Pascal's Wager Casualty

No, please. Please. No!

Once you're discharged, straight home. And no more rummaging

-through bins.

-I ain't got a home.

-Is there a hostel you can go to?

-If there's spaces, maybe.

Then do that. And don't think because I asked that I give a damn.

You're religious, yeah?

I suppose this is a bit of a giveaway.

Do you wear it all the time?

-First time at work.

-Ah. Looks good.

Ahem.

I'm fairly sure I told you to find somewhere clean and safe to sleep.

-Well, did you find somewhere?

-What do you care?

Come on, Derv.

Come on.

So take one puff.

Good. Take another puff.

-Better?

-Thank you.

Good.

£7.40, please.

You can pay us next time. OK?

Should I not make a living?

Meshugana.

-I may be slow, but my ears work just fine.

-What?

-I hear things.

-What do you hear?

I hear there's a lot of nice single women in Florida.

So you've got two years to get rid of me?

One year, 11 months and four days.

I'd rather keep what I have.

So take your pills and stop getting worked up.

OK.

What do you want?

Is this about Rani?

You don't ever say her name.

You will never contact her again.

If she tries to contact you, you will ignore it.

Understood?

-Understood?

-Yeah. Can I go, please?

Of course.

You're wrong, Jay.

So the red cabbage and chilli flakes he's got all down him?

Could be stir-fry.

What? I'm only saying.

It's not food.

-Right, he's losing colour.

-He's going into anaphylactic shock. Let's get him to resus.

You promised.

-Things change.

-But you said.

-You get away from her. You deal with me.

-Come on then, old man.

No more.

-Yes, more.

-No, we've done everything for you.

-It's enough.

-I decide when it's enough.

No. Give them nothing, Rachel.

Give me what I want. Come on, darling. Give it to me, and we're gone. All right?

-I won't need to come back here again.

-That's what you said

last time.

You should've gone before we got in the car.

I gave her the keys. Oh.

Come on, then.

-What's going on back there?

-I'm coming, I'm coming.

Great.

Just great.

-Can you stand?

-Just give me a minute.

Mendel!

It's all right.

This couldn't have happened tomorrow or three days ago?

Or basically any day that avoids me waking up to an unconscious girl in my houseboat.

This isn't happening.

OK. Sats at 91%, BP's still falling.

OK, talk to me.

Right, we've given him 0.5 mg of one in 1,000 adrenaline IM.

-200 mg hydrocort...

-Come on, Mads.

10 mg chlorphenamine.

Right, let's bag him and intubate, please.

Right, can we get a size eight tube and a bougie, please?

-Mads?

-Come on.

Get another one!

Vitals?

Pulse tachy at 120. Sats now 92.

I'm telling you, darling. Don't argue with me. That bruise wasn't there yesterday.

There's no obvious cause. I haven't even moved her!

What do you think, nurse? Any ideas?

No, I didn't think so.

Right, come on. Time to go.

It's OK. I'm a doctor.

-Just leave it. I'm fine.

-No, you're not.

-I am.

-You're not.

-Lenny, just leave me alone.

-It's starting to affect your work.

-I apologised to Mr Jordan.

-What about me?

-I don't need to explain myself to you.

Not as a doctor, no. But I kind of thought perhaps as a friend.

-As a friend, you know to leave me alone.

-Right, yeah.

-You've been saying that for weeks as well.

-Exactly.

All right, so I'll just leave you alone and let you give up your life to some guy who two months ago could

-not have identified you out of a line-up.

-It's not about that.

-It is.

-It isn't.

-It is.

-It isn't!

-It is!

-Lenny, sod off.

Just go, please.

-I'm sorry, I...

-Please.

You might have mentioned you were only a child before I let you collapse in my house.

Come on!

SIREN WAILS

Patient on board!

Patient on board.

Here we go, darling. Thank you very much.

-All right, take your time.

-OK.

-OK, got it?

-Yep.

-OK, take your time. Good girl.

-Jeff?

-Yeah?

-Can you and Gary take Mr Lan in, please?

-Er, yeah, sure.

-You all right?

-Yeah, yeah. I'm fine.

If you just want to follow Jeff, he'll take you to where they're going to treat your husband.

Thanks. Wayne?

Good luck.

-Why is she back?

-She's a patient.

-I can take it from here.

-Come here.

Let me help you, OK? Got her?

Yeah.

Weapon's still in situ. On arrival GCS was 14, it's now 12.

-He's had fluids, oxygen, 10 of morphine.

-Tess?

-Middle bed, please.

-Thank you.

-Do we know what happened?

-He was pushed. I didn't see.

-I'm here, darling.

-Nearly there.

-Take care of him.

-All right, when you're ready, please.

-Everybody got some?

-Yeah.

-On three.

One, two, three.

And across gently. One, two, three. OK, good.

Great. Thank you, Jeff. Have a safe day.

Right, can I get one unit O negative blood, please, cross-match two units?

Oh, nasty, yep. OK, let's get a trauma series, please.

Folks, can we get the ultrasound in here? Linda?

Er, let's get his history.

Mr Lan, I'm Mr Jordan. I'm the clinical lead here.

I'm just going to have a feel around. Tell me if it hurts anywhere.

Rebecca Matlock. Get her patient number from yesterday's records.

I still think we should have taken her to resus. They've got the equipment.

-She's my patient.

-OK, let's get her over then.

On three. One, two, three.

-I don't understand.

-She's my responsibility.

But this place doesn't work like that.

Dylan, you're putting her at risk.

Your patient, the one that you brought in, he's tachy and he's in atrial fibrillation.

-You saw the monitor.

-Even with the anti-coag I'd give him a 50:50 chance at best.

That's just guesswork.

The injury, together with the anti-coagulation, is consistent with his condition. This is not guesswork.

Abdominal injury is a special interest of mine.

If I can't fix my patient,

rest assured, I will be the first to say I can't fix my patient.

-I thought you'd already fixed this patient.

-Long story.

I look forward to hearing it.

Cheers, Dixie.

She followed me home. It was late.

-Did you let her in?

-What else was I supposed to do?

-You're an idiot.

Thank you so much.

-Mads?

-Yeah?

Thank you.

96 over 64.

-He's tachy at 120.

-Right, thank you.

His INR's through the roof.

OK, we need to reverse the anticoagulation. Right, listen up.

Vitamin K and PCC please. Let's repeat the INR every 30 minutes.

-We need to get this down, otherwise he'll bleed out. OK?

-Yep.

-Thank you.

They will want to talk to you.

I've got nothing to say.

It's a little late for them to be offering their assistance, don't you think?

Police protection. Huh!

We put our faith in a different covenant.

He guides us.

Have you got it?

No more of that hospital crap.

You do it.

These fractures are stable. Even yesterday's.

There's a hell of a lot of them.

-They're not the cause.

-Well, something must have been missed yesterday.

-No. No, no, no.

She's got Cullen's sign, Dylan!

-Well, she wouldn't have been able to leave the room, let alone walk out of the hospital.

-Hmm.

And all the way to your little boat?

You know what, I'll guess this is traumatic pancreatitis.

-I wouldn't have missed that. Come on!

-Dylan...

-It's not pancreatitis.

It's not something you would have been looking for, Dylan.

It's something I would have missed. It's something I would have found.

She's developing Grey Turner's.

-Zoe! Of course!

-What? What!

His blood is very thin, it's not clotting as it should.

Is his GP prescribing and any anti-coagulation tablets at all?

He doses himself.

90 over 65. Down by 100.

He's obviously developed a temporary tamponade with partial clotting.

Well, that's safe for now. But we do need to stabilise your coagulation, we'll get you up to theatre.

The surgeons are already aware.

It's OK. It's fine. Everything'll be all right.

You'll be asleep.

It's much more difficult for the people who are awake.

-Tell them.

-What's happening?

Hey. All right. OK, lie still.

-Tell me!

-Let's get him down.

-N- No!

4 milligrams lorazepam, now, please. Quickly.

Mrs Lan?

How's your husband?

See for yourself.

The emergency call, it was logged as a stabbing?

And this has been corroborated by the two paramedics who attended?

-My husband is very ill. This is not the time.

-I've been through your case notes.

-And it says on the 7th January last year, you reported an aggravated assault.

-Can I get some air?

And then, after an arrest was made, you withdrew that complaint?

That's history.

A year and a half...

That's a long time.

-Thank you.

-OK.

A new face.

They're all the same.

What did he mean? A year and a half?

Today...

It's not the first time.

He's come to us many times.

In our shop... Sometimes our home.

This has been going on for a year and a half?

-What about your protection?

-He'll get through this.

We're retiring next year...

It's all planned.

It comes down to faith.

You don't think anyone might miss that?

CDU should have an ultrasound.

Her systolic's 106 and dropping.

You need to send an amylase, Dylan.

No. Triple A - she has an abdominal aortic aneurism.

Secondary to malnutrition, more specifically a vitamin deficiency.

-What's her surname?

-Matlock.

If it's only bled into the aortic wall for the time being we should

manage it by keeping her blood pressure on the low side.

-I think she needs...

-There is no need, to open her up just yet.

Gel please.

Thank you.

OK, this might feel a little bit cold.

-OK, fine.

-OK.

-How is he?

-We think that reversing the anti-coagulation has

-caused a clot to form in his brain.

-You think he's had another stroke?

Can you still operate on him?

With the wound stable, the priority is a head scan, as soon as that's done we'll get him up to surgery.

We've fast bleeped the stroke team and we're all on stand-by

so as soon as we can, we'll get him up, OK? Thank you, Tess.

Would you like to see him?

Mind your backs. Excuse me. Thank you.

OK, mate. Can you hear me?

-Ooh, hello. Hello, hello.

-Drugs.

There seems to be some free fluid around the peritoneal space.

It's unclear. Could be an intramural bleed.

We need to visualise the aorta. Look, her bruising's getting worse.

-We need to get her full history.

-No, we need to get her to Resus.

She's holding the key to this, I'm sure of it.

-Hi!

-You are a liar.

-Dylan!

What happened to you yesterday?

If you want me to save your life, you're going to have to tell me.

Or, don't tell me and you'll die.

-I told you, I got mugged.

-I'd say you've got until about two o'clock.

-That's enough, Dr Keogh!

-He punched me.

-No.

-Is this your bedside manner?

Tell me the words I want to hear.

Itold you the truth.

-No. Wrong. Try again.

-Dylan...

There is something you're not telling me.

-Where do all these old injuries come from?

-I really don't know what you're on about.

You need to start trusting me.

If you don't tell me what I need to know, I can't save you.

-Dylan... Listen to me.

-Right. Fine.

What are you testing for now, hmm?

Lipase, Trypsin and Amylase.

Oh, so you are testing for pancreatitis?

-No, I'm testing against pancreatitis.

-What she needs is an abdominal CT and to get to resus, now!

It doesn't matter because it isn't pancreatitis.

How do you know that?

Why did you steal my wallet?

I had £700 in there.

-I wasn't going to take all of it. I just needed 340 quid.

-Why?

Found a flat. I can get away from him once and for...

-Pressure's dropping.

-Right, I can handle this. We need her notes.

Stop. Dylan, we can't keep her here any more.

There's something that we're missing, I know it. It's something important.

I can't... The key to this is in her history.

-Stop this!

-We need to get the notes from where she was last treated.

Yeah. You'll need that.

Is this why you didn't want to sign her in? She is 15!

No-one will blame you, Dylan.

Up to right now, no-one will blame you.

But if you keep her here any longer, they will.

Just get me her old notes. Please.

Shouldn't be long now.

We do need to talk, Mrs Lan.

Not here.

-Whatever he said to you.

-Who?

-You know now that it's not true.

All the promises, all the reassurances.

Do you know what I've learnt?

I've learnt that, at some point, when things don't quite go to plan,

they bite the hand that feeds them.

-Every time.

-Lenny. Sister Bateman. I need your help.

Right, go with the Lorazepam.

Sats dropping, 88%... Right.

We need to get the stroke team here now!

Is that in yet?

Yep.

Get his head scanned and get him up to theatre.

-I know they're backed up.

-Tough!

Good to go. Go!

Hi, er...Rani. It's...

It's Mads.

St Barts have faxed over her casualty notes.

Where's the rest of them?

There isn't any more.

It can't be. She's got dozens of old injuries! This says she's only been in three times!

-There must be another hospital!

-Dylan.

I can fix this!

No, you can't!

She's in hypovolemic shock and needs to go to resus.

-I just need to find the source!

-No! You've tried.

Damn it!

Tarik!

Damn it!

Resus.

Look, I'll take her.

No! No, no, no, no. Very kind of you.

I can do this.

Dylan.

You need to hang on to those.

The answer is in the history. I remain sure of it!

She's not on the computer. She's not in the department.

Dr Keogh?

I can't fix this patient.

Don't just stand there! Let's get her through!

Who is she? Where did she come from?

She came in yesterday. She discharged herself.

She spent the night at mine. She's 15 by the way.

And I missed something.

15?

All right, I missed a couple of things.

On my count. One, two, three.

What have you established?

She has a bleed of unconfirmed source.

Although initially stable, her blood pressure is now falling.

Ultrasound was inconclusive.

She's has Grey Turner's as well as Cullen's sign.

Dr Hanna has been urging me to bring her in.

I prefer to solve a situation on my own.

To be fair I am normally spectacularly good at it.

On this occasion, it seems, that was not the case.

Your actions reflect on the department, Dr Keogh, on all of us.

We're a team. You should act responsibly - as a team!

Hang on. Nick.

I will accept your resignation with immediate affect. Now get out!

Zoe.

Lenny?

Ah, Mads.

Listen, I was thinking, maybe I would like to start this day again.

There's something I'd like to tell you.

What's that?

That night.

That night when we all went out for that drink and...

I got into the minicab.

Mm-hm.

On my way home...

On my way home, I was attacked.

You...?

BP 82 over 47. She's tachycardic.

OK. We're up next.

No, forget the CT. We haven't got time.

She's deteriorating badly.

She needs a laparotomy. Call Keller.

Get a general surgeon on stand-by.

This is a pancreatic bleed until someone tells me otherwise.

How's he doing?

He's being scanned. It doesn't look good.

I'm very sorry.

GCS was 8 on arrival BP 120 over 67.

Pupils were pinpoint.

Evidence of IV drugs use. Administered oxygen.

0.8 milligrams Naloxone, repeated twice.

And?

GCS rose briefly to 12 then back down to eight.

Breathing's been shallow and irregular throughout.

Even with all the naloxone?

Yep. 'Fraid so.

Let's get him over please, ladies and gents.

On three. One, two, three.

And over, one, two, three.

Sats at 86%.

Oh, hello. How's the old man doing?

Get that a lot with women.

Not from this one, Jeffrey.

S'pose you heard about Wonder Doc? Off again apparently.

-Why?

-Oh, I dunno.

Some patient he tried to cure all by himself. Didn't quite work out.

Good riddance I say.

Jeff.

He deserves it, Dix. He's dangerous.

Ah, come on, mate.

After everything that's happened.

Blimey, what are you thinking?

I'm thinking that our wanting him to suffer won't bring Polly back.

It ain't going to change anything.

-It clearly hasn't changed him, has it?

-Maybe.

And what's that supposed to mean?

I'm just saying none of us have offered him the warm hand of welcome back.

Well, blimey! He's really got to you, in't he?

What's not to like?

He's intelligent, confident, good looking.

I think I quite fancy him really.

No! I'm joking! Obviously!

Right, you go on. I'll see you in five minutes.

Yep. See ya.

I just heard what happened.

You shouldn't have let me bring her in here. I did tell you.

You were trying to do the right thing by your patient.

You sure about that?

You know Pol?

It wasn't your fault, OK?

That's not what your colleague thinks. He wanted to reposition my nose.

Jeff was upset. We all were.

And she was killed by my patient.

And you weren't to know.

I think that's the point. Don't you?

I just...

I don't like them very much. Patients.

I don't know, I....

I don't care, I don't have feelings about them one way or the other.

You've quit, right?

So what's all this then?

Blood results.

Right.

I don't get it.

His sats and respiratory rate keep falling.

Right, let's go again. Another 0.8 milligrams of Naloxone, please.

Something isn't right.

You can stop this here you know, Rachel. You can end the suffering.

What do you want from me?

I want a name. Come on.

We both know who did this to your husband.

Tell me, why do you care so much?

We don't know each another.

You talk of my pain. What do you know of my pain?

I've done this job a long time.

I'm sure.

I like putting bad people behind bars.

Excuse me, Mrs Lan, coming through.

Linda, will you let theatre know that Mr Lan's ready to go up.

The problem is, long after you've moved on to bigger and better things,

we're left dealing with the consequences.

The effects of a stroke are unpredictable.

Could he recover, in time?

Yes, I have seen some recovery with the right care and support.

At least he has that.

The problem is, when blood is prevented from getting to parts of the brain...

When a cubicle becomes free, we'll get you in there.

The stroke team have reviewed him. They'll see him when he's back from theatre.

Right, we'll leave you in peace.

Sure you're OK?

You're all right, mate. You're OK.

Let's see.

PATIENT WHEEZES AND COUGHS

OK. Let's get you up a bit.

My name is Dr Lyons. You collapsed earlier and your breathing's still erratic.

Can you tell me what you've taken.

Methadone.

OK. Anything else?

Are you sure?

All right. Any underlying conditions we should be aware of?

Right, you're not very well at the moment.

You're not breathing properly. Without the right treatment, you'll have a respiratory arrest.

There's not much more we can do, do you understand?

We'll have to just hope that whatever he's taken wears off.

I'll be back in a second.

Do urine tox screen and repeat blood gas.

OK.

I did this to you..

-You don't understand.

-Let me go.

-You shouldn't have come to the shop.

-My girlfriend...

-You're a bad boy.

-What are you doing?

-Let me go.

-Let her go.

It's my girlfriend as well!

Please! Please! Let go!

Let go! Let go. You OK?

You're not listening to me.

HE COUGHS Please.

She's pregnant.

Just calm yourself down.

BP's still falling and she's peripherally shut down.

That's it, we've run out of time.

I'll have to do the operation down here.

Tess, you get a urinary catheter in, please? Zoe?

If a theatre becomes available

before I make the incision, we'll take her directly up, OK?

-Good. Let's get on with it.

-I'll put a central line in.

I need an ambulance, please.

-Hey.

-Did you remember?

-Skimmed milk, yes.

-It'll save your life.

I hardly think that's likely.

'Holby Control to 3004.'

3004 receiving, over.

'We've got an anonymous call reporting an overdose on Farmead.'

Wouldn't be the first time.

'34 Mandela Heights. A young female. Pregnant. Over..'

Take that for us, now. Thank you.

-Ah. Dr Keogh?

-Neil.

-Noel.

Good. Yes, what can I do for you?

Blood results.

Amylase. Electrolytes, all normal.

-That's good isn't it?

-Er, no.

Of course. The gel.

Of course. Thank you, Nigel.

It's Noel.

-I know what's wrong with her.

-Out, please.

-This patient is sterile!

-Listen, her bloods.

-We've seen her amylase.

-It doesn't mean anything.

-The bleeding came from somewhere.

-We know where her bleed comes from.

-I didn't just test her amylase.

I tested her lipase and her trypsin. All perfectly normal.

If you go by the modified Glasgow criteria

even by Ranson's criteria, she does not have pancreatitis.

I told you the answer was right under my nose!

The ultrasound gel.

It's always cold.

Patient's always react in the same way.

Contraction of the small muscles.

-And?

-Hers didn't contract.

I noticed at the time, I didn't think anything of it.

And your point being?

She didn't know how she got old injuries.

There's a reason she's only been to hospital three times.

She didn't know how she got them

because she never knew she had them in the first place.

She has congenital analgesia.

She hasn't felt pain since birth.

We didn't think to look for a leg injury

because she was walking fine.

I even sprang her hips. No response.

I think she has a fractured acetabulum.

This would have worn away at the common femoral artery.

This could have caused a retroperitoneal bleed.

She is bleeding into the retroperitoneal space, so...

-It's obviously incredibly unstable.

-OK.

Thank you. We'll take it from here.

Cancel the general surgeon. It doesn't change anything.

No, it doesn't.

Get an orthopaedic and vascular surgeon on standby.

Wake up, darling.

Please.

Mrs Lan?

He swore to us. No more visits.

He should never have been there.

-What happened?

-Mendel had enough.

"No more," he said.

I could've stopped him.

Why?

All you had to do was keep quiet.

Sometimes it's hard to keep quiet.

-Nothing is harder than this.

-Did you make the right choice?

Should you have gone to the police?

This all started because Mendel went to the police.

After our very first visit.

They made an arrest, assured us we'd be protected,

but he was out within a week pending trial.

They didn't care.

He paid us another visit.

He was angry - very.

He pushed me. I fell.

Whilst I was in the hospital, Mendel dropped the case.

If we'd done what he wanted that first time,

he would've gone away.

OK, let's, er, get up there as quickly as you can, please.

-I'll get the lift, Zoe.

-OK.

Where's Dylan?

Dr Keogh has lost his job

because you stayed with him last night, Becca.

Will you tell me exactly what happened? Please.

-He took me in.

-And?

And nothing, he stayed in his crappy car. He insisted on it.

-Mr Jordan.

-Yeah.

Mads? This came for you.

-Thank you.

-All right.

You all right?

-Here. I want to come with you, OK?

-Where?

To the police, when you go.

I'm not going to the police.

Mads! The guy's got to be punished!

I don't want it to become a part of my life and it will.

-You have a responsibility.

-Don't tell me about my responsibility.

The guy assaulted you.

-And I want to move on with my life.

-So why come to me?

Because... I wanted you to know.

Please, Lenny, I need you to respect my wishes.

I don't like the idea of someone hurting you

-and getting away with it.

-But that is my wish.

I just want to forget about it. Please.

On arrival Mother's GCS was 8, pulse 56, BP 98 over 48.

GCS raised back to 10. Gave her 1.2 milligrams of Naloxone.

She responded after three shots, GCS came up to 10,

then it went back down to 8.

Get the foetal heart monitor over, please.

That's my girlfriend.

Is she going to be all right?

That depends, young man.

And what about the baby?

You need to tell us what you've taken.

Look, I can't. She can.

Do you know these people?

I thought it was for him.

If we're going to save them, we need to know what they've been given.

I introduced Azactam into the methadone.

The effects would be masked.

It would appear to be a methadone overdose,

-and the standard treatment...

-Wouldn't work.

No wonder the Naloxone had no effect.

Wayne, we need to amend their treatment regime.

Keep a close eye on their GCS and respiratory effort,

start them both on Flumazenil straightaway, please.

-Will it affect the baby?

-Everyone's chances will be better,

now we know what we are treating.

She's out of surgery.

You very likely saved her life today

But you also put her life at risk.

There you go. Don't do it again.

Shortest resignation in history.

Have I you to thank for that?

I'd offer you out for a drink, but we know it would end in sex.

How about we just start off as friends, yeah?

-With the possibility of sex later on.

-Oh, of course(!)

Oh, does that mean I get to go in this?

-Well, I... I have to really like a woman.

-Shame.

Awesome air-conditioning system.

I can tell, clearly. One day, hmm.

-Well, see you tomorrow then.

-Can't wait.

-Stop waggling.

-Stop looking.

I think she would like to start her day again.

He'll carry on, Lenny.

I know that now.

As long as no-one says anything he'll just...

What would you like to do?

Will you come with me?

Yeah. If you're sure, then yeah.

Mads?

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