Episode 3 An Hour To Save Your Life


Episode 3

Similar Content

Browse content similar to Episode 3. Check below for episodes and series from the same categories and more!

Transcript


LineFromTo

'Hello, ambulance service.' 'There's a guy just got hit by a bus.

0:00:050:00:08

'He was on a bike. He's been really badly injured.'

0:00:080:00:11

From the moment an emergency call is made, a clock starts ticking.

0:00:110:00:14

'Female lying on the road, struggling to breathe.'

0:00:180:00:20

The golden hour is the opportunity that we have to save the patient.

0:00:200:00:26

Deep breaths, George.

0:00:260:00:28

The longer the clock ticks, the increased likelihood there is of death.

0:00:280:00:32

In the fight for survival, time is the enemy.

0:00:360:00:39

I'm ventilating fast on purpose.

0:00:390:00:41

Yes. I'm hoping that heart rate will pick up any second.

0:00:410:00:44

Now, new techniques and technology are bringing emergency medicine to the roadside...

0:00:440:00:49

We can use the infra scanner to maybe give us a slightly

0:00:490:00:51

clearer picture of what's going on underneath the skull.

0:00:510:00:54

..breaking new ground and treating patients faster than ever before.

0:00:540:00:59

We can now provide emergency surgery,

0:00:590:01:02

blood transfusions, anaesthesia, at the scene of the accident.

0:01:020:01:05

Yep, through the cord. Tube, please. Tube on.

0:01:050:01:09

We follow three patients through the crucial first hour of care.

0:01:120:01:16

In north London, a man is hit by a bus and fights for his life.

0:01:170:01:21

I'm not happy. I'm just going to pull the tube back a little bit.

0:01:210:01:24

Near Bristol, a rider lies unable to move

0:01:240:01:27

after being thrown from his horse.

0:01:270:01:29

Can you move your fingers?

0:01:290:01:30

No. Can you feel me touching you here? Yes.

0:01:300:01:33

And in St Albans, a tree surgeon falls 30 feet off a ladder

0:01:330:01:37

while cutting branches.

0:01:370:01:39

I'm worried about him. We're a long way from hospital.

0:01:390:01:41

He could be bleeding into his abdomen or his pelvis.

0:01:410:01:44

60 minutes that will change their lives forever.

0:01:470:01:50

You'll constantly be surprised

0:01:500:01:52

just what you can bring back from the jaws of death.

0:01:520:01:56

This programme contains scenes which some viewers may find upsetting

0:01:560:02:02

At ambulance control in Waterloo,

0:02:090:02:11

an emergency call has just been received from north London.

0:02:110:02:16

He's making noises?

0:02:270:02:29

Consultant Gareth Greer and paramedic Sue Trow

0:02:360:02:39

from London's Air Ambulance are on their way to the incident.

0:02:390:02:42

'We know very little, apart from someone's been hit by a bus.'

0:02:450:02:49

It could be an injury to any part of the body.

0:02:490:02:51

It could be that the patient has multiple injuries.

0:02:510:02:54

We're kind of ready for any eventuality.

0:02:540:02:58

A London ambulance service crew are already on scene,

0:03:010:03:05

struggling to assess the patient. HE MOANS

0:03:050:03:09

Yeah.

0:03:100:03:11

Understood.

0:03:130:03:14

HE GROANS

0:03:140:03:15

See the damage to the bus? He smashed a light casing. Yeah.

0:03:150:03:20

37-year-old Dusan, a fitness instructor,

0:03:220:03:25

was walking to the gym when he was hit by the bus.

0:03:250:03:28

When the ambulance arrived, he was found highly confused.

0:03:280:03:31

We're going to look after you.

0:03:330:03:35

'If someone's agitated,'

0:03:350:03:36

to me, it signifies it's going to be quite a severe head injury.

0:03:360:03:40

Some people appear like they're drunk through having a head injury

0:03:400:03:43

like that, but with the injuries that he had around his face,

0:03:430:03:46

you have to suspect that he had a bad head injury.

0:03:460:03:49

This strange behaviour is a clue

0:03:490:03:51

that Dusan's brain is suffering from the impact.

0:03:510:03:54

'The knock on the head has damaged all of the connections in his brain.

0:03:550:03:59

'He is disorientated, he doesn't know where he is,'

0:03:590:04:01

he doesn't know what's happening.

0:04:010:04:03

He can't put all of these things together.

0:04:030:04:05

HE CRIES We're going to help you.

0:04:050:04:08

We're going to help you, all right?

0:04:080:04:11

'If there is bleeding in his brain,'

0:04:110:04:13

that needs to be sorted very, very quickly

0:04:130:04:15

otherwise it could be catastrophic for him.

0:04:150:04:20

What I'm going to do is try him with a little bit of sedation.

0:04:200:04:22

We'll just have a look at his veins, just to see what...

0:04:220:04:25

'We need to get on top of the agitation

0:04:250:04:27

'before we can do anything else.'

0:04:270:04:29

If you just draw up 4mls for now.

0:04:290:04:31

Gareth gives Dusan Midazolam, a powerful sedative.

0:04:320:04:36

The impact from the bus may have caused other internal injuries

0:04:370:04:40

and he needs to assess him properly.

0:04:400:04:42

Yeah, we'll move him up... Once...

0:04:420:04:44

Let's just cut the front of his clothes off first.

0:04:440:04:46

HE GROANS

0:04:460:04:48

Let's start moving him out because we need to start getting

0:04:480:04:50

the tube down, because he's not ventilating too well.

0:04:500:04:53

Dusan is breathing abnormally and has very low oxygen levels.

0:04:540:04:59

To boost them, Gareth gives pure 02 through a mask and prepares

0:04:590:05:04

to take control of his airway with a breathing tube,

0:05:040:05:07

but, for this procedure, he needs more space.

0:05:070:05:09

If the breathing carries on in this abnormal way, that can result in

0:05:120:05:15

increasingly bad brain damage...

0:05:150:05:18

very, very quickly over a period of minutes rather than hours.

0:05:180:05:21

This one has just kinked a little bit.

0:05:210:05:23

To take over Dusan's breathing,

0:05:230:05:25

Gareth must first anaesthetise him and paralyse his muscles.

0:05:250:05:29

OK, guys, so we're going to do the anaesthetic.

0:05:290:05:32

This procedure usually takes place in a calm operating theatre...

0:05:320:05:36

..but Gareth must act now.

0:05:370:05:38

110 miles away in Bristol,

0:05:500:05:52

an ambulance control room has just received a call about a man involved

0:05:520:05:56

in a serious horse-riding accident.

0:05:560:05:59

Great Western Air Ambulance critical care team Dr Greg Cranston

0:06:150:06:19

and paramedic John Wood

0:06:190:06:21

have been dispatched to a field just north of the M4 near Bristol.

0:06:210:06:25

We go to a fair number of riding accidents.

0:06:250:06:29

We'll probably go to one every couple of weeks.

0:06:290:06:33

The most common injury that a patient would sustain from a fall

0:06:330:06:36

from a fall from horse would be a bony-type injury, so a fracture.

0:06:360:06:40

They're looking for a 63-year-old man who's been thrown at speed

0:06:420:06:45

from his horse.

0:06:450:06:47

We were told that the patient had come off,

0:06:470:06:51

was conscious but had difficulty in breathing

0:06:510:06:55

and couldn't move his limbs,

0:06:550:06:58

so that information immediately rang alarm bells.

0:06:580:07:02

Straight ahead. Horse tripped on landing. He fell off.

0:07:060:07:10

He's got pain in his neck, he can't move his hands,

0:07:100:07:14

he is conscious, he is talking.

0:07:140:07:16

Breathing is shallow.

0:07:160:07:17

My priorities are to establish the range of injuries that he has and to

0:07:200:07:25

work out if any of those are likely to be immediately life-threatening.

0:07:250:07:28

We just haven't moved him.

0:07:280:07:31

We haven't touched him. Excellent.

0:07:310:07:33

Covered him up, that's all we've done. Hello, there.

0:07:330:07:36

Hello. My name is Dr Cranston, one of the doctors with the Air Ambulance.

0:07:360:07:40

What's your name?

0:07:400:07:42

George. Hello, George. Are you in any pain?

0:07:420:07:45

My neck hurts quite a bit.

0:07:450:07:47

OK. Can you open your eyes for me? Yeah.

0:07:470:07:50

Open your eyes. Can you look at me?

0:07:500:07:52

You can see me OK. Excellent.

0:07:520:07:55

Can you move your fingers? No.

0:07:550:07:57

Can you give me a squeeze at all here? No. OK.

0:07:570:08:00

Falling from a horse is a potentially serious mechanism of

0:08:010:08:05

injury and people aren't generally ready for this fall,

0:08:050:08:08

so they often don't have time

0:08:080:08:09

in order to manipulate themselves or control the way in which they land.

0:08:090:08:13

'I'm starting to worry already that this may be a spinal cord injury.'

0:08:140:08:19

Can you feel me touching you here?

0:08:210:08:22

Yes. You're well tucked in, aren't you?

0:08:220:08:25

Yes. Can you feel me touching you here on your chest?

0:08:250:08:28

I think a little bit.

0:08:280:08:29

A little bit. Can you feel me touching you on your hand? No.

0:08:290:08:31

You can break a bone of your neck and your spinal cord

0:08:310:08:35

could be completely intact, and it's painful and it gets better.

0:08:350:08:38

But a spinal cord injury is a significant injury,

0:08:380:08:43

because that's the thing that can cause you paralysis.

0:08:430:08:47

The extent of George's spinal injury is not yet known.

0:08:470:08:51

Greg can't rule out the impact this might have on his other vital signs.

0:08:510:08:55

Don't be scared, OK?

0:08:560:08:58

We're going to look after you, all right?

0:08:580:09:00

We'll get you sorted bit by bit, slowly,

0:09:000:09:04

one bit at a time, and we'll fly you to hospital. OK?

0:09:040:09:07

There's no way that we can tell at this point how serious that injury

0:09:070:09:11

is until he arrives at hospital.

0:09:110:09:14

I'm just wondering how much of this we'll cut off.

0:09:140:09:16

Just cut it off so we can see what's going on down the back. Yeah?

0:09:160:09:20

Before they can move George,

0:09:200:09:22

Greg needs to check the rest of his body for injuries.

0:09:220:09:25

We're going to cut some of your clothes off, OK?

0:09:250:09:28

We will keep you warm.

0:09:280:09:30

It's really important that we get to assess you fully.

0:09:300:09:32

It's almost certainly going to be my neck.

0:09:320:09:34

I agree with you. I agree with you,

0:09:350:09:38

but there is a danger that you could have other injuries that we wouldn't

0:09:380:09:42

easily know about.

0:09:420:09:44

Stay with us, George.

0:09:460:09:47

George, take some deep breaths for me.

0:09:490:09:52

Big, deep breath.

0:09:530:09:55

His breathing is very shallow.

0:09:580:10:00

As I ask him to take deep breaths,

0:10:000:10:03

it doesn't appear that he does take any breaths at all.

0:10:030:10:06

Deep breaths, George.

0:10:090:10:11

He's breathing but it's so shallow that I'm unable to detect that by

0:10:120:10:16

either looking or listening with my stethoscope.

0:10:160:10:19

The spinal cord is a connection between the brain and the body and,

0:10:210:10:25

if you break that connection,

0:10:250:10:27

then the muscles of the body are unable to respond.

0:10:270:10:29

My main concern is whether George will continue to breathe.

0:10:300:10:35

He's breathing now, but will he continue to do that?

0:10:350:10:38

Deep breaths, George.

0:10:380:10:40

Go on, nice and deep.

0:10:400:10:41

Oxygen mask on tight, reservoir moving with ventilation.

0:10:520:10:55

In north London, 37-year-old Dusan has been hit by a bus,

0:10:560:11:01

suffering a massive head injury, and he's not breathing properly.

0:11:010:11:04

Baseline blood pressure seen and monitor set to two minutes. Check.

0:11:060:11:10

Despite Gareth's efforts to improve Dusan's oxygen levels,

0:11:100:11:14

they're still very low,

0:11:140:11:16

a sign he may have significant injury to his lungs.

0:11:160:11:19

This could damage other vital organs and his already injured brain.

0:11:190:11:23

'What I'm trying to do is to take over Dusan's breathing'

0:11:230:11:26

so that we have control of the oxygen levels in his bloodstream.

0:11:260:11:30

We're just starting the RSI now and then we'll be...

0:11:310:11:34

A rapid sequence induction will take over Dusan's breathing,

0:11:340:11:38

enabling Gareth to deliver oxygen down a tube to his lungs.

0:11:380:11:42

He is having 4mls of fentanyl.

0:11:420:11:44

Just hold his arm for me.

0:11:460:11:48

Thank you.

0:11:490:11:50

For this, Gareth must anaesthetise him and force his muscles to relax.

0:11:500:11:55

Fentanyl's in. Ketamine next.

0:11:560:11:59

It's essentially giving someone an anaesthetic, like you would have

0:12:030:12:06

if you went in for an operation,

0:12:060:12:07

but it's doing it in an emergency situation,

0:12:070:12:10

which is a high-risk procedure.

0:12:100:12:12

OK, the jaw is nice and floppy.

0:12:150:12:17

OK.

0:12:170:12:18

The drugs have worked quite quickly,

0:12:180:12:20

so we might be able to proceed relatively quickly with this.

0:12:200:12:23

Dusan is now completely paralysed.

0:12:240:12:27

Gareth has just minutes to manoeuvre a breathing tube

0:12:270:12:30

through his vocal cords and into his windpipe.

0:12:300:12:32

If you can't get the tube down into the windpipe,

0:12:340:12:36

then the patient won't breathe.

0:12:360:12:37

OK, grade one view.

0:12:420:12:44

Just won't go through the cord.

0:12:540:12:55

Sue, just pass me the tube a second. Hmm-hmm.

0:12:550:12:57

Thank you.

0:12:570:12:59

Yeah, tube's in.

0:13:060:13:08

Just deflate the cuff a minute, Sue.

0:13:090:13:11

I'm not happy that's in.

0:13:130:13:15

I'm just going to pull the tube back a little bit...

0:13:150:13:17

and it's going to go in again. Nope.

0:13:170:13:21

OK.

0:13:210:13:22

I can see the tube between the chords.

0:13:220:13:24

Can I just borrow your stethoscope for a minute?

0:13:240:13:26

Just to listen to his tummy.

0:13:260:13:28

Just hold the tube there for me.

0:13:280:13:29

Although Gareth is now in full control of Dusan's breathing,

0:13:290:13:33

his oxygen levels are still low,

0:13:330:13:34

suggesting something is seriously wrong with his lungs.

0:13:340:13:38

Air entry.

0:13:410:13:42

Pretty grotty.

0:13:480:13:50

I'm hoping that heart rate will pick up any second.

0:13:520:13:55

Just keep holding the tube.

0:13:550:13:57

'Dusan's heart rate has gone down catastrophically.'

0:13:570:14:00

It's gone down to 30 beats a minute.

0:14:010:14:04

This is very, very bad.

0:14:040:14:06

If that gets any worse,

0:14:060:14:07

he'll be in cardiac arrest and his heart will effectively stop.

0:14:070:14:12

A normal heart rate would be around 60 beats per minute,

0:14:120:14:15

but Dusan's low oxygen levels

0:14:150:14:17

are now impacting on his heart's ability to pump.

0:14:170:14:20

Gareth must get as much oxygen in as quickly as he can.

0:14:200:14:25

I'm ventilating fast on purpose. Yeah.

0:14:250:14:27

'I want his heart to be able to fill properly and have enough oxygen to

0:14:290:14:34

'allow itself to work properly,'

0:14:340:14:35

and I'm hoping his heart will kick in and come back to normal.

0:14:350:14:39

OK, heart rate's come back up. That's good.

0:14:500:14:52

Just give him a little bit more bagging.

0:14:520:14:54

Sue, can you pass me some long suction catheters from the bag?

0:14:560:14:59

Yep. Thank you.

0:14:590:15:00

So, this is pulmonary oedema.

0:15:020:15:04

'Fluid leaks out of the little blood vessels inside the lungs,

0:15:050:15:09

'into the air spaces.'

0:15:090:15:12

And then, when you put someone on the breathing machine,

0:15:120:15:15

you see that fluid coming up.

0:15:150:15:17

A bloodstained fluid coming out of the tube suggests

0:15:170:15:20

Dusan's lungs have been seriously damaged by the impact of the bus.

0:15:200:15:24

This is all pulmonary oedema that you get on the chest. Is it?

0:15:240:15:27

But the scale of his injuries is still not clear.

0:15:270:15:30

Dusan is critically ill and Gareth must get him to hospital fast.

0:15:300:15:35

I just want to have a quick look at the rest of him and then I'll...

0:15:350:15:37

'As well as the possibility of a really bad head injury,'

0:15:370:15:41

Dusan could have bleeding in other areas

0:15:410:15:43

that could also kill him quickly.

0:15:430:15:45

The tummy was distended before.

0:15:470:15:49

We'll cut these off in a minute.

0:15:490:15:51

Nothing obviously there.

0:15:510:15:53

Dusan's stomach is worryingly tight.

0:15:530:15:55

This could be caused by internal bleeding from yet another injury.

0:15:550:15:59

We do need to get moving.

0:15:590:16:01

Let's start packing up, getting ready to go.

0:16:010:16:03

We need to get him to the hospital to try and work out

0:16:060:16:08

if there are any other injuries that we can't see at the moment

0:16:080:16:11

that could also kill him very, very quickly.

0:16:110:16:14

Ready, steady, go.

0:16:140:16:16

SIREN BLARES

0:16:160:16:18

Are you aware of us taking your boots off?

0:16:230:16:26

No. No, OK.

0:16:260:16:28

Near Bristol, rider George has lost all feeling in his body

0:16:280:16:32

from the neck down, having been thrown from his horse

0:16:320:16:34

while jumping a hedge.

0:16:340:16:35

He's unable to move and his breathing has become very shallow.

0:16:370:16:40

A high-level spinal cord injury

0:16:400:16:43

disconnects your brain from the muscles in your ribcage,

0:16:430:16:47

so you can't breathe using those muscles.

0:16:470:16:50

There's another nerve, which takes a different pathway,

0:16:510:16:55

and it connects directly to the diaphragm.

0:16:550:16:59

So the diaphragm can continue to assist in breathing,

0:16:590:17:04

but you become very tired very quickly

0:17:040:17:06

and you can progress to not being able to breathe at all.

0:17:060:17:09

This separate nerve comes out of the spinal cord, high up in the neck,

0:17:100:17:14

and might be the only thing keeping George alive.

0:17:140:17:17

I'll tell you what we'll do, let's split this,

0:17:170:17:19

roll him onto half of it.

0:17:190:17:21

George's heart rate is also worryingly slow,

0:17:210:17:24

but this, too, has a dedicated nerve,

0:17:240:17:26

as well as special cells that keep it beating on its own.

0:17:260:17:29

Our heart has an intrinsic ability to keep beating.

0:17:290:17:33

Even if it came out of the body,

0:17:330:17:34

it would still keep beating for a short period.

0:17:340:17:37

However, it would continue at a slow rate only.

0:17:370:17:40

With his breathing and heart rate critically low,

0:17:420:17:45

it's not clear how long George can survive.

0:17:450:17:48

We're going to roll you onto your back, OK?

0:17:480:17:51

Is that all right?

0:17:510:17:53

I'm going to take good control of your head and neck,

0:17:530:17:56

that's going to be my job, OK?

0:17:560:17:57

We're going to do everything very slowly.

0:17:570:17:59

If anything hurts, just shout out.

0:17:590:18:01

I'm listening, OK?

0:18:010:18:02

I think the important thing here, guys,

0:18:030:18:05

is we do everything very carefully. Very, very carefully.

0:18:050:18:08

There's no rush, OK? We'll do things carefully.

0:18:080:18:10

What we have to be careful is that we don't worsen the injury,

0:18:110:18:14

we don't cause any further damage to the spinal cord.

0:18:140:18:18

Therefore, we have to move him as carefully as possible.

0:18:180:18:22

So, has everyone got appropriate hands on the position

0:18:220:18:24

and knows where...? I've just got his pelvis area, really.

0:18:240:18:27

We'll just very slowly go over,

0:18:270:18:29

nice and controlled, straightening him out as we go.

0:18:290:18:32

OK. We're doing this slowly. OK?

0:18:320:18:34

'We need to get George into a neutral alignment,'

0:18:340:18:37

perfectly aligned, on his back,

0:18:370:18:39

with as little movement as possible to his entire spine.

0:18:390:18:43

So, ready, steady, we'll start.

0:18:430:18:45

The spinal cord has the consistency of toothpaste.

0:18:470:18:50

It's very delicate.

0:18:500:18:52

It can be damaged if the bones that surround it are broken

0:18:540:18:59

and impinge or push onto the spinal cord.

0:18:590:19:02

If anyone's got any problems as we go,

0:19:020:19:04

just shout out and we'll pause, OK?

0:19:040:19:05

We're doing this slowly, OK?

0:19:050:19:07

That came off easily. Good. Just keep him coming.

0:19:080:19:11

That's it.

0:19:130:19:14

You've got his head, mate? I have his head.

0:19:140:19:17

How are you doing?

0:19:170:19:18

Is that uncomfortable? There.

0:19:180:19:20

Where? In your neck?

0:19:200:19:21

I'm delighted to say that pins and needles are now beginning to start.

0:19:220:19:27

Pins and needles? They're going down further...

0:19:270:19:30

Further down my biceps.

0:19:300:19:32

Down your arms? Yeah. OK.

0:19:320:19:33

My collar bones are fantastically sensitive.

0:19:350:19:37

'What I think is happening here

0:19:400:19:42

'is that his brain is unable to process or understand

0:19:420:19:45

'the information that it's receiving,

0:19:450:19:48

'so it tries to fill in the gaps and imagine what should be there.'

0:19:480:19:52

This would probably just be a perception

0:19:520:19:55

rather than a genuine sensation.

0:19:550:19:57

Is this pain or is it a funny feeling? Pain. Real, real pain.

0:19:590:20:02

Pain. And that's pain to your...?

0:20:020:20:04

Neck. Neck, OK.

0:20:040:20:05

Going down to my collarbone and round to the top of my shoulders.

0:20:050:20:09

Yeah.

0:20:090:20:10

Christ, it hurts.

0:20:130:20:14

With George's pain now rapidly increasing,

0:20:170:20:20

Greg gives him intravenous morphine to ease his distress.

0:20:200:20:24

It's started going in, George, OK?

0:20:240:20:25

So you'll start to feel some effects of that. Yeah.

0:20:250:20:28

But I don't want to just blast so much of it in all at once

0:20:280:20:30

that you get knocked off, OK?

0:20:300:20:32

'Morphine depresses your brain's drive to breathe'

0:20:320:20:35

and that's the last thing we wanted to do.

0:20:350:20:37

Lift!

0:20:390:20:41

With George's breathing a major concern,

0:20:410:20:43

Greg must get him to hospital as fast as possible.

0:20:430:20:46

His son was also riding with him when he came off his horse.

0:20:480:20:51

So, he will have a scan within...

0:20:540:20:56

I would give an estimate of ten minutes of walking through the door

0:20:560:20:59

and we'll know to quite a degree what the damage is.

0:20:590:21:02

It's a bit of an unanswerable question.

0:21:050:21:07

What I've said to him is, "Don't lose hope. Don't give up hope."

0:21:070:21:10

Things aren't always as bad as they seem straight off.

0:21:100:21:13

That's true, but we do have to be prepared for everything.

0:21:130:21:17

It's not a great rate, actually, even in here.

0:21:210:21:25

George's heart rate is also still worryingly slow.

0:21:250:21:29

Greg alerts the nearest major trauma centre.

0:21:290:21:32

ETA is probably 15 from now.

0:21:320:21:34

1-5.

0:21:340:21:36

In Chelmsford, East of England Ambulance Control has received

0:21:490:21:52

an emergency call about a man who's fallen from a tall ladder.

0:21:520:21:56

Essex and Herts Air Ambulance doctor Sam Sadek

0:22:080:22:12

and critical care paramedic Simon Probert

0:22:120:22:15

have been called to St Albans.

0:22:150:22:17

An ambulance crew already with the patient

0:22:170:22:19

are concerned about his condition.

0:22:190:22:22

The difficulty with a fall from height

0:22:230:22:25

is it really could be anything, sometimes everything.

0:22:250:22:27

When a person hits the floor, they decelerate

0:22:270:22:29

and you can get a lot of hidden injuries with a fall like that.

0:22:290:22:33

Some of the internal organs can be very badly damaged.

0:22:330:22:37

23-year-old Seb, a tree surgeon,

0:22:370:22:39

was cutting branches with a long pole pruner

0:22:390:22:42

when he fell to the ground.

0:22:420:22:43

He's now in an ambulance, braced on a stretcher.

0:22:430:22:46

It's Seb, isn't it? Seb. Yeah. What were you doing?

0:22:500:22:52

You were cutting trees, were you?

0:22:520:22:54

Yeah.

0:22:590:22:59

And you landed how?

0:23:040:23:07

Onto your feet, like this, or onto your side?

0:23:070:23:09

Yeah, OK.

0:23:120:23:14

We'll cut all your clothes off.

0:23:140:23:15

We'll keep you in the ambulance so you're warm for now, OK, buddy?

0:23:150:23:18

'My first impression of Seb'

0:23:180:23:22

is a man who is in a lot of pain,

0:23:220:23:26

is not breathing quite normally -

0:23:260:23:29

either because of his injury, or because of his pain -

0:23:290:23:32

and a man who is very scared, and that worries me.

0:23:320:23:36

Do you mind if, while I do a primary survey...?

0:23:360:23:39

'Not everybody looks that scared after they've had an injury,'

0:23:390:23:42

so, yeah, it's a sign of something bad going on.

0:23:420:23:45

Someone tries to pop in another cannula.

0:23:450:23:48

We're going to get you really warmed up now

0:23:480:23:50

and give you loads of painkillers, OK, mate?

0:23:500:23:52

Sam needs to find the source of Seb's pain

0:23:520:23:54

to work out what's going on inside.

0:23:540:23:57

I'll have a gentle feel of your tummy.

0:23:570:23:59

Does it hurt? Yeah. Everywhere?

0:24:010:24:04

Yeah. OK.

0:24:040:24:05

When I pressed his tummy, he was desperately tender and rigid,

0:24:050:24:09

which can be a sign of a real disaster going on in the abdomen.

0:24:090:24:11

If I press here, does that hurt?

0:24:110:24:13

It's hurting down there when I'm pressing here?

0:24:160:24:19

I'm just undoing your trousers to have a look at your pelvis.

0:24:190:24:22

Paramedic Simon Probert is concerned about the risk of internal bleeding.

0:24:220:24:26

With all trauma patients that we attend,

0:24:260:24:28

we'll always perform an examination of the pelvis.

0:24:280:24:31

It's a very strong, rigid structure, but it can be broken.

0:24:310:24:35

Because of the amount of blood vessels that sit within your pelvis,

0:24:350:24:38

pelvic fractures can be fatal.

0:24:380:24:40

They can be life-threatening and you can lose your entire blood volume

0:24:400:24:44

within your pelvis without any external bleeding.

0:24:440:24:47

Does that hurt your back at all?

0:24:470:24:49

OK.

0:24:490:24:50

That hurts you where in your back?

0:24:530:24:55

Lower back, yeah. OK.

0:24:550:24:57

How much morphine has he had? Ten.

0:24:570:24:59

Ten. Let's try more morphine and I'll be back in a second.

0:24:590:25:02

Time is critical because, every second that the body is bleeding,

0:25:030:25:09

your chance of death increases.

0:25:090:25:11

I leave to gather probably one of the most important

0:25:120:25:15

bits of information for myself and that is to look at the exact scene -

0:25:150:25:20

where he fell from and what he landed on.

0:25:200:25:22

Yeah.

0:25:250:25:26

Oh, really? OK.

0:25:270:25:28

Right. From where?

0:25:300:25:32

A-frame meaning what? Scaffolding? A great big ladder. A ladder.

0:25:350:25:38

Metal, an A-frame ladder that goes like that.

0:25:380:25:41

OK, and what branches was he cutting?

0:25:410:25:43

Those broken top ones up there? Yep. OK.

0:25:430:25:46

'Seeing that tree, seeing the height and what he landed on,'

0:25:490:25:52

for me, was the clincher.

0:25:520:25:54

I thought, "This is enough.

0:25:540:25:55

"I'm not going to take any chances with this man."

0:25:550:25:58

Concerned Seb could be bleeding from internal injuries sustained in the

0:25:590:26:02

high fall, Sam must get him to hospital fast.

0:26:020:26:06

He's fallen a fair old way onto the base of a bush,

0:26:060:26:09

so a big deceleration.

0:26:090:26:10

I mean, he's extremely tender in his abdomen.

0:26:110:26:14

I think we should go to a major trauma centre

0:26:140:26:16

because I'm worried he's bleeding. Yeah, yeah. I agree.

0:26:160:26:19

In the last 60 minutes,

0:26:300:26:31

emergency clinicians have battled to

0:26:310:26:33

treat three critically ill patients.

0:26:330:26:35

Horse rider George is being

0:26:360:26:38

airlifted to hospital

0:26:380:26:39

after suffering major damage

0:26:390:26:40

to his spinal cord.

0:26:400:26:42

Dusan has been anaesthetised

0:26:430:26:45

after an accident

0:26:450:26:46

has left him with multiple injuries.

0:26:460:26:48

And after falling from a tall ladder,

0:26:480:26:51

Seb is showing signs of potential internal bleeding.

0:26:510:26:53

Dusan has been rushed to the Royal London Hospital

0:26:590:27:02

after being hit by a bus while walking to the gym.

0:27:020:27:04

Gareth is concerned about his head and chest injuries.

0:27:060:27:10

He's also worried he may be bleeding into his abdomen.

0:27:100:27:13

I just wanted to let you know there's a trauma patient arriving.

0:27:130:27:16

The 40-year-old male pedestrian versus bus.

0:27:160:27:19

OK.

0:27:190:27:20

Emergency medicine consultant Simon Walsh is preparing

0:27:200:27:24

to take over the patient and assess the scale of his injuries.

0:27:240:27:27

OK, everyone, this gentleman is approximately 40 years of age.

0:27:300:27:34

He was hit by a bus.

0:27:340:27:36

I think he's hit the bus with his head.

0:27:360:27:38

His saturations where 85% and his last blood pressure was 88 systolic.

0:27:380:27:42

OK. Let's start the primary survey, please.

0:27:420:27:44

Can we get the...? Is the scoop undone?

0:27:440:27:48

Dusan has both critically low oxygen and blood pressure.

0:27:480:27:52

As well as his head injury,

0:27:520:27:53

the impact of the bus may have damaged his lungs

0:27:530:27:56

and Simon is also concerned he's bleeding

0:27:560:27:58

from other internal injuries.

0:27:580:28:00

'Firstly, why has his blood pressure become so low?'

0:28:010:28:05

Is he bleeding?

0:28:050:28:06

Do we need to give him some blood to replace blood loss immediately?

0:28:060:28:11

So I'm thinking, "Does he have another injury?"

0:28:130:28:16

Is there more to this than meets the eye?

0:28:160:28:19

Chest X-ray has got a lot of opacification

0:28:190:28:21

of the right hemithorax,

0:28:210:28:22

so presumed contusion, plus or minus hemothorax.

0:28:220:28:26

The X-ray shows what could be severe bruising

0:28:270:28:30

to Dusan's right lung, or an area of blood around it,

0:28:300:28:33

which could be preventing him from getting enough oxygen.

0:28:330:28:37

Sats still reading 84.

0:28:370:28:39

If you could do anything with the ventilation to improve that...

0:28:390:28:42

Consultant anaesthetist Mit Lahiri is also concerned

0:28:420:28:45

about the impact of his damaged lungs on the rest of his body.

0:28:450:28:49

The things that were worrying me initially

0:28:500:28:52

were that his oxygen levels were low,

0:28:520:28:55

despite the fact we were on as much oxygen as we could give him.

0:28:550:28:58

So we take a sample of blood from the artery,

0:28:580:29:01

and that gives us a huge amount of information.

0:29:010:29:04

Got bloods. Thank you.

0:29:040:29:06

This blood sample is processed within minutes

0:29:060:29:09

and reveals another major problem.

0:29:090:29:12

He is very acidotic, got a pH 6.97.

0:29:120:29:15

Dusan's body has been starved of oxygen

0:29:150:29:18

and is now creating lactic acid in his blood.

0:29:180:29:21

A pH of 6.9 is a potentially unsurvivable level of acid

0:29:210:29:26

without immediate intervention.

0:29:260:29:29

The longer the body is acidic,

0:29:290:29:31

the more likely the cells are going to die.

0:29:310:29:34

This acidic blood could trigger yet more complications.

0:29:340:29:37

Increased levels of acid can cause problems with the blood clotting,

0:29:380:29:42

which can cause more bleeding and so it goes on.

0:29:420:29:46

In my experience,

0:29:470:29:49

you're more likely to die than live with numbers like that.

0:29:490:29:52

We're spiralling towards a point

0:29:530:29:55

where we're not going to be able to come back,

0:29:550:29:58

so we need to do something pretty sharp.

0:29:580:30:02

OK, so, obviously, he has got a significant head injury,

0:30:020:30:06

but he probably is also bleeding, so we'll request a pack A

0:30:060:30:11

and get him to CT and see what else is going on. OK?

0:30:110:30:14

Hi, can I request a pack A, please?

0:30:150:30:17

Simon rushes Dusan to the CT scanner and requests

0:30:170:30:21

an urgent blood transfusion.

0:30:210:30:23

He needs to find out exactly what's wrong with Dusan's lungs

0:30:250:30:28

and locate the source of his internal bleeding.

0:30:280:30:30

Ultimately, the question is, does he need an operation

0:30:320:30:35

to stop bleeding in his belly?

0:30:350:30:37

Does he need any procedures done to

0:30:370:30:40

improve his ventilation function in his chest?

0:30:400:30:43

And does he need neurosurgery?

0:30:430:30:44

ALARM BEEPS

0:30:470:30:50

But as Dusan enters the scanner,

0:30:500:30:52

his blood pressure plummets to its lowest yet.

0:30:520:30:56

This chap is a code red. Dropped his blood pressure to 71/50.

0:30:560:31:00

He's just in CT now.

0:31:000:31:01

ALARM CONTINUES

0:31:040:31:06

Code red lets key staff know there's a patient bleeding to death,

0:31:060:31:10

and makes blood and blood products quickly available.

0:31:100:31:15

The team start an urgent transfusion while Simon begins the scan.

0:31:150:31:18

Getting a CT scan allows us to see exactly what the brain injury is,

0:31:210:31:26

it allows us to see, is he bleeding into his chest?

0:31:260:31:29

Is he bleeding into his abdomen?

0:31:290:31:31

Any one of those things, in itself, can be life-threatening.

0:31:310:31:35

Simon consults neurosurgeon Emma Sillery.

0:31:360:31:40

The impact of the bus could have given Dusan

0:31:400:31:43

a major bleed in his head.

0:31:430:31:44

Your brain is a soft, pliable thing

0:31:470:31:50

that you could compress with your fingers,

0:31:500:31:52

so it's a delicate and easily damaged.

0:31:520:31:54

And heavy bleeding inside the head can push on the brain

0:31:540:31:57

and, if things push on the brain, it's only a small step, really,

0:31:570:32:01

before life-threatening conditions can develop.

0:32:010:32:06

His head doesn't look like it's got any large haematoma

0:32:060:32:08

that needs to be evacuated.

0:32:080:32:09

He's got an injury and some intracranial air.

0:32:090:32:13

The scan reveals an area of air in Dusan's head

0:32:130:32:15

which has entered through fractures to his face,

0:32:150:32:19

but there's no obvious signs of bleeding.

0:32:190:32:21

His brain, serious though it is, wasn't too bad,

0:32:210:32:24

and we could then at that point make a quick call

0:32:240:32:27

that they could leave this for now.

0:32:270:32:29

Simon decides to monitor Dusan's head injury

0:32:300:32:33

and continues scanning the rest of his body.

0:32:330:32:36

He's got a bit of blood in his right chest, doesn't he?

0:32:360:32:39

He's got a chest injury with some bleeding

0:32:390:32:42

on the right side of the chest, and some air escaped from both lungs.

0:32:420:32:46

The scan reveals Dusan has blood and air trapped around his lungs.

0:32:470:32:52

This is affecting his breathing and reducing his oxygen levels.

0:32:520:32:56

But before Simon can see to this,

0:32:560:32:58

he must find the main source of bleeding.

0:32:580:33:01

He's got a lot of blood around his spleen and some around his liver.

0:33:030:33:06

Then the scan locates a large area where blood is collecting.

0:33:070:33:10

The CT appearance, showing blood within his abdomen,

0:33:120:33:15

makes me concerned that he's actually bleeding to death.

0:33:150:33:18

Harriet, we're going to need chest drain on each side.

0:33:210:33:24

Simon must now drain the blood and air trapped around Dusan's lungs

0:33:240:33:28

and, without immediate surgery to stop the bleeding in his abdomen,

0:33:280:33:32

Dusan may not survive.

0:33:320:33:33

In Bristol, Great Western Air Ambulance

0:33:420:33:44

has just landed with horse rider George.

0:33:440:33:47

He's a 63-year-old male,

0:33:470:33:48

fall from horse, who's got a sensory level of C4 and is in spinal shock.

0:33:480:33:53

Emergency department consultant Adam Brown

0:33:530:33:55

is preparing to receive a handover.

0:33:550:33:58

He needs to rapidly determine the full scale of George's spinal damage

0:33:580:34:02

and any hidden injuries he might have from the riding accident.

0:34:020:34:06

We, as a medical profession,

0:34:060:34:08

quite rightly withhold our prognosis with these sorts of injuries.

0:34:080:34:12

But the reality of the fact is that,

0:34:120:34:14

if you see a devastating spinal cord injury,

0:34:140:34:17

you know, nearly all of the time, it's life-changing.

0:34:170:34:20

You all know about trauma calls by now - it's in, assess, stabilise.

0:34:200:34:23

If the patient's stable, off to CT.

0:34:230:34:25

Any questions? Groovy.

0:34:250:34:27

Red bag, please. And can we get the TX8 out but not drawn up?

0:34:270:34:30

Just park up.

0:34:340:34:35

OK, guys, just listen in for the handover, please.

0:34:350:34:37

This is a horse riding incident.

0:34:370:34:39

He's come off, he knows he has a neck injury,

0:34:390:34:42

neck pain was his only complaint.

0:34:420:34:45

I suspect he has a neck injury with probably a C3 for complete level.

0:34:450:34:50

Any questions from anyone? OK.

0:34:500:34:51

This is what I want to happen, please.

0:34:510:34:53

I'd like to undo all this blanket. He's on a yellow scoop.

0:34:530:34:55

I'd like people to come around the sides, lift up the scoop,

0:34:550:34:58

get out all the orange stuff

0:34:580:35:00

and then we'll do the monitor change after that.

0:35:000:35:02

Despite George's obvious neck injury,

0:35:020:35:04

Adam must be thorough and look for other possible internal injuries.

0:35:040:35:08

I know that George has a potentially life-threatening,

0:35:080:35:13

life-changing, high-neck injury.

0:35:130:35:16

I do not want to be complacent or focused on George's neck injury.

0:35:160:35:21

He has fallen, at speed, off a horse.

0:35:210:35:25

We need to ensure we do not miss any injuries

0:35:250:35:28

because we are so focused on the obvious, devastating,

0:35:280:35:31

life-changing injury that he may have.

0:35:310:35:34

Got good CO2.

0:35:340:35:36

Sats are 96.

0:35:360:35:38

What we're going to do then is we're going to get off the scoop,

0:35:380:35:41

package for CT, draw up presses, please, and we will go to scan.

0:35:410:35:43

11 minutes after arrival to resus,

0:35:450:35:48

George is taken for a full body scan to rule out other internal injuries

0:35:480:35:52

and look for damage to his spine.

0:35:520:35:54

On the word slide. Ready, steady, slide.

0:35:540:35:57

Well done.

0:35:570:35:58

The CT images actually looked remarkably OK.

0:36:110:36:13

It was as if George had injured his neck,

0:36:130:36:17

restored his neck back to its normal position,

0:36:170:36:20

and you couldn't really see any injury at all.

0:36:200:36:23

The CT scan is reassuring from the point of view of

0:36:230:36:26

we know there's no other injuries, but we haven't got the answer

0:36:260:36:30

to why George can't move his arms and his legs.

0:36:300:36:32

With no sign of injury to any of George's organs or bones

0:36:320:36:35

on the scan, Adam will need to run further tests.

0:36:350:36:38

George, can you try and bring your toes of both feet

0:36:450:36:47

back up towards your chin?

0:36:470:36:49

OK. And then can you try and push your toes down on both feet?

0:36:510:36:54

Try and push your feet down.

0:36:540:36:56

OK. So he's going to need an MRI. That's effectively it, isn't it?

0:36:560:36:59

He's going to need an MRI scan of his spinal cord

0:36:590:37:01

because we found no bone injury at all. The scans were normal.

0:37:010:37:05

An MRI scanner will show tissue detail

0:37:050:37:07

and any damage to George's spinal cord.

0:37:070:37:10

I think the important thing to communicate with George,

0:37:100:37:14

who is fully aware,

0:37:140:37:18

is to be honest and to be sensitive.

0:37:180:37:22

Without a shadow of a doubt, on some level,

0:37:220:37:24

I know that George knows what's going on.

0:37:240:37:27

And...as George's trauma team leader,

0:37:270:37:31

I'd don't really want to say it,

0:37:310:37:34

but that doesn't help anybody.

0:37:340:37:36

Obviously, you're behaving like somebody who's got an injury

0:37:360:37:39

to their spinal cord because you can't move your arms

0:37:390:37:41

and can't move your legs, but you can feel certain things.

0:37:410:37:46

So what you're going to need is an MRI scan,

0:37:460:37:48

which is a much more detailed scan, in a tunnel,

0:37:480:37:52

to have a look at detail of the spinal cord

0:37:520:37:54

because I think that's where the injury is that's giving you this.

0:37:540:37:57

It might be that you've just got bruising of that,

0:37:570:38:00

but, either way, we need to know.

0:38:000:38:02

And until we know, we need to keep you laying flat like this.

0:38:020:38:05

Will it show any damage? It will show, yes.

0:38:050:38:07

All right, OK. All right.

0:38:070:38:09

So that will show, basically, what the future is for me?

0:38:090:38:17

Yes, yes, it will. OK.

0:38:170:38:19

Let me go and sort that out now. Thank you. OK.

0:38:190:38:22

In St Albans, young tree surgeon Seb

0:38:300:38:32

is complaining of severe abdominal pain,

0:38:320:38:35

having fallen 30 feet from a ladder.

0:38:350:38:37

Concerned his injuries could be life-threatening,

0:38:400:38:42

Sam has decided to fly him to the nearest major trauma centre.

0:38:420:38:46

I'm looking at Seb, I'm worried about him,

0:38:460:38:49

I'm telling everybody and telling myself that he could be bleeding

0:38:490:38:52

into his abdomen or his pelvis,

0:38:520:38:54

and I know that we're a long way from hospital.

0:38:540:38:57

Ready, brace, lift.

0:38:570:38:58

Another injury which is very likely from that type of fall

0:38:590:39:03

is a spinal injury, particularly as he was complaining

0:39:030:39:07

of pain in his lower back as well as his abdomen.

0:39:070:39:09

With that always comes the risk of damaging your spinal cord,

0:39:090:39:12

even though he can move his legs,

0:39:120:39:14

and that could be devastating in the long run.

0:39:140:39:17

I know that I can't just chuck him on the helicopter.

0:39:170:39:19

He needs his spine to be kept very still

0:39:190:39:22

because it could well be broken.

0:39:220:39:24

Ready, set, lift.

0:39:240:39:25

Claire, we are bringing you a trauma patient by air.

0:39:270:39:29

He's a 23-year-old adult male.

0:39:290:39:32

He's fallen 25 feet, possibly a pelvic fracture.

0:39:320:39:37

It's a 17-minute flight to the Royal London Hospital,

0:39:390:39:42

where emergency medicine consultant Ben Clarke and his team

0:39:420:39:45

are preparing to receive Seb.

0:39:450:39:47

A fall from height is dangerous because, essentially,

0:39:470:39:50

you suddenly accelerate and then you very, very suddenly decelerate

0:39:500:39:54

and, by that, you come to a very abrupt stop.

0:39:540:39:56

And what can happen with that deceleration

0:39:570:39:59

is you can tear bits of the bowel, you can tear big blood vessels

0:39:590:40:03

and the impact itself can cause

0:40:030:40:04

damage to any number of different organs and bones.

0:40:040:40:07

Hello, guys. This is Seb.

0:40:100:40:12

He's 23 years old.

0:40:120:40:14

He fell around about 25-30 feet from the top of a tree.

0:40:140:40:18

He's a tree surgeon cutting branches.

0:40:180:40:20

'I'm hearing in this handover that Sebastian

0:40:200:40:23

'has fallen a great distance.'

0:40:230:40:24

He was complaining of very severe lower back pain and abdominal pain,

0:40:240:40:28

and those automatically point me to thinking about internal bleeding

0:40:280:40:31

and organ injuries, but also, most importantly, a pelvic injury.

0:40:310:40:35

Let's get the bed down.

0:40:350:40:36

We'll aim to do a primary survey nice and quickly.

0:40:360:40:39

Chest X-ray.

0:40:420:40:43

Ben decides to do an ultrasound scan to look for internal bleeding.

0:40:460:40:51

The purpose of it is to look at certain parts inside the belly

0:40:510:40:55

and the heart to see whether there's

0:40:550:40:58

any clear signs of internal bleeding.

0:40:580:41:01

Let's have a quick look down in his pelvis, if you don't mind.

0:41:010:41:04

Negative thus far.

0:41:050:41:07

It gives us an indication as to whether Sebastian's path may be

0:41:070:41:10

to the theatre, or whether he is stable

0:41:100:41:12

and we can go through the Cat scanner.

0:41:120:41:14

OK, guys. If we're good and we've got him disconnected,

0:41:140:41:16

let's go through to scan, if they're ready.

0:41:160:41:20

The ultrasound hasn't revealed any bleeding,

0:41:200:41:22

so Ben takes Seb through to the CT scanner

0:41:220:41:25

for a more detailed look inside.

0:41:250:41:27

The CT is a very sensitive,

0:41:270:41:30

very specific tool for showing us everything that is going on,

0:41:300:41:33

from his head down to his pelvis,

0:41:330:41:35

and see whether there is any clear sites of injury or bleeding.

0:41:350:41:39

Just be gentle, just be really gentle.

0:41:400:41:42

At the Royal London Hospital,

0:41:500:41:52

scans have revealed Dusan has suffered life-threatening injuries

0:41:520:41:56

to his chest and abdomen after being hit by a bus.

0:41:560:41:59

A build-up of blood and air trapped around his lungs has caused them

0:41:590:42:03

to collapse and he's bleeding inside his abdomen.

0:42:030:42:05

First priority is to put chest drains in

0:42:090:42:11

to allow his lungs to fully reinflate and allow them

0:42:110:42:15

to deliver as much oxygen into his circulation as is possible.

0:42:150:42:19

Is that drain doing anything? It was bubbling.

0:42:220:42:25

Yeah? Still bubbling? Bubbling.

0:42:250:42:27

With chest drains releasing the blood and air

0:42:270:42:30

trapped around Dusan's lungs,

0:42:300:42:32

Simon turns his attention to the abdominal bleeding.

0:42:320:42:35

Since the accident, this has been causing Dusan's blood pressure

0:42:360:42:39

to fall dangerously low, and they need to operate soon.

0:42:390:42:44

So how much blood have we actually given him so far?

0:42:440:42:46

240. 240, OK.

0:42:460:42:48

That's all we need.

0:42:480:42:49

For Dusan to survive long enough for surgery,

0:42:490:42:52

Simon has been giving him a blood transfusion.

0:42:520:42:55

He also hopes this will help make his blood less acidic

0:42:550:42:58

and enable it to clot.

0:42:580:43:00

You have a window where they're heading down

0:43:010:43:04

a slope of worsening acidosis,

0:43:040:43:07

and, if you don't reverse that very quickly,

0:43:070:43:10

then death can follow within minutes.

0:43:100:43:14

OK, the gas has improved a bit.

0:43:160:43:18

Ph 7.11.

0:43:180:43:20

Lactate's come down to 4.4.

0:43:200:43:23

With his blood gas results and blood pressure improving,

0:43:240:43:27

Dusan now has a window of opportunity for surgery.

0:43:270:43:30

Simon rushes him to the operating theatre

0:43:320:43:34

and hands over to consultant trauma surgeon Wayne Sapsford.

0:43:340:43:37

There are a number of areas within the body

0:43:390:43:41

which have a huge amount of potential space

0:43:410:43:45

in which blood can accumulate

0:43:450:43:46

and in the abdomen, in particular,

0:43:460:43:48

you can lose most or all of your blood.

0:43:480:43:51

Wayne begins the process of locating the source of Dusan's bleed.

0:43:550:43:59

When I opened Dusan's abdomen, there was 1-1.5 litres of free blood,

0:43:590:44:07

which we removed.

0:44:070:44:08

And then I did a thorough examination of all of his abdomen.

0:44:110:44:17

Major organs and vessels in the abdomen and pelvis

0:44:170:44:19

must be checked meticulously for active bleeding.

0:44:190:44:22

When I got to the liver and examined that in more detail,

0:44:250:44:29

he had a 6-7cm laceration on the right lobe of the liver

0:44:290:44:33

which wasn't actively bleeding.

0:44:330:44:36

The impact of the bus has torn part of Dusan's liver,

0:44:360:44:40

but this bleeding now appears to have stopped.

0:44:400:44:42

The liver is a manufacturer of clotting products

0:44:440:44:47

and is very good at stopping bleeding by itself.

0:44:470:44:51

However, I left packs around the liver to compress the laceration

0:44:510:44:56

in order to try and prevent it from bleeding again

0:44:560:44:58

in the ongoing hours and days.

0:44:580:44:59

Wayne leaves Dusan with a temporary closure of his abdomen.

0:45:020:45:06

The packs will help prevent any further bleeding from his liver

0:45:060:45:09

and will be removed at a later date.

0:45:090:45:11

But Dusan is not out of danger yet.

0:45:120:45:14

We're going to be doing an insertion of a right frontal ICP bolt,

0:45:160:45:20

so this is the patient's right,

0:45:200:45:21

and it's just going to be a little probe into the brain.

0:45:210:45:24

Despite there being no obvious bleed in Dusan's head,

0:45:240:45:27

neurosurgeon Emma Sillery is keen to monitor the pressure

0:45:270:45:31

around his brain over the coming days.

0:45:310:45:33

He does have fractures,

0:45:340:45:35

he did have some bleeding and we think he is at the risk of swelling.

0:45:350:45:38

The skull is a rigid structure

0:45:380:45:40

and Emma is worried that bruising on his brain could create swelling.

0:45:400:45:45

This would dangerously increase the pressures in his head.

0:45:450:45:47

Your heart has to be able to push blood into your head -

0:45:470:45:50

that happens all the time. You have an natural pressure in your head,

0:45:500:45:53

and your heart overcomes it and pumps blood into your head.

0:45:530:45:56

The pressure on the brain gets too much,

0:45:560:45:57

the heart can't pump blood into it,

0:45:570:45:59

and you have a brain without blood, and that's...

0:45:590:46:03

That doesn't last very long.

0:46:030:46:05

This probe will enable Emma to accurately monitor

0:46:050:46:08

the pressure in Dusan's head, minute by minute.

0:46:080:46:11

You use a small, thin wire that we put inside the brain

0:46:110:46:14

to measure the pressure inside the skull.

0:46:140:46:17

We have to put a screw into the skull

0:46:170:46:19

with a little tunnel through it,

0:46:190:46:21

and then we can put our delicate, little probe

0:46:210:46:24

through that screw tunnel and into the brain.

0:46:240:46:26

When I put the little pressure monitor in,

0:46:260:46:29

initially, his pressures were fine.

0:46:290:46:30

We could tell that from the scan, we were expecting that.

0:46:300:46:34

What we were really doing was to make sure that,

0:46:360:46:38

over the coming days, if his brain got big and crowded in there,

0:46:380:46:41

that we would pick that up on the monitor.

0:46:410:46:44

We can keep a little eye on his brain, 24 hours a day,

0:46:450:46:48

while he's in such a critical situation.

0:46:480:46:51

Dusan will be kept in a coma

0:46:510:46:53

while they monitor for swelling and bleeding.

0:46:530:46:56

They must now wait to see how well he recovers.

0:46:560:46:59

In Bristol, doctors are trying to figure out why rider George

0:47:100:47:14

has lost all control from the neck down after coming off his horse.

0:47:140:47:18

His CT scan showed no broken bones,

0:47:190:47:22

but the results are now back from a more detailed MRI.

0:47:220:47:25

Effectively, George's neck has been thrown forward with force,

0:47:280:47:32

backward with force.

0:47:320:47:33

So this is George's neck

0:47:330:47:35

and what we are seeing

0:47:350:47:37

is a possible disruption of three on four,

0:47:370:47:41

and that's visible on his CT scan,

0:47:410:47:43

but it doesn't give us enough information to say

0:47:430:47:46

that's exactly what the problem is,

0:47:460:47:48

which is why we moved to the MRI scan.

0:47:480:47:51

You can see the grey and the white of the cord in the spinal canal.

0:47:510:47:55

The cord should look like this -

0:47:560:47:58

pristine, continuous.

0:47:580:48:00

And, as you can see,

0:48:000:48:01

when you get here, there's a significant amount of disruption.

0:48:010:48:04

What has happened to George's spinal cord is it's not severed,

0:48:050:48:09

the cord is intact, but it's been stretched rather than torn.

0:48:090:48:13

If the injury had been a complete tearing of the cord,

0:48:140:48:17

it would be very easy to say, "This is probably not going to get

0:48:170:48:21

"any better and that is it."

0:48:210:48:23

In George's case, it's very complicated

0:48:230:48:25

because it's what we call an incomplete injury

0:48:250:48:28

and we just do not know how that is going to improve

0:48:280:48:32

over the coming hours, days, weeks and months.

0:48:320:48:35

George is unable to move any of his muscles below the neck

0:48:370:48:40

apart from his toes.

0:48:400:48:42

And relax.

0:48:430:48:45

His wife, Sarah, is working with him to regain any possible control.

0:48:470:48:51

I think that's enough exercise.

0:48:510:48:54

It is exhausting, isn't it?

0:48:560:49:00

Very encouragingly, there are one or two muscles

0:49:000:49:04

that I can move a tiny amount

0:49:040:49:07

and so I'm at that very, very tense stage, at the moment,

0:49:070:49:12

when I don't know whether I'll be what I think is called

0:49:120:49:16

a tetraplegic - someone who cannot move any of their limbs,

0:49:160:49:19

other than their neck.

0:49:190:49:21

At the Royal London Hospital, tree surgeon Seb is undergoing

0:49:320:49:36

an urgent head-to-toe CT scan to look for the source of his pain.

0:49:360:49:40

'Looking at Sebastian's scan,

0:49:420:49:44

'I am most worried about excluding injuries.'

0:49:440:49:48

I want to make sure I can't see any obvious signs of bleeding,

0:49:480:49:52

any very clear fractures.

0:49:520:49:55

Otherwise, that looks pretty good, doesn't it?

0:49:550:49:57

Full at the top, full at the bottom. Yeah.

0:49:570:49:59

He needs a wee. He definitely needs a wee.

0:49:590:50:02

He did say that. Yeah, bless him.

0:50:020:50:04

The initial scan rules out any life-threatening bleeding

0:50:040:50:07

that would require immediate surgery.

0:50:070:50:10

For Ben to find the source of Seb's pain,

0:50:100:50:13

he must wait for the scan to be fully processed.

0:50:130:50:15

Hello, mate. Everything's looking pretty good so far,

0:50:150:50:18

so what we're waiting on is

0:50:180:50:19

we're waiting on just the formal report of the scan.

0:50:190:50:22

There's still just a little bit of pain.

0:50:220:50:24

Where is that pain? Stomach. In the stomach, all right.

0:50:240:50:27

No worries.

0:50:270:50:29

What we'll do is I'm going to go and have a good look through

0:50:290:50:31

the scan as well and make sure there is nothing subtle that I can see.

0:50:310:50:34

With the full images now available, Ben makes a further assessment.

0:50:380:50:42

That explains a lot of his pain then, doesn't it?

0:50:490:50:53

The scan reveals Seb's fall has severely crushed one of his vertebra

0:50:530:50:57

and this is where his pain is coming from.

0:50:570:50:59

We've got all these lucencies,

0:50:590:51:01

it's irregular, it's got what looks to be cracks.

0:51:010:51:04

We can see that L1, which is this one here,

0:51:040:51:08

has been crushed, basically.

0:51:080:51:11

It's been fractured. It's been basically squashed down.

0:51:110:51:14

Despite the crushed vertebra, Seb's spinal cord is currently intact,

0:51:140:51:18

but a sudden movement could cause significant nerve damage.

0:51:180:51:22

All right, mate. We've got the results.

0:51:220:51:25

So your lumber spine, which is about here in your back,

0:51:250:51:30

it looks like one of the bones there has been broken -

0:51:300:51:33

and it's called your L1 vertebra.

0:51:330:51:35

The way you've fallen,

0:51:350:51:36

what's happened is that vertebra has been squashed a bit.

0:51:360:51:39

It's what we call unstable.

0:51:390:51:40

What we're going to do is get our neurosurgical doctors,

0:51:400:51:43

they're going to have a look at you

0:51:430:51:45

and then tell you exactly what the plan will be from there.

0:51:450:51:49

Simon hands over to consultant neurosurgeon Jonathan Bull,

0:51:490:51:53

who takes the decision to operate the next day.

0:51:530:51:56

The risk is that, having had it partially fractured,

0:51:580:52:01

as he started to walk around on it,

0:52:010:52:03

the bone would then further collapse and push fragments

0:52:030:52:05

into the spinal canal, which would then squash the spinal cord

0:52:050:52:08

and risk, basically, paralysis in his lower limbs.

0:52:080:52:11

One option was to treat him in a brace,

0:52:130:52:15

so he wouldn't have had an operation.

0:52:150:52:17

He would have worn that for around 10-12 weeks.

0:52:170:52:19

The alternative was a surgical option,

0:52:190:52:21

particularly for trauma patients,

0:52:210:52:23

a fixation with screws, but done through the skin.

0:52:230:52:25

It's like a scaffolding. It's like a support for the fractured bone.

0:52:280:52:32

X-ray.

0:52:350:52:36

'Rather than making a large incision,

0:52:370:52:40

'we make small sequential incisions at each level and pass a guide wire

0:52:400:52:44

'into the vertebral body, and then put a screw into it.'

0:52:440:52:47

Have that screw, please?

0:52:490:52:50

Jonathan uses the fixation as a scaffold

0:52:500:52:53

to support the fractured bone.

0:52:530:52:55

This is braced to a healthy vertebrae above and below,

0:52:550:52:58

all done through keyhole surgery.

0:52:580:53:00

It means the wound is smaller,

0:53:020:53:03

there's less damage to the surrounding muscle,

0:53:030:53:05

so they can often mobilise more rapidly.

0:53:050:53:07

Theoretically, if the fracture heals satisfactory,

0:53:070:53:10

you'll have a full range of motion, or near-full range of motion.

0:53:100:53:13

He sent me a WhatsApp from the hospital.

0:53:370:53:41

It was a little ambulance emoji, so of course I was quite scared.

0:53:410:53:46

I knew he had a dangerous job and I didn't know what had happened.

0:53:460:53:50

You're with the tree.

0:53:520:53:53

When it's windy and raining, you're sort of up there and it's...

0:53:530:53:56

Sometimes it's scary, but you...

0:53:560:53:59

I was never really scared of heights.

0:53:590:54:02

When I saw him in that hospital bed,

0:54:020:54:04

he just looked so small and...

0:54:040:54:07

he was scared.

0:54:070:54:08

Sebastian, I think, was lucky

0:54:100:54:11

insofar as the fracture didn't compromise his spinal cord

0:54:110:54:15

and he didn't have a deficit or weakness in his limbs from it.

0:54:150:54:18

I'm hoping he'll make a good recovery from it.

0:54:180:54:21

I'm fortunate for not being paralysed.

0:54:210:54:26

It could have been a lot worse.

0:54:260:54:29

I'm glad that I'm up and walking.

0:54:290:54:33

I just found out I was pregnant.

0:54:350:54:36

I told him just the week before.

0:54:370:54:39

We have a little boy on the way,

0:54:390:54:43

so that's really good.

0:54:430:54:45

A new chapter.

0:54:450:54:47

He's relying a lot on me,

0:54:470:54:48

but we're grateful that we still have each other, alive and walking.

0:54:480:54:52

He's doing incredibly well.

0:55:080:55:09

From seeing him in the CT scanner, with a blood pressure that low,

0:55:090:55:14

I was concerned as to whether he would survive.

0:55:140:55:16

Picture the scene, where you're just going about doing your thing,

0:55:180:55:20

and then you wake up and it's a month later.

0:55:200:55:23

And you're somewhere you've no idea where you are,

0:55:240:55:26

looking at somebody and you don't know who they are.

0:55:260:55:29

And that's a weird thing, because it affects you as a person.

0:55:290:55:33

The natural course of untreated bleeding and acidosis

0:55:380:55:42

with a brain injury is quite commonly death...

0:55:420:55:45

..but our aim is to intervene, to try and stop that process,

0:55:470:55:51

but it has to be done at the very early stage,

0:55:510:55:54

otherwise it's too late.

0:55:540:55:55

So, if we put your arm in there...

0:56:040:56:09

Now that his elbow is held up...

0:56:100:56:13

I...

0:56:170:56:19

They're quite short ropes.

0:56:210:56:23

If they were longer ropes, it would go further, I promise you.

0:56:230:56:27

I think, if I had the choice,

0:56:360:56:39

I would elect not to have jumped that hedge

0:56:390:56:41

in the way that I jumped it.

0:56:410:56:43

But I've had such an enjoyable life

0:56:450:56:47

and that's partly because of the things I've been able to do.

0:56:470:56:51

You look around for the positives

0:56:510:56:54

and it's a reminder that this isn't a practice for anything,

0:56:540:56:58

this is the real thing, and you only get one...

0:56:580:57:04

One go.

0:57:040:57:06

Can I have some water?

0:57:060:57:07

If you live your life protecting yourself

0:57:090:57:11

from every single potential outcome,

0:57:110:57:15

you'll never do anything.

0:57:150:57:17

So...life is there to be lived,

0:57:170:57:19

George was doing that,

0:57:190:57:21

and we're there to support the next life George has.

0:57:210:57:25

My current efforts, as indeed are this hospital's efforts,

0:57:260:57:32

are to make the best of what I've got

0:57:320:57:35

and follow the road where it takes me.

0:57:350:57:38

We both... Well, I don't know if we both,

0:57:410:57:43

I would love it if you could scratch your nose by yourself

0:57:430:57:46

and I didn't have to do it.

0:57:460:57:48

Thank you.

0:57:490:57:50

I'm going to put lots of scratch posts in my house,

0:57:530:57:56

so I can go up to them and...

0:57:560:57:58

Next time...

0:58:000:58:02

We follow three patients through the crucial first hour of care.

0:58:020:58:06

In central London, a man suddenly collapses at work

0:58:060:58:09

with a suspected cardiac arrest.

0:58:090:58:11

We are going to anaesthetise him here.

0:58:110:58:15

In Newcastle, a mother of three

0:58:150:58:17

fights for her life after being stabbed in the chest and neck.

0:58:170:58:20

How big was the knife?

0:58:200:58:22

And a cyclist in Durham suffers horrific crush injuries to his chest

0:58:220:58:26

after being run over by a bus.

0:58:260:58:29

Let's get the blood in.

0:58:290:58:30

Unparalleled talent, unprecedented access.

0:59:010:59:04

BBC Two takes a sneaky peek behind the celebrity curtain.

0:59:040:59:07

One piece of advice...

0:59:070:59:08

Go out there, grab it with both hands and stick it in your mouth.

0:59:080:59:11

Job done!

0:59:110:59:13

Download Subtitles

SRT

ASS