At the Scene An Hour To Save Your Life

This programme contains scenes which some viewers may find upsetting

'Emergency ambulance...'

The moment an emergency call is made.

A battle against time begins.

-'Is she awake?

-No, she looks dead.'

MOANING

The decisions that are made in the first 60 minutes

of major trauma patients will make the difference between life and death.

If we can intervene within the first 60 minutes or so, the so-called golden hour,

then we know we can positively affect your outcome.

The sooner a doctor can reach their patient,

the more likely they are to survive.

We now have the ability to reverse

the initial effects of the injury if we are given the chance

and we are able to act quickly enough.

In their race against the clock, doctors and paramedics are now

taking the hospital to those at the very edge of life.

We're getting close...

SIRENS BLARE

MOANING

The more equipment and expertise and knowledge we can get

out on to the street or the scene of the accident,

then we will save more people's lives.

Armed with new treatments and equipment...

I'll get the auto pulse going.

..They're performing surgery on the roadside.

I could do the operation

in the back of the ambulance if necessary.

Administering powerful drugs.

Draw us up two ampoules of tranexamic acid.

Using innovative techniques...

If you pull that one and I'll pull this one.

And pushing the boundaries of science...

Let's get cold fluids going and oxygenation.

..To save time, and to save lives.

We've got to go.

This series will count down second by second, minute by minute,

the crucial decisions made in the first 60 minutes of emergency care.

One hour - the difference between life and death.

62 million people live in Britain.

Whether at home or at work,

in the city or in the countryside,

today over 900 of us will face a life-threatening emergency.

This film will follow three patients through 60 minutes of care

that will push the limits of scientific innovation.

In central London 29-year-old Zoe collapses on Oxford Street.

-'Is she awake?

-No. She looks dead.'

A farming accident in rural Lincolnshire

leaves 66-year-old Bill with life-threatening injuries.

He's been crushed by a 650kg cow.

And in north London, 30-year-old Rumen is hit by a car.

From the moment each one of these emergency calls is made,

the clock starts ticking.

'Emergency ambulance, what's the address of the emergency?

'It's a car accident.'

In London, Ambulance Control

receives a call about a serious road accident.

A specialist paramedic scans the thousands of calls

that come in each day looking for the most critical emergencies.

If we're quick enough to listen to a call then we can dispatch

the team in less than a minute.

Mr Jeffers, we have a job for you,

you're going to White Hart Lane, N22.

A 31-year-old male - car versus pedestrian.

Paramedic Steve tasks London's Air Ambulance.

This elite medical service can get to any patient inside the M25 within 12 minutes.

Our helicopter service is a dedicated trauma service.

We only get sent to the most serious and severely injured patients.

The co-pilot comes up, hands me piece of paper.

It said pedestrian versus car.

As soon as I hear that I immediately start thinking,

what could the potential problems be?

You're going to get hit by something that's pretty hard

at speed potentially, you know, you will have some injuries.

And my mind started going through what I could expect when I arrive.

Police and a London Ambulance crew are already at the scene.

Sorry, guys, give us space.

Move back.

OK, he looks pretty sick.

You guys all right?

Hi, I'm MJ and this is Graham.

Rumen.

This is Rumen. Hi, Rumen.

HE GROANS

Within seconds of arriving,

MJ needs to assess Rumen for life-threatening injuries.

Just going to have to do a quick primary survey.

He's 30 years old.

He's been bull's-eyed by that car over there.

Just going to have a quick look at you, sir.

Is it Rumen? Is that sore?

-HE GROANS

-OK.

Rumen had lots of injuries to his face, and he was lying awkwardly,

halfway on the road and halfway on the pavement.

So all of these things are clues that already gets my mind going.

Sorry, Rumen, say again?

Your backside?

Is your tummy sore,

is that sore when I press?

Is that painful?

Yes, can you squeeze my hand, Rumen? Squeeze my hand.

I'm going to have a quick look at your face.

..And then bilateral ankles.

It's mostly likely that Rumen's legs took the initial impact,

right direct force that really broke the two legs.

Then the next impact was on the bonnet where I think

probably his ribs started hitting that,

and then the windscreen, which was mostly his arms, possibly his head.

I could see just by getting close to him that he had lots

and lots of cuts on his arms and... and on his face.

It was quite evident.

And then also just being flung over the top of the car

made me concerned about spinal injuries

and further injuries to his ribs, rib cage and his abdomen.

-Can you feel the doctor touching your foot?

-OK, good.

OK guys, what we have is someone with a minor head injury,

possible fractured ribs, possible pelvis, possible abdomen,

definite bilateral tib fib fractures.

HE GROANS

OK, Rumen. Good man.

I was concerned that there was possible bleeding,

possibly in his abdomen, possible in the pelvis

so in my mind there's a good chance that he might deteriorate.

Can you feel me touching?

MJ must decide which of Rumen's injuries to treat first.

The fact that Rumen can't feel his feet

could show a potential spinal fracture,

but it could also be lack of blood supply to his lower legs.

If you leave it too long there's a risk that he could lose his legs.

So we will to need to straighten these.

It was clear that both his legs were badly, badly fractured.

MJ is concerned about all of Rumen's injuries but decides

to prioritise his legs.

Just by putting it in the correct position

you can improve the blood supply and prevent long term damage.

We're going to have pull it slightly to get it back into line.

The paramedic crew can administer painkillers

like morphine and have already given Rumen 10 mg - but it's not enough.

Any movement would cause absolute agony to him

so he definitely needed good painkillers just to realign his feet.

Because MJ is a doctor she can give pain relief such as ketamine,

more powerful than morphine.

Everything's fine. Sorry.

I don't want to put someone in a helicopter

if I'm not 100% sure they're stable

and in the best possible condition.

Is that his family over there?

Are you family?

-He's OK, is he your husband?

-Yes.

OK. He broke both his legs...

We're going to do some medicine on him

to make him nice and without pain. All right?

Having straightened Rumen's legs, MJ turns her attention

to his abdomen and the possibility of major internal bleeding.

Just gently slide it in. Everyone ready?

RUMEN CRIES OUT IN PAIN

Rumen needs to get to hospital

and we have to remember the clock is ticking.

Eight minutes ago,

another emergency call was made.

On one of London's busiest streets

a young woman called Zoe collapsed.

'It's Oxford Street and we've got someone here having a fit.'

Think she's had a heart attack, can you get here quick?

-Is she awake?

-No, she's unconscious.

-Is she breathing?

-No.

I've got three units on the way to you now.

Just stay out there and make sure there's someone there to flag them

down when you see them, it might be one of our bicycle responders

coming to you on a pedal bike.

-Be really quick.

-Yeah, they're not too far away.

A cycle-mounted paramedic arrives on the scene.

She was motionless,

she was pale, her eyes were open,

and she was receiving CPR

with an absence of a pulse. I certainly yelled at people

initially just to... Just to move on because, you know,

this is a very undignified place to have a cardiac arrest.

But is there any dignity in death?

Roger, that's all copied.

Across the city, the 999 call has also

triggered London's only response car specialising in cardiac arrest.

It delivers life-saving medical equipment, drugs and expertise.

It is very rare, not just within the UK

but around the world, to have a team that really is

just focused on cardiac arrest.

We should be...head on for Oxford Street.

Basically, the heart has stopped functioning,

for whatever reason, either it's not beating at all

or it's trying to beat

and can't eject the blood out of the ventricles.

And of course, for the rest of the body that's a catastrophe

because the rest of the body simply isn't getting the oxygen

and glucose that it needs for life.

Set of traffic lights at the bottom and straight across. OK?

'Although we are going on blue lights and sirens - you know'

for every minute or few seconds at a junction you're delayed

there is literally brain tissue paying the price and a patient

may either be severely disabled because of that or may not live.

-We're estimating about two minutes now.

-'Roger that.'

That's Oxford Street ahead of us.

After battling through the traffic, Gareth arrives on scene.

-Where's the patient?

-Oh, just there.

After CPR and an electric shock,

paramedics have re-started Zoe's heart.

But her pulse is weak and it could stop again at any moment.

So just give me the history, she just collapsed?

Probably had about ten minutes of CPR.

-We checked the pulses after ten minutes.

-OK.

She had a pulse...

They'd managed to restart the heart and there's some activity there.

I was always worried that she would go into cardiac arrest again.

Whatever precipitated it before we got there was an ever-present risk.

She looks very young, doesn't she?

I noticed that she had an engagement ring on and a wedding ring on

and I think that's hard not to be at least a little bit

emotional about that. You see that, you realise that someone's

got a life, she's got a husband or recently married.

-This is her blood pressure?

-Yeah.

When I saw she was so young, your mind goes into a bit of a spin,

"What's actually caused this?"

Most of the patients we go to in cardiac arrest

are at least in middle ages or elderly.

But Zoe is not responding in the way she should

and is still in terrible danger.

It'd be great if she'd just simply woken up

the minute her heart started

but we're in a different situation now, she wasn't waking up at all.

Her pupils are big, aren't they?

When I looked in her eyes her pupils were massively dilated

and fixed, just like you see in dead people...

It was obvious that she had sustained some brain damage.

And that is the shock, that's what's worrying me at that point.

Minutes after a cardiac arrest,

brain cells begin to die from lack of oxygen.

The sooner Gareth starts treating her the better.

He must act now, or Zoe may suffer irreparable brain damage.

Outside an urban centre like London, the challenges of

delivering medical care in the first critical hour are even greater.

150 miles away, a specialist trauma team are en route

to a remote farm in Lincolnshire.

33 minutes ago,

a 999 call came in about an injured farmer fighting for his life.

As the nearest major trauma centre is over an hour's drive away,

the helicopter is his only hope.

Hi, guys, it's Dr Topham...

A local ambulance crew is already on scene

but Bill now needs the interventions of a doctor.

-Bill, 66-year-old male.

-Yes.

-Today Bill's been crushed against the

-side of a wall by a cow.

-Yeah.

-He's not lost any consciousness at all.

-OK.

-He's made his way to here,

he was crushed a bit further away, when we arrived

he was conscious and breathing, we cannulated,

he's got equal air entry.

He's complaining of pain right-side abdomen,

-and around the lower right of his chest.

-OK.

Hi, Bill, its Dr Topham here.

I'm one of the doctors with the air ambulance, OK?

Sounds like you're having an interesting day, doesn't it?

I think there is, er, every chance that this could have proved

a life-threatening injury, or at the very least, a life-changing injury.

How you are feeling with your breathing just now?

HE MUMBLES AND GROANS

-There's no particular difficulty in breathing at the moment?

-No.

Bill's already had 10 mg of morphine

but he's still in severe pain and Simon needs to work out why.

Just going to feel around the tummy now, OK? Just let me know

if it's too uncomfortable.

GROANS

Where's that? Where's it hurting...?

How heavy was the cow - big one? Baby one?

About 650 kg. Right.

BILL GROANS

This is a significant beast,

650 kg - that's probably about seven or eight fairly standard humans

squashing one person against a concrete wall.

What does that feel like down there?

But Bill's symptoms are causing Simon some confusion.

Is it aorta, liver, spleen?

My concern, given the mechanism of injury,

was that he was going to have some internal organ damage

in his abdomen. I expected to see that his blood pressure

was dropping due to blood loss, and I expected to see that his...

his heart rate was increasing as his heart tried

to compensate for the, er, the loss of blood.

But those things weren't there. But my gut feeling still was that

there's something going on in the abdomen.

Having had the morphine and this degree of pain,

it didn't seem right to think there was nothing happening there.

Simon doesn't know exactly how Bill was crushed by the cow,

or which part of his body is injured.

Where's that hurting you?

What does that feel like down there?

He could bleed to death.

He might only have a small rupture to a liver or an internal organ

but basically, you know, it might be a trickle,

it could burst at any moment, you just don't know.

You haven't got X-ray eyes.

If Bill has internal bleeding they need to

try and stem the blood loss before they put him on the helicopter.

There was a degree of conflict at the scene,

between a need to get him to the trauma centre and the need to

ensure he wasn't going to deteriorate before he got there.

GROANING

..Just get him onto the scoop...

In London, MJ and the paramedics have straightened

Rumen's broken legs in the hope of restoring blood flow.

She now has to think about getting him to hospital.

But given the force of Rumen's impact with the car,

she's worried about moving him.

Everybody bleeds once they've been hit by something

and the body starts forming clots to stop that bleeding.

If I don't care for him in a careful way

and I disturb his clots - we always say the first clot is

the best clot - there's always a chance of him bleeding more.

Three, four, five -

just flush it for us.

Squeeze that in, concentrate.

Don't look anywhere else. Sorry, it's very important.

Any sudden physical movement could dislodge Rumen's clots.

MJ decides to give him a drug called Rocuronium.

It will paralyse all the muscles in his body

including those in his chest.

The effect of a drug like Rocuronium is it stops the intercostal muscles

working, stops diaphragm working, he will stop breathing.

16.30.

Over the next 60 seconds

Rumen will become unable to breathe for himself.

This makes the drugs kick in.

It takes a bit of time to work - about 60 seconds.

-Everything good, sats, pulse 99.

-Excellent.

You have to remember not to rush,

I always tell paramedics it's medicine, not magic.

That 60 seconds or 45 you have to wait can feel like an eternity

when all you're thinking about is momentum, momentum, momentum.

OK. See how his jaw feels.

Feels good.

MJ now only has seconds to act.

Through a procedure called rapid sequence intubation

she will insert a tube into Rumen's windpipe

and start breathing for him.

It's still quite a scary procedure to perform,

especially by the roadside in someone who's bleeding, potentially

has blood in their airway, who's got a high risk of vomiting.

Yep... Put your hands over my hands, perfect.

It is risky. Anything that can go wrong, has, at some point.

Everybody concentrate here now.

Anything as bad as death, brain damage,

someone's blood pressure completely dropping.

You've got your windpipe essentially running from your mouth,

all the way to your lungs, right behind it is the food pipe,

which goes from your mouth to your stomach.

You don't want to put the breathing tube in that cos no air will go in

to the lung.

OK - tube's on.

What we want to see is when we squeeze air into lung

that the little monitor that we have turns from purple to yellow.

That's an indication that carbon dioxide is coming out of the lungs

and we are in the right place.

-Yellow.

-Perfect.

OK, excellent job.

Can I have one of the paramedics listening to chest?

-Great job.

-Air entry.

Rumen is now intubated, paralysed and sedated.

With suspected multiple internal injuries,

MJ has done all she can for him at the roadside.

Excellent job, guys. Next we put blocks on, tape, collar back on,

and then trolley push to the aircraft.

In the heart of London's West End,

29-year-old Zoe is still unconscious.

OK. Let's get cold fluids going and pre-oxygenate her as much as we can.

Gareth is worried that Zoe's brain is suffering irreparable damage.

I knew I needed to act and I needed to act fast by

infusing some cold fluids to try and drop the brain temperature,

which actually stops some of the really deleterious

effects of oxygen starvation,

which start to literally eat into the brain

in the ensuing hours and days after a cardiac arrest,

the cooling actually stops those processes and protects

the brain from it literally sort of digesting itself from within.

Evidence suggests,

the sooner Zoe is cooled, the slower her brain cells will die

and the less brain damage she will suffer.

Gareth wants to bring her core body temperature down

from a normal 37 degrees to 34 degrees,

putting her into a state of hypothermia.

Have we got the saturation on?

So once that fluid gets into Zoe's body,

eventually it gets to the brain,

and it's the brain that's the most important bit.

The cells of the brain start to lower their temperature,

and as that temperature falls they need less oxygen,

they need less glucose.

Zoe's metabolism will slow down,

reducing the speed at which her brain cells die.

Pioneered in London, this pre-hospital cooling

is only offered by a handful of services in Britain.

Most patients in the world, most patients in the UK don't have

that cooling process initiated in the pre-hospital phase.

They have to wait until their heart is stable,

they have to be transported to the hospital.

So this is quite innovative to have that

cooling process started as close to the cardiac arrest as Zoe's was.

Every 1-degree drop in Zoe's temperature

will slow the process of brain cells dying.

But as her temperature drops, there's a risk that she will

start to shiver.

I knew I had to stop

the patient's body from shivering because that muscle activity is

what keeps the temperature up and we are trying to lower the temperature,

so by giving her the drugs or the anaesthetic we stop her shivering

and that means all our cold fluids will have a maximum effect.

Whilst under anaesthetic, Zoe will be paralysed,

blocking her shivering reflex.

But this will also stop her breathing by herself.

Gareth needs to insert a tube into her windpipe to breathe for her.

It's a balance of risk,

and I felt that doing this was far more in her interests,

compared to the risks of her brain damage.

If we can't pass that tube through her mouth

and into her lungs that could ultimately be fatal for her.

If you could just get ready with suction...

OK, tube please.

Right. Two seconds, mate.

It's stuck there.

Right.

GROANING

Bill?

Bill? Bill?

Bill. Hello.

You were away there for a minute.

In Lincolnshire, Simon is concerned

that Bill could be harbouring life-threatening injuries.

I'm just a bit worried you've crushed one of your internal organs

and may be bleeding a bit, so I'll try and give you some medication

that will try and protect that.

Bill could bleed to death before he gets to hospital,

so Simon decides to give him a clotting drug.

Draw us up to 2 ampoules of tranexamic in a 20ml syringe.

We did give him a drug called TXA or tranexamic acid.

It was used for heavy menstrual bleeding initially, and childbirth.

It's a drug that binds the clots together.

OK, Bill, this is the painkiller going in now,

you might feel a bit strange.

So when someone stops bleeding from a clot, the tranexamic acid

actually stops that clot breaking down, so hopefully reducing bleeding

and making the patient stabilise prior to getting to A&E.

39.

Since 2013,

this drug is being introduced to all Britain's roadside trauma teams.

Simon now hopes it will buy him enough time to get Bill to hospital.

Going to have a little feel around here.

Can you give me a score for your pain out of ten?

If ten's the worst you've ever known.

-9 or 10.

-9 or 10, OK.

I think we're going to have to give you something

a bit stronger for the pain to try and help with that.

When I arrived he'd already had 10mg of morphine,

which for most people of his age

and size should give very good pain control, yet he was still in pain.

BILL GROANS

OK, 15 minutes and still 9 out 10.

No, we're going to give him some ketamine.

Bill's pain levels are still worryingly high

and might cause him to struggle when they try to move him.

GROANING

Pre-hospital trauma teams now have access to ketamine,

a drug that until a few years ago, outside London,

was only given on arrival at hospital.

-Check that for me - 4 ml.

-Yes.

It's a horse tranquiliser.

It's a very strong drug. It's been used by vets for many years.

It's quite strong stuff but his pain scale's 9 or 10. He's had morphine

but it's not subsiding, so he may...

Simon hopes the ketamine

will sedate Bill enough to keep him still on the journey to hospital,

reducing the risk that he will disturb vital clots inside his body.

I'll start with 10 milligrams...

Just keep giving a little bit more at a time.

We'll give you 10 ml. Start you now.

The medicine we're going to give can you feel strange,

it can make you see things...

OK. Bill, can you hear me?

Bill, what is it that's bothering you?

BILL CONTINUES TO GROAN

I don't know whether that's the emergence of the ketamine

or he's actually in pain.

It's really a great drug for what we need it to do,

but it dissociates the patient from their environment

and frequently you see people having hallucinations.

They can also still appear to be in pain -

probably because of that dissociation.

Give more TXA and then get him on the...

It's whether he's going to be adequately analgaesed for shifting,

but we need to get him moved.

Simon can't tell whether Bill's reaction

is just the effect of the ketamine or due to organ damage.

He decides to take one last precaution.

Try not to move your head, Bill...

GROANING

What we're going to do

is we're also going to put a splint round your pelvis -

it's like a wide band to support your pelvis

in case there's any bleeding around there.

All right, Bill, you'll feel this get tight round your pelvis.

'The whole point of putting on a pelvic binder is to

'stabilise the pelvis if there is a fracture within it,'

and by stabilising it reduce blood loss further. But also so that

we know he's going to be physically stable through the journey.

9.45.

Out here, there's nothing more Simon can do. Only a CT scan

will reveal the full extent of Bill's injuries.

Back in north London, MJ has fully anaesthetized Rumen.

Only now does she decide he's stable enough

to be transferred to a major trauma centre.

PHONE RINGS

When you stand in Resus, there is a moment

when that phone rings - it makes a very distinctive noise.

PHONE RINGS

-Hello.

-Hello. We are bringing in an adult male patient.

Pedestrian versus car.

It just goes a bit quieter for a few seconds

and people tend to look to the phone and person writing down notes.

He has been RSI'ed, he's potential poly trauma,

and our ETA with you guys is about 15 minutes.

Good to go.

It was obvious from MJ's call that Rumen was badly injured

and this could still get worse.

On Oxford Street, Gareth is taking over Zoe's breathing.

That's good, so yes, for yellow.

In the trachea, that's fine.

-Happy. Feels good your side?

-Yep.

OK, let's just... Two seconds, slowly, slowly.

Well done. Are you OK to do that tie?

-Yeah.

-You're a star.

OK, that's great, so we can control her ventilation.

It's in normal parameters now. She's well and truly oxygenated.

MACHINE IS SWITCHED OFF Let's do it again.

-OK, that's good air into both sides.

-You can slow that down a bit.

-Right.

Paralysed and unable to shiver,

Zoe's body temperature finally drops.

Bless here. Right, OK, we've got her controlled.

Her brain is protected and she's getting enough oxygen.

After 51 minutes of roadside treatment, Gareth decides Zoe

is stable enough to travel to hospital.

-How long do you reckon it will take us from here?

-About six.

-Brilliant.

Brilliant. Six minutes.

It's a lady approximately 20-30 years of age,

who has had a sudden collapse on Oxford Street.

-The bottom line is she looks pretty pink.

-She does, doesn't she?

'I felt that the next pressure was really to

'take Zoe to the most appropriate hospital.'

Zoe is en route to St Mary's Hospital where she will be kept

in an induced coma to try and let her body and brain recuperate.

Only time will tell what kind of recovery, if any, she will make.

I can't do any more. This is all medicine can do now for Zoe.

Mother Nature needs to do the rest.

SIREN WAILS

INAUDIBLE

PERSON GROANS

-One, two, three, lift.

-MAN GROANS

-All right, sweetheart.

-MAN GROANS

MAN CONTINUES GROANING

We're on our way with a patient if the aircraft's

prepared for us, buddy. Be with you within a couple of minutes.

Straight in, mate. Ta. Yeah.

MAN CRIES OUT IN PAIN

One, two, three, lift.

TELEPHONE RINGS

He's a 65-year-old gentleman

who's been crushed by 650kg cow,

between cow and a concrete wall.

He's sustained blunt abdominal trauma.

-Can you ring us when you've landed? Is that all right?

-OK, thank you.

See you shortly. Bye.

OK, cheers. Bye-bye.

Crushed by a cow!

SIREN WAILS

For the last 60 minutes, doctors and paramedics have fought to keep

three critically injured patients alive.

'Airborne with the patient.'

For Zoe, Rumen and Bill, the decisions made in

this first hour of care have given them a greater chance of survival.

But the fight is not over.

Now new hospital teams will race against the clock to uncover

the full extent of their injuries.

The discoveries they make - and decisions they take -

will determine whether each of them lives or dies.

HELICOPTER COMMS CRACKLE

HE GROANS IN CONTINUAL PAIN

In Nottingham, trauma surgeon Adam Brookes is standing by to try

and find the cause of Bill's extreme pain.

This is Bill, he's a 66-year-old gentleman

who was crushed by a 650kg cow between the cow and a concrete wall.

'When Bill came in he had a significant amount

'of pain in his abdomen predominantly,

'especially as he'd had quite a lot of pain relief,'

morphine and ketamine, so two very powerful drugs

to help him with his pain.

What it suggested to me was there was some pathology,

some issue going on, there was an injury in his abdomen.

Starting with 5mg of morphine by the crew,

which didn't give him relief, still 10 out of 10

so we've given him ketamine, titrating 10mg.

-So he's had a total of 50.

-50.

Isabel?

Open your eyes for me, Bill.

Very early on, I make the call that he needs to go to the CT scan.'

In Nottingham, the trauma team aims to get patients scanned within

15 minutes of arrival, to diagnose injuries as quickly as possible.

Should we do a quick check-up before we leave for CT?

-So, anaesthetist, you are happy with airway, need any drugs?

-Yes.

HE GROANS

OK, injection starting.

CT scanning does give us the opportunity within minutes

of getting a complete picture of the injuries.

Adam is looking for signs of internal bleeding,

but the answers aren't immediately apparent on the CT scan.

It's always a concern when the investigations we have

and the clinical picture don't marry up,

as they just don't seem to fit together.

And that sets us out on more of a detective story -

what is the issue here? What are we missing?

ARRIVAL UPDATE FROM PILOT ON COMMS SYSTEM

MJ is preparing to hand over severely injured Rumen

to the trauma team at the Royal London Hospital.

There was a chance he could still die in our department seconds after arriving.

So there's a degree of anticipation.

And you think anything could still happen.

Patient's here.

Everybody keep quiet.

Hand over the airway and then get the handover.

OK, guys. This is Rumen, we think in his 30s,

he was a pedestrian hit by a car,

bull's-eyed the windscreen, completely cracked it,

was found on opposite side of car,

halfway on the pavement, half on road.

They didn't see scene, they didn't see the car,

they didn't see the windscreen, they didn't see the bump,

they didn't see how Rumen looked when I arrived.

Injuries top to toe, multiple facial lacerations, no body swelling,

pupils equal and reactive.

The handover from MJ is crucial.

In those few seconds she gives us a picture,

a little snapshot of the preceding hour.

He's not had any fluid with us

-and he's got bilateral cannulas.

-Brilliant. Thank you very much.

That handover defines what we do in the next few minutes.

-Steven, on your count we'll move him.

-Yep, OK.

Having just flown in a chopper, the paramedics

and the doctors have just had a very emotional

involved experience, and it's good then for a second person to come back

and look at everything they've done.

And sometimes a fresh pair of eyes can see smaller things now

in the brighter lights of Resus

that they may have not picked up pre-hospitally.

Five, four, three, two, one.

Because Rumen was anaesthetised at the roadside

and delivered in a stable condition he's ready for any operational

intervention that Johann thinks he needs.

Can we have three people on each side? We're going to

move him across on to the centre of the trolley

and then take the scoop out.

Three people on the patient's right. Scoop on the left to come out first.

I was primarily concerned that he may still be

bleeding from somewhere.

He had bad injuries to his legs and possibly

to his pelvis and his abdomen, so we were worried that there may

be something going on inside him that we haven't discovered yet.

We wanted to make sure he was stable

and to get him into the CT scanner as soon as possible

to see if there's anything else going on inside

that we can't see from the outside.

OK, pupils are 2mm equal and non-reactive.

But before they can get him to the CT scan,

Johann is concerned about Rumen's legs.

He'd obviously fractured both his lower legs

and we were worried that the blood was not getting into his feet.

If the pulses were not there, that means that he may lose his feet.

No surgical emphysema. Equal chest movement bilaterally.

-Anything?

-He's got a pulse on the left.

So he's got pulses on his left ankle.

-He's got bilateral pulses present.

-After a worrying few seconds,

the team find a stable pulse in both of Rumen's legs

and can now focus on his suspected pelvic injuries.

All right, folks listen up. As a summary, our primary survey is OK.

He's obviously badly injured.

We're going to take him now for a CT head down to pelvis.

The whole hospital has been designed around

the Emergency Department and around Resus.

The CT scanner is right next to him.

All the equipment that we need has been designed to be right there,

right next to him, available whenever necessary.

The team itself, they all know where they need to go.

All right.

His pelvis looks OK. All right, let's get him off.

His injuries, especially the ones

we were worried about, are not there,

especially the life-threatening ones are not there.

I think Rumen can consider himself lucky to be alive.

After Rumen left the Emergency Department he went

to Intensive Care and the primary concern then was with his legs, to

make sure that they can repair them to a point where he can walk again.

If MJ hadn't put his feet back into a straight position

pre-hospitally, they would have been without blood or nerve supply

for a prolonged period of time.

I think it would have definitely made his chance of walking a lot less.

In Nottingham, Adam is still trying to work out the root cause of Bill's pain.

You always look at the patient,

listen to the patient, examine the patient, and that really has

got to have primacy in your decision-making.

So his pain was out of proportion

and then we had nothing on the scan. That didn't sit comfortably.

HE GROANS

All right. Let me have another look at your scan.

I think for anyone involved in medicine

and certainly major trauma, to get balance between new technology

and instinct, experience is actually quite difficult.

Basically suspicious that there's something happening

but we haven't yet spotted it on the CT scan.

The new scanners are very accurate, but we still miss things on them

such as injuries to the small bowel,

you don't see free air all the time, injuries to the pancreas,

even on the new scanners you don't necessarily pick that up early.

So nothing's definitive. Nothing in medicine is 100%.

I think there's something going on here.

I think there's some fluid here.

After radiologists examine the scan in more detail,

they alert Adam to a potential injury.

When I went back and looked at the scan I saw a bit of subtle fluid

underneath the liver, and that's fluid that shouldn't be there

and also where he was markedly tender.

Adam thinks he's finally detected the cause of Bill's extreme pain.

If he's been trapped there's two things that could happen,

one of which is he's going to squash an organ against the bones,

split it, and make it bleed, the other is can increase

pressure in the bowel where the air is

and you'll get a blowout somewhere.

And at the moment my money's on the latter,

that we'll find that he's got a small bowel or duodenal perforation.

A ruptured bowel can lead to blood poisoning.

Hey. You OK? How's your pain?

Still got a lot of pain in your tummy?

Yeah?

Not too bad?

I think you've got a little bit of fluid in your tummy

and maybe a loop of bowel has popped and leaked some fluid out

and that's why you've quite so much pain there.

It looks like it's squashed against lower ribs

and the upper part of your tummy

and there's little bit fluid where it shouldn't be on CT scan

and that's probably what's causing all that pain,

because it's sore in your tummy, isn't it?

I think what we need to do is

we need to pop up to the operating room and look inside, OK?

My wife. My wife.

Don't worry, we'll let your wife know. OK, mate.

OK, don't worry.

We were best off doing an operation and having a look inside

and look at the injuries, as the ultimate investigation,

but also it gives us the opportunity to treat any injuries that we find.

-Can we start?

-Yes, please do.

Bill is taken to the operating theatre for surgery.

What we do is look around the whole of the abdomen, we look at all

the organs internally, in sequential fashion, looking for injuries.

Can't see anything at the moment. Have you spotted anything yet?

Good, small bowel, lots of it.

His bowel was all fine, which was good, that was a relief.

If it had been the bowel leaking then that would need more

extensive work to make sure it was repaired and didn't leak again.

But he had some ongoing bleeding.

It's around his liver, we'll have a look at that,

it's not bleeding very much by our standards.

A look at the colon, a bit of fluid.

Having discounted a bowel injury

Adam continues to check all Bill's major organs for bleeding.

Ooh, look, here's his liver injury.

So he's got a little liver injury which is bleeding.

There's a little bridge there that he's torn. That'll stop.

He had some ongoing bleeding from a fairly subtle liver injury right at

the back of his liver, tucked away near one of the big blood vessels.

So although this is a pretty small liver injury, by scale of things,

it's actively bleeding, it's under my finger there.

So that's exactly what he's done, he's been squashed at the front

and where his liver overlies his spinal column

he's got a couple of little tears in his liver.

They've caused his pain.

So Mark, I'm going to put a couple of stitches

and a couple of things around the liver.

Good. OK, we're going to close and get out of here.

-Mark, are you happy?

-Yeah.

-The team are just going to close. OK?

'I kept going through my mind,

' "Am I dead, is this... is this the end, like?" '

I wouldn't wish it on no-one.

But they did good, marvellous what they did for me.

Else I shouldn't be here today.

-Do you want the rest of the morphine?

-No, we'll give him some ketamine.

Bill did very well. He's made a full recovery.

Er, and I think a lot of that is

because we made the right decisions at the right time.

In that first "golden hour",

in the first 60 minutes of his care we made the right decisions.

BILL GROANS All right, Bill. Bill?

HE CONTINUES GROANING IN AGONY

Yeah, I thought I was dying, to be honest.

I didn't want to leave anybody behind. Just not easy.

Is it Rumen? Hi, Rumen.

Rumen's injuries to his legs were quite devastating.

It's going to take months, if not years of intensive physiotherapy,

learning how to walk again, learning how to live with his injuries.

The simple fact is that most patients don't survive

a cardiac arrest, perhaps less than 10%,

and some of those that do survive are blighted by brain damage.

So what I'm going to do is pop a few stickers on,

just to monitor your heart while I'm checking.

My husband told me that he was holding my hand

and as I started to come round,

he said, "If you love me squeeze my hand." And I squeezed his hand.

Sorry.

He said, "Squeeze it tighter, if you love me...

"squeeze my hand really tight," and so I squeezed it really tight.

And they knew then that I was in there.

Zoe's cardiac arrest was caused by a rare heart condition.

Doctors hope they can prevent another.

-NURSE:

-And the good thing is your device is wireless, so...

-Yes.

I've had an ICD fitted -

an Implantable Cardiovascular Defibrillator,

so if my heart needs to be paced it will kick

in and try and pace it out of a rhythm, an arrhythmia,

and if it needs to try and give me a shock, to get my heart

working properly, then it will be able to administer a shock as well.

I don't know if I expected it to be really heavy or not.

It feels quite light.

It's the ultimate, it's taking someone whose life has just gone,

literally stopped,

and rekindling it through some very complex diseases to a point

where she's not just alive, but she's alive like she was.

She hasn't got any disabilities,

she can go on and lead a completely normal family life.

That's one thing I really want to know.

Can you skydive if you have an ICD?

NURSE CHUCKLES

EMERGENCY CALL COMES IN

Next time, a high-speed road accident critically injures Michael.

-Is blood running?

-Yep.

-OK.

And in North London, 68-year-old Mick collapses.

I must admit, I can't feel a cardiac output in this chap.

You can find out more about Trauma and Emergency Care

with The Open University's free booklet.

Call 0845 030 3043 or go to the bbc.co.uk/anhourtosaveyourlife

and follow the links to the Open University.