Doctor Reacts To The Pitt Season 2 Episode 4

Season 2, episode 4,

lots of surprises incoming. Let's get started. Be well.

>> Is Harlow feeling light-headed

or faint It's not as bad as it was before,

but my head still hurts.

>> Okay, so this is a really good example

of what those who speak a different language,

in this case sign language,

have to go through

often times in hospitals where we can do better.

And I've made this mistake in the past.

Whenever we have an interpreter,

whether it's a iPad

video interpreter or an actual

living person interpreting, we need to face the patient

and continue the conversation

with the patient while

allowing them to look at the interpreter

for guidance because there's a lot of human interaction

that happens that is non-verbal

that is important for them to grasp.

And when you're interacting

with a patient who is perhaps hard of hearing or deaf, some may be

comfortable lip reading, but that can get tricky at times when there are new

diagnoses made that they're not aware of or medications

that are very difficult to pronounce, therefore lip read.

That's why every now and then in checking in and making sure that

the way that you're communicating

is still optimal for them.

And if you are going to be using difficult terms,

adding in a second layer, writing them down, or showing pictures or images.

And now my stomach does, too.

What did she >> Yeah, so like

this issue of speaking

to the interpreter rather than the patient is one that I have made in

the past and definitely have learned from.

It's okay to look at me. >> I'm sorry.

Um we're going to get started with some blood tests.

And another good intention

that actually has bad outcomes because it makes it more difficult to communicate

is when people try to over-enunciate

when they're speaking to someone who is hard of hearing or perhaps deaf.

And it actually makes it difficult to understand what they're saying or especially raising

the volume and that may not be necessary. Uh good news.

No swab came back negative

for COVID, influenza, and RSV.

>> Usually it's a whole

viral respiratory panel of all sorts of viruses,

parainfluenza, I don't know why I'm

on viruses, but there's a lot of them.

But a lot of other viruses

can cause a cough. Lucky me.

You can take off your mask. >> Well, wait.

>> If she has a virus and you're diagnosing

her with one that is not

one of the three you've tested for, perhaps we should still keep the mask

on for respiratory precautions.

>> Your oxygen level is down

since we checked you an hour ago and your temp is up to 102.4.

Let's get you some Tylenol.

Have you been outside today?

It's already >> Tylenol doesn't really make sense here.

Um figuring out why the temperature

is spiking is probably the more important

thing because when a person

has an underlying illness, let's say a viral respiratory

infection, they can get a bacterial

superinfection on top of it.

And that's usually symbolized

by a fever curve that is down-trending

over several days and then randomly

spikes back up with worsening symptoms.

And if that's what's happening here, I would investigate

for a bacterial cause

of this cough rather than just treat with Tylenol

and antipyretic fever medication. Could be heat-related. >> It's not heat-related.

No one is hanging out in the hospital

with an oxygen sat that's dropping

with a temperature of

>> Well, we're going to take you back to the big ER for full evaluation.

Can't you just write me a prescription for some medicine?

I'm sure it's just a summer cold.

You got somewhere to be?

I don't know how you guys do it.

Live together and work together?

It's my cross to bear.

I love that they're

I think this is the first time that I've seen them spend extended

periods of time in front of the computers,

which we do a lot. Dr.

Santos, making progress on your charting, I hope.

>> That's the conversation I have every

>> Efficient charts leave a gap for the providers who give continuity of care.

It delays hospital billing.

I always try and even if my note is not complete

to complete the after-visit

summary summarizing to the patient

so that they know

what we diagnosed them with, what the plan is, but also

that allows the future providers,

even if they're seeing them the following day and your note's not complete,

an idea of what the diagnosis

was, what the plan was, etc.

Who do we have here?

>> John Samba, 54, half an hour of left-sided chest pain, history of hypertension

on lisinopril and Crestor.

>> So he has high blood pressure, he has high cholesterol,

and he's having left-sided chest pain.

In a situation like this, you want to get an EKG right away to

see if there's any ST elevations

or depressions, which are signs that a person might be having a heart attack.

There are obviously other signs that we look for as well on the EKG,

but those are the more common ones.

And then we draw

these enzymes called troponins

to see if there is cardiac muscle damage, which leak into the blood,

and we get them

in a sequence over a period of time to see if they're

trending upwards, trending downwards, etc.

Some relief with two nitro.

>> Nitro is a medication that we give to vasodilate

blood vessels to allow perfusion of the heart.

>> Decent vitals, no STEMI on 12 lead, gave him 324 chewable aspirin.

>> We used to have this reflexive

recommendation that if someone is experiencing chest pain to take aspirin.

We've kind of moved away from that reflexively.

We want people to be

given that guidance by someone with medical experience

because there have been side effects as a result of people taking them inappropriately

because if you confuse

a different condition for a heart attack

and you end up taking aspirin,

there is a world where you can bleed internally.

So it really needs to be thought about a bit more,

which is why having a good relationship

with your doctor and planning

for these worst-case outcomes is really

>> Here, we're going to give you a full evaluation, sir.

I I would like to know more in-depth history on a patient like this.

Do we know if he's ever had a heart attack before

because if he has had one, that puts him at a much higher

risk for having a heart attack in the

And who do we have here?

Vince Cole, 23, fell through the skylight of a florist shop,

then be down to a bunch of ferns,

complain of headache, asking repetitive questions, no response to pain.

So he's obviously having some neurologic damage.

Could be related from

a very heavy brain injury

from a brain bleed

or something like a concussion,

but obviously needs further evaluation.

>> Multiple lacerations, BP 118 over 72.

>> Stable blood pressure, meaning that he's not hypotensive,

he's not losing a lot of blood or fluids.

Were you with him?

Yeah, we were parkouring

and he overshot a con wall. Oh, parkour.

That's uh the thing from THE OFFICE.

HE WAS VERBALLY UNRESPONSIVE. >> WHAT DO YOU GOT?

>> a 10-ft fall, altered.

That's a long way

>> 10 ft is the threshold for trauma center activation.

10 ft, 10% mortality.

0% anything over 0% is a concern.

Somebody's annoying and it's not me.

The gunner mentality is in full effect.

He's trying to pull out random stats that he read out of the textbook

in order to flex on his fellow colleagues.

And if you do that and get it wrong, oof.

It's much better that if someone calls on you asking that question and if

you were to get it wrong, it's okay because you were called upon

than if you were volunteering

wrong information to show off.

Remember, mechanism of injury is part of the evaluation

in deciding whether or not someone needs imaging.

And a fall from that height absolutely

warrants imaging, pan scanning, etc.

You also want to establish

the Glasgow Coma Scale to decide if this person can protect their airway.

If they can't, they might need to be intubated.

>> Ogilvie, Joy, GCS, please.

Open your eyes, sir.

Two for eyes, two for verbal.

Uh good lung sliding bilaterally. >> Joy, finish GCS. Squeeze my hand.

He gets a four for motor.

Pulse ox 99, heart rate 102,

blood pressure 114 over 78.

Somebody shooting a documentary here? Whoa, whoa, whoa.

You can't film in here.

We've got patient privacy laws. Grab my hand. Got it.

Uh can somebody show Spielberg

here out to the waiting room and get him registered at triage, please?

>> He's my creative partner.

I have his written consent to film everything for our TikTok page. >> A TikTok page?

He's near death and you're talking about a TikTok page.

And it's not just for the privacy of this patient.

While she's moving around the camera, there's also the privacy of all the other

patients and the things that are being discussed,

which is why it's unethical to film.

Pan scan head through pelvis.

Let's get him to CT. ASA. Absent gag.

We need to intubate before CT.

So remember, even if someone has

a GCS over eight, but they can't protect their airway because they have an

absent gag reflex, there could be

indication to intubate them nonetheless.

Can I do it?

I I'm keeping a procedure log and I need more intubations on this rotation. If Dr.

McKay wants to teach. Okay.

I need suction, 802, etomidate, and sux.

>> I love that he's

full gunner mode right now.

This is This is max gunner energy.

Reminds me of someone I know very well.

I wonder who she's talking about. Can you not? Yeah, I'm sorry.

Hot off the press.

No STEMI, doesn't need to go right to the cath lab. Orders are in.

>> This is the first EKG that I think I'm watching

I I've seen on this show, but

there are some ST depressions in V1, V2.

I feel like they're showing this for a Anterior ST depression.

So even if you have

a non-ST elevation MI, you'd still treat it medically,

but there could be indication for intervention.

You probably need to do

a a posterior EKG

to rule out a posterior

MI in a scenario like this. >> Hey, hey, Jesse.

Do you think you could repeat this but with the chest leads on his back? Why?

Um T waves are kind of high with ST depression anterior.

We see ST depression all the time.

Yeah, but could be a posterior MI.

Yeah, so that pattern doesn't necessarily

prove that someone is having a posterior MI.

Remember, posterior meaning the posterior

wall of the heart is impacted.

And because of the way the electricity

travels through the heart and gets shown on the EKG,

this could be an ST elevation

MI posteriorly, which then presents

itself with a non-ST

elevation MI in the anterior leads.

It kind of uh throws you a bit, but it does happen.

And uh the arteries

that are most often implicated

in this is the right coronary

artery or the left circumflex,

which end up giving circulation

to the posterior descending

artery, which is usually the one that's not getting enough circulation

in a posterior MI.

So, that's why like you need to

take the clinical picture,

the EKG picture, the

treatment potential picture, and

phase that all together in order to help the

>> Run it by the attending.

If they agree, we'll do it.

>> I mean, this guy

has done all sorts of invasive medical procedures,

but now he asked

for an EKG to be done slightly differently,

and he's getting shot down.

This is This is probably

the least realistic part of the show this far.

This is Jada Davis' >> Oh, thank you. Hi. Is he okay?

And why is he asleep?

He was uncooperative when he first arrived and needed to be

That doesn't make any sense. What happened?

We're still trying to piece the story together.

He was brought in by a campus security guard who tased him after he

was allegedly combative and

>> what do you mean tased him?

We've treated his injury,

and now we're trying to understand

why he was so agitated.

Okay, this doesn't sound like my brother.

His drug screen came back negative, so now we're taking Jackson to get a

CT of his brain to look for any

>> Can I go with him?

You can't go into the CT,

but you can wait for him to come back.

See, I would reassure

the patient's family member in a scenario like this and say that that's really

helpful information that he's usually not like this, which strengthens

our belief that something is going on, which is why we need to do

all of these tests.

Now, all of a sudden, instead of being argumentative,

you're working Just did my first ER intubation. That's great, man.

Such a crack head, you guys.

So, my 12-lead on my chest pain patient shows no STEMI,

but the anterior leads might be suspicious for a posterior MI. agreed.

Yeah, I was going to repeat, but with the chest leads on the back.

>> V7 through V9, good idea.

I don't know why he needed clearance

to do an EKG.

And I I think like posterior

wall is impacted in around 10%

fact check on screen

uh of all MIs

in this scenario, so Hey, Dr.

Robbie gave the go-ahead for the back leads. Sorry, man.

I got to call I'll report on a septic patient to the ICU. Yeah.

Time to cath is of utmost importance,

so making this diagnosis

early is really important.

I would not accept that answer,

or I would go and do the EKG myself.

Oh, yeah, doing EKG sometimes is really frustrating, especially with gloves on, because

those uh those stickies sometimes stick to the gloves, and then you're trying to

peel off the glove. What's wrong?

Uh some of the leads aren't sticking here.

>> And he's really sweaty, so wiping him down is smart.

Let me lie down now. I'm tired.

Yeah, see, like to me, he's having a heart attack.

>> I'm having some trouble here with um

Oh, of course you are. Uh try this.

Yeah, that makes sense.

>> That's the skin glue.

Do you mind if I paint some sticky stuff on you?

I'm not 100% sure why he has defibrillator

patches on him as if he went into cardiac arrest.

Maybe from the Bit strange. Perfect, Mr. Samba. All good here.

We'll put you down in a second. Oh.

Holy Uh ST elevation

in V7, V8, V9.

It's a posterior STEMI.

So, what's interesting here is that

depending on if the heart is left or right dominant,

you're going to have different blood vessels impacted.

It's not like left versus right, like where it's found on the body.

It's about which blood vessel

on the heart is causing

uh the lack of blood flow.

In a right dominant patient, this would be the right coronary artery.

In a left dominant patient, this would be the left circumflex artery.

Sometimes, there's a codominant

where both supply it, but it's important to figure that out.

When you do send the patient for cath lab,

they'll be able to

diagnose that issue with the catheterization,

injecting the contrast, seeing the blood flow,

deciding whether or not to put a single stent, multiple stents, etc. Great.

It's the worst kind of heart attack. Mr. Mr. Samba?

Well, it's really great that he has a defibrillator

pads on now, because

he's pulseless, I'm assuming,

uh and will need chest compressions

and potentially defibrillation if it is a shockable rhythm.

Hey, I could use a second set of hands here.

Pulseless V >> Pulseless V tach is a shockable rhythm.

You have the defibrillator pads on them.

If they're active, you can shock the patient.

But, if you're having difficulty

or the machine needs time to be set up,

one person should be performing chest compressions first. Start compressions.

Great great anal- great job so far.

Oh, the chest compressions isn't great.

Oh, no, the pit.

Okay, resume Code STEMI, it was posterior? Yeah, good call.

You put the defib pads on?

Yeah, just in case. Hold compressions.

I mean, that was really quick.

You You should be doing 2 minutes of compressions

before you check pulse again and rhythm. ROSC?

Do we have ROSC? Normal sinus. All right.

Got a strong pulse and BP.

Well, we'll prep him for cath lab. Hey, Mr. Samba.

You're going to be okay.

Again, stop saying they're going to be okay. He just arrested.

That is not a good prognostic indicator.

Get him to the cath lab.

Say that you're doing everything.

Say what you know, what you don't know, what the possibilities are.

Do not make promises you can't keep.

No pearly gates today.

Really good pick up, William.

Re- HOW ARE THEY SO CONFIDENT? HONOR, get here.

You fell at your construction site.

A coworker brought you in.

He's a lot better, but doesn't remember anything.

>> That's common after a concussion or DKA. DKA?

It's a serious complication

of your husband's diabetes. >> How serious?

Can he go home?

We still have to clear the ketones from his bloodstream.

So, we're using a lot of vocabulary,

which makes it very difficult

for the family to understand what's happening. You're hearing abbreviations.

You're hearing words like ketones

that are not words that you typically

hear, which makes it very difficult during an emotional state to understand what's going on.

So, explaining that the sugars are very elevated,

and that leads to

uh abnormalities uh with certain

blood variables, and that we need to get them normalized

before getting him home, and that we're moving in the right direction.

This is a explanation

that people can understand,

wrap their heads around,

and then when they need to ask for more details moving forward, you can

absolutely supply the intricacies.

He'll need to be on an insulin drip for a while

until things get back to normal.

Best if he stays in the hospital. It's okay, Mom.

Things are headed in the right direction, Mrs. Diaz.

He's going to be better.

Again, making promises is not great.

Saying that we're moving in the right direction is perfect.

Oh, do you mind? Absolutely.

the thing is, we don't have health insurance.

I don't think that we can afford this.

I'll have our case manager,

Noel Hastings, come by.

She's an expert in health insurance.

She might have some options for you for coverage.

Yeah, cuz we definitely

do have options for

people who don't have coverage themselves,

that are living below the poverty line.

That's why social work comes in handy in these scenarios,

because while we as doctors want to help in a scenario like that to

help them get care,

if we spend a lot of time managing the social situations,

we're not dealing with the medical situations

that other patients are coming in with.

So, this needs to be a team-based approach. So, now what?

You can wait 1 to 2 weeks for the super glue to break down on its own.

I'm hosting a 4th of July party tonight.

You want me to show up like this?

The other option is I trim your

>> We said that in the earlier episode. >> halfway down.

That'll lower the strength of the glue holding them together. Let's do that. Lie back, please.

Got to be really careful with the sharp objects around the orbit.

I need you to hold your head perfectly still.

Keep your eye closed.

My eye can't open.

That's why I'm here.

No, I mean, your other eye, too.

Cuz when you signal to open one eye, it moves both eyes. Okay.

I also don't like the angle that he's going on.

The bottom edge is the safety edge, so I would use that to get underneath the eyelashes. I'm Mr. Bronson. Alicia, please.

She's still very tachy at 104.

Not very tachy, but tachy given the fact that she's at rest with supplemental

oxygen, normal O2 sat.

Respiratory rate's also 20. She's breathing quick.

I've had this pretty bad cough for a few days now. Do you smoke?

You coughing up anything? Any chest pain?

No, no, and no.

I honestly think I picked it up at work.

It was going around.

>> It could be an office bug.

Or I got it from the gym.

I'm there all the time.

Lung sounds are going to be really important here.

Okay, what did you hear?

Maybe some crackles at the right base. Okay.

Well, we're going to need a chest x-ray to check your lungs.

To see if she has a community-acquired pneumonia.

How are we doing in here?

Oh, this is thrilling.

Definitely worth $200,000 worth of student debt. >> Huh.

Superficial ones get a steri-strip,

full thickness triderma bond.

How can you tell

they need a suture, Joy?

>> If the edges are under significant

I didn't realize your name was Joy.

I'm going to have to tell my parents how trendy they were.

>> I love this battle that's happening.

She has a tendon laceration. in here.

CT head, neck, chest, abdomen, pelvis all normal.

Improved mental >> Lucky guy.

Little bit of oozing.

Uh pressure for 2 minutes, lidocaine and Epi if that doesn't work.

>> Lidocaine and Epi is

uh a treatment to decrease bleeding in an area like that because the epinephrine

constricts the blood vessels decreasing the bleeding.

Are the admin orders in for surgical Oh, no.

I hope she didn't get poked

because now she has to go to occupational

health and unless the patient has very clear results from this visit or wishes

to get results for certain communicable

diseases, she might have to get post-exposure

prophylaxis, which is not fun. Ah.

The first thing you should do is wash your hands as quickly as possible

in these scenarios because

that decreases transmission risk the most.

No past records on this guy.

We don't know HIV or hepatitis status.

I'll put the orders in.

HIV anybody, hep B surface and hep C.

And they're washing it with

saline, it looks like, but you could just run this under water.

It's the same principle.

The new radiologist is a hottie. >> Um Side note.

>> His head CT is normal,

as are his blood and urine tests.

Then then what's wrong with him?

We're not um sure yet.

There is another test, a a spinal tap.

So this could be um an infection

in the fluid that surrounds the brain, viral encephalitis.

Um they can also cause

altered mental status and confusion.

Can you treat it if it is? Yes.

It would be a very unusual

presentation, but absolutely can happen with altered mental status.

So in a patient

where you can't get a thorough history,

a lot of times you have to do more tests, sometimes invasive tests in

order to get a clear answer.

Just what we thought.

It's a it's a fracture of your coccyx. Ah, the tailbone.

You're going to need a donut pillow.

That's going to hurt for a while.

Do I need surgery? No.

No, no, these heal pretty

But it'll take about 6 weeks. 6 weeks?

I was going to say 8 weeks.

Especially in an older population

where uh the healing is not as great as if you were 18 years old.

Is there something else you can do?

Well, there there is a procedure

to push the fragments back in place.

Oh, is this the internal

one that you have to go rectally?

That's uh not one I've ever learned.

Do what you must, my lady. Mhm. Okay.

First, I need to get a good grip for the reduction. Interesting.

I've never done this,

but I guess it can be done.

This is high level. Here we go. Try to relax.

>> Ah, I like that this is

embarrassing bodies level of footage here.

That is a show that was shown in the UK,

which allowed people to see that we all have human bodies

and there's no need to be embarrassed. Got it.

Now on three, okay?

This is not going to be pleasant.

I I I I know. Sorry.

Keeps you from tensing up.

>> I'm surprised ortho's not involved in

Take off the glove.

Both parents work, but neither of them have health coverage?

Orlando and his wife have multiple

part-time jobs that don't offer insurance.

Can they qualify for Medicaid?

Unfortunately, no, because their combined

annual income is over the Medicaid threshold

for a family of five.

>> So they make too much money?

And not enough at the same time.

They live over the poverty line

and yet they are still living paycheck to paycheck.

>> People fall through the cracks like this in our health care system so often.

That's why bankruptcies are skyrocketing

this country related to medical debt.

I think their best option

would be to buy

private insurance through the Affordable Care Act.

Which is becoming more and more expensive as the days goes on.

There are some hospitals

that are non-for-profit that have charity care systems, but again, usually

this is reserved for patients

that have a very low income.

So in a situation

like theirs, they may not qualify for the charity care either. How is he? He's stable. He's doing great.

He doesn't look great.

Is there brain damage?

The head CT showed no bleeding or skull fracture.

But you won't know until they wake up and you can do a clinical

examination and you wait and see if there are some deficits

and how quickly they improve.

It's most likely a bad concussion.

It's hard to know when he'll regain consciousness.

But even with a bad concussion,

you can have neurologic symptoms.

Uh chest and abdomen CT scans also showed no major internal injuries. What's that?

We need respiratory >> Why is he so excited about this bleed?

1 2 3 over. Yes.

Is there a problem with the vent?

No, he's bleeding from the back.

Got to prone him to take a look. Back away, Tanya.

1 2 3 up.

1 2 3 over. Good.

Oh, >> Okay, left flank area. Careful, careful everybody.

There might be glass.

2 cm simple laceration.

Open a suture kit 4 O proline.

It wasn't bleeding when we flipped him on arrival.

>> No, but when we moved him around for CT, it might have rubbed off a clot. Slow venous oozing.

It's good that it's venous flow, which means that it's slower.

When you have arterial flow, it's pulsating and fast.

You could lose a lot of blood very quickly.

Yeah, little piece of glass in there.

It's just under the skin.

Oh, you got to be careful with the glass.

What do we say when we watched the good doctor?

Never pull it out.

Yeah, I can wiggle it around.

Here, I'll pull it out. >> NO, DON'T. OH! UH OKAY.

It that's it's bigger than I thought it was. That looks arterial.

So that piece of glass was actually putting pressure

on the artery stopping it from bleeding and removing

stopped that tamponade event and as a result, he's bleeding out.

That being said, once you open it, you should be able to clamp off

the artery, but now the patient's getting an unnecessary procedure.

Probably still would have had it.

It just would have happened

under way more controlled circumstances.

I I can push it back in. No. No, my god.

Should I should I keep pulling it out then? Absolutely not.

The glass was tamponading a vessel. Not anymore. BP's down. Page surgery.

God, what artery was it putting pressure on, Riddle?

Pressures up with one unit type

What the He was stable.

Likely change in status.

Okay, get the clamp

Who's the genius who pulled that out?

I thought it was a loose fragment.

Next time leave the decisions to the adults. Okay, Dick.

Okay, ready to go?

Uh it's a deep deep piece.

I'm surprised they didn't see that on the CT scan where he said everything is normal. Very very unique.

Okay, I am injecting the XSTAT.

And what is that?

It's a syringe filled with tiny rapid expanding hemostatic sponges.

Putting pressure on the area where there's blood loss in order to get him

stabilized to go for surgery.

Radiology attending says a resident missed something.

There's a radiopaque foreign body in the left paralumbar musculature.

>> Why is the student reading the scans?

Do they not have radiologists?

Sounds like first weekend July. Mhm.

Except he's not a resident, so he shouldn't be the one reading the scans.

This is a classic

issue in this hot pit hospital

where they let students

just do all sorts of

moves that I don't support.

Um the x-ray came back on the lady with the cough. Weird infiltrate.

Have you seen it yet?

I've been trying to catch up on my

Stringy right lower lobe.

That looks like aspiration pneumonia.

Why would she have aspiration pneumonia?

That's a bit Think about it.

How do you oral

and gastric fluids end up in lungs? Vomiting?

Um dysphagia, swallowing disorders.

But she's not an old person choking on their food.

Right, and there's projected vomiting.

Maybe recent gastroenteritis, food poisoning.

I mean, you can't know that for sure from just looking at the x-ray.

I don't know how they were able to

very clearly denote that this is an aspiration pneumonia.

Or an eating disorder.

I think she's bulimic.

I mean, she's fixated on working out.

Check the enamel behind her front incisors.

So dental erosions can happen with someone who's vomiting often and believe me, it

doesn't always have to involve vomiting.

It's more about consuming

an a large amount of food

and then feeling negatively

about that leading to some sort of compensatory

mechanism, whether it's vomiting,

forced vomiting, uh exercising

excessively, or restrictive eating patterns.

Any What kind of super glue did you use? It doesn't matter.

My eye is still shut.

Okay, there's one other thing I can try. >> No, I'm done.

I asked for Dr.

J earlier and I would like to see her now.

I haven't been in the hospital for a while.

I don't know a Dr. J.

She's one of the best doctors in

She going to show someone from like Grey's Anatomy? Oh, Dr. J.

She's not a doctor. Aspiration pneumonia.

how does that happen?

Uh it's when bacteria

from the mouth or stomach get into the breathing tube

uh when you're choking

if you're eating or vomiting.

Do you ever drink a lot of alcohol?

Maybe so much that you pass out?

>> No, no, I'm not a big drinker.

Have you had the stomach flu recently? Food poisoning?

Why don't you just ask if the patient has vomited recently

instead of finding ways to ask around that question?

Do you mind if we take a look inside your mouth?

>> You can lean your head back and open wide.

The enamel on the back of your teeth is worn away.

What does that mean?

Um it can happen

if someone makes themselves vomit repeatedly.

All the stomach acid

dissolves the What does that have to do with having

It may have caused it.

Can you just give me some medicine?

Yeah, we can do that.

I don't like the sequence of events

that happened here because it looked like they were trying to find evidence

to confront the patient,

whereas this is the patient's

own body, there's an infection, you treat it.

You want to ask the patient questions

to help them prevent this from recurring,

you can, but looking for evidence to catch them in something is not necessarily the best approach.

What if I have been making myself vomit.

Bulimia is um a condition

that usually is treated with sometimes dual approaches,

but cognitive behavioral therapy, there's enhanced versions of it that

can help individuals, but also

there are pharmacological options especially for adults.

For adolescents, it's not as well proven, but there is some promise there.

Yeah, it's like a full team approach in those scenarios

and understanding that sometimes there's comorbidities

that can come with a diagnosis

of BN related to depression,

anxiety, obsessive-compulsive disorder, Bulimia is treatable.

I was going to stop. I stopped before.

My family gathers around food.

We eat eat when we're celebrating,

when we're mourning, we just eat.

But then I got to college and it was all about how you looked.

That's a lot of pressure.

Validating the patient is so good there. I started vomiting.

Everyone said I looked great.

So I went to the gym more.

I didn't need to purge as much.

>> Last year I went through a breakup, it all came back.

And shame is this added

layer of complexity on top of having this condition.

And remember, this is not just

a psychological condition, this is also

metabolic because it can impact

electrolytes, can cause dehydration,

and those electrolyte shifts can be problematic,

even deadly at times, obviously in more extreme cases. Dr. J.

It is so nice to meet you, Dr. J.

This is Willow, your new patient.

I'm actually a student doctor.

I uh watch all of your videos.

The one about coping with difficult co-workers was super helpful.

Hold on a second, is she a YouTuber?

Um so so what is Willow's health issue?

Uh my eye, it's super glued shut.

Halfway trimmed in mineral oil didn't work.

Then I would suggest cutting the full lash down. I concur, Dr. J.

>> Is that her handle? Here we go.

How many followers do you have, Dr. J?

A question that's never been uttered in an hospital

emergency room except with Dr.

Bea Sharp, of course.

More than you'd guess, Dr. Langdon.

Wow, that was the most confident I've seen her.

I heard a really uh motorcycle

crash come through about an hour ago. Yeah. Couldn't save him.

I know he was not wearing a helmet. Interesting.

One motorcycle crash is not going to scare me off my trip.

I didn't say it should.

I hope he died

doing what he loved.

I am not on your couch. >> I'm aware.

Conflict of interest here. >> Why? Because we're friends?

Ooh, look at you.

Using the F word, it's growth.

I use F words all the time.

I guess this therapy must be working.

It's great that he's getting therapy and understands

that it could benefit him because

a lot of times health care providers,

especially frontline health care workers,

will be reluctant to do so for fear of judgement,

judgement onto themselves that they project,

so this is reassuring.

I got somebody new for you.

She takes no You'll love her. I hope so.

The last two have not exactly been my speed.

The connection between the patient and the therapist

is one of the most important

variables that decides whether or not there will be a good outcome.

There's also situations where someone's going through so many therapists

that someone, usually the initial prescriber

of the referral for the therapy,

needs to ask the patient if this is something they're actually interested in because

repeated therapy failures can actually lead to recurrent therapy failures, so that needs to

be How are you feeling, Mr. Diaz? Much better.

We need to talk about how your diabetes

progressed to this place.

Is this room doctor-patient?

What you say here remains between us.

I'm taking a lower dose of insulin than I should be.

So this is a real scenario

where patients try and ration their medications

cuz they can't afford the full doses,

and with insulin that is a non-starter

because as you've seen here,

if you ration your insulin

in an uncontrolled way, consume

too much of a certain food,

you can get your sugar levels to a point of diabetic ketoacidosis,

which usually requires an ICU stay.

I used to have insurance through work, but

I lost that job when the pandemic hit.

It was easy to keep up with my medication then.

I had a great primary doctor, too.

Now I'm kind of on my own.

>> So there are other alternatives

instead of using the long-acting

insulin that he's probably

taking, and while it is most convenient to take that, sometimes it can be expensive.

We have intermediate-acting insulin, which is sometimes cheaper,

that we then compare

with bolus dosing insulin with meal time.

A lot of clinics that I worked with where we have patients

that struggle to pay for their long-acting

insulin, that was a strategy

that we Can we not talk about this in front of my family? They're my girls.

Did you call your brothers?

They're still in shock.

>> I have good news.

I started a GoFundMe for Dad. A what?

To help raise money for Dad's medical care since we don't have insurance.

That is unfortunately how a lot of Americans

are paying for their medical care.

There's actually been articles about it, and it's truly disappointing

that that's the state of our country as it exists today.

I got to bounce back.

You remember Debbie Cowan?

Not really, I've seen 16 patients this >> The restaurant

worker we saw you light us on the dorsum of the foot?

>> Yes, yes, she's on Keflex.

I marked the >> Yeah, I got a hot pack on it, but

uh you should take a look. A hot pack.

I wasn't expecting to see you back so soon.

Meds upset your stomach? Uh no.

The pain got worse,

and you said to come back if the redness spread outside the Sharpie line.

That's important because the cellulitis could be spreading

to the joints, to the bone, creating an osteomyelitis.

Let's take a look.

It looks like the infection

isn't responding to the pills I prescribed you.

So she's going to need IV antibiotics.

I don't think it's actually erysipelas.

We need to get you on some IV antibiotics

and get you back to the ED now.

Uh is it bad?

Not if we can get a handle on it.

Worse, or maybe worse.

Maybe worse than The hospital

could not stop this nurse from killing.

Click here to check that out, and as always, stay happy >> and healthy.