Doctor Reacts To The Pitt Season 2 Episode 5

All right, season 2 episode 5, The Pit.

Let's get started with this episode.

Be Hello, I'm Dr. Robbie.

Want if I take a

Uh how long do you think this is going to take?

I took an early lunch break.

I don't know that you're going to make it back to work today.

Erythema and warmth halfway up her knee.

When did you see her, Donnie? He didn't. I did.

>> Yeah, so usually when a patient comes in with cellulitis,

the go-to treatment is oral antibiotics.

We don't even go for topical treatment once cellulitis is present.

If it continues to spread past

the demarcation that we usually

draw using a skin marker,

we say that this is spreading.

It can potentially be resistant

to the oral antibiotics

that we chose, or perhaps the oral antibiotics

are not strong enough reaching

enough the skin, the tissues that are being impacted.

So, we do IV antibiotics

to prevent that spread,

not just in the skin, but also to prevent the spread to other parts

of the body, bones, joints, etc.

>> About 4 hours ago, I gave her a dose of Keflex.

Told her to come back if things got worse.

>> That's a cephalosporin, one of the classic

agents that we use for cellulitis.

But, you always have to wonder if a patient

has risks for developing cellulitis from MRSA.

So, a patient that's a healthcare

worker, someone that resides in a long-term

care facility or works in a long-term care facility, these are risk factors

for having MRSA, which is a type of bacteria

that is resistant to certain antibiotics.

You need to think of coverage for that.

And traditionally, we use

doxycycline or Bactrim as coverage

to cover for MRSA bacteria.

Things have definitely gotten worse. Dating, what's up? Trauma two.

Jesse, can you get her started in trauma two with some vanco and blood

cultures, >> Got it, boss.

>> So, the reason he's starting with vanco

is he's starting with a big gun.

Usually with a bacterial infections in the hospital,

we start with a antibiotic

in a serious infection, not for mild.

We start with a big antibiotic

that's broad, that covers a lot of different bacteria.

And then as we get cultures

back, uh we're able to identify the organism, we can narrow down

which antibiotic we're giving so that we're not creating

and fueling more antibiotic

Consider the diagnosis of aortic aneurysm or dissection.

>> Got a new one for you in 13.

I'm 20 charts behind and the new attending is threatening to make me repeat

ER if I can't catch up.

It's really hard to get your charts done while you're working.

A lot of times doctors are spending time after their shift.

There's a really great stat somewhere, maybe we could pop it up on screen,

how much time for each patient a doctor has to spend after hours

charting for that visit.

>> Coronary liver old lady with bad abdominal pain.

Somebody's got to see him.

Dana, please do me a solid.

Holiday weekend, Westbridge is down and our waiting room's on overdrive.

I'm sorry, but your charting's going to have to wait until after your shift. Dr.

Santos needs you to pick up a new patient in 13. Y- yes, ma'am. I'm on it.

That's where med students really do shine.

When you're having patients wait for a long period of time, they can do

the preliminary assessment, have that conversation

with the patient, present

it to the resident.

The resident then can go see the patient and they should.

They should not rely on the med student's assessment,

and then present that to their attending

with a plan in mind. Oh.

Uh hypoactive bowel sounds,

soft with moderate tenderness in the left lower

>> Uh he's saying that the

bowels are not moving normally.

That's when you say that you have hypoactive bowel sounds.

Soft non-tender is reassuring

because that's less likely that a patient is having an acute abdomen

from, let's say, colitis,

appendicitis, all the itises. This is Randolph.

You said you don't take Percocet every day, but when was the last time you took some?

Maybe three or four times last week. Yeah.

Assisted living had a ballroom

dance competition and I tweaked my back. Mhm.

Any further questions, Ogilvie?

Uh when was your last bowel movement? I don't know.

Sometime week, I've been stopped

up for at least 5 or 6 days.

A good question after

a patient answers about when their last bowel movement

was, is that typical for you?

Because for some people,

going every 3 days

could be normal and that's part of their normal digestive system.

So, this old rule that we used to have where we say you have

to have a bowel movement every day and that's normal

is not exactly true.

There is a range there.

Painkillers can cause constipation. >> I know.

That's why they put me on a stool softener

and then they tried an enema.

And and no movement? Nope.

What's interesting is when someone has a true

colonic impaction from stool,

what can happen and throws

young doctors off the scent of constipation,

not to be pun intended, but that you could actually have diarrhea

with this impaction where the diarrhea kind of goes around

the impaction and they think, oh, well, they're having bowel movements, but it's not

a complete bowel movement.

There's still this stool load that's very dry

and not passing creating a lot of discomfort.

Let's get you an x-ray and see how we can help you, Mrs. Randall. Thank you.

Uh probable stool impaction, but with her history of cholecystectomy,

it could be small bowel obstruction.

Every time someone has a prior

abdominal surgery, that puts them at a higher risk for developing

adhesions and adhesions across the small bowel can create obstructions

cuz imagine it's literally like a piece of scar tissue that wraps itself around

the intestine, creates a small bowel obstruction.

Usually a person's not able to tolerate

any oral intake, fluids,

food and as a result, they're vomiting profusely.

And in some cases, we do put an NG tube in into their nose

and then reaching into their stomach.

It's called the nasogastric

tube and we put it on intermittent

suction in order to allow all the fluids that naturally

occur in the upper part of the

GI tract to stop putting pressure on this obstruction,

potentially opening it up and letting it pass.

And notice I said specifically

intermittent suction because if you keep it on constant

suction in order to get all the fluids out, what can happen is the

tube can actually attach to the wall

of the stomach and constantly

put pressure on it, therefore damaging

it and you'll start seeing blood

inside the nasogastric emptying

bowl or collection I don't even know what it's called >> Or worse. Sigmoid volvulus?

But that's a surgical emergency.

Wouldn't you have tons of pain?

Not always, especially when you're in your 80s.

They're talking about a malrotation of the intestine.

Setting up a GoFundMe

that's what our generation does.

That's how they support each other. Doctor, tell him. >> Your wife's right.

Staying here is going to cost more than we can afford.

Look, I'm feeling better. I'll just leave. Mr.

Diaz, even if your blood sugar is back to normal, we have to continue

with the insulin drip until we clear the ketones from your bloodstream.

Otherwise, you could experience electrolyte

disorders, heart and kidney problems

>> That's why when a patient comes in with DKA,

a lot of times they don't stay in the ER for long and they

get admitted into the ICU

because this type of electrolyte

management needs to be very carefully managed cuz you could easily

overdo it or underdo it leading to,

as she said, cardiac or kidney failure.

I'll make you a deal.

You agree to stay on the insulin drip and I'll go find our case

manager to discuss cost-cutting

options for your stay. Deal.

And I'm sitting here making sure he doesn't move.

You should go look for Anna. Mhm.

I can find her. Hang in vanco. Uh what's vanco?

A really strong antibiotic

to kill skin >> And we uh generally

only give vancomycin uh IV.

There is one indication

that you give it orally

and that is for the treatment of C.

difficile, which is a type of bacteria that can cause one of the meanest

forms of diarrhea in patients. It's very transmissible.

That's why if there's a patient who has it on service,

we have contact precautions.

We're not just using hand sanitizer.

We're washing our hands to get rid of those spores.

The reason we give vancomycin

orally in those situations

is because it's not well absorbed.

So, it's action actually happens

inside the intestine, which is what we would want in a C.

diff infection, but not in a skin infection where we need it to be absorbed.

That's why we give it IV.

Uh let's send off a CBC,

blood cultures, and CMP.

And also lactic acid, CRP, and calcitonin.

But she's not febrile, not tachycardic,

no evidence of SIRS.

They're debating whether or not she has criteria

matching for sepsis, which is basically

an overreaction to an infection

by the body, which

can lead to septic shock and organ failure

and ultimately death if you don't act quick enough.

So, time is of the essence there. What's SIRS?

Systemic inflammatory response syndrome.

We used to uh make the diagnosis

of sepsis by saying

they need to have

this criteria of SIRS

plus a source of infection.

And for some billing purposes, we still do that,

but there are new recommendations

that we use to make the diagnosis

of sepsis using the sepsis 3 criteria

with the acronym SOFA,

and technically that is the more accurate way to make the diagnosis of sepsis.

An exaggerated defense response.

>> So, what a what Sometimes

the human body can have an overreaction to an infection.

So, we're going to monitor you and make sure that this does not progress.

That is very aggressive

uh given the fact that yes,

the skin redness is worsening,

but unless she has signs

of liver failure, kidney failure,

and organ damage, significant

white blood cell count,

vital sign disruption, it's going to be very unlikely that it is sepsis.

But maybe he knows something I don't know, cuz a lot of this is

based on clinical judgment. It's my boss.

Sorry, I have to take this or he's going to fire me.

Uh no, I'm still at the hospital.

I'm being seen right now.

did just stick me with a needle?

Um, I don't know.

You want to talk to them?

I love that he just goes, "Nah." Second IV's in.

Well, I'm not overreacting.

My My body's overreacting.

That's actually a very valuable point because that's what sepsis technically is. This is Dr. Michael Rabinovich.

I am the chief of emergency medicine at PTMC.

If you fire her, she will sue you and I will testify on her behalf. Okay. Well done.

I am getting concerned.

This is a millimeter past the line.

Or my line was sloppy.

Any increase in pain? Oh. Okay. Sorry.

Let's try four more feet.

White counts only 10,000.

It'd be over 12 for sepsis.

There are other criteria. She's still afebrile.

Did you ask about past history of MRSA?

They're really spending a lot of time

dedicating themselves to a patient with a rash.

And that's probably signaling that something's going to happen with this patient, but in

reality in a hospital,

you take a look,

you get the vitals, you get the initial lab results, and you make a plan.

Not specifically, but she's never been

>> Any evidence of an immunocompromised >> No, she's healthy. Steroid use? >> Never.

Maximum heart rate's only 89. Is that okay? That's good. Very good. Stay with her. Monitor her closely.

If there's any change in her condition, come find me.

I mean, any change.

Why he's so certain that something bad is about to happen.

It's like he's in the writer's room.

Roxy Hamler, 42, home hospice patient with a history of lung cancer.

New onset tonic-clonic seizure with right lower leg pain.

She hit it on the coffee table.

Initially non-verbal, now coming around.

>> That's normal after a seizure.

A lot of times patients

after a seizure have a moment of confusion.

And sometimes uh the confusion is so bad that they can actually become

angry, combative, and they do not remember

this uh postictal state.

Uh that's what we call it.

She hit her head? No, I there. I caught her. No IV?

Couldn't get one in.

Give her four of IV versed for the seizure, 25 of fentanyl for the pain.

Maybe an IO would do well here.

This is an intraosseous

line where you could put into the tibia.

Literally fluids going directly into the bone.

It looks really painful

and I wouldn't say it's comfortable, but if done correctly,

it's not really painful.

In a situation where someone's hospice, it doesn't mean you do not treat this patient.

It means you treat the patient's

symptoms and you make sure that they're comfortable

and part of that

uh can mean medical intervention.

Gus Varney, 54, victim of assault with a few blunt trauma.

He's got bruising to the face, the right chest, 10 cm laceration

to the left arm.

BP's 136 over 84, pulse 102,

good sats 95 on room air.

Reassuring, but obviously someone that needs to be scanned based on the mechanism of injury.

Some sutures need to be put in and

uh we need to make sure that he's not bleeding internally.

Gus, do you know who hurt you?

One of the fine upstanding citizens of cell block six.

It's a deep lack in the through the muscle fascia.

Um can we get the cuffs off once he settles? Not a chance.

Orange jumpsuit, he's cuffed for a reason.

Some of these episodes

can get quite bloody.

I've worked in an inner city

uh Brooklyn hospital when I was

um in my I believe third-year rotations

in medical school and there was a person who came in with an illegal

firearm that ended up,

I believe, shooting themselves by accident in the hand.

While we were trying to help this individual because they were under some illicit

substance use, they were waving their hand all over the place, blood went everywhere

and uh it's very difficult to manage and you have to be careful for

infection protection for yourself as a provider.

Not just from open wounds, but also getting it into your eyes, your mouth,

so you're wearing face shields, etc. One, two. Hold on. One, two, three. Eat fast.

They're doing a ultrasound

to see if there's any internal bleeding.

And they need to cut off all the clothing to make sure that they

find all sources of bleeding and all potential avenues of trauma. Oh, weird bruise.

Did he fall on something? Footprint. Got stomped. Jesus.

Broken ribs can easily be in your pneumothorax.

You want to listen to the lungs and see if you have decreased breath sounds.

Uh if you do, that potentially warrants intervention.

Uh usually at the end by a chest tube, but a needle could do the trick initially. Airways patent.

Good lung sliding on the left. Ugh. Sorry.

Good on the right, too.

How are the lungs?

Uh good breath sounds.

No >> Good, there's no air

inside, which means uh in the chest cavity.

Uh most people think there should be air in the chest cavity, and there

should be air in lungs, but not in the chest cavity itself.

That would mean that there's some kind of break

uh either in the lung or in the chest wall.

Wade, could I hear your assessment?

Fractured left mandible, multiple

rib fractures, complex forearm lac.

Okay, log roll to the left then pan scan?

Where were you when Mr. Varney got assaulted? I just move them.

I don't get to know them.

CT's ready for us.

They're checking for tenderness to palpation

across the vertebrae in the

Probably they're doing the entire spine.

So, the cervical, thoracic, lumbar, and sacral areas.

And it's definitely extra

because they're also going to be doing a pan scan, which they would be

able to see all these vertebrae.

And given the level of trauma that he had,

you'd want to check all those areas for fractures on the scan.

Okay, this redness is now a centimeter over that line.

And this might be a bullet for me.

Vancomycin takes a little time to work.

Vitals are still stable. 122 over 78. I got it.

How are you feeling, Debbie?

I'm feeling a little warm.

There is a condition called

uh red man syndrome,

uh which happens if you give

uh vancomycin by IV

with too fast of an infusion.

One of the treatments

for it is actually slowing

the rate of vancomycin

infusion in order to decrease this flushing impact that happens.

And it's it's pretty benign, but it is uncomfortable to the patient. Lactic acid 4.2. Oh. Uh okay. What's wrong?

That can be a sign of a more serious infection, but the good news

is we know what to do.

Jesse, 2 L of LR wide open.

So, they're giving fluids in order to decrease

the impact from this infection

because when you're starting to experience

sepsis, what ends up happening is you have

uh metabolic disturbance as well as a circulatory

disturbance, which ultimately can harm organs.

This is severe sepsis.

I know, but at 7:00 a.m.

it was a simple cellulitis.

Anyone would have given her Keflex.

We could add carbapenem or Zosyn to broaden our antibiotic coverage.

Okay, I'm on it. Got it.

1 g meropenem, 900 mg clindamycin page Dr. Garcia, please.

>> Oh, clin- clindamycin is another good coverage for MRSA. What's going on?

We're adding new antibiotics. It's serious.

We want to get ahead of it and make sure it doesn't become serious.

What else can I do?

I think you've done enough. You can go.

Interpersonal conflict is making this patient

encounter worse than it needs to

Hold on to him, Louie.

They're worried about uh alcohol withdrawal.

And in his case, delirium tremens. He's shaky.

Oh, I can take care of myself

if you if you cut me loose right now.

Well, he would actually solve it by drinking alcohol,

and the doctor would give Librium,

which is a benzo medication

to decrease the side effect

of the alcohol withdrawal.

Let's get Louie 50 mg of Librium.

I'll put in the order.

I will get it from the PDS.

Oh, yeah, that is a little awkward.

It was negative for both.

I considered the diagnosis

of cauda equina syndrome.

You read the Great American Novel?

needs to be a thoughtful balance

between providing enough information

and not too much information

where it distracts you from patient care.

And that's a tough line to teach.

>> Who is the lucky patient?

A huntress woman with a bad cough.

Ogilvie's all over it. Okay.

Okay, deep breath in,

blow it out real hard.

You haven't heard enough already?

I need to check for wheezing with forced exhalation.

Wheezing is a sign of some kind of asthmatic process or reactive airways

because what can happen is

due to inflammation and smooth muscle contraction,

you get like thinner airways

and as a result you hear this whistling which people describe as

>> This cough is killing me. You smoke, Mrs. Yardley?

Yeah, but I haven't able to for a couple days cuz this cough.

You ever consider You ever considered

minding your own business?

Not an unusual conversation

in the ER, by the way.

Well, the good news is that your test from earlier came back negative for

both COVID and influenza,

but I'm going to order a chest x-ray so that we can see what's

really going on in those lungs.

You got time to let us do that?

How the hell do you think I got to be? It's interesting.

I think this is the second patient where they act like they just tested

for COVID and flu.

And while we do have a swab that checks for those two viruses,

the usual swabs we get in the ER are the respiratory

viral swabs which check a whole host of viruses.

So I'm surprised they're not doing that swab instead

and just doing the duo.

I have word in

3 g Keflex for 10 minutes.

That'll prevent another seizure. Thank you.

Nobody can ever get an IV in her.

Yeah, a midline cath is the way to go when your veins are shot.

A midline is a line that we can put in under the presence of

an ultrasound which is a little bit longer,

not like a central line cuz it's still peripherally inserted.

A central line kind of goes to the midline of the body

and it's easier to put in in someone who has veins that are hard

to find cuz you're doing it under ultrasound guidance.

And it could stay in a little bit longer than a traditional IV.

Tachy to 114, BP 94

over 70, sat 91 on 2 liters.

Uh is it possible to get her a blanket and some socks?

And a lot of people

point that out that in hospitals

it's always quite cold.

There's a reason for that.

A, uh, when we're in the operating rooms and the ERs,

we're wearing a lot of equipment,

so we want to keep staff comfortable.

There's also a lot of equipment

that's running and it creates a lot of heat, so we want to make

sure that's cooled off.

Also, you want a low humidity

environment, which is part of infection control.

So, when a patient who's already sick, who sometimes has fever, chills,

uh, they feel colder

and quite uncomfortable, so we have to be, uh, cognizant of that and bring

them blankets and make sure they're comfortable.

When was she diagnosed? 7 years ago. Resected a lobe.

Four cycles of platinum chemo gave us a couple good years, but

then it spread to the bones.

Has she had radiation

It shrunk down the mets, but they're still there.

It's interesting that they're having

the conversation about the type of treatment

this individual is getting because this is the ER.

That's not generally where these conversations take place.

If this person was going to be admitted to a hospice

floor, which we do have in some hospitals,

that discussion would be had there, but not again with the ER doctors.

That's why you're at hospice at home. I'm sorry. Me, too.

Uh, swelling and bruising

over the distal tibia? Probably a fracture.

50 fentanyl what's her systolic over

What do you usually take for pain?

That's an important question because

in those who are opioid naive,

uh, opioids can have a really powerful impact, both

good in the sense of

creating a lot of pain control, but also a lot of side effects.

And in those who are

opioid tolerant, meaning they've been taking opioids for a while, like people who are

on hospice, perhaps you need a much higher dose than the average person who's

opioid naive would never be able to tolerate.

>> MS Contin 30 milligrams

twice a day, oxycodone

for breakthrough and sublingual

Actiq for, um, when it gets really bad.

>> 50 micrograms might not be enough.

It's Do you handle her pain meds? All the time.

A hospice nurse comes by

a few times a week, but I was alone when she had the seizure.

They told us that it could happen, but she couldn't breathe. I freaked out. I called 911.

We try and do our best with hospice patients,

especially when you get paged about hospice patients that are on our service,

to keep them at home as much as possible

because they do not want to go to the hospital.

That is not a place where they're going to get good quality care, they're

going to feel comfortable.

They could better be served

by having their visiting nurse

treat their current symptoms.

And remember, they're not being very aggressive

in their treatment, so they might not need all of the full workup that

might happen in the ER.

So sometimes unnecessary treatments can happen there.

So ideally, we try and do our best to keep these patients at home

while adequately treating what's going on.

How are you doing? I'm sorry, Mayda. You're being thoughtful. Just blew up. Well, Mrs.

O'Neil was just telling us that the hospital

is going to give us a big discount.

We can knock 40%

off your final bill.

And I'm sure they could probably knock off some more after the fact.

And in reality, you should always be arguing your medical bills anyway

because hospitals are already

used to negotiating with insurers.

So when debating or arguing with them about your bills and you're going to

be paying cash essentially yourself,

you could usually get huge discounts

by having that conversation.

I stay here for a few

my bill could be over 100,000, right? Yes, unfortunately.

It could end up being lower depending

on your level of needed care. Or higher?

So we'd still have to pay

Which we don't have.

She has to stay here to get better, right? Yes. No. Excuse me?

I mean I'm not necessarily.

Couldn't we just admit to med surge instead of ICU?

Wouldn't that be a lot cheaper?

Med surge won't accept him with an insulin drip.

Usually true, but let me talk to the charge nurse upstairs.

You don't want to deliver sub par care to someone who is

having a very critical

life condition because ultimately

then it could be your fault that that person decompensates

even if it's not truly your fault.

Remember you're putting so much pressure on your staff.

Nurses are already taking care of

too many patients on regular med surge floors.

In the ICU they have less patients per nurse

and as a result

now you're asking the nurse not just to take care of more patients

and watch over them but also manage pumps and things that are reserved for

nurses that are taking care of one or maybe two patients at a time.

I considered the diagnosis

of cauda equina syndrome

but the motor and sensory exam

were both intact in the >> Our in-house scoffer has pneumonia. I'm cursed. I'm cursed.

That is a cavitary

lesion in the right upper lobe.

Cavitary lesion in the right upper lobe,

upper lobe in general,

is tuberculosis until proven otherwise.

So you're putting precautions,

airborne precautions, right away.

You got to ask for history of exposure.

Someone who is homeless,

you need to even think

higher possibility that they have tuberculosis.

There are other conditions

that sometimes if you get a cat scan,

you can lean towards.

Even malignancy can appear with a lesion.

Depending on the thickness

of the cavitary lesion could point you in one direction versus another.

Traditionally malignancies are thicker

and tuberculosis ones are thinner walled.

There's fungal cavitating lesions.

There's even septic emboli

where you can get these clots but usually there's multiple

lesions in that regard.

So the differential still here is broad

but you have to be thinking about tuberculosis. Active TB. What's next?

Uh AFB standing to confirm.

Move her to a negative airflow room.

Start her on Call infection control and public health.

It's a reportable disease,

so you need to right away call the local health department to let them know. Dr. Langdon. Hey, man. Alex.

Let's take a look. Is it bad? It's not good.

So, your church is your burn with dry ice? What happened? My jackass brother.

Does he not like you?

I asked him to do it, just not like this exactly.

Was he doing it for content

or >> Dry ice essentially functions like frostbite.

It's a thermal burn just in the direction of cold.

It dry ice like minus

100° F or something, so it's extremely cold. What? Why?

He was going to brand me like I branded him. Branded? Like cattle?

Instead of hot branding, you stick the iron in dry ice, let it get

super cold, and then you put it on your skin. Cool, huh?

And a lot of people think you need to rewarm the area with hot water.

Please do not do that.

Gentle rewarming with just room temperature water is enough.

Seeking care at an ER is obviously wise.

You think it's going to leave a scar?

I don't think it, I know it.

>> He's doing a a form of physical debridement

where he actually takes off the dead tissue

in order for there to be less chance of infection.

We also have some chemical debridements

that we can put on the wound actually

eat away at that tissue in a way that's controlled, obviously. Dr.

King, how are the chest and belly?

Uh, we have three anterior rib fractures

and a small pulmonary contusion. Not too bad.

When do pulmonary contusions peak?

After a few hours.

And do we always admit for three rib fracture?

Uh, in the elderly, yes, but not if a patient can manage the pain

and doesn't need supplemental

>> And they're not displaced

uh, putting them at a risk for a pneumothorax. Good.

Okay, he's really hurting here.

You think you could set us up with a serratus anterior field block? >> No problem.

Oh, as long as that's okay with Dr.

>> If the patient consents.

They're basically uh numbing the area

across the nerve that gives sensation

to a specific area.

Like I'll do this sometimes if I'm

uh treating an ingrown toenail

or I'm doing something to a finger a procedure.

We do uh digital nerve block where we actually

block the sensation distally

from the area where we make the injection.

You could do the same with

uh many different nerves. Mr.

Varney, we want to give you a shot to numb your broken ribs so

you can breathe easier. Uh-huh.

It's basically what you get when you're at a dentist.

And the reason you breathe easier is because you feel less pain so you're

able to breathe more deeply.

Well, part of the problem is when you break a rib is that you

start breathing more shallow in order to experience

less pain, but when you breathe more shallow,

you end up developing

atelectasis at the bases of your lungs which essentially

means that that part of the lung is not getting oxygenation

not getting filled and therefore dying.

And I don't mean dying like necrosing, just not functioning.

How we doing in here?

Uh spiked a temp to 102, gave Tylenol.

Check out her leg.

That is a definite bulla.

Did surgery come down yet? Not yet. I need surgery? Page them again.

Surgery would be a last resort.

We would like them to come down and check out your leg in case

we need to remove this infected skin.

I thought it was just a little swelling cuz I wore my feet all day.

BP's down to 85 over 40.

Uh-oh, she's becoming hypotensive

so the worry is that she's going to septic shock.

>> Start Levophed titrate to a MAP of 65.

The MAP of 65

is that magic number

uh mean arterial pressure

to make sure that the patient is adequately

providing perfusion blood flow

aka oxygen to vital organs.

It's usually a MAP of 65

and a lactate of two.

>> Can someone please tell me what's going on?

Pulse ox down to 89% non-rebreather.

Sometimes an infection can cause your blood pressure to drop and lower the amount

of oxygen in your blood.

Am I going to be okay?

>> We're doing everything that we can to make sure that you are, Jessie.

It's a be ready to intubate if you need to.

Am I going to call Langdon?

>> No, I will be right back and you can call surgery and tell them

to get their heads out of their asses and get down

You have a non-displaced fracture distal tibia.

So, if you look at the bone here, it's pretty well aligned. Sorry, hi.

Hi, I was in the shower

and I came as soon as I got Paul's message.

>> I'm sorry, I'm confused.

Aren't you off duty?

I'm Roxy's death doula. Mhm. Her Her what?

I help advocate for people like Roxy to make their transition

to death a more peaceful process.

I've never experienced meeting someone like that.

Uh I didn't even know they existed.

Um we were just explaining that Roxy has a pathological

fracture through a metastatic lesion.

Means that the cancer has spread to that area

and as a result that area of the bone is weak, more susceptible to

fracture, and it ended up fractured.

The bones are well aligned, so she won't need surgery.

The treatment is immobilization

and a long leg boot. Ah.

Maybe we up her pain meds? Uh yeah.

>> Yeah, the 50 micrograms was never enough.

The bones should heal in about 6 weeks.

You don't know that the healing process will take it

uh take place in an area of metastatic cancer spread.

Nice job on the subs Qs.

Really took the tension off the wound. Thanks.

I can help with the skin layer.

Yeah, it's very important

that when you're suturing

uh a deep a deep laceration,

you don't just suture the top portions of the skin.

Number one, because there is still an opening below

and as tension builds, the skin can break.

But you actually rebuild

the tissue from the bottom up

and there's different types of sutures that we can do to decrease the tension. >> Woah.

Uh that just tore right through the skin.

May I to take bigger bites farther away from the wound edges. Oh.

this is not working.

He has the skin strength of an 80-year-old.

But, down sterile strips

with benzoin, not across the wound, but along each wound edge, both sides.

And that could be a source of infection.

What say you, Dr. Robby?

McGyver remove, go for it. Does that Dr. McGyver work here? I don't know. The generational divide. Mrs.

Randolph >> Pulled up her x-ray.

Okay, no volvulus, no air fluid levels.

What do you think of this?

Big stool burden, fecal material. A ton.

Sorry, it had to be said.

So, what, she needs an enema?

No, tried and failed, remember? Yeah.

Time to dig in.

How are we going to do that?

Oh, there is no we in disimpaction.

And you have to be careful with disimpaction,

especially in the elderly.

You don't want to

literally pierce the colon.

So, you generally do this stepwise approach.

You remove some of that

impacted stool, and then you give another enema, and you see how it progresses.

Sometimes you have to do it more than once.

I haven't done one before.

Shouldn't I observe first?

I know just the guy to teach you.

It's always the PGY-1s,

interns, which is the same, or the students that are doing the disimpactions.

Nice of you to join us, Huckleberry.

What do you need?

Some help with a

That is a med student procedure.

>> Well, you know the old adage,

see one, do one, teach one.

Say hello to teaching young Ogilvy here. Double glove, Ogilvy. Right. Mrs.

Randolph, we're going to need to manually

unblock your rectum so that we can get your bowels moving again.

Those who are older,

sometimes children, those are who who are taking some medications

uh that slow the transit time of stool

can increase the risk of this developing. Nice and deep.

Curve the finger like an ice cream scoop. bring it out.

Remember, for whatever medical provider

feels in that moment,

the patient feels two, three times as much.

And I don't mean the actual sensation of the disimpaction.

I mean, the the discomfort,

the idea that someone else has to do this for them.

So, you want to do your best to try and make the patient comfortable.

Some more pressure, Mrs. Randolph? I'm ready.

And making sure your fingernails

are cut are really important. Sorry.

Passing gas is good.

Means we're making progress.

Does that mean that I can I can stop? >> No. No, keep going.

Interesting, uh when a patient is admitted

for any kind of GI surgery,

one of the things we have to wait for

and document on the patient's

interval notes is whether or not they are passing gas cuz that means that

the bowels are starting to move again.

Okay, okay, you you might want to

And that could be the diarrhea that's just passing around the impaction.

I spoke to the charge nurse in med-surg.

They can take Orlando today. Yes, that's wonderful.

And 5 days on med-surg

is going to cut your hospital bill down by 2/3.

And does he actually

need to stay that long, or can we get him comfortable,

have his metabolic gap close,

anion gap close, and sugar normalize,

and send him home?

Uh morphine PCA looks ready to go.

This should do the trick.

Uh do you notice a difference? Better. Oh, great.

That's a pump that a patient

can control their own analgesia.

So, it's patient-controlled analgesia.

That's what PCA pump means.

And it has a lockout feature so that a patient can't overdose themselves,

but they can give it to themselves

when they're feeling that they need it.

And what's good about it is we actually see patients use less medication,

and the medication is more effective because they're in control of >> Though you'll need

more equipment for the house now that you can't bear weight on her leg. Okay, like what?

Uh a wheelchair to go to the bathroom,

a shower chair, uh wall bars if you don't already have them.

And a hospital bed could be helpful,

How do we get all that? You don't. I do.

>> Generally, the pharmacies that have surgical

supply as part of them or perhaps as a sister location,

they usually have a lot of these supplies.

And we can write them as a prescription

using like a miscellaneous order form.

What's the status of your septic >> Next batch.

Surgery's taking her up.

Think they'll be able to save her leg?

Right now, I'm just hoping they can save her life.

Hey, uh how's old Ruby doing?

A little TB exposure,

a touch of asplosion.

All in all, pretty good day so far.

Hey, ain't no way I was going to let you miss Peter Aubrey's epic

Fourth of July party. Come on now. Hey. Bratwurst, huh?

>> No, you can't do that pre-op. >> Man.

Appreciate the romance over here, but no food cuz you might go into surgery

and no beer cuz we're a god damn

>> The reason why we have patients

NPO or without food before surgery

is for the risk of them vomiting

and then because their airway's unprotected,

potentially some of that food aspirating

and entering the lungs, and that is obviously a problem for pneumonia, pneumonitis, etc.

Starting your sabbatical early?

>> I know somebody who could really use a drink right now. >> In the hospital?

Is he giving it to

You lose your pulse ox again, bud? Is he flatlining?

A pulse ox doesn't usually have flat line sound like that.

He kept pulling off his pulse ox.

That's usually as a result

of EKG leads, not the pulse ox.

I'm not getting the carotid.

I got the airway.

Hey Carla, crash cart innovation tray, please. No pulse. >> Chest compressions. Chest compressions.

Remember, asystole is not a shockable rhythm, so running to get the defibrillator

is not of utmost importance.

And you want your chest compressions to be better than that, which means on

top of the patient, 2 in deep.

That's not 2 in deep, so.

Great nurses on the pit, but what happens when a hospital

hires a nurse that's killing patients?

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