Doctor Reacts To The Pitt S2 Ep 6 w/ Sepideh Moafi

We're about to watch and react to episode

6 of The Pit,

but for this episode,

I need to call a consult

from the one and only Dr.

Al Hashimi, Stephanie Al Mouafi.

Are you ready to take on episode 6 of The Pit? >> Let's do it. Foreign ready, baby. >> let's do it.

And huge thanks to Zocdoc

for sponsoring this video. >> I'm in. Bag him.

>> I am notorious for pointing

out chest compressions not being done

>> or being done perhaps not perfectly.

>> Okay, how's Robbie doing?

>> So, I'm a bit of a stickler for form

only because what I've come to realize

in my years of practicing medicine and making YouTube content,

people learn from television

on what they should do, what they shouldn't do, what they think is correct.

So, I would love to see the chest compressions be a little bit deeper,

but otherwise it looks great.

>> It's hard because when they teach it's a real person, so you're having to

keep your arms straight

and sort of push your chest

forward and kind of act with your shoulders.

And so, it's a very

sort of artificial movement,

but but yeah, it's it it's actually harder than it looks.

>> I think it's really smart

in the way that they manipulate

the camera angles because honestly

it doesn't let me give her credit

because like, "Oh, we're just seeing the shoulders bouncing and that looks good already

because most people are doing stuff like this."

>> Yes, you should text

Noah though and let him know that he needs to >> No, he's doing a good job.

No, because then poor Louie over there is going to start

really feeling it on his rib cage the next morning. >> That's right.

>> Okay, how many compressions?

>> Good square line on the entitle CO2. >> Be firm. Charging 200.

>> I'll stand by with Epi.

>> So, that's very concerning.

We're starting to see blood

enter the ET tube

signaling that there's some kind of bleeding process

going on and I believe this patient is one who's come in multiple times

for alcoholism and already has

fluid building up in his abdomen.

They had to do a paracentesis.

In those patients, they have scarring of their liver.

That increases blood pressure

in the portal venous system.

And what happens there is the body tries to decrease this pressure

by shunting blood in different directions.

But the problem is the venous system is not meant to be a high pressure system.

They're thin-walled and they don't respond well to pressure.

So when that blood flow starts getting redirected

to areas like the stomach,

the esophagus, those blood vessels that are thin start becoming wider.

They are more susceptible to rupturing.

Any amount of slight

friction, pressure, ET tube going in, all of that can risk bleeding.

And in general, patients who are end-stage

liver disease also have issues with platelets,

clotting factors cuz a lot of that

happens from the liver.

A lot of problems with bleeding in these patients.

So very tough to see a situation

like this where it's already terrible cuz we're in cardiac arrest

and now there's problem on problem on

>> And this is a character that

we as an audience

have grown so attached to, Louie. This is yeah. >> Yeah.

Such a nice too.

Not in the esophagus, so definitely not.

I passed right through the cords.

Good breath sounds in trachea.

CO2 >> His lungs are filling up with blood.

It never gets easy by the way.

>> Watching this amount of blood and >> Are you squeamish of blood in general?

>> I I didn't think I was squeamish, but yeah, my first

day we did the clamshell

procedure for episode 1.

And so I yeah, I I felt like I was getting a bit lightheaded

but cuz the the full body prosthetics,

they look so real. >> exactly.

>> Every detail, every every is accounted for.

So I do I still am watching the show

like during the clamshell

even though I was in the room for however many days that took,

it was hard for me to watch.

>> Are you filming a scene like this straight through

or are there stops

for angle swaps, camera changes, etc.?

>> No, we actually have less downtime

than most film and television

Yeah, shows and and

films because the light is already prefixed

into this so it's basically hospital lighting that we're using and there's a switch board.

They Yeah, there's very little downtime

between setups but we do take

a good amount of time to rehearse the trauma procedure.

So, we have a med

tech advisor for every episode.

Usually I I call them and bother them for as long as they'll talk

to me and let me pick their brain.

So, on the day of the procedure,

we'll go through they'll talk to each one of us individually,

sort of give us the lay of the land

and then put it all together,

run it at 25%

speed, 50%, 75 and then bring it up to speed and once

you know, they feel it's ready then then we roll

and yeah, like I said there's very little downtime between shots.

>> Yeah, this 25, 50, 75,

100 approach is very similar to the see one, do one, teach one that

has been discussed on the show.

It allows you to get more and more comfortable

without feeling like you're going to make a mistake and it comes off perhaps less genuine.

>> Yes, yes, yes, absolutely.

But I mean once you get in that that flow state, once you're in

the pocket, it's thrilling.

I mean, I'm glad there are no lives

actually at stake here for us but

but it it really is because it's

it's the the sort of codependence

or interdependence of your of your colleagues,

of your scene partners

and and everything we just rely on each other so heavily. >> Full compressions.

Uh resume CPR, another amp of Epi. >> Use the suction.

Pulmonary hemorrhage from liver failure.

>> Is he going to make it?

>> See, it's hard to know if

uh at for me watching if this is a pulmonary

hemorrhage or as Noah mentioned in the scene,

was this a situation

where the ET tube was inserted incorrectly?

>> Because of those fragile blood vessels that can occur from advanced liver failure in this esophagus.

If you insert there

and you injure one of those blood vessels,

you can't tell is this bleeding from the mouth coming

from the esophagus or from the airways.

There are obviously situations

from this pressure build up,

the coagulopathy that happens as a result of liver failure, that could lead this

to be alveolar bleeding.

So, like the smallest

little pockets, air sacs

within the lungs that can cause bleeding, but very difficult to know.

And in an ER setting it almost doesn't matter cuz you're trying to do

your best to bring this person back.

But in a scenario like this, it's just

it feels very far gone.

>> Should we give PCC?

>> Too late for that.

And he's not an ECMO candidate.

>> Nothing else we can do.

No, I I think we're done. >> I'm awake.

>> Why do I need to see a psychiatrist?

Jada, why do I need to see a

>> Oh, it's going to be okay, Jackson. Dr.

Jefferson says he can help.

>> Do you know how you got here?

>> The medics brought me.

I don't really remember.

I I was in a library.

>> What were you doing there?

>> I was I was trying to study.

But then they wouldn't stop talking.

>> Who wouldn't stop talking?

>> They don't want me to pass the bar.

>> Who doesn't want you to pass the bar?

>> That's what they told me.

This is a situation

where paranoia is entering

the equation because there may have been no other people

actually interrupting his studies.

Schizophrenia is a possible

diagnosis, especially in this age demographic,

is when it can start.

And the interesting part about schizophrenia

is sometimes it's brought on by some acute stress state

where we cannot even predict

why it started at this moment,

but something happens in someone's life, something very stressful,

a critical illness, and then

full-on schizophrenia begins where before that there were no signs of the schizophrenia. Very interesting.

I was fascinated by that

in talking to our tech advisors,

our medical advisors, that this is apparently very common for

young males in their early 20s

in college, high stress environments,

and especially with marijuana,

when they're smoking marijuana. Everything okay, Roxy?

I can't get off the bedpan.

Oh, that's what I'm here for.

>> Your husband seems like a saint.

How long have you been married? Too long. 20 years.

I always find it tough in scenarios

like this where a patient is obviously in a lot of pain,

is going through final stages of their life, it's hospice situation.

So, you want to approach the situation with reverence.

You want to be serious,

you want to be compassionate.

At the same time, it's it's

so important to also

interject some happiness, some humor,

some joy, but then it's very

easy to cross that line.

And finding that line with each patient

is I think the most valuable

part of being a clinician.

>> I was just admiring

Kristen's work because she's so

beautiful and alive and real

and just present in everything that she does.

I think she's just such a beautiful, brilliant actor.

But I it's a cast of people like like her who are just making

really smart choices with the the script that we have, which is so well

written and loaded and

really kind of like a um

a treasure chest or a minefield

and you just continue to mine as an actor and you get more and

more and um these moments of levity that you're talking about.

Yeah, I was I was thinking as we were watching it the way that

the camera is panning down to the bed and then up to them.

It makes you feel like you're inside

of the room with them, like you're experiencing

it and and it creates

this this other dimension

of humanity and and authenticity

for the show that makes you then

in these quiet moments

relate even deeper to these characters,

whether it's the patient or the nurse.

>> This feels like I'm shadowing

a nurse for the day to see what they do.

It's there there is no difference between this and what I experienced in the hospital.

I think it's the same.

>> this one's directed, if I'm not mistaken, by Noah. >> Oh, really? Okay. >> Yeah.

So, it's always interesting.

You'll see this season Sean directs an episode two, episode nine.

This kind of like this level of detail

is so important for them because they are actors.

They come at this from the inside

out, whereas a director

that comes from maybe a photography

background or a filmmaking background,

it's more of an outside-in

approach and both are right.

Both are equally as effective,

but I think as an actor

it's it's really satisfying

working with somebody who understands

it from the inside out and

and cares, like pays attention to these

because they know that the audience will feel that.

>> Let's discuss our incarcerated patient, Gus.

Prison infirmaries tend to be short-staffed,

so we need to be

What's in the differential diagnosis

for >> Uh inadequate intake,

uh methamphetamine use, severe alcoholism, ADHD medication. >> What else?

>> Cancer of the oropharynx,

esophageal strictures, prior strokes,

malabsorption, inflammatory bowel disease,

none of which were in his medical record.

>> I don't think it was noted also past bariatric surgeries.

>> So, patients who have a bariatric

surgery sometimes have a malabsorption

syndrome where they don't get their nutrients as well.

And this type of

questioning happens very often.

In the House MD days, they would be in front of a whiteboard,

and that's so not realistic

with the exception of if you're doing like a

We have these rounds called M&M rounds,

morbidity mortality rounds, where if someone dies or someone's very sick.

At the end of the month, we collect these cases, we present them, and

then write on a board.

But, when we're actually taking care of a patient, this is the exact way that they're done.

>> And we sneak in little,

you know, drink or food breaks

to kind of, you know,

make sure the audience knows

that we're not Yes, that doctors need eat too.

Let's start with a nutrition

history once he's back from CT.

>> What is the story with your incarcerated

>> Gus Varney, three rib fractures

with normal O2 sats currently.

Waiting on CT >> Okay, if he's stable with the two arm work, I'd say

he's good to go.

Let's get the ball rolling on discharge.

>> Wait on the CT results.

>> We can move him out of trauma one at >> Yes, we can. What's open?

>> 13 and 14 will be discharged soon.

15, once we can move Louis to the viewing room and get it cleaned up.

>> A paracentesis patient, Mr. Copperfield?

>> He's stable at rest.

We'll do a debrief when we know how many patients we're getting from Westbridge.

>> So, Gus goes to 13, 14, or 15?

>> I kind of want to keep him in plain sight. What about BH2?

>> So, why not give him some privacy?

Everyone can see him in BH2,

like he's a monkey at the zoo.

>> Because he came in with an orange jumpsuit, and we need to think about

patient and staff safety.

>> Safety first, Two bits of prison >> Not by much.

>> You guys have a lot of tension going on

>> There is some tension.

>> There is push and pull.

>> I think friction can be generative, though.

And I think that's what's interesting

about the dynamic that Dr.

Al Hashimi has introduced into the pit.

It's It's a different tune.

It's a different melody.

It's a clearly a well-established

culture, ensemble, ecosystem, and she sort of steps in, and

and brings something kind of radically

different, and tries to

to harmonize as best she can,

but but there are some clashes

sometimes between her and Robbie.

And I think um

just as an audience member at this point and episode

six, if they can find a way

to work together, I think they could be an unstoppable team.

And I think what they represent

is, you know, more of this old-school,

hands-on, intuitive approach, Dr.

Robbie, and and Bodan

Al-Hashimi, who who represents

this newer, more progressive,

you know, the modernization

of medicine, what could >> I'm sorry, man.

We didn't have time to find you. >> What happened?

>> He was apneic and pulseless.

We started CPR and intubated him.

He had a massive pulmonary hemorrhage. Robbie called it.

>> Could it be as simple as because

he has this liver failure,

and he has the high capacity

for bleeding or high risk for bleeding,

and doing chest compressions you break a rib, punctures the lung?

>> That alone could have caused this.

>> Now, we'll clean up the body.

Find out the same way either.

No one tells you what it looks,

feels, or smells like, but

you get used to it over time.

>> This is mostly for dignity purposes

to have the patient

be available uh for someone to view

uh before sending him to the morgue.

But you're not doing like an embalming process here, so.

Pull off the gown.

Wipe him down with towels, then we'll roll him on his side.

Clean his back, stuff the sheet under

>> Pads for mucus and other bodily fluids that might come out after the fact.

they leave the ET tube in for the coroner, but

he was a chronic alcoholic

with end-stage liver disease, it's a coroner's case.

>> Yeah, so usually uh we would call the coroner as residents,

present the case, and they would decide

whether or not this was

necessary to be a coroner's case or not.

The most difficult part is this doesn't happen as much in the ER, but

when someone's admitted to the hospital

and someone dies, you go in

as the resident and you have to formally

diagnose the patient as dead, deceased.

You're looking for certain reflexes,

pupillary, corneal, listening for extended period of time for lung and breath sounds.

And the whole family's

So you're you're trying to be respectful,

you're talking to them about the process

of what will happen in the coming days.

And there's times where you're talking,

but you just know none of it's landing.

So you just have to be there,

ask a lot of times if they have questions,

and suspend talking and listen more, even though your job is to talk.

Because in that moment,

the information's not landing, it's not valuable. So.

>> And it's a way, I mean, this is um

reminds me of you know, how

how we approach our work as actors.

Sometimes you have the language

on the page or what you're saying, you're you're taking this family through this

process, but you're really communicating something else.

You're communicating love and care and presence with this language.

And And so often as actors, we have the language in the script

that we're communicating so much more with. So.

>> What's up with Eva Canaval?

>> Brandon Lee, 52, fell off a motorcycle

pyramid at 25 mph.

>> Motorcycle pyramid, you recruiting?

Got a fellow rider in your midst. >> No kidding.

>> How high up were you?

>> On top of a 3-2-1,

but the bottom guys are sitting down driving the choppers. I'm fine.

I don't need all this. >> wearing a helmet?

>> Oh, what do you know, the stolen style.

Good vitals, tender right wrist, and big left knee lack.

>> Hey, Joy, perla, trauma two.

What else can I have?

>> Santos and Whitaker in with Louis.

>> Yeah, give me Whitaker, he could use a distraction.

And Santos has been ducking traumas all day.

>> She's behind in her charts. >> Who isn't?

If I'm being honest, >> So.

I'm currently very behind in my charting and

I'm getting messages right now about it.

I can feel my phone

getting the vibrational alerts.

But interestingly, my hospital

is beta testing an AI system

to try and figure out how to make this

clean, quicker, more effective

with the concern from every doctor that

oh, will we now

be seeing double the amount of patients because we have this AI system.

>> That's a slippery slope,

but it feels like

yeah, most people that I've talked to, most doctors that I've talked to

welcome this change because especially

people who are of

a sort of like in maybe I'm assuming we're kind of in a similar

age bracket and and older

you've you've trained with hands-on,

you know, medicine and

and you know how to use this as a tool not as a replacement.

>> My biggest thing when I was in residency

training, I would get in trouble because I refused

to do the rule was do your note in the room with the patient

and I'll just refuse

to type when I wanted to interact with the person.

I just I couldn't be that keyboard warrior

and that meant after hours I would be sitting and doing notes and trying to catch up.

But now with these AI tools,

perhaps we can just have something

on the desk that is no longer creating

a barrier to communication

and kind of stays out of the way.

>> Well, and it strengthens

the bond between physician and patient, right?

Because there's that psychological

emotional attunement and they feel and you earn their trust that way and people

who are coming whether it's a checkup

or or for some sort of illness,

um, there is this power dynamic

of, you know, you you guys

are we're coming to you for your expertise

and you have the answers

and so when you do see

your your provider, locked in and

sort of at at same place with you emotionally,

mentally, it makes a world of difference.

And then, you feel like, "Okay, anything you say, I'm I'm happy to do.

I'm happy, you know?"

Rather than having to fight to earn the trust.

>> I don't even like getting to the point where a patient feels that they

need to make the decision

to do what I'm telling them to do.

I want it for to be an educational

experience where I'm explaining

what the options are,

perhaps giving recommendations, but ultimately,

it should be their choice

to want to or not want to do something.

>> Good lung sounds bilaterally.

>> Pupils equal and reactive.

What do you ride? A Bullet.

A Royal Enfield, ankle breaker, thumper.

>> BP 138 over 80,

pulse 94, pulse ox 98.

>> So far, everything's very reassuring

and he's all mentally there, being able to memorize

or call back the name of his

motorcycle, so >> Um does anyone have any trauma scissors?

I'll check the knee. >> Uh not yet. >> Why not? >> Dr. Santos. >> Primary survey.

>> Means rule out the life threats.

Don't get distracted by lacerations or fractures.

No free fluid in the belly.

Airway, breathing, circulation are fine. >> Okay, that's ABC.

That just leaves two letters to go. >> Disability.

Wiggle your toes, sir.

>> Any pain in your arms or legs? >> Not really.

>> Does it hurt when I push here?

>> Okay, uh no midline tenderness,

NEXUS >> No obvious brain injury or spinal cord

>> That just leaves E. Joy.

>> Can I borrow another vowel? >> Dr. Whitaker.

>> AKA strip and flip.

Cut off his clothes

and we'll log roll him.

>> A lot of times in the hospital, that is one of the most

anger moments from the patient cuz they're like, "This is my favorite shirt.

This is Don't cut it >> Oh, really?

>> Yeah, but they've experienced a serious trauma.

You don't want to miss something cuz

there have been instances

where someone comes in,

adrenaline rush because they got into a fight,

they got shot as a bystander,

and they don't realize they have a bullet

hole in their leg that went through their tissue and had we not exposed

their full body we would have never seen it. >> Oh my gosh.

>> Very important to check the entire body.

>> Would you have you do you ride a

I've crashed a motorcycle

interestingly enough when I was really young

and I haven't rode a motorcycle since.

But I do race cars.

>> And you wouldn't Oh, you would do race car but that's different, right?

>> I mean, you still crash I guess it's just safer. >> Sure.

Helmeted motorcycle acrobat, 8-ft fall standing on top of five riders,

primary survey normal E-fast negative.

>> So in a scenario

like this where the exam seems fine,

it's tempting to not do

However, one of the

criteria that we used to decide whether or not someone should get imaging

stems from also the mechanism of injury.

And an 8-ft fall

at speed is a pretty

serious mechanism of injury that would usually warrant >> Another motorcycle accident.

Hello sir, I'm Dr. Garcia from surgery.

>> Okay, we will roll him in three, two, one.

>> THEY CLOSED THE DRAPE.

>> I'M ALWAYS TALKING ABOUT

the drapes not being closed but I assume it's for filming purposes, right? >> Yeah.

Most of the time.

Yeah, yeah, >> Because a big part of what I do and what I train

residents is they'll walk into the exam room, they'll do everything perfectly correct like

before they'll say a pap smear

and they'll introduce to the patient what they're about to do.

They're very calm, very kind

and they're about to start the procedure and I'm like, "Hold on a second,

if someone opens this door right now,

>> the patient's fully exposed.

You have to close the secondary drapes."

I'm always yelling that.

>> ever tell you Well, they don't on the pit

and everything in the pit.

>> No, they don't do that yet.

Back to the show in just a second but first I want to tell

you about my sponsor

Zocdoc, a free website

where you can easily search and compare high-quality

in-network doctors so you can find the right one for you. Dr.

Robby seems like a great doctor to me, and he delivers exactly

the quality of care I'd expect to find on Zocdoc,

who can help you book in-network

appointments with more than

providers in all 50 states.

Look, I get it.

Finding a doctor is not just hard for patients,

but for me, too. That's right.

Just because I'm a physician

doesn't mean I get how insurance

and all this stuff works.

My dad and I have actually struggled with this together.

He's a family medicine doctor, too, and ran into

problem of his own and needed to find a new doctor.

We tried to find someone, but we ran into all those same roadblocks you do.

Confusing websites, endless voicemails.

So, we tried Zocdoc

and found the right person.

They specialized in exactly

what my dad needed,

were close to his home, and actually had openings for new patients. My favorite part?

You can see the doctor's

actual appointment openings, choose a time that works for you,

and click to instantly book a visit.

So, stop putting off those doctor's appointments

and go to also linked in the description,

to find and instantly

book a top-rated doctor today.

All right, let's get back to the pit.

>> Uh Gus here is wondering if he's cleared to eat.

>> Uh as long as it's a liquid diet.

We have the results of your CT scan.

Your jaw should heal without surgery,

which is good news,

but it will be a few

>> Before I can eat? >> Solid foods, yes.

>> Um we have a calorie-rich

supplement drink called Ensure.

Comes in chocolate, vanilla, or strawberry. chocolate, please. >> Good choice.

>> How many can I have?

>> Two a day is recommended.

I'll get it for you.

You have an appetite. It's good. >> Mr.

Varney, your blood tests indicate low levels of protein and vitamins.

>> This actor, uh John Lee Ames, I think is his name,

he was so and so

specific about his pain.

I mean, you he broke your heart.

I couldn't watch him on my coverage

because I'm supposed to be tough

and I would just crumble. I'd start crying.

I I love that they've sort of

folded this case in into the

the the conversation that that you know, because it it really makes us reflect

on who gets care, who deserves care, who's afforded care, what kind of care do they deserve?

Cuz he looks initially

>> They made him look like kind of a

serial killer or something, you know?

He he looks the part,

but he there is a softness,

this childlike quality about him that even though when she says chocolate, he says

chocolate, his eyes light up.

It just broke your heart.

So again, going back to what what the show does beautifully

is it it reveals

the humanity in all of us.

At the surface, we would might judge somebody like that, but then you see

he's just a kid who wants to eat, who wants to be taken care

>> Which there should be no barriers

for anyone to get care,

criminal, not criminal person,

uh who wants care,

who can't afford care.

Like the idea is we should be giving care, especially in an ER setting,

to everyone at the highest

>> CT's ready for Brendan

as soon as we take a look at this knee.

>> Through the deep fascia. >> How's it look?

Definitely going to need >> How many? >> A lot.

>> It could be an open joint.

>> We'll do a saline load after CT. >> Leave her side. >> Negative ACL intact.

>> Okay, ready to roll.

>> I'm not going to lie.

It's really tough to know if the ACL's intact from doing that sign

when the knee is in that shape,

when there's that much damage.

During global swelling like that, it's very difficult to have clear tests,

with the exception if there's a full full tear

and there's just full laxity

when you're doing certain special tests.

But in general, it's tough to point that out.

>> We need to admit our incarcerated patient, Gus.

>> What did the CT show?

>> Moderate pulmonary contusion, three rib fractures,

no intra-abdominal bleeding, and oblique fracture in the body of the mandible

anterior to the angle.

>> All favorable for healing.

What's the treatment plan?

>> A pain Pain medication,

antibiotics, liquid diet, um a pulse ox a few times a day, and then

also um dressing changes for the laceration.

>> Which he can get at his correctional

he stays here for a few days and we get him on the right track to healing.

>> Why don't you two go check on your

>> What am I missing?

>> That's a great question.

I was expecting conflict,

but he's admitting that he might be missing something.

That's very >> Do you think that's enough information

for him to have to

admit the patient or

>> In a situation where

in the pit they're already

overloaded, beds are premium,

you have to be

aware that you need space.

So, you try and

decrease the need for people to spend time at the hospital.

In addition to thinking about the fact that every time you bring a patient

into the hospital, you're risking

them getting a hospital-associated infection.

And in a hospital traditionally,

you're not resting well.

The lights are always on, people moving around.

Maybe a correctional facility

isn't comparable to home,

but if you spent years there and you're comfortable there,

maybe you're resting there as well.

But, if he's not aware of something,

some risk, some healing factor, perhaps

this will change his guidance.

>> He's not getting enough to eat at his correctional facility.

The portions are tiny, too many carbs, not enough fruits or vegetables.

He's lucky he hasn't developed a chronic illness.

>> We don't have any inpatient beds.

He would board down here for 3 days.

We're still getting runs from Westbridge,

and we cannot tie up behavioral for that

>> Also, based on his presentation,

it'd would very unique

to understand why he's so advanced

in his malnutrition as a single individual.

Like, are they not feeding him specifically?

Are Are inmates stealing his food?

Some further questioning would be helpful here because if that's the case,

you can have social work actually begin the process of investigating

the correctional facility and asking them questions.

>> Why don't I call the prison doctor and find out what they're working with him on there? >> Thank you. >> My pleasure.

>> But see, in a scenario like this, it would be great to palm this

off to a med student

or perhaps social worker,

not the director of the ED, so.

>> What do you say, kid?

Ready to go home?

>> How's your pain, Mrs. Hamler? >> It's the same.

>> We're going to write you a script for Keppra.

You'll take that to prevent seizures

once a day starting tomorrow.

>> Between your broken leg and the bruises from your seizure, the pain will probably

get a little worse.

>> Yeah, the most important thing is to let others help you.

You want assistance showering and getting to the bathroom. >> Yeah, no problem.

I won't leave her

>> In a scenario like this, giving the plan is smart,

but then asking the patient,

does she have any concerns about going home?

Cuz it seems like >> There's a Yeah,

there's >> There's some kind of hesitation there.

>> All right, fill me in. This is Halogram.

She was seen in triage.

CBC and CMP came back normal.

IT was supposed to bring the VRI down, but they're slammed.

I know a bit of sign

Hello, this is Dr.

Hi Halogram, how are you feeling?

She has a headache. Okay, what else?

What is she saying?

I think she had a stomach ache

and she might have passed out.

>> This is getting into not great territory

because when you're trying to understand

someone uh, who speaks in sign language

uh, or communicates in sign language,

or perhaps even just a different language.

There is this temptation

to take a shortcut

of have someone who kind

of knows the language to interpret.

But, there is a fine line between presenting accurate information

and dangerously inaccurate information.

So, in a scenario where someone's not sure, it's better to communicate

by writing in a scenario like this.

It's actually why a lot of channels on YouTube

will have their content

dubbed in a different language.

We have not yet done that in many languages.

We've done professional transcriptions

in Spanish, but not dubbing. Why?

Because if someone is to dub

my voice in a different language

and slightly, uh, change

the inference of what I'm saying,

that can lead someone to making a bad healthcare choice for themselves

or their family members

in a different country.

And it's very expensive

to have a medical

professional actually do that dubbing.

So, we have held off on that.

But, interesting to show how

nuance really matters in healthcare

>> I'm not 100% sure. Okay.

Um, we're just going to need to wait for an interpreter cuz I need

to ask a million questions and I can't do it this way.

So, just call me when IT comes down.

>> Talk to the patient, though.

>> For the assessment, palpate

all long bones starting with the clavicle. >> Got it.

We'll take the lower

Distal radius tender, no deformities, needs an x-ray.

>> No bony tenderness down here, no laxity of the knee.

>> Any concern about that knee joint?

if it's an open joint, he'll need a washout in the OR.

>> We could try a fluorescein injection.

Okay, we'll need a wood splint.

>> lidocaine with epi, sterile saline, sterile basin, sterile fluoro strip,

18 and 27 gauge needles, 5 and 60 cc

>> Interesting what they're doing.

I guess they're trying to figure out if

the potential opening has

gone into the joint itself

because the skin and the superficial

tissues there, the fascia,

they can experience some infection,

some bacteria, but if it starts entering

the joint, that requires IV antibiotic treatment.

So, what they do typically

is insert this dye

that actually has been used in a previous episode to check for a corneal abrasion.

Similar premise just with saline

to see if it actually starts entering the knee joint.

If it does, high risk

for infection, so you want to be

uh prepared for that.

>> Lights out, was lamp on?

I want to use some of that on Halloween.

>> That is 250 cc's

of sterile saline with one small touch of a sterile

We are going to inject this fluid into your knee, Brandon,

and if there's anything glowing

in your wound, we know we have a leak.

>> This could also be done to check for fistulas.

If there's an abnormal connection somewhere in the body,

you can inject into one part of the body and see if it transports

there because of this new path that's created.

And sometimes fistulas and these abnormal connections form just from friction within organs.

So, this is pretty wild,

but you can actually develop

your colon rubbing against your bladder

to the point where you can create

a feces end up in the bladder

and you end up urinating feces. >> Yeah.

So, imagine how scary that is to a patient when they start experiencing

that and they present that way and they go, "What is going on?"

Recurrent UTIs, foul smell, etc.

That's why you need to always think about

potential fistulas as part of your diagnosis.

>> You'd have to surgically operate. >> Correct.

Like you'd have to Yeah, yeah, yeah. >> That looks good.

Last irrigation did not enter into the joint space. >> Surgery not needed. >> Excellent.

I can get back to the grave.

>> No, we'll still need to stitch you up and splint your wrist.

>> Hang in there, grandma. Vancomycin.

>> Wait, he has a penicillin allergy.

>> No, Pen V test was negative. We're okay.

>> My mom said I got a rash with amoxicillin

when I was 2.

>> 90 plus percent grow out of their penicillin allergies from childhood.

So, a lot of people come in saying they have a penicillin

allergy, and sometimes we do some testing to rule out

if they still do.

Because if they don't,

it's better to use

a medication like penicillin, which has lower rate of side effects

and is more targeted to the type of bacteria

that we expect to find,

therefore creating less bacterial resistance to antibiotics.

>> Yeah, probably not a true allergy.

Go ahead and give her the Kim.

>> But have epinephrine standing by, right?

>> Yes, to be on the safe side.

>> Well, it's the ER.

I'm hoping that there >> epinephrine and Benadryl.

>> Most people who think they have a penicillin allergy actually don't.

>> Always listen to the nurses.

They run the ER.

We just try and stay out of their way.

>> And in general, when people tell me they have a drug allergy,

many times it's something like, "Oh, my stomach gets upset when I take this medicine."

It's not exactly an allergy.

And it's important to differentiate

between the two because,

look, having an upset stomach

but decreasing the risk of a complication

might be worth it

versus someone has anaphylactic

shock as a result of a medication.

Way different proposition, so.

>> Hey, uh I just got word that the at-home morphine pump is going to be delayed.

Hospital pharmacy has to mix it and then deliver it later today.

>> Well, should we keep her here until it's

>> No, you can give her a 200-mg

tablet of MS Contin. >> 200 mg?

>> Biggest pill they make.

Releases over 12 hours for patients with opiate >> Got it.

>> I'm surprised you're not doing fentanyl patches for her, cuz that

is a much more potent medication,

but it's a patch, so

it doesn't have to be taken by mouth, and you can get really high

doses, which is why fentanyl could be so dangerous.

But for someone who's,

as he said, opiate tolerant, meaning they've taken

huge doses, their body has become accustomed to those doses.

>> You gave us a clozapine

ileus about an hour ago.

Your resident reported no surgical history, but the chart says they've had an appendectomy.

We're not admitting the patient without a surgery >> Who called it in? >> A Dr. Chaney Santos. >> Dr.

Santos, you had an ileus patient,

you neglected to mention a history of

>> There was no history of appendectomy.

It was in your note.

I may have forgotten to proof check it.

I was using the app that Dr.

Al Hashimi suggested to catch up on my charting. >> Ah, Dr. Al Hashimi. >> Dr.

Santos was just using your AI tool.

>> Oh, that's I can't be blamed on you.

You have to proofread the note. >> I said it.

>> It hallucinated a history of

>> As I mentioned to Dr.

Santos, generative AI is not perfect.

We still need to proofread

every chart it creates.

>> The patient also has a history of headache followed by Dr.

Park from >> That should probably be neurology.

>> Unless urology is her now treating

>> Another example that should have been caught by proofreading.

AI's 2% error rate is still better than

>> Yeah, I don't really give a whether or not you want to use robots down here.

I need accurate information in the medical record.

>> You know what I will say?

We're having all these wars about this 2% accuracy.

>> When I was on wards,

you should have seen

the handwriting of the specialist.

>> Yeah, yeah, yeah, yeah. >> Completely illegible. Completely.

In fact, there were some it wasn't even worth looking at the note.

You would just know that they were there because their note was semi-present,

and you have to page them every time.

And you know what's weird?

They were so sweet,

and they would explain everything that

But why do you want the call?

Since you're already writing it, make it

>> If they knew how we practiced medicine 20 years ago when there were no

computers involved, this is a miracle. >> Compared to that.

>> I mean a friend of mine who who is a doctor

specializes in end-of-life care.

He he says that I mean he's the most

hyper-vigilant obsessive perfectionist and he's terrified

of making a mistake cuz you're human.

You know, you deserve to have a bad day.

You deserve to be sleep deprived.

The fact that that could affect someone's care or someone's diagnosis

or so he is

team AI because it can

reduce human blind spot at the end of the day but needs strict supervision.

>> I just got off the phone with the

physician assistant at the prison.

They've got a 16-hour

day infirmary with NP and PA coverage giving everything that we need and they've

got an RN for

>> Even so he's here because they're ignoring his basic needs.

>> He's here because someone kicked the out of him.

>> I think you're missing the point.

We have more to offer.

Robbie the four more coming our way. >> Okay, got it.

Um what you're trying to do is very noble.

We don't have the resources to spare.

>> Okay, then why admit him to our house demanding Digby?

Why not send him back to the street with antibiotics

and a roll of gauze?

>> Because Digby lives on the street

and your incarcerated patient has a mid-level provider

and a nurse looking after him.

>> We both know the quality of care is not the same.

>> Sorry, you're waiting for me? >> No, uh Dr.

Al-Sheemy for the patient in

A few days here could make a world of difference for Gus's health.

>> We are a safety net

but nets have holes.

We are not admitting him because this is not about social justice.

>> Everything I've done in my career is an effort to improve the system.

Just because you know it's broken

doesn't mean you stop trying.

>> I think in a scenario

like that fixing the system

could mean a lot of different things.

Maybe it's not about admitting this patient to fix the system

but using that as an opportunity

to create a line of communication

dialogue with the prison system to find out why these holes in the safety net exist.

Because in an ER setting

I would have to agree

with Noah here in that

in an ER you're trying to stabilize a patient and either make the choice

that they need to be admitted for medical reasons

or they need to go

we call it disposition

where they'll be looked after.

And if it's not a high complexity

of illness we can send them to a different facility to get care.

But now if we feel like that facility is not doing a great job,

we can start an investigation.

We can start a line of dialogue.

If you make the decision

to universally bring people in, you'll get to the point where you can't deliver

>> care to almost anyone.

>> Just from a story

perspective and what this moment represents

these two characters is

they're both coming in with their

their experiences, their biases.

We'll learn a bit a little bit later why Dr.

might favor the incarcerated

patient in this instance,

but I think she's had experience

where where these kinds of things are sort of pushed under the rug

>> and and that that's more the norm

than anything else and

it also just shows

their position and their philosophies

as >> That he's somebody

the hardship that she's experienced

that we'll learn more about

has made her lean in more and become more empathetic

and want to sort of refine

and find creative solutions.

And for him it's

it's made him in ways more callous

and more um detached.

And so I think what what this moment represents

more is that the pair are

or how they are coming at this from

diametrically opposed in a diametrically opposed way.

They're just polar >> I think it shows how

while health care is a science, it's also an art and two good doctors

can have reasonably different plans for a patient. >> their experiences, yes. Yes.

>> Robbie, pulse ox just dropped. >> What happened? >> I don't know.

I stepped out for a >> It's down to 85%.

>> You having some trouble breathing? >> A little.

>> Start him on 2 L oxygen nasal cannula. Titrate to 5.

Keep the pulse ox at 92

or higher unless >> Unless you have a pneumothorax.

>> He's going to have to stay? >> For how long? >> Not sure. >> Sorry, boss.

I only stepped out for a

>> Let me know if anything changes.

>> You were in the room when his pulse ox

>> What were you doing?

>> They still can't get a hold of ortho.

Leave him in the maze.

>> What did What did she She put tape on it so it didn't catch a signal?

Can I assume that you've already called upstairs to get Gus Forney a bed?

Do you want to tell me what you did?

>> I don't know what you're talking about.

>> His pulse ox was steady.

We were about to discharge him. Did Dr.

Elshtain put you up to that? >> Dr. Elshtain me? No.

>> You know he's going to go back to prison after they discharge him upstairs.

I thought you didn't go the extra distance for your patients anymore.

>> This is This is a little bit

>> Saying that she's going to extra

distance faking something for him

is not necessarily going to extra distance.

Now, he might be exposed to extra testing that he doesn't need.

>> Can also create side effects of that and more problems for him.

Also, as an ER doc, you can call upstairs for an admission

from us in internal medicine or family medicine ward.

We'll come down, examine the patient.

If we don't feel like it's a good admission,

it might get rejected. Yeah, so.

>> You're creating some interpersonal conflicts as well.

>> Could this be Is this illegal what she

>> I mean, no one will know.

That That's the That's the real answer.

In reality, all she needed to do was say,

"Hey, his blood pressure was low.

His pulse ox was low."

She didn't even need to create that scene.

And something to point out there is the pulse ox is such an imperfect

device to capture someone's pulse.

So, if they have their nails painted, if their fingers are cold,

it doesn't catch a good signal.

So often someone's pulse ox drops and we readjusted and it's fine.

The fact that his pulse ox dropped for 30 seconds

and we readjusted and it was good and that's the reason why he's staying

is also a little bit >> overblown perhaps.

>> Found this with his stuff.

Who knew he was married?

That's Rhonda, Louis' wife. High school sweetheart.

He never really wanted kids.

But Rhonda wore him down

and when she finally got pregnant,

he changed his tune. He got excited.

And then about a month before the baby was due,

Rhonda and the baby were killed in a car crash.

Though he never really came back from

May his memory be a blessing.

>> May his memory be a blessing.

>> It's so important to have those moments to not lose humanity

for not just the patients, but also for the providers.

It's so easy to get cold

to death and destruction

and mayhem when you're seeing it all day long.

>> But at the end of the day,

there's always reasons for why things happen and sometimes we're not aware of them

and we're quick to judge.

So moments of reflection like that are so powerful.

>> Yeah, and it's almost like a ritual, right?

It's a practice that that becomes

part of the humanity and care.

>> Interesting that again, in an episode

that highlights the humanity of patients

and providers, we're also on one hand talking about

how important it is to talk about humans,

but also AIs in this >> Yes. Yes.

>> There are so many topics covered in this one episode.

It's it's really >> It's what's so

um compelling about this show because on the surface

it's about a hospital.

It's about these healthcare workers, but it really

in essence it's about everything

and everyone, all these societal

issues that walk through the door.

From immigration, we'll see in later episodes with ICE

episode with ICE and

last season gun violence

um you know, sex trafficking,

grief, poverty, houseless community I mean, there's so many different things

and and to for example,

with the the mass shooting last season, we see unfortunately

in this country too often

these cases we'll read about it or it'll be in the news cycle for

a day or even a week, but then it's gone

and what The Pit has done I think for the first time

in history beyond documentaries

um really showed not just the the cost on on patients,

but also on the health care workers and how

Robbie last season was housing

this PTSD and grief from his mentor's passing,

but now this season

they all have a shared

collective traumatic experience that they're holding

and like I said before this scar tissue that forms that just gets

you know, harder and harder to get rid of

>> Yeah, there's some kind of metaphor to be had where scar tissue

in the human body, whether it's on the skin or inside the body

it helps you stay functional

because that's what it's goal is

but at the same time it doesn't replace

the the tissue that was there one to one

and it does make you

from tensile skin strength a little bit

a little bit less effective.

So, it leaves its lasting

mark on you and unless you address it and know that it's there,

it's easy to think that oh, you're fine

but in reality it's not quite fine

you're functional, but that chronic stress can wear you down

and and the practice

of post surgery, at least So know this from a a dance injury that I had.

You know, you have to massage the point.

You have to care for and and take care of

>> um consistently or else that scar tissue forms, right?

>> And so I think all of these can be can be viewed as as

metaphors for, you know, our inner experience,

too, our emotional >> And uh I can't let you go without pointing out that

speaking of societal issues,

you've been very vocal about what's going on in Iran.

>> Uh first with protests,

now with the war.

Any statement you want to leave with the audience about what what's important to you?

You Correct me if I'm wrong, you were an Iranian refugee? >> Okay. Yeah.

So this must mean even more to you then. >> It does.

And I mean a big

uh population of Iranians

migrated before the revolution

in '79 and um even more

um I believe, if I'm not mistaken, after the revolution.

My family stayed and and fought for democracy

essentially for as long as they could and were there during the Iran-Iraq

War as well until they were forced to flee like most refugees.

Um and lived in camps for a while.

I was born in a refugee camp and and so

that experience and this

medieval despotic regime has

really forged my my my worldview

and my existence at like many Iranians.

And and seeing this right now, not only this

uprising that's been um

repressed brutally as always.

We've seen this throughout the past 47

years where there's mass uprising

met with violent >> And so we saw

late December, early January,

there was a wave of protests

that were the the biggest in Iran's modern

history about, you know, economic

um decline and inflation.

And so bazaar owners, shop owners closed their shops and stormed the streets.

And then as per usual,

it's a similar pattern

where the regime will

will um cut out the internet.

So, there's an internet blackout

still um a few months in

and um just you know ruthless execution.

There are over 7,500

confirmed dead from the regime from those protests

and another 15 or 17,000

bodies that haven't been accounted

for, but if history has told us anything, it's that the number is often

it's so so much more.

It's far higher than than what we know.

They don't want reform. They've tried reform.

Uh they want a regime change

and they want to have a voice in change.

There needs to be a regime that

that accounts for for the plurality

that exists uh in in Iran

of of ethnic backgrounds,

uh political backgrounds, religious backgrounds.

And so, it's been a 47-year struggle.

It's been a century-long struggle in Iran.

It didn't start with this regime, but

um it's certainly worse than anyone could have ever imagined.

And now with the war, obviously,

things have intensified and and

I I don't know of an example in modern history where

where we've been able to bomb our way into

democracy, uh you know, from from an airstrikes campaign.

It's it's very complicated,

but what's not complicated

is the humanitarian cost

and that people in Iran need a need our attention.

They need our voices

um to know that the world has not turned their back,

that they're not being killed and repressed in silence.

I think they arrested

something like 50,000 protesters

in in a few days.

And all of these people,

they don't get proper trials.

They're kangaroo trials and they're given sentences

like you you've created acts upon that that disservice

God or or an enemy of God or excuse me.

Um and then they're they're publicly hanged.

They're were >> Even some doctors are being held liable for giving care to the protesters. That's >> That's right. That's right.

That's >> Being pulled out of their beds in the middle of the night.

It's just >> That's right.

And this this new precedent

of of health care workers being targeted,

it's it's really horrific.

Um and so you know, as best we can, we have to amplify

and use our voices

and and there are international

laws against this that are obviously ignored.

>> And you work with the IRC, right?

>> Yes, the IRC International

Rescue Committee, which is a refugee um resettlement agency.

They provide services in 40 different countries and all over the the United States as well. >> Do they accept donations? >> Yes. Yes.

>> Yes, with lots of help. >> Absolutely.

I'd love to donate $10,000

on your behalf for

for being such a great advocate for an important cause.

So yeah, >> That means so much.

Thank >> Well, I think it's a small part where we can play a role.

Um there's people all around the world that are struggling in these terrible circumstances

where you wish you could be there to help everyone,

but perhaps the a small token of just our attention

>> can start a >> And something

one last thing that I want to layer in here that you'll see starting

the next episode with my character.

It's not a spoiler,

but she worked with Medecins

Sans Frontieres, Doctors Without Borders, as a humanitarian

aid worker, as a doctor.

And right now when we're living through or we're witnessing

unprecedented humanitarian crises from

global disaster, I mean, climate disaster

to war and displacement

to rising authoritarianism and

you know, the shutting down of of of medical facilities,

clinics around the world,

um I think having

a character like this

adds a certain gravity

to to the world of The Pit and an important

representation or visibility that so many of

you know, your brave colleagues

go and fly across the world to help in

war devastated um places

and and leave forever

um affected and forever scarred

and and forever indebted

to be the voice of the people their colleagues abroad because

medicine as you know, it's a language

and once you're doctor in one place you're needed everywhere.

And so it it's it's the same medicine

different dialects, but but I think that the practices

we were talking earlier about the edge effect

of you know, diversity

actually creates is generative

and and can help us all improve

and help our health care workers

as we've heard from testimonies

of people who are humanitarian

aid workers who serve as doctors in

in different crisis zones.

That that it does only make us better to to keep our eyes open

and and use our

our platforms and and our

areas of expertise specialties

or anything we can do to help.

>> Well, I thank you for using your platform in that way and we're going

to leave some sources

in the description of this video to push people in that direction. So, thank you.

And if you'd like to see me interview Dr.

Al-Hashimi's adversary, click here to check that out and as always stay happy and healthy.