me correct your fentanyl order.
It's micrograms, not milligrams.
Oh, God.
That could have led to a really serious mistake.
- It was caught in time, no harm done.
- I'm so sorry.
Thanks for fixing it.
It's okay.
You gotta learn somehow.
What you got? A 37-year-old with a deltoid abscess.
Never done an I&D, thought you might wanna supervise me.
- Any other history? - Chronic IV drug use, that's about it.
Physical? Four-by-five fluctuant lesion on the lateral aspect of the upper arm.
Remainder of the exam was entirely normal.
Hey, doc.
You ready to slice open this bad boy? This is Dr.
Rasgotra.
She's my supervisor.
Just wanna take a quick listen.
It's so satisfying when you guys cut it open and all that pus comes pouring out.
Ten blade, saline, swabs, packing gauze.
Anything else? - Mr? - Kingsley.
We'll be back in a minute.
Okay? - Did you listen to his heart? - Of course I did.
So when you said his exam was entirely normal were you just forgetting to mention his murmur? - He has a murmur? - Four over six at the left sternal border.
- He has a thrill.
It's not subtle.
- Wow.
Big miss.
I'll listen again.
You can't miss a murmur in an IV drug user.
Could be endocarditis.
He needs an echo and antibiotics before the I&D.
I heard you were smart, but I had no idea you were such an awesome teacher.
Thanks for saving my ass.
What was that? I don't know.
Oh, God.
Wait here.
What is it? A deer, I think.
Is it dead? No.
I don't think so.
I don't know.
You folks need help? - I didn't- I didn't see it.
- Antelope.
Did a real number to your car.
- You both all right? - Yeah.
I got a rifle in the truck.
- Sam.
- We gotta keep going.
Sam, the car's wrecked.
The radiator's leaking.
The windshield's shattered.
You won't be able to see.
Come on.
Come on! Our syphilis guy's had over 50 partners in the last 90 days.
Wants to know if they can come for treatment.
As long as they wait till sunrise.
Pen G, 2.
4 million units IM.
Neela! Your COPD'er isn't looking so good.
Sats dropped to 87 on room air.
Can hardly catch my breath.
He was fine when I saw him, he wasn't wheezing.
You can't wheeze if you're not moving air.
We'll give you medicine to help.
Albuterol, 5 migs with 500 of Atrovent.
Sure that's a good idea? His theophylline's 53, he's throwing PVCs.
What? You didn't bother mentioning a toxic theophylline level? I didn't know.
I hadn't checked.
Didn't think we'd have the level back till tomorrow.
Breathing's been bad.
I took some extra pills.
A hundred of lidocaine and move him to Trauma.
Hold off on the albuterol until we stabilize his arrhythmia.
You got it.
We'll be right back, Mr.
Canberra.
Whoa, you were great in there.
You really took control.
- Teddy, listen- - I'm sorry about the theophylline thing.
- I'll have to thank Chuny for fixing it- - Just listen, okay? You wanna know a secret? You don't have to be that smart to be a good doctor.
You just have to be thorough, systematic and meticulous.
- I'm trying.
- Not hard enough.
You've missed glaring physical findings, overlooked critical labs and I've been correcting your med orders all night.
It's my first shift.
I realize that, but you're responsible for real people here and I can't watch your every move.
I know that.
And I wanna thank you- And your attitude It's just so contrite and appreciative.
It's just weird.
I- I guess I just don't get it.
- Wait- - I'm getting some coffee.
Need anything? Teddy, wait! We'll do a head-to-toe H & P together.
Might help identify where some of your deficiencies are.
Bollocks.
They're gonna send a truck to tow the car in.
Did you call Chicago? The guy inside gets off at 7.
Offered us a ride back to North Platte.
From there, we can catch a bus to Denver, or maybe rent a car.
North Platte's an hour east? What are you doing? Sam? Sam.
Sam! - What are you doing? - What does it look like? - You gonna hitchhike? - He's been off his insulin for two days.
He's out there dying.
Hey! - How'd it go? - Not well.
Will you take a look at this board? It's not 8 a.
m.
and the day sucks.
- Morning.
- You should've called me.
I hate leaving a mess for the day shift.
Most of them are waiting for beds.
This is ridiculous.
Antifreeze overdose has been here since yesterday morning.
Case in point.
What have you been doing all night? Taking a bubble bath and eating bonbons.
- Lewis will make you run the board.
- I know.
Just remember that fomepizole's an alcohol dehydrogenase inhibitor.
Hey, come on, come on.
Present this thing already.
Okay, let's get the night shift home.
You are? - Lana Clemons, new intern.
- You've met Dr.
Sackowitz.
Pratt's the senior and Dr.
Lewis is our Attending.
- Neela, where's your intern? - Sent him home a bit early.
Okay, day shift, let's go.
Curtain Number 1, 22-year-old with myelomeningocele.
What's that? - Spina bifida? - Excellent.
Most common congenital neurologic deficit compatible with life.
How does it happen? Neural tube doesn't close in utero.
Uh-huh.
Most likely due to an interaction of genetic and environmental factors.
Ladies, remember to take your folate.
On to why the patient is here.
Rule out shunt obstruction, common ER complaint.
- What's your approach? - Shunt series? - Before that? - Tap the reservoir.
Guys.
Before you do anything? Take a history.
Classic symptoms of shunt obstruction: headache, nausea, vomiting, lethargy.
I'm like a bad trailer-park version of myself.
What are you doing here, Luka? Sam, I care about Alex.
But you can't replace his father.
I know that.
I'm just not ready for this to be all there is in my life.
I can't bring your kids back.
I have a child of my own, and if it's a choice between you and Alex I am always going to choose Alex.
- I'm not asking you to choose.
- Of course you are.
I don't want what happened to my family to be the end of my story.
I was a good father.
I can be a good father again.
And what if it's not what I want? Why don't you wanna have children with me? It's not about you.
I don't wanna have any more kids.
I'm done.
I want my life back.
They can stop the run, but the secondary is suspect, Champ or no Champ.
I tell you what, they make the playoffs again, Colts will eat them up.
My brother and I got tickets.
Raiders.
Should be able to beat up on those jokers.
What's this idiot doing? You wanna ticket him? - Hang on.
I'll be right back.
- What do you got? Alex Taggart? Hey.
Alex? Are you Alex Taggart? - I'm Samantha Taggart.
- Dr.
Collins.
How is he? He was lethargic when they brought him in here.
Glucose was 375.
It's not too critical.
After a little insulin and saline, he's doing much better.
Can you give us a minute, please? Damn it, Alex.
I'm okay.
I drank lots of water.
- You were lucky.
- I know how to monitor my sugar.
You're 12 years old and diabetic.
What the hell are you thinking? I couldn't find him.
What? Dad.
I looked in the phone books, I called Information a bunch of different rafting companies.
He's not here.
How we doing? I'm losing the battle, and we're knee-deep in triage.
- Well, I'm going as fast as I can.
- More than I can say for your interns.
Well, say no more.
- Dr.
Sackowitz.
- Four-centimeter scalp lac.
After copious irrigation I'm using a 4-0 nylon interrupted, the wound's edges are- Abby.
Cosmetic repair is not an issue at the scalp.
- I've never used a skin stapler.
- You'll do it next time.
Just point and shoot.
Grab another two patients.
There's a guy with abdominal pain in distress.
I sent off a CBC, Chem-20, ordered an abdominal series and a Surgical consult.
- Hello.
George, how are you feeling? - I can't get comfortable.
Okay, tell me, does it feel worse when I do this? Okay.
All right.
You have a kidney stone.
- How'd you know that? - I just do.
- Four plus blood.
- Okay, 30 of IV Toradol and 10 of MS.
Get a CT urogram and cancel all the other orders.
- Got it.
- Ten minutes, you'll be feeling no pain.
- Thank you.
- Should I see if the analgesics take effect? No, you should pick up another chart.
You sure? Because you don't have to.
I'm sorry, Alex.
I wish that this wasn't your life.
I can't tell you how much I wish that.
It's okay, Mom.
I wanna go.
Here? Here? How about here? - Okay, 3 cc's, 1 percent lidocaine.
- Lidocaine? You have a knot in your muscle, which this shot should help.
Okay.
All right.
Be right back.
Okay.
Right-lower-quadrant tenderness, low-grade fever.
- No white count, anorexia or rebound.
All right.
Can you stand up for me? - Do you think it's appendicitis? I'll tell you in a minute.
Okay.
Can you do this? - Yeah.
- Let's see.
Can you do it again? Okay.
Excellent.
It's not an appy.
Clear liquids, recheck in the a.
m.
- How's your headache? - Completely gone.
Thank you, doctor.
I'm about to clear the rack.
Oh, yeah? If I saw all the patients myself, we wouldn't get behind.
Bet you're feeling pretty good about that.
Mm-hm.
I can't believe it took me so long to figure it out.
- You haven't.
- What? You didn't show Sackowitz how to staple.
You didn't teach Clemons about your approach to kidney stones.
You did a trigger point, a jump test and completely ignored your interns.
They were moving like slugs.
You told me to step it up.
Yeah, but your job isn't to just move the meat.
You're a Resident now.
The lady in Exam 3 spiked to 104.
Guess I better go.
Nice job on the board, Abby.
- What's the matter with her? - She's a new R-2.
- It's gonna be a long year.
- She'll catch on.
But she's not supervising, she's not teaching.
She's doing everything herself.
You know, that reminds me of someone I used to know.
How is he? Full of crap, like always.
I meant Alex.
He's okay.
He wants to spend some time alone with his dad, so There's only 10 more minutes of visiting hours, so I figure Steve can't screw him up that bad in 10 minutes.
God knows, I'm sure he'll try.
Alex is a good kid.
He'll figure it out.
Goddamn it, that bastard.
He couldn't care less about us but that little boy loves him anyway.
What the hell is right about that? - Thank you.
- For what? Coming.
Now what? Home, I guess.
I don't- Luka, you cannot possibly want this for your life.
- Want what? - This! This mess.
Isn't that something I get to decide for myself? No.
If it were just me? Maybe.
I'd better go in and check on him.
Steve's in prison.
You don't have to run anymore.
I'm not running.
I just don't want what you want.