- Clive's all right. - Be careful.
You don't know what he's like.
Now I can see you're upset.
Well, then some of us need to raise their game.
Where is Lorraine?
I 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.
Ripped By mstoll
I saw you do it!
Major trauma Foxtrot Hotel. Proceed.
- Major trauma Foxtrot Hotel. Proceed. - If you go into the queue.
Take him in there, will you, please, love?
Calm down, we can't treat you if you're shouting.
Sister Nerys, staff nurse Costello!
Nice party.
Uh, we have this invention called a Tannoy.
- Do you know what that is? - 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 8 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.
Mmm, no exit wound.
- Probably still in there. - Oh, we'll try and find you
something more exciting, next time.
Clooo...
- Clover. - Clover.
- Mmm. - Thought they had you chained to a desk.
I broke loose.
- 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?
- On to taxpayer's oxygen? - Yeah.
- Immediate needs? - Uh, sat rate's at 2,
we bagged with100% oxygen, but her numbers didn't improve.
- BP? - 110 over 95 and stable.
Just check if there's any obvious obstructing the airway.
There's nothing to see.
What are the sats now?
Uh, 81.
- Let's get a tube in. - Yeah.
I'll do a GCS.
Any other points before we start primary?
Uh, who do I put in as the team leader?
Uh, 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. - Okay.
And, Nerys, would you put up another bag
- of O-neg for me, please? - Yes, of course.
C-spine is protected.
Trachea, central.
Pupils are equal and reactive.
O-pos dated and checked.
Breathing laboured, lips cyanose.
My name's Dr Chandramohan, can you hear me?
Patient doesn't open eyes in response to verbal stimulus,
that's E1.
Making incomprehensible sounds, V2.
Strong pulses.
Withdrawals from trach pinch, M4.
GCS 7.
A round of my usual, please, Billy.
Coming right up, boss.
Can we have a bit of speed there please, Justin?
- Yeah. - Forensic bag, Justin.
- Okay. - Why, isn't she already exposed?
Uh, there were loads of people about.
For God's sake, Bob.
Patient dignity.
Yeah, good call.
It's not that dignified if she died?
Okay, let's do a log roll and get this coat out.
One, two, three.
Thank you, Bob.
Let me have a look?
Okay, let's have a look at the other side. Harry.
Scooch down, Bob?
Okay, 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.
Okay, mate. Grab on.
I thought she was still off sick.
Billy, cricoid.
250 of Thio going in.
And a 100
of sats.
Wash.
Diminished breath sounds and hyper resonance on the right side.
Clinically there's a pneumo.
- Chest drain kit please, Nerys. - Yes.
Three minutes gone.
I'm gonna put in a chest drain to relieve the pneumothorax.
Scope, please.
Okay, scoping chords, visualise tube...
And...
- Bulls-eye. - Mmm-hmm. Nice one, Rama.
Cath up.
- Justin, can you do bloods, please? - Yeah.
Patient is on vent.
- Let's do the handover. - Yeah.
Uh, patient is female,
no ID, appears to be late 20s.
Uh, we arrived at 00:37
time of the injury was 00:15.
According to police, a witness saw her being shot
falling down three concrete steps.
Small penetrative injury to the left lumbar region,
three centimetres from the lumbar spine.
Police on scene believe that to be a gunshot wound.
Suspect bullet still inside.
Stats at scene,
GCS 9, sats 82%.
Resp, spontaneous but laboured.
BP, 118 over 74.
Pulse, 119.
We gave her 100% of oxygen by mask.
IV established on the left arm
and one 250 ml bonus of saline given.
Okay, guys, thank you.
VBGs.
- Ramakrishna. - Hey, do 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'm so calling you back.
Don't forget, the muscle relaxant masks abdominal signs.
Really? Cause I'm stupid, me.
Rama.
Okay, let's prep for CT.
Justin, will you call Brian, tell him we're on our way?
Yeah.
Hi.
Lorraine.
- It's good to see you. - Yeah. It's good to see you, too.
I'm glad you're well again.
Yeah.
So, what have we got?
Gunshot wound, but she's stable.
- That's you for the night. - Oh, hallelujah for that.
Lorraine, good to have you back.
- Well, it's good to be back. - Good.
Nerys, would you do the sitrep for Lorraine, please?
Yes, be glad to.
Hi, yeah, yes, this is staff nurse Costello in resus,
we've got a major trauma, Foxtrot Hotel here.
Lorraine, sweetie.
Uh, do I put you down as team leader?
Yeah, of course.
Do you mind if I nip out for a second?
- Is everything okay? - Yeah.
I'm not interested in you given time off.
- It's not my problem. Listen. - Giles.
Listen, I've had three fights in ED already.
- I need some backup. - Giles.
Yeah, we've got the police...
Can you tell me who the on-call consultant is tonight?
Yeah, I'll get back to you. I've had the police.
What's going on?
I just got called out 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. Uh...
Hi, I'm Lorraine Rappaport. Trauma consultant.
Glen Boyle, same.
Oh, why has that happened?
Look, as we're both here,
I suggest we get on with it together
and sort it out later, if that's okay with you?
Yeah. 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's just being friendly.
And what were you doing?
I was just being friendly as well.
Okay.
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.
No, it's terrific,
if you're a student.
But 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 skull.
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.
All right, okay. Thank you.
Brian,
could 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.
Okay, so we have piece of metal, possibly a bullet...
Or a bullet fragment.
About 12 millimetres 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 seizure aneurysm 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.
Can you fast beep 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.
Uh, 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.
Thank you.
Good blood, got products, got Bruce.
Oh, that's an improvement.
We'll prime the rapid infuser in theatre, thank you.
- Good decision. - Okay. Yes, thank you.
Trauma theatre's prepped and ready.
Trauma line's in place.
Let's get some blood running through her, then, please.
O-pos, dates have been checked.
Starting across on three. Everyone ready?
- One... - Like she is an IED, please.
Gently across, on three.
One, two, three.
Excuse me.
- Shit. Sorry. - Sorry.
Sorry.
It's okay, BP's stable.
Yeah, in the corridor. Yeah. They got out of ED.
Be back in a second.
I've got one nurse and one security guard...
They're all over the place.
Why can't you just send someone down?
- How about the basic security? - Giles, the on-call trauma consultant.
Uh, it's, it's Glen Boyle.
Okay, what if one of this nutters gets out of here and gets into theatre?
Of course, it could happen.
There's no on here. No one to stop 'em.
Harry.
Hello, darling.
You rang?
Tom.
Are you okay?
Glen Boyle's in there.
- What? - He's the locum consultant.
How long has he been working here?
They brought him in to cover for Lorraine's suspension.
Couple of months?
Look, I was wrong not to tell you,
but let's not argue about it now.
So, what's happened here?
Yeah, the police think she was shot in the back
then fell down some concrete steps.
All right.
Is it alive?
- Yes. - What's the gestation?
22 to 24 weeks.
Given as a question mark over viability,
- I suggest... - You 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.
Yeah.
Thank you.
Hi, it's Tom Farrow, O&G consultant.
Can I have a neonatology team on standby, please?
I'm at the trauma theatre.
Yeah, thanks. Bye.
Have you dealt with a foetus in a trauma situation before?
Can get intense.
Bastion.
M馘ecins Sans Fronti鑽es.
Hanoi province.
Tom Farrow.
- Glen Boyle. - Yeah.
I know.
Could we tilt the table to the left, please?
Yeah.
Say when.
- Yeah. - Yeah?
Angio packs.
23 minutes gone.
I intend to stent the tear on the left common iliac artery
by the right femoral artery.
You're going to lead.
I am the vascular.
Excuse me.
Can I have a word, please?
Uh...
Fiona.
Lorraine, you'll be under Glen's supervision tonight.
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. 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, anaesthetic registrar.
Billy Finlay, anaesthetic ODP.
Bruce Colby, rapid infuser operator.
Dalisay Guinto, scrub nurse.
Tom Farrow, ONG consultant.
Shelley Imms, radiographer.
Jason Marshall, staff nurse.
Joe Allen, documentation nurse.
Lorraine Rappaport, consultant vascular surgeon.
Our patient is major trauma
Foxtrot Hotel,
date of birth, 1-1-1900.
And I've signed consent from 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.
Scion, please.
Needle out.
Blade.
Screening.
Okay.
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.
Road map, please.
Terumo wire, please.
Cobra catheter, please.
- You're on the road map. - I can see.
- God damn it! - You're off the road map.
I'm going to have a second attempt
at getting the wire across the tear.
- Lorraine. - Oh, shit! I'm off!
- I've gone through the tear. - BP dropping 100 over 78.
- Sat's dropping. 87, 86... - Heart rate's rising.
Let's get the BP up, shall we?
Uh, contrast, please.
- Run of 5 at 10. - Okay.
- Breathing off. - Breathing off.
Screening.
Shit. 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.
- Come on. - 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.
- So, you don't have to do this. - That could have happened to anyone.
No, no, I agree. That's not what I meant.
It's Clive. He's gunning for you, and this could turn into a shit storm.
So, let's not give him the ammunition, yes?
Fiona, are you okay 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. - 90 over 76.
Tear extends higher than I thought.
I'm going to occlude it more proximally.
Okay, but that's not going to take care of the back-bleed.
I can't risk enlarging the tear.
BP's still dropping.
The left common iliac artery is occluded above the tear.
Stop screening, please.
- Uterus is becoming tense and woody. - Can you relax it?
250 micrograms of terbutaline, please.
- Yeah, um... Billy, have we got it? - It's in there.
250 mics going in now.
- Another 250, please. - Come on.
Another 250 going in.
- May I see the BP, please? - Yeah, 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?
Uh, depending on weight, between 30 and 40 percent max.
And the long-term prognosis, if it does survive?
There is about 60 percent 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 you could lose mother and the foetus.
- Okay. - Right.
- Excuse me. - Twelve units of O-neg, eight FFP,
- four platelets and two cryo, please. - Yeah.
I need my team here now.
We're doing an emergency C-section.
Billy, we need neonatal here right now.
Hello. Yes. Billy Finlay, ODP in trauma theatre.
We have a neonatal team on standby. We need them here right away.
Thanks.
On their way.
Okay, we have to wait.
So, what made you hang up your boots?
Who said I have?
Twelve units of O-neg, eight FFP, four platelets, two cryo.
Bosch.
- 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.
Faye Ovenden, consultant neonatologist.
Steven Ken Jung, midwife.
- Midwife? - Anna Simison, neonatal...
- Zorton Vacques, neonatal nurse. - Ready, Faye?
Ready.
Yeah, namaste, boys.
Right. Let's get cracking then, shall we?
Excuse me.
The uterus is 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. - Could you move the uterus?
Not much.
And it could trigger placental abruption.
She abrupts, she dies.
- Let's prep for a laparotomy, everyone. - Oh, God.
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 okay to cut? - Yeah.
Cutting.
Mayo, please.
RAMC finesse.
- You can join in anytime you want. - Happy to watch and learn.
Deaver retractor, please.
You ready?
- Yeah. - Over to you.
Tom.
Moving the uterus.
That's as far 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.
- In danger of stimulating uterus. - I have to get in.
- 73 over 61. - Unstable.
Bruce, increase the blood.
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.
- It's 30 seconds. - Few more seconds.
75 over 64.
Okay. Common iliac artery clamped distal to the metal fragment.
Good. Keep going.
You 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. - Okay.
Uterus is contracting.
Jesus! I think she's about to abrupt.
I need a little more space and a little more time.
You're out of both. Get out now!
Okay!
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.
Foetus is in distress. Thank you.
Let's get cracking.
- Ta. - Joins?
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.
The C-section could just as easily dislodge it.
You've had your chance.
- Step away. - I won't.
Cause 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.
Set the Lahey ready, please.
I'm going to need you to retract it. Think you can do that?
- Yeah. - Thank you. Tom.
Please.
That is as far as it will go.
Numbers are stable for now.
Okay, I got it.
Lahey.
Okay. I'm around the artery distal to the tear.
Vicryl ties, please.
Thank you.
Okay. Clip.
Let's do it again.
- Any more room you can give me? - I can't risk moving it.
Okay.
Come on.
Clip.
The vicryl ties are in position
distal and proximal to the tear.
Shunt, please.
Thank you.
Uterus is hardening a little.
- Let's remove the Dardik. - Yeah.
Okay. The shunt is in
and I'm passing it down the left common iliac distal to the tear.
Just need to ligate it.
- Scissors, please. - It's unstable.
Cut.
Shunt is ligated distal to the tear. Can we get a clamp on this, please?
Clip.
Now we're 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 a 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.
Okay. The shunt is in
and it's going up the left common iliac artery
proximal to the tear.
- Okay. 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, check.
- Clamp off. - Done.
Jesus Christ.
I could have just worked in my dad's chippy.
So could I.
Ultrasound, please.
Thank you.
Her placenta appears to be intact.
- I can't find a heartbeat. - Come on.
I feel a heartbeat.
I'll get the bullet.
Metal one, please.
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, you okay? - She's fine.
That was good work, everyone.
Nice one.
Pack up, guys.
You didn't follow my guidance.
No.
Police still here?
Duty hygiene assistant to staff canteen.
- You the GSW? - I am.
This ricocheted off of a hard surface
but it's a piece of copper jacket from a high-velocity round.
It's an SA80.
How'd 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.
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.
Now, 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 he put you in a difficult position.
Both of us.
Bastard wants us to fight for the same job!
- See you later. - Bye.
Shall we talk?
Maybe we should leave it alone.
Why didn't you tell me about Tom?
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.
Ripped By mstoll