- Season 11, episode 21, McDreamy says goodnight.
Let's watch it together.
Beep-wop.
(engine revving)
(vehicles slamming)
(brakes squealing)
Okay, first mistake he's making here,
you need to call for help.
(record scratching)
(light, whimsical music)
- My phone's not working.
- Because there's very limited things
you can do on the road without any tools.
You you need to call for help and get emergency transport
to get them to a hospital
where they could actually be taken care of.
- Hey, I can't open the door.
- Winnie, Winnie.
- Ma'am.
- Winnie.
- Hey, hey, what's your name?
- Sarah.
- Sarah, who's Winnie?
- My daughter.
- Hey, you're Winnie?
- I think I'm dead.
- Well, you're not dead.
I can feel a purse in your wrist,
and you can't be dead if your heart's still beating.
See, I'm a doctor and I'm telling you.
You ever wanna know if you're dead?
Feel your pulse.
- Maybe that's a little dark thing
to say to a child.
- [Derek] Listen, I'm gonna get you out.
It's gonna hurt a lot.
- I don't know if it's shock, or if it's that
my leg hurts so badly that I almost can't recognize it.
It almost feels normal, so maybe it won't be so bad
getting me out.
- Sounds like you dislocated your hip.
- How does he know that?
He's just feeling around over there and he's like,
yeah, dislocated the hip.
Yeah, no special tests, eh.
- I'm gonna get you out of this car.
- Okay. - Down on the ground,
and then pop it back into the socket.
- How does he know it's dislocated
versus like a full-on fracture that's displaced?
He just has miraculous hands that have x-ray field.
(Sarah screams)
- The dislocation has cut off the blood supply to your leg.
If I don't do something, you could lose it.
- So that's the only time you would do a reduction
in the field like this.
If you see that the vascular supply, meaning the blood flow
that is going to the lower limb is obstructed,
because of the dislocation.
That can happen.
In this case, yeah, he should try and put it back
so that he restores blood flow.
Otherwise, literally the rest of her leg
starts dying in necrosing.
(bone cracks) (Sarah yells)
Whenever you do a reduction of dislocation, initially,
worst pain ever afterwards, it feels kind of good.
- Help, help.
- Does it hurt anywhere?
- No.
I'm not supposed to be here,
I have to go.
- Listen to me, you're probably in shock.
Okay?
You got a lot of adrenaline going to your head right now.
There might be something wrong with you
that you don't feel right now.
So I need you to slow down.
- That is very accurate.
In fact, paramedics are trained to tell folks
who've been in car accidents to calm down
because it's very easy to say, I'm fine, I'm fine.
I don't need to go get emergency care
because you are on adrenaline.
You don't feel your internal injuries
and you could potentially be bleeding out.
And it's also so important to know
the mechanism of the injury.
Like the fact that this was such a high speed car accident
already puts her at a risk of severe fractures.
Vertebral fractures, internal bleeding.
- I just need to undo a button
so I can look at your stomach.
- He's going to see it like bruising
or he's going to see a giant laceration with intestines.
- Got a hand it to you, you got it,
go home and have yourself a drink, you earned it.
(soft music)
(phone buzzing)
- Oh, and that's why you don't stop
in the middle of the road.
- Blunt force trauma to the head,
chest and abdomen, persistent hypotension
after two liters of saline.
Pulse is thready at 130.
- Okay so that's important information.
So after giving him two liters of fluid
to try and bump up his blood pressure,
it's still persistently low,
which means that he's in a dangerous spot.
Ideally they want to give him more fluids,
more blood products if that fails,
you have to start them on pressors
in order to keep his blood pressure up,
to give sufficient blood flow to the vital organs.
Also, they sent his blood.
His pulse is 130, which means that it's fast tachycardic.
Reason being is when the blood pressure's low.
The heart tries to compensate by beating faster
in order to like fake increase the pressure.
- [Doctor] Can you hear me?
- Yes, yes.
I can hear you.
Loss of verbal skills,
possible bleeding in the brain.
- [Doctor] His pupils are equal and reactive.
- Good sign.
Still should get a CT.
- He's got a flail chest in the right.
I need a 36 french tube now.
- Alright so they said he has a flail chest.
That means he has significant rib fractures,
like complete fractures on one side,
maybe even a pneumothorax,
because what happens is when you have a complete disconnect
of your chest like that,
your breathing happens paradoxically on the side
where you have your injury.
- This is gonna to hurt, but we have to do it.
(incision sounds)
(deep breathe)
- They're basically putting in a chest tube to drain it.
His chest of blood because he's bleeding internally,
which will allow his lungs and potentially his heart
to expand when they are beating and filling up
with either air or blood respectively.
You also, sometimes if you have a pneumothorax,
a collapsed lung, when you equalize the pressure,
you allow the lung to expand as well.
- He fixed our ride.
He helped Charlie.
And then he put all of us inside his back and he saved us.
- He saved you?
- All of us.
He's a doctor.
- He's a doctor.
- So you should treat him differently
than you would any other patient what.
- We've got you, and it's all gonna be okay.
- This isn't right.
You should have taken me to get a head CT.
- Anytime you have blunt force trauma to the head
with a serious accident again, mechanism of injury.
Semi-truck hitting you at a fast rate of speed.
Get CT's.
We over-order CT's in emergency rooms for things
that don't really matter yet when people
have a really high-speed car accident,
people are like should we get a head CT?
Yes. You need to figure out if there's bleeding internally.
Because you're management completely changes.
- We have to work fast people.
- I'm stable guys, I'm stable.
Take me to get the head CT.
- The way you decide if someone's stable
is you look at their vitals.
If his blood pressure's not tanking,
you know that the patient is stable enough
to go get a head CT.
And if there's bleeding in the brain,
you want to save the brain because without the brain,
there is no body.
- He's got a great tooth blown apart.
- Meredith would leave it.
- Let's leave it.
- At the four quadrants.
- And she'd double-check the retrohepatic space.
- The retrohepatic space is a very commonly known one
that you learned in your surgery rotations,
where you can lose a lot of blood and not even know it.
- He is still hypertensive.
- Heart is intact.
He's not bleeding in his chest,
this makes no sense.
- I'm missing something.
- Start on TEE.
- Not that.
That's not what you're missing.
- A TEE is transesophageal echocardiogram
where essentially you put an ultrasound probe
into the esophagus in order to better visualize the heart.
- You got a headlock check.
Check his pupils.
- His right pupil is blown.
- Anisocoria can happen when you are having bleeding
into the brain.
- Pave to neurosurgery, right freaking now.
- The hell have you people screwed up now.
- Us, you're on call for trauma.
What took you so long?
- Who the hell are you?
- Your response to him was supposed to be 20 minutes.
- It wouldn't have made a difference.
- If you guys had ordered a head CT,
you would call me sooner.
- You were supposed to be here in 20 minutes,
not an hour and a half.
We have a chance. He had a freaking chance.
Get him an IOR.
- What?
- That type of blame game can happen in a hospital setting
where there's big egos.
I mean, obviously both are in the wrong.
Does it matter who's more wrong?
No.
The only thing that should matter is the patient
and try to do the best that they could now.
- It's too late.
- The call to not get a head CT was a bad call.
- We're not a trauma center or a teaching--
- You did the best you could.
- I mean a head CT.
Like if they made a mistake with some kind of protocol,
I get it because they're not a trauma center.
That makes sense.
But not getting a head CT is just incredible to me.
Like that's the first thing you would do in a car accident
of that nature.
Remember the mechanism of injury there,
in fact, there's like a Canadian head CT protocol.
And one of the points is the mechanism of injury.
And it's like, if it's a high speed accident, boom,
you get the head CT.
Like I still even remember that from med school.
I also don't quite understand how they were certain
that he had abdominal bleeding over,
like how do they know he wasn't bleeding
into his brain versus his abdomen?
Like it seemed like they just guessed that
because if you're doing anything,
your pants scanning the patient,
you're scanning the head.
You're scanning the lungs.
I mean the chest and the abdomen,
you're doing it all at once.
- Mrs. Shepherd.
There's some things you need to know.
Some things we need to discuss.
Difficult things.
- I'm a doctor.
You've waited the requisite number of hours
and now you can officially declare him dead.
So yes, you needs a bed.
And those must be the papers.
- Essentially, the ICU wants to clear the patient out
if there's no improvements being made.
And while that is part of what goes
into medical decision-making obviously
when it comes to triage,
but also it's in the patient's best interest
to not be further tortured
if there is no potential chance of recovery.
- I'd stop all curative intervention.
Discontinue all routine monitoring,
remove all the catheters, drains, and tubes
and any and all treatments that might provide comfort
to the patient.
Terminate all life-sustaining measures.
- Well see that's not exactly true.
When we fill out a POLST form,
we actually can put orders in
that would put a patient on comfort care.
So we would put orders in to make sure
the patient is comfortable.
Giving them high sedation,
giving them pain control, mucus control,
cough control, hiccup control.
There's all sorts of things that we need to think about
for a patient who's at the end of their lives.
And we do that with our comfort care order set.
When we choose to say that aggressively treating someone
causes them more harm than actual benefit.
We're not saying discontinue everything.
We're discontinuing certain things
that we feel like harm the patient.
And we continue certain things or begin things
that we think would benefit the patient,
meaning that the goal is no longer
to make the patient live longer,
but to make the patient as comfortable as possible.
Oh no McDreamy is going to die.
(somber music)
One of the mistakes I've seen residents make
is when they are putting a patient on comfort care
and they're discontinuing the ventilator
and all these things.
They forget to turn off the alarms
because remember the alarms just notify you
when a patient's crashing and it's very discomforting
for a family to watch their loved one go peacefully.
But then the alarms going off like crazy
that the patient's dying.
So you've got to turn those off as well.
(alarm beeping)
And they didn't turn off the alarms.
McDreamy.
One of the hardest conversations in medicine
is the end of life conversation.
And this is supposed to happen,
not just with someone who's terminally ill,
someone who's just been in a car accident.
It's supposed to happen with your primary care doctor.
So you can have a plan because without a plan,
so many things can go wrong.
What's to happen?
What are their wishes?
Who's going to be the power of attorney?
What do they want from their care, medically speaking.
And an important aspect of that is understanding that
there's never a sure-fire correct answer
because patients a lot of times will ask of me as a doctor.
Should I do this?
Should I take them off life support?
Do they have a chance to get better?
A lot of times you have to give the most accurate answer,
but it's not a hundred percent accurate answer.
A lot of folks are not comfortable with that.
But the unfortunate reality is that's life.
Every decision cannot be a hundred percent.
And ultimately it's your choice
that has to be decided upon.
Based on the wishes of what the patient wanted.
Here's the difference between real doctors and TV doctors,
click here to check that out.
Great video I share some epic patient stories
and as always, stay happy and healthy.
Unlike McDreamy.
(upbeat music)