Original subtitles

Clive's all right. Be careful, you don't know what he's like.

I can see you're upset, but... Then some of us need to raise their game.

Where's Lorraine? I've told you, I don't know.

Did you come straight to us from active service?

Sorry, dying man waiting for me.

I'm actually heading back to my digs.

I saw you do it!

TANNOY: 'Major trauma Foxtrot Hotel received.

'Major trauma Foxtrot Hotel received.'

If you go into the cubicle. Take him in there, will you, please?

Calm down! We can't treat you if you're shouting.

Sister Nerys, Staff Nurse Costello!

Nice party?

Right, we have this invention called a Tannoy.

We need more security. It's mental in there.

Oh, dear. Major trauma Foxtrot Hotel. Gunshot wound.

Started to unload two minutes ago. Right. Oh, funny! Hi, Bob.

Major Trauma Foxtrot Hotel for you, love. Gunshot wound.

Bay A, please, Nerys.

Nerys, you don't mind if I scribe on this one do you?

Scribe away, love. Thank you.

Where's this bullet hole then? Left lumbar region.

No exit wound? Probably still in there.

We'll try and find you something more exciting next time.

Cl...

Clover. Clover. Mmm.

I thought they had you chained to a desk. I broke loose.

Are we ready to transfer? One, two, three.

Unclipping top and bottom.

One, two, three.

My name is Fiona Lomas. We're at City General Hospital.

Can you hear me? Onto taxpayers' oxygen. Yep.

Immediate needs? Sats were 82.

We bagged with 100% oxygen, but her numbers didn't improved.

BP? 110 over 95, and stable.

I'll just check if there's anything obvious obstructing the airway.

There's nothing to see.

What are the sats now?

Er, 81. Let's get a tube in. Yeah. I'll do a GCS.

Any other points before we start primary?

Who do I put as Team Leader?

Glen will be here shortly. Has anyone seen him?

Sorry I'm late. I got puked on. Can you believe it? Nice.

Harry, I need IV access, right side.

All the usual bloods through the Venflon plus Beta HCG. OK.

And, Nerys, would you put up another bag of O neg for me, please?

Yes, of course. C spine is protected.

The trachea is central.

Pupils are equal and reactive.

O pos, dated and checked. Breathing laboured. Lips cyanosed.

My name is Dr Chandramohan. Can you hear me?

QUIET GROANING

Patient doesn't open eyes in response to verbal stimulus.

That's E1.

Making incomprehensible sounds. V2.

Strong pulses.

Withdraws from trap pinch. That's M4. GCS, 7.

Round of my usual, please, Billy. Coming right up, boss.

Can we have a bit of speed there, please, Justin? Yeah.

Forensic bag, Justin. OK.

Why isn't she already exposed? There were loads of people about.

For God's sake, Bob. Patient dignity.

Yeah, good call.

Not that dignified if she died.

OK. Let's do a log roll and get this coat out.

One, two, three. Thank you, Bob.

Let me have a look.

OK. Let's have a look at the other side. Harry?

Scooch down, Bob.

OK, one, two, three. Thank you, Bob.

Let's have a look.

There's a small penetrating wound consistent with a gunshot.

One, two, three.

Justin, collar? Yeah.

Come on, mate, grab on.

I thought she was still off sick.

Billy, cricoid.

250 of thio going in.

And 100...of sux.

Flush.

Diminished breath sounds and a hyperresonance on the right side.

Clinically, there's a pneumo. Chest drain kit, please, Nerys. Yes.

Three minutes gone.

I'm going to put in a chest drain to relieve the pneumothorax.

Scope, please.

OK, scope in, chords visualised. Tube?

And...

..bull's-eye. Mmm-hmm. Nice one, Rama.

Cuff up.

Justin, can you do bloods, please? Yep.

Patient is on vent.

Let's do the hand over. Yep.

Patient is female. No ID. Appears to be late 20s.

We arrived at 00.37. Time of the injury was 00.15.

According to police, a witness saw her being shot

and falling down three concrete steps.

Small penetrating injury to the left lumbar region,

three centimetres from the lumbar spine.

Police on scene believed that to be a gunshot wound.

Suspect bullet still inside.

Stats at scene - GCS 9, sats 82%. Resps spontaneous but laboured.

BP 118 over 74. Pulse 119.

We gave her 100% oxygen via mask.

IV established on the left arm.

One 250ml bolus of saline given.

OK, guys, thank you.

VBGs.

Ramakrishna. Do you want me to finish the primary?

Yes, thank you, Harry.

Nice seeing you again, Rama. Yeah. You too.

Call me.

"Why don't you give me a call sometime?"

"I am SO calling you, babes."

THEY LAUGH

Don't forget the muscle relaxant masks abdominal signs.

Really? Cos I'm stupid, me, "Rama".

OK, let's prep for CT.

Justin, will you call Brian, tell him we're on our way? Yep.

Hi.

Lorraine. It's good to see you.

Yeah, it's good to see you too.

I'm glad you're well again. Yep.

So, what have we got? Gunshot wound, but she's stable.

That's you for the night. Hallelujah for that.

Lorraine, good to have you back.

It's good to be back. Good.

Nerys, would you do the sitrep for Lorraine, please? Yes, be glad to.

Hiya, yes, this is Staff Nurse Costello in resus.

We've got a major trauma Foxtrot Hotel here.

CT available? Lorraine, sweetie, do I put you down as Team Leader?

Yeah, of course. Do you mind if I nip out for a second?

Is everything OK? Yeah.

I'm not interested in your rota.

I'm not interested in who you're giving time off.

It's not my problem. Giles? Listen, I've had three fights in ED already.

I need some backup. Giles... We've got the police...

Can you tell me who the on call consultant is tonight?

I'll get back to you. I've had the police...

What's going on? I just got cornered by Clive.

I mean with the rota. Nothing.

What have we got? A GSW in the lumbar region.

The patient is stable

and we're imaging the bullet track in CT. Good.

Oh, hi. I'm Lorraine Rappaport. Trauma Consultant.

Glen Boyle. Same. Oh, why's that happened?

Look, as we're both here, I suggest we get on with it together

and sort it out later, if that's OK with you?

Yep, sounds very sensible.

Can I assume all lines and tubes are safe?

All safe and secure, Brian.

Everybody in position, please.

Starting control scan.

She was just being friendly.

And what were YOU doing? Just being friendly as well.

OK.

Control scan complete. Running head scan.

No abnormalities.

Nobody touch any buttons.

How did the flat hunting go?

There's not much out there on short-term leases.

Well, you can't stay in that hospital room.

Why? It's not that bad.

It's terrific...if you're a student.

Well, like I said, there's not much choice.

Contrast connected.

Go long-term and cancel.

Starting contrast run.

What is that?

Can we see that again, please, Brian?

Could it be a cyst?

That's a scull.

She's pregnant.

How the hell did we miss that?

It's Fiona Lomas, Trauma Fellow.

We need an O&G consultant immediately.

Can you tell me who's on call today, please?

Tom Farrow. Oh, right, OK. Thank you.

Brian, can we get the images with the reduced artefacts, please?

How did we miss this pregnancy? I was responsible for the primary.

We skipped FAST and went straight to CT.

I palpated the abdomen. Images up.

OK, so we have a piece of metal,

possibly a bullet... Or a bullet fragment.

..about 12mm long, against the left common iliac artery,

about four centimetres below the bifurcation.

3D, please, Brian.

We also have a rupture of the left common iliac artery,

which looks like a pseudoaneurysm of about six centimetres.

There's no active extravasation of contrast,

but there is some retroperitoneal fluid.

Fast bleep the trauma theatre staff, please.

Justin, pack A from resus, please.

Nerys, we need a trauma line kit and rapid infuser, please.

Harry, you may as well return to ED. No, Harry, you come with me.

Fiona Lomas, Trauma Reg. We need trauma theatre immediately

and can you fast bleep trauma theatre staff?

And we need the radiographer and a vascular C-arm, thank you.

Lines and tubes secure. Prep for transfer.

We're not moving her until we've got a trauma line in.

You can't do that there.

One knock and her iliac artery could haemorrhage.

Mother and foetus will die. We're doing it.

I think her weight's made it almost impossible to pick up.

These things happen, yes? Yeah.

SHE MOUTHS

Got blood, got products, got Bruce. Oh, that's an improvement.

We'll prime the rapid infuser in theatre, thank you. Good decision.

OK, yes, thank you.

Trauma theatre's prepped and ready. Trauma line's in place.

Let's get some blood running through it then, please.

O pos, dated and checked.

Sliding across on three. Everyone ready? One...

Like she is an IED, please.

Gently across on three. One, two, three.

Excuse me.

SHOUTING

Sorry, sorry!

It's OK, BP's stable.

They're in the corridor. Yeah, they've got out of ED.

Be back in a second.

I've got one nurse and one security guard

trying to keep about 50 people out. They're all over the place.

Why can't you just send someone down?

How about a bit of basic security?

Giles, the on call trauma consultant?

Er, it's Glen Boyle.

What if one of these nutters gets out of here and into theatre?

Well, of course it could happen.

There's no-one here, no-one to stop them.

Harry.

Hello, darling. You rang?

Tom...

Are you OK?

Glen Boyle's in there.

He's the locum consultant. How long has he been working here?

They brought him in to cover for Lorraine's suspension.

A couple of months? I was wrong not to tell you.

But let's not argue about it now.

So, what's happened here?

The police think she was shot in the back,

then fell down some concrete steps. Right.

Is it alive?

Yes. What's the gestation?

22 to 24 weeks.

Given there's a question mark over viability, I suggest...

We'll put the neonatal team on standby.

I want to keep the foetus where it is, if that's at all possible.

Billy, she needs to be on the table now. Yep.

Thank you.

Hi, it's Tom Farrow, O&G Consultant.

Can I have a neonatology team on standby, please?

I'm in the trauma theatre.

Yeah, thank you. Bye.

Have you dealt with a foetus in a trauma situation before?

It can get intense. Bastion.

Medecins Sans Frontieres, Helmand Province.

Tom Farrow. Glen Boyle.

Yeah...I know.

Could we tilt the table to the left, please?

Yep. Say when.

Yep. Yeah.

Mind your backs.

23 minutes gone.

I intend to stent the tear in the left common iliac artery

via the right femoral artery.

You're going to lead... I AM the vascular.

Excuse me. Can I have a word, please?

Er...

Fiona.

Lorraine, you'll be under Glen's supervision tonight.

But what does that mean? I'm sorry. It came from Clive.

We should just get started.

Could I have the jelly, please?

I'm sorry, Mrs Rappaport, but we haven't done a WHO.

Oh... I suppose that's over to you.

I'm Glen Boyle, I'm the Trauma Consultant.

Fiona Lomas, Trauma Fellow.

Ramakrishna Chandramohan. Anaesthetics Registrar.

Billy Finlay, Anaesthetic ODP.

Bruce Corby, Rapid Infuser Operator.

Dalisay Guinto, Scrub nurse.

Tom Farrow, O&G Consultant.

Shelley Imms, Radiographer.

Jason Marshall, Staff Nurse.

Jo Hallam, Documentation Nurse.

Lorraine Rappaport. Consultant Vascular Surgeon.

Our patient is major trauma Foxtrot Hotel.

Date of birth, 01/01/1900.

I have signed consent form four,

to stent the tear in the common iliac artery

via the right femoral artery.

The patient is between 22 and 24 weeks pregnant.

Ultrasound, please.

Needle.

Femoral artery located.

Swab.

Wire, please.

Wire going in.

C-arm, please.

Needle out.

Blade.

Screening.

OK. Cutting.

Terumo sheath, please.

Pigtail catheter, please.

Position's good. Thank you. Contrast, please.

Let's have a run of 10 at 10. Sure.

Breathing off. Breathing off.

Screening.

Breathing on.

Breathing on.

Roadmap, please.

Terumo wire, please.

Cobra catheter, please.

You're on the roadmap. I can see.

Oh, damn. You're off the roadmap.

I'm going to have a second attempt at getting the wire across the tear.

Lorraine! No. Shit. I've gone through the tear.

BP dropping, 100 over 78.

Sats dropping, 87. Heart rate rising.

Let's get the BP up, shall we? Contrast, please. Run of 5 at 10.

OK. Breathing off. Breathing off.

Screening.

Shit. The pseudoaneurysm is expanding.

To about eight centimetres.

Breathing on. Breathing on. Another run of 5 at 10, please.

Breathing off. Breathing off. Screening.

Nine centimetres. It could burst.

Another run of 5 at 10, please. Screening.

No further expansion. No extravasation of contrast.

Breathing on. Breathing on. BP is holding.

There's a large defect in the artery I can't get around.

I want to put an occlusion balloon across the tear.

Can I have a moment, please?

Now? Please.

Fiona, please. Yes.

Listen, you don't have to do this. That could have happened to anyone.

Oh, I agree, that's not what I meant. It's Clive.

He's gunning for you and this could turn into a shitstorm...

..so let's not give him the ammunition. Yes?

Fiona, are you OK to take over?

Of course. If that's all right with you?

In which case, I shall leave you to it.

Let's go, please.

Cobra catheter coming out.

Berenstein balloon, please.

Check the balloon.

Yeah.

Hey... You're fine.

Inflating the balloon.

No, deflate it. It's not conforming to the artery.

BP dropping. It's 105 over 84.

Let's increase the blood, please. 90 over 76.

The tear extends higher than I thought.

I'm going to occlude it more proximally.

OK. But that's not going to take care of the back-bleed.

I can't risk enlarging the tear.

BP still dropping.

The left common iliac artery is occluded above the tear.

Stop screening, please.

The uterus is becoming tense and woody. Can you relax it?

250 micrograms of terbutaline, please.

Yeah, Billy, have we got that? It's in there.

250 mics going in now.

Another 250, please. Come on.

Another 250 going in.

Can I see the BP, please? Yep, sorry.

It's not going to go up until you get that baby out.

It's relaxing a bit, but it's unstable.

I need to get the foetus out immediately.

What are its chances of survival?

Depending on weight, between 30 and 40%, max.

And the long-term prognosis if it does survive?

There's about 60% risk of some impairment -

more if there's been significant hypoxia.

No, I want to control the back-bleed with the foetus in place.

The uterus is irritable. It could contract

or the placenta could abrupt.

Caesarean now, or we could lose mother and the foetus.

OK. Right. Excuse me.

12 units of O neg, 8 FFP, 4 platelets and 2 cryo, please.

Yep. I need my team here now.

We're doing an emergency C-section.

Billy, we need neonatal here, right now.

Hello, yeah, it's Billy Finlay ODP, in trauma theatre.

We have a neonatal team on standby, we need them here right away.

Thanks. On their way.

OK, we have to wait.

So, what made you hang up your boots?

Who said I have?

12 units of O neg, 8 FFP, 4 platelets, 2 cryo. Bosh!

There you go, Bruce. What about you?

Oh, I just thought it was time to settle down.

All right, we are prepping for a classical C-section.

Sign in as you set up, please.

Fay Ovenden, Consultant Neonatologist.

Stephen Canja, Midwife. Midwife!

Hannah Simonson, Neonatal SHO.

Zoltan Farkas, Neonatal Nurse.

Ready, Fay? Ready. Yeah, numbers stabilising.

Right, let's get cracking then, shall we? Excuse me.

The uterus has relaxed.

Means there's no immediate need to do a C-section now, is there?

Fiona, if I did a laparotomy, can you clamp the artery?

Maybe. With the foetus still in place? Yes.

But could you move the uterus? Not much.

It could trigger placental abruption.

If she abrupts, she dies.

Let's prep for a laparotomy, everyone.

This can't be easy for you.

It's a tough case.

Hmm... We'll talk about it at home.

48 minutes. I'll take a blade, please.

Am I OK to cut? Yeah.

Cutting.

Mayo, please.

RAMC finesse.

You can join in any time you want. Happy to watch and learn.

Deaver retractor, please.

Are you ready?

Yeah. Over to you.

Tom?

Moving the uterus.

That's as far as it will go.

BP's holding.

Dissecting scissors, please.

I'm going to enter the retroperitoneum.

Suction.

Dardik clamp, please.

OK.

A bit further.

That's it. I need more room.

BP dropping. 94 over 78.

I'm in danger of stimulating the uterus. I have to get in.

73 over 61. Unstable. Bruce, increase the blood, please.

Tom, just give me 30 more seconds. Please.

30 seconds.

I've got it.

A bit further, please. I can't. I have to stop the back-bleed.

BP dropping. 79 over 68.

I can't get it.

That's 30 seconds. A few more seconds. 75 over 64.

OK. Common iliac artery clamped, distal to the metal fragment.

Good. Keep going.

You've controlled the back-bleed. I need to put this back now.

We need to clamp, proximal to the metal. Dardik, please.

It's controlled by the balloon. It's not enough.

Ten seconds. OK.

The uterus is contracting. Jesus, I think she's about to abrupt.

I need a little more space and a little more time. We're out of both!

Get out now. OK! Still unstable.

Right, why is this baby still in there?

We need to stabilise the iliac. Let me make myself crystal clear.

If that mother dies, it's going to be all over national news.

Foetal death doesn't make local radio. Get it out.

Ultrasound, please.

Why didn't you tell me he was working here?

I was going to. Right.

Placenta's position is normal.

The foetus is in distress. Thank you.

Let's get cracking. Ta. Doyens. Thank you.

Scalpel.

We should try to shunt it, give the baby a chance.

You're kidding, right?

The iliac's just on the balloon.

A C-section could just as easily dislodge it.

You've had your chance. Step away. I won't.

Cos we should at least try, we should give it a shot.

Tom.

For God's sake!

Shunt kit, please. 55 minutes gone.

I'm going to try and shunt the left common iliac artery.

Let's have the Lahey ready, please.

I going to need you to retract. Do you think you can do that?

Yeah. Thank you. Tom.

Please.

That is as far as it will go.

Numbers are stable, for now.

OK, I've got it. Lahey.

OK, I'm around the artery, distal to the tear. Vicryl ties, please.

Thank you.

OK, clip.

Let's do it again.

Any more room you can give me? I can't risk moving it.

OK.

Come on.

Clip.

The Vicryl ties are in position, distal and proximal to the tear.

Shunt, please.

Thank you.

The uterus is hardening a little.

Let's remove the Dardik.

OK, the shunt is in

and I'm passing it down the left common iliac, distal to the tear.

I just need to ligate it.

Scissors, please. It's unstable.

Cut. The shunt is ligated, distal to the tear.

Can we get a clamp on this, please?

I'm now going to try and shunt, proximal to the tear.

Give me as much space as you can, please. I can't.

I need to put it back. I just need 30 seconds. Oh, come on!

BP crashing. 71 over 60.

The balloon's failed. Fill her up, please. Let's get the balloon out.

Dardik. The uterus is hardening again. 65 over 44.

No, I can't get a hold of it. It's too traumatised.

Give me your hand. I need you to compress with your fingers.

She's going to abrupt. Just a few more seconds.

It's slipping. I can't keep hold of it.

She hasn't got a few more seconds. I've lost it.

55 over unreadable. As much blood as you can get into her, please.

The uterus needs to go back now. Everybody, just be calm.

OK.

The shunt is in and is going up the left common iliac artery,

proximal to the tear.

OK. Ligate it. I need to put it back! Ten seconds.

Ten, nine, eight,

seven, six, five,

four... Systolic dropping.

Three... Cut it. ..two, one.

Clamp off. Clamp off. We've done it. Jesus Christ.

I could have just worked in my dad's chippy. So could I.

Ultrasound, please.

Thank you.

The placenta appears to be intact.

I can't find a heartbeat. Come on!

HEARTBEAT

Healthy heartbeat.

I'll get the bullet.

Metal one, please.

CLINKING

You can take the surgeon out of the army...

The patient needs to stay here for a while and then go up to ICU, yes?

Yeah.

Fiona, are you OK? She's fine.

That was good work, everyone. Nice one.

Pack up, guys.

You didn't follow my guidance.

No.

Police still here?

TANNOY: 'Duty hygiene assistant to the staff canteen.

'Duty hygiene assistant to the staff canteen, please.'

For the GSW? I am.

It's ricocheted off of a hard surface,

but it's a piece of copper jacket from a high velocity round.

It's an SA80. How did he get hold of that?

Well, he's ex-army.

He shot his wife.

This should send him down. Thank you.

Dr Archerfield? Yes.

We all thought Lorraine was off sick. Yes.

Well, someone told me that she's now working under supervision.

Lorraine's better than that! Indeed she is.

TANNOY: 'Staff and members of the public are reminded

'not to leave bags or personal items unattended. Thank you.'

Glen's CV said he finished deployment

immediately before starting here.

But his last deployment ended three months before.

What did he do for those three months?

Lorraine. I'm in the middle of a conversation. We need to talk.

There's a blank he refuses to account for. Thank you.

You cancelled the competency hearing

because the complaints against me were unsubstantiated.

Yes, but the accusations remain. Remain? Well, how can they remain?

They're unsubstantiated. That means they're bullshit.

Lorraine, please. Where do they remain?

Look, this hasn't been easy for either of us.

I'll keep the file closed. In return, I want you back to work.

I'm trying to help you.

Excuse me, can you take this? Sure.

When Clive told me that you were under my supervision,

I assumed that he had told you too.

I'm sorry it put you in a difficult position.

Both of us. Bastard wants us to fight for the same job.

See you later.

Should we talk?

Maybe we should leave it alone.

Why didn't you tell me about Tom?

I mean, why didn't you even mention him?

Fiona? You'll fight for a stranger's baby.

I was mad to call you.

Lorraine's back.

You should go.

We don't need you.

Oh, God!

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