Doctor Reacts To The Pitt Season 2 Episode 7

0:00 Season two, episode seven.

0:02 Who's ready to take on another hour on shift?

0:05 Huge thank you to Odoo for sponsoring this video.

0:07 Let's get started.

0:10 A SANE is a Sexual Assault Nurse Examiner.

0:13 We do forensic exams, collect evidence,

0:15 and hand it over to the police if a report is made.

0:17 We also provide resource to support, sometimes even testimony.

0:21 You go to court?

0:22 SANEs are very valuable in a hospital, so.

0:24 Yes, and we're facing a current shortage of them

0:26 and we're actually encouraging people to sign up for this.

0:29 I believe there's like a forensic nurses association where

0:32 people can sign up for this type of accreditation.

0:35 It's extra in-person in-classroom learning,

0:38 both combined many hours in order to make

0:41 sure that you're comfortable in these types of encounters,- I'm the charge nurse

0:45 in the (indistinct) and a sexual assault nurse examiner.

0:48 This is Emma, will be assisting.

0:50 And I'm Dr.

0:50 Al-Hashimi.

0:51 I'll be checking you for any injuries that need immediate attention.

0:55 You can just call me Alana.

0:57 Um, I don't have any injuries.

0:59 The lack of injuries does not mean that no assault took place,

1:05 that no sexual assault took place.

1:07 You still move forward with the exam, and you still collect evidence and allow

1:12 the patient to decide the course of action.

1:15 You are in control now, Alana.

1:18 We're here to help and support you.

1:19 That's patient-centered care where the patient gets to decide what happens.

1:22 And remember, a big part of sexual assault is the loss of control

1:27 and the mental health repercussions that come as a result of that.

1:30 So by allowing the patient to be in charge of the medical exam,

1:34 the treatments, the reporting,

1:36 all of that is giving the patient back their power,

1:39 making them feel a bit more safe.

1:41 A lot of these kits come with many,

1:43 many tools and several steps along with instructions.

1:46 It's important to know that not every patient

1:48 needs every one of those steps to be taken.

1:51 And maybe some patients don't want some of the steps to be taken.

1:54 And again, that should be completely acceptable.

1:57 So you're having a headache and abdominal pain?

2:04 Yeah, that's right.

2:05 Okay.

2:05 And which would you say is worse?

2:07 I like that she's talking to the patient.

2:09 Even though the interpreter's off to the side.

2:12 [Interpreter] My headache was terrible last week, but now...

2:15 (static buzzes)- Hey, you're, you're breaking up.

2:18 Can you run that back again?

2:20 These types of technical glitches happen all the time.

2:22 Whether it's an internet connectivity issue,

2:24 a phone connectivity issue, it does happen.

2:27 Now my abdominal pain- (static buzzes)- God, come on, you piece of...

2:32 (hand bangs) Um...

2:36 (pages flapping) (pen scratches)- It's not enough to just say,

2:52 "We'll do a specific exam." You have to offer it as an option

2:55 to the patient because maybe the patient doesn't want to consent for this exam.

2:59 And especially in this scenario where

3:01 the communication is obviously having a breakdown,

3:03 it's even more important to provide extra information.

3:11 I'll, I'll be right back.

3:13 Sorry.

3:14 It doesn't help to whisper.

3:15 It doesn't help to raise your voice.

3:16 Again, you want to talk normal volume.

3:19 What the hell's going on?

3:21 He's barely conscious.

3:22 Jackson's just a little tired due to the sedative he was given.

3:25 You sedated him.

3:26 Oh, your son was brought in extremely agitated.

3:29 You'd be too if you were tased.

3:30 And why the did they do that?

3:32 This is bullshit.

3:34 We're taking him home.

3:35 Why don't we step out for a second?

3:37 Deescalating the situation, moving them away.

3:39 Very smart move here.

3:41 Very high level.

3:42 Because emotions are starting to creep up, and by just changing the scenario,

3:46 by changing the setting,

3:48 that already deescalates and makes everyone feel a bit more at ease.

3:52 Right now, Jackson is on an involuntary psych hold.

3:55 What?

3:55 That's not necessary.

3:56 He just needs some rest.

3:58 He's been studying for the bar exam.

4:00 We can watch him at home.

4:01 So far, all of his tests look good, but Jackson has reported hearing voices.

4:06 This could be serious.

4:07 Dr.

4:08 Jefferson will come back and speak with you.

4:10 He can explain more of what may be going on with Jackson.

4:13 [Mr.

4:13 Davis] And who is Dr.

4:14 Jefferson?

4:14 [Javadi] He's from psychiatry and he's excellent.

4:16 He can explain next steps and answer all of your questions.

4:19 Javadi, why don't you take the Davises to the family room?

4:21 Sure.

4:22 Excuse me.

4:22 [Javadi] It's just this way.

4:28 Getting worried.

4:29 What's going on with Dr.

4:30 Al-Hashimi?

4:31 Hi, this is Dr.

4:32 Baran Al-Hashimi.

4:32 I'm a patient of Dr.

4:34 Fairgraves.

4:34 I need to speak to him if he's on call.

4:39 If he's not, I'll take his next available appointment.

4:42 And please call me if he has a cancellation.

4:45 Thank you.

4:46 I wonder if she's calling for mental health support

4:49 or is this something going on with her body.

4:53 It's gonna be really noisy here and you won't get any rest.

4:55 At home, you'll be surrounded by your family and be more comfortable.

5:01 It's your choice, Roxy.

5:06 It's not that I don't wanna go home but-- Hi, Mom.

5:10 Mom.

5:11 Lena texted me to come back.

5:12 I figured I'd bring the boys.

5:14 What's going on?

5:15 Is everything okay?

5:18 police officer.

5:19 Incoming trauma.

5:21 Coming.

5:21 I'll be right back.

5:23 We'll give you a chance to talk.

5:25 See, in this scenario where there's clearly some,

5:28 again, breakdown of communication.

5:29 It seems like this is a theme of this episode.

5:31 But within the family, separating them,

5:34 and allowing someone to speak to the patient

5:36 in an unfiltered way to get a better

5:38 understanding of where this hesitation's coming from, can

5:41 help make a better decision all across the board.

5:44 Intubated neck wounds.

5:45 SATs not great.

5:45 We were diverted here.

5:46 Is there a trauma room open?

5:48 Trauma one.

5:49 What's the story?

5:49 My buddy officer Hero.

5:50 High velocity GSW.

5:52 He's getting harder to bag.

5:53 Warehouse robbery gone sideways.

5:56 One, two, three.

5:57 (person thuds)- You guys wait here, we'll take care of him.

5:59 I promise.

6:00 Dr.

6:00 Santos, let's make sure these lungs are up.

6:02 Can you see the cords?

6:03 Yeah, it was a great view but it was hard to pass after I cleared 'em.

6:06 Yeah, SATs only 85.

6:07 So the vitals are telling us a picture that there's not

6:11 enough oxygen reaching his organs because the oxygen saturation is low.

6:15 Heart rate is elevated to 110 saying that his heart is trying

6:18 to compensate for this lack of oxygenation by circulating the blood faster.

6:22 Dr.

6:22 Santos, what could cause respiratory failure in an intubated patient?

6:25 Uh, there are a lot of possibilities.

6:27 Think DOPE.

6:28 Displacement, Obstruction, Pneumothorax, Equipment failure.

6:32 Good lung sighting.

6:33 No pneumo.

6:34 It is displacement.

6:36 Okay, that is a transected trachea.

6:38 Oh, the displacement that they're talking about,

6:41 my assumption is that the ET tube is displaced because the trachea is injured.

6:47 So much so from this GSW that the ET

6:51 tube literally went through it or out of it.

6:53 So it's not in the lungs inflating the lungs.

6:56 'Cause remember the ET tube's job is to bypass the upper airway

7:01 and deliver air directly into the lungs at least more closely to the lungs.

7:05 So that if the upper airway gets blocked from vomiting,

7:08 from bleeding, you could still deliver good oxygen to the lungs.

7:12 And you have a balloon that you can inflate there,

7:14 which help protect fluid from entering the lungs that shouldn't be there.

7:18 But when there is a tracheal injury to this level, that's very hard to do.

7:23 This is a condition with very high mortality.

7:27 [Doctor] Pulling out, bag.

7:30 But if you intubate again, won't it just come straight out the wound?

7:33 So basically you need to find a way to guide the ET

7:36 tube into the lower portion of the trachea below the injury.

7:40 Either starting from the site of injury or perhaps finding a way

7:44 to guide it through that injury by either inserting something into the trachea.

7:49 I'm obviously not an ER doctor, but I'm trying to be creative here.

7:52 Okay.

7:53 And those bubbles is a sign that there is air inside the chest cavity,

7:57 which means that the airway is open, it's ruptured.

8:00 Frequently, we'll hear that as crackling underneath the skin.

8:03 But here, we're seeing it with bubbling on the liquid, on the superior surface.

8:08 Yeah, he's not moving in the air.

8:09 Okay, I need a neonatal mask.

8:11 Neonatal?

8:11 Yep.

8:14 I'm just going to finish my initial exam.

8:16 Let me know if you feel any pain.

8:18 Okay?

8:22 My legs are fine.

8:25 Uh, looks good.

8:25 I don't like using good, bad.

8:27 I like to say normal or describe the finding.

8:31 No need for X-rays or advanced imaging.

8:33 Got it.

8:34 Two areas of ecchymosis.

8:36 That means bruising.

8:37 [Doctor] Over the shoulders bilaterally.

8:38 It's great to have someone translate

8:40 in that way because sometimes in the medical field,

8:43 we use vocabulary that can make a patient

8:45 feel uncomfortable because they don't know what's going on.

8:47 (bell dings) So to have someone there to help you translate that, catch it,

8:51 make the patient feel at ease is very powerful.

8:54 Where does it hurt?

8:55 Like here under my belly button.

8:59 Okay.

8:59 Do you have any fever, vomiting, diarrhea?

9:03 No, it's, it's just a stomachache.

9:05 Okay, let's still go see the nurse and have her call me.

9:08 Okay.

9:08 But I'm still having ice cream tonight.

9:12 Let's just see how you feel later.

9:13 Good diversion for the conversation there because I'm not

9:17 gonna try and get ahead of myself with predictions.

9:19 But appendicitis can sometimes happen surrounding the umbilical cord.

9:24 Umbilical cord.

9:25 (chuckles) (static buzzes) Appendicitis can

9:28 sometimes begin surrounding the belly button,

9:30 and then start to move to the right lower quadrant,

9:33 and not immediately be present in the right lower quadrant.

9:36 So it tricks people sometimes away from the diagnosis,

9:39 when in reality, it just early onset appendicitis.

9:44 Elliot Green, 17, syncopal episode at football practice.

9:47 Look, I just got dizzy.

9:48 Okay?

9:49 So sometimes this is due to dehydration,

9:52 concussion, heat intolerance, sometimes full on heatstroke.

9:56 So it's really important to monitor these patients,

9:59 not just from a cardiac standpoint

10:00 but also from a metabolic electrolyte standpoint.

10:03 A and O.

10:04 Systolic of 95, tachy at 122.

10:06 No meds, no allergies.

10:08 So he's tachycardic,

10:09 meaning that his pulse is high and his blood pressure is low.

10:13 So that's interesting why that's happening.

10:15 How long were you at practice?

10:16 Started at 9:00.

10:17 So like four hours.

10:19 Four hours in this heat with all that gear?

10:21 Yeah, so heatstroke is obviously a leading possibility,

10:23 but also severe muscle damage from rhabdomyolysis can also occur.

10:28 Orlando, where are you going?

10:30 Home.

10:30 You take these out?

10:31 Uh, no, it takes 48 hours for you to get out of DKA.

10:33 Your blood is still full of acid.

10:35 Look, I can't add thousands of dollars to the a hundred grand I already owe.

10:38 I'm, I'm sorry, a hundred grand?

10:40 The medical debt.

10:41 My wife doesn't even know.

10:43 I'll never be able to pay it off as it is.

10:44 Where are your wife and daughter?

10:45 Maybe we can all talk.

10:47 I told them to go back to work a couple hours ago.

10:48 But the hospital is giving you a big discount.

10:50 And Mr.

10:50 Diaz, I know it's not ideal, but can you stay for at least 12 hours?

10:54 It will get you out of the danger zone.

10:56 No, I really can't.

10:58 Every minute I stay is a meal, shoes, school supplies.

11:01 Plus I have a second job I have to get to by 4:00.

11:04 The problem is if you don't take care of yourself and then you decompensate,

11:07 you make the problem worse with the financial stress becoming worse,

11:11 with the fact that you can't show up for work for a longer period of time.

11:15 So you have to really take into consideration

11:17 a lot of factors when making decisions surrounding your health.

11:20 How about this?

11:21 You stay and I'll get together everything you'll need at home.

11:24 Also a referral to Northside Christian Health Center.

11:28 Come on.

11:29 You don't work until 4:00.

11:30 It'll keep you from passing out on the job again.

11:32 She's doing a really great job encouraging him to stay,

11:34 going way above and beyond what a normal

11:36 physician would do in a scenario like this.

11:38 SATs up to 98.

11:40 Neonatal mask is working.

11:41 Santos, (indistinct).

11:43 Yeah.

11:43 What, what are you injecting?

11:44 Lido with epi.

11:45 It'll clamp off any little bleeders.

11:46 Remember, the reason they're doing lido with epi

11:49 is because the epinephrine constricts the superficial blood vessels,

11:52 which decreases the bleeding.

11:53 Allows you to have not just a better visual field,

11:56 but also less potential blood to enter into the lungs.

12:00 What is going on here?

12:01 You have a field medic assistant here?

12:03 Dr.

12:03 Abbott is an attending, and he is also a SWAT physician.

12:06 My buddy Hero here is in bad need of an airway.

12:09 Cut it right here.

12:10 We can do this.

12:11 Oh, no, I got it.

12:12 You must be Gloria's new hire.

12:13 Yes, Dr.

12:14 Al-Hashimi.

12:14 Well, I'd shake your hand but my tube is ready.

12:16 And if I could find a secure the distral trachea, we have a shot at this.

12:19 Okay, keeping an eye on the SATs.

12:20 She doesn't even know what's going on.

12:22 She just walked into the room.

12:23 (chuckles) It's like maybe we have

12:25 to learn about what's happening with the patient.

12:27 What's up now?

12:28 GSW with tracheal transaction.

12:30 Very retracted but I think I can get it.

12:33 Both lungs are up.

12:34 (device beeping)- SATs standing in the valley now.

12:38 Okay, just...

12:38 (device beeping) I got it.

12:41 I got it.

12:42 (device beeping)- Gently, gently, or we're gonna lose it.

12:47 [Doctor] Down to 89.

12:49 Oh.

12:50 I'm in, balloon up.

12:51 (device beeping)- End tidal.

12:55 Excellent wave form.

12:56 There's obviously gonna have to be a revision surgery after the fact,

12:58 or he's gonna get a trach placed that's gonna

13:01 be a little bit more long-lasting in the meantime.

13:04 Mm, while you're playing him with that airway,

13:06 you missed a big bruise in the left upper quadrant.

13:08 He was wearing body armor.

13:10 High velocity projectile doesn't have to penetrate to do damage.

13:13 Oh, my God.

13:13 Is it a spleen rupture?

13:14 That's a lot of blood loss.

13:16 Looks like a subcapsular hematoma of the spleen.

13:18 Must have been a big impact.

13:19 AR 15 muzzle velocity is 3,000 feet per second.

13:22 CT angio of the neck ASAP along with CT chest, abdomen, and pelvis.

13:26 Yep.

13:27 Just as soon as we secure this tube.

13:30 Back to "The Pitt" in just a second.

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14:33 All right, let's get back to "The Pitt."- First leaders in.

14:36 Mucus membrane's dry.

14:37 Pupils, four millimeters reactive.

14:39 Did you get tackled today?

14:41 No.

14:41 Just running drills.

14:42 Any chest pain?

14:43 Palpitations?

14:44 No.

14:45 Hands off, please.

14:45 Running the 12 lead.

14:47 How we looking?

14:48 Good.

14:49 Healthy kid.

14:50 No history, no trauma.

14:51 Differential for syncope in an adolescent.

14:54 Uh, cardiac arrhythmia from drugs-- Hyper bulimia, seizure.

14:56 Long QT, HOCM-- Sepsis.

14:58 Or brugada.

14:59 Uh, brugada is more common in Asian males.

15:01 Brugada is possible but definitely a bit of a reach

15:04 given that we don't know much about the patient.

15:07 Long odds, Earl.

15:07 Brugada prevalence is one in 20,000 in North America,

15:10 as high as one in 300 in Asia and the Middle East.

15:13 And first described in 1992, has a high incidence of sudden death

15:17 among young patients with otherwise structurally normal hearts.

15:20 Oof, wait.

15:21 Did you just say sudden death?

15:23 Temp is 102.5.

15:24 Sorry, our student doctors are discussing a rare condition you don't have.

15:27 (doctor laughs)- I just love the description there.

15:30 I just didn't drink enough water.

15:32 I overheated.

15:36 Not my type, bud.

15:37 (doctor sputters)- Other than standard labs.

15:40 What else to order?

15:41 You could make the argument for ordering a head

15:43 CT given that it's such a high-contact sport.

15:46 CK to rule out rhabdo.

15:48 To make sure you don't have any muscle breakdown from the heat.

15:51 Which we talked about earlier when he was initially brought in.

15:53 Rhabdo, the typical presentation that we talk about is a marathon

15:57 runner who hasn't trained well or perhaps just overdid it,

16:01 ultra-marathon runners.

16:02 There's severe muscle breakdown and starts

16:03 impacting the kidney from the myoglobin.

16:06 And I'll run a blue light over your skin.

16:08 Anything glows, I'll swab it with a wet then dry Q-tip.

16:14 Is that okay?

16:15 Yeah, sure.

16:19 All right.

16:19 I'm glad they're showing this just to explain how comprehensive the exam is,

16:24 and how someone who's just went through something terrible,

16:27 basically has to go through that as an additional

16:30 step through already the trauma that they experienced.

16:33 What's the story?

16:35 Neck angio is negative.

16:36 Missed the carotids.

16:37 That's really important, and I think we would've known if the carotids were

16:40 torn because the amount of bleeding would've been absolutely incredible.

16:44 And the survivability of that without treatment for as long as that's been,

16:48 would probably be near zero.

16:50 What about the belly?

16:51 Small splenic injury.

16:51 No free fluid in the abdomen.

16:53 That's great.

16:54 That's reassuring that no part of the GI

16:57 tract was harmed in a sense of penetration.

17:01 But the fact that there was blunt force trauma

17:03 to the spleen meant that there was a lot of blood loss,

17:06 and potentially some bruising that's formed.

17:08 That's why they discussed the hematoma there.

17:10 Remember, the body will work to resorb

17:12 this hematoma and this excess blood that has formed.

17:15 So that's part of the body's natural mechanism there.

17:20 Hey, you gonna be okay here.

17:22 We're getting you to surgery.

17:24 So wild.

17:25 Just put into your head how amazing healthcare is.

17:28 He was shot into his trachea.

17:31 It got severed, and they were able to pull

17:35 the trachea up and stick a tube into the severed trachea,

17:39 attach it to his skin, and allow him to survive all of this.

17:44 Medicine healthcare is amazing.

17:46 And the fact that there are people out there in our government that are

17:49 actively seeking to defund it and destroy

17:51 it is just so devastating and depressing.

17:55 SWAT?

17:55 Really?

17:56 I suck at golf.

17:58 You spend time in the Middle East?

18:00 More than I would've liked.

18:02 I worked in Kabul with Medecins Sans Frontieres,

18:04 and in 2020 at the maternity hospital.

18:07 I met the most incredible bravest doctors there.

18:11 I'm assuming she's talking about Doctors Without Borders,

18:13 who we actually supported with our Patreon where

18:16 we charge $10 a month to join our Patreon.

18:19 And every month we have a live stream,

18:20 where we together, nominate some charities,

18:23 and then vote on where all that $10 of every individual goes to.

18:27 We keep none of the money.

18:28 (cash register dings) All of it is donated.

18:30 Pretty cool.

18:30 You should join.

18:31 That's the link down below.

18:33 I wish this day never happened.

18:34 Would you like some medicine to help you relax?

18:36 You've experienced a horrific trauma.

18:42 You've been doing this a while?

18:43 Let's just say Florence Nightingale and I were roommates.

18:47 (patient gags)- (chuckles) I rest my case.

18:52 An attempt to introduce humor in such a dark situation sounds like a bad idea.

18:57 But if done appropriately, perhaps in cheesy, in a cheesy way,

19:03 perhaps in a self-deprecating way, could be a good way to break tension.

19:07 But it is so difficult to do that and can

19:11 only be done after years and years of experience,

19:13 (bell dings) as our favorite nurse here clearly shows.

19:17 Rumor has it you're still interested in booking a room with us?

19:21 I don't wanna go back home yet.

19:24 It's all set up, Rox.

19:25 You're gonna be more comfortable at home.

19:27 Oh, I changed my mind.

19:29 It is our home.

19:33 I don't, I don't want you living with my ghost.

19:36 I will happily live with your ghost.

19:38 Can we just all stop talking about ghosts, please?

19:42 Yes, I'm sorry.

19:43 Sorry, sweetie, you're right.

19:44 That situation has been ongoing for quite

19:47 a long time for them to have never asked

19:50 the question directly one-on-one with the patient

19:53 as to why she doesn't want to go home.

19:55 The longer they drag this out,

19:57 the more potential conflict that can come from this.

19:59 'Cause it seems like there's just a misunderstanding from all parties.

20:03 The healthcare workers don't understand why she doesn't wanna go home.

20:05 The husband doesn't understand.

20:07 So it seems like no one is communicating well in this scenario.

20:10 This is where a leader, hopefully Dr.

20:13 Robby, can take control of the situation,

20:15 ask to be one-on-one with the patient, have a very thorough discussion,

20:19 like he's done so well in the past, and get down to the bottom of the scenario.

20:22 Once you do, you can then make decisions on how to best serve the patient.

20:27 It's a boating accident.

20:28 Swimmer versus propeller.

20:30 Ouch.

20:30 What body parts involved?

20:32 They didn't say.

20:33 How old?

20:34 Nope.

20:34 Anything?

20:35 All I got was boating accident.

20:36 Swimmer versus propeller.

20:37 Propeller.

20:38 Got it.

20:39 That's a wide differential that you have there.

20:41 Could be as small as a nick, a lost finger, a neck dissection.

20:47 Like a lot of things could be happening.

20:55 (doors whooshing) You could cut the tension with a propeller.

21:00 (drum tapping)- I'm sorry.

21:03 I've betrayed your trust.

21:05 I've betrayed our patient's trust.

21:07 And I'm really fucking sorry.

21:08 It'll never happen again, I swear.

21:10 (helicopter whirring)- I'm really glad that you got the help that you need.

21:17 He doesn't have to instantly accept his apology.

21:20 Like just because you apologize,

21:23 if you immediately expect someone to forgive you,

21:25 that kind of makes the apology disingenuous.

21:29 But I don't know if I want you working in my ER.

21:33 And you have to understand how that could be a reasonable take.

21:35 And he also said, "I don't know." He didn't say,

21:37 "You need to leave my ER."- Why'd you intubate him?

21:40 He was splinting from the pain.

21:41 Barely moving the air with SATs in the 80s.

21:43 Wow, that's so interesting.

21:44 So he was breathing so shallow,

21:48 meaning not deeply that he was actually desatting.

21:52 That he was not maintaining a good oxygen level due to pain.

21:55 So it goes to show that when we have

21:58 a patient with a broken rib and they're not breathing deeply,

22:01 it could impact their oxygen level.

22:04 So we want to have good pain control when someone has a rib injury,

22:08 and at the same time encourage them through incentive spirometry usually,

22:11 or physical therapy in order to stretch out their lungs to breathe deeply,

22:15 and make use of their entire lung.

22:19 You need me in here?

22:20 Nope.

22:20 We have a senior resident and an attending.

22:23 Mel, can we start with a-- E-FAST.

22:26 Sure.

22:26 Yes, please.

22:27 Why?

22:28 To check and make sure there's no pneumothorax.

22:30 Otherwise it could become a tension.

22:31 Pneumothorax, but also to see if there's any internal bleeding.

22:34 You want O-neg?

22:35 Not without a BP first.

22:37 108 over 64.

22:38 Pulse is 102, SATs are good.

22:40 Okay, let's have O-neg ready, but don't give it just yet.

22:44 Anything else?

22:44 Why does it sound like it's his first time treating a trauma patient?

22:47 Ceftazidime is up.

22:48 They're giving him an antibiotic.

22:50 First hemoglobin, 8.2.

22:52 A hemoglobin of 8.2 is obviously low.

22:54 In a situation where there's a trauma,

22:56 the hematocrit is usually a better indicator 'cause there's

22:59 less things that could impact it from a medical standpoint,

23:03 and really focuses on the amount of fluid found in the circulation.

23:08 Eight's pretty low.

23:09 He must have bled down from 14.

23:10 Well, I mean he has multiple wounds where he's bleeding a lot.

23:13 Also, you don't know what his normal is.

23:15 So perhaps he has a condition where he has iron deficiency anemia,

23:18 he has Crohn's disease, he was bleeding out of his bowels.

23:21 There's a lot of factors to consider there.

23:23 Anything you wanna do about that?

23:25 You don't want to transfuse a hemoglobin of eight.

23:27 I believe the protocols are around seven when I was training.

23:31 I'm curious what it is in this scenario.

23:33 Young healthy guy.

23:34 We transfuse at seven.

23:35 (triumphant music)- Yay.

23:37 Could be in real trouble if he equilibrates from a acute blood loss.

23:40 Am I interrupting something?

23:42 Multiple lacerations.

23:44 (indistinct)- Jesus!

23:47 This looks like some Jurassic Park shit.

23:50 Is that your official surgical diagnosis?

23:53 ICD-10 code for Jurassic Park shit.

23:56 He's hemodynamically stable.

23:57 What else do we know?

24:00 Uh, intubated in the field due to poor tidal volume.

24:03 Tidal volume is how much air that he was taking in.

24:06 And no free fluid in the abdomen.

24:08 Good hemostasis inside the wounds.

24:10 Nothing arterial.

24:11 At first, he had a hemoglobin of 8.2.

24:14 We'll follow that closely.

24:15 With no active bleeding, I wouldn't transfuse just yet.

24:20 Dr.

24:20 Langdon agrees with you.

24:22 (laughs) So does Doctor Mike.

24:24 Let's get him to CT.

24:26 And by the way, this idea of transfusing only at seven

24:29 is really a clinical decision based on if there is active bleeding,

24:33 if there are specific symptoms happening,

24:35 and also needs to be individualized for the patient.

24:39 This has been trialed,

24:40 and the idea is to not overuse blood because blood is a rare commodity.

24:45 That's why I've been so vocal about getting

24:48 people to donate blood as much as possible.

24:51 What's the word from CT?

24:53 Nothing intrathoracic.

24:54 Nothing intraabdominal.

24:55 Propeller just missed gutting him.

24:56 Very fortunate.

24:57 Yeah.

24:58 Repeat hemoglobin is eight.

25:00 We're holding off on transfusing.

25:02 What's this?

25:04 Daniel Scott.

25:04 32.

25:05 Weak and dizzy while washing his car.

25:07 Tachy at 106.

25:07 BP 90 over 60.

25:09 Temps too high to register.

25:10 Now we have a heatstroke.

25:12 We have a cooling room set up in North Five.

25:13 [Doctor] Okay, how you feeling, Mr.

25:14 Scott?

25:15 Thirsty.

25:15 You can do a cooling protocol on him.

25:17 Core temp, a CMP.

25:18 Whoa.

25:19 Oh, hey, we need a trauma room.

25:20 Oh, he's having a seizure.

25:22 I'll grab the Ativan.

25:22 (bell dings)- [Doctor Mike] Ativan will break the seizure.

25:24 It's a type of benzodiazepine.

25:26 Any past medical history?

25:27 No.

25:27 Wife says he's healthy.

25:28 No meds, no allergies.

25:30 I'm surprised the ambulance didn't start putting ice

25:32 bags underneath his armpits or something, on his groin.

25:34 And reason why those areas is 'cause there's a lot of blood flow.

25:37 So it impacts and cools a lot of blood very quickly.

25:40 We also have IV liquids that we can give that are cooled.

25:42 So it actually cools the core body temperature down faster.

25:45 Orders.

25:46 Second IV with saline, open, sepsis panel, UA, urine drug screen, EKG, and CK.

25:52 I don't see any apparent trauma.

25:53 These are all good tests.

25:54 She's trying to rule out infection, metabolic causes,

25:57 cardiac causes, neurologic causes with this exam.

26:02 Pupils reactive.

26:04 Mr.

26:04 Scott, Daniel, can you talk to me?

26:06 Mm.

26:07 Postictal, but moving all extremities.

26:08 In that postictal state after a seizure, sometimes there's a lot of confusion,

26:11 especially with Ativan on board, which can be a bit sedating.

26:16 What are you thinking, Dr.

26:17 Santos?

26:17 Heatstroke but consider sepsis or drugs.

26:21 Yeah, you also want to do a full survey to make sure there's

26:23 no random bleeding that's happening from a trauma that you weren't aware of.

26:27 You want to avoid getting pigeonholed into a diagnosis saying,

26:29 "Oh, well, it's hot outside.

26:30 His temperature's high.

26:31 It must be heatstroke." It could be sepsis,

26:34 it could be a raging infection, it could be meningitis.

26:37 So you want to keep your differential open at this point.

26:40 Rectal temp is 104.6.

26:43 Okay, let's start with four ice packs on the groin and axilla.

26:47 And remember, we talked about why those areas,

26:50 but specifically the arteries involved.

26:52 There is the brachial artery that's bringing

26:53 a lot of circulation underneath the armpit, and the femoral artery in the groin.

26:57 Should we do a full body ice bath?

26:59 That'll take too long.

26:59 You have an Arctic Sun?

27:00 Yeah, we do.

27:01 Get pats on the chest, abdomen, and both legs.

27:03 I'm guessing the Arctic Sun is some kind of device that's a cooling device

27:06 that perhaps they use during cardiac arrest

27:10 in order to do a hypothermic protocol.

27:13 But it could be used in this scenario.

27:15 Temp, 102.9.

27:17 Labs back.

27:18 Mostly signs of dehydration.

27:19 Tad hypernatremic, mild BUN and creatinine bump.

27:23 CK 400 something, nothing worse than that.

27:26 Okay, good.

27:26 Keep cooling.

27:27 When they say a patient is hypernatremic,

27:29 they're saying that the sodium level is high.

27:30 But remember, when we say the sodium level is high,

27:32 we're talking about the sodium level in the blood

27:34 based on how much fluid is there.

27:36 So when a patient is dehydrated and fluid is taken away,

27:39 the level of salt looks higher even though

27:42 the same amount of salt particles might be there.

27:46 So it's really this like balanced

27:48 equation of dissolved substances within the fluid.

27:51 So, for example, if you hydrate a patient, you give IV fluids,

27:53 you increase the amount of fluid in the blood vessel,

27:56 you decrease the sodium level.

27:58 But you also need to not do that too

28:00 quickly and overcorrect too quickly because that has also ramifications.

28:04 The balancing of taking care of someone who's

28:07 hyper or hyponatremic must be done very carefully.

28:13 Oh, sorry.

28:16 It's okay.

28:16 Have you, have you seen my patient?

28:18 Orlando?

28:19 Mr.

28:19 Diaz?

28:21 Room was empty.

28:24 Seriously?

28:25 Yeah.

28:25 I will say she's having a very strong reaction to the patient leaving.

28:30 And while I have worked with residents

28:31 that have this type of relationship with patients,

28:34 where every time something happens where

28:36 a patient decides against getting good quality care,

28:39 they make a decision against their health, they get upset.

28:42 The reality, and perhaps this is a harsh reality,

28:46 is that so many patients make decisions that are not great for their health.

28:51 Whether it's leaving against medical advice,

28:54 doing habits that continuously land them in the ER.

28:59 Like I'm thinking about patients who have congestive heart failure,

29:01 who continuously have huge sodium meals that land them

29:07 with CHF flare-ups where they can't breathe and they're fluid overloaded,

29:11 and we need to diurese them,

29:12 and they repeatedly come back to the ER and then get admitted.

29:16 You end up becoming a bit numb to it.

29:18 Not in a bad way all the time because there are scenarios.

29:23 And interestingly, it kind of connects back

29:25 to the sexual assault nurse examiner situation,

29:29 where you have something known as vicarious trauma,

29:31 where you start almost changing your worldview

29:34 based on your experiences as a provider.

29:36 You start potentially changing for the positive where you grow from it,

29:40 and you feel more compassion for people.

29:43 Perhaps you have a neutral response where not much changes.

29:46 Or you have a negative response where you develop compassion fatigue

29:49 and you no longer could care about your patients at all.

29:52 Or perhaps you start feeling negatively about the world.

29:54 You become cynical, you feel negative about yourself, and you need treatment.

29:58 So it's important to know that the mental health

30:01 of providers in dark scenarios can be impacted as well.

30:06 And that has large ramifications obviously across a society as a whole.

30:11 What happened to you?

30:12 Oh, bullet grazed my vest.

30:16 You were shot?

30:17 Shot at.

30:18 Jesus.

30:21 Why do you do this?

30:23 My therapist said I needed a hobby.

30:25 (laughs) Humor is a defense mechanism.

30:28 Maybe.

30:29 Shit, this, this sucks.

30:32 Oh, it's nothing.

30:33 I'm watching vicarious trauma play out right now.

30:36 Did you make a chart?

30:38 No.

30:39 This can stay off the books.

30:41 Don't need the paperwork from the hospital or the police department.

30:45 Okay.

30:46 Our little secret.

30:49 Maybe don't do it in the hospital ER.

30:52 Maybe have one of your buddies come home with a medical kit.

30:56 Had a Pap smear before?

30:58 Yeah.

30:58 Every few years.

31:00 Ideally every three years starting at age 21.

31:02 After age 30, you could do co-testing with HPV, which can,

31:06 if both are negative and you've had negative results in the past,

31:09 potentially be stretched out to every five years.

31:11 Same position.

31:13 But I'll start with swabs on the outside external genitalia.

31:16 Then I'll use the speculum to get internal swabs.

31:19 You ready?

31:20 Okay, help you get your feet in the stirrups.

31:22 I don't like calling them stirrups.

31:24 Call 'em leg rests.

31:27 Yeah, a little bit more.

31:30 Little more.

31:31 Sorry, I, I can't.

31:32 Patient-centered care.

31:33 You're allowed to stop.

31:34 You're allowed to give the patient time.

31:36 All of that is under their control.

31:38 Is this about reporting?

31:40 Because you can do this collection without a police report for now.

31:43 Facts.

31:44 And none of it goes in your permanent medical record.

31:46 I don't wanna do this anymore.

31:48 I would ask the patient why they're interested

31:50 in stopping instead of assuming why they're stopping.

31:52 But good opportunity to present some information.

31:55 Tell me why you wanna stop.

31:58 (panting) He's my friend.

32:03 He knows all my friends.

32:07 It was just a dumb...

32:10 He was drunk.

32:11 He didn't mean it.

32:12 It didn't mean anything.

32:14 Okay.

32:15 Validation here is very important.

32:16 And explaining that the choice to collect does not

32:20 mean that anything needs to happen down the line.

32:23 Why don't you take a breather and come back,

32:25 and whatever you wanna do, we'll do.

32:32 (door slams)- Jesus Christ.

32:34 I'm trying to get to the bathroom for over an hour now.

32:37 Yeah, you and me both, sister.

32:40 (toilet flushes)- Hmm.

32:44 Some potential cutting marks there.

32:45 When I say potential cutting marks, 'cause it could be a genuine trauma.

32:49 The internal disaster at West Bridge has been identified as a cyber attack.

32:53 Their ambulances are being diverted over to St.

32:55 Mary's, but we can expect more walk-ins and West Bridge diversions.

33:00 Uh, for how long?

33:01 We don't know how long.

33:02 If the ransom is paid-- Ransom?

33:05 What?

33:06 Are we next?

33:07 Our IT protection system has blocked thousands of intrusion attempts

33:11 in the hour since West Bridge was hit this morning.

33:14 But IT believes we're still vulnerable.

33:18 So we're gonna preemptively shut down all the computer systems.

33:22 Oh, going to paper charts is the worst,

33:25 especially for these young docs who haven't spent years

33:32 reading charts that are illegible from specialists coming by.

33:37 Patient registration, electronic health records,

33:40 lab, and radiology interfaces, email, internet.

33:43 You wanna talk to me first.

33:44 You wanna consult my department?

33:45 I consulted your fellow attending.

33:47 Don't hospitals have their own intranet so that they

33:50 don't necessarily have to be connected to the network,

33:53 like the worldwide network but still be connected where

33:56 you can use the computer to locally document things?

34:01 When are we going down?

34:04 Soon.

34:05 Very soon.

34:06 Okay.

34:07 Hey, somebody get a picture of the board.

34:09 Quickly, quickly!

34:10 We're about to go analog.

34:13 (phone camera clicks)- Oh!

34:15 Oh.

34:15 Oh, this reminds me of one of the largest hacks

34:19 in healthcare history that we actually covered on this channel.

34:22 Click here to check that out.

34:23 And as always, stay happy and healthy.

34:25 (upbeat music)