8:00 A.M.

Robby.

Robby.

College kid in respiratory distress is here.

- All right. - You OK?

Yep.

I wanted to talk to the patient in Central 12's son,

but he took off.

Is there a problem?

Uh, according to Mom,

she found a list of high school girls

that he'd like to eliminate.

- What's wrong with kids these days?

- Uh, you mean besides social media

and the worldwide pandemic and the environmental crisis?

- Yeah, yeah, yeah. - And gun violence?

- You're a fucking fountain of hope today, aren't you?

- Nick Bradley, 19, found unresponsive by parents.

No meds, no allergies.

On arrival, he was barely breathing

with pinpoint pupils, bradycardic at 38.

Pupils responded to Narcan,

but we tubed him when his respirations didn't pick up.

- Any drugs or alcohol on the scene?

- No. - Signs of trauma?

Nothing.

- OK. Open your eyes, Nick.

On three. One, two, three.

- Where was he found? - In bed by his mom.

- Pupils are 6 millimeters, non-reactive.

- Heart rate's 64. BP is cycling.

- No response to pain. GCS 3.

- Does that fit any toxidrome? - No.

If it was just opiates with Narcan,

he'd be breathing on his own.

- Uh, beta blockers shouldn't get pinpoint pupils.

Maybe parents had some

prescription meds in their bathroom.

They're on their way.

- Code trauma, tier 1, ETA five minutes.

- That's a stand-up scooter rider versus car door.

No helmet. - No blood in the belly.

No pericardial effusion, and lungs are up.

Hemocue's good, 15.

BP 84 over 58. - OK.

What's your plan, Dr. Collins?

- Um, push dose epi, 0.1 milligram.

Foley for urine, stabilize for CT,

and throw a wide net.

- Where-- where are we going now?

- We need the room for someone else,

but you can rest in the hall till we get your labs back.

Your parents must be proud.

Having a son for a doctor.

Yeah, I guess.

Um, you know,

I was the first one in my family to go to college.

You know, they sacrificed a lot to get me here.

How's your pain, Mr. Milton?

Uh, I'm fine.

Could use a latte, though.

- That could bring back the gallstone pain.

How about a bourbon?

- It's barely 8:00.

Uh, how about some ice chips?

- No, thanks.

I prefer my whiskey neat.

- Yeah, that's not happening.

Systolic back down to 90.

Another 0.1 of epi.

- Flaccid paralysis of all four extremities.

- No eye movement with ice water.

So no brainstem function.

Due to?

- Hypoxic injury, massive hemorrhage.

Samira, escort him to CT.

Take the drug box with you.

Call me if you need me.

Hey, are you OK?

- Yep. - Are you sure?

- Have you ever had to worry about me?

- No, but it never hurts to check in.

It's part of my job.

Consider yourself checked in.

OK.

Ah, ah, ah, ah, ah.

Got something?

- Oh, I had a case for Dr. Collins.

- May I see? - Yeah.

A 68-year-old male, history of hypertension,

one hour of right upper quadrant pain

after eating a fatty meal, now resolved.

Afebrile, non-tender.

There was a gallstone present on POCUS.

EKG shows no acute ischemic changes,

but I'm still waiting on LFTs and lipase.

Why did you order the EKG?

- The nurse suggested it to rule out any cardiac issues.

- Well, good call on both your parts.

Nurses know what they're doing.

Never hesitate to listen to them.

Come find me when those labs are back.

Hey, how's that finger? - Oh, it's nothing.

- Dr. Robby? - Yep?

- The son and daughter of Mr. Spencer

from assisted living, they're here.

OK. I'll be right there.

Your father has pneumonia and a condition called sepsis.

- What is-- what is that exactly?

- It means that the bacteria has spread from his lung

to his bloodstream.

So far, he's been responding well to treatment.

Hey, Pop.

It's Helen and Jereme.

Jereme...

Hillary...

Boob...

Fud.

It's the "Nowhere Man" from "Yellow Submarine."

It's what he used to call me when I didn't do my homework.

Is this his baseline?

- He has good days and bad days.

- Why don't we step out for one more second?

So your father came in with low blood pressure,

which is improving.

- Can he go back to assisted living?

Eventually, we hope so.

Your dad has an advanced directive

expressing his wishes, which says that

IV fluids and medications are OK,

but no artificial life support, no CPR.

- He doesn't want a bunch of machines keeping him alive.

OK.

Then we will continue with oxygen

and IV fluids and antibiotics,

but if his lungs stop working,

we're not going to place a tube in his windpipe

for a breathing machine.

But pneumonia is treatable?

Most of the time, it is.

- But if he can get better in a week,

then put him on a machine.

That's not what he wanted.

- Do either of you have durable power of attorney

for health care?

- Yes. - We both do.

OK.

Well, this is a decision

that does not need to be made right now.

Why don't you think about it?

Talk about it.

If things get worse, sometimes allowing

for a comfortable natural death can be the most humane path.

- No routine cases until we assess the tier 1.

Thanks.

Dr. Langdon?

So, uh, how was the VA?

- Yeah, it was, uh good, uh, you know, challenging.

I learned a ton. I just think it--

maybe it should be mandatory

that all doctors spend time there,

like, on a regular basis

because of all they've sacrificed for us.

- That's a nice thought. Why'd you choose the Pitt?

- Oh, I have a sister with special needs

and she got into this really great facility

here in Pittsburgh.

And PTMC has such a great reputation,

I thought, you know, it'd be a good fit.

- Can I present my headache to you?

Uh, yeah, what do you got?

- A 36-year-old woman with severe headache

due to paracervical trigger point.

Her pain went from 11 to zero after 2 ccs of IM Marcaine

to the-- - Wait, wait, wait.

You did a trigger point injection

before presenting the case? - Yeah. I--

Interns always present first.

- I spent a month at the pain clinic at Hopkins.

- No, it's not OK. - Incoming!

- I'm very comfortable with-- - It's definitely not OK.

- 23-year-old Ben Kemper, no helmet,

got doored riding an e-scooter.

Neck versus handlebar then face-planted to the pavement.

Obvious facial fractures,

but alert and oriented with good vitals.

Here we go.

One, two, three.

[elevated vitals monitor beeping]

How are we doing, Ben?

- Blood, back in my throat.

- That's probably from the nosebleed.

Short Rapid Rhino, please.

- Tachy at 120, pulse ox borderline at 90.

Blow by at 15 liters for now.

- Neck contusion. - BP 138 over 84.

- Larynx shifted to the right, no crepitance.

4 of morphine.

I'm going to stick something in your nose to stop the bleeding.

No hemotympanum.

Inflate the balloon.