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00:00This program dramatizes true medical enigmas reported by the doctors themselves.
00:06The names and characteristics of the people have been altered.
00:10When we enter a hospital, we think the doctors have all the answers.
00:16They don't.
00:20I'm fine.
00:21I decide that. She was a professional athlete.
00:23Where do I have to sign?
00:24All right, Steph?
00:26No.
00:27That alerted me right away.
00:29It wasn't just a fracture, it was something else.
00:36It's cold here.
00:38Miranda Lee.
00:39Main condition, severe stomach pain.
00:42I didn't have the right diagnosis.
00:44And I didn't have time to lose.
00:50As soon as I saw the results of the pulse resonance, it was obvious.
00:54I had no idea how much pressure she was taking every day.
00:57So the hypothesis is cancer.
00:59I started to think and I was very worried.
01:02TRUE ENIGMAS
01:04She fainted. She has paralysis on the right side.
01:07The pressure I felt in the beginning was multiplied by a thousand.
01:11I'm paralyzed.
01:15X-DIAGNOSIS
01:19Camera A.
01:20I'm Dr. Armandoian.
01:22I'm a real doctor.
01:23I specialize in emergency medicine.
01:25I was an emergency doctor for eight years.
01:28I think emergency medicine is perhaps more important.
01:31Urgency is essential when attending to someone.
01:35The time of truth.
01:36The diagnosis must be quick, under great pressure.
01:39I take care of babies, grandmothers.
01:41And I like to make decisions on the spot.
01:43I don't like to sit and think about the case.
01:46This case involved an athlete who had some health problems.
01:49It was a difficult case to diagnose.
01:52Diseases don't choose anyone.
01:54They don't know wealth or social position.
01:57But when there are more people watching you, it's a little more difficult.
02:01It's a lot of pressure and you have to decide.
02:03I'm studying my speeches.
02:05Oh yeah? Have you memorized everything?
02:07I'm trying to speak with an accent.
02:09You could do this episode with Sean Connery's voice.
02:12What? Sean Connery?
02:14I can try.
02:16Sean Connery is an endocarditic bacterian.
02:21And you're not going to be okay.
02:24Hi, I'm Kent C. Tang.
02:26I'm a general practitioner.
02:29It's one of those careers where we feel satisfied with what we do.
02:33We work a lot, we study even more.
02:36But in the end, I feel like I've done something that I'm very proud of.
02:41That I value.
02:42I have small children at home.
02:44And sometimes they ask me,
02:46Mom, why do you have to go to work?
02:49And it's nice to explain to them that my job is to help people.
02:54And they understood.
02:55And now they keep asking me,
02:57Mom, are you going to work to help people?
02:59And they don't feel bad about it.
03:01It's better than mom having to go out and work.
03:06Or we won't have food on the table.
03:08They can see that they like what I do.
03:10And even though they're small, they understand the value of what I do.
03:12And I'm proud of that.
03:14This is a fascinating case.
03:16It was something I experienced when I started the private practice.
03:19It was an example of what we call a diagnostic dilemma.
03:23Well, in the office we see routine problems almost every day.
03:27And we have confidence in our training.
03:30And we count on that.
03:31But this was a situation that was not predictable.
03:35And it was a big challenge.
03:39There was a lot of tension.
03:41Because I was responsible for that person's life.
03:44I had an intuition that it was something serious.
03:46But I wasn't sure what it was.
03:48Are you nervous?
03:49Of course.
03:50Are you?
03:51Yes.
03:52Why?
03:53I've never done this.
03:54It's like starting the residency again.
03:56Scene 1, take 1, cut.
03:58And action.
03:59Now?
04:00Go.
04:01Okay, I'm going.
04:05A hospital is a real pressure cooker.
04:08Lorraine, where are the residents?
04:10Yours are out there studying a little.
04:12Come on.
04:13Come on.
04:14Residents live under a lot of pressure because they don't know much yet.
04:17Wrong again.
04:18What?
04:19Let me see that.
04:20And there is a great expectation for them to try to diagnose or at least think about pressure.
04:25It looks like I'm going to get the most out of this test, huh?
04:27News.
04:28Okay, go.
04:29Very well.
04:30Gene.
04:31Metabolic alkalosis.
04:33Give me three causes.
04:34Go.
04:35Have you ever thought about hypovolemia with contraction?
04:37Diuretics.
04:38Renal insufficiency.
04:39Supervisors support the additional pressure to accompany the residents.
04:43These answers will be of no use if they are rejected in this program for neglecting their patients.
04:48Let's go.
04:49Let's go.
04:50Let's go, Semi.
04:51That's right.
04:53Let's go, doctors.
04:56Let's go.
04:57We used to say, if you can't stand the heat, it's better to get out of the kitchen.
05:01Let's go.
05:02Hey, looser, get your stuff.
05:03I have to go.
05:04We have a personal visit.
05:06When you become a supervisor doctor, every day is a constant pressure.
05:10And that pressure becomes part of you.
05:12I'm coming, I'm coming.
05:16At the time, we realized that she was in great shape.
05:19It was obvious that she was an athlete.
05:21It's Stephanie Yates.
05:23According to my resident, she played professional volleyball.
05:26Let's work, Stark.
05:28What do we have here?
05:29The patient is 20 years old.
05:30Pressure 12 by 8.
05:31Pulse 88.
05:32Saturation 95.
05:34Pulse fracture suspect.
05:35The team doctor looked, said it should be a twist, but we want to be sure.
05:38I'm fine.
05:39I'll take care of it.
05:40Take her inside.
05:41When dealing with professional athletes, you can try in the dark.
05:45Often, athletes provide the least amount of information.
05:48Very well, take her to bed 2.
05:50Because they believe they know their body like no one.
05:53Right, when I count.
05:54I'm not invalid.
05:56Okay.
05:57And often they omit symptoms because they just want to play again.
06:04I always see you on the sports channel.
06:06It's strange to see you here.
06:08Okay.
06:11Does it hurt?
06:12What do you think?
06:13Sorry.
06:14Sensitivity, swelling, hematoma, all together.
06:16Stephanie, let's do some x-rays.
06:18Dr. Stark, can you call the radiologist?
06:20Of course.
06:21I think it's not broken.
06:22I've had torsions in the wrist before.
06:29Broken or not, you're not going to play this afternoon.
06:31So it's better to relax, okay?
06:33Did you hit your head?
06:40No.
06:41Temperature 37.5.
06:42With half a beat because of a flu, it's too demanding.
06:53Are you the coach?
06:54Coach.
06:55Are you taking medication?
06:59It's all ready in the radiologist.
07:00Very well, then let's take her there.
07:02Yeah, I'm with her now.
07:03At first I thought her presence had caused more agitation than necessary.
07:08She seemed to have just hurt her wrist and was brought in an ambulance.
07:13Where there are celebrities, there is the media, and where there is the media...
07:16Dr. Dorian.
07:17There are public relations.
07:18I assume you know who this patient is.
07:20They are a stone in the shoe.
07:23I want your tests to be very quick, you know?
07:25We'll see what we can do.
07:29Focus on the patient.
07:31I'll take care of her.
07:32Okay, thank you.
07:33It was just what was missing, right?
07:34Yeah.
07:41I can't believe it.
07:42I had to come from Santa Monica, for God's sake.
07:44I was in a meeting.
07:45Yeah, if you had signed the papers.
07:47Why didn't you fill out the paperwork?
07:48What is this hospital?
07:49I filled out the paperwork.
07:50You just had to sign it, that's all.
07:51You just complain.
07:52Miranda Lee.
07:53Main complaint, severe stomach pain.
07:55And according to my notes, it's not the first.
07:58I don't know.
08:00Let's see what we have.
08:02You can't have a meeting over the phone.
08:04Yeah, if you had signed the paperwork.
08:06Excuse me.
08:08Hi, I'm Dr. Tang.
08:09Nice to meet you.
08:11A handshake can mean a lot of things.
08:14She shook my hand lightly, and I had the impression
08:17that either she was too weak for that,
08:20or she was already emotionally overwhelmed.
08:22What's going on?
08:23When I eat, I feel like my stomach is on fire.
08:27My stomach is on fire.
08:35She's been very stressed lately.
08:37Why is that?
08:40She said she lost six pounds.
08:43In just one month.
08:45Why did she come to the hospital now?
08:47I can't take this pain anymore.
08:49I can't take this pain anymore.
08:56I tried cutting food, I tried antacids, but so far...
09:00Very well.
09:02Tell me where it hurts.
09:05When I examined her, I couldn't reproduce your pain.
09:08It gets worse when you move.
09:10At least I was sure it wasn't a surgical problem.
09:14But on the other hand, it was complicated
09:16because I didn't know what was going on.
09:18Do you have any other pain?
09:20I'm all sore, no energy.
09:23Miranda, has anyone ever told you about
09:25the Irritable Intestine Syndrome?
09:27All the doctors have told me about it,
09:29or just indigestion.
09:30The doctor thought it was a calculation,
09:32but so far they haven't found anything.
09:34They also said it could be psychosomatic.
09:37The husband seemed to think she was exaggerating
09:40or making up the symptoms.
09:42She's 38 and a half, and the pressure is 15 by 8.
09:46She was convinced there was something wrong.
09:48She had a fever. No one makes that up.
09:50No one believes there's a problem.
09:53We do.
09:55Really? So what is it?
10:02My patient, Stephanie Yates, is back from radiology.
10:05I have recommendations.
10:07I know she's not far from the beach,
10:09and she had a fracture in her wrist.
10:11Put a plastic bag in the plaster so no sand gets in.
10:14You have to keep your arm up all the time.
10:17You know how it is.
10:19I know. Where do I sign?
10:21Look, I want you to read and sign, okay?
10:30When she tried to sign with her right hand,
10:32she started shaking.
10:34Stephanie, are you a cane?
10:36No.
10:39Are you all right, Steph?
10:41I'm just nervous, I guess.
10:43When I saw there was something wrong,
10:45it wasn't just a fracture.
10:47You're not going to have a heart attack yet.
10:49There's something else going on.
10:56So?
10:58Well, after seeing her with her husband,
11:00I thought of ulcer.
11:02We did an endoscopy and ruled it out.
11:04I felt there was something wrong with her wrist.
11:07I felt there was something wrong with Miranda's digestive tract.
11:10And since the other doctors had failed with her,
11:12I didn't want to fail this time.
11:14Listen, what if it's an inflammatory bowel disease like Crohn's?
11:17She didn't have diarrhea.
11:19Cancer can cause acute pain,
11:21and it occurs with fever and progressive weight loss.
11:23She only had an ultrasound.
11:25She would have revealed a tumor.
11:27Maybe they found it.
11:29Only if it's some kind of lymphoma that doesn't show up in the exam.
11:32Then the hypothesis is cancer.
11:35I started to think,
11:37what would be the worst thing that could happen?
11:39Always the big question.
11:41Would she have cancer?
12:04Steven, you don't have to stay here.
12:06I know you'd rather be in the office.
12:08If I wanted to be in the office, I would be.
12:10Miranda came in with severe abdominal pain,
12:13fever and weight loss.
12:15Excuse me.
12:17Miranda, I understand you've consulted many doctors
12:20and taken many exams,
12:22but there's something that could have happened
12:24in the routine exams that I'd like to rule out.
12:26What is it?
12:28It's called gastrointestinal lymphoma.
12:30Oh, my God.
12:32Cancer is definitely the disease
12:34that most people are most afraid of.
12:36I'm going to have to do chemo.
12:38Maybe, but it's too early to speculate.
12:40How do you do an exam for that?
12:42I told them I was looking for some hidden form of cancer.
12:46Unfortunately, they thought it was cancer
12:49and got nervous, which is always possible
12:52when you mention that word.
12:54I tried to calm them down because it was just a hypothesis,
12:57not a confirmation.
12:59There was just one thing that needed to be ruled out.
13:02I want to do a barium enema in the small intestine.
13:05You're going to take a substance
13:07that will give us a good view of the intestinal lining
13:10so that we can rule out any danger.
13:12When the barium passes,
13:14you can see if there's any irregularity
13:17or any mass that shouldn't be there or any blockage.
13:21If the liquid doesn't go down,
13:23you know there's some kind of obstruction.
13:25Don't worry. We'll do our best to help.
13:29Let me examine you.
13:31My patient, Stephanie Yates,
13:33had a fracture in her wrist,
13:35but she began to show strange neurological symptoms.
13:38She was having trouble holding a pen
13:40and signing her name.
13:42Stephanie, which was a tomography of the head.
13:44I already said I didn't hit the head.
13:50I know, but the weakness in your hand
13:52may indicate cerebral hemorrhage.
13:54I don't know if it's a hemorrhage.
13:56I know, but the weakness in your hand
13:58may indicate cerebral hemorrhage.
14:02Stephanie, we still have a long way to go.
14:05Okay.
14:07Dr. Stark, speed up the tomography.
14:09Of course. Sorry.
14:19The intestines look normal.
14:21No irregularities in the mucosa, no tumors.
14:24We have a barium enema in Miranda's delicate intestine.
14:27So we can rule out cancer?
14:29At least that's what it looks like.
14:31Everything looked very normal.
14:33Anything else? No, thank you.
14:35Shall we repeat the exam?
14:37Yes. Do you know the date of those tomographies?
14:39I asked for an emergency. They'll deliver.
14:42Okay. Take care of that. Keep an eye on Miranda.
14:44Beep me if anything changes.
14:47Dr. Stark, please call 499.
14:50The problem with athletes is that they're very stubborn.
14:53Like doctors.
14:55What is it, Chris?
14:57My patient, Stephanie Yates, did a brain tomography
15:00to see if there were hemorrhages, tumors, or even a spill.
15:05Did you beep me?
15:07Did you know beach volleyball is the second most popular sport
15:09in the world after football?
15:11Oh, yeah?
15:13Where did you get that information?
15:15Uh...
15:17No.
15:19I don't see anything that suggests hemorrhages.
15:21Well, at least that's not it.
15:23The tomography was normal, which was good,
15:25because she didn't have hemorrhages or a tumor,
15:27but it was bad because it didn't give us answers to a diagnosis.
15:30Something's wrong.
15:32Thank you, Lila. Let's go.
15:36Doctors?
15:38How are you?
15:40Dr. Miller?
15:43Yeah, I should get surgery.
15:46Well, if it's not neurological, maybe it's a problem with the other hand.
15:49Are you going to ask for x-rays of the right arm?
15:52For sure, before she leaves.
16:02Hey, hey, what's up?
16:04Oh, she insisted. I'm fine, really.
16:06Is there anything in the tomography?
16:08Well, no, but...
16:10The tomography didn't say anything.
16:12We didn't have an answer, and the patient wanted to leave.
16:14But there are other tests we want to do,
16:16and I'm your doctor, and I suggest you stay.
16:18I already said that.
16:20I said it, too.
16:22Look, I know you're worried about me, but I'm fine, really.
16:24And staying in this hospital doesn't work.
16:26But we suspect that...
16:28You know, I know my body.
16:30Where's the autopsy report?
16:32It's right here.
16:34The hospital isn't a prison.
16:36We couldn't keep her there against her will.
16:38I'm fine.
17:08You told me to call you if anything changed.
17:10What happened?
17:12We just got Miranda's tests. You need to see this.
17:14In the urine test, there was blood and protein.
17:18There was definitely something wrong with her kidneys.
17:21Is she suffering from kidney failure?
17:23Maybe she's dealing with a multisystemic disorder.
17:29That's it.
17:31My patient, Stephanie Yates, left to watch a volleyball game.
17:34Dr. Donia?
17:36Is this the same VIP, Ross?
17:38No, the same VIP.
17:43Okay, put her on bed two.
17:45She's paralyzed on the right side.
17:47Your right side was paralyzed.
17:49We were doing routine training on the beach when she fell and passed out.
17:52She can't move her leg, her arm, she can't talk.
17:54What's going on with her?
17:56Calm down. Give me your hand.
17:58The pressure I felt in the beginning...
18:00Dr. Donia?
18:02Not now, Ross. It was multiplied by a thousand.
18:04Are you okay? Are you going to be okay?
18:06I'm not okay.
18:08What's going on?
18:10Can you raise your arm?
18:12Stephanie Yates is back with acute paralysis on the right side.
18:14Push with your hand.
18:16Can you feel it here?
18:18What's going on?
18:20Calm down.
18:22What about the foot, Stephanie? Can you touch my hand?
18:24Dr. Donia?
18:26Not now, Ross.
18:28I'm paralyzed.
18:30There was a lot of confusion and agitation when she first came.
18:32What are we going to do?
18:34What are we going to do?
18:36My obligation was to solve the problem I had in my hands and ignore the pressure around me.
18:40Okay, Lorraine?
18:42We have to go down for a resonance.
18:44Mike, I want you to stay here with Ross.
18:46Okay.
18:48Dr. Stark?
18:50Come on, let's go down.
18:52Stephanie, you're going to be okay.
18:54Mike!
19:02Although Miranda Lee arrived with abdominal pain,
19:04now she had kidney failure.
19:06When the kidneys start to fail,
19:08it increases the pressure because you don't know when they're going to stop.
19:10It's necessary to prepare for the worst.
19:12But you can treat problems in the brain, right?
19:14Only when we know what the cause is.
19:16Usually, kidney failure occurs due to dehydration,
19:18or what she had,
19:20but she would have reacted when we gave her liquids.
19:22You haven't taken any medication, have you?
19:24No, I haven't.
19:26You haven't taken any medication, have you?
19:28No, I haven't.
19:30Nothing.
19:32It's cold in here.
19:34Could it be an infection?
19:44No, according to the tests.
19:46There's no bacteria, you're right.
19:48What if they don't know what's causing kidney failure?
19:50That made me think of multisystemic diseases.
19:54Diseases that generate blood.
19:56That made me think of multisystemic diseases.
19:58Diseases that generate blood.
20:00Diseases that generate blood.
20:02What?
20:04It could be something very serious.
20:06It could be something very serious.
20:18As soon as I got the results of the MRI,
20:20as soon as I got the results of the MRI,
20:22well, it was obvious.
20:24It was a brain ischemia.
20:26And very serious, considering she's still conscious.
20:28It was a serious ischemia.
20:30We have to act before she gets worse.
20:32Chris, we have to get her out of here.
20:34Dr. Stark, call Lorraine.
20:36Take Stephanie down there and start with the thrombolytics.
20:38But why does she have that?
20:40I know as much as you do.
20:42We had to look back
20:44and think of all the possibilities
20:46for someone healthy or so young
20:48to have a serious ischemia.
20:50Hi, Lorraine, it's Tom Stark.
20:52I need thrombolytics for Stephanie.
20:54It's the volleyball player.
21:04Miranda Lee had kidney failure,
21:06which was a big shock, a complete surprise for me.
21:08Excuse me.
21:10Miranda Lee, let's review.
21:14I felt very pressured to find out
21:16what to do with her kidneys and why they were failing.
21:18Abdominal pain and...
21:20kidney failure.
21:22Hypertension, fever, anemia.
21:26Joint pain and weight loss.
21:30What does all this lead to?
21:32Lupus, for sure.
21:34It fits perfectly.
21:36Lupus usually attacks the kidneys and joints,
21:38causes fever and weight loss.
21:40It was what she had.
21:42So it was a very good hypothesis,
21:44but I was bothered by the fact
21:46that abdominal pain showed up first.
21:48I think we're forgetting about abdominal pain.
21:50I've never seen a case like this.
21:52Lupus can inflame many organs.
21:56It's the closest we can get.
21:58Let's go.
22:08Stephanie Yates was being treated
22:10with thrombolytics to dissolve
22:12the coagulant in her brain.
22:14Although we found an answer,
22:16this answer led to a thousand other questions,
22:18because someone as young as her
22:20shouldn't have an ischemia.
22:22Paroxysmal fibrillation?
22:24No history of palpitations,
22:26and her heart rate has been normal since she arrived.
22:28Moyamoya disease?
22:30Moyamoya is a brain injury,
22:32and moyamoya in Japanese means smoke.
22:34Moyamoya disease? Where did you get that?
22:36I got it from Sam. She did it for the tests.
22:38When you make a resonance with an angiography,
22:40the distribution of blood vessels in the brain
22:42looks like a lot of smoke,
22:44and that's why it's called Moyamoya disease.
22:46It's not possible.
22:48There's nothing in the form of smoke in the resonance.
22:50What if it's a congenital heart defect?
22:52What do you think?
22:54Maybe the heart is in the coagulants.
23:02Coagulants. Maybe you're right.
23:04Remember the bruises on your hands?
23:06I remember, but they were fractured, weren't they?
23:08Maybe. Or they could be something totally different.
23:10There was a good chance
23:12that they weren't simple bruises,
23:14but that we were dealing with another type of process.
23:16Let's go.
23:18Can you tell me what's going on at least once?
23:20Stop thinking and go.
23:28I went to the lab to check Miranda's results.
23:30If that's to screw over a supposedly famous flight attendant...
23:32That's not it.
23:34You said Miranda's lupus test had arrived.
23:36See?
23:38People can have smart conversations in the hospital.
23:40I did the blood tests again.
23:42Maybe you need that.
23:44It was nothing.
23:48Negative lupus.
23:52I was lost.
23:54I had discarded all possible hypotheses,
23:56and the lupus was all that was left.
23:58How was the creatinine this morning?
24:001.8. What was it?
24:022.0.
24:04Creatinine is a by-product of the muscles,
24:06and should be filtered by the kidneys
24:08when they're working properly.
24:10What caused your kidney function to deteriorate so quickly?
24:12A lot of things,
24:14but we should consider that something is obstructing the kidneys.
24:16And the tomographies?
24:18They haven't arrived yet.
24:20Let's repeat the test.
24:22That contrast can further damage your kidneys.
24:24Well, in this case Harper is right.
24:26We don't have time to lose.
24:28Good job, Dr. Harper.
24:30I'm proud of you.
24:38I decided to examine the hematomas
24:40in the hands of Stephanie Yates.
24:44What was that?
24:46You'll find out.
24:48What are you looking for?
24:50Take a look at this.
24:52The hematomas were in the palms of the hands,
24:54and if they were caused by volleyball,
24:56they would appear on the outside of the hand.
24:58They're not hematomas.
25:00They're Janeway injuries.
25:02Give me the ophthalmoscope.
25:04What are Janeway injuries?
25:06Janeway injuries are microembolias,
25:08or microischemias,
25:10in the palms of the patient's hands.
25:12I'm going to examine the eyes.
25:14Another classic symptom occurs in the eyes.
25:16Rot spots.
25:18What was that?
25:20See for yourself.
25:22What are you looking for?
25:24There was ischemia,
25:26Janeway injuries,
25:28and rot spots.
25:30Tell me what you're seeing.
25:32I think we know what's causing the symptoms.
25:34I started to understand
25:36why the professional volleyball player,
25:38Stephanie Yates,
25:40had an ischemia.
25:42These are classic signs of a heart infection,
25:44called endocarditis.
25:46Is there something wrong with my heart?
25:48If that's the case,
25:50now you know why you had the flu.
25:52Endocarditis can occur with fever
25:54and symptoms of the flu.
25:56Wait a minute.
25:58Is this very serious?
26:00It depends on the extent of the damage to the heart.
26:02We're going to need another exam to be sure.
26:04Dr. Stark calls Dr. Hammond
26:06and asks for an echocardiogram now.
26:08As we suspected
26:10that Stephanie had a heart infection,
26:12we called a cardiologist
26:14to perform an echocardiogram.
26:22As the renal function began to worsen,
26:24I decided to repeat the tomography.
26:28The intestines look good.
26:30No gallbladder.
26:32No enlarged liver.
26:34Normal ovaries.
26:36We examined the liver and it looked normal.
26:38We examined the stomach and it was normal.
26:40There seemed to be nothing in the intestine.
26:42No signs of abscesses either.
26:44No calculations either.
26:46Excuse me, please.
26:48Excuse me.
26:50Wait a minute.
26:52Wait. Where are you going?
26:56There were certain dark spots
26:58triangular in the outer part of the kidneys.
27:02Dr. Miller?
27:04Please.
27:08What is this?
27:10Let me see.
27:12Come here in the kidneys.
27:14You can hardly see.
27:18Oh, I see.
27:20They look like heart attacks.
27:22Heart attacks occur when tissue cells
27:24die from lack of oxygen at some point.
27:26What is this?
27:28This is the last thing I needed.
27:30As a resident, it was certainly not common
27:32to see kidney attacks.
27:34I was very worried.
27:36Let's call a nephrologist.
27:46Is it very serious?
27:48There are scars.
27:50Tissue erosion.
27:52Stephanie, your heart was affected
27:54by an infection.
27:58As soon as we did the echocardiogram,
28:00we found that she had an infected valve.
28:02Do you see these spots?
28:06They are infected parts of the valve
28:08that we call vegetation.
28:10It happens that some of them move
28:12causing mini ischemia
28:14in which you feel weakness,
28:16as you felt in your hand.
28:18Today I had a more significant ischemia,
28:20but for the same reason.
28:22This valve is triple.
28:24It is tricuspid.
28:26They are three sheets that come together.
28:28Usually they are normal, smooth
28:30and connect perfectly.
28:32There is no blood regurgitation.
28:36It happens that this valve
28:38is damaged with these vegetations.
28:40Small groups of tissue pieces
28:42form that look like grapes.
28:46And with the agitation of the blood flow,
28:48these grapes also agitate
28:50and sometimes pieces of them,
28:52pieces of tissue, move,
28:54go up and reach the brain
28:56causing an ischemia.
29:00But what causes such a thing?
29:02She got too heavy?
29:04Excessive exercise?
29:06Dr. Donner, the infection
29:08is in the tricuspid valve.
29:10What do you mean?
29:14The tricuspid valve is usually
29:16infected by unfavorable habits
29:18such as the use of injectable drugs.
29:22She needs to replace the valve.
29:24I'll ask Brotherly
29:26to schedule the surgery early tomorrow.
29:28Right. Thank you, Bill.
29:30Sport is no longer the same thing.
29:32Even volleyball players today
29:34take anabolic steroids.
29:36Maybe, but it still doesn't explain
29:38why she has endocarditis.
29:40It does explain.
29:42The use of injectable drugs
29:44introduces bacteria into the bloodstream
29:46to take care of a patient.
29:48Yes, that's true.
29:50But the use of steroids
29:52is intramuscular,
29:54not intravenous.
29:56But if she's injecting into the muscle,
29:58how did it get into the bloodstream?
30:00Almost, Doctor.
30:02What? What?
30:12Hey, Sammy, do you have a minute?
30:14Well, Tung keeps bugging me.
30:16I haven't slept all day, and this thing is broken.
30:18I seem to have time.
30:20What do you want?
30:22I have a patient with endocarditis in the tricuspid valve.
30:24The urine tests for drugs were negative.
30:26I was thinking, are they common drugs or not?
30:28Does she have a heartworm?
30:30No, we didn't find anything.
30:32Did you ask if she had any dental treatment?
30:34No, but she said she had the flu.
30:36The flu, I know.
30:38Did you ask me if she took antibiotics?
30:40No.
30:42Hold this.
30:44Hold this.
30:46It's Doreen. I have to go.
30:48Got it?
30:50Call me if you have any idea.
30:52Sorry.
30:54We have to study, Stark.
30:56We're going to study.
31:06I understand your difficulty in understanding this picture.
31:08I hope I can.
31:10As I was intrigued by the problems in Miranda's kidneys,
31:12I called a nephrologist.
31:14Sclerosis or thromboembolia
31:16can cause kidney infarctions.
31:18Yeah, but we've already taken that into account.
31:20Not to mention that she has no other risk factors.
31:28She has an organ injury,
31:30and we don't have much time.
31:32Here are the tests we recommended.
31:34Thank you, Chung.
31:36HIV?
31:38Her husband is going to love this.
31:40Wow, hepatitis C.
31:42Well, take the tests and keep an eye on the blood pressure.
31:44It's 18 out of 10.
31:46I was frustrated.
31:48It's not very...
31:50common not to have a clear diagnosis at this point.
31:52Stark, did you find time to study?
31:54If you keep using the chips
31:56he made for him,
31:58he'll have to study until the end of time.
32:00Where did you get Muya-Muya?
32:02May I know?
32:04Come on, move it.
32:08My patient, Stephanie Yates,
32:10underwent a cardiac surgery
32:12to replace the patient's valve with an artificial one.
32:16Is she okay?
32:18Yes, the surgery went well,
32:20but we'd like to talk to you a little.
32:22Sentes.
32:24What happened?
32:26Well, the type of endocarditis she has
32:28is caused by bacteria present in contaminated needles.
32:32What do you mean?
32:34I thought you'd know if she was using...
32:36How dare you?
32:38How dare you make such an accusation?
32:40Do you have any idea how hard she trains?
32:42How hard she works?
32:44How much pressure does she have to put up with every day?
32:46Do you think she'd risk it all using drugs?
32:48It's not a trial.
32:50Maybe you should ask your client.
32:52She fit perfectly
32:54into the profile of someone who uses steroids,
32:56given the circumstances in which she lived.
32:58We're not judging anyone.
33:00We just want to help.
33:02Okay?
33:04Please, when Stephanie leaves the surgery,
33:06send a blood sample for a toxicological test.
33:08We already did that.
33:10I know, but can you test steroids this time?
33:16Dr. Tang.
33:18While I was waiting for the blood and urine tests,
33:20the nurse arrived with Miranda's urine bag.
33:22I was collecting samples for the tests I asked for.
33:24Look, I just got this.
33:26That's all?
33:28She's not producing urine.
33:30No, she's been hydrated since she was hospitalized.
33:32The fact that she's not producing urine
33:34is a terrible sign.
33:36And what does that mean?
33:38That her kidneys are getting worse.
33:40If she stops producing urine,
33:42we'll have to go through a dialysis.
33:44Take whatever you have to the lab.
33:46We need answers. Come on, let's examine her.
33:48She didn't have an adequate diagnosis,
33:50and there's not much time to lose.
33:58It's already the third day
34:00of the dialysis to take care of patients.
34:02I thought you were so smart you didn't have to study.
34:04Do you have Stephanie Yates' test results?
34:06I have good news and bad news.
34:12There's no trace of her.
34:14Clean like water, clean like water.
34:16When I was surprised
34:18by the negative test for steroids,
34:20I had to go back to my head
34:22to talk to the patient
34:24and start all over again.
34:26They can make these drugs
34:28very expensive nowadays.
34:30What now?
34:32What now?
34:34Let's start again to see
34:36what we've neglected.
34:38Let's go.
34:42The tapes are a good option
34:44for decoration,
34:46as well as colored napkins.
34:48At that time,
34:50Miranda Lee had several symptoms.
34:52She had abdominal pain
34:54that brought her to the hospital.
34:56She had weight gain and weight loss
34:58and also renal failure and uncontrollable hypertension.
35:00Oh, it's cold here.
35:02Can they turn on the heater?
35:04Yeah.
35:06It's very hot here, about 26 degrees.
35:08For me, it looks like 10.
35:10Most people come
35:12with one or two problems,
35:14but there were so many problems
35:16happening to her,
35:18it was impressive.
35:20I needed
35:22to find out what it was.
35:26She has a very high
35:28sediment rate.
35:30Which naturally means
35:32that there's an inflammatory process going on.
35:34It helps a lot.
35:36I know. Dr. Seliger,
35:38we're talking about Miranda Lee.
35:40Can you help us?
35:42It looks like the tests we did didn't help.
35:44No, not really.
35:46At that time,
35:48when I saw that she was back to normal,
35:50and in my case it was worse than normal,
35:52because there was a new kidney problem,
35:54my goal was to talk to the patient
35:56to make sure she had examined everything.
35:58Miranda, the last tests
36:00didn't give us any answers,
36:02so let's examine her again.
36:04So it's not HIV.
36:06No, it's not.
36:08And it's not hepatitis C either.
36:10The patient should think,
36:12you haven't done this to me a thousand times.
36:14The resident looked at me and thought,
36:16how long are we going to do this?
36:18And now?
36:20I don't see anything new.
36:22Okay.
36:24I'll be quick, okay?
36:26Just a second.
36:30No edema.
36:32No, take off her socks.
36:34The residents looked at me
36:36as if they wanted to kill me
36:38when I suggested they take off their socks,
36:40because the question was, why take them off?
36:42Hang in there a little longer, Miranda.
36:44I looked like an annoying supervisor
36:46who just wanted to annoy them a little longer.
36:52A petechial eruption.
36:54What?
36:56The type of injury Miranda had
36:58is called a petechial eruption,
37:00and it indicates the existence
37:02of a small bleeding under the skin.
37:04Because of the socks?
37:06No, exactly.
37:08She was asymmetric,
37:10which was an important medical indication.
37:12And we didn't notice
37:14because she was cold all the time
37:16and never took off her socks.
37:18Miranda, how long has this been going on?
37:20Suddenly I realized
37:22that abdominal pain all the time
37:24could not have an anatomical cause.
37:26It must be something totally different.
37:38How can you do this, Stephanie?
37:40How can you do this?
37:48She was right.
37:52I can't believe she did this.
37:54As soon as I found out
37:56that she was using steroids,
37:58the first reaction was,
38:00we have the answer.
38:02Everything made sense.
38:04It wouldn't be the first time
38:06that tests don't detect.
38:08Many steroids were negative,
38:10but the fact is
38:12that many steroids are undetectable
38:14because nowadays
38:16they are made synthetically
38:18to deceive the test.
38:24The whole story finally fit
38:26and now we could present
38:28a definitive diagnosis.
38:30You know, you were killing yourself.
38:32I didn't know this would happen.
38:34What did you think would happen?
38:36Mike, there are millions of dollars
38:38in advertising contracts
38:40and you never helped me.
38:42You never listened to me.
38:44You only pressured me and pressured me.
38:46And the fans only support me
38:48when I win.
38:50I didn't want to disappoint anyone.
38:52I didn't want to disappoint anyone.
38:54I didn't want to disappoint anyone.
38:56I didn't want to disappoint anyone.
38:58I didn't want to disappoint anyone.
39:00Only the fact of using steroids
39:02already creates a very heavy stigma
39:04in the career of professional athletes.
39:06Yeah, so now your career is over
39:08and you don't need to worry anymore.
39:10The problem is that this compromises
39:12everything they have achieved,
39:14because there will always be the doubt
39:16that they wouldn't be able to do what they did
39:18if they weren't using steroids.
39:20Listen, let's get help.
39:22There's a psychiatrist
39:24I'd like you to talk to.
39:26Is everything okay with you?
39:28Great.
39:30It's the first step.
39:32In the meantime, rest.
39:34Although we managed to solve
39:36part of her health problems,
39:38there would still be a long physical
39:40and emotional therapy
39:42until the patient recovers.
39:44Please.
39:46Can you tell Mike
39:48that I'm sorry? I'm so sorry.
39:50You better tell him that.
39:56I'm sorry.
39:58I felt like I was about to discover
40:00what was wrong with Miranda Lee.
40:02Seeing the eruption gave me some ideas.
40:04I had seen similar eruptions before
40:06and I knew she didn't have problems
40:08with platelets or blood,
40:10and that made me think
40:12about some kind of inflammatory process.
40:14There's a group of diseases
40:16that cause inflammation
40:18of various blood vessels,
40:20the so-called vasculites.
40:22Dr. O'Toole?
40:24Excuse me.
40:26What is it, Lila?
40:28Do you understand that if you inject
40:30the contrast again,
40:32you can intoxicate her kidneys?
40:34If I'm wrong about that...
40:36Lila, I'm aware of the risks.
40:38The exam I wanted to do
40:40was a mesentery angiography.
40:42It's a radiological exam
40:44where the radiologist injects
40:46a contrast to be able to visualize
40:48the outline of the blood vessels.
40:50Normally, the blood vessels are smooth.
40:52I was looking for something
40:54that was irregular.
40:58Dr. Miller said you need to see something.
41:00Okay, I'll be right back.
41:04What did you see, Lila?
41:06It's impressive.
41:10My God.
41:12I was completely stunned.
41:14I had never,
41:16never seen anything like it.
41:18Finally, I had a diagnosis.
41:24We did a mesentery angiography
41:26in Miranda Lee.
41:28What happened? Is it bad?
41:30Am I okay?
41:32I was looking for a problem
41:34in your blood vessels,
41:36specifically those that feed the intestines.
41:38Do you see this image here?
41:40From what I know,
41:42it can only mean one thing.
41:44There were lesions in your blood vessels.
41:46I had never seen that
41:48and I don't think I'll ever see it again.
41:50Take a good look, doctors.
41:52Many doctors only know this kind of disease
41:54from pictures in books
41:56or studying for tests.
41:58All right, let's go.
42:00As soon as Miranda's sedation is over,
42:02I want to tell you the news.
42:04I was really relieved
42:06because I had reached the correct diagnosis.
42:10Polyarteritinodosis,
42:12also known as PAN.
42:16Miranda, I think we finally have an answer.
42:18This is not a very easy disease
42:20to explain to a patient.
42:22This is a classic sign of a specific type,
42:24so I explained that she had a disorder
42:26that caused several blood vessels
42:28to become inflamed,
42:30which affected the flow of blood
42:32to different areas of the body.
42:34Is that why she couldn't eat?
42:36Exactly. It's hard to digest food
42:38without adequate circulation.
42:40Miranda, all the symptoms you had
42:42are due to this inflammation.
42:44In fact, I read that the pain was similar
42:46to that of a heart attack,
42:48so if I thought
42:50it was just an irritable gut
42:52and I had never been hospitalized,
42:54your prognosis would have been very bad,
42:56but PAN usually responds to treatment.
43:00Miranda's reaction was relieving.
43:02Let's give her steroids to reduce the inflammation.
43:04And a GCA inhibitor
43:06to lower the blood pressure.
43:08Take good care of her.
43:10I'm ready to take her home.
43:12Do you want to leave?
43:14I'll stay here until she...
43:16until she gets better.
43:18All right?
43:20I'll do whatever it takes
43:22to get my life back.
43:26Get well soon.
43:28All right, dear?
43:30In this situation,
43:32if she hadn't asked for help,
43:34she could have died.
43:36Cynic.
43:38Fool.
43:46Hi.
43:48How do you want us
43:50to respond to this?
43:52Tell the media that I fully support her.
43:54Her health is more important than anything else now.
43:56All right.
43:58The best part of this case
44:00is that we not only
44:02discovered the diagnosis,
44:04the patient also obtained
44:06a complete recovery,
44:08physical, emotional and also mental.
44:16This case was very gratifying
44:18because I felt I made the difference
44:20between life and death.
44:22Wow.
44:24Look at you.
44:26Nowadays, sometimes medicine
44:28receives criticism
44:30and you have to fight for the profession.
44:32But it's always worth it.
44:34That's why we keep going.
44:36I never thought hospital food
44:38was so good.
44:40Great.
44:42Sorry.
44:44Sorry.
44:46It's all yours.
44:48Doctor,
44:50her blood pressure is 14.7
44:52and it's dropping more and more.
44:54You're doing well, Miranda, very well.
44:58It's always exciting when a patient
45:00thanks you for saving his life.
45:02And he's serious.
45:04We need to find a place to study now.
45:06Tori and Tang are going to marry us
45:08where...
45:10I know a place.
45:42It's here, look.
45:44Cool, I loved it.
45:50We were just...
45:52Checking the digestive tract.
45:54Yeah.
45:56Of course.
45:58I was going to leave it here.
46:08I should have done surgery.
46:10I should have done surgery.
46:12Yeah.
46:14Tang, you know what?
46:16Let's study right here.
46:18Okay.
46:20So, what's the rule
46:22for a medical diagnosis?
46:24This one is hard.
46:262% of the population.
46:28It's 2 inches.
46:30You'll get there.
46:32No, no, no.
46:34I asked you to lock the door, doctor.
46:36I'm sorry, I thought I locked it.