01x02 - Episode 2
Posted: 03/04/15 16:17
This is Mrs Rappaport. I'm the consultant on call for major trauma.
Resources are stretched.
Well, then, some of us need to raise their game.
Where is this going, exactly?
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 think my boss just got suspended.
SIREN BLARES
'Trauma Call - attend Emergency Department... Trauma Call - attend Emergency Department.'
She went off a couple of minutes ago.
Shit!
Let's get her inside.
Move. Move!
Right, mid-40s female, next door neighbour at 4.30.
Not now, luvvie. Wait till we're inside. Sorry, Nerys.
Is this the...?
Yes.
Have you got who's Trauma Consultant, today?
Uh, that information's not come through yet.
Call Clive, please. Colleague call -
Dr Archerfield, please attend Trauma Resus, urgently.
Starting the clock.
Critical airway.
Straight into the bay. No hand-over.
Where's Dr Chandramohan?
On study leave, today.
Who's covering?
Dr Busby. Fast bleep him, we need an anaesthetist.
On three - one, two, three.
What's with the whole Elephant Man thing?
Right. Oh, my God.
Bloody hell.
Can you fast bleep Dr Busby for me, please, and Dr Archerfield.
100% oxygen, and bag as best you can.
I don't know if you can hear me, but we're going to do something to help you breathe.
Thio, sux, 'scope, bougie, narrow tube.
Don't be daft.
You'll never get a tube in.
Cannot intubate. OK. Fiona!
Could you fast bleep Dr Barnby, please?
Busby.
Busby, sorry, and Dr Archerfield.
To Trauma Resus.
Well?
Thanks.
Yep. Put the call out. Getting any in?
The wood's in the way. What is it?
Fence post. She fell out a window.
Poor ventilation across both lung fields. "Cannot ventilate."
Give me a sat. Yeah, in just a second.
OK?
OK.
Yep.
Oxygen saturation 60%. Shit.
Fence post. 60%.
This is the situation, "Cannot Intubate, Cannot Ventilate."
She needs a tracheotomy.
Nerys, can you write that down, as stated by me.
And the time is...one minute, 20 seconds.
Oxygen saturation now 50%.
And falling.
"Cannot Intubate, Cannot Ventilate."
You've covered your arse.
Now let's do it.
Looks like Clive isn't joining us.
Nerys. Nice and calmly, please, get a Quicktrach ready to go. Bloody hell!
Uh, Thiopentone and Suxamethonium doses?
200, 100. Got it.
Let's get the blocks off. Harry, can you give me a hand?
I'll give in-line immobilization.
Thiopentone.
Flush. Sucks.
Thiopentone, 200 milligrams, suxamethonium, 100 milligrams - given.
Flush.
Quicktrach to me right now, please.
sh1tting shit!
It's coming up to two minutes 30 - no airway.
Anyone heard from the anaesthetist?
It's just us.
OK.
Step away.
PATIENT CRIES OUT Shit, she's not under.
Ketamine, 30 milligrams, now, Billy!
Yep, yep, yep. It's all right. It's OK.
I'm drawing it. Billy! Come on, quicker!
I'm coming, I'm coming, I'm drawing. One second.
Come on, Billy! Come on!
Come on, Billy. Give it!
Stay still, stay still.
Now coming up to three minutes.
Still no airway.
Good girl, come on, that's it.
You'll be fine.
It's OK, it's OK.
Come on, darling, here we go.
Ketamine, 30 milligrams, given.
OK, she's under. Step away.
You have done this before?
I have now.
I'm getting air.
Thanks, Billy. Sorry.
Water off a duck's back.
I'll hold the trach in place.
Attach the strap and loop it around her neck, will you?
Bagging.
It's OK.
Oxygen and saturation climbing, now 70%.
Yeah, under the wood. That's it.
Strap's on. OK.
Sats now 80%.
90%. Good.
Airway secure. Scoop out.
Thanks, Justin.
Brace.
Brace. OK, let's get the blocks back in, Justin, please.
Yep, I'll do blocks.
Yeah, I'll help with the blocks.
Well done.
I'm not covering my arse, I'm helping my colleagues make the right decision at the right time.
Stress of the moment.
Mm-hmm. Blocks in?
They're in.
Can someone cut her out of her clothes, in the meantime, please?
Yep. Excuse me, love.
Airways secure.
Ventilating both lungs.
Strong pulses. Good blood pressure.
If only it was always this easy.
Oh, here he is.
Ah. Good of you to join us, Dr Busby.
Shit. The call said ten minutes. She went off in the back of the truck.
It didn't get updated till the last minute.
I never got the update.
Let's not discuss it now. OK.
The trach will tide us over until we get ENT involved.
Sats normalising.
Nice job on the quicktrach.
Thank you.
Can we have the handover now, please?
The patient is female, believed to be mid-40s, but we don't have an I'D yet.
999 call was made by the next-door neighbour, but he couldn't ID the patient.
Said he didn't know her name - she kept herself to herself.
This was at 4.30. Neighbour heard a crash and saw her lying in her back garden.
A first-floor window was open and he thinks she was cleaning the windows.
She landed on a fence-post, hence the penetrating mandibular injury.
No other major injuries apparent on examination.
She was semi-conscious at the scene, GCS - 11.
En route, she started to have difficulty with the airway.
She wouldn't take a Guedel and there was difficulty bagging.
Primark. Important medical information, that is!
Don't be silly. Concentrate.
Sorry. Thank you.
Any questions?
Any analgesia given?
No, due to the GCS.
She's been given 30 milligrams of ketamine here.
She has stuff in her pockets.
All right, let's do a BA3, then.
She's also had 200 of thio and 100 of sux.
Thanks, Billy. Mobile phone.
Mobile phone. Anything with a name?
No, no credit cards.
Tesco Club Card?
Oh! Dry cleaning ticket.
Fruit... Fruit pastilles.
Fruit pastilles.
Can you sign off on the paperwork with Nerys for me, please?
Sorry, she needs to complete a PS20.
Huh?
Major Trauma Patient Experience Survey.
She's unconscious.
Can someone do bloods? Harry?
Yeah. Sure, no problem.
So you're Harry?
Yep, that's me.
Dominic. Dom.
Hey.
Hi, Dom, nice to meet you.
So, you trauma team leader now?
Now?
Instead of Lorraine. No.
Shall I do these?
Billy can do those for you.
HE SIGHS All right.
There's fullness in the abdomen, could be fluid.
Let's get O-neg on standby and G&S and TEG, as well as the usual bloods. Yeah.
Can you run off a VBG?
Yep.
And can someone call CT straight away, please?
I'll call them.
I'd love images of her pelvis and legs.
X-rays now?
If the scanner's free, I'd prefer a CT.
Time is coming up to eight minutes.
Eight minutes, Mark.
That's you done. Thank you, guys.
Thanks, Nerys.
'Leave a message for Dr Ramakrishna Chandramohan, Anaesthetics Registrar. You know you want to.' Hey. It's me, Harry.
Um, what's this about study leave?
This is Mrs Hicklin.
We've got Major Trauma Foxtrot Bravo for a top-to-toe.
No major limb trauma.
Thank you.
Yeah, they can take her right away.
Great. I'll see you there.
Yeah.
Yes. Well, well, let's just keep at it, shall we?
Clive, Sorry. Hi, Fiona.
They put out a call for you.
Yep, I'm sorry, I'm snowed under.
How's it going?
Patient's stable.
I saw earlier, Lorraine's name's not on the rota for today.
No. I tried calling her in the week but she hasn't got back to me.
Yes, well she's still feeling under the weather, poor thing.
If you speak to her, give her my best, will you?
Yeah ... OK...so...we haven't got a trauma consultant.
No, there is somebody coming in.
Isn't he here yet?
No.
A major trauma case needs a trauma team leader.
Yep, well I'm here if you need me.
I'm sure you can cope.
OK.
'Trauma call - attend emergency department.'
Fiona! You better come quick.
Let's keep filling her up and try to get her BP back.
Surgical airway is established, there's apparent haemostasis in the mandible, so I propose we leave for a max-fax opinion once she's stable.
Stop messing about with the blood gas and get back over here.
As I've said, once we have a CT we can send to max-fax and ENT, but right now our priority is addressing the low BP by pushing the blood transfusion.
Agreed.
Uh, did we get gases?
I'm the Trauma Consultant.
Most likely, this in an internal haemorrhage, so we need to find the bleeding and stop it before it kills her.
Let's run a unit of O-neg into each of the Venflons, please.
We're doing that.
Then have another one ready to go up straight after.
Plus two units of FFP, continuing at a ratio of 3:2.
And let's give her a gram of TXA.
We're already 20 minutes into our golden hour, so...
Right now, please.
Who's he?
Nerys, get another two units of O-neg from the fridge. Yep. get them running ASAP.
Who are you, please?
Glen Boyle, Locum Trauma Consultant.
Pleased to meet you. You are?
Nicola Hicklin. Nurse Consultant.
I'm the Deputy Clinical Lead in this department.
You should've introduced yourself earlier.
BP's still down.
So, let's get the transfusions going.
Pressure bags, please.
Yep. Anyone called a Code Red?
No. Well, let's make the call, or call Blood Bank and request 12 units of crossmatch or O-neg, whichever is most quickly available, eight of FFP and four of platelets, please.
OK. You need to sign in.
There?
Do we have the bloods yet?
Sent off about five minutes ago.
This is Mrs Hicklin. I need the following to Trauma Resus, re: patient... EtOH.
Christ, EtOH, I'd forget me head, me.
Tranexamic acid.
One gram IV bolus. Infusion to follow.
Need more access.
I'll do a trauma line. Yep.
And let me know when that's done, please.
Hello, this is William Finlay, ODP, I'd like to request an EtOH.
I can't... If you're not on the system yet, just choose "temporary staff" from the drop-down list. Temporary?
Yep.
Excuse me?
You were going to show us her VBGs?
Oh.
Thank you.
Who's he?
Glen Boyle.
Trauma line's in. Thank you.
Let's run two more units of O-neg through the trauma line, and two of FFP through the Venflons, once the first two units of O-neg are through.
More or less through now.
Crack on. You are?
Justin.
Blood pressure's moved up - now 100 over 80. Sats remain good.
Airway stable pending ENT?
Just about.
Then...let's get her a CT.
OK, but I'd rather... Then...let's get her a CT.
I'll call them. Thank you.
Who's he?
Glen Boyle.
Ms Lomas, Trauma Fellow. We've got a Major for you.
Thanks.
CT can take her now. Blood running in fast now. Cheers.
BP's coming up a little more.
Now 105.
Then let's get her a CT.
Harry, take the drip stand, will you?
Yep, on it.
Finish that for you.
When did you start?
Today.
So, you're not Lorraine Rappaport's replacement?
Who? No.
Temporary. How long are you here for?
Not sure. Just filling in.
You do know that we're a Centre of Excellence?
Absolutely. We're the referral centre for major trauma for the whole region.
I got it.
Get a move on, please.
So, how's it going?
Great.
These trauma calls!
Yeah, I know.
You'll have to back up.
You'll have to back up.
We're here, Brian, if you could open the doors for us, please.
You looked as if you'd seen a ghost.
Could've warned me.
I should have.
I should've called.
No, really?
Sorry.
I thought you would have grown out of trying to catch me off guard.
It's good to see you.
You too.
Sorry. Scan's about to start.
Thank you.
We've been trying to enact a major transfusion protocol, but some of the haematology consultants insist on it going through them.
Well, then someone needs to speak up.
Someone already did.
Lorraine Rappaport.
Hence the vacancy you've just filled.
The orthopod? Where is she?
Rebecca?
Must've gone back to the ward.
Back in a mo. I'm busting.
Usual story, once we reach CT, they start catching up with their normal jobs.
Small subdural.
We're going to need a neuro opinion.
You really are new, aren't you?
Are you chewing?
No.
I'm going to connect up the contrast and start the body scan.
Nobody press any buttons.
Don't worry about Brian.
His bark's worse than his bite.
What a relief.
I don't know if you know, but I teach an intubation tutorial...
Really... ?
Starting contrast run.
Stop the scan!
Stopping...
What's going on in there?
He's heard that if he gives you extra teaching, you're bound to put out.
Dr Busby?
Keep your hair on, Brian.
I cannot work like this.
This is anarchy. Sorry.
What happened to blondie?
Scanning...
The police called. They went to the house and obtained an ID on the patient, but on the system she'll still be Foxtrot Bravo. OK.
Small contrast extravasations.
No tamponade or thoracic aortic rupture.
Fruit pastille?
No.
OK. So now we know. If there is a haemorrhage, it's in the abdomen.
I'll go and see if there's any progress on tracking down next-of-kin. Thanks.
What's that around the liver?
It's a bit of this, it's a bit of that, nothing major.
Shit, she's haemorrhaging...
Left renal tear plus various intraperitoneal extravasations Fast-bleep the Trauma Theatre. I want them ready to cut in ten minutes.
I'll fast-bleep the general surgeons. Chase the blood bank.
Excuse me?
This patient needs to go to theatre to stop the internal bleeding.
I'd be more comfortable if it went through Clive. Clive?
Clive Archerfield. He's in the ED.
Right.
Fiona Lomas, Trauma Fellow.
Would you kindly fast-bleep the trauma theatre staff and the general surgeon on call, straight away please?
And put me through to blood bank again.
Tannoy: Would the on-call general surgeons please report to Trauma Theatre.
..as well as the Nof, X-ray the chest and get the bloods done, so there are no delays taking her up to the ward.
She's been here two hours already...
Sorry, I'm in a hurry. Glen Boyle.
Trauma Locum. Ah, Clive Archerfield.
My patient needs an urgent laparotomy and, apparently, I need to ask for your approval.
That hasn't come from me.
Good. Thanks.
But also I'd like to discuss the major transfusion protocol.
Yep, sure. I'll fix a time.
No, it's not working today so it needs fixing today.
Look, you run the trauma call, I run the entire department, so, leave it with me.
Thanks.
..we're receiving a pleomorphic xanthoastrocytoma from the Children's...
It's an acute neurosurgical referral.
Someone just needs to tell me if the patient's in transit or not.
You're the neurosurgical reg?
Guilty. Any chance you could take a look at a CT for me?
No!
I'm the consultant on call for major trauma.
You could be George Clooney.
You'd still have to e-mail it.
Er, he's new. Hi.
Hi.
We're the tertiary referral centre for neuro.
The other hospitals complain of favouritism if we provide a faster service for intramural referrals.
The thing is, hombre, we're not that into head injuries.
You're taking the piss.
I couldn't help but overhear...
Let me get you on the system and let's find this patient of yours.
Oh, thanks...
OK, let's get moving.
We're taking her to theatre.
I am not happy with this at all.
With what?
Him. He's the Trauma Consultant.
Locum consultant. We don't know the first thing about him.
This patient needs opening up right away or she's going to bleed to death.
Let's get the blood delivered to theatre. Yep.
OK, 1, 2, 3...
Come on, let's get moving.
Hello switch this is theatre.
We have fast-bleeped the general surgeons.
Can you chase them, please?
Tannoy: On-call general surgeons please report to Trauma Theatre.
That's on-call General Surgeons to Trauma Theatre, please.
Re next of kin, there's a grown-up daughter, name of Rachel, coming up from London. Thanks.
How far away is General Surgery, please?
It's a big hospital.
Can you fast-bleep the general surgeons again please? Thank you.
BP's still dropping.
No. Can't wait. Scrub in, please.
We need to stop the haemorrhage.
Would you like me to prep?
Please do.
Is it always like this?
Lorraine told Clive over and over that other specialities should automatically come to the trauma calls.
You think I can change things when this Lorraine couldn't?
You...
You're a bull in a china shop.
Um, the Neurosurgical Registrar just reviewed the CT scans for us.
You're kidding.
I have my moments. Let's hear it.
"Insignificant subdural haematoma.
"No gross brain injury visible on the CT.
"No other morphological changes visible.
"No neurosurgical intervention is indicated at this time." Good.
Thanks. Well done.
Do my ties, please.
Gen-Surg are operating on another...
You shouldn't be here.
Return to seeing patients in the ED.
Yes, sorry, Mrs Hicklin.
It's OK.
May I ask, what on earth are you doing?
If we do not stop the internal haemorrhage, organ damage will be irreversible and fatal.
There's a reason why this is called the Golden Hour.
So I'm going to get started and the general surgeons can muck in when they get here. I'm not happy.
And why are you not happy?
What exactly do you mean when you've described yourself as a "trauma surgeon"?
What I mean is I've practised all over the world, in the Forces and civilian hospitals.
I specialise in critical injuries.
Unfortunately too many trauma services in this country are formed from a jumble of general surgeons and orthopods.
We provide a major trauma service of dedicated professionals in which the general surgeons perform the laparotomies.
I'm comfortable in the abdomen.
We've only got your word for that.
Then you should write in the patient's notes that you are blocking a life-saving procedure.
You're very quiet.
I hope the procedure goes well.
Call me if there is anything you need.
Thank you.
Bull 1, China Shop 0.
Let's who... I'm Glen Boyle.
I'm the Trauma Consultant.
Sister Dalisay Guinto, Scrub Nurse.
Dominic Busby, Gas Reg.
Billy Finlay, Anaesthetic ODP.
Armin Khular, ODP.
Alex Badger, Staff Nurse.
Clara Lloyd, Staff Nurse.
Polly Mason, Documentation Nurse.
Fiona Lomas, Trauma Fellow.
Charlotte Brase, Circulating.
Can we confirm who the patient is, please?
Major Trauma Foxtrot Bravo.
Date of Birth 1.1.1900.
Thank you.
OK, I've signed a consent form four.
I'm performing a laparotomy to arrest a life-threatening haemorrhage.
Everyone good with that?
All: Yes.
Are we ready?
Ready, Mr Boyle.
Blade.
OK to cut?
OK.
Cutting...
RAPID BLEEPING Shit. Suction. Vacuum.
Pressure's dropping like a stone.
Packs. I can't see a thing.
I'm trying. Then try harder!
Here.
Five packs in the abdomen. Five in.
Ring.
You know what I'm going to say...
So don't say it.
I've got to say it.
BP's dropping, sats are dropping.
OK. OK. I need an aortic clamp.
I, don't er...
I need an aortic clamp.
Right, er, yes... I need an aortic clamp. We don't have...
I need an aortic clamp.
Upstairs theatres! Go!
Ow! Careful!
BP's 65 over 38.
More packs, please! Now!
Hands.
Get your hands in there, press down on the bleed.
OK.
BP... We can see.
Five more in the abdomen.
Ten in.
PHONE RINGS Turn that off!
Shit, sorry.
It's OK.
BUZZER STARTS Pressure's falling.
Packs not working.
We unpack quadrant by quadrant, and we deal with the bleeds as we get to them.
Starting with the left upper quadrant. OK?
Spleen's haemorrhaging.
There's an expanding retroperitoneal haematoma. Shit! Repack.
Pressure dropping again.
The spleen is controllable. It's the renal bleed that's k*lling her.
I really need that clamp.
She's going down.
Yeah, pressure.
We're losing her!
"I'm sorry. I miss him so much.
OK, she needs more blood - let's fill her up.
Code was called 30 minutes ago.
This is Trauma Theatre, for patient Foxtrot Bravo.
We are still waiting on...
12 units, eight of FFP, four of platelets.
12 units of crossmatch, eight units of fresh frozen plasma and four units of platelets.
Thank you.
I've got the aortic clamp.
To me! Quickly!
To me! Quickly!
OK. So we can clamp off the aorta and stop all bleeding in the lower body.
That means unpacking her to get the clamp on.
Yes, it does.
PHONE RINGS For Christ's sake!
Whose phone is that?
Must be the patient's.
There's a text trail here.
Later.
You ought to know what it says.
The last text she sent was to someone called Rachel.
That's her daughter.
Can we do this later?
No, we do it now, quickly.
"I'm sorry. I miss him so much.
"I love you with all my heart, but he was my baby.
"I thought one day I'd get over it, but I never will.
"I'm sorry. I love you.
"Mum."
She jumped.
When I say "go" we rip out the packs and we open up the retroperitoneal space.
You got it?
Yes.
Pressure.
Pressure dropping.
Suction!
I need more suction if I'm going to see what I'm doing here.
Still falling.
OK.
I'm going to do a medial rotation to access the aorta.
Shit! Where is it?
Let's get the blood out of there, please. Clear the blood.
I can't locate the aorta!
No, I can't do this blind.
I need you to clear the field with suction.
OK, clamp.
Have you got it?
Yes, I've got it.
OK, clamp.
Clamp on. Is it on?
Yes. Numbers? Quickly.
Still falling, 50 over 20.
Hold on, wait a minute.
BP climbing.
Good work.
BP 70 over 45.
OK, let's mop up, suction and swabs, please.
OK, We've got haemostasis.
BP now 100 over 70.
Good.
I'm going to ligate the left renal artery.
Dardic.
Thank you.
Renal artery clamped above the rupture.
Hold that clamp.
Got it. 2-0 tie, please.
Thank you.
Sorry, we had someone on the table.
Are you the general surgeon?
Robert Street. Glen Boyle.
The abdominal aorta is cross-clamped.
The left renal artery has been ligated.
The patient is currently awaiting a splenectomy and a nephrectomy.
Hemodynamically stable.
The patient is settled.
Okey-dokey.
Thanks, I'll take it from here.
Are we done?
You're done. Good work.
Thank you very much, everybody.
Thanks, guys.
That's haematology. Good, we can fill her up. Thanks, mate.
Let's get those transfusions running...
DOOR BLEEPS Do you want to grab a coffee?
Thanks for what you did... but best not.
No-one knows you called me, do they?
No.
Clive and Nicola, they're, um... defensive.
Well, it's a state-of-the-art unit and no-one thought to stock the theatre with an aortic clamp.
Every speciality under the sun and not one of them are available to attend the trauma call.
I'd say they've got a lot to be defensive about.
Now you might understand why I called you.
Now you don't think that was such a great idea. I didn't say that.
No?
DOOR BLEEPS Let's set aside the you-and-me part.
As a registrar receiving critically injured patients on a day-to-day basis, I'm glad you came.
The set-up here... the NHS politics it's difficult.
Give me Helmand any time.
So why did you come, then?
I thought you needed me.
This unit needs you. Right.
I should think this through.
You own me.
You mean, I "owe" you.
That's what I said.
Good work. Well done. Thank you.
Thanks.
Yeah, she's in Trauma Theatre.
That's Max-Fax and ENT.
Here to take care of the fence post.
I'd better get in there and make sure they don't step on each other's toes.
Very good work. Cheers.
Have you got a moment to speak to the patient's daughter?
You're Rachel?
Yes.
Mr Boyle and Ms Lomas are the trauma surgeons.
Hello, Rachel.
So we've done our part successfully.
Your mum was in a bad way but now she's stable.
All being well, she should make a full recovery.
We'll show you to our Relatives' Room.
Thank you.
If you wouldn't mind, Natasha...
Sorry, Fiona, can you complete the trauma record?
No problem.
Thank you.
Good outcome. Yep.
There's a motorcyclist on his way into us, severe lower limb injuries, ETA 15.
Tannoy: Trauma call, ETA 14 minutes.
Trauma call, ETA 14 minutes.
Well?
Bring it on.
Resources are stretched.
Well, then, some of us need to raise their game.
Where is this going, exactly?
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 think my boss just got suspended.
SIREN BLARES
'Trauma Call - attend Emergency Department... Trauma Call - attend Emergency Department.'
She went off a couple of minutes ago.
Shit!
Let's get her inside.
Move. Move!
Right, mid-40s female, next door neighbour at 4.30.
Not now, luvvie. Wait till we're inside. Sorry, Nerys.
Is this the...?
Yes.
Have you got who's Trauma Consultant, today?
Uh, that information's not come through yet.
Call Clive, please. Colleague call -
Dr Archerfield, please attend Trauma Resus, urgently.
Starting the clock.
Critical airway.
Straight into the bay. No hand-over.
Where's Dr Chandramohan?
On study leave, today.
Who's covering?
Dr Busby. Fast bleep him, we need an anaesthetist.
On three - one, two, three.
What's with the whole Elephant Man thing?
Right. Oh, my God.
Bloody hell.
Can you fast bleep Dr Busby for me, please, and Dr Archerfield.
100% oxygen, and bag as best you can.
I don't know if you can hear me, but we're going to do something to help you breathe.
Thio, sux, 'scope, bougie, narrow tube.
Don't be daft.
You'll never get a tube in.
Cannot intubate. OK. Fiona!
Could you fast bleep Dr Barnby, please?
Busby.
Busby, sorry, and Dr Archerfield.
To Trauma Resus.
Well?
Thanks.
Yep. Put the call out. Getting any in?
The wood's in the way. What is it?
Fence post. She fell out a window.
Poor ventilation across both lung fields. "Cannot ventilate."
Give me a sat. Yeah, in just a second.
OK?
OK.
Yep.
Oxygen saturation 60%. Shit.
Fence post. 60%.
This is the situation, "Cannot Intubate, Cannot Ventilate."
She needs a tracheotomy.
Nerys, can you write that down, as stated by me.
And the time is...one minute, 20 seconds.
Oxygen saturation now 50%.
And falling.
"Cannot Intubate, Cannot Ventilate."
You've covered your arse.
Now let's do it.
Looks like Clive isn't joining us.
Nerys. Nice and calmly, please, get a Quicktrach ready to go. Bloody hell!
Uh, Thiopentone and Suxamethonium doses?
200, 100. Got it.
Let's get the blocks off. Harry, can you give me a hand?
I'll give in-line immobilization.
Thiopentone.
Flush. Sucks.
Thiopentone, 200 milligrams, suxamethonium, 100 milligrams - given.
Flush.
Quicktrach to me right now, please.
sh1tting shit!
It's coming up to two minutes 30 - no airway.
Anyone heard from the anaesthetist?
It's just us.
OK.
Step away.
PATIENT CRIES OUT Shit, she's not under.
Ketamine, 30 milligrams, now, Billy!
Yep, yep, yep. It's all right. It's OK.
I'm drawing it. Billy! Come on, quicker!
I'm coming, I'm coming, I'm drawing. One second.
Come on, Billy! Come on!
Come on, Billy. Give it!
Stay still, stay still.
Now coming up to three minutes.
Still no airway.
Good girl, come on, that's it.
You'll be fine.
It's OK, it's OK.
Come on, darling, here we go.
Ketamine, 30 milligrams, given.
OK, she's under. Step away.
You have done this before?
I have now.
I'm getting air.
Thanks, Billy. Sorry.
Water off a duck's back.
I'll hold the trach in place.
Attach the strap and loop it around her neck, will you?
Bagging.
It's OK.
Oxygen and saturation climbing, now 70%.
Yeah, under the wood. That's it.
Strap's on. OK.
Sats now 80%.
90%. Good.
Airway secure. Scoop out.
Thanks, Justin.
Brace.
Brace. OK, let's get the blocks back in, Justin, please.
Yep, I'll do blocks.
Yeah, I'll help with the blocks.
Well done.
I'm not covering my arse, I'm helping my colleagues make the right decision at the right time.
Stress of the moment.
Mm-hmm. Blocks in?
They're in.
Can someone cut her out of her clothes, in the meantime, please?
Yep. Excuse me, love.
Airways secure.
Ventilating both lungs.
Strong pulses. Good blood pressure.
If only it was always this easy.
Oh, here he is.
Ah. Good of you to join us, Dr Busby.
Shit. The call said ten minutes. She went off in the back of the truck.
It didn't get updated till the last minute.
I never got the update.
Let's not discuss it now. OK.
The trach will tide us over until we get ENT involved.
Sats normalising.
Nice job on the quicktrach.
Thank you.
Can we have the handover now, please?
The patient is female, believed to be mid-40s, but we don't have an I'D yet.
999 call was made by the next-door neighbour, but he couldn't ID the patient.
Said he didn't know her name - she kept herself to herself.
This was at 4.30. Neighbour heard a crash and saw her lying in her back garden.
A first-floor window was open and he thinks she was cleaning the windows.
She landed on a fence-post, hence the penetrating mandibular injury.
No other major injuries apparent on examination.
She was semi-conscious at the scene, GCS - 11.
En route, she started to have difficulty with the airway.
She wouldn't take a Guedel and there was difficulty bagging.
Primark. Important medical information, that is!
Don't be silly. Concentrate.
Sorry. Thank you.
Any questions?
Any analgesia given?
No, due to the GCS.
She's been given 30 milligrams of ketamine here.
She has stuff in her pockets.
All right, let's do a BA3, then.
She's also had 200 of thio and 100 of sux.
Thanks, Billy. Mobile phone.
Mobile phone. Anything with a name?
No, no credit cards.
Tesco Club Card?
Oh! Dry cleaning ticket.
Fruit... Fruit pastilles.
Fruit pastilles.
Can you sign off on the paperwork with Nerys for me, please?
Sorry, she needs to complete a PS20.
Huh?
Major Trauma Patient Experience Survey.
She's unconscious.
Can someone do bloods? Harry?
Yeah. Sure, no problem.
So you're Harry?
Yep, that's me.
Dominic. Dom.
Hey.
Hi, Dom, nice to meet you.
So, you trauma team leader now?
Now?
Instead of Lorraine. No.
Shall I do these?
Billy can do those for you.
HE SIGHS All right.
There's fullness in the abdomen, could be fluid.
Let's get O-neg on standby and G&S and TEG, as well as the usual bloods. Yeah.
Can you run off a VBG?
Yep.
And can someone call CT straight away, please?
I'll call them.
I'd love images of her pelvis and legs.
X-rays now?
If the scanner's free, I'd prefer a CT.
Time is coming up to eight minutes.
Eight minutes, Mark.
That's you done. Thank you, guys.
Thanks, Nerys.
'Leave a message for Dr Ramakrishna Chandramohan, Anaesthetics Registrar. You know you want to.' Hey. It's me, Harry.
Um, what's this about study leave?
This is Mrs Hicklin.
We've got Major Trauma Foxtrot Bravo for a top-to-toe.
No major limb trauma.
Thank you.
Yeah, they can take her right away.
Great. I'll see you there.
Yeah.
Yes. Well, well, let's just keep at it, shall we?
Clive, Sorry. Hi, Fiona.
They put out a call for you.
Yep, I'm sorry, I'm snowed under.
How's it going?
Patient's stable.
I saw earlier, Lorraine's name's not on the rota for today.
No. I tried calling her in the week but she hasn't got back to me.
Yes, well she's still feeling under the weather, poor thing.
If you speak to her, give her my best, will you?
Yeah ... OK...so...we haven't got a trauma consultant.
No, there is somebody coming in.
Isn't he here yet?
No.
A major trauma case needs a trauma team leader.
Yep, well I'm here if you need me.
I'm sure you can cope.
OK.
'Trauma call - attend emergency department.'
Fiona! You better come quick.
Let's keep filling her up and try to get her BP back.
Surgical airway is established, there's apparent haemostasis in the mandible, so I propose we leave for a max-fax opinion once she's stable.
Stop messing about with the blood gas and get back over here.
As I've said, once we have a CT we can send to max-fax and ENT, but right now our priority is addressing the low BP by pushing the blood transfusion.
Agreed.
Uh, did we get gases?
I'm the Trauma Consultant.
Most likely, this in an internal haemorrhage, so we need to find the bleeding and stop it before it kills her.
Let's run a unit of O-neg into each of the Venflons, please.
We're doing that.
Then have another one ready to go up straight after.
Plus two units of FFP, continuing at a ratio of 3:2.
And let's give her a gram of TXA.
We're already 20 minutes into our golden hour, so...
Right now, please.
Who's he?
Nerys, get another two units of O-neg from the fridge. Yep. get them running ASAP.
Who are you, please?
Glen Boyle, Locum Trauma Consultant.
Pleased to meet you. You are?
Nicola Hicklin. Nurse Consultant.
I'm the Deputy Clinical Lead in this department.
You should've introduced yourself earlier.
BP's still down.
So, let's get the transfusions going.
Pressure bags, please.
Yep. Anyone called a Code Red?
No. Well, let's make the call, or call Blood Bank and request 12 units of crossmatch or O-neg, whichever is most quickly available, eight of FFP and four of platelets, please.
OK. You need to sign in.
There?
Do we have the bloods yet?
Sent off about five minutes ago.
This is Mrs Hicklin. I need the following to Trauma Resus, re: patient... EtOH.
Christ, EtOH, I'd forget me head, me.
Tranexamic acid.
One gram IV bolus. Infusion to follow.
Need more access.
I'll do a trauma line. Yep.
And let me know when that's done, please.
Hello, this is William Finlay, ODP, I'd like to request an EtOH.
I can't... If you're not on the system yet, just choose "temporary staff" from the drop-down list. Temporary?
Yep.
Excuse me?
You were going to show us her VBGs?
Oh.
Thank you.
Who's he?
Glen Boyle.
Trauma line's in. Thank you.
Let's run two more units of O-neg through the trauma line, and two of FFP through the Venflons, once the first two units of O-neg are through.
More or less through now.
Crack on. You are?
Justin.
Blood pressure's moved up - now 100 over 80. Sats remain good.
Airway stable pending ENT?
Just about.
Then...let's get her a CT.
OK, but I'd rather... Then...let's get her a CT.
I'll call them. Thank you.
Who's he?
Glen Boyle.
Ms Lomas, Trauma Fellow. We've got a Major for you.
Thanks.
CT can take her now. Blood running in fast now. Cheers.
BP's coming up a little more.
Now 105.
Then let's get her a CT.
Harry, take the drip stand, will you?
Yep, on it.
Finish that for you.
When did you start?
Today.
So, you're not Lorraine Rappaport's replacement?
Who? No.
Temporary. How long are you here for?
Not sure. Just filling in.
You do know that we're a Centre of Excellence?
Absolutely. We're the referral centre for major trauma for the whole region.
I got it.
Get a move on, please.
So, how's it going?
Great.
These trauma calls!
Yeah, I know.
You'll have to back up.
You'll have to back up.
We're here, Brian, if you could open the doors for us, please.
You looked as if you'd seen a ghost.
Could've warned me.
I should have.
I should've called.
No, really?
Sorry.
I thought you would have grown out of trying to catch me off guard.
It's good to see you.
You too.
Sorry. Scan's about to start.
Thank you.
We've been trying to enact a major transfusion protocol, but some of the haematology consultants insist on it going through them.
Well, then someone needs to speak up.
Someone already did.
Lorraine Rappaport.
Hence the vacancy you've just filled.
The orthopod? Where is she?
Rebecca?
Must've gone back to the ward.
Back in a mo. I'm busting.
Usual story, once we reach CT, they start catching up with their normal jobs.
Small subdural.
We're going to need a neuro opinion.
You really are new, aren't you?
Are you chewing?
No.
I'm going to connect up the contrast and start the body scan.
Nobody press any buttons.
Don't worry about Brian.
His bark's worse than his bite.
What a relief.
I don't know if you know, but I teach an intubation tutorial...
Really... ?
Starting contrast run.
Stop the scan!
Stopping...
What's going on in there?
He's heard that if he gives you extra teaching, you're bound to put out.
Dr Busby?
Keep your hair on, Brian.
I cannot work like this.
This is anarchy. Sorry.
What happened to blondie?
Scanning...
The police called. They went to the house and obtained an ID on the patient, but on the system she'll still be Foxtrot Bravo. OK.
Small contrast extravasations.
No tamponade or thoracic aortic rupture.
Fruit pastille?
No.
OK. So now we know. If there is a haemorrhage, it's in the abdomen.
I'll go and see if there's any progress on tracking down next-of-kin. Thanks.
What's that around the liver?
It's a bit of this, it's a bit of that, nothing major.
Shit, she's haemorrhaging...
Left renal tear plus various intraperitoneal extravasations Fast-bleep the Trauma Theatre. I want them ready to cut in ten minutes.
I'll fast-bleep the general surgeons. Chase the blood bank.
Excuse me?
This patient needs to go to theatre to stop the internal bleeding.
I'd be more comfortable if it went through Clive. Clive?
Clive Archerfield. He's in the ED.
Right.
Fiona Lomas, Trauma Fellow.
Would you kindly fast-bleep the trauma theatre staff and the general surgeon on call, straight away please?
And put me through to blood bank again.
Tannoy: Would the on-call general surgeons please report to Trauma Theatre.
..as well as the Nof, X-ray the chest and get the bloods done, so there are no delays taking her up to the ward.
She's been here two hours already...
Sorry, I'm in a hurry. Glen Boyle.
Trauma Locum. Ah, Clive Archerfield.
My patient needs an urgent laparotomy and, apparently, I need to ask for your approval.
That hasn't come from me.
Good. Thanks.
But also I'd like to discuss the major transfusion protocol.
Yep, sure. I'll fix a time.
No, it's not working today so it needs fixing today.
Look, you run the trauma call, I run the entire department, so, leave it with me.
Thanks.
..we're receiving a pleomorphic xanthoastrocytoma from the Children's...
It's an acute neurosurgical referral.
Someone just needs to tell me if the patient's in transit or not.
You're the neurosurgical reg?
Guilty. Any chance you could take a look at a CT for me?
No!
I'm the consultant on call for major trauma.
You could be George Clooney.
You'd still have to e-mail it.
Er, he's new. Hi.
Hi.
We're the tertiary referral centre for neuro.
The other hospitals complain of favouritism if we provide a faster service for intramural referrals.
The thing is, hombre, we're not that into head injuries.
You're taking the piss.
I couldn't help but overhear...
Let me get you on the system and let's find this patient of yours.
Oh, thanks...
OK, let's get moving.
We're taking her to theatre.
I am not happy with this at all.
With what?
Him. He's the Trauma Consultant.
Locum consultant. We don't know the first thing about him.
This patient needs opening up right away or she's going to bleed to death.
Let's get the blood delivered to theatre. Yep.
OK, 1, 2, 3...
Come on, let's get moving.
Hello switch this is theatre.
We have fast-bleeped the general surgeons.
Can you chase them, please?
Tannoy: On-call general surgeons please report to Trauma Theatre.
That's on-call General Surgeons to Trauma Theatre, please.
Re next of kin, there's a grown-up daughter, name of Rachel, coming up from London. Thanks.
How far away is General Surgery, please?
It's a big hospital.
Can you fast-bleep the general surgeons again please? Thank you.
BP's still dropping.
No. Can't wait. Scrub in, please.
We need to stop the haemorrhage.
Would you like me to prep?
Please do.
Is it always like this?
Lorraine told Clive over and over that other specialities should automatically come to the trauma calls.
You think I can change things when this Lorraine couldn't?
You...
You're a bull in a china shop.
Um, the Neurosurgical Registrar just reviewed the CT scans for us.
You're kidding.
I have my moments. Let's hear it.
"Insignificant subdural haematoma.
"No gross brain injury visible on the CT.
"No other morphological changes visible.
"No neurosurgical intervention is indicated at this time." Good.
Thanks. Well done.
Do my ties, please.
Gen-Surg are operating on another...
You shouldn't be here.
Return to seeing patients in the ED.
Yes, sorry, Mrs Hicklin.
It's OK.
May I ask, what on earth are you doing?
If we do not stop the internal haemorrhage, organ damage will be irreversible and fatal.
There's a reason why this is called the Golden Hour.
So I'm going to get started and the general surgeons can muck in when they get here. I'm not happy.
And why are you not happy?
What exactly do you mean when you've described yourself as a "trauma surgeon"?
What I mean is I've practised all over the world, in the Forces and civilian hospitals.
I specialise in critical injuries.
Unfortunately too many trauma services in this country are formed from a jumble of general surgeons and orthopods.
We provide a major trauma service of dedicated professionals in which the general surgeons perform the laparotomies.
I'm comfortable in the abdomen.
We've only got your word for that.
Then you should write in the patient's notes that you are blocking a life-saving procedure.
You're very quiet.
I hope the procedure goes well.
Call me if there is anything you need.
Thank you.
Bull 1, China Shop 0.
Let's who... I'm Glen Boyle.
I'm the Trauma Consultant.
Sister Dalisay Guinto, Scrub Nurse.
Dominic Busby, Gas Reg.
Billy Finlay, Anaesthetic ODP.
Armin Khular, ODP.
Alex Badger, Staff Nurse.
Clara Lloyd, Staff Nurse.
Polly Mason, Documentation Nurse.
Fiona Lomas, Trauma Fellow.
Charlotte Brase, Circulating.
Can we confirm who the patient is, please?
Major Trauma Foxtrot Bravo.
Date of Birth 1.1.1900.
Thank you.
OK, I've signed a consent form four.
I'm performing a laparotomy to arrest a life-threatening haemorrhage.
Everyone good with that?
All: Yes.
Are we ready?
Ready, Mr Boyle.
Blade.
OK to cut?
OK.
Cutting...
RAPID BLEEPING Shit. Suction. Vacuum.
Pressure's dropping like a stone.
Packs. I can't see a thing.
I'm trying. Then try harder!
Here.
Five packs in the abdomen. Five in.
Ring.
You know what I'm going to say...
So don't say it.
I've got to say it.
BP's dropping, sats are dropping.
OK. OK. I need an aortic clamp.
I, don't er...
I need an aortic clamp.
Right, er, yes... I need an aortic clamp. We don't have...
I need an aortic clamp.
Upstairs theatres! Go!
Ow! Careful!
BP's 65 over 38.
More packs, please! Now!
Hands.
Get your hands in there, press down on the bleed.
OK.
BP... We can see.
Five more in the abdomen.
Ten in.
PHONE RINGS Turn that off!
Shit, sorry.
It's OK.
BUZZER STARTS Pressure's falling.
Packs not working.
We unpack quadrant by quadrant, and we deal with the bleeds as we get to them.
Starting with the left upper quadrant. OK?
Spleen's haemorrhaging.
There's an expanding retroperitoneal haematoma. Shit! Repack.
Pressure dropping again.
The spleen is controllable. It's the renal bleed that's k*lling her.
I really need that clamp.
She's going down.
Yeah, pressure.
We're losing her!
"I'm sorry. I miss him so much.
OK, she needs more blood - let's fill her up.
Code was called 30 minutes ago.
This is Trauma Theatre, for patient Foxtrot Bravo.
We are still waiting on...
12 units, eight of FFP, four of platelets.
12 units of crossmatch, eight units of fresh frozen plasma and four units of platelets.
Thank you.
I've got the aortic clamp.
To me! Quickly!
To me! Quickly!
OK. So we can clamp off the aorta and stop all bleeding in the lower body.
That means unpacking her to get the clamp on.
Yes, it does.
PHONE RINGS For Christ's sake!
Whose phone is that?
Must be the patient's.
There's a text trail here.
Later.
You ought to know what it says.
The last text she sent was to someone called Rachel.
That's her daughter.
Can we do this later?
No, we do it now, quickly.
"I'm sorry. I miss him so much.
"I love you with all my heart, but he was my baby.
"I thought one day I'd get over it, but I never will.
"I'm sorry. I love you.
"Mum."
She jumped.
When I say "go" we rip out the packs and we open up the retroperitoneal space.
You got it?
Yes.
Pressure.
Pressure dropping.
Suction!
I need more suction if I'm going to see what I'm doing here.
Still falling.
OK.
I'm going to do a medial rotation to access the aorta.
Shit! Where is it?
Let's get the blood out of there, please. Clear the blood.
I can't locate the aorta!
No, I can't do this blind.
I need you to clear the field with suction.
OK, clamp.
Have you got it?
Yes, I've got it.
OK, clamp.
Clamp on. Is it on?
Yes. Numbers? Quickly.
Still falling, 50 over 20.
Hold on, wait a minute.
BP climbing.
Good work.
BP 70 over 45.
OK, let's mop up, suction and swabs, please.
OK, We've got haemostasis.
BP now 100 over 70.
Good.
I'm going to ligate the left renal artery.
Dardic.
Thank you.
Renal artery clamped above the rupture.
Hold that clamp.
Got it. 2-0 tie, please.
Thank you.
Sorry, we had someone on the table.
Are you the general surgeon?
Robert Street. Glen Boyle.
The abdominal aorta is cross-clamped.
The left renal artery has been ligated.
The patient is currently awaiting a splenectomy and a nephrectomy.
Hemodynamically stable.
The patient is settled.
Okey-dokey.
Thanks, I'll take it from here.
Are we done?
You're done. Good work.
Thank you very much, everybody.
Thanks, guys.
That's haematology. Good, we can fill her up. Thanks, mate.
Let's get those transfusions running...
DOOR BLEEPS Do you want to grab a coffee?
Thanks for what you did... but best not.
No-one knows you called me, do they?
No.
Clive and Nicola, they're, um... defensive.
Well, it's a state-of-the-art unit and no-one thought to stock the theatre with an aortic clamp.
Every speciality under the sun and not one of them are available to attend the trauma call.
I'd say they've got a lot to be defensive about.
Now you might understand why I called you.
Now you don't think that was such a great idea. I didn't say that.
No?
DOOR BLEEPS Let's set aside the you-and-me part.
As a registrar receiving critically injured patients on a day-to-day basis, I'm glad you came.
The set-up here... the NHS politics it's difficult.
Give me Helmand any time.
So why did you come, then?
I thought you needed me.
This unit needs you. Right.
I should think this through.
You own me.
You mean, I "owe" you.
That's what I said.
Good work. Well done. Thank you.
Thanks.
Yeah, she's in Trauma Theatre.
That's Max-Fax and ENT.
Here to take care of the fence post.
I'd better get in there and make sure they don't step on each other's toes.
Very good work. Cheers.
Have you got a moment to speak to the patient's daughter?
You're Rachel?
Yes.
Mr Boyle and Ms Lomas are the trauma surgeons.
Hello, Rachel.
So we've done our part successfully.
Your mum was in a bad way but now she's stable.
All being well, she should make a full recovery.
We'll show you to our Relatives' Room.
Thank you.
If you wouldn't mind, Natasha...
Sorry, Fiona, can you complete the trauma record?
No problem.
Thank you.
Good outcome. Yep.
There's a motorcyclist on his way into us, severe lower limb injuries, ETA 15.
Tannoy: Trauma call, ETA 14 minutes.
Trauma call, ETA 14 minutes.
Well?
Bring it on.