Previously on The Good Doctor…
You need to take a break, clear your head.
You need a vacation.
I'm gonna quit my job.
I'm not looking forward to moving
to Hershey, Pennsylvania.
I don't want kids.
Ever.
I've just been fired for physically assaulting an employee.
Go ahead. Chop us in half.
When will they wake up?
They should've already.
We were worried about you, Jenny.
So glad you're back.
I am gonna give you three words.
Try to remember them.
Apple. Ball. House.
Can you count back from 100 by 7 for me?
I'm going to Harvard, you know.
93, 86, 79, 72, 65.
And what city are we in?
San Jose.
And what were those three words?
Apple. Ball. House.
Look out, Harvard.
We'll be doing a lot more tests to know for sure,
but your heart does sound better.
How's Katie?
You woke up before her, so too soon to tell.
There's virtually no alpha or beta brain activity.
We must have missed something during the separation surgery.
We didn't.
Katie's BP was steady, sats were fine,
regional blood supplies were reconstructed.
Just like Jenny, yet she's awake,
Katie's in a coma.
Katie's got the new sagittal graft.
A problem with blood flow in that vein could cause her condition.
An MRI angiogram should tell us if the graft is open or not.
Hello.
I will proceed with the angiogram.
Whoa!
Murphy, you've been gone for two days.
How about we start there?
Okay.
Just because you talked to the president
doesn't qualify as permission.
Okay. Yes.
I… will notify Dr. Melendez
next time I go on a road trip with my girlfriend.
Amazing.
"Road trip"?
Dr. Glassman said you were dealing with a personal crisis.
That is true.
Do you know the definition of personal crisis?
Yes. A stage in a sequence of events
at which the trend of all future events is determined.
- A death, an illness. - Yes.
No, not a road trip.
Okay.
You and Dr. Browne
get going on Katie's angiogram, unless, of course,
you have any personal emergencies to attend to.
No. My crisis is over.
Come in.
Hey.
How are the twins doing?
Jenny's in recovery.
Her numbers look good. She's talking.
Katie… not so good.
We need to talk about Murphy.
I told you he's on personal leave.
Yeah, well, that's not what he said.
You talked to him?
Yes.
In the surgical unit five minutes ago.
There's the sagittal vein graft we constructed for Katie.
It's open with good flow.
Graft is fine.
Which means we still have no explanation for her coma.
Go in closer.
The middle cerebral vein,
it has low flow out of the brain.
You're thinking low flow out means low flow in?
Yes, that is what I'm thinking.
We should look at the arterial inflow phase.
We'd like to look at the arterial inflow phase, please.
So, what'd you do on your trip?
Well, sometimes when we take a road trip,
we're running away from something.
I kissed Lea.
And Dr. Glassman is mad at me.
What is he mad at you about?
It's almost entirely blocked.
And…there's a malformation in the Circle of Willis.
Katie is barely getting any blood to her brain.
Excuse me. Shaun?
May I speak with you, please?
Dr. Melendez… He was not angry.
Oh, no, Shaun. Dr. Melendez is angry with you.
He's also angry with me.
W-Why?
"Why"? Because I lied to him for you.
Why did you run away?
I didn't… didn't run away.
When you leave without notifying your attending,
when you drop all of your responsibilities at this hospital…
When you leave without telling anyone, including me,
then you are running away.
Did this trip with this girl help?
Yes. Yes, it did.
Okay. How?
I would like to give two-weeks' notice.
Mom, can you ask them to bring me some more ice chips?
I'll get them, sweetie.
- I'll get a doctor. - No.
I'm just…
When you left, there was no one here.
For the first time in my life, I was alone.
Sweetie.
It felt… cold.
Well, sometimes it is cold.
But you know what?
Someday, you might find that you like it.
Wrongful termination.
Dr. Kalu assaulted an attending surgeon.
I don't think you have strong legal footing here.
There's more to the story.
And I am sympathetic to Dr. Kalu,
but his ends don't justify his means.
Obviously we can't tolerate staff members…
And yet you do.
Please read on.
The middle cerebral has narrowed.
It's less than two millimeters.
We bypass the artery here and restore blood flow.
Open her back up?
She's just been through a massive operation.
The brain tissue hasn't settled.
Another could very well stroke Katie out.
Other options.
Intravascular.
I don't see how an intravascular ultrasound
- gives us a better picture. - No, not imaging.
He wants a stent in the middle cerebral artery
in the angio lab. I like it.
Stenting is usually reserved for the heart and the carotid.
It's not the usual, but we are way past the usual.
It would lower the danger of a stroke.
Dr. Murphy, would you like to assist?
Y-Yes.
Dr. Melendez, would you like to write me a letter of recommendation?
You see the narrowing there, in the horizontal segment
- of the middle cerebral artery. - Middle cerebral artery.
Yeah. I've heard about you.
You're the one making the old guard nervous.
W-Why would I make people nervous?
'Cause you have a gift.
And surgeons judge themselves against their peers,
and right now, you're winning.
We're in position.
Dr. Murphy, please inflate the balloon.
Give us another squirt of contrast.
And we should have good blood flow.
Yes, the proximal end of the artery is dissecting.
The balloon is damaging her artery.
Waveform is worsening.
Stent won't hold.
She's gonna stroke. I'm aborting.
Okay.
Waveform is normalizing.
We're right back where we started.
Katie's brain is starving.
I want to see Katie.
I know she's in a coma. I still need to see her.
I miss her.
We can't risk contamination for either of you.
She needs to know I'm there.
We understand.
You can't understand.
No one can.
We have always been there for each other,
and now when she needs me most, I'm not there.
You've just been through a 40-hour surgery.
We need you to focus on your own healing.
And what about her heart?
We're going to do a cardiac catheterization test
to see if her heart circulation has improved.
Inject the contrast to evaluate the heart's blood supply.
How's my soul looking?
That's a different specialty.
Katie says the eyes are the window to the soul.
I say the eyes lie. It's the heart.
Well, then, so far your soul is looking good.
Strong, unobstructed blood flow.
Ventriculogram will tell us how the muscle function's doing.
So quiet. Is everything okay?
Ventricle's strained and dilated.
We were hoping for some improvement post-separation,
but it's barely pumping.
It just doesn't make any sense.
The separation was supposed
to relieve the stress on Jenny's heart.
Half the need, half the work.
Jenny's heart was even sicker than it appeared.
Seems we couldn't see that because Katie's heart
was doing all the work for Jenny's.
What can we do to fix it?
Give her a new heart.
We're not gonna find a donor match in time.
Yes, we already have the perfect heart for Jenny.
The sisters are monozygotic and therefore a genetic match.
On the other hand, Katie is alive.
- She is GCS-3. - Her heart is still beating.
Yes, but she is unresponsive.
And I don't see a way to return blood flow to the brain.
In all likelihood, Katie's not coming back.
Yes, Katie very well may die, but we can't predict when that'll be.
It could be today. It could be 20 years from now.
If Katie stays on the ventilator.
- That's not up to us. - I know.
But I also know that, based on these scans,
Jenny might not make it through the night.
We need to propose this to the mother.
There's no chance Katie will wake up?
We can't say with 100% certainty,
but from what we saw on Katie's brain scan…
we have little reason for hope.
But what we can say with certainty
is that without Katie's heart, Jenny will die.
Can we wait?
Just a little. Maybe you'll know more.
Maybe something will change.
If we don't do anything, Jenny's heart will stop before the morning.
How do you…
Would it be painful?
No. We simply power down Katie's ventilator.
Once off life support, she will peacefully pass.
Do you want us to explain this to Jenny?
I'm sure she'll want to be present.
No.
I put trust in them from an early age,
thinking responsibility would build strength.
I think it worked.
But this… No.
Jenny can't be part of this in any way.
It'd destroy her.
I'll tell her Katie died.
"Dr. Shaun Murphy
"exhibits technical skills beyond his years."
- You wrote that? - Yes.
That's why I signed my name at the bottom.
You think Shaun survives at another hospital?
I didn't think he'd survive here.
Without your endorsement, Shaun isn't going anywhere.
I may have my issues with him,
but no matter how stupid an idea this may be,
I'm not gonna stop him from going after what he wants.
There's another signature line next to mine.
It's where the president of the hospital has to sign.
The chief oncologist.
This is before I came here in December of '14.
Dr. Marshall shoved a scrub nurse
during a post-op discussion of some sort.
Do you remember that?
I do.
Your response was to settle with the nurse
while Dr. Marshall was let off with a warning.
There's another almost identical instance earlier in that year.
In both cases, the doctors in question were white.
They were censured. Dr. Kalu was fired.
You think this was a racial matter?
Do you think I'm racist?
That I favor white people?
Then why the leniency then and not now?
They're stars…
that happened to be white.
Doctors like Marshall allow St. Bonaventure
to compete with other West Coast institutions.
So, that's our defense?
"We're not racist. We just allow our doctors
to assault people as long as they bring in enough donors."
They were reprimanded.
And there were no further incidents.
And how do you think all of this is gonna play out in court?
Settle.
Okay.
Hi.
- Floor? - Four.
Shaun asked Dr. Melendez for a letter of recommendation.
Yeah.
All I have to do is sign it and off he goes.
I think…
he might think that you're mad at him.
If you don't sign, it reinforces what he thinks.
But if you do,
it lets him know that you believe in him.
Can I touch her?
Of course.
Goodbye, baby.
- Are you ready? - Yes.
She's stabilizing.
I don't understand.
What's going on?
Katie's not ready to go.
She's breathing on her own, which means Katie has
normal brain stem function, correct?
When a ventilator is removed, life can continue.
It's rare, but it can happen.
It doesn't change the prognosis for awakening.
Off the ventilator with normal vitals
suggests long-term vegetative state, right?
Yeah.
We just lost our remedy for Jenny's heart.
What about ECMO?
Use the machine as a replacement for Jenny's heart.
Buys us… two weeks of life?
I don't like it.
ECMO requires blood thinners. She just had brain surgery.
It could cause a catastrophic bleed.
Well, ECMO and its complications may be our only avenue.
R-Re-conjoin them.
You want… You want to put their heads back together?
Not the heads.
The thighs, the femoral vessels.
Is it a funny idea?
I think it's funny that I didn't think of it.
The girls' blood is identical.
No need for anti-clotting meds, so no possibility of a bleed.
As long as they're attached, Katie's heart will beat for Jenny.
When Katie dies, we sever the femoral connection
and transplant Katie's heart into Jenny.
We just spent 40 hours separating them,
and now we want to put them back together.
- You tried to kill Katie? - No.
You took her off life support.
What do you call that?
Mercy. Not just for her.
You need a heart or you're going to die.
Katie's alive.
She was then, and she's even more now.
Katie's alive in the sense that she has basic organ function,
but she has no higher-cognitive brain activity.
She's surviving,
but she is not living.
Hours ago,
you thought she'd die
as soon as you pulled the plug.
You were wrong.
How do I know you're not wrong this time, too?
The demand on… on Katie's heart
is minimal in her resting state.
She can easily tolerate helping you.
I won't ask Katie to be my life-support machine.
Dr. Andrews.
Let's put the sisters in the same room overnight.
I don't think that Jenny sees herself as an individual yet.
You know, I'm thinking the only thing that'll change Jenny's mind
about the reattachment is Katie.
Being close might help Jenny to see her as lifeless.
Could backfire…
and cement her feelings that she's killing her sister.
Yeah, possibly.
And then we're in the same position anyways.
Okay, do it.
Well, what about baseballs
that this girl caught at a Giants game
signed by Mr. Hunter Pence?
He didn't hit it, but that doesn't matter.
- So, where is the sporting-goods one? - There.
Oh, no, that does not go in sporting goods.
It doesn't?
I'm applying to move my residency to Hershey, Pennsylvania.
Really?
Yes. Penn State Medical Center.
Are you following me?
I need to make sure
you're not just doing this to stay close to me.
No.
Shaun.
I want my own life.
I want a life that I control, not Dr. Glassman.
Dr. Glassman is just trying to help you.
I don't want help.
But what if… you need help?
How will I know if I stay?
Too much stuff. You have too much stuff.
We should book a trip.
Maybe somewhere warm.
Wow. You are so slow.
You're only folding underwear. Underwear's easy.
Mnh-mnh.
Okay.
No, Neil, I don't want to…
Fine.
Let's go, Preston.
I'm ready.
Go.
Boom.
You're the only good thing about my day.
I couldn't sleep last night.
I couldn't even close my eyes until…
…I could feel Katie's heartbeat in my hand.
If I do this,
at some point Katie's heart will beat for me, right?
That's the plan.
Then wherever I go, she will always be with me.
Okay. I'll do it.
How you doing, Jenny?
I can't feel anything.
That would be the magic of local anesthetic.
Vessels are clamped.
Okay, Doctor.
We're ready to proceed with the anastomotic grafts.
It's done, isn't it?
I can tell.
Let's put both the girls' vitals next to each other, please.
Come on now.
Give it a few cardiac cycles to adjust.
How'd we do?
You did great.
Why Hershey?
Lea is moving there.
Ah.
Well, they… they make good candy bars.
I don't like candy bars.
I love pancakes.
Well, they make those, too.
I brought you here because…
I thought this place
would provide a challenge for your abilities.
But I realized I really brought you here
because I thought you needed me.
This is a now signed letter of recommendation.
But…
I don't want you to go.
If you stay, I'll… I'll back off. I'll…
I'll let you make your own choices, your own mistakes.
I believe in you, Shaun.
Their blood pressure dropped.
5 millimeters of Mercury.
I like when you say "their."
You're gonna see some fluctuation.
BP drops 5 millimeters every complete cardiac circulation.
Shouldn't the fluctuation be inconsistent?
Maybe Katie's heart isn't picking up the workload for Jenny as expected.
Jenny.
I'm… I'm right h-here, Katie.
Right next to you.
Take Murphy and get a shotgun work-up on Katie.
I want everything… EKG, EEG, and labs,
and an echo on Jenny.
Ooh
This hate
Mm, mm
Katie has an awake alpha rhythm on her EEG.
She's doing remarkably well.
We're still not entirely sure what caused Katie to regain consciousness.
Attaching them again
could have redistributed fluid into Jenny's system,
possibly decreasing the swelling in Katie's brain.
Just don't know.
I know.
They need each other. They always have.
The issue right now has become Jenny and her heart.
When Katie was in a coma,
the metabolic demand on her heart was very low,
but now that she's alert and active,
there just isn't enough heart for both of them.
What does that mean?
We're awaiting test results.
We're not sure how long Katie's heart
can tolerate the strain of supporting Jenny's circulation.
We'll closely monitor them with cardiac labs and echoes.
We need to find a donor heart for Jenny as soon as possible.
- No. - "No"?
I've had CEOs settle for half of what I just got for you.
I don't care about the money.
That's beautiful. It's admirable, even.
But, you see, this is how it works because we live in a civilized society…
they hurt you,
we hurt them by making them cut you a massive check.
I don't want them to hurt.
I want them to give me my job back.
A third of "your job back" is,
by my calculation, uh, almost nothing.
I'll pay you a third of this settlement.
What are you talking about?
You'll be paying me more than you earn in a year.
I want my job back.
Lunch is on you.
Lunch is on me.
Are you moving to Pennsylvania to be with Lea?
Does she know that?
Lea knows I'm moving to Hershey.
Yeah, but does she know you're going there
because she is going there?
I'm not.
Lea makes me happy.
Well, Lea's not the only one that can do that.
I'm gonna miss you.
Your BNP.
Jenny Kunkler's cardio protein levels are…
I've never seen anything like it.
That's because the levels are for two hearts, not one.
Now Jenny is killing Katie!
- What's going on? - We got to separate them now
- or we lose them both. - Twins on the way?
In transit.
J.L.'s gonna do a local on the fly.
On my count. Three, two, one.
We can't do this. You'll die.
- We're gonna do it. - No.
We're in this together.
The way we've always been.
The way we were meant to be.
It's Jenny! She's in v-fib!
Push a milligram epinephrine now!
Prepping Ambu bag.
Murphy, start chest compressions!
It's Jenny.
Her heart had nothing left to give.
Katie?
She's stable.
Her vitals are good,
but we have an issue that we need your help with.
Okay.
Um, Katie won't allow us to separate her from Jenny.
If she doesn't acquiesce, Katie will clot and die.
Bring 10,000 units on board.
We'll clear out and give you some privacy.
Baby.
We have to let her go.
I won't let them separate us.
I never wanted to do this.
You used to say we were made this way for a reason.
I won't let them do this.
Even if it kills me.
I want you to look at your sister.
Look at her.
I can't lose both of my daughters.
Dr. Andrews. Evening.
I, uh, checked out the twins' file.
It's an amazing case.
To be clear, Jared, I don't want you here.
What we presented to Miss Preston was the truth.
I understand that.
And those problem doctors and the ways we police ourselves
will be dealt with, should have been dealt with a long time ago,
but you stepped over a line.
I fought for my job.
You compromised your integrity.
The incident with that jerk Coyle had nothing to do with black or white,
but that's what you and your lawyer sold or leverage.
And when you misrepresent racism for something it's not…
…it sets us two steps back.
She's ready.
Jared, you're on suction.
Mayos.
You were alone
Left out in the cold
- Clinging to the ruin of your broken home - I'm cold.
Too lost and hurting
To carry your load
We all need someone to hold
You've been fighting the memory all on your own
Gone fishing.
- Nothing worsens, nothing grows - Store's closed.
I spoke to Claire.
I know how it feels being by yourself in the rain
We all need someone to stay
Hear you, falling and lonely, cry out
Will you fix me up?
Will you show me hope?
At the end of the day, you were helpless
Can you keep me close?
Can you love me most?
Hey.
I want to break up.
Why?
Because I love you.
Odd reason to break up with somebody.
I want you to have everything in your life.
Which includes kids.
I told you I was willing to not have kids.
You're gonna regret that decision one day.
- I won't. - Yes, you will.
You're just too decent to think it, but you will.
So what?
We all have regrets.
I-I wanted to play third base for the Astros.
It's not the same. That is a child's dream.
This is your life!
This is my life,
and it'd be more devastating to be resented by you
than to have my heart broken.
And you are going to be a great dad.
Shaun.
I wanted to give you something.
I'm letting you borrow it.
Bring it when you come visit?
Okay.
Promise?
You're gonna come visit, right?
I promise. I like Hershey.
- You've never been to Hershey. - Lea's there.
Can I put my arms around you?
Are you a good doctor?
'Cause when I think of you, I think you are.
You were alone
Left out in the cold
Clinging to the ruin of your broken heart
You were falling and lonely, cry out
Will you fix me up?
Will you show me hope?
At the end of the day, you were helpless
Can you keep me close?
- Can you love me? - Remember, I said borrow.
I know how it feels being by yourself in the rain
We all need someone to stay
Hear you, falling and lonely, cry out
Will you fix me up?
Will you show me hope?
At the end of the day, you were helpless
Can you keep me close?
Can you love me most?