- 2 days ago
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00:01so you are the new resident what's the Wi-Fi password for the on-call room I'm talking to
00:06you Cedar Bay Medical College medical degree no research background no awards and only average
00:12residency evaluations who pulled strings for you hospital administration medical affairs
00:17or some executives relative probably the HR lady she said you were short-staffed short-staffed
00:22I need doctors who can work not people who just show up and sleep through their shifts I can work
00:28but first where's the on-call room this thing is heavier than it looks come on I'll show you
00:33the ER has no room for people who can't pull their weight three-month probation failure evaluation
00:39and you're gone sure Dr. Lawson this is the trauma bay the busiest place in the ER yeah treatment
00:46rooms wound care happens here the infusion area fills up fast during busy hours Dr. Bennett are
00:53you here to work or just move in either works where's the quietest spot the on-call room is
00:58at the end of the hall but don't expect much sleep on ER nights I'll be fine I can sleep
01:02anywhere
01:05we got a strange one don't expect much from her probably a nepotism higher what else
01:16clear the way MVC GCS 7 unequal pipples don't move him he's actively bleeding get him to the trauma bay
01:31now
01:31Mara Bennett eight minutes late do you think the ER rules are just for show bad traffic you live in
01:37hospital housing it's a three-minute walk the elevator was slow Mara Bennett explain this what
01:43am I looking at a medical record I thought it was a shopping list three patients three lines no chief
01:50complaint no history no physical exam you're a resident you document everything required so tell
01:56me what exactly did you leave out how did someone like this get in maybe we should look into it
02:02just
02:02lucky and luck alone makes her a doctor enough ER documentation follows protocol no exceptions if this
02:10happens again I'm reporting it to medical affairs yes dr. Lawson I will go to the on-call room hold
02:16on
02:16handoff isn't over oh don't make it so obvious if something goes wrong no one's covering for you
02:23thanks for the reminder
02:30bed three acute thermosum on chronic proximal LAD applusion repeat trochanine and coronary CT within 24
02:37hours pull up bed three's ECG now get cardiology down here bed three needs a coronary CTR now chronic
02:44proximal LAD applusion with acute thermosum prepare for intervention now she called it exactly
02:50doctor is his abdominal pain serious it looks like acute gastroenteritis start fluids and keep
02:56them under observation should we run more tests no fluid should be enough for now
03:07Dr. Bennett bed seven's family filed a complaint against you which one
03:13the family of the patient with abdominal pain they said you were cold ignored the patient and
03:19barely answered their questions did you check the medical orders I did any problem with them no
03:25treatment depends on the orders not on smiling I will report the complaint as it is okay Donna
03:40are you sure you know what you're doing yes yes I can
03:48ease your pressure line up the edges keep your stitches even your angle is off hey these stitches are pretty
03:56good what is teacher Bennett's background anyway what background no research background barely made it through
04:06residency do not let her fool you anyone can talk a good game if she is really that good let
04:12her spend a day in the
04:12resuscitation room internal bleeding his BP is dropping you are here hmm listen to tonight's shift arrangement the observation ward
04:29has 12 beds
04:30resuscitation is currently empty but Friday nights are never quiet I handle resuscitation and emergency surgery you take
04:36admissions in the observation ward and infusion hall any problem no handle minor issues yourself call the director for
04:44major ones do not call me what do you mean exactly what I said you are the doctor on duty
04:50not here to sleep I know but I
04:54sleep badly so do not disturb me unless you have to I have been a resident for a year and
05:01this is the first time my night shift
05:02partner told me not to call him either works suit yourself that's it something will go wrong tonight
05:09fuck up wait hey rise set first out here on my word we're gonna happen oh shut up
05:15I am telling you he hit me first bullshit you started it Mara Bennett come out and give me a
05:20hand Mara Bennett come
05:21out and give me a hand Mara Bennett come out and give me a hand Mara Bennett done Mara Bennett
05:28are you deaf or just
05:29pretending I handled it alone three trauma cases plus debrugement and suturing you did nothing they're all
05:35superficial wounds a few stitches can you not stitch them yourself Cedar Bay Regional Medical Homer ER 44 year
05:43old male car crash abdominal trauma BP 90 over 60 and dropping ETA seven minutes
05:56internal bleeding his BP's dropping Priya get two large-bore IVs call for four units of Oneg page of
06:01surgery now okay positive payment aerial signs massive internal bleeding possible spleenic rupture
06:06Mara trauma case massive bleed left or right
06:16don't call surgery yet it's not the spleen something's wrong in the right upper quadrant get
06:20imaging then explain the left upper quadrant tenderness if this were a splenal rupture the
06:25left side would hurt more but his right blank is worse his abdomen isn't reacting like a bleed this
06:30severe and his BP is dropping too slowly this isn't the spleen there's a tear in the left lobe of
06:36the
06:36liver the bleeding is manageable embolization will do less damage than surgery if Sutton's on call tell
06:42him to watch for an accessory branch of the left heparic artery one wrong move in the embolation fails
06:49Ryan are you saying she figured all that out just by feeling it the embolization went perfectly
06:54Sutton confirmed she was right the patient really did have an abnormal branch of the heptary artery tell
07:00her it was our new resident the one who plays games all day Priya how lazy can someone be she'd
07:06rather
07:06hide in the on-call room eating chips the embolization went perfectly the left heptated artery really had an
07:16unusual origin I've never seen a pathway like that who made that call that wasn't a residence judgment
07:21that's attending level experience a first-year resident Mara Bennett a resident you're serious tell
07:27her that for pre-op judgments like this she can call me anytime dinner is on me I need to
07:32meet
07:32her she is asleep Mara Bennett I need to ask you something that judgment you made the left hepatic
07:41lab injury and the arterial variant how exactly did you see it lucky guess last night you handled six
07:49cases before that crash victim came in three traumas two abdominal complaints one fever and somehow you
07:56spotted a left hepatotic limb luceration and sent him for embolization before anyone else did your
08:01deferential was flawless did you write this record for her kind of I knew it there's no way she wrote
08:14this herself why is Ryan not explaining explain what that the lazy gamer everyone complains about is
08:20is actually a genius do you really think dr. Lawson would believe that fair point
08:28dr. Lawson calm down look at this yourself two weeks since she joined six write-ups four records
08:35returned two patient complaints someone like this stays in my department who takes responsibility when
08:42there is a medical incident Richard do not rush my ER was already short-staffed and we finally filled one
08:48vacancy and somehow we ended up babysitting her she does not work and she drags down the whole
08:54department I know something about her situation if someone powerful pulled strings to get her here
08:59just tell me no who the director director Sinclair one month one more mistake one more complaint
09:10and she's gone I don't care who approved her transfer
09:18Mara Bennett come out here Mara Bennett
09:22dr. Lawson take the earphones off if you're late again submit another sloppy chart or get another
09:29patient complaint I don't care who signed off on your transfer you're gone
09:34is that clear fine see you in a month get back to work one month she won't make it two
09:43weeks
09:44I give her one week dr. Lawson said one month aren't you worried worried about what if they transfer me
09:52even better I can finally sleep Natalie you think Lawson's really doing it this time worry about your own
09:59charts what is this woman's background I heard she was transferred in with special administration
10:09approval from administration and no one questioned it special approval from administration Peter just
10:15said director Sinclair signed the transfer order himself Natalie Natalie what are you thinking about
10:23nothing go do your work how long have you been having this pain more than half an hour it's a
10:32tight
10:32pressure like pain get an ECG have you had anything like this before yes a previous check said I needed
10:42to watch this area I was given medication but I did not take it seriously finish the test first to
10:50keep
10:50him under observation if anything changes call me immediately what happened did he get the nitro he
11:08took it it did not help Mara Bennett when you passed bed five just now you looked at the ECG
11:12glanced at it
11:14did you notice something take another look at leads v1 to v3 damn Priya activate STEMI protocol for bed
11:22five repeat the ECG now tell the cat lab to prepare for emergency PCI repeat the ECG now lab to
11:28prepare for
11:28emergency PCI aspen 300 chewable tick adrict on 180 heparin 5,000 units IV move you saw it earlier didn't
11:41you
11:43what there was a detail on this sheet you saw it when you walked past did you not oh that
11:48you saw
11:49it why didn't you say anything what if I had not noticed you did not ask this is a patient's
11:55life
11:55not some game first you caught it within 10 minutes no harm done second the troconine result would have
12:03confirmed it you ordered it right third if I had to speak up every time what is wrong with you
12:08you saw something and said nothing waiting until it nearly blew up nothing happened he is alive next
12:17time you see something say something don't wait for me to ask what did she say she said nothing but
12:25she really did see it she picked up hyper acute changes in v1 to v3 with a single look then
12:31just
12:31how good is she
12:40cardiac arrest witnesses say he was down for about four minutes a bystander performed chest
12:44compressions we continued CPR after arrival one defibrillation in the ambulance no recovery
12:48put him on the monitor continue compressions get IV access prepare to defibrillate 200 jolts clear
12:53continue compressions epidephrine one milligram IV push 300 jolts clear
13:01no conversion continue compressions another round of epidephrine charge complete clear still no response
13:10continue compressions
13:14director what are you doing here get out director try a different approach what try an isotherm infusion
13:21the monitor clearly shows ventricular fibrillation are your eyes failing you
13:26what did you say he is not in v-fib look at his baseline heart rate then look at the
13:30record right
13:31before the arrest the PR interval was 0.32 seconds he already had first degree atriovalesional block
13:37now look at those two seconds of flat line after defibrillation it is not a true isoelectric line
13:42zoom in and there are p waves but the QRS complements are completely dropped this is third degree
13:48atriovalenial block causing ventricule standstill the v-fib was triggered by hyperxia not primary v-fib
13:54isoseminine isoseminine start at one microgygrin per minute and run it as an IV infusion
14:02continue compressions do not stop
14:09we have a rhythm
14:18wait director is there something else
14:19what do you suggest for follow-up treatment use a temporary pacemaker first
14:24once hemodynamics are stable contact cardiology for a permanent pacemaker
14:29also check cardiac enzymes and troclin to see whether ethan brooks has myocardial injury
14:34get back to work do not just stand there
14:40pull up the patient's ecg record from before the arrest and print me a copy
14:44okay
14:49the PR interval is indeed prolonged but during an emergency resagitation who would notice that
15:03what are you looking up nothing literature i've worked in the ER for three years i thought i knew ecgs
15:09pretty well but that PR change today even if i had time to sit down and study
15:14i might have missed it this is not something luck can explain should we tell director
15:33and the patient came back i saw it with my own eyes less than two minutes in total
15:37then just how good is she dr lawson did not catch it and she saw it with one glance who
15:42knows i'm never calling her a slacker again
15:45dylan what do you make of yesterday what do i make of it i make of it what i always
15:50make of it one correct call does not prove anything
15:52but what about the hyperague and ecg changes last time
15:56what exactly you trying to say i just think teacher bennett might really have something
16:01if she truly had something why does she play games all day why write three lines for a medical record
16:07why not care after two complaints
16:09dr angela are you not curious little natalie what do you think her background really is i cannot figure her
16:15out either
16:24teacher bennett lunch is here just leave it at the door that patient yesterday the one who went into cardiac
16:30arrest
16:31how did you know it was third degree atrio vendivinal block can you teach me you want to learn first
16:37solidify
16:37your ecg fundamentals then come back after you understand the theoponology it was obvious it is
16:42all in the textbook read every patient's ecg yourself do not rely only on the machine's automatic
16:48diagnosis after a hundred of them you will develop a feel for it
16:54did you get anything out of her no she told me to read a hundred ecgs myself
17:01what is going on director lawson is reviewing medical records whose records mara bennett's every
17:06case she has handled since joining 23 minutes every record and order she has handled not a single error
17:12i checked them myself old peter can you pull mara bennett's personnel file richard what are you
17:18trying to do it cannot be pulled correct the director's exact words were no need to look
17:26mara bernett close the game director what do you need another lecture let me use your computer
17:32take a look at this for me director is this your patient
17:39yes admitted last week the diagnosis is unclear and i want your opinion
17:46finished what is your opinion there is a lesion in the pancreatic groove the margins are irregular
17:51arterial phase enhancement is not obvious but there is mild enhancement in the portal vacuumers phase
17:56the main pancreatic duct is dilated with an abrupt cutoff consider an introductal pepular meatic
18:01neoclosis likely branch duct type but mixed type cannot be excused recommend contrast enhanced mri plus
18:08mrcp to clarify the communication with the main pancreatic duct and the internal cystic structure
18:13are you certain but the final answer still depends on pathology imaging only provides direction
18:18have you seen this kind of case before i have where a community health center director you did not
18:24really call me here just to read a scan did you i wanted to confirm one thing confirm what your
18:29level confirmation complete i sent this case to the state teaching hospital for consultation last
18:37week director hoffman from their imaging department has 30 years of experience she studied it for half
18:44an hour and her conclusion was exactly the same as yours then it seems i guessed right do you think
18:49i
18:49believe that whether you believe it is your business director i am just an ordinary resident who happens
18:56to be familiar with pancreatic imaging
19:01mara bennett about the one month deadline i withdraw it what does that mean it means you do not need
19:07to
19:07worry about being fired for now director i actually do not mind either way i know you do not mind
19:12but i do
19:13the er cannot afford to lose you can afford to lose me then can you schedule me for a few
19:18fewer night shifts
19:28director sinclair this is richard lawson richard what is it last time you told me to observe her a little
19:34longer i have finished observing what did you find this person is not an ordinary resident her skill
19:42is at least attending level maybe higher richard some things only need to be known do not spread them
19:50around i understand make good use of her do not pressure her and do not let others bully her director
19:56sinclair who exactly is she you do not need to know who she is you only need to know that
20:03having
20:03her in your er is a privilege i understand
20:18director lawson is not firing her anymore seems so little priya said she heard director lawson tell
20:23her she does not need to worry about being fired for now why on what grounds because she guessed
20:27right once brother dylan it seems like more than once dr bennett there is a problem with this medical
20:34record which one the elderly woman with dizziness yesterday in the history of present innis you wrote
20:40peridictus vertigo with nausea and vomiting for three days but the nursing record says two days oh what does
20:46oh mean the medical record and nursing record do not match that is a fundamental error do you understand
20:52you came all the way here just to tell me this i am reminding you the medical record is a
20:56legal
20:56document if you write it wrong and something happens you will bear the consequences alone i will fix it
21:01you are not changing it i said i would fix it i did not say right now
21:10what did you eat yesterday i had some drinks with friends and ate barbecue last night
21:18right here the stomach area any history of stomach problems yes an old stomach problem
21:25it flares up whenever i drink get a cbb and liver panel start them on gastric meds and observe
21:32dylan carven
21:36what order an amylaid test why just order it
21:39i asked you why he drank last night and now his stomach hurts there's nothing here screaming
21:45pancreatitis and you want me to order amylase
21:56mara how did you see it see what pancreatitis you glanced at him in passing and knew how
22:03exactly did you tell his posture when he bent over what with gastroenteritis the pain makes
22:10people curl up and hug their stomach with pancreatitis they lean forward and sit up because leaning
22:14forward reduces pressure around the pancreas and eases the pain a little that is it that is it
22:22basic physical exam
22:26something you learn early in residency go read it again anything else
22:37mara if you're really this good why do you act like you don't care
22:41i care are you sure playing games and sleeping all day writing medical records like scrimbles
22:47you call this working dylan carver let me ask you a question go ahead tell me this have i ever
22:55misdiagnosed a patient no right a perfect chart with the wrong diagnosis or an ugly chart that saves a
23:03life which one matters more that is not the same thing to me it is a doctor's job is to
23:10treat patients
23:11not to write essays next time you notice something tell me directly do not wait until after i have written
23:17all the orders that depends on my mood
23:28attention emergency department
23:32an ems ambulance will arrive in five minutes with a male 58 years old cerebral hemorrhage gcs 7 unequal
23:39pupils who's on duty me dylan carver and sister natalie prepare the resuscitation room notify ct to
23:45stand by second ambulance eta eight minutes acute chest pain male 63 ecg shows extensive anterior
23:53st segment elevation myracolic inversion
23:56little priya notify the cardiology intervention team and activate the chest pain green pathway
24:01third ambulance eta 12 minutes severe burns female 41 approximately 40 body surface area with inhalation
24:10under dylan carver you come with me for the mi natalie pierce take the burn patient start initial
24:16management and call burn surgery for consultation what about the cerebral hemorrhage patient
24:20mara bennett
24:24director what is it get out here and work the cerebral hemorrhage patient arrives in five minutes
24:31can it be transferred today's not my shift it is now
24:37fine
24:41male 58 sudden altered consciousness for two hours blood pressure 210 over 130 left people dilated light
24:48reflex absent right limb strength zero left people five millimeters brain hermination manorol 250
24:54milliliters rapid infusion for gas selling 20 milligrams iv push desinfestazane 10 milligrams iv push
25:00contact neurosurgery at the same time all at the same time yes at the same time
25:07but if manathoid and forestlin are used together we do not have time to wait one by one
25:12the hermination is progressing fast lower the intracranial pressure first go take him to ct i am going
25:19with him put on cardiac monitoring on the way left basal grandiose hemorrhage about 60 milliliters
25:25midline shift over one centimeter ventricles compressed call the neurosurgery attending tell
25:30them this is my assessment and they need to come down for the patient within 10 minutes any later and
25:34it will be too late director do you need help no keep an eye on your own patient i have
25:41finished mine
25:41wait for neurosurgery to come down and take over you finished