[Robby introduces his newest group of medical students and interns to the key players of his emergency department day shift]
MRDr. Michael "Robby" Robinavitch
Actually, this is the most important person that you're gonna meet today. This is Dana. She's our charge nurse. She is the ringleader of our circus. Do what she says, when she says it. As you can see, our house is always packed, and our department is mostly clogged up with boarders. Those are admitted patients waiting for a room upstairs, sometimes for days. Beds are a very precious commodity around here, so please be quick and efficient with your workups. What else? We treat the sicker patients back here, but please keep your eye on that waiting room. Make sure nobody's gonna die out there. Your senior residents are Dr. Collins and Dr. Langdon. You report to them, and they report to me. Senior residents, you got your sign-outs?
Patients, they check in for registration here. A nurse eyeballs them, makes sure they're not dying. If not, they're moved to one of two triage rooms for vitals and a quick chair exam where you can order your labs and your X-rays. And then they come back to Waiting room, until a bed opens up.
MVMS3 Victoria Javadi
For how long?
Eight hours, if they're lucky. A lot of times, 12.
MDMS4 Dennis Whitaker
Uh, is it always this busy?
Uh, no. It gets a lot busier.
GUGloria Underwood
We need to talk about your numbers.
Our door-to-balloon times beat federal standards.
I'm talking about Press Ganey scores. Patient satisfaction.
If they're still alive, they should be satisfied.
Our goal is 36% very satisfied with their care. Your department is at 8%. Do you know how likely patients are to recommend this hospital?
This is an emergency department, not a Taco Bell.
Well, if you want people to be happier, don't make 'em wait for 12 hours.
There's a nursing shortage across the country.
Most of our patients are boarders who are waiting for a bed upstairs.
That's bullshit. The beds are up there. You just don't want to hire the staff you need to care for them.
Like I said, there's a nursing shortage.
Well, if you paid them a living wage, they'd be lining up to work here.
Our budget can't support that.
[laughs] Here's a dirty little secret. The hospital saves money keeping patients down here in the Pitt. It's way cheaper than staffing upstairs.
I have asked you repeatedly to stop referring to the emergency department as the Pitt. It is derogatory and incompatible to the institution's image.
You know what's incompatible with the institution's image? Me speaking to the media about people who code in our waiting rooms and people who get shitty care in our hallways waiting for an ICU bed for days.
I've heard about doctors who have tried that and find themselves out of work.
I know today is difficult for you.
Every day is difficult down here.
Boarding is a nationwide problem. Your predecessor, Adamson, sure as hell knew that. Or wasn't that something he taught you?
Yes, really. Other hospitals are managing this crisis much more effectively. So, you can either step up your game, or you can step aside.
OWOtis Williams
Am I gonna be OK?
Yeah. You just need to take it easy on yourself. Muscle breakdown and myoglobin damaged your kidneys.
OWOtis Williams
Why'd you shock my heart?
When your kidneys don't work, potassium builds up and messes with the electrical activity in your heart.
OWOtis Williams
Can it happen again?
We gave you medicine to lower your potassium, and you'll need dialysis to clear it all out.
OWOtis Williams
Then I'll be OK?
Yeah. You might need a week or two for your kidneys to recover, but yeah. You really need to hydrate like crazy before and after a triathlon.
OWOtis Williams
Trust me, I won't let this happen again.
Good. Be kind to yourself.
You have to be more specific.
Are there rats in the ED?
Apparently, if somebody already snitched!
Do you know how bad this looks? One more reason to shutter this place. Only the emergency department admits rats.
Emergency department would never admit rats, unless they had the right insurance.
Did you catch any of them?
One, and I charged him for a full visit.
I'm glad you think this is funny.
I'm sorry that you don't.
Did you call an exterminator?
He's waiting on a second opinion.
[chuckles] You're pushing your luck today.
Don't worry. Last I heard, they were headed for the cafeteria, so they should be dead within the hour.
I got to go tell those parents their 18-year-old son is brain-dead.
Want me to come with you?
What are you going to say?
I'm going to say that it's likely, but we still need to do an apnea test and a cerebral perfusion study.
There's no cranial nerve activity.
Those people need some hope.
Is it? What, are we praying for miracles today?
They need time to process before they can accept what's happening.
You ever consider taking that advice? Physician, heal thyself.
Because your son tested positive for THC, the psychoactive ingredient in cannabis, we're going to have to admit him for overnight observation and monitoring.
AJAmanda Jones
And what about his brain? Is there a chance that much pot is going to do some damage? He's only four.
The honest answer is we don't know. There haven't been any long-term studies, but the fact that this is a one-time occurrence suggests that there should be no long-term effects.
AJAmanda Jones
But you don't know. So my son could end up with learning disabilities, psychiatric problems, or even autism because of this.
There's no evidence to suggest any of that.
KAKiara Alfaro
Hello. I'm Kiara Alfaro. I'm the department social worker.
Kiara will help you navigate the next steps.
AJAmanda Jones
What steps?
Well, a case like this requires mandatory reporting to child services and sometimes law enforcement.
DJDrew Jones
Why why do you have to involve the police?
It's a controlled substance.
AJAmanda Jones
They're not taking my kid away.
DJDrew Jones
They were pot gummies.
KAKiara Alfaro
No one's suggesting that.
AJAmanda Jones
Well, fuck your suggestions! No one is touching my child! In fact, we're leaving.
Well no, you can't take your son. He could stop breathing. He could have a seizure.
AJAmanda Jones
I will observe him at home.
DJDrew Jones
Amanda, please.
AJAmanda Jones
Fuck off, Drew.
Get security. If you can't cooperate, I'm going to have to ask you to leave.
DJDrew Jones
Amanda, please. He needs to stay here.
AJAmanda Jones
And you need to get a fucking hotel.
Your son can't leave the hospital, but I can have you removed.
AJAmanda Jones
Don't you dare touch me. Get out! All of you!
KAKiara Alfaro
Mrs. Jones, I know this is scary and stressful.
AJAmanda Jones
Oh, fuck you! Fuck you! This is my son. My son! And nobody is touching him!
[enters] Whoa, whoa, whoa. What's going on?
SGSecurity Guard Olsen
How can I help you?
AJAmanda Jones
By backing the fuck off!
KAKiara Alfaro
Mom's worried a CYF investigation.
DJDrew Jones
Amanda, just calm down!
OK, OK, OK, enough! This is a hospital. This isn't "The Jerry Springer Show." Ma'am, nobody's trying to take your child, so why don't you stay here with him while your husband talks to our social worker outside and straightens all this out?
AJAmanda Jones
Well, I don't want him speaking for me and my son.
Well, it is either you or him. Your son is not leaving, but you can be escorted out and even arrested if you refuse to cooperate. Nobody wants that. So you tell us. What do you want to do?
AJAmanda Jones
I'm staying with my son.
OK, great. You do that. We all on the same page here? Thank you, Olsen. You know where to find me.You OK?
All good. It's all yours.
Dr. Mohan, do you have a minute?
Is there a problem over there?
No, her pain is well controlled.
You understand that's my polite way of asking why are you spending so much time with one patient? You're an R3. As an R3, you should be seeing at least two patients an hour.
I have two, Joyce and Mr. Wallace, our Good Samaritan.
Who's comatose and stable. You should have four by now.
I have the highest patient satisfaction of anyone.
I don't doubt it, but we just had this conversation a couple of hours ago.
I know people call me Slow-Mo. You don't have to confirm or deny. It used to hurt my feelings a lot, but I can't help it. I work at the speed I'm comfortable at.
Because you're afraid of making a mistake?
I'm always afraid of making a mistake. Aren't you?
Yeah, of course I am. But you know what I mean. You make a mistake once, and somebody dies, and you feel so badly about it, you'll never let it happen again
Because you waste time and money on unnecessary tests. You keep sick patients waiting too long. You miss out on cases you could be learning from. You shortchange your own education. I'm not saying this to be a hard-ass. I'm saying this because I know you could do this, but you need to do it at a level I also know you're capable of.
Then you should look into a specialty that better suits you. Have you thought about psychiatry?
I don't want to go into psychiatry. I want to be here.
Being here means no matter how good you are or how hard you try, you're gonna make another mistake, and someone else might even die. That's called being an emergency medicine doctor. And if you can't accept that, then maybe this isn't the place for you.
OK, good. Go save some lives. Clear some beds while you're at it.
Mr. Gellin, you're having a very big heart attack right now. Major artery that carries oxygen to your heart is almost totally blocked.
GMr. Gellin
That doesn't sound too good.
No, it's not very good. We're gonna send you up to the cath lab. A cardiologist is gonna unblock that with a balloon and leave it open with a stent.
GMr. Gellin
But I'm still having a heart attack?
If everything goes as planned, it'll be like you never had a heart attack. We're gonna put a catheter in this artery right here. We're gonna shave the hair with a clipper.
GMr. Gellin
Long as you stop short of a Brazilian.
It's an option we offer. Costs a little bit more. A lot of people's insurance won't cover it.
HSHelen Spencer
He keeps trying to pull away.
We're giving him some more sedation.
JJereme
Why is he so agitated?
He could have some awareness of the tube in his throat or that he's in a strange place, or it could be lack of oxygen to his brain.
HSHelen Spencer
Does he need more oxygen?
He's on 100%. That's as high as it goes. [vitals monitor beeps loudly] That is his blood pressure dropping.
JJereme
Oh, is that even fixable?
Normally, yes, with IV fluids, but we now know that that will just fill up his lungs, drop his oxygen even more.
HSHelen Spencer
Well, isn't there something else we can do?
We can place a long, large IV catheter in his jugular vein down into his heart and administer Levophed, which is a very powerful medicine to constrict his arteries, raise his blood pressure. But that could cause other organ damage, organ failure. I'm really sorry, but each new step is even more invasive, could cause more suffering with minimal benefit.
