Trauma call, attend emergency department.
- Whoa! Bad luck! - Sorry, Billy.
Morning. Full English, please.
Trauma call, attend emergency department.
- That's us, Justin. - Awesome!
Ripped By mstoll
Trauma call, attend emergency department.
You're all right. We're going to take care of you.
Stay calm.
Sorry, early.
- Sorry. - Oh, sorry.
- Hi. - Morning.
Morning.
Major trauma, ETA, one minute.
Thanks, Justin.
- Thanks. Er, Harry. - Fiona.
6, 6.5.
- That's a bit harsh. - Tube.
6.5.
- Hi, everyone. Morning. - Morning.
Here we go.
Level six.
Level five.
Level four.
Oh, shit!
Shit! Let's go, let's go!
- Here we go. - Let's go!
Get the door!
Coming through!
We're taking you straight through to our resus room.
This way.
Starting the clock.
Ejected passenger, found unconscious, pulse 130, weak, BP 90/70.
- Diminished breath, sounds on the left. - Let's move the scoop on your count.
Okay, unclip top and bottom, please.
- Clear a space around him. - Oh, sorry.
- Everyone ready? - Yeah.
One, two, three.
Thank you. One, two, three.
Great, well done.
- Mate, has he got thoracostomies? - No. Massive haematemesis,
scarlet yawn...
Suction...
One conversation at a time, please.
Sorry.
Okay, great.
All right, mate, all right, we're sorting you out.
Mate, you're in the emergency department at CGH.
I'm Dr Chandramohan, one of the anaesthetists.
I need to look down your throat.
- I'm just going to take this strap off. - Leg support, please.
- Blocks coming off. - Thanks.
Sir, I'm just going to hold your head to keep it still.
Sorry I'm late.
Nice of orthopaedics to show up.
- Airway clear. - Resps 30.
Sir, my name is Fiona Lomas, I'm the trauma registrar.
We're going to do our best to get you better.
- Tachypneic, decent pulses. - Okay, thank you.
Okay, nice and quiet everyone while we listen to the handover, thanks.
Trauma Air Service arrived on the scene at 6:45
after an RTC called in at 6:30.
Multiple vehicles involved in a collision
on the Kingsgate underpass.
Patient was found on the roadside
after having been an ejected passenger from a bus.
Multiple soft tissue injuries, lacs, grazes, haematomas, top to toe.
There is a lac on the interior chest wall,
left wrist is fractured, left tib is an open fracture.
Diminished breath sounds on the left.
100% oxygen given via mask at the scene.
Haematemesis in the service lift and corridor.
Thank you very much.
You wanna sign off some paperwork with Nerys?
Come and sign your lives away.
I could act as scribe if you'd like.
Ugh!
Need to tube him.
Fiona.
Dullness to percussion on left side.
- He needs a thoracostomy. - Yeah.
Sir, we're going to do something to help your breathing.
- Justin, thoracostomies. - Oh, right.
Trachea deviated to right.
Loads more on the way. First of many, apparently.
- Oh, great! - Oh, great!
Okay, let's get him intubated.
Oh, what now?
- VT. - Argh.
- Carotid output. - Femoral output, defibbing.
Off the chest, please, Justin, VT with output.
- All right. - Shockable rhythm, no CPR.
Sync shock, 150 joules.
150 joules selected. Charging.
Okay, everyone, clear oxygen away.
- Away. - Shocking on three.
One, two, three.
Still in VT.
- Output. - Oh, damn it!
Charging.
- Charging. - Shocking on three. One, two, three.
Shit!
Come on!
- Output. - Charging.
- Shocking on three. One, two, three.
Sinus rhythm. Good output.
Okay. We have ROSC.
Well done. Thank you.
Well done.
Okay, I'll do the thoracostomies to help with his breathing.
Give him, um, Ramakrishna?
- 30 of ket? - Ketamine.
Okay, and I'll pause for a top-up if he protests too much.
There's an open tib that needs IV Augmentin?
Thank you, in a minute.
Phones off, please.
Mate, just going to give you something to take the edge off.
Can you bring me the trolley, please?
Try looking in the pockets of her coat.
Well, he's not protesting, I think we're all right.
Yep.
Pulse 130, BP 80/65.
I think he'd benefit from some more blood.
Okay. Thank you. Constance, could you, please?
Yep.
Let's keep a close eye on the BP, please.
- Thank you. - No response to trap pinch.
- One. - GCS?
- Four. - Four with sedation.
Sorry.
Bilateral thoracostomy patent.
- Time for drains? - Sats 88.
- Prefer to get him under first. - Okay.
That's the lads off.
- Okay, thanks, guys, have a good one. - See you next time, lads.
I thought he was sedated?
He was. He was.
- Suction. - Okay.
- Need to RSI, Billy. - Yeah, I'm on it, I'm on it.
- Okay, do it fast, please. - BP's dropping.
Severely hypotensive, no radial pulse.
You need to put the tube in.
Yeah. I can't get a tube in with the BP down this low.
Okay, blood straight away, just squeeze it in.
Justin! Quickly.
We need to get his blood pressure up.
Sir, we're going to clear your throat.
Please try to be calm so we can help you.
The sats are going down, we really need to get the tube in.
For God's sake, I'm trying.
I've got a radial pulse.
Okay, you've got enough pressure, you need to get the tube in, please.
Okay, here we go.
Are you the new SHO?
Er, yeah, everyone calls me Harry.
Okay, can you give me inline C-spine immobilisation
while we take the blocks off, please?
No, get your hands in there.
Okay. Hold tight.
- That's it. - Oh!
Jesus. You got him?
Yeah.
- Yeah. - Ta.
- Hold tight. - Yeah.
- Thiopentone, 250 mg. - Okay.
Thio, 250, going in.
Going in. Just sending you off to sleep, mate.
Push. Yeah.
Finally, some peace and quiet.
Sux 100,
going in.
We use sux in trauma 'cause it works fast.
That's not the only thing around here.
Takes a while to paralyse the patient.
Here we go.
Okay, yeah.
Suction.
- Make sure you do ABGs and an ECG. - Yes, Dr Archerfield.
All those staff to one patient.
No, that's a trauma call, critical injuries.
It's madness.
This guy feels cold. Did we get a temperature?
Not that anyone's given me.
How long till they scooped him?
They were there in 15 minutes, scooped after 25.
Carotid core, 36.1.
Yeah, he's cold for someone they scooped inside 30 minutes.
- 15 and 25 is 40. - 40 minutes then.
How much blood is left in the fridge?
We're down to three bags.
Intrathoracic haemorrhage, get me a swab, please.
Okay, here we go. I'm calling a code.
- We need more blood. - Another Venflon?
- Yes, and a trauma line. - I can do Venflon.
Sister Merrick, resus, we're coding.
- Tranexamic acid, please. - Coming up.
- Let's stop this haemorrhage. - Major transfusion protocol.
No, no, don't put me through to blood bank.
Oh, I know you don't need me to say this, everyone,
but nice and fast, please.
Crosscheck.
- O pos, dated and checked. - Crosschecked.
Hello, 24?
No, I know, I'm still holding.
Two units of O pos remaining.
TXA, one gram IV, one gram infusion to follow.
Yes, this is Mrs Rappaport, I'm the consultant on call
for major trauma and we have just enacted
the major transfusion protocol.
You send us 12 units of O positive immediately.
Eight of FFP and four of platelets.
- Do you have authorisation? - What?
I make that the third unit of blood now.
- One unit of O pos. - Okay, then, please put me through.
No, thank you!
Let's put the next unit of O pos
through the trauma line and pressure on the thoracostomy bleed.
Harry, pressure, please.
Okay, let's take bloods as I do the trauma line.
Oh, hi, yes, this is Lorraine Rappaport, consultant on call...
Let's have another bag of O pos from the store, please.
We have a major trauma patient in resus
and blood bank won't enact the major transfusion protocol
without your say-so.
You have his haemoglobin measured?
No, we haven't measured the patient's Hb,
and if we did, it would be normal
because the concentration of haemoglobin in his blood
won't have changed.
But what has changed is he has a lot less blood circulating
than he did half an hour ago.
And if we don't transfuse him, he will die.
- Excuse me. - Thank you!
Sorry.
- Sorry! - Yes.
This thoracostomy's really bleeding.
He's bleeding out.
We need more blood, we're losing him.
What the hell's going on in this guy's chest?
We need someone to do a chest drain, please.
- Me. - We have a volunteer.
Justin, get on that bleed now.
Swap gloves, eye guards, gown.
I want you ready to go in two minutes.
Billy, where are those blood gases?
PaO two, 5.3. PaCO two, 4.5.
PH, 7.1. Lactate, 8.
- Base excess, minus six. - Thank you.
Airway secure. Patient ventilated.
O pos transfusing, bloods away,
patient maintaining sats and blood pressure.
Anything outstanding?
- Anaesthetists, happy? - Over the moon.
Good.
Elapsed time, 11 minutes 30.
BP's down.
Keep squeezing the blood in, please.
- That's it through now. - Thank you.
You've got to start that chest drain now, please.
This an RTA?
First of multiple casualties.
Is that me done?
I thought trauma was mainly RTAs?
Why are you doing the drain?
You're the new SHO.
Yeah, everyone calls me Harry.
I'm Mrs Hicklin, everyone calls me Mrs Hicklin.
I'm Ramakrishna.
Yeah, it's mainly car crashes and stabbings.
Thanks.
- There's a bit of resistance. - Push.
- Cardiac kebab, here we come. - Just push.
Ugh!
Ooh, God! Oh, okay. Is that good?
Yes, yes, that's exactly what we expect.
- Suture it, please. - Er, yes.
Can someone please phone ahead to CT, let them know we're on our way?
And blood bank will be delivering some blood very soon.
If they're not here in the next two minutes,
we need to chase them.
Yeah, I'll call CT and blood bank.
Is this anyone's Twix?
Are we getting x-rays of the wrist and tibia?
Wait for the CT.
Yeah, sorry. Um...
- I could reduce the tibia now? - Sure.
Okay.
Shall we replace the TXA infusion?
Uh, yes, of course, yes, thank you.
Justin, can you expose the leg, please?
Just a sec.
- Cheers. - Prick.
Nice one.
Traction?
Yes, this is Mrs Hicklin.
We'll be bringing in major trauma, Mike Alpha, for CT, very shortly.
Will you be ready for us?
Good.
Thank you.
O positive, FFP and platelets for Mike Alpha.
Great. Let's get a couple of bags of this O pos up immediately, please.
Patient Mike Alpha. O positive.
Has anyone seen my cardie?
And a Twix?
Sorry.
Okay, soon as the blood's up, transfer to CT.
You can leave that.
- Nerys, this TXA is ready to go up. - Yep, of course.
I'm so sorry that's taken so long.
Make sure those x-rays are uploaded straight away
this patient's been here for three hours.
Lorraine. How's it going?
- Trauma call. - Anything juicy?
We agreed that the major transfusion protocol
was to be acted by the trauma team leader.
Absolutely.
So why, then, yet again, am I talking to a haematology consultant
who pompously asks me the patient's Hb?
Well, agreeing to the trauma protocol is one thing,
getting the other departments to actually
put it into practise is something completely different.
You said it had been agreed.
Well, they're territorial, and I'm stuck in the middle.
No, I am, and the patient is.
I know, I can see you're upset.
This used to be a bog standard A&E.
- We are now a major trauma centre... - Whoa! Just a second. Hold on.
I resent that description.
We used to be the best-performing unit in the region.
Now we take more patients overall,
more critical patients, resources are stretched.
Supposedly, we're not doing as well.
Well, then, some of us need to raise their game.
Where is this going exactly?
Good morning.
I will be ready to start the scan in approximately one and a half minutes.
Thank you, Brian.
He's already bled 1000 mills.
- He's coagulopathic because he's cold. - Cold.
So if he was on the road for longer than 40 minutes...
Wait, let's deal with the coagulopathy.
I want FFP and platelets up now.
Where's our leader got to?
Can someone please just go and check that Lorraine's on her way back?
Kill the alarm.
Nerys.
Will you bring either Mrs Rappaport or Dr Archerfield?
- Just right now, please. - Yes, Mrs Hicklin.
- Shit, he's in VF. - Billy.
Yeah.
No output.
Fail.
Back into resus.
- Slowly with CPR. - Fast, and we'll do it there.
- Come on. - Quickly, let's go.
Turn.
Careful. Get the door.
Yeah, got that, got that.
Justin, take over compressions.
Connect electrodes. Electrodes connected.
Diagnosing rhythm.
Ventricular fibrillation.
Advising 150 joules by fading shock.
150 joules selected.
Charging.
Justin, off the chest.
- Shocking, three, two, one. - Stand clear. Warning...
Two minutes of CPR to come at 31 minutes.
Adrenaline and amiodarone on standby, please.
Yeah.
- Where's Lorraine? - Lorraine wasn't there.
- Well, where is she? - I don't know.
Fetch Clive then.
He wasn't there either.
CPR counting towards two minutes.
Then get ready to give another 150 biphasic.
After that, be ready with adrenaline one mg,
amiodarone, 300 mgs.
Staying alive, staying alive...
Hello, this is Lorraine Rappaport.
Please leave a message.
Lorraine, it's Fiona.
Please call me right back.
I need you here, boss.
Absolutely starving.
I missed breakfast because of this.
- You shouldn't have a... - One minute to go.
Ordered it, then the beeper went.
It's just sat there then?
I don't know, I didn't pay for it, so I doubt it.
Not good for your insides.
Staying alive, staying alive...
You're in a bit earlier, aren't you?
The Fiesta didn't start this morning so I was a bit late.
40 seconds to go.
Coming up to two minutes.
Check pulses, stop compressions.
- No pulse. Still VF. - Justin.
Joules selected. Charging.
Charged. Warning...
- Everybody clear. - Stand clear.
Justin, off the chest.
Shocking in three, two, one.
Diagnosing rhythm.
Sinus rhythm.
Follow the guidelines, please, Justin.
Sorry, Mrs Hicklin.
I'm hearing heart sounds. We might have ROSC.
- Justin, you need to stop for a second. - Stop.
Output.
- Thank you. - Good job.
We have ROSC.
Put the bloods up, please.
- All right, now what? - CT.
You're happy the patient's stable enough to be moved?
Lorraine wanted a CT next.
That was before he arrested.
Well, we need to know what's going on in the chest.
That's a decision for the trauma team leader.
Lorraine isn't here.
So, someone needs to lead.
CT.
Take two, let's get him ready to go.
Let's get him on the fourth floor...
Hello, this is Lorraine Rappaport.
Please leave a message.
Lorraine, the patient just had a VF arrest.
I've no idea why.
I'm really worried I'm missing something here.
We're going to take him to CT.
I'll see you there.
Are you doing anything about the wrist and tib?
We need to fix the chest first.
Okay. I'll be on the ward if you need me.
- She's got the right idea. - What?
Not being here if all this goes tits-up.
Smart.
- Shall we try again? - Sorry, Brian.
Patient clock synchronised.
On three. One, two, three.
Well done.
Brian Zhao, CT radiographer
and deputy assistant department coordinator.
For you.
Lorraine?
Oh, just a second.
All the results you've got please.
Er, nobody touch any buttons.
One, two, three.
Thank you. Bye.
- Do you know what? - What?
I think we're going to lose this one.
Control scan.
- Have I missed anything? - Just starting.
- Starting head scan. - Where's Lorraine?
Hmm?
She's not with you?
Head scan complete.
Nobody touch any buttons.
Right, your head is NAD,
you've got no obvious intracranial lesions or bleeding.
Are you happy, Fiona?
- Here. - Hmm.
Right.
Contrast run.
Tube's in the right place.
If I'd messed up the tube,
he'd be on his way to pathology outpatients.
I really wish I'd had more practise at it.
We could find some time this week.
- Only if it's not too much trouble. - I'll find a way to fit you in.
Back to the ED.
And you.
I really wanted to see this case through.
When we lose you to a major trauma, patients stack up.
Right.
Best bit's over anyway.
The left side's filled up with blood again.
We've got an uncontrolled intrathoracic haemorrhage.
Where is Lorraine?
I told you, I don't know.
Clive Archerfield.
Yeah, thanks for getting back to me.
If you need me, I'm in ED.
Hello. Yes, sorry about that.
Yes, we're being advised...
Streaks! Metal!
Who put metal in my machine?
- Going in. - Er, clear to enter.
What's that?
Manifestly, it is the blade of a knife.
Is it penetrating the heart?
Okay.
- Turn. - Yeah.
- Got it? - Open the door.
Clear the bay!
Get all the monitors back as they were. Defib on standby.
Can you see if the ED reg can help?
Let's get these bags up.
- Justin, back to resus. - Excellent!
- Yes, Harry, and you. - Yes! Um...
Can you get the reg to sign off on this? Thank you.
- The reg coming? - Just me.
They're never going to give you the reg.
Too busy keeping admissions moving.
He seems to be maintaining a blood pressure.
Let's keep transfusing him while we chase cardiothoracics.
Hello, switch, it's Sister Merrick.
Please can you fast bleep cardiothoracic again for us?
Thanks.
Cardiothoracic's fast bleeped.
Told you, car crashes and stabbings.
- Where's Lorraine? - I don't know.
We're fine here.
Just grab a coffee or something, you look like shit.
Tsk, Dr Chandramohan,
using strong language in front of a patient?
He's unconscious.
Police are already checking the traffic cams
to establish the cause of the accident.
No-one was ejected from the bus.
Instead, there was a body in the road which caused vehicles to swerve
and that's how the collisions happened.
They now think our patient must have fallen
or been thrown from a bridge following an assault.
- Thanks, Giles. - You're welcome.
Cardiothoracics will be here in five minutes.
- Good. - What did I say?
Too cold just to have been there since the crash?
Oh, genius!
He's bleeding out.
No output.
PEA.
No compressions, there's a knife in the heart.
We need to stop this bleeding.
Cardiothoracics needs to stop this bleeding.
They're not here.
No BP.
- Clamshell. - Brilliant!
I'll find Clive.
- Bag him, please. - Yeah.
Take this.
- What, me? - Yes.
Okay to cut?
It's not my call.
- Cutting. - Shit, shit.
Oh, my God!
Harry, get in here.
Grab the wound edges, and pull apart.
Mind your fingers.
Hold it open.
Turn the lever.
Other way.
That's it.
Wider.
Suction.
Do this.
I can feel the knife.
Switching.
- Justin, bring the light over, will you? - Yeah.
Contractions but no output.
The blade has made a tiny hole in the ventricular wall.
- Any bigger, he'd be long dead. - Yeah, he's got all the luck.
I need scissors.
Listen, love, you can't do this without a consultant here.
- Best wait for Clive. - Or cardiothoracics.
He can't wait.
Heart exposed.
Keep the suction going, clear as much blood as you can.
Suture.
Justin, wait.
I need you to do something very important for me.
I need you to put your finger in this hole in the patient's heart.
Will you do that for me, please? Harry?
Okay.
Oh, my God.
Finger out.
That's got it.
Bring another bag of blood up, please.
Still no output.
Give it a minute.
Got a pulse.
Cardiothoracics are here.
Good. Who did this?
Let's transfer to theatre and complete the repair job.
Sister Merrick, TNP.
We need trauma theatre staff fast bleeped.
Thank you.
You just helped save his life.
Thank you.
Orthopaedics, Sister Merrick, resus.
Mike Alpha is ready for you now. Thank you.
You shouldn't have done that.
You're right.
Clive should have.
Clive has a responsibility to this entire department.
It supersedes the needs of individual cases.
Two questions.
What's happened to Lorraine?
Not your concern.
- And the other question? - Who's covering?
It's in your best interest to stay out of this,
so stay out of this.
Hi, Mum. You won't believe what I've just been doing.
No, no, I'm fine.
Colleague announcement.
Multiple incoming casualties.
Will trauma team please return to resus?
Colleague announcement.
Multiple incoming casualties.
Will trauma team please return to resus?
Morning, sir.
Morning.
Hello, this is Glen Boyle.
I can't take your call, please leave a message.
It's me. I...
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.
Hi, Glen.
Come in.
Thanks.
Good to see you again.
How are you?
You could have opened with an easier one.
Whatever the grown-ups think, that was the dog's bollocks.
Right here.
Who's leading?
Okay, let's get him wired up, let's get to work.
What's with the whole Elephant Man thing?
- Right. - Oh, my God.
A major trauma case needs a trauma team leader.
Somebody coming in, isn't he here yet?
It's good to see you.
I've practised all over the world.
In the forces, and civilian hospitals.
I specialise in critical injuries.
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