ER 3x6

1. Oh, God.

2. The flight rotation was, like

3. the highlight of my residency.

4. You'll be fine.

5. I'll be thousands of feet in the air

6. in something shaped like a baked potato

7. with a frat beanie on it.

8. Actually, it's only hundreds of feet.

9. Oh, God!

10. Don't they have ambulances in the sticks?

11. They don't have a trauma center

12. in Boone County.

13. So if it's bad, we go.

14. How far?

15. 50, 60 Miles.

16. Oh, no. Didn't you know

17. this was a requirement for your residency?

18. What was I thinking?

19. All right, deep breath.

20. Let it out slowly.

21. Okay.

22. My knees won't move!

23. Come on. Stay low.

24. Dee McManus, Susan Lewis.

25. Hi.

26. First flight?

27. The sum of the angles

28. in a triangle equals 180 degrees, right?

29. Mm-hmm.

30. Hey, Carol.

31. Hi, uh, Doug.

32. Hi.

33. Doug Ross, this is William Litman.

34. William is my lab partner.

35. No kidding.

36. How's it going?

37. You know, I have an

38. intuitive 19th-century Euclidean mind.

39. Congratulations.

40. It's actually crippling

41. to the understanding of the geometric

42. projection of the universe.

43. I'm flunking out.

44. So, what are you working on?

45. I used to be pretty good at physics.

46. String theory. It explains

47. the multi-dimensional curvature of time and space.

48. Oh.

49. "Oh" is right.

50. So, the Riemannian manifold is N-dimensional space

51. that locally looks like M-dimensional space

52. when M is less than N.

53. Situation, one five Yankee.

54. We're at contact point five miles...

55. Susan, take a look.

56. It's beautiful.

57. W-what are you doing?

58. I'm hyperventilating.

59. Leave me alone.

60. Oh, God.

61. You should really

62. check out the view, okay?

63. 'Cause it helps you set your gyroscope.

64. What was that?

65. It was the pilot.

66. He was just

67. adjusting the rotor pitch.

68. Absolutely normal.

69. Right. Normal.

70. I got a visual on you, Air-Vac.

71. Do you read?

72. There it is.

73. Oh, man.

74. We're first on scene.

75. We're going to need

76. the o-neg and blood y's.

77. There's a field to your 5:00.

78. Oh... God.

79. Oh, God.

80. Oh, oh, God.

81. Oh, God.

82. Stay low and watch the tail rotor.

83. We got five victims.

84. A truck and a van hit head-on.

85. Two ejected, three are trapped.

86. Where's fire response?

87. Two engines and an ambulance are en route.

88. ETA?

89. 30 Minutes. They're all volunteer out here.

90. We'll triage first. Susan, you check the car.

91. It's all right, sweetie.

92. Oh, my God!

93. It's okay.

94. Please get us out of this car!

95. Okay.

96. Yes, I'm still holding for authorization.

97. Hello?

98. So, Dallas by three, you think?

99. ER, Hold on.

100. I don't think, Bubba. I know.

101. ICU's got no beds until 1999.

102. And they're sending us two vents.

103. Terrific.

104. Way to go, Mr. Gomez. Good job.

105. Chuny, we need more ivacs in three.

106. Patrick Brazil, Metastatic prostate cancer.

107. Cough, fever, two months progressive weakness.

108. BP 150/70.

109. Gave 300cc's of saline.

110. He's a no-code.

111. Inn's full. Exam four.

112. I've been Mr. B's caretaker for 22 years.

113. He wants to be cryogenically preserved

114. when he deanimates.

115. He wants to what?

116. Be put on ice when he croaks.

117. Frozen? Like a Popsicle.

118. He's been waiting eight years

119. to join Mrs. B.

120. In their suspension capsule.

121. Easy, now. One, two, three.

122. His wife's been frozen for eight years?

123. Yes, it was their 50th-anniversary present

124. to each other.

125. Faint pulse, poor respiratory effort.

126. They want to be preserved together so that they

127. can come back in the future

128. just like those dinosaurs in that movie.

129. Isn't it romantic?

130. Let's hang a Dobutamine drip,

131. start at ten mikes per kilo

132. and titrate to a systolic of 100.

133. Settle down, Mr. Sotcheck.

134. Rescue 116's bringing in a rule-out MI.

135. We're swamped.

136. Who's covering Haleh's vacation shift?

137. Got a float coming at 9:00.

138. The last nurse who floated down

139. here hid in the bathroom all day.

140. Who is it?

141. Sterling, from Med-surg West.

142. Rhonda Sterling?

143. Yeah. What's wrong with her?

144. She's a floor nurse.

145. Oh, come on, guys. Give her a chance.

146. I'm not baby-sitting her.

147. Me, neither.

148. Fire's out!

149. What's your name?

150. Gail. She's only ten days old.

151. Is she all right?

152. She's moving and crying.

153. Those are good signs.

154. I'm Dr. Lewis.

155. What's your name?

156. Zach.

157. Uh-huh.

158. Gail, does your neck hurt?

159. Is he all right? Gail?

160. Please help him.

161. Get a c-collar on her.

162. Sir? Sir, can you hear me?

163. That's brain matter.

164. Guy's a goner.

165. Let's get him on oxygen.

166. Where, Zach? Your neck?

167. No. No!

168. Does this hurt?

169. David? David!

170. Where's my husband?

171. Gail, where are you hurt?

172. My... my right leg and my side.

173. David, please!

174. Dr. Greene's working on him.

175. My husband's a doctor.

176. He has to check on the children.

177. Susan!

178. He's a pediatrician.

179. Susan!

180. Go. I'll stand by.

181. Okay. I'm going to go check on your husband.

182. I'll be right back.

183. The trucker's gone.

184. I need you over here.

185. He's still moving.

186. He's pulseless, with massive head trauma.

187. I've got a tension hemo-pneumo that we can save.

188. Needle him, left side.

189. He's decompressing.

190. 32 French.

191. This guy's a pediatrician.

192. Really?

193. Yep. His family's in the van...

194. Wife and newborn baby girl.

195. Both stable.

196. There's a boy about eight years old...

197. Leforte two facial fracture.

198. I'm worried about his airway.

199. I'm in. Hook it up to the Foley bag.

200. He's hemorrhaging.

201. Grab two units o-neg

202. out of the cooler. Okay.

203. I'll start a line.

204. Please! What about my baby?

205. Gail, we're getting you out.

206. Hang in there.

207. Yeah, I'm still holding.

208. Hey, you like Green Bay, minus seven, over Washington?

209. I thought the World Series was over. Excuse me.

210. Hang on one second.

211. Please don't tell!

212. Please don't tell! Mommy!

213. Where do you want him?

214. Don't tell my mom, please!

215. Curtain area three, end of the hall.

216. Don't tell her! Don't tell her!

217. Don't tell her, please!

218. No! Don't tell her!

219. Uh...

220. Carol Hathaway.

221. Carol...

222. Hi.

223. I was pulled off my ward and assigned down here.

224. Rhonda, right?

225. What patient do you want me to take?

226. Well, actually

227. we share patients here.

228. Let me show you.

229. Over here are the patients that are waiting to be seen.

230. Nursing orders are flagged and put over here.

231. So, when you're going to have a...

232. I'll take Mr. Washington.

233. Where is Curtain Area Three?

234. There.

235. Thank you.

236. Secure his head.

237. All right, we need to start a second line.

238. Got it right here.

239. Dr. Lewis, the boy stopped breathing.

240. Oh, my God!

241. Go, go, go.

242. Watch his c-spine.

243. Keep in-line traction.

244. You're in the way.

245. Uh... there's too much blood.

246. I need suction.

247. 6.0 Tube.

248. Another 6.0.

249. That was it.

250. Damn it.

251. Okay... 5.5.

252. Mark, I need your help!

253. Get him on the chopper.

254. David!

255. We're taking care of him, Gail.

256. Please don't let him die!

257. I can't see. Turn it up.

258. It is up.

259. There's better control in the chopper.

260. Let's bag him and move him.

261. Ready?

262. One, two, three.

263. Doctor, I need you to start this I.V.

264. Okay.

265. Go on. I'll check it out. Thanks.

266. What's up?

267. She needs an I.V. I tried and missed.

268. Oh, usually we try a few times

269. before we call a doc... Especially an intern.

270. Up in Med-Surg, we call the doctor

271. when we miss.

272. All right, I'll do it.

273. Mrs. Fesmire needs 20 of KCL in her I.V. in Three.

274. Why don't you go do that?

275. Where's the potassium?

276. It's in the med room under "P."

277. I can see the vocal cords.

278. I'm in.

279. I'll be right back.

280. Susan!

281. All right, Fred. Fire it up.

282. Susan!

283. How much longer?

284. 20, 30 Minutes.

285. Gail, we're taking your son and your husband

286. to County General Hospital by helicopter.

287. Are they all right?

288. They're stable now, but they need to go to a trauma center.

289. How will I know what's happening to them?

290. I will get word to you, Gail.

291. Oh, please! Oh please! I promise. I promise.

292. Oh, God! Oh, God!

293. Are you okay?

294. Uh... yeah.

295. It's Dr. Greene calling from the whirlybird.

296. Why hasn't Mrs. Fesmire gotten her potassium?

297. I'm on break. I'm getting to her.

298. This is County General on Beta Two. Go ahead.

299. We're incoming on Air-Vac One with two major traumas.

300. Seven-year-old boy and his dad, both multiple trauma.

301. Never mind that.

302. Grab Lydia and Chuny

303. and tell them to clear the trauma rooms.

304. Go ahead, Air-Vac One.

305. I'm going to need a vent.

306. Good-bye, Mr. B.

307. You will keep him cold until they come for him, won't you?

308. So that he could be with his wife?

309. Mm. Okay.

310. Please. Sure.

311. Thank you.

312. Should I clean out the fridge?

313. What have you got?

314. Dad's got a hemo-pneumo and a head trauma.

315. Seven-year-old had an obstructed airway.

316. He's getting shocky.

317. Good job, Susan.

318. What?

319. I said good job.

320. Draw up meds.

321. Go.

322. Watch that I.V. fluids wide open.

323. Let's get a cross-table, CBC.

324. Type and cross for four units

325. and dip a cath urine.

326. Move that.

327. Draw up a saline flush, crash cart.

328. Where is the saline?

329. BP's only 65 palp. Pulse 160. Thready

330. Whoa. He's waking up.

331. Hey, Zach. Hi. I'm Carol.

332. That tube in your throat is helping you breathe.

333. Set up for a lavage.

334. Want a gas? Yep.

335. Blood gas kit, top drawer.

336. Got it. You do that.

337. All right.

338. See if you can

339. give me a hand.

340. Okay.

341. We got a bloody tap.

342. Page Benton.

343. See if the Dad'll sign

344. a consent form for an ex-lap.

345. Put that o-neg on the rapid infuser.

346. He conscious?

347. He's responding to pain.

348. Dr. Herlihy

349. open your eyes.

350. Somebody needs to sign

351. his son's surgical consent

352. if he can't.

353. We'll do it.

354. BP's low, 70 palp.

355. Pulse ox is only 85.

356. Lydia, ask Jerry

357. to track down the number of the hospital

358. in Boone County where they're taking the mother and the baby.

359. I promised I'd let her know how they are doing.

360. Did the heart sound seem distant to you?

361. What are you thinking?

362. Tamponade?

363. Hang in there, Zach.

364. Will you hold him still?

365. He's scared to death.

366. He's got to be sedated.

367. Get him versed, one milligram I.V.

368. Where is it? Top drawer.

369. It's clotted.

370. I need that saline. Let's go.

371. Zach, we're going to to give you something

372. to help you sleep, okay?

373. It will help you sleep.

374. All right, here we go.

375. Hold him.

376. Whoa!

377. What was that? Does that hurt?

378. It hurts.

379. Are you sure

380. that's saline?

381. Oh, my God!

382. That's potassium.

383. How much went in?

384. Uh... about a quarter cc.

385. Insulin and glucose?

386. Where is it?

387. Second drawer.

388. Okay, hold on.

389. It's probably not enough to stop his heart.

390. I think we're going to be okay.

391. What do you got?

392. Got a seven-year-old

393. TC, Passenger, space intrusion

394. airway compromise at the scene, intubated.

395. Peritoneal lavage was positive.

396. BP's crashing, 60 palp.

397. Pericardiocentesis tray.

398. Go ahead.

399. I'll draw up a central line.

400. Okay.

401. Hook an alligator clip to an EKG lead.

402. Use V-1.

403. Not mine.

404. Uh, it's the patient's.

405. He's a doctor.

406. It might be his office.

407. Why don't you try dialing the number?

408. Susan, Jerry called Dwight Hospital.

409. The wife and baby haven't arrived yet.

410. Are they on their way?

411. I don't know.

412. Well, find out.

413. What do we have?

414. Blunt abdominal trauma

415. Hypotensive Intraperitoneal Hemorrhage

416. confirmed by lavage.

417. Probably his spleen.

418. Facial trauma, intubated in the field with an RSI.

419. H and H is 11, 32.

420. Type and cross four.

421. 650cc's of saline.

422. Versed on board.

423. Way to go, Carter.

424. All right, let's take him up.

425. Can I tie?

426. Where are his parents?

427. Second unit's in.

428. You've got his partner to take call?

429. Right. Okay.

430. Okay, we'll let you know.

431. 40cc's non-clotting blood...

432. Out.

433. Dr. Herlihy, you've been in an accident.

434. You're in the ER.

435. BP's back up...

436. 120/80. What do you got?

437. I'm worried about an intracranial bleed.

438. Is he stable enough for a head CT?

439. Nurse goes with him.

440. Am I on call?

441. No. You're a patient.

442. You were involved in

443. a serious traffic accident.

444. An accident?

445. Your son, Zach, has just been taken up

446. to surgery.

447. Surgery?

448. He was injured

449. in the accident.

450. Accident? What accident?

451. Get a rush on that head CT.

452. Zach, everything's going to be okay.

453. We could have killed that boy.

454. I got confused.

455. You have no business

456. working the ER.

457. You think I don't know that?

458. I want you to restock supplies

459. for the rest of the day.

460. I don't want you anywhere near my patients.

461. Yes, this is Carol Hathaway in the ER.

462. Clear a CT room, please.

463. Where's the number for chopper dispatch?

464. Mark, can I run something past you?

465. Sure.

466. I've just got a sweet old guy who died

467. and I don't know what to do

468. about his cryogenics request.

469. His what?

470. He and his wife bought a tank for two

471. so they could be frozen side-by-side when they died.

472. Where's his wife now?

473. In the tank.

474. Oh.

475. I have an 800 number

476. for a cryogenics company in California.

477. Call it.

478. Yeah. Still holding.

479. What?

480. Nothing.

481. Yeah. Yeah, page me as soon as you know.

482. Helicopter's standing by.

483. We may have to go back

484. and get the wife and the baby.

485. Okay. De Bakey.

486. 5-0 Prolene on a castro viejo.

487. Retract caudally.

488. Retractor.

489. Splenic vein's repaired.

490. What about this pancreas?

491. The tail has most of the devitalized tissue.

492. I'd resect rather than do a subtotal pancreatectomy.

493. Good. I agree. Metz.

494. How would you repair after resection?

495. Interrupted horizontal mattresses

496. and a figure eight in the pancreatic duct.

497. Go ahead. Do it. De Bakey.

498. 3-0 Silk on a needle driver.

499. Anything else to do?

500. Irrigate, run the bowel under control

501. insert a Jackson-Pratt drain

502. through a separate stab wound

503. and, uh, use cautery instead of a scalpel

504. to minimize bleeding.

505. And after that?

506. Close. Keep it simple.

507. Do exactly what you just described...

508. No more, no less.

509. Okay. All right,

510. cut the suture, three millimeters

511. no longer.

512. Irrigate, normal saline.

513. Make sure it's warm.

514. Park her in the hall

515. until we can clear an exam room.

516. Jerry, you seen Susan?

517. Yeah, she got paged to chopper duty.

518. You're kidding.

519. What's up?

520. I need ice, lots of ice.

521. Huh?

522. California cryonics said to put him on ice

523. till their local rep arrives.

524. They'd better hurry.

525. Dr. Lewis.

526. Susan!

527. Are you sure you're all right?

528. Yeah. I want to bring them in.

529. I'll go.

530. No. No, I'm fine.

531. Really? You can stay here with Herlihy.

532. No, really. I'm okay.

533. Dr. Lewis! We've got to go!

534. May I?

535. Hmm?

536. See your orders.

537. Okay.

538. John, will you take these to ICU

539. and make sure they're carried out

540. as meticulously as written?

541. Sure.

542. Peter, care to join me in a sarcoma resection?

543. Uh, yeah, yeah, I'd love to.

544. Good. Gant can cover in trauma call.

545. Scrub in in 45 minutes.

546. Don't you just love her?

547. Where's Zach?

548. Where's my husband?

549. Your husband was unconscious for quite a while.

550. He woke up confused and disoriented.

551. He has a head injury?

552. What about my son?

553. He's in surgery.

554. Don't worry, Gail. Your family's in good hands.

555. Move. Move.

556. Does this hurt?

557. Ah!

558. Yeah.

559. BP's okay. 115/65.

560. Get a c-spine, H and H, type and cross for four

561. and dip a cath urine.

562. Got a good set of lungs on her.

563. Respiratory rate's kind of high.

564. Who knows with all that crying?

565. It's 60. Pulse 160.

566. Abdomen's distended

567. but she's been taking in a lot of air.

568. Do you want a pedes surgery consult?

569. Yeah. Get a baby-gram, CBC, and a gas.

570. Hey, darling, are you hurt

571. or are you just mad at the world?

572. What'll it be?

573. Do you believe in reincarnation?

574. Sure. Why not?

575. Next life, I'm coming back

576. as Cindy Crawford.

577. Could you do us a favor?

578. A deceased patient of mine wants to be cryogenically preserved.

579. We got to freeze a dead guy.

580. You got any ice?

581. Neck looks okay.

582. CT was normal, but dad's still altered

583. so they're doing an MRI.

584. Why did they take Megan away?

585. She's next door. It's crowded in here.

586. We called upstairs. Zach's out of surgery.

587. He's going to be all right?

588. He's in ICU.

589. I'll check on him as soon as I can.

590. Oh, God. Oh, God.

591. I need my husband.

592. Please. Where...?

593. David. Please, where's David?

594. Please.

595. Her abdomen's kind of firm.

596. She swallowed a lot of air.

597. It's a tough call with a newborn.

598. What should we do?

599. All right, what is it, Gant?

600. Well, I'm not sure. Abdomen's persistently distended

601. she keeps crying and the resps are high, in the 60s

602. but the BP, pulse and color are okay.

603. Why didn't you drop an NG?

604. We considered it...

605. Stool guaiac.

606. In such a small baby?

607. Do it off the rectal thermometer.

608. You didn't do a full surgical evaluation

609. of the patient, Dr. Gant.

610. Shh, shh.

611. It's positive for blood.

612. All right, prep a cutdown tray, type and cross

613. for two units and page Keaton.

614. Where's her mother?

615. Trauma one.

616. Dr. Ross and I thought it was an equivocal exam.

617. Ross is a pediatrician.

618. If you don't know what you're doing call someone who does.

619. Hi. I'm Dr. Benton.

620. Your daughter has internal injuries

621. that's going to require an operation.

622. She-she's only ten days old.

623. It's okay.

624. Dr. Keaton will be with her.

625. And, look, she's the best

626. pediatric surgeon in Chicago.

627. Now, we need your consent

628. for what's called an exploratory laparotomy.

629. Where's my husband? I want him to sign for it.

630. Her husband's a pediatrician.

631. He can't do it right now.

632. He handles all the family medical decisions.

633. I don't know anything about this.

634. You can do this, Gail.

635. I don't know.

636. I don't know.

637. Your baby needs it.

638. Okay.

639. Okay.

640. Okay.

641. Cutdown tray.

642. Use a Volutrol.

643. We may have to transfuse.

644. Gant was on track.

645. I just talked him out of it.

646. Hang D5, quarter normal.

647. What do you think, Peter?

648. She has an acute abdomen.

649. Hi, pretty girl.

650. Vitals?

651. BP's 80/40, pulse 160

652. resps 65, temp's 101.4.

653. Pulse ox?

654. Oh, what blue, blue eyes.

655. 92 room air.

656. Oh, Teacup, that's too low.

657. Let's get her on O2, four liters by mask.

658. Did you appreciate the periumbilical redness?

659. The abdomen's a little tense.

660. No, no, I missed it.

661. Well, it's easy to miss.

662. Why a cutdown?

663. No veins.

664. 22 Angio.

665. This was a nice pickup, Peter.

666. Thank you.

667. Ah, yes.

668. There we go.

669. Wow. I couldn't see or feel a vein.

670. Well, it's just a matter of knowing where it is.

671. Let's get her a cross-table lateral

672. and check for free air. She may be perved.

673. Any thoughts on antibiotics?

674. Well, since you don't need anaerobic coverage on newborns

675. I'd go with amp and gent.

676. You've been reading.

677. Dennis, since you did the trauma assessment why don't you scrub in

678. and follow the case through.

679. Uh, Peter, let's talk to mom.

680. Good girl.

681. There you go, Mr. Brazil.

682. Shrimp cocktail time.

683. Hubert Skinner, California Cryonics.

684. Mr. Brazil.

685. Do you have some kind of I.D.?

686. It's all there.

687. Give him 10,000 units of heparin, stat.

688. I'll pack him up

689. and we'll be on our way.

690. Is he a doctor?

691. I don't think so.

692. What do we do?

693. Well, the heparin can't hurt, him being dead and all.

694. In the newborn

695. I use a transverse abdominal incision.

696. The rectus is thin, so there's less pain post-op.

697. Adson,

698. we're using a respirator, so atelectasis isn't an issue.

699. Exactly. Zap that little bleeder.

700. Cautery.

701. 15 Blade.

702. If there's a perforation

703. we should get a gush of air when I nick the peritoneum.

704. Yep, there it is.

705. She's easier to ventilate.

706. Very little bleeding.

707. Dennis, why do we want to keep bleeding to a minimum?

708. Transfusions are dangerous.

709. You can't type and cross match

710. the blood as quickly

711. because of the baby's fetal hemoglobin.

712. There it is... perfed jejunum.

713. You're teaching your interns well.

714. He's in and out.

715. MRI was normal.

716. Dr. Herlihy, do you remember my name?

717. Where's my wife and kids?

718. I'm Mark Greene.

719. Your family was involved in a traffic accident.

720. Your wife's in the ER with a tib-fib fracture.

721. Zach had facial trauma and hemoperitoneum.

722. He's out of surgery, in ICU.

723. Was it his spleen?

724. No. Pancreatic injury.

725. What about Megan?

726. Megan just went up

727. to rule out intestinal perforation.

728. Why? What happened to her?

729. She was in the accident with you.

730. What accident?

731. Dr. Herlihy, do you know my name?

732. No.

733. Should I?

734. It's okay. It's okay.

735. Gently.

736. To repair, we use a 4-0 silk interrupted. Hufnagel.

737. The field looks dry.

738. You don't need a two-layer anastomosis.

739. Cautery alone gives you hemostasis.

740. Let's irrigate.

741. Warm saline, please.

742. Dr. Keaton, Zach's abdomen is distending.

743. Any change in his vitals or pulse ox?

744. No, but he might be bleeding again.

745. Damn.

746. Peter, you think you're ready to finish alone?

747. Yeah.

748. Nothing fancy. Just close.

749. Yeah, yeah. Okay.

750. All right, people, let's go.

751. Thank you.

752. One more. Thank you.

753. His abdomen is more distended than before the surgery.

754. Has he regained consciousness?

755. No. No.

756. Four by eight.

757. Okay. Thank you.

758. All right. Completely dry.

759. What's that?

760. Oh.

761. Oh, looks like a little fibrin debris on the liver surface.

762. Should I call Dr. Keaton?

763. No, no, no. I'll clean it up.

764. Come on.

765. Come on.

766. Okay, got it.

767. All right, let's close the peritoneum first.

768. 3-0 Vicryl.

769. Mm-hmm.

770. Now...

771. Retract medially.

772. Cut.

773. Mm-hmm.

774. Good.

775. There's a little blood.

776. Where?

777. Oozing from the liver

778. where you just touched it.

779. Alright, Uh... I'll put a little pressure on it.

780. You suction.

781. Gently, okay?

782. Damn it!

783. It's still oozing.

784. All right, I don't want to close while it's bleeding.

785. I'll put a stitch in for hemostasis.

786. 4-0 Chromic on an s-h. Now, move.

787. Thank you.

788. Come on. Here we go.

789. All right.

790. Retract caudally.

791. Come on, Gant, retractor.

792. Is anesthesia standing by?

793. I called them.

794. You're right.

795. He is distended.

796. Vitals?

797. Stable. BP's 90/60.

798. Pulse is 96, pulse ox is 99%.

799. Should I clear an OR?

800. Hang on.

801. Disconnect the NG from the wall.

802. Yep.

803. Sometimes, you get an erosive gastritis.

804. Hook it back up.

805. Clots can block the NG, Causing acute dilatation.

806. Irrigate it out and crisis resolved.

807. It's just experience, Doctor.

808. She's still bleeding.

809. I can see that.

810. I'll put a gelfoam on the bleeding site

811. and you apply pressure.

812. Come on.

813. Do you want me to get Dr. Keaton?

814. No.

815. Suction.

816. All right, I'm going to oversew.

817. 2-0 Chromic on an S-H.

818. Heart rate's starting to fluctuate.

819. Give me a bolus of normal saline, 40cc's.

820. Damn it!

821. The liver's so fragile my stitch cut right through.

822. I should be getting Keaton. I'm going to take a bigger bite.

823. Gant, retract this way. I can't see.

824. Pulse ox is falling. You need to get

825. this baby off the table.

826. Bag her faster, damn it!

827. I'm getting Keaton.

828. No.

829. Go! Go!

830. You really think it'll help her

831. to see her husband like this?

832. Megan's still in surgery, Zach's in ICU.

833. And your husband just got out of X-ray.

834. He's okay?

835. His tests are normal

836. but there's still

837. memory loss.

838. Could it be permanent?

839. Probably not.

840. You can see these things in a concussion.

841. But... but it might be.

842. We'll just have to wait and see.

843. Blood loss?

844. 100cc's.

845. That's a third of her volume.

846. Damn it. What the hell did you do to her liver?

847. I just tried to peel away some fibrin debris.

848. Cut me a one centimeter square of gelfoam.

849. Move.

850. 2-0 chromic on an S-H.

851. It started to ooze. Clear!

852. You ripped away the liver capsule.

853. No way to control the bleeding.

854. I'll have to resec the left lobe.

855. Peter, handle the suction.

856. Dennis, retract distally.

857. Cautery. Crank it up to 18.

858. Pulse and BP. Are destabilizing.

859. We'll have to transfuse with unwashed o-neg.

860. 80cc's. 2-0 Chromic. Keep them coming.

861. She's bradying down. Rate's 80.

862. You've got to get out.

863. 3-0 Vicryl for the peritoneum and muscle

864. and staples for the skin.

865. David?

866. Oh, my God. David.

867. What happened to you?

868. Didn't you tell him?

869. We did, many times.

870. Zach's condition has stabilized.

871. He should wake up soon.

872. Zach?

873. It's okay. It's okay.

874. What about Megan?

875. Dr. Benton's closing right now.

876. That's wonderful news.

877. Was... was there a truck?

878. Yeah.

879. Yeah, there was a truck.

880. What on earth were you thinking?

881. I told you, there was debris.

882. And I told you not to do anything but close.

883. Look, in my judgment... I felt that...

884. I didn't ask for your judgment.

885. Perry, Dennis, set up a vent.

886. Call up respiratory and get a blood gas right away.

887. Does that say "chicken belt"?

888. Conjunctivitis.

889. I hate chart QA.

890. What?

891. Nothing.

892. Thanks for helping me in the chopper.

893. No problem.

894. Things can get really pressured in here.

895. It just isn't a place

896. for someone who isn't experienced.

897. I can't have you work here again.

898. Zach?

899. Oh, God.

900. Can I touch him?

901. Sure.

902. Zach, honey, it's Mommy.

903. I'm going to stay right here

904. until you wake up.

905. What about Megan?

906. No one from surgery's talked to you?

907. No.

908. Okay, I'll go find out what's going on.

909. Thank you.

910. Carter...

911. Why hasn't anyone been down to talk to her?

912. I don't know.

913. Benton was closing her an hour ago.

914. Blood gas is improved.

915. Not by much.

916. Um, could you excuse us, Kit, Dennis?

917. Thank you.

918. I'm sorry.

919. I should never have left you unsupervised.

920. There are nuances in neonatal surgery.

921. The liver's more friable in newborns.

922. I wanted a clean field

923. before I closed.

924. Yeah, you said that.

925. It seemed appropriate.

926. What's at issue here is that you ignored

927. my specific instructions.

928. No, I didn't ignore anything.

929. I followed standard operative procedures.

930. Look, I've done it at least a dozen times

931. in other patients.

932. This is not another patient.

933. This is an infant.

934. Outside. Now.

935. You don't know anything about pediatric surgery.

936. Look, I felt it was necessary...

937. Are you unwilling to learn from your mistakes?

938. It doesn't say in the text not to stitch a liver!

939. It isn't in the text!

940. You didn't know what the hell you were doing.

941. The second you realized you screwed up

942. you should have called me.

943. Why did I find three stitches in there?

944. Because I was trying to... I'll tell you why!

945. Because you arrogantly and blindly think you have all the answers.

946. If that baby dies, it'll be my responsibility

947. but it will be your fault.

948. Dr. Keaton, she's crashing.

949. Pulse ox is 86, heart rate's down to 45.

950. Decreased breath sounds on the right.

951. Atropine,04.

952. Sounds like a pneumothorax.

953. Chest x ray.

954. Don't need it.

955. Increased transillumination on the right side.

956. It's a pneumo.

957. Chest tube tray.

958. This is no longer

959. a teaching case. 12 French.

960. She's going to need a repeat ABG.

961. Pulse is up to 72 but it's thready.

962. Dynamap's not registering a BP.

963. Get ready with that thoraseal.

964. She's arresting! Heart rate's down to 20.

965. Damn.

966. Start CPR.

967. Epi, 1 to 10,000.4

968. Atropine,08 milligrams.

969. How's the blood gas?

970. Ph 7.3, PO2 45

971. PCO2 30 and 100% oxygen.

972. We're going to have to put her on an Ecmo bypass.

973. Kit, call the tech. Get two units O-neg to prime the system.

974. I'll cut down to the internal jugular.

975. So do we bring her back up to the OR?

976. No, we're going to bring the OR to her.

977. Dr. Greene?

978. Dr. Herlihy.

979. What time is it?

980. 8:00.

981. PM?

982. Where's my family?

983. Your wife's upstairs

984. and both the kids had laparotomies.

985. A bed opened up for you in ICU.

986. How'd they do?

987. Well, your son's out of surgery

988. in ICU.

989. I don't know about your daughter.

990. How do I find out about my daughter?

991. Well, I'll check for you.

992. Thank you, Dr. Greene.

993. Mark.

994. Mark.

995. Pedes OR called.

996. His daughter decompensated in surgery.

997. She's crashing in NICU.

998. She's still flatline.

999. Repeat.4 Of epi.

1000. Go ahead, Kit. How long has she been down?

1001. 22 Minutes.

1002. Is the ecmo circuit primed?

1003. Yes.

1004. Good. I'm ready.

1005. Venous connection first.

1006. Arterial.

1007. Turn it on.

1008. We've got a heartbeat.

1009. And a pulse.

1010. Faint.

1011. She's pinking up.

1012. Okay, let's get a repeat gas.

1013. We need to anticoagulate her.

1014. Kit, heparin, 150 units IV

1015. Start a drip at ten units an hour.

1016. How can we anticoagulate her?

1017. We have to or her blood will clot

1018. in the ecmo circuit.

1019. Yeah, but won't she bleed out?

1020. We have to hope that she doesn't.

1021. I'll dictate an operative report.

1022. Meet me in pedes ICU In five minutes.

1023. ICU?

1024. Yeah, we've got to tell the parents.

1025. Peter, how'd it go?

1026. How's the baby?

1027. Not good.

1028. Dr. Benton.

1029. You didn't sign the code sheet.

1030. Hey, we're all human.

1031. You know, we all make mistakes.

1032. Any other words of wisdom, Gant?

1033. You're a real prick, you know that?

1034. Mrs. Herlihy, this is Dr. Keaton.

1035. She's the doctor who operated on both Zach and Megan.

1036. Mrs. Herlihy, uh, Megan had a perforated intestine

1037. from the accident.

1038. When we operated to repair it

1039. there were complications.

1040. Wh-what are you saying?

1041. Well, she's in the NICU now on a device

1042. that helps her heart and lungs

1043. oxygenate her blood.

1044. There was bleeding during the operation

1045. and she went into shock.

1046. Then her lung collapsed

1047. and finally, her heart stopped

1048. but we got it started again

1049. by putting her on a bypass machine.

1050. Is she going to die?

1051. She's in extremely critical condition.

1052. It's...

1053. it is a possibility.

1054. The Lord is my shepherd.

1055. I shall not want.

1056. He makes me lie down in green pastures...

1057. He...

1058. The Lord is my shepherd, I shall not want.

1059. He makes me to lie down in green pastures.

1060. He's...

1061. Dr. Benton?

1062. I can't remember the words.