SCENE 22

 

Scene 22 opens the following morning with Richard on the phone in a nursing station. He's wearing the same outfit we saw in the CLL patient scene, as this is a few hours later. Richard looks like he's been on hold for a while and is falling asleep. We hear the voice of the medical records clerk.

 

Medical records clerk (OS)

Medical records.

 

Richard is startled.

 

Richard

Hello?

 

Medical records clerk (OS)

with attitude

This is medical records. What do you need.

 

Richard

Hi I need an old chart, because my patient can't give us any-

 

Medical records clerk (OS)

interrupting

Medical record number.

 

Richard starts hunting through some papers.

 

Richard

It's, uh, okay it's 746459.

 

medical records clerk (OS)

Thank you for calling medical records.

 

Richard

Wait! How am I going to know when it's ready?

 

Medical records clerk (OS)

We'll page you.

 

Richard

Do you want my-

 

<click> medical records clerk hangs up.

 

Richard

pager number?

 

Richard stares at the receiver. Only the second day of medicine, and he's feeling beat down. Dr. Mehta walks up, sees Richard staring at the phone. He takes the phone out of Richard's hand, looks at it to see if there's something interesting to note about the phone. There's not, so he hangs it up.

 

dr. mehta

You need to change before attending rounds.

 

He starts to walk away, turns around to say one more thing.

 

Dr. mehta

Don't be late.

 

Cut to Richard walking quickly down the ward hall as he adjusts his tie. He has changed into the outfit we saw as he approached the hospital yesterday, but now all wrinkled and disheveled. Cut to shot of the hallway from Richard's POV, the entire team is standing outside a patient room in a circle waiting for him, all watching him walk quickly down the hall.

 

dr. toto

You must be Richard.

 

They do not shake hands. Richard takes his place in the circle.

 

dr. toto

I'm Dr. Toto, your attending.

 

Richard

How do you do.

 

Dr. toto

I write your evaluation.

 

Everyone stares at Richard, waiting for him to respond to this. Richard has no response.

 

Dr. toto

You missed most of your colleague's excellent presentation. Please continue Becker, sorry for the interruption.

 

Becker

That's okay Dr. Toto, I'm sure Richard has a good reason to be late. In summary, this is a 44 year old Hispanic female with sharp nonradiating flank pain of three days duration. Her heart rate has been in the high 90s since admission, with other vital signs within normal limits. Physical exam is notable for a nondistressed patient with mild left lower quadrant tenderness and without costovertebral angle or cervical motion tenderness. Laboratory examination is notable for a negative urine HCG, small urine red blood cells, a mild anemia and borderline leukocytosis without a left shift.

 

Camera to Richard, who is both impressed and disgusted. Camera slowly pans across the group as Becker finishes his presentation.

 

The differential diagnosis for a perimenopausal woman with flank pain and this constellation of nonspecific findings includes appendicitis, gastroenteritis, nephrolithiasis, pelvic inflammatory disease, urinary tract infection, ovarian pathology such as a ruptured cyst, and a left lower lobe pneumonia. Less likely possibilities include pancreatitis, a GI malignancy, pyelonephritis, aortic aneurysm, endometriosis, and irritable bowel syndrome. I would like to continue the workup of this patient with diagnostic imaging studies such as a supine and upright abdominal plain film, a transabdominal ultrasound or perhaps a pelvic CT.

 

dr. toto

Thank you Becker.

 

Dr. Toto turns to Richard.

 

dr. toto

Richard, I hear you did a pelvic exam on our lady with chest pain. Seeing how enthusiastic you are about obstetrics, tell me: how do we know this patient is not pregnant?

 

Richard

Well the urine HCG is negative.

 

Dr. toto

The urine HCG is negative, you say. Does a negative HCG rule out pregnancy?

 

Richard

hesitates

I guess not.

 

dr. toto

You guess not?

 

Richard

Well-

 

Dr. toto

In almost all cases a negative urine HCG does rule out pregnancy.

 

Richard’s face says: why is this ass hole doing this to me?

 

Dr. Toto

I have an intern-level question.

 

Steve perks up.

 

Dr. toto

When does a negative urine HCG not rule out pregnancy?

 

steve

Very soon after conception - before embryonic trophoblasts make enough hormone to be detectable in urine.

 

Dr. toto

True. If we suspect this to be the case, are there any tests we can use to verify or rule out pregnancy?

 

Steve

Serum beta HCG.

 

Dr. toto

Correct. Richard if this patient had been beta HCG positive, would that change our management?

 

Richard looks at Dr. Toto, pausing, thinking. He opens his mouth to speak but it’s too late.

 

dr. toto

Becker?

 

Becker

confident, business-like

In a pregnant patient with abdominal, flank, or pelvic pain we must consider an ectopic pregnancy.

 

dr. toto

Richard, what is the triad of ectopic pregnancy?

 

Richard doesn't know.

 

Richard

slowly

The triad of ectopic pregnancy.

 

Toto doesn’t wait around.

 

Dr. toto

 Becker?

 

Becker

Vaginal bleeding, abdominal pain, and an adnexal mass in a sexually active patient.

 

As Becker says this, the camera slowly zooms in on Richard’s face and holds his face front and center while Toto begins to speak. This cut to Richard's face must be sufficiently unusual as to indicate to the audience that something bizarre is about to happen.

 

Dr. toto

Richard what is the most common site of an ectopic pregnancy?

 

As Toto speaks, the camera zooms out, revealing Richard to be completely naked, his hands covering his genitals.

 

Richard

The fallopian tubes?

 

No shit, Dr. Toto thinks.

 

Dr. toto

Yes Richard. Where in the fallopian tube do most ectopic pregnancies occur?

 

Richard didn’t realize that there were different parts to the fallopian tubes. He looks hopeless.

 

Richard

Where?

 

Dr. Toto

Becker?

 

 

The camera shift to Becker, who as before looks confidently at Dr. Toto.

 

Becker

The ampulla.

 

Dr. toto (OS)

That's right.

 

Becker punches the air in front of him, overly satisfied with himself. He turns to Richard and starts dancing wildly saying "Yeah, baby – the ampulla, uh-huh, the ampulla, uh-huh." He dances over to Richard and starts twisting on both of Richard’s exposed nipples while continuing to sing and dance. Richard stands there placidly, hands on genitals. As Becker dances circles around Richard, The camera goes back to Toto (we hear Becker singing in the background).

 

Dr. toto

Richard, please tell us the three parts of the fallopian tube.

 

Richard

obviously frustrated

I haven’t the slightest fucking idea.

 

Camera to Toto, who looks at Richard and shakes his head. He responds calmly.

 

Dr. toto

Richard, please show us your penis.

 

View from behind Toto, we see Richard taking his hands off his genitals. The team all stares at Richard's crotch, shaking their heads in disapproval. Toto speaks to Richard while staring at his groin and shaking his head.

 

Dr. toto

Your performance disappoints us Richard.

 

Dr. Toto continues to gaze at and motions to Richard's penis, then looks Richard in the eye.

 

Dr. toto

You're going to have to do better than that.

 

He shakes his head one more time disappointedly.

 

Where were we? Yes, the ampulla of the fallopian tube is the most common site of an ectopic.

 

The camera is now slowly zooming in on Becker’s face, who is back in his original position, impossibly recovered from the antics of five seconds ago (i.e. we're back to reality for a moment, before we shift to Becker's perspective-world).

 

Becker’s face held front and center as Toto talks.

 

Dr. toto

Richard what are the risk factors for ectopic pregnancy?

 

Camera to Richard, who is dressed as he was before.

 

Richard

I don’t know, but that's okay because my only role here is to make Becker look good.

 

Camera to Richard as Dr. Toto speaks.

 

Dr. toto

And you’re doing a marvelous job. So, Becker...

 

Camera back to Toto, who is now on a pitcher’s mound in an empty stadium. We hear Toto continue his sentence but the camera shows him in the classic pitcher’s pose, glaring at the batter, lips unmoving.

 

Dr. toto (OS)

Tell me the risk factors for ectopic pregnancy.

 

Toto winds for the pitch and the camera pans to Becker at the plate, waving the bat around like Mark McGuire about to slug the shit out of whatever comes his way. From the catcher’s view we see Toto after his windup pitch the slowest, easiest underhand lob. Becker speaks just before he crushes the pitch into the stands.

 

Becker

Previous tubal surgery.

 

Repeat the windup and home run as Becker says, "history of diethylstilbesterol exposure" and "history of pelvic inflammatory disease."

 

During the last half of Becker saying "history of pelvic inflammatory disease," cut back to Becker standing normally at rounds. He finishes the answer and stands there, satisfied.

 

Camera slowly zooms in on Toto, front and center. After freezing on Toto’s face front and center long enough to make clear we are shifting to his perspective, the camera continues to zoom it so that ultimately his moving mouth takes up the entire screen.

 

Dr. toto

slowly, authoritatively

Excellent, Becker. An extrauterine gestational sac is one of the obstetric emergencies; the astute clinician must be able to promptly recognize and manage the possible ectopic pregnancy. In any female of reproductive age with a presenting complaint between the chest and the knees, the most important test is the qualitative urine pregnancy. In the setting of a positive urine HCG, the patient’s vital signs and general appearance must be assessed for stability. If she is unstable, it is presumed the tube has ruptured and must be managed surgically.

 

The camera slowly zooms out as Toto's lips stop moving though we hear him continue speaking, to reveal Dr. Toto dressed as Moses. He is walking through some natural setting, carrying two enormous stone tablets.

 

Dr. toto (OS)

In the stable patient, the next step is a transvaginal ultrasound examination to look for an intrauterine pregnancy. If a gestational sac is found in the uterus, it may be safely presumed that there is not an additional ectopic pregnancy as the risk of a heterotopic pregnancy is classically estimated at one in 30,000.

 

As he says this, he comes upon the team, dressed in biblical attire, kneeling in a semicircle facing him.

 

Dr. toto (OS)

The exception is the patient on fertility-enhancing drugs, in which case you must have a much lower threshold for presuming an ectopic pregnancy if the clinical scenario is suggestive.

 

Toto approaches Steve and as the rest of the team demonstrates their reverence, bowing, kneeling, worshiping Dr. Toto, Steve humbly receives the tablets. Cut to black.