01x03 - Episode 3

[bunniefuu]

This is Mrs Rappaport, I'm the consultant on call for major trauma.

What's happened to Lorraine? Who's covering?

It's in your best interests to stay out of this, so stay out of this.

You're the last person I want to call but... you're the only one who can help.

I've practised all over the world, in the Forces and civilian hospitals.

I specialise in critical injuries.

I thought you needed me.

This unit needs you.

You think I can change things when Lorraine couldn't.

Bring it on.

♪ Well, you can tell by the way I use my walk ♪

♪ I'm a woman's man, no time to talk ♪

♪ Music loud and women warm ♪

♪ I've been kicked around since I was born ♪

♪ And now it's all right, it's OK, you may look the other way ♪

♪ We can try to understand ♪

♪ The New York Times' effect on man ♪

♪ Whether you're a brother or whether you're a mother ♪

♪ You're stayin' alive, stayin' alive ♪

♪ Feel the city breakin' and everybody shakin' ♪

♪ And we're stayin' alive, stayin' alive ♪

♪ Ah-ha-ha-ha, stayin' alive ♪

That's 31 minutes.

♪ Stayin' alive ♪

What output are we getting from compressions now?

Some.

But SATS are still very low. One minute of compressions given.

One minute to go. Jason, you'll continue compressions until the last possible moment before Nerys shocks.

There will be a pulse check before the shock.

This will be the third shock.

Do we have adrenaline and amiodarone ready to go in?

We do.

Adrenaline one milligram, amiodarone 300 milligrams. Thank you.

Jason will restart compressions immediately after defibrillation.

Justin! Then the dr*gs will be given unless we observe sudden obvious ROSC. Everyone clear?

♪ You can tell by the way ♪

(BEEPING)

♪ I use my walk, I'm a woman's man, no time to talk ♪

♪ Music loud and women warm, I've been kicked around since I was born ♪

♪ And now it's all right, it's OK, you may look the other way ♪

♪ We can try to understand The New York Times' effect on man ♪

Pause compressions. Pulse check.

Flat line on arterial pressure.

Compressions, go, please. Shock in ten, please. Charging, 150 biphasic.

"150 joules selected. Biphasic shock. Charging."

Do you know what? I think I'll just...

"Charged." Everyone clear.

"Warning." Justin, off the chest. "Stand clear. Warning." Shocking after three, two, one.

dr*gs and compressions, go, go.

♪ And now it's all right, it's OK, you may look the other way ♪

Adrenaline given.

♪ We can try to understand The New York Times' effect on man ♪

♪ Whether you're a brother... ♪

Jason, you OK?

♪ You're stayin' alive, stayin' alive ♪

(cr*ck)

That'll be a rib.

sh*t! Sorry.

Easy, tiger.

Someone take over from Jason before he gives him a flail chest, please.

One, two, three...

Amiodarone given.

..eight, nine, ten, eleven...

Arsehole!

Blood going in, adrenaline. How many units is that now?

12 units... 12 units of O pos, eight FFP, four platelets. That is correct.

That's impressive. Arse... hole.

Girl, do your business.

Sorry, Sister. This was supposed to be a scoop and run.

It takes them half an hour to get him off the roadside.

Barely getting anything with compressions. Boss?

Yeah, yeah. I hear you.

I want to move on to other interventions.

We haven't completed this CPR cycle yet. We're pissing in the wind here.

So let's prep for a clam-shell, please. Right now. Yes!

Not you, Harry. Keep CPR going until we're ready to cut. Get on it, move!

Sorry.

Sorry, what the hell are you all doing?

The kit needs to be out, opened and ready to go in seconds.

Very sorry, Mr Boyle. Justin!

And there better be an aortic clamp this time, otherwise I am going to flip my lid.

Aortic clamp in trauma theatre now.

Me? Don't test me, boy!

Approaching 34 minutes since admission to resus.

Patient has been down... Seven minutes. Thank you.

Nerys, shock again. Harry, continue until the last possible moment.

No dr*gs on this cycle. Understood?

Yes.

Another set of shears, please.

Ten seconds.

Charging, 150 biphasic. Bring that closer, please. "150 joules selected. Biphasic shock."

"Charging."

Not you, Harry.

"Charged. Warning." Everyone clear. Harry off the chest. "Stand clear."

Shocking after three, two, one. "Stand clear."

(BEEPING)

Flatlining arterial pressure. VF. Carotid absent.

Stop compressions.

No, no. Keep going.

We'll work round you. And we're cutting. Drains. Mind your fingers.

I said mind, not move!

Sorry, Mr Boyle.

OK, Jason, get back on compressions please. Justin.

What?

His name's Justin.

Is it?

Yeah.

Stop.

Sorry, urgent potassium result.

Don't mind me.

Internal compressions, please.

Pericardium open.

Where's the clamp?

Really?

There's no clamp.

Excellent.

OK. I'm going to need to get some access here.

OK, I have manual control of the aorta.

I've shut off circulation to the lower part of the body while we wait for the clamp.

On its way, Mr Boyle.

Got an arterial pressure now.

Good.

So why didn't you say anything earlier?

Didn't like to.

Why?

You can be a bit...

Bit what?

Fierce.

Huh! You pick your moments.

Bosh!

Convert back to vent, Billy.

Aorta cross-clamped. Distal flow is down. Now listen, everybody, that was piss-poor.

But you will get better at this and do you want to know why?

So that when you look this man's family in the face and you say you did everything you possibly could for him, it is not going to be a bloody lie!

We're cross clamped. Distal flow is down.

OK, let's get the rapid infuser going into the subclavian, please.

Yeah, on it. Is this a bad time to ask about the legs?

Yeah. Yes. Right, sorry.

Bung.

Thank you.

OK. That's the rapid infuser connected to the subclavian.

I'm feeling contractions.

Stop compressions.

Got spontaneous contractions.

(BEEPING)

Yes.

Looks like sinus. Keep filling him up with pink please, three to two.

Still on pack B. OK.

Registering a proper BP now.

60 over 35. Sats coming up sluggishly.

BP 90 over 60, sats climbing.

Thanks, Ramakrishna.

He gets Ramakrishna right. OK, let's fast-bleep the theatre staff.

Patient ETA two minutes.

Fast-bleep cardiothoracics and gen-surg. We're taking him now.

And we need the radiographer to do portables in theatre.

This is Fiona Lomas. X-ray the legs. Get scrubbed up. Get in.

Brakes off. Let's go. Brakes off. Rolling.

You're letting that girl make a fool of you, boy. I'm not your boy.

Haven't seen each other all week, then the scramble of a trauma call.

I never got to say hello.

Hello.

How are you settling in?

Fine. What's the problem?

Well, you said it, "Haven't seen each other all week."

Hi.

Hi. The fiancee's here.

Does someone have a minute to talk to her?

Yes. Sure. OK.

Lauren, this is Mr Boyle, the trauma consultant.

I'm sorry this has to be quick, Lauren. Adam is critically injured.

His bike was involved in a collision with a lorry resulting in multiple serious wounds.

His heart stopped b*ating and we opened his chest and got it pumping again.

It stopped because he's bleeding internally.

And now we have to find out from where and to operate on some serious crush injuries to both of Adam's legs.

But we're going to do everything we can to save them.

Right now, we really should get back to him. Right.

I'm going to ask Mr Dhillon to sit you in our relatives' room.

Is there anyone that you need me to call?

You need to get on with it.

Because, ready or not, in five minutes, I'm cutting.

Scissors, quickly.

OK to prep?

Please do. Yes, please.

Splints off, please. And whatever's left of his trousers.

Trainers too.

I'm going to lift him. On my count. One, two, three.

OK. Now we lift the leg. Clear out.

OK. One, two, three.

BP's now a very respectable 100 over 80. Sats sitting pretty at 96.

Thank you.

Clamp's been on for eight minutes.

We need to cr*ck on.

Watch your backs, please.

Rays coming up after three.

One, two, three, rays.

And lift.

Down.

Let's who.

I'm Glen Boyle, trauma consultant.

Fiona Lomas, trauma fellow.

Ramakrishna Chandramohan, anaesthetics reg.

Billy Finlay, anaesthetic ODP.

Rebecca Osgood, orthopaedic registrar.

Khaali Osman, scrub nurse.

Lucy Hartwell, staff nurse.

Heather Dooley, staff nurse.

Andrei Kovac, documentation nurse.

Armen Khular ODP. Daniel Insalaco, rapid-infuser operator.

Shelley Imms, radiographer. Daisy MacDonald, circulating. Thank you.

Rays in three.

One, two, three, rays.

Thanks very much. All clear.

Excuse me.

Let's confirm the patient.

Patient's name Adam Richards, date of birth 16-11-1989, Patient number G893677498.

Cyclist crushed by HGV.

Confirmed.

Run off a new set of ABGs?

Thank you.

I've signed a Consent Form 4, for a laparotomy to stop a life-threatening intraperitoneal haemorrhage.

I've signed a Consent Form 4, for fixation of lower-limb fractures and debridement of crush injuries.

Swabs to me please.

One, two, three.

Nice and high.

Radiographs coming up on screen now.

No, not now. Blade.

Am I OK to cut?

Yep.

Cutting.

Scissors to me.

Still waiting.

Sorry.

Trauma patient, aortic clamp.

We're going to be moving fast.

I'll try to keep up.

Massive blood pooling in abdomen.

OK, I'm opening the peritoneum.

Everybody ready?

Ready.

Ready.

Then here we go.

Suction. Packs.

Morris.

Hit me.

To me.

Three.

One.

Two.

Ten in the abdomen.

15 in.

Am I OK to unclamp?

Yeah. Ready?

Ready. OK, boss.

I'm going to unclamp by a half.

Fine.

OK?

OK.

Half. There.

Pressure dropping.

(BEEPING)

Holding.

(BEEPING)

Holding.

OK.

Am I OK to risk three-quarters?

Fine. Yeah?

Yep.

Three-quarters.

There.

Dropping.

Holding.

(BEEPING) Holding.

OK. OK.

Can I go all the way?

Do it.

That's all the way.

(BEEPING)

Dropping.

(BEEPING)

Dropping.

Come on.

Come on!

(BEEPING)

Dropping.

(BEEPING)

(RAPID BEEPS)

Holding.

Patient is stable. Looking good.

(BEEPING)

Ooh! Bit of a rise.

Ha! Nice.

Maybe we could look at the legs now?

Yeah, quickly. Images, please.

Image.

Image.

Image.

Oh! Oh!

sh*t! OK. Thank you very much.

No problem.

Why's the shoe still on?

No-one dared take it off.

Can we double glove Rebecca, please. Seven's please. Gloves.

Clamps off. Let's re-pack the chest before we hunt down the bleeds.

Packs, please.

And again.

Two in the chest. Two in.

(CRACKING)

Two in the chest.

Glen?

You OK?

Yes.

I'll take it.

Get the gloves.

Mr Boyle?

Yeah?

Actually, I'm not OK.

Can I have a minute, please?

Absolutely.

Someone bring her a cup of water, please.

I'll go.

Oh! You need to hear his gases.

Go on.

Well, he's knackered.

When you restore his circulation, a whole pile of sh*t is going to come out of those legs.

Save the legs but the patient dies?

Oh, no. Not on my watch.

Tell me his haemodynamics.

Pressure's holding off-clamp. Good.

We're taking his legs.

I'm going to proceed with haemostasis.

Billy, can you put in another call to blood bank, please.

Pack C. 12-8-4-2.

Can I have the ring-plates?

12 units of crossmatch, eight units of FFP,...

Thank you.

..four of platelets and two of cryo.

I'm going to sloop the iliacs while I'm here. Sloops.

You good?

Thank you.

OK. Take the legs. cr*ck on in your own time, wide debridement, yes?

OK, we're going to unpack quadrant by quadrant, lock down the bleeds.

I need the legs supported in knee flexion 45 degrees. Wedge.

Blade.

One out.

Two.

Saw.

You OK?

Yep. Thank you.

(SAW WHIRS)

Lower quadrants are unpacked.

Blade.

There are no obvious sources of bleeding in the lower quadrants.

And no obvious retroperitoneal bleed. BP is holding.

I'll go for the iliacs now.

Can you hold that?

Thank you.

Can you do the other side, please?

(WHIRRING)

Clips.

OK, we have control of the iliacs.

You can release the tourniquets.

Four out.

Four packs out.

Those are going straight down the canteen.

Don't waste time making them look pretty. (LAUGHS)

Have we seriously still not got anyone from cardiothoracics or gen-surg?

Someone chase them, please.

We shouldn't have to be chasing...

We shouldn't have to be chasing them.

Hello, this is trauma theatre.

Can you please advise us when we will be able to welcome the cardiothoracic and general-surgeons?

Yes. Thank you very much.

They're fast-bleeping them again.

Well? What's next?

Unpack the left upper quadrant and continue the haemostasis, please.

One out.

Two.

sh*t!

Haemorrhaging around the spleen.

(BEEPING)

BP is dropping.

(LOUD BEEPING)

It's crashing!

sh*t! sh*t! He's bleeding out!

Suction!

Get him reclamped, please.

Clamp. Quickly!

Where's that blood? Quick, quick, quick, Billy. Just bang it in.

Yeah, banging it in.

Come on, it's still dropping.

(BEEPING)

Reclamped.

(BEEPING)

Delivery from blood bank.

Quick. Quickly. The clamp's controlling the abdominal bleeding for now but we're taking the spleen.

BP's still very low. He's shutting down. Well, let's fill him up.

Well, we can keep going with the rapid infuser... Then let's do that.

Keep the crossmatch, FFP and platelets going. Dardik, please.

Gauze and bandages.

Gauze and bandages times two.

Forceps, Lahey, ties.

Mayo, please.

Mr Street, gen-surg consultant.

Who's consulting here?

We met before.

Glen Boyle, I'm trauma.

Sorry, Glen. Hello, again.

Splenectomy in progress.

You took the legs?

Had to.

I'm sure it was the right decision.

But for medico-legal reasons I'll be requesting two orthopaedic consultants review the notes.

Absolutely fine.

Scrubbing in. Mayo.

Cut.

So you must be Lorraine Rappaport's stand-in?

How long's Lorraine going to be off for?

Unstable angina, I heard.

That's what's being said but we don't know yet for sure.

Poor thing.

I'm sure Clive filled you in the other night.

I hear it was very convivial.

We've waited here long enough.

I need you now, please.

Cut.

Ties.

Um, if we're all done with the legs...

I...

Yep.

No, I mean we are done with them.

You should go.

And well done.

Cheers.

Cut.

Yes.

Mr Street?

Rob.

We need to tackle the liver.

Go for it. Be right with you.

Cut.

Mac.

Dish, please.

Spleen out.

Thank you.

Let's unclamp. I've got this.

Half off.

(BEEPING)

Dropping.

(BEEPING)

Holding.

Yeah.

Three-quarters off.

(BEEPING)

(RAPID BEEPING)

(SIGHS) Dropping.

Holding.

Go on.

Let's go.

Unclamped.

(BEEPING)

Dropping.

Liver's haemorrhaging. Leave the clamp off and unpack the RU.

I'll do the Pringle.

OK.

Fractured right lobe, some torn mesenterics.

Pringle's not working. Reclamp.

BP remains very low.

Every time you unclamp, he loses more than we can put back in.

We can ligate the mesenterics.

I reckon so. Reclamped.

Boss, I need some senior support in trauma theatre.

I'll get on and ligate these vessels.

Two clips, 2.0 vicryl. Mounted ties.

I'll pack the liver.

Good idea. Packs, please.

Scissors, please.

Liver packed.

OK, cut.

Cut.

He's bleeding again.

Has the clamp come loose?

Aorta's clamped.

sh*t!

Everything below the clamp is tied off. Where's it coming from?

(BEEPING)

Oh, God!

BP dropping. 30 over unreadable.

Clamp's on.

I just told you it was on.

Then he's bleeding above the clamp.

Diaphragm's ruptured, it's getting into the abdomen.

He's blown off clots in the chest.

This is sounding like DIC.

Death Is Coming.

Haemostatic gauze. Now, please.

You unpack, I'm going to get the haemostatic in.

Thank you.

Cut.

Scissors, quickly.

We need to tamponade the bleed.

Hit me.

Cut.

Pack, please.

Hit me.

(RAPID BEEPING)

Oh, come on!

He's down.

(RAPID BEEPING)

Keep the rapid infuser going. It never stopped.

Coming up to 71 minutes, 30 seconds.

The heart's empty.

Fresh blade and a Foley, please.

Foley.

Blade.

I'm going to put the Foley...

Get it going right into the right atrium, fill him up from there and you're going to inflate the cuff. Glen...

Just do as you're told. Listen, you gave it a good go, but he's down.

If you want a say, you're going to have to show up when you're bloody called!

72 minutes, now been down 30 seconds.

Cuff prime.

Yes. Get that connected to the rapid infuser. Now. Billy.

Yeah, it's going. Yep. Reddy.

OK. Compressions.

Carotid? Thank you.

Very weak output.

I need to secure the Foley.

2-0 Vicryl, please.

Stop compressions. He's been down for almost a minute and a half.

Scissors, quickly.

Pulse absent.

Cut.

Start compressions again.

(BEEPING)

Let me see what we've got.

Thank you.

You can stop now.

Thank you.

Patient pronounced dead at 74 minutes.

I want to thank everyone.

Sorry, mate. Yeah.

I'll email you my notes later.

Everybody leave anything that's connected to the body exactly as it is for now.

I'm sorry.

Is Mrs Hicklin there?

It's Fiona.

He went down.

Pronounced a minute ago.

I'm very sorry.

You all have my sympathy.

At this stage, and I can see you're already following the protocol, nobody should touch anything connected to or entering the deceased.

Can I do anything for anyone?

No. No. OK.

The wounds are still open?

Yes.

Once the photos have been taken, would you be able to close the wounds or would you like me to ask someone else?

No, I'll do it.

Thank you.

You mentioned Lorraine's illness.

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

From Clive?

Yes.

Well, I heard different.

It's all right for you, you don't have three kids.

Where's the girlfriend, please?

Fiancee. I'll take you.

Thank you.

I'll come.

I'm very sorry.

Thank you.

Lauren?

If there's anything I can do...

Thank you.

Arse... hole.

The major trauma d*ed.

Oh, right.

I didn't know, I've been on minors.

Still, doesn't make you any less of a cock.

I just don't know what I'm meant to have done wrong. No?

Then why did one of your mates ask if I wanted an intubation tutorial?

Mate? What mate?

Dominic Busby.

sh*t!

Hmm!

What did you tell him? "There's a slapper down in the ED."

"Give her a bit of teaching and she'll feel your tube."

(LAUGHS)

Harry, listen... I'm not going to have this out at work.

So I'll call you.

Don't bother.

You blind? Scaphoid.

Scaphoid.

Poor bloke.

We lost valuable time because gen-surg and cardiothoracics were not on scene. They can't be in two places at once.

So on-call rotas need to be synchronised.

Yep. I've raised the issue.

There's some resistance.

Hopefully, they'll change their minds.

We need the right specialities coming to the trauma calls now, so it should be more than just a hope.

You know, I was quite surprised to receive your application. Really?

Yeah. I wouldn't have necessarily put you together, you and this unit.

I want to give it the benefit of my experience.

Mmm!

Yeah, of course.

Sorry, sorry. Can we just...? That's fine. Promise we'll just be a sec.

Can I get a medium cappuccino. please?

Double espresso.

Don't be silly. Thank you.

Maybe I could talk to gen-surg and cardiothoracics?

Look, this is going to sound very patronising but you're a locum and you've been here a week.

I led a trauma unit in Bastion.

You could've had half your body blown off, you came into Bastion with a pulse, you've got a 98% chance of survival.

That's the best in the world.

Well, things are different here.

Look, you've had a terrible night.

I know.

Why don't you leave this lot with me?

This lot, it can be a bit like herding cats.

Here's your coffees.

Thanks.

Eh!

Thank you.

Oh, sorry.

No, not at all.

How's the fiancee? Has the bereavement counsellor been able to see her?

It's all in hand.

Thank you.

I want it made clear that this death occurred on the trauma service.

It is not an emergency department death.

Right.

Hey!

Did I say?

One of our nurses was at Camp Bastion last year.

Oh, yeah?

When were you there? Only, your name didn't seem to ring a bell.

It's a big place, people came and went.

I'll try not to take it personally.

Thanks for closing.

There's a trauma call.

I heard.

Do you believe that crap about Lorraine being on sick leave?

Thank you, everybody.

No worries.

It's a lie. And to cap it all, you're on the town with Clive.

So what?

Big boys get it sorted out over a pint so I can stop worrying my little head.

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

Now you're pissed off. Why?

Because a complete stranger could be arsed to take me out to welcome me to the job?

Was it really too much to ask for me and you just to go for a drink?

I didn't return your messages for a reason. You know exactly why.

Boss? Trauma call.

Yeah.

"Trauma call, ETA one minute."

"Will trauma teams please return to resus."

"Trauma call, ETA one minute."

Another RTC.

Really? Not seen one of those before.

We can still work together.

Yeah. Work.

That I can do.

Here we go.

And let's do better this time, please.