Doctor Reacts To The Pitt Season 2 Episode 7

- Season two, episode seven.

Who's ready to take on another hour on shift?

Huge thank you to Odoo for sponsoring this video.

Let's get started. - A SANE is a Sexual Assault Nurse Examiner.

We do forensic exams, collect evidence,

and hand it over to the police if a report is made.

We also provide resource to support,

sometimes even testimony. - You go to court? - SANEs are very valuable in a hospital,

so. - Yes, and we're facing a current shortage of them

and we're actually encouraging people to sign up for this.

I believe there's like a forensic nurses association where people can sign up for

this type of accreditation.

It's extra in-person in-classroom learning,

both combined many hours in order to make sure

that you're comfortable in these types of encounters,

- I'm the charge nurse in the (indistinct)

and a sexual assault nurse examiner. - This is Emma,

will be assisting. - And I'm Dr.

Al-Hashimi.

I'll be checking you for any injuries

that need immediate attention. - You can just call me Alana.

Um, I don't have any injuries. - The lack of injuries does not mean

that no assault took place,

that no sexual assault took place.

You still move forward with the exam,

and you still collect evidence

and allow the patient to decide the course of action. - You are in

control now,

Alana.

We're here to help

and support you. - That's patient-centered care where the patient gets to decide what

happens.

And remember, a big part of sexual assault is the loss of control

and the mental health repercussions

that come as a result of

that.

So by allowing the patient to be in charge of the medical exam,

the treatments, the reporting, all of that is giving the patient back their power,

making them feel a bit more safe.

A lot of these kits come with many,

many tools and several steps along with instructions.

It's important to know

that not every patient needs every one of those steps to be taken.

And maybe some patients don't want some of the steps to be taken.

And again, that should be completely acceptable. -

So you're having a headache

and abdominal pain? - Yeah,

that's right. - Okay.

And which would you say is worse? - I like

that she's talking to the patient.

Even though the interpreter's off to the side. - My headache was terrible last week,

but now... (static buzzes) - Hey, you're, you're breaking up.

Can you run that back again? - These types of technical glitches happen all

the time.

Whether it's an internet connectivity issue, a phone connectivity issue,

it does happen. - Now my abdominal pain- (static buzzes) - God, come on,

you piece of... (hand bangs) Um... (pages flapping) (pen scratches) - It's not enough

to just say,

"We'll do a specific exam."

You have to offer it

as an option to the patient

because maybe the patient doesn't want to consent for this exam.

And especially in this scenario where the communication is obviously having a breakdown,

it's even more important to provide extra information. - I'll, I'll be right back.

Sorry. - It doesn't help to whisper.

It doesn't help to raise your voice.

Again, you want to talk normal volume. - What the hell's going on?

He's barely conscious. - Jackson's just a little tired due to the sedative he

was given. - You sedated him. - Oh,

your son was brought in extremely agitated. - You'd be too

if you were tased. -

And why the did they do

that?

This is bullshit.

We're taking him home. - Why don't we step out for a second? -

Deescalating the situation,

moving them away.

Very smart move here.

Very high level.

Because emotions are starting to creep up, and by just changing the scenario,

by changing the setting,

that already deescalates and makes everyone feel a bit more at ease. - Right now,

Jackson is on an involuntary psych hold. - What?

That's not necessary. - He just needs some rest.

He's been studying for the bar exam.

We can watch him at home. - So far, all of his tests look good,

but Jackson has reported hearing voices.

This could be serious. - Dr.

Jefferson will come back and speak with you.

He can explain more of what may be going on with Jackson. -

And who is Dr.

Jefferson? - He's from psychiatry and he's excellent.

He can explain next steps and answer all of your questions. - Javadi,

why don't you take the Davises to the family room? - Sure. - Excuse

me. - It's just this way. - Getting worried.

What's going on with Dr.

Al-Hashimi? - Hi, this is Dr.

Baran Al-Hashimi.

I'm a patient of Dr.

Fairgraves.

I need to speak to him if he's on call.

If he's not, I'll take his next available appointment.

And please call me if he has a cancellation.

Thank you. - I wonder

if she's calling for mental health support

or is this something going on with her body. - It's gonna be really

noisy here and you won't get any rest.

At home, you'll be surrounded by your family

and be more comfortable. - It's your choice,

Roxy. - It's not that I don't wanna go home but- - Hi,

Mom. - Mom. - Lena texted me to come back.

I figured I'd bring the boys.

What's going on?

Is everything okay? -, police officer.

Incoming trauma. - Coming.

I'll be right back.

We'll give you a chance to talk. - See,

in this scenario where there's clearly some, again, breakdown of communication.

It seems like this is a theme of this episode.

But within the family, separating them,

and allowing someone to speak to the patient in an unfiltered way to get

a better understanding of where this hesitation's coming from,

can help make a better decision all across the board. - Intubated neck wounds.

SATs not great.

We were diverted here.

Is there a trauma room open? - Trauma one. - What's the story? -

My buddy officer Hero.

High velocity GSW.

He's getting harder to bag.

Warehouse robbery gone sideways. - One, two, three. (person thuds) - You guys wait here,

we'll take care of him.

I promise. - Dr.

Santos, let's make sure these lungs are up.

Can you see the cords? - Yeah,

it was a great view

but it was hard to pass after I cleared 'em. - Yeah,

SATs only 85. -

So the vitals are telling us a picture

that there's not enough oxygen reaching his organs

because the oxygen saturation is low.

Heart rate is elevated to 110 saying

that his heart is trying to compensate for this lack of oxygenation by circulating

the blood faster. - Dr.

Santos, what could cause respiratory failure in an intubated patient? - Uh,

there are a lot of possibilities. - Think DOPE. - Displacement, Obstruction, Pneumothorax, Equipment failure.

Good lung sighting.

No pneumo. - It is displacement.

Okay, that is a transected trachea. - Oh, the displacement that they're talking about,

my assumption is that the ET tube is displaced because the trachea is injured.

So much so from this GSW

that the ET tube literally went through it

or out of it.

So it's not in the lungs inflating the lungs.

'Cause remember the ET tube's job is to bypass the upper airway

and deliver air directly into the lungs at least more closely to the lungs.

So that if the upper airway gets blocked from vomiting, from bleeding,

you could still deliver good oxygen to the lungs.

And you have a balloon that you can inflate there,

which help protect fluid from entering the lungs that shouldn't be there.

But when there is a tracheal injury to this level,

that's very hard to do.

This is a condition with very high mortality. - Pulling out,

bag. - But if you intubate again,

won't it just come straight out the wound? -

So basically you need to find a way to guide the ET tube into

the lower portion of the trachea below the injury.

Either starting from the site of injury

or perhaps finding a way to guide it through

that injury by either inserting something into the trachea.

I'm obviously not an ER doctor,

but I'm trying to be creative here. - Okay. -

And those bubbles is a sign

that there is air inside the chest cavity,

which means that the airway is open, it's ruptured.

Frequently, we'll hear that as crackling underneath the skin.

But here, we're seeing it with bubbling on the liquid,

on the superior surface. - Yeah, he's not moving in the air.

Okay, I need a neonatal mask. - Neonatal? - Yep. - I'm just going

to finish my initial exam.

Let me know if you feel any pain.

Okay? - My legs are fine. - Uh, looks good. - I don't like using good, bad.

I like to say normal

or describe the finding. - No need for X-rays

or advanced imaging. - Got it. - Two areas of ecchymosis. -

That means bruising. - Over the shoulders bilaterally. - It's great to have someone

translate in that way

because sometimes in the medical field,

we use vocabulary that can make a patient feel uncomfortable

because they don't know what's going on. (bell dings)

So to have someone there to help you translate

that,

catch it, make the patient feel at ease is very powerful. - Where does

it hurt? - Like here under my belly button. - Okay.

Do you have any fever, vomiting, diarrhea? - No, it's, it's just a stomachache. - Okay,

let's still go see the nurse and have her call me. - Okay.

But I'm still having ice cream tonight. - Let's just see how you feel

later. - Good diversion for the conversation there

because I'm not gonna try

and get ahead of myself with predictions.

But appendicitis can sometimes happen surrounding the umbilical cord.

Umbilical cord. (chuckles) (static buzzes) Appendicitis can sometimes begin surrounding the belly button,

and then start to move to the right lower quadrant,

and not immediately be present in the right lower quadrant.

So it tricks people sometimes away from the diagnosis, when in reality,

it just early onset appendicitis. - Elliot Green, 17, syncopal episode at football practice. - Look,

I just got dizzy.

Okay? - So sometimes this is due to dehydration, concussion, heat intolerance,

sometimes full on heatstroke.

So it's really important to monitor these patients,

not just from a cardiac standpoint

but also from a metabolic electrolyte standpoint. - A

and O.

Systolic of 95, tachy at 122.

No meds, no allergies. - So he's tachycardic,

meaning that his pulse is high and his blood pressure is low.

So that's interesting why that's happening. - How long were you at practice? -

Started at 9:00.

So like four hours. - Four hours in this heat with all that gear? - Yeah,

so heatstroke is obviously a leading possibility,

but also severe muscle damage from rhabdomyolysis can also occur. - Orlando,

where are you going? - Home.

You take these out? - Uh, no,

it takes 48 hours for you to get out of DKA.

Your blood is still full of acid. - Look,

I can't add thousands of dollars to the a hundred grand I already owe.

- I'm,

I'm sorry, a hundred grand? - The medical debt.

My wife doesn't even know.

I'll never be able to pay it off

as it is. - Where are your wife

and daughter?

Maybe we can all talk. - I told them to go back to work

a couple hours ago. -

But the hospital is giving you a big discount.

And Mr.

Diaz, I know it's not ideal,

but can you stay for at least 12 hours?

It will get you out of the danger zone. - No, I really can't.

Every minute I stay is a meal, shoes, school supplies.

Plus I have a second job I have to get to by 4:00. -

The problem is if you don't take care of yourself

and then you decompensate,

you make the problem worse with the financial stress becoming worse,

with the fact that you can't show up for work for a longer period

of time.

So you have to really take into consideration a lot of factors

when making decisions surrounding your health. - How about this?

You stay and I'll get together everything you'll need at home.

Also a referral to Northside Christian Health Center.

Come on.

You don't work until 4:00.

It'll keep you from passing out on the job again. - She's doing a

really great job encouraging him to stay,

going way above and beyond what a normal physician would do in a scenario

like this. - SATs up to 98. - Neonatal mask is working.

Santos, (indistinct). - Yeah.

What, what are you injecting? - Lido with epi.

It'll clamp off any little bleeders.

Remember, the reason they're doing lido with epi is

because the epinephrine constricts the superficial blood vessels,

which decreases the bleeding.

Allows you to have not just a better visual field,

but also less potential blood to enter into the lungs. - What is going

on here?

You have a field medic assistant here? - Dr.

Abbott is an attending, and he is also a SWAT physician.

My buddy Hero here is in bad need of an airway.

Cut it right here. - We can do this. - Oh, no, I got it.

You must be Gloria's new hire. - Yes, Dr.

Al-Hashimi. - Well, I'd shake your hand

but my tube is ready. -

And if I could find a secure the distral trachea,

we have a shot at this. - Okay,

keeping an eye on the SATs. - She doesn't even know what's going on.

She just walked into the room. (chuckles) It's like maybe we have to learn

about what's happening with the patient. - What's up now? - GSW with tracheal

transaction. - Very retracted

but I think I can get it. - Both lungs are up. (device beeping)

- SATs standing in the valley now. - Okay,

just... (device beeping) I got it.

I got it. (device beeping) - Gently, gently,

or we're gonna lose it. - Down to 89. - Oh. - I'm in,

balloon up. (device beeping) - End tidal.

Excellent wave form. - There's obviously gonna have to be a revision surgery after

the fact,

or he's gonna get a trach placed that's gonna be a little bit more

long-lasting in the meantime. - Mm,

while you're playing him with that airway,

you missed a big bruise in the left upper quadrant. - He was wearing

body armor. - High velocity projectile doesn't have to penetrate to do damage. -

Oh,

my God.

Is it a spleen rupture?

That's a lot of blood loss. - Looks like a subcapsular hematoma of the

spleen. - Must have been a big impact. - AR 15 muzzle velocity is

3,000 feet per second. - CT angio of the neck ASAP along with CT

chest,

abdomen, and pelvis. - Yep.

Just as soon as we secure this tube. - Back to "The Pitt" in

just a second.

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All right, let's get back to "The Pitt." - First leaders in. - Mucus

membrane's dry. - Pupils,

four millimeters reactive. - Did you get tackled today? - No.

Just running drills. - Any chest pain?

Palpitations? - No. - Hands off, please.

Running the 12 lead. - How we looking? - Good.

Healthy kid.

No history, no trauma. - Differential for syncope in an adolescent. - Uh,

cardiac arrhythmia from drugs- - Hyper bulimia, seizure. - Long QT, HOCM- - Sepsis. - Or brugada. - Uh,

brugada is more common in Asian males. - Brugada is possible

but definitely a bit of a reach given

that we don't know much about the patient. - Long odds,

Earl.

Brugada prevalence is one in 20,000 in North America,

as high as one in 300 in Asia and the Middle East.

And first described in 1992,

has a high incidence of sudden death among young patients with otherwise structurally normal

hearts. - Oof,

wait.

Did you just say sudden death? - Temp is 102.5. - Sorry,

our student doctors are discussing a rare condition you don't have. (doctor laughs) -

I just love the description there. - I just didn't drink enough water.

I overheated. - Not my type, bud. (doctor sputters) - Other than standard labs.

What else to order? - You could make the argument for ordering a head

CT given that it's such a high-contact sport. - CK to rule out rhabdo.

- To make sure you don't have any muscle breakdown from the heat. -

Which we talked about earlier

when he was initially brought in.

Rhabdo, the typical presentation

that we talk about is a marathon runner who hasn't trained well

or perhaps just overdid it,

ultra-marathon runners.

There's severe muscle breakdown

and starts impacting the kidney from the myoglobin. -

And I'll run a blue light over your skin.

Anything glows, I'll swab it with a wet then dry Q-tip.

Is that okay? - Yeah,

sure. - All right. - I'm glad they're showing this just to explain how

comprehensive the exam is,

and how someone who's just went through something terrible,

basically has to go through

that as an additional step through already the trauma

that they experienced. - What's the story? - Neck angio is negative.

Missed the carotids. - That's really important,

and I think we would've known

if the carotids were torn

because the amount of bleeding would've been absolutely incredible.

And the survivability of that without treatment for as long as that's been,

would probably be near zero. - What about the belly? - Small splenic injury.

No free fluid in the abdomen. - That's great.

That's reassuring that no part of the GI tract was harmed in a sense

of penetration.

But the fact that there was blunt force trauma to the spleen meant

that there was a lot of blood loss,

and potentially some bruising that's formed.

That's why they discussed the hematoma there.

Remember, the body will work to resorb this hematoma

and this excess blood

that has formed.

So that's part of the body's natural mechanism there. - Hey,

you gonna be okay here.

We're getting you to surgery. - So wild.

Just put into your head how amazing healthcare is.

He was shot into his trachea.

It got severed, and they were able to pull the trachea up

and stick a tube into the severed trachea,

attach it to his skin, and allow him to survive all of this.

Medicine healthcare is amazing.

And the fact that there are people out there in our government

that are actively seeking to defund it

and destroy it is just

so devastating and depressing. - SWAT?

Really? - I suck at golf. - You spend time in the Middle East?

- More than I would've liked. - I worked in Kabul with Medecins Sans

Frontieres,

and in 2020 at the maternity hospital.

I met the most incredible bravest doctors there. - I'm assuming she's talking about

Doctors Without Borders,

who we actually supported with our Patreon where we charge $10 a month to

join our Patreon.

And every month we have a live stream, where we together, nominate some charities,

and then vote on where all that $10 of every individual goes to.

We keep none of the money. (cash register dings) All of it is donated.

Pretty cool.

You should join.

That's the link down below. - I wish this day never happened.

Would you like some medicine to help you relax?

You've experienced a horrific trauma. - You've been doing this a

while? - Let's just say Florence Nightingale

and I were roommates. (patient gags) - (chuckles) I rest my case. - An

attempt to introduce humor in such a dark situation sounds like a bad idea.

But if done appropriately, perhaps in cheesy, in a cheesy way,

perhaps in a self-deprecating way, could be a good way to break tension.

But it is so difficult to do

that and can only be done after years

and years of experience,

(bell dings) as our favorite nurse here clearly shows. - Rumor has it you're

still interested in booking a room with us? - I don't wanna go back

home yet. - It's all set up,

Rox.

You're gonna be more comfortable at home. - Oh, I changed my mind.

It is our home.

I don't, I don't want you living with my ghost. - I will happily

live with your ghost. - Can we just all stop talking about ghosts,

please? - Yes, I'm sorry.

Sorry, sweetie, you're right. -

That situation has been ongoing for quite a long time for them to have

never asked the question directly one-on-one with the patient

as to why she doesn't want to go home.

The longer they drag this out,

the more potential conflict that can come from this.

'Cause it seems like there's just a misunderstanding from all parties.

The healthcare workers don't understand why she doesn't wanna go home.

The husband doesn't understand.

So it seems like no one is communicating well in this scenario.

This is where a leader, hopefully Dr.

Robby, can take control of the situation,

ask to be one-on-one with the patient, have a very thorough discussion,

like he's done so well in the past,

and get down to the bottom of the scenario.

Once you do, you can

then make decisions on how to best serve the patient. - It's a boating

accident.

Swimmer versus propeller. - Ouch.

What body parts involved? - They didn't say. - How old? - Nope. -

Anything? - All I got was boating accident.

Swimmer versus propeller. - Propeller.

Got it. - That's a wide differential that you have there.

Could be as small as a nick, a lost finger, a neck dissection.

Like a lot of things could be happening. (doors whooshing) You could cut the

tension with a propeller. (drum tapping) - I'm sorry.

I've betrayed your trust.

I've betrayed our patient's trust.

And I'm really fucking sorry.

It'll never happen again,

I swear. (helicopter whirring) - I'm really glad

that you got the help

that you need. - He doesn't have to instantly accept his apology.

Like just because you apologize, if you immediately expect someone to forgive you,

that kind of makes the apology disingenuous. -

But I don't know

if I want you working in my ER. -

And you have to understand how

that could be a reasonable take.

And he also said, "I don't know."

He didn't say, "You need to leave my ER." - Why'd you intubate him?

- He was splinting from the pain.

Barely moving the air with SATs in the 80s. - Wow, that's so interesting.

So he was breathing so shallow, meaning not deeply that he was actually desatting.

That he was not maintaining a good oxygen level due to pain.

So it goes to show

that when we have a patient with a broken rib

and they're not breathing deeply,

it could impact their oxygen level.

So we want to have good pain control when someone has a rib injury,

and at the same time encourage them through incentive spirometry usually,

or physical therapy in order to stretch out their lungs to breathe deeply,

and make use of their entire lung. - You need me in here? - Nope.

We have a senior resident and an attending. - Mel,

can we start with a- - E-FAST.

Sure. - Yes, please. - Why? - To check and make sure there's no pneumothorax.

Otherwise it could become a tension. - Pneumothorax,

but also to see

if there's any internal bleeding. - You want O-neg? - Not without a BP

first. 108 over 64.

Pulse is 102, SATs are good. - Okay, let's have O-neg ready,

but don't give it just yet. - Anything else? - Why does it sound

like it's his first time treating a trauma patient? - Ceftazidime is up. -

They're giving him an antibiotic. - First hemoglobin,

8.2. - A hemoglobin of 8.2 is obviously low.

In a situation where there's a trauma,

the hematocrit is usually a better indicator 'cause there's less things

that could impact it from a medical standpoint,

and really focuses on the amount of fluid found in the circulation. - Eight's

pretty low.

He must have bled down from 14. - Well,

I mean he has multiple wounds where he's bleeding a lot.

Also, you don't know what his normal is.

So perhaps he has a condition where he has iron deficiency anemia,

he has Crohn's disease, he was bleeding out of his bowels.

There's a lot of factors to consider there. - Anything you wanna do about

that? - You don't want to transfuse a hemoglobin of eight.

I believe the protocols are around seven when I was training.

I'm curious what it is in this scenario. - Young healthy guy.

We transfuse at seven. (triumphant music) - Yay. - Could be in real trouble

if he equilibrates from a acute blood loss. - Am I interrupting something? -

Multiple lacerations. (indistinct) - Jesus!

This looks like some Jurassic Park shit. - Is

that your official surgical diagnosis? - ICD-10 code for Jurassic Park shit. - He's

hemodynamically stable. - What else do we know? - Uh,

intubated in the field due to poor tidal volume. - Tidal volume is how

much air that he was taking in. -

And no free fluid in the abdomen.

Good hemostasis inside the wounds.

Nothing arterial. - At first,

he had a hemoglobin of 8.2. - We'll follow that closely.

With no active bleeding, I wouldn't transfuse just yet. - Dr.

Langdon agrees with you. - (laughs)

So does Doctor Mike. - Let's get him to CT. -

And by the way,

this idea of transfusing only at seven is really a clinical decision based on

if there is active bleeding,

if there are specific symptoms happening,

and also needs to be individualized for the patient.

This has been trialed,

and the idea is to not overuse blood because blood is a rare commodity.

That's why I've been

so vocal about getting people to donate blood

as much as possible. - What's the word from CT? - Nothing intrathoracic.

Nothing intraabdominal. - Propeller just missed gutting him. - Very fortunate. - Yeah. - Repeat hemoglobin is eight.

We're holding off on transfusing. - What's this? - Daniel Scott.

32.

Weak and dizzy while washing his car.

Tachy at 106.

BP 90 over 60.

Temps too high to register. - Now we have a heatstroke. - We have

a cooling room set up in North Five. - Okay,

how you feeling, Mr.

Scott? - Thirsty. - You can do a cooling protocol on him. - Core temp, a CMP.

Whoa. - Oh, hey, we need a trauma room. - Oh,

he's having a seizure. - I'll grab the Ativan. (bell dings) - Ativan will

break the seizure.

It's a type of benzodiazepine. - Any past medical history? - No.

Wife says he's healthy.

No meds, no allergies. - I'm surprised the ambulance didn't start putting ice bags

underneath his armpits or something,

on his groin.

And reason why those areas is 'cause there's a lot of blood flow.

So it impacts and cools a lot of blood very quickly.

We also have IV liquids that we can give that are cooled.

So it actually cools the core body temperature down faster. - Orders. - Second

IV with saline,

open, sepsis panel, UA, urine drug screen, EKG,

and CK. - I don't see any apparent trauma. - These are all good tests.

She's trying to rule out infection, metabolic causes, cardiac causes,

neurologic causes with this exam. - Pupils reactive. - Mr.

Scott, Daniel, can you talk to me? - Mm. - Postictal,

but moving all extremities. - In that postictal state after a seizure,

sometimes there's a lot of confusion, especially with Ativan on board,

which can be a bit sedating. - What are you thinking, Dr.

Santos?

Heatstroke but consider sepsis or drugs. - Yeah,

you also want to do a full survey to make sure there's no random

bleeding that's happening from a trauma

that you weren't aware of.

You want to avoid getting pigeonholed into a diagnosis saying, "Oh, well,

it's hot outside.

His temperature's high.

It must be heatstroke."

It could be sepsis, it could be a raging infection, it could be meningitis.

So you want to keep your differential open at this point. - Rectal temp

is 104.6. - Okay,

let's start with four ice packs on the groin and axilla. - And remember,

we talked about why those areas, but specifically the arteries involved.

There is the brachial artery that's bringing a lot of circulation underneath the armpit,

and the femoral artery in the groin. - Should we do a full body

ice bath? - That'll take too long.

You have an Arctic Sun? - Yeah, we do. - Get pats on the chest, abdomen,

and both legs. - I'm guessing the Arctic Sun is some kind of device

that's a cooling device

that perhaps they use during cardiac arrest in order to do a hypothermic protocol.

But it could be used in this scenario. - Temp,

102.9. - Labs back. - Mostly signs of dehydration.

Tad hypernatremic, mild BUN and creatinine bump. - CK 400 something,

nothing worse than that. - Okay, good.

Keep cooling. - When they say a patient is hypernatremic,

they're saying that the sodium level is high.

But remember, when we say the sodium level is high,

we're talking about the sodium level in the blood based on how much fluid

is there.

So when a patient is dehydrated and fluid is taken away,

the level of salt looks higher even

though the same amount of salt particles might be there.

So it's really this like balanced equation of dissolved substances within the fluid.

So, for example, if you hydrate a patient, you give IV fluids,

you increase the amount of fluid in the blood vessel,

you decrease the sodium level.

But you also need to not do

that too quickly and overcorrect too quickly

because that has also ramifications.

The balancing of taking care of someone who's hyper

or hyponatremic must be done very carefully. - Oh,

sorry. - It's okay. - Have you, have you seen my patient?

Orlando?

Mr.

Diaz? - Room was empty. - Seriously? - Yeah. - I will say she's

having a very strong reaction to the patient leaving.

And while I have worked with residents

that have this type of relationship with patients,

where every time something happens where a patient decides against getting good quality care,

they make a decision against their health, they get upset.

The reality, and perhaps this is a harsh reality,

is that so many patients make decisions that are not great for their health.

Whether it's leaving against medical advice,

doing habits that continuously land them in the ER.

Like I'm thinking about patients who have congestive heart failure,

who continuously have huge sodium meals

that land them with CHF flare-ups where they can't breathe

and they're fluid overloaded,

and we need to diurese them,

and they repeatedly come back to the ER and then get admitted.

You end up becoming a bit numb to it.

Not in a bad way all the time because there are scenarios.

And interestingly, it kind of connects back to the sexual assault nurse examiner situation,

where you have something known as vicarious trauma,

where you start almost changing your worldview based on your experiences as a provider.

You start potentially changing for the positive where you grow from it,

and you feel more compassion for people.

Perhaps you have a neutral response where not much changes.

Or you have a negative response where you develop compassion fatigue

and you no longer could care about your patients at all.

Or perhaps you start feeling negatively about the world.

You become cynical, you feel negative about yourself, and you need treatment.

So it's important to know

that the mental health of providers in dark scenarios can be impacted

as well.

And that has large ramifications obviously across a society

as a whole. - What happened to you? - Oh,

bullet grazed my vest. - You were shot? - Shot at. - Jesus.

Why do you do this? - My therapist said I needed a hobby. -

(laughs) Humor is a defense mechanism.

Maybe. - Shit, this, this sucks. - Oh,

it's nothing. - I'm watching vicarious trauma play out right now. - Did you

make a chart? - No.

This can stay off the books.

Don't need the paperwork from the hospital or the police department. - Okay.

Our little secret. - Maybe don't do it in the hospital ER.

Maybe have one of your buddies come home with a medical kit. - Had

a Pap smear before? - Yeah.

Every few years. - Ideally every three years starting at age 21.

After age 30, you could do co-testing with HPV, which can,

if both are negative and you've had negative results in the past,

potentially be stretched out to every five years. - Same position.

But I'll start with swabs on the outside external genitalia.

Then I'll use the speculum to get internal swabs.

You ready?

Okay, help you get your feet in the stirrups. - I don't like calling

them stirrups.

Call 'em leg rests. - Yeah, a little bit more.

Little more. - Sorry, I, I can't. - Patient-centered care.

You're allowed to stop.

You're allowed to give the patient time.

All of that is under their control. - Is this about reporting?

Because you can do this collection without a police report for now. - Facts.

- And none of it goes in your permanent medical record. - I don't

wanna do this anymore. - I would ask the patient why they're interested in

stopping instead of assuming why they're stopping.

But good opportunity to present some information. - Tell me why you wanna stop.

- (panting) He's my friend.

He knows all my friends.

It was just a dumb...

He was drunk.

He didn't mean it.

It didn't mean anything. - Okay. - Validation here is very important.

And explaining that the choice to collect does not mean

that anything needs to happen down the line. - Why don't you take a

breather and come back,

and whatever you wanna do,

we'll do. (door slams) - Jesus Christ. - I'm trying to get to the

bathroom for over an hour now. - Yeah,

you and me both, sister. (toilet flushes) - Hmm.

Some potential cutting marks there.

When I say potential cutting marks,

'cause it could be a genuine trauma. - The internal disaster at West Bridge

has been identified as a cyber attack.

Their ambulances are being diverted over to St.

Mary's, but we can expect more walk-ins and West Bridge diversions. - Uh,

for how long? - We don't know how long.

If the ransom is paid- - Ransom? - What? - Are we next? -

Our IT protection system has blocked thousands of intrusion attempts in the hour since

West Bridge was hit this morning.

But IT believes we're still vulnerable.

So we're gonna preemptively shut down all the computer systems. - Oh,

going to paper charts is the worst,

especially for these young docs who haven't spent years reading charts

that are illegible from specialists coming by. - Patient registration,

electronic health records, lab, and radiology interfaces, email,

internet. - You wanna talk to me first.

You wanna consult my department? - I consulted your fellow attending. - Don't hospitals

have their own intranet

so that they don't necessarily have to be connected to the network,

like the worldwide network

but still be connected where you can use the computer to locally document things?

- When are we going down? - Soon.

Very soon. - Okay.

Hey, somebody get a picture of the board.

Quickly, quickly!

We're about to go analog. (phone camera clicks) - Oh! - Oh.

Oh, this reminds me of one of the largest hacks in healthcare history

that we actually covered on this channel.

Click here to check that out.

And as always, stay happy and healthy. (upbeat music)