Critical

'Trauma call, attend emergency department.

'Trauma call, attend emergency...' Whoa! Sorry, Billy. Bad luck!

Morning. Full English, please.

'Trauma call, attend emergency...'

That's us, Justin. Awesome!

'Trauma call, attend emergency department.

'Trauma call, attend emergency department.'

You're all right. We're going to take care of you.

Stay calm.

Sorry, early.

Sorry... Oh, sorry.

Hi. Morning. Morning.

'Major trauma, ETA one minute. Major trauma, ETA one minute.'

Thanks, Justin.

Thanks. Er, Harry.

Fiona.

6, 6.5?

Bit harsh. Tube.

6.5.

Hi, everyone. Morning.

Here we go.

'Level six.

'Level five.

'Level four.'

Oh, shit!

Shit! Let's go, let's go! Here we go. Let's go!

Get the door! Coming through!

We're taking you straight through to our resus room.

This way.

Starting the clock. Ejected passenger,

found unconscious, pulse 130 weak,

BP 90/70. Diminished breath sounds on the left.

Let's move the scoop on your count. OK, unclip top and bottom, please.

Clear a space around him. Oh, sorry.

Everyone ready? Yeah. One, two, three.

Thank you. One, two, three.

Great, well done. Mate, has he got thoracostomies? No.

Massive haematemesis, scarlet yawn... Suction...

One conversation at a time, please.

Sorry. Sorry.

OK, great. All right, mate, all right, we're sorting you out.

Mate, you're in the emergency department at CGH.

I'm Dr Chandramohan, an anaesthetist.

I need to look down your throat. I'm just going to take this strap off.

Leg support, please.

Blocks coming off. Thanks.

Sir, I'm just going to hold your head to keep it still.

Sorry I'm late.

Nice of orthopaedics to show up. Airway clear. Resps 30.

Sir, my name is Fiona Lomas, I'm the trauma registrar.

We're going to do our best to get you better.

Tachypneic, decent pulses. OK, thank you.

OK, nice and quiet everyone while we listen to the handover, thanks.

Trauma Air Service arrived on the scene at 6:45am after an RTC

called in at 6:30am.

Multiple vehicles involved in a collision on the Kingsgate underpass.

Patient was found on the roadside after having been

an ejected passenger from a bus.

Multiple soft tissue injuries, lacs, grazes, haematomas, top to toe.

There is a lac on the interior chest wall, left wrist is fractured,

left tib is an open fracture.

Diminished breath sounds on the left.

100% oxygen given via mask at the scene.

Haematemesis in the service lift and corridor. Thank you very much.

Can you sign off some paperwork with Nerys? Come and sign your lives away.

I could act as... scribe if you'd like.

Acch...

Need to tube him. Fiona.

Dullness to percussion on left side. He needs a thoracostomy. Yeah.

Sir, we're going to do something to help your breathing.

Justin, thoracostomies. Oh, right! Trachea deviated to right.

Loads more on the way. First of many, apparently. Oh, great! Oh, great!

OK, let's get him intubated.

Oh, what now? VT. Carotid output.

Femoral output, defibbing.

Off the chest, please, Justin, VT with output. All right.

Shockable rhythm, no CPR. Sync shock 150 joules.

'150 joules selected. Charging.'

OK, everyone, clear. Oxygen away. Away. Shocking on three.

One, two, three.

Still in VT.

Output.

Damn it!

Charging. 'Charging.' Shocking on three. One, two, three.

Shit!

Come on! Output. Charging.

'Charging.' Shocking on three. One, two, three.

Sinus rhythm. Good output. OK. We have ROSC.

Well done. Thank you.

Well done.

OK, I'll do the thoracostomies to help with his breathing.

Give him, um, Ramakrishna? 30 of ket? Ketamine.

OK, and I'll pause for a top-up if he protests too much.

There's an open tib that needs IV Augmentin? Thank you, in a minute.

Phones off, please.

Mate, just going to give you something to take the edge off.

Can you bring me the trolley please?

Try looking in the pockets of her coat.

Well, he's not protesting, I think we're all right. Yep.

Pulse 130, BP 80/65.

I think he'd benefit from some more blood. OK.

Thank you. Constance, could you, please? Yep.

Let's keep a close eye on the BP, please.

Thank you. No response to trap pinch. One. GCS?

Four. Four with sedation. Sorry.

Bilateral thoracostomy patent. Time for drains? Sats 88.

Prefer to get him under first. OK. That's the lads off.

OK, thanks, guys, have a good one. See you next time, lads.

I thought he was sedated?

He was. He was.

Suction. OK.

Need to RSI, Billy. Yeah, I'm on it, I'm on it.

OK, do it fast, please.

BP's dropping.

Severely hypotensive, no radial pulse. We need to get a tube in.

Yeah. I can't get a tube in with the BP down this low.

OK, blood straight away, just squeeze it in. Justin! Quickly.

We need to get this blood pressure up.

Sir, we're going to clear your throat.

Please try to be calm so we can help you.

The sats are going down, we really need to get the tube in. ..sake, I'm trying.

Clock's ticking, fast as you can, please.

I've got a radial pulse.

OK, you've got enough pressure,

you need to get the tube in, please. OK, here we go.

Are you the new SHO? Er, yeah, everyone calls me Harry.

OK, can you give me inline C-spine immobilisation

while we take the blocks off, please?

No, get your hands in there!

OK. Hold tight.

That's it.

Ohhh... Jesus.

You got him? Yeah.

Ta.

Hold tight. Yeah.

Thiopentone, 250mg. OK.

Thio, 250. Going in.

Going in. Just sending you off to sleep, mate.

Finally, some peace and quiet.

Sux 100, going in.

We use sux in trauma cos it works fast.

That's not the only thing around here.

Takes a while to paralyse the patient.

Here we go.

OK, yeah. Suction.

Make sure you do ABGs and an ECG. Yes, Dr Archerfield.

All those staff to one patient.

No, that's a trauma call, critical injuries.

It's madness.

This guy feels cold. Did we get a temperature?

Not that anyone's given me. How long till they scooped him?

They were there in 15 minutes, scooped after 25.

Carotid core, 36.1.

Yeah, he's cold for someone they scooped inside 30 minutes.

15 and 25 is 40. 40 minutes then.

How much blood is left in the fridge? We're down to three bags.

Intrathoracic haemorrhage, get me a swab, please.

OK, here we go. I'm calling a code. We need more blood. Another Venflon?

Yes, and a trauma line. I can do Venflon.

Sister Merrick, resus, we're coding. Tranexamic acid, please. Coming up.

Let's stop this haemorrhage. Major transfusion protocol.

No, no, don't put me through to blood bank.

Oh, I know you don't need me to say this, everyone,

but nice and fast, please.

Crosscheck.

O pos, dated and checked. Crosschecked.

No, I know, I'm still holding.

Two units of O pos remaining. TXA, 1g IV, 1g infusion to follow.

Yes, this is Mrs Rappaport,

I'm the consultant on call for major trauma

and we have just enacted the major transfusion protocol.

You send us 12 units of O positive immediately.

Eight of FFP and four of platelets.

'Do you have authorisation?' What?

I make that the third unit of blood now. One unit of O pos.

OK, then, please put me through.

No, thank you!

Let's put the next unit of O pos through the trauma line

and pressure on the thoracostomy bleed.

Harry, pressure, please.

OK, let's take bloods as I do the trauma line.

Oh, hi, yes, this is Lorraine Rappaport, consultant on call...

Let's have another bag of O pos from the store, please.

We have a major trauma patient in recess and blood bank won't enact

the major transfusion protocol without your say-so.

No, we haven't measured the patient's Hb,

and if we did, it would be normal because the concentration

of haemoglobin in his blood won't have changed.

But what has changed is he has a lot less blood circulating

than he did half an hour ago. And if we don't transfuse him, he will die.

Excuse me... Thank you.

Sorry...

Sorry! Yes.

This thoracostomy's really bleeding. He's bleeding out.

We need more blood, we're losing him.

What the hell's going on in this guy's chest?

We need someone to do a chest drain, please. Me.

We have a volunteer. Justin, get on that bleed now.

Swap gloves, eye guards, gown. I want you ready to go in two minutes.

Billy, where are those blood gases?