01x06 - Episode 6

[bunniefuu]

I thought she was still off sick.

I don't know if you know, but I teach an intubation tutorial...

What did you tell him?

"There's a slapper in the ED, just give her a bit of teaching and she'll feel your tube."

It's Clive. He's gunning for you.

And this could turn into a sh*t storm.

When Clive told me that you were under my supervision I assumed that he had told you too.

Bastard wants us to fight for the same job.

I was mad to call you.

Lorraine's back. You should go.

We don't need you.

(Phone rings)

What do you want?

'You in yet?'

Missing me?

'Always. Get us a coffee, will you?'

Why don't you ask your paramedic friend, I'm sure she'd love to.

'Triple sh*t capp, no sugar. Go on.'

I've just been past the coffee place and I haven't got any hands free.

'No bloody heart.'

Well, it's comments like that that mean...

(Thump)

(Screaming)

'Harry? What was that? What's going on? Harry?'

There's been an accident, you should come.

'What accident? Are you OK? What's happened?'

Oh, God.

Hello.

Can you hear me?

Can you... ?

Oh, my God. Nuala? Nuala? Are you OK?

Oh, God. Oh, God.

She's Harry and I'm Justin and we're going to take care of you.

Yeah?

Airway. Airway.

What?

She's got an airway.

OK. I'll check the pulse, yeah?

She's breathing.

What?

She's... Take them...

Be careful!

What are you doing? Get back!

Back!

Moving back please. Yeah. Would you mind?

Come on, give them some room to...

Oh, my word.

Mind out, doctor coming through. Harry?

13.

Look, I'll take it from here.

26 resps. She's breathing?

Yes.

Is this the cardiac arrest?

No, she just fell, from up there.

We need suction, O2, a guedel and NPs.

It's not us, it's not an arrest.

Put out a trauma call.

Leave the kit, leave the kit.

Right, there's a suction pump in there and a green guedel.

Harry? You OK?

It's not a cardiac arrest.

Did you put out a trauma call?

Yes. She's breathing.

Pulse 120.

You taking it?

It's not an arrest, and if you're on call...

What's going on?

Trauma call, prep for an RSI. And tell someone to bring a scoop. Might need a binder too.

All right.

If you feel you can't handle it... Fine, I'll take it.

Thanks, Harry.

I'm sure Doctor Busby's got to rush off and give another SHO an intubation tutorial(!)

Have you done a primary?

I'm trying to get an adjunct in.

Harry?

Not complete.

OK. Doesn't look like you need this.

Just bleep me if you get into trouble, yeah?

High flow O2 please.

Yep, coming.

Cheers.

Nicola, is there anything I can do?

You could book her in.

Yeah, yeah, I'll leave you to it.

It's not going in.

OK, we need to roll her.

Harry, come on.

Yeah, so we're rolling gently on three. One, two, three.

OK. Are we there?

Others: Yeah.

OK. Well done.

O2 ready?

Yeah.

Tolerating a guedel.

Pulse 120, resps 24.

I need everybody to take a step back, please.

All of you, right now, take a step back so we can do our jobs.

We need a scoop.

Billy's on it. Should be bringing a binder too.

Primary?

Already doing it. Airway clear with a guedel.

Pulse 120, resps 24.

Can you hear me? My name is Fiona.

We're going to help you.

Patient has an obvious head injury.

Pupils equal and reactive, a little sluggish, possibly a four.

She fell from up there, yes?

Anyone know who she is?

No?

E1, V1, no response from trap pinch.

M1, GCS3.

Who was first on scene?

Me.

You see it happen?

Yep.

Need to know how she landed.

Feet first, and then she hit her head on the floor.

OK. There's a slight fullness in the abdomen.

So she's fallen from height, onto marble, feet first.

She's got a serious head wound and possible spinal fractures and intra-abdominal injuries, and there's an open tib-fib.

So we'll be doing scoop and binder, resus, repeat primary and then CT.

Everybody clear?

All: Yeah. I'll grab a trolley and I'll let CT know that we're on our way.

Bleep me if you need me.

What in heavens...?!

Harry, collar and blocks.

Fiona, can you take the pelvis?

Harry, I need you on the shoulders, and I've got the legs.

Sorry, bloody lifts, I was just...

Ohh, nasty-looking tib-fib.

Can you do the scoop first, please?

From the head.

Rolling on three - one, two, three.

Tell me when. Yep.

Back on three - one, two, three.

Let's reverse, please.

Rolling on three - one, two, three.

Ready. OK, back on three - one, two, three.

I know this girl!

Haven't we seen her before?

She's not staff, is she?

No, a patient.

There's no vascular compromise.

Thank you.

I started the clock.

We're just over three minutes in.

We need the trolley.

Ow!

You been lying on that?

I didn't expect to find glass on the floor! You should sue, mate.

I will. Ow!

Can we focus, please? I need the BP.

104 over 65. Pulse 113.

OK, let's get ready for the transfer, please.

Everybody ready?

Yep.

One, two, lift.

And down.

CT's occupied at the moment.

Excellent(!)

Come on. Resus, go. Brakes off, go.

Under the circumstances, I'll let you off about the coffee.

Almost four minutes.

Could do better.

What are you doing here?

I'm leading the trauma call.

You know what I mean.

Am I supposed to give you a call and ask permission?

I thought you'd have gone.

Why's that?

I don't think either of us wants history to repeat itself.

Nuala. That's it.

I knew I had the name.

Nuala Barrington.

You remember her, Harry?

I need to change.

Glen: Has the patient's identity been established?

Constance: Yes, Nuala Barrington.

Trachea central.

Thanks, Harry. What?

You just volunteered to be the scribe.

Oh. Right.

Good bilateral chest expansion.

Breathing symmetrical, resps rate 16.

You were also the first on the scene, so you'll have to do the handover as well.

Er...sure.

Patient's name is Nuala Barrington.

IV's in. What bloods do you want?

FBC, U and Es, LFTs, give me glucose, a VBG, clotting and crossmatch, please.

Ramakrishna?

Pretty much there.

Can we see if CT's free, please?

Harry? Is she on the system?

Ah, yeah, Major Trauma Foxtrot Charlie.

Resus, are you ready for patient Nuala Barrington, Major Trauma Foxtrot Charlie, in the system?

Thanks.

They've got someone in there.

(Excellent...)

Harry?

Harry! You're up.

Er, right, right...

Em... This is Nuala Barrington.

She fell about 30 feet onto the Atrium floor about 13 minutes ago.

GCS three, she has a likely head injury, a possible pelvic fracture and an open tib-fib.

Haemodynamically, she's...stable.

Trauma call?

Yes, Lorraine.

It's good to have you with us.

Look at that.

Blood. You guys are witnesses for my personal injury claim, right?

Got to be worth a fortnight in Ibiza at least.

Nice pants.

Yeah. Your dad got them for me.

(Billy sniggers)

The abdo's tight.

Where's the Fast scanner?

Justin, the Fast!

Yeah, I'm there, I'm there.

She's lost the dorsalis pedis.

Let's get the scoop off.

Unclip top and bottom.

One, two, three.

I've got it.

Brace, one, two, three. Go on three.

One, two, three Justin, give us a hand, please?

Yeah.

No.

We really need to pull this tib-fib, or she'll lose her foot.

OK. But quick as you can, yes?

Thank you.

Sorry, would you mind...?

Lift to 30 degrees when I say.

Ready, brace... lift.

(Whispers) Is it me, or is this really arousing?

(Bones crunch)

(Ooh!) Sorry, could I have a hand, please?

Ready, brace...down.

I'm ready to go.

We have dorsalis pedis.

Excellent.

RSI now, please.

Harry, can I get cricoid, please?

Er...sure.

I'll do this. No, I...I got it.

Thio, 200.

Thiopentone, 200 milligrams.

Can we give Neuro a shout, please?

Sure.

Head injury from this height, it'd be nice if they came and looked at her CT wouldn't it?

You'd think.

Mrs Hicklin, Trauma.

We need an opinion on a serious head injury.

Major Trauma Foxtrot Charlie, she's on the system.

We'll be in CT.

Free fluid in the abdomen and the pelvis.

Sorry.

sh*t.

Both: She needs to...

CT and then we need to get her to theatre, fast.

Ready to intubate.

BP 152/79, pulse 99.

Sats 82. Alert Theatre.

Tell them we could be there on the run.

Mrs Hicklin, Trauma.

We have Major Trauma Foxtrot Charlie for you. She is on the system.

Thank you.

Scope.

There you go.

(Whispers) Billy!

OK, that's time.

Hello, CT? Mrs Hicklin, Trauma.

Are you ready for Major Trauma Foxtrot Charlie yet?

Bougie.

Thank you.

CT. They'll call us when it's free.

Right...!

Tube.

Sorry, who's scribing?

There we go. That's me.

That's through.

- No rush.

- Bougie out.

Got it.

Breath.

Breath.

We're in.

Cricoid off, thanks.

There you go.

Regarding Major Trauma Foxtrot Charlie...

Tell me about her pupils, please.

I'm concerned about the head.

Nuala Barrington.

Her medical files are on the system already.

They should be linked?!

Pupils equal, but much slower to react.

Yep, there we are.

Regular, apparently.

Just so we're all up to speed.

Come on, back to work!

CT?

They'll call us.

OK, I'll take the head, you get the blocks on.

You've never been a first responder before, have you?

She made it to resus, Harry.

You did fine.

Numbers, please?

BP 156/81, pulse 78, sats 81.

That's really pushing the ICP.

Could be Cushing's response.

We should get a catheter in.

Yep, let's do that.

Constance?

Right away, Mrs Rappaport.

Stow lines and prep for a move to CT now, please.

(Phone rings)

Mrs Hicklin.

CT's ready.

Forget the catheter and let's go.

Now, please.

Lines attached, brakes off.

Let's go.

Let's do it.

I'm sorry. Sorry.

Have you been involved in an accident at work?

I have.

Oooh, no...

Justin! Door, please.

Glen?

Yes?

This incident, Major Trauma Foxtrot Charlie, it's probably going to be declared an SI.

I thought you should know, so you can document everything, make sure those files are buffed.

Not that I actually said that!

Thanks, Giles.

I just thought you should know.

Pupils unequal.

Can we chase Neurosurgery, please?

Yep.

It's not working. You're making it very difficult for Lorraine.

Mrs Hicklin, CT.

We need that opinion.

Yes.

Everybody ready?

So, yeah, we'd appreciate... Yes.

Yes. Thank you.

Very good. Control scan.

I must apologise for not clearing the previous patient more quickly.

This was due to unfortunate but understandable technical errors.

I'm still here.

Control scan complete.

Major Trauma cases need to be prioritised.

Neurosurgeon needs more information.

Like what? Her hat size? What?

This is something I've learned in my CBT sessions that I've been taking.

Starting head scan.

Lorraine: Right-sided extradural, midline shift and associated contusions on the right.

And fractures to the right-side occipital and parietal bones.

This brain looks really tight.

Let's fast bleep Theatre, please.

Head scan complete.

No, no, put me back through to Switchboard.

I would appreciate it if you would avoid touching any buttons.

Who replaced Brian with a friendly robot?

Mrs Hicklin, CT. Can you fast bleep the trauma theatre team, please?

Stepford Radiographers.

I, Radiographer.

Rise Of The Radiographers.

(He makes robot noises)

ROBOT VOICE: Robot radiographers.

Oi!

Sorry.

Mrs Hicklin, CT.

(That was our best material.)

We need an ETA on the neurosurgeon.

Contrast connected, I think we can continue.

Starting contrast run.

Rib fractures.

That's the least of her worries.

Jesus Christ.

What the hell's that?

Some kind of foreign material. Brian?

I wouldn't like to say without more information. I'm uploading these images for the radiologist's report.

(Phone rings)

Mrs Hicklin, CT. Thank you.

Trauma theatre's ready.

(Machine beeps, they groan)

She's blown a pupil and she's coning.

I need neurosurgery down here, right now!

Gently on three. One, two, three.

Quick as you can, folks.

Brakes off.

Hypertonic's going in.

Is the intra-abdominal fluid due to extravasation?

Yeah, there's bleeding. What is the material in her stomach?

God knows.

Get the Radiologist to report to me in theatre, please. I'll go ahead.

Right.

You're welcome.

Lorraine didn't create this situation. Neither did I.

She's a good surgeon.

But maybe we need better than good right now.

(She scoffs)

You're incredible.

I'll see you in there.

Patient is Major Trauma Foxtrot Charlie, AKA Nuala Barrington.

Consent, please.

We need to prep for a laparotomy and a craniotomy, please.

Someone from neurosurgery may or may not be on his way.

(Clock beeps)

Thank you.

Have you seen Fiona?

Changing.

What's the numbers?

156 over 78, pulse is 61.

Hypertonic's bought us some time.

Yeah, not long.

Keep checking her pupils, please.

Yep.

Fiona, can I have a word?

If you're quick.

I saw her in the ED yesterday.

Who?

Nuala.

She came in complaining of stomach pains.

I've seen her before, everyone knows her, she's a regular...

Did you examine her?

Yes. I palpated her abdomen, BP, heart rate -

I even did bloods just to keep her happy.

Did you assess her mental state?

She seemed normal at first.

Normal for Nuala.

But she did kick up more than usual, and I did... Yeah?

I did think she needed a psych assessment.

Did you discuss this with anyone?

The duty consultant.

Doctor Archerfield.

Clive.

I told him her history, and that I thought she should see a psych liaison nurse.

But he said she was about to breach the four hour rule and to discharge her.

Does it say this in your notes?

Just says I discussed it with him.

OK.

Don't worry.

I've got this.

Radiologist has just uploaded her report.

There's free fluid in the abdomen with active bleeding.

Any news on the material in her gut?

Take a look.

"Dense foreign bodies within the stomach and the small bowel suggesting recent ingestion. The largest measures 1.9 by 2.4cm."

So, not prepared to risk an opinion about what it actually could be?

There's an active bleed in the abdomen.

We need to unzip her now.

Right behind you.

I'll do this unless...

OK. Numbers, please.

158 over 80, pulse 60.

SATS could be better.

Let's do a WHO. I'm Glen Boyle, I'm the trauma consultant.

Lorraine Rappaport, consultant vascular surgeon.

Khaali Osman, scrub nurse.

Heather Dooley, support nurse.

Ramakrishna Chandramohan, gas reg.

Billy Finlay, anaesthetic ODP.

Jason Marshall, support nurse.

Fiona Lomas, trauma fellow.

Armeh Khalor, ODP.

Daniel Insalaco, rapid infuser operator.

Patient is Major Trauma Foxtrot Charlie. Date of birth 17/4/1988.

She fell from a height, there's a right-sided extradural haematoma, intra-abdominal bleeding plus foreign bodies.

I've signed a consent form four for laparotomy plus proceed.

Any word from neurosurgery?

No.

Packs to me, please.

OK, let's have the blade.

Am I OK to cut?

OK.

Cutting.

Standby Suction, please.

Give me two clips, please.

Let's have the mayo.

You do the other side.

OK, there's plenty of blood there.

Let's get ready to flush with warm saline, please. Everybody ready?

Yeah. Yeah. Yeah.

Cutting.

Oh!

Jesus Christ.

Thank you very much(!)

Was that you, Billy?

No.

Take this, please.

There's generalised peritonitis with loculated puss just everywhere: the pelvis... paracolic gutters...

Is it caused by the foreign bodies?

I don't know. Just a mess in here.

We should get Gen Surg to have a look at it.

Yeah, that's not a bad idea.

OK. Fast bleep Gen Surg, please.

Balfour and Morris retractor, please.

The bleeding's mostly in the left upper quadrant. Let's have a look.

Yep, ruptured spleen.

We're gonna have to have that.

Packs, please.

Hit me.

Again.

Let's move down, again.

Hit me. Keep 'em coming.

Hit me.

Again.

How many's that in?

Eight.

Hit me.

Yep.

Ten in the abdomen.

Ten packs in. How we doing?

Better, but let me catch up with some volume before you go any further.

Two units of blood, two FFP.

Yep.

Left eye looking very sluggish.

Two dardik, please.

Thank you.

Mayo.

Dish.

Here comes the spleen.

Let's have 2-0 VICRYL, please.

Thank you.

I'm ligating the artery.

What are the numbers?

She's looking a little better.

This pus has been here a while.

There's got to be a perforation in there somewhere. Shall I flush it?

Yeah, just let me finish off these ties first, please.

sh*t.

What?

You really don't wanna hear this, but she's blown the other pupil.

Come on! Where the bloody hell is neuro?!

Pressure's k*lling her.

Prep for a burr hole.

That means you need to go and rescrub and I need someone to hold the head, now, please.

Is there anyone here who's been cleared to scrub in?

Maybe call someone down from Theatres?

Not enough time.

What about Harry?

Yes. Harry.

Fast bleep Doctor Bennett-Edwards.

Have you done a burr before?

Twice in the field. Once at Brum.

When was that?

It was a few years back.

Cut, please.

I'd prefer it if you waited for neurosurgery.

And I'd prefer neuro were here right now with their fingers in her head, but they're not, and if we wait we lose her.

I'm not happy with you doing a burr hole.

But if I don't do it, she dies.

Look, I know this puts you in a difficult situation.

It puts us all in a difficult position.

Yes.

It does.

I know you're concerned about the mess you're in with management.

But my only concern is I've got a patient who's going to die unless someone cracks her skull.

And that someone should be a neurosurgeon.

OK.

You know I'm right.

So do you.

What is it?

We're opening up the head.

You need to scrub in.

Short back and sides, boys.

Let's have a couple of swabs ready as well, please.

Harry, hurry up.

Pressure right here, please.

Blade.

Retractor.

Brace with the cutter burr, please.

I need you to hold the head here and here, please. Saline, please.

I'm going to have to run this bowel through to find the perforation.

Thank you.

How's she doing?

I'm worried she's gonna arrest.

OK.

(He exhales)

Whatever you do, Harry...

..don't sneeze.

(He exhales)

I can't see. I need some light here, please.

How's that?

Yep.

OK.

Let's get some irrigation here.

Suction.

Pass me the burr, please.

Thank you.

Come on.

Let's have some more irrigation, please.

OK.

The flush.

Pressure is released.

Ramakrishna?

Shock versus ICP, these numbers are impossible to interpret.

Yeah. Let's lift the drape, please.

Yeah.

OK.

It's slow, but it's reactive.

Nice work.

Thank you.

The burr hole did the job.

Brains.

Here we go.

What the hell's going on?

Burr hole. She was coning.

Not bad. For an amateur.

We're just so happy to have you with us.

At last.

Prep the power perforator.

It's not the 18th century.

(He mouths)

Help them to scrub in, please.

And, Harry... good job.

I can finish this if there's somewhere else you need to be.

Sure.

I'll just...rescrub.

Seems like you two make a good team.

Torvill and Dean.

Let's tidy up this mess, shall we?

Kn*fe.

Raney clips.

Retractor.

Perforator.

sh*t!

There's a tear in this splenic flexure.

Drilling second burr.

I've located one of the foreign bodies.

What's that?

Glass.

She swallowed glass.

Radical approach to dieting.

Well, at least we found the perforation.

Got it.

Last burr.

All yours.

Linear stapler, please.

How are the OBS now?

Uh, not good.

Curette.

Flush.

So, who was that supporting the head?

The ED SHO.

Not Harry, by any chance?

Yeah, that's right.

Heard all about her.

One of our Reg's smashed it last month.

Craniotome.

(Drill whines)

Gen Surg. Got held up in theatre.

What's the situation?

We're sealing the perforation in the splenic flexure.

We did a splenectomy.

And a burr hole.

Well, leave some for me.

Be right with you.

Almost there.

Mayo.

Let's have a dish, please.

Thank you.

Yes.

Elevator.

Here's the boy.

Malleable retractor.

Suction.

You gonna pull the clot or you gonna frame it?

Spend as much time as I do in the brain, and you'd know you don't wanna rush things.

Swab.

Bipolar diathermy.

BP 141 over 74, pulse 72, SATS 95.

It's going the right direction.

She won't be Einstein after this, but as she jumped 30 feet on to a marble floor I'm guessing she wasn't that before.

I'm sure he's got the wrong end of the stick. About Harry.

There's another perforation in the D-colon. Right.

Well, let's have a look.

I think we've got this now.

Yes?

Fine.

Thank you.

Is she out of the woods?

Seems so.

She's stable.

Tickety-boo.

Hi.

Hi.

Oh, God, I'm gonna stink all day now.

I'm sorry about Glen.

Well, I'm sorry you got caught in the middle.

You did your Gen-Surg up in Birmingham, didn't you?

At the QE, yeah.

With Glen?

I wouldn't say "with."

It didn't end well.

Well enough for you to get him to come here and take my job.

Sorry.

I didn't know what to do.

Clive gave me the impression that you weren't coming back.

You know she came in to the ED yesterday?

Who did?

Nuala.

Harry wanted to do a psych assessment but Clive insisted that she be discharged to meet the four hour target.

Thank you.

PA System: 'Trauma call, attend emergency department. Trauma call, attend emergency department.'

Hi. Is the next case coming in here?

ETA three minutes.

CT available?

Here. Holding for us.

How's Nuala?

Oh, she's fine, yeah, it's looking good.

Great. Listen...

Nuala Barrington is one case that you don't need to worry about, OK?

Hi!

Yep?

What can I do for you, Lorraine?

I hear you're going to call it an SI?

Yes, it's a very unfortunate incident. Very sad.

How's the patient?

Looks like she's going to make it.

Which is probably just as well. Mmm.

Y'know HSE are going to be all over us. Yes.

I'm sure they'd be particularly interested to learn that she was discharged from the ED last night, with a stomach full of glass.

When she should have had a psych assessment.

Yes, well, I see how that might raise questions about the member of staff who examined her. I can see how it might raise questions about the duty ED consultant who puts targets before patient welfare.

Oh, you know what?

I can take this one.

OK.

Thank you.

So, with everything going on, you really think she's up to the job?

That isn't fair.

I'm making this work.

You said so yourself. Whatever's going on between me and you, that's what's really important is that I am making this unit work.

Yes, of course, but you have to understand - I'm not going anywhere.

I'm not leaving.