I thought she was still off sick.
I don't know if you know, but I teach an intubation tutorial.
What did you tell him?
"There's a slapper in the ED.
"Just give her a bit of a teaching and she'll feel your tube."
It's Clive. He's gunning for you, and this could turn into a shit storm.
When Clive told me that you are under my supervision,
I assumed that he had told you too.
Bastard wants us to fight for the same job!
I was mad to call you.
Lorraine's back.
You should go. We don't need you.
- Eh, what do you want? - You in yet?
Missing me?
Always. Get us a coffee, will you?
Why don't you ask your paramedic friend? I'm sure she'd love to.
Triple shot cap. No sugar. Go on.
Look, I've just been past the coffee place and I haven't got any hands free.
Ugh, no bloody heart.
You know, it's comments like that mean you're gonna go without your...
Harry, what was that? What's going on? Harry?
There's been an accident. You should come.
What accident? Are you okay? What's happened?
Oh, God.
Hello.
Can you hear me?
Oh, my God. Nuala?
Oh, Nuala.
Nuala, you okay?
Oh, God. Oh, God.
She's Harry. And I'm Justin. And we're gonna take care of you.
Yeah?
Airway. Airway.
What?
She's got an airway. Okay.
I'll check pulse, yeah?
- She's breathing. - What?
- She's. Take them... - Careful.
What are you doing?
Get back!
Back!
Moving back, please. Yeah, would you mind?
Come on. Come on. Give them some room to... Oh, my word.
Doctor coming through.
- Harry? - Thirteen.
- Look, I'll take it from here. - 26 resps.
- She's breathing? - Yes.
- Is this a cardiac arrest? - No. She, she just, she...
She just fell from up there.
We need suction, O2, a Guedel and NPs.
It's not us. It's not an arrest.
Put out a trauma call. And leave, leave the kit. Leave the kit.
Right, there's a suction pump in there and a green Guedel.
Harry, you okay?
- It's not a cardiac arrest. - Did you put out a trauma call?
Yeah, she's breathing.
- Pulse 120. - You taking it?
- This one? - It's not an arrest. If you're on call.
- What's going on? - Trauma call.
Prep for an RSI and tell someone to bring a scoop.
- Might need a binder, too. - All right.
If you feel you can't handle it...
Fine. I'll take it. Thanks, Harry.
I'm sure Dr Busby's got to rush off
and give another SHO an intubation tutorial.
Have you done a primary?
Trying to get an adjunct in.
- Harry? - Not complete.
Okay.
It doesn't look like you need this.
Just bleep me if you get into trouble, yeah?
- High flow O2, please. - Yep, coming.
Chest.
Uh, Nicola, is there anything I can do?
You could book her in.
Yeah, yeah, yeah. I'll leave you to it.
Argh, it's not going in.
Okay, we need to roll her.
- Okay. - Harry, come on.
Yeah, so we're rolling gently on three. One, two, three.
- Okay, there. - Yep.
Okay, well done.
- O2 ready? - Yep.
Tolerating a Guedel.
Pulse 120, resps 24.
I need everybody to take a step back, please.
All of you, right now. Take a step back so we can do our jobs.
I need a scoop.
Yeah, Billy's on it. Bringing you a binder, too.
- Primary? - Already doing it.
Airway clear with a Guedel, pulse 120, resps 24.
Can you hear me?
My name is Fiona, we're going to help you.
Patient has an obvious head injury.
Pupils equal and reactive, a little sluggish, possibly a 4.
She fell from up there, yes? Anyone know who she is?
No?
E, 1. V, 1.
No response from trach pinch.
M, 1. GCS, 3.
Who was first on scene?
Uh, me.
- See it happen? - Yep.
Need to know how she landed.
Feet first, and then she hit her head on the floor.
- Okay. - There's a slight fullness
in the abdomen.
So she's fallen from height, onto marble, feet first.
She's got a serious head wound and possible spinal fractures
and intra-abdominal injuries.
And there's an open tib-fib.
So, we'll be doing scoop and binder.
Resus, repeat primary and then CT. Everybody clear?
Yeah. I'll grab a trolley and I'll let CT know that we're on our way.
Bleep me if you need me.
What in heaven's...
Harry, collar and blocks.
Fiona, can you take the pelvis?
Harry, I need you on the shoulders and I've got the legs.
Sorry. Bloody lifts, I was just...
Oh! Nasty-looking tib-fib.
Can you do a scoop for us, please?
From the head.
Rolling on three. One, two, three.
- Tell me when. - Yeah.
Okay, back on three. One, two, three.
And let's reverse, please.
Rolling on three. One, two, three.
- Ready. - Okay, back on three.
One, two, three.
I know this girl.
Haven't we seen her before?
She's not staff, is she?
No, a patient.
There's no vascular compromise.
Thank you.
I started the clock. We're just over three minutes in.
- We need the trolley. - Ow!
You been lying on that?
Didn't expect to find glass on the floor.
- You should sue, mate. - I will.
Can we focus, please? I need the BP.
104 over 65. Pulse 113.
Okay, let's get ready for the transfer, please.
- Everybody ready? - Yeah.
One, two, lift.
And down.
CT's occupied at the moment.
Excellent. Come on.
- Resus, go. - Yep, quick, go.
Under the circumstances, I'll let you off without the coffee.
Almost four minutes. Could do better.
What are you doing here?
Leading a trauma call.
You know what I mean.
What? Am I supposed to give you a call and ask permission?
- I thought you'd have gone. - Why is that?
I don't think either of us wants history to repeat itself.
Nuala. That's it. I knew I had the name.
Nuala Barrington.
You remember her, Harry?
I need to change.
Ripped By mstoll
Patient's identity been established?
Yes, she's Nuala Barrington.
Trachea's central.
- Thanks, Harry. - What?
You just volunteered to be the scribe.
Oh. Right.
Good bilateral chest expansion.
Breathing's symmetrical.
Resp rate's 16.
You were also the first on scene,
so you're going to have to do the handover as well.
Uh, sure.
Patient's name is Nuala Barrington.
IV's in. What bloods do you want?
FBC, U&Es,
LFTs, give me glucose,
a VVG, clotting and cross-match, please.
- Ramakrishna. - Pretty much there.
Can we see if CT's free, please?
Harry? She on the system?
Uh. Yeah.
Uh, major trauma Foxtrot Charlie.
Resus. Are you ready for patient Nuala Barrington?
Major trauma Foxtrot Charlie, in the system.
Thanks. They've got someone in there.
Excellent.
Harry.
Harry, you're up.
Oh. Right, right.
Um, this is Nuala Barrington.
She fell about 30 feet onto the atrium floor about 13 minutes ago.
GCS, 3.
She has a likely head injury, a possible pelvic fracture and an open tib-fib.
Haemodynamically, she's stable.
Trauma call?
Yes, Lorraine.
It's good to have you with us.
Look at that. Blood.
You guys are witnesses, for my personal injury claim, right?
It's probably worth a fortnight in Ibiza at least.
- Nice pants. - Yeah.
Your dad got 'em for me.
The abdo's tight.
Where's the fast scanner?
- Justin, the fast. - Yeah. I'm there. I'm there.
She's lost the dorsalis pedis.
- Let's get the scoop off. - Unclip top and bottom.
One, two, three.
I got it.
Brace. One, two, three. Go on three. One, two, three.
- Justin, give us a hand, please. - Yeah.
No.
We really need to pull this tib-fib, or she'll lose her foot.
- Okay. But quick as you can. Yes? - Thank you.
Sorry, would you mind?
Lift to 30 degrees when I say.
Ready, brace, lift.
Is it me or is this really arousing?
Ooh.
Sir, could I have a hand, please?
Ready, brace, down.
I'm ready to go.
- We have dorsalis pedis. - Excellent.
RSI now, please.
Harry, can I get cricoid, please?
Uh, sure.
- I'll do this. - No, I... I got it.
Thio 200.
Thiopentone, 200 milligrams.
- Can we give neuro a shout, please? - Sure.
Head injury from this height,
it'll be nice if they came and looked at her CT, wouldn't it?
You think?
Mrs Hicklin, trauma.
We need an opinion on a serious head injury.
Major trauma Foxtrot Charlie. She's on the system.
We'll be in CT.
Free fluid in the abdomen and the pelvis.
Yeah, sorry.
Shit.
She needs to...
CT and then we need to get her to theatre, fast.
Ready to intubate.
BP 152 over 79.
Pulse 99, sats 82.
Alert theatre, tell 'em we could be there on the run.
Mrs Hicklin, trauma.
We have major trauma Foxtrot Charlie for you.
She is on the system. Thank you.
- Scope. Billy. - There you go.
Okay. It's time.
Hello, CT, Mrs Hicklin, trauma.
Are you ready for major trauma Foxtrot Charlie yet?
Bougie.
Thank you.
CT, they'll call us when it's free.
Right.
- Tube. - Sorry, who's scribing?
Here we go.
Uh, that's me.
- Through. - No rush.
Bougie out.
Got it.
Breath.
We're in.
Cricoid off. Thanks.
There you go.
Regarding major trauma Foxtrot Charlie.
Tell me about her pupils, please. I'm concerned about the head.
Nuala Barrington.
Her medical files were on the system already?
They should be linked.
Pupils equal but much slower to react.
Got them now.
Regular, apparently.
Just roll up to speed.
Come on, back to work.
CT?
They'll call us.
Okay, I'll take the head.
You go get the blocks on.
You've never been a first responder before, have you?
She made it to resus, Harry.
Did fine.
Numbers, please.
BP 156 over 81, pulse 78.
Stats 81.
She's really pushing the ICP, could be Cushing's response.
We should get a catheter in.
- Yeah, let's do that. - Constance.
Right away, Mrs Rappaport.
Stow lines in prep for her move to CT. Now, please.
Mrs Hicklin.
CT's ready.
Forget the catheter and let's go.
Now, please.
Lines attached. Brakes off. Let's go.
Let's do it.
I'm sorry.
Sorry.
Have you been involved in an accident at work? I have.
Oh, no...
Justin. Door, please.
- Glen. - Yes.
This insta-major trauma Foxtrot Charlie, it's probably gonna be declared an SI.
Thought you should know, so you can document everything.
Make sure those file are buffed, not that I actually said that.
Thanks, Giles.
Just thought you should know.
Pupils unequal.
- Can we chase neurosurgery, please? - Yeah.
It's not working. You're making it very difficult for Lorraine.
Mrs Hicklin, CT. We need that opinion.
Yes.
- Everybody ready? - Yes.
So, yeah, we'd appreciate...
Thank you.
Very good.
Control scan.
I must apologise for
not clearing the previous patient more quickly.
This was due to unfortunate, but understandable technical errors.
I'm still here.
Control scan complete.
Major trauma cases need to be prioritised.
- Neurosurgeon needs more information. - Like what?
Her hat size? What?
This is something I've learned in my CBT sessions that I have been taking.
Starting head scan.
Right-sided extradural,
midline shift,
associated contusions on the right.
And there's fractures to the right side occipital and parietal bones.
This brain looks really tight.
Let's fast bleep theatre, please.
Head scan complete.
No, no. Put me back through to switchboard.
I would appreciate it if you would avoid touching any buttons.
Who replaced Brian with a friendly robot?
Mrs Hicklin, CT. Can you fast bleep the trauma theatre team, please?
- Stepford Radiographers. - I, Radiographer.
Rise of the Radiographers.
- Robot radiographer! - Oi!
Sorry.
Mrs Hicklin, CT.
It was our best material.
We need an ET on the neurosurgeon.
Contrast connected.
I think we can continue.
Starting contrast run.
Weird fractures.
That's the least of our worries.
- Jesus! - Jesus Christ!
What the hell's that?
Some kind of foreign material.
Brian?
I wouldn't like to say without more information,
I'm uploading these images for the radiologist report.
Mrs Hicklin, CT. Thank you.
Trauma theatre's ready.
Oh, shit.
She's blown her pupil and she's coning.
I need neurosurgery down here, right now.
- Gently on three. One, two, three. - Yeah.
Quick as you can, folks.
Quick as you can, everyone.
Brakes off.
Hypertonic's going in.
It's the intra-abdominal fluid, due to extravasation?
Yeah, there's bleeding.
What is the material in her stomach?
God knows.
Just get the radiologist to report to me in theatre, please.
I'll go ahead.
Right.
You're welcome.
Lorraine didn't create this situation.
Neither did I.
She's a good surgeon.
But, maybe we need better than good right now.
Well, you're incredible.
I'll see you in there.
Patient is major trauma Foxtrot Charlie,
aka Nuala Barrington.
Consent, please.
We need to prep for a laparotomy and a craniotomy, please.
Someone from neurosurgery may or may not be on his way.
Thank you.
You seen Fiona?
Changing.
What's the numbers?
156 over 78, pulse is 61. Hypertonic's bought her some time.
Yeah, not long.
- Keep checking her pupils, please? - Yep.
Fiona, can I have a word?
If you're quick.
Uh, I saw her in ED yesterday.
Who?
Nuala.
She came in complaining of stomach pains.
I've seen her before, everyone knows her. She's a regular.
Did you examine her?
Uh, yes. I palpated her abdomen,
BP, heart rate, I even did bloods just to keep her happy.
Well, did you assess her mental state?
She seemed normal at first, normal for Nuala.
But she did kick up more than usual and I did...
Yeah.
I did think that she needed a psych assessment.
Did you discuss this with anyone?
The duty consultant.
Dr Archerfield.
Clive.
I told him her history,
and that I thought she should see a psych liaison nurse.
But he said that,
She was about to breach the four-hour rule and to discharge her.
Does it say this in your notes?
Just says I discussed it with him.
Okay.
Don't worry.
I've got this.
Radiologist has just uploaded her report,
it says free fluid in the abdomen with active bleeding.
Any news on the material in her gut?
Take a look.
Dense foreign bodies within the stomach and the small bowel
suggesting recent ingestion.
The largest measures 1.9 by 2.4 centimetres.
So, you're not prepared to risk an opinion about what it actually could be?
There's an active bleed in her abdomen, we need to unzip her now.
Right behind you.
I'll do this, unless...
Okay. Numbers, please.
158 over 80, pulse is 60. Sats could be better.
Let's do a who.
I'm Glen Boyle, I'm the trauma consultant.
Lorraine Rappaport, consultant vascular surgeon.
Kylie Osman, scrub nurse.
Heather Duley, support nurse.
Ramakrishna Chandramohan, gas reg.
Billy Finley, anaesthetic ODP.
Jason Marshall, support nurse.
Fiona Lomas, trauma fellow.
Armin Khular, ODP.
Daniel Insalaco, rapid infuser operator.
Patient is major trauma Foxtrot Charlie.
Date of birth, 17/4/1988.
She fell from a height.
There's a right-sided extradural haematoma.
Intra-abdominal bleeding,
plus foreign bodies.
I've signed a consent form four for a laparotomy plus procedure.
Any word from neurosurgery?
No.
Packs to me, please.
Okay, let's have the blade.
- Am I okay to cut? - Okay.
Cutting.
Give me standby, suction, please.
Give me two clips, please.
Check the mayo.
You do the other side?
Okay, there's plenty of blood there.
Let's get ready to flush with warm saline, please.
Everybody ready?
Cutting.
Oh, thank you very much.
- Was that you, B? - No.
Take this, please.
Ugh.
There's generalised peritonitis with loculated pus.
Just everywhere. Her pelvis.
Paracolic gutters.
Is it caused by the foreign bodies?
I don't know. Just a mess in here.
We should get gen surg to have a look at this.
Yeah, that's not a bad idea.
Okay, fast bleep gen surg, please.
Balfour and Morris retractor, please.
The bleeding's mostly in the left upper quadrant.
Let's have a look.
Okay.
Yeah, ruptured spleen.
We're gonna have to have that. Packs, please.
Hit me.
Again.
Let's move down. Again.
Hit me.
Keep 'em coming.
Hit me.
Again.
How many is that in?
Eight.
Hit me.
- Yeah. - Ten in the abdomen.
Ten packs in.
- How we doing? - Better.
Let me catch up with some volume before you go any further.
- Two units of blood, two FFP. - Yep.
Left eye looking very sluggish.
Two Dardik, please.
Thank you.
Mayo.
The dish.
Here comes the spleen.
Let's have 2-0 VICRYL, please.
Thank you.
I'm ligating the artery.
What are the numbers?
She's looking a little better.
This pus has been here a while.
There's gotta be a perforation in there somewhere.
Shall I flush it?
Yeah, just let me finish off these ties first, please.
Shit!
What?
Maybe you don't wanna hear this, but she's blown the other pupil.
Oh, come on. Where the bloody hell is neuro?
Pressure's killing her.
Prep for a burr hole.
That means you need to go and rescrub
and I need someone to hold the head now, please.
Is there anyone here who's been cleared to scrub in?
Maybe call someone down from theatres?
- Not enough time. - What about Harry?
- Yes, Harry. - Fast bleep Dr Bennett-Edwardes.
Have you done a burr before?
Twice in the field, once at Brom.
When was that?
It was a few years back. Cut, please.
I'd prefer if you waited for neurosurgery.
And I'd prefer neuro were here right now
with their fingers in her head, but they're not.
And if we wait, we lose her.
I'm not happy with you doing a burr hole.
But if I don't do it, she dies.
Look, I know this puts you in a difficult situation.
It puts us all in a difficult position.
Yes.
It does.
I know you're concerned about the mess, you're in mid-management.
But my only concern is that my patient is gonna die
unless someone cracks her skull.
And that someone should be a neurosurgeon.
Okay.
You know I'm right. So do you.
- What is it? - We're opening up the head.
You need to scrub in.
Short back and sides, please.
Let's have a couple of swabs ready as well, please.
Harry, hurry up.
Pressure right here, please.
Blade.
Retractor.
Set the Hudson brace with the cutter burr, please.
I need you to hold the head, here and here, please.
Saline, please. I'm gonna have to run this bowel through
to find the perforation. Thank you.
How's she doing?
Worried she's going to arrest.
Okay.
Whatever you do, Harry...
...don't sneeze.
I can't see. I need some light here, please.
- How's that? - Yeah.
Okay?
Let's get some irrigation here. Suction.
Pass me the burr, please.
Thank you.
Come on.
Let's have some more irrigation, please.
Okay.
Flush.
Pressure is released.
Ramakrishna?
Shock versus ICP. These numbers are impossible to interpret.
Yeah. Let's lift the drape, please.
Yeah.
Okay.
It's slow, but it's reactive.
- Nice work. - Thank you.
Burr hole did the job.
Brains.
Here we go.
- What the hell is going on? - It's a burr hole, she was coning.
Not bad. For an amateur.
We're just so happy to have you with us...
At last.
Prep the power perforator.
It's not the 18th century.
Help them to scrub in, please.
And, Harry, it's a good job.
I can finish this, if there's somewhere else you need to be.
Sure.
I'll just re-scrub.
Seems like you two make a good team.
Torvill and Dean.
Let's tidy up this mess, shall we?
Knife.
Cranial clips.
Retractor.
Perforator.
Shit.
There's a tear in the splenic flexure.
Drilling second burr.
I've located one of the foreign bodies.
What's that?
Glass.
She swallowed glass.
Radical approach to dieting.
Well, at least we found the perforation.
- Got it. - Last burr.
All yours.
Linear stapler, please.
How are the obs now?
Uh, not good.
Curette.
Flush.
So, who was that supporting the head?
The ED SHO.
Not Harry, by any chance?
Yeah, that's right.
Heard all about her.
One of our regs smashed it last month.
Credit to him.
Gen surg.
Got held up in theatre.
What's the situation?
We're sealing the perforation in the splenic flexure.
We did a splenectomy and a burr hole.
Well, leave some for me.
I'll be right with you.
Almost there.
Mayo.
Let's have the dish, please. Thank you.
Yes.
Elevator.
Here's the boy.
Malleable retractor.
Suction.
You gonna pull the clot or you gonna frame it?
You spend as much time as I do in the brain,
and you'd know you don't want to rush things.
Swab.
Bipolar diathermy.
BP 141 over 74. Pulse 72, sats 95. It's going in the right direction.
She won't be Einstein after this,
and as she jumped 30 feet onto a marble floor,
I'm guessing she wasn't that before.
Here, come here.
I'm sure he's got the wrong end of the stick
about Harry.
There's another perforation in the D colon.
Right.
Let's have a look.
- I think we've got this now. - Yes.
Fine.
Thank you.
- Is she out of the woods? - Seems so.
- And she's stable. - Tickety-boo.
Hi.
Oh, God, I'm gonna stink all day now.
I'm sorry about Glen.
Well, I'm sorry you got caught in the middle.
You did your gen surg up in Birmingham, didn't you?
At the QE, yeah.
With Glen?
I wouldn't say "with".
It didn't end well.
Well enough for you to get him to come here and take my job.
Sorry.
I didn't know what to do.
Clive gave me the impression that you weren't coming back.
You know she came in to the ED yesterday?
Who did?
Nuala.
Harry wanted to do a psych assessment,
but Clive insisted that she be discharged to meet the four-hour target.
Thank you.
Trauma call. Attend emergency department.
Hi, is the next case coming in here?
ETA three minutes.
Is CT available?
Clear, holding for us.
How's Nuala?
Oh, she's fine. Yeah. It's looking good.
- Great. - Listen.
Nuala Barrington is one case that you don't need to worry about, okay?
Hi.
Yeah.
What can I do for you, Lorraine?
I hear you're gonna call an SI.
Yes, it's a very unfortunate incident. Very sad.
How's the patient?
Looks like she's going to make it, which is probably just as well.
Hmm. You know, HSE are gonna be all over us.
Yes.
And I'm sure they'll be particularly interested to learn
that she was discharged from ED last night with a stomach full of glass.
When she should have had a psych assessment.
Yes. Well, I see how that might raise questions
about the member of staff who examined her.
I can see how it might raise questions about the duty ED consultant
who puts targets before patient welfare.
Oh, you know what? I can take this one.
Okay.
Thank you.
So, with everything going on, you really think she's up to the job?
That isn't fair.
I'm making this work.
You said so yourself.
Whatever's going on between me and you, that's what's really important,
is that I am making this unit work.
Yes, of course, but you have to understand that...
I'm not going anywhere, Fi.
I'm not leaving.
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