Critical (UK) (2015) s01e11 Episode Script
Episode 11
HEARTBEAT PUMPS I'm not leaving.
But you will, because that's what you do.
WOMAN ON PHONE: 'It's official, you can return to active service.
' Don't.
Glen Boyle's in there.
We couldn't have gone back to yours.
It wasn't that I didn't want to.
Didn't? This can't be easy for you.
If anyone even sees us FAST-PACED MUSIC PLAYS ALARM BELL RINGS 'Trauma call to Thames lower ambulance bay.
'Trauma call to Thames lower ambulance bay.
' Are you stuck? Yeah, I'm stuck.
SHE LAUGHS Help me.
OK.
Yeah.
Yeah.
OVER SPEAKER: The lower ambulance bay is a restricted area.
Essential personnel only.
The lower ambulance bay is a restricted area.
Essential personnel only.
Not exactly in a hurry, are they? Must be a slow bleed.
Huh.
You OK? Yeah.
Can we get these sides down, please? Yeah.
POLICEMAN SHOUTS INSTRUCTIONS You're the one who found him? Yeah.
He's my son.
I'm Glen Boyle.
Frank Howker.
I'm the trauma consultant.
Frank I need you to stay here, please.
Thank you.
Stepping up.
Fiona.
Yeah.
Oh Patient is impaled at three points.
He's got a pulse.
Somebody start the clock, please.
We can't move him until the fire team get here So we're going to have to stabilise him where he is.
Let's set up the kit on the trolley.
Constance, scissors, please.
Here you go.
All right to come up, boss? One at a time.
Mark, I need you to make some room for me here, please.
OK.
Yep.
LORRY CLANGS Whoa.
Be careful, guys.
Excuse me.
Thank you.
SHE LAUGHS Shit a brick.
Going to need to RSI.
Definitely going to need some volume as well.
An RSI kit, please.
O positive on the blood, please.
Constance, a Venflon, please.
On its way.
Thank you.
No chest movement on the right side.
I'm doing a needle decompression to relieve the tension pneumothorax.
FRANK BREATHES HEAVILY Oh, God.
Frank.
Is there any way you can stabilise this lorry? I can bring the legs down.
That would help, please.
OK.
Thank you.
So heart rate's 125, BP is 78/56.
Sats are 80%.
ENGINE STARTS Going to need to tube him and he definitely needs volume.
Harry, IV access on the left for RSI drugs.
I'm Dr Chandramohan, can you hear me? Blood out.
O pos through the Venflon and a trauma line in, please.
No eye opening, E1.
No verbal response, E1.
Abnormal flexion in response to pain, so that's M3.
GCS is five.
SUCCS 100mg and let's play it safe and give him 250mg of thiopentone as well.
Sharps bin, please.
OK MACHINE WHIRS Can you fill these up and run them? Whoa, whoa! Frank.
It's really important that this lorry doesn't move.
I know.
It's OK.
SIREN RINGS OK, let's get that vehicle stabilised.
Nice and gently, please, guys.
OK, I'm going to do a formal thoracostomy.
Can I have the kit, please, Constance? Yes.
I'm doing a trauma line.
On VET.
Curtis Taylor, station manager.
Glenn Boyle, trauma team leader.
Aw, shit.
We need to get him off this lorry Are you OK? Yeah.
.
.
and our priority is that these spikes don't move inside him.
BPGs! Lactate 12, pH 7.
19.
Dismantling it would be best, but those bolts are rusted in.
That's 15 minutes.
We can cut, but there could be some movement.
He doesn't have 15 minutes.
You're going to have to cut.
Get the cutting gear! I want one of O pos, one of FFP to go straight in as soon as Harry's ready.
I'll go.
Where are we? OK, sats at 84%, heart rate is 102 BP is 89/65.
Need to hurry, please.
Thoracostomy's completed.
FFP and blood in.
Good.
Frank You should go inside.
Nicola? Yeah.
I want to stay.
We're going to do our very best for him.
And they are.
Lydia, can you get him into the relatives room, please? Make him comfortable.
Let's make some space.
Over to you.
OK, we need to get on with this.
Can somebody help me here, please? OK.
Spikes that have penetrated.
One, two, three.
Yes? Yep.
Steady.
Ready.
Watch your eyes.
Cutting.
Cutting.
MACHINE STARTS METAL CLANGS Fiona, can you get a hand on that spike, please? Yeah.
He's stable.
Ready.
Cutting! METAL CLANGS Yeah, stable.
Cutting.
METAL CLANGS Pulse check.
OK, stable.
Release the spikes, please.
Just in.
Scoop in now.
That's it? Yes.
Thank you.
So we are bracing to the patient's right on three.
One, two, three.
Back on three.
One, two, three.
That's great.
Coming in.
Bracing to the patient's left this time.
One, two, three.
OK, we're in.
Back on three.
One, two, three.
Great.
Next step is a short lift just to the foot of the truck.
On three.
One, two, three.
Whoa.
MONITOR BEEPS Put him down.
Put him down.
Don't go back any further.
Heart rate's through the roof.
BP's 53/46.
He's losing blood.
Get blood in, please.
OK, there's no bleeding from the chest area.
It must be lower down.
Do a left anterolateral thoracotomy and clamp the aorta.
Get me the kit, extra gloves! Quick as we can! Mr Boyle.
Yes.
Give me the blade.
Give me the blade, please! Yes, yes.
Thank you.
Good to cut? Yeah, yeah, yeah.
Cutting.
Scissors.
Thank you.
Blood going.
Ready.
Give me that.
Let's get the aortic clamp.
Thank you.
Aortais clamped.
OK, let's cover him up, keep him warm.
BP's stabilising.
OK, we're on the clock, we need to go.
Ramakrishna, on your call.
One, two, three, lift.
Bring the trolley in, please.
Stop there, down.
Down.
Reposition.
Sort these lines out.
Mind your backs there.
Heads.
Got it? Yeah.
On three.
One, two, three.
Ania, Justin, Constance.
You manage the spikes, please.
ALL: Yeah.
OK, let's go.
Guys.
Thank you very much.
Our pleasure.
Yes, thank you.
Good luck with this one.
Thank you.
On the spikes Hit the button, please.
LIFT ANNOUNCER: Doors closing.
MONITOR BEEPS We've lost the output.
Check the LV, please.
We've got something here.
Blood in.
Let's try and get some volume.
LIFT ANNOUNCER: Ground floor.
Jesus Christ.
Harry, keep the blood going.
Go away! Nice and easy, please.
Keep it steady, please.
Harry Tom? .
.
stay on the blood.
Hi.
Yeah, I was just wondering about tonight.
But I didn't know we'd anything planned.
I'm going to take you for dinner.
Thanks.
MONITORS BEEP Seems like a bit of a long shot.
I've seen people survive worse.
How's Tom? What do you mean? You know what I mean.
Tom isn't your concern.
You need to tell him what's going on.
And frankly Glenn, I .
.
you need to tell me.
SPEAKING ON PHONE: And I love you too, Danny.
Bye-bye.
Let's do the hoops.
I'm Glen Boyle, I'm the trauma consultant.
Fiona Lomas, trauma fellow.
Ramakrishna Chandramohan, anaesthetics registrar.
Bruce Corby, rapid infuser operator.
Billy Finlay, anaesthetic ODP.
Debbie Wong, scrub nurse.
Patient is major trauma, Edward Howker.
Date of birth is 17/07/77.
Aorta has been clamped for eight minutes 30.
Consent form four signed to do a thoracotomy, a laparotomy for haemorrhage control.
Good.
16 minutes gone.
I'm going to complete the clamshell to find and fix the bleed.
Blade, please.
Cutting.
Ready to cut.
Vacuum those, please.
Thank you.
Shears.
Thank you.
BODY PART CRUNCHES Spreaders.
And let's be really careful placing these, please.
A spike has gone through the diaphragm and is crushing the IVC.
Sats dropping, end tidal CO2 is dropping.
There's a small tear in the IVC.
Satinsky, please.
I'll try and clamp it.
MONITOR BEEPS Christ.
Sats level to 79%.
This spike's in the way, I'm going to have to pack it.
Hit me.
Hit me.
Two packs in.
OK, the pack's controlling the bleed but keep the blood going, please.
The aortic clamp's been on for? 11 minutes.
11 minutes.
Right, I'm going to do a laparotomy to control the haemorrhage so we can take the clamp off and reperfuse his lower half.
Blade, please.
Thank you.
OK to cut, Mr Boyle.
Thank you.
McIndoes, please.
Thank you.
Forceps in bleed, please.
MACHINES BEEP STEADILY Sutures, please.
Just hold it here.
Thank you.
Scissors, please.
HE SIGHS Cut.
Thank you.
Cut, please.
Balfour retractors, please.
Thank you.
Oh.
I need suction.
Where are we? The heart rate is 109.
Sats 87.
BP's 88/64.
The top spike has gone through the liver on its way to the diaphragm.
No sign of haemorrhage from the liver.
That's cardiothoracics coming in now.
The middle spike has perforated the hilum of the left kidney.
Evidence of extensive bleeding.
BBG.
Lactate 18, pH 7.
13.
We've got to get this clamp off and reperfuse his organs.
OK, we will take in the kidney, tie off the renal vessels and we'll bin it later, yes? There is no access with the spike in place.
Let's disinfect the middle spike please, Billy.
Get ready to pull it.
Me? Scrub up, please.
All right.
(Get in.
) No pressure.
D-do I need to gown up? No, that's not sterile.
It's covered in cow shit.
Let's go.
HE EXHALES Hey.
Look at me.
Nice and gently.
Like Excalibur.
Yeah.
Pull.
HE STRAINS Harder.
Harder.
Stop.
He can't move.
Yeah, I know but it's not bloody shifting.
HE GROANS Step, please.
This one sounds interesting.
The thoracic aortic clamp has been in place for 16 minutes.
The middle spike has perforated the hilum of the left kidney.
We need to ligate the left renal vessels before we can take the aortic clamp off.
But in order to get access to the vessels we need to pull this middle spike.
Better get on with it.
The spike is firmly embedded so if you could monitor the tissues at the top spike while we pull the middle one, please.
Thank you.
Just pull it out.
Harder.
Stop! Bleed from the IVC.
Pack! Packs are controlling the bleed.
One pack in.
Go, Billy.
No, don't move it at all.
We have to pull it out.
I understand but the movement made the tear open.
Any more movement could extend the tear.
We can leave the clamp where it is.
In which case, he dies in the ITU tonight of organ failure.
Or we give him a chance and take a risk.
OK.
Thank you.
Billy? Pull it out.
But I don't want to kill him.
OK, I'll take over.
Sorry.
STEADY BEEPING CONTINUES Be ready.
OK.
Thank you.
Packs are controlling the bleed.
You can relax now.
He's no worse.
Heart rate is 105.
Sats are 88.
BP is 87/63.
Gloves.
Size eight, please.
And then let's sort out that kidney and reperfuse his organs.
ASAP.
Coming up to 26 minutes.
I'm going to ligate the renal vessels.
We're a pair of hands short.
Can you retract the small bowel for me? Under the circumstances.
Hmm.
Thank you.
Excuse me.
Forceps and McIndoes, please.
Clamp.
Renal artery is clamped.
Clamp.
The renal vein is clamped.
Forceps.
Scissors, please.
The renal artery is ligated.
Tie, please.
Forceps, please.
27 minutes gone.
That's 20 minutes now with the aortic clamp on.
Scissors, please.
The renal vein is ligated.
Nice work.
I'm going to move the aortic clamp infrarenally.
Thank you.
OK, the aorta has been clamped infrarenally.
Fiona will remove the thoracic aortic clamp on my say so.
Let's get ready, please.
And let me know when you are.
Increase the blood.
Yep.
Yep.
OK, BP rising.
102/85.
Ready.
Good.
Let's release the clamp by half.
Unclamped by a half.
Thank you.
BP dropping.
MACHINES BEEP RAPIDLY Bleed from the IVC.
Shit! Pack.
Increase the blood, Billy.
Pack.
Two packs in.
Five packs total.
Packing isn't controlling the bleed.
We have to reclamp the aorta.
That's a long time for the aorta to be clamped.
Better than being dead.
Let's fully re-clamp the aorta, please.
Fully re-clamped.
Reduce the blood pressure.
Tear is slightly bigger.
I'm going to clamp the IVC and fix it.
Vascular clamp.
I'll pull the top spike, give you a little bit more room.
OK, I'm going to pull it out my half a centimetre.
Are you ready? Ready.
Pulling.
I can't quite see what's happening.
Slowly.
Yeah.
It seems to be pulling the IVC.
Back up.
Stop.
Swab and forceps.
It's hooked.
It's torn the IVC.
Shit.
The tear is approximately 2cm.
MACHINE BEEPS RAPIDLY Oh, come on! BP crashing.
The aortic clamp is in place.
There's back bleeding into the liver.
Pack.
One pack in.
Six packs total.
Billy? Yes.
Mrs Murkherjee, I need you to compress the IVC to stop the back bleeding.
I can close the tear but I can't compress the IVC with the spike in the way.
I can't pull it out and I can't clamp it.
I can't pull the hook through the liver.
It will destroy it.
There is no possibility of him getting a liver transplant tonight.
Maybe you can open the liver and lift the spike.
No.
He'll bleed to death.
Let's face it, we can't proceed surgically.
We've reached the end.
Hello.
Please take a seat.
One of the spikes went through Edward's liver.
In order to save his life, obviously we need to remove the spike.
But pulling it out will almost certainly destroy his liver.
I'm afraid there's no tissue match for an available donor liver.
And any further efforts we make run the risk of killing him, Frank.
Y-you're giving up? It's an impossible dilemma for a surgeon.
So you're giving up?! All we can do is tidy this up.
'Dr Green Please leave a message.
' Shit.
Hi, boss.
If you get this message in the next few minutes, can you come down to trauma theatre cos I think this one's going to go tits up on the table.
Glen? I'm going to need tying.
Orthopaedic instrument set.
OK.
What are we going to do? I'm going to try and cut the tip off of the spike.
Largest K-wire cutter you've got, please! OK.
Look, I'm sorry to interrupt but that is not a healthy colour for bowel.
Look, we are losing the bowel.
We need to get a move on.
Thank you.
I need space on your left, please.
There is no space.
Stick a hand in.
Retract the liver and the diaphragm, please.
If you damage the IVC, he will die on the table.
Mind your fingers.
This is pointless! Just hold on a few seconds.
His organs have had no profusion for a protracted period.
Do you think we have a few seconds? Come on! Fiona, help me, please.
Come on.
Dish.
Let's pull the spike.
Can you see if I damaged the IVC? Thank you.
Good.
Got it.
Someone take this.
We've got a bleed in the liver.
Hit me.
Hit me.
Two packs in.
Eight packs total.
The IVC is clamped.
We've got control of the hepatic bleed.
OK, let's fix the tear and finally get this bloody aortic clamp off, eh? I can't.
Cutting off the hook made a 3cm diameter hole in the IVC.
Stitching it would only stenos the IVC completely.
Patch it.
I honestly don't think I could do it in time.
We've come this far.
Can we at least try? 20mm vasa tunica sheet.
Thank you.
I'll need more access to the chest, please.
It's a contaminated wound.
We'll need to revise later to a full autologous graft.
Double-ended fibro-prolene and forceps.
Help me guide it down, please.
APGs.
Lactating 19, pH 6.
97.
OK, it's down to minutes, at best.
Does anyone have a condom? I'm going to improvise a balloon tamponade for the liver.
Anyone? (Give him the one you've had in your wallet since school.
) (Can't.
Used it on your girlfriend.
) Locker 54.
The key is in my pocket.
Did you get all that? Locker 54.
Miss Lomas' condoms.
Now, please! ETA, please? Three minutes.
I need you to do it in two.
I can't do it.
You can do it.
You can.
Miss Lomas' condoms for Mr Boyle.
Billy.
Quick as you can, please.
Not my size.
I use extra large.
Billy! Never mind.
Nice flowers, by the way, Miss Lomas.
Fold the catheter, please.
Put a syringe in sterile water.
Just here, Billy.
Yeah.
Tie.
Thank you.
Cut.
Three packs out.
Five packs total.
Balloon going in.
Syringe, please.
With any luck, the condom will expand and seal the tear in the liver.
There you go.
Beep the hepatobiliary surgeon, please.
Hi, this is trauma theatre.
Could you beep the hepatobiliary surgeon, please? OK, I need to get this clamp off.
Now! Scissors, please.
Done.
Good work.
If it doesn't come apart.
OK, I'm going to take the clamps on the IVC off first.
You ready? Yeah.
Balloon seems to be holding.
Be ready for the aortic clamp.
Ready.
OK.
I'm going to take it off by a half.
Ready? Here.
BP dropping.
Fill 'em up, Billy.
Blood and FOP.
Holding.
Climbing slightly.
OK.
I'm going to take it three quarters.
Now.
MACHINE BEEPS RAPIDLY Dropping.
Come on.
IRREGULAR BEEPS Shit.
Broadening QRS complex.
We've got to get his potassium down, otherwise he's going to arrest.
Need 10ml of 10% calcium chloride.
Yep.
Thank you.
And 20ml of 50% glucose solution with ten units of insulin.
Yep.
Slow bolus, Billy.
Let's get some bicarb for his acidosis.
RAPID BEEPING CONTINUES Yeah? Yep.
Ten seconds, boss.
OK, glucose-insulin solution is running.
OK, I'm going to take the clamp fully off.
Go.
The aorta is fully unclamped.
Dropping.
Dropping.
Dropping.
Dropping.
Holding.
Holding.
Climbing.
BEEPING SLOWS ECG returning to normal.
Maintaining BP 88/53.
Heart rate 112.
Sats 97.
Is it me or did we just save him? Well done.
That's good work, everyone.
Really.
It's great work.
Let's have a full set of bloods, please, ABG Dionysus Stematelayos.
Consultant hepatobiliary surgeon.
Let's do the swap.
Is thata condom? CAMERA CLICKS What's his haemo-dynamic? He's stable.
He's looking good.
Thank you.
I need to see you.
Now, if I can.
I can't.
Because of Tom? Because you're leaving.
I'm going to need some eyes, please.
Hey.
You saved him.
Yes.
Wow.
Lieutenant Colonel Bryan, please.
Um Can you put me through to her answering machine? Hi, Tom.
Thank you for the flowers.
They're lovely.
So, what's the big occasion? Yes, Jane.
This is Glen Boyle.
I just wanted to talk to you about my redeployment.
I'm not absolutely sure I'm ready to come back.
I've been offered a chance to extend my contract at City General and .
.
I have decided to stay.
accessibility@bskyb.
com
But you will, because that's what you do.
WOMAN ON PHONE: 'It's official, you can return to active service.
' Don't.
Glen Boyle's in there.
We couldn't have gone back to yours.
It wasn't that I didn't want to.
Didn't? This can't be easy for you.
If anyone even sees us FAST-PACED MUSIC PLAYS ALARM BELL RINGS 'Trauma call to Thames lower ambulance bay.
'Trauma call to Thames lower ambulance bay.
' Are you stuck? Yeah, I'm stuck.
SHE LAUGHS Help me.
OK.
Yeah.
Yeah.
OVER SPEAKER: The lower ambulance bay is a restricted area.
Essential personnel only.
The lower ambulance bay is a restricted area.
Essential personnel only.
Not exactly in a hurry, are they? Must be a slow bleed.
Huh.
You OK? Yeah.
Can we get these sides down, please? Yeah.
POLICEMAN SHOUTS INSTRUCTIONS You're the one who found him? Yeah.
He's my son.
I'm Glen Boyle.
Frank Howker.
I'm the trauma consultant.
Frank I need you to stay here, please.
Thank you.
Stepping up.
Fiona.
Yeah.
Oh Patient is impaled at three points.
He's got a pulse.
Somebody start the clock, please.
We can't move him until the fire team get here So we're going to have to stabilise him where he is.
Let's set up the kit on the trolley.
Constance, scissors, please.
Here you go.
All right to come up, boss? One at a time.
Mark, I need you to make some room for me here, please.
OK.
Yep.
LORRY CLANGS Whoa.
Be careful, guys.
Excuse me.
Thank you.
SHE LAUGHS Shit a brick.
Going to need to RSI.
Definitely going to need some volume as well.
An RSI kit, please.
O positive on the blood, please.
Constance, a Venflon, please.
On its way.
Thank you.
No chest movement on the right side.
I'm doing a needle decompression to relieve the tension pneumothorax.
FRANK BREATHES HEAVILY Oh, God.
Frank.
Is there any way you can stabilise this lorry? I can bring the legs down.
That would help, please.
OK.
Thank you.
So heart rate's 125, BP is 78/56.
Sats are 80%.
ENGINE STARTS Going to need to tube him and he definitely needs volume.
Harry, IV access on the left for RSI drugs.
I'm Dr Chandramohan, can you hear me? Blood out.
O pos through the Venflon and a trauma line in, please.
No eye opening, E1.
No verbal response, E1.
Abnormal flexion in response to pain, so that's M3.
GCS is five.
SUCCS 100mg and let's play it safe and give him 250mg of thiopentone as well.
Sharps bin, please.
OK MACHINE WHIRS Can you fill these up and run them? Whoa, whoa! Frank.
It's really important that this lorry doesn't move.
I know.
It's OK.
SIREN RINGS OK, let's get that vehicle stabilised.
Nice and gently, please, guys.
OK, I'm going to do a formal thoracostomy.
Can I have the kit, please, Constance? Yes.
I'm doing a trauma line.
On VET.
Curtis Taylor, station manager.
Glenn Boyle, trauma team leader.
Aw, shit.
We need to get him off this lorry Are you OK? Yeah.
.
.
and our priority is that these spikes don't move inside him.
BPGs! Lactate 12, pH 7.
19.
Dismantling it would be best, but those bolts are rusted in.
That's 15 minutes.
We can cut, but there could be some movement.
He doesn't have 15 minutes.
You're going to have to cut.
Get the cutting gear! I want one of O pos, one of FFP to go straight in as soon as Harry's ready.
I'll go.
Where are we? OK, sats at 84%, heart rate is 102 BP is 89/65.
Need to hurry, please.
Thoracostomy's completed.
FFP and blood in.
Good.
Frank You should go inside.
Nicola? Yeah.
I want to stay.
We're going to do our very best for him.
And they are.
Lydia, can you get him into the relatives room, please? Make him comfortable.
Let's make some space.
Over to you.
OK, we need to get on with this.
Can somebody help me here, please? OK.
Spikes that have penetrated.
One, two, three.
Yes? Yep.
Steady.
Ready.
Watch your eyes.
Cutting.
Cutting.
MACHINE STARTS METAL CLANGS Fiona, can you get a hand on that spike, please? Yeah.
He's stable.
Ready.
Cutting! METAL CLANGS Yeah, stable.
Cutting.
METAL CLANGS Pulse check.
OK, stable.
Release the spikes, please.
Just in.
Scoop in now.
That's it? Yes.
Thank you.
So we are bracing to the patient's right on three.
One, two, three.
Back on three.
One, two, three.
That's great.
Coming in.
Bracing to the patient's left this time.
One, two, three.
OK, we're in.
Back on three.
One, two, three.
Great.
Next step is a short lift just to the foot of the truck.
On three.
One, two, three.
Whoa.
MONITOR BEEPS Put him down.
Put him down.
Don't go back any further.
Heart rate's through the roof.
BP's 53/46.
He's losing blood.
Get blood in, please.
OK, there's no bleeding from the chest area.
It must be lower down.
Do a left anterolateral thoracotomy and clamp the aorta.
Get me the kit, extra gloves! Quick as we can! Mr Boyle.
Yes.
Give me the blade.
Give me the blade, please! Yes, yes.
Thank you.
Good to cut? Yeah, yeah, yeah.
Cutting.
Scissors.
Thank you.
Blood going.
Ready.
Give me that.
Let's get the aortic clamp.
Thank you.
Aortais clamped.
OK, let's cover him up, keep him warm.
BP's stabilising.
OK, we're on the clock, we need to go.
Ramakrishna, on your call.
One, two, three, lift.
Bring the trolley in, please.
Stop there, down.
Down.
Reposition.
Sort these lines out.
Mind your backs there.
Heads.
Got it? Yeah.
On three.
One, two, three.
Ania, Justin, Constance.
You manage the spikes, please.
ALL: Yeah.
OK, let's go.
Guys.
Thank you very much.
Our pleasure.
Yes, thank you.
Good luck with this one.
Thank you.
On the spikes Hit the button, please.
LIFT ANNOUNCER: Doors closing.
MONITOR BEEPS We've lost the output.
Check the LV, please.
We've got something here.
Blood in.
Let's try and get some volume.
LIFT ANNOUNCER: Ground floor.
Jesus Christ.
Harry, keep the blood going.
Go away! Nice and easy, please.
Keep it steady, please.
Harry Tom? .
.
stay on the blood.
Hi.
Yeah, I was just wondering about tonight.
But I didn't know we'd anything planned.
I'm going to take you for dinner.
Thanks.
MONITORS BEEP Seems like a bit of a long shot.
I've seen people survive worse.
How's Tom? What do you mean? You know what I mean.
Tom isn't your concern.
You need to tell him what's going on.
And frankly Glenn, I .
.
you need to tell me.
SPEAKING ON PHONE: And I love you too, Danny.
Bye-bye.
Let's do the hoops.
I'm Glen Boyle, I'm the trauma consultant.
Fiona Lomas, trauma fellow.
Ramakrishna Chandramohan, anaesthetics registrar.
Bruce Corby, rapid infuser operator.
Billy Finlay, anaesthetic ODP.
Debbie Wong, scrub nurse.
Patient is major trauma, Edward Howker.
Date of birth is 17/07/77.
Aorta has been clamped for eight minutes 30.
Consent form four signed to do a thoracotomy, a laparotomy for haemorrhage control.
Good.
16 minutes gone.
I'm going to complete the clamshell to find and fix the bleed.
Blade, please.
Cutting.
Ready to cut.
Vacuum those, please.
Thank you.
Shears.
Thank you.
BODY PART CRUNCHES Spreaders.
And let's be really careful placing these, please.
A spike has gone through the diaphragm and is crushing the IVC.
Sats dropping, end tidal CO2 is dropping.
There's a small tear in the IVC.
Satinsky, please.
I'll try and clamp it.
MONITOR BEEPS Christ.
Sats level to 79%.
This spike's in the way, I'm going to have to pack it.
Hit me.
Hit me.
Two packs in.
OK, the pack's controlling the bleed but keep the blood going, please.
The aortic clamp's been on for? 11 minutes.
11 minutes.
Right, I'm going to do a laparotomy to control the haemorrhage so we can take the clamp off and reperfuse his lower half.
Blade, please.
Thank you.
OK to cut, Mr Boyle.
Thank you.
McIndoes, please.
Thank you.
Forceps in bleed, please.
MACHINES BEEP STEADILY Sutures, please.
Just hold it here.
Thank you.
Scissors, please.
HE SIGHS Cut.
Thank you.
Cut, please.
Balfour retractors, please.
Thank you.
Oh.
I need suction.
Where are we? The heart rate is 109.
Sats 87.
BP's 88/64.
The top spike has gone through the liver on its way to the diaphragm.
No sign of haemorrhage from the liver.
That's cardiothoracics coming in now.
The middle spike has perforated the hilum of the left kidney.
Evidence of extensive bleeding.
BBG.
Lactate 18, pH 7.
13.
We've got to get this clamp off and reperfuse his organs.
OK, we will take in the kidney, tie off the renal vessels and we'll bin it later, yes? There is no access with the spike in place.
Let's disinfect the middle spike please, Billy.
Get ready to pull it.
Me? Scrub up, please.
All right.
(Get in.
) No pressure.
D-do I need to gown up? No, that's not sterile.
It's covered in cow shit.
Let's go.
HE EXHALES Hey.
Look at me.
Nice and gently.
Like Excalibur.
Yeah.
Pull.
HE STRAINS Harder.
Harder.
Stop.
He can't move.
Yeah, I know but it's not bloody shifting.
HE GROANS Step, please.
This one sounds interesting.
The thoracic aortic clamp has been in place for 16 minutes.
The middle spike has perforated the hilum of the left kidney.
We need to ligate the left renal vessels before we can take the aortic clamp off.
But in order to get access to the vessels we need to pull this middle spike.
Better get on with it.
The spike is firmly embedded so if you could monitor the tissues at the top spike while we pull the middle one, please.
Thank you.
Just pull it out.
Harder.
Stop! Bleed from the IVC.
Pack! Packs are controlling the bleed.
One pack in.
Go, Billy.
No, don't move it at all.
We have to pull it out.
I understand but the movement made the tear open.
Any more movement could extend the tear.
We can leave the clamp where it is.
In which case, he dies in the ITU tonight of organ failure.
Or we give him a chance and take a risk.
OK.
Thank you.
Billy? Pull it out.
But I don't want to kill him.
OK, I'll take over.
Sorry.
STEADY BEEPING CONTINUES Be ready.
OK.
Thank you.
Packs are controlling the bleed.
You can relax now.
He's no worse.
Heart rate is 105.
Sats are 88.
BP is 87/63.
Gloves.
Size eight, please.
And then let's sort out that kidney and reperfuse his organs.
ASAP.
Coming up to 26 minutes.
I'm going to ligate the renal vessels.
We're a pair of hands short.
Can you retract the small bowel for me? Under the circumstances.
Hmm.
Thank you.
Excuse me.
Forceps and McIndoes, please.
Clamp.
Renal artery is clamped.
Clamp.
The renal vein is clamped.
Forceps.
Scissors, please.
The renal artery is ligated.
Tie, please.
Forceps, please.
27 minutes gone.
That's 20 minutes now with the aortic clamp on.
Scissors, please.
The renal vein is ligated.
Nice work.
I'm going to move the aortic clamp infrarenally.
Thank you.
OK, the aorta has been clamped infrarenally.
Fiona will remove the thoracic aortic clamp on my say so.
Let's get ready, please.
And let me know when you are.
Increase the blood.
Yep.
Yep.
OK, BP rising.
102/85.
Ready.
Good.
Let's release the clamp by half.
Unclamped by a half.
Thank you.
BP dropping.
MACHINES BEEP RAPIDLY Bleed from the IVC.
Shit! Pack.
Increase the blood, Billy.
Pack.
Two packs in.
Five packs total.
Packing isn't controlling the bleed.
We have to reclamp the aorta.
That's a long time for the aorta to be clamped.
Better than being dead.
Let's fully re-clamp the aorta, please.
Fully re-clamped.
Reduce the blood pressure.
Tear is slightly bigger.
I'm going to clamp the IVC and fix it.
Vascular clamp.
I'll pull the top spike, give you a little bit more room.
OK, I'm going to pull it out my half a centimetre.
Are you ready? Ready.
Pulling.
I can't quite see what's happening.
Slowly.
Yeah.
It seems to be pulling the IVC.
Back up.
Stop.
Swab and forceps.
It's hooked.
It's torn the IVC.
Shit.
The tear is approximately 2cm.
MACHINE BEEPS RAPIDLY Oh, come on! BP crashing.
The aortic clamp is in place.
There's back bleeding into the liver.
Pack.
One pack in.
Six packs total.
Billy? Yes.
Mrs Murkherjee, I need you to compress the IVC to stop the back bleeding.
I can close the tear but I can't compress the IVC with the spike in the way.
I can't pull it out and I can't clamp it.
I can't pull the hook through the liver.
It will destroy it.
There is no possibility of him getting a liver transplant tonight.
Maybe you can open the liver and lift the spike.
No.
He'll bleed to death.
Let's face it, we can't proceed surgically.
We've reached the end.
Hello.
Please take a seat.
One of the spikes went through Edward's liver.
In order to save his life, obviously we need to remove the spike.
But pulling it out will almost certainly destroy his liver.
I'm afraid there's no tissue match for an available donor liver.
And any further efforts we make run the risk of killing him, Frank.
Y-you're giving up? It's an impossible dilemma for a surgeon.
So you're giving up?! All we can do is tidy this up.
'Dr Green Please leave a message.
' Shit.
Hi, boss.
If you get this message in the next few minutes, can you come down to trauma theatre cos I think this one's going to go tits up on the table.
Glen? I'm going to need tying.
Orthopaedic instrument set.
OK.
What are we going to do? I'm going to try and cut the tip off of the spike.
Largest K-wire cutter you've got, please! OK.
Look, I'm sorry to interrupt but that is not a healthy colour for bowel.
Look, we are losing the bowel.
We need to get a move on.
Thank you.
I need space on your left, please.
There is no space.
Stick a hand in.
Retract the liver and the diaphragm, please.
If you damage the IVC, he will die on the table.
Mind your fingers.
This is pointless! Just hold on a few seconds.
His organs have had no profusion for a protracted period.
Do you think we have a few seconds? Come on! Fiona, help me, please.
Come on.
Dish.
Let's pull the spike.
Can you see if I damaged the IVC? Thank you.
Good.
Got it.
Someone take this.
We've got a bleed in the liver.
Hit me.
Hit me.
Two packs in.
Eight packs total.
The IVC is clamped.
We've got control of the hepatic bleed.
OK, let's fix the tear and finally get this bloody aortic clamp off, eh? I can't.
Cutting off the hook made a 3cm diameter hole in the IVC.
Stitching it would only stenos the IVC completely.
Patch it.
I honestly don't think I could do it in time.
We've come this far.
Can we at least try? 20mm vasa tunica sheet.
Thank you.
I'll need more access to the chest, please.
It's a contaminated wound.
We'll need to revise later to a full autologous graft.
Double-ended fibro-prolene and forceps.
Help me guide it down, please.
APGs.
Lactating 19, pH 6.
97.
OK, it's down to minutes, at best.
Does anyone have a condom? I'm going to improvise a balloon tamponade for the liver.
Anyone? (Give him the one you've had in your wallet since school.
) (Can't.
Used it on your girlfriend.
) Locker 54.
The key is in my pocket.
Did you get all that? Locker 54.
Miss Lomas' condoms.
Now, please! ETA, please? Three minutes.
I need you to do it in two.
I can't do it.
You can do it.
You can.
Miss Lomas' condoms for Mr Boyle.
Billy.
Quick as you can, please.
Not my size.
I use extra large.
Billy! Never mind.
Nice flowers, by the way, Miss Lomas.
Fold the catheter, please.
Put a syringe in sterile water.
Just here, Billy.
Yeah.
Tie.
Thank you.
Cut.
Three packs out.
Five packs total.
Balloon going in.
Syringe, please.
With any luck, the condom will expand and seal the tear in the liver.
There you go.
Beep the hepatobiliary surgeon, please.
Hi, this is trauma theatre.
Could you beep the hepatobiliary surgeon, please? OK, I need to get this clamp off.
Now! Scissors, please.
Done.
Good work.
If it doesn't come apart.
OK, I'm going to take the clamps on the IVC off first.
You ready? Yeah.
Balloon seems to be holding.
Be ready for the aortic clamp.
Ready.
OK.
I'm going to take it off by a half.
Ready? Here.
BP dropping.
Fill 'em up, Billy.
Blood and FOP.
Holding.
Climbing slightly.
OK.
I'm going to take it three quarters.
Now.
MACHINE BEEPS RAPIDLY Dropping.
Come on.
IRREGULAR BEEPS Shit.
Broadening QRS complex.
We've got to get his potassium down, otherwise he's going to arrest.
Need 10ml of 10% calcium chloride.
Yep.
Thank you.
And 20ml of 50% glucose solution with ten units of insulin.
Yep.
Slow bolus, Billy.
Let's get some bicarb for his acidosis.
RAPID BEEPING CONTINUES Yeah? Yep.
Ten seconds, boss.
OK, glucose-insulin solution is running.
OK, I'm going to take the clamp fully off.
Go.
The aorta is fully unclamped.
Dropping.
Dropping.
Dropping.
Dropping.
Holding.
Holding.
Climbing.
BEEPING SLOWS ECG returning to normal.
Maintaining BP 88/53.
Heart rate 112.
Sats 97.
Is it me or did we just save him? Well done.
That's good work, everyone.
Really.
It's great work.
Let's have a full set of bloods, please, ABG Dionysus Stematelayos.
Consultant hepatobiliary surgeon.
Let's do the swap.
Is thata condom? CAMERA CLICKS What's his haemo-dynamic? He's stable.
He's looking good.
Thank you.
I need to see you.
Now, if I can.
I can't.
Because of Tom? Because you're leaving.
I'm going to need some eyes, please.
Hey.
You saved him.
Yes.
Wow.
Lieutenant Colonel Bryan, please.
Um Can you put me through to her answering machine? Hi, Tom.
Thank you for the flowers.
They're lovely.
So, what's the big occasion? Yes, Jane.
This is Glen Boyle.
I just wanted to talk to you about my redeployment.
I'm not absolutely sure I'm ready to come back.
I've been offered a chance to extend my contract at City General and .
.
I have decided to stay.
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