The Resident (2018) s05e10 Episode Script

Unknown Origin

1 Previously on The Resident Dr.
Bell? Here's the clamp.
Something's wrong with me, and I'm not quite sure what, - but I think it may be serious.
- Want me to examine you? The results all under the radar.
We're gonna need to set some rules.
No one here needs to know that we're related, or that you're my biological son.
- Agreed.
It's none of their business.
- Mm-hmm.
I talked to your boy.
He thinks I recommended him to Chastain.
- I did no such thing.
- I did.
You didn't just break protocol.
You broke every rule of medicine.
Are your patients just pawns to prove how smart you are? Now that you're spending more time on research and clinical trials, we need a new ER doctor.
All I know is that Nic wouldn't want you to be alone forever.
For your sake and for Gigi's, you deserve to be happy.
Hey, Marion! We are gonna go get some ice cream - if you would like to join us.
- I would love to.
Marion, I just want to say it again.
I know.
Boundaries clear.
- We both had fun.
- Yes, we did.
Conrad, it's okay.
Truth? You're not my type.
Well, okay.
Besides, I've got a mad crush on someone else.
- Someone much younger.
- Oh, ouch.
And shorter.
Like your daughter.
- Daddy? - And there she is.
She never gets up this early.
I'll be quiet.
See you later.
Daddy, you need a shirt.
Yes, I do.
You're up so early.
I wanted to pick out the perfect outfit for my trip to the aquarium.
Oh, look at that.
- Yeah? - Yeah.
Yeah, definitely thumbs up.
Get this sucker on you, okay? What are you gonna color over here? - I don't know.
- Huh? You don't know? Hmm.
Let me think.
What is that? What if I color that in there like that, with that blue? Oh, my gosh, who is that? My favorite babysitter! Hey, my love.
Are you ready to go see the fish? Yes! I will bring her back tonight, Dr.
Thanks for this.
Your purse, sweetheart.
There's some mad money in there for both of your tickets and a nice lunch.
Make sure you pick up the check.
Have fun.
- Come on.
- Bye-bye.
Your heart and lungs sound good, your blood pressure and cholesterol are both low.
You're in good shape.
But? I'll see you later, and we'll talk.
Talk here.
Let's go.
Lots of the tests aren't in yet.
I'm not gonna speculate.
You have a differential.
I know you do.
Cancer? Stroke? ALS? I thought of that one, too.
I just And I'm reassured because the lack of muscle fasciculations, - but just perhaps? - No.
Your exam isn't consistent with ALS.
This could be something simple and treatable.
- You know it's not.
- I don't know anything yet.
I'll have more information at the end of the day.
- But in the meantime - Yeah.
No, I know.
I know.
Don't operate.
Trust me, I don't want a repeat of what happened in the OR.
Bolting mid-surgery, leaving Dr.
Devi, who I'm supposed to be teaching, for God's sake.
I got to go.
Kit's new Flight Go just got activated for the first time.
Yeah, that's a big step forward for any hospital with a level-1 trauma center.
Doctors flying to emergencies EMTs can't handle.
Okay, go.
We're finished here.
- Till later today, all right? - Yup.
- I'll see you then.
- Yup, yup.
There's been an accident on I-20 involving a bus.
Multiple victims are being transported here, but one is trapped, can't be moved, and is in need of the highest level of critical care.
This is why you created the Flight Go Team, right? Listen to me.
The situation is dangerous for the victims and the rescuers.
- Save lives, but stay safe out there.
- Copy you.
Bus carrying a college women's softball team flipped over the guard rail, landed on that car.
The passengers in the car died instantly.
We got everyone out of the bus except one.
She's critical, and if we tried to move her, she won't make it.
She's pinned down with a penetrating abdominal injury.
The firefighters are trying to cut her out, but - they're running out of time.
- Top windows the only access? Yeah, it's the front of the bus.
The door's jammed shut.
We're working on opening something else up, but no luck yet.
Ah, so it's like that, huh? Pass me the stuff.
It's a good thing they called in the Go Team, 'cause this is definitely something EMTs couldn't handle.
I know what you're thinking, but the first rule of penetrating trauma never pull it out.
If we pulled that out of her, and it lacerated any vessels, she could bleed out in seconds.
I'm well aware.
Pulling it out is a risk, but we can manage that risk.
Okay, what's your plan? Go on.
You get the meds, I'll get ready to intubate.
Let's push 100 of ketamine and 150 of roc.
Keep her paralyzed and sedated so she doesn't move an inch.
Then we get her unpinned.
Okay, we got a good plan.
Help me.
We got you.
Push the meds now.
Now for the tough part.
Let's pack that with wet gauze.
And tape it.
I'm on it.
I'm here.
Give me the bag.
On my count.
Three Two, one.
Perfect timing.
There's someone else in here.
There's a gas leak under this thing.
Smoke means there's fire, too.
It's gonna blow.
Keep going.
We'll catch up.
Come on, guys.
- What's your name? - Jill.
Jill, you're gonna be okay, all right? Oh, God.
Oh, God.
Posterior elbow dislocation, possible fracture, with brachial artery compromise.
This is gonna hurt.
Take a deep breath.
Got it.
Hey, you, get out of the bus, now.
I thought I heard a noise.
It's a cat.
It must be the team mascot.
- Not exactly a bobcat.
- Run! At least you saved the cat.
Okay, that was kick-ass.
Yeah, it was all right.
Uh, Dr.
Look, I know I gave you some trouble the last time I worked with you, and I just want to let you know that Apology accepted, but you have one strike and a lot to prove, so don't forget it.
Now, I hope you have your big boy pants on because we have a very difficult case.
Hi, there.
How we doing? Temp 102.
BP 170/100.
We gave Mr.
Parker meds 40 minutes ago, and his fever hasn't budged.
Parker is my dad.
Call me Jerome.
Uh, I've had the fever for ten days.
Oh, um That's the, that's the call bell.
We're here.
I wanted to make sure it works.
Um, preliminary test results came back inconclusive.
Your chest X-ray and urine tests did not show any sign of infection.
No headache, diarrhea, stiff neck, nausea, sore throat.
Which means we can consider this a fever of unknown origin.
Unknown origin? Wait, so you have no idea what's wrong with me? Well, it's a mystery for now, but you have two motivated detectives on the case.
What we need is more information, so we're gonna run some more tests and a thorough history, and that should be the key to figuring this out, okay? Oh, God.
Where's BooBooBear? - That's his service dog.
- I have panic attacks.
Boo is the only thread that, um, keeps me from unraveling.
Your dog is tied up outside.
We don't allow animals in the ER.
No, no, wait, no.
Um, please, you don't understand.
I-I need her.
- I'm beginning to freak out.
- O-Okay.
Okay, um, I might be able to clear the dog through social work.
I'll call Winston.
Three, two, one, mark.
Two patients.
That's the limit.
We'll hitch a ride on an ambulance.
You okay? You got pretty cut up.
- Let me take a look.
- I'm fine.
That needs to be cleaned up.
Might need a stitch or two.
Are you two headed back to Chastain? I got space in the back of my rig.
Thank you for getting me off that bus.
I almost went up in flames.
I was worried about the cat.
That you didn't know existed.
Good point.
Truth is, I'm more of a dog person.
I'm a chicken guy.
- No way.
- Oh, yeah.
I'll have to hit you up for some eggs.
Oh, man.
Is that little fluff nugget here to comfort stressed out doctors? Because I am in need.
That little fluff nugget is an infection risk.
Service dogs are allowed in hospitals, Nurse Hundley.
Some areas are off-limits, but this isn't one.
- BooBooBear.
- Hey, hold on.
Lyme disease is on the differential.
Uh, Boo has no parasites, ever.
She's groomed, gets a monthly topical tick repellant, and her paws barely touch the ground.
See? I-I carry her in this pup pack.
We'll run a Lyme test anyway.
Preliminary history is unremarkable.
No contact with anyone else who was sick.
No recent travel or relevant medical issues.
Jerome is a computer programmer who works from home.
- Okay.
What next? - You build the differential using the latest test results, but be patient.
Fever of unknown origin can stump the most experienced doctors.
- What do we got? - Two adult females.
Young 20s.
Traumatic penetrating abdominal injury, evisceration.
Intubated at the scene.
And the other one? Posterior elbow dislocation with vascular compromise.
Hawkins reduced in the field.
She's C.
Repetitive questioning, possible head injury.
Is Mindy going to be okay? Easy.
We'll take care of her.
We need to page Sutton and Voss now.
Okay Hey.
Good work.
I only have a few minutes.
We have traumas from the crash site coming in.
What can we rule out? Jerome took an HIV test a week ago.
That came back negative.
Plus, he has an elevated white blood count.
So? That means we cross off all AIDS-defining illnesses, fungal infections like, uh, PJP.
What else? Lupus, R.
, probably out.
I mean, the list is brutally long.
He could have almost anything.
- Go talk to him again.
- Okay.
- About what? - Anything.
What did he have for breakfast two days ago? Do his parents have heart trouble? - Does he kiss his pet salamander? - Wait.
What does a salamander have to do with it? Well, salamanders carry salmonella, specifically osteomyelitis, which can cause a fever.
My point is, the answer is almost always in the patient history.
I'll tag in when I can.
You aren't on the Go Team.
Where'd the chopper pick you up? Atlanta General? Yeah.
They're not level-1 trauma.
Where'd you learn your field medicine? A lot of places.
How about you? Afghanistan.
Yeah, Navy corpsman.
Two tours.
Back to you.
Are you an ER doc? Trauma surgeon? I'm double board certified.
Emergency med and We're picking up a patient en route.
Female, 35, pregnant and in active labor.
Who doesn't love babies? Looks like we're in for more fun.
We're stacked up and more are incoming.
Medivac just landed.
We need a bay.
Severe abdominal lac.
She needs to be top of the list.
I saved you a trauma bay.
Follow me.
Looks like Conrad repacked the bowel on-site.
- Team did a good job.
- Free fluid in the abdomen.
Her intestines may have been lacerated by the impalement.
My name is Dr.
You've been in an accident, but we're gonna take care of you, okay? Hundley, start her on her propofol drip.
I'll get someone to book an OR.
Gonna get you down to X-ray.
Ortho and neuro page? Uh, Bay Two.
Jill Rhinehart.
Dislocated elbow and an epidural hematoma.
I thought you could use an extra hand.
Hi, Jill.
I'm Dr.
And I'm Dr.
I'm just gonna do a quick exam.
How's the arm feel? It hurts bad, really bad.
We'll get you something for the pain.
Let's get her 25 mikes of fentanyl.
Can you follow my finger? She needs an OR.
I'll join you.
Compartment syndrome.
We'll likely need to take that down with a fasciotomy.
- I'll prep her.
- Thanks.
Jill, I'm gonna need your consent for surgery.
You're in good hands with Dr.
- What a mess.
- And more coming.
- Who are you operating on? - I'm not.
It's-it's better if I stay here.
If they need a trauma surgeon, they'll page me.
All right.
- I'll see you in a bit.
- Mm-hmm.
Ten times out of ten, a person with injuries like this dies in the field.
Genius work by the Go Team.
Well, she has gross contamination of her abdomen, and she's in septic shock.
Okay, so we get in and out fast.
What's first? Identify the ligament of Treitz, run the bowel, look for vascular injuries, and cut out anything that's not viable.
Very good.
We cannot miss anything.
- If we leave contaminants - She dies.
So, we're fast, but we're meticulous.
We need to avoid ICP elevating meds and prep her for a right-sided decompressive craniotomy.
The arm looks terrible.
Life and limb, literally.
Thank you.
Thank you.
Ma'am, how far apart are your contractions? Creole.
She's Haitian.
Guess I know where you learned your field medicine.
It's her third child.
Which means it can come very quickly.
Uh, no exotic foods? Raw fish? Wild mushrooms? I have a a delicate stomach.
Um Any sexual encounters recently? I need my dog just to leave the apartment.
Definitely not hooking up with some rando.
Jerome? Uh Uh Hey, I-I need help in here.
He's burning up.
Fever 104.
We're heading into the red zone.
Orders, doctor? Dr.
Uh, let's push 30 ketorolac, get a cooling blanket on him.
- Okay.
- I'll call Dr.
Significant hemorrhage and ecchymosis, but the compression on the brain should be much less.
Now, I have to find the source.
100% compartment syndrome.
Thank goodness Conrad reduced it on-site.
Found the bleeders.
Middle meningeal artery.
Cauterizing now.
Good job, Dr.
Now, if I can just try not to nick an artery.
Won't be pretty, but when the swelling goes down, she'll have a functional arm.
Banner day for the Go Team.
Quick question.
Is Bell okay? What do you mean? He's a surgeon, not emergency.
Pulled himself from the board for the entire day.
Austin's taking a case for him in OR One.
I did not know that.
I'm not one to tattle.
Something's up.
Uh, pink bowel is healthy.
Gray we resect.
BP's dropping to the 70s.
Heart rate's 130.
Cranking pressors.
She's already had four liters of fluid.
We got a bit of luck here.
Looks like the blood vessels escaped getting torn apart.
I've got eyes on the duodenum.
First part of jejunum looks good.
Oh, no.
Bowels are leaking into the abdomen.
All right, find the healthy margins and staple them, both sides.
We're at 100 centimeters.
Now 125.
150's the limit.
She's gonna be at risk for short gut syndrome.
I'm about to clip the next segment.
Uh, s-slow down.
You can adjust to make the viable tissue a little more visible in the field.
Clip, and then you can staple, and toss.
This is my OR, thank you very much.
However, good advice is good advice.
Adjusting to get a better view.
Just under 150 centimeters total.
BP's coming up.
Backing off pressors.
Good call, Bell.
How far are we from Chastain? 20 minutes.
Ever delivered a baby before? A few.
Ever delivered one in a moving ambulance? This day just keeps getting more and more interesting.
It's one for the record books.
That was good work with your hematoma and compartment syndrome patient.
It'll be a tough recovery, but she should make it.
You checked in on us during surgery? N-No.
I-I got the report from Jessica.
Oh, by the way, is Conrad back yet? No.
- What do you want with Conrad? - He wanted to see me.
AJ mentioned that you were in his bowel trauma in OR Two.
It is my area of expertise.
Thought I could be there if they ran into the weeds.
He said you made a good call.
Uh, it was nothing.
I was superfluous.
No other procedures that need your experienced hands? I understand you've canceled your surgeries.
Yeah, I felt some flu-like symptoms, just a touch it's an abundance of caution.
Of course.
No fever.
Perhaps, when you feel up to it, you'll tell me what's really going on.
How's it going? Fever spiked to 105, and he's hypotensive.
We broadened his antibiotics, got cool saline, ice packs, acetaminophen, ketorolac.
We finally found a cooling blanket, but he's so - It's not doing a thing.
- Give me the service dog.
I'll take care of her.
- Come on.
- I think this is beyond BooBooBear's expertise.
Good girl.
How'd he get this bad this quickly? Whatever it is has been building in his system for days.
I don't like where it's going.
He was just talking to me a bit ago, but he's so altered.
I Well, he might need to be intubated.
Let's get an ABG.
- Hold on, hold on.
- Here.
Your patient.
You do it.
Oh, come on.
He-he won't settle.
This is awful.
- I can't do this.
- I'll hold him.
Got it.
I'm in.
Oh! Uh - Hold pressure, quick.
Come on.
- Yeah, yeah, yeah.
Hold pressure.
- Did you check his platelets and INR? - Of course.
160 and 1.
Not normal, but not catastrophic.
Well, they must be getting worse.
He's not clotting.
Possibly in DIC or liver failure.
He's decompensating.
I don't understand what's happening.
I can't.
We can't fix him if we don't know what's wrong, and we're running out of time.
You mean he could die? - I - Hundley.
35-year-old woman, BP steady, pulse in the 70s, but also we have a newborn male, healthy, Apgar off the charts.
Who could use labor and delivery and an OB-GYN.
She gave birth in the ambulance.
Peachtree and Seventh.
Perfect corner to come into the world.
Great deli there, too.
Hey, Conrad, listen.
We've got a 30-year-old male who came in with a week of fever.
No clear source, and he's going downhill fast, and we're nowhere closer to a diagnosis than when he first came in.
We need all the help we can get.
The antipyretics, cooling blankets, antibiotics, none of it's making him better.
He's going into shock.
We're gonna get started on norepinephrine.
Let's get him to the ICU.
Still waiting on a bed.
ICU is short-handed today.
Well, we can't keep him down here indefinitely.
I'm double board certified.
Emergency med and intensive care.
If there's anything I can do to help.
This is my patient.
I'm sorry, I don't know you.
Do you have privileges here? He has a point.
I'm vouching for her.
I'll get Kit to meet us in the ICU.
Sounds good.
Let's grab you some scrubs.
I'm Chastain's CEO, Kit Voss.
Thanks for pitching in.
I know we're desperately short-staffed here in the unit, but I have to clear you.
My name is Kincaid Sullivan.
I'm an ER doctor, and I also cover the ICU at Atlanta General.
You can call them for recommendations.
- And the state board, of course.
- Hey, Go Team.
You with us? I'm issuing you privileges on an emergency basis.
Come to my office when you have a moment, and we'll do the paperwork.
Ejection fraction's at 15%.
His heart is failing, too.
Damn it.
She's the ICU doctor.
She should run the room.
Okay, as far as I can tell, we've got a 30-year-old man, otherwise healthy, febrile, now in multisystem organ failure, with undifferentiated shock, respiratory failure, liver failure, all complicated by disseminated intravascular coagulopathy? That cover it? No urine output in the last three hours.
Add renal failure to the list.
He's nearly maxed out on norepi and vaso.
I think we should start epi next.
Agreed, but he needs more access.
We'll need to place four lines, minimum, a central, - a dialysis catheter.
- An arterial, and a PA-line.
All right, team.
Let's keep this man alive long enough to find out what's wrong with him.
What should I do? Go back to the white board and go over every detail we know.
Find answers, and be ready to report back.
My sixth surgery of the day starts in ten minutes.
Please tell me this coffee is hot.
That's why God made microwaves.
Oh, bless you.
I smell panic.
I'd rather smell a warm muffin.
What's going on? We have a patient who started out with a fever of unknown origin, and is now the sickest guy in the unit, and if we don't get a diagnosis soon, he's gonna die.
- And this is the differential? - Uh-huh.
Good luck.
I mean, how do they expect me to figure this out? I'm supposed to see what Hawkins and Pravesh don't? Wild guess, they're teaching you to look.
And you may never get an answer.
You know, by some estimates, one in four patients who die in the ICU never get properly diagnosed.
Despite our best efforts, the human body is a mystery that keeps its secrets more than a quarter of the time.
- Okay, that's-that's so - Imperfect.
What have you got? Well everything on that board and nothing at all.
It's okay.
It happens.
We'll keep looking.
But there is something you can do for your patient.
What? What's going on? A kid came in, drowning victim.
They couldn't save her.
They tried over an hour.
I need BooBooBear.
For Jerome.
I was wrong about this little pup.
She's really good at her job.
- Don't forget this.
- Thanks.
His bacterial cultures all came back negative.
We have him on broad-spectrum antibiotics and added antifungals.
Looks like the labs are negative for vasculitis and autoimmune.
What if it's something more insidious? Like an underlying malignancy leading to HLH? It's a good thought, but the ferritin isn't consistent.
- Ingestions? - Tox screen, negative.
Extended panel, negative.
This was in the dog's backpack.
- A map? - Uh-huh.
A trail map to a state park.
We've already established the dog's feet never touch the ground, and we've already - tested for Lyme.
- No, no, no.
Boo's feet didn't touch the ground, but Jerome's have.
In a Georgia state park, where there are other tick-borne diseases, not just Lyme.
I looked it up.
It could be babesiosis.
Babesiosis is rare.
So rare we never considered it.
But the symptoms fit.
It's an incredible long shot.
But possible.
So we start him on clindamycin and quinine, stat, and if the smear is positive, we start pheresis.
No matter if this is wrong or right, good work, Trevor.
How's Jerome? Blood test confirmed babesiosis.
- Wow.
- Yeah, he's responding to the meds.
His fever is still high, but it's coming down.
Incredible save.
Who was that kid? An intern? He's gonna be one of our best.
All credit to him.
And to the team.
You You ran the room.
Does every day on the job with you go like this one? Just one surprise - after another? - No, thank God.
Today was particularly intense.
And I still don't know your name.
I don't know yours, either.
Although, "Hey, you" - worked surprisingly well.
- Conrad Hawkins.
Kincaid Sullivan.
Cade to friend and foe alike.
I'd like to have a word with your foes.
No, you wouldn't.
Believe me.
I'm gonna guess you were in Haiti doing earthquake relief.
How long you been at Atlanta General? Not long.
What's with the third degree? Dr.
Pravesh, Jerome's doctor, is gonna be spending more time doing clinical trials, and we need somebody to fill his slot in the ER, so He's having a hard time finding good people.
You seem like good people.
- Is that a job offer? - No.
That's up to Dr.
Voss, our CEO.
But Pravesh already talked to her.
She's making a few calls.
She'd like to talk to you.
I don't remember much.
I guess it got bad.
It did.
Don't go hiking in the woods again without buttoning up your shirt, tucking your pants into your socks, and wearing a hat, okay? Trust me, I won't.
I might not ever leave my apartment again.
I'll be back to check on you later, okay? How does it feel? Making a diagnosis no one else could make? Feels good.
It was one of the good days.
We live for these.
You were the hero.
And I'm proud of what you did.
We have to care about our patients, Trevor, but this could've gone the other way.
If it had, it would not have been your fault.
That was odd.
What's that? She keeps on being nice to me.
Possible she has a heart? She does have a heart, Trevor.
Bigger than you know.
Fever's still high, but he's starting to feel better.
Hey, guys.
Sullivan checks out.
The folks at Atlanta General sang her praises.
Though, she's only been there a few months.
Well, where was she before that? An ER in Chicago, also briefly.
Before that, there's a two-year gap in her record.
Yeah, she said she spent some time in Haiti - doing earthquake relief.
- She told me that as well.
Well, how'd she do on her interview? We didn't talk for long, but she's obviously smart and capable.
I could see her ICU leadership was top notch.
But? She was a bit evasive, frankly.
Like she was hiding something.
Did you hire her temporarily? We need someone now.
Yes, but if we're going to make her a permanent hire, I'll need more information, considerably more.
That's odd.
Eh, she wasn't real talkative about her past with me, either, but she's a hell of a doctor.
I'd hate to lose her.
Well, you'd be amazed at what a five-minute Internet search can dig up on a person.
That's worth a look.
So, one in two people leave their social media open to the public.
Pay attention and you can find out somebody's favorite color and who they dated in high school.
All right.
Atlanta, Georgia.
No Facebook.
No Insta.
Okay, um, I'll try broadening the search.
I'll add her work history and education.
No results.
Try changing the spelling of her name.
Add that she's an ER doc.
Not a single hit.
That's weird.
Given that she's not an 80-year-old with a flip phone, yeah.
It's like someone scrubbed her entire Internet presence.
Test results.
Patient's been waiting for them all day.
I'll keep digging.
Yeah, thanks.
I've got what we need now.
I think I know what's going on.
Let's sit down.

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