RobinavitchHow you feeling, Mr. Pugliesi?
IPIvan Pugliesi
Oh, so much better. Thank you. You guys think that I could have a little bit more of that medicine, just for the few days that I'm out here? I just want to be able to walk my daughter down the aisle without shitting myself.
Robinavitch
The medication we gave you wasn't morphine. It was something called buprenorphine, or BUPE.
IPIvan Pugliesi
Yeah, no, she said that. I mean, whatever you call it, Doc, it worked great.
Robinavitch
It's a medicine specifically targeted to treat opioid withdrawal. That's why it worked.
IPIvan Pugliesi
Wait, I-I don't I don't understand.
Robinavitch
All indicators are that you have been using opioids. That would include pain medication like hydrocodone, oxycodone.
IPIvan Pugliesi
I told them I don't do drugs. Wow. You lied to me.
I didn't lie. I said I was giving you a morphine-like drug that got rid of your cravings.
IPIvan Pugliesi
Well, you know what? This is bullshit. I mean, you know, I could sue all of you. You hear me? I'm not some junkie on the street. Look, look, I-I got a family. I got a job. I make good money. I, you know, I return my shopping carts. I pay my taxes. That sound like a drug addict to you?
Robinavitch
Yes, because anybody can be an addict. You are proof of that. These pills that you were taking, they're not helping you with your pain. They are keeping you stuck in it. A lot of really good people struggle with addiction. It is a brain disease. But social environment and personal choice are also factors.
IPIvan Pugliesi
I don't have a problem.
Robinavitch
The good news is that the brain is highly dynamic, as is the environment. But you need to stop now before the damage is irreparable.
IPIvan Pugliesi
No, screw this hospital, okay? And screw you.
Robinavitch
Hey. Doctor Mohan -- Doctor Mohan will advise you on our proposed action plan. You can either choose to follow it or not. That is entirely up to you. I wish you luck, Mr. Pugliesi.
We're giving you a seven-day supply of a drug called Suboxone. We can set you up with a medic...
IPIvan Pugliesi
Fuck off. I'm not interested.
["Code Triage, Emergency Department now." over Public Address system]
We're locking down the hospital and setting up a command center in Administration. We'll coordinate logistics, supplies, communication.
Robinavitch
Unclear, but initial reports are not good.
Robinavitch
The night shift is gonna be here soon, but we are gonna need more help, especially from Surgery and Anesthesiology.
MCI group text and email went out to everyone, including Transport and Environmental Services.
Robinavitch
OK, good. [to Dana] Hey, everyone's gonna want to come in to help. Keep enough in reserve. Tell them to come in eight hours later to give us a break. And can you try and reach Jake?
Robinavitch
Surgery's got to call in the cavalry. We're gonna need all 25 ORs.
Ahead of you. Four ORs are prepped and staffed, and we're working on getting the rest up and running.
Robinavitch
What about disaster supplies?
Robinavitch
Every patient in the ER needs to go up. Beds or no beds, they'll get better care in an upstairs hallway than ignored down here.
There's a whole wing that's empty on the eighth floor. I don't know if that's...
But no nurses to staff it.
Robinavitch
No comment on that one. Waiting room and Triage can go to Family Medicine Urgent Care. And we should turn off the TVs. We don't need to cause any extra panic.
Robinavitch
The cafeteria will handle the family members and survivors.
Robinavitch
Prayers wouldn't hurt.
Robinavitch
Keep the press out of here.
Gladly. Call me directly if you need anything else.
Robinavitch
OK, will do. Thank you.
Robinavitch
This is how it's going to work. Our ambulance bay is now our Triage. EMS will be overwhelmed. Most will probably arrive by car, several victims per vehicle. For all you newbies that don't know, Dr. Shen is our night shift attending. John, I'm gonna put you on Point Triage.
Robinavitch
Triage will decide who goes where depending on their injury.
Every department will have a designated primary who will oversee their staff. If you need someone, look for the vest. We're all gonna have walkies. We can get you whatever you need.
Robinavitch
No patient goes into a room unless it's a trauma bay, and they will have four patients each. We need to keep everybody out in the open so we can keep an eye on everything, OK? Triage is gonna assess and assign every patient to a specific zone with a colored slap band. Patient who comes in with a red slap band goes to the Red Zone, which is the trauma rooms, with overflow out here. These are the most critical patients who will die without immediate attention. Samira, where are you? You are here with Dr. Abbot and me. Jack's gonna run traffic.
We have five minutes to try and stabilize the reds. After that, it's OR, ICU, or morgue.
Robinavitch
The south and central common area over there will be the Pink Zone. That is for patients who will die in under an hour without treatment. McKay and Javadi, you are over there, with help from incoming night shift and surgical staff. Yellow Zone is the North Corridor. Those are gonna be mostly extremity wounds good vitals, talking. Mel, you're gonna run point there with Santos and Whitaker.
Uh, what if what if there's a-a pulseless extremity?
Oh, if you if you can't feel a pulse, check for Doppler flow with this. It's a mini-ultrasound. Follow the screen prompts.
Robinavitch
But a yellow can change to a red if they go south. You got to stay on top of them, even if they seem stable.
Robinavitch
You got this, Dr. King. Green minor lacs and sprains. They go to Family Medicine. Black and white bands are DOA, imminent death. Pedes is now our morgue. Let's hope we don't get too many of these.
We're a MASH unit now. There's no charting, no electronic medical records, no board.
How do we document treatment?
Oh, you'll all get Sharpies, and every patient has a wrist chart to document treatment and procedures. You run out of room, write on the patient's forehead.
Robinavitch
Each wrist chart has a unique mass-casualty-incident barcode and patient number. That's how the patients are gonna get identified.
This is no-frills combat-zone medicine. No ultrasound, no X-rays, no CT, no labs. Assess based on mental status and pulse strength. Every critical patient gets an IO, intubation, a unit of blood and chest tube if needed. Everything you need blood, drugs, bandages everything will be in the Behavioral Health rooms. That's our supply depot. Um oh, keep a couple of 11 blades in your pocket. Goal is to resuscitate ASAP so they'll make it upstairs for definitive care.
Robinavitch
Trauma surgery and neurosurgery will decide who goes up to the OR immediately and who goes to the ICU for further treatment and evaluation. Communicate. Ask for help if you need it. Trust your attendings. We will get through this together.
That's a lot of wrist charts.
Robinavitch
Let's hope we don't need them all. Were you at the last mass-casualty faculty meeting?
Oh, no. I was still a resident three months ago.
Robinavitch
Right. Wow. Well, one patient at a time, right? The goal is to triage each patient in ten seconds.
Robinavitch
Mental status is [w:AVPU|]]. Alert, response to verbal, response to pain, unresponsive.
Robinavitch
Next, do they have a pulse? Radial, carotid, or femoral tells you where to send them. That's it.
OK. Cool. Oh, I heard it might rain today.
Robinavitch
John?
Robinavitch
Mental status and pulse gives you everything you need.
Robinavitch
Unresponsive with no pulses, slap a black and white band on them, send them to the morgue. Responds to pain with a faint groan, weak femoral pulse, no radial?
Robinavitch
Right. Slap a red band on them, send them back. Awake, alert with strong radial?
Trick question. Could be green, Family Medicine for scrapes or sprains, but stable, penetrating extremity wounds go to yellow.
Robinavitch
Perfect.
Dude, relax. I got the front door. You worry about the back.
Oh, um, and four of Ancef. Sorry, I forgot the Ancef. Thank you... .
PAPerlah Alawi
Mel! Mel, I need you to reassess, please, now.
Sylvia? Oh, Sylvia. Her pulse is weak and thready. She's, uh, bleeding out from her liver lac. I need O-neg!
O-neg's gone, honey. Gloria's got more flying in. Incident Command, what's the ETA on our blood?
[Incident Command relays it would take eight to ten minutes]
The patient's gonna have to get by with a liter of saline.
No, no, she needs blood, not crystalloid. Um, can she go to surgery?
All right, she's next to go, as soon as we get an open OR.
She's not gonna last that long -- Dr. Robby. Dr. Robby! Dr. Robby, we're out of O-neg, but I'm O-neg. Can I donate?
Robinavitch
Gloria's got more blood flying in.
Robinavitch
What is our blood status?
Just used the last units of O-neg and O-pos. More flying in.
Robinavitch
ETA?
Some patients are not gonna last that long. And I'm sure there are other O-neg donors that probably work here, so...
Robinavitch
It would take hours to screen for HIV and hepatitis.
Well, I have neither, and I donate all the time.
[Robby sighs]
Robinavitch
Fuck it. If the patient's gonna die before they get to the OR, then the benefits outweigh the risks.
My man. All right, kid, roll up your sleeve I'll meet you in 7. Listen up. Central 7, 8, 9 is now the blood donor center. Anyone who's O-neg or O-pos, we need you to donate now. Hands where I can see them. OK, let's do this.
Robinavitch
[to his adopted son, about his girlfriend] Leah's injuries were really serious. She stopped breathing. We put a tube down her throat to deliver oxygen. We were able to drain the blood that was collapsing her lungs. We gave her as much blood as we could. We even transfused some of her own blood that was in her chest. But we were unable to get ahead of the massive blood loss. Her heart stopped. You saw me doing CPR. We did everything that we could.
JMJake Malloy
She's dead?
Robinavitch: Her heart was damaged beyond repair. There was nothing that we could do to save her. And I don't know how many people I've helped today, but I can tell you every other person who has died. There was a man named Mr. Spencer, who died in front of his children, and an 18-year-old who who was brain dead from a fentanyl overdose and a guy with a heart condition and a little girl who drowned trying to save her sister. [sobbing] And I'm gonna remember Leah long after you've forgotten her.
Robinavitch
I just wanted to say thank you for earlier when I was, um
Oh, your brief moment of silent reflection?
Robinavitch
Yeah. You didn't mention that to anybody?
Robinavitch
I don't know what that was. I was just felt like I was drowning.
What was that you were reciting?
Robinavitch
It's called the Shema prayer. It's a declaration of faith in God. I lived with my grandmother when I was little, and she and I used to recite it every morning.
"Even youths grow tired and weary, "and young men stumble and fall. "But those who hold hope in the Lord "will renew their strength and soar on wings like eagles." It's Isaiah 40. I was an undergrad theology major.
DDuke
I can see why you liked restoring this bike. You're a fixer. I fix bikes, but you fix people. That's pretty damn impressive, man.
Robby
Some people can't be fixed.
DDuke
Look, I'm-- I've done plenty of things I'm not proud of.
Robby
Yeah, me too.
DDuke
No, bad things. Hurt people on purpose, hurt myself. And I did my time, but that doesn't wash away the regret. I... wish I'd done things differently. I think about it every day.
Robby
You know, they say that it's never too late to change.
DDuke
Some things can't be changed, like death. Death can't be changed.
Robby
Hey, I know the surgery is scary--
DDuke
I'm not talking about me.
Robby
Yeah, I don't know if I wanna be here anymore.
DDuke
I don't know how you stand 12 minutes in there, let alone 12 hours, 20 years.
Robby
No. That's the only place I can be. I have purpose in there. I can be distracted in there. I don't know that I wanna be…anywhere anymore.
DDuke
So what's the plan?
Robby
Ride.
Robby
I don't know.
Robby
Everything.
DDuke
Well, that's not riding. That's running. Is that your final lesson for these kids?
You know who I saw in rehab? I saw a bunch of guys just like you. The only difference is, they've accepted that they need help. I think you're afraid to admit the mighty Dr. Robinavitch isn't perfect.
Robby
I never claimed to be perfect.
No, but you expect it of yourself and it's not realistic, man. How can any of us live up to your standards if you can't even do it? You need help, Robby. You need help.
You want to know why I never killed myself? After what I saw, lived through? Losing my leg, losing...my wife? Because it comes for all of us, man. You and I know it more than most. We see it every shift, but we can't let ourselves succumb to it. Yes, life can suck. It can be unbearable and-and-and brutal and ugly and heartbreaking; but it's also beautiful, and hilarious, and that woman today, her baby? They'd both be in the morgue if you hadn't been here. That's us. That's you and me. That's what we're here for.
Robby
The most important things I've ever done in my life have been in this hospital. Nothing will ever matter more than what I've done in this hospital, but it is killing me. You know how they say that a part of you dies when you lose someone you love? I'm not convinced that a part of you doesn't die every time you see a fellow human pass. And I've seen so many people die that I feel like it's leaching something from my soul.
Go on a cruise, man. Knock off this helmet-less motorcycle shit. Yeah, people talk. That's death wish behavior.
Robby
I'm tired of being a role model. Tired of feeling like you can't get ahead. Tired of feeling like I'm drowning every day. Tired of all of it.
You need to get away for a while. You need to get some help. You need this place as much as it needs you.
Robby
Am I fucked up?
100 percent. But nobody works here as long as you and me and doesn't get screwed up. You've gotta find somebody to help you dance through the darkness.
Robby
[pause] Did you just make that up?
Maybe it's a song lyric. I don't know. Maybe my therapist said it.
The Pitt · 77 quotes
