The Pitt · Season 1
[to Gloria] Glad to know the authorities are looking for this psycho, but what are you gonna do to protect the rest of us?
Violence against health care workers is a national problem.
And it's only getting worse. No surprise there's a nursing shortage everywhere.
An intern has a problem around here, they come to the senior resident, not the attending.
He is my attending, and I wanted his input on a patient. Is that not OK with you?
Just, um come to me first next time. Got it?
Yep.
Look, do I think he needed to chill out a little bit? Yes. But he's a parent, and this might be his way of coping with the stress of a very frightening situation.
I'm sorry. I don't know what came over me.
No, I do. You and that baseball kid are two pressure cooker prodigies in a pod. Just as physicians, we gotta learn to keep our emotions in check and not let our personal experiences interfere with our professional responsibilities.
How long did it take you to learn that?
I'm still learning. And I also learned to never get on your bad side.
So, in this ER, we all need to work together as a single unified entity. And if two people on my team can't work together, it kind of throws the rhythm of the place off.
Understood.
My duty, regardless of personal relationships, is to make sure everybody on my team is doing OK. So are you doing OK?
Uh, it's not a big deal. I can handle it.
Handle what?
Nothing. It it's fine. I... I don't wanna get anyone in trouble.
Hmm. OK, if there is anything that could affect my ER, I need to know about it, and you have a responsibility to tell me.
Remember how I said you get good at spotting the fakers?
Yeah.
He's exhibiting every sign of opiate withdrawal. Eyes dilated, tearing, skin has piloerection and goosebumps. Hypertension, tachycardia. Agitation, restlessness, perspiration. He's checking every box.
Right, but he said he doesn't take drugs and seldom drinks alcohol, so...
That's exactly what he would want you to believe if he was drug-seeking.
Wow. You're good.
Thanks. I am.
So how do we treat him?
By getting him to admit his opiate usage.
Right. How do we do that?
By being smarter than the patient.
Got it. He said he isn't an addict, so why give him an opiate agonist to treat his withdrawal symptoms?
Because I don't believe him. And I know this will work. Then once he feels better, we can get him to admit to his addiction and treat him long-term.
The psychologist spoke to me about becoming a petitioner to place David on an involuntary psychiatric hold.
Yes.
But can that be anonymous?
No. To call a 302 in the state of Pennsylvania, the petitioner needs to admit to having witnessed the concerning behavior, and you need a physician and a social worker to sign off, which both Kiara and I can do.
What if I'm wrong?
Then you apologize. And we will help you explain that this came from concern for his safety. What if you're right?
But if I become a petitioner, what am I doing to my son?
You are trying to get him the help that it sounds like he needs. David lost his father. That would affect anyone. But we are failing young men, because we don't teach them how to express their emotions. We just tell them to man up, and then we let them get their lessons in manhood from toxic podcasts. And these young men then feel isolated from themselves and society, and they find community and comfort in all the wrong places. David needs help. We don't want to fail him, too.
[about drinking] You ever think about quitting?
[chuckles] I'm not a quitter.
Oh, I know you're a happy drunk today. But one day, when your liver fails and believe me, it will fail you won't be so happy. It's not a nice way to go.
I'm digging my own grave. Let me.
I don't have to give you the shovel.
I'm already in a bad mood.
I'm just getting some air.
[scoffs] Yeah, right. You're a terrible liar. Hope you're better at security.
Hey, now you're just being mean.
You realize that this is the second person to accuse you of that today. - You starting to see a pattern?
No. But I am starting to see why Gloria's unhappy with your patient-satisfaction scores.
[Robby laughs]
You need something? Or you just here to ruin one of the few things that still brings me a little joy in life?
I sent Collins home.
You don't want to work with anybody today. You must be in a mood.
She's had a rough day.
It's going around.
You should leave, too.
[chuckles] Yeah. You're good. You're not that good.
...
You do help. You do make a difference. One asshole doesn't get to change that.
I think I'm done. [sighs]
Yeah. I know that one. And I don't blame you. I, uh...I-I-I-I don't know. I don't know. Maybe what I want and what the patients need isn't what's best for you anymore.
Yeah.
I just honestly don't know what I'm going to do without you.
You'll figure it out. You always do. You're a good man, Robinavitch. Don't let this place take that from you.
How you feeling, Mr. 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.
The medication we gave you wasn't morphine. It was something called buprenorphine, or BUPE.
Yeah, no, she said that. I mean, whatever you call it, Doc, it worked great.
It's a medicine specifically targeted to treat opioid withdrawal. That's why it worked.
Wait, I-I don't I don't understand.
All indicators are that you have been using opioids. That would include pain medication like hydrocodone, oxycodone.
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.
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?
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.
I don't have a problem.
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.
No, screw this hospital, okay? And screw you.
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...
Fuck off. I'm not interested.
There is an active shooter at PittFest. As the nearest trauma center, we are going to be getting the majority of the victims. We don't know yet how many we are getting, but we are instituting hospital-wide emergency protocols. We need to move every patient out of here. They either go home, they go upstairs, or they go to Family Medicine. Call your loved ones now if you need to. I can guarantee you cell service will soon be overwhelmed. Eat something. Stay hydrated. Use the bathroom while there's time and meet back here for a full briefing in five minutes.
["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.
How many casualties?
Unclear, but initial reports are not good.
OK.
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.
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?
Of course.
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.
What about disaster supplies?
On their way.
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.
Agreed.
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.
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.
Will do.
The cafeteria will handle the family members and survivors.
What else do you need?
Prayers wouldn't hurt.
Amen to that.
Keep the press out of here.
Gladly. Call me directly if you need anything else.
OK, will do. Thank you.
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.
Cool.
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.
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.
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.
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.
OK, yeah.
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.
Really?
Yeah, really.
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.
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.
Damn right we will.
That's a lot of wrist charts.
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.
Right. Wow. Well, one patient at a time, right? The goal is to triage each patient in ten seconds.
Ten seconds, got it.
Mental status is [w:AVPU|]]. Alert, response to verbal, response to pain, unresponsive.
Yep.
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.
John?
Yeah, man.
Mental status and pulse gives you everything you need.
Cool.
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?
Uh, red.
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.
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... .
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?
Gloria's got more blood flying in.
But I need it now.
What is our blood status?
Just used the last units of O-neg and O-pos. More flying in.
ETA?
Less than 10.
Some patients are not gonna last that long. And I'm sure there are other O-neg donors that probably work here, so...
It would take hours to screen for HIV and hepatitis.
Well, I have neither, and I donate all the time.
[Robby sighs]
Please.
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.
[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.
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.
These quotes come from Wikiquote's The Pitt pages and are available under the Creative Commons Attribution-ShareAlike License.
