01x12 - Episode 12

[bunniefuu]

Hi, Tom. Thank you for the flowers. They're lovely.

What's the big occasion?

You need to tell him what's going on. And, frankly, you need to tell me.

I need to see you. I can't.

Because of Tom?

Because you're leaving.

'Major traffic incident. Multiple critical injuries. Imminent. Trauma call...'

Rhythm check. BF. No pulse.

Back on. Charging?

Yeah. Everyone except Justin stand clear.

We need to open his chest.

'150 joules selected. Charging.'

'Charged.'

Justin, stand clear.

Shock in three, two, one. Shocking.

Back on the chest.

Rebecca, gown up. What size gloves?

Em, six, please.

You ever done this before?

Er, no.

OK, we cut fast and we cut deep.

OK?

You follow my lead.

I'm not shaking. It's cramp.

Harry, what are you doing?

Checking for signs of life. No, he's dead.

Move on. Harry...

We did everything we could.

Time of death: 17.31.

And get the mortuary technicians up here straight away.

Ties.

Carry on with the CPR. I'm going to work around you. 'Trauma call.

'An estimated further 6-8 critically-injured patients due within the hour.'

Can you give us some more room in here?

Blade.

Off the chest.

Ready to go?

Fast and deep.

'Due to a major incident, we're experiencing severe delays in all departments. We apologise for any inconvenience or distress this may cause.'

The shears, please.

Yeah?

Asystole now. sh*t.

Get an aortic clamp ready.

No outputs.

Tractor.

OK, as soon as we're open, get in there, compress the aorta. Yeah?

Yeah. Go, now.

Harry, in my pocket is my mobile.

Call Fiona, tell her we need more hands down here.

Other pocket.

OK, clamp it up.

I need her on the phone immediately.

Nice.

(Phone buzzes)

No nagging doubts?

No, it's time.

It makes sense for us.

I'll get our coffees. OK.

'You have one saved message. Fiona, we need you in Resus.'

'Due to a major incident, there are severe delays in all departments. We apologise...'

Constance, how are we doing?

Well, there's three for Resus and plenty more coming.

Let's just start getting them moved through.

OK, motorcyclist pulled under a lorry, which started a pile-up.

De-gloving injuries to his limbs and thorax. He was given needle decompression at the scene.

OK. Obs?

Rests 24.

Pulse 116. BP 102 over 70.

And low GCS.

Any extra staff here yet?

Leave it with me!

Where's the receiving team, then?

Er...

It's just me for now.

We've been through triage.

That's just a queue. Who's this?

P1 from major incident.

Coach passenger - leg fractures and chest pain.

OK, in here, please. Er, right.

I'll try and get some extra hands.

'Staff please ensure that all walking wounded are held...'

Anybody free to give me a hand, please?

You OK?

Let me get to it.

The quickest way to get his heart started is to get blood in fast.

OK, you just hold this, please.

Thank you. Just cut there, please.

Thank you.

Thank you.

OK...

Thank you.

Can you just take that top off, please?

OK, I'm going to run the blood straight into this line and, hopefully...

..the volume will get his pulse back up. Connected. Get back on the heart massage, please.

Let's get some more O Pos from the fridge, please.

No O Pos left. Crossmatch?

No, he'll take longer to match.

OK, let's get Nicola. We need to find some O Pos from somewhere.

First major incident, Justin?

Er...

Aww, we've got a Maj Acc virgin.

Don't worry. This won't hurt much.

He's no virgin.

Ready for rays. Stand clear, please.

Billy... Don't tell, Billy...

Rays in three.

One, two, three, rays.

How's it going?

Looks like it'll be a busy evening.

Anything I should know?

They're heading for theatre.

What happened to you on Wednesday?

It wasn't possible.

There's something I need to speak to you about. Yes. I need to talk, too.

I've been offered a post. Sorry.

I don't know what to do next.

OK. I'll take this one.

Sure. We'll talk later.

Yes, let's.

He's got bilateral femoral fractures and chest pain. OK. Is he stable?

Yes, but in a lot of pain.

25 seconds to pulse check.

I called the medical registrar, but there's no doctor to see him. OK.

I'll come as soon as I can.

Let's get him started on morphine and fluid.

Let me know if anything changes.

OK?

OK. Thanks.

This is the last of the O Pos from theatre. That's not enough. We don't know how long crossmatch will take.

I'll send Giles for more. And the chances of moving that body are...?

Heart's contracting. Let me see.

As soon as I can. Thank you. There's a pulse. Give me BP. 77 over 48.

Do we have him?

Yes.

OK, let's get that blood into him fast, Harry. And then package him for transfer.

'Clinical Lead please contact Head of Human Resources immediately.'

Blood.

Can you chase CT?

Mm-hm.

You're in there, mate. Think so?

There's only one way to find out.

It's CT.

We'll be there in five minutes.

Harry, get started on the patient in A, please. He's for Theatre 7.

Rebecca, cardiothoracics, general surgery and your boss'll take over.

Thank you.

On vents. Sats are good.

15 minutes 'til CT. Book it.

..We'll take it.

We'll do an extended fast.

Can you get the ultrasound, please?

Coming through.

Harry, start the primary.

I'll be back in a sec.

Justin, keep going with what's prescribed. I need another ECG.

OK, tell me the story. This one, asthma att*ck, resp 33. Thank you.

A head injury, lost consciousness, GCS 14 with neck pain.

Pulse 104, but otherwise he's stable.

And this one?

Em...

Needs a tube.

Spinal injury, GCS 8.

OK. He goes to ED.

The other two stay here. Harry, leave him, I need you here now.

Justin... Yeah.

This guy goes to Bay B. Constance will help you. I've got him sorted.

We're going to double bed.

The spinal in there. I'll start, Rebecca can take over.

We really need more hands down here.

Enough!

Glen, everybody's asking me about this. I've chased it and they're on their way, OK?

Abdomen's distended.

Get more O Pos, please. Yeah.

They're full for half an hour. sh*t.

Yeah. OK, book it. Yes, please.

We'll have to manage him here until then.

Weak radials.

Right ankle pulses are absent.

Right's cold compared to left.

Billy, Doppler, please. Yeah.

The calf is hard and dull.

This guy needs an urgent fasciotomy and theatre.

This can't wait 30 minutes.

Can you call them again? Thank you.

Yeah, Resus.

We now need urgent fasciotomy.

Yes, now.

No DP or PT flow.

Knee...

Try fascic flow. Billy, can you see if the x-rays are up yet?

Yeah.

They're up.

And no fractures.

Compartment syndrome?

Yes.

About 90 minutes post-injury.

No luck with the theatres. OK, you're right. He'll lose a leg.

So you'll do it here and...you, Anna, you'll assist.

Scrub up, please.

Now.

OK, Ania, come on. Are you sure about this?

Absolutely.

I'm not prepared to accept an ischemic leg. Time is muscle.

(You don't see this every day, do you?)

Billy, Ramakrishna, get him set up.

Just have a feel of your chest.

A lady outside is looking for her husband. He's been in half an hour.

It's Jim Waters.

Er...that's Jim Waters.

Oh, God.

OK...can you talk to her?

Er, no. No, I can't leave this patient. I'll bring her here.

No...! Give us a minute to get rid of him. sh*t.

Guys, you need to go away. Now.

Let's move it, please. Constance, can you hook up the oxygen?

Yes.

OK, we're just going to put a clean sheet on and then we'll move you straight over.

Billy, my ties. Thanks.

Antiseptic, please, Billy. Yeah.

Drapes. Yeah.

I need you to lift up the leg.

Here we are.

Another drape, Billy. Yeah.

Ania, I need you to hold the ankle.

I need you to keep it steady. OK.

Billy, will you support the thigh?

Yeah.

OK?

I'm going to expose the lateral intermuscular septum.

Cutting.

(Beep)

sh*t!

OK, airway's secure.

Chest is...

Clear. But BP's in his boots.

He needs a laparotomy, boss.

Rapid infuser to maximum.

Can I get some blood?

At maximum. Thank you.

Billy?

Yeah, I'm here!

Pulse is really weak.

BP's gone. Let's squeeze some blood in through this vent.

He needs to be in theatre, boss.

I know! Billy, on the chest.

Are you OK?

Dr Bennett Edwardes?

This is Mrs Waters.

Take these.

I'm very sorry, but I have some bad news for you.

We did our very best, but your husband's injuries were too severe for us to help him.

I'm afraid he d*ed a short while ago.

I'm terribly sorry for your loss.

Let's get you a seat.

(Sobbing)

We'll get you sat down.

It's all right.

There.

Pulse check, please.

BP's back. It's weak, but it's there. Good. Let's keep going on the rapid infusion. Yeah.

Another one for you. OK.

I don't have another reg.

And all the trauma bays are busy.

Congratulations on your news, by the way. Thank you.

And we're sure ED can't take her?

She needs to be in here. OK.

This way, please.

Harry?

OK, let's hear it.

OK, Mavis, 82.

Just discharged from ED at four hours to keep beds free.

Collapsed in the car park with difficulty breathing.

OK, Harry, I need you to take care of her for me, please. Yes?

Of course. Thank you. Hi.

Tell me. BP rising. 88 over 44.

Let's get back to the fasciotomy.

I'm starting the medial incision.

Cutting.

Could you just sign this?

Yeah, sure.

Is this the guy?

Er, yes. Known asthmatic. Thanks.

Brought in from the incident.

Tachynoeaic, tachycardic on arrival and unable to speak. He's been given nebs, steroids and...

Yes, this one. Ipratropium.

Just started on magnesium, but his obs have worsened.

Why wait so long to give him magnesium?

That turns these around.

He might have avoided a tube.

The line was really difficult.

I was drawing stuff up myself.

Sorry. I should have done better.

Get over here and help.

Mavis, I'll be back in just one minute, OK? Could you watch her?

Can we get some help here? Help!

Some help, please.

Go. I'll be fine here.

Can't you find an alternative route?

All right. See you when we see you.

'Due to a major incident, we're experiencing severe delays in all departments. We apologise for any inconvenience or distress this may cause.'

Major incident's shut the motorway.

Extra staff are stuck in gridlock.

What's he doing here?

Oh, yeah.

Turns out he refused to go quietly.

So they had to promote him.

Clive.

Nicola. I hope you don't mind us commandeering your office.

David, Ruth, this is Mrs Hicklin.

We're struggling to move patients to CT, theatres or the wards.

It's in hand.

I'm trying to clear the decks elsewhere. Do we not have any space?

All I can see is that you're coping admirably, especially after all the marvellous changes you brought in.

..and after all that, it turns out I had it on me all along.

You're so funny.

You make me laugh so much.

Lovely Billy.

Well, what do you say to a night out?

You, me, some dinner, lots of laughs?

Yeah, that would be lovely.

But as friends.

You know I have a boyfriend.

Y-Yeah. Of course.

You thought I meant...

Nah, just as friends. Cool.

OK.

'Due to a major incident...'

Billy... Billy! With me - now.

Please. Bay C.

BP's still dropping.

Systolic 84, pulse is 120 and MAT is getting worse.

Look, this is new. This bruising.

Retroperitoneal bleed's more extensive.

Ania, can you chase theatre again?

We need to move him now. Don't bother. I'll check trauma theatre.

Excuse me, sorry. Coming through.

Mind your backs, please! Sorry.

Mind your back. Sorry.

I've got to get through.

Sorry to disturb, Mr Street.

How long will you be?

You're the third person to ask.

It takes as long as it takes.

Don't know what his problem is.

At least he regularly gets his digits inside a bird.

Here.

I got a three-month contract to continue working here.

What about your army deployment?

I've deferred it.

There's her bloods.

Right, her potassium's not helping.

OK, 10ml of calcium chloride, then magnesium and insulin dextrose.

She's still in VT with output.

Can I have help with her airway?

I'm busy with your other patient.

Calcium chloride, 10ml going in.

OK, can we have another synchronised sh*t, please?

Shouldn't we wait until that's gone through?

It's nearly run through and the calcium should stabilise her heart temporarily.

Yes, this is Glen Boyle, Trauma Consultant. I need a theatre for an emergency laparotomy, please.

Maj Acc. MO 0005.

Well, it's an emergency so, yes, I need it now. OK, understood.

News?

Another 15 minutes at best, but Street knows about him and Nicola's trying to find a theatre upstairs.

BP's still abysmal.

OK, let's keep transfusing him.

Aim for 90 systolic.

CT and theatre are busy, so let's get Shelley to redo the x-rays.

Justin, you can do that. Call X-ray.

Em, Billy can you...?

I'm busy.

Thank you.

'Due to a major incident, we're experiencing severe delays. We apologise for any inconvenience or distress.' Justin here.

Hi, Shelley.

Yeah, fine. Can we get more x-rays in Resus Bay C, please?

Thanks.

Glen?

We have a prolonged entrapment on its way. Low GCS.

They intubated him on scene.

I've cleared an ED cubicle for an extra Resus bay.

And what about those extra hands?

Clive won't reallocate onsite staff.

Clive?

He's been moved up to management.

I know. What I need is you to cope until people start arriving.

I've got the on-call surgical SHO coming and we can ask Dominic after he hands over the asthma patient.

Can you spare anyone?

(Beep)

Oh, sh*t.

Do I have a choice?

Thanks, Glen.

BP's dropping again.

It's 68 over 34... sh*t!

He's oozing from his lines.

Give him calcium and more clotting factors. He's cold. Bair Hugger!

Yeah, switch, give me theatres, please.

OK, this is Glen Boyle.

Maj Acc MO 0005.

He's deteriorated.

I really need to bring him up now.

Coagulopathic, yes.

Transfusing, yes.

OK, thank you.

OK, let's prep for transfer.

They'll be another five. We'll continue transfusions as we go.

I need to check the other bays.

Give me a shout if anything changes.

Carry on with x-rays?

Yes, please.

Harry? Update, please.

Er, yeah. This one is medical and this lady, the medics are taking her. Good.

I heard your news. Well done.

I hope you have more luck than I did choosing the right one. Thank you.

Harry, Constance, with me, please.

Anna, here.

I need you to go with Harry and Constance to ED. There's a surgeon and I'll send Dominic over ASAP. Go.

Em...it's Ania.

Right.

Harry?

Hm?

I need you to take the lead on the prolonged entrapment.

No, I...

If there's a problem, call me. Yes?

Yes. And thank you.

I'm ready for rays. Thanks.

Rays in three.

One, two, three, rays.

Cubicle four, please.

Hi. Handover first, then we'll put him on the trolley.

Shouldn't we wait for the Trauma Team leader?

That's me. Oh.

OK, I've got a male in his late-30s, came off his motorbike.

He was trapped in a lateral position between two vehicles for an hour.

He told me he hadn't been KO'd and he had a pain in his chest. Tubed at the scene due to difficulty breathing.

We needed a high flow of oxygen to keep his sats acceptable.

Equal air entry, but bilateral surgical emphysema and rib fractures.

Surgical emphysema has extended to his upper chest and neck.

He had bilateral thoracostomies.

Circulation is stable. Pelvis and leg seemed to escape major damage.

OK, great, thanks. Move him across and I'll manage him on vent.

Sorry.

Can you help us?

On three. One, two, three.

I've got it. That was trauma theatre. Street's been delayed.

You'll have to start on your own.

You're not coming?

I can't. I'm needed in Resus.

You'll be OK from here?

I will.

About extending your contract. Yeah.

Make sure it's the right move.

Don't mess up your army career.

Need to go.

Yeah.

Equal bilateral air entry.

That feels weird.

Er...I mean surgical emphysema and...

..bilateral rib fractures.

The abdomen is not distended.

(Beep)

Why are his sats dropping?!

Oh, sh*t! The tube's come out.

I'll go get help!

Got it?

C-spine immobilisation here.

Bag and mask, please.

(Come on...)

Guedel!

Come on...

His chest's not moving and his sats aren't going up.

Check the thoracostomies, see if they're open.

And then a laryngoscope and a tube, please. ..sh*t.

Come on, come on. Sats are dropping.

I can't see anything.

Surgical emphysema... Tube.

OK, I think I can...

Come on.

Oh, sh*t... I can't.

Oh, sh*t! I've made him bleed.

(Beeping intensifies)

Constance... Hang on! Easy.

Let's try and get this tube in him.

Here, let me.

Look, his sats are 61!

One sec. He needs an airway, Dominic! Hang on!

This is in the way.

His sats are still falling!

If you don't stop, he's going to die! Damn it!

Stop! He can't ventilate. Move.

We do this now. Blade.

(Constant beeping)

We're in.

Cuff up and ventilate.

Hold this, please.

Ventilating.

Sats rising.

Roberts out. Scissors.

Splenectomy is complete. Packs.

Two in.

Two in, eight in total.

BP still dropping, systolic is 70.

OK, moving on to the retroperitoneal bleed. Um, hang on.

Yes?

Shouldn't we examine the rest of the abdomen first?

We have to address this bleed. But...

We don't have a consultant present.

Someone has to lead. Yes?

Thank you.

Evidence of an expanding retroperitoneal haematoma.

BP still dropping, systolic now 67.

Let me see the pelvic x-rays. Yup.

Four out.

Four out, four in.

OK. No pelvic fractures in evidence.

So the haematoma is... probably venous in origin.

Agreed?

Agreed.

Forceps, McIndoes.

Can I just say something?

Quickly!

Shouldn't we be treating this a bit more conservatively?

His BP is still falling. He can't wait. If the bleed is venous, why risk opening him up further?

OK, I'll do some extraperitoneal packing to stabilise him until Street gets here.

Mains forceps.

Pack.

Six in.

Six in, ten in total. OK...

BP?

It's holding.

Holding.

Holding.

(Beep)

Oh! Come on!

Forceps, McIndoes - now!

Dropping. Systolic is 64.

Massive arterial bleed. Suction.

Billy, whack it in! Yes!

I can't see a thing here. I need another suction. Suction, quickly!

I can't see anything here! Quickly!

I can't locate the bleed.

It's got to be in the pelvis.

There's no fracture!

(Beeping)

sh*t! BP's dropping! Billy!

Yes, we're on it!

Packs! And again.

Where's Street?

Systolic is 60!

Billy, faster with the blood!

Going full pelt! Systolic is 57.

It's dropping. 53.

sh*t, he's crashing.

Fiona?

Glen, I need your help. I can't control this retroperitoneal bleed.

Where's Street?

He's not here.

I need you in theatre now.

Bay B, please. I've got seven patients here, three are unstable.

There's no way I can leave. Sorry.

Glen, I'm losing him.

Tell me exactly what's happening.

OK, I've packed him, but his BP is still falling. Systolic's around 50.

It doesn't make any sense - there are no torn vessels and the pelvis is intact.

And we're sure it's not a fracture?

I'm looking at the x-ray right now.

Hold on, hold on. Glen...

Stop. Where are we taking him?

OK, in there. We're double bedding.

The x-ray, is the pelvic binder on?

Yes. OK, listen...

Put me on speaker.

You heard him.

OK, go ahead.

OK, everybody listen to me.

If this is what I think it is, the chances are the pelvis is fractured.

The binder has reduced it, so we can't see the break, but it is there.

X-rays are too low-res to reveal it.

sh*t. We skipped CT. Yeah.

Analgesic?

Er, morphine. 10mg?

Yeah. 2.5 at a time, yes?

Go. This is what you need to do.

You need to unpack, get in there and clamp off one of the arteries.

If you can't determine which one, well, you'll have to do both.

Both of them?

Yeah, I know.

It's crap, but yes.

OK, got it. Good.

Take me off speaker, please. ..Stop.

Go. You're off speaker.

You're more important to me than the army. OK?

That's why I'm staying.

I have to go.

I'll speak to you later. Good luck.

Thank you.

Right.

We're unpacking.

And this is going to be fast.

Is everybody ready?

Yes, Miss Lomas.

Ready.

Ramakrishna?

Yeah, let's do this.

Unpacking.

Four out.

Four out, ten in. sh*t.

OK, get in there with suction.

I can't get to it. The vessels have collapsed. Get me another suction.

I have the common iliac bifurcation.

I'm searching for the internal iliacs.

OK, let's be ready with McIndoes, Dardicks, sling.

How's it going?

What happened?

He was can't intubate, can't ventilate. Needed a cric.

Otherwise stable.

OK, well done, Dominic. Is he going to CT?

Yes. I need to book him in.

Then get him booked in!

Then get him to Resus Bay C, OK?

Yes, Mrs Hicklin.

Dardick.

That's the right internal iliac artery clamped.

No good. He's still hosing. Give me another suction. Blood, please.

Systolic's 50. It's no good.

OK, I'll have to clamp the other artery. Sling.

Quick!

Ta.

Got it.

OK, clamps. Let's get his volume up.

It's happening.

Systolic still 50.

Rising. 55.

Systolic still rising.

Now 60.

65.

Mr Street, Gen Surgery consultant.

Scrubbing in.

Thank you.

We've got another P1 coming in now.

I found you an anaesthetist and a gen surg reg. Good. This way.

Go and get ready in Bay A, please.

Em, two theatres are clear and a CT list has been cancelled, so we can start moving patients. OK.

Thank you very much for today.

You're welcome.

I'm glad you're staying.

Is there any news on his ITU bed?

It's free. A team's coming now.

Great. OK, everyone happy?

It's easy to manage patients that are completely stable.

At least I did something when he lost his airway. You did the cric?

I threw a lot at you today.

Very impressed.

Yeah, well done, Harry.

Did we win?

Yes.

Good.

Can we talk?

I hear congratulations are in order. When's the big day?

I asked him not to say anything.

Have you got the ring? Can we see?

Go on, show the ring.

Oh! Put it on. Let's see it. Go on.

Aww, it's beautiful.

That is gorgeous. Congratulations.

We've got another patient coming in.

ETA is five minutes.

If we could go and get prepared in Bay A, please.

Please.

I'm so... Yeah.