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00:03After dark, while the nation sleeps, the A&E night shift begins.
00:10It can be very dangerous.
00:13We deal with a lot of aggressive patients.
00:16Things can escalate.
00:18It can be quite scary when it's just you and one violent patient.
00:24Across the UK, we join the staff of three of the most challenged emergency departments.
00:29It's always busy, it's always under pressure.
00:31Time is of the essence.
00:34And the medics who face danger each shift.
00:37Most shifts, I see more place than nurses.
00:40With the amount of drugs and alcohol admissions rising.
00:43Have you been drinking today?
00:44The risk of violence and abuse looms large every night.
00:48Please don't swear like that.
00:50They try to attack and stuff.
00:51Calm yourself down.
00:54People can become aggressive.
00:56You've been punched, kicked.
00:58You see the good, bad and the ugly.
01:00I don't do a ****.
01:02Yeah, we'll get security.
01:03The emergency department is like a battlefield.
01:05It's like organised chaos.
01:17I don't like your attitude and I don't like your attitude.
01:20Across the UK, after dark, A&Es can become a hostile environment.
01:24We have zero tolerance for any sort of physical abuse.
01:28No one comes to work to be abused, let alone hit, punched.
01:32Especially not within a hospital.
01:36Guys, have a seat please for me.
01:38Statistically, an attack on an A&E member of staff happens every two hours.
01:43We've seen people kick off simply because they feel like it will be a way for them to get seen
01:49quicker.
01:49Some people, because they're under the influence, there can be a large variety of reasons why people kick off within
01:55A&E.
01:56So you, and you, and you, and you, and ****.
02:09Listen, don't tell me to come back.
02:13In Newham, security, led by team leader Hasib, are on their way to a disturbance in A&E.
02:19She's the one in the role, not me. Don't lay on blame like butter, mate.
02:26A patient has become abusive to a nurse while being triaged.
02:29When he initially presented, he did disclose to the nurse that he had drunk quite a large amount of alcohol
02:35tonight.
02:36So we believe that's obviously one of the primary factors for his outburst.
02:40Listen to what I'm saying to you.
02:43She interviewed me, right, and she said early on in that little triage thing,
02:49are you intoxicated?
02:51The reason why she asks you, because if he cannot have sex to you, why you are drunk, mate?
02:56I'm not drunk.
02:58I understand, I understand.
03:00She said I was.
03:01We're taking you to another area where you're going to be seen, alright? Just follow up.
03:05De-escalation for me should always be the number one route for managing violence and aggression
03:10and bring it to a place where we can manage and control it
03:13without having to apply any sort of physical intervention or restraints.
03:18Oh, ****.
03:19That's it, though.
03:20Yeah, yeah, I appreciate that.
03:22You are like a ****.
03:23Hey, alright?
03:24Calm down, calm down, calm down.
03:25What do you want to do?
03:26I want to just shut the door, walk away.
03:29That way, walk away.
03:30Pull up.
03:32I'm going through.
03:33You're not listening to what I'm saying to you.
03:34I understand what you're saying.
03:35I am in a terrible state.
03:38So you're going to come round with me, right?
03:40You think I don't know what you geese is doing?
03:42Sweet F-A.
03:45With the patient refusing to calm down,
03:48the police have been called in to assist Haseeb and his team.
03:51We are on quite close proximity to the police station.
03:54They do arrive within quite a short time.
03:57And in terms of safety, we always believe it is better
04:00to have the police around to help manage these situations.
04:03Is everything OK?
04:05Obviously not.
04:07This ain't my ideal of a night at.
04:10That three-arse one said I was intoxicated.
04:13I said to her, I'm not intoxicated, right?
04:16This character's come out with a plain plump-putting BS that you are.
04:20I'm not in any trouble.
04:22If you had any bit to drink, is that why they...
04:25Listen, I told her I'm a alcoholic.
04:28That's what I ought to do with it.
04:29I'm going out with cigarettes.
04:31Oh, Chris, do you want to go that way?
04:33Yeah.
04:34Just go that way.
04:35Why do you think people gradually...
04:38I don't...
04:39I don't...
04:39That doesn't work.
04:41The police officers escort the patient outside
04:44in case he becomes aggressive again.
04:46So, the plan for now would be we just continue to monitor him,
04:49allow him some more time outside to settle down and calm down,
04:52and then we'll get him to be seen by the medical team to try and diagnose and help him with
04:57whatever the issue is.
05:05Oh!
05:06Oh, oh, oh, oh, oh, oh.
05:10Hello.
05:12My name's Nick.
05:13I'm one of the doctors.
05:13What's your name?
05:15Also in Newham, Dr Nick is conducting a primary survey on a patient who's been ambulanced in after collapsing on
05:22the street.
05:23Let's just keep you covered up.
05:25Have you been drinking today?
05:27No.
05:28Really?
05:28The ambulance said you had some alcohol with you when they found you.
05:32It smells a bit like you've been drinking, but if you haven't, we're going to have to do a lot
05:36of tests to work out what's wrong with you.
05:39But I think probably you've just had too much to drink, have you?
05:43No, no, no, no.
05:45Okay, I'm sorry. Fair enough.
05:47She denies having had a drink, which makes it trickier because, of course, our dilemma is often is the patient
05:53just drunk
05:54or is the patient ill or injured and happens to have had a drink.
06:00Have a look in your eyes. Is that all right?
06:01Okay. Just rest your head back for me.
06:06Unresponsiveness, erratic behaviour and struggling to communicate could all be signs of a brain injury from a fall.
06:13There's definitely a concern.
06:14You don't ascribe somebody's unconsciousness to alcohol without making sure that their brain is okay.
06:22The important thing is to make sure that we don't miss something more serious because we're assuming that somebody's had
06:29a drink.
06:31Can you help nurse to get her out? Get all her wet clothes or what? Yeah. Get her covered up
06:36with a gown. Try and keep her warm. Start just seeing what her blood show, what time does.
06:44We'll keep monitoring her heart rate, blood pressure, oxygen levels and we'll see whether she comes back to normal.
06:53If she doesn't get more alert, she'll just go ahead.
06:58The patient's intoxication could be hiding an underlying serious injury.
07:03If a patient's had a head injury, then they won't sober up as expected and we need to then think
07:10about a CT scan.
07:11If there is blood there, that might need some brain surgery.
07:28She may be having a type of heart attack.
07:32Sweetheart, we need all the leaves.
07:33No, she's going to leave me. It's disgusting.
07:36In Northern Ireland, A&E admittance has risen by nearly 30% since 2020.
07:43Night shifts are busy. They're very busy.
07:46Right, we can't have that in this department.
07:48You just walk in and there could be wee fires everywhere. We need to just go around putting them out.
07:54Up to 40% of A&E admissions in Northern Ireland are related to some form of intoxication.
08:01High numbers coming through, a lot of them obviously under the influence of drugs, alcohol.
08:06So it can be a really hectic shift with less support in a way.
08:11You can still feel very overwhelmed but we all get through it.
08:14Well, you're standing in the waiting room just stressing other people.
08:25Deputy sister Rebecca and senior nursing assistant Gemma are on duty in ambulance triage.
08:31We are expecting a cocaine overdose.
08:35We're going to bring him in here, eyeball him, check his obs, and then move him to a resource area.
08:43Injecting cocaine is quite big of an issue at the minute, so every shift there will be several.
08:48It wouldn't be a one-off. It's not an isolated thing.
08:53My name's Gemma. Would you mind if I got a wee tracing of your heart?
08:56I just need to do a couple of wee stickers across your chest.
08:59Is that okay? Is that all right? No.
09:03Too much cocaine, that's so much pressure and stress that's put on your heart.
09:07Whenever your heart's under pressure then all your other organs are under pressure as well.
09:12You're at risk of more and more damage.
09:15We need to do your blood pressure, okay?
09:18How does your wee blood pressure?
09:19Yeah.
09:20The patient is refusing to let the staff assess him.
09:24Are you able to let us lift your arm?
09:26Oh, yeah.
09:27We can't help you unless you let us do your blood pressure, okay?
09:30Listen to me. We need to try your blood pressure so to make sure you're safe.
09:34You're all right. You're okay. You're all right.
09:37No.
09:39No.
09:39He's refusing all intervention. He's refusing investigations and he's getting kind of combative whenever we're trying to.
09:45So to reduce his stress and reduce obvious risk to us, we're stepping back for the minute.
09:52Admissions related to drink and drugs from the night time economy only grows as the night wears on.
09:59I'm Rebecca, one of the nurses. I'm going to do your blood pressure, okay?
10:02You've had a seizure tonight. We need to do some blood. Is that okay?
10:06A 64-year-old man has been found unresponsive and rushed in by ambulance.
10:11He has a history of alcohol-related seizures. He's allegedly had two seizures tonight.
10:17Back-to-back lasts about 22 minutes.
10:19Yeah, he's pretty flat. Let's get the wee ops machine here.
10:22He would be in with us quite frequently.
10:24I haven't seen him in a wee while to be fair, but he scared me at the start there.
10:28I haven't seen him quite as flat, but he's coming right now.
10:30So I feel a wee bit more reassured.
10:32Your wee blood test was okay.
10:34So we're going to get you into one of the major seizures and get you seen by one of the
10:38doctors, okay?
10:39Is that all right?
10:42Let me go. Finish.
10:45Right.
10:46Go on.
10:46A third patient has been brought in.
10:48A homeless man found in the street who has also been having seizures.
10:52The ambulance area can be very, very busy.
10:55They either don't come at all or they all come at once.
10:58There's a massive, massive percentage of people who are IV drug users in Belfast.
11:03Okay.
11:04Someone was worried you had a seizure tonight and phoned an ambulance.
11:06I don't go.
11:07I thought no, no.
11:09Right.
11:09Yeah, we'll get security.
11:11We have a gentleman in. He's adamant he doesn't want to stay.
11:14Unfortunately, we have to keep him safe, so I've had to reach out to security
11:19because he'd become quite fairly abusive and was shouting at us.
11:22It's not nice to have to put up with that sort of stuff.
11:24I suppose we're used to it in here.
11:27Some of us are quite...
11:29Security.
11:30Oh.
11:33He's had a seizure.
11:34The patient in question suffers another seizure.
11:41What happened to you?
11:42Are you all right?
11:43Are you all right?
11:43You have a wee look around you.
11:45Where are you?
11:47He's coming around a wee bit there, so we'll get him on the trolley, yeah.
11:49We'll get him on...
11:50Is he in the trolley?
11:50No, it's just because that's all over there.
11:55We're here to care for people despite what they might give us back or what their history
12:00might be.
12:00We're all very immune to it and we treat everybody the same regardless.
12:05I wouldn't want to work anywhere else.
12:07Everything just changes so quickly, so, yeah.
12:16One, two, three.
12:19In Norwich.
12:20Norfolk, Norwich. Red Foam, medical trauma.
12:23Recess have received notice that an 84-year-old woman is being brought in by a paramedic team.
12:29Yeah, bye.
12:32This is Marjorie.
12:33She's an 84-year-old female.
12:35Approximately two weeks ago, she hit the head on the back of a bed frame.
12:40And then today, she was told the family that she hit the back of her head.
12:44Since then, she's become really confused.
12:45She's vomited twice, not with us, so really disorientated.
12:49We've carried out a neuro-assessment.
12:52One pupil is bigger than the other on the left-hand side.
12:55Coordination is literally off.
12:57She wasn't here this morning for a UTI.
13:01However, the tests have actually come back clear.
13:03There's kind of really good coordination and provisional vision
13:05and literally not knowing where she is.
13:08Even though she's lived in her house, like, 25 years,
13:10she didn't know where the bathroom was.
13:12She went that way and it was that way.
13:15I'm just going to shine a light in your eye.
13:18You might keep the small in the left.
13:21Different sized pupils can be an indicator of a serious issue with the brain.
13:26Yeah.
13:27Another blanket, sweetheart.
13:28I was going to say, you've got cold hands.
13:29Are you cold?
13:30You are cold, yeah?
13:32Marjorie's nieces, Sarah and Liz, have arrived at hospital after following the ambulance.
13:38She rang us last night and she said she's very confused, doesn't know if it's day or night.
13:42Normally, she's very independent.
13:44She knows what she's doing.
13:45So, to get a call like that, we know that there's something wrong.
13:50My name's Zach.
13:51I'm one of the doctors.
13:52And you hit your head a couple of weeks ago.
13:54Is that right?
13:55Yeah, well, more than that.
13:57Yeah?
13:57Can you see my whole face?
13:59Yeah.
13:59Yeah?
14:00And just keep looking at my face.
14:02Can you see my fingers?
14:05Yes.
14:06Yeah?
14:07Okay, fine.
14:07What about this side?
14:08Keep looking at my nose.
14:10Can you see my fingers wiggling?
14:12Yeah.
14:12Yeah, okay.
14:13We're going to need to do a scan on your head.
14:15Yeah.
14:16Okay?
14:16You let us know if you need anything, okay?
14:20The concern with Marjorie is, she's got complete left-sided neglect.
14:24That's what that means.
14:24She can't see the left side.
14:26And that can be due to increased swelling around the brain.
14:30So, the nerves that supply the site can be compressed.
14:34So, I would say this was time critical.
14:35And the quicker we can get her through the scan, the quicker we find out what's causing it.
14:40Yeah.
14:40In older people, their brains, for want of a better term, shrunk down a little bit.
14:45Yeah, my mum died last week.
14:47Yeah.
14:47Yeah, yeah.
14:48The blood vessels that attach the brain to the outer layer of the skull are therefore stretched a little bit.
14:54And if they do have a head injury, they can tear much easier.
14:58And if that brain has shrunk a little bit, that blood can sometimes collect over time and not cause too
15:03much issue, but actually then move its head a bit later.
15:06Yeah.
15:07So, this might be a fall that she's had a long time ago.
15:10I'm not told that she's very independent, so she wouldn't always tell us.
15:15If there's bleeding inside the brain or within the skull, that is increasing pressure.
15:21And that pressure is exerted on the brain.
15:24And the brain only has so much space to swell.
15:27And if we don't treat that quickly, that can have a lasting impact on disability and actually patient survival.
15:35See you when you get back, Margie.
15:56I'm just going to reassess his vision.
15:57The maximum that they would request would be like 24 hours of neuro orbs.
16:04You've got loads of glass in your hand.
16:06Oh, look, can you put it on the bed?
16:09In Newham Resus, doctors have been monitoring a patient for an hour to see if her unresponsive behaviour is a
16:15result of drinking or a head injury.
16:17So, she's just found a bottle of vodka in her bed that was smashed.
16:24Luckily, she didn't injure herself on it.
16:26But, yeah, it just shows you've got to be careful with patients who are intoxicated.
16:31Upon arrival, the patient insisted they'd not been drinking, but has managed to sneak a bottle of alcohol into their
16:36bed.
16:37But I guess we now have some evidence for why she came in the way she did.
16:44Do you remember me from before?
16:45And, Nick, I'm one of the consultants.
16:47Yeah.
16:48Yeah? How are you feeling now?
16:50I'm feeling good.
16:51We look after a lot of patients in the emergency department who have used alcohol.
16:57Some of those patients have a long-term relationship with alcohol that's unhealthy.
17:02We see them a lot and we see them not managing to cope with life because of their alcoholism.
17:09But also people who are regular users of alcohol can have other health problems that have been triggered by their
17:16alcohol excess.
17:18You seem much better.
17:20Yeah.
17:22Have you got any pain anywhere?
17:24No.
17:25Do you remember what happened? Why did you have to come to the hospital?
17:29I don't know. I was sitting outside for begging.
17:34Okay. And begging and drinking?
17:36No. Not drinking. Just begging.
17:40Okay.
17:40For food.
17:41Where do you live at the moment?
17:43I'm living in the moment in the forest.
17:46Okay.
17:47In the tent.
17:48In the tent?
17:50Yeah.
17:51How long have you been living in the tent?
17:53Three years ago.
17:55Three years?
17:56Yeah.
17:57Okay.
17:57Do you live there on your own?
18:00No.
18:02Newham has the highest rate of homelessness in England, with one in 18 people living rough.
18:08Patients who are homeless have a lot of extra risk associated with their healthcare.
18:14It's also almost impossible to arrange the routine sort of follow up that the system offers people when they don't
18:25have a fixed address.
18:27Homeless people are up to six times more likely to attend A&E than the rest of the population.
18:32I think it would be better to stay here until the morning.
18:36I can't.
18:38I'm sorry.
18:39I can't.
18:39Because I'm not ill.
18:42I think that because you had a drink earlier, it's good for you to have some fluid now.
18:47And then we'll let you go home.
18:49If you want to go home, that's okay.
18:52I'm a bit worried about her going home at this time of night to the forest where she's been living.
18:57But it's not for us to decide where and when she can and can't go once we know that she
19:03understands the decision she's making.
19:05And she does.
19:06So we'll try and find her some clean dry clothes and let her go.
19:22That's it.
19:23Open nose eyes.
19:26In Belfast, the resus team are preparing for a patient who is being raced in after being stabilised at another
19:32hospital.
19:33I'm going to get a scan of her chest.
19:35We may as well do her abdub pelvis and just complete the trauma scan.
19:38Dr. Orler is managing the department on the night shift.
19:40The patient has had a fall and had a traumatic pneumothorax, so a collapsed lung and some rib fractures.
19:49A status update comes in for the patient who was injured in a fall at home.
19:54There has been a change in her condition.
19:56So her oxygen levels went from only needing one or two litres to suddenly needing 15 litres.
20:01That makes us suspicious that this collapsed lung has tensioned or increased in size.
20:06So we're now in a more emergent scenario.
20:16Ready, steady.
20:18Good.
20:22Alright, and set her right up.
20:23Okay, right up.
20:24Michelle?
20:25Yeah?
20:25My name's Orl.
20:26I'm one of the doctors on today.
20:28We've been expecting you so I know a wee bit about you, okay?
20:30Okay.
20:30We know we've got a clapped lung on this left side, okay?
20:33I think we quite urgently need to put a drain into this chest to help with that pneumothorax, okay?
20:38It's going to be a little bit uncomfortable, so we're going to give you some medication
20:41to help with that discomfort, all right?
20:43Are you allergic to anything?
20:44No.
20:45Are you happy if we go ahead?
20:46The risk is if I take too long, this gets worse and makes you feel more unwell, okay?
20:51Hold her arm up above her head, come on, okay?
20:53I'm going to take this arm for you.
20:55Sorry, Pat, I know this is a bit uncomfortable, okay?
21:00So my name's Mark.
21:03One of the plastic surgery doctors, are you okay?
21:05All right, I'm fine.
21:05So I need to make a little cut from the chest to keep you safe, okay?
21:10There are some risks to this, but the most important thing is we'll do what we can to keep you
21:15safe, okay?
21:17I know it's not comfortable, we're going to give you a bit of medication here.
21:20Just take the edge off, all right?
21:22You're doing very well.
21:23With a tension pneumothorax, people can very quickly die without intervention.
21:28All right.
21:29Getting a chest wound in is a pretty uncomfortable procedure.
21:32Oftentimes the patient's quite distressed, they're scared, they can't breathe,
21:35probably, so we will often give them some sedation medication.
21:39Yeah, sorry, a bit of a lift of your arm, Michelle.
21:41Right over the tail, I know, I'm sorry.
21:44I'm going to be relaxing there, okay?
21:46We should start with you in the next couple of minutes.
21:49You just breathe away, it's normal.
21:52Michelle is given pain medication, including local anaesthetic where the tube will be fitted.
22:05We use a mixture of lidocaine, which is a local anaesthetic and adrenaline,
22:09which helps sort of constrict some of the local blood vessels,
22:12which will reduce the risk of bleeding when we make the cut.
22:21If chest strain goes wrong and you've hit a major organ or hit a major blood vessel,
22:25they will bleed significantly.
22:29They could die from this, so it's not without its risk.
22:35Yeah, you're doing very well.
22:38He's the uncomfortable bed, okay?
22:40If we don't get the chest strain in quickly,
22:42the person will become more unwell and more unstable.
22:45It's time-critical.
22:46The kid go into cardiac arrest.
23:01Medical trauma, can I just confirm GCS?
23:04At night in A&E, the proportion of patients under the influence of alcohol or drugs increases.
23:12Here we do see quite a lot of alcohol and drug-related incidents in the younger population,
23:17but we do also see a lot of alcohol, liver cirrhosis, liver disease,
23:22in those that have drank alcohol for a long time.
23:24At peak times after dark, as much as 70% of A&E attendances can involve alcohol.
23:31There's a lot of young people would use drugs and night out,
23:34and then obviously alcohol, that side of things,
23:37disorderly behaviour, so the police are always in with them kind of cases.
23:43We get patients caught in by the police that have been found intoxicated,
23:48maybe alcohol misuse or drug misuse that will come into the department.
23:52It can lead to increased violence and aggression.
23:55It can lead to them hallucinating and acting out in particular ways.
23:59We've burned that in your mouth.
24:12Amongst dealing with dangerous and difficult people,
24:15the staff still care for gravely ill patients.
24:18So we hold on to the fluids and repeat the observation.
24:26In Norwich, 84-year-old Marjorie is having a CT scan
24:30after becoming confused and disorientated following a head injury.
24:35OK, we're just going to step out now and start that scale.
24:38It takes about five minutes, OK?
24:40E-scan is a vital investigation that we do to see if there's any signs of either
24:47an area where there's not enough oxygen getting into the brain
24:50or an area where there's bleeding.
25:00Yep, that wasn't too bad, was it?
25:03Was it OK?
25:06Marjorie's nieces have been waiting for her in resus.
25:10Yeah.
25:10Have we realised on what's going to happen?
25:12No.
25:13Well, you're in the best place now.
25:16Yeah?
25:17They'll be able to help you, won't they?
25:21Dr. Zak is waiting for the scan results to find out what has happened to Marjorie
25:26and if it's permanent.
25:27She's losing.
25:28Yeah.
25:29Um, I've had a quick look at the scan and the report's back,
25:32so I've looked through the images.
25:34There was no obvious amount of bleeding.
25:38So the next question is, is this a stroke?
25:43Looking at the scan, it does look like there's a patch
25:45that looks like there has been a stroke.
25:50The stroke team is going to admit her.
25:52She may need further tests and things like that,
25:54um, but they're the best people to do that.
25:58Looking at the CT scan, it has shown a patch that suggests
26:02that an ischemic stroke that has happened in the last 24, 48 hours.
26:07An ischemic stroke is caused by a blood clot blocking one of the arteries in the brain
26:12and depriving the area of oxygen.
26:16Is she going to recover from this then?
26:18So we'll have to see how things go.
26:21You don't know, stroke rehab is one of those things that's really different for different people.
26:25So, and that's why we have stroke wards, because they're amazing.
26:29And they've got brilliant teams that work really intensively with people.
26:33So, and that's why we've got a lot of pain in the brain.
26:35Ischemic stroke treatment is time-critical.
26:38Night-time incidents can often go undetected,
26:40missing the treatment window and leaving the patient with serious complications.
26:44Patients who present later or have more significant strokes
26:48can be left with a significant disability.
26:51And that can range from weakness on one side of the body,
26:55speech problems, swallowing issues, seizures.
26:59And you can imagine all of those symptoms have a massive impact on
27:02not only their quality of life, but also their relatives' lives.
27:08It's a bit of a shock, to be honest.
27:10You couldn't tell it was a stroke.
27:12And I think, you know, I think even the doctors this morning didn't know it was a stroke.
27:18Giving difficult news to relatives and to patients can be a challenging part of the job.
27:25But it's part of the job that I think if we do it right,
27:28it can make the most difference.
27:32Marjorie will be moved to the stroke ward for further assessment and treatment.
27:36We knew it just wasn't her, it wasn't right.
27:38I think she's calm now.
27:40Yeah.
27:40Not calm, but a bit more chilled.
28:02I'm going to put your head back, okay?
28:05And then we're going to move you.
28:06Ready, steady, slide.
28:08Lovely.
28:08Great.
28:09And pop it back down.
28:12In Belfast, Royal Victoria, 21-year-old Sam is being rushed in with his mum
28:17after seriously injuring his ankle during an evening rugby match.
28:22I took a picture of you on the edge.
28:24So, this is your knee and your leg and then that's the foot off at the wrong angle.
28:30So, your leg's that way and your foot should be facing that way and it's going the other way.
28:38Dr. Phil is reviewing x-rays Sam had when he first arrived.
28:43What's happened to your ankle tonight?
28:45I don't really know what happened.
28:46He just slugged around and hit me and then the ankle was...
28:50The ankle was not where it should look.
28:54So, yeah, obviously, you know your ankle's fractured and got a dislocation there, okay?
29:01This outside sticky outfit is here.
29:03Yeah, is that okay or is that...?
29:05So, you want...
29:06This gap here is far too big so you want these two to...
29:09All right.
29:09So, basically, all the ligaments and things that are holding your ankle together have all been torn
29:13whilst it's sort of fractured here.
29:15They allow this to be so floppy.
29:18We're going to squish these together so that this gap on either side is a lot more narrow
29:23and bring your foot up like this and put it into a cast in that position and get another x
29:28-ray
29:29and hopefully this gap on either side is a lot more narrow.
29:35If the ankle isn't reduced, the patient will be left in pain,
29:39with his arteries and nerves under tension, which could lead to permanent damage.
29:44In terms of what happens on a rugby pitch, it's probably up there seven, eight,
29:49those sort of bad things that can happen. If you get a nasty fracture dislocation of a joint,
29:52it's one of the worst things you could see.
29:56Dr. Mike is going to be manipulating the ankle into the correct position,
30:00while Dr. Phil sedates and monitors Sam.
30:03Just wiggle the toes for me, Sam.
30:07That's great.
30:08So, basically, we'll be getting you nice and comfortable, a little bit sleepy,
30:12and then we'll be getting this back into place.
30:15This is some sleepy medicine now, okay?
30:17Yeah.
30:18Sam will be sedated with fentanyl and propofol, extremely powerful drugs that can affect respiration.
30:26With ankle joints, they're often very unstable joints, but we will have to put it in a cast
30:33within a very particular position to try and make sure it's as stable as possible. But if you have an
30:38unstable ankle fracture, often if it is significant ligamentous injury associated, then it will need some
30:44sort of surgical intervention.
30:47All right, Sam.
30:57Bit of a lift of your arm, Michelle.
30:59Right over the tail.
31:00I know, I'm sorry.
31:02Also in Belfast, the Resus team are performing an emergency chest drain on 59-year-old Michelle.
31:09Oh, please.
31:10All right, Pat. You're doing really, really well.
31:15Michelle punctured her lung during a nasty fall at home, which has led to a tension pneumothorax,
31:21trapped air between the lung and the chest wall.
31:24Oh, please.
31:25Oh, please.
31:25You're doing really well.
31:27When we're putting in a chest tube, if you're doing it on the left side, you're making cut
31:30near where the heart is. There's nerves, there's arteries. It can cause bleeding. It can be a risk
31:35of infection. We want to make sure that we're putting it in the right place, that we're not
31:39going to cause injury to other structures around.
31:44You're doing really well, Michelle. Keep that arm up for us.
31:47We're nearly there, okay? Just don't want to lose a tract at the minute.
31:50Yeah. Thoracic specialist Dr. Mark has his fingers between Michelle's ribs.
31:57If she moves, they could lose the path for the tube to be inserted.
32:01Come on up. We'll get a wee bit walking, really quickly. Just take three minutes to kick in.
32:07You're doing really well, Michelle. Nice big deep breaths for us.
32:11Dr. Mark has to ease the tube into the gap his fingers were keeping open without losing his place.
32:16Sorry, Michelle.
32:20If you want to drain air, you want to get it right in the top of the lung as best
32:24you can.
32:25The most important thing is that it's sitting within the pleural space. If it sits within the skin,
32:29that can expand and cause air collecting under the skin, which is not helping drain the pneumothorax.
32:35It can potentially make people more unwell.
32:38Yeah, nearly over. Just putting the tube in, okay?
32:42That's the air coming out now. Okay, well done.
32:46The chest tube is now positioned between the inside of Michelle's chest and the outside room,
32:52allowing the air to be released, the pressure to drop, and her lung to inflate.
32:57There's a good bit of air come out already, which is good. Your lung's starting to inflate again,
33:01so that should make the breathing a bit easier. The wee tube has to stay in the chest while okay.
33:09Just a wee, wee neck there. Normally, if we have more time, we'd like to get people a bit more
33:16time to prep for this, but yours is a bit more emergent, Michelle.
33:22Can you just give us some deep breaths?
33:28Sorry, Michelle. You're doing really well.
33:30Last wee bit, okay? Just one wee stitch to secure the tube, all right? You've done very, very well.
33:43So, Michelle, when you put your arm down, there's a drain that's coming out of your side of your chest,
33:48okay?
33:48It's really important that you don't tug on it or catch it, all right? It's attached to your little box,
33:52and that box stays below you at all times. Could be swinging it about, okay?
33:56Okay. The drainage bottle is an air trap. It allows gas to leave the cavity, but not flow back in,
34:03creating a vacuum. There we go. Just be careful of that, just in case you accidentally catch it.
34:08I'm leaving. Can you just sit forward from it?
34:16With any chest tube, there's a chance it could be misplaced, causing damage to her internal organs,
34:22so she's x-rayed. So, Michelle's had her check x-ray after her drain's gone in.
34:28Her drain's in the right position, and her lungs are inflated, and she looks clinically much better,
34:32so we're very happy. Do you feel comfortable?
34:34No.
34:35Well, your oxygen saturations are improving, and the chest actually is reassuring, so the N.A. team
34:40are going to do some more walk-up, get you a scan of your... a CT scan, you know, like
34:45a big donut,
34:45to make sure you know how much injury is okay. With Michelle's immediate injuries treated,
34:52focus turns to how the fall might have affected the rest of her body.
34:56We apologise that it's so flat. Okay, Pep. When a patient comes in with one very obvious injury,
35:02it's easy just to focus on that injury and miss other potential injuries that might make them more
35:08unwell, but slowly, and might not be as immediately obvious.
35:13You're going to be sick.
35:16Vomiting could be related to pain medication, but it could also be a sign of a head injury from the
35:22fall.
35:23I've asked Orla to prescribe some empty sickness for me, and then we'll lifelong get up a CT scanner,
35:28but I just want to make sure that she doesn't be sick, because if she's sick when she's laying flat,
35:31then she'll aspirate. Aspirating is when vomit enters the lungs and can create deadly pneumonia.
35:38Hopefully that helps. I'm just checking these new wires.
35:44We're going to head up now for your scan, okay, Levi?
35:47Yeah. All right.
35:50Just putting your drain under your hand, okay? I'll take our grab bag.
35:55Michelle is still in a vulnerable condition and could have serious injuries, including a bleed on
35:59the brain, so medics take her to the CT scanner with an emergency bag.
36:03When we have a patient in the CT scanner, if the chest drain was to come out and we don't
36:07have the
36:08right equipment or staff to reinsert it, they could redevelop that tension pneumothorax, potentially could
36:13die from that. Okay, see that wee box? It can't head off anything and it can't fall on the floor
36:18and it
36:18can't get pulled, okay? Only a CT scan will reveal if Michelle is still in a life-threatening condition.
36:24I'm just watching wee and drain box there.
36:45Thank you, bye.
36:47All right. Can we get IC recall then?
36:50I think a little bit of counter traction, but I'm not sure it might do.
36:53Yeah, we'll see. There we go.
36:55In resus, the team are about to attempt to realign 21-year-old rugby player Sam's fractured and dislocated ankle.
37:02Yeah, go ahead there. I think we're still awake. We could get more if it needs to be.
37:08Dr. Mike is going to be manipulating the ankle while Dr. Phil manages the sedation.
37:20I think it's all a day moving there.
37:26It's fighting me a little bit.
37:28It's hard to keep that tension.
37:30With Dr. Mike holding the ankle in a correct and safe position,
37:33the team need to work quickly to secure it in place with a backslab plaster.
37:39Try and get that fibula wiped.
37:41Keep it out of tension here.
37:43Sam, you're doing really well. Just keep taking nice big deep breaths.
37:48I'm like, what is fucking metal?
37:51Yeah, it should be good.
37:54We're going anywhere near three.
37:59Sam's just chatting away to us.
38:02Yep, that's you all done.
38:04That was a good one.
38:04Was I out there?
38:06You were talking away to us a wee bit, but...
38:08You didn't remember anything?
38:11I was out there.
38:12One sec, we'll just put it down on a pillow here.
38:14Yeah, I know that.
38:15The sedation has meant that Sam has forgotten the manipulation
38:18and any pain he was feeling during it.
38:20Is that her back in normal?
38:22Yeah.
38:22We'll get an x-ray. I think it's the best we'll get for the moment.
38:24Do you have any chance of recovery time now?
38:28Actually, we'll chat about it after.
38:31So we'll give you a few minutes,
38:32then we'll get you back around for another x-ray
38:33and see what it looks like, okay?
38:35Yeah.
38:35Cool, Matt.
38:38We pulled it a bit straighter
38:39and tried to compress the joint back to normal.
38:42He has quite a lot of fluid in his joint,
38:44so that doesn't allow you to compress it back to looking anatomically normal,
38:48but it's probably as best we'll get for this evening.
38:53Even if the x-ray shows the ankle is in a safe position protecting the nerves and tendons,
38:58Sam may still require surgery to fix the ankle permanently.
39:01I tell you, I'm just glad it's that endy and not the other end.
39:06At least that'll heal, son.
39:14Sam, I'm going to get these images up and then I will show you the before and after.
39:17Is that all right?
39:18Yep.
39:21So that's the front one.
39:22It looks, we're pretty happy with that.
39:23That's as good as we're going to get that.
39:24Does that mean you don't need surgery?
39:26Not necessarily.
39:28So these type of fractures quite often are unstable and will need an operation anyway,
39:34but it'll be up to the orthopaedic or the fractures doctors to make that call.
39:37We'll get the other one up.
39:40So you can hopefully appreciate that.
39:43See the fracture there?
39:44Here, yeah.
39:45So this, it's hard to see because that's behind.
39:48That's your fibula and this is your tibia, but you can see the angle of it,
39:52you know, and there's the break in a few wee places.
39:54We'll see what the orthopaedic doctors or the fracture doctors want to do next,
39:57but the next step really is that they'll come and have a chat with you.
40:02They'll hopefully have seen this already,
40:03and then they'll come down and make an assessment and probably
40:06give you a bit of an idea of the timeline from here.
40:08That'll do, thank you very much.
40:09Fair enough.
40:10Yep, thank you very much.
40:11Cheers.
40:11No problem.
40:25You keep nice and still for us, okay?
40:28Also in Belfast, Dr Ola is accompanying 59-year-old Michelle for a CT scan after she suffered a serious
40:34fall.
40:36So we're going to have to lay it a bit flatter, all right?
40:39Not for too long, just until I get through the scan, and then we'll pop you back up again, all
40:43right?
40:45All right, it's done it.
40:47Michelle has had a chest tube fitted to inflate her collapsed lung,
40:50but may still have other serious injuries from her fall.
40:53The first couple of scans we do is if you just put your arms down.
40:58You need to keep your head nice and still, it won't be long here.
41:03So we're expecting her to have some rib fractures for definite,
41:06and she will still have some collapse of her lung, but hopefully it's re-expanded.
41:09We're scanning her head because she's got a laceration on the back of her head.
41:15And the next scan, so we just need to do the body now.
41:19I think it was just that.
41:19Just that and the injection of dye now.
41:21Contrast dye helps with the scan to show up some structures a little bit better.
41:27The iodine-based contrast injection will help to identify the source of any bleeding
41:32and damage to internal organs.
41:36Start your breathing again.
41:38OK, so the scan's done, so we can transfer it back.
41:44One, two, three.
41:46All right.
41:50So we'll get her down now, and then we'll get the radiologist to report the scan.
41:54We'll get her back to the resource area, get her a bit more comfortable.
42:01I'll maybe try and get you on a hospital bed shortly, if that's all the moving and moving things.
42:06The radiologist has assessed Michelle's scans.
42:09Hi, Mark.
42:10Michelle's is back from her CT.
42:12The heart report actually is exclusively pneumothorax.
42:15From an injury point of view, it seems to be just exclusively the left side of pneumothorax.
42:20They can't see any other big injuries, which is great.
42:22She's going to be admitted to the thoracic ward.
42:24She will probably need some pain relief and physio, and then the chest ring will come out, hopefully, in a
42:29couple of days.
42:43Can you give me your hand?
42:45Let's just stand up.
42:46We'll get you on the chair, and then I'll bring you your stuff, all right?
42:49Because it's a bit dangerous, you being that.
43:03That's your knee, and that's the ankle going.
43:05All right, you're supposed to be going that way.
43:20Thank goodness that Daphne didn't die, no.
43:22I'm still here to torture people.
43:35She's an independent 84-year-old lady who lives at home on her own, who manages very well on her
43:41own.
43:41So, again, that's how we knew that there was an issue, that something was wrong.
44:28They won't go back toительstadt, or they won't go back all night in total time.
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