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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.
00:10Get out of my way!
00:11It 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 position.
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.
00:51There's nothing wrong.
00:53Calm yourself down.
00:54People can become aggressive.
00:56What are you going to do?
00:57You'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 organization and see us.
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 can f***.
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 they cannot have sex to you, why you are drunk?
02:56I'm not drunk.
02:58I understand, I understand.
02:59When are you saying you are?
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, **** up, set up out.
03:20It's okay, calm down.
03:20Yeah, yeah, I appreciate that one.
03:22You are like a ****.
03:23Hey, alright?
03:24Calm down, calm down, calm down, calm down.
03:25What do you want to say?
03:26Why don't you shut the door and walk away?
03:29That way, what do you want to do?
03:32What do you want to do?
03:33What do you want to do?
03:33Yeah, but you're not listening to what I'm saying to you.
03:34Oh, that's not what you're saying.
03:35I am in a, I 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 to help manage these situations.
04:03Is everybody okay?
04:05Obviously not.
04:07This ain't my idea of a **** night at.
04:09Yeah.
04:09Shit, that, that three-arse run said I was intoxicated.
04:13Yeah.
04:13I said to her I'm not intoxicated, right?
04:16This character's come out with a plain,
04:18plump-putting BS that you are.
04:20I'm not in any **** trouble.
04:23Have you had any bit to drink for some wine?
04:25Listen, I've told her I'm a **** alcoholic.
04:28That's got **** all to do with it.
04:29Okay.
04:30I'm going out with cigarettes.
04:31Oh, okay.
04:31Come to, oh, Chris.
04:33Do you want to go out that way?
04:34Yeah.
04:34Why do you think people gradually have had a ****?
04:39Yeah.
04:40Listen to me.
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 to 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 with whatever the issue is.
05:05Ow!
05:06Ow, ow, ow, ow.
05:10Hello.
05:12My name's Nick.
05:13I'm one of the doctors.
05:14What's your name?
05:15Also in Newham,
05:17Dr 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?
05:29No.
05:29The ambulance said you had some alcohol with you when they found you.
05:32It smells a bit like you've been drinking,
05:34but if you haven't, we'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, no.
05:45Okay.
05:45I'm sorry.
05:46Fair enough.
05:46She denies having had a drink which makes it trickier because, of course, our dilemma is often
05:52is the patient just drunk or is the patient ill or injured and happens to have had a drink.
06:00Have a look in your eyes.
06:01Is that all right?
06:02Okay.
06:03Just rest your head back for me.
06:06Unresponsiveness, erratic behaviour and 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 without making sure that their brain is okay.
06:22The important thing is to make sure that we don't miss something more serious
06:26because we're assuming that somebody's had a drink.
06:31Can you help the nurse to get her out, get all her wet clothes or what?
06:34Yeah.
06:35Get her covered up with a gown, try and keep her warm.
06:40Start 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.
06:52If 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 relief.
07:33No.
07:34No.
07:34Is it shit at me?
07:36It's disgusting.
07:37In 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.
07:48You 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 stay 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, a 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 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 odds,
08:38and then move him to a resource area.
08:43Injecting cocaine is quite big of an issue at the minute,
08:46so 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.
09:13You're at risk of more and more damage.
09:15We need to do your blood pressure, okay?
09:18We need to do your blood pressure, okay?
09:19We need to 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, okay?
09:30Listen to me. We need to track your blood pressure so to make sure you're safe.
09:34You're all right, you're okay, you're all right.
09:37No.
09:39He's refusing all intervention, he's refusing investigations and he's getting kind of combative whenever we're trying to.
09:46So 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.
10:00I'm Rebecca, one of the nurses. I'm going to do your blood pressure, okay?
10:03You'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.
10:12He has a history of alcohol-related seizures.
10:15He's allegedly had two seizures tonight, back-to-back, last 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.
10:25I haven't seen him in a wee while, to be fair, but he's scaring me at the start there.
10:28I haven't seen him quite as flat, but he's coming round now, so I'm feeling a wee bit more reassured.
10:32Your wee blood test was okay, so we're going to get you into one of the major deadcharts
10:37and get you seen by one of the doctors, okay?
10:42Let me go. Finished. Right. Gone.
10:46A third patient has been brought in, a homeless man found in the street who has also been having seizures.
10:53The ambulance area can be very, very busy. They either don't come at all or they all come at once.
10:57There's a massive, massive percentage of people who are IV drug users in Belfast.
11:03Okay.
11:03Someone was worried you had a seizure tonight and phoned an ambulance.
11:09Right. Yeah, we'll get security. We have a gentleman and 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 because he's become quite fairly
11:21abusive and was shouting at us.
11:22It's not nice to have to put up with that sort of stuff. I suppose we're used to it in
11:26here.
11:27Some of us are quite, um, security. Oh.
11:33He's had a seizure?
11:34The patient in question suffers another seizure.
11:41What happened to you?
11:42Are you all right?
11:44Can you have a wee look around you? Where are you?
11:47He's coming around a wee bit there, so we'll get him on the trolley, yeah?
11:49Is he in the trolley? No, it's just because that's all over there.
11:54We're here to care for people despite what they might give us back or what their history might be.
12:01We'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, Redfield, medical or trauma.
12:23Recess have received notice that an 84-year-old woman is being brought in by a paramedic team.
12:29Yeah, hello. Thank you.
12:32This is Marjorie, she's an 84-year-old female.
12:35Properly two weeks ago, she hit the head on the back of a bed frame.
12:40And then today, she's 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.
12:56Coordination 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.
13:18I'd like you to the small of your left.
13:21Different-sized pupils can be an indicator of a serious issue with the brain.
13:27Another blanket for your heart.
13:28I was going to say, you've got cold hands. Are 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,
13:41doesn't know if it's day or night.
13:42Normally she's very independent, she 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, 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, if you keep looking at my nose, can you see my fingers wiggling?
14:12Yes.
14:12Yeah, okay.
14:13We're gonna need to do a scan on your head.
14:15Yeah.
14:16Okay?
14:17You let us know if you need anything, okay?
14:20The conservative artery is, she's got complete left-sided neglect,
14:24so what that means, she 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,
14:37the quicker we find out what's causing it.
14:40In older people, their brains, for want of a better term,
14:44shrunk down a little bit.
14:45Yeah, my mum died last year.
14:47Yeah.
14:47Yeah, yeah.
14:48The blood vessels that attach the brain to the outer layer of the skull
14:52are 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,
15:01that blood can sometimes collect over time,
15:03and not cause too much 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 period ago.
15:10Yeah.
15:10I'm not told that she's very independent,
15:12so she wouldn't always tell us.
15:16If 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.
16:02See you when you get back, Margie.
16:03You've got loads of glass in your hand.
16:06Hold on, can you put it on the bed?
16:07No, my God.
16:09In Newham Resus, doctors have been monitoring a patient for an hour
16:12to see if her unresponsive behaviour
16:15is a result of drinking or a head injury.
16:18So she's just found a bottle of vodka in her bed that was smashed.
16:24Luckily, she didn't injure herself on it,
16:25but, 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.
16:57Some of those patients have a long-term relationship
17:01with alcohol that's unhealthy.
17:02We see them a lot and we see them not 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.
17:21Yeah.
17:22Have you got any pain anywhere?
17:24No.
17:25No.
17:25Do you remember what happened?
17:26Why did you have to come to hospital?
17:29I don't know.
17:30I was sitting outside for begging.
17:34OK, and begging and drinking?
17:36No, not drinking.
17:38Just begging.
17:40OK.
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.
17:57OK.
17:58Do you live there on your own?
18:00No.
18:03Newham has the highest rate of homelessness in England,
18:06with 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.
18:36I can't.
18:38I'm sorry.
18:39I can't.
18:39Because I'm not ill not here.
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 OK.
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.
19:06So we'll try and find her some clean, dry clothes and let her go.
19:20Cute, ma'am.
19:21Cute, ma'am.
19:22That's it.
19:23Open nose eyes.
19:26In Belfast, the resus team are preparing for a patient who is being raced in
19:30after being stabilised at another hospital.
19:33I'm going to get a scan of her chest 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 canina thorax,
19:44so 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, so her oxygen levels went from only needing one or two litres
19:59to 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.
20:18Go ahead.
20:20Go ahead.
20:21Go ahead.
20:22And center, right up.
20:23Okay, right, right up.
20:25Michelle, my name's Orler.
20:26I'm one of the doctors on today.
20:28We've been expecting you so I know a wee bit about you, okay?
20:30We know we've got a collapsed 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, all right?
20:43Are you allergic to anything? No. Are 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.
20:53I'm going to take this arm for you.
20:55Sorry, Pat. I know this is a bit uncomfortable, okay?
20:59Okay.
21:00Hello.
21:00So my name is Mark. Hello.
21:02Hello.
21:03One of the classic surgery doctors, okay?
21:05All right.
21:05So I need to make a little cut in the chest, into 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 to take the edge off,
21:21all right?
21:22You're doing very well.
21:23With the tension pneumothorax, people can very quickly die without intervention.
21:27All right.
21:28Oh!
21:29Getting a chest drain in is a pretty uncomfortable procedure.
21:32Often times the patient's quite distressed.
21:34They're scared.
21:35They can't breathe properly.
21:36So we will often give them some sedation medication.
21:39Yeah.
21:39Sorry.
21:39A bit of a lift of your arm, Michelle.
21:41Oh!
21:41Right over the tent.
21:42I know.
21:43I'm sorry.
21:45And a wee relaxing chair.
21:46Okay, we should start the kick in in a couple of minutes.
21:49If you just breathe away, it's normal.
21:52Michelle is given pain medication, including local anaesthetic, where the tube will be fitted.
21:57Oh!
21:58I'm just looking for the noise.
22:00I'm just thinking about okay, but that will help for the rest of it.
22:02Is that a second to work okay?
22:04Yeah.
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?
22:19Can you feel that?
22:19Can you feel that?
22:21The chair 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.
22:38Is that uncomfortable about okay?
22:40If we don't get the chair strain in quickly, the person will become more unwell and more
22:44unstable.
22:45It's time critical.
22:46Kid going to cardiac arrest.
22:48Ah!
23:00Medical 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.
23:09Not, not, not.
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
23:23drank 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 with used drugs and night outs and then obviously alcohol,
23:36that side of things, disorderly behaviour, so the police are always M of them kind of
23:41cases.
23:43We get patients brought in by the police that have been found intoxicated.
23:48Whether 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.
24:12Amongst dealing with dangerous and difficult people, the staff still care for gravely ill patients.
24:18So we hold on on 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.
24:40The CT scan is a vital investigation that we do to see if there's any signs of either an
24:47area where there's not enough oxygen getting into the brain or an area where there's bleeding.
24:54Yep, that wasn't to mine, was it?
25:03Was it OK?
25:06Marjorie's nieces have been waiting for her in resus.
25:10Yeah.
25:10Did we realise that that was going to happen?
25:12No.
25:14Well, you're in the best place now.
25:16Yeah?
25:17They were at the counter to help you, weren'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.
25:30I'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 is 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.
26:22Stroke 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.
26:35Ischemic stroke treatment is time critical.
26:38Night time 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 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.
27:11Yeah.
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 part of the job that I think if we do it right, it 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.
27:39She's calm now.
27:40Yeah.
27:40I'm calm, but I'm getting more chills.
28:02I'm going to put your head back, okay?
28:04Yeah.
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.
28:38Dr. Phil is reviewing x-rays that Sam had when he first arrived.
28:42Dr. 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 worse than he looked.
28:54Yeah, so obviously you know your ankle's fractured and got a dislocation there, okay?
29:01This outside sticky output is here.
29:04Yeah, is that okay or is that...?
29:05So you want...
29:06This gap here is far too big, so you want these two to...
29:09Alright.
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.
29:16They 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.
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,
30:00while 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,
30:12and then we'll be getting this back into place.
30:15That's some sleepy medicine now, OK?
30:17Yeah.
30:18Sam will be sedated with fentanyl and propofol,
30:22extremely powerful drugs that can affect respiration.
30:26With ankle joints, they're often very unstable joints,
30:30but we will have to put it in a cast within a very particular position
30:34to try and make sure it's as stable as possible.
30:37But if you have an unstable ankle fracture,
30:39often if it is significant ligamentous injury associated,
30:43then it will need some sort of surgical intervention.
30:47All right, Sam.
30:57A bit of a lift of your arm, Michelle.
30:59Right over the tail.
31:00I know, I'm sorry.
31:02Also in Belfast, the resource team are performing an emergency chest drain
31:06on 59-year-old Michelle.
31:11You're doing really, really well.
31:15Michelle punctured her lung during a nasty fall at home,
31:18which has led to a tension pneumothorax,
31:21trapped air between the lung and the chest wall.
31:25You're doing really well.
31:26When we're putting in a chest tube, if you're doing it on the left side,
31:30you're making a cut near where the heart is.
31:32There's nerves, there's arteries.
31:33It can cause bleeding.
31:34It can be a risk of infection.
31:36We want to make sure that we're putting it in the right place,
31:39that we're not going to cause injury to other structures around.
31:44You're doing really well, Michelle.
31:45Keep that arm up for us.
31:47True.
31:47We're nearly there, OK?
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.
32:01Come on up.
32:02We'll get a wee bit more keen, really quick.
32:04It took three minutes to cook in.
32:07You're doing really well, Michelle.
32:09Nice big deep breaths for us.
32:11Dr Mark has to ease the tube into the gap his fingers were keeping open,
32:14without 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,
32:33which is not helping drain the pneumothorax and potentially make people more unwell.
32:37Is it nearly over?
32:38Yeah, nearly over.
32:39Just putting the tube in, OK?
32:42That's the air coming out now.
32:43OK, 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.
32:59Your lung's starting to inflate again, so that should make the breathing a bit easier.
33:02The wee tube has to stay in the chest wall, OK?
33:09Just a wee, wee neck there.
33:13Normally, if we have more time, we'd like to get 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, OK?
33:31Just one wee stitch to secure the tube, all right?
33:33You've done very, very well.
33:40The level's getting better, so that's good.
33:42The drain's working.
33:43So, Michelle, when you put your arm down, there's a drain that's coming out of your side of your chest,
33:48OK?
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, OK?
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 anything.
34:22OK.
34:22So, 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 were inflated, and she looks clinically
34:31much better, so we're very happy.
34:33Do you feel comfortable?
34:34No.
34:36Well, your oxygen saturations are improving, and the chest is actually reassuring, so the
34:40A&E team are going to do some more walk-up, get you a scan of your, a CT scan,
34:44you know,
34:45like a big donut, to make sure you know an injury's OK.
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.
34:58OK, Pep.
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, and might
35:10not 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.
35:25And then we'll lie flat and 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
35:31lying flat, 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 be wired.
35:44We're going to head up now for your scan, OK, Levi?
35:47Yeah.
35:48All right.
35:50Just putting your drain under your hand, OK?
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.
36:14OK, see that wee box?
36:16It can't hit off anything, and it can't fall on the floor, and it can't get pulled, OK?
36:20Only a CT scan will reveal if Michelle is still in a life-threatening condition.
36:24I'm just watching wee train box there.
36:47Bye.
36:47Do we get ICU recall then?
36:50I can go with a countertraction, but I'm not sure it might look.
36:53Yeah, we'll see.
36:53There we go.
36:55In 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.
37:22Yeah.
37:22I think it's a holiday moon, actually.
37:26You're fighting me a little bit.
37:28I'm just trying to keep that attention.
37:29With 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 back-slab plaster.
37:39Try and get that fibula piped.
37:41Keep it out of tension, huh?
37:43Sam, you're doing really well.
37:45Just keep taking nice, big, deep breaths.
37:48I'm not in fucking middle.
37:51That should be good.
37:52That should be good.
37:54We're going to learn at day three.
37:55Yeah.
37:56I'm just going to keep that person fast.
37:59Sam's just chatting away to us.
38:01No.
38:01Sam.
38:02Yep.
38:03That's you all done.
38:04What's a good one?
38:04Is that all right, then?
38:06You were talking away to us a wee bit, but...
38:08Do you remember anything?
38:11I was out there.
38:12One sec.
38:13We'll just put it down on a pillow here.
38:14Yeah, no more.
38:15The sedation has meant that Sam has forgotten the manipulation and any pain he was feeling during it.
38:20Is that her back in normal?
38:22Yeah.
38:22We'll get an x-ray.
38:23I think it's the best we'll get for the moment.
38:25Hopefully you've got any chance of recovery time now.
38:28Sure, we'll chat about it after.
38:30Yeah.
38:31So we'll give you a few minutes, then we'll get you back around for another x-ray and see what
38:34it looks like, okay?
38:35Yeah.
38:35Good, Matt.
38:37We pull it a bit straighter and try to compress the joint back to normal.
38:42He has quite a lot of fluid in his joint, so that doesn't allow you to compress it back to
38:47looking 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, Sam may
38:58still require surgery to fix the ankle permanently.
39:02I 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?
39:18Yeah.
39:21So that's the front on.
39:22We're pretty happy with that.
39:23That's as good as we're going to get that.
39:25Does 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.
39:50But 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.
40:10Fair enough.
40:10Yep, thank you very much.
40:11Cheers.
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 and then we'll pop you back up again, all
40:43right?
40:45All right.
40:46It's done.
40:47Michelle has had a chest tube fitted to inflate her collapsed lung,
40:50but may still have other serious injuries from her fall.
40:54The first couple of scans we do is just put your arms down.
40:58You just keep your head nice and still, it won't be long yet.
41:03So we're expecting her to have some rib fractures for definite.
41:06She will still have some collapse of her lung, but hopefully it's re-expanded.
41:10We'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.
41:19Just 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 and 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.
41:47Sorry.
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. Michelle's is back from her CT.
42:12The heart report actually is exclusively pneumothorax.
42:16From 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's ward.
42:24She will probably need some pain relief and physio,
42:27and then the chest drain will come out hopefully in a couple of days.
42:32There.
42:44Can 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, you're supposed to be going that way.
43:20Thank goodness I definitely didn't die, you know.
43:23I'm still here to torture 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.
43:42So, again, that's how we knew that there was an issue, that something was wrong.
43:48She's a good kid, and her husband was just generous enough to keep having quite a long time.
43:52You're welcome!
44:02By the way, I never fall back.
44:26I'll see you next time.
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