01x07 - Episode 7

[bunniefuu]

I thought you'd have gone.

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

You're making it very difficult for Lorraine. She's a good surgeon.

Maybe we need better than good right now.

You're going to go without...

(Scream)

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

So who was that supporting the head? Not Harry, by any chance?

Yeah. That's right.

One of our regs smashed it last month.

I'm making this work.

Yes, but you have to understand... I'm not going anywhere, Fi.

I'm not leaving.

I'll lead. Mrs Rappaport will assist.

On my count of three. Brace. 1, 2, 3. Go.

OK, we're gonna both scrub in.

'Trauma call, Emergency Department. Trauma call, Emergency Department. ETA imminent.'

Others are on their way.

Starting clock.

Brakes on.

OK, starting overhead camera.

That's on.

Transfer on three. 1, 2, 3.

Sarah, are you OK to stay?

I'll call down one of the regs to cover resus.

Thank you. Lorraine?

If you're on your own, you need to check in with Clive.

Yeah, right.

Glen?

OK, so, Kevin Parish, he's a butcher, Kn*fe slipped...

What the hell was that about?

I felt like she was trying to make a point.

She's an experienced consultant, and this situation is humiliating.

Yeah, but there's more, isn't there?

OK.

The patient last week who jumped.

Yeah?

I found out it was Clive who discharged her, not Harry.

And you told Lorraine?

Yes, I did. Because she has the right to defend herself.

And you think if Lorraine stays, then that's me gone?

'Trauma call. Attend Emergency Department. Trauma call. attend Emergency Department.'

Ta.

OK, twenties female. She was the passenger in the front seat of a minicab, two-vehicle RTC.

OK, thanks.

Right, let's get this scoop off.

Right. Brace on three.

1, 2, 3.

Patient's jacket on the side.

Ana! That ours as well?

No, that's the minicab driver. He's not major trauma.

Harry, take him to ED, would you, please? Ana!

Is Billy back yet? I'm starving.

Oh, bloody hell, she's here already.

I'm Dr Bennett-Edwardes. I'm going to be examining you.

Is she going to be OK?

They need to assess her.

Yeah, but do you think she'll be OK?

Try to stay calm, sir. She's gonna be fine.

Heart rate's jumped.

She's awake.

Whoa! Hold her down!

It's all right, love, we're here to...

Oh, that's gotta hurt!

Need sedation - 5mg of Midazolam.

I'm on it.

I'm Mrs Nicola Hicklin...

Bollocks!

You're at City General Hospital. You've been in an accident.

Oh, jeez!

Get hold of her, get hold of her!

(Patient speaks own language)

sh*t, sh*t! She's pulled out the Venflon.

I'll get another one.

I take it this is our patient.

Do we have a name?

Ana. I'm not sure if she speaks English.

And I was hoping for a ten-minute kip in the office chair.

You should be so lucky.

Midazolam. She pulled out the line.

Can you lie down, please?

Ana, Ana, it's OK. You're OK. My name is Fiona.

We're gonna try and help you. We're gonna help you. You're OK.

Let's hold her still.

You're OK.

Oh! And now for your next trick.

It's OK. Ssh.

Another grey Venflon, please, Nerys.

Coming up.

Bloody well hold her still!

It's OK. It's OK.

Let's try again, shall we?

Crap veins.

Want to tell me what's going on?

We've got an agitated patient.

Where's Lorraine?

In theatre.

It's OK, Ana.

Midazolam is going in. Should kick in in about 20 seconds.

It's OK, Ana. You're OK.

It's OK.

(Ana falls silent)

OK, done.

Let's stop pissing around and get her hooked up and intubated.

The clock's ticking.

Are you OK?

I've been called to a serious case review.

About what?

A complaint. An internal complaint.

Mrs Rappaport, who's supervising this operation?

It's a vascular case. I don't need supervision.

This trauma department's a leech on resources.

Two patients - 20 staff.

Just so long as she gets what she needs.

And she's got the gall to report me for seeing the bigger picture.

Do you want me to call someone down to supervise her?

No.

Leave it.

I'm just gonna go with the excuse that you've lost your phone.

It's been a crazy week, sorry. Shifts all over the place.

Airway secure.

Good. Excuse me, you are...?

Lola. You OK to do the hand-over now?

Yep.

OK, female, twenties - involved in an RTC at 2.45am, involving two vehicles.

She was the front-seat passenger in a minicab, and sustained contusions to the front and left of face, possible fracture to the left humerus.

GCS 9 to 12 on scene, deteriorated en route.

Heart rate on scene was 120, and it was creeping up on the way in.

BP on scene was 90 over 65.

It's going down.

We inserted IV access to the right arm, which she pulled out.

Have given oxygen, fluids, no meds.

Thank you.

OK. Let's get her out of her clothes. Top half first, please.

Let's take blood, usual suspects. FBC, U and E.

TEG and cross match, EtOH, VBGs and Beta-HCG, please.

This fracture's highly unstable.

Seatbelt sign. Cool.

Trachea central.

No obvious flail chest.

Any belongings?

Yeah, there's a couple of bags in the truck. We'll go and get them.

Good luck.

Equal air entry. Chest clear.

Couple of left-sided rib fractures.

Need a hand there, Sister Campbell?

Just offering my services.

Be my guest. OK.

Pupils, please.

Thank you.

Abdomen is distended, rigid.

Pupils are... reactive, but unequal.

Left three mil, right five mil.

Intracranial bleed?

Fits with the fluctuating consciousness.

Pelvis is stable.

BP remains low.

I still want to get a CT of the head.

Can we call CT and neuro, please.

Whoopee - neuro!

This is Mrs Hicklin, resus.

Can you fast-bleep the on-call neurosurgeon, please?

Thank you.

Ah, that was lovely, that.

If you don't need me for the arm just yet, they've got a proximal radius fracture in the ED.

Go. Thank you.

This is Mrs Hicklin.

We need to bring Major Trauma Foxtrot Echo down to CT in the next 15 minutes.

Sorry.

Did her hand just move?

With the amount of sedation she's had, she's not moving anywhere.

I can see you've got the touch.

Great. ..CT will be ready for us.

Thank you.

She's peripherally shut down.

I can't get access here.

Keep trying.

She's got really crap veins.

Heart's racing, 159, 160.

Whoa! Whoa, whoa, whoa!

She's going to self-extubate.

OK, OK...

I need swabs and a tourniquet, please, now!

Someone grab Rebecca!

It's OK, Ana. It's OK.

I need two more, open and ready to go.

It's OK, Ana. It's OK.

You take this, please?

Billy, pressure there.

Got it.

Thank you.

You're OK, Ana. You're OK.

OK, propofol going in.

OK, lift.

Easy. Keep the pressure on.

We've got about 60 minutes before this needs to come off.

Someone get me a pen, please.

Altered conscious level...

Agitation.

Right, I wanna get her to CT right now.

We need to know if this is a head injury.

Time, 3.43am.

(Beeping)

Oh, come on! sh*t! VT.

There's no output. It's a shockable rhythm.

Justin, compressions, yeah?

Charge to 150.

'150. Charging. Charged.'

Shocking in 3, 2, 1. Everybody clear.

Shocking.

Airway secured. Again.

OK. Coming up on two minutes.

Let's charge to 150.

And let's pause before shocking to check the pulse.

Harry, go and get yourself cleaned up.

And can you get me a scrub top, please?

Sure.

'Charged. Warning - stand clear. Warning - stand clear.'

Pulse check.

Hold the shock. Sinus rhythm.

Nice.

Albeit tachy at 140.

♪ Stayin' alive, stayin' alive... ♪

(She hums along)

You've so got to find a new tune.

Let's put up an infusion of hypertonic for the head injury, help reduce any intracranial pressure. OK.

BP is still dropping. She's got to be losing volume somewhere.

I agree.

I'm calling a code red.

Let's grab pack A and run one unit of O-neg through the Venflon, please.

Nerys, trauma line kit, please.

We're gonna be in CT in five.

But can you run a trauma line, please?

OK. Nerys, trauma line kit, please.

I'm on it.

Calling through to blood bank.

Thank you.

Box splint to go.

Don't ask.

It's Sister Campbell. We have a code red in resus.

Yep. Patient reference, Foxtrot Echo.

From Pack B, we need six units of O-neg, four of FFP and two of platelets.

You know there's no circulation?

Brachial rupture.

I'm going to need to pull this.

Yeah. I'll just do the trauma line first.

Let's get it up.

(Tittering)

Try to grow up!

Sorry.

O-neg, dated and checked. O-neg, dated and checked.

I need antibiotic.

1.2 gram bolus of Augmentin, dressings, drape and gloves, please.

Yep, on the way.

Administering 1 gram TXA. 1 to follow through infusion.

Have we got that line yet?

It's coming. Thank you.

Harry, can you get some gauze and assist Rebecca, please?

Yep.

Augmentin, 1.2 grams given. Good.

OK, this trauma line's good to go.

She looks flushed. Can we take her temperature?

Yep.

Carotid core, 38.7. OK.

We don't need the Bair Hugger, but can you keep checking on her?

Yep.

BP coming up - it's 87 over 60.

Good. She's responding to blood products.

What if she has?

Has what?

Shagged the neuro reg.

If you could support the shoulder and could you give traction, please?

Ask her. Do you think I should?

Mate, you ask her, you're admitting you don't trust her.

There's no coming back from that.

You're right.

You ask her.

No. No. No, no, no, no way.

Box splint, please.

I really want to be in CT now.

I'll do the honours.

Now I see the suitcase.

Well, it's your lucky day - it's locked.

Could be a b*mb. Quick as we can.

(Beeping)

One locked suitcase.

Justin, can you see if there's any hint to her next of kin?

Yeah. Thanks, Lola. Let's go.

Sorry.

If the brachial is transected, I'll need to ex-fix before it's repaired.

Could you give me a shout before you go to theatre, please?

Yes. Thank you.

You know I'm here because you wanted me here.

You're here because I needed someone to fill in for Lorraine.

Bollocks! I was upset.

And I needed you.

I thought I could do this.

That we could work together.

I thought I'd be OK with this.

And you're not.

So I'm supposed to just leave.

I'm not leaving.

But you will.

Because that's what you do.

You'll leave when it suits you.

When people come to rely on you.

When I've... Hey.

I'm sorry, Fi.

I don't suppose you speak Spanish?

No.

(She speaks rapidly)

Huh?

Come here.

You could be in luck. That one looks like a British number.

Oh, yeah. Thanks.

(Phone rings)

Hi, this is Staff Nurse Costello calling from City General Hospital.

I'm trying to trace contacts for...

Garcia.

..Ana Garcia.

We need to lose the tourniquet before we do the contrast scan. Yes?

BP's steady at 98 but heart rate tachycardic at 140.

It's too high.

Pupils are still dilated, uneven.

Anyone who's not needed, can we please head back to ED?

You can stay.

See you got stuck on the graveyard shift as well, huh?

Stuck?

Forced.

I don't work Thursdays. I never work Thursdays.

Everyone knows that and still they call in sick.

What happened to the counselling?

Didn't work.

Hi.

Shall we?

Of course. Of course.

Starting control scan.

Query intracranial and abdominal haemorrhage.

There's also a left-sided brachial rupture we need to include in the contrast scan.

Head injury, huh?

Looks like we could be in a for a cheeky visit from neuro.

Some right Bobby Dazzlers in neuro, though, eh?

Control scan complete.

What's that?

Could we maybe do that later?

Could people not touch the screen?

sh*t! What? What are they?

She's packing dr*gs.

And my guess is one of the packets is leaking.

Head CT's clear. There's no intracranial bleed.

It's got to be the dr*gs.

I better cancel the neuro before they get here, then.

Brachial is completely transected.

It'll need to be revascularised or she'll lose the arm.

This is Mrs Hicklin.

I'd like to cancel the neurosurgical opinion in CT.

Oh, that doesn't look good.

Bowel enhancement.

Ischaemia would explain the shock.

The dr*gs are causing splanchnic vasoconstriction.

We need to get her into theatre right now. Come on.

Mrs Rappaport's patient is still on the table.

They reckon another 10 or 20 minutes. Oh, come on!

We need to open a second theatre.

OK. And in the meantime, take her back to resus.

Do a tox screen of bloods and urine.

I wanna know exactly what's going on here.

OK, boss, I'm on it.

Nerys, liaise with Giles, call round for theatre staff.

Don't worry about who's on call - just get whoever lives closest.

Billy, theatre eight, get the anaesthetic machine set up.

Constance, Justin, go with him - we need to set up for a laparotomy.

I'll notify the police of events.

Thank you.

I'll check in with Lorraine, see if she can free up a circulation nurse who can assist.

What?

I should have been there for you.

I should've. I, erm....

I messed up.

We both did.

It's not that terrible having me here, is it?

If you're not working tomorrow night, maybe you could come over?

I'm shattered. It's been a long week.

Well, you still have to eat. I could make you something.

You don't cook.

OK, what is it? What?

You, avoiding me all night.

Billy acting like a weirdo.

(Beeping)

She's burning up.

40.1.

OK, do the tox, and grab a cooling blanket on the way back.

Yep, sure.

sh*t!

If you're looking for the emergency department, it's the other way.

I just wanted to check on...

Is she going to be OK?

Who are you?

I was driving her. The minicab.

It was my fault.

We're doing the best we can for her, but you shouldn't be in here.

Really, I need you to leave.

Whoa, whoa, whoa! It's all right, mate.

Lorraine has freed up a circulating nurse. Khaali is on her way.

We've got a few more to try.

Good.

Hi. This is Giles Dhillon, Trauma Manager at CGH.

Yeah, I appreciate it's late, but...

The police will be here in the next ten minutes.

OK. I'll get the patient, take her up to theatre. OK.

Nice - hung up.

We're gonna need to bring her...

Jesus!

The police are on their way.

Ramakrishna!

(He groans)

Ramakrishna!

sh*t! sh*t, sh*t, sh*t!

I need you to get help!

Harry, move!

Help!

Harry, what's wrong? Harry? What the...?

Let him go - he's got a Kn*fe!

Get in here!

Call security.

Harry!

Gloves and face shield now.

Oh, my God.

Large right-sided retroperitoneal haematoma, and it's displacing the right colon.

She needs more blood. Can you put it up, please?

Yep.

BP's sliding - 67 over 43.

I'm OK.

We need to get this patient to theatre or she's not gonna be OK.

Harry, we need you here.

OK, put your hand in over mine. Come on.

We don't have much time. You can do it.

All the way down.

Can you feel the aorta?

No.

OK, under my fist.

Yes! I've got it. I've got the pulse.

OK, on three, I'm going to remove my hand, and I need you to keep the pressure up on it. Are you ready?

Yes. 1...2...3.

Got it. Got it?

Mm-hm. Good.

It's the mini cab driver...

Nerys, get the blood products from the fridge and load them on the trolley, please.

Yeah.

You two, one on either side of the trolley. Now!

Nicola, I need you to stay with Ramakrishna. OK.

Ring theatre, tell them we're on our way and they need to prep for an IVC repair and we need an anaesthetist.

We good to go?

Yes. Let's go.

Billy? Billy, it's Mrs Hicklin.

You need to prep for an IVC repair and we need to get hold of another anaesthetist.

Say that again?

Yeah.

Yeah, yeah, I've got that.

You OK?

Yeah, got it, got it.

Grab the doors.

Through.

Move the operating table.

We can't move them across together, so we're gonna leave the patient on the resus trolley.

There.

Anaesthetics here.

We've got it from here, thanks.

You two stay on the doors, please.

(Alarm screeches)

Let's get her hooked up. Can someone turn that off?

We have a young female, twenties, packing cocaine, rupture to contents and ischaemic bowel.

She has also been att*cked by a Kn*fe.

There are multiple lacerations to the small bowel, and a zone one vascular injury with expanding haematoma.

And also I suspect damage to the IVC.

So the only thing keeping this woman alive right now is Harry.

I'll start to cut. Thank you.

BP 62 over 40 and heading south. Saturations only 80 percent.

We're going to extend the incision to get access.

I'm going to clamp the aorta and isolate the retroperitoneal bleed.

Let's get that set up. We need blood in her now.

Yep.

OK, let's do the who. I'm Glen Boyle, Trauma Consultant.

Fiona Lomas, Trauma Fellow.

Harry Bennett-Edwardes, EMSHO.

Dominic Busby, Anaesthetic Registrar.

Billy Finlay, Anaesthetic ODP.

Khaali Osman, Scrub Nurse.

Heather Dooley, Support Nurse.

Daisy McDonald, Documentation Nurse.

Daniel Insalaco, Rapid Infuser Operator.

Trauma patient, Miss Ana Garcia. DOB 14.04.1992.

Consent form 4 signed.

Laparotomy, plus proceed, repair of inferior vena cava.

Blade, please. Scalpel.

OK to cut?

She's not getting any better.

Cutting.

BP's still sliding. 59 over 33. Heart rate 120.

Let's push the blood.

Yep.

Keep the pressure on the aorta.

Yep, there's still a pulse.

We need swabs to pack out. Can you get them ready, please?

57, 55... Heart rate's 150.

Push it.

Yep.

A retractor and swabs, please.

54, 53... We need more volume.

We can't push it any further.

Heart rate's still climbing.

OK, I get the picture. sh*t. Glen!

Oh, come on!

OK, let's switch. Somebody tie me, please.

She's in VT. We're losing her.

Dooley. Defib. Now.

You OK, Harry?

Yeah.

Quick as we can, please. Yep.

Stand clear. Shocking.

Hand straight back in, please.

Got it?

Yep, got it.

Still in VT. Some output.

Shock her again?

No. We need to control the bleed. She's got no volume.

I'll pack the quadrants.

More packs, please.

One.

Two.

Three.

Four.

Five.

Six.

Seven.

Eight.

Nine.

Ten.

Ten packs in. Ten packs in.

I'm going to clamp the aorta above your hand now, Harry, OK?

OK.

Let's have the supraceliac.

In VT for 60 seconds.

Thank you.

Hold still.

Steady.

OK, clamps on.

Let's release the pressure nice and slowly.

Good.

Aortic pulse above the clamp.

She'll be glad of that.

Harry, you did really well.

Let's fit the retractor, please.

Give me a large. Thank you.

Let's have a dish. OK.

Suction.

I can't see a thing in here.

Shall I control the IVC?

OK. I'll clear the way.

You should be in ED. I'm fine.

Well, you're no use in here.

So go and get yourself some rest.

Thank you.

Harry, go and get yourself cleaned up.

Looks like your man's having a bad day.

How are you doing?

I mean, you look almost as bad as me, but you did well.

Do you want to come over?

Look, I need to ask you. You and this neurosurgeon... Did you...?

No! No.

When you say no, that means nothing happened between you, right?

Keep up the suction.

Got it?

OK, I've got control.

OK, I'm gonna clamp off the IVC, make it easier to do the repair.

Satinskys, please. Thank you.

One.

Two. Done.

Numbers are going the right way.

Are we going to shock her again?

Let's fill her up a bit more first, please.

'150 Joules selected.'

Ready when you are.

OK, we're shocking.

'Electrodes connected. Diagnosing rhythm. Ventricular tachycardia. Advising 150 Joules...'

Clear.

3-2-1, shocking.

Looks like we've got sinus.

Output good. That's good. Yes!

OK, we're back in the game.

I'm going to extend the wound.

Potts, please.

I've got it.

Thank you.

Suction.

sh*t! What?

Back wall of the IVC's punctured.

OK. I'm gonna need you to hold it open.

Forceps, please.

BP's holding at 62 over 40.

5-0 double ended prolene, please.

Here?

Yep.

5-0 double ended prolene. OK.

What's he doing here?

Someone's been att*cked in his department on his shift.

I imagine he's having kittens, don't you?

Lining up the scapegoats, no doubt.

How could she have been att*cked in resus? Where was everyone?

They were rallying staff to open up this theatre.

Because the trauma theatre was blocked?

The previous case was in there, yes.

Posterior wall sutured.

You can let it go now.

OK. Thank you.

Are we winning?

Suturing IVC.

Flush, please.

BP's falling again - 56 systolic.

Nearly there.

Billy, Metaraminol, half-milligram bolus. Yeah.

BP 54 over 34.

Distal clamp off.

Put up an extra two units of blood, two FFP.

Only one pair of hands, bud.

Releasing Satinsky clamp.

Repair looks fine. Metaraminol, half-milligram bolus given.

Taking off aortic clamp.

Let's go nice and slow.

Releasing halfway.

Keep pushing the blood as the clamp comes off. Yeah.

Here we go. 68 over 27.

The repair looks good.

Releasing to three-quarters.

BP dropping to 59 over 24.

OK.

Take it off.

Clamp off.

It's steadying.

Steadying.

ST depression. She's showing signs of cardiac ischaemia.

OK, let's get the rest of the dr*gs out before they k*ll her.

Nice work.

Saline, please.

Kidney dish, soft bowel clamps and swabs, please.

Thank you.

Wash this through.

Numbers are looking a lot better.

Nice.

I tell you what, wish I had a stomach full of cocaine.

Well, you look like crap.

Cheers.

It's not been one of my best nights.

Oh, I don't know.

I'd say she was lucky to have you here.

What the hell's happened?

Someone said a patient was att*cked in resus. A Kn*fe att*ck.

Hospital security nabbed him outside.

Can you give us a minute?

Yep.

They were forced to leave the patient unattended while they opened up a second theatre.

Theatres get blocked. It happens.

You were in breach of your supervisory directive.

I'm a vascular consultant.

Operating without supervision.

You'll be charged with serious professional misconduct.

You'll destroy my career?

You put in a complaint about me.

You put hospital targets above patient welfare, and then you tried to let an SHO take the fall.

This conversation is over.

You're over.

Fiona?

Yeah? Sorry.

Can we fast-bleep Rebecca Osgood to ex-fix the arm?

And we're gonna need a radiographer, please.

Dish.