Previously, on The Good Doctor...
Going to the club or work?
These early calls need some getting used to.
- Brown Retractor. - No brown Retractor.
I thought I put it on your tray.
Dr. Kalu is not your peer.
He's your employee, you're his boss.
I do not plan to give Jared special treatment.
And if I see it, it won't be good for either of you.
I'm not expecting special treatment.
I don't appreciate being treated like an intern.
Dr. Andrews is judging my performance off yours
and it is not good.
You come in with your fancy car, and your old tricks
and think, "Ta-da. I'm a surgeon." But you're not.
I want to prove I belong.
When I checked Yara post-op, I noticed you only used eight sutures
and she had a small bleed. You should've used ten.
Dr. Glassman closed the galea and skin.
- Dr. Glassman skipped two sutures? - Guess so.
At what time did you wake up yesterday morning?
The usual, 5:30. Why?
At lunch, you had a Cobb salad.
450 calories ingested, assuming you kept it down?
- Yes. - Did you use a sauna,
engage in rigorous exercise and/or experience diarrhea?
No, I didn't do any of those things. What's with the questions?
You made an error in yesterday's craniotomy.
I'm trying to evaluate various factors that would negatively impact focus.
I made an error?
You closed with only eight sutures. The size of the wound required ten.
We need to figure out why--
Why do we need to figure out why? Two sutures.
It's a blip. It's not a thing.
It could be part of a troubling pattern needing attention--
Shaun, the surgery was a success, right? The patient had a great outcome.
There is no pattern.
Goodbye.
I'm a surgeon and I belong here.
You are a surgeon and you belong here.
I just keep imagining you in the mirror,
like, you have the hair of Tracee Ellis Ross,
- and the swag of Beyoncé. - Do not shame my self-care.
Affirmations are backed by research.
FMRI evidence shows a correlation with positive changes in the brain.
I've just put the finishing touches on a surprise.
Drum roll, please.
Or not. Well, get your song lists ready
because you are all officially invited to
"Star Karaoke. 7:00 p.m. until question mark, question mark."
It's gonna be a party when there's double punctuation involved.
Just the chance to unwind, get to know you all better.
- Sounds fun. Thanks. - Prepare to be destroyed.
My "Someone Like You" slays.
Need a surgical consult for a patient with a dislocated patella.
Sorry, ER.
You two are it. Room One.
When did the chest pains start?
I first noticed it Tuesday morning, along with shortness of breath.
Are you taking any medications?
I started with one, then switched a few times.
- These are used to treat ADHD. - And brain fog.
I'm a COVID long hauler, and I just started Guanfacine
and N-acetylcysteine, which may actually be helping, finally.
When was your initial infection?
Eight months ago. Just felt like a mild flu. But then it got worse.
like someone poured molasses on my brain.
I've done cognitive therapy,
memory exercises. Still am.
Whatever I can do to get back in the field.
- Which one? - Clover.
I'm an evolutionary biologist.
I have been studying how white clover adapts to environmental changes.
And I'm on indefinite leave.
Please stop talking now.
Bluish skin, low O2 levels, rapid heart rate.
And increasingly labored breathing. Possible pulmonary embolism.
Order a chest CTA and echo, stat.
I have to go.
You will need this. I sent one half of a high-volume order to your printer.
- These are Glassman's op reports? - For the last three months.
January to March. October to December is printing in Park's and my office.
So you sent reports for, like, 100 surgeries to my printer?
No. 176 surgeries. 473 pages.
I've emailed operations to replace your toner.
Many elements are in color.
And why exactly do you need all of this?
To find out if his mistake was "a blip".
Second time I've dislocated my knee.
First was a few months ago, I think?
That was the sprained ankle.
The dislocation was last year.
Your MRI shows no associated damage to bones or ligaments.
She's also been complaining about dizziness,
swollen ankles, maybe menopause related.
Dr. Reznick wants her on hormone replacement therapy.
Orion insisted I get everything checked out
before she leaves and moves 6,000 miles away to live alone.
I'm moving to Prague next week, for a new job.
And you can visit me anytime you want, Mom.
Not with a busted knee.
To move forward with HRT,
I need to confirm all your medications over the last five years.
There was a purple triangle one.
But they took me off that last year. And an orange-shaped one.
I'll review it with you.
We need to see how your knee's moving. Lay back, please.
Go ahead with the exam, Dr. Kalu.
- I thought I'd observe. - It's a knee exam,
not a multi-ligament reconstruction.
You told me last time not to assume I know everything.
This is just making me do your job.
That sounded like an apneic spell. Check her tonsils.
Ms. Garcia?
Did I fall asleep again?
Yes.
Could I take a quick look in your mouth?
Kissing tonsils.
They're so enlarged, they're touching and obstructing your airway,
causing severe apnea. You need a tonsillectomy right away.
No pulmonary embolism, but multiple cardiac issues,
severe narrowing of the pulmonic valve,
hypertrophied right ventricle an opening between the lower chambers.
This set of defects almost looks like Tetralogy of Fallot, but--
It is.
She has the fourth malformation. Overriding aorta.
I've never seen Tet in an adult before.
How is she still alive?
Hang on a sec. I have to write everything down now.
Tet is almost always diagnosed in infancy.
Doctors missed it in your case.
You have a rare presentation.
The right ventricle obstruction is balanced
by an increased flow into the left ventricle.
Damage from COVID disrupted the balance. The virus may have saved your life.
Very few undiagnosed Tet patients survive past childhood.
A mere 2% make it to 40.
I would've just dropped dead at some point?
It's very likely.
We can remove that risk with two separate procedures.
First, we'll close the extra vessels that have formed
to compensate for your heart defects.
Then we'll do a surgery to repair those defects.
Is it possible the Tet is connected to my long COVID symptoms?
Could fixing my heart clear up my head--
The brain?
No, I'm sorry.
You snagged our table.
- Beat Hawks and Nuñez to it. - You're a champion.
One Splenda, half sugar in the raw, light almond milk.
Now who's the champion?
- I have something for you. - Really?
An agreement acknowledging a consensual relationship.
I, Marcus Andrews, would like to take you Dalisay Villanueva on a date.
And as hospital president, I've already signed it.
This is so romantic.
Give me the pen.
- Dinner this weekend? - Let me see.
I'm needed on the ward. Sorry.
- Lock it down later? - Sure.
- Iced coffee? - I'm good.
How about hot coffee?
In honor of Daphne's successful tonsillectomy.
I got a few options.
Is that a latte?
It was a routine tonsillectomy.
Those were unusually large tonsils. Good thing her daughter brought her in.
You think Daphne was better off not breathing?
I don't think it's a daughter's job to make sure mom goes to the doctor.
It's Daphne.
- Heart rate's spiked, she's hypoxic. - Turn up oxygen to max.
Loud murmur, right ventricle and atrium.
Chronic damage from apnea could have increased the pressure,
causing right heart failure.
- BP's dropping. - Get her to the cath lab.
Positioning coiling system.
Two vessels left to close.
Deploying the coil.
Her O2 sats are dropping.
Her infundibular muscle is clamping down. She is having a Tet spell.
Give phenylephrine and 100% oxygen.
I have never seen one in person before.
We need to move blood up to the lungs. Give her a bolus and up the opiates.
If we don't stop the spasm, she could have permanent brain damage.
The chance of a future infundibular spasm is very high.
Tet repair surgery will be much more risky.
Pressure in Daphne's lungs is critically high,
Not a routine tonsillectomy at all.
Puncturing the atrial septum.
Right heart is decompressing.
Give nitric oxide to relax and dilate the vasculature.
Her apnea really did a number on her pulmonary vessels.
No wonder she's clumsy, forgetful.
She's been sleeping oxygen-deprived for decades.
Still doesn't make her her daughter's responsibility.
Would you want Kellan to put his life on hold to take care of you?
Not his whole life, no. But I don't think being overly-devoted
is the worst quality in a kid. Remove the catheters.
I was one of six growing up. Only girl. Mom and Dad worked a lot.
So I was basically second mom since kindergarten.
I love my brothers.
but there's a lot you miss out on
if you're all about caring for someone else.
She's throwing a lot of PVCs. Maybe an electrolyte issue?
BP is dropping, heart rate 172.
Barely getting a pulse. She's in v-tach. Defib paddles.
BP and heart rate stabilizing.
Get a new chemistry, chest X-ray, EKG.
We need to learn what else is going on with her heart.
Please don't disturb my materials.
Which are what exactly?
Dr. Glassman made an uncharacteristic surgical error.
I am determining if it was an anomaly or part of a pattern.
Glassman must be pleased about that.
He is not. You are being sarcastic.
Performance review is a standard practice, benefits doctors and patients.
I've noted three additional errors from last four months.
- I don't see a pattern. - Dural tear on scar tissue,
closing with a running nylon instead of Monocryl. That a mistake?
Dr. Glassman has always used subcutaneous Monocryl.
These are variations, minor missteps.
Pore through four months of any surgeon's reports
- and you'll find discrepancies like this. - No.
- Yes. - Not in mine.
- That's probably true. - Yeah.
If you're not finding a pattern, maybe it's because there isn't one.
My patient is awake.
Does this mean you can't do the Tet repair?
There's a medication, propranolol, that'll significantly reduce the risk
of having another spasm during surgery.
But 'cause of your long COVID, you're at risk for some rare side effects.
- Are they serious? - Yes.
Not some, like nausea, vomiting, muscle aches.
But others, such as hypoglycemia or visual--
Start with propranolol.
Good chance you won't experience the side effects.
But we'll need to keep a close eye on you.
And are those patients ahead of her also seniors with diabetes?
Do not hang up, or I'll head down to do this in person.
I'll wait.
Hey.
There is a great new Portuguese spot I read about.
I can make reservations for us Friday or Saturday at 7:00?
I'm working a double both days. Been hectic since Baker and Linh left.
- Two travelers are starting Monday. - I need staff nurses.
They're highly skilled.
Doesn't matter. Travel nurses disrupt workflow,
don't build long-term relationships.
We don't have the resources for permanent staff.
You just hired a new full-time resident to replace someone who left recently.
That was Lim's department.
Yes. Great. I'm sending her down.
- Sorry. We'll talk later? - Of course.
So you're watching to see if I throw up?
Or faint, seize or have muscle spasms.
You know, before COVID, my brain was.
I did evolutionary patterns, genetic...
how genes go together.
The sequence.
Now my brain can't handle the sequence of brushing my teeth.
My focus, my working memory, all of the...
Oh, my...
The executive function.
It's not always happening.
Please page Dr. Wolke to monitor her and stay until he comes.
Push your hand against mine.
The pattern is errors in executive function.
- I'm in the middle of something. - Your brain cancer may have returned.
- All errors tied to executive function. - Shaun.
Specifically procedural memory in the dorsolateral prefrontal cortex,
a common site for a recurrent glioma,
which strongly suggests your cancer has returned.
My last scan came back completely clear.
- I'm fine. - Last scan was six months ago.
These errors are from last four months. You need another scan.
- The evidence is very compelling. - It's not.
I perform complex surgeries,
more so than any other doctor on this staff, by the way.
So the percentages would dictate
that I might make more minor and irrelevant missteps,
if that's what you wanna call 'em.
The rate of errors has increased.
Yeah, 'cause I take on tougher cases.
The ones no one else will.
- No. You need another MRI, now. - Shaun,
what I need is to get back to my patient, and you need to knock first, next time.
"It's the greening of the trees."
My turn.
Trying to get my cognitive exercises in.
What're you memorizing?
It's a poem from The Carrying, Ada Limón.
The collection is mostly about.
not having the life you thought you'd have, I guess.
The one I was just reading. it's about spring coming.
"Instructions on Not Giving Up."
- Sounds useful. - Too bad I can't read it all at once.
I've just graduated from haikus.
Never even thought to look at a poem before I got sick.
Didn't have the patience for it, or the time.
That's basically all I read now.
Started writing, too, as kind of a...
creative therapy.
There was a kind of poetry
to the genetic variations in white clover, too.
I'd give anything to...
Your blood pressure's dropping, heart rate's climbing.
- I'm dizzy. - Checking your glucose.
She's having a seizure. Crash cart now.
We thought it was your heart, but it's a kidney issue.
Narrowing of your renal arteries, which was exacerbated
by the pulmonary hypertension, causing kidney failure.
- This is 'cause of my sleep apnea? - We believe so. Yeah.
Can she get a transplant? I can do a test, see if I'm a match.
Unfortunately, your other health concerns rule out a transplant.
But a renal artery bypass would allow your kidneys to heal on their own.
There's risk of complications. Some quite serious.
But in success, you could live a full, independent life.
But serious, as in I could die?
Some complications can be fatal.
But the risk is relatively low.
Are there other options?
Well, there's dialysis,
but you'd need multiple sessions a week for the rest of your life.
That's less risky, but I don't think I could handle all that on my own.
Mom, if you want to choose the dialysis, I'll stay in San Jose.
I'm sorry.
- I don't want to keep you. - You have nothing to be sorry for.
You know, all this time you've been sick and struggling, and I judged you.
But your new job.
It's just a job.
So the medication you gave me to make my surgery safer
will actually make it more risky?
That's right.
But without that medication, I'm much more likely to have another Tet spell.
Yes, and possibly more severe than the last time.
Brain fog, all my deficits. could get worse?
For possibly forever?
Yes.
But if we don't do the Tet repair, your heart will stop at some point.
I've already been through losing my thoughts,
my whole self.
I can't do that again.
Find another way to fix my heart.
New idea. We go back to the old idea and just do the surgery.
It's a nonstarter. We need to present a way to help her Tet
without triggering her Tet.
A percutaneous valve and VSD closure could help with blood flow.
That involves catheters in the heart, which would cause the muscle to spasm.
All right. It's time for some WWSMD.
Whatever you and Jerome do on your own time is--
"What would Shaun Murphy do?"
What about a shunt? It would improve blood flow.
Buy a few months to continue her cognitive recovery.
When she feels better about her heart, maybe she lets us fix her heart.
Her Tet would likely kill her before that.
But placing a shunt won't trigger a spell, making it something she'd actually accept.
I'll take it to her.
I can stay only 45 minutes. Have to review Dr. Glassman's OR videos.
- Didn't you do that? - Not for glioma recurrence symptoms.
New evidence will convince him to get a scan.
You binged months of data in one day. You'll have a clearer head in the morning.
Until then, here we are. Karaoke rager.
- Yay. - It is "yay". We have a song list.
Plus Jared's our friend. He just moved back. Celebration is in order.
I will review the videos in the morning.
Sounds pretty wild in there.
Because maybe
You're gonna be the one that saves me
And after all
I was just warming up.
- Where is everyone? - There is a lot of food.
Yeah, I had it catered. You're the first to arrive.
And so far, last minute rain checks from Morgan, Park, Asher, Danny.
And Jerome.
So it's just us four.
Which means that all these snacks
and song binders are for us.
Yes. The low turnout is the perfect opportunity to discuss symptoms.
In your recent surgeries with Dr. Glassman, do you recall observing
any balance issues, tremors or motor weakness?
That sounds like the perfect option.
How soon can you do the shunt procedure?
I'll try to schedule it for tomorrow.
I've had a strange year myself.
Eleven months ago, I was attacked and paralyzed from the waist down.
I thought it was permanent. Almost everyone did.
At first, all I wanted was to walk again.
I was ready to risk my life to get back to the old me.
But as time went on, I started to appreciate my new life.
My new self.
I started a new relationship that wouldn't have happened otherwise.
In many ways, my life improved.
You recognize you walked in to tell me this story?
I only agreed to do the surgery once I knew my life wasn't at risk.
And even then, I had doubts.
I liked who I'd become. I wanted to hold on to her.
I'm not...
losing my mind...
all over again.
You don't strike me as someone who's lost her mind.
That covers the thrombectomy. In February, you assisted--
Okay. I'm playing the pregnant lady card.
- We're going, Shaun. - Okay.
Thank you. Goodbye.
I should head out, too.
Early morning.
Maybe focus on being a first year resident
before adding party planner to your resume.
The catering may have been a bridge too far.
Yeah.
I bounced around growing up.
at different schools, cities, countries.
But wherever we were,
my parents had a big house and I knew how to throw a party.
Closest I get to feeling like I fit.
Old habits die hard, I guess.
Fitting in takes time.
But I never have, anywhere.
Maybe not everyone finds their place.
Daphne is getting septic. We have to go.
- Morning. - Hello.
- You should not have that. - I'm permitted 12 ounces a day.
Experts agree.
Yes, but that was brewed when I woke up at 3:30 a.m.
- You make it through the videos? - Yes, and integrated the observations
Doctors Kalu and Allen made last night regarding possible glioma symptoms.
I am now ready to present Dr. Glassman
with the revised evidence, which is very compelling.
Thankfully, your infection is responding to the antibiotics.
The infection started around your dialysis port,
that could easily happen again.
The renal artery bypass is still an option.
It's too risky.
So is sepsis.
Thank you, doctor, but I'll settle for being alive.
You shouldn't.
You deserve more than that.
I know you've had a whole life of feeling sick and stuck
and repeating the same old bad patterns.
But your past does not have to tell your future where to go.
You can choose a different path, and who you're going to be on it.
And let your daughter do the same.
Prague is beautiful in the spring.
We've scheduled a shunt placement for this afternoon.
- And that whole speech last night? - I stand by it, but it's your decision.
I've been waiting for the old me to come back.
and that person may not exist anymore.
And...
maybe I should be okay with that.
Do the Tet repair.
Releasing the proximal clamp.
What made Daphne change her mind?
Dr. Allen has a way of getting through to people.
Blood flow looks obstructed. There's a kink in the graft.
We could redo it. But most likely it happens again.
We could anchor the bypass off of the aorta instead.
At that angle, less chance of a kink.
That could work.
- Extending the incision. - Sternal saw.
Starting the sternotomy.
O2 dropped to 78. Sixty-five.
She's having a Tet spell.
Give her 500cc fluid bolus and 100% oxygen,
Giving a mini-bolus to increase pulmonary flow.
Oxygen sat's on 50. Forty-five.
Come on, come on.
Give her more oxygen and up the opiates.
It has stopped registering.
O2 is rising.
Heart rate's stabilizing.
She was in prolonged gross hypoxia.
That could extend cognitive deficits.
or worse.
We won't know until she wakes.
Let's get her on bypass before she has another one.
Okay.
To a successful renal artery bypass.
Cheers. Facilitated by a moving speech from a wise and persuasive surgeon.
With a great surgical save by a guy
who's about to have some life changing tacos.
Okay.
Oh, my God. Okay, this is amazing.
- It's amazing. - Told you. Blue. Corn. Tortilla.
I could get used to this.
You have some lettuce.
Here. No, mirror image.
- Now? - No.
No laughing.
No. Right. Very serious matter.
Here, let me.
There. Just.
We should go.
Yeah.
We need to get back early for Daphne post-op.
Yeah, right.
The bypass went smoothly and post-op labs look good.
We expect a full recovery.
How are you feeling, Mom?
I am breathing.
Kind of feels like the first time in my life.
The post-op swelling from the tonsillectomy has gone down.
You're finally breathing without any obstruction.
You need to stay on top of your medications
and follow-up visits, observe some dietary guidelines.
But the discharge plan lays it all out.
I'll be there to help, Mom.
No.
You won't.
You need to live your own life.
But I will accept FaceTime calls.
And once I recover, I'll come visit.
I hear that Prague is beautiful in the spring.
It sounds like a plan.
Things not go well with Glassy?
He returned the files with a note
saying he did not look at them and does not intend to.
I'm sorry.
It probably was a mistake to leave them for him to read.
I'll reorder the files and go to his office to review with him.
He doesn't want to see them.
But he doesn't know about the new evidence.
Maybe he doesn't want to know.
Cancer survivors have to live with an uncertainty--
Knowing is better than not knowing.
If he's not ready to look at this, you can't force him.
Maybe he's scared, Shaun. And I think maybe you're scared, too.
We're about to have a baby.
You're about to be a dad.
And I think you're worried about family and Glassman is a part of that.
But if you keep pushing, you risk damaging
one of the most important relationships in your life.
- Hey. - Hey.
I've been thinking, and I need a break from our coffees.
Dalisay.
I don't think dinner's a good idea, either.
So we have a different point of view about hospital business.
That doesn't change the way I feel about you.
On or off the clock, I'm the same person.
To me, if you don't value what the nurses do,
enough to treat us like a resource to invest in, not a line item to be cut.
How much can you care about me?
And to be honest, if that is your point of view,
it undercuts the respect I have for you.
Harper Louise Decrane, March 30th, 1994.
And do you know why you're here?
For my heart issues.
I had another Tet spell, didn't I?
We'll need to conduct more tests. But your speech and memory seem intact,
and with regard to your heart, we expect a full recovery.
And with time, you may recover your full cognitive abilities as well.
Maybe.
But for now, I'll just focus on being here.
"It's the greening of the trees that really gets to me.
When all the shock of white and taffy
leave the pavement strewn with the confetti of aftermath,
the leaves come.
patient, plodding.
a green skin growing over whatever winter did to us.
a return to the strange idea of continuous living,
despite the mess of us, the hurt, the empty."
Shaun, what?
Lea thinks that because I am going to be a dad,
I am worried about my family.
Okay.
She also thinks you are scared.
I'm not scared, Shaun. I'm fine.
She says if you don't want to do the scan, I should let it go.
She...
is right.
Good. Thank you.
I am scared.
Dr. Glassman.
I am asking you to do the scan.
Because...
the data and the evidence are sound.
And because...
it would be hard to lose my father just as I am about to become one.
Do the scan for me.
Shaun, I'll do the scan.
"'Fine, then, I'll take it,'
the tree seems to say. A new slick leaf unfurling like a fist to an open pond.
'I'll take it all.'"