Doctor Reacts To The Pitt Season 2 Episode 7

Season 2, episode 7. Who's ready to take on another hour on shift? Huge thank you to ODU for sponsoring this video. Let's get started. — Assain is a sexual assault nurse examiner. We do forensic exams, collect evidence, and hand it over to the police if a report is made. We also provide resources, support, sometimes even testimony. You go to court. Saints are very valuable in a hospital. — Yes. And we're facing a current shortage of them and we're actually encouraging people to sign up for this. I believe there's like a forensic nurses association where people can sign up for this type of accreditation. It's extra in-person uh in-classroom learning both combined many hours in order to make sure that you're comfortable in these types of encounters. — I'm the charge nurse in the ED and a sexual assault nurse examiner. This is Emma. I'll be assisting. — And I'm Dr. Al-Hashimi. I'll be checking you for any injuries that need immediate attention. — You can just call me Alana. Um I don't have any injuries. The lack of injuries does not mean that no assault took place, that no sexual assault took place. You still move forward with the exam and you still collect evidence and allow the patient to decide the course of action. — You are in control now, Alana. We're here to help and support you. — That's patient centered care, where the patient gets to decide what happens. And remember, a big part of sexual assault is the loss of control and uh the mental health repercussions that come as a result of that. So, by allowing the patient to be in charge of the medical exam, the treatments, the reporting, all of that is giving the patient back their power, making them feel a bit more safe. A lot of these kits come with many, many tools and several steps along with instructions. It's important to know that not every patient needs every one of those steps to be taken. And maybe some patients don't want some of the steps to be taken. And again, that should be completely acceptable. — So, you're having a headache and abdominal pain. — Yeah, that's right. — Okay. And which would you say is worse? — I like that she's talking to the patient even though the interpreter's off to the side. — My headache was terrible last week, but now — Hey, you're breaking up. Can you run that back again? These types of technical glitches happen all the time. Whether it's an internet connectivity issue, a phone connectivity issue, it does happen. — Now, my abdominal pain. — God, come on. You piece of [ __ ] — Um water. it it's not enough to just say we'll do a specific exam. You have to offer it as an option to the patient because maybe the patient doesn't want to consent for this exam. And especially in this scenario where the communication is obviously having a breakdown, it's even more important to provide extra information. — I'll be right back. Sorry. — It doesn't help to whisper. raise your voice. again. You want to talk normal volume? — What the hell's going on? He's barely conscious. — Jackson's just a little tired due to the sedative he was given. You sedated him. — Oh, your son was brought in extremely agitated. — You'd be too if you were tased. — And why the did they do that? This is [ __ ] We're taking him home. — Why don't we step out for a second? — Deescalating the situation, moving them away. Very smart move here. Very high level because emotions are starting to creep up. And by just changing the scenario, by changing the setting, that already deescalates and makes everyone feel a bit more at ease. — Right now, Jackson is on an involuntary cycle. — What? That's not necessary. — He just needs some rest. He's been studying for the bar exam. We can watch him at home. So far, all of his tests look good, but Jackson has reported hearing voices. This could be serious. — Dr. Jefferson will come back and speak with you. He can explain more of what may be going on with Jackson. — And who is Dr. Jefferson? He's from psychiatry and he's excellent. He can explain next steps and answer all of your questions. — Javi, why don't you take the Davises to the family room? — Sure. Excuse me. It's just this way. — Getting worried. What's going on with Dr. Alashimi? — Hi, this is Dr. Bon Al-Hashimi. I'm a patient of Dr. Fairgraves. I need to speak to him if he's on call. Um, if he's not, I'll take his next available appointment. and please call me if he has a cancellation. Thank you. — I wonder if she's calling for mental health support uh or is this something going on with her body? — It's going to be really noisy here and you won't get any rest at home. You'll be surrounded by your family and be more comfortable.

comfortable. — It's your choice, Roxy. — It's not that I don't want to go home, but — Hi, Mom. Mom — Lena texted me to come back. I figured I'd bring the boys. What's going on? Is everything okay? — Robbie, police officer, incoming trauma. — Coming. I'll be right back. We'll give you a chance to talk. See, in this scenario where there's clearly some again breakdown of communication, it seems like this is a theme of this episode, but within the family, separating them and allowing someone to speak to the patient in an unfiltered way to get a better understanding of where this hesitation's coming from can help make a better decision all across the board. Intubated neck wound stats not great. We were diverted here. Is there a trauma room open? — Trauma one. — What's the source? My buddy Officer Hero, high velocity GSW. He's getting harder to bag. Warehouse robbery gone sideways. — 1 2 3. You guys wait here. We'll take care of him. I promise. — Dr. Santos, let's make sure these lungs are up. Could you see the courts? — Yeah, it was a great view, but it was hard to pass after I cleared them. — Yes, that's only 85. — So, the uh vitals are telling us a picture that there's not enough oxygen reaching uh his organs because the oxygen saturation is low. heart rate is elevated to 110 saying that his heart is trying to compensate for this lack of oxygenation by circulating the blood faster. — Dr. Santos, what could cause respiratory failure in an intubated patient? — Uh, there are a lot of possibilities. — Ain't dope. — Displacement, obstruction, pneumthorax, equipment failure, good lung sliding, no numo. — It is displacement. Okay, that is a transsected trachea. Oh, the displacement that they're talking about, my assumption is that the ET tube is displaced because the trachea is injured so much so from this GSW that the ET tube literally went through it or out of it. So, it's not in the lungs inflating the lungs. Because remember the ET tube's job is to bypass the upper airway and deliver air directly into the lungs, at least more closely to the lungs, so that if the upper airway gets blocked from vomiting, from bleeding, you could still deliver good oxygen to the lungs. And you have a balloon that you can inflate there, which help protects fluid from entering the lungs that shouldn't be there. But when there is a tracheal injury to this level, uh that's very hard to do. This is a condition with very high mortality. — Pulling out bag. — But if you intubate again, won't it just come straight out the wound? — So basically, you need to find a way to guide the ET tube into the lower portion of the trachea below the injury. Either starting from the site of injury or perhaps finding a way to guide it through that injury by either inserting something into the trachea. I'm obviously not an ear doctor, but I'm trying to be creative here. Okay. And those uh bubbles uh is a sign that there is air inside the chest cavity which means that the airway is open. It's ruptured. Uh frequently we'll hear that as crackling underneath the skin but here we're seeing it with bubbling uh on the liquid uh on the superior surface. — Yeah. He's not moving in the air. Okay. I need a neonatal mask. — Neonatal? — Yep. — I'm just going to finish my initial exam. Let me know if you feel any pain. Okay. My legs are fine. Uh, looks good. — I don't like using good, bad. I like to say normal or describe the finding. — No need for X-rays or advanced imaging. — Got it. Two areas of echimosis. That means brazen over the shoulders bilaterally. — It's great to have uh someone translate in that way because sometimes in the medical field we use vocabulary that can make a patient feel uncomfortable because they don't know what's going on. So to have someone there to help you uh translate that, catch it, make the patient feel at ease is very powerful. — Where does it hurt? — Like here under my belly button. — Okay. Do you have any uh fever, vomiting, diarrhea? — No, it's just stomach ache. — Okay. Let's still go see the nurse and have her call me. — Okay. But I'm still having ice cream tonight. — Let's just see how you feel later. — Good diversion for the conversation there. Um because I'm not going to try and get ahead of myself with predictions, but appendicitis can sometimes happen surrounding the umbilical cord. Umbilical cord appendicitis can sometimes begin surrounding the belly button and then start to move to the right lower quadrant and not immediately be present in the right lower quadrant. So it tricks people uh sometimes away from the diagnosis when in reality it's just early onset appendicitis. Elliot Green, 17, single episode of football practice. Look, — I just got dizzy. Okay, so sometimes this is due to dehydration, concussion, heat uh intolerance, sometimes full-on heat stroke. So, it's really important to monitor these patients, not just from a cardiac standpoint, but also from a

metabolic electrolyte standpoint. — Ano systolic of 95, tacket 122, no meds, no allergies. So he's tacoc cartic meaning that his uh pulse is high and his blood pressure is low. So it's interesting why that's happening. — How long were you at practice? — Started at 9. So like 4 hours. — 4 hours in this heat with all that gear. — Yeah. So heat stroke is obviously a leading possibility. But also uh severe muscle damage from rabdomiolyis can also occur. — Orlando, where are you going? — Home to take these out. — Uh no, it takes 48 hours for you to get out of DKA. Your blood is still full of acid. Look, I can't add thousands of dollars to the hundred grand I already owe. — I'm sorry. 100 grand? — It's a medical debt. My wife doesn't even know. I'll never be able to pay it off as it is. — Where are your wife and daughter? Maybe we can all talk. — I told him to go back to work a couple hours ago. — But the hospital is giving you a big discount. And Mr. Diaz, I know it's not ideal, but can you stay for at least 12 hours? It will get you out of the danger zone. — No, I really can't. Every minute I stay is a meal. Shoes, school supplies. Plus, I have a second job I have to get to by 4. The problem is if you don't take care of yourself and then you decompensate, you make the problem worse with the financial stress becoming worse with the fact that you can't show up for work for a longer period of time. So, you have to really take into consideration a lot of factors when making decisions surrounding your health. — Okay, how about this? You stay and I'll get together everything you'll need at home. Also, a referral to North Side Christian Health Center. Come on. You don't work until 4:00. It'll keep you from passing out on the job again. She's doing a really great job encouraging him to stay. Going way above and beyond what a normal physician would do in a scenario like this. — That's up to 98. Neonatal mask is working. Santos, finish the test. — Yeah. What are you injecting? — Lido with EP. It'll clamp off any little bleeders. — Remember, uh the reason they're doing lido with EP is because the epinephrine constricts the superficial blood vessels which decreases the bleeding, allows you to have not just a better visual field, but also less potential blood to enter into the lungs. — What is going on here? Do you have a field medical assistant? — Dr. Abbott is an attending and he's also a SWAT physician. My buddy Hero here is in bad need of an airway. I cut it right here. — We can do this. — Oh, no. I got it. You must be Gloria's new hire. — Yes, Dr. Alashimi. — Well, I'd shake your hand, but my tube is ready. And if I could find it, secure the distant tricky. We have a shot at this. — Okay, keeping an eye on the stats. — She doesn't even know what's going on. She just walked into the room. It's like we maybe we have to learn about what's happening with the patient. — What's up now? — GSW with tracheal transsection. very retracted, but I think I can get it. — Both lungs are up. — Sat's scanning the belly now. — Okay, just I got it. Gently. Oh, we're going to lose it. — Down to 89. — I'm in. Balloon up. — End title. Excellent waveform. There's obviously going to have to be a revision surgery after the fact or he's going to get a tra placed that's uh going to be a little bit more long-lasting in the meantime. — While you were playing him with that airway, he missed a big bruise in the left upper quadrant. He was wearing body armor. — High velocity projectile doesn't have to penetrate to do damage. — Oh my god. Is it a spleen rupture? That's a lot of blood loss. — Looks like a subcapsular hematoma of the spleen. Must have been a big impact. — TR15 muscle velocity is 3,000 ft per second. CT angio of the neck ASAP along with CT chest, abdomen, and pelvis. — Yep, just as soon as we secure this tube. — Back to the pit in just a second. But first, I want to tell you about ODU, a business management software with a full suite of integrated apps. It allows you to bring every element of managing your business into a single platform. They've got apps for point of sale, accounting, integrated CRM, manufacturing, you name it. I have an e-commerce business selling merch down below. By the way, if you have a business that's similar, you'd love ODU. They have apps for scheduling and production planning, as well as realtime inventory tracking. It's so helpful having access to every tool you need in one place. Their interface is customizable and really userfriendly, making it super easy to move around between different apps, improving efficiency no matter what kind of business you're in. And get this, your first app is free for life. From there, you can pick and choose which apps you really need. I love not having to pay for a bloated package of products you'll never actually use. So, click the link in the description to get started with a free 14-day trial or even request a demo of ODO and level up your business. All right, let's get back to the pit. — First looters in — mucous membranes try — pupils 4 mm reactive. — Did you get tackled today? — No, just running drills. — Any chest pain, palpitations? — No. — Hands off, please. Running the 12 lead. — How we looking? Good. Healthy kid, no history, no trauma. — Differential for syncopy in an adolescent. Uh, cardiac arhythmia from drugs, longt or bugata. — Uh, bugata is more common in Asian

males. — Bugatta is possible, but definitely a bit of a reach given that we don't know much about the patient. — Long odds, sir. Briata prevalence is one in 20,000 in North America, as high as one in 300 in Asia and the Middle East. and first described in 1992 has a high incidence of sudden death among young patients with otherwise structurally normal hearts. — Wait, did you just say sudden death? — Temp is 102. 5. — Sorry, our student doctors are discussing a rare condition you don't have. — I love the description there. I just didn't drink enough water. I overheated. — Not my type, bud. — Other than standard labs, what else to order? You could make the argument for ordering a head CT given that it's such a high contact sport. — CK to rule out Rabbdo — to make sure you don't have any muscle breakdown from the heat — which we talked about earlier uh when he was initially brought in. Rabbdo uh the typical presentation that we talk about is a marathon runner who hasn't trained well or perhaps just overdid it. Ultramarathon runners there's severe muscle breakdown and starts impacting the kidney from the myoglobin. — And I'll run a blue light over your skin. Anything glows, we'll swab it with a wet and dry Q-tip. Is that okay? — Yeah, sure. — All right. I'm glad they're showing this just to uh explain how comprehensive the exam is and how someone who's just went through something terrible basically has to go through that as an additional step through already the trauma that they experienced. — What's the story? Neck angio is negative. Missed the corateeds. That's really important and I think we would have known if the corateeds were torn because the amount of bleeding would have been absolutely incredible and the survivability of that without treatment for as long as that's been would probably be near zero. — What about the belly? Small splenic injury, no free fluid in the abdomen. — That's great. That's reassuring that no part of the GI tract was harmed uh in a sense of penetration, but the fact that there was blunt force trauma to the spleen meant that there was a lot of blood loss and uh potentially some bruising that's formed. That's why they discussed the hematoma there. Remember, the body will work to resorb this hematoma and this excess blood that has formed. So, uh that's part of the body's natural mechanism there. — Hey, you're going to be okay here. We're getting you to surgery. So wild. Just put into your head how amazing healthc care is. He was shot into his trachea. It got severed and they were able to pull the trachea up and stick a tube into this severed trachea, attach it to his skin and allow him to survive all of this. Medicine, healthc care is amazing. And the fact that there are people out there in our government that are actively seeking to defund it and destroy it is just so devastating and depressing. — SWAT really — I suck at golf. — You spend time in the Middle East — more than I would have liked. — I worked in Kbble with Medsan Frontier and in 2020 at the maternity hospital. I met the most incredible bravest doctors there. I'm assuming she's talking about Doctors Without Borders, who we actually supported with our Patreon, where we charge $10 a month to join our Patreon. And every month we have a live stream where we you together nominate some charities and then vote on where all that $10 of every individual goes to. We keep none of the money. All of it is donated. Pretty cool. You should join. That's linked down below. — I wish this day never happened. — Would you like some medicine to help you relax? You've experienced a horrific trauma. You've been doing this a while. — Let's just say Florence Nightingale and I were roommates. Who? I rest my case. — An attempt to introduce humor in such a dark situation sounds like a bad idea, but if done appropriately, perhaps in cheesy in a cheesy way, perhaps in a self-deprecating way, could be a good way to break tension. But it is so difficult to do that and can only be done after years and years of experience as our favorite nurse here clearly shows. — Rumor has it you're still interested in booking a room with us. — I don't want to go back home yet. — It's all set up, Rox. You're going to be more comfortable at home. — Paul, I changed my mind. It is our home. I don't I don't want you living with my ghost. I will happily live with your ghost. — Can we just all stop talking about ghosts, please? — Yes. I'm sorry. Sorry, sweetie. You're right. — That situation has been ongoing for quite a long time. For them to have never asked the question directly one-on-one with the patient as to why she doesn't want to go home. The longer they drag this out, the more potential conflict that can come from this because it seems like there's just a

misunderstanding from all parties. The healthcare workers don't understand why she doesn't want to go home. the husband doesn't understand. So, it seems like no one is communicating well in this scenario. This is where a leader, hopefully Dr. Robbie, can take control of the situation, ask to be one-on-one with the patient, have a very thorough discussion like he's done so well in the past, and get down to the bottom of the scenario. Once you do, you can then make decisions on how to best serve the patient. — It's a boating accident. Swimmer versus propeller. — Ouch. What body parts involved? — They didn't say. — How old? — Nope. — Anything. All I got was boating accident, swimmer versus propeller. — Propeller. Got it. — That's a wide differential that you have there. Could be as small as a nick. Uh lost finger. Uh a neck dissection. Like a lot of things could be happening. — You could cut the tension with a propeller. — I'm sorry. I betrayed your trust. I betrayed our patients trust. And I'm really [ __ ] sorry. It'll never happen again. I swear. — I'm really glad that you got the help that you need. — He doesn't have to instantly accept his apology. Like just because you apologize. If you immediately expect someone to forgive you, that kind of makes the apology disingenuous. — But I don't know if I want you working in my ER. And you have to understand how that could be a reasonable take. And he also said, "I don't know. " He didn't say, "You need to leave my EO. " — Why'd you intubate? — He was splitting from the pain, barely moving air with sats in the 80s. — Wow. That's so interesting. So, he was breathing so shallow, meaning not deeply, that he was actually desing, that he was not maintaining a good oxygen level due to pain. So it goes to show that uh when we have a patient with a broken rib and they're not breathing deeply, it could impact their oxygen level. So we want to have good pain control when someone has a rib injury and at the same time encourage them through incentive sperometry usually or physical therapy in order to stretch out their lungs to breathe deeply and make use of their entire lung. — Do you need me in here? — Nope. We have a senior resident and an attending. — Mel, uh can we start with a — fast? Sure. — Uh, yes, please. — Why? — To check and make sure there's no pneumothorax, otherwise it could become attention. — Pneumothorax, but also to see if there's any internal bleeding. — You want on egg? — Not without a BP first. — 108 over 64. Pulse is 102. Sats are good. — Okay, let's have on ready, but don't give it just yet. — Anything else? — Why does it sound like it's his first time treating a trauma patient? — Sethadm is up. — They're giving him an antibiotic. — First hemoglobin 8. 2. — A hemoglobin of 8. 2 two is obviously low. In a situation where there's a trauma, the hematocrit is usually a better indicator because there's less things that could impact it from a medical standpoint and really focuses on the amount of fluid found in the uh circulation. — Eight's pretty low. He must have bled down from 14. — Well, I mean, he has multiple wounds where he's bleeding a lot. Also, you don't know what his normal is. So, perhaps he has a condition where he has iron deficiency anemia. He has Crohn's disease. He was bleeding out of his bowels. There's a lot of factors to consider there. — Anything you want to do about that? — You don't want to transfuse a hemoglobin of eight. I believe the protocols are around seven. Uh when I was training, I'm curious what it is in this scenario. — Young healthy guy, we transfuse at seven. — Yeah. — We'd be in real trouble if he equilibrates from acute blood loss. — Am I interrupting something? — Motor. — Jesus. This looks like some Jurassic Park [ __ ] Is that your official surgical diagnosis? — ICD10 code for Jurassic Park [ __ ] — He is hemodynamically stable. What else do we know? — Uh intubated in the field due to poor tital volume. — Title volume is how much air that he was taking in — and no free fluid in the abdomen. Good heostasis inside the wounds. Nothing arterial. — At first, he had a hemoglobin of 8. 2. We'll follow that closely. With no active bleeding, I wouldn't transfuse just yet. Dr. Langon agrees with you. — So does Dr. Mike. — Let's get him to CT. — And by the way, this idea of transfusing only at seven is really a clinical decision based on if there is active bleeding, if there are specific symptoms happening and also needs to be individualized for the patient. This has been trial and the idea is to not overuse blood because blood is a rare commodity. That's why I've been so vocal about getting people to donate blood as much as possible. — What's more from CT? — Nothing introthoracic, nothing intraabdominal. Compeller just missed gutting of him. — Very fortunate. — Repeat, hemoglobin is 8. We're holding

off on transfusing. — What's this? — Daniel Scott 32. Weaken dizzy while washing his car. Tacky at 106. BP90 over 60. Temp's too high to register. — Now we have a heat stroke. — We have a cooling room set up in North 5. Okay. How you feeling, Mr. Scott — thirsty. — You can do a cooling protocol on him. — Core temp, a CMP. — Oh, hey, we need a trauma room. — Oh, he's having a seizure. — I'll grab the Adavan. — Adavan will break the seizure. It's a type of benzoazipene. — Any past medical history? — No. Watch says he's healthy. No meds, no allergies. — I'm surprised the ambulance didn't put start putting ice bags underneath his armpits or something on his groin. And reason why those areas is because there's a lot of blood flow. So, it impacts and cools a lot of blood very quickly. We also have IV liquids that we can give that are cooled. So it actually cools the core body temperature down faster. — Orders, second IV with saline open, sepsis panel, UA urine drug screen, EKG, and CK. I don't see any apparent trauma. — These are all good tests. She's trying to rule out infection, metabolic causes, cardiac causes, neurologic causes with this exam. — Pupil's reactive. Mr. Scott, Daniel, can you talk to me? — Postal but moving all extremities. In that postal state after a seizure sometimes there's a lot of confusion especially with Adevent on board uh which can be a bit sedating. — What are you thinking Dr. Santos? — Uh heat stroke but consider sepsis or drugs. — Yeah. You also want to do a full survey to make sure there's no random bleeding that's happening from a trauma that you weren't aware of. You want to avoid getting pigeon holed into a diagnosis saying, "Oh, well it's hot outside. His temperature is high. It must be heat stroke. It could be sepsis. It could be a raging infection. It could be menitis. " So you want to keep your differential open at this point. — Rectal temp is 104. 6. — Okay, let's start with four ice packs on the groin and axilla. — And remember uh we talked about why those areas, but specifically the arteries involved there is the brachial artery that's bringing a lot of circulation underneath the armpit and the femoral artery in the groin. — Should we do a full body ice bath? That'll take too long. Do you have an Arctic sun? — Yeah, we do. — Get pads on the chest, abdomen, and both legs. I'm guessing the Arctic Sun is some kind of device that's a cooling device that uh perhaps they use during uh cardiac arrest in order to do a hypothermic protocol, but it could be used in this scenario. — Temp 2. 9 labs back mostly signs of dehydration, tad hyperremic, mild bun, and creatinine bump CK400 something. Nothing worse than that. Okay, good. Keep cooling. — When they say a patient is hyperremic, they're saying that the sodium level is high. But remember when we say the sodium level is high, we're talking about the sodium level in the blood based on how much fluid is there. So when a patient is dehydrated and fluid is taken away, the level of salt looks higher even though the same amount of salt particles uh might be there. So it's really this like balanced equation of dissolved substances within the fluid. So for example, if you hydrate a patient, you give IV fluids, you increase the amount of fluid in the blood vessel, you decrease the sodium level. But you also need to not do that too quickly and overcorrect too quickly because that has also ramifications. The balancing of taking care of someone who's hyper or hyponetriic must be done very carefully. — Oh, sorry. — It's okay. — Have you seen my patient Orlando? Mr. Diaz — room was empty. — Seriously? — Yeah. I will say she's having a very strong reaction to the patient leaving. And while I have worked with residents that have this type of relationship with patients where every time something happens where a patient decides against getting good quality care, they make a decision against their health, they get upset. The reality, and perhaps this is a harsh reality, is that so many patients make decisions that are not great for their health. Whether it's leaving against medical advice, doing habits that continuously land them in the ER, like I'm thinking about patients who have congestive heart failure, who continuously have uh huge sodium uh meals that land them with uh CHF flare-ups where they can't breathe and they're fluid overloaded and we need to diarase them and they repeatedly come back to the ER and then get admitted. You end up becoming a bit numb to it. Not in a bad way all the time because there are scenarios um and interestingly it kind of connects back to the uh sexual assault nurse examiner situation where you have something known as vicarious trauma where you start almost changing your world view based on your experiences as a provider. You start uh potentially changing for the positive where you grow from it and you feel more compassion for people. Perhaps you have a neutral response where not much changes or you have a negative response where you develop compassion fatigue and you no longer care about your patients at all or perhaps you start feeling negatively about the world. You become cynical. You feel negative about yourself and you need treatment. So it's important to know that the mental health

of providers in dark scenarios can be impacted as well and that has large ramifications obviously across a society as a whole. — What happened to you? Oh, well it graze my vest. — You were shot. — Shot at? — Jesus. — Why do you do this? — My therapist said I needed a hobby. — Humor is a defense mechanism, baby. — [ __ ] This sucks. — Oh, it's nothing. — I'm watching vicarious trauma play out right now. — Do you make a chart? — No, this can stay off the books. Don't leave the paperwork from the hospital or the police department. — Okay, we're a little secret. — Maybe don't do it in the hospital ER. Maybe have uh one of your buddies come home with a medical kit. — You had a pap smear before? — Yeah, every few years. — Ideally, every 3 years, starting at age 21. After age 30, you could do co- testing with HPV, which can, if both are negative and you've had negative results in the past, potentially be stretched out to every 5 years. — Same position, but I'll start with swabs on the outside. External genitalia, then I'll use the speculum to get internal swabs. You ready? Great. Help you get your feet in the stirrups. — I don't like calling them stirrups. Call them leg rests. — Yeah. A little bit more. A little more. Sorry. I can't — patient centered care. You're allowed to stop. You're allowed to give the patient time. All of that is under their control. — Is this about reporting? — Because you can do this collection without a police report for now. And none of that goes in your permanent medical record. — I don't want to do this anymore. — I would ask the patient why they're interested in stopping instead of assuming why they're stopping. But good opportunity to present some information. — Tell me why you want to stop. He's my friend. He knows all my friends. It was just a dumb. He was drunk. He didn't mean it didn't mean anything. — Okay. — Validation here is very important. And explaining that the choice to collect does not mean that anything needs to happen down the line. — Why don't you take a breather and come back and whatever you want to do, we'll do. Jesus Christ. I'm trying to get to the bathroom for over an hour now. — Yeah, you and me both, sister. Some potential cutting marks there. And I say potential cutting marks cuz it could be a genuine drama. — The internal disaster at West Bridge has been identified as a cyber attack. Their ambulances are being diverted over to St. Aries, but we can expect more walk-ins and Westbridge diversions. — Uh, for how long? — We don't know how long. If the ransom is paid. — Ransom. — Are we next? — Our IT protection system has blocked thousands of intrusion attempts in the hours since West Bridge was hit this morning. But it believes we're still vulnerable. So, we're going to preemptively shut down all the computer systems. Oh, going to paper charts is the worst. Especially for these young docs who haven't spent years reading charts that are illegible from specialists coming by, — patient registration, electronic health records, lab and radiology interfaces, email, internet. — Talk to me first. You want to consult my department? I consulted your fellow attending. Don't hospitals have their own intranet so that they don't necessarily have to be connected to the network like the worldwide network but still be connected where you can use the computer to locally document things. — When are we going down? — Soon. Very soon. — Okay. Hey, somebody get a picture of the board quickly. We're about to go analog. Okay. Oh. Oh. This reminds me of one of the largest hacks in healthc care history that we actually covered on this channel. Click here to check that out. And as always, stay happy and healthy.