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A and E After Dark - Season 7 - Episode 04
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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.
00:18This gentleman has been punched, kicked.
00:20It 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.
00:31Stop CPR.
00:32Time is of the essence.
00:34And the medics who face danger each shift.
00:37Most shifts, I see more police 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.
00:59You see the good, bad and the ugly.
01:00I am done.
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.
01:34Let me stop you in the conversation and see you.
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, are ****.
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.
03:18I'm f***ing upset about it.
03:19It's okay, calm down.
03:20Yeah, yeah, I appreciate it.
03:22You are like a f***.
03:23Hey, alright?
03:24Calm down, calm down, calm down.
03:25What do you want to say?
03:26What do you want to say?
03:27What do you want to say?
03:29What do you want to say?
03:30What do you want to say?
03:30What do you want to say?
03:31Come on.
03:32I'm going through it.
03:33You're not listening to what I'm saying to you.
03:34That's not 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's do?
03:43Sweet F.
03:43Oh.
03:45With the patient refusing to calm down,
03:48the police have been called in to assist Haseeb and his team.
03:51We are in 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
03:59it is better to have the police around
04:01to help manage these situations.
04:03Is everybody okay?
04:05Obviously not.
04:07This ain't my idea of a f***ing night act.
04:09That three-arsed one said I was intoxicated.
04:13I said to her I'm not intoxicated, right?
04:16This character has come out with a plain plump-putting BS
04:19that you are.
04:20I'm not in any f***ing trouble.
04:22Have you had anything to drink?
04:25Listen, I told her I'm a f***ing alcoholic.
04:28That's got f***ing all to do with it.
04:30I'm going out with cigarettes.
04:31Oh, come to...
04:32Oh, Chris?
04:32Do you want to go out that way?
04:34Yeah.
04:35Just go out that way.
04:36Why do you think people gradually
04:38had a f***ing nothing wrong?
04:41The police officers escort the patient outside
04:44in case he becomes aggressive again.
04:46So the plan for now would be
04:48we just continue to monitor him,
04:49allow him some more time outside
04:51to settle down and calm down,
04:52and then we'll get him to be seen by the medical team
04:55to try and diagnose and help him
04:57with whatever the issue is.
05:10Hello.
05:12My name's Nick.
05:13I'm one of the doctors.
05:13What's your name?
05:15Also in Newham,
05:16Dr Nick is conducting a primary survey on a patient
05:19who's been ambulanced in after collapsing on the 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
05:31when they found you.
05:32It smells a bit like you've been drinking,
05:34but if you haven't,
05:35we're going to have to do a lot of tests
05:37to work out what's wrong with you.
05:39But I think probably you've just had too much to drink.
05:41Have you?
05:43No.
05:44No, no, no.
05:45Okay.
05:45I'm sorry.
05:46Fair enough.
05:46She denies having had a drink, which makes it trickier
05:50because, of course, our dilemma is often
05:52is the patient just drunk
05:54or is the patient ill or injured
05:57and happens to have had a drink.
06:00Can I have a look in your eyes?
06:01Is that all right?
06:02Okay.
06:03Just rest your head back for me.
06:06Unresponsiveness, erratic behaviour
06:08and struggling to communicate
06:09could 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
06:18without making sure that their brain is okay.
06:22The important thing is to make sure
06:23that we don't miss something more serious
06:26because we're assuming that somebody's had a drink.
06:31Can you help nurses get all their wet clothes off?
06:34Yeah.
06:35Get her covered up with a gown.
06:37Try and keep her warm.
06:39Start just seeing what her blood show, what time does.
06:45We'll keep monitoring her heart rate, blood pressure, oxygen levels
06:48and 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
07:08and we need to then think about a CT scan.
07:12If 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!
07:34No!
07:35It's disgusting!
07:36In Northern Ireland, A&E admittance has risen by nearly 30% since 2020.
07:44Nightshifts are busy, they're very busy.
07:46Right, we can't have that in this department.
07:48How long?
07:48You just walk in and there could be wee fires everywhere.
07:50We need to just go around putting them out.
07:52I need you to stand still.
07:55Up to 40% of A&E admissions in Northern Ireland
07:58are related to some form of intoxication.
08:01High numbers coming through.
08:03A lot of them obviously under the influence of drugs, alcohol.
08:06So it can be a really hectic shift with, I suppose, 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 distressing other people.
08:25Deputy sister Rebecca and senior nursing assistant Gemma
08:28are 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,
08:38and then move him to a recess area.
08:43Injecting cocaine is quite big of an issue at the minute,
08:45so every shift there will be several.
08:48It wouldn't be a one-off.
08:49It's not an isolated thing.
08:53My name's Gemma.
08:54Would 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 OK? Is that all right? No.
09:03Too much cocaine, that's so much pressure and stress
09:06that's put on your heart.
09:07Whenever your heart's under pressure,
09:09then 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, OK?
09:18Let us do your wee blood pressure.
09:20The patient is refusing to let the staff assess him.
09:24Are you able to let us touch your arm?
09:26We can't help you unless you let us do your blood pressure, OK?
09:30Listen to me.
09:31We need to track your blood pressure so to make sure you're safe.
09:34You're all right. You're OK. You're all right.
09:36Be careful.
09:37No.
09:39He's refusing all intervention.
09:42He's refusing investigations and he's getting kind of combative
09:44whenever we're trying to.
09:46So to reduce his stress and reduce obvious risk to us,
09:50we're stepping back for the minute.
09:52Admissions related to drink and drugs from the nighttime economy
09:55only grows as the night wears on.
09:59I'm Rebecca, one of the nurses.
10:01I'm going to do your blood pressure, OK?
10:03You've had a seizure tonight.
10:04We need to do some blood.
10:05Is that OK?
10:06A 64-year-old man has been found unresponsive
10:09and rushed in by ambulance.
10:11He has a history of alcohol-related seizures.
10:14He's allegedly had two seizures tonight, back-to-back.
10:18It lasts about 22 minutes.
10:19Yeah, he's pretty flat.
10:21Let'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,
10:26but he's scaring 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 OK,
10:34so we're going to get you into one of the major seizures
10:37and get you seen by one of the doctors, OK?
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
10:50who has also been having seizures.
10:52The ambulance area can be very, very busy.
10:55They either don't come at all,
10:56or they all come at once.
10:58There's a massive, massive percentage of people
11:00who are IV drug users in Belfast.
11:03OK.
11:03Someone was worried you had a seizure tonight
11:05and phoned an ambulance.
11:09Right.
11:09Yeah, we'll get security.
11:11We have a gentleman in.
11:12He's adamant he doesn't want to stay.
11:14Unfortunately, we have to keep him safe,
11:16so I've had to reach out to security
11:19because he'd become quite fairly abusive
11:21and 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?
11:44Can you have a wee look around you?
11:45Where are you?
11:47He's coming around a wee bit there,
11:48so we'll get him on the trolley, yeah?
11:49Is he in the trolley?
11:50No, it's just because that's all over there.
11:54We're here to care for people,
11:56despite what they might give us back
11:58or what their history might be.
12:01We're all very immune to it
12:02and 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 in Norwich Redfield Medical Trauma.
12:23Recess have received notice
12:24that an 84-year-old woman
12:26is being brought in by a paramedic team.
12:29Yeah.
12:32This is Marjorie.
12:33She's an 84-year-old female.
12:35Approximately two weeks ago,
12:37she hit the head on the back of a bed frame
12:39and then today she was told the family
12:42that she hit the back of her head.
12:44Since then, she's become really confused.
12:45She's vomited twice, not with us,
12:47so really disorientated.
12:49We've carried out a neuro-assessment.
12:52One pupil is bigger than the other
12:54on the left-hand side.
12:55Coordination is literally off.
12:57She was in here this morning for a UTI.
13:01However, the tests have actually come back clear.
13:03It's kind of really good coordination,
13:04provisional 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.
13:18Light pupils smaller than the left.
13:21Different sized pupils can be an indicator
13:23of a serious issue with the brain.
13:26Yeah.
13:27Another blanket for your heart.
13:28You've got cold hands.
13:29Are you cold?
13:30You are cold, yeah?
13:32Marjorie's nieces, Sarah and Liz,
13:34have arrived at hospital after following the ambulance.
13:38She rang us last night and she said she's very confused,
13:41doesn't know if it's day or night.
13:42Normally she's very independent,
13:43she knows what she's doing,
13:45so to get a call like that,
13:46we know that there's something wrong.
13:50My name's Zach, I'm one of the doctors.
13:52And you hit your head a couple of weeks ago, is 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? Okay, fine.
14:07What about this side?
14:08Can you see?
14:09Keep looking at my nose.
14:10Can you see my fingers wiggling?
14:12Yes.
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,
14:22she's got complete left-sided neglect
14:23is what that means.
14:24She can't see the left side.
14:25And that can be due to increased swelling
14:29around 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,
14:37the quicker we find out what's causing it.
14:40In older people, their brains,
14:43for want of a better term,
14:44shrunk down a little bit.
14:45Yeah, our mum died last year.
14:47Yeah.
14:47Yeah, yeah.
14:48The blood vessels that attach the brain
14:50to the outer layer of the skull
14:52are therefore stretched a little bit
14:54and if they do have a head injury,
14:56they can tear much easier.
14:58And if that brain has shrunk a little bit,
15:01that blood can sometimes collect over time
15:02and not cause too much issue,
15:04but actually then move its head a bit later.
15:07Yeah.
15:07So this might be a pull that she's had a long period ago.
15:10Yeah.
15:10I'm not told that she's very independent,
15:12so she wouldn't always tell us.
15:15If there's bleeding inside the brain or within the skull,
15:20that 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,
15:29that can have a lasting impact on disability
15:32and actually patient survival.
15:35See you when you get back, Margie.
16:00See you when you get back, Margie.
16:04You've got loads of glass in your hand.
16:06Hold on.
16:06Can you put it on the bed?
16:07Oh my God.
16:09In Newham Resus,
16:10doctors have been monitoring a patient for an hour
16:12to see if her unresponsive behaviour
16:14is a result of drinking or a head injury.
16:17So she's just found a bottle of vodka in her bed
16:22that was smashed.
16:24Luckily, she didn't injure herself on it.
16:26But yeah, it just shows you've got to be careful
16:27with patients who are intoxicated.
16:30Upon arrival, the patient insisted they'd not been drinking
16:34but has managed to sneak a bottle of alcohol into their bed.
16:37But I guess we now have some evidence
16:40for why she came in the way she did.
16:44Do you remember me from before?
16:45Nick, 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
16:54who have used alcohol.
16:56Some of those patients have a long-term relationship
17:01with alcohol that's unhealthy.
17:02We see them a lot and we see them
17:04not managing to cope with life
17:07because of their alcoholism.
17:09But also people who are regular users of alcohol
17:12can have other health problems
17:13that have been triggered by their alcohol excess.
17:18You seem much better.
17:20Yeah.
17:22Have you got any pain anywhere?
17:24No.
17:25Do you remember what happened?
17:26Why did you have to come to the hospital?
17:29I don't know.
17:30I was sitting outside for begging.
17:34Okay, and begging and drinking?
17:36No, not drinking.
17:38Just begging.
17:40Okay.
17:40For food.
17:41Where do you live at the moment?
17:44I'm living in the moment in the forest.
17:47In the tent.
17:49In a tent?
17:50Yeah.
17:51How long have you been living in the tent?
17:53Three years ago.
17:55Three years?
17:56Yeah.
17:57Okay.
17:58Do you live there on your own?
18:00No.
18:03Newham has the highest rate of homelessness in England,
18:05with one in 18 people living rough.
18:08Patients who are homeless have a lot of extra risk associated with their healthcare.
18:15It's also almost impossible to arrange the routine sort of follow-up that the system offers people
18:24when they don't have 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 till the morning.
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,
19:01once we know that she understands the decision she's making, and she does.
19:07So we'll try and find her some clean, dry clothes and let her go.
19:22That's it. Open nose eyes.
19:25In Belfast, the resus team are preparing for a patient who is being raced in after being stabilized at another
19:32hospital.
19:33I'm going to get a scan of her chest.
19:35You may as well do her abdo 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 canema thorax,
19:43so 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.
20:17Ready, steady, steady.
20:21Right, and centre, right up.
20:23Right, right up.
20:24Michelle?
20:25My name's Orl.
20:26I'm one of the doctors on today.
20:28We've been expecting you so we know a wee bit about you, okay?
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 to help with that
20:42discomfort, alright?
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, 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 okay?
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.
21:18We're going to give you a bit of medication here to take the edge off, alright?
21:22You're doing very well.
21:23With a tension pneumothorax, people can very quickly die without intervention.
21:28Alright.
21:29Sorry.
21:29Getting a chest drain in is a pretty uncomfortable procedure.
21:32Oftentimes the patient's quite distressed.
21:34They're scared, they can't breathe properly, so we will often give them some sedation medication.
21:39Yep.
21:39Sorry, a bit of a lift of your arm, Michelle.
21:41Oh!
21:41Right over the tent, I know, I'm sorry.
21:44And then we relax in there, okay?
21:46She'll start with kicking in the next couple of minutes.
21:49Alright.
21:49You just breathe away, it's normal.
21:51Michelle is given pain medication, including local anaesthetic where the tube will be fitted.
21:58I'm just looking for the noise.
22:00I'm just thinking about okay, but that will help for the rest of it.
22:02You got a second to work okay?
22:04No.
22:05We use a mixture of lidocaine, which is a local anaesthetic and adrenaline, which helps sort
22:10of constrict some of the local blood vessels, which will reduce the risk of bleeding when
22:15we make the cut.
22:16Can you feel that?
22:17Can you feel that?
22:19No!
22:20I'm joking.
22:21A chest drain goes wrong when 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.
22:38You feel uncomfortable, but okay?
22:40If we don't get the chest drain in quickly, the person will become more unwell and more
22:44unstable.
22:45It's time critical.
22:46You can go into cardiac arrest.
23:01Medical trauma.
23:02Can I just confirm GCS?
23:04At night in A&E, the proportion of patients under the influence of alcohol or drugs increases.
23:10Not.
23:10Not.
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 in those who have
23:23drunk alcohol for a long time.
23:24At peak times after dark, as much as 70% of A&E attendances can involve alcohol.
23:30There's a lot of young people who would use drugs and night out, and then obviously alcohol,
23:36that side of things, disorderly behaviour, so the police are always in with them kind of cases.
23:43We get patients brought in by the police that have been found intoxicated.
23:48May it be 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 burn on your lungs.
24:12Amongst dealing with dangerous and difficult people, the staff still care for gravely ill patients.
24:18So we hold on to the flutes and repeat the observation.
24:26In Norwich, 84-year-old Marjorie is having a CT scan after becoming confused and disorientated
24:33following a head injury.
24:35OK, we're just going to step out now and start that scale.
24:38It takes about five minutes, OK?
24:40The CT scan is a vital investigation that we do to see if there's any signs of either an area
24:48where there's not enough oxygen getting into the brain or an area where there's bleeding.
25:00That wasn't too bad, was it?
25:03Was it OK?
25:06Marjorie's nieces have been waiting for her in resus.
25:10Have you realised I was going to happen?
25:12No.
25:13Well, you're in the best place now.
25:16Yeah?
25:17Yeah?
25:17They'll do it 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 dirty.
25:28Yeah.
25:30I've had a quick look at the scan and the report's back.
25:33So 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 that looks like there has been a stroke.
25:50The stroke team are going to admit her.
25:52She may need further tests and things like that, but they're the best people to do that.
25:58Looking at the CT scan, it has shown a patch that suggests an ischemic stroke that has happened in the
26:04last 24, 48 hours.
26:07An ischemic stroke is caused by a blood clot blocking one of the arteries in the brain and depriving the
26:13area 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 awards because they're amazing and they've got brilliant teams that work really intensively
26:32with people.
26:35Ischemic stroke treatment is time critical.
26:38Nighttime incidents can often go undetected, missing the treatment window and leaving the patient with serious complications.
26:44Patients who present later or have more significant strokes can be left with a significant disability.
26:50And that can range from weakness on one side of the body, speech problems, swallowing issues, seizures.
26:59And you can imagine all of those symptoms have a massive impact on not only their quality of life, but
27:05also 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, 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 a part of the job that I think if we do it right, it can make the most
27:28difference.
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 after seriously injuring his ankle
28:20during 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.
28:38Okay.
28:39Dr. 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 have looked.
28:54Yeah, so obviously you know your ankle's fractured and got a dislocation there, okay?
29:01This outside sticky outfit is here.
29:04Yeah.
29:04Is that okay or is that...?
29:05So you want...
29:06This gap here is far too big so you want these two to...
29:09Alright.
29:09So basically all the ligaments and things that are holding your ankle together have all been torn whilst it's sort
29:14of fractured here.
29:15We 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 and bring
29:23your foot up like this.
29:26And put it into a cast in that position and get another x-ray and hopefully this gap on either
29:31side is a lot more narrow.
29:35If the ankle isn't reduced, the patient would be left in pain with his arteries and nerves under tension which
29:42could lead to permanent damage.
29:44In terms of what happens on a rugby pitch, it's probably up there seven, eight, those sort of bad things
29:49that can happen.
29:50If you get a nasty fracture dislocation of a joint, it's one of the worst things you can see.
29:56Dr. Mike is going to be manipulating the ankle into the correct position, while Dr. Phil sedates and monitors Sam.
30:03Just wiggle the toes for me, Sam.
30:05Perfect.
30:07That's great.
30:08So basically we'll be getting you nice and comfortable, a little bit sleepy, and then we'll be getting this back
30:13into place.
30:15That's some sleepy medicine now, okay?
30:17Yeah.
30:18Sam will be sedated with fentanyl and propofol, extremely powerful drugs that can affect respiration.
30:25With ankle joints, they're often very unstable joints.
30:30We will have to put it in a cast within a very particular position to try and make sure it's
30:35as stable as possible.
30:37But if you have an unstable ankle fracture, often if it is significant ligamentous injury associated, then it will need
30:44some sort of surgical intervention.
30:47All right, Sam.
30:57Bit of a lift of your arm, Michelle.
30:59Right over the tent.
31:00I know, I'm sorry.
31:02Also in Belfast, the resource team are performing an emergency chest drain on 59-year-old Michelle.
31:09Oh, okay.
31:10Sorry, Pat.
31:11You did really, really well.
31:15Michelle punctured her lung during a nasty fall at home, which has led to a tension pneumothorax, trapped air between
31:22the lung and the chest wall.
31:23Oh, please, okay.
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 a cut near
31:31where the heart is, there's nerves, there's arteries, it can cause bleeding, it can be a risk of infection.
31:36We want to make sure that we're putting it in the right place, that we're not going to cause injury
31:40to other structures around.
31:44You're doing really well, Michelle, keep that my arm up for us.
31:47True.
31:47We're nearly there, okay?
31:49Just don't want to lose a tract at the minute.
31:53Thoracic 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.
32:01Open that up.
32:02We'll get a little working, really quickly, just take three minutes to kick in.
32:07Oh.
32:08You're doing really well, Michelle.
32:09Nice big deep breath, of course.
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.
32:28If it sits within the skin, that can expand and cause air collecting under the skin,
32:32which is not helping drain the pneumothorax and potentially make people more unwell.
32:37Is it not over?
32:38Yeah, nearly over.
32:39Just putting the tube in, okay?
32:42That's the air coming out now.
32:43Okay, 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 that's come out already, which is good.
33:00Your lung's starting to inflate again, so that should make the breathing a bit easier.
33:03The wee tube has to stay in the chest while okay.
33:09Just a wee, wee neck there.
33:13Normally, if we have more time, we'd like to give people a bit more time to prep for this,
33:17but yours is a bit more emergent, Michelle.
33:22Can you just give us some deep breaths?
33:28Sorry, Michelle.
33:29You're doing really well.
33:30Last wee bit okay?
33:31Just one wee stitch to secure the tube, all right?
33:33You'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?
33:51It's attached to your little box, and that box stays below you at all times.
33:55Don't be swinging it about, okay?
33:57The drainage bottle is an air trap.
33:59It allows gas to leave the cavity, but not flow back in, creating a vacuum.
34:05There we go.
34:05Just be careful of that just in case you accidentally catch it on moving.
34:22Okay.
34:22I hope she's x-rayed.
34:25So, 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
34:31much better, so we're very happy.
34:33Do you feel comfortable?
34:34No.
34:34Okay.
34:35Well, your oxygen saturations are improving, and the chest actually is reassuring.
34:39So, the A&E team are going to do some more work-up, get you a scan of your, a
34:43CT scan,
34:44you know, like a big donut, to make sure you know how much injury is okay.
34:50With Michelle's immediate injuries treated, focus turns to how the fall might have affected
34:55the rest of her body.
34:56We apologise that it's so flat.
34:58Okay, Pat.
34:59When a patient comes in with one very obvious injury, it's easy just to focus on that injury
35:04and miss other potential injuries that might make them more unwell, but slowly,
35:10and 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
35:21from the fall.
35:23I've asked Orla to prescribe some anti-sickness for me, and then we'll lie flat and get up
35:27a 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
35:31flat, then she'll aspirate.
35:33Aspirating is when vomit enters the lungs, and can create deadly pneumonia.
35:38Hopefully that helps.
35:39I'm just checking these new wires.
35:44We're going to head up now for your scan, okay, Levi?
35:47Yeah.
35:47All right.
35:50Just putting your drain under your hand, okay?
35:53I'll take our grab bag.
35:54Michelle is still in a vulnerable condition and could have serious injuries, including
35:59a bleed on the brain.
36:00So medics take her to the CT scanner with an emergency bag.
36:03When we have a patient in a CT scanner, if the chest drain was to come out and we don't
36:07have the right equipment or staff to reinsert it, they could redevelop that tension pneumothorax,
36:13potentially could die from that.
36:15See that wee box?
36:16It can't head off anything and it can't fall on the floor and it can't get pulled, okay?
36:20Only a CT scan will reveal if Michelle is still in a life-threatening condition.
36:24Just watch a wee train box there.
36:46Thank you, bye.
36:47Do we give a IC recall then?
36:50I think we have a counter-attraction but I'm not sure it might have made up.
36:53Yeah, we'll see.
36:53There we go.
36:54In resus, the team are about to attempt to realign 21-year-old rugby player Sam's fractured
37:00and dislocated ankle.
37:02Yeah, go ahead there.
37:04I think we're still awake.
37:06We could get more if it needs to be.
37:08Dr. Mike is going to be manipulating the ankle while Dr. Phil manages the sedation.
37:20Oh, you're trying to clunk.
37:22I think it's all...
37:22I think it's all...
37:23I think it's all a demon.
37:24That's right.
37:26Fight.
37:27Fight me a little bit.
37:28Just try to keep that tension.
37:30With Dr. Mike holding the ankle in a correct and safe position, the team need to work quickly
37:35to secure it in place with a backslab plaster.
37:39Try and get that fibular height.
37:41Cut out of tension here.
37:43Sam, you're doing really well.
37:45Just keep taking nice big deep breaths.
37:48Matt is fucking metal.
37:51Actually, we could.
37:54We're going to have layer three.
37:57I'm just going to keep back the doors first.
37:59Sam's just chatting away to us.
38:01Hello.
38:01Sam.
38:02Yep.
38:03That's you all done.
38:04That was a good one.
38:04Is that all right then?
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.
38:13We'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 and any pain he was feeling
38:19during it.
38:20Is that her back in normal?
38:22Yeah.
38:22We'll get an x-ray.
38:23I think that's the best we'll get for the moment.
38:25Hopefully you're back in some recovery time now.
38:28Actually, we'll chat about it after.
38:30Yeah.
38:31So we'll give you a few minutes and then we'll get you back around for another x-ray and see
38:34what it looks like, okay?
38:35Yeah.
38:35Cool, Matt.
38:38We pulled it a bit straighter and tried to compress the joint back to normal.
38:41He has quite a lot of fluid in his joint, so that doesn't allow you to compress it back
38:46to looking anatomically normal, but 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.
39:08Right, well.
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?
39:18Yeah.
39:21So that's the front one.
39:22We'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.
39:38We'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, that's your fibula and this is your tibia,
39:49but you can see the angle of it, you 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 and then they'll come down and make an assessment
40:05and probably give 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. Cheers.
40:11No problem.
40:25You keep nice and still for us, OK?
40:28Also in Belfast, Dr Ola is accompanying 59-year-old Michelle for a CT scan
40:33after she suffered a serious fall.
40:36So we're going to have to lie a bit flatter, all right?
40:39Not for too long, just until I get through the scan
40:42and then we'll pop you back up again, all right?
40:45All right.
40:47Michelle has had a chest tube fitted to inflate her collapsed lung,
40:50but may still have other serious injuries from her fall.
40:54First couple of scouts we do is just put your arms down.
40:58You just keep your head nice and still, won't be long here.
41:03So we're expecting her to have some rib fractures for definite.
41:06She will still have some collapse of her lung,
41:08but hopefully it's re-expanded.
41:10We're scanning her head
41:11because she's got a laceration on the back of her head.
41:15Head and neck scan, so we just need to do the body now.
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 breathing again.
41:38OK, so the scan's done, so we can transfer her back.
41:44One, two, three.
41:46Sorry.
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.
42:00I'm going to 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. Michelle'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 the pneumothorax.
42:20They can't see any other big injuries, which is great.
42:22She's going to be admitted to the thoracic wards.
42:24She will probably need some pain relief and physio,
42:27and then the chest strain will come out hopefully in a couple 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.
43:06All right, it's supposed to be going that way.
43:20Thank goodness that Daphne didn't die, no.
43:22I'm still here to talk to your people.
43:35She's an independent 84-year-old lady who lives at home on her own,
43:40who manages very well on her own.
43:41So, again, that's how we knew that there was an issue, that something was wrong.
43:47Yeah.
43:48Like you and I will help me out.
43:52There is a problem black.
43:56People.
44:03And that's that's why you're hurting him,
44:04And that's her feet and edge.
44:06And that's where you're doing things like guinhing.
44:07And that's the thing that's keeping that idea of tough work.
44:07And you might find a lot, like a little, like a ninja town,
44:11what I think that's dove on or who is right?
44:14I was being in the back
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