- 12 minutes ago
A&E After Dark - Season 7 Episode 6
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Short filmTranscript
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 the staff.
00:52I ain't got nothing wrong.
00:53Calm yourself down.
00:54People can become aggressive.
00:57You've been punched, kicked.
00:58You see the good, bad and the ugly.
01:01I don't do a ****.
01:02Yeah, we'll get security.
01:03The emergency department is like a battlefield.
01:05It's like organised chaos.
01:21The NHS record, on average, 340 incidents of threats, assaults, weapon-related attacks and destruction of equipment every day.
01:31Can we just quickly brief this?
01:33Because obviously she might kick off as soon as you've removed the handcuffs.
01:36With the night shift having a higher proportion of these events.
01:39No.
01:39Please.
01:40They're trying to help.
01:41Yeah.
01:41I'm fine.
01:42I'm fine.
01:43This is disgusting.
01:44Let's use your chicken damage before you're getting some chicken arms.
01:48No.
01:58Sir, before you there are people waiting.
02:02Waterfall's need to be checked.
02:03If you just have a sit down, then we will kind out.
02:06Yeah, you don't know the pain.
02:08Let me stab you one and then you find out how much pain there is in you.
02:12Sir, ask another time. Can you just sit down?
02:15In Newham, a patient with stab wounds to the chest and hand is refusing to wait his turn for treatment.
02:21This guy cannot tell me how much pain I got.
02:23Sir, he's not a doctor.
02:26If you can, have a sit and wait for a minute.
02:29I'll tell you.
02:30Sir, take him first.
02:32Sir, no more than talking.
02:36Both the patient and his friend are under the influence of alcohol.
02:44I need to go outside.
02:46No, no.
02:47You also come with a treatment.
02:49Sir, I'm going to go to the hospital.
02:50He can wait for you outside but not inside the department.
02:53No, he needs to be checked as well.
02:56No, no, no. There is no patient.
02:58At the moment, you are the patient. You need to be looked. If you want to take a seat.
03:01Okay. Take this off. Take this off. I'm going outside as well.
03:05Security are trying to defuse the situation by separating the man who was stabbed from his friend.
03:11But he won't stay without him.
03:13I need to go.
03:17Hello. I remember I'm one of the doctors.
03:19So, what happened to your hand?
03:21We were having real parties.
03:23Yeah.
03:31Have we seen the chest wound as well?
03:34Yeah.
03:34Sure.
03:35Did you do a stab check?
03:37Push me.
03:37We haven't looked to check whether he's got any other ones.
03:40I haven't physically, but she says there's no other injuries.
03:43Okay.
03:44What we want to do is a stab check and a look check.
03:47We're not missing any significant stab wounds.
03:49So, that's really important.
03:51Will you let me check that you haven't got any wounds anywhere else?
03:55Yes.
03:55Yeah?
03:55In those situations, you often don't know what injuries you've got.
03:58It's often hard, particularly with stabbing, that you don't notice all of the injuries.
04:06I know you think you're sure about where you've been stabbed, but because you've been stabbed,
04:10sometimes when there's lots going on, you can miss things.
04:13We're going to undress you and have a look everywhere, from the head to the toes.
04:17Is that okay?
04:19Despite seeming well when having his outburst, the patient may still have serious injuries
04:24from the stabbing.
04:25Just having a look on your head.
04:27Nothing on your head.
04:28No injuries there and no pain here.
04:30No.
04:30There's nothing there.
04:31Let's just have a look under here, darling.
04:33That's it.
04:34Well done.
04:34It's really difficult to be sure that, one, that the reason that their behaviour is about
04:40alcohol or their behaviour is about adrenaline from fear.
04:45The trick here is to see them as an individual and, on some level, try and move away from the
04:52labels there and establish a rapport with the individual in front of you.
04:57I don't always get that right.
04:58But sometimes it works and sometimes it's more difficult.
05:00You've got this one stab wound here.
05:03Okay.
05:04You're standing up.
05:04Yeah.
05:05I know.
05:05I know.
05:06I can see that.
05:07And that's why we're going to do a scan to look at that.
05:11The wound to the man's chest has a small diameter.
05:13But until he has a CT scan, Dr. Emma can't be sure how deep it is and if it's caused
05:19serious
05:20damage.
05:20Okay.
05:21Let's have a look at this hand.
05:23Okay.
05:24See what we got.
05:25Can you bend that?
05:26And again this bit.
05:27Can you bend that bit?
05:29Yeah, so I think that's superficial but it's sore.
05:32What we'll do is give it a little wash and we'll wrap it up.
05:34It probably will need stitches.
05:35We need to think about a chest x-ray or a scan of your chest and we need to make
05:39sure
05:39you're safe and we need to sort this hand out.
05:41Yeah?
05:42And I would like you to be a bit more sober before you leave because I'm worried about
05:46you not noticing if things get more difficult.
05:49Yeah?
05:51I'm hoping his CT scan will show that he hasn't really penetrated anywhere into his lungs,
05:57into his heart.
05:58We need a cigarette.
05:59Cibarate?
05:59Yeah.
06:00We need to sort this one out first, isn't it?
06:02But what we know from the experience of major trauma centres and from trauma as a whole is
06:07that we miss things if we don't look.
06:24I can triage her and then I'll discuss it with one of the doctors to see.
06:32What happened to you?
06:34I fell in the garden.
06:3681-year-old Nicola was brought in moments ago by ambulance and headed straight to x-ray
06:41before coming to recess.
06:43Let me see.
06:48Oh, Jordan.
06:49She smashed her leg into a concrete bar when she slipped in a muddy garden.
06:54Can I just tell you what we're doing first?
06:55So we're going to take this towel off.
06:57Then we are going to take anything that's on it.
07:00We're going to cover it with wet gauze just to protect it till the doctors come and see it.
07:03Is that okay?
07:04Perfect.
07:06Yep.
07:06You keep puffing away on that.
07:09It's great stuff.
07:13Nicola is using a self-administered pain-relieving inhaler of Penthox.
07:17Right.
07:18Nice big deep breaths, darling.
07:20Sorry.
07:21We're just lifting up.
07:22Take a couple of deep breaths.
07:22Well done.
07:23You're doing fantastic.
07:24Well done.
07:27Right, darling.
07:28We'll set this down again.
07:29Well done.
07:30Well done.
07:31Well done.
07:32While Deputy Sister Shannon is temporarily dressing Nicola's large wound, Dr. Orler has her
07:38x-ray results.
07:39She has a really nasty fracture through her distal tibia.
07:43So she had previous metal work in her leg from an ankle injury following a car accident
07:48about 12 years ago.
07:49So she still has a plate and some pins in her leg.
07:52She's a very nasty open wound.
07:54Nicola has an open fracture, which is when the sharp end of a broken bone painfully tears
07:59through the skin.
08:00So the problem with those is that they can be more at risk of infection, can be more
08:06at risk of neurovascular compromise, so there's damage potentially to nerves and blood vessels
08:11in the leg.
08:12And then if you look at the open upper part of her fibula, which is the other bone in
08:16her leg, she's fractured through the neck of that as well.
08:20And just one last remove of these toes to get to the side of this bed up.
08:25There we go.
08:27And it's just protecting it from anything in the kind of environment.
08:31It's also keeping it damp, so you don't want to put a dry dressing on as it will when
08:36we peel it off, we're going to peel any of that blood off and it'll just be more painful
08:39for her.
08:40Yeah, you have a really nasty fracture in that leg, but there's an open wound overlying
08:45the fracture okay.
08:46So there's a big risk of that for infection and we need to get it properly sorted out
08:51and it may need an operation okay.
08:53It's an operation.
08:54Yeah.
08:55So the orthopaedic doctors, the bone doctors are going to come down and have a look at it
08:58all right.
08:59Brilliant.
09:00A serious infection could be deadly for someone in their 80s.
09:03It's now a race against time to get Nicholas seen by the specialists and her wound closed
09:08safely.
09:09So if there's an open fracture, they've opened their skin so there's a direct tract into the bone
09:15for infection to settle in.
09:17So the sooner we can get them to theatre, the better.
09:19If we don't treat it quickly, there's a potential that you could end up losing that limb.
09:39At night, A&D's across the country see an influx of police, bringing in suspects and victims
09:45of crime and then often remaining on guard.
09:48Lovely, who are you at guard?
09:50Who?
09:51All the while, medics are treating a higher proportion of seriously injured people.
09:56They've definitely gone into muscle and that's why it's bleeding.
10:09We're getting away stand-bying, do you know?
10:12No.
10:12He's on a lot of pain as well as his blood pressure is high.
10:14He's 30 over 80.
10:17Hi, Bowie.
10:18Hello.
10:18I'm one of the orthopedic doctors.
10:20Yes.
10:21In Belfast Royal Victoria Hospital, Dr. Alok has arrived to examine 81-year-old Nicola,
10:26who has a severe open fracture in her leg.
10:29Why did it happen?
10:31I fell in the garden.
10:33It was a bank and it was very muddy and I slipped and I hit the concrete path.
10:38The leg is at risk of infection getting into the wound and bone, which could be particularly
10:43serious for an older patient.
10:45These kind of fractures, open fractures, the trick is to bring the patient to the hospital
10:50as fast as possible.
10:51So every hour you're late from reaching to the theatre, the chances of getting infected
10:56of that fracture and losing the limb were also so high.
11:00Do you mind if I have a small check on you?
11:02Oh no, far away.
11:04Wiggle your toes for me.
11:06Oh.
11:07Just the toes, yeah?
11:09Are you able to feel me touching you?
11:11Yes, I can.
11:12Are you feeling, yeah?
11:14Oh, that's so whatever that is.
11:16Can you lift this leg up for me?
11:19Yeah?
11:20You don't have any pain there, right?
11:22We definitely need to operate you on an emergency basis today.
11:25So you're not going to eat and drink anything from now on.
11:29Right.
11:29Yeah.
11:31Dr Ola from the A&E department is managing Nicola's care until she can go into surgery.
11:36Any fracture involved in previous metal work is also a little bit more complex to treat.
11:41So she's going to need to go to theatre for an operation, A to wash out and close the wind
11:46and then B to fix the fractured site itself.
11:50From our point of view in A&E, we just want to get it into a better position, get her
11:54comfortable,
11:55clean up her wind, but we wouldn't rush to close the wind here because it's going to need
12:00properly washed out in theatre under anaesthetics.
12:03Nicola's leg needs to be realigned as much as possible and put in a temporary cast to reduce
12:09the chances of further damage before surgery.
12:12We're just going to take a couple more pictures of this wound before we put the plaster cast
12:16on, OK?
12:17OK.
12:17As we were saying, you will need an operation.
12:20It will need to go to theatre, but it won't happen tonight, OK?
12:22Oh, right.
12:22So the plaster cast is going to get you into a better position for this fracture.
12:27There.
12:28Yeah, just for you to go.
12:30The pictures are for the orthopaedics and plastic surgery teams so they can prepare.
12:36This is your...
12:37Oh, yeah.
12:37OK?
12:38You remember this one from before?
12:39Yes, I had this earlier.
12:40Yes, it might make you cough a little bit at the start, but it's quite good for pain relief,
12:43OK?
12:44Have a couple of wee breaths for me, just so I can get it in your system.
12:49She's had some antibiotics to hopefully prevent infection and she's had a tetanus vaccine
12:53booster as well, just because there could be some grass and soil contaminating the wound.
12:58Can you pop away on your wee whistle for us there, OK?
13:01Correcting the position of the bones can be extremely painful, but if not done,
13:05the nerves and blood supply in the leg are at risk.
13:08So, a bit of manipulation of the leg, OK?
13:10You'll feel a wee bit of pulling and touching, but not too much, all right?
13:13Just in a better position.
13:14If it gets sore, take a nice big breath for me.
13:17That's it.
13:17Well done.
13:19Well done.
13:21Nice big breaths of that medicine.
13:22You're doing very well, Nicola.
13:24We're just putting a wee dressing over the wind, OK?
13:27Nice big breaths.
13:28You're doing very well.
13:30I'm slow.
13:31Yeah.
13:32Nice big slow breaths of that medicine for me, Nicola.
13:35Yeah, well done.
13:36Well done.
13:38Is that about as much manipulation as we're doing?
13:41Yeah, yeah, yeah.
13:42That's OK.
13:45Just a bit of wrapping going around, OK?
13:47So you feel a wee bit warm and a bit tight, OK?
13:53Just wrapping now, yeah?
13:54Yeah, just wrapping.
13:56Nearly finished.
13:57Just wrapping it up.
13:58Sorry, we'll catch a wee sore a bit there.
14:03Just lifting your leg up on a pillow for a bit of support, OK?
14:06That's the last movement, hopefully.
14:08You've done very well, Nicola.
14:09OK.
14:10That's us all done.
14:13She's very stoic.
14:14She didn't complain very much.
14:16She didn't ask her very much pain relief.
14:17And she tolerated her cast being put on very well.
14:21Now Nicola's leg is aligned and she's been treated with antibiotics for tetanus,
14:26she's safe to be transferred to the ward until she can receive corrective surgery.
14:30Hello, darling.
14:31How are you feeling?
14:32Oh, not terrific.
14:34Not terrific.
14:35Did you have a wee dose there?
14:37Yep.
14:37I think I did.
14:38That's OK.
14:39You've had some strong pain relief, so it might make you feel a bit snoozy, but that's
14:43OK.
14:43We're keeping a close eye on you, but you can have a wee dose if you want one.
14:47You've had a long day.
14:48OK?
14:49Yes.
14:49You're welcome.
14:50Right.
15:15In Norwich, Deputy Nurse Jessica has just received a patient who was
15:19brought in by ambulance.
15:20A 90-year-old gentleman has come in who has been found in his shower with the hot water
15:26running, and he's basically come in with a low GCS and burns to his torso.
15:30This is someone who is extremely unwell and may or may not survive this event.
15:35Same war.
15:36The human body runs around 37 degrees Celsius.
15:40A change of even two degrees can be serious and put organs under stress.
15:46Sharp scratch, lovely.
15:48With a patient that's been subject to temperatures like this, it's hyperthermia, so basically heat
15:55exhaustion, the organs start to fail, the muscles start to break down, and it can be really dangerous
15:59and it becomes critical.
16:02Eric's son Steve has rushed to his bedside.
16:05He should have gone around his girlfriend's at seven o'clock this evening.
16:08He didn't turn up, so she rung her daughter-in-law.
16:11She found him unconscious in the shower.
16:14She had to resuscitate him and sort of bring him back to life.
16:17Pretty shocking, really.
16:18Not a nice evening, but, yeah, he's still holding up just.
16:22Eric was unconscious and under hot running water for 12 hours.
16:28What's his temperature now?
16:3036.9.
16:31Oh, nice.
16:33With Eric's temperature now near 37 degrees Celsius, he's no longer hypothermic, but with
16:39prolonged exposure to hot water, it could have caused permanent damage.
16:43He's got some fluids running.
16:45We're going to get him some morphine.
16:48The team needs to determine what caused Eric to fall in the shower and what injuries occurred
16:53as a result.
16:54So, either we think he's probably had some sort of medical event and collapsed in the shower,
16:58or he's slipped and hit his head because he has a head injury as well.
17:04X-ray, everyone.
17:06OK, if you can hear me, just take a deep breath in.
17:09Lovely.
17:10Breathe normally, sir.
17:11Yeah, yeah, that's fine.
17:15Eric also needs a CT scan.
17:17For the CT, we're probably looking for any signs of bleeding on the brain, stroke,
17:22anything that would have caused him to collapse and lose consciousness.
17:25So, we're still sort of in the dark about why what's happened has happened.
17:29But we have had a discussion with the family to say that it's unlikely that Eric is probably
17:34going to survive.
17:37Even though he's naughty, you know, you kind of expect the worst, but you don't ever
17:42want to say goodbye, do you?
18:00Sorry, I'm pressing down.
18:03What happened?
18:04Somebody went at him with a knife?
18:05Yeah.
18:05And he grabbed the knife?
18:07Baby.
18:08Dr. Emma is handing over care of a patient who came in intoxicated with stab wounds in
18:13the hand and chest.
18:15I settled him down was really what I do.
18:18I went in.
18:19Was he agitated?
18:19His mate was agitated and I just felt like being in a corridor was really not the right
18:24place for an upset man who'd been stabbed.
18:26He's calmed down a bit now.
18:27That's okay.
18:28Hold on.
18:28I'll just put extra bandage in because you're going out.
18:31No problem.
18:31No problem.
18:32I need to because I'm a pain smoker than I've been craving for the last four or five
18:37hours.
18:37Yeah.
18:42I'm Nick Jenkins.
18:43I'm the consultant in charge here tonight.
18:44Okay.
18:45Somebody came at you with a knife, I hear.
18:47Yeah.
18:48What happened?
18:48He went in the kitchen and he said, are you me?
18:51I'll stress you up and this and that.
18:53Oh dear.
18:54I'm sorry.
18:55It's a big knife.
18:56It's a big knife.
18:57So he stabbed you once in the chest.
18:59Yeah.
19:00Can I have a look?
19:02It's ready enough now.
19:03I know.
19:04Just because it doesn't look deep, we will need to check and do a scan.
19:08Okay.
19:08And then we'll have a worry about your finger as well.
19:10But we'll worry about your finger afterwards.
19:14Because under there is your lung.
19:15So we've got to worry about that first.
19:17Is that all right?
19:18Mm-hmm.
19:19Until we do the scan, no smoking.
19:22I've been waiting for five hours for my fingers.
19:24I'm sorry.
19:25I've been waiting for five hours.
19:27I'm going home.
19:28Don't go home.
19:29You've been stabbed.
19:30I don't care.
19:31If you don't allow me to have to go home right now.
19:34It can be difficult with patients who are drunk, who one minute want some help and then
19:40the next minute don't want some help.
19:42It can be difficult to help them understand our priorities.
19:47Not all life-threatening injuries are immediately obvious.
19:52And so we need imaging to make sure that they are safe.
19:57Let me get you scanned.
19:58And I'll come and see you again.
19:59Okay.
20:00All right?
20:00Do as quick as possible.
20:04Dr. Nick has only been gone moments.
20:10But the patient is preparing to leave for a cigarette.
20:12They're ready for your scan.
20:14Ready right now.
20:15Ready right now.
20:15Come on.
20:17Let me walk you around.
20:18Let me walk you around.
20:20Come with me.
20:22And then you can go and have your smoke after.
20:28Oh my days.
20:29This hand is bleeding too much.
20:31Despite the bleeding in his hand becoming more serious, the patient still needs an emergency
20:36scan of his other stab wound to his chest.
20:41I'm just going to add pressure.
20:44I'm not going to do anything because I don't know the extent of the injury.
20:47Okay?
20:51You'll go back for the proper dressing.
20:53Later.
20:54Okay?
20:55Okay.
20:56I need your arms on the pillow.
20:58And the other one as well.
21:06That's right.
21:07You should do it too.
21:11So you're going back to A&M?
21:15While the patient waits to find out if the stab wound to his chest is serious, his hand
21:20continues to bleed at an alarming rate.
21:23This blood is not stopping for some reason.
21:25I need all hands on deck for this.
21:27He's bleeding quite a bit.
21:29Sir, I need you to press really hard on it.
21:31Don't follow the blood.
21:33Don't worry, sir.
21:34We'll get you back.
21:48Don't worry.
21:49Don't bother me.
21:49You've been skipping years ago.
21:51Nice.
21:51Don't tell me to come down.
21:53She's the one in the wrong, not me.
21:55The number of violent attacks in UK A&Es has almost doubled in the last five years.
22:02I'd say violence and aggression used to be rare.
22:06I think we're seeing more of it now.
22:08Nobody goes to their workplace wanting to experience violence and aggression.
22:12So it's not something that we're, you know, particularly keen to see more of.
22:16We're not going to be able to let you back in whenever you're behaving like this, OK?
22:19So...
22:20A&Es at night still treat 10 million people a year.
22:23Hello, Jenny.
22:26Every person that comes in, whoever they are, whatever they may or may not have done,
22:31our job is to see them as a patient, as a person, assess them top to toe,
22:36as we would for anyone else.
22:38He has the side of his face.
22:40Stop it!
22:41You know what I am!
22:5590-year-old Eric was found after being unconscious in the shower
22:58under hot running water for 12 hours.
23:02He's a bit more responsive now to voice.
23:05Eric's son Steve is with him and has been told that his father may not recover.
23:10I saw him coming out of the ambulance and I thought,
23:14well, that's not looking good, bless him.
23:15He's very frail.
23:17He's not very responsive at the minute.
23:19It would be nice if it didn't happen, but we are expecting the worst, so...
23:23Dr Lucia is working with Deputy Nurse Jessica in recess tonight.
23:27He's a stubborn old thing.
23:29Well, this is a good thing for him.
23:30He's very independent.
23:31He is very independent.
23:32He's got a stair lift and he wouldn't use it.
23:34Has he got a pendant alarm?
23:35Don't even go there.
23:36I said, do you want a necklace or a bracelet?
23:38I'll have a bracelet.
23:39A week later, he says, I ain't wearing that bracelet.
23:41Give me a rash.
23:42So I said, right.
23:43So I got...
23:43I changed it for a necklace.
23:45No, I ain't wearing that.
23:46Give me a rash.
23:47So now I put it on a boot lace.
23:48I put it on a boot lace round it.
23:50Has he got it on?
23:51No.
23:52But he was in the shower though, wasn't he?
23:54Yeah, but you let your day are shower proof.
23:56But I bet it's still sitting on his bedside cabinet, so...
23:59Eric had a CT scan to determine if he had any further injuries from his fall
24:03and what could possibly have caused it.
24:06Eric's CT has come back and that's normal.
24:09But his bloods have come back and it shows an elevated troponin,
24:13which is the cardiac enzyme.
24:15It's come back very, very high, which suggests you might have had a cardiac event.
24:19While Eric's heart now seems stable, the impact of the hypothermia from the hot water
24:24could have caused irreparable damage.
24:27Basically, the plan is just to sort of monitor him overnight to see how he does.
24:31He is obviously still very frail, so it could still be a poor outcome,
24:35but we hope for the best.
24:37His family said he's quite a stubborn man, so hopefully he fights on.
24:54Yep, go ahead. Yep.
25:00In Belfast Royal Victoria Hospital,
25:03Sister Carleen has been alerted by red phone of an incoming ambulance.
25:09It was a very chaotic scene, so they haven't given me any offs.
25:12He's a 42-year-old in our residential home.
25:14Uh-huh.
25:15Fine seizing in a chair.
25:16At 10 past 10, they got there, he was still seizing.
25:23Dr Rachel is managing incoming emergencies in resus tonight.
25:27So his GCS is three, his ongoing seizure activity for over an hour.
25:32Unknown epileptic.
25:33Yeah.
25:33A Level 3 GCS is the lowest level of consciousness that can be assessed,
25:39indicating no eye-opening and no verbal or motor response.
25:42On three, right?
25:44One, two, three.
25:47I have suction here as well.
25:49Yes, he's rigid.
25:52Okay, vomiting.
25:57Started to vomit in the ambulance, so we don't have a secure airway.
26:00He's still seizing.
26:01Not bad.
26:01With the patient seizing and vomiting, he could either choke or inhale vomit,
26:06causing aspiration pneumonia.
26:08Do you want me to do airway?
26:09Yeah, you take a airway there.
26:11Can somebody listen to that phone if anesthetics?
26:13Carleen?
26:14Yes.
26:14I believe anesthetics.
26:16Would you listen to the phone?
26:17Okay, so he's got a very rigid jaw and he's actively vomiting.
26:22So he's going to need rapid sequence.
26:24The medics prepare for a rapid sequence induction,
26:27an emergency procedure inducing paralysis in the patient
26:31to allow him to be intubated with a breathing tube.
26:35Okay, so Michael's doing airway.
26:36Stacy, you're doing monitors.
26:38You're doing line and I'm going to do line
26:39and then I'm going to stand here and lead.
26:41So we've got one line in, yeah.
26:43It's not working, none of them are working.
26:46Anyone have scissors?
26:47Because this is wrapped up properly here.
26:49So we're going to have soiled airway.
26:50It's going to be a difficult airway, Michael, yeah.
26:53Let's try and get access.
26:54So we'll try once more for ID and with no success,
26:57which can go I-O.
26:58The medics are struggling to put in a cannula
27:00to give the patient the paralysing agent.
27:03Line's in, guys, or do we need to go I-O?
27:05Probably I-O.
27:07The team needs to get I-O, or intraosseous access,
27:11where medication is given directly into the bone marrow.
27:16Access is a difficulty, so we're going I-O now
27:18because we've tried twice.
27:20You're okay, you're okay.
27:26If the medics can't paralyse the patient
27:29and insert a breathing tube,
27:30he may choke on his own vomit
27:32or starve organs of oxygen,
27:34causing death within minutes.
27:37You're all right, sir, you're okay.
27:53Let me press it for you.
27:55In Newham, a patient stabbed in the hand
27:58and under the influence of alcohol
27:59has begun bleeding profusely.
28:01I know it's painful, but I need to...
28:03This is what it's going to do,
28:04and I'm going to get you some medicine
28:05to stop the bleeding, okay?
28:08He's bleeding quite a bit for a finger injury.
28:11Dr Sid has taken over the patient's care in Majors.
28:16Okay, this is the medication going on to stop the bleeding,
28:18and then I'm going to clamp down hard on top of it, okay?
28:22And on top of the wound, go, go, go.
28:28Dr Sid.
28:33So we've put down some TXA, which is medication to help the bleeding,
28:37and then we're going to put on some local anaesthetic in bits
28:41and go from there.
28:44The local anaesthetic contains adrenaline,
28:47a vasoconstrictor which narrows blood vessels
28:49and should reduce the bleeding.
28:51I will hold your hand for you
28:52because the injection stings a very little bit when we start.
28:57I'm just going to go under the stuff for a second.
29:00You want to touch deeper?
29:02Yeah, perfectly.
29:04Good, good, good.
29:07Good.
29:09The next best thing we can do is close the wound
29:12so that it stops bleeding.
29:19I found an artery.
29:20I think it's hurting.
29:22It's hurting, yeah?
29:23Yeah.
29:23Registrar Rosie is supervising Dr Sid.
29:26Because it took a lot of cleaning and controlling
29:27to get to this point,
29:28but I finally found the source of the actual bleeding.
29:32And it's right there.
29:33Yeah.
29:36Let's just try and get hemostatic control for now,
29:38have a chat with plastics.
29:41We're not going to get it with pressure is the problem.
29:43Yeah.
29:44Because even his last two dressings bled through.
29:46That's fine.
29:47You put direct pressure on that.
29:48Let me go have a chat with them.
29:49Yeah.
29:50Arteries carry oxygenated blood away from the heart under high pressure,
29:55which, if punctured, can cause rapid blood loss.
29:57When there's an injury to an artery,
30:00we're worried because if it's delivering essential oxygen
30:03to a part of your body,
30:04that area is now starved of oxygen,
30:06so it becomes at risk for essentially dying.
30:11If the bleeding isn't controlled quickly,
30:13there's a chance the patient could lose his finger.
30:15Yeah.
30:15We can put a pressure dressing on for the time being.
30:19It will just, he will eventually soak through it.
30:22But I think he would be suitable for the transfer.
30:27We've had a chat with the surgeons who look at the hands,
30:30the plastic surgeons,
30:31I don't know if they said this thing,
30:32but they aren't based in this hospital.
30:34They're in the Royal London Hospital.
30:36So after we get a bit of control on the bleeding,
30:39we need to get you over there by ambulance.
30:44I would be very worried about having you go out
30:46with the act of bleeding in your hands, OK?
30:51OK, OK, but let's get the bleeding stopped first, at least.
30:57It's a huge bandage that we can do.
31:02Sorry, it's a lot of bandage, I know.
31:04Do you want to see the end of the tip?
31:06Ready, just to...
31:06That's fine.
31:07Then we can, um...
31:12How are you feeling?
31:13OK?
31:14OK.
31:16I'm calling from Newham Hospital, Edie.
31:18I've got a patient that needs to transfer to the Royal London
31:20for an acute limb-saving procedure that we cannot perform here.
31:25The intoxicated patient has decided not to wait.
31:29Look, I'm...
31:30Medically, I'm advising you not to go and just stay with us.
31:33When patients are drunk,
31:34naturally their inhibitions are lowered
31:36and they become the biggest obstruction to giving them the care that they need.
31:40They have the potential to make it a very painstaking interaction
31:44and a much longer process to deal with.
31:46If you are going to go for a cigarette, I need you back as soon as possible.
31:51Here.
31:51Just know it's going to be a little bit harder to get everything done
31:54that needs to be done.
31:56One cigarette and back here.
31:57Yeah.
31:57Not anymore.
31:58Straight back here, yeah?
32:00Patients don't always do what we ask them to do or what we say.
32:03It really depends.
32:04But at the end of the day, it's a hospital, not a prison.
32:07Sometimes it's challenging when they're working against
32:08what you're trying to do to help them.
32:10But at the end of the day, it's their decision.
32:27The adult cardiac arrest team to A&E majors.
32:31I mean, how much did it cost you anyway?
32:34You need 20 quid.
32:36Don't make me laugh, it hurts.
32:39That's me.
32:41Let's go.
32:43In the waiting room, 23-year-old Amina and her friend, Millie,
32:47have come to A&E after an accident while out drinking.
32:50What's what we talked about tonight?
32:52So, I was at a club and I fell down like two flights of stairs.
32:59I hit my head really, really hard.
33:03Nurse Vastine is running triage tonight, assessing the urgency of patients.
33:07Did you lose consciousness?
33:09I don't think so.
33:11I don't think, no.
33:12I don't think so.
33:13And have you had any vomiting at all?
33:16No.
33:16No.
33:17And do you feel dizzy at all?
33:20Not dizzy, I just have a bit of headache.
33:24You've got an earring in there.
33:25Mm-hmm.
33:26Mmm.
33:28So you've already got some Steri-Strips on it,
33:30and you've got the Steri-Strips on.
33:32We went to...
33:32You went to the musical town.
33:33Yeah, bless them.
33:37Any visual disturbances?
33:39I don't think so, no.
33:42Head injuries can be deadly,
33:44but alcohol consumption makes them hard to assess,
33:47so Nurse Vastine needs support from Dr Harris.
33:50She's fallen down roughly eight to nine steps.
33:54Eight to nine steps?
33:55Yeah.
33:55So I fell head first.
33:57She's consumed some alcohol tonight.
34:00Any bleeding from anywhere else?
34:01No, just here.
34:06Let me speak to Ella.
34:09Yeah.
34:10The mechanism of Amina's fall and her alcohol consumption
34:13could indicate serious hidden injury.
34:16So head injuries are quite serious.
34:17We're taking it seriously,
34:18especially if the mechanism matters a lot,
34:20and if there's alcohol involved.
34:22You can sometimes miss intracranial bleed,
34:26which is bleeding in the brain.
34:28We've got a young lady in front door,
34:31resting her scene,
34:33um...
34:34..failed on eight to nine steps.
34:35Underneath her alcohol.
34:37OK.
34:37She has some bruises in her eyes.
34:39And she's self-presented?
34:40She's walked in with her friend.
34:43If Amina has a major bleed on her brain,
34:45it can lead to a coma.
35:03Do you want this up, just in case we fall off?
35:04Yeah, yeah.
35:05We're gonna need to get in more positions anyway.
35:07Dr Rachel and the team are trying to insert
35:09a breathing tube into a patient
35:11who's been vomiting and seizing for an hour.
35:14So just to summarise,
35:16you have to do risky airway with the bone marrow, for sure.
35:19Then we'll do intubation.
35:20Yeah.
35:21So give two mls of fentanyl.
35:23To insert the breathing tube,
35:25the patient is going to be given fentanyl to sedate him,
35:28which is being injected directly into his bone marrow.
35:31OK. Give one minute's airway.
35:35That's blood pressure.
35:37Yep.
35:38That's your friend.
35:39If the medics can't insert the breathing tube,
35:42the patient's airway won't be protected.
35:44He could choke on his own vomit and die.
35:47I've won't do it.
35:56You told me it's OUR right play.
36:01It was my sonny.
36:02That Verb야지irable thing is she won't be taken away.
36:02It was so fun.
36:04I don't know.
36:05Thatron novio is okay.
36:08Yes, I don't know.
36:09Look at theTrawarznut too about me too.
36:10Why.
36:10A man who's walked down.
36:10Uhh handlite,
36:11That's good.
36:12I'm ready to go.
36:19So we had to intubate this man. He was actively vomiting with a low GCS, so his airway wasn't
36:26secure and he was still seizing, so we needed the sedative drugs to stop. Seizures was thankfully,
36:33thankfully that worked.
36:37Between the intubation and fentanyl, the patient has stabilized, but he could still
36:42have underlying issues.
36:43CT brain, if it's okay, on a 42-year-old status, over an hour, just been tubed. GCS is three.
36:51No TBI, that's all I know, history-wise. He was actively seizing, yeah. Like, rigid, tonic-clonic, yeah.
37:01So for this gentleman, he's known epileptic, so that's the most likely thing to have caused
37:07his seizures tonight. We do have to consider other causes, things like alcohol,
37:13drugs, and trauma. So if he had a large bleed in his brain, that could cause him to have
37:20a seizure, so he was going for a CT scan.
37:25CT's ready for him.
37:26He's stable, but he is critically unwell. The worry is that he's been seizing for over an
37:32hour, so there's going to be a large element of hypoxia there to his brain prior to coming
37:38in the hospital.
37:40Hypoxia is a lack of oxygen to the brain, which can cause permanent damage.
37:45The concern would be, has he got a hypoxic brain injury because of that? So only time will
37:52tell how he's going to do it.
38:06So, did you just tell me exactly what happened?
38:08I fell down some stairs.
38:11OK.
38:11I, like, fell, like, face first, and I tumbled down all the way to the bottom.
38:16Dr Mahmood is taking over care of Amina, who smashed her face on a night out raving.
38:22OK.
38:22Did you lose your consciousness?
38:24I don't think so, no.
38:25I think the main concern is missing a bleed or swelling inside the brain. You need to be
38:31very careful and monitor them. And our goal is to prevent small injuries becoming more
38:41life-threatening injuries.
38:43Dr Mahmood will need to fully assess Amina to clear her of any serious injury.
38:48Any pain in the neck?
38:50No, not in my head.
38:51Can I just feel...
38:52No, of course.
38:53It's OK.
38:53Any pain?
38:55No.
38:55Excellent.
38:56Can I just see your hands?
38:58Is it tingling or not?
39:00No tingling, no.
39:01Excellent.
39:02The patient, she is fit, healthy, young, she has a stinted injury, she doesn't have any
39:05lip flaws, so basically she is not fitting the criteria of having any scalp.
39:11With a serious brain injury ruled out, Dr Mahmood can now take a look at the wound next
39:16to Amina's eyebrow piercing.
39:22So, basically, superficial wound. It does not need stitching, actually. I think it's a strip
39:29and glue should be fine.
39:31So I don't need stitches.
39:33Yay!
39:33I'm so excited, I'm scared of needles.
39:35How is it?
39:37No.
39:37I don't know what you're saying.
39:39Can we take it...
39:40No.
39:40Can we take it out?
39:41Because basically...
39:42You can always get it repaired.
39:45No!
39:45Yeah, because it might stop the healing and it might leave a scar, so better to just take
39:50it off.
39:51And also it might cause some sort of infection.
39:54Yeah, infection or anything.
39:56Because it's in...
39:56Yeah.
39:57I have to, though.
39:59Yes.
40:01That's what I do.
40:02Sorry, it's so dramatic.
40:04I've had it done three times and this is the only time it's healed.
40:09We all know that alcohol can, you know, exaggerate emotions and reduce inhibitions.
40:16So I think the most important thing is to stay calm and explaining what we are doing
40:23and giving reassurance to the patients.
40:28Do you know how to do it? Do you know how to take it off?
40:30No, I can't take it off.
40:31Should we put it on my hand?
40:33Should we put it on my hand because it's going to hurt?
40:35So, how to take the...
40:36Ow, ow, ow.
40:37Just that, should I?
40:38Sorry, I would just try to be as gentle as I can.
40:41Ow!
40:42Sorry.
40:43So, no, it's fine.
40:43I think it's working.
40:46Just hang on.
40:48Okay, let me just bring the...
40:50The tweezers?
40:51The tweezers.
40:51Ooh.
40:52Try the tweezers.
40:53Very soft.
40:53With this one, I will try to twist.
40:56Ow, it already hurts.
40:58Sorry.
40:58Sorry.
41:00Ow.
41:00Ow! Sorry, sorry.
41:03It's part of me. It's all supposed to happen.
41:06Oh, that's weird.
41:08It's out!
41:09I'm sorry.
41:10Sorry, but this is going to help you heal.
41:13I just need to clean the wound.
41:16Look, there's worse to be going through.
41:18So this one, I'm going just to clean it.
41:20I will try to be as gentle as I can.
41:21No, just, it's fine.
41:24Ow!
41:25So the wound now is clean?
41:27Yeah, it really hurts when you do that.
41:29Okay, sorry.
41:29Makes my headache a bit worse.
41:32Wow, that hurts.
41:35Keep this one for 48 hours.
41:37Okay.
41:37Don't apply any water.
41:38Don't remove the dressing.
41:40Okay?
41:41We might need to give her tetanus toxoid.
41:44It's just a vaccination.
41:46Because, basically, the wound, it was looks dirty a little bit.
41:50I was going to be talking about.
41:51I'm scared.
41:53Tetanus is a potentially fatal infection
41:55that can be prevented with regular immunisation.
41:58Do you always hold your hand?
41:59Yeah, so you have to hold my hand.
42:00I can't do an ejection alone.
42:03Relax.
42:05I am!
42:06I am!
42:06I am!
42:06I am!
42:07I am!
42:07I am!
42:07I am scared!
42:08I am scared!
42:10Okay, it's fine.
42:11I am actually, I am fine.
42:12Yeah, it's fine.
42:12It's fine.
42:13It's fine.
42:14It's fine.
42:15Amina, do a look at it.
42:17See, I am glad I stayed calm and collected.
42:20Yes, you stayed very calm.
42:22Calm, collected, and didn't panic at all.
42:26Right, I guess it's home time for me.
42:29Amina and Millie are free to go.
42:32I think this is her life lesson.
42:34You should have wore flats.
42:36It's fine.
42:37It's fine.
42:46Stay there for me, please.
42:47Don't leave yet.
43:02No, I wouldn't plan for this.
43:04I don't recommend it, honestly.
43:06Even though I am being so well looked after.
43:45I've had a whole nice night.
43:47I know it didn't end the way we wanted it to, but it could have ended worse.
44:17ANE AND CLEARS
44:170
44:17tangible
44:170
44:170
44:170
44:1804
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44:31Transcription by CastingWords
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