Oh, God!
The flight rotation was
the highlight of my residency.
I'll be thousands of feet in the air
in something shaped like a potato.
Well, actually,
it's only hundreds of feet.
Oh, God!
Don't they have
ambulances in this sticks?
They don't have a trauma center
in Boone County. If it's bad, we go.
- How far?
- Fifty, miles.
Head up. Didn't you know this
was a requirement of your residency?
All right, deep breath.
Let it out slowly.
Okay. My knees won't move!
Come on. Stay low.
- Dee McManus, Susan Lewis.
- Hi. First flight?
The sum of the angles of a triangle
equals degrees, right?
- Hey, Carol.
- Hi, Doug.
- Hi.
- Doug Ross, this is William Litman.
- William is my lab partner.
- No kidding?
How's it going?
I have an intuitive th-century
Euclidean mind.
It's actually crippling to the
understanding of the geometric...
- I'm flunking out.
- What are you working on?
String theory. The multi-dimensional
curvature of time and space.
The Riemannian manifold is
"M" dimensional space...
...that locally looks
like "N" dimensional space...
...when "M" is less than "N."
Susan, take a look. It's beautiful.
- What are you doing?
- Hyperventilating. Leave me alone.
You should really check out this view.
It helps you set your gyroscope.
- What was that?
- The pilot.
He was just adjusting
the rotor pitch. Absolutely normal.
Right. Normal.
There it is.
Oh, man! We're first on scene.
We're gonna need
the O-neg and blood Y's.
There's a field near : .
Oh, God!
Stay low and watch the tail rotors.
We've got five victims.
Hay truck and a van hit head-on.
Two ejected and three are trapped.
- Where is the fire response?
- Two engines and an ambulance en route.
- ETA?
- Thirty minutes.
Triage first.
Susan, you check the car.
It's all right, sweetie.
Please get us out of this car!
Yes, I'm still holding
for authorization. Hello?
Dallas by three, you think?
ER. Hold on.
ICU's got no beds till ,
and they're sending us two vents.
Way to go, Mr. Gomez!
Chuny, we need
more IVAC's in .
Patric Brazil,
metastatic prostate cancer.
Cough, fever, two months
progressive weakness.
Gave cc's of saline.
He's a no-code.
I've been Mr. B's
caretaker for years.
He wants to be cryogenically preserved
when he deanimates.
- He wants to what?
- Be put on ice when he croaks.
He's been waiting eight years to join
Mrs. B in their suspension capsule.
His wife's been frozen
for eight years?
It was their th anniversary
present to each other.
They want to be preserved so that
they could come back in the future.
Just like those dinosaurs
in that movie.
Isn't it romantic?
Let's hang a dobutamine drip.
Start at mcg per kilo...
- Watch the IV.
- Settle down, Mr. Sotcheck.
Rescue - for you to rule out MI.
- We're swamped.
- Who's covering Haleh's vacation?
The last nurse who floated down here
hid in the bathroom.
- Sterling from Med-Surg West.
- Rhonda Sterling?
- Yeah, what's wrong with her?
- She's a floor nurse.
- I'm not babysitting her.
- Me neither.
The fire's out!
- What's your name?
- Gail. She's only days old.
- Is she all right?
- She's moving and crying.
- I'm Dr. Lewis. What's your name?
- Zach.
- Gail, does your neck hurt?
- Is he all right?
Get a C-collar on her.
Sir? Sir, can you hear me?
It's brain matter. The guy's a goner.
Get him on oxygen.
Where, Zach? Your neck?
Does this hurt?
David? Where's my husband?
Gail, where are you hurt?
My right leg and my side.
David. Please!
- Dr. Greene's working on him.
- My husband is a doctor.
He has to check on the children.
- He's a pediatrician.
- Go, I'll stand by.
Okay, I'm gonna
go check on your husband.
The trucker's gone.
I need you here.
He's still moving.
He's pulseless
with massive head trauma.
I've got a tension hemopneumo
that we can save.
Needle him, left side.
He's decompressing.
Thirty-two French.
This guy's a pediatrician.
- Really?
- His family's in the van.
Wife and newborn baby girl.
Wife's stable.
There's a boy about years old.
Number four-two facial fracture.
I'm worried about his airway.
I'm in. Hook it up to the Foley bag.
He's hemorrhaging.
Grab two units
O-neg out of the cooler.
I'll start a line.
- What about my husband?
- Gail, we're getting you out.
Yeah, I'm still holding.
Do you like Green Bay
minus seven over Washington?
- Excuse me.
- Hang on one second.
Please don't tell!
Mommy!
Where do you want him?
Curtain Area . End of the hall.
Don't tell her!
- Carol Hathaway?
- Carol.
I was pulled off my ward
and assigned down here.
What patient do you want me to take?
Actually, we share our patients here.
Let me show you.
Here are the patients
that are waiting to be seen.
Nursing orders are flagged
and put over here, so when you're...
I'll take Mr. Washington.
Where is Curtain Area ?
- There.
- Thank you.
- Secure his head.
- We need to start a second line.
Dr. Lewis!
The boy's stopped breathing.
Go!
Watch his C-spine!
Keep in-line traction.
You're in the way.
Too much blood. I need suction.
. tube.
- Another . .
- That was it.
Okay, . .
Mark, I need your help.
Get him on the chopper.
We're taking care of him, Gail.
Please don't let him die!
- I can't see. Turn it up.
- It is up.
There's better control in the chopper.
Ready? One, two, three.
- Doctor, I need you to start this IV.
- Okay.
Go on, I'll check it out.
- What's up?
- She needs an IV.
Usually we try a few times
before we call a doc.
Up in Med-Surg
we call the doctor when we miss.
I'll do it. Mrs. Fesmire needs
of KCL in her IV in .
- Where's the potassium?
- In the Med Room under "P."
I can see the vocal cords.
I'm in.
- I'll be right back.
- Susan!
All right, Fred, fire it up.
Susan!
- How much longer?
- or minutes.
Gail, we're taking your son and your
husband to County General Hospital.
- Are they all right?
- They need to go to a trauma center.
- How will I know what's happening?
- I will get word to you, Gail.
- Please!
- I promise.
- Are you okay?
- Yeah.
- It's Dr. Greene from the whirlybird.
- Where's Mrs. Fesmire's potassium?
I'm on break. I'm getting to her.
This is County General on Beta-two.
Go ahead.
We're incoming on Air-vac One
with two major traumas.
Grab Lydia and Chuny.
Tell them to clear the trauma rooms.
- Go ahead, Air-Vac One.
- I'm gonna need a vent...
Goodbye, Mr. B.
You will keep him cold
until they come for him, won't you?
So that he could be with his wife.
- Please?
- Sure.
Should I clean out the fridge?
The dad's got
a hemopneumo and a head trauma.
-year-old had an obstructed
airway. He's getting shocky.
- Good job, Susan.
- What?
I said good job.
Draw up meds.
Watch that IV. Fluids wide open.
Let's get a cross-table, CBC,
type and cross for four units...
Draw up a saline-flush crash cart.
- Where is the saline?
- Pulse , thready...
- He's waking up.
- Hey, Zach.
That tube in your throat
is helping you breathe.
- Set up for lavage.
- Want a gas?
Got it. You bet.
Chuny, give me a hand right here.
Okay, we got a bloody tap.
Page Benton.
See if the dad will sign
a consent form for an ex-lap.
- Put that O-neg on the rapid infuser.
- Is he conscious?
He's responding to pain.
Dr. Herlihy, open your eyes.
Somebody needs to sign
his son's surgical consent.
BP's low, palp.
Pulse ox is only .
Ask Jerry to track down
the number of the hospital...
...in Boone County where they're
taking the mother and the baby.
Do the heart sounds
seem distant to you?
Tamponade?
- Hang in there, Zach.
- Hold him still.
- He's gotta be sedated.
- Give him Versed, one milligram IV.
Where is it?
It's clotted.
I need that saline.
- Another liter.
- Let's go!
Zach, I'm gonna give you
something to help you sleep, okay?
Hold him.
What was that? Did it hurt?
Are you sure that's saline?
- Oh, my God! That's potassium.
- How much went in?
- About a quarter cc.
- Insulin and glucose.
- Where is it?
- Second drawer.
Hold on. It's probably
not enough to stop his heart.
I think we're gonna be okay.
- What do you got?
- -year-old TC.
Airway compromised at the scene.
Peritoneal lavage was positive.
- BP's crashing, palp.
- Pericardiocentesis tray.
- Go ahead.
- I'll drop the central line.
Hook an alligator clip
to an EKG lead. Use V- .
Not mine.
It's the patient's.
He's a doctor. It might be his office.
Why don't you dial the number?
Jerry called Dwight Hospital.
The baby and wife haven't arrived.
- Are they on their way?
- I don't know.
- What do we have?
- Blunt abdominal trauma.
Hypotensive intraperitoneal hemorrhage
confirmed by lavage.
Facial trauma intubated in the field
with an RSI. H&H is , .
Type and cross four, cc's
of saline. We're set onboard.
- Way to go, Carter!
- Let's take him up.
Where are his parents?
Second unit's in.
So you got his partner to take calls?
Okay, we'll let you know.
Forty cc's non-clotting blood, out.
Dr. Herlihy, you've been
in an accident. You're in the ER.
BP's back up, over .
I'm worried about
an intracranial bleed.
- The nurse goes with him.
- Am I on call?
You're a patient.
You were involved in traffic accident.
Your son, Zach, has just
been taken up to surgery.
- Surgery?
- He was injured in the accident.
What accident?
Get a rush on that head CT.
Zach, everything's gonna be okay.
- We could've k*lled that boy.
- I got confused.
- You have no business working the ER.
- You think I don't know that?
I want you to restock supplies
for the rest of the day.
This is Carol Hathaway in the ER.
Clear a CT room, please.
Where's the number
for chopper dispatch?
Mark, can I run something past you?
A guy d*ed, and I don't know what to do
about his cryogenics request.
He and his wife bought a t*nk so
they could be frozen when they d*ed.
- Where is his wife now?
- In the t*nk.
I have an number for
a cryogenics company in California.
Yeah, still holding.
- What?
- Nothing.
Page me as soon as you know.
The helicopter's standing by.
We may have to get the wife and baby.
- Okay, DeBakey.
- . Prolene on a Castroviejo.
- Retract caudally.
- Retractor.
Splenic vein's repaired.
What about this pancreas?
I'd resect rather than
do a subtotal pancreatectomy.
I agree. Metz.
How would you repair after resection?
Interrupted horizontal mattresses and
a figure eight in the pancreatic duct.
- . silk on a needle driver.
- Anything else to do?
Irrigate. Run the bowel under control.
Insert a Jackson-Pratt drain
through a separate s*ab wound.
And use cautery instead of a scalpel
to minimize bleeding.
- Then close.
- Do exactly what you just described.
All right, cut the suture
three millimeters, no longer.
Irrigate. Normal saline.
Make sure it's warm.
Park her in the hall
till we can clear an exam room.
- Have you seen Susan?
- She got paged to chopper duty.
- What's up?
- I need ice, lots of ice.
California Cryonics said to put him
on ice until their local rep arrives.
They better hurry.
Dr. Lewis!
- Susan, are you all right?
- Yeah, I want to bring them in.
- I'll go.
- No, I'm fine.
Really?
You can stay here with Herlihy.
Dr. Lewis.
We gotta go.
May I?
See your orders?
John, take these to ICU
and make sure they're carried out...
...as meticulously as written.
Peter, care to join me
in a sarcoma resection?
- Yeah, I'd love to.
- Good.
Gant can cover any trauma calls.
Scrub in, in minutes.
Don't you just love her?
- Where's Zach? Where's my husband?
- Your husband was unconscious.
He woke up confused and disoriented.
He has a head injury?
What about my son?
- He's in surgery.
- Don't worry. They're in good hands.
Move!
Does this hurt?
BP's okay, over .
Let's get a C-spine.
H&H, type and cross for four.
- Good set of lungs on her.
- Respiratory rate's kind of high.
- Who knows with all that crying?
- It's , pulse .
Abdomen's distended.
She's been taking in a lot of air.
Get a baby Gram,
CBC and a gas.
Darling, are you hurt
or just mad at the world?
- What'll it be?
- Do you believe in reincarnation?
Next life I'm coming back
as Cindy Crawford.
A deceased patient wants
to be cryogenically preserved.
We gotta freeze a dead guy.
You got any ice?
- Neck looks okay.
- CT was normal.
Dad's still altered,
they're doing an MRI.
- Why did they take Megan away?
- She's just next door.
- Zach's out of surgery.
- He's gonna be all right?
He's in ICU.
I'll check on him as soon as I can.
Oh, God! I need my husband.
Please. Where is David?
- Her abdomen's kind of firm.
- She swallowed a lot of air.
- What shall we do?
- What is it, Gant?
Her abdomen's persistently distended.
She keeps crying.
Her resps are high.
The BP, the pulses and color are okay.
- Why didn't you drop an NG?
- We considered it...
- In such a small baby?
- Do it off the rectal thermometer.
You didn't do a full surgical
evaluation of the patient, Dr. Gant.
It's positive for blood.
Prep a cutdown tray.
Type and cross for two units
and page Keaton.
- Where's her mother?
- Trauma .
Dr. Ross and I thought
it was an equivocal exam.
If you don't know what you're doing,
call someone who does.
Hi, I'm Dr. Benton.
Your daughter has internal injuries
that's gonna require an operation.
She's only days old.
It's okay.
Dr. Keaton will be with her.
And she's the best
pediatric surgeon in Chicago.
We need your consent
for an exploratory laparotomy.
Where's my husband?
I want him to sign for it.
Her husband's a pediatrician.
He can't do it right now.
He handles all
the family medical decisions.
- You can do this, Gail.
- But I don't know.
Your baby needs it.
Okay.
Cutdown tray. Use a volutrol.
We may have to transfuse.
Gant was on track.
I talked him out of it.
Hang D , normal.
- What do you think, Peter?
- She has an acute abdomen.
Hi, pretty girl.
- Vitals?
- BP's over , pulse .
Resps , temp's . .
- Oh, what blue, blue eyes!
- room air.
Teacup, that's too low.
Let's get her on O- ,
four liters by mask.
Did you appreciate
the periumbilical redness?
- The abdomen's a little tight.
- No, I missed it.
Well, it's easy to miss.
- Why a cutdown?
- No veins.
Twenty-two angio.
This was a nice pickup, Peter.
Thank you.
Ah, yes. There we go.
I couldn't see or feel a vein.
It's just a matter
of knowing where it is.
Let's get her a cross-table lateral
and check for free air.
- Any thoughts on antibiotics?
- Since you don't need...
...anaerobic coverage on newborns,
I'd go with amp and gent.
Dennis, since you did the trauma
assessment, why don't you scrub in?
Peter, let's go talk to Mom.
Good girl.
There you go, Mr. Brazil.
Shrimp cocktail time.
Hubert Skinner, California Cryonics.
Mr. Brazil.
- You got some kind of I.D.?
- It's all there.
Give him
, units of heparin stat.
I'll pack him up,
and we'll be on our way.
- Is he a doctor?
- I don't think so. What do we do?
The heparin can't hurt,
him being dead and all.
In the newborn, I use
a transverse abdominal incision.
The rectus is thin
so there's less pain post-op.
We're using a respirator,
so atelectasis isn't an issue.
Zap that little bleeder.
- Cautery.
- Fifteen blade.
If there's a perforation...
...we should get a gush of air
when I nick the peritoneum.
- There it is.
- She's easier to ventilate.
Dennis, why do we want
to keep bleeding to a minimum?
Transfusions are dangerous.
You can't type and cross-match blood
because of the fetal hemoglobin.
There it is. Perfed jejunum.
You're teaching your interns well.
He's in and out. MRI was normal.
Dr. Herlihy,
do you remember my name?
- Where's my wife and kids?
- I'm Mark Greene.
Your family was involved
in a traffic accident.
Your wife's in the ER,
with a tib-fib fracture.
Zach had facial trauma
and hemoperitoneum.
He's out of surgery in ICU.
- Was it his spleen?
- No. Pancreatic injury.
What about Megan?
Megan just went up
to rule out intestinal perforation.
Why? What happened to her?
She was in the accident with you.
What accident?
Do you know my name?
No. Should I?
It's okay.
Gently. To repair it, we use
a . silk, interrupted Hufnagel.
Field looks dry.
You don't need
a two-layer in anastomosis.
Cautery alone gives you hemostasis.
Let's irrigate. Warm saline, please.
Zach's abdomen is distending.
- Any changes in his vitals or pulse?
- I think he's bleeding.
Damn! Peter, do you think
you're ready to finish alone?
- Yeah.
- Nothing fancy. Just close.
All right, people. Let's go.
Thank you. One more.
His abdomen is more distended.
- Has he regained consciousness?
- No.
Four-by-eight. Thank you.
- All right. Completely dry.
- What's that?
Looks like a little fiber and debris
on the liver surface.
- Should I call Dr. Keaton?
- No. I'll clean it out.
Okay, got it. Let's close
the peritoneum first. . Vicryl.
Now, retract medially. Cut.
Good.
- There's a little blood.
- Where?
Oozing from the liver
where you just touched it.
I'll put a little pressure on it.
Use suction. Gently, okay?
Damn it!
- It's still oozing.
- I'm not closing while it's bleeding.
I'll put a stitch in for hemostasis.
. chromic on an S-H now.
Retract caudally.
Come on, Gant. Retractor.
- Is Anesthesia standing by?
- I called them.
- He is distended. Vitals?
- Stable. BP over . Pulse is .
Pulse ox is percent.
Should I clear an O.R.?
Hang on.
Disconnect the NG from the wall.
Sometimes you get
an erosive gastritis. Hook it back up.
Clots can block the NG
causing acute dilatation.
Irrigate it out
and crisis resolved.
It's just experience, doctor.
- She's still bleeding!
- I can see that.
I'll put a gelfoam
on the bleeding site.
You apply pressure. Come on.
- Do you want me to get Dr. Keaton?
- No.
More suction. I'm gonna oversew.
. chromic on an S-H.
Heart rate's starting to fluctuate.
Give me a bolus
of normal saline, cc's.
The liver's so fragile,
my stitch cut right through.
I'm gonna take a bigger bite.
Retract this way.
You need to get this baby
off the table.
All right, bag her faster, damn it!
- I'm getting Keaton.
- No!
Go! Go!
Do you think it'll help her
to see her husband like this?
Megan's in surgery. Zach's in ICU.
Your husband got out of X-ray.
- He's okay?
- His tests are normal, but...
...there's still memory loss.
Could it be permanent?
You can see these things
in a concussion.
- But it might be?
- We just have to wait and see.
- Blood loss?
- A hundred cc's.
One third of her volume.
What did you do to her liver?
I was trying to peel away
some fiber and debris.
Move.
- . chromic on an S-H.
- It started to ooze. Clear.
There's no way
to control the bleeding.
Peter, handle the suction.
Dennis, retract distally.
Cautery. Crank it up to .
Pulse and BP are destabilizing.
We have to transfuse
with unwashed O-neg.
. chromic. Keep them coming.
She's bradying down. Rate's .
. Vicryl for the peritoneum
muscles and staples for the skin.
David?
Oh, my God! David.
- What happened?
- Didn't you tell him?
- We did. Many times.
- Zach's condition is stabilized.
Zach?
- What about Megan?
- Dr. Benton's closing right now.
That's wonderful news.
Was there a truck?
Yeah. Yeah, there was a truck.
- What were you thinking?
- There was debris.
- I only told you to close.
- In my judgment...
I didn't ask for your judgment!
Perry, Dennis, set up a vent.
F-I O- at percent.
Stand by with dopamine...
- Does that say chicken belt?
- Conjunctivitis.
I hate chart QA.
- What?
- Nothing.
Thanks for helping me in the chopper.
No problem.
Things can get pressured in here.
It just isn't a place
for someone who is inexperienced.
I can't have you work here again.
Zach?
Oh, God!
- Can I touch him?
- Sure.
Zach, honey, it's Mommy.
I'm gonna stay right here
until you wake up.
- What about Megan?
- No one from Surgery's talked to you?
- I'll go find out what's going on.
- Thank you.
- Why hasn't anyone talked to her?
- I don't know.
Benton was closing over an hour ago.
- Blood gas has improved.
- Not by much.
Could you excuse us, Kit?
Dennis? Thank you.
I should never
have left you unsupervised.
There are nuances in neonatal surgery.
The liver's more friable.
I wanted a clean field before
I closed. It seemed appropriate.
What's at issue here is that you
ignored my specific instructions.
I followed standard
operative procedures.
I've done it a dozen times
in other patients.
This is not an "other" patient.
This is an infant!
Outside now.
You don't know anything
about pediatric surgery.
Are you unwilling
to learn from your mistakes?
Does it say not to stitch a liver?
You didn't know what you were doing.
You should've called me!
Why did I find
three stitches in there?
Because you arrogantly and blindly
think you have all the answers.
If that baby dies,
it'll be my responsibility...
...but it'll be your fault.
- Dr. Keaton, she's crashing.
Pulse ox is .
Heart rate's down to .
Decreased breath sounds on the right.
Sounds like a pneumothorax.
Chest x-ray.
Don't need it.
Increase transillumination
on the right side.
- Chest-tube tray.
- This is no longer a teaching case.
- She's gonna need a repeat ABG.
- Pulse is up to .
- Dynamap's not registering a BP.
- Get ready with Thermo-Seal.
She's arresting.
Heart rate's down to .
Let's start CPR.
Epi one to ten thousand point four.
Atropine. milligrams.
How's the blood gas?
PH . . PO- . PCO-
on percent oxygen.
We have to put her
on an ECMO bypass.
Kit, call the tech. Get
two units O-neg to prime the system.
- Do we bring her back up to the O.R.?
- No, we'll bring the O.R. To her.
Dr. Greene?
Dr. Herlihy?
- What time is it?
- Eight o'clock.
P.M.?
Where's my family?
Your wife's upstairs.
Both the kids had laparotomies.
A bed opened up for you in ICU.
How'd they do?
Your son's out of surgery.
I don't know about your daughter.
- How do I find out about my daughter?
- I'll check on her.
- Thank you, Dr. Greene.
- Mark.
Mark.
Pedes O.R. Called. His daughter
decompensated in surgery.
- She's still flatline.
- Repeat. of epi.
Go ahead, Kit.
How long has she been down?
Twenty-two minutes.
- Is the ECMO circuit primed?
- Yes.
Good. I'm ready.
Venous connection first.
Arterial.
Turn it on.
- We've got a heartbeat and a pulse.
- Faint.
She's pinking up.
Let's get a repeat gas.
We need to anti-coagulate her.
Heparin, units IV.
Start drip at units an hour.
- How come we anti-coagulate her?
- We have to, or her blood will clot.
- Won't she bleed out?
- We have to hope that she doesn't.
I'll dictate an operative report.
Meet me in Pedes ICU in five minutes.
We gotta tell the parents.
Peter, how'd it go?
- How's the baby?
- Not good.
Dr. Benton...
You didn't sign the code sheet.
Hey, we're all human.
We all make mistakes.
Any other words of wisdom, Gant?
You're a real prick, you know that?
Mrs. Herlihy, this is Dr. Keaton.
She operated on both Zach and Megan.
Mrs. Herlihy...
Megan had a perforated intestine
from the accident.
When we operated to repair it,
there were complications.
- What are you saying?
- She's in the NICU on a device...
...that helps her heart and lungs
oxygenate her blood.
There was bleeding during
the operation, and she went into shock.
Then her lung collapsed,
and finally, her heart stopped.
We got it started again by
putting her on a bypass machine.
Is she gonna die?
She's in extremely critical condition.
It's... It is a possibility.
The Lord is my shepherd,
I shall not want.
He makes me lie down
in green pastures.
He...
The Lord is my shepherd,
I shall not want.
He makes me lie down
in green pastures. He's...
Dr. Benton?
I can't remember the words.