Previously on The Resident...
Have either of you heard from Devon?
Hey, can I get some help in here?!
They found him collapsed in the elevator on the roof.
What happened?
Hey, sweetheart.
Hey, how's it going so far?
Mama isn't here.
We talked about that.
Hey, it's me. Just trying again. Call me back.
She's gonna be back tomorrow night.
Conrad Hawkins? There's been an accident.
This is Traumahawk Three
requesting landing field briefing at Chastain.
Chastain
- helipad is clear. Go ahead. - Chastain,
we are inbound, five souls on board, ETA five minutes.
We are requesting an overhead
level-1 trauma on arrival.
Request granted.
Handing you off to the medics.
Patient is female, 30s, status post-MVC, GCS 3
at the scene.
Single car collision.
Significant intrusion on the driver's side.
Intubated at the scene, tachy's to the 120s,
stable BP.
Dr. Hawkins?
ER.
Whoa. Where's the fire?
Got us a table for two at Ray's.
I adore Ray's.
I thought you said you were off the clock.
Do we have an ID on the patient?
Nicolette Nevin.
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Conrad!
Hold on, man.
They have to bring her to us!
Okay. I'm good, I'm good, I'm good, I'm good.
On my count.
One, two, three.
We got a problem here.
Her pressure's tanking.
Why haven't they brought her out yet?
They must not be able to move her.
Conrad!
Doc, we got this.
I'm not her doctor. I'm her husband.
Nic.
I'll update the transport team.
Nic, I'm here. What happened?
Police don't have a cause.
There were no other vehicles at the scene,
no inclement weather.
No idea where she was coming from or where she was headed.
She was coming home.
Wait. You're Dr. Conrad Hawkins, right?
I've heard the other medics mention you.
You're ex-military, right?
Corpsman. Afghanistan.
Syria. Air Force Para-rescue.
You know what they teach us?
Watch the monitors, not the patient.
She needs an ultrasound.
There. No lung sliding.
It's a tension pneumo.
We can decompress her here.
Pass me an angiocath.
I got it.
Really.
She didn't even flinch. What did you sedate her with?
Nothing. She's not sedated with anything.
Nic, wake up. Wake up.
On my count. Three, two.
- One. - One.
At some point, we will have to intervene.
He can't take control of Nic's care.
I know, and we will once we know what we're dealing with.
The pneumothorax was easily resolved,
but Nic hasn't done anything purposeful
since the paramedics found her.
Which could mean a myriad of things.
Accidental ingestion, electrolyte abnormality.
Sure, it's a possibility.
I mean, from the neck down, Nic appears to be okay.
But the impact from the crash may have damaged her brain.
Badly.
Let's not catastrophize just yet.
Where's Nic?
Ooh, Dr. Pravesh, you're not looking too good.
She's right, Devon. Slow down. You're still recovering.
I'm fine.
Hey, where's Nic?
She's in CT. Conrad is with her.
Kit's keeping me posted.
Whoa, buddy, hold on. Hey, didn't I just discharge you?
It's Nic. I'm not going home.
Okay, but you're also not going to badge in.
Let's find you a place to lie down.
I'll order you a neb. Come on.
No. It's fine.
It's subtle, but there's some evidence of edema.
Yeah, but we're used to looking at scans of older people.
A young brain is bound to look full in contrast.
Well, these tiny petechial hemorrhages in
the basal ganglia tell us there's damage.
Well, the question is... how will it evolve?
Dr. Sutton, what's our plan?
Place an ICP monitor
and treat her with meds
to lower her intracranial pressure if it's high.
And repeat the CT in four hours.
Sooner. I want to know if there's any changes.
Nic is strong. She's healthy.
I've had patients make it through injuries like this.
We all have.
Got here as fast as I could.
Oh, my God. I'm so sorry.
There's nothing to be sorry about.
Nic is gonna be fine.
Does everyone hear that?
Nic is gonna be fine.
Go home, Pravesh. You shouldn't be here.
I need help over here!
Mrs. Sandoval?
It's not me. It's Gabe.
He's having trouble breathing again.
Hey, it's my favorite long-haul COVID survivor. You missed us?
Not really.
No offense.
Let's get you checked out.
Only oxygen. No tubes.
Now you know I don't make the rules, Mr. Sandoval.
Just try and relax. We've got you.
He's been doing so well since the surgery.
I wrote down his pulse oximeter reading.
This is 94, 96, 93, 94.
My wife is paranoid.
She's thorough.
We like that.
I try to keep him alive.
His health has never been the same since he had COVID.
That's a lot of wheezing I'm hearing.
How do you feel about checking in to the Hotel de Chastain?
- Huh? - I told you they'd admit me.
- Shh. - Page Dr. Austin.
- Mm-hmm. - Let's get Mr. Sandoval started on a neb,
order a chest X-ray, and give him 125 IV Solu-Medrol.
Um, is Nurse Nevin here?
She always likes to know how Gabe is doing.
Uh, not tonight.
Sit tight.
We'll get you fixed up, Mr. Sandoval, okay?
Shh.
You need to stop beating yourself up.
You saw the look on his face.
He's not angry with you.
He's terrified.
Which is exactly
how I felt when we didn't know what happened to you.
And Conrad was with you the whole time I was unconscious.
I need to be there for him.
Just give him time.
If Nic doesn't turn a corner soon,
there may not be much time.
Inserting the electrode into the dura.
Tox screen negative.
She doesn't have a drop of alcohol in her.
So her EKG and her echo were normal.
There's no evidence of any arrhythmia
that could have preceded this.
Swelling on the CT wasn't an overcall.
Her intracranial pressure is high.
- Then we start her on hypersaline... - Dr. Sutton?
Uh, we start her on hypertonic saline, Lasix and mannitol.
- If that doesn't work... - It has to work.
Let me talk to you for a second.
Billie is a strong neurosurgeon, but if you would like
a second opinion, you just name the doctor, and I'll deliver...
- I don't want another surgeon. - No, I-I get... I know.
What you want is to direct Nic's care, but you cannot.
Doing so would be a risk to Nic that we can't let you take.
You can't expect me to do nothing.
I'm not saying that,
but you must give this team the chance.
You don't have to stay for this.
Oh, don't mind me, dear. There's nowhere else I need to be.
Oh, no. Cherry's an old pro.
She sat beside Gabe for the six months
he was in ICU recovering from COVID.
Six months, one week, five days.
Is "bronchoscopy" two Os or three?
- That's three. - Ah.
I-I like to write everything down.
I-I know you keep Gabe's records in the clouds or whatever,
but I like to keep my own account right here.
Hey, Devi, park the scope right there.
See how his trachea collapses every time he breathes?
That's what's causing the wheezing.
It's the tracheomalacia again.
Okay, Devi, we're good.
He needed all that time on the breathing tube for COVID,
but it made his trachea weak and floppy.
And given his history, I'm afraid we're gonna have
to go back to the tracheostomy tube.
- Oh, he hated that so much. - I know.
How long will he need it?
Indefinitely.
And he's most likely going
to need the ventilator at home, as well.
I mean, the damage to his own trachea is so extensive,
it's the only way we can get Gabe to breathe safely.
Cherry, I know this is not what any of us wanted,
but I promise you, it is the best that we have.
No explanation from the police on what caused the accident?
Not yet.
I texted my prayer group to include Nic.
I hope that's okay.
How's she doing?
Listen, about earlier. I should...
- What's this? - Elaine Quinn, patient from last winter.
40 years old? She had the dogs?
Two huskies.
I remember. Her car got hit by a snowplow.
Worst TBI we'd seen, but she recovered.
If I can figure out why she made it through,
I can help Nic make it through.
Elaine Quinn's scans were entirely different than Nic's.
She had a brain bleed.
We were able to intervene on that.
I know that's not what you want to hear.
You think I'm in denial?
I don't.
I don't pretend to know at all what this is like for you.
I want to help you.
I just don't want to say the wrong thing.
No. I want you to be honest with me.
I know it's bad.
It is.
How you doing?
Me? I'm fine.
Well, then you're made of something much stronger
than the rest of us. It's okay not to be okay
when your critical patient is also your friend.
How are you, really?
This is one of the worst nights of my life as a doctor.
And I want to cry and scream and throw things
because my best friend should not be in an ICU bed
fighting for her life.
And how's Nic's progress?
Her ICP is higher than I would like, but it's stable.
Stable's not the same thing as recovering. Right?
Which is why I think it's time
to put her in a phenobarbital coma.
And you're worried Conrad won't agree?
This is your call... how you approach this.
You're the doctor.
If we put her in a coma, she can't wake up
until the sedatives wear off.
How can I know she's improving
if she's being flooded with sedatives?
- We rely on monitoring parameters. - Mm-mm.
Listen, I have to do something I don't want to do.
I have to talk to you the way
I would the spouse of any other patient.
Unfortunately, despite our meds,
the pressure in your wife's brain is still too high.
If we don't put her in a medically-induced coma,
we risk compromising any chance she has at recovery.
Oh, Conrad.
Nic has been my best friend since we were children.
I love her, too, and I will do anything for her.
It doesn't compare to what you're going through,
but you have to trust me.
I can't. I can't let go.
What if we do this and it's the end, and...
... and I-I can't ever talk to her again?
This is her best chance,
maybe her only chance.
You know that.
What would Nic tell us to do in this situation?
What would she say right now?
She would say, "Start the drip".
It's herbal.
Caffeine never does anyone any good at this hour.
Thank you, Mrs. Sandoval.
How are you?
Is it Gabe?
Dr. Austin said he needs another trach tube.
I have a feeling that's gonna go over like a lead balloon.
You can't imagine how relieved we were
when Nic got Gabe diagnosed.
Neither one of us had ever heard of tracheomalacia.
She helped us understand what long-haul COVID would mean
for Gabe, for both of us.
And she made us believe that we could face it together.
Maybe it's silly at my age,
but Nic made me want to go back to school and become a nurse.
She gave us hope.
I wish I could thank her again for that.
You can... when she wakes up.
I hope to God you won't have to.
- No updates? - No, there's-there's nothing yet, um,
but I brought you a visitor.
This is Santina Lopez from Nexus Life.
Hello, Santina.
I'm sorry you made the trip up here,
but I have no need of you at this time.
I'm sorry. Could you just give us a minute?
Of course.
You know, there's never a good time to make this call,
and if this were
- any other patient... - It isn't.
... with a severe TBI
and no trauma to major organs...
Just given everything we know at this moment,
we have to consider every possible outcome.
There are tens of thousands of people
in this country waiting for organ transplants.
I know, I have patients of my own on that list.
If the time comes to discuss Nic's wishes,
I promise I will handle it.
Oh, there you are.
You miss me?
How's your breathing, Mr. Sandoval?
We should talk about what we found on the scope.
We want to put in another tracheostomy tube.
No? Honey, this isn't a yes-or-no question.
Page Dr. Austin.
He should be a part of this conversation.
We'll be right back.
When the trach tube came out last time,
we agreed I'd never have another one.
It's okay. Our insurance can cover it.
It's not the cost, honey.
I'll be tethered to a machine.
The noise, the inconvenience.
All you do is take care of me.
With a trach, it's endless.
I signed up for better or worse, sickness and health.
I love you.
And I love you.
That's why I've made up my mind.
I'm done, honey.
No more tubes, no more chest compressions.
Uh-uh.
No.
Doctor? Dr. Devi!
We need a code airway!
DNI. DNI. DNI.
- DNI. - Mr. Sandoval, you could die without intubation.
Dr. Devi?
Cancel the code. Mr. Sandoval just informed me he's DNI.
Get the BiPAP machine, please.
We can keep you breathing for now, but you need
a permanent solution.
Conrad told me not to come, but I had to.
How's Nic?
I think he'll be happy you're here.
All right. Kyle's on his way.
He, understandably, is taking this very hard,
and I'm worried.
I'll see to Kyle.
Why don't you get GiGi to the nursery,
and I'll have one of the staff from Peds come
- and help you get her settled? - Okay.
- Her ICP is up again. - I can get more mannitol.
No. Her osmolarity is already 320.
Asymmetric pupils. Nonreactive on the right.
That's new.
So is the bradycardia. This could be a bleed.
That could be something we can fix.
Let's get her to CT to find out. Now.
Kyle.
Hey. Hi. Hi. Hi.
Hi. I, uh... I, uh, found this, you know, message board online.
They said that sensory reminders can be helpful.
Uh, where's Nicky?
She's just been brought to CT.
I want to prepare you for when you see her.
Oh, is it... ? It's that bad?
On the outside Nic looks okay, like she's sleeping.
Well, that's good, right?
Not exactly.
The impact from the accident was powerful enough
to injure her brain.
- It's, uh, like a severe bruise you can't see. - Don't.
And we don't know if or when
that bruise will improve or worsen.
It's got to improve.
It will improve.
I'm afraid, at the moment, that's far from certain.
Okay, I want... I want to... I want to see her.
I need to talk to her.
I want her to know that I'm here.
Of course. You can see her after the CT.
Can... can-can-can... can I wait in her room?
Yes.
There.
I see it.
Diffuse effacement of the gray-white junction.
Ventricular compression.
Her brain is herniating.
All right. So, we do a decompressive craniotomy.
That could stop the herniation.
- No, I can't. - Yes, you can.
I can't reverse the injury.
Nic won't recover from this, Conrad.
That's my wife in there.
GiGi's mother. The center of our world.
We are not giving up on her.
I love you.
This is unsurvivable.
Yeah, I know.
These images make it clear.
Nic is gone.
There's only one thing left to do to confirm the diagnosis.
The brain death exam. I...
I don't think Billie should handle that.
She's going through enough.
Conrad will insist on performing the tests.
No, we can't allow it.
Who does that leave?
Are you sure you're up for this?
Am I up for it?
No.
Is it gonna destroy me? Yes.
But it's not about me.
It's about two people I love and their child.
And I'm gonna do it for Nic.
And Conrad.
And GiGi.
I got you.
GiGi's asleep in the nursery.
Kyle, I'm so sorry.
Well, she looks okay.
Right?
I think she's gonna be okay.
Kit said there are tests?
Why don't we, uh, take a walk, get some air?
Nah, I'm gonna stay here in case she wakes up.
The doctors have to run some more tests.
We can come back as soon as they're done.
Need a hand?
I called them just in case.
We want to help.
Thank you.
Pupils are fixed and dilated. No corneal reflex.
No oculocephalic reflex.
Negative oculovestibular reflex.
Now I'm gonna test her pain response.
She's not feeling any pain.
Once I disconnect the vent, we wait eight minutes
to see if she breathes.
- Enough. - You're a fall risk. Lie back.
- Give me my clothes. - Why? You got a hot date to get to?
- I want to go home. - I'm not taking you home.
- Then I'll call a cab. - I won't give you the phone.
I'd rather die at home than in this hospital room.
Sweetheart, can't you just let me go?
Don't sweetheart me, you pain in my ass!
Everything okay?
Is it Nic?
When Gabe was at his worst,
people would tell me it was God's will.
Or "The universe won't give you
more than you can handle".
They didn't mean any harm,
but they didn't make things any easier.
She's going to live forever in your heart.
You need to carry Nic inside you now.
For you and your daughter.
Cherry.
Don't let him give up.
_
Time.
I appreciate it.
What are they doing?
Wait, whoa, whoa, wait, stop! Stop! What are you doing?
Conrad, they're... What are they doing?
- They're pulling the plug? - No.
No, Mr. Nevin. That is not what's happening.
No one here wants to hurt Nic.
Don't-don't manage me, Marshall. That's my daughter in there.
What you saw was a test
of Nic's brain stem responses.
We had to confirm her diagnosis.
What diagnosis? What?
Diagnosis?
I'm sorry. Nic is brain dead.
N-No, no. We... uh, we saw her hand move earlier.
Conrad, tell them. We saw it.
Involuntary movements can be triggered by spinal reflexes.
I-I can see with my own eyes.
She's not dead.
The way Nic talks about you,
she thinks you're a miracle worker.
You can save everyone in this damn hospital,
but you won't save her?
Her heart is still beating!
Her heart is beating because of a machine.
Her lungs are inflating because of a machine.
Fine, fine. Then let them do their work. J-Just go,
please, do your work.
I don't care if it takes days or weeks
or months for her to wake up.
- Just do it... - She won't wake up.
Nic is gone.
And being kept here, hooked up like this...
that was her idea of hell, and I'm not gonna do that to her.
I will not lose another daughter in this hospital.
She's all I've got left.
Please.
I intend to honor Nic's decision.
It's all I can do for her now.
I will never forgive you for this.
Uh... are they here?
I don't normally discuss
a... a patient's wishes with the family.
Nexus Life does that for us.
But I insisted.
While nothing can compare to your pain,
I hope you know how much we all loved her.
I do know that.
She loved you.
In time,
I hope it will be a comfort to you and GiGi
that Nic chose to be an organ donor.
She'll be able to save the lives
of eight critically ill patients...
... and vastly improve the lives of dozens more.
She helped so many people during her time at Chastain.
It's quite miraculous
that her life-saving work will continue.
If there is anything I can do...
This is what she wants.
So...
... this is what I want.
So, we need to get Mr. Sandoval
on my surgery schedule immediately.
He is a match for a donor
who can provide a trachea replacement.
A trachea transplant?
We never knew that was an option.
Oh, it wasn't. Until now.
This is an extremely rare opportunity for Gabe.
It could mean an end to his pain.
I don't know how to convince him to have another surgery.
He is refusing any and all treatments.
Where are my shoes?
Did my wife hide my shoes?
- Mr. Sandoval, please. - Mr. Sandoval.
Word has it that you want to check out.
That's right. No surgery.
No surgery? Wow, you talk a big game
for a man who can barely breathe.
I can't live with that tube.
Okay, so how about we ditch the tube?
Huh? No more looking for a quick fix.
I'm talking a total trachea replacement.
A trachea transplant would mean breathing on your own again.
- What if it doesn't work? - What if the sky falls?
What if the simulation fails?
Most importantly, Gabe, what about your wife?
- Cherry knows my wishes. - Don't fool yourself.
You're not making wishes. You're giving up.
Damn straight you are.
And there's not a soul in this hospital
who wants to hear anything about giving up.
Not today. Not after we've lost the best nurse practitioner
we've ever known.
Nurse Nevin?
She didn't make it.
And now Dr. Hawkins has to figure out
how to live without the love of his life.
Like you want me to do.
Gabe, listen to me.
When millions lost their lives
during the pandemic, you survived.
There's no rhyme, there's no reason.
You are a unicorn, Gabe.
And every person in this room knows
that your party is not over.
So come on, brother, what do you say?
You want to see what life still has left to offer?
Let's do it.
You heard the man, Dr. Devi.
Let's do this.
You know, you don't have to do this right now.
Not until you're ready.
I don't think I'll ever be ready.
Thank you, Dad.
Look who's here, Nic.
Brought your favorite person.
GiGi...
Why do you do this?
Not many people get a chance to make a difference.
A good nurse can.
Jess? Hey. Jess?
Jessie, hi.
Can you please tell Raylee I love her again?
You will tell her yourself
because you will wake up.
Now let us fight for you.
She's moving.
- Devon. - Nic.
Watch and learn.
Conrad's the guy who tightens the bolt.
_
No tears, Devi.
Nic gave us a gift.
We're going to save this man right here, right now.
We focus on that.
Be grateful for the miracle.
She's going to save so many lives.
Exactly.
Mama.
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