- Previously on The Resident... - I hope it will be
a comfort that Nic
chose to be an organ donor.
"We, Jake and Gregg, solemnly swear to treat
Sammie as our natural child".
Dr. Pravesh
is gonna be spending more time doing clinical trials,
and we need somebody to fill his slot
- in the ER. - Is that a job offer?
I need a photo
of my son.
Mom!
Perhaps when you feel up to it,
you'll tell me what's really going on.
This could be something simple, treatable.
You know it's not.
And?
Would you like to talk in your office?
Let's just talk here.
It's multiple sclerosis.
Mixed white and gray matter
with black holes consistent with worsening damage.
It's hard to know how long it's been going on.
Months, at least. Years, maybe.
But the science is advancing in this field,
and there are some amazing treatments.
There's no cure.
We will find ways to help you get through this.
A specialist
- can tell you more. - Okay. Thanks, Conrad.
Not now. Let's talk about it later.
Thanks.
Of course.
- Synced and corrected by Firefly - - www.addic7ed.com -
? Feel like I gotta do it today ?
? Crossing the street, don't look no both ways ?
? I'm duckin' 'em all like a weekday... ?
- What? - Nothing.
You're staring.
No.
I'm just watching my boyfriend get ready to change the world.
It's a tie.
On a doctor-turned-scientist
who's basically going to cure cancer
with his new clinical trial.
You are the one that is crushing her neurosurgery rotation.
Billie's been telling everyone
what a star you are.
She's a great mentor.
And you're changing the subject.
Starting today, we get to finally enroll
our first patients.
This is the beginning of a new journey.
One which will end with you
receiving a Nobel Prize.
Let's not get ahead of ourselves.
But you did forget one of the best parts
of running a clinical trial.
- More than winning a Nobel? - Oh, yeah.
Fewer hours at work
mean more time with you.
? So be cool ?
I like the sound of that.
? Just be cool. ?
I am so glad you could come.
Randolph has been so looking forward to seeing you.
We both have.
- Will there be drums and firecrackers? - So many.
And a lion dance from local performers, darling.
But tonight is more than just a party.
Celebrating Lunar New Year is just one of the ways
we hope to look out for the well-being
of our Asian American community.
Yeah, well, I'm all for that.
And I'm happy to help out with the free hep B screenings.
- Thanks. - Mm-hmm.
Look who's here!
- Hey! - Grandpa!
Hi.
- Hey, Jake. - Hey. Good to see you.
I'm so glad you guys could make it.
We love celebrating Lunar New Year
with Sammie,
and when she heard about what you were doing,
she practically booked the whole trip herself.
Where's Gregg?
He had to work last-minute, but he sends his love.
Uh, the three of us need to talk.
Okay. What-What's this about?
Well, let's get Sammie settled first.
How would you like to help the preschoolers
make some decorations, honey?
- How's that sound? - Yes.
Yeah? Wonderful. All right, come on. Let's do it.
Bay Two, drop an NG tube
for a gastric lavage to identify if it's an upper
or lower GI bleed.
Bay Three, grab some sugar packets from the breakroom.
Sprinkle them on the prolapsed stoma, then reduce it.
- On it. - Bay Four,
avoid sutures for that poor girl's head lac.
Just use her hair and some Dermabond.
Dr. Sullivan, I see why Kit hired you.
- Bet you put the "go" in "go, team". - If I'm not ordering
new sneakers every other month,
- I'm not doing my job. - Me, too.
So, how's your first week been?
Fine.
A bunch of us are gonna hit the Lunar New Year party
after work. You should join.
- Free food. - Yeah, tonight's not gonna work.
Dr. Sullivan, I'm starting to think you don't like us.
I don't know you well enough to like you or not, Dr. Feldman.
Exactly. So maybe come hang and, you know, find out.
Unfortunately, I have plans.
I don't think
she really has plans.
So, what do we say to everyone
who keeps asking us who the new ER doctor is?
Tell them I believe in the soul.
The hanging curveball. High fiber. Good Scotch.
That the novels of Susan Sontag are self-indulgent crap.
I believe Lee Harvey Oswald acted alone.
And I believe there ought to be
a constitutional amendment outlawing Astroturf
and the designated hitter. I believe in opening
- your presents... - ... in opening your presents Christmas morning
rather than Christmas Eve.
Crash Davis's speech from Bull Durham.
- Great movie. - It's the best.
Evidence suggests you and I could be friends, Feldman.
I'm impossible not to like, Sullivan.
So, you aren't on social media.
I tried to find you to make sure you weren't a psychopath.
Well, I'm not an exhibitionist
- or a narcissist. - Harsh.
- But a picture is emerging. - Love to get back
- to my patients now. If you don't mind. - Mm.
Do your thing.
I so agree with everything you just said, by the way.
I, too, am tired of the humblebrags
and the... You're just gonna keep wa... Okay.
Thanks, Dr. Sullivan.
Another successful interaction, Zach.
You paged?
29-year-old female.
Had a syncopal episode during spinning class.
She had a heart transplant,
so figured you should take a look.
What do we have here? Initial EKG,
chest X-ray and head CT negative.
Vitals are stable. She's awake and oriented.
Call Hawkins.
- For a consult? - Just call him.
- What's up? - Hey.
- Is it your mom? - No. No, no,
this is about a young lady here in the ER
with a syncopal episode and a cardiac history.
They called me to do a consult
because she had a heart transplant.
- Okay. Let's have a look. - It's...
a little more complicated than that.
The transplant was performed by a former colleague of mine
at Redman Hospital three years ago.
Three years ago.
- In September. - When in September?
September 17th.
Yeah, there's no doubt about it.
She has Nic's heart.
Gigi, this is Sammie, and she'd like to help you
- with some decorations. Is that okay? - Okay.
Hi, Sammie. I'm not very good with scissors.
I can help. I'll show you how.
You're a great dad, Jake.
She's a sweetheart.
It's all Sammie. I think she was born this way.
So, what's this all about?
Let's get a coffee,
- find a quiet place to talk. - Okay.
Don't say anything to her.
There's no reason she has to know.
And I don't want to talk about it. At least
- not until we know what's wrong and fix it. - Understood.
Hannah.
Hey. I'm Dr. Austin,
- and this is my colleague Dr. Hawkins. - Hello.
- Nice to meet you both. - So, we heard you had a bad fall.
Yeah. I started taking a spin class.
Been getting in good shape, and I love it.
So, you think maybe you pushed yourself too hard?
That's what's weird. I mean, I don't think so.
I forgot my spin shoes at home, so I had to come back.
And I remember I'd just joined
the class when "Nonstop" came on.
Ah, I love that song.
Uh,
and all of a sudden, I couldn't catch my breath
and just collapsed on the bike.
Paramedics had to unclip me, and I came to in here.
Well, let's take a listen to your heart, shall we?
Your turn.
Hmm?
Heart sounds normal.
All right, let's lie you down for an echo.
Okay.
We saw that you had
a heart transplant a few years ago.
Yeah. I'm one of the lucky ones.
Well, aside from the shortness of breath
in class, you have any leg swelling?
Wake up with trouble breathing?
No, um,
not since my transplant.
It was like a miracle.
I was born with a bad heart.
I mean, I suffered
with every symptom of heart failure
for so long, it felt like I was dying every day.
And then after I got my new heart,
I was alive again.
Any other symptoms? Anything at all?
I have headaches occasionally.
Well, the echo shows
that your heart's ejection fraction is low.
Meaning it's-it's not pumping as well as we'd like,
which is probably the cause of your collapse.
Uh, Hannah,
I'm sorry to tell you this,
but you are in early heart failure.
No. No, no.
Um, I prayed that I'd never hear those words again.
This heart can't fail.
It can't.
After my transplant, I did everything
the doctors told me to do. I-I never missed an appointment.
I mean, I...
- How could this happen? - Don't worry.
We're gonna run some labs, and we're gonna figure this out.
Relax.
Take a deep breath.
- Okay? - Okay.
There you go.
It's gonna be okay.
- What's the story there? - Hmm?
Why do you ask?
Why the urgent page?
Now Hawkins seems concerned.
So, are we sharing personal tidbits now?
Okay. All right. I deserve that.
That young woman was the recipient of a donor heart,
and it belonged to Conrad's wife,
who died in an auto accident three years ago.
Damn.
She was a legendary nurse practitioner.
One of us.
And Nic and Conrad were a great couple.
A true love story.
That's tragic.
It's taken him years to recover.
He's finally starting to live again.
And...
if that woman has something seriously wrong
and should happen to die...
- Who knows how he's gonna react. - Yeah.
A few weeks ago, I started feeling... off.
Numbness in my hands and a loss of dexterity.
That's why I pulled myself out of surgery.
I just wanted to make sure I knew what it was first
before-before I worried you.
So I waited.
But I got the final results today.
And I...
I don't want to spoil this visit.
I've been so looking forward to it. But you're here,
- so... - What is it?
P-Please, just tell us.
I have multiple sclerosis.
Oh, darling, I'm so sorry.
- We're-we're here for you. - And I...
I know. You know, I just learned this morning,
so I'm...
still kind of processing.
A-And to be honest,
I'm just... I'm just reeling.
Of course.
But there's hope.
Whatever you've been experiencing
- can be treated with meds. - Yeah.
W-We need to jump into this right away.
We need to find the best place for you
- to get treatment. - I, you know, I have to round
on some patients that I've been asked to consult on, so...
Of course. Go. We'll get more information,
and come find us in my office when you're done.
Yeah. Okay.
Now the decompression.
Placing the needle into the subdural hematoma.
Nicely done.
I can see why AJ is courting you for cardiothoracic.
Choosing a specialty is gonna be so hard.
I wish I could do it all.
I think being a heart surgeon's great.
If you want to be a plumber.
Do not let Dr. Austin hear you say that.
No shade to Dr. Austin, but the heart is just a pump.
The brain is more complex than the universe
and the source of everything that makes us human.
It's the source of my dyslexia and the key to overcoming it.
See, it's personal to you.
That's how passion for a field is born.
You think I could do this?
We could always use more women in neurosurgery.
We are overloaded with arrogant men.
But I would never try to recruit you.
Why?
Well, Devon would kill me,
- for one thing. - Oh. He...
- He'll support whatever I choose to do. - I know.
But as a neurosurgeon, your life becomes the hospital.
To be truly excellent requires total commitment,
and the pressure is intense.
If you ever want
- to have kids... - That's far in the future.
If ever.
I really want to consider this.
All right.
Well, we can talk about it.
You have both the brains and the guts.
Okay, you ready to try it blind?
Oh, hell yeah.
Lunar New Year was your father's favorite holiday.
And I also remember as a kid,
he would give me those little red envelopes.
And I thought today,
perhaps you could use one.
Can always use a little luck.
Do you really think this drug trial
could beat my cancer?
Most success rates are low, generally, in clinical trials,
but this one's different.
I mean, they're thinking this could be
the next big thing in lung cancer.
But one step at a time, Mom.
First, we have to get you enrolled in the trial.
So, my mother's cancer is spreading.
Her lung masses are growing,
and there's a new met in her liver,
and if it continues to spread...
The next step will be hospice.
Yeah.
We're not there yet,
but I do want to give her the best chance to live,
and-and right now, it's your trial.
But have you looked at the side effects
- of this trial? - Yeah.
She can do this, Pravesh.
I'll need to assess that for myself
- very carefully. - Yeah.
Yeah, please do.
But...
This is our last hope.
- Hey. I heard. - How?
The gossip mill at Chastain
is alive and well.
We're all pulling for her.
- Do you know what's wrong? - Heart failure.
We're seeing what we can do.
How are you holding up?
I'm keeping perspective. The heart is a muscle.
Hey.
This is me, Conrad.
Inside this woman who walked into our ER
is a part of someone we both loved.
That means something.
After Nic died, I kept seeing things
that made me feel like she was near me.
A song we loved would suddenly come on the radio.
A woman in the park with her laugh.
I'd find an old note she left for me in the drawer.
That type of thing.
Then eventually, it faded.
But now a small part of her,
a real part of her, is here.
Alive.
Hannah, talk to me.
I can't... I can't breathe.
- I can't breathe. - She's hypotensive,
tachycardic, and her sats are dropping.
This looks like cardiogenic shock.
- I need a norepinephrine drip. - And page Austin.
Her ejection fraction is only 15%.
We need to get her to the cath lab now.
Inserting
the pump into the aorta.
That should help her heart pump a little easier.
But it's only a stopgap. Her heart failure
- is getting worse. - She must be rejecting
the transplanted heart.
I wish there were some other explanation.
Well, she stabilized enough to tolerate
the biopsy. That should tell us more.
Biopsy catheter to me.
So, AJ told me you've discussed how, um,
brutal and, uh, dangerous this trial would be.
And you're sure you'd want to do it?
I'm sorry to ask you again, but given the risks,
I need to hear it from you directly.
Yes.
And...
do you have any concerns that you want to discuss with me?
I'm not just doing this for myself
but for others.
I mean,
it will help advance the science, right?
Yeah.
That's the point of the clinical trials.
They're experiments.
Okay. I'm in.
I admire that enormously.
But we still have to determine if you meet the criteria,
which means one more test.
- Okay? - Okay.
So,
I'm gonna put this over your nose.
Now I want you to put your mouth
around this mouthpiece and breathe in normally.
All right, Carol. I want you
to pant. In and out.
Good.
Now take a deep breath in.
Now breathe all of the air out.
Keep going.
Come on.
And we're done.
Let me try that again.
Okay. One more time.
The rules of the trial are clear.
We need an FEV1 of 50% or more.
Hers were 45 both times.
I'm so sorry.
She didn't pass.
So, you're telling me that she doesn't meet the criteria
based on what's essentially a rounding error?
No, it's more than a rounding error.
There are other issues.
I reviewed Carol's chart.
Her echo and performance status were borderline, AJ.
A-Are you cherry-picking
only healthy patients to protect
your numbers?
I'm not protecting my data.
I'm protecting Carol.
And given her condition,
I'm not sure how likely it is
this incredibly difficult regimen
would even help her.
"Not sure"
doesn't cut it when we're talking about my mother's life.
I'm sorry,
but these criteria exist
for a reason.
Who are you?
No, really, is-is this who you are?
A numbers dude
who blocks a desperate woman's last hope?
Wh-What happened?
Your heart failure is worsening.
We're waiting for tests to confirm,
but we're worried that...
your body is rejecting your transplanted heart.
You have to fix it.
Please.
We're trying.
I'll let you know as soon as we get the results of the biopsy.
Okay.
If you need anything
or you feel any discomfort,
I want you to push this red button, okay?
I trust you.
I know you'll help me.
I will.
Hey.
I'm doing a split shift,
so I'll be taking care of Hannah in the ICU.
- Want me to catch you up? - No. Already did that myself.
I'll keep a close eye.
Page you if anything comes up.
Conrad?
Yeah?
I'm sorry about your wife.
Thanks, but this isn't about Nic.
It's about Hannah, okay?
Open. Ah. Open...
It's good. It's okay.
It's okay.
Oh!
Dr. Bell, are you okay?
Yeah, fine. Thanks.
We have great news.
Kit and I have been calling in
every favor. We're really excited
to tell you what we've come up with.
Sit down.
It's all right. I'm not completely incapacitated yet.
Uh, n-no, I know. I just...
The landscape around MS is always evolving.
New immunomodulator therapies reduce relapses
and progression.
If you experience a relapse
after, uh, starting
one treatment, many patients try another,
and-and they keep trying until they're symptom-free.
Finding the right specialist is paramount,
so Jake pulled some strings
and got you a neuro consult at the Mayo Clinic on Tuesday.
The chair of the department's a friend.
I did his nephew's cleft palate surgery a few years ago.
He's already been filled in.
Thank you. Both of you.
So you'll go?
Yeah, of course.
And I'm-I'm grateful.
I'm so encouraged.
- Jake, I need a couple minutes alone with Kit. - Yeah.
I'll, uh, let Mayo know you're confirmed.
Kit, I'm leaving Chastain.
A leave of absence.
- Of course. To heal... - No. Permanently.
What?
I'll-I'll try the treatments,
and I'm grateful for the help,
but I'll never operate again,
- even if I get markedly better. - Why not?
You at 95% is better than anyone at 100.
It's more complicated than that.
Then, please, explain it to me.
- Optic neuritis. You familiar? - Of course.
Eye pain, vision loss.
Are you experiencing any?
I just had an episode. It cleared up.
But it's a sign the disease is progressing rapidly.
I'll lose my strength, then the ability to walk
and speak and eat.
And at some point,
- I'll end up paralyzed in a hospital bed... - Okay, stop.
- ... unable to feed myself. - Stop.
Stop.
See, you fell in love with the man that I wanted to be.
And I became him because of you.
What are you saying?
I love you.
And I will not saddle you with this.
I have a welcome speech to give, but don't leave.
- We have to talk about this. - No, we don't.
I have an office to pack.
Kit!
Hey, Kit!
Kit!
What'd he say?
What happened?
Gigi, wait! Sammie, wait!
Sammie!
She's seizing. Two milligrams of lorazepam now.
I'm gonna get her on her side before she aspirates.
So, she came in with heart failure,
rapidly developed cardiogenic shock.
- And now seizures? - Despite everything
we're throwing at her, she continues trending
- in the wrong direction. - She has a bleed.
Likely caused by the blood thinners we put her on
for the balloon pump.
I mean, thankfully, it's small, so we can just monitor.
But look at the meninges lining her brain.
Usually they're smooth, but here they're bumpy.
Something more serious is happening here.
Infection.
An infection while we're blasting her with meds
to suppress her immune system would be deadly.
- Devi and I will do a spinal tap. - I'll get her a full body scan.
I'll send off autoimmune labs and talk to pathology,
see if the biopsy results are back.
- So what did I miss? - Hannah's labs came back normal.
Spinal tap was negative. No cancer on the full body scan.
Pathology told me her biopsy proves
she's rejecting her heart.
Tacro levels are in the basement.
So her heart's failing because she's probably not taking
- her immunosuppressants. - I don't think she would do that.
Not based on everything she told us.
Well, we don't really know her, do we?
You know, people can surprise you.
I got to check on a patient.
I'll be back in five.
You all right?
My mom's not getting into Devon's trial.
He said she missed the cut.
Why don't you talk to Hannah about those meds?
I'll talk to Devon.
Carol was outside the FEV1 entry criteria by five percent?
Those are the rules. My hands are tied.
Protocol exists for a reason.
I taught you to break the rules for the patients.
You taught me to also follow the science.
And what you're saying now is to ignore it.
Yeah, we both know her odds
are long and this is your first trial,
but to turn her down because she'd skew your statistics?
Do you think it was easy for me
to tell AJ that she wasn't a candidate?
But I know it was the right thing to do.
The right thing to do for who?
The patient, the pharma company or for you?
For everyone.
If your father were still alive,
and you had a chance to save him with this trial,
but he didn't fit the criteria by a small number,
would you make the same call you did for Carol?
I have spent all day trying to convince myself
it is okay to let her into this trial.
But I know that if I do, she will likely end up
on dialysis when her kidneys fail.
Fluid in her lungs will make her feel like she is drowning.
But what if she makes it through?
I don't see that happening.
Carol is brave.
She wants to help the science.
But if I bend the rules to let her in,
her sacrifice, it won't even do that.
I am not going to torture
an older immunocompromised woman.
She's already been through enough. I won't do it.
- You talk to Devon? - I did.
- And? - I'll explain later.
But we will do what's right for Carol, I promise.
We're out of time. She's getting worse.
What about the immunosuppressants?
She insists she's been taking them. She has from the start.
She told us she had headaches off and on.
She had seizures.
Maybe she thinks she's taking the meds.
She could be forgetting to take them,
because of an underlying neurological problem.
How long has she been tapping like that?
For hours.
It's the same consistent tempo.
Her tapping matches the beat of her heart on the monitor.
Maybe she's hearing her heartbeat in her ears.
You're right. I can hear it.
Must be a dural arteriovenous fistula.
An abnormal connection
of blood vessels in the brain.
Explaining all her symptoms.
From the headaches to the seizures
to forgetting to take her meds, resulting in the heart failure.
So, her heart problem is really a brain problem.
And that can be fixed through surgery.
One second.
Unequal pupils.
Her brain bleed is getting worse.
I'll page Billie now.
Dr. Austin?
If you don't mind, I'd like to monitor
our patient's intraoperative cardiac function.
Of course.
This one's for Nic.
- Sammie? - Gigi?
- Sammie, Gigi! - Gigi?
- Sammie! - Gigi?
Sammie!
- Girls? - Sammie!
Once there was a little bunny
who wanted to run away.
So he said to his mother, "I'm running away".
"If you run away", said his mother,
"I'll run after you, for you are my little bunny".
"If you run after me", said the little bunny,
"I'll become a fish in a trout stream,
and I will swim away from you".
So the mommy keeps him safe?
Yes, you see? No matter what the little bunny does,
he's always protected.
Like you protected me from the dragon?
That's right, Gigi.
Pickups and dural scissors to me.
Opening the dura now.
It was unavoidable.
Two large bore suctions.
Sutures. We have to repair the sinus.
Cardiac Doppler to me.
We got an air embolism.
If air in the blood hits the heart,
it could be fatal.
Chu, drop the head of the bed.
Devi, flood the field with irrigation.
I need a central line to aspirate the embolism.
Heartrate's stable.
All good, man.
All right.
All right, let's keep it going.
You can run, but you can't hide.
I will find you.
Wherever you go, I will follow.
We will go to the Mayo Clinic together.
And wherever the road leads after that.
But it will lead back here, to Chastain.
Because you will get better.
You will operate again.
And you will save lives as you have before.
Well, you don't know that.
I do know
that whatever complications may be ahead,
we will face them together.
Because you are the great love of my life,
and I'm pretty sure I'm the great love of yours.
It's gonna be okay.
It's okay.
So?
Is my mother in your trial or what?
No. I'm sorry, AJ.
I agree with the decision.
What?
Wow.
Wow. I really expected more from you.
When Nic came into this hospital gravely injured,
I would have died to save her, but I couldn't.
No one could.
I know better than anyone there is nothing harder
than not being able to deliver a miracle.
This trial would not help your mom.
It would harm her.
But that doesn't mean there's nothing we can do
for your mother.
I'm...
actually a little relieved.
If I'd qualified for the trial,
I'd have given it everything I've got.
But...
I'm tired.
Part of me was doing it for you.
Wow. Mom, I'm sorry.
I-I didn't mean to push this on you.
Hush. Hush, son.
You've been an angel.
Carol, I'm gonna call your oncologist
about starting you on palliative care right away.
It's not hospice.
You don't need that yet.
No, no. Palliative care doctors will treat your symptoms
and make sure you live your best life without pain.
It's something we should've started
the day you were diagnosed.
Studies have shown that people with metastatic lung cancer
can actually live longer...
- And better. - ... than those who continue
aggressive and sometimes harmful treatment.
And this will give us more time to do the things that we love.
Together.
AJ, honey, I would love that.
That should heal in a few weeks.
And your neurologic symptoms should start resolving soon.
The fistula in your brain
didn't just cause headaches.
It affected your memory.
That made you forget to take the meds,
which led to the rejection.
- And my heart? - We've begun treatment,
and your heart is already showing signs of recovery.
Dr. Hawkins made the diagnosis.
Dr. Hawkins.
How can I thank you?
All of you.
Get some rest.
I wasn't sure if I was gonna tell you this, but...
My wife was an organ donor.
And she saved a lot of lives.
Including yours.
What?
I...
I have your wife's heart?
Can I see her picture?
I do have a favor to ask.
Yeah, anything.
Could I introduce you to my daughter?
Of course.
Gigi, I want you to meet a very special person.
This is Hannah. Hannah, this is Gigi.
Hi, Gigi.
Hi.
Can we listen?
Yeah.
Hi, Mommy.
- Synced and corrected by Firefly - - www.addic7ed.com -