by Nina Raine
REG. Pre alert transfusion, CT and theatres, tell them to activate the code-red protocol.
They start to align themselves around the bed. JAMES starts setting up a drip.
EMILY and REBECCA stand by their bed.
MARK. What was he doing up a ladder at two in the morning, anyway?
REG. Well he’s either a fireman or a burglar.
MARK. Or very keen to fix his Sky dish.
JAMES. How long have we got?
REG. ’Bout a minute and a half?
Suddenly, there is relative silence. While people are not entirely still, they don’t seem to feel like talking. The silence lasts for about ten seconds, at which point the ANAESTHETIST comes hurriedly in, tying a cap on.
ANAESTHETIST. Hi. Not here yet?
EMILY (she is very relieved). Oh great, you’re here. (Introducing herself.) Emily. Two minutes. Less. Minute and a half.
ANAESTHETIST (gesturing with his head at the surgical team in their aprons). Why all the Orthopods?
EMILY. Trauma call.
A NURSE has come in shortly after the ANAESTHETIST and positioned herself at EMILY’s bed.
NURSE. Hi.
EMILY. Hi.
Beat. EMILY looks around at her ‘team’.
Sorry – but – is this all the team we’re going to get?
NURSE. Looks like it. There’s been another cardiac arrest over in CCU and they’re busy with that. The cardiology reg’ll head over here soon as he can.
ANAESTHETIST. So who’s going to be leading this?
EMILY. I am.
ANAESTHETIST. I assume you want me here? (The head of the bed.)
EMILY. Yes.
Beat.
NURSE. How long did they say?
EMILY. About a minute, now.
There is another, short silence. The groups around both beds are now simply waiting.
REG (to MARK). See you got rid of the goatee, Marco.
MARK. Yeah.
JAMES. Now you just need to get a girlfriend.
MARK. Yeah, yeah, yeah.
Both groups now lapse into silence. Ten seconds. The ANAESTHETIST and the REG have both adopted the same pose – head down, arms folded – and one by one, everyone else unconsciously adopts the same stance.
Suddenly an approaching siren is heard. Everyone rouses themselves. Then there is commotion outside resuss. Sound of doors opening and banging shut, muffled instructions. The teams hover at their beds, waiting to see who it will be for. Finally an ambulance crew manoeuvres a stretcher in through the double doors. The second they are through the PARAMEDIC is talking.
PARAMEDIC. Thirty-five-year-old man, fallen fifteen feet off scaffolding.
ANAESTHETIST. Us?
NURSE (shaking her head). Trauma team.
Suddenly, with the PARAMEDICS and the stretcher, the room feels full of people. Everyone, as if choreographed, makes way for the stretcher, carried in by two AMBULANCE MEN. There is something balletic, stylised, about the way the surgeons move as a team. EMILY’s ‘team’ simply watch, dispassionately.
PARAMEDIC. Suspected multiple fractures…
The surgical team are all arranging themselves in a line down each side of the stretcher. The stretcher is manoeuvred until it is by the bed. The MAN is on a spinal board and in a neck brace.
GCS of fifteen.
MARK. Okay, sir, do you know where you are?
MAN. Uhhh… .
REG. Okay, great. (To the PARAMEDIC.) Are there any immediate needs or can we transfer the patient and then we’ll take your handover?
PARAMEDIC. Okay.
MARK (with thinly veiled disapproval). Oh, he’s on an extrication board.
PARAMEDIC. Yeah, sorry, the scoop broke.
They get ready to pull the board across onto their bed.
Ready, brace, move.
The board is shifted onto the bed.
REG. Everyone quiet for the handover.
PARAMEDIC. Thirty-five-year-old male. At 02:15 fell approximately fifteen feet off a ladder after locking himself out of his house. His injuries identified top to toe are occipital scalp lac, back injuries, open left tib fib, bilateral foot fractures, hard to tell they’re a crunchy mess really. Treatment-wise he’s had twenty of morphine, a gram of tranexamic, we tried to box-splint his tib fib but he couldn’t tolerate it so we just manually straightened it…
During this MARK has become impatient and started to do his primary survey of the MAN, having gained the non-verbal assent of the REG. JAMES links him up to the drip.
…He’s supposed to be going to Ibiza on Friday, don’t think he’ll be doing that. Any questions?
REG. No, thorough job, thank you.
MARK. ABC’s fine. Injuries are just what was in the handover.
REG. Right, so let’s get him off this board.
(Speaking loudly, clearly). Hello, sir, can you hear me?
MAN. Yes.
REG. Please don’t try to nod your head. We’re going to ask you where it hurts in a minute and I don’t want you to nod or shake, just say yes or no.
Okay?
MAN.…Yes.
REG (she has positioned herself at the MAN’s head). Very good, okay, sir… What we’re going to do is, roll you onto your side, all together… so we will be acting as a splint for you… okay?… and I’m going to feel down your back to check and see if any of that glass is stuck into you. Okay, sir?
Beat.
MAN (indistinctly). Okay.
REG. It’s very important you understand you don’t make any movement yourself. If you’ve got any breaks you could damage your spinal cord. You – let us – move you. Okay, sir?
MAN. Okay.
REG. Mark, you okay with the head?
MARK. Yep.
REG. Okay, team, get ready to log roll…
Everyone places their hands at intervals along the MAN’s body, MARK holding the head. JAMES undoes the straps on the MAN’s head-blocks, takes the blocks away peeling in an outwards direction, dumps them on the floor while MARK simultaneously slips his hands in place to maintain the position of the MAN’s head.
MARK. I’m going to say ready, brace, move. (Raises his voice.) Ready, brace, move.
Swiftly, the MAN is turned onto his side, the surgeons with three hands under, three hands over the MAN. The coordination of all the surgeons together, so they move as one, is impressive. EMILY is watching, fascinated. The ORTHOPAEDIC REG takes away the board and dumps it on the floor, the PARAMEDIC whisks it away and leaves.
REG. Okay, how’s that feeling, sir?
Beat.
Now what I’m going to do, is feel down your back, and I want you to tell me if at any point I touch a tender point. Okay?
Beat.
All right, sir, here we go.
She starts to feel swiftly down his back, kneading gently with both hands.
Is that tender?
No?
And that?
And that?
That?
The MAN winces and she immediately stops.
Is that tender, sir?
Beat.
MAN. It’s… no…
REG. It’s not tender?
MAN. No.
REG. When I feel just there? (Does so, delicately.) It’s not tender?
MAN (wincing). No.
Beat.
REG (carefully). If it’s not tender… then why did you squeeze your eyes shut when I touched it?
MAN. Because… because of the sound it made.
Commotion outside. More doors banging. Another stretcher is brought in. It is a GIRL. One PARAMEDIC is wheeling, the other is performing chest compressions on the GIRL.
EMILY snaps to attention. As this scene unfolds, the surgeons continue examining their MAN, quietly.
PARAMEDIC. Twenty-four-year-old girl, cardiac arrest, received fifteen minutes CPR in the ambulance…
EMILY, REBECCA, the NURSE and the ANAESTHETIST are all readying themselves round the bed.
Been intubated… No past medical history.<
br />
EMILY. Okay.
Activity on all sides. They slide the GIRL off the ambulance trolley onto the A&E one using the sheet she is lying on. She is transferred from the ambulance life-pack and connected onto the hospital’s equipment: airbags/ventilator, defibrillator and drip. The dots are ripped off her half-bare chest and replaced by the hospital dots onto the stickies on her chest. The ANAESTHETIST listens to the GIRL’s chest. The NURSE busies herself getting venous access.
Can we check for an output… (To the NURSE.) Gel pads please.
Bilateral air entry?
ANAESTHETIST. Air entry but no respiratory effort, not a dicky bird.
EMILY. Somebody get her tympanic temperature –
The NURSE busies herself with this, sticking a thermometer in the girl’s ear.
Somebody get venous access, a BM and gases please. I’ll assess the rhythm.
The NURSE looks at the ANAESTHETIST – both have their hands full.
NURSE. ‘Somebody’?
EMILY does not notice, she is looking at the screen to assess the rhythm of the heart.
ANAESTHETIST (to REBECCA, taking charge).You do venous access, bloods and gases.
REBECCA starts to take another sample of blood.
EMILY. She’s in VF. So we’re going to need to shock.
ANAESTHETIST (craning to have a look). No wait, that’s asystole.
EMILY. It can’t be asystole, it isn’t totally flat.
ANAESTHETIST. That’s just interference. No rhythm. She’s flat as a pancake, take it from me.
EMILY. But if there’s any doubt we should shock.
PARAMEDIC (a note of apology in his voice). She’s been flat for a while.
Small beat.
EMILY. Fine, we’re on the non-shock side. Restart compressions –
The NURSE does so.
One milligram adrenalin please and somebody check for an / output.
ANAESTHETIST (sharply).Don’t say, ‘somebody’. It helps if you give the job to someone. Like her. (Indicates REBECCA.)
EMILY (taking this in). Fine, you do pulse, I’ll do adrenalin.
She struggles to open the drugs while REBECCA signals with her hand for compressions to stop and obediently checks for a pulse.
REBECCA. I don’t think I can feel a pulse, do you want to check it?
EMILY. Fucking…thing. Okay. You get on with these – (Hands REBECCA the unopened needle pack.) I’ll take over with compressions.
She starts to administer chest compressions.
Meanwhile, the surgeons are still examining their MAN.
REG (raising her voice for the benefit of the team).…So, no obvious signs of bleeding but we’re dealing with suspected burst fracture probably L2, left tib fib, and bilateral calcaneal fractures.
James, you be plaster monkey, go and get the plaster trolley ready and make sure the water’s warm this time.
JAMES. Sure.
REG. Mark, label the bloods…
MARK busies himself doing so.
CT’s in use so let’s have some X-rays.
The surgeons continue their survey of the MAN, quietly, as the X-ray machine is slowly wheeled over.
EMILY has just reached the end of her cycle of CPR.
EMILY. Stop. Rhythm check –
ANAESTHETIST. Asystole.
EMILY. Are you sure that’s asystole?
ANAESTHETIST. Yes, I’m sure! Her heart has stopped. Look at her. She’s blue.
EMILY. Have you checked the leads? Have we turned up the gain?
ANAESTHETIST. The gain is fine.
EMILY. Have we got a pulse?
ANAESTHETIST (under his breath). She’s dead, for Christ’s sake.
The NURSE feels.
NURSE. No. –
EMILY starts compressions again.
EMILY. Where’s that gas?
REBECCA rouses herself to go and get the forgotten results printout.
Tympanic temperature?
NURSE. Thirty-four degrees C tympanic.
EMILY. Okay, can we get a bag of warmed Hartmann’s.
NURSE. It’ll take me a couple of minutes.
ANAESTHETIST. Worth it?
EMILY. Yes. We can try and warm her up.
The ANAESTHETIST looks sceptical, but says nothing. The NURSE goes.
(To REBECCA, who has just returned.) What’s the gas?
REBECCA. She’s really acidotic. Ph six-point-nine.
EMILY. Okay – bicarb please.
REBECCA goes to look for it in the crash trolley.
Four Hs, four Ts – have we checked all reversible causes?
ANAESTHETIST. Yes.
EMILY. Anything else? Any traces of any drugs? Track marks? Heroin?
REBECCA. No. But let’s give her the Narcam, can’t make her worse.
EMILY. Another milligram adrenalin, and four hundred mics of Narcam.
REBECCA. What do you want first? Cos there’s no… fucking bicarb here.
ANAESTHETIST. They’ve taken it off the trolley. (Under his breath.) Because it’s pointless.
EMILY. Fuck’s sake. Okay, forget the bicarb, I’ll give her Narcam and adrenalin. (Instructing REBECCA.) Two minutes’ CPR.
REBECCA takes over, EMILY uncricks her neck, exhausted.
The X-ray machine is in place over with the SURGEONS.
REG. Chest, lateral c-spine and pelvis.
The team take a token step away from the machine as the RADIOGRAPHER prepares to take the X-rays.
Are we ready.
RADIOGRAPHER. Ready.
The three X-rays are taken.
One.
Two.
Three. Now we’ll have a clearer picture of what we’ve got inside.
And the team move in as one around the MAN again.
EMILY’s team has been joined by the NURSE, and the Hartmann’s has been hooked up to the GIRL’s arm.
EMILY (exhausted, she has just finished the last cycle of CPR). Pulse check?
REBECCA (feeling the girl’s groin). None.
EMILY. Rhythm check –
(Unwillingly.) Asystole.
The NURSE goes back to doing chest compressions.
Okay, I think we should try and shock her out of this now.
ANAESTHETIST. You’re not going to shock her out if it, she’s asystolic. It’s not a shockable rhythm.
EMILY. What have we got to lose by shocking her?
ANAESTHETIST. It’s not what the ALS guidelines say. I think we should go down the asystole pathway.
EMILY. Which is what? We’ve tried everything else, we’ve got to do what we can to revert her out of it.
ANAESTHETIST. We’re not going to get her ‘out of it’. She’s dead.
EMILY (gives him a hard look, lifts the defibrillator paddles ready). Charging, oxygen away –
The ANAESTHETIST disconnects the oxygen bag.
– everybody clear? Preparing to shock at two hundred…
She can’t find the right button.
Where’s the shock button?
ANAESTHETIST (quietly pointing). There.
EMILY. Clear at the head, clear at the feet, clear at the sides, I’m clear, shocking at two hundred, now.
She shocks the GIRL.The GIRL’s neck tenses and her arms lift and drop in a ripple. In a frozen moment ‘out of time’, EMILY is not looking at the GIRL but up at the corner of the ceiling.
REBECCA (baffled). What?
EMILY.…
She collects herself, with difficulty.
Pulse?
REBECCA. No pulse.
EMILY. What about the interference?
REBECCA (looking at the monitor). Totally flat. It’s gone. Asystole.
Beat.
EMILY. Okay. So here we go. Two minutes CPR. Rebecca –
ANAESTHETIST (turns to EMILY). I think we should stop.
EMILY. Stop?
ANAESTHETIST. The girl is dead. She was dead when she came in.
You’ve done everything you can.
EMILY.
She’s twenty-four.
ANAESTHETIST. I know she’s twenty-four. I also know, she’s dead.
EMILY. There was something there.
ANAESTHETIST. There was nothing there. It was interference.
(To the others.) Any objections to stopping?
…Okay, thank you everybody. Thank you. Thank you.
Time of death, 03:03.
The team start to disperse. The NURSE and REBECCA disconnect the GIRL from the machinery, and pull a sheet over her. They rip their plastic aprons down off their necks, splitting them. They wheel the bed off. EMILY speaks directly to the ANAESTHETIST.
EMILY. I was meant to be leading that arrest. It’s up to me to say when it’s over.
ANAESTHETIST. You checked and treated all the reversible causes. There was nothing else we could do. You have to know when to say, enough.
EMILY is silent.
We weren’t going to get her back.
He carries on thanking, releasing everyone. As EMILY’s team breaks up and disperses around her, she takes a few steps towards the surgical team, watching their ballet, as they work as one, now moving their MAN once more onto a different bed to take him to theatre.
SURGICAL REG.…They’re ready for us to go into CT now. All right, everybody. Everybody ready. All together now, team…
EMILY’s team have nearly all gone. She carries on watching.
And the MAN is taken out of resuss, the surgeons moving as one. Then, they are gone. EMILY sinks down onto a small wheeled chair.
VASHTI has come in – to read a folder, in private. She does not register EMILY slumped in the chair.
A moment later, JOHN comes in.
JOHN. Hi. Sorry, have I missed it?
EMILY looks at him.
We had an arrest in CCU.
EMILY. Where were you when we needed you?
JOHN. What?
EMILY. I was leading that arrest. Where were you when I needed you?
JOHN. I told you, we had an arrest in CCU. I got here as soon as I could.
EMILY. Yeah, some ninety-year-old, right? Well, it wasn’t a piece of ninety-year-old crud we got, you know, it was a twenty-four-year-old girl.
Beat. VASHTI is discreetly eavesdropping on their conversation.
JOHN. I didn’t know she was twenty-four. They said –
EMILY. I bet you fucking walked here, didn’t you.
JOHN. What difference would it have made if I’d run?
EMILY. The anaesthetist decided to call it off. He wouldn’t listen to me. You could have stopped him.
JOHN. What rhythm did she come in with?
EMILY. Asystole.
