The Good Doctor Season 3 Episode 15
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00:00you're doing great really great it's gonna be okay you promise
00:13baby's out umbilical clip suction please can i see my daughter yes of course
00:24sorry we'll need to get her into surgery we'll take good care of her
00:45your new chief is fashionably late our chief just because i endorsed dr hong to the board doesn't
00:53mean i don't have any concerns connections like dr hong's come at a premium and he assures me
00:57will be well worth it given our current predicament with the medical board i'm not just worried about
01:01the money when you pay that much they tend to think they're worth it makes a person think
01:08they don't have to show up for their own welcome brunch
01:10the baby's bowel protrusions seem less severe in the prenatal imaging
01:26and it'll have to wait until we're done with her heart problem
01:29now that i'm in here her septum looks more like swiss cheese
01:33page the on-call neonatal cardiac surgeon that won't be necessary i'll scrub in
01:41and who are you i'm jackson han your new chief of surgery
01:46echo probe please
02:04and let's turn that music on
02:09advance the delivery sheath
02:15it's in the patient's heart dr murphy
02:19i think the music is a little distracting
02:22i feel the same way about operating without music
02:25take a longer sheath and dr murphy will need some forceps
02:30five second rule
02:37it was a joke
02:42what about her bowels why isn't dr limb inserting it into the abdomen right now
02:50there is not enough room
02:52there's there's not enough room without increasing abdominal pressure which would
02:57critically decrease blood flow to the bowel
03:00according to what hemodynamic principle
03:02dr brown
03:04vascular impedance blood flow is driven by the force induced by the pressure we gain
03:08and how do you calculate it
03:09i'd have to look it up
03:15eight times l nu divided by pi r4
03:19very good dr murphy
03:21that's also why the secluder won't work
03:23won't hold up against a huge pressure
03:25i need umbilical tape and pe tubing
03:27you're making a pulmonary artery band
03:37that should buy us some time to come up with a plan before we lose this baby
03:41you canceled my hernia repair
03:55with no advance notice sorry about that
03:59but so great to meet you jackson han
04:01you melinda's oh i know
04:03you did great work on that piggyback heart transplant
04:06i need a consult
04:08on manesh goyle he's the founding ceo of a company
04:11what's his diagnosis
04:11he doesn't have one
04:13he's here for a full physical complete diagnostic workup
04:16i have a long-standing executive wellness
04:19i'm a surgeon
04:20not an internist
04:21i don't do preventative medicine
04:23no matter how rich the patient is
04:25you know what's great about rich patients
04:28they allow us to treat poor patients
04:31also i promised manesh the very best
04:34so really who else am i going to get
04:36pp is 110 over 70
04:45it's jackson
04:47dr han says great things about you
04:50that's very kind
04:52normal ekg optimal bmi heart and lungs sound good
04:58any reason you're worried enough about your health
05:00to endure an entire day of tests
05:01i'm not worried
05:03knowledge is power
05:06whenever i enter a new market
05:09i learn everything i can about the landscape
05:11consumer needs
05:13target market
05:14competitors
05:15you're aware your body isn't a business
05:16i know i sound like a rich lunatic
05:20with fantasies about controlling every aspect of my life
05:23and i guess i kind of am
05:26my dad was in good shape too
05:31until he dropped dead on his daily jog
05:35are they okay then
05:45yes i know how much change
05:46hi
05:47hi
06:00Hi, I'm Larry Childs. I'd shake your hand, but no functioning immune system.
06:15Aaron, hi.
06:17Good to meet you. What flavor of cancer do you have?
06:20What flavor?
06:23Glioma.
06:24Shut the front door. Brain or spine?
06:28Brain.
06:28Dude, we're tumor twins. What do they have you on?
06:34Ooh, Vincristine. I hear that's intense. My dog thought it would wipe me out.
06:39You doing okay or longing for death?
06:41I am hanging in there. Thank you.
06:43I'm on my third round at Tamizolamide.
06:56I've seen you in here a few times.
06:58I've seen you in here a few times. You kind of keep to yourself, huh?
07:05Yeah.
07:06Well, I'm happy to introduce you around. It's a really friendly group.
07:09I'm okay. Thank you.
07:10You have the support group you go to?
07:13I do not.
07:15Everyone needs a cancer community.
07:17I do not.
07:22I'm trying to hold still.
07:52Thank you for bringing us in.
07:57This is the new chief's patient.
07:58It's a great opportunity.
07:59Oh, it's a bunch of pointless tests for which I thank you.
08:07Tell us about Dr. Han.
08:08He's direct, charming, very sure of himself, big ego.
08:18There's nothing wrong with an ego if you can back it up.
08:21Dr. Han's arterial switch technique is performed all over the world.
08:25The tests aren't all pointless.
08:27Way to stand firm, Park.
08:28Now look at the monitor.
08:30He has a tumor.
08:31Percy's stable?
08:43We're naming her Persephone.
08:47Yes, I put in a central line for nutrition.
08:53Percy is stable right now.
08:54We're looking for solutions to her problems.
08:59Why does she have all these birth defects?
09:03Diane.
09:04We spoke to our obstetrician.
09:05She said these defects can happen for no reason, right?
09:10That's true.
09:11Over 50% have no known cause.
09:14I was taking paroxetine for clinical depression.
09:18And you went off the meds as soon as you found out you were pregnant.
09:22She was five, six weeks at most.
09:24My OB told me studies show antidepressants are safe to take during pregnancy.
09:26But is that true or is she protecting me?
09:30There was a study that associated paroxetine with these kinds of defects.
09:35It is a possibility.
09:37it most my ob told me studies show antidepressants are safe to take during pregnancy but is that
09:43true or is she protecting me there was a study that associated paroxetine with these kinds of
09:52defects it is a possibility you can't tell whether it's cancerous or benign not until we do the biopsy
10:10which i've scheduled for later we'll know what's going on by the morning good that's good
10:17maybe you'd like to call someone a family member a friend i'll worry when i know it's cancer
10:38we could use a transcatheter route and patch each hole individually
10:43your heart's the size of a walnut it's too small to maneuver inside
10:48a single large patch to close the holes would withstand the pressure yes
10:54it would also block electrical conduction causing deadly arrhythmias dr murphy
11:02did you tell the mom that she caused her baby's birth defect no i said that her antidepressants
11:08could have why did you tell her that it's the truth and is that relevant to her current medical
11:16situation no and how do you think that answer would make her feel what did you think would happen
11:27the mother is devastated the father is furious i would be too sean is a resident residents make
11:35mistakes managing these parents emotional concerns is as much a part of this job as operating on their
11:41daughter social cues are hard for sean but we've been working with him you should be focused on
11:47your own shortcomings like retaining the formula for vascular impedance
11:50dr han we could patch each individual hole in the heart if we cut open the ventricle don't change
12:01the subject dr murphy i didn't dr han we were talking about the baby really
12:06you don't see a difference in the nature of your discussion before i arrived and after
12:12we were talking about the baby
12:23they tried the approach you suggested at la children's the baby died a week later the suture
12:28line didn't hold and the cardiac wall ruptured keep looking dr murphy
12:33do not talk with those parents again
12:41i'll walk with you
12:46you're pretty tough on my residents rebuking them in public pimping them with questions during surgery
12:51shame-based learning isn't my style i'll bear that in mind but this isn't about my treatment of the
12:57residents you're concerned about dr murphy a lot of doctors have less than ideal bedside manner he's young
13:02would you ever have said something like that to a patient as a resident as a med student and
13:07murphy doesn't even understand he did anything wrong sean has hardwired differences in the way
13:11he perceives things exactly no matter how hard he works no matter how hard you try and help him
13:17his limitations are not going to change he's going to continue to inflict them on our patients
13:23all in the name of diversity and inclusion
13:25sean deserves to be here once you see what he's capable of you'll agree i look forward to being
13:35proven wrong
13:41stay seated for 20 minutes i don't want you passing out in the lobby i know i know thank you
13:46this disease changed my relationships changed my priorities changed who i am cancer is an
13:58identity cancer is a cellular mutation people in this room are my people what are you 20 years old
14:04i'm triple your age i don't think you're my people last time i hung out with my law school friends
14:10epic fail the fact that you use the phrase epic fail kind of case in point they're all focused on
14:15what firm they're gonna land at and i'm all about whether candace's leukemia is responding to her
14:20new chemo regimen by the way she has this peppermint oil it is great for headaches
14:29oh i know that look
14:38got you brother whether you like it or not
14:45show me where we are that angle runs pretty close to the sacral nerve roots
14:52how we doing tumors are butting the iliac artery try not to disrupt the entire blood supply to his
14:57lower body dr hon i'm morgan resnick i really enjoyed your article on myotomy for infantile
15:03hypertrophic pyloric stenosis i appreciate the thorough research behind your sucking up
15:09and you are alex park park you were a cop medicine has a second career good stuff tends to bring a fresh
15:18perspective
15:22he had an artery take the needle blood's falling in the pelvis should we open him up no prep the
15:27femoral artery give me an arcath set pressure's dropping platinum coil
15:38nice save next time don't hit the vessel
15:44there is no next time the biopsy is too dangerous
15:47it is likely that it's a benign notochord cell tumor they look like chordomas but they're harmless
15:59and way more but you don't know since we can't do the biopsy now this is the problem with broad testing
16:08everyone has abnormalities most of them are nothing but when we do find them we have to make some tough
16:13choices so what exactly is my tough choice we could remove the tumor this is a very risky surgery
16:23there's a chance of paralysis or worse you may not make it off the table or you do nothing
16:30we continue to monitor it do imaging every few weeks but chordomas move very quickly by the time
16:36any change showed up on imaging it's most likely metastasized throughout your body
16:42so it probably isn't cancer but if it is and i wait then i'll die that's true and if i don't wait
16:52and i get the surgery then there's a good chance i'll die yes
16:57this is the may annals of neonatal surgery i just finished march
17:25i need to read april now oh i have april sean no no you're supposed to be reading new approaches
17:33in neonatal surgery claire has the british journal of neonatology
17:46sean i think maybe you should be quiet around han for a little while
17:52but then how will i answer his questions direct questions absolutely answer otherwise
18:02outside of the o.r you should stay out of his way
18:08if someone had convinced sean to do that with dr melendez he would still be on suction
18:12code blue nick you bed four code blue nick you bed four
18:24o2 sets dropped in central venous pressure shot up pulmonary artery band is failing aid of dopamine
18:29let's get a mask on her she won't last much longer we need other options i'll update the parents
18:34let's get her on full cardiac support
18:54what do you got anything this cleveland group repaired a bowel protrusion using enterolysis i could cut out this
19:01excess inflammatory tissue and segment of bowel atresia might make her intestines small enough
19:06to fit promising given the size of our abdomen i need to remove a lot of bowel there's
19:11a good chance she wouldn't be able to absorb food we'll have to find the right balance it's
19:15only workable plan best bet on the heart is to cut through the ventricle like murphy suggested
19:21uh you were concerned about the suture line holding well i still am hopefully horizontal
19:26mattress sutures will work they should be able to withstand the tension at the suture line
19:38dr limb i have an idea i'd like to share even though dr hon didn't ask me a question
19:49yep go ahead john if we go in through the atrium we wouldn't have to worry about the suture line it's
19:55the same issue we discussed there's not enough room inside the baby's heart to stitch the patches
19:59into place no you don't need to dr hon we can make a plug small enough for her heart a ptfe disc with
20:06a stem like a mushroom then we can insert the stem through one of the holes until the disc presses
20:10against the wall covering all the holes like a stopper in a bathtub yes the higher pressure on the left
20:19side of her heart would keep it in place we wouldn't even need to stitch great idea we should take this
20:28to the parents great idea for the heart but we need to tell them that our current plan for the abdominal
20:34repair is considerably more of a long shot and that fixing the heart takes an option off the table
20:38you can't move that card excuse me who cheats at solitaire you're literally only cheating yourself
20:58again good morning larry is it a macho thing like a real man should be able to make it through without
21:04leaning on a label or the people who go with it embracing cancer as an identity is the last thing
21:11any one of us should be doing it underscores everything horrible right now we're in a daily
21:18battle for our lives i see no value in dwelling on that candace is late which means either her niece
21:30forgot to pick her up again or she got some bad news or she's already dead
21:41we are in a daily battle
21:46i'd rather have some company
22:00i spoke to my mother and brother and they both think i shouldn't do the surgery
22:09apparently they're more scared of your surgical skills than they are of this tumor
22:12and where do you stand i need numbers please
22:23stats on something like this
22:26there are a lot of variables what are the odds i make it through the surgery
22:30without any complications it's a challenging procedure zero complications i'd say eighty percent
22:37but it is very unlikely this tumor is malignant give me a number about five percent chance it's a chordoma
22:47the numbers agree with your family the numbers agree with your family so do i
22:59i've always been more comfortable with action than inaction
23:09i want you to do the surgery
23:20certainty comes at a price
23:21she'll be able to get off the life support machines if everything goes well yes
23:35she'll have a strong heart how soon can you do it
23:37you should know we feel less confident about our plan for her bowel
23:44the chance of failure is quite high how high i put it at ninety percent that the repair won't work
23:51which would lead to irreversible malnutrition your daughter would slowly starve to death over months
23:57right now her body is working very hard just to stay alive
24:05if we were to turn off the machines turn off the machines
24:12she would pass quickly and peacefully if the heart surgery is a success that won't be an option
24:23why not try to fix the bowel first to see if it works
24:25we won't know if the bowel is viable until after the heart is
24:30we have to do the surgery
24:33but if this doesn't work she could starve to death
24:35it's worth the risk it's not our risk it's hers
24:38so instead you're ready to give up on our daughter
24:41i mean it's like we're right back at the ultrasound
24:44we decided together to continue this pregnancy so this is as much my fault as it is yours my fault
24:50because of the medication
24:51i cannot turn off that machine
24:58your guilt is stopping you from admitting what we need to do
25:00my guilt has nothing to do with this
25:03i am fighting for my daughter so am i
25:08since the parents can't agree the decision about the baby's care will be made by a judge
25:13who will rely on our recommendation so we make the choice but the parents live with it
25:21well maybe that's a good thing
25:25for parents to have to decide between letting their daughter die
25:28or fighting for her life knowing she may suffer horribly
25:31maybe it's better if we carry that burden
25:37dr limb your decision would be
25:42take her off life support the odds are stacked against the bowel repair working those numbers
25:46reflect the general population of doctors i think dr limb and i are better than that
25:51we can beat the odds
26:01one of the things i'm not going to miss about being chief of surgery
26:04is being responsible for choices like this
26:07dr han it's your department it's your call
26:21you've been here all night i've been working on a case with the new chief of surgery dr han
26:27how's that going not very well he plays music in the operating room oh geez one of those and he says i
26:34need to focus on our patient's emotional needs well that's a tough assignment for you
26:46you ever wish you had you know friends co-workers on the spectrum
26:52not usually but maybe dr han wouldn't notice me as much if i weren't the only doctor with asd
27:03there's this kid in chemo just obsessed with having cancer that's all he talks about he wants
27:09to be friends with everybody in the ward that's very smart of him spiegel et al showed an increase
27:15in overall survival and quality of life measures in breast cancer patients who formed social bonds
27:19with others battling the disease what should i do about dr han
27:27i don't know um just do your work be a good surgeon be an excellent surgeon over time i'll
27:34forget about the autism why would that happen i'll see that you have the skill you have dedication i
27:41have autism it's part of who i am
27:55the judge accepted our recommendation ruled in favor of surgery thank you doctor
28:01okay percy mama loves you
28:16i love you percy
28:31should we remove more bowel that would take us to the ileum she won't gain enough weight to thrive
28:58her abdominal muscles are tight from developing around an empty cavity
29:05they're cinched around her tummy like a corset what if we unbuttoned it released the muscle and
29:11increase the abdominal circumference those muscles are part of her abdominal
29:14not if we separate the layers create a plane between the skin and the muscle
29:20you good if murphy and i start on the heart dr brown you're with me on the abdomen
29:25clear in the field hon is on the call schedule next weekend maybe carmen will switch with me so
29:31i can cover with him maybe you shouldn't try so hard retract her some of us don't have a cool
29:39former career or an easygoing melodemeanor people are never going to crowd in my corner because i'm
29:43just so likable you could try being nice to them this is easier there it is
29:48does it look like cancer it's not labeled we're all gonna have to wait for the pathologist report
29:58probe
30:05the artery's in the way we can't get at the tumor without him bleeding out
30:08we're gonna have to take it from the back but that's one nerve root is something you can live
30:17without dissecting scissors
30:24pledge at anchor
30:38the plug is in position you're ready to test the bowel repair
30:45let's take her off cardiac support dr murphy was your idea you do the honors
31:01abdominal pressure is normal intestines are profusing
31:08pulmonary pressure spiking prostacycline and nitric oxide we need to get her lung pressure down
31:14oxygen sats are dropping in response to pulmonary vasodilators the heart's too strong it's
31:19overpowering her lungs she needs to go back on cardiac support
31:22pulmonary vasodilators the heart
31:31persephone won't starve to death but she will drown in her own fluid
31:46and i'll talk to the parents may i come
31:54now that persephone's heart is pumping at full power her lungs are overwhelmed
32:10the humane thing to do is to turn off the machines and let her go
32:18no i can't i can't give up on her
32:25because you fought for her every minute since she was born before that when you were taking your
32:32medication for the depression you were fighting to keep going so you could bring her into the world
32:37and letting go of mercy is not giving up on her
32:56and letting go of mercy is not giving up on her
32:59it's listening to what her body is telling us
33:06she's hit her limit
33:16she's hit her limit
33:25okay
33:26okay
33:28okay
33:30okay
33:32okay
33:34okay
33:36okay
33:38okay
33:40okay
33:42okay
33:44i want persephone to look as good as possible for the parents
34:04let's
34:10let's turn off cardiac support
34:17ventilator
34:20let's take a minute
34:34hold
34:42okay
34:50okay
34:52now
34:53Lord
34:55we can go
34:55thanks
34:56okay
34:57and
34:57first
34:57check valve
35:06every time the heart contracted blood went into the opposite side of the heart and raised
35:16lung pressure the hole reduced the pressure when it got too high because it allowed backflow but
35:21our repair of the defect blocked this backwards flow what if we made it so she still had a heart
35:27defect but only when she needed it and it'd be like an unlatched door in the wall of the heart
35:32when the pressure gets too high on the right side the door swings open releasing the pressure on
35:37the lungs the rest of the time it stays shut it should reduce lung pressure by a third is that
35:43enough depends on how high our pulmonary vascular resistance is pvr is pulmonary artery pressure
35:48minus wedge pressure divided by cardiac output times 80.
35:57the last time i saw my doctor he told me i had six months to live
36:06he also told me i should marry an accountant and move to north dakota
36:10you don't say
36:11i asked if it would help with my cancer he said nope just make the six months seem much longer
36:17what's the difference between a neo-nazi and cancer cancer doesn't discriminate
36:25i knew a guy once his zodiac sign was cancer it was really ironic how he died
36:35uh uh uh how's that he was eaten by a giant crab
36:41oh jeez
36:44iron glioma
36:48candace leukemia
36:50jen write me a blackjack how fast you want to take my money
36:54blackjack
36:56cut him
36:57did you get it all
37:11yes
37:15totally clear margins
37:18but the only way to achieve that involves removing the nerve that controls your left foot
37:22rehab and an advanced orthotic may help
37:27but you will walk with a limp
37:29final pathology will let us know if it was worth it
37:33i'll let you know when he comes in
37:38it doesn't matter anymore
37:42it's not like you can put the tremor back in
37:48is she okay
38:05she still has a surgery or two in her future but yes
38:10she's gonna be great
38:12can i hold her
38:17i think that would be very nice
38:19for both of you
38:22angel
38:39my baby
38:43come hold her
38:50come hold her
38:56you were fighting for her too
39:02nice work
39:14thank you
39:17she's beautiful
39:20manesh's biopsy results
39:42you don't want to know if we wasted our time almost killing him
39:57can't put the tumor back
40:03hello dr haan
40:16you take the bus too
40:19no sean
40:20i just wanted to talk to you
40:23you really do have remarkable diagnostic skills
40:30i have to admit you're an asset to this hospital
40:33i am
40:35i spoke to the residency director of pathology
40:40and we both agree you'll be a great fit there
40:47i am a surgical resident
40:51as a pathology resident
40:53you'll touch cases and lives across all the medical departments
40:57it's an opportunity for you to help patients without having to deal with patients
41:04given your difficulties with communication and social cues i think it will be a much better fit
41:12no thank you
41:15i have been working very hard at my communication skills
41:21hard work isn't enough
41:24you have to do the job
41:27i am a surgical resident
41:33you were
41:35and you're going to do great work in pathology
41:46oh and when the storms come
41:50flooding through the hall
41:53rising to the landing
41:56tearing pictures from the walls
41:59you
42:00you