The Good Doctor (2017) s02e15 Episode Script

Risk and Reward

GARCIA: I'm incising the uterine wall.
You're doing great, really great.
It's gonna be okay.
You promise? [SMOOCHES.]
- Baby's out.
- Umbilical clip.
- Please can I see my daughter? Yes.
Of course.
LIM: Sorry.
We'll need to get her into surgery.
We'll take good care of her.
Your New Chief is fashionably late.
Our Chief.
Just because I endorsed Dr.
Han to the Board doesn't mean I don't have any concerns.
Connections like Dr.
Han's come at a premium and, he assures me, will be well worth it given our current predicament with the Medical Board.
I'm not just worried about the money.
When you pay that much, they tend to think they're worth it.
Makes a person think they don't have to show up for their own welcome brunch.
CLAIRE: The baby's bowel protrusion seemed less severe on the prenatal imaging.
LIM: And it'll have to wait until we're done with her heart problem.
Now that I'm in here, her septum looks more like Swiss cheese.
Page the on-call neonatal cardiac surgeon.
That won't be necessary.
I'll scrub in.
LIM: And who are you? I'm Jackson Han.
Your new Chief of Surgery.
Echo probe, please.
And let's turn that music on.
Advance the delivery sheath.
It's in the patient's heart, Dr.
I think the music is a little distracting.
I feel the same way about operating without music.
I'll take a longer sheath, and Dr.
Murphy will need some forceps.
- Well, the neon lights Glowed red and gold - I came to hear my fortune told - 5-second rule.
I can't imagine what she saw - While gazing in her crystal ball - It was a joke.
What about her bowels? Why isn't Dr.
Lim inserting it into the abdomen right now? There is not enough room.
There's There's not enough room without increasing abdominal pressure, which would critically decrease blood flow to the bowel.
According to what hemodynamic principle Dr.
Browne? Vascular impedance blood flow is driven by the force induced by the pressure gradient.
And how do you calculate it? Uh.
Um I-I'd have to look it up.
8 times L.
divided by Pi.
Very good, Dr.
That's also why this occluder won't work.
It won't hold up against the huge pressure gradient - in her heart.
- Is there a fix? Long-term, I don't have one.
Right now, I need umbilical tape and PE tubing.
I gotta get away from here I'll never see the golden sunrise Oh, I gotta get away from her You're making a pulmonary artery band.
That should buy us some time to come up with a plan before we lose this baby.
Oh, if I leave this place alive [BEEPS.]
: Lab technician to O.
Lab technician to O.
You canceled my hernia repair? With no advance notice.
Sorry about that.
But so great to meet you.
Jackson Han.
- Neil Melendez.
- Oh, I know.
You did great work on that piggyback heart transplant.
I need a consult on Minesh Goyal.
He's the founding CEO of a company - What's his diagnosis? - He doesn't have one.
He's here for a full physical, complete diagnostic workup.
I have a long-standing Executive Wellness I'm a surgeon, not an internist.
I don't do preventative medicine.
No matter how rich the patient is.
You know what's great about rich patients? They allow us to treat poor patients.
Also, I promised Minesh the very best.
So, really, who else am I gonna get? [BEEPS.]
: Dr.
Johansen to pre-op.
Johansen to pre-op.
BP's 110 over 70.
Uh, Jackson Dr.
Han says great things about you.
That's very kind.
Normal EKG, optimal BMI, heart and lungs sound good.
Any reason you're worried enough about your health to endure an entire day of tests? I'm not worried.
Knowledge is power.
Whenever I enter a new market, I learn everything I can about the landscape consumer needs, target market, competitors.
You're aware your body isn't a business.
I know I sound like a rich lunatic with fantasies about controlling every aspect of my life.
And I guess I kind of am.
My dad was in good shape, too.
Until he dropped dead on his daily jog.
: Dr.
Markiel, please come to the mental health unit.
Markiel, please come to the mental health unit.
I'm Larry Childs.
I'd shake your hand, but, you know, no functioning immune system.
- Aaron.
- Good to meet you.
What flavor cancer do you have? [CHUCKLES.]
- What flavor? - Yeah.
Shut the front door.
Brain or spine? - Brain.
- Dude we're tumor twins.
Wh-What do they have you on? Ooh.
I hear that's intense.
My doc thought it would wipe me out.
You doing okay or longing for death? I am hanging in there.
Thank you.
I'm on my third round of temozolomide.
I've seen you in here a few times.
I've seen you in here a few times.
You kind of keep to yourself, huh? Yeah.
Well, I'm happy to introduce you around.
It's a really friendly group.
I'm okay.
Thank you.
You have a support group you go to? I do not.
Everyone needs a cancer community.
- And try to hold still.
Thank you.
For bringing us in.
This is the new Chief's patient.
It's a great opportunity.
Or it's a bunch of pointless tests.
Uh, for which I thank you.
Tell us about Dr.
He's direct, charming, very sure of himself.
Big ego.
There's nothing wrong with an ego if you can back it up.
And Dr.
Han's arterial switch technique is performed all over the world.
The tests aren't all pointless.
Way to stand firm, Park.
No, look at the monitor.
He has a tumor.
NIGEL: Percy's stable? We're naming her Persephone.
I put in a central line for nutrition.
Percy is stable right now.
We're looking for solutions to her problems.
W-Wh-Why does Why does she have all these birth defects? Diane.
We spoke to our obstetrician.
She said these defects can happen for no reason, right? That's true.
Over 50% have no known cause.
I was taking paroxetine for clinical depression.
And you went off the meds as soon as you found out you were pregnant.
She was five, six weeks at most.
My OB told me studies show antidepressants are safe to take during pregnancy.
But is that true, or is she protecting me? There was a study that associated paroxetine with these kinds of defects.
It is a possibility.
You can't tell whether it's cancerous or benign? Not until we do the biopsy, which I've scheduled for later.
We'll know what's going on by the morning.
That's good.
Maybe you'd like to call someone? A family member, a friend? I'll worry when I know it's cancer.
We could use a transcatheter route and patch each hole individually.
Her heart's the size of a walnut.
It's too small to maneuver inside.
A single large patch to close the holes would withstand the pressure.
It would also block electrical conduction, causing deadly arrhythmias.
Murphy did you tell the mom that she caused her baby's birth defect? No.
I said that her antidepressants could have.
Why did you tell her that? It's the truth.
And is that relevant to her current medical situation? No.
And how did you think that answer would make her feel? What did you think would happen? The mother is devastated.
The father is furious.
I would be, too.
LIM: Shaun is a resident.
Residents make mistakes.
Managing these parents' emotional concerns is as much a part of this job as operating on their daughter.
Social cues are hard for Shaun, but we've been working with him You should be focused on your own shortcomings, like retaining the formula for vascular impedance.
We could patch each individual hole in the heart if we cut open the ventricle Don't change the subject, Dr.
I didn't, Dr.
We were talking about the baby.
Really? You don't see a difference in the nature of your discussion before I arrived and after? We were talking about the baby.
They tried the approach you suggested at L.
The baby died a week later.
The suture line didn't hold, and the cardiac wall ruptured.
Keep looking.
Murphy, do not talk with those parents again.
I'll walk with you.
LIM: You're pretty tough on my residents.
Rebuking them in public, pimping them with questions during surgery.
Shame-based learning isn't my style.
I'll bear that in mind.
But this isn't about my treatment of "the residents.
" You're concerned about Dr.
Well, a lot of doctors have less than ideal bedside manner.
- He's young - Would you ever have said something like that to a patient as a resident? As a med student? And Murphy doesn't even understand he did anything wrong.
Shaun has hard-wired differences - in the way he perceives things.
- Exactly.
No matter how hard he works, no matter how hard you try and help him, his limitations are not going to change.
He's going to continue to inflict them on our patients all in the name of diversity and inclusion.
Shaun deserves to be here.
Once you see what he's capable of, you'll agree.
I look forward to being proven wrong.
Stay seated for 20 minutes.
Don't want you passing out in the lobby.
I know, I know.
Thank you.
This disease changed my relationships, changed my priorities, changed who I am.
Cancer is an identity.
Cancer is cellular mutation.
The people in this room are my people.
What are you 20 years old? I'm triple your age.
I don't think you're my "people.
" The last time I hung out with my law-school friends epic fail.
The fact that you use the phrase "epic fail," kind of case in point.
They're all focused on what firm they're gonna land at, and I'm all about whether Candice's leukemia is responding to her new chemo regimen.
By the way, she has this peppermint oil that is great for headaches.
Ooh, I know that look.
Here, here.
Got you, brother whether you like it or not.
Show me where we are.
That angle runs pretty close to the sacral nerve roots.
How are we doing? MELENDEZ: Tumor's abutting the iliac artery.
I'm trying not to disrupt the entire blood supply to his lower body.
Han, I'm Morgan Reznick.
I really enjoyed your article on Myotomy for infantile hypertrophic pyloric stenosis.
I appreciate the thorough research behind your sucking up.
And you are? Alex Park.
Park you were a cop.
Medicine as a second career good stuff.
Tends to bring a fresh perspective.
I hit an artery.
Take the needle.
Blood's pooling in the pelvis.
- Should we open him up? - No.
Prep the femoral artery.
Get me an art cath set.
- Pressure's dropping.
- Platinum coil.
- Nice save.
Next time, don't hit the vessel.
There is no next time.
The biopsy's too dangerous.
MELENDEZ: It is likely that it's a benign notochord cell tumor.
They look like chordomas, but they're harmless and way more common.
But you don't know.
Since we can't do the biopsy, no.
This is the problem with broad testing.
Everyone has abnormalities.
Most of them are nothing.
But when we do find them, we have to make some tough choices.
So, what exactly is my tough choice? We could remove the tumor.
This is a very risky surgery.
There's a chance of paralysis or worse you may not make it off the table.
Or you do nothing.
We'd continue to monitor it, do imaging every few weeks.
But chordomas move very quickly.
By the time any change showed up on imaging, it's most likely metastasized throughout your body.
So it probably isn't cancer, but if it is and I wait, then I'll die.
That's true.
And if I don't wait and I get the surgery, then there's a good chance I'll die.
I'm gonna need to think this over.
This is the May Annals of Neonatal Surgery.
I just finished March.
I need to read April now.
LIM: Oh, I have April, Shaun.
No, you're supposed to be reading New Approaches in Neonatal Surgery.
Claire has the British Journal of Neonatology Shaun I think maybe you should be quiet around Han for a little while.
But then how will I answer his questions? Direct questions, absolutely answer.
Otherwise, outside of the O.
, you should stay out of his way.
If someone had convinced Shaun to do that with Dr.
Melendez, he would still be on suction.
: Code blue NICU, Bed 4.
Code blue NICU, Bed 4.
O2 SATs dropped and central venous pressure shot up.
The Pulmonary Artery Band is failing.
- Eight of dopamine.
- Let's get a mask on her.
She won't last much longer.
We need other options.
I'll update the parents.
LIM: Let's get her on full cardiac support.
What have you got? Anything? This Cleveland group repaired a bowel protrusion using enterolysis.
I could cut out this excess inflammatory tissue and segment of bowel atresia.
Might make her intestines small enough to fit.
Given the size of her abdomen, I need to remove a lot of bowel.
There's a good chance she wouldn't be able to absorb food.
We'll have to find the right balance.
It's our only workable plan.
Best bet on the heart is to cut through the ventricle, like Murphy suggested.
Uh, you were concerned about the suture line holding.
Well, I still am.
Hopefully, horizontal mattress sutures will work.
They should be able to withstand the tension at the suture line.
There's still a risk of an aneurysm forming in the tissue underneath.
Lim? I have an idea I'd like to share, even though Dr.
Han didn't ask me a question.
Yeah, go ahead, Shaun.
If we go in through the atrium, we wouldn't have to worry about the suture line It's the same issue we discussed.
There's not enough room inside the baby's heart to stitch the patches in the place.
Oh, we don't need to, Dr.
We can make a plug small enough for her heart a PTFE disc with a stem like a mushroom.
Then we can insert the stem through one of the holes until the disc presses against the wall, covering all the holes.
L-Like a stopper in a bathtub.
The higher pressure on the left side of her heart would keep it in place.
We wouldn't even need to stitch.
Great idea.
We should take this to the parents.
Great idea for the heart.
But we need to tell them that our current plan for the abdominal repair is considerably more of a long shot.
And that fixing the heart takes an option off the table.
Withdrawing care.
LARRY: You can't move that card.
Excuse me? Who cheats at solitaire? You're literally only cheating yourself.
Good morning, Larry.
Is it a macho thing? Like a real man should be able to make it through without leaning on a label or the people who go with it? Embracing cancer as an identity is the last thing any one of us should be doing.
It underscores everything horrible right now.
We're in a daily battle for our lives.
I see no value in dwelling on that.
Candice is late.
Which means either her niece forgot to pick her up.
Or she got some bad news.
Or she's already dead.
- We are in a daily battle.
I'd rather have some company.
I spoke to my mother and brother, and they both think I shouldn't do the surgery.
Apparently they're more scared of your surgical skills than they are of this tumor.
And where do you stand? I need numbers.
The stats on something like this, it there are a lot of variables.
What are the odds I make it through the surgery without any complications? It's a challenging procedure.
Zero complications, I'd say 80%.
But it is very unlikely this tumor is malignant.
Give me a number.
About 5% chance it's a chordoma.
The numbers agree with your family.
So do I.
I've always been more comfortable with action than inaction.
I want you to do the surgery.
Certainty comes at a price.
DIANE: She'll be able to get off the life support machines? HAN: If everything goes well, yes.
She'll have a strong heart.
How soon can you do it? You should know we feel less confident about our plan for her bowel.
The chance of failure is quite high.
How high? LIM: I put it at 90% that the repair won't work.
Which would lead to irreversible malnutrition.
Your daughter would slowly starve to death over months.
Right now, her body is working very hard just to stay alive.
If we were to turn off the machines Turn off the machines? she would pass quickly.
And peacefully.
If the heart surgery is a success, that won't be an option.
Why not try to fix the bowel first to see if it works? We won't know if the bowel is viable until after the heart is.
We have to do the surgery.
But if this doesn't work, she could starve to death.
- It's worth the risk - It's not our risk.
It's hers.
So, instead, you're ready to give up on our daughter? I mean, it's like we're right back at the ultrasound.
We decided together to continue this pregnancy.
So this is as much my fault as it is yours.
My fault? Because of the medication? I cannot turn off that machine.
Your guilt is stopping you from admitting what we need to do.
My guilt has nothing to do with this.
- I am fighting for my daughter.
- So am I.
Since the parents can't agree, the decision about the baby's care will be made by a judge who will rely on our recommendation.
So we make the choice, but the parents live with it? Well, maybe that's a good thing.
For parents to have to decide between letting their daughter die or fighting for her life, knowing she may suffer horribly, maybe it's better if we carry that burden.
Lim? Your decision would be? Take her off life support.
The odds are stacked against the bowel repair working.
Those numbers reflect the general population of doctors.
I think Dr.
Lim and I are better than that.
We can beat the odds.
One of the things I'm not going to miss about being Chief of Surgery is being responsible for choices like this.
Han, it's your department it's your call.
GLASSMAN: You've been here all night? I've been working on a case with the new Chief of Surgery, Dr.
- How's that going? - Not very well.
He plays music in the operating room.
Oh, geez.
One of those.
And he says I need to focus on our patients' emotional needs.
Well, that's a tough assignment for you.
You ever wish you had, you know, friends, co-workers on the spectrum? Not usually.
But maybe Dr.
Han wouldn't notice me as much if I weren't the only doctor with ASD.
There's this kid in chemo, just [CHUCKLES.]
obsessed with having cancer.
It's all he talks about.
He wants to be friends with everybody in the ward.
That's very smart of him.
Speigel et Al.
showed an increase in overall survival and quality of life measures in breast cancer patients who formed social bonds with others battling the disease.
What should I do about Dr.
I don't know.
Um just do your work, be a good surgeon, be an excellent surgeon.
Over time, he'll forget about the autism.
Why would that happen? He'll see that you have the skill, you have dedication.
I have autism.
It's part of who I am.
The judge? Accepted our recommendation and ruled in favor of surgery.
Thank you, Doctor.
Okay, Percy.
Momma loves you.
I love you, Percy.
CLAIRE: Should we remove more bowel? That would take us to the ilium.
She won't gain enough weight to thrive.
Her abdominal muscles are tight from developing around an empty cavity.
But the days, girl, just slip away, oh, yeah They're cinched around her tummy like a corset.
What if we unbuttoned it? Released the muscle and increased the abdominal circumference.
Those muscles are part of her abdominal wall.
Not if we separate the layers create a plane between the skin and the muscle.
You good if Murphy and I start on the heart? Dr.
Browne, you're with me on the abdomen.
Clearing the field.
Han is on the call schedule next weekend.
Maybe Carmen will switch with me so I can cover with him? Or maybe you shouldn't try so hard.
Some of us don't have a cool former career or an easy-going, mellow demeanor.
People are never gonna crowd in my corner because I'm just so likable.
Well, you could try being nice to them.
- Well, this is easier.
- There it is.
Does it look like cancer? It's not labeled.
We're all gonna have to wait for the pathologist's report.
The artery is in the way.
We can't get at the tumor without him bleeding out.
We're gonna have to take it from the back.
- But the S1 nerve root - Is something he can live without.
Dissecting scissors.
HAN: Pledget anchor.
You'll be leaving me soon, like hell you will The owl gazing at the moon Is the feeling that I get when I'm lookin' at you The sun will rise and fade the stars The plug is in position.
You ready to test the bowel repair? And you're leaving me soon, like hell you are Let's take her off cardiac support.
Murphy, it was your idea.
You do the honors.
Abdominal pressure is normal.
The intestines are perfusing.
- HAN: Pulmonary pressure's spiking.
Prostacyclin and nitric oxide we need to get her lung pressure down.
Oxygen SATs are dropping.
No response to pulmonary vasodilators.
Now the heart's too strong.
It's overpowering her lungs.
She needs to go back on cardiac support.
Persephone won't starve to death but she will drown in her own fluids.
I'll talk to the parents.
May I come? Now that Persephone's heart is pumping at full power, her lungs are overwhelmed.
The humane thing to do is to turn off the machines and let her go.
No, I-I can't I can't give up on her.
Because you fought for her every minute since she was born.
Before that, when you were taking your medication for the depression, you were fighting to keep going so you could bring her into the world.
But letting go of Percy is not giving up on her.
It's listening to what her body is telling us.
She's hit her limit.
HAN: I want Persephone to look as good as possible for the parents.
Let's turn off cardiac support.
Let's take a minute.
Check valve.
Every time the heart contracted, blood went into the opposite side of the heart and raised lung pressure.
The hole reduced the pressure when it got too high because it allowed backflow.
But our repair of the defect blocked this backwards flow.
What if we made it so she still had a heart defect, but only when she needed it? It'd be like an unlatched door in the wall of the heart.
When the pressure gets too high on the right side, the door swings open, releasing the pressure on the lungs.
The rest of the time, it stays shut.
It should reduce lung pressure by a third.
Is that enough? It depends on how high her pulmonary vascular resistance is.
PVR is pulmonary artery pressure minus wedge pressure divided by cardiac output times 80.
CANDICE: The last time I saw my doctor, he told me I had six months to live.
He also told me I should marry an accountant and move to North Dakota.
LARRY: You don't say.
When I asked if it would help my cancer, he said no, just make the six months seem much longer.
What's the difference between a Neo-Nazi and cancer? Cancer doesn't discriminate.
I knew a guy once his Zodiac sign was Cancer.
It was really ironic how he died.
Uh, uh, how's that? He was eaten by a giant crab.
- Oh, geez.
Aaron, glioma.
Candice, leukemia.
Gin rummy or blackjack? How fast do you want to take my money? Blackjack.
Cut 'em.
Did you get it all? Yes totally clear margins.
But the only way to achieve that involved removing the nerve that controls your left foot.
Rehab and an advanced orthotic may help, but you will walk with a limp.
Final pathology will let us know if it was worth it.
I'll let you know when it comes in.
It doesn't matter anymore.
It's not like you can put the tumor back in.
Is she okay? She still has a surgery or two in her future, but, yes.
She's gonna be great.
Can I hold her? I think that would be very nice.
For both of you.
Hi, angel.
Oh, my baby.
Come hold her.
You were fighting for her, too.
- She's beautiful.
Nice work.
Thank you.
- She's beautiful.
Listen to her.
Thank you.
Minesh's biopsy results? [SIGHS.]
You don't want to know if we wasted our time almost killing him? Can't put the tumor back.
Hello, Dr.
You take the bus, too? No, Shaun.
I just wanted to talk to you.
You really do have remarkable diagnostic skills.
I have to admit, you're an asset to this hospital.
Yes, I am.
I spoke to the Residency Director of Pathology.
And we both agree you'll be a great fit there.
I'm a surgical resident.
As a pathology resident, you'll touch cases and lives across all the medical departments.
It's an opportunity for you to help patients without having to deal with patients.
Given your difficulties with communication and social cues, I think it will be a much better fit.
No, thank you.
I have been working very hard at my communication skills.
Hard work isn't enough.
You have to do the job.
I am a surgical resident.
You were.
And you're gonna do great work in pathology.
1" PLAYS.]
Oh, and when the storms come Flooding through the hall Rising to the landing Tearing pictures from the walls The currents pull us underneath That bright tide rips us out Into a tangled coral reef Where we could never drown Now that We're at the end
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