01x04 - Episode 4

[bunniefuu]

Clive and Nicola, they're, er... defensive.

I'd like to discuss the major transfusion protocol.

You run the trauma call, I run the entire department.

You mentioned Lorraine's illness.

I was just wondering where you got that from. Hmm?

Seven, eight, nine...

Arsehole!

Blade.

Glen... Just do as you're told.

You called, told me you needed me, and I came running.

(Loud g*nf*re)

(Men yelling)

(Recording of g*nf*re and yelling)

(He sighs)

(Beeper alert)

Recording: Attend emergency department. Trauma call.

Attend emergency department.

Will you get him out?!

Starting the clock.

You've got your hands full here.

Bunch of pricks! That's the spirit, my friend. You're idiots!

Patient hypotensive at the scene with a suspected fractured pelvis.

I've activated a code red.

No ID, so he's in the system as Mike Oscar. What mechanism?

He was found bound and gagged with a ligature around his neck.

Let's get ready to transfer, please.

Slide, one, two, three.

Giles will liaise with the police.

Have Gen, Surg and Cardiothoracics been fast bleeped?

Yes, that's all done.

One minute hatred, the next minute dogs on heat.

And where's orthopaedics?

Afternoon off, it's her baby's birthday.

Can we fast bleep the other orthopod, please?

Rebecca: I don't care.

No nuts on the table, no nuts in the party bags.

Just no nuts, Magda.

Oh, that bloody clown.

Great.

Sorry.

I'm still here, but then three more hours and I'm gone.

Part-timers.

Suspected fractured pelvis.

Move the scoop on your count.

Unclip top and bottom, go on three.

One, two, three.

Brace. One, two, three, go on three.

One, two, three.

Thank you.

I'd prescribe a nice chest drain.

What's that smell? Really?

I'm not keen on his perfume. I think it's from an animal.

Jacket's covered in crap, too. That's cows.

Everyone got goggles? You might want to double glove.

You requested a general surgeon?

Appreciate you coming.

Situation understood.

Let's do the handover.

Nerys, will you scribe, please?

Yeah, of course.

Harry, Venflon, please. Yep.

Quietly: You and her back on, then?

Male, estimate early 20s. Call was made at 12.28.

Ambulance arrived on scene at 12.40.

Patient was found by a worker on a landfill site hands tied, ligature marks around neck and gagged.

Unknown mechanism.

Best guess, violent as*ault, blunt instrument. Whack.

Semi-conscious at scene.

Multiple soft tissue injuries, lacerations, grazes, haematomas.

Airway blocked with a piece of fabric, which we cleared.

Old bit of rag stuffed down there.

I pulled it out.

Oh, good thinking, Bob(!)

Trachea deviated to the right.

Diminished breath sounds on both sides.

Left side tension pneumothorax.

Abdomen is soft, suspected pelvic fracture.

Pulse 110. BP 89 over 59. GCS 8.

Needle decompression and oxygen for tension pneumothorax, and pelvic binder.

500ml bag of normal saline running in.

Thank you.

Go on, bugger off, please.

Fiona: I'll do the primary.

Cardiothoracics attending, if needed.

Your presence is appreciated.

I hope this is a good use of my time.

Airway?

Ligature marks round the neck.

(Patient gasps for breath)

Breathing is noisy.

There's no surgical emphysema. Sats are low.

Pulses are bounding but his pressure's well down.

Let's get him a Bair Hugger, please.

Poor expansion on right, percussion dull...

Poor expansion on left, percussion dull.

Airway's compromised. There's something in the oropharynx.

No, we cleared what was in there.

I think he may have...

(Patient coughs wetly)

..swallowed some.

Better out than in.

Can't see anything with this blood pouring down his throat.

Get a tampon for the epistaxis, please.

He coughed something up.

Excuse me, ladies.

Looks like a piece of cloth.

The police will need to see it. Bag that up. Stick it with his clothes.

I'll take it through when there's a minute.

It appears I'm not needed. Bleep me if that changes.

Hey! We haven't even done the CT yet.

I'm surprised she lasted this long.

We good to go now?

Yeah, you go. Get cleaned up, Bob. I can smell you from here.

Can we complete the primary, please?

There's a number on the skin under his arm.

"365-995."

Like cattle branding.

Let's make sure we mention that to the police. Yeah, course.

Abdomen is soft.

Pelvis feels unstable on stress assessment.

Possibly SIJ instability.

No other major limb trauma.

Six units blood, O positive. Four units of FFP, plus two units of platelets, please.

Justin. On it.

Sats are still low.

Sats are below 90%. Let's get bilateral chest drains in, please.

Me. I'll do the other.

Slow and steady wins the race.

Rebecca, can I have a hand, please?

I'm not happy with his airway. I need to RSI. OK.

Bio-Sats, 250-100. Yep.

Can you sort that side for me, please, love?

Thiopentone, 250 milligrams, suxamethonium, 100 milligrams.

Tie us, please.

One second.

250 thio.

Justin?

Ties, please.

Sux, 100.

Thanks.

How long before we can intubate?

About a minute.

Everyone, stand by.

I'd like imaging of his pelvis. It sounds like a fracture.

We will get straight to CT as soon as.

(So...

(you and her - how'd you pull that off?)

(Shut up.)

Get the GlideScope ready in case we need it. Yep, on it.

I'll try the laryngoscope first.

OK. That's time.

OK.

Sats are still falling.

That's not working. We'll try the GlideScope, please.

There's loads of oedema.

Can't get a view.

Can't see much of the epiglottis.

Let's try a blind bougie.

Thank you.

Excuse me.

(It's not going in the trachea.)

No, it's not going in the trachea.

Course of action?

Bagging.

Tell me how the chest drains are.

Swinging and bubbling.

(Alarm beeps)

Sats are below 60%.

Let's try two person. Yep.

Anything?

No, it's not going in.

OK. Let's try a Guedel airway, please.

Come on!

Can I have a gown, please?

OK, go, go.

Sats below 50%. Come on.

It's also not happening. OK.

I don't think you're moving any air. Can't intubate. Can't ventilate.

He needs a crike. Yep. I need a crike kit now, please.

Yes!

Harry? Ties, please.

Thank you.

There's lots of swelling and bruising.

It's OK. I've got it.

Let's have the blade.

The forceps.

There we go.

Let's have the bougie.

Thank you.

Trach.

OK, bougie out.

I've got it.

OK, hold till we secure.

Safe hands. Cuff up. Thanks.

Cuff.

Yep.

Breath.

(Low hiss of air)

Breath.

(Low hiss of air)

Patient's ventilated.

Sats are rising. Good.

I'll do a subclavian line.

Thank you.

Suture, please.

Could you?

Yep.

He's warmed up.

That was fast.

Let's get the Bair Hugger off and give him a 250ml bolus of saline, please. Yep.

And when the subclavian line is ready, let's do the usual bloods.

So that's FBC, U&E, EtOH, crossmatch, teg, LFTs and VBGs.

Lots of blood on that blanket.

Let's clean up these lacerations and compress.

Pulse 113, BP 88 over 58. Falling.

OK. We need to get blood in.

We will transfuse through the subclavian line when it's clear.

So, that's platelets, FFP and let's get in one gram of TXA.

And, please... let's move on this.

VBGs and samples ready to go.

Nerys. I'll sort it.

Harry, will you put the blood in for me, please?

Er, yep. These are flushed.

TXA going in through the Venflon.

Tachycardic. BP 80 over 50.

It's too low.

And he's clammy.

Tell me his temperature, please?

39.7. He's cooking.

Yeah. Bollocks.

Looks like he's septic.

What's your instinct? Is he septic or is it internal haemorrhaging?

Probably both, but that'll be me being pessimistic.

Not like you, then(!)

So, er... how'd you get her back then?

Trade secrets, Billy.

Right.

Thank you.

Sliding up on three.

One, two, three.

Thanks very much.

Please be careful with the drips.

Non-essential people may leave us.

That's me, you... (Knocks on glass) ..and you.

That's harsh.

Control scan.

(Mobile rings)

Oh, for God's sake...

What is it?

Yes to Hula Hoops, no to Wotsits.

Control scan complete.

Scanning head.

I don't care how much make-up he's got, he can get changed in the downstairs toilet.

He's a clown.

Brian: Head scan complete.

(Sorry.)

There's no obvious intracranial haemorrhage.

Nobody touch any buttons.

Both: Sorry.

Does Clive know you brought the other consultants down for the trauma call?

He's fine with it.

Clive's all right. Is he?

Ask Lorraine.

I don't know her.

I do know him.

Be careful.

You don't know what he's like.

Oh, come on.

You said you wanted this to be just about work.

So can we focus on the patient in front of us?

Please?

OK.

Excuse me.

I've got the VBG results.

..piss up in a brewery!

How'd he get in here?

Stopping scan! He must've followed me in!

Get him out of there!

I'm not lying in a bed where people try to look up my arse!

Security to CT scanner. Why have you got that bucket?

Mr Devlin, you've got to stay off this fracture!

..haematology results will be ready, but I'm looking at it now, there's nothing.

Oh, yeah, I see it, thanks.

Conscious patients are a pain in the arse.

Unpleasant, unprofessional!

Just a moment, please.

VBG results and some from haematology. Thank you.

INR 4 and he's also thrombocytopenic.

And there's a leukocytosis.

Let's try again, shall we?

So, apparently this is where all the action is.

Starting contrast run.

The abdomen is clear.

That's me off the hook.

Bleep me if anything changes.

Thank you. We'll be in touch.

Just a minute.

There it is.

That's an open book pelvic fracture confirmed.

It's a pelvic haematoma, but there's no active extravasations.

Thank you.

So, how are we doing?

Well, we have a fractured pelvis so we're going to theatre.

I'll go prep. Nerys Merrick, trauma nurse practitioner.

Could you fast bleep trauma theatre?

No abdominal complications?

No. I'm a precautionary measure. But happy to attend.

Glen will do a first-class job.

Mmm.

I'd better push off.

Can we get ready for theatre, please?

Can I get 30 seconds?

Absolutely.

Mrs Murkherjee from Cardiothoracics has been complaining to her line manager about the new policy.

Now he's phoned me and I've told him there is no new policy.

I just asked for Gen, Surg and Cardiothoracics to routinely attend all major trauma calls.

Yeah, so I see.

You didn't run it past me?

We could wait months for a rubber stamp, or we implement it and we start saving lives now.

I know where you're coming from.

But this is the stuff of nightmarish hospital politics and it's best left to me. Just seems obvious.

Doesn't it?

Look, I'll handle it this time, but, er... next time, talk to me.

You know where I am.

Mr Boyle, before you go, I have an admin query for our files, about your CV.

We're having difficulty verifying your dates of deployment in Camp Bastion.

Oh, I really don't have time for this.

Did you come straight to us from active service?

Glen, we need you in here.

Whatever it says on the form.

Sorry, dying man waiting for me.

He's sweating buckets.

Check his temperature again, please.

Yep.

Up to 40.

He looks flushed. Face and neck.

Pulse 114, BP 86 over 56.

That's still low.

I've ordered more Pack B bloods, but I'm not sure if he's responding to blood or fluids.

High temp, low BP.

We need to get him open and deal with the haematoma ASAP.

It may not be the cause of his problems. OK.

I think we need further investigations. I agree.

Police update.

What have you got for us?

I passed on the information about the unusual branding marks on the patient's arm.

And what did they say?

Well, it can be characteristic of trafficking from East Africa.

A mark of ownership. OK...

People get brought over for sl*ve labour, often in agriculture.

So someone's exploited this guy and then they tried to k*ll him?

We don't know how long he's been in the country.

The police are anxious for any news.

Tell them they're in the loop.

And if anything comes up about his ID... You'll be the first to know.

Thank you. We shouldn't rule out an imported existing condition.

I think we need to get him back into resus. The fracture is the priority.

This patient needs to go to theatre now.

We'll put an ex-fix over his pelvis and see how he responds.

If he's unstable, then we'll need to pack the pelvis. OK then, let's go.

Oh, no, you pissing don't, you minges!

Mr Devlin, I thought we'd sorted this. Can you step aside, please?

That's what you want.

Come on! That is enough, you've got to watch that fracture!

Mr Devlin, this isn't helping anyone. Up yours!

(Sickening crunch)

Your problem, Harry. Let's move around him.

Just stay still, Mr Devlin. It's all right.

Cheers, Nerys.

What's all that?

Gin-breath man.

Twat. Right, let's take him through.

It's changing.

Lesions are becoming confluent.

And the rash on his arm is looking purpuric.

Pulse 114, BP 86 over 56.

Can we lift him up to look at his back?

No more than 20 degrees. OK.

We're rolling on three.

One, two, three.

Thank you. Back on three. One, two, three.

It's spreading very fast.

Right, they're ready to get him on the table.

No, can we just wait a moment?

Everybody take a step back.

Let's check his eyes.

He's bleeding in the sclera.

So if he's recently arrived...

I've got a house full of kids this afternoon.

We need to call a microbiologist.

We need them here right away.

You think it's a haemorrhagic virus?

What's the procedure?

This is Mrs Hicklin.

We need full barrier precautions.

With immediate effect, we're in lockdown.

The on-call microbiologist - put me through, please.

I need to know where we stand on the possible haemorrhagic virus - what our risk of infection is.

And the expert will tell us.

But right now, you need to operate on his pelvis. OK?

Trauma theatre. This is urgent!

Dr Howe? Where is he?

Yes, I do, immediately, please!

The microbiologist serves three different centres.

He's at a different hospital.

That could be 60 minutes plus.

Well, we're not waiting.

Dr Howe is Wes Howe, isn't he?

That's what the technician called him.

Justin's friendly with Wes.

OK.

I'll find Justin.

Tannoy: 'You have entered an infection control area.

'Strictly authorised personnel only.'

Have you seen Justin?

No.

So in the light of a possible haemorrhagic virus, surgery is a clear health and safety issue.

I'm not willing to participate.

But you've got two hours left on your shift!

I'll catch up with some admin off site.

Rebecca, where are you going?

Look, Giles will inform my department superior.

He'll get you a substitute.

We're just about to start the operation.

I can't take the risk. Not with kids.

Look, I understand where you're coming from, I...

No offence, but you don't. I'm sorry.

Mrs Osgood...

I'll call upstairs.

Have you seen Justin?

Justin? Do you know Wes Howe?

What?

Look, we're just into the same music. Wes is...

It doesn't matter. We need a favour.

We urgently need a clinical picture for the trauma patient.

Can you call Wes? Please?

Yeah, OK. Thank you.

We're an orthopod short.

Tell me you're joking. The part-timer just became a no-timer.

Oh, great(!)

So, how long for a replacement?

Calls have been made.

Do we postpone?

No time. No choice.

He needs this ex-fix immediately.

This is life-saving.

He needs us to start now.

Where's Rebecca?

We will be proceeding without her.

Yummy Mummies who you can't sack.

I need a pelvic external fixator seven and a major O tray, please.

Let's do the WHO.

I'm Glen Boyle. I'm the trauma consultant.

Fiona Lomas, trauma fellow.

Ramakrishna Chandramohan, anaesthetics registrar.

Billy Finlay, anaesthetic ODP.

Debbie Wong, theatre scrub nurse.

Heather Dooley, staff nurse.

Jason Marshall, staff nurse.

Shelley Imms, radiographer.

Bruce Corby, rapid infuser operator.

Patient's name is Mike Oscar. Date of birth 1/1/1900.

The patient has an unknown infection that may or may not be a haemorrhagic virus.

We have all been exposed.

But if there's anyone else here who feels they can't take part in this operation and they need to leave, you should do so now.

Thank you.

Drapes, please.

This operation is to perform an external fixation of the pelvis for which I have signed a consent form four.

The patient has been given one gram of tranexamic acid in resus.

The critical step in the operation will be the placing of the ex-fix.

There should be minimal blood loss, but if the patient is still unstable, he'll need packing.

He's got no urine output, so I am going to put in a vascath which I can use as a volume line afterward.

He's been transfused blood and blood products.

And we are expecting crossmatch from Blood Bank.

I've got Dr Howe on Skype.

Thank you. Put on a hat and come through.

Can we try and patch him up to one of the monitors, please?

Yep.

My name is Fiona Lomas.

Do you know where we're at, Dr Howe?

Wes. Mrs Hicklin has given me the basics.

Apologies for the virtual presence, I'm off site.

It would be really great to get your take.

Let me have a look at the rash.

It's evolving quickly.

Closer, please.

OK, yep.

Patient is shocked, has leukocytosis and thrombocytopenia.

OK. Can I see the teg?

Yeah, it should be up now.

Yeah.

OK, Fiona? Yes?

Have you taken barrier precautions?

Yes.

Good.

Worst case scenario, it's a haemorrhagic virus.

Could be a staph sepsis or pneumococcus.

I can short cut with a sample.

OK, what do you need?

I need you to scrape a skin lesion with the point of a sterile needle until blood starts to appear, then blot the blood onto a microscopic slide and allow it to dry.

Sterile needle and slide, please.

We've got slides. Thank you.

Get it straight up to the lab and I'll process it as soon as I get there. What else should we be doing?

Usual supportive measures.

Give him ceftriaxone and two grams IV stat.

And I can't be sure what it is yet, so give him a slug of vancomycin as well.

Let's get two grams ceftriaxone IV stat and one gram vancomycin IV, please.

What about fluids?

Fluids as usual.

Keep them coming.

Same with the blood products.

But we will need to start inotropes if fluids don't pick things up.

Let that dry.

Which personnel should we list for prophylactic antibiotics?

Sorry, I didn't catch that.

Who else needs prophylactic antibiotics?

Anyone exposed to body fluids or aerosols directly who wasn't wearing personal protection equipment.

Give them ciprofloxacin, 500 milligrams. One dose.

Not perfect, but it helps.

I've called the paramedics in.

The cardiothoracic and general surgeons were both exposed to aerosols in resus.

And Rebecca.

I'll contact them. Nerys will distribute the cipro.

OK, all sounds good.

Let's see at the next stage.

And I'll report this to the Health Protection Unit, OK?

Thank you.

Pulse is 120, BP 80 over 60. He's pyrexial, over 40.

Justin.

Hi, Wes. I'm Glen Boyle.

The patient has a pelvic fracture with contained haemorrhage requiring urgent surgery and we were just about to get started.

Well, the coagulopathy means that any bleed could lead to exsanguination. Yep.

Let me see what bugs I can find, I'll get back to you, OK?

OK. I appreciate it.

The minute you hear anything back from him, you bring the news straight in here. Sure.

He's burning up. Nothing is improving it.

OK, let's get the C-Arm in, please.

What do you think?

It's the ex-fix or we lose him.

Can we arc it, please?

That's good.

OK to rays?

Yep.

Rays.

(Beeping)

Rays off.

Thank you.

Blade, please.

(Knocking on window)

Glen, you got a sec?

No.

It's not Ebola, is it?

Might be. Might not be...

Well, I can fight most infections, but that...

Talk to Nerys about prophylactic antibiotics. Now piss off, Bob.

And focus.

The Spencer Wells, please.

Thank you.

OK, I'll need a drill with a 150 pin and a drill sleeve, please. Give me a hand.

Just there.

Thank you.

Take a sh*t, please.

Rays.

(Beeping)

Rays off.

OK. Thank you.

(Drilling)

Let's get the T-handle, please.

Thank you.

Let's have another sh*t.

OK. Rays.

(Beeping)

Rays off.

Good. I'm going to need another pin.

OK, need you again.

Open, just there.

Thank you.

Let's have another sh*t.

Rays.

(Beeping)

Rays off.

Thank you.

Let's have the T-handle, please.

Pulse is rising.

BP dropping.

Another sh*t.

Rays.

Push the Belmont, please. Yep.

(Alarm blares)

OK, he's crashing.

Is it blood loss?

Yes, we're losing lots of blood fast.

Can you see where these crossmatch bloods have got to, please?

OK, let's repeat the teg. We need to open him up.

Blood Bank?

This is the ODP in trauma theatre. Come on.

We need Pack C, ASAP.

(Alarm continues)

Still crashing.

Let's prep for a full laparotomy for PPP.

Come on!

BP's still very low, his numbers are crap. Blade.

Cutting.

Mayo.

Balfour, please.

Thank you.

Morris retractors, please.

Suction, please.

It's no better.

OK, I can see the pelvic haematoma.

Receptor, please.

Here.

Suction.

I'm going to need swabs, one at a time. Hit me.

Hit me.

Hit me.

Hit me.

(Glove tears)

Agh, sh...!

Hmm...

Glen, the glove is torn.

It's just a nick.

See to it.

Gloves.

OK to proceed?

Hit me.

Hit me.

5-packs in. Any improvement?

No. I've given him a second dose of tranexamic acid.

And he's still crashing.

Bleeding is continuing through the packs.

We've got an active arterial bleed in a branch of the internal iliac.

It didn't show on the CT scan.

It must've blown off a clot.

It's a rupture.

Push the Belmont. I'm going to need to ligate.

Get some suction in here, please. New teg.

Should be on the system.

Let's see it.

That's the previous one. The new one... Lahey.

Old, new.

Old, new.

He's doing really well(!)

So much more deranged.

2.0 Vicryl, please. BP still falling.

We need to reverse this man's coagulopathy, otherwise he's going to bleed out very, very quickly.

He needs cryo, platelets and FFP.

They're in Pack C.

It's not here yet.

Where the hell is Pack C?!

Blood Bank, please.

Yes, this is the ODP in the trauma theatre again.

We're still waiting for Pack C!

They're refusing to bring it.

They're waiting for advice from their line manager on whether to go near an infection area. You're joking.

Tell them you'll meet them at the infection barrier.

Tannoy: The trauma department is an infection control area.

Strictly authorised personnel only.

Do you want me to sign for it?

Knobhead.

Suction, please, and packs.

Got it. Well done. Hit me.

I'm your orthopod consultant, Joseph Whitnell.

Substitute for the reluctant Mrs Osgood.

We've abandoned the ex-fix at the moment.

We've got an internal iliac bleed and some other issues.

I'll come through.

Oh, no, listen, Joseph. We've got a pathogen in here and there's no point in exposing anyone else to it.

We'll need to fix the fracture. I'll take full precautions.

Microbiology results.

Come on through.

What can you tell us, Wes?

OK, so I found the bugs.

Good news, ruled out a haemorrhagic virus.

It's only meningococcal sepsis.

Great news. But we should treat this seriously.

Continue ceftriaxone, two grams BD.

And make sure that someone is getting those prophylaxis sorted.

Once you're done, get him up to ITU and I'll be there as soon as I can.

OK?

OK. Scissors.

Ligation is completed.

Seems as if the bleeding is under control.

Pulse rate 110.

Large swabs, please. Thank you, Wes. Yep.

Thanks for doing that. No problem.

Give me the Robinson tube.

Numbers are improving slowly.

Give me a Spencer, please.

Systolic up to 100. Come on.

That's it, my friend.

I think the coagulopathy is being corrected by the blood products.

Morris out.

(Alarm stops)

He's stabilising.

Piece of piss, this game.

That's terrific news.

I'll finish the ex-fix for you.

Yeah, I'll just go and organise a side room in ITU. Thank you.

Listen, everyone.

I think we got there.

We saved him and...

..I just wanted to say thank you.

Hi, it's Ramakrishna in trauma theatre.

Can I have a side room for Mike Oscar, please?

Joseph: Can I have the CT image on screen, please?

That's blood.

Is it yours or the patient's?

Is it cut?

Not my blood.

We get a result?

Yes, he's come through it.

Pre the diagnosis, we had to take both the general and cardiothoracic consultants temporarily off duty, down to possible exposure.

They both missed their clinics.

That's down to unnecessary trauma attendance.

It's not ideal, is it?

No, I suppose not.

But, you know, on a case-by-case basis, this is going...

You've put me right in the middle of the schedule managers.

But the most important thing is that the patient didn't die.

And that's down to your intervention and the team's hard work.

Thanks.

Fiona...

..Glen's just a locum.

He's here one day, he's gone tomorrow.

You know how we do things here.

But he has a point!

Sorry, excuse me.

It's your career.

So, he's doing well.

Ramakrishna will take him to ITU when they're done.

I'll let Dr Howe know. Mr Boyle...

We re-checked the Camp Bastion dates.

There's a three-month gap between your deployment and your arrival here.

Is there?

For the records, can you account for the time?

I can, yes.

We need to write up our notes.

Good.

You all right?

Our patient will live to testify against the people who did that to him.

Very all right.

Remember to take the... cipro.

Yes.

Thanks.

And I wanted to apologise.

For what?

You've been dealing with the hospital protocols.

All that crap.

And I don't want you to feel compromised.

I don't want it to be professionally difficult for you.

But it's working.

You're making the team a unit.

Seems so.

Look... maybe I've been a bit defensive.

There's... no reason why we can't talk to each other more.

Good.

(Button beeps)

I'm actually heading back to my digs.

Yeah.