Should have been there for you. I messed up.
We both did.
It's not that terrible having me here, is it?
- What if she has? - Has what?
- Shagged the neuro reg. - Ask her.
Mr Boyle, before you go,
I have an admin query.
Did you come straight to us from active service?
Sorry, dying man waiting for me.
You were in breach of your supervisory directive.
You'll be charged with serious professional misconduct.
You're destroying my career?
We're evacuating patients,
but no one's telling us where the fire is.
I need information, now.
Can we get him now?
Yeah, this is Giles Dhilon, trauma manager.
Do we have a location
for the fire alarms yet?
This way.
- Theatre changing rooms. Changing rooms! - All right, Justin...
Staff changing rooms. This way!
Me too?
Let's go, yes, you too.
Staff changing rooms on the right.
All clear.
Yeah, I'm personally leading a trauma team down to the incident now.
Resus trolley, straight away, please.
Not until we've cleared it, please.
Quickly, she's in a bad way.
Sister, let's get that trolley, please.
- Yes, Mr Boyle. - And a scoop, Harry.
Giles, make sure there's an anaesthetist on their way down
and have the rest of the trauma core divert to resus.
- Yes, Mr Boyle. - Thank you.
- You okay? - Yeah.
All clear.
The fire's out but it's still a bit smokey in there.
If anyone starts with any problems breathing, let me know,
and we'll get out straightaway.
... exercise extreme caution
and report evidence of fire or smoke at once.
Oh, my God.
- Who is she? - Don't know.
Hello?
Can you tell me your name?
Yeah, I thought of that.
We're going to take care of you.
We're going to give you something for the pain.
- Get me morphine. - Yeah.
- Controller? - Control.
Theatre one changing room fire out.
- One serious casualty... - Mind the head.
Okay, roll to the left first.
To the right, on roll.
Ready, set, roll.
Designate theatre area a red zone...
You're not serious?
Okay, lift on "lift".
Ready, set, lift!
...exercise extreme caution
and report evidence of fire or smoke...
- Good? - Let's go.
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- Oh, my God. - Giles.
Get security to check CCTV and find out who this is, please.
Yes, yes, of course.
Gangway, major trauma coming through. Gangway.
Turn.
Changing room fire. Someone was trapped.
- A member of staff. - Who?
Don't know, Mrs Hicklin's asked me to check the CCTV.
- Male or female? - Female.
CCTV, you show me first.
Yeah, okay.
Starting the clock.
Does anybody recognise her?
There's not much to recognise.
Ramakrishna, I'm leaving you to the airways.
Fiona will do the primary survey.
Harry will give us venous access via a large bore cannula.
And then we will immediate give 30 milligrams of ketamine,
one gram of paracetamol
and one litre of warmed Hartmann's, please.
- I've got the ketamine. - I've got the paracetamol
- and Hartmann's. Justin? - Yeah.
We're gonna need cold swabs.
Yeah, I'll get them.
That's it, just open up.
I'm Dr Chandramohan, the anaesthetics registrar.
Can you tell us your name?
Name?
We need to check your airway.
Let's get that scoop out.
- Yeah. - Make her more comfortable, please.
Unclip top and bottom.
Unclipped.
Okay, bracing to the patient's left
very gently on three.
One, two, three.
Okay, I need to look at her back.
- Okay. - Back on three. One, two, three.
Brace right on three.
One, two, three.
Back on three. One, two, three.
All right, my love, well done.
I'm Fiona Lomas.
Trauma reg.
I need to examine you.
Just keep the non-burnt areas warm, please.
Right you are.
I'll scribe.
Look, we don't know who she is yet, so clear off, please.
Thank you, Nerys.
Can you understand me?
What's your name?
Facial burns, partial thickness.
Soot in mouth.
A small amount.
Suctioned.
Carbonaceous sputum.
Again, small amount. Suctioned.
Singeing of nasal hairs.
Good peripheral perfusion.
Someone has got to have seen her go into the changing room.
Giles is checking the CCTV.
Has anybody seen Lorraine today?
Oh, my God, it's Lorraine?
- We don't know who it is. - That's right, we don't.
I'm calling the burns unit.
Excuse me. Erm, look, everyone, I know this
is not easy, but, please,
can we just treat her like any other...
Yeah, this is Mrs Hicklin,
can you put me through to the consultant on call for burns?
Can you open your mouth for me, my sweet?
I can't get anything.
Keep trying.
Any intraoral burns? Oedema?
No signs of either. Upper airway appears clear.
I need to give you some oxygen, my love.
The mask might be a bit uncomfortable
while the painkillers kick in.
Okay, well done.
100%% O2, 50 metres a minute.
Just waiting for the sats reading to come up.
Patesh? Nicola Hicklin.
We have a woman over here at CGH
with greater than 50% full and partial thickness burns.
No, we have no ID yet.
I'll let... I'll let you know.
Okay, cheers, Patesh.
Reasonable ventilation across both lung fields.
Good carotid and femoral pulses.
Widespread full and partial thickness burns across the chest.
Can you upload the referral form to the central infirmary burns unit
once we've got all the necessary information?
- Yeah. - Adding to that, that we believe
it may be a member of staff.
Of course, Fiona.
Oxygen saturation?
One hundred.
We'll confirm that with ABGs.
Okay, so better IV access first,
tubes second, ABGs third.
- Let's do it. - Subclavian line.
Can you do us a favour
and bleep the consultant anaesthetist on call, it's Malloy.
What did your last slave die off?
That's a bit racist.
Go away, please.
I'm pausing the primary survey till the patient gets something for the pain.
I've done your 30 of ket, Lomas. It's in there.
Thank you.
You'll feel a sharp scratch just underneath your collarbone.
Okay, we're going to take care of you.
We're going to give you something for the pain.
Yes, I'm calling on behalf of Dr Chandramohan.
Could you fax me Dr Malloy's...
So this will be the sequence of events.
Once Ramakrishna has cannulated the subclavian vein
he'll take a syringe of blood.
Harry, you'll receive that syringe and you'll send it for FBC
U&Es, G&S, TEG,
ETOH, Beta-HCG and drug screen.
And don't forget the drug screen.
ABGs to follow, including carboxyhemoglobin. Yes?
- Yes. - No...
Malloy!
Consultant anaesthetist, yes. Yeah, that's it. Thanks.
Thank God for that.
Send those straight off,
come back for an ABG.
What's going on?
- Someone prep me for an out-line. - I'll get it.
Mrs Hicklin, can we catheterise the patient
so we can monitor her urine output and start a fluid chart, please?
Okay.
Sister, let's prepare some sterilised gauze to remove any loose
flesh or burnt clothing.
Let's source some cling film, please.
Yes, Mr Boyle.
Justin, burns kit.
We haven't had the handover yet.
I was in the male changing room.
Heard shouting and ran over to the female side.
She'd barricaded herself in.
So it was hard work getting to her, but,
luckily, there was an extinguisher in the corridor, so...
You put the fire out?
Yes.
Well done.
Yes. Well done.
We're going to give you something to make you more comfortable.
Ketamine and paracetamol given.
Thank you.
Hartmann's running in.
You're gonna feel a strange feeling at the top of your chest.
That's just the fluid running in.
Okay.
I'm resuming the primary survey.
Bloods have gone.
Cheers.
Harry, ABG.
You bastard.
She's very pink.
Cherry.
She was in an enclosed space!
She's hypoxic.
Can't be. The sats are still 100!
- Oxygen. - Yeah.
Diazemuls.
Need to oxygenate.
- But what about the sats? - Shut up, Billy!
Come on, Justin! Come on!
Coming, coming, coming, coming, coming, coming.
It's okay.
Shit!
Come on!
Shit!
- She's asphyxiating. - Coming, coming, coming, coming.
Yeah. Okay.
Diazemuls 10 milligram IV given.
It's okay. You're okay.
Okay.
- Okay. - Good.
What's her carboxyhemoglobin?
Er, 30%. And her CO2 is 12...
Whatever. She's got severe CO toxicity.
- I need to tube her now. - We.
Fire one-two-five sux.
- Get the GlideScope ready. - Yeah.
- Are you ready for the cricoid? - Yeah.
- Done it before? Great. - Yeah.
- Thank you. - Biopentone.
- One-two-five. - In.
- Come on, Billy. Come on. - You'll have it. You'll have it.
- Breath sounds diminishing. - Come on.
Sux 100.
- Here you are. - In.
- Bougie at the ready. - Lady wand?
Not the time or the place, Billy.
Shit.
Not liking what I'm seeing.
Shit.
Bougie.
Tube.
Tube's on the clip. I've got the bougie.
Yeah.
Subglottic oedema.
- Okay. - Shit.
Shit!
It's closing off the airway.
Can we get the tube in?
I need you to tell me what's happening.
- Laryngeal mask. - Yeah, cover that.
Glen, please.
We need trache gloves and gown, please. Now.
Need an answer, Ramakrishna.
Okay.
I need an answer.
And up. In you go.
Yeah, okay.
Okay. LMA in place.
Oh, God's sake, why me?
VF arrest.
Get me gloves, please.
Femoral absent, carotid absent.
Swap, please.
Compressions and defibrillation.
Okay, so we're bagging via LMA, so it's 30 to two.
Go. One, two, three, four.
Okay, so, 150 biphasic.
150 biphasic.
One hundred and fifty joules biphasic shock charging.
Charged. Prepare for shock.
Warning, stand clear.
- Warning, stand clear. - Shocking in three...
Everybody off.
Oxygen away. Justin, off the chest.
One, two, three, shock.
- Back on. - Okay, come on.
Restart compressions. Two minutes of CPR, please.
I'm not happy with this ventilation. I'm going to try and tube her again
- at the end of this cycle. - Okay.
What's the smallest tube you've got there?
A six.
So what's the story with the sats?
Pulse ox misreads carbon monoxide poisoning as a normal oxygen saturation.
- I knew that. - Yeah.
Radiographer.
Sorry.
Well done for rescuing her from that fire.
- Thirty seconds gone, 90 to go. - Thanks.
I want to apologise for badgering you
over apparent discrepancies in your CV.
An army contact
told me what happened.
- Right. - No wonder you needed some time off.
Your actions in Afghanistan were admirable.
Thank you.
Sixty seconds gone, sixty to go.
Okay, let's use this time to calculate surface area of burns.
Anyone?
Er, by rule of nines,
and with visual estimation it's 65%.
Okay.
Using the Parkland formula with estimated weight of 60 kilos,
that gives us four times 60 times 65,
which equals 15.6 litres over the first 24 hours
with 50% given in the first eight hours,
- i.e. 7.8 litres. - Good.
65% of body surface area is burned.
Gives her a 50% chance of survival.
As per Harry's calculation,
that's one litre per hour for the first eight hours.
Did you really work that out for yourself, or did you cheat?
Five seconds.
We weren't even going out properly at the time,
and you were acting like an arse, so no change there.
- Time. - Need to get in during the pulse check.
- Okay. - Need quick hands, Billy.
Yeah.
- Charging. - Shock charging.
Charged. Ready to shock.
- Shocking. - I need to get in.
It's oxygenation that she needs.
- Warning, stand clear. - Delay shock. Justin, off the chest.
Yeah.
Femoral absent, carotid absent.
Okay, let's go.
- Okay, tube in. - Get in!
Shocking after three. Everybody clear.
- Stand clear. Warning, stand clear. - Oxygen away.
- Stand clear. - One, two, three.
Compressions. Come on.
Another two minutes of CPR.
Time is 22 minutes and 30 seconds.
Let's be ready with adrenaline for after this cycle, please.
Okay, we can go easy now.
That Mini fell through.
A black one with 20 thou on the clock.
The guy got a better offer.
I'm gutted.
Okay, we're moving more air now.
We've got ROSC.
Could we stop CPR, please?
Sinus.
Carotid output, femoral output.
Okay, that's well done, everybody.
Let's get a plain chest film, please.
And then we're going to transfer her to the burns unit.
Okay. Portable machine's in use.
Okay to move the patient down to the overhead.
Okay, let's go. Quick as we can, please. Quick as we can.
- Go. - Let's get going.
Harry?
You should be back in ED.
Will all staff please return to their stations.
All staff return to their stations...
Security sent me the CCTV footage.
Raise in three.
One, two, three, raise.
Patient is intubated and ventilated.
Tonic-clonic seizure and VF arrest due to CO toxicity,
- but she's stable now. - All clear.
Get in there and finish the cling film, please.
Okay, thanks, boss.
Image on screen.
Doesn't look good.
Is there a problem?
Move, please.
Chest compliance is down.
Poor oxygenation.
The burns are constricting her chest.
Yeah, she needs escharotomies. Right now, please.
Okay.
It's Fiona Lomas, trauma reg.
Could you fast beep trauma theatre staff urgently, please?
What's that she's got there?
Sanitiser gel.
Highly flammable.
After she barricades herself in,
nothing happens for some time.
Oh, God.
Best tell the trauma team.
I don't think that's a good idea.
They need to know who their patient is.
I don't think that's going to help anybody right now.
Diathermy, please.
- Thank you. - Swabs, please.
Chest compliance is even worse.
Her lungs are getting really badly compressed.
Okay.
Trying to loosen the chest.
Lung compliance and tidal volumes are still way down.
Hi, boss. I'm having some real issues with ventilation here.
Emergency escharotomies are in progress.
Right.
It's definitely Lorraine.
Thought you should know.
You don't have to do this.
Yes, I do.
It's not changing.
No, it's not enough. You need to release more scar tissue.
Okay, we'll do transverse incisions.
I can do it if you want.
I'm doing it.
Chest compliance improving.
Tidal volumes increasing.
Tidal volume continues to improve.
And tidal CO2 is dropping, sats now rising.
I'm happy to do the transfer.
I'll call my opposite number in the burns unit.
All right, cheers, boss.
Let's get her a face mask.
Prep her for the burns unit, please.
Face mask, burns box, resus.
Cheers, Billy.
She stands a decent chance.
Of what?
A lifetime of pain and disfigurement?
She was misguided, I had to challenge her for the good of the department.
- Yeah. - There are hundreds of members
of staff whose careers and livelihoods and families depend on the success
of this unit. I couldn't let one person derail that.
No, you couldn't.
- Anything to say? - Who told you?
Doesn't matter, I've been told.
If I'd ever thought Lorraine would do something like this...
What?
Then you wouldn't have ruined her career?
The only thing Lorraine ever did
was challenge the way you run this department.
We don't yet know the range of emotions that motivated her.
No?
Someone should inform the next of kin.
Well, not you.
There's a husband and two young children.
Joshua's six, Olivia's four.
John Rappaport.
Mr Rappaport.
My name's Fiona Lomas.
I'm one of Lorraine's junior colleagues.
Yes?
I have very bad news.
I'm afraid Lorraine's been involved in an accident at work.
God.
She has sustained severe burns.
Oh, God.
We're transferring her to the burns unit at the central infirmary.
And I think it would be best if you made your way there directly.
Yes, I'll, erm...
I am so sorry to have to give you this news over the phone.
Mr Rappaport?
Fiona...
I've got it.
Mr Rappaport, it's Giles Dhilon.
I'm very sorry.
Sats are still dropping!
- You check the circuit? - Yes.
Ramakrishna, what's happening?
No. No, there's no leaks. No.
- It must be the tube. - Yeah.
- Another 6.0. - Yeah.
No, make that 5.5.
- Tell me. - We're not ventilating the lungs.
- Sats are now 80%%! - Yeah, I can read.
Come on.
This facial oedema is pulling out the bloody tube.
- Off the vent. - Yeah.
- Crike set. - Crike, over here.
Yes, got it.
Come on, move!
- No, would you... - There you are.
Ties.
Tube.
- Get it on. - Yeah, yeah.
Okay...
Sats are now 60%.
Ramakrishna?
I'm giving you 10 seconds.
- Nine... - Eight...
- Seven... - Six...
- Five... - Four...
- Three... - Two...
- Shit... - One...
- Blade, please. - Clear. Clear.
Hemostat.
Track.
Inflate, please.
Okay.
- Ventilating. - Good.
Thanks.
Patient back on vent.
Sutures.
Just cut it.
- Okay. - Okay.
We keep her warm
and then we transfer her to the burns unit.
Yeah.
Let's make sure she gets there this time.
Brake on.
Moving on three. Everyone ready?
- Yeah. - One, two, three.
I'll call as soon as I hand her over to the burns team.
Get up.
The transfer time's five to ten minutes, right?
- Nearer five. - Okay, good.
I need to unstrap.
Got 200 milligrams of hydrocortisone.
Great. Thank you.
We've got a bit of a problem back here. We need to get down there ASAP.
Shit, no suction.
Here.
Sorry.
Tube.
Oh, shit!
Come on.
Shit!
We need to vent.
Oh, shit!
Can you do compressions? I need to bag her.
I don't have enough room. I'm going to be landing ASAP.
- I should bag her. - No, we're going to be landing.
- You need to be... - I need to bag her!
Locked in tight in the front.
Locked in tight to the back. Patient secure.
Locked in tight, front right.
Down.
Ambu bag and adrenaline.
- Get on the chest, mate. - Right.
Thanks.
Okay. Thanks.
All right, done and given.
Oh, Jesus.
She's drowning.
Massive ARDS reaction to smoke inhalation.
We're done.
This is a coroner job so we need to leave everything attached.
Sorry, mate.
We'll take her in.
Thanks.
Mate, it's Billy.
All right.
I've got it.
- Billy? - It's Giles again.
Ramakrishna, stay where you are and I'll organise some transport for you.
Er...
She died en route.
Yeah, she's here.
Talk to Bennett-Edwards.
He wants to talk to you.
Er, yeah, tell him I'll ring him.
She's going to give you a call.
She must have been in a terrible ordeal.
And we're all thinking of you.
Yeah, I'll call you back when I know who's coming to get you.
- Fiona? - Fiona?
Yet she didn't even get there.
You bastard!
I'm terribly, terribly sorry!
Stop!
You will stop!
I'm so sorry.
No...
There's something I need you to see.
Please.
Okay.
I wasn't on active service when you called me.
My last deployment finished months ago.
I've been on, erm...
I've been on long-term leave.
What is this?
It's a helmet camera, it's not mine.
It's our, er,
forward operating base in Afghanistan.
The guy shooting at us is Afghan.
He's meant to be one of ours.
They shot him three times.
- He was your friend? - He was.
I thought I knew him.
I need a medic!
Medic!
- Why didn't you tell me? - What?
I...
Because I'd have known?
Known?
Known what?
That this is why you're here.
Another chance to save lives.
- And now, look. - Lorraine...
Lorraine wasn't anyone's fault...
...but Clive's.
Okay.
And your friend,
- you did the best you could for him. - Yeah.
You don't understand.
Okay.
I can't
pretend to understand what you've been through.
But it wasn't your fault.
- You couldn't save him. - I wasn't trying to save him.
I wasn't trying to save him.
It was completely the opposite.
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