Somebody call 911! Help is on the way!

We are down to our last four available ventilators.

This is my lucky day.

Hi, I'm Annie Onishi. [bell dinging]

[Narrator] Annie is a trauma surgeon

based in Bend, Oregon.

Today I'm back critiquing medical scenes in TV and movies.

Gunshot wound, John Wick.

[John gasping] Puncture wound.

Ah, it went deep, nicked the artery.

So this doctor person is saying

this bullet nicked the artery.

Nicked the artery. If it nicked the artery,

you would expect some sort of arterial hemorrhage.

You don't just sew up the skin of a gunshot wound,

that's not how you treat gunshot wounds.

If you close the skin over an arterial injury,

you're gonna develop what's called a hematoma,

so a giant collection of blood,

as this thing continues to actively bleed.

So the treatment for a gunshot wound

is not just to close the skin, it's to go in

and address whatever's been damaged.

John Wick, ex-communicado, in effect in.

Three. [clock ticking]

Two.

One.

I could definitely close something,

if I had to with a time countdown going on,

in fact, I do that on a daily basis.

For example, the cafeteria is gonna close,

or I really have to go to the bathroom.

[mellow upbeat music]

John Wick is doing a great job,

it's probably really hard to sew looking at a mirror,

that's called working backwards.

[mellow upbeat music]

[John grunting]

[John spitting] [object clanking]

The only reason I don't bite sutures,

'cause I'm usually wearing a mask.

Mr. Wick.

You'll never believe I stopped on the hour.

Where?

Here, be sure not to hit my-

[gun firing] [man thudding in chair]

Alright. [breathing heavily]

Be sure not to graze my- [gun firing]

Those are not good spots to elect to be shot in.

If I had to have somebody shoot me,

I would definitely have them shoot me below the knee,

it's a very easy place to get a tourniquet on.

These two places are really bad,

lower quadrant abdominal gunshot wounds are really bad,

destructive gunshot injuries to that structure

will make you end up with a colostomy bag.

And then here he's shot right under the left clavicle,

so that's where the subclavian vein and artery run,

that is notoriously difficult to fix,

often involves actually removing the clavicle.

Really, really poor choice of a elective gunshot wound.

Good luck, Mr. Wick.

A colonoscopy in Uncut Gems.

Few scattered diverticula there.

[mellow melodic music]

Heading towards a splenic flecture now.

Yep, that's what a colonoscopy looks like,

but it looks like they've got a couple things wrong here.

[Howard] I don't wanna talk about it.

He says a couple of colon sounding words,

a little bit out of order. There's the ileocecal valve

going up the sigmoid colon,

few scattered diverticula there.

The endoscopist puts the camera in as far as they can go

to the ileocecal valve,

which is the first part of your colon

and once they're all the way at the end of the colon,

they slowly withdraw, you would see the ileocecal valve,

you'd see the ascending colon, the hepatic flexure,

transverse colon, splenic flexure, descending and sigmoid.

I don't know if that's an editing issue

or maybe he's doing his colonoscopy backwards, I'm not sure.

I disagree.

Waking up for surgery, E.R.

[John snoring] Carter.

Carter, wake up! Yeah.

GSW to the head coming, Benton's in surgery

and Greene's got an MI.

He's taking a nap in an unused, either,

it looks like a recess bay or an operating room.

There are plenty of other more reasonable places to sleep

in the hospital for doctors, we always have a call room,

it's usually very sad and depressing, windowless,

like you could probably reach out and touch both walls,

but it's quiet, it's dark, it's got a phones,

it's got a computer, everything you could need.

Everywhere I've ever worked has either a phones

or a pager system, you can't miss the alarm,

when a trauma's coming in.

I've never had to be woken up by another person.

Carter! What?

Let's go!

Carter gets brought some PPE, that yellow gown to put on.

Nobody ever brings you PPE,

that is a every woman for herself kind of thing.

Two large bore IVs, 15 liters 02,

BP's 80 over 50. Ready, one, two, three.

And he's cyanotic.

They say a couple of doctor sounding words here,

one is cyanotic, that refers to when a patient

is losing oxygen levels

and they start to actually turn blue.

Is that the membrane? Hm-mm.

Horizontal or vertical? Horizontal, no, no,

vertical skin incision first.

Two things are accurate about this,

one is vertical skin incision.

So we make a vertical skin incision

of the cricothyroid membrane.

So if you feel your thyroid cartilage,

in a man, that's the Adam's apple,

below that you'll start to feel the cricoid cartilage,

in between that is a small dent,

that is a little membrane called the cricothyroid membrane.

That's a great place to pop in an emergency airway,

if for some reason you can't intubate from the top.

[soft tense music] [machines beeping]

Here's some Hollywood make up

demonstrating a bunch of oral facial trauma.

Pulse is 54, tried to intubate him,

but there was too much blood tissue occluding his airway.

I was just about to start a cricothyroidotomy.

Alright, alright, alright. I think this kid

looks intubatable, just looking at him,

you can see his cheek is kind of blown off,

but his actual mouth itself looks okay

and importantly, the sort of the structures

of the oral pharynx and the neck

don't look affected by this injury.

So we don't jump straight to a cric,

we at least take one or two good college tries

at an oral tracheal intubation,

just because that is safer and easier.

I hope medical malpractice covers this.

The Heimlich Maneuver in Mrs. Doubtfire.

[Stu coughing]

Stu. [patting back]

I think the most important thing to do,

when someone's choking is first have somebody else call 911,

that way, while you're helping the person who's choking,

some real professional help could be on the way.

Mrs. Doubtfire, help us, he's choking!

Help is on the way, dear!

[melodic orchestral music] Mrs. Doubtfire!

Help is on the way!

This is exactly what I shout,

when I'm paged to the emergency room.

[Stu choking] [melodic orchestral music]

Oh, dear. Oh!

Oh, dear. Oh!

Oh, one more time, dear, oh, dear.

Mrs. Doubtfire is doing

a really excellent Heimlich Maneuver here.

Your landmarks are right underneath the rib cage,

you can sort of feel where the ribs come up and under.

It's a two-handed kind of thrust in a J shape motion.

You do that until the object is-

Oh! [melodic orchestral music]

[Stu thudding to floor]

[Stu coughing]

[object thudding on table]

Ejected.

Virtual reality test run in The Good Doctor.

[soft suspenseful music]

Let's take them off bypass.

What they have is a three-dimensional model

of the patient's specific anatomy

and they are planning their approach

to fixing whatever the problem is here.

[machine beeping steadily]

His outflow is perfect at 13 millimeters.

[Doctor] Which is irrelevant, if the mitral valve

doesn't have enough support to close.

All of the technical surgery, anatomy words they're using

is essentially nonsensical, but the technology

and the idea of using VR to prep for a surgery

is definitely real.

Simulation is definitely

a part of surgical education these days.

We have entire rooms that are pretend operating rooms,

they look like operating rooms,

they sound like operating rooms,

they've got all the monitors.

We can run whole simulations with different teams,

so we can practice crisis situations in an operating room.

Robot assisted surgery, Grey's Anatomy.

Oh no, you did not.

Oh, yes. I did.

The Da Vinci Si HD Surgical System.

General surgeons do not get that excited about the robot.

This is not an instrument that we use routinely,

it is more used by colorectal surgeons,

OBGYN doctors and urology doctors.

[Surgeon] Feels pretty good, doesn't it?

[Dr. Bailey imitating light saber]

One major advantage of robotic surgery

is these so-called degrees of motion.

So if you actually look at the end of these robot arms,

they move like a wrist and a hand,

it's basically like your real hand,

but working in a tiny, tiny space.

This is a big advantage over a laparoscopy.

So laparoscopy uses just long instruments,

that can only move in certain planes,

because it's a long basically stick.

[Dr. Bailey imitating light saber]

Dr. Bailey, are you making light saber noises.

Er, not anymore.

This is what the screen really does look like.

The view in the console

is much more three-dimensional and realistic,

that's the big difference

between robotic surgery and laparoscopy.

You may have seen this demo video,

where they're doing robotic surgery on a grape.

These are the Da Vinci people trying to show how delicate

and precise the robotic surgical technology can be.

I mean, can you peel a grape with this amount of precision?

[Surgeon] Let me retract that small bowel,

so you'll have better visualization.

I think the major misconception,

that the public has about robotic surgery

is that the robot is actually doing the surgery,

that's not the case.

The surgeon is still doing the surgery.

The job of a surgeon is not going anywhere,

we're not being replaced by robots.

The robotic surgical platform is just that, it's a tool.

Rebar injury, 9-1-1.

[soft melodic music] Is it tied right?

[belt locking] Good.

[police radio broadcasting quietly]

Are we good?

[Man] Alright, can you move?

Not a bit.

This is accurate,

because if a patient is impaled on anything,

the recommendation is not to remove that object.

That object may be stopping

major, life-threatening hemorrhage,

so we need to transport the patient

with the object impaled to an operating room,

where it can be removed under controlled circumstances.

Let's get OR3 prepped for a decompressive hemicraniectomy.

It's pretty reasonable that this guy

would need a hemicraniectomy or a hemi,

that refers to the removal of half of the skull flap

in order to evacuate blood, control damage.

[soft melodic music] [drill whirring]

That incision doesn't quite look

like what a craniectomy incision would look like.

The way you get the skull off is you connect

a bunch of little dots that are made with a little drill

and then the [mouth pops] thing pops right off

and it makes that noise.

[soft melodic music] [machines beeping steadily]

The angle of that rebar

looks like it's crossing the midline,

it's going in on this side of his forehead

and looks like it's coming out the back.

I don't imagine that this patient will be talking,

but again, stranger things have happened.

[soft melodic music] [machines beeping steadily]

[rebar squelching]

Once you are totally prepared in the operating room, yes,

you would just have to eventually just take the rebar out.

Here in the background, it looks like they made a pit stop

in the CT scanner before they zipped up to the OR

and their radiologist made some really beautiful

and real life 3D reconstructions of the guy's head

and this piece of rebar.

We do actually have these really amazing 3D models,

that can be made to help you visualize an injury.

Oh, crap.

Another rebar injury in Sirens.

Six feet of rebar goes right through me

and then I'm like holy [beep], Tim, do you see this?

And then Carl runs over and he's all, See what?

And then boom, Carl's out cold.

I have seen some patients after the shock of an accident

ignore some insane injuries.

This looks like some pretty bad penetration here,

your liver, your kidney, your colon.

The main thing I would be worried about here

is your inferior vena cava,

which is a giant vein about that big.

We're gonna have to take you to the hospital.

Mike, it's bad, it's really bad.

Are you kidding me? This is my lucky day.

Adrenaline will keep people going,

even if they're gravely injured.

Testing a patient's orientation, Stranger Things.

This doctor is checking Will's pupillary reflexes,

it's just kind of a basic neuro exam

just to make sure all the circuits are linked up.

Do you know your name?

Will.

Your full name? William Byers.

Kiddo, do you know who I am?

If we're gonna try to assess a patient's orientation,

I don't usually go into this amount of detail,

especially if they've had some head trauma.

I would start with what's your name?

What's today's date and what is this place?

[trolley rattling]

Now Will, I want you to just let us know,

if you feel anything, okay.

[blowtorch whooshing]

[soft tense music]

I don't know any hospital,

that allows blowtorches inside of them.

There's a lot of reasons not to have compressed gas

in a hospital environment.

[soft tense music] [machines beeping steadily]

[creature hissing] How about now?

It burns.

[creature hissing] [Will groaning]

It burns.

Where?

You can hear in the background

Will's heart rate is going up,

that's that high-pitched beeping sound.

Where? [machine beeping rapidly]

I certainly would imagine,

if you held the blowtorch to a patient's limb,

they would have some tachycardic response

as a stress response and as a response to pain.

Abdominal stab wound, 1917.

Oh, God. No.

Oh, my God, no! [groaning in pain]

Jesus!

Jesus, no!

We have to stop the bleeding.

This looks like a pretty grievous injury.

You can see the amount of blood,

that's immediately pouring out.

We're going to get up. [both grunting]

See how pale he gets pretty quickly.

[fire roaring] [Schofield panting]

In the early 20th century, with limited access

to antibiotics, IV fluids, surgical care

and good postop care, I think nine times out of 10,

this would have been a lethal wound.

Let's just sit, let me sit.

No, we can't, we have to find the second, remember?

I would just recommend if your buddy gets stabbed

out in the field, just do your best.

Try to stuff some gauze into that hole

and just hold direct pressure until help can come.

When a patient comes in to recess, having bled out a bunch,

they are white as a ghost,

no matter what their skin tone is,

they're drenched in sweat and they just,

they got this crazy look in their eye.

It's called the fight or flight response.

What's today?

One thing that Hollywood does notoriously badly

is these scenes of young men dying of hemorrhagic shock,

where they're lying there all angelic

and wishing for their mom.

That's not what happens to them, they go down swinging,

the body is just totally amped up on adrenaline,

when you're bleeding out, you can't hold them down,

they're crazy, they're strong,

they're waving their arms around.

It takes four people to hold them down,

then [snaps fingers] their heart stops.

Now I'm gonna talk about how medical shows

have covered the COVID-19 respiratory pandemic.

Patient in respiratory failure, Chicago Med.

[Man] Mr. Booker, I'm afraid your x-ray looks wet.

He says the x-ray looks wet, I 100% disagree.

The most important thing I see are big lung fields

and sharp costophrenic angles.

What that tells me is this patient

is able to take big, deep breaths.

They have a lot of capacity to aerate their lungs,

those sharp costophrenic angles,

which is the angle between the ribs and the diaphragm,

that's nice and sharp,

meaning that the patient's nice and dry,

they're not fluid overloaded.

The airways themselves, you can kind of see

some hazy stuff, bilaterally on both sides,

that we would call that an infiltrate.

I don't feel that bad. I know,

but the thing that makes people feel bad,

a rise in CO2 doesn't happen with COVID.

That's false, COVID-19 causes both hypoxemic

and hypercarbic respiratory failure,

which means the lungs can't do anything,

they can't bring oxygen in,

they can't get carbon dioxide out.

So what now?

I suggest we intubate and put you on a ventilator.

I would not intubate this guy,

based on what I know right here, which is limited.

We don't intubate based on an x-ray,

an x-ray is a piece of the puzzle.

One thing that we discovered early on in the pandemic

was that the amount of support,

that COVID-19 patients need from the ventilator

requires so much airway pressure to be delivered

from the machine, that the ventilator

was actually hurting the patient's lungs.

So as time went on, over the spring and summer,

we really started dragging our feet on intubation.

Basically with this patient, yeah,

he sort of sounds like he's not doing awesome.

I would be willing to give this guy some more time.

If we wait and you go into cardiac arrest,

we can't resuscitate you.

I know it's terrible, but we can't run a code in here,

chest compressions release so much virus.

I wish we couldn't code patients with COVID,

but that's absolutely not the case.

We've definitely been doing chest compressions, CPR,

defibrillations on patients with COVID 100%.

That's called aerosolizing procedure,

meaning it generates bajillions of, that's the medical term,

bajillions of aerosolized particles containing the virus.

But with everybody in PPE,

yes, we were absolutely coding COVID patients.

[Doctor] 20 of Etomidate and 100 of roc.

20 of Etomidate and 100 of roc,

that is a pretty standard medication regimen for intubation.

So you give a slug of Etomidate, the patient falls asleep

and then you paralyze with 100 of rocuronium,

so that's a medication that just completely paralyzes

every muscle in the body

and allows you to get the breathing tube in.

Ventilator shortages, Grey's Anatomy.

As of five o'clock this morning,

we are down to our last four available ventilators.

So until relief arrives, I need us all to think creatively.

It's very nice that these people have enough time

every morning to have a little staff meeting,

where they can talk about their resources.

In real life, in my experience in two hospitals,

during the COVID pandemic, this type of information

would be discussed by sort of the suit types

and then disseminated via an email.

[woman gasping] [gentle piano music]

Okay, come on.

This lady looks like she's in trouble.

So she's already wearing high flow nasal cannula,

which is a pretty aggressive form of respiratory support.

It delivers a very high degree of inspired oxygen.

The other thing you see her doing is leaning forward.

[woman gasping] Okay.

That's called tripodsding, that is a sign

of respiratory distress and impending collapse.

Ventilators are our last resort,

put them on BiPAP, the hyperbaric chamber, proning,

let's exhaust all options first.

Here you hear the chief naming

all the different other strategies besides intubation

in order to support somebody in respiratory failure.

This is a spectrum, but they're all not mutually exclusive

meaning, yes, the first thing we start with

is a simple nasal cannula.

That's what you sort of always see in Hollywood

is that thin tubing that sits right here on your face.

The next level up from nasal cannula is something called

a simple mask and then a non-rebreather mask,

that delivers inspired oxygen to the whole nasal pharynx

and the oral pharynx.

The non-rebreather is what pops down from the ceiling

of an airplane in the event of an emergency.

The next level up would be

something called high flow nasal cannula.

That's what this lady is wearing,

that is able to deliver very, very high flows

of very, very concentrated and humidified oxygen

to really boost somebody's oxygen levels.

The next thing after that prior to intubation

is something called BiPAP,

which is a mask that is sealed to the face

and actually gives the patient some positive pressure

meaning the machine is actually pushing air

and oxygen into the patient's lungs

and then finally, after that would be intubation.

Check-check pat, pat and cuff tube, ready?

[soft tense music] [machines beeping steadily]

[Woman] Code blue, code blue.

So this cowboy is gonna intubate without medication?

So as opposed to the other doc,

who asked for Etomidate and rocuronium.

[Doctor] 20 of Etomidate, 100 of roc.

This guy is just gonna intubate her

without any sedation or paralytic.

That's actually really difficult

without a patient being paralyzed.

ECMO in my favorite, The Good Doctor.

Dr. Lemke, can you hear me? [machine beeping rapidly]

[Nurse] O2 stats are still dropping?

We got a whole bunch of tricks up our sleeve

to help somebody between nasal cannula

and when they arrest like this.

These doctors sort of missed the boat

on other forms of respiratory support.

We put her on ECMO, oxygenate her blood outside her body.

Their very brief explanation of ECMO is correct.

ECMO stands for extra corporeal membrane oxygenation,

it's for patients in severe, severe respiratory failure.

Getting a patient cannulated onto ECMO

is not a one-person job, blood is removed from circulation,

passed through an oxygenator,

where oxygen is delivered to the blood

and then passed over a membrane,

where carbon dioxide is removed from the blood,

basically doing the entire job of the lungs,

like this lady says.

We take her lungs out of the equation.

We put her on ECMO, oxygenate her blood outside her body,

her lungs will have time to heal.

You can't do ECMO in the ER.

We aren't supposed to do abdominal surgery

in the ER either, please walk me through it.

First of all, ECMO is not a thing,

that you get walked through, okay.

ECMO is a very complex medical intervention,

that requires the expertise of somebody,

who really knows how to, first of all, put it in,

second of all, run it.

You got to have a perfusionist at the bedside,

who knows what the machine is doing

and who knows how to troubleshoot

all the various components

and it's not something that you can just like do on the fly,

like I'm sure, I guarantee you that no ER

has all the components for ECMO just lying around.

All the places I've worked that have been ECMO centers

have entire ECMO closets, that need to get mobilized

in the event that a patient needs to crash onto ECMO.

This is just completely off,

this is just not something that would happen,

that's just not how ECMO works.

[patient gasping] [machines beeping rapidly]

Push paralytics.

Starting intubation.

And here they go again,

pushing paralytics without sedatives.

That would mean is that the patient is completely paralyzed,

cannot move a single muscle in their body,

but they're potentially still awake.

That is a nightmare come true, big no-no.

Black market organs, Riverdale.

[lid clattering] [ominous music]

Oh my God, is that?

Yes.

That doesn't look like anything human.

I think it's pretty common in Hollywood

for them to use bovine or cow organs.

To me that looks like a beef heart.

Normally I would immediately say no.

Transplanted organs, they come on sterile ice,

wrapped in two separate little plastic baggies in a box,

in a box, in a box, in a cooler.

Here's another clip from Futurama.

Psst, you want to buy organ?

Fresh and cheap, ready for transplant.

That's a really beautiful piece of colon.

That's a eyeball, I think that's gonna be a stomach,

looks like a heart, yeah, there's some good stuff.

Do you take cash?

Uh!

I think it's probably pretty difficult

to keep these organs alive, perfused and sterile

in this man's smelly jacket.

Hypothermia in The Fall.

What's going on here? He's hypothermic,

core temp 28.2, paramedics got a line in

and I got some bloods from what I put in.

Where was she found? In a forest

in the boot of a car, we think she was there

for at least four days.

This patient has severe hypothermia from exposure,

you can hear them explain that she was stuck

in the trunk of a car for a few days.

Her core temperature is 28 degrees,

that is extreme hypothermia,

your body temperature runs about 36, 37.

Those patients would be hemodynamically unstable,

they would have poor blood pressure,

probably very slow heart rate.

They would have a lot of organ damage,

they wouldn't look as stable as this girl looks.

[doctor sniffing]

I can smell pear drops, what are her keytones?

2.3.

[Doctor] We can't move her until an ICU bed is ready

and attempt's going in the right direction.

So here he's reporting the odor of pear drops,

that's sort of the, what sounds like

the Irish or English version

of what we would describe as a fruity odor.

When patients are starving,

they haven't eaten in three or four days,

they start going into what's called ketosis,

when your body doesn't have enough glucose to burn,

it starts burning other amino acids and proteins

and a byproduct of that is ketones.

So ketones can be detected in the blood

and the urine and the exhaled gas,

so classically a patient in ketosis

will have this fruity odor about them.

A leg laceration and jewelry sutures, The Shallows.

You're not gonna feel the stitches, okay.

[waves lapping] Okay.

[soft tense music]

[Nancy screaming in pain]

We have a surfer, who's been injured here.

From what I can see, this is merely a flesh wound,

this does not look very serious.

I would put a little pressure on that,

maybe wrap that in a t-shirt, head on home

and take a shower and get it cleaned up.

[soft melodic music] My God.

[waves lapping] [soft tense music]

[Nancy groaning]

You absolutely would not be able to get through your skin

with a piece of jewelry like that.

She should just relax, take a couple deep breaths,

hold some pressure and head on home.

A deaf patient in Switched at Birth.

Why haven't you told her what's going on?

She's completely confused.

She's deaf, she needs an interpreter.

Can you do it?

This is really poor form here,

this patient has no interpreter at her bedside

to help her navigate this scary trauma situation

and the healthcare provider here is relying

on the patient's friend to interpret sign language.

What's going on, why isn't there an interpreter here?

[Nurse] We're working on it.

So medical interpreting is a very specific field.

We have a really great ipads on wheels thing,

it's a big screen that you roll up right to the patient.

You can pick any language,

it scrolls for like four or five pages to pick a language.

There's a lot of specific training, it's many hours,

it's not just translating, it's interpreting,

there's a difference.

So you really should not be using friends or family members

to help a patient understand what's going on.

There are no doctors or nurses here,

that know sign language, alright.

Well, there should be.

[Narrator] [bell dinging] Conclusion.

Well, we've looked at a lot of scenes today.

I know a lot of this is for dramatic effect,

but sometimes it's pretty fun to look at what's well done

and what's not so well done.

[light melodic music]