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A and E After Dark - Season 7 - Episode 05
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00:03after dark while the nation sleeps 16 year old male who was shot the A&D night shift begins
00:10it can be very dangerous he has a knife with him we deal with a lot of aggressive patients
00:16things can escalate this gentleman has been punched it can be quite scary when it's just
00:21you and one violent patient across the UK we join the staff of three of the most challenged
00:27emergency departments it's always busy it's always under pressure time is of the essence
00:33and the medics who face danger each shift most shifts I see more place than nurses with the
00:40amount of drugs and alcohol admissions rising have you been drinking today the risk of violence and
00:45abuse looms large every night please don't swear like that they try to attack and stuff
00:51calm yourself down people can become aggressive you've been punched cake you see the good bad
01:00and the ugly yeah we'll get security the emergency department is like a battlefield it's like
01:05organized chaos
01:18after dark violence against NHS staff is at a record high and doctors and nurses face it every time
01:29they're on shift sometimes we have to call the police they can attack the security they can they attack
01:42nurses I don't think the public is aware they don't understand what we're going through
01:49violence and aggression doesn't just stop at our doors it continues on the streets that can be quite
01:55scary for us and for everybody you're right there a better day than me put into a fight
02:1836 year old miss arc is in resource
02:24after being assaulted outside his home he's just minutes away from losing his vision
02:36emergency doctor fraser will be treating him
02:41we see a lot of patients come in who are victims of assaults being punched in the face can be
02:45fatal
02:45with this patient he had bleeding behind his eye the pressure that that bleeding causes can squash
02:54the nerve and so you can go blind in the space of an hour it's a real time critical emergency
03:01this is just oxygen you have to do a procedure called a lateral canthotomy
03:06where you cut the ligaments that keep the eyeball in place and essentially relieve the swelling
03:14that's squashing the nerve that goes into the back of the eye
03:18with the pressure building behind his eye they have just minutes to act
03:24element's going in right we're going to make you feel funny just have nice dreams
03:30dr ed administers a fast acting sedative hey buddy you there so the night team can fight to save his
03:44vision
03:44that looks like ligament there yeah that's the superior ligament let's cut it's supposed to cut the
03:50inferior first cut this superior because it's advisable to cut both in this circumstance so it'll
03:56give us some really to me but
03:57on the left
04:05right
04:06oh that
04:08should we tighten the inferior
04:11oh
04:13i'm gonna give a little soft application
04:25the swelling is making the next cut much more difficult
04:30oh
04:35patient had bleeding under the surface of their eye so it was it was particularly swollen it made it quite
04:42difficult to see exactly what we were supposed to be cutting
04:52consultant dr susie is also on shift
04:56when someone has increasing pressure on the back of the eye you will start to get compression of the nerve
05:02fibers that provide
05:03the sensation of a vision so if you don't release that pressure that person will lose their sight and they
05:11will become blind and it will be permanent
05:25this lady's new she can probably step down but not to the corridor also working the weekend in newham's recess
05:31is dr ella
05:34gcs
05:37who can step down
05:38a patient drifting in and out of consciousness is being brought in by ambulance
05:47you're at hospital now okay
05:49give us two minutes and then we'll come in alright
05:51yeah
05:52yeah
05:52yeah
05:55yeah
05:57yeah
05:58yeah
05:58yeah
05:58yeah
05:59yeah
06:01yeah
06:03hiya my love
06:04my name's ella i'm one of the doctors
06:06i'm just gonna hear what's going on and then we're gonna make you feel better okay
06:10okay
06:11was witnessed by bystanders to collapse on the side of the pavement tonight outside of her address
06:17planning of abdominal pain has defecated herself and had five vomits with us okay i'm still complaining of abdominal pain
06:24she's been in and out of her altered conscious state with gcs 14 as her best with us
06:29what do we think it is
06:30oh she has said that for the last three days she's been having crack and heroin
06:36i do see drug overdoses all the time and it's an enormous part of our workload
06:40pupils
06:41pupils are size two even reactive but they may be size one now
06:45the main questions to ask are what have they overdosed on
06:48do we need to reverse that drug
06:50do they need any life support for that overdose
06:54can you open your eyes for me
06:57have you got any pain anywhere
06:58there in your stomach
07:02sorry honey
07:02it's gonna feel this for me here okay
07:05vomiting in a painful hard stomach
07:06can indicate life-threatening internal bleeding
07:10oh
07:12i wanna have a little listen to your breathing
07:16so gretchen let's do some fluids clean her up a little bit i don't think we need to do any
07:20scans or anything now
07:23currently we're gonna give her some fluids some anti-sickness so she can tell us a bit more about why
07:27she's vomiting how she feels
07:29her tummy's nice and soft so i'm not in a rush to do any scans right now she's quite young
07:33drop scratch
07:35sorry
07:36oh
07:38my main concern for her is is she withdrawing from cracking heroin and it's making her feel really miserable
07:43it's gonna be quite hard to manage that so we might need to give her some other things to make
07:47her feel a little bit better
07:48can we clean her up a bit
07:50thanks guys i know it's not the nicest
07:52well be quick don't worry
07:54be quick don't worry
08:11yes it does add burden to the nhs but that is what we're here for we're here for accidents and
08:15emergencies and drug overdoses are emergencies
08:31shut the f*** out
08:33security
08:34oh
08:35no no
08:37shut up
08:38alcohol related emergencies are on the rise
08:43you're a lot drunker when you first came in to me
08:45now you're not in Israel
08:46obviously drugs and alcohol are a big problem
08:49i've been witness the violence and aggression
08:51it is difficult to be on the receiving end
08:54i think that's definitely gotten worse
08:58from 2023 to 24 the nhs saw over 1 million alcohol related admissions
09:04many arriving after dark
09:06so you and you and you can f*** off
09:10at night everything gets worse
09:12when you mix in alcohol and violence and aggression against our staff
09:17and it can feel like a police station sometimes
09:20f*** every part four i f***
09:39in east london 36 year old nissarg has been violently assaulted outside his home
09:45well done my friend
09:48he's at imminent risk of losing his sight
09:50the night team are performing an emergency procedure
09:53we made a small lateral cut through the skins that you need to try and buy yourself through the window
09:58the procedure we need to do is called the natural camphotomy
10:01it's not something that we do very often
10:03it is a time critical intervention
10:07identified a bit of the ligament but we couldn't get enough of it clamped to cut
10:12he's got quite a large swelling to the globe itself
10:15to relieve the pressure on his optic nerve
10:18the night team have to cut the ligament inside his eye socket
10:22if i take away the upper leg with the two four steps
10:25yeah
10:26now dr susie needs to work around the swelling to cut a second one
10:32oooooh
10:33it does kill me doc
10:36oooooh
10:37i'm gonna give him another 28k
10:38okay
10:39what?
10:40i'm gonna kill you
10:41yeah
10:42it's pelted
10:44pop out though isn't it
10:45yeah
10:47oooooh
10:48see if we get any three
10:52i'm just gonna hold it for a little bit
10:55respon
10:59it's got it
11:00top
11:01right here
11:02how's it done with it
11:04i'm sure it's nice
11:04feels a lot better
11:09well done my friend
11:12my eye's more forward
11:13so no good
11:15i'm trying to find
11:16And a very small piece of anatomy to cut was really challenging.
11:21We will see if we've been successful.
11:24The team must wait to see if Nisarg's site is saved
11:28and if the damage goes any deeper.
11:31We're going to do a CT just to assess the bones
11:33and see if there's any fractures in the socket itself
11:36and be sure that there's nothing beyond that and into the brain.
11:41You OK? It's coming round from your sedation, my friend.
11:46When someone is punched in the face with significant force,
11:50there are all sorts of complications.
11:52You would be thinking about significant brain injury, facial fractures.
11:57These things can happen in an instant and change that person's life forever.
12:01And it's something that we need to do some other investigations.
12:16A&E Norfolk, Norwich, medical trauma.
12:19We've got some IV fluids up.
12:21Nearly 3am in Norwich.
12:23So it's been going at this rate since midnight, really.
12:27Dr Lucia is looking after a patient whose heart is racing out of control.
12:33Still going fast, isn't it?
12:35His heart rate on the monitor was 200 beats per minute.
12:38The normal rate is 60 to 100.
12:42He can't maintain that heart rate of 200 for a long time.
12:46Eventually, it will become tired and potentially stop.
12:50All right, sweetheart.
12:51So if you can pop your hands straight for me, that's fine.
12:54It is unusual, it's rare, but sometimes people do have this condition
12:59where they go into the spontaneous fast rhythm.
13:02Even the slightest jolt drove his heart into this fast rate.
13:08Dr Lucia consults the cardiology department
13:11for the first critical move in his treatment.
13:15I've given him a bladder syringe and he's tried about four or five attempts
13:19and basically it's not really changed.
13:22So we're going to give you six milligrams of adenosine, yes, yes.
13:26Adenosine is a little bit like a jump-starting for heart again.
13:30You give it quite fast into a vein.
13:34It stops the heart and then restarts it.
13:37And hopefully it comes back at the right rhythm
13:41between 60 to 100 beats per minute, which is the normal rate.
13:45All right, sweetheart.
13:46So adenosine going in now and the flush.
13:50The first time I did it a number of years ago
13:53when I gave the adenosine, it was quite scary.
13:56When you didn't see the heart rhythm on the monitor,
14:00lift your arm up.
14:04Raising his arm helps the drug hit his heart in seconds.
14:10Still going fast, isn't it?
14:12It is, yeah.
14:14It's not done it, has it?
14:16With the heart still racing at 200 beats per minute,
14:20the adenosine has failed.
14:22So, once we're ready...
14:26Dr Lucia tries again, with double the dose.
14:3012 milligrams of adenosine going through and big flush.
14:35There we go.
14:36Lift his arm up.
14:37Beautiful.
14:39Nice breathing.
14:41Can we get a little bit of oxygen on?
14:43If that's all right, two litres?
14:46Extra oxygen supports the patient's heart
14:48as the 19 fight to slow it down.
14:51The rate hasn't made a blind bit of difference, has it?
14:55So, I'm going to do 18 now.
14:59Dr Lucia administers a third and final dose.
15:03Any more could stop his heart altogether.
15:06Okay, so, we're going to do 18.
15:09So...
15:11Adenosine gone through.
15:13Flush gone through.
15:14Lift it up.
15:17That was awful.
15:19Sorry, sweet.
15:22Adenosine acts fast,
15:23triggering an overwhelming wave of nausea and breathlessness.
15:28During that episode, when the heart is racing,
15:31it is scary.
15:32They feel terrible.
15:33They tell us that they feel terrible.
15:37We're looking promising.
15:39We're looking promising.
15:43Oh, hang on.
15:47And then it kicks in again.
15:50The final dose has failed.
15:53The patient's heart is still stuck in critical overdrive.
15:57The fact that we've done the third one and it hasn't worked,
16:00I'll just give her a ring now so she's fully aware.
16:03Basically, the heart's beating differently.
16:06There's no set pattern.
16:09If you don't intervene,
16:11ultimately, the outcome can be for it to stop.
16:28On average, ambulance crews respond to nearly 3,000 falls every 24 hours,
16:33bringing some of the most life-changing emergencies into A&E after dark.
16:40I'm just going to have a look at your arm, OK?
16:42In the middle of his night shift,
16:44Dr. Aditya has been called to see 40-year-old delivery driver Akram.
16:50You can feel my heart?
16:51Yeah.
16:52Who was brought in by ambulance after falling down the stairs.
16:56It's really quite swollen here.
16:57Yeah, here's the pain.
16:59Are you able to bend your elbow?
17:01No.
17:02I don't think.
17:03No.
17:03I can't.
17:04OK.
17:05We'll get you some pain relief sorted.
17:07Thank you, but before you do it, just give me any pain.
17:10Oh, we'll get you some pain relief.
17:11I've already prescribed it to you, OK?
17:13Do you need some help getting up?
17:14No, OK, OK.
17:16Getting an x-ray as quick as possible is really crucial
17:19because the further we delay the x-rays,
17:22it can lead to nerve damage, can lead to vessel damage.
17:25To reveal the impact of Akram's fall,
17:28Dr. Aditya needs to check all the bones in his arm,
17:31from shoulder to wrist.
17:34Yeah, forearm's fine.
17:36Forearm wrist is OK, yeah.
17:38Ah, that's desiccated.
17:42Oh, yeah.
17:43Not for a mask.
17:44This location is serious, can lead to nerve damage,
17:47making the lymph unusable for the patient.
17:50With Akram's mobility and his job on the line,
17:54Dr. Aditya and the team need to urgently realign his elbow.
17:58This part of your bone should be in this socket,
18:01so we need to put it back in the right place.
18:18Yeah, we've got the maid who's just been in a road traffic collision.
18:24She's been crossing the road, driver hasn't seen her,
18:27he's turned the corner and hit her.
18:28OK.
18:29Any past medical history, any blood thinners she's on?
18:32Clopidogrel.
18:32Clopidogrel, OK.
18:33Tonight in Newham, Dr. Rosie's in charge of the Rhesus team.
18:37We've got a head injury, a pedestrian versus car.
18:40Rhesus can be often the most chaotic place in the whole hospital.
18:44Can you tell me if you're in pain there?
18:46Often the patients are really sick,
18:49especially when it's a pedestrian hit by a car,
18:50we're super careful about those,
18:52because the risk of injuries is really high.
18:56After dark, pedestrians are over twice as likely to be struck,
19:00and the consequences can be life-threatening.
19:03I see you, he's here.
19:05OK, that's good.
19:08Bollipogrel's in the back, aren't they?
19:11Some dishes for her.
19:17OK.
19:17OK, here we go, well done, well done.
19:23Our main concern is she's got a significant head injury,
19:26especially given that she's vomited now two times,
19:29especially when she's lying flat,
19:31which can suggest a raise in her intracranial pressure.
19:34OK.
19:35Hello, my name is Tosin, one of the A&E doctors.
19:38You can just lie your head back for me, OK?
19:41The night team must run urgent neurological checks
19:44in case 63-year-old Paramuswari
19:46has a critical bleed on the brain.
19:49Deep breath.
19:51Big breath.
19:53Very good.
19:53Good, again?
19:55OK, my dearie, that's fine.
19:57I'm just going to shine this in your eyes, OK?
19:59There's a light coming in your eyes, OK?
20:03Good.
20:07OK.
20:08PPU is equal, I'm reactive, two millimeters.
20:13Any pain in your legs?
20:16Just the hand, OK?
20:17Just the hand, OK?
20:17And your head.
20:18Brilliant.
20:19Let's leave the wrist for now, because we'll get it x-rayed, so I don't want to...
20:22Yeah.
20:22And then there's this obvious...
20:25Is it boggy?
20:26Yeah, it is.
20:27It is? OK.
20:28All right.
20:28OK.
20:29There's a particular type of boggy swelling that you can get on the head.
20:34They're fairly rare, but it can suggest a skull fracture.
20:39Sorry, my dear.
20:40We're going to keep her in that position.
20:42We've got a sort of CT trauma series for her.
20:46We're going to get you some scan for your head, OK?
20:49OK.
20:49We'll get you some...
20:50And some painkillers, OK?
20:52Hopefully, we can get her into a scan fairly quickly, so we'll know exactly what we're dealing with.
21:01Following the crash, Paramuswari's sons called for an ambulance.
21:05I was in shock.
21:06I quickly came, and I saw my mother on the floor.
21:10It was the last thing I wanted to see, but I'm seeing it.
21:13I was the strongest woman I've met in my life.
21:18Hi, how are you doing?
21:19So, I'm Rosie, one of the doctors.
21:21I'm worried about her head at this point, so I definitely want to make sure there's nothing in her head.
21:24She vomited the place as well, isn't it?
21:24Yeah.
21:25There's lots of reasons people vomit, including if they are shocked from an injury, but having something worrying in the
21:30brain is a reason why people vomit as well.
21:32So, we're going to sit and see everything and then x-ray the wrist as well.
21:36If you have bleeding on the brain, it can expand.
21:39All that blood expands.
21:41It has nowhere to go.
21:42The skull can't expand, so it just compresses the really critical areas of the brain, the ones that control your
21:48motor function or your speech.
21:55Obviously, the worst case is your ability to regulate your breathing and your heart rate as well.
22:01It can lead to disabilities and possibly death in really severe cases.
22:33The skull is a bit of a bit of a bit of a bit of a bit of a bit
22:35of a bit of a bit of a bit of a bit of a bit of a bit of a
22:35bit of a bit of a bit of a bit of a bit of a bit of a bit of
22:35a bit of a bit of a bit of a bit of a bit of a bit of a bit
22:35of a bit of a bit of a bit of a bit of a bit of a bit of a
22:35bit of a bit of a bit of a bit of a bit of a bit of a bit of
22:36a bit of a bit of a bit of a bit of a bit of a bit of a bit
22:36of a bit of a bit of a bit of a bit of a bit of a bit of a
22:36bit of a bit of a bit of a bit of a bit of a bit of a bit of
22:36a bit of a bit of a bit of a bit of a bit of a bit of a bit
22:36of a bit of a bit of a bit of a bit of a bit of a bit of a
22:36bit
22:36After dark, A&Es across the country are facing more aggressive patients than ever before.
22:43The night shift can be a bit chaotic, a bit crazy.
22:49It can suddenly make the department feel very unsafe.
22:52It can really ramp everyone's anxiety levels up.
22:57Ain't no matter why you can handle me, I'm sorry.
23:01But many patients on the night shift are also the victims of aggression and assault.
23:20Oh, my God.
23:23Well done, my friend. You're coming around.
23:25In Newham, Dr. Fraser is looking after 36-year-old Nisarg.
23:30He was attacked outside his home and rushed into emergency eye surgery.
23:35I'm just going to pop this off. We don't need the oxygen anymore, OK?
23:38Now the pressure around his eye has dropped.
23:41The night team need to check whether they were able to save his eyesight.
23:45Can I just have a look at your vision again? Are you awake enough for me to look at your
23:49vision?
23:50Here you go.
24:01Oh, my God.
24:03OK.
24:04Now I can see.
24:06That's good. Cover your left eye.
24:08Yeah.
24:08Can you see my face?
24:10I can see your face.
24:11How many fingers?
24:12Four.
24:14Music to my ears.
24:16He's had a punch that's forceful enough to give him bleeding behind his eyes.
24:22So what else might that have done? Has that broken any bones in his face?
24:25Make sure he's not got any bleeding in his brain.
24:27What we need to do now is just because you've had a quite significant head injury, we're going to do
24:32a scan of your head, OK?
24:36Nisarg is taken for an urgent head scan.
24:39This time will take about two or three minutes, OK?
24:42To check for any life-threatening injuries.
24:47Yep.
24:48Yep.
24:48Got it.
24:50He waits in majors while the night team examine the scans.
24:54The thing is, I'm celebrating festival with my two-year-old daughter.
25:00The guy came, you know, he's arguing me, like, I have my daughter in my hand, and he's trying to
25:06punch me.
25:07And I just pulled her back, and that's why my face is like this, and he just punched me in
25:15my face and my eyes.
25:21Is your eye painful?
25:23Yes.
25:24And now it's been here as well.
25:26Yes.
25:27The CT scan showed that there's a broken bone in your face and around your eye.
25:33What we're going to need to do is get you followed up by the facial surgeons as well for an
25:38appointment to see whether they need to do anything.
25:40Sometimes when you've got, you know, a fractured eye socket, then the muscles that move your eye can squish through
25:45the gaps in the broken bones,
25:47and that can mean that you can't move your eyes properly.
25:49But the immediate priority for him was getting him seen by an eye doctor.
25:55We're going to get you seen by the ophthalmologist in the morning.
25:57All right.
25:58Some of the most dramatic cases of, you know, injury and trauma from violence in the community will happen at
26:05night.
26:06It was a pretty horrible assault. It's what sounds like a completely trivial argument and someone's punching him in the
26:11face.
26:11So it's a pretty horrible thing to happen.
26:28It's still in SVT. He did revert back five cyber speeds, but then just went straight back into SVT.
26:36On the night shift, Dr Lucia is looking after a patient whose heart is beating around double the speed it
26:42should be.
26:44We give six milligrams at 246, no effect. And then at 250, I gave 12 milligrams of adenosine, no effect.
26:55With the first treatment failing to calm his heart, Dr Lucia calls the cardiology specialists.
27:01So we just, we just need to DC. Well, I'll have a word with Daniel because obviously she needs to
27:06be in resources if we're going to do that as well.
27:09They devise a new treatment plan.
27:12So, spoken to cardiology. So what he's recommended is actually DC cardioversion.
27:21The quickest way to get the heart back to the normal rhythm is we put defibrillator pads on and jolt
27:31the heart with electricity back into the normal rhythm.
27:34But you can imagine that situation not being very, very, you know, pleasant.
27:43So you have to put yourself in the position of the patient. It makes people really, really, really frightened.
27:51It's more than one way to skin a cat. So don't worry. It's all good.
27:57Dr Lucia refers back to the cardiology specialists on what else can be done.
28:03Give him metoprolol. What dose would you recommend?
28:08There is one other medication they can try.
28:12Metoprolol is a beta blocker. This works in a different way and slows the heart down.
28:19There is metoprolol now.
28:22Yep. So give that a 312.
28:25Unlike adenosine, which resets the heart, metoprolol works the opposite way.
28:31Blocking adrenaline to gently calm the heart rate.
28:35It's coming down. It's getting there slowly.
28:39And then once you go back to normal, get your nice cup of tea.
28:45Nearly.
28:47Nearly.
28:51Get out of it.
28:53The rate is better than what it was.
28:56Whereas before you were sort of like about 200.
28:59You feel better?
29:01Much better.
29:03Good.
29:05A sigh of relief. A sigh of relief.
29:07As soon as you get the rate back to the normal rate,
29:12the patient just feels miraculously better.
29:15And that's what we're here to do.
29:18Do an ECG and then unfortunately you're going to have to look at our ugly faces for a couple of
29:22hours now.
29:23Ha, ha, ha, ha, ha, ha, ha.
29:31Okay.
29:38In Newham, 63-year-old Paramaswari is having urgent scans after she was hit by a car while
29:46walking to temple after dark.
29:54Her sons are translating for the night team.
30:19Leading her care, Dr Rosie is reviewing the scans.
30:30Hello. Hello, how are you doing?
30:33Yeah, I've just come to explain about the scan.
30:36Are you guys happy to translate or do you want a translator here?
30:38No. Are you sure?
30:40OK, so obviously we've scanned head, neck and all the body here.
30:45What it does show, which is what we were suspecting, unfortunately there is a bleed on the brain.
30:52OK, there's a bleed over where she's got the bump, but there's also a little bit on the back.
30:56She does have a fracture of her wrist as well, unfortunately, but that is very manageable.
31:02We can sort that out, OK?
31:04So, unfortunately, the CT scan has showed that she has a bleed on the brain.
31:12CT scan only shows exactly what's happening at one point in time.
31:16So it's really, really important we monitor her carefully.
31:18That means doing neurological observations regularly.
31:22Keep your head nice and still for me. Just follow finger with your eyes, OK?
31:27Kind of OK.
31:32There's lots of things that can happen after you have a bleed on the brain.
31:36The main concern is that if you have bleeding, it can expand.
31:40It can compress certain areas of the brain.
31:44Can you squeeze my hand for me?
31:47And this side, can you pull my hand into you?
31:51Very good. And pull out, push out.
31:54Out, out, out.
31:56So, the neurology is assessed in various ways.
31:59For example, the power of your limbs, the coordination, your ability to feel on your skin.
32:05These are all things that can be affected by the bleed on the brain.
32:10If I touch her there, does she feel the same on both sides?
32:19She can feel it less on that side and more on this side.
32:21Less on this side? What about here?
32:22No, less on this side.
32:24Less on this side, OK. OK, what about here?
32:33The same?
32:35Feels the same, yeah?
32:37No.
32:37Here?
32:44On that side, she doesn't feel anything.
32:45This side?
32:46Yeah.
32:46OK, OK, OK, that's right.
32:48So, we'll have to have a chat with the neurosurgeons.
32:50Obviously, I'm one of the A&E doctors, but one of the neurosurgeons will have to have a look at
32:53all the scans
32:54and decide what's best for her.
32:56OK, all right, thank you.
33:00At the moment, her neurological assessment is actually pretty good,
33:03but my biggest concern is the risk of further bleeding.
33:08She's on a blood thinner as well, clopidogrel, for a previous stroke,
33:12which makes it a little bit more concerning.
33:14Blood thinning medication protects Paramuswari from a stroke by preventing her blood from clotting.
33:21But with the bleed on the brain, it could make things far worse.
33:26I have spoken to the haematologist at the London, and they have suggested to give the platelets.
33:31Yes, one pool of platelets.
33:34Given the risk, Dr Rosie speaks to out-of-hours blood specialists.
33:39The platelets are a component you get in your blood,
33:42so we all have platelets just swimming around in our blood to help us clot when we bleed.
33:46This patient is on an anti-platelet agent called clopidogrel.
33:49So we've asked the haematologist, and we are giving her some extra platelets to help that clotting process.
33:57The main concern if she re-bleeds is that we get a big collection of blood in the brain
34:02that then compresses the brain, including a lot of the major areas that are in control of our speech,
34:08our movements, our breathing.
34:10With the emergency treatment on its way, Paramuswari stays in recess under close monitoring,
34:17giving her the best possible chance of survival.
34:20It's a shock. It's a massive shock.
34:23But fingers crossed, praying to God that everything will be fine again.
34:43In Belfast, 83-year-old Ian is brought into recess.
34:49Hello.
34:50Taking the lead on his care is Dr Alice.
34:54What brought you in tonight?
34:56The pain is in the stomach and vomiting.
34:59Okay.
35:00Have you had trouble with the tummy before?
35:02Not really, no.
35:05Can I have a failure tummy?
35:07Just grab some gloves.
35:09There's a severe pain.
35:11See there?
35:13Ah!
35:14Not there, no.
35:15Just there?
35:16Ah!
35:17There.
35:17What came first, the pain or the vomiting?
35:20Well, the pain.
35:21The pain came first.
35:22And a bit of a stiffness or something.
35:24Oh, okay.
35:25The pain was.
35:26Okay.
35:26It came in at times.
35:28Is your health usually good?
35:30It's reasonable, yes.
35:32Yeah.
35:33I'm a farmer.
35:35I always worry whenever a farmer comes in, because you don't come to see us with nothing.
35:40No.
35:40No.
35:42He's come in with tummy pain, he's got a high lactate, he's tender, he's been vomiting,
35:47his bowels aren't opening.
35:48So I'm worried he's either got a blockage in his bowel or a blockage in an artery supplying
35:52the bowel.
35:52Yeah.
35:53Here's Joe.
35:58Ian's wife has arrived to sit with him.
36:00We've been married, well, since 1967.
36:03A long time.
36:06And we don't really have arguments.
36:09He has a heart problem, he has a pacemaker, fitted quite some time.
36:14But this is different, this is around the tummy area.
36:19He just felt poorly after he had his evening meal.
36:23Really sick and was actually vomiting.
36:28It happens with age, or as I say, too many birthdays.
36:35So here we are, the right place.
36:38Hi Keeva, it's Alice, one of the ED regs in the Royal.
36:41Could I talk to you about CT abdomen pelvis?
36:44I can only feel his tummy and look at him, I can't see what's going on in the inside.
36:48Whereas the CT can give me good images of the abdomen and they can tell us a bit more
36:53about what's going on.
36:55Uh, what did you farm?
36:59Cattle, sheep.
37:00Beef or dairy?
37:02Beef, well, rare breeds.
37:06Oh?
37:06Still on the farm, are you?
37:09Still live on the chest.
37:10Yeah.
37:11Alright, we'll give you a little bit of this morphine, okay?
37:14And then if you need more, I can give you some more in a wee bit, okay?
37:19I was just hoping that you weren't scared of needles,
37:21because it's always the big strong men that cope on me whenever I put a needle into them.
37:25And they do a lot of shouting, this needle.
37:27They do do a lot of shouting.
37:29Oh!
37:31And I was snuck in while you were distracted there.
37:33Ah!
37:34Ah!
37:37Oh!
37:38Ah!
37:40Ah!
37:44You did do a bit of shouting there.
37:46I did, yes.
37:48You're going to go up for your scan now.
37:50So we are going for the CT scan, okay?
37:55For this gentleman, I'm worried about a bowel obstruction.
37:59I'm worried about an aortic aneurysm.
38:01I'm worried about mesenteric ischemia.
38:03I'm worried about pancreatitis.
38:05Any older gentleman that presents with tummy pain, it can be potentially fatal.
38:28You can feel my hand.
38:30Yeah.
38:30It's fine.
38:31Yeah.
38:31Everywhere.
38:32In the middle of the night, 40-year-old delivery driver Akram has blown his elbow out of its
38:37socket.
38:39So clearly, from the x-rays, it shows that you have dislocated your elbow.
38:44It's going to be a difficult procedure to put it back to care.
38:46We'll try to sedate you as much as possible.
38:47With his ability to drive on the line, it needs to be realigned urgently.
38:53A treatment that requires two senior doctors, Dr. Aditya and Dr. Zoe.
38:59So I'm going to use a mask just because it makes it a little bit easier for you to get
39:03gas and air into your system.
39:05The night team use Penthox for fast-acting pain relief.
39:10Deep breaths.
39:11You're doing well.
39:13It will relax Akram's muscles within minutes.
39:17Deep breaths.
39:18In, out, sir.
39:19Let's go and see.
39:21Good man.
39:23Nice move on in that one.
39:25Keep going.
39:26Good man.
39:27It's quite physically intensive procedure, both for the patient and for the doctors who
39:31are performing the procedure.
39:34Oh, do it.
39:35It requires traction and counter traction and put the bone back in place.
39:39Keep you taking deep breaths.
39:43Still awkward to bend, is it?
39:45The procedure needs extra force.
39:49While Zoe anchors Akram's elbow in place, Dr. Aditya pulls the forearm further from the
39:55socket, giving the joint more opportunity to slot back into natural alignment.
40:03I think it's all right.
40:08You okay?
40:09You've done so well there.
40:11Looks better.
40:13How's it feeling?
40:16I know the next bit's getting this cast on.
40:20Falling down the stairs can be quite serious.
40:22It can result in head traumas and other severe traumas like chest trauma.
40:26How does your elbow feel?
40:27This is pain.
40:29Still pain?
40:29We'll keep you in here for now, okay?
40:31Until the next day are ready to come and get you.
40:33Okay?
40:34So all in all, yeah, he was pretty lucky to just have a dislocated elbow rather than any
40:38other traumas.
40:39Yeah, you feel it.
40:40It was stupid.
40:42Did you like that?
40:43No, I liked it.
40:55On the other side of the hospital, emergency doctor Alice wants to diagnose 83-year-old Ian's
41:04severe abdominal pain.
41:06Breathe in and hold your breath.
41:12He waits for his CT results with wife Joan.
41:16Is this still as painful as it was?
41:18Very painful up there.
41:20Oh, that's right.
41:21You have a right selection of stuff here, as long as you don't move.
41:25All right, yeah.
41:26And have you felt sick again?
41:29No.
41:30Your report's back.
41:32You report your scan's back.
41:34Hmm?
41:35So it's not actually the tummy at all, it's the pancreas.
41:39Right.
41:40It's not very happy right now.
41:42It's got a bit inflamed.
41:45Right.
41:46Your pancreas can cause loads of issues.
41:49It's really important in regulating a lot of things, including the sugar levels in your
41:53blood, but it can be incredibly sore.
41:55It can also become necrotic, so it can die.
41:58And then that can make you really, really sick.
42:00And his hasn't reached that stage yet.
42:02It's just inflamed.
42:03It's very important.
42:04But he needs careful observation and pain management.
42:07Do you have any questions for me?
42:09No.
42:09What am I going to be?
42:10Yeah.
42:10Well, I would say you're coming in for bed and breakfast.
42:13He doesn't need to go for theatre.
42:15He can be managed conservatively, which is good, because in somebody his age, going for
42:20a big operation can be very difficult.
42:23You might want to get yourself home.
42:25I'm here, okay, if you need me.
42:29Most people with pancreatitis, you can tell from the front door, because they are screaming,
42:33and they are writhing in agony.
42:35He is, like, just very stoic.
42:40Okay.
42:41Yes.
42:42See you in the morning.
42:44Bye-bye.
42:45Bye-bye.
42:47Sorry about all that.
42:49Classic farmer.
42:50Yeah.
42:52It's farmers.
42:55$8.
42:56You're very welcome.
43:05What's really important is that we continue to check your vision.
43:17So we're going to do a few scans for you, for the head and the neck.
43:31I have checked the x-ray, it's perfect.
43:33Do you feel less pain?
43:35Now it's less pain, yeah?
43:36Oh, very good.
43:46What's next?
43:47What's next is that the surgeons will come and see you.
43:50Okay.
43:51Okay, all great.
43:53What?
44:12That's okay.
44:15Maybe we are okay.
44:20vedere your teams will look their heads up and look his four weeks away.
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