Critical (UK) (2015) s01e10 Episode Script
Episode 10
You'll destroy my career? Clive will pay for this.
Take his side, you'll pay for it too.
Harry! The break-up.
Is it over then? Got to be professional.
So she's single now? Clive, you're relieved.
The Chief Executive has made me Acting Clinical Lead.
I'm grateful you're here.
I'm grateful you came running, when I called.
'The lower ambulance bay is a restricted area.
'Essential personnel only.
'The lower ambulance bay is a restricted area.
'Essential personnel only.
' - This way, quick! - What've we got? Dog attack.
And one of the dogs, he won't let go! Dog.
We've been in transit for 15 minutes.
Is the dog still alive? Yeah.
Bob, you OK? Just about.
The dog, where is it exactly? Pinned to the floor.
You need to hurry, though.
Yeah, OK.
Listen, we're going to open the door now.
ALL EXCLAIM All we had was Diazepam, If this bastard thing wakes up OK.
Give me the ketamine, please.
Justin, ketamine.
Now, please.
Thank you.
Easy, boy.
Why doesn't someone just kill it? Shoot it when it's this close to the guy? You don't have to shoot it, just DOG SNARLS.
Shi Just be careful, please.
Sorry.
Just be careful.
Sorry.
Any sign of the vet? Yeah, he's called.
He's on his way.
Call him back, tell him we need access to a vein, hind leg, if that's at all possible, yes? We'll need an ETA.
I wouldn't.
I was just switching it off.
Good.
The ketamine by itself is going to make it hold on tighter.
You've got to give it diazepam to counter muscle rigidity.
No, don't give any more diazepam - if it relaxes and let's go, matey's going to bleed like stink.
His brachial artery's been torn open.
That's why we didn't kill it.
Its jaws are like a clamp.
Soon as it releases peeow.
We're going to stick to 50mg of ketamine for now, that should make him nice and happy.
I'd double it.
OK, he says the best vein's on the lateral aspect of the hock.
Hock, what the bloody hell's the hock? Don't ask me.
Well, I'm not asking you, am I, Giles! Oh, yeah.
What's the? He can hear.
It's halfway up the back of the leg, it's the bit that sticks out.
Yeah, it's what she said.
Fiona, butterfly cannula, please? Yeah.
Sure you've got it? Got it.
Now, if someone constricts the stifle No It's the next joint up, its knee, then the vein can be palpated.
Thank you.
GROWLING OK? I think.
Here.
OK, there, I've got it.
SNARLING It's OK, boy.
OK.
That's 50mg of ketamine going in now.
OK, he says his ETA's five, six minutes.
Thank you.
We need a resus trolley.
The patient, any pain relief? 10mg morphine.
We couldn't get a line in.
OK.
He's called Charlie Walton and he's blind.
Apparently it was his guide dog they went for and he was trying to save it.
They? Three of them.
The dog is now sedated.
We ready to transfer? They're not coming inside.
Er, what? A live dog? With patients and staff all about? No.
Management has spoken.
If you can hear me, Charlie, my name's Glen, I'm a trauma consultant.
We need to stabilise you, before we can sort out the dog.
OK? Manage to get a GCS? Best we could tell, five or six.
GCS five or six.
OK, we've got to secure the airway.
Yes, we do.
Around the side, please.
Radial and brachial pulse absent.
Thank you.
I'm going to put a cuff around the leg.
Harry, can you help me? Yeah.
OK to come up? I'm not making any promises.
Great, so I'll just stay and let it chew the F out of me, shall I? GROWLING Calm down, boy, calm down.
We need to tube him sooner rather than later.
Oxygen sats at 90%.
Thank you.
BP? It's cycling - I'm not getting a read.
We'll need to give him volume before we tube him, otherwise he might arrest on induction.
We need access.
Well, good luck with that - no chance of a subclavian.
Justin, can you get me an I/O kit, some O pos, and I need scissors, please.
Yep.
Thank you.
Can someone prime two three-ways for me, please? Got it.
Hey, Charlie.
Listen, you hang in there, we're doing the best we can.
In case it can, I'm going to let the dog hear the sound of the drill.
That's a good idea.
DRILL BUZZES / DOG GROWLS Steady.
No, leave it, don't wake it up! Harry, swab.
Look, forget about the vet.
Just sux, paralyse the shit out it, then send it on its merry way once you've If we have to, yes, with a massive dose of thio so it doesn't suffer.
Suffer? After what it's done? There's no need to be cruel.
Yeah, Ramakrishna! OK, Charlie, my name is Fiona Lomas.
We're going to take care of you.
I'm afraid this is going to hurt a little.
Listen, Charlie, you've lost a lot of blood so we need to get some fluids into you before we send you off to sleep, OK? Unfortunately, we have to do that through your shin and your shoulder.
OK? WOMAN: Yeah.
MUFFLED CRIES It's all right, Charlie, they've got you.
I'm sorry, Charlie, I'm sorry.
You're all right, mate.
It's all right.
You're doing really well, mate.
I'm with you, mate.
You're OK.
I'm not going anywhere.
You're OK.
OK, Charlie, I need to do the same again to your shoulder.
OK? CHARLIE WHIMPERS SNARLING It's OK.
OK, Charlie, it's done now.
That's it.
C02 sats? Er, 75 and dropping.
We can't wait, I've got to intubate.
Do it.
Billy, this port's looking a bit ropey.
Can you administer the RSI drugs into the tibia? Yeah.
'The lower ambulance bay is a restricted area.
'Essential personnel only.
'The lower ambulance bay is a restricted area.
'Essential personnel only.
' Thank you for, you know, sticking up for the dog.
Cricoid? Er, yeah, thanks.
Listen, Charlie, you're going to feel me pushing gently down on your throat, OK? But it's nothing to worry about.
Thiopentone, 250mg.
Just sending you off to sleep, mate.
Suxamethonium 100mg.
MOBILE PHONE RINGS SNARLING He's waking up! Easy there, boy, easy boy.
It's OK.
Just keep going.
There's a good dog.
It's OK.
Good boy.
I said give it double! And I did.
OK, sats down to 55.
RAPID BEEPING OK.
SNARLING Mind your hands there, guys.
Just keep bagging.
OK, oxygen sats rising to 65.
Billy, sux, please.
Pass that over.
OK.
I need you to hold on to him bloody tight and don't let go until I say so, yes? Yes.
OK, boy.
I'm really sorry I have to do this.
I really love dogs, me.
What are you doing? You're not killing it? Too right.
No, no, no.
The vet'll be here any minute.
Giles, Giles.
We need to get this dog off him now.
No, no, no.
Dangerous drugs cannot be given to a dog on hospital premises without a vet's prescription.
For Christ's sake! No, we don't have the authority to It's on mine, as acting clinical lead, OK? Management has spoken.
Right, we've lost far too much time so we dispatch this dog and get this man upstairs quickly.
Thiopentone.
Pass that.
Thank you.
Let's get a field dressing ready, please, and hit me again.
Ta.
Thank you.
It's going in.
Here.
Ta.
It's dead.
THEY EXHALE Never mind.
Oxygen sats back up to 90.
OK, let's get him out of here, please.
O2 bottle, please, Billy.
Yeah.
OK, I need to get major control of this artery.
Where are your tourniquets? Fiona, I know we've had our difficulties, but I'm hoping things are going to be better now Eurgh! Whoa, whoa, whoa, whoa, whoa! Let me get it.
Hold the doors, please.
I've still got haemorrhage control.
Move, please.
Move! THEY GROAN No, don't stop.
We have to keep going.
Keep going! I've got I've got it! Any news on the agency nurse? Um, no.
Then get on it.
Yeah, I have.
Sorry, we're still a nurse down.
Fast-bleep the theatre staff.
Say we'll have him there in five minutes, please.
Yep.
Up there.
This is Mrs Nicola Hicklin, acting clinical lead.
On the ventilator now.
Let's remove the scoop on your count.
Can you fast-bleep the trauma theatre staff and general surgery? On three, everyone ready? Yeah.
It's all re: Charlie Walton.
One, two, three Major trauma Mike Papa.
Easy.
On three - one, two, three.
And brace left on three.
One, two, three.
Just check the back.
No, that's not good enough.
We need to get him there in about five.
OK.
It's over half an hour since the attack.
Well done.
Harry, can you take over from Bob, please? They're getting someone off the table now.
It's going to be about 10, 15 minutes.
Come on.
It's the best they can do.
PHONE RINGS Setting elapsed time.
Hi, I'm Ania Wasenska, the agency nurse.
Nice of you to come(!) Sorry, I was sent to the wrong hospital.
This tourniquet is doing nothing.
The injury's too high.
Can someone get me some shears (Thank you.
) Scribe, please.
Me? OK.
You need to sign in first.
Keep the pressure on the neck.
Temporary staff, and just drag that over to there.
Thanks.
Thank you.
Hey.
We're in luck.
Yeah? Yeah.
He's on night shift, custody duty.
Ah, great.
Formal handover now, please.
OK, this is Charlie Walton, 29.
He was attacked at, er Approx 10.
40.
.
.
by three dogs.
Considerable blood loss at scene.
No BP, no vital stats, GCS was approximately 5 to 6.
I'm just going to get an apron.
We put him on high-flow oxygen, and gave him 10mg of IM morphine, got him here as fast as we could, basically.
He was brought in with one of the dogs still alive and attached.
Further defence wounds to both forearms, tear to the right side of the neck Got this for you.
.
.
and large wound lower left side of his abdomen.
The presence of the dog hampered any further effective treatment of the patient.
Delivery from blood bank for Mike Papa.
Lovely fit, that.
Did he touch your arse? Whoa.
He's been torn right open.
Patient needs to get to theatre.
If I'm not back in ten minutes, just bring him in.
So let's not waste any more time.
Anyone got questions for Tessa or Bob? No? Thank you.
You can sign off.
Rapid infuser operator is here.
Hello.
Prime the Belmont, six units of blood, six of FFP, please.
He's also going to need 1g of TXA bolus and then 1g infusion to follow, Augmentin 1.
2g, and a tetanus booster, please, Billy.
Good air entry bilaterally.
There's no surgical emphysema.
I'm leaving the abdomen for now.
OK, as I'm here, I might as well do the left arm.
Oh, those can be nasty.
Anything with teeth, you can't trust.
I won't let my Immy have a hamster.
Obviously, no peripheral or even brachial pulse.
Sorry, do I know you? No.
I'm Ania.
Oh OK.
Ragged wound to the right-hand side of the neck.
Active bleeding from superficial vessel.
BLOOD POURS Shit.
Must've been a spasm.
We need to ligate this in theatre.
No, we ligate it here.
Got it.
Harry, continue with the primary.
Justin? Yep.
IO's too slow, I'll do a femoral line.
Do it.
Justin.
Yep.
Harry, let's hear it, please.
Multiple bite wounds.
Superficial shredding to the forearm.
Heavily soiled.
More defensive wounds to the hand and wrist.
Extensor tendons exposed.
He must've fought like hell.
And imagine you can't see a thing.
I'm a cat person from now on, me.
I love dogs, me.
Thready radial pulse.
With small, ring and middle fingers missing.
Oh, any sign of them? No.
OK.
I'll still need imaging of what's left.
Won't be able to get it here.
So, is that me out, then? Yeah.
Yeah, but she's No, we're going to wait till theatre.
But if you could interest the plastic surgeon, please? OK.
Thank you.
Justin, I'll call you later.
OK.
Yeah.
INDISTINCT CHATTER Whoa! Bollocks.
I think you meant to say that in the singular.
Yep, he's a man down.
OK, let's just swab and dress it for now, please.
Yep.
We also need blood, FBC, U&E, VBGs, cross-match and coag, please Yep.
It's clamped.
Blood coming up.
Justin, scissors, please.
Thank you.
Let's have a Foley as well, please.
Say what you see, Harry.
Oh, shitting shit.
Oh, I mean, sorry.
That doesn't look good.
The abdomen is filling up with blood.
It's everywhere.
OK, pack it for now.
We'll be in theatre soon.
Packs! They're over there.
Foley.
Can you open it, please? Thank you.
Hopefully, this'll inflate enough to stem the bleeding from the arm until we're in theatre.
Justin, I need you on the syringe, please.
Yep.
Now, please.
OK.
OK, squeeze gently Good.
That is good.
Thank you.
OK, let's see if this holds.
That should do until we get to theatre.
Good.
So he needs blood, so as soon as the femoral line is up, whack it in, please.
Ah Harry, reapply pressure.
Swabs.
I'm sorry.
We need to get to theatre now! Pack.
Hit me.
Hit me.
Yes.
Clear for theatre.
OK, let's get him ready to move, please.
OK, not yet, I'm still suturing.
Sorry, can't wait.
Done.
OK, let's go.
Move, please! Oh! Whoa! AINA EXCLAIMS You got it? Yeah, yeah, I think so.
Good job, Harry.
Let's keep going, please.
Forget the Foley, keep the pressure on it.
(Well done.
) Daisy, we're going to need hats on these guys.
Grey and green, please.
Yep.
Side down.
Right, we need to get him across very carefully so that Harry can maintain Maintain what? Pressure.
Very carefully, please.
Everyone ready? Harry, you happy? Happy.
OK, on three.
One, two, three PHONE BEEPS Are you OK to stay here while we scrub in? Mm-hm.
You two go on.
I'll sort this.
Thank you.
Where shall we prep him? Neck to knee, please.
We'll need arm boards.
And we need a cell saver.
Brian, arm boards, please.
PHONE BEEPS Guys, let's do an instrument check.
'Glen, it's Jane Bryant.
Call me when you get a chance.
' Did you know that was invented by a doctor in the Victorian times? I'm serious.
Because he was embarrassed about putting his ear near to your Spoils the fun, though, eh? Not if you warm up your bell-end first.
Could you get me a wipe, please? Yep.
(You have GOT to tell him.
) I had to get back.
I just had to.
Tom was waiting.
Did he say anything? No, but you understand why I couldn't.
We couldn't have gone back to yours.
(It wasn't that I didn't want to.
) Didn't? What about now? Oh, look! A souvenir.
That's another for the black museum.
No, no, that might look nice on a chain.
The police'll need it.
Oh.
Well, in that case you'd better, um Thank you.
I'll find out where this general surgeon is.
Thank you.
Fiona It's not that simple.
It is for me.
OK, let's do the WHO.
I'm Glen Boyle, I'm the trauma consultant.
Fiona Lomas, trauma fellow.
Khaali Osman, scrub nurse.
Ramakrishna Chandramohan, anaesthetic reg.
Billy Finlay, anaesthetic ODP.
Harry, get the arm, please.
Brian Austin, support nurse.
Sandra, support nurse.
Daisy Macdonald, documentation nurse.
Scott, rapid infuser operator.
Come round this side.
Do you need any extra help? Has your shift finished? Mm-hm.
Glen? Suits me.
Great, thanks.
Harry Bennett-Edwardes, EM SHO.
Can we identify the patient, please? Yeah, patient is major trauma Mike Papa.
Date of birth 18/10/1985.
The right external jugular has been ligated.
Defect in the abdominal wall, eviscerated omentum and bowel.
There's significant blood loss through left brachial artery injury, which Fiona has her finger on - it's the only way we've been able to control it so far.
Consent form four signed for damage-control laparotomy, haemorrhage and contamination control with a laparostomy, and limb revascularisation.
OK to start? All set.
Number 10 blade.
And I need the cell saver suction around here, please.
I'll take the suction.
Arterial clamp.
Good.
Clamp's holding for now.
OK, I need to access the axillary artery below the clavicle.
OK.
We'll open him up and see what we can do.
22 blade, please.
10 blade, please.
Thank you.
Am I OK to cut? Yep, OK.
Cutting.
Cutting.
Do we have a temperature? Yes, 35.
0.
Heart rate? 140.
BP holding at 75 over 45.
Topping him up as fast as we can.
Mayo, please.
More FFP, cryo, platelets.
Thanks.
I'll take the ring, please.
Hi, yeah.
This is Billy Finlay ODP in trauma theatre Thank you.
Yeah.
Can we order more FFP, platelets and cryo for patient Mike Papa, please? Yes.
Yep.
I'm going to need warm saline.
Jugs of it, please.
Warm saline, please.
Packs, please.
One.
Hit me.
Two.
Hit me.
Three.
Three in.
Three in.
(Um, look mate, about Harry (She and I We're (It's back on.
(Sorry.
(It's (It's early days (so we're trying to keep it under the radar.
) No worries.
Thanks for the heads-up.
It's good to know before I make a right tit of myself.
Oh If you could assist.
Course.
Retractor, please.
Scissors and forceps, please.
I thought it was only the brachial that was torn.
We need proximal control first and then to explore the injury.
As it's so high up, it's easier to clamp the axillary.
As well as the clamp, I'm also going to put a vascular sling around the artery - it's easier to control later on if we run into any problems.
Clamp, please.
Hit me.
One.
Hit me.
Two.
Two more in.
Sling, please.
Five in the abdomen.
Voila - success.
Middle and ring fingers recovered from the scene.
Where's the plastic surgeon? Be waiting for the drumroll.
Reckon they're saveable.
Well, one, maybe.
Take a picture, send it to Nicola.
Tell her we need plastics down here now, please.
In fact, you should use my phone.
That way she'll think it's coming from me.
It's over here in my pocket.
Yep.
Over on this side.
No, sorry, you're going to have to go up from under.
Um sorry.
Got it? Yep.
Cheers.
OK, so now we unpack and clean out each section at a time.
If it was me, and he could repair one thing, I'd rather have a scrotum than a finger.
I don't think most of us in here would necessarily agree.
I'm going to need more.
Much more.
More saline, please.
Do you have a Javid shunt? Sorry I There wasn't time.
Mr Simpson had his carotid list this morning.
We haven't any left on the shelf.
OK Um A giving set.
I'll need I'll need about a foot of it, please.
Nurse, a giving set, please.
Yep.
And I'll need a sterile field.
Sure.
Blade, please.
Here.
Hit me.
Blood's going in but BP's still falling.
This bowel's a mess.
Severed in multiple places.
Come on.
Where's your friend? OK, I need Get me a TLC stapler and more gauze, please.
Hit me.
One more in.
Four in the abdomen.
Retractor, please.
Not those, darling.
BP's still dropping.
Now the shunt.
Khaali, I need heavy Vicryl ties or silk.
Two of them, please.
Sure.
I've got one end and I cannot find the other.
This bowel is a bloody mess, and we're running out of time.
Clamp, please.
And I'll take the stapler.
I've still got an odd number of ends.
For now, I'm just going to have to staple them.
Thank you.
BP's still dropping.
Reload.
And I'll take saline and suction, please.
Thank you.
Cut, thank you.
Thank you.
Photos sent and plastics called.
Is that me done? Yes.
OK, do you want me to put your phone back in your No.
Thank you.
Cut.
Thank you.
OK, shunt's in.
Let's see how it holds.
Will you check his pulse? Thready.
OK, it will spasm a bit.
But the capillary return's much better.
Right, I have control.
I'm glad someone does.
I've now got three bloody ends.
MACHINE BEEPS BP dropping - 60 over 40.
Billy, whack it in.
It could be a revascularisation bleed? Axillary NAD, brachial NAD.
Show me the jugular.
There's nothing here.
Jugular NAD.
Shit.
Whole sections have been torn away from the mesentery.
Dish.
Glen Yes? Oh, Christ! He's bleeding out! BEEPING Let's keep filling him up, please.
I am, but as fast as I'm topping him up, it keeps on pissing out of him.
This goes on much longer, we're looking at DIC, and then he's buggered.
Tie.
Thank you.
And release, please.
Thank you.
Cut.
He's still bleeding like a sieve.
I'm going to have to start at the upper abdomen and work my way down, haemorrhage control as we go.
Morris retractor.
The liver The liver's OK, let's go to the spleen, please.
BP is continuing to fall.
Spleen is also good.
The stomach is OK.
Jejunum is well perfused.
Be easier to take the rest of it out.
Yes.
OK.
We're going to need more warm saline and more gauze - both wet and dry.
Lay them out here and here, please.
BEEPING CONTINUES Thank you.
BP's still dropping.
More saline.
Here.
One.
Here.
Two.
Here.
Three out.
One left.
OK, he needs Metaraminol.
I've got to get his pressure up.
He's full of holes.
I've got no choice.
He'll just pump out blood.
If I don't give him some perfusion, there's going to be nothing to salvage Glen! Let's just run the bowel.
Please.
Billy, Metaraminol.
Shit, we haven't got any.
Billy! OK, retract.
Need you to flush.
And suction.
Where the hell is this bleed? Here, please! OK, a number of mesenteric vessels are severed.
Give me a clamp! And again.
Tie.
And release.
Thank you.
Cut it.
Sorry.
Thanks.
Thank you.
And release.
Thank you.
Cut.
Metaraminol going in.
That should push up his BP.
OK, we're winning up here.
Well, we're losing in here.
Blood is increasing and we need to pack.
Hit me.
General Surgeon Mr Street's here.
Another two in, Daisy.
Back to three.
The dogs have played tear and share with his small intestine, and his mesentery's been ripped to shreds.
OK, I'll be right with you.
Plastics is on his way.
I need to isolate the bleeding.
You want me to cancel? No.
No, we live in hope.
Well, it shouldn't be a problem in the future, co-ordinating the specialities.
Thanks.
OK.
Let's keep going, one section at a time.
Here.
Can you retract, please? One out.
OK.
Yeah.
It's venous bleeding from the root of the mesentery.
Roberts, please.
And I'm going to need a transfixion stitch.
If this is the main source of the bleed, he might stand a chance.
Scissors, please.
Forceps.
Thank you.
OK, let's cut.
Mr Doughty, plastics, here.
I think we're there.
Not exactly keyhole surgery(!) We thought you'd like to see a proper operation for once, Henry.
Hit me.
And again, please.
Yep.
Two more in.
Back to five.
So how long ago did this happen? Just over an hour ago.
Fingers are over there.
8½ gloves.
And can you open the bag for me, please? OK.
Let's scoop.
Think you can save them? Yeah, the fingers are in pretty decent shape, actually, but that's only half the story.
I'll need to assess the hand.
Thank you.
How's Tom? Yeah, he's fine.
OK, the arm looks pretty decent but I'll need to scrub before I make a definitive assessment.
OK, can you call up a microscope? And I'll need an arm board, drapes and a stool, please.
Brian, help the plastic, please.
Ohh! Oh, sorry! We need the microscope in trauma theatre for Mr Doughty.
Thank you.
What's up? One sec.
OK, so his small intestine - no wonder it doesn't all match up and the mesentery's so badly torn - there are huge sections missing.
Missing? And not all accounted for.
I would say we're about a metre-and-a-half down.
Somebody won't need to feed his dog tonight.
Can he survive it? Yes, he's got enough.
And at least he won't end up on home TPN.
But you've found and stapled all the ends? Yes.
Haemorrhage control? All bleeding mesenteric vessels have been ligated.
Where are we? Yeah, he's responding to filling.
BP is 100 over 60.
So, he'll make it, then? Oh, yes.
Look, there's just a few serosal tears I need to deal with I think I can manage, mate.
It won't take me that long.
Glen, go.
Give a poor general surgeon a chance.
He'll be fine.
Go.
Oh, Harry, can you assist? Yes, Mr Street.
Until my registrar turns up.
We need to get more blood in him and warm him up before Mr Doughty performs his magic.
OK, I'll need the micro-vascular and handsets, please.
Actually, why don't you just call up to theatre five and get them to send my whole trolley down.
I'll need an assistant, too, but I'm all right to carry on for now, just need a knife and fork, please.
Need someone to push your stool in for you, Mr Doughty? Ha-ha(!) 'Hi, Glen, thanks for calling back.
It's good news.
' It's, um yeah? 'Re: our last session, I passed on my recommendation 'and it's been approved.
'It's official - you can return to active service.
' That's great.
That's, um 'So well done.
' Thanks.
Thanks for everything, Jane.
'Deployment papers should come through in about ten days, OK?' Yeah, yep, bye.
'See you soon.
Bye.
'
Take his side, you'll pay for it too.
Harry! The break-up.
Is it over then? Got to be professional.
So she's single now? Clive, you're relieved.
The Chief Executive has made me Acting Clinical Lead.
I'm grateful you're here.
I'm grateful you came running, when I called.
'The lower ambulance bay is a restricted area.
'Essential personnel only.
'The lower ambulance bay is a restricted area.
'Essential personnel only.
' - This way, quick! - What've we got? Dog attack.
And one of the dogs, he won't let go! Dog.
We've been in transit for 15 minutes.
Is the dog still alive? Yeah.
Bob, you OK? Just about.
The dog, where is it exactly? Pinned to the floor.
You need to hurry, though.
Yeah, OK.
Listen, we're going to open the door now.
ALL EXCLAIM All we had was Diazepam, If this bastard thing wakes up OK.
Give me the ketamine, please.
Justin, ketamine.
Now, please.
Thank you.
Easy, boy.
Why doesn't someone just kill it? Shoot it when it's this close to the guy? You don't have to shoot it, just DOG SNARLS.
Shi Just be careful, please.
Sorry.
Just be careful.
Sorry.
Any sign of the vet? Yeah, he's called.
He's on his way.
Call him back, tell him we need access to a vein, hind leg, if that's at all possible, yes? We'll need an ETA.
I wouldn't.
I was just switching it off.
Good.
The ketamine by itself is going to make it hold on tighter.
You've got to give it diazepam to counter muscle rigidity.
No, don't give any more diazepam - if it relaxes and let's go, matey's going to bleed like stink.
His brachial artery's been torn open.
That's why we didn't kill it.
Its jaws are like a clamp.
Soon as it releases peeow.
We're going to stick to 50mg of ketamine for now, that should make him nice and happy.
I'd double it.
OK, he says the best vein's on the lateral aspect of the hock.
Hock, what the bloody hell's the hock? Don't ask me.
Well, I'm not asking you, am I, Giles! Oh, yeah.
What's the? He can hear.
It's halfway up the back of the leg, it's the bit that sticks out.
Yeah, it's what she said.
Fiona, butterfly cannula, please? Yeah.
Sure you've got it? Got it.
Now, if someone constricts the stifle No It's the next joint up, its knee, then the vein can be palpated.
Thank you.
GROWLING OK? I think.
Here.
OK, there, I've got it.
SNARLING It's OK, boy.
OK.
That's 50mg of ketamine going in now.
OK, he says his ETA's five, six minutes.
Thank you.
We need a resus trolley.
The patient, any pain relief? 10mg morphine.
We couldn't get a line in.
OK.
He's called Charlie Walton and he's blind.
Apparently it was his guide dog they went for and he was trying to save it.
They? Three of them.
The dog is now sedated.
We ready to transfer? They're not coming inside.
Er, what? A live dog? With patients and staff all about? No.
Management has spoken.
If you can hear me, Charlie, my name's Glen, I'm a trauma consultant.
We need to stabilise you, before we can sort out the dog.
OK? Manage to get a GCS? Best we could tell, five or six.
GCS five or six.
OK, we've got to secure the airway.
Yes, we do.
Around the side, please.
Radial and brachial pulse absent.
Thank you.
I'm going to put a cuff around the leg.
Harry, can you help me? Yeah.
OK to come up? I'm not making any promises.
Great, so I'll just stay and let it chew the F out of me, shall I? GROWLING Calm down, boy, calm down.
We need to tube him sooner rather than later.
Oxygen sats at 90%.
Thank you.
BP? It's cycling - I'm not getting a read.
We'll need to give him volume before we tube him, otherwise he might arrest on induction.
We need access.
Well, good luck with that - no chance of a subclavian.
Justin, can you get me an I/O kit, some O pos, and I need scissors, please.
Yep.
Thank you.
Can someone prime two three-ways for me, please? Got it.
Hey, Charlie.
Listen, you hang in there, we're doing the best we can.
In case it can, I'm going to let the dog hear the sound of the drill.
That's a good idea.
DRILL BUZZES / DOG GROWLS Steady.
No, leave it, don't wake it up! Harry, swab.
Look, forget about the vet.
Just sux, paralyse the shit out it, then send it on its merry way once you've If we have to, yes, with a massive dose of thio so it doesn't suffer.
Suffer? After what it's done? There's no need to be cruel.
Yeah, Ramakrishna! OK, Charlie, my name is Fiona Lomas.
We're going to take care of you.
I'm afraid this is going to hurt a little.
Listen, Charlie, you've lost a lot of blood so we need to get some fluids into you before we send you off to sleep, OK? Unfortunately, we have to do that through your shin and your shoulder.
OK? WOMAN: Yeah.
MUFFLED CRIES It's all right, Charlie, they've got you.
I'm sorry, Charlie, I'm sorry.
You're all right, mate.
It's all right.
You're doing really well, mate.
I'm with you, mate.
You're OK.
I'm not going anywhere.
You're OK.
OK, Charlie, I need to do the same again to your shoulder.
OK? CHARLIE WHIMPERS SNARLING It's OK.
OK, Charlie, it's done now.
That's it.
C02 sats? Er, 75 and dropping.
We can't wait, I've got to intubate.
Do it.
Billy, this port's looking a bit ropey.
Can you administer the RSI drugs into the tibia? Yeah.
'The lower ambulance bay is a restricted area.
'Essential personnel only.
'The lower ambulance bay is a restricted area.
'Essential personnel only.
' Thank you for, you know, sticking up for the dog.
Cricoid? Er, yeah, thanks.
Listen, Charlie, you're going to feel me pushing gently down on your throat, OK? But it's nothing to worry about.
Thiopentone, 250mg.
Just sending you off to sleep, mate.
Suxamethonium 100mg.
MOBILE PHONE RINGS SNARLING He's waking up! Easy there, boy, easy boy.
It's OK.
Just keep going.
There's a good dog.
It's OK.
Good boy.
I said give it double! And I did.
OK, sats down to 55.
RAPID BEEPING OK.
SNARLING Mind your hands there, guys.
Just keep bagging.
OK, oxygen sats rising to 65.
Billy, sux, please.
Pass that over.
OK.
I need you to hold on to him bloody tight and don't let go until I say so, yes? Yes.
OK, boy.
I'm really sorry I have to do this.
I really love dogs, me.
What are you doing? You're not killing it? Too right.
No, no, no.
The vet'll be here any minute.
Giles, Giles.
We need to get this dog off him now.
No, no, no.
Dangerous drugs cannot be given to a dog on hospital premises without a vet's prescription.
For Christ's sake! No, we don't have the authority to It's on mine, as acting clinical lead, OK? Management has spoken.
Right, we've lost far too much time so we dispatch this dog and get this man upstairs quickly.
Thiopentone.
Pass that.
Thank you.
Let's get a field dressing ready, please, and hit me again.
Ta.
Thank you.
It's going in.
Here.
Ta.
It's dead.
THEY EXHALE Never mind.
Oxygen sats back up to 90.
OK, let's get him out of here, please.
O2 bottle, please, Billy.
Yeah.
OK, I need to get major control of this artery.
Where are your tourniquets? Fiona, I know we've had our difficulties, but I'm hoping things are going to be better now Eurgh! Whoa, whoa, whoa, whoa, whoa! Let me get it.
Hold the doors, please.
I've still got haemorrhage control.
Move, please.
Move! THEY GROAN No, don't stop.
We have to keep going.
Keep going! I've got I've got it! Any news on the agency nurse? Um, no.
Then get on it.
Yeah, I have.
Sorry, we're still a nurse down.
Fast-bleep the theatre staff.
Say we'll have him there in five minutes, please.
Yep.
Up there.
This is Mrs Nicola Hicklin, acting clinical lead.
On the ventilator now.
Let's remove the scoop on your count.
Can you fast-bleep the trauma theatre staff and general surgery? On three, everyone ready? Yeah.
It's all re: Charlie Walton.
One, two, three Major trauma Mike Papa.
Easy.
On three - one, two, three.
And brace left on three.
One, two, three.
Just check the back.
No, that's not good enough.
We need to get him there in about five.
OK.
It's over half an hour since the attack.
Well done.
Harry, can you take over from Bob, please? They're getting someone off the table now.
It's going to be about 10, 15 minutes.
Come on.
It's the best they can do.
PHONE RINGS Setting elapsed time.
Hi, I'm Ania Wasenska, the agency nurse.
Nice of you to come(!) Sorry, I was sent to the wrong hospital.
This tourniquet is doing nothing.
The injury's too high.
Can someone get me some shears (Thank you.
) Scribe, please.
Me? OK.
You need to sign in first.
Keep the pressure on the neck.
Temporary staff, and just drag that over to there.
Thanks.
Thank you.
Hey.
We're in luck.
Yeah? Yeah.
He's on night shift, custody duty.
Ah, great.
Formal handover now, please.
OK, this is Charlie Walton, 29.
He was attacked at, er Approx 10.
40.
.
.
by three dogs.
Considerable blood loss at scene.
No BP, no vital stats, GCS was approximately 5 to 6.
I'm just going to get an apron.
We put him on high-flow oxygen, and gave him 10mg of IM morphine, got him here as fast as we could, basically.
He was brought in with one of the dogs still alive and attached.
Further defence wounds to both forearms, tear to the right side of the neck Got this for you.
.
.
and large wound lower left side of his abdomen.
The presence of the dog hampered any further effective treatment of the patient.
Delivery from blood bank for Mike Papa.
Lovely fit, that.
Did he touch your arse? Whoa.
He's been torn right open.
Patient needs to get to theatre.
If I'm not back in ten minutes, just bring him in.
So let's not waste any more time.
Anyone got questions for Tessa or Bob? No? Thank you.
You can sign off.
Rapid infuser operator is here.
Hello.
Prime the Belmont, six units of blood, six of FFP, please.
He's also going to need 1g of TXA bolus and then 1g infusion to follow, Augmentin 1.
2g, and a tetanus booster, please, Billy.
Good air entry bilaterally.
There's no surgical emphysema.
I'm leaving the abdomen for now.
OK, as I'm here, I might as well do the left arm.
Oh, those can be nasty.
Anything with teeth, you can't trust.
I won't let my Immy have a hamster.
Obviously, no peripheral or even brachial pulse.
Sorry, do I know you? No.
I'm Ania.
Oh OK.
Ragged wound to the right-hand side of the neck.
Active bleeding from superficial vessel.
BLOOD POURS Shit.
Must've been a spasm.
We need to ligate this in theatre.
No, we ligate it here.
Got it.
Harry, continue with the primary.
Justin? Yep.
IO's too slow, I'll do a femoral line.
Do it.
Justin.
Yep.
Harry, let's hear it, please.
Multiple bite wounds.
Superficial shredding to the forearm.
Heavily soiled.
More defensive wounds to the hand and wrist.
Extensor tendons exposed.
He must've fought like hell.
And imagine you can't see a thing.
I'm a cat person from now on, me.
I love dogs, me.
Thready radial pulse.
With small, ring and middle fingers missing.
Oh, any sign of them? No.
OK.
I'll still need imaging of what's left.
Won't be able to get it here.
So, is that me out, then? Yeah.
Yeah, but she's No, we're going to wait till theatre.
But if you could interest the plastic surgeon, please? OK.
Thank you.
Justin, I'll call you later.
OK.
Yeah.
INDISTINCT CHATTER Whoa! Bollocks.
I think you meant to say that in the singular.
Yep, he's a man down.
OK, let's just swab and dress it for now, please.
Yep.
We also need blood, FBC, U&E, VBGs, cross-match and coag, please Yep.
It's clamped.
Blood coming up.
Justin, scissors, please.
Thank you.
Let's have a Foley as well, please.
Say what you see, Harry.
Oh, shitting shit.
Oh, I mean, sorry.
That doesn't look good.
The abdomen is filling up with blood.
It's everywhere.
OK, pack it for now.
We'll be in theatre soon.
Packs! They're over there.
Foley.
Can you open it, please? Thank you.
Hopefully, this'll inflate enough to stem the bleeding from the arm until we're in theatre.
Justin, I need you on the syringe, please.
Yep.
Now, please.
OK.
OK, squeeze gently Good.
That is good.
Thank you.
OK, let's see if this holds.
That should do until we get to theatre.
Good.
So he needs blood, so as soon as the femoral line is up, whack it in, please.
Ah Harry, reapply pressure.
Swabs.
I'm sorry.
We need to get to theatre now! Pack.
Hit me.
Hit me.
Yes.
Clear for theatre.
OK, let's get him ready to move, please.
OK, not yet, I'm still suturing.
Sorry, can't wait.
Done.
OK, let's go.
Move, please! Oh! Whoa! AINA EXCLAIMS You got it? Yeah, yeah, I think so.
Good job, Harry.
Let's keep going, please.
Forget the Foley, keep the pressure on it.
(Well done.
) Daisy, we're going to need hats on these guys.
Grey and green, please.
Yep.
Side down.
Right, we need to get him across very carefully so that Harry can maintain Maintain what? Pressure.
Very carefully, please.
Everyone ready? Harry, you happy? Happy.
OK, on three.
One, two, three PHONE BEEPS Are you OK to stay here while we scrub in? Mm-hm.
You two go on.
I'll sort this.
Thank you.
Where shall we prep him? Neck to knee, please.
We'll need arm boards.
And we need a cell saver.
Brian, arm boards, please.
PHONE BEEPS Guys, let's do an instrument check.
'Glen, it's Jane Bryant.
Call me when you get a chance.
' Did you know that was invented by a doctor in the Victorian times? I'm serious.
Because he was embarrassed about putting his ear near to your Spoils the fun, though, eh? Not if you warm up your bell-end first.
Could you get me a wipe, please? Yep.
(You have GOT to tell him.
) I had to get back.
I just had to.
Tom was waiting.
Did he say anything? No, but you understand why I couldn't.
We couldn't have gone back to yours.
(It wasn't that I didn't want to.
) Didn't? What about now? Oh, look! A souvenir.
That's another for the black museum.
No, no, that might look nice on a chain.
The police'll need it.
Oh.
Well, in that case you'd better, um Thank you.
I'll find out where this general surgeon is.
Thank you.
Fiona It's not that simple.
It is for me.
OK, let's do the WHO.
I'm Glen Boyle, I'm the trauma consultant.
Fiona Lomas, trauma fellow.
Khaali Osman, scrub nurse.
Ramakrishna Chandramohan, anaesthetic reg.
Billy Finlay, anaesthetic ODP.
Harry, get the arm, please.
Brian Austin, support nurse.
Sandra, support nurse.
Daisy Macdonald, documentation nurse.
Scott, rapid infuser operator.
Come round this side.
Do you need any extra help? Has your shift finished? Mm-hm.
Glen? Suits me.
Great, thanks.
Harry Bennett-Edwardes, EM SHO.
Can we identify the patient, please? Yeah, patient is major trauma Mike Papa.
Date of birth 18/10/1985.
The right external jugular has been ligated.
Defect in the abdominal wall, eviscerated omentum and bowel.
There's significant blood loss through left brachial artery injury, which Fiona has her finger on - it's the only way we've been able to control it so far.
Consent form four signed for damage-control laparotomy, haemorrhage and contamination control with a laparostomy, and limb revascularisation.
OK to start? All set.
Number 10 blade.
And I need the cell saver suction around here, please.
I'll take the suction.
Arterial clamp.
Good.
Clamp's holding for now.
OK, I need to access the axillary artery below the clavicle.
OK.
We'll open him up and see what we can do.
22 blade, please.
10 blade, please.
Thank you.
Am I OK to cut? Yep, OK.
Cutting.
Cutting.
Do we have a temperature? Yes, 35.
0.
Heart rate? 140.
BP holding at 75 over 45.
Topping him up as fast as we can.
Mayo, please.
More FFP, cryo, platelets.
Thanks.
I'll take the ring, please.
Hi, yeah.
This is Billy Finlay ODP in trauma theatre Thank you.
Yeah.
Can we order more FFP, platelets and cryo for patient Mike Papa, please? Yes.
Yep.
I'm going to need warm saline.
Jugs of it, please.
Warm saline, please.
Packs, please.
One.
Hit me.
Two.
Hit me.
Three.
Three in.
Three in.
(Um, look mate, about Harry (She and I We're (It's back on.
(Sorry.
(It's (It's early days (so we're trying to keep it under the radar.
) No worries.
Thanks for the heads-up.
It's good to know before I make a right tit of myself.
Oh If you could assist.
Course.
Retractor, please.
Scissors and forceps, please.
I thought it was only the brachial that was torn.
We need proximal control first and then to explore the injury.
As it's so high up, it's easier to clamp the axillary.
As well as the clamp, I'm also going to put a vascular sling around the artery - it's easier to control later on if we run into any problems.
Clamp, please.
Hit me.
One.
Hit me.
Two.
Two more in.
Sling, please.
Five in the abdomen.
Voila - success.
Middle and ring fingers recovered from the scene.
Where's the plastic surgeon? Be waiting for the drumroll.
Reckon they're saveable.
Well, one, maybe.
Take a picture, send it to Nicola.
Tell her we need plastics down here now, please.
In fact, you should use my phone.
That way she'll think it's coming from me.
It's over here in my pocket.
Yep.
Over on this side.
No, sorry, you're going to have to go up from under.
Um sorry.
Got it? Yep.
Cheers.
OK, so now we unpack and clean out each section at a time.
If it was me, and he could repair one thing, I'd rather have a scrotum than a finger.
I don't think most of us in here would necessarily agree.
I'm going to need more.
Much more.
More saline, please.
Do you have a Javid shunt? Sorry I There wasn't time.
Mr Simpson had his carotid list this morning.
We haven't any left on the shelf.
OK Um A giving set.
I'll need I'll need about a foot of it, please.
Nurse, a giving set, please.
Yep.
And I'll need a sterile field.
Sure.
Blade, please.
Here.
Hit me.
Blood's going in but BP's still falling.
This bowel's a mess.
Severed in multiple places.
Come on.
Where's your friend? OK, I need Get me a TLC stapler and more gauze, please.
Hit me.
One more in.
Four in the abdomen.
Retractor, please.
Not those, darling.
BP's still dropping.
Now the shunt.
Khaali, I need heavy Vicryl ties or silk.
Two of them, please.
Sure.
I've got one end and I cannot find the other.
This bowel is a bloody mess, and we're running out of time.
Clamp, please.
And I'll take the stapler.
I've still got an odd number of ends.
For now, I'm just going to have to staple them.
Thank you.
BP's still dropping.
Reload.
And I'll take saline and suction, please.
Thank you.
Cut, thank you.
Thank you.
Photos sent and plastics called.
Is that me done? Yes.
OK, do you want me to put your phone back in your No.
Thank you.
Cut.
Thank you.
OK, shunt's in.
Let's see how it holds.
Will you check his pulse? Thready.
OK, it will spasm a bit.
But the capillary return's much better.
Right, I have control.
I'm glad someone does.
I've now got three bloody ends.
MACHINE BEEPS BP dropping - 60 over 40.
Billy, whack it in.
It could be a revascularisation bleed? Axillary NAD, brachial NAD.
Show me the jugular.
There's nothing here.
Jugular NAD.
Shit.
Whole sections have been torn away from the mesentery.
Dish.
Glen Yes? Oh, Christ! He's bleeding out! BEEPING Let's keep filling him up, please.
I am, but as fast as I'm topping him up, it keeps on pissing out of him.
This goes on much longer, we're looking at DIC, and then he's buggered.
Tie.
Thank you.
And release, please.
Thank you.
Cut.
He's still bleeding like a sieve.
I'm going to have to start at the upper abdomen and work my way down, haemorrhage control as we go.
Morris retractor.
The liver The liver's OK, let's go to the spleen, please.
BP is continuing to fall.
Spleen is also good.
The stomach is OK.
Jejunum is well perfused.
Be easier to take the rest of it out.
Yes.
OK.
We're going to need more warm saline and more gauze - both wet and dry.
Lay them out here and here, please.
BEEPING CONTINUES Thank you.
BP's still dropping.
More saline.
Here.
One.
Here.
Two.
Here.
Three out.
One left.
OK, he needs Metaraminol.
I've got to get his pressure up.
He's full of holes.
I've got no choice.
He'll just pump out blood.
If I don't give him some perfusion, there's going to be nothing to salvage Glen! Let's just run the bowel.
Please.
Billy, Metaraminol.
Shit, we haven't got any.
Billy! OK, retract.
Need you to flush.
And suction.
Where the hell is this bleed? Here, please! OK, a number of mesenteric vessels are severed.
Give me a clamp! And again.
Tie.
And release.
Thank you.
Cut it.
Sorry.
Thanks.
Thank you.
And release.
Thank you.
Cut.
Metaraminol going in.
That should push up his BP.
OK, we're winning up here.
Well, we're losing in here.
Blood is increasing and we need to pack.
Hit me.
General Surgeon Mr Street's here.
Another two in, Daisy.
Back to three.
The dogs have played tear and share with his small intestine, and his mesentery's been ripped to shreds.
OK, I'll be right with you.
Plastics is on his way.
I need to isolate the bleeding.
You want me to cancel? No.
No, we live in hope.
Well, it shouldn't be a problem in the future, co-ordinating the specialities.
Thanks.
OK.
Let's keep going, one section at a time.
Here.
Can you retract, please? One out.
OK.
Yeah.
It's venous bleeding from the root of the mesentery.
Roberts, please.
And I'm going to need a transfixion stitch.
If this is the main source of the bleed, he might stand a chance.
Scissors, please.
Forceps.
Thank you.
OK, let's cut.
Mr Doughty, plastics, here.
I think we're there.
Not exactly keyhole surgery(!) We thought you'd like to see a proper operation for once, Henry.
Hit me.
And again, please.
Yep.
Two more in.
Back to five.
So how long ago did this happen? Just over an hour ago.
Fingers are over there.
8½ gloves.
And can you open the bag for me, please? OK.
Let's scoop.
Think you can save them? Yeah, the fingers are in pretty decent shape, actually, but that's only half the story.
I'll need to assess the hand.
Thank you.
How's Tom? Yeah, he's fine.
OK, the arm looks pretty decent but I'll need to scrub before I make a definitive assessment.
OK, can you call up a microscope? And I'll need an arm board, drapes and a stool, please.
Brian, help the plastic, please.
Ohh! Oh, sorry! We need the microscope in trauma theatre for Mr Doughty.
Thank you.
What's up? One sec.
OK, so his small intestine - no wonder it doesn't all match up and the mesentery's so badly torn - there are huge sections missing.
Missing? And not all accounted for.
I would say we're about a metre-and-a-half down.
Somebody won't need to feed his dog tonight.
Can he survive it? Yes, he's got enough.
And at least he won't end up on home TPN.
But you've found and stapled all the ends? Yes.
Haemorrhage control? All bleeding mesenteric vessels have been ligated.
Where are we? Yeah, he's responding to filling.
BP is 100 over 60.
So, he'll make it, then? Oh, yes.
Look, there's just a few serosal tears I need to deal with I think I can manage, mate.
It won't take me that long.
Glen, go.
Give a poor general surgeon a chance.
He'll be fine.
Go.
Oh, Harry, can you assist? Yes, Mr Street.
Until my registrar turns up.
We need to get more blood in him and warm him up before Mr Doughty performs his magic.
OK, I'll need the micro-vascular and handsets, please.
Actually, why don't you just call up to theatre five and get them to send my whole trolley down.
I'll need an assistant, too, but I'm all right to carry on for now, just need a knife and fork, please.
Need someone to push your stool in for you, Mr Doughty? Ha-ha(!) 'Hi, Glen, thanks for calling back.
It's good news.
' It's, um yeah? 'Re: our last session, I passed on my recommendation 'and it's been approved.
'It's official - you can return to active service.
' That's great.
That's, um 'So well done.
' Thanks.
Thanks for everything, Jane.
'Deployment papers should come through in about ten days, OK?' Yeah, yep, bye.
'See you soon.
Bye.
'