What would he want to talk to us about?
I wish I knew.
I'm honored to have the pride and joy of L&P's doctors
assembled here.
On March sixth, a week from now,
I'd like you to operate on a five-year-old boy with ASD.
Wakisaka Sho
Wakisaka Sho-kun.
Atrial Septal Defect Defect Size: 20mm
ASD, atrial septal defect.
ASD would normally call for cardiac cath, not surgery.
That's right.
But this patient's defect
is more than 20 millimeters across.
It's also with a deficient posterior rim.
No posterior rim?
And large to boot.
With your skills,
the procedure will not be difficult.
I just ask that you exercise the utmost caution.
This patient must be very important.
I knew you'd understand, Kato-chan.
You're as perceptive as ever.
He's the son of L&P Leasing's Vice President Wakisaka.
L&P Leasing is the parent company of L&P Hospital.
Still, I can't believe you pushed back scheduled operations without a single word.
Vice President Wakisaka
is said to be the next L&P president.
There can be no failure.
Make sure your preparations are flawless.
Well, you are making steady progress.
There are no issues.
If you have any concerns, call us anytime.
Thank you.
How's everyone else doing?
Fine, thank you.
Please don't push yourself.
I am trying not to get too excited, just the way you told me to.
My BP was 108 over 62 this morning.
I'm taking my antihypertensives, too.
I see.
I'm sure it's difficult to find a neurosurgeon
capable of doing a simultaneous operation with a cardiac surgeon.
There's America.
America, huh.
But a good neurosurgeon from America
will take money and time to secure.
I heard Dr. Baldwin will be a two-year wait.
That's why we're looking for another neurosurgeon.
Oh, but there is no one better.
We can't afford to wait two years
given Dr. Sakurai's condition.
Dr. Baldwin will come in one month.
We will have Dr. Sakurai's operation at L&P Hospital.
But—
It's for Dr. Sakurai.
I asked a favor of Dr. Baldwin, and he acquiesced.
He's an old acquaintance of mine
from when I was restructuring hospitals across America.
If Dr. Baldwin and Team Dragon work together in a simultaneous operation,
there's no doubt Dr. Sakurai will be saved.
Even though Dr. Baldwin does not have a Japanese medical license,
he can operate at L&P Hospital, a super medical zone.
We will foot the costs, as well.
You need not worry about them.
So.
This means you have everything your team wanted.
I'd like...
you to hear what I want, as well.
What you want?
Yes.
Dr. Asada.
Please come work for L&P.
With Dr. Arase's reform
and Dr. Ijyuin's teaching,
L&P is better than ever.
All we need now
are your miraculous skills as a surgeon.
Your only choice is to come to L&P
if you...
want to save Dr. Sakurai.
Ministry of Health, Labour, and Welfare
Special Permission for Operation
Date of Operation: 3/27/2014 Location: L&P Hospital Operating Surgeon: Mike Baldin, M.D. Neurosurgeon
Patient: Sakurai Shuzo
I heard there will be an operation
for Vice President Wakisaka's son.
Yes. And?
I hadn't been informed.
Huh?
I didn't tell you?
Maybe you forgot because you're so busy, Okamura-chan.
I hear you're trying to lure an American neurosurgeon
with an exorbitant sum of money
for Dr. Sakurai's operation.
It's for securing Dr. Asada.
I hadn't been informed.
Emi!
Are you all right?
Emi!
Stay with me! Emi!
Are you all right?
Patient's female, age 39.
Stay with me!
She was brought in by an ambulance due to fever and difficulty breathing.
Emi!
23 weeks pregnant
Okay, Kiriyama-san.
I want you to hold your breath.
Dr. Kihara,
what were Kiriyama Emi-san's test results?
We suspect peripartum cardiomyopathy.
"Peripartum cardiomyopathy."
It's a difficult condition.
Peripartum Cardiomyopathy
She'll likely need long-term hospitalization,
so once she stabilizes,
we'll have her transfered—
We'll admit her to our hospital.
Oh, but cases of heart disease in expectant mothers
have a high likelihood to result in legal action,
so based on L&P's management principles—
This patient...
will be admitted here.
Your only choice is to come to L&P
if you...
...want to save Dr. Sakurai.
I'll put this here.
Thanks.
Come in.
I am Dr. Ijyuin, your attending from Cardiothoracic Surgery.
"Cardiothoracic Surgery"?
Kiriyama-san,
we suspect that you have peripartum cardiomyopathy,
which is when pregnancy triggers poor heart function.
If your condition progresses,
we may need to perform surgery to augment your heart.
"Surgery"?
What about our babies?
She finally conceived
after many rounds of infertility treatment.
The babies will be fine, right?
I'll be able to give birth to them?
Yes.
Kiriyama-san is currently 23 weeks pregnant with twins.
We will manage your condition with non-surgical treatment until 24 weeks,
when safe delivery is possible.
If the situation allows,
we will deliver the babies by C-section,
then consider your operation as appropriate.
Doctor.
No matter what happens,
please save my babies.
Hey, what are you saying?
It's going to be okay.
Let's work together to make sure you can leave
the hospital with your children.
Thank you.
We've been waiting for you, Vice President Wakisaka.
This is Dr. Kato, who will be the operating surgeon.
She is an expert in pediatric cardiac surgery
and is one of the top five surgeons in the nation.
I'm counting on you, Dr. Kato.
Tests have revealed
that your son's ASD is the type where the lower septal rim is missing.
We cannot close the defect with cardiac cath,
but given that your son weighs 20 kilos,
he is a good candidate for surgical repair.
I see.
You have nothing to worry about.
Thank you.
Sho-kun,
don't worry.
It'll be all over when you wake up.
Okay.
Patient's male, age 35.
While working high above ground after lunch,
he fell approximately three meters.
He's suffered trauma to the entire body, including his head.
His level of consciousness has decreased.
Let's hurry.
Gurney coming in.
Lowering bars.
Got it.
Transferring.
Got it.
One, two, lift.
Nogi-san, can you understand me?
You're in a hospital.
We're going to cut your clothes.
Glasgow Coma Scale E1, V1, M4.
Intubating.
Remove his cervical collar.
Got it.
Hayakawa, the patient has a full stomach.
Got it.
Let's go with the Sellick maneuver.
I'll apply pressure.
You okay?
I'm good.
His femoral artery's damaged.
Bring a blood vessel suture kit.
Got it.
Curved Kelly.
Here.
Vessel loop.
Here.
5-0 proline.
Give me the clamp to secure the stomach tube.
Here.
Hayakawa.
Yes?
When there's bleeding from the nose,
you should do oral insertion for the stomach tube.
Got it.
What if CT scans confirm that there's no skull base fracture?
Then you can intubate through the nose.
Got it.
Oh, Ijyuin.
You going home now?
I'm going to Sakurai Hospital.
Oh, right.
There's gonna be a VIP...
Oops, that was close.
An operation on a VIP, right?
He's a five-year-old boy.
It's to repair his ASD.
Dr. Kato will be operating,
so there's no need to worry.
Then I guess I don't need to be there.
Right.
Let us handle it.
There's also a patient with peripartum cardiomyopathy, right?
If anything happens, I'll—
Okamura-san requested that I be her attending.
Oh.
I finally got a "win."
Here.
Win
Ijyuin!
Damn.
What's with him?
Is he in tsundere mode?
I wonder if they'll be born healthy.
It'll be fine.
The doctor said so, too.
It'll be fine.
Right.
Why?
Treating expectant mothers who are close to term
carries high risk of being sued if anything happens.
From what I know of you, typically you wouldn't admit this patient.
This patient won't be saved
if she is transferred to a different hospital.
We will save her here.
Why is Okamaura-san...
partnered with Noguchi,
even though he says they're different?
They probably believe the other is useful as a business partner.
Are you sure it's for purely business reasons?
Unlike Team Dragon,
they are not a united front.
They have completely different endgames in mind.
What does he...
have in mind?
That'd involve getting to know who he is as a person.
What?
Unlike Noguchi,
Okamura can keep his emotions in check.
But when he finally lets them surface,
you will see who he truly is.
Dr. Sakurai.
Doctor?
Oh, I just found something.
I'll take care of it.
Sure.
You've been a godsend, Asada.
Even if I fall,
this hospital will be fine
as long as you and your people are here.
The patients will have somewhere to go.
Here.
Okay.
Wakisaka Sho-kun, age 5.
He has secundum ASD with deficient posterior septal rim.
We will reconstruct the posterior rim
and close the ASD.
We're going with surgical treatment
because of the deficient posterior rim.
His family wishes for complete recovery in time
for his entrance into elementary school.
Should we go with a partial sternotomy
to minimize the scar?
Sounds good.
Please prepare 5-0 thread.
Got it.
We'll aim for keeping anesthesia time to under 90 minutes.
Got it.
We'll keep aortic cross-clamp time to 10 minutes.
We should all run through the procedure and prepare.
Got it.
Thank you.
Oh.
Here you go.
Thank you.
How are you feeling?
Oh, I'm feeling much better right now.
It must mean the medicine is working.
If all goes well,
you and your babies will all be fine.
I see.
That's a relief.
We had trouble conceiving,
and the fertility treatments weren't working very well.
My husband said we could give up if I wanted to,
but then I conceived.
He looked so happy when he found out I had twins.
Oh, I want to knit a ribbon in pale blue on this one,
but I forgot to bring the yarn.
Even you'll be going to L&P, Ryutaro-chan?
I haven't made up my mind yet.
I see.
But if you go,
Dr. Sakurai can have the operation.
Yes.
Shouldn't you prioritize Dr. Sakurai before this hospital?
Do everything you can for the patient you have.
It's to save him.
Sho, hang in there.
Don't worry, okay?
Sho, hang in there.
It's going to be okay.
Please do everything you can.
He'll have the best facilities
and doctors L&P has to offer.
You have nothing to fear.
Stand.
Got it.
L&P is performing surgery
on some VIP patient.
Dr. Kato, Dr. Ijyuin, and Dr. Arase are all on it.
A VIP?
Do you want to go observe?
You can if you want.
We don't have to make any house calls today.
Asada and I can hold the fort.
Of course I'd love to see a top-notch operation.
But Ikeno-san in 402
gets cranky when I'm not around.
I'll go on my rounds.
We have an emergency—a patient with blunt chest trauma.
Please come.
5...
6...
7...
Okay, he's under.
Get Kato and Ijyuin.
Yes, sir.
We will now begin ASD repair.
Scalpel.
Here.
Forceps.
Here.
Gauze.
Here.
Bovie.
Here.
Yes?
What?
Please.
Emi.
Dr. Kihara.
There's been a sudden onset of aortic regurgitation.
AR?
The hormone fluctuations and stroke volume
caused by her pregnancy
accelerated the dilation of her aortic annulus
and resulted in aortic regurgitation...
Doctor.
Doctor, is Emi going to be okay?
My babies...
Will they be okay?
Under these circumstances...
Please.
Emi.
Take her to the OR.
Now!
Dr. Ijyuin, Kiriyama-san has severe AR due to AAE.
She needs immediate surgery.
What are you talking about?
He's in the middle of an operation.
This patient is a VIP!
Dr. Ijyuin.
I won't allow Ijyuin to step away from this operation.
I can't step away right now when the aortic cross-clamp's on.
Please ask someone else.
But—
Kiriyama-san, stay with me.
She's going into shock.
She's not going to make it if we don't do something.
Hook her up to the monitors once we reach the OR.
Hurry!
Got it.
Let's transfer her.
One, two, lift!
Okamura-san, let's save the mother.
I will do a Bentall procedure.
That won't work.
Please connect the pump to the power source.
Hey!
Doctor.
How much oxygen?
Five liters!
Got it.
Please get me through to Dr. Asada.
I'm sorry, Dr. Asada is seeing to his patients right now.
Up the O-2 to 10 liters.
Got it.
God, what are we going to do?
Dr. Asada.
Please come help.
There's a patient only you can save.
I can't let that patient die.
Please.
Her oxygen saturation's steadily decreasing.
She has pulmonary edema.
The mother and her fetuses will all die if we don't do something.
I have to do a Bentall procedure.
Get Dr. Harada and the scrub nurse, Kashima!
Yes, sir.
We will now perform a Bentall procedure
with hypothermic cardiopulmonary bypass.
Scalpel.
Here.
Asada.
Asada?!
We'll do a David procedure.
"A David procedure"?
Not a Bentall procedure?!
We're going with hypothermic cardiopulmonary bypass, and—
You might be able to save the mother,
but not her fetuses.
But—
In addition,
if you do a Bentall, she will need to take anticoagulants.
Even if this operation succeeds,
she may suffer massive bleeding during delivery.
"Delivery"?!
Look at her condition!
We can't attempt a David procedure!
We should give up on the fetuses—
We won't!
What?
If we do the David procedure with normothermic cardiopulmonary bypass,
we can save them all.
"Normothermic"?
That's insane!
The brain won't tolerate hypoxia for long if we do that—
If you take that kind of risk and we get sued,
who's going to take responsibility?
Not even you can manage this by yourself.
The David procedure, huh?
I guess I can pull out all the stops for once.
Let's save the mother and her twins.
How?
Hey, wait a minute.
You have an important operation to attend to.
Metz.
Here.
Do you find me inadequate to serve as the first assistant?
Ms. Kito.
Arase has been managing the patient's vitals flawlessly up till now.
She's taken over without any problems.
She is a talented anesthesiologist who's been trained by Arase.
Who gave permission?
I harvested the pericardial patch.
We're doing a patch closure, right?
We'll use a running stitch.
5-0 thread.
Here.
Dr. Arase, you did this?
I believe I'm in charge of staff placement in operations.
Wait!
An open-chest surgery on a pregnant patient with cardiopulmonary bypass?
I'm not comfortable—
That's why I'm here.
Set up the fetal heart monitor.
Stand.
Yes, sir.
Sorry I'm late.
Thank you for waiting.
Thank you for coming.
We'll now...
begin the David procedure.
Scalpel.
Here.
Forceps.
Here.
Gauze.
Bovie.
Here.
In the Bentall procedure,
the aortic root itself is replaced with a synthetic graft and valve.
It'll require the patient to take the anticoagulant, warfarin,
for the rest of her life,
which increases the risk for bleeding during delivery
and causes the death of the mother and her fetuses in the worst case.
On the other hand, in the David procedure,
the patient's valve is retained,
so no warfarin will be necessary.
However, it requires the surgeon to have an accurate image of the valve
and the precision to prevent regurgitation.
In order to complete the procedure within the time constraints,
the surgeon must have extremely high expertise.
But...
Dr. Asada should be capable.
Please save her.
In her current condition,
she can tolerate cardiopulmonary bypass for only 60 minutes at most.
"Sixty minutes."
How are we supposed to do precision work
in such a short time?
Let's do this.
Pump on.
Pump's on.
We have full flow.
Start countdown.
Got it.
Patient's on pump.
All right.
Fetal heart rates are 120 and 133.
Fetal Heart Rate
Cross clamp.
Here.
Flow down.
Provide backup.
Give retrograde cardioplegia.
Giving plege.
The mother's in cardiac arrest.
Fetal heart rate stable at 120 and 130.
Resecting the aorta.
Metz.
Here.
Harken clamp.
Here.
Yankauer suction tip.
Here.
Five minutes since cardiopulmonary bypass.
Aorta's resected.
The opening for the RCA is lower than normal.
Trimming it will be difficult.
The left cusp is also low.
We'll need to repair the cusp, as well.
I'll do the cusp repair.
Ijyuin, you will trim the coronary artery buttons.
Got it.
We'll trim the sinus of Valsalva.
Metz.
Here.
The fetal heart rates are increasing.
Clinical engineer,
what's the blood inflow temperature?
35.1 degrees.
What's the blood volume?
3.2 liters.
Warm the patient's abdomen,
and increase blood inflow temperature by two degrees.
Also, increase blood volume to 3.5 liters.
Got it.
Starting magnesium drip.
Dr. Arase, can we continue?
You guys just focus on the surgery.
I'll let you handle the fetuses' vitals.
No problem.
Ritodrine, IV push.
Got it.
Kihara, mark the synthetic graft.
Got it.
Bring a 26-millimeter straight graft.
Got it.
Trimming's done.
Proceeding to repair left cusp.
5-0 thread.
Here.
Metz.
Closing up right atrium.
5-0 thread.
Forceps.
Lavage.
Metz.
Operation's complete.
The opening's small.
Well done.
Good job, everyone.
Forty-five minutes in cardiopulmonary bypass.
Metz.
Here.
Proximal anastomosis of synthetic graft complete.
How're the coronary buttons coming?
I've finished trimming them.
Proceeding to reattach coronary arteries.
5-0 thread.
Here.
Increase suction.
Got it.
Maintain flow rate, start filtration.
Got it.
Fifty minutes.
Metz.
Coronary arteries reattached.
Proceeding to distal anastomosis of synthetic graft.
4-0 thread.
Here.
Forceps.
Fetal heart rates are dropping.
Let's hurry!
Got it.
Should we give her neosynesine?
Vasopressors may trigger contractions.
Increase blood volume to 3.9 liters!
We don't have enough blood in the reservoir for that.
Use the cell saver blood.
Got it.
Rewarm.
Got it.
4-0 thread.
Here.
Mikulicz gauze.
Here.
Give more retrograde cardioplegia.
Got it.
Increase suction.
Got it.
Fibrin glue.
Here.
Amazing.
Doing a David procedure at this speed
without even inducing circulatory arrest...
Asada's incredible.
Anastomosis complete.
Flow down.
Flow's down.
Declamped.
Provide backup.
Providing backup.
Spontaneous heartbeat restored.
What about the fetuses?
I can hear only one heartbeat.
What?
There's only one being detected by the monitor.
Maybe something happened when the fetal heart rates decreased.
Saving them all was too much to hope for!
Quiet!
Arase, tilt down.
Rotate 30 degrees to the left.
Got it.
What?
I can hear both heartbeats.
Thank god.
Yeah.
Pump off.
Pump's off.
Patient's off cardiopulmonary bypass.
Bypass time was 59 minutes.
We'll decannulate.
Tube clamp.
Here.
Sternal wire.
Here.
Wire clamp.
Here.
CVP's looking good.
Wire cutters.
Here.
Sternal wire.
They're both moving around.
Yeah.
We successfully performed a David procedure to save
you and your babies.
An extremely difficult procedure,
not normally undertaken under such circumstances...
Thank you,
Doctor.
I wish you the best of luck in the delivery.
Thank you.
We are so, so grateful.
Dr. Asada.
About what happened today...
I am sorry for the trouble.
It's not like you?
You did good work.
The other operation was also a success.
I see.
But...
why did he...?
While I was in America,
I lost someone I knew
to peripartum cardiomyopathy.
She was 23-weeks pregnant.
She suddenly went into heart failure.
She was promptly diagnosed with peripartum cardiomyopathy,
and she and her unborn children...
died.
She and Okamura were engaged.
The hospital she was taken to
had a doctor capable of treating peripartum cardiomyopathy.
They had beds and an operating room available,
but her health insurance
did not cover treatment at that hospital.
In the end,
she died in her own bed.
I...
lost all three of them at once—
people precious to me.
That's how...
it is in American healthcare.
There are patients who can't be saved
no matter how many competent doctors there are.
It sent Okamura into despair.
That's why he became a management consultant specializing in healthcare.
So that's...
who he really is.
Patients still fall through the cracks in Japanese healthcare.
I wish to create a new healthcare system
that is neither American nor Japanese.
I now owe you...
a huge favor, Dr. Asada.
There's no debt or favor involved
when a doctor saves a patient's life.
You looked like...
a doctor today.
You're not going to bring Asada over?
I have decided to wait until
Dr. Sakurai's operation is complete,
and he can resume his work as a doctor.
You've gone soft.
So soft
that it makes me sick just listening to you talk.
Excuse me.
Entlassen.
Sakurai General Hospital
Well, that sounds well enough.
If anything feels different, call us right away.
Hm?
Yes, I know.
What?
Fine, fine.
Did a patient just worry about you?
No, it wasn't about my health.
What? Then what was it about?
Thank you for...
all your good work.
Huh?
She scolded me that I need to voice my gratitude
if I want people to know.
Really?
Yeah.
Dr. Baldwin's coming.
Then we can operate on Dr. Sakurai?
But he doesn't have a Japanese medical license.
L&P is a super medical zone.
Mike Baldwin can operate here.
How'd you make it possible?
Okamura helped us.
We'll be simultaneously performing extremely challenging
procedures on the heart and the brain.
We must be fully prepared.
Got it.
Right.
You seem quite buddy-buddy with Okamura-chan lately.
Yes?
What?
You won't be able to save Sakurai.
Next Episode Preview
Asada to go to L&P...
It seems Dr. Asada has decided to come to L&P.
Noguchi vs. Okamura
Entlassen.
You'll now be able to do Dr. Sakurai's operation.
Save him.
A Reunion 46 years in the Making
It's been forty-six years.
Get better already!
I'm having to work too hard!
I will create the ideal hospital!
Emergency Press Conference at L&P Hospital New Organization Announced
Ryutaro-chan and his team are going to India?!
I don't care as long as I get Team Dragon.
I received word from Dr. Baldwin.
Asada.
It'll be the first operation of its kind in the world.
Simultaneous Operation on the Brain and Heart
This is a work of fiction.
We can make it happen.