This is Mrs Rappaport.
I'm the consultant on call for major trauma.
What's happened to Lorraine? Who's covering?
It's in your best interest 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've practised all over the world.
In the forces and civilian hospitals.
I specialise in critical injuries.
- I thought you needed me. - This unit needs you.
And you think I can change things when Lorraine couldn't?
Bring it on.
That's 31 minutes.
What output are we getting from compressions now?
- Some. - But sats are still very low.
One minute of compressions given. One minute to go.
Jason, you'll continue compressions until the last possible moment
before Nerys shocks.
There'll be a pulse check before the shock.
This will be the third shock.
Do we have adrenaline and amiodarone ready to go in?
We do. Adrenaline one milligram,
- amiodarone 300 milligrams. - Thank you.
Jason will restart compressions immediately after defibrillation.
Justin.
And then the drugs will be given unless we observe sudden obvious ROSC.
Everyone clear?
Pause compressions. Pulse check.
Flatline on arterial pressure.
Compressions, go, go, please.
Charging, 150 biphasic.
150 joules selected.
Biphasic shock. Charging.
Do you know what? I think I'll just...
- Charged. - Everyone clear.
- Warning. - Justin, off the chest.
- Warning. Stand clear. - Shocking after three, two, one.
Drugs and compressions, go, go.
Adrenaline given.
That'll be a rib.
- Shit, sorry. - Oh, easy, tiger.
Okay, Someone take over from Jason
before he gives him a flail chest, please.
- One, two, three... - Amiodarone given.
...five, six, seven, eight, nine, 10, 11...
Arsehole!
- Blood going in, adrenaline. - How many units is that now?
- 12 units... - 12 units of O pos,
- eight FFP, four platelets. - That is correct.
- It's impressive. - Arsehole.
- Girl, do your business. - Sorry, sister.
This was supposed to be a scoop and run.
It takes them half an hour to get him off the roadside.
Nine, 10, 11...
Barely getting anything with compressions.
- Boss? - Yeah, yeah. I hear you.
...13, 14...
I want to move on to other interventions.
We haven't completed this CPR cycle yet.
Hey, we're pissing in the wind here.
So let's prep for a clam-shell, please. Right now.
- Yes. - Not you, Harry.
Keep CPR going until we're ready to cut.
- Get on it. Move, move. - Sorry.
Sorry, what the hell are you all doing?
The kit needs to be out, opened, ready to go in seconds.
Very sorry, Mr Boyle. Justin.
And there had better be an aortic clamp this time,
otherwise I am going to flip my lid.
Aortic clamp in trauma theatre now.
- Me? - Don't test me, boy.
Approaching 34 minutes since admission for resus.
- Patient has been down... - Seven minutes.
Thank you. Nerys will shock again.
Harry, you'll continue till the last possible moment.
No drugs on this cycle. Understood?
- Yes. - Yeah.
Another set of shears, please.
Ten seconds.
- Charging, 150 biphasic. - Move that closer, please.
Selected. Biphasic shock.
Charging.
Not you, Harry.
- Charged. - Everyone clear.
- Harry, off the chest. - Warning. Stand Clear.
- Charging after three, two, one. - Warning. Stand Clear.
Flatlining arterial pressure.
VF. Carotid absent.
- Stop compressions. - No, no. Keep going.
We'll work around you. And we're cutting.
Drains. Mind your fingers.
- I said mind, not move. - Sorry, Mr Boyle.
Okay, Jason, get back on compressions, please.
- Justin. - What?
His name is Justin.
- Is it? - Yeah.
Stop.
Ripped By mstoll
Sorry, urgent potassium result.
Don't mind me.
Internal compressions, please.
- Okay. - Okay.
Pericardium open.
Where's the clamp? Really?
There's no clamp?
Excellent.
Okay. I'm going to need to get some access here.
Okay, I have manual control of the aorta.
I've shut off circulation to the lower part of the body
while we wait for the clamp.
On its way, Mr Boyle.
- Got an arterial pressure now. - Good.
So why didn't you say anything earlier?
- Didn't like to. - Why?
- You can be a bit... - Bit what?
Fierce.
Huh! You pick your moments.
Bosh.
Convert back to vent, Billy.
Aorta cross-clamped.
- Distal flow is down. - Now, listen, everybody.
That was piss-poor.
But you will get better at this and do you want to know why?
So that when you look this man's family in the face
and you say you did everything you possibly could for him,
it is not going to be a bloody lie!
We're cross-clamped. Distal flow is down.
Okay, let's get the rapid infuser going into the subclavian, please.
Yeah, on it.
Is this a bad time to ask about the legs?
- Yeah. - Yes. Right, sorry.
- Bung. - Thank you.
Okay, that's the rapid infuser connected to the subclavian.
I'm feeling contractions.
Stop compressions.
Got spontaneous contractions.
Yes.
Looks like sinus.
Let's keep filling him up with pink, please, three to two.
- Still on pack B. - Okay.
Registering a proper BP now,
60 over 35.
Sats coming up sluggishly.
BP 90 over 60, sats climbing.
Thanks, Ramakrishna.
He gets Ramakrishna right.
Okay, let's fastbleep the theatre staff.
Patient ETA two minutes.
Fastbleep cardiothoracics and gen-surg. We're taking him there now.
And we need the radiographer to do portables in theatre.
This is Fiona Lomas.
X-ray the legs. Get scrubbed up.
Get in.
- All right, brakes off. Let's go. - Brakes off.
Rolling.
You're letting that girl make a fool of you, boy.
I'm not your boy.
Haven't seen each other all week,
then there's the scramble of the trauma call.
I never got to say hello.
Hello.
How are you settling in?
- Fine. - What's the problem?
Well, you said it. Haven't seen each other all week.
- Hi. - Hi. The fiancée's here.
Does someone have a minute to talk to her?
- Yes. - Sure.
Okay.
Lauren, this is Mr Boyle, the trauma consultant.
I'm sorry this has to be quick, Lauren. Adam is critically injured.
His bike was involved in a collision with a lorry,
resulting in multiple serious wounds.
His heart stopped beating and we opened his chest
and got it pumping again.
It stopped because he's bleeding internally.
And now we have to find out from where
and to operate on some serious crush injuries to both of Adam's legs.
But we're going to do everything we can to save them.
Right now, we really should get back to him.
Thanks.
I'm going to ask Mr Dhilon to sit you in our relatives' room.
Is there anyone that you need me to call?
You need to get on with it.
'Cause ready or not, in five minutes I'm cutting.
Okay to prep?
- Please do. - Yes, please.
Splints off, please.
And whatever's left of his trousers.
Trainers, too.
I'm going to lift him. On my count. One, two, three.
Okay.
I'll lift the leg, you pull it out.
Okay. One, two, three.
BP's now a very respectable 100 over 80. Sats sitting pretty at 96.
- Thank you. - Clamp's been on for eight minutes.
We need to crack on.
Watch your backs, please.
Rays coming up after three.
One, two, three, rays.
One, two, three.
Down.
Let's who.
I'm Glen Boyle, trauma consultant.
Fiona Lomas, trauma fellow.
Ramakrishna Chandramohan, anaesthetics reg.
Billy Finlay, anaesthetic ODP.
Rebecca Osgood, orthopaedic registrar.
Khaali Osman, scrub nurse.
Lucy Hartwell, staff nurse.
Heather Dooley, staff nurse.
Andrei Kovac, documentation nurse.
Armen Khular, ODP.
Daniel Insalaco, rapid-infuser operator.
Shelley Imms, radiographer.
Daisy MacDonald, circulating.
Thank you.
Rays in three.
One, two, three, rays.
Thanks very much. All clear.
Excuse me.
Let's confirm the patient.
Patient's name Adam Richards, date of birth 16-11-1989.
Patient number G893677498.
- Cyclist crushed by HGV. - Confirmed.
Care to run off a new set of ABGs? Thank you.
I've signed a Consent Form 4 for a laparotomy
to stop a life-threatening intraperitoneal haemorrhage.
I've signed a Consent Form 4 for fixation of lower-limb fractures
and debridement of crush injuries.
Okay, big swabs to me, please.
One, two, three.
Nice and high.
Radiograph's coming up on screen now.
No, not now. Blade.
- Am I okay to cut? - Yep.
Cutting.
Scissors to me.
Still waiting.
- Sorry. - Trauma patient, aortic clamp.
- We're going to be moving fast. - I'll try to keep up.
Massive blood pooling in the abdomen.
Okay, I'm opening the peritoneum. Everybody ready?
- Ready. - Ready.
Then here we go.
Suction. Packs.
- Morris. - Morris.
Hit me.
To me.
Three.
One.
Two.
- Ten in the abdomen. - Fifteen in.
Am I okay to unclamp?
Yeah.
- Ready? - Ready.
Okay, boss.
- I'm going to unclamp by a half. - Right.
- Okay? - Okay.
Half. There.
Pressure dropping.
Holding.
Okay.
- Am I okay to risk three quarters? - Fine.
- Yeah? - Yeah.
Three quarters.
There.
Dropping.
Holding.
- Okay. - Right.
- Going to go all the way. - Do it.
That's all the way.
Dropping.
Come on! Come on.
Dropping.
Holding.
Patient's stable. Looking good.
Ooh, bit of a rise.
Ha. Nice.
- Maybe we could look at the legs now? - Yeah, quickly. Images, please.
Image.
- Oh. - Oh.
Shit.
- Okay. Thank you very much. - No problem.
- Why is the shoe still on? - No one dared take it off.
- Can we double-glove Rebecca, please? - Sevens, please.
Gloves.
Okay, clamps off.
So let's re-pack the chest before we hunt down the bleeds.
Packs, please.
And again.
- Two in the chest. - Two in.
Glen.
You okay?
Yes.
I'll take it.
Get the gloves.
- Mr Boyle? - Yeah?
Actually, I'm not okay. Can I have a minute, please?
Absolutely.
Someone bring her a cup of water, please.
I'll go.
You need to hear his gases.
- Go on. - Well, he's knackered.
And when you restore his circulation,
a whole pile of shit's going to come out of those legs.
Save the legs but the patient dies?
Oh, no. Not on my watch.
- Tell me his haemodynamics. - Pressure's holding off-clamp.
Good.
We're taking his legs. I'm going to proceed with haemostasis.
Billy, can you put in another call to blood bank, please?
Pack C. 12-8-4-2.
- Can I have the ring-plates? - Twelve units of crossmatch,
- eight units of FFP... - Thank you.
Four units of platelets and two of cryo.
I'm going to sloop the iliacs while I'm here.
Sloops.
- You good? - Thank you.
Okay, take the legs.
Crack on in your own time, wide debridement, yes?
Okay, we're going to unpack quadrant by quadrant.
I need the legs supported in knee flexion 45 degrees.
Wedge.
Blade.
One out.
Two.
Saw.
- You okay? - Yeah. Thank you.
- Lower quadrants are unpacked. - Blade.
There are no obvious sources of bleeding in the lower quadrant
and no obvious retroperitoneal bleed.
BP is holding.
Going to go for the iliacs now.
Mayo. Can you hold that?
Thank you.
Can you do the other side, please?
Clips.
Okay, we have control of the iliacs. You can release the tourniquets.
- Four out. - Four packs out.
Those are going straight down the canteen.
Don't waste time making them look pretty.
Have we seriously still not got anyone
- from cardiothoracics or gen-surg? - Someone chase them, please.
We shouldn't have to be cha...
We shouldn't have to be chasing them.
Hello, this is trauma theatre. Can you please advise us
when we will be able to welcome the cardiothoracic and general surgeons?
Yes.
Thank you very much.
They're fastbleeping them again.
Well, what's next?
Let's unpack the left upper quadrant and continue the haemostasis, please.
- One out. - Two.
Shit!
Haemorrhaging around the spleen.
It's dropping.
It's crashing!
Shit! Shit! He's bleeding out.
Suction.
- Get him reclamped, please. - Clamp. Quickly.
Come on.
Where's that blood? Quick, quick, quick, Billy.
- Just bang it in. - Yeah, banging it in.
Come on. It's still dropping.
Reclamped.
Delivery from blood bank.
Quick. Quickly.
The clamp's controlling the abdominal bleeding for now,
but we're taking the spleen.
BP's still very low.
- He's shutting down. - Well, let's fill him up.
Well, we can keep going with the rapid infuser.
Then let's do that.
- Keep the crossmatch. - Dardick, please.
- Gauze and bandages. - Gauze and bandages times two.
Forceps, Lahey, ties.
Mayo, please.
Mr Street, gen-surg consultant.
Who's consulting here?
We met before. Glen Boyle, I'm trauma.
Sorry, Glen. Hello again.
Splenectomy in progress.
- You took the legs? - Had to.
I'm sure it was the right decision.
But for medico-legal reasons, I'll be requesting
two orthopaedic consultants review the notes.
Absolutely fine.
- Scrubbing in. - Mayo.
Cut.
So you must be Lorraine Rappaport's stand-in?
How long's Lorraine going to be off for?
Unstable angina, I heard.
That's what's being said but we don't know yet for sure.
Poor thing.
I'm sure Clive filled you in the other night.
I hear it was very convivial.
We've waited here long enough.
I need you now, please.
Cut.
Ties.
Um, if we're all done with the legs,
- I should... - Yep.
- No, I mean, we're done with them. - You should go.
And well done.
Cheers.
Cut.
Yes.
- Mr Street. - Rob.
We need to tackle the liver.
Go for it. Be right with you.
Cut.
Mac.
Dish, please.
- Spleen out. - Thank you.
Let's unclamp. I've got this.
Half off.
Dropping.
Holding.
Yeah.
Three quarters off.
Dropping.
Holding.
Go on.
Let's go.
Unclamped.
Dropping.
Liver's haemorrhaging.
Leave the clamp off and let's unpack the RU.
- I'll do the Pringle. - Okay.
Fractured right lobe, some torn mesenterics.
- Pringle's not working. - Reclamp.
BP remains very low.
Every time you unclamp, he loses more than we can put back in.
- We can ligate the mesenterics. - I reckon so.
Reclamped.
Boss, I need some senior support in trauma theatre.
I'll get on and ligate these vessels.
Two clips, 2.0 vicryl. Mounted ties.
- I'll pack the liver. - Good idea.
Packs, please.
Scissors, please.
Liver packed.
Okay. Cut.
Cut.
Okay.
- He's bleeding again. - Has the clamp come loose?
- Aorta's clamped. - Shit!
Everything below the clamp is tied off. Where's it coming from?
Oh, God.
BP dropping, 30 over unreadable.
- Clamp's on. - I just told you it was on.
Then he's bleeding above the clamp.
Diaphragm's ruptured. That's how it's getting down into the abdomen.
He's blown out clots in the chest.
This is sounding like DIC.
Death is coming.
Haemostatic gauze. Now, please.
You unpack. I'm going to get the haemostatic in.
Thank you.
- Cut. - Scissors, quickly.
We need to tamponade the bleed.
Hit me.
Cut.
Pack, please.
Hit me.
- Oh, come on! - He's down.
- Keep the rapid infuser going. - It never stopped.
- Coming up to 71 minutes, 30 seconds. - The heart's empty.
- Fresh blade and a Foley, please. - Foley.
Blade.
Right. I'm going to put the Foley,
get it going right into the right atrium
and fill him up from there and you're going to inflate the cuff.
- Glen. - Just do as you're told.
Listen, mate, you gave it a good go but he's down.
If you want a say, you're going to have to show up when you're bloody called.
72 minutes. Now been down 30 seconds.
Cuff prime.
Yes. Get that connected to the rapid infuser, now.
- Billy. - Yeah, it's going.
- Yeah, ready. - Okay.
Compressions.
Carotid. Thank you.
Very weak output.
I need to secure the Foley.
2-0 vicryl, please.
Stop compressions.
He's been down for almost a minute and a half.
Scissors, quickly.
Pulse absent.
Cut.
Start compressions again.
Let me see what we've got.
Thank you.
You can stop now.
Thank you.
Patient pronounced dead at 74 minutes.
I want to thank everyone.
- Sorry, mate. - Yeah.
I'll email you my notes later.
Everybody leave anything that's connected to the body
exactly as it is for now.
I'm sorry.
Is Mrs Hicklin there? It's Fiona.
He went down. Pronounced a minute ago.
I'm very sorry. You all have my sympathy.
At this stage, and I can see you're already following the protocol,
nobody should touch anything connected to or entering the deceased.
- Can I do anything for anyone? - No.
- Thanks, guys.
- The wounds are still open? - Yes.
Once the photos have been taken, would you be able to close the wounds
or would you like me to ask someone else?
- No, I'll do it. - Thank you.
You mentioned Lorraine's illness.
I was just wondering where you got that from?
Hmm?
- From Clive? - Yes.
Well, I heard different.
It's all right for you.
You don't have three kids.
Where's the girlfriend, please?
- Fiancée, I'll take you. - Thank you.
I'll come.
- Really sorry. - Thank you.
Lauren?
- If there's anything I can do... - Thank you.
Arsehole.
The major trauma died.
Oh, right.
I didn't know, I've been on minors.
Still, doesn't make you any less of a cock.
I just don't know what I'm meant to have done wrong.
No?
Then why did one of your mates ask if I wanted an intubation tutorial?
- Mate? What mate? - Dominic Busby?
- Shit! - Hmm.
What did you tell him? "There's a slapper down in the ED.
"Give her a bit of teaching and she'll feel your tube."
- Oh, Harry, listen... - I don't want to have this out at work.
- So I'll call you. - Don't bother.
You blind?
Scaphoid.
Poor bloke.
We lost valuable time because gen-surg and cardiothoracics were not on scene.
They can't be in two places at once.
So on-call rotas need to be synchronised.
Yeah. I've raised the issue.
There's some resistance. Hopefully they'll change their minds.
We need the right specialities coming to the trauma calls now,
so it should be more than just a hope.
You know, I was quite surprised to receive your application.
- Really? - Mmm, yeah.
I wouldn't have necessarily put you together, you and this unit.
I want to give it the benefit of my experience.
Mmm.
Yeah, of course.
Sorry, sorry. Can we just...
- That's fine. - We'll just be a sec.
- Can I get a medium cappuccino, please? - Yeah, sure.
- Double espresso. - Don't be silly.
Thank you.
Maybe I could talk to gen-surg and cardiothoracics?
Look, this is going to sound very patronising
but you're a locum and you've been here a week.
I led a trauma unit in Bastion.
You could have had half your body blown off,
you came into Bastion with a pulse,
you've got a 98% chance of survival.
- That's the best in the world. - Yeah, well, things are different here.
Look, you've had a terrible night. Er, why don't you leave this lot with me?
This lot, it can be a bit like herding cats.
- Here's your coffees. - Mmm. Thanks.
- Hey. - Thank you.
- Oh, sorry. - No, not at all.
How's the fiancée faring?
Has the bereavement counsellor been able to see her?
- It's all in hand. - Thank you.
I want it made clear that this death occurred on the trauma service.
It is not an emergency department death.
Right.
- Hey. - Did I say?
Erm, one of our nurses was at Camp Bastion last year.
Oh, yeah?
When were you there? Only your name didn't seem to ring a bell.
It's a big place. People came and went.
I'll, erm, try not to take it personally.
Thanks for closing.
- There's a trauma call. - I heard.
Do you believe that crap about Lorraine being on sick leave?
- Thank you, everybody. - No worries.
It's a lie.
And to cap it all, you're on the town with Clive? So, what?
Big boys get it sorted out over a pint so I can stop worrying my little head?
You called, told me you needed me and I came running.
Now you're pissed off. Why?
Because a complete stranger could be asked to take me out
to welcome me to the job?
Was it really too much to ask for me and you
just to go for a drink?
I didn't return your messages for a reason. You know exactly why.
Boss? Trauma call.
Yeah.
Trauma call, ETA one minute.
Will the trauma team please return to resus?
Trauma call, ETA one minute.
- Another RTC. - Really?
Not seen one of those before.
- We can still work together. - Yeah. Work.
That I can do.
Here we go.
And let's do better this time, please.
Ripped By mstoll