01x08 - Episode 8

[bunniefuu]

Should've been there for you.

I messed up.

We both did.

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

(What if she has?)

(Has what?)

(Shagged the neuro reg.)

(Ask her.)

Mr Boyle, before you go, I have an admin query.

Did you come straight to us from active service?

Sorry, dying man waiting for me.

You were in breach of your supervisory directive.

You'll be charged with serious professional misconduct.

You'll destroy my career?

(Fire alarm sounds)

(Voices in background)

We're evacuating patients, but no-one's telling us where the fire is. I need information now.

Yes, this is Giles Dhillon, trauma manager.

Do we have a location for the fire alarms yet?

This way.

Theatre changing rooms.

Changing rooms!

Staff changing rooms. This way.

Connie... Me, too?

Let's go.

Yes! You, too!

Staff changing rooms - on the right.

All clear.

I'm personally leading a trauma team down to the incident now.

Resus trolley straight away, please!

Not until we've cleared it, please.

Quickly! She's in a bad way.

Sister, let's get that trolley, please. Yes, Mr Boyle.

And a scoop, Harry. Giles, make sure there's an anaesthetist on their way down, and have the rest of the trauma call divert to Resus.

Yes, Mr Boyle. Thank you.

You OK?

Yeah.

All clear.

The fire's out, but it's still a bit smoky in there.

If anyone starts with any problems breathing, let me know and we'll get out straight away.

Got it.

Tannoy: 'Exercise extreme caution and report evidence of fire or smoke at once.'

Oh, my God!

Who is she?

Don't know.

Hello?

Can you tell me your name?

'Evacuate immediately. Alarm areas sounding an intermittent tone.'

Yeah, I thought of that.

Right, we're going to take care of you.

We're going to give you something for the pain.

Give her morphine. Yep.

Controller. Control.

Theatre one changing room fire out.

One serious casualty, medics in attendance.

OK. Roll to the left first.

To the right on "roll".

Ready, set, roll.

Designate theatre area Red Zone, rest of Emergency Department Amber.

Lift on "lift".

Ready...set... lift.

'Alarm areas sounding an intermittent tone.

'Exercise extreme caution.

'Report evidence of fire or smoke.'

Let's go.

'Alarm areas sounding a continuous tone, evacuate immediately.'

Oh, my God.

Giles.

Get security to check CCTV and find out who this is, please.

Yes, yes, of course.

Gangway! Major trauma coming through.

Gangway.

Changing room fire, someone was trapped. Member of staff.

Who?

Don't know. Mrs Hicklin's asked me to check the CCTV.

Male or female?

Female.

CCTV, you show me first.

Yeah, OK...

(Alarm continues)

Starting the clock.

Does anybody recognise her?

There's not much to recognise.

Ramakrishna, I'm leaving you to the airways, Fiona will do primary survey, Harry will give us venous access, via a large-bore cannula, and then we will immediately give 30 milligrams of ketamine, one gram of paracetamol and one litre of warmed Hartmann's, please.

I've got the ketamine.

I've got the paracetamol and Hartmann's. Justin?

Yep.

We're going to need cold swabs.

Yeah, I'll get them.

That's it. Just open up.

'Evacuate immediately. Alarm areas sounding a continuous tone. Exercise extreme caution and report evidence of a fire...'

I'm Dr Chandramohan, the anaesthetics registrar.

Can you tell us your name?

(Faint murmur)

Name?

We need to check your airway.

Let's get that scoop out. Yeah.

Make her more comfortable, please.

Unclip top and bottom. Unclipped.

OK. Brace and to the patient's left. Very gently on three.

One, two, three.

OK, I need to look at her back.

OK. Back on three. One, two, three.

Brace right on three.

(Machines beep rapidly)

One, two, three.

Back on three. One, two, three.

All right, my love. Well done.

I'm Fiona Lomas, trauma reg.

I need to examine you.

Let's keep the non-burnt areas warm, please.

Right you are.

'Alarm areas sounding a continuous tone...'

I'll scribe.

'Alarm areas sounding a continuous tone. Exercise extreme caution and report evidence of fire or smoke at once.'

Look, we don't know who she is yet, so clear off, please.

Thank you, Nerys.

Can you understand me?

What's your name?

(Faint groans)

Facial burns, partial-thickness.

Soot in mouth.

Small amount...

Suctioned.

Carbonaceous sputum.

Again, small amount...suctioned.

Singeing of nasal hairs.

Good peripheral perfusion.

OK, someone has got to have seen her go into the changing room?

Giles is checking the CCTV.

Has anybody seen Lorraine today?

Oh, my God. It's Lorraine?

We don't know who it is.

That's right. We don't.

I'm calling the Burns Unit.

Excuse me.

Look, everyone, I know this is not easy, but please can we just treat her like any other patient.

Yeah, this is Mrs Hicklin.

Can you put me through to the consultant on call for Burns?

Can you open your mouth for me, my sweet?

I can't get anything. Keep trying.

Any intra-oral burns, oedema?

No signs of either.

Upper airway appears clear.

I need to give you some oxygen, my love.

The mask might be a bit uncomfortable while the painkillers kick in.

OK, well done.

100% O2, 15 litres a minute.

Just waiting for the sats reading to come up.

Vitesh, Nicola Hicklin.

We have a woman over here at CGH with greater than 50% full and partial-thickness burns.

No, we've no ID yet.

I'll let you know.

OK, cheers, Vitesh.

Reasonable ventilation across both lung fields.

Good carotid and femoral pulses.

Widespread full and partial-thickness burns across the chest.

Can you upload the referral form to the Central Infirmary Burns Unit once we've got all the necessary information?

Yeah.

Adding to that, that we believe it may be a member of staff.

Of course, Fiona.

Oxygen saturation?

100.

We'll confirm that with ABGs.

OK, so better iv access first, tube second, ABGs third.

Let's do it. Subclavian line.

'Alarm areas sounding a continuous tone, evacuate immediately.'

Can you do us a favour and bleep the consultant anaesthetist on call. It's Molloy.

What did your last sl*ve die of?

That's a bit r*cist.

Go away, please!

I'm pausing the primary survey till the patient gets something for the pain.

I've done you 30 of ket, Lomas. It's in there.

Thank you.

You'll feel a sharp scratch just underneath your collar bone.

OK, we're going to take care of you.

We're going to give you something for the pain.

Yes, I'm calling on behalf of Dr Chandramohan.

Could you fast bleep Dr Molloy?

So, this will be the sequence of events.

Once Ramakrishna has cannulated the subclavian vein, he'll take a syringe of blood.

Harry, you'll receive that syringe and you'll send it for FBC, U and E's, G&S, TEG, EtOH, beta-HCG and drug screen.

And don't forget the drug screen.

ABGs to follow, including carboxyhaemoglobin.

Yes. Yes.

No...MOLLOY.

Consultant anaesthetist.

Yes. Yeah, that's it. Thanks.

(Fire alarm ends)

Thank God for that.

Send those straight off, come back for an ABG.

(What's going on?)

(She groans)

Can someone prep me for an art line, please?

I'll get it.

Mrs Hicklin, can we catheterise the patient so we can monitor her urine output, and start a fluid chart, please?

OK.

Sister, let's prepare some sterilised gauze to remove any loose flesh or burnt clothing.

And let's source some clingfilm please.

Yes, Mr Boyle. Justin, burns kit.

We haven't had the handover yet.

I was in the male changing room.

Heard shouting and ran over to the female side.

She'd barricaded herself in, so it was hard work getting to her, but luckily, there was an extinguisher in the corridor, so...

You put the fire out?

Yes.

Well done.

Yes.

Well done.

We're going to give you something to make you comfortable.

Ketamine and paracetamol given.

Thank you.

Hartmann's running in.

You're going to feel a strange feeling at the top of your chest.

That's just the fluid running in.

OK.

Resuming the primary survey.

Bloods have gone.

Cheers.

Harry, ABG.

(You bastard.)

She's very pink.

Whoa, whoa, whoa!

Cherry.

She was in an enclosed space.

She's hypoxic.

Can't be. Her sats are still 100.

Guedel, oxygen. Yep.

Diazemuls.

Need to oxygenate.

But what about the sats?

Shut up, Billy.

Come on, Justin, come on.

Justin: Coming, coming, coming!

Glen: She's asphyxiating.

It's OK... sh*t!

Come on!

sh*t!

sh*t! Come on, Justin, come on.

Coming, coming!

Yep.

Diazemuls ten milligram iv, given.

It's OK, you're OK.

(OK.)

Good.

What's her carboxyhaemoglobin?

30% and her CO2 is 12 point...

Whatever, she's got severe CO toxicity. I need to tube her now.

We. Thio 125, sux.

Get the GlideScope ready. Yep.

Ready for the cricoid?

Yeah.

Done it before?

Yeah. Great.

Thiopentone, 125...in.

Come on, Billy, come on!

You'll have it. You'll have it.

Breath sounds diminishing...

Come on!

Sux, 100... Yeah.

..in.

Bougie at the ready.

Lady wand.

Not the time or the place, Billy.

(sh*t!)

Not liking what I'm seeing...

(Alarm beeps)

(sh*t!)

Bougie.

Tube.

She's on the bougie. Yep.

Subglottic oedema.

OK.

sh*t.

sh*t.

It's closing off the airway.

Can we get the tube in?

I need you to tell me what's happening.

Laryngeal mask.

Yeah, copy that.

Backs!

Mini-Trach, gloves and gown, please, now.

Need an answer, Ramakrishna.

I NEED an ANSWER.

There you go.

Yeah, OK.

OK, LMA in place.

Oh, Godsake, why me?

VF arrest.

Get me gloves, please.

Femoral absent, carotid absent.

Compressions and defibrillation.

OK, so we're bagging via LMA, so it's 30:2. Go.

(Continuous alarm)

OK, go.

150 biphasic. 150 biphasic.

Defibrillator: '150 joules biphasic shock. Charging. Charged. Prepare for shock. Warning. Stand clear. Warning. Stand clear.'

Shocking in three.

Everybody off.

Oxygen away, Justin off the chest.

One, two, three... shock.

Back in. Come on. Restart compressions.

Two minutes of CPR, please.

I'm not happy with this ventilation.

I'm going to try and tube her again at the end of this cycle.

OK. What's the smallest tube you've got there?

6.0.

So what's the story with the sats?

Pulse ox misreads carbon monoxide poisoning as a normal oxygen saturation.

I knew that. Yeah.

Radiographer.

Sorry.

Well done for rescuing her from that fire.

30 seconds gone, 90 to go. Thanks.

I want to apologise for badgering you over apparent discrepancies in your CV.

An Army contact told me what happened.

Right.

No wonder you needed some time off.

Your actions in Afghanistan were admirable.

Thank you.

60 seconds gone, 60 to go.

OK, let's use this time to calculate surface area of burns.

Anyone?

By rule of nines and with visual estimation, it's 65%.

OK.

Using the Parkland formula, with estimated weight of 60 kilos that gives us four times 60 times 65 which equals 15.6 litres over the first 24 hours with 50% given over in first eight hours, ie 7.8 litres.

Good.

65% of body surface area is b*rned.

Gives her a 50% chance of survival.

As per Harry's calculation, that's one litre per hour for the first eight hours.

Did you really work that out for yourself or did you cheat?

Five seconds.

We weren't even going out properly at the time and you were acting like an arse.

So no change there, then.

Time. I need to get in during the pulse check. OK.

Need quick hands, Billy.

Yep. Charging.

Defibrillator: 'Shock charging. Charged. Ready to shock. Warning, stand clear.'

I need to get in.

It's oxygenation that she needs.

Glen: Delay shock.

Justin, off the chest.

Femoral absent, carotid absent.

OK, let's go.

OK, tube in! Get in!

Defibrillator: 'Ready to shock...'

Shocking after three. Everybody clear.

Oxygen away.

One, two, three.

Compressions, come on.

Another two minutes of CPR.

Time is 22 minutes and 30 seconds.

Let's be ready with adrenaline for after this cycle, please.

OK, we can go asynchronous now.

That Mini fell through.

The black one with the 20 thou on the clock.

Guy got a better offer.

I'm gutted.

OK, we're moving more air now.

We've got ROSC.

Can we stop CPR, please?

Sinus.

Carotid output, femoral output.

OK, OK, that's well done, everybody.

Let's get a plain chest film, please, and then we're going to transfer her to the Burns Unit. OK.

Portable machine's in use.

OK to move the patient down to the overhead?

OK, let's go. Quick as we can please, quick as we can.

Go. Get going.

Nicola: Harry, you should be back in ED.

Tannoy: 'Will all staff please return to their stations?'

(He knocks)

'Will all staff return to their stations? Thank you.'

Security sent me the CCTV footage.

(Machine beeps)

Rays in three.

One, two, three...rays.

Patient is intubated and ventilated.

Tonic-clonic seizure and VF arrest due to CO toxicity, but she's stable now. All clear.

Get in there and finish the clingfilm, please.

OK. Thanks, boss.

Image on screen.

Doesn't look good.

(Machine beeps rapidly)

Got a problem.

Move, please.

Chest compliance is down.

Poor oxygenation.

The burns are constricting her chest.

She needs escharotomies.

Right now, please. OK.

This is Fiona Lomas, trauma reg.

Could you fast-bleep Trauma theatre staff urgently, please.

What's that she's got there?

Sanitizer gel.

Highly flammable.

After she barricades herself in, nothing happens for some time.

Oh, God.

(He sighs)

I'd best tell the trauma team.

I don't think that's a good idea.

They need to know who their patient is.

I don't think that's going to help anybody right now.

(Machines beep)

Diathermy, please.

Thank you. Swabs, please.

Chest compliance is even worse.

Her lungs are getting really badly compressed.

OK.

That loosened the chest.

Lung compliance and tidal volumes are still way down.

Hi, boss. We've some real issues with ventilation here.

Emergency escharotomies are in progress. Right.

It's definitely Lorraine.

I thought you should know.

You don't have to do this.

Yes, I do.

It's not changing.

It's not enough.

You need to release more scar tissue.

OK, we'll do transverse incisions.

I can do it if you want.

I'm doing it.

Chest compliance improving, tidal volumes increasing.

Tidal volume continues to improve.

End tidal CO2 is dropping, sats now rising.

I'm happy to do the transfer.

I'll call my opposite number in the Burns Unit. All right. Cheers, boss.

Let's get her a face mask.

Prep her for the Burns Unit, please.

Face mask, burns box, resus.

Cheers, Billy.

She stands a decent chance.

Of what?

A lifetime of pain and disfigurement?

She was misguided.

I had to challenge her, for the good of the department.

(Yeah.)

There are HUNDREDS of members of staff whose careers, livelihoods and families depend on the success of this unit.

I couldn't let one person derail that. No, you couldn't.

(Door opens)

Anything to say?

Who told you?

Doesn't matter. I've been told.

If I ever thought Lorraine would do something like this... What?

Then you wouldn't have ruined her career?

The only thing Lorraine ever did was challenge the way you run this department.

We don't yet know the range of emotions that motivated her.

No?

Someone should inform the next of kin.

Well, not you.

There's a husband and two young children.

Joshua's six, Olivia's four.

(Phone rings)

'John Rappaport.'

Mr Rappaport...

My name's Fiona Lomas.

I'm one of Lorraine's junior colleagues.

'Yes?'

I have very bad news.

I'm afraid Lorraine's been involved in an accident at work.

She has sustained severe burns.

'My God.'

We're transferring her to the Burns Unit at the Central Infirmary... and I think it would be best if you made your way there directly.

'Yes, I will.'

I am so sorry to have to give this news over the phone.

Mr Rappaport...

Fiona...

I've got it.

Mr Rappaport, it's Giles Dhillon.

I'm very sorry.

Sats are still dropping.

Have you checked the circuit?

Yep.

Ramakrishna, what's happening?

(Multiple machines beep rapidly)

No.

No, there's no leaks, no.

Must be the tube. Yeah.

Another 6.0.

Yeah.

No, make it a 5.5.

Tell me.

We're not ventilating the lungs.

Sats are now 80%. Yeah, I can read.

(Come on.)

Facial oedema's pulling out the bloody tube!

Off the vent. Yeah. Crike set!

Crike, over here. Yes, got it.

Come on, move.

No, bougie. There you go.

Ties!

Tube.

Get it out. Yep.

OK.

Sats are now 60%.

Ramakrishna, I'm giving you ten seconds.

Nine. Eight.

Seven. Six.

Five. Four.

Three. sh*t. Two.

One.

Blade, please. Clear, clear.

Haemostat.

Trach.

Inflate, please.

(Single machine beeps)

Ventilating. Good.

Thanks.

Patient back on vent. Sutures.

Cut it.

OK.

We keep her warm and then we transfer her to the Burns Unit.

Yep.

Let's make sure she gets there this time.

Brake on.

Moving on three, everyone ready?

Yep.

One, two, three.

I'll call as soon as I hand her over to the Burns Team.

(Radio communication in background)

Transit time is five, ten minutes right?

Nearer five. OK, good.

(Machine beeps)

I need to unstrap.

(He sighs)

You got 200mg of hydrocortisone?

Great, thank you.

We've got a bit of a problem back here, we need to get down ASAP.

Radio: 'En route to City General...'

sh*t. Got suction?

Yep.

Sorry.

Oh, sh*t.

Come on.

(Continuous beep)

sh*t.

Oh, sh*t!

Can you do compressions?

I need to bag her.

Not enough room.

We're going to be landing ASAP.

I should bag... We're going to be landing. You need to be strapped...

I need to bag her! ..in!

Locked and tight in the front.

Locked and tight to the back. Patient is secure.

Down.

Ambubag and adrenaline.

Get on the chest, mate. Right.

Adrenaline given.

She's drowning.

Massive ARDS reaction to smoke inhalation.

We're done.

This is a coroner job, so we need to leave everything attached.

Sorry, mate.

We'll take her in.

Thanks.

Mate, it's Billy.

All right.

(He sighs)

I've got it.

Billy?

It's Giles again. Ramakrishna, stay where you are and I'll organise some transport for you. Billy.

She d*ed en route.

Yes, she's here.

Dr Bennett-Edwardes, he wants to talk to you.

Er, yeah, tell him I'll ring him.

She's going to give you a call.

It must have been a terrible ordeal and we're all thinking of you.

Yep. I'll call you back when I know who's coming to get you.

Fiona...

Fiona! She didn't even get there.

You bastard!

I'm terribly, terribly sorry.

Stop!

You will stop!

I'm so sorry, baby.

No.

There's something I need you to see.

Please.

OK.

I wasn't on active service when you called me.

My last deployment finished months ago.

I've been on...

I've been on long-term leave.

(Soldiers shout)

What is this?

It's a helmet camera. It's not mine.

It's our... forward operating base in Afghanistan.

(g*nf*re and shouting)

The guy sh**ting at us is Afghan.

He's meant to be one of ours.

We sh*t him three times.

He was your friend?

He was.

I thought I knew him.

Soldier: 'I need a medic!'

Why didn't you tell me?

What?

I...

Because I'd have known?

Known?

Known what?

That this is why you're here.

Another chance to save lives.

And now look. Lorraine...

Lorraine wasn't anyone's fault... but Clive's. Hah! OK.

And your friend... you did the best you could for him.

You don't understand.

OK.

I can't... pretend to understand what you've been through... but it wasn't your fault.

You couldn't save him.

I wasn't trying to save him!

I wasn't trying to save him.

It was completely the opposite.