Making the Invisible Visible An Hour To Save Your Life

This programme contains scenes which some viewers may find upsetting

The moment an emergency call is made, a battle against time begins.

'And is she awake?'

'No, she looks dead.'

GROANING

The decisions that are made in the first 60 minutes of a major

trauma patient 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 pretty close.

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 and we'll get him on the auto pulse.

..they're performing surgery on the roadside...

I could do the operation in the back of the ambulance if necessary.

..administering powerful drugs...

Would you draw us up some Tranexamic acid?

..using innovative techniques...

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

..and pushing the boundaries of science...

I'll let you know once the balloon is up.

..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,

every hour, over 35 of us will face a life threatening emergency.

This film will follow three stories

through 60 minutes of care

that will push the limits of scientific innovation.

In Birmingham, Gudrun collapses in a hotel room.

'She's a 77-year-old woman, she's had a stroke.'

In a leafy suburb of London, tree surgeon Ben falls 20 feet

onto the pavement.

-OK, so he's landed more on his side than his back?

-More on his side.

'Don't move him, don't move him.'

'Do not move him unless he's in danger.'

And in Shropshire, a road accident leaves 49-year-old Vincent with

life threatening injuries.

He's had a head-on collision.

His motorbike is in the hedge there in numerous pieces.

From the moment each one of these emergency calls is made

the clock starts ticking.

'We've got a motorcycle. The cyclist is not responding at the moment.'

West Midlands Ambulance Control has just received an emergency

call from the police.

There's been a high speed collision between a motorbike

and a car on a remote country lane in Shropshire.

Its location and severity triggers an air ambulance,

carrying a trauma team on board.

You're always trying to imagine what the scene might be like.

We knew it was a warm sunny day,

so it might be quite a high speed impact.

It makes you concerned that there may be major injuries

that you'll be faced with when you arrive on scene.

Local ambulance staff are already treating the patient.

A motorcyclist. His motorbike is in the hedge there

-in numerous pieces.

-Oh, blimey.

We can't even find the number plate.

-Wow.

-He's travelled an additional 20 yards up the road.

He has travelled.

'When we arrived on scene and looked at the severity and damage to the'

bike it suggested that the mechanism of injury was quite significant.

He'd also travelled a fair distance from his bike

Hi, Vince, I'm Collette, one of the doctors here.

He was quite sweaty, he was clammy,

he looked very ashen in colour - all of which can suggest signs of shock.

Collette is worried that Vincent is going into shock,

meaning the organs and tissues in his body

aren't receiving an adequate supply of blood.

He had quite a weak pulse which suggested his blood pressure

was on the low side and also his heart rate was fast as well,

which made us concerned there may be an element of internal bleeding.

Your main pain... You've got a funny sensation in your pelvis

-and the leg. Is that the main issue?

-My hips.

-Your hips.

-Is there any pain in your tummy at all?

-I don't know.

You don't know. If I have a quick feel there, is there anything?

-I'm not sure, it just feels funny.

-It just feels funny.

When I assessed Vincent's leg, there was an obvious open fracture

so I could see the bones exposed through the skin

of Vincent's lower leg.

However, there wasn't a huge amount of blood loss occurring

from the wound and the bones didn't look overly deformed.

Vince, I'm just having a feel of your feet, mate.

-My boots feel ever so tight.

-Vince, you haven't got your boots on,

you've got some splints to hold it. We think you've broken your leg.

But your foot is very, very pale.

That's a mess, isn't it?

They look a horrible colour. Really pale feet.

One of our concerns was that maybe he wasn't getting blood

supply to that right foot.

Although concerned about Vincent's foot, Colette has to deal

with any potentially life threatening injuries first.

'The problem that we faced is that you can't see what's going on'

within Vincent's body.

Although we could anticipate there was some internal bleeding.

we had no idea where the source of the bleeding was.

What we might try and do is just get a splint on his pelvis.

Colette is worried that a fractured pelvis might be causing

massive internal bleeding inside Vincent's body.

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

That's it, that's it.

She hopes the splint will keep the pelvis stable,

reducing any internal blood loss

If you can't prevent bleeding or you can't keep up with the blood loss

then, eventually, your patient will die.

'I decided that we'd give him some Tranexamic acid,'

and essentially that's a drug that encourages clot formation

if there's a bleeding point that we can't see externally.

Having taken steps to control Vincent's internal bleeding,

Collette must now decide

whether she has time at the roadside to treat his leg.

Every minute is vital in deciding what interventions you do,

how many interventions you do, and at what point you decide to

package a patient for transfer to hospital.

DIALLING TONES

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

Ten minutes ago, Ambulance Control in London received

a call about a man who's fallen 20 feet from a tree.

'Don't move him, don't move him.'

'Do not move unless he's in danger.'

I've got a job for you. Map reference is 32 November Bravo.

Call connect is 13.45,

and dispatched at 13.50.

Falls from heights are the number one cause of death at work.

In London, any fall over 20 feet triggers

the dispatch of the air ambulance.

Patients that fall from a height can do a myriad of injuries.

If they land on their head, that can cause head injuries,

they can damage their chest, they can break ribs,

they can collapse lungs, they can damage their spine,

and if they fall from a very high height they can damage the pelvis,

one of the biggest bones in the body.

We're going to be landing on a playing field,

which is just to the south of the scene.

Time is really important, not just in getting them to hospital,

but getting to the scene, correcting as many of these

issues as quickly as possible.

Speed is part of the deal.

I suppose the things I was worried about fall into two groups.

One of which is very difficult - spinal injuries.

-Left here.

-Yes.

But the others are injuries that may actually kill him,

but we know that we can treat, we can save him from,

we can repair him, we can get him back into a normal life.

Just watch your safety here, mate.

19 minutes after the 999 call, Gareth arrives

in the leafy suburban street.

London Ambulance Service are already treating the tree surgeon.

He was in a position that he'd obviously fallen.

That's never a good sign because

the natural reaction, when you've fallen, is to get up,

dust yourself down, and hobble away from the scene.

Yeah.

He's fallen from there, landed on his back.

-He's been in this position since.

-Yeah.

OK, what's his name?

What's your first name?

-Hello, Ben. Ben, can you hear me?

-Yes.

My name's Dr Davies. Hi there, mate.

I'm a consultant with the air ambulance, all right?

-Air ambulance?

-Yeah, the helicopter. All right?

You're going to be fine,

-I just need to find out what damage you've done on yourself, OK?

-OK.

He said the pain is right in his back

-and he rates it at seven out of ten.

-OK, all right.

I was worried he might have broken his back and not been able to move.

Now, can I ask you to move your legs?

'I wanted to see that he wasn't paralysed.'

Your arms and legs feel normal, do they?

OK, fella.

Ben can move his limbs, meaning there's no damage

to his spinal cord, but Gareth thinks that some of Ben's vertebrae

or bones, around his spinal cord, could be fractured.

He may also have other injuries to his head and internal organs.

Your pain, where is it?

When I looked at Ben, he did look quite unwell.

He looked very pale, he looked very sweaty.

All of these are signs that he might be bleeding and in shock.

-Can you describe how he landed?

-He landed on his side, his right side.

So, sort of his right arm, his hip,

and he was sort of covering his head with this right arm.

OK, so he landed more on his side than his back.

More on his side, yes.

The awkward thing is you can't see that bleeding.

You have to predict it. You have to assess the fall,

look how high he's come,

try and examine his pelvis and look for other signs of bleeding.

If Ben is bleeding internally, his life is at risk.

But the full extent of his injuries can't be diagnosed at the roadside.

Gareth needs to move him to a Major Trauma Centre as soon

as possible, but any movement could make Ben's condition worse.

-So where are we near?

-Erm, N4, London.

How long's the drive?

I'd say 15 but...

I was really concerned for Ben.

He had symptoms that suggested a fracture of his lower back

or his pelvis, which is often associated with bleeding,

and has a very high mortality rate.

Having treated Vincent for suspected internal bleeding.

Colette turns her attention to the open wound on his leg.

It's very common that an open fracture can cause

compression of the blood vessels and prevent blood flow to the lower leg.

I was quite confident that that could be a possible

source for the paleness and mottled colour of his foot.

If left for too long without blood, the muscles will die

and the limb may not survive.

Before treating his leg, Colette decides to give Vincent

an analgesic - or pain killer.

Vin, one of your foot has gone a funny colour

so we're going to give you something to relax you a little bit...

Yeah, do it.

..and then we're going to have to pull it.

One of the things you can do is try

and straighten the bones which not only helps with analgesia, it helps

with blood loss, but would also regain blood flow to the lower limb.

It can be a very painful procedure so I administered

some ketamine which is not only an analgesic in its own right,

it's also a sedative medication.

You might have to give me a heave-ho.

Vince, just some pulling, mate.

I don't think it's going to do anything.

'Unfortunately, it didn't have the desired effect

'and there wasn't much dislocation of the fractured bones.'

SHE WHISPERS Yeah.

I think that's as good as you're going to get.

It's just the oozing.

'So again, it makes you think, "Is there something going

'"on within his body that's preventing

'"blood flow to his lower limbs?"'

-How you doing there, Vince?

-Just... My legs...

Yeah, we're going to sort that out, sweetheart.

There's nothing more Colette can do for Vincent at the scene.

'I think the most difficult decision was deciding

'when to stop performing any interventions at the roadside

'because delaying time on scene would delay any further

'interventions that he could receive in hospital.'

ALL TALK OVER EACH OTHER

PHONE DIALS

-OPERATOR:

-Emergency. Which service?

She's a 77-year-old woman and she's had a stroke.

-Is she conscious and breathing?

-I don't know.

33 minutes ago, a 999 call was made when Gudrun, a holiday

maker from Germany, collapsed in her hotel room.

She's lost all feeling down the left-hand side of her body

and is having trouble speaking.

She's rushed into the Queen Elizabeth Hospital in Birmingham.

So, tell me, how were you feeling when you first woke up this morning?

I want to run through an assessment with you.

It allows me to see how your brain is working at the moment.

-Is that all right? Can I get you to shut your eyes tightly for me?

-What?

Shut your eyes really tightly.

Open them wide. Give me a really big smile.

Show me your teeth. Lovely.

'It's really clear to me that she's got a facial droop

'and that she's not moving the left side of her body,

'which is a really good indication that it's probably a stroke.'

A stroke is caused by a lack of oxygen to the brain

due to a bleed or blockage in the blood vessels.

Rachel begins by assessing Gudrun's reactions.

Look that way for me.

The assessment was really important because it showed me

Gudrun could follow basic commands, and that she did understand

what I was saying because it allowed me to see that her cognition was

not damaged. So she understood what was going on,

and it was likely that that part of the brain

wasn't affected from the stroke.

Can you lift this leg up in the air? Hold it there.

'When someone's experiencing a stroke,

'it's really vital that we get someone to scan

'so that we know what's happening so we can give that treatment,

'and potentially save the brain cells from dying.'

During a stroke, almost two million brain cells can die every

minute, so Rachel needs to establish quickly

exactly what kind of stroke Gudrun is having.

There are two types of stroke.

There's ischemic stroke, which is basically a clot which

forms in a blood vessel in the brain.

And then there's also a hemorrhagic stroke,

which is when bleeding occurs in the brain.

And they're both treated very differently.

There we go.

Gudrun needs to have a CT scan as fast as possible

so the team can see what's going on inside her brain.

I'm just going to wheel you round for a scan now, OK?

-Could someone be able to give me a hand?

-Yeah, sure.

Complaining of low back pain and right shoulder pain.

INDISTINCT CHATTER

On a quiet residential street in North London,

Gareth and the paramedics are treating Ben,

who has fallen 20 feet from a tree.

Possible spinal fractures and rib fractures on the left side.

Ben.

We're going to roll you on to a stretcher now.

It's going to be a bit cold. We're going to give you some morphine

to help you with this roll. OK?

We need to get Ben moved to hospital,

and we're not going to do that if every time we move him he cries out.

That will delay his transport from the scene.

OK. All the way. All the way.

That's the worst bit over with, mate.

As well as back and head injuries, Gareth also suspects Ben may

be bleeding internally from a broken pelvis.

Ready, brace, lift.

Just going to get you off the road and into the ambulance.

In my mind's eye, I'm inside his pelvis and inside his pelvis

are lots of broken bones, and around those bones are blood clots.

And I know that every time I move him or roll him, those bones pull apart

and those clots disappear. And when they disappear, bleeding ensues.

HE GROANS

CHATTER

He's still in a lot of pain. He's asking for some more analgesia.

-What do you want to give?

-Just give him a little bit of medaz and ket.

Yeah, that's what I was going to say.

-Do you want to go up to ketamine?

-Yeah. All right, mate.

I'm just a little bit worried

that you might have broken your back there.

We may have a couple of fractured ribs.

I'm going to give you some pain relief.

Just give him ten of ketamine to begin with.

SIREN BLARES

In Birmingham, Gudrun started suffering from a stroke

around 45 minutes ago and is about to have a CT scan.

Stroke consultant Don Sims needs to decide whether her stroke is being

caused by a clot or a bleed inside her brain.

The time pressure in stroke is much more acute than in many other

conditions, even a heart attack.

We know brain tissue is exquisitely sensitive to losing its blood

supply and the damage is happening right from the start.

A stroke caused by a clot can be treated

effectively by administering a blood-thinning drug.

But if Gudrun's stroke is being caused by a haemorrhage,

then the drug will intensify the bleeding, which could kill her.

Brain scans really don't diagnose blood clot type of strokes.

The brain scans are really there only to rule out the bleeding type

of stroke, so the diagnosis is based on my assessment of the patient.

If Gudrun's stroke is being caused by a clot then the affected

area of her brain may not appear on the CT scan

until several hours after the onset of her stroke.

But if she has a bleed on her brain, it will show up straightaway.

There's absolutely no blood in it at all...so it has to be a clot.

That's fine. We can get her off.

Once I'm happy that there's no bleeding on the brain scan,

the priority is to get her straight back to the emergency department and

deliver the clot-busting treatment without any further hesitation.

We target ourselves giving the treatment within half

an hour of their arrival to the emergency department.

Gundrun, hello. My name is Don Sims. I am one of the stroke doctors.

Nice to see you. Can you squeeze my hand for me?

Can you shut your eyes?

Can you show me all your teeth?

Hold that one up for me. Just keep it up.

Can you do this one at all for me?

That's more difficult, isn't it?

Gudrun...we think that you're having a Stroke.

The brain scan didn't show any bleeding,

so it's a small blood clot that's caused the stroke.

Because you're here quickly enough,

we would like to give you the clot busting treatment,

which breaks down the clot.

Don has decided to treat Gudrun

using a process called thrombolysis.

Through an injection,

the treatment dissolves blood clots using a powerful drug.

Suddenly there was a clot busting drug treatment that seemed to

be really very effective.

Before thrombolysis, there was really no acute stroke treatment,

so this is all quite new and novel.

But to stop the clot doing permanent damage to Gudrun's brain,

it must be given within four and half hours

of the onset of her symptoms.

All right?

There is a small risk with it. About two to 3% of people

we give it too have a significant bleeding,

that can be in the brain.

And then the outcomes is obviously much worse for them.

But the majority of people - the overwhelming majority people -

either get better or it doesn't affect them

in any way for good or bad.

They just have the same symptoms that they were going to have anyway.

-Is that OK?

-Yes.

Yeah?

OK.

Brilliant. Thank you. OK. Yeah, just got for it.

'The clot-busting treatment dissolves the protein strands,'

'it breaks down the mesh of the blood clot,

and then your body helps to clear the rest of it.

10:04.

And then, hopefully, blood flow

continues through where the blood clot was.

It's one injection,

and then we give you continuously over 60 minutes, then it is all done.

Because we're going to be giving you some medication,

we have to make sure we've got lots of access to your vein. OK?

SIREN BLARES

In Shropshire, the team are preparing

to fly motorcyclist Vincent to hospital.

'We've tried to re-align his lower leg

'and his foot was exceptionally pale.'

He ten of morphine, 40 of ket.

Right is open tib fib, left is the ankle.

-ETA is still the same.

-Say half past.

That's great. Thank you very much. See you soon. Bye.

All right, Vince, I think we're ready to go, mate.

CHATTER

Over the last hour, emergency doctors have battled to keep three

critically ill patients alive.

RADIO CHATTER

For Ben, Vincent and Gudrun, the crucial decisions

made by the front line medics in the first hour have given them

a greater chance of survival.

But the fight is not over.

As the race continues, hospital clinicians will build on these

decisions and uncover the full extent of their injuries.

The discoveries they make will determine what type of recovery,

if any, they will make.

Some oxygen. OK.

-You all right?

-Good?

-Yeah, I'm good.

At the Royal London Hospital,

Gareth is about to hand over Ben to the waiting trauma team leader.

The information we had prehospitally,

I was concerned that he had an unstable spinal injury,

so we had to make sure we didn't allow his spine to move at all.

This is Ben brown, a gentleman that works as a tree surgeon,

and has been working on a tree today and has fallen 20 feet onto concrete.

Witnessed by a colleague. No loss of consciousness.

Has been GCS 15 throughout.

Has moving all four limbs.

He's had 10mg of morphine, 50mg of ketamine and 2mg of medaz.

No further interventions.

-Did he fall on his back?

-He landed on his left side.

OK, thank you.

So can you start the primary survey and find out where it's hurting him?

Very few patients come in with a big thing

stamped on their forehead saying what's wrong with them.

What I was trying to do with Ben is make the invisible visible.

I'm just going to have a quick listen to your breathing.

-Which side is hurting the most?

-Left side.

Deep breaths for me now.

OK. Chest x-ray in three, two, one...

An x-ray machine above the bed allows Helen to

check for fractures immediately.

It's painful on the left side, is it?

Any pain when I press here?

'The other really serious injury people who have fallen

from a height can sustain from a height is a pelvis fracture,

which can be associated with massive bleeding.

Pelvis x-ray in three, two, one...

I'm just looking at the chest x-ray.

The chest x-ray and pelvic x-ray are important things to do because

if they are abnormal, they tell us what we're dealing with early on.

Yeah, and the chest.

Chest and pelvic x-rays look pretty normal.

'I was surprised about that because he was complaining of pain'

in his lower back when he took a deep breath in.

If they're normal, it doesn't rule out a serious underlying injury.

Hello. My name's Helen. I'm another one of the doctors.

Hiya.

Is your pain getting better?

The X-ray won't give a complete picture of Ben's

injuries as it may not pick up enough fine detail.

Plain x-rays are not very good at showing soft tissue injuries.

They're good at showing bone injuries, but not internal bleeding.

Whereabouts in your back, Ben?

At this level? Where my hand is?

A bit lower?

Down here?

Yeah, right in there.

So you've got pain in your back, about there.

Further behind there. OK.

Can you feel me touching your feet?

-Yeah.

-And this side?

-Yeah.

Your toes are wiggling.

That's a good sign.

We'll go through to CT, so can you request

head, neck and whole spine?

'There is a sense that you need to think quickly'

and things need to happen quickly.

81 minutes after his 999 call,

Vincent arrives at the Queen Elizabeth Hospital.

This is Vince. He's 49.

He's been involved in a motorcycle accident. Tummy's tender.

Pelvis was tender. He's got an open tib fib on the right.

I've tried to reduce it cos it's looking very pale but...

It looked quite straight and I just couldn't do anything with it.

He's been GCS 15 on arrival

-BP?

-BP is being.... Last one was 143/63.

So, treatment wise, he's had 60 of ketamine...

He's had 60 of ketamine. Ten of morphine with the crew.

He's had a gram of transanic acid

100mls of normal saline and four of...

Crack on with primary survey.

Vincent is suffering from internal bleeding

and a severe leg injury.

Trauma lead Jitender must decide which to treat first.

He was driving the bike at a very high speed,

and in a big crash. And the pre-hospital team did tell us

that there was a major damage to the car and Vincent's bike,

so you do start to imagine that he must have multi system injuries.

-What's your first name, sir?

-Vincent.

-Do you prefer to be called Vincent or Vince?

-Vince.

'When you see his observations,'

you look at his colour and you think,

"There is some serious blood loss going on inside his body."

We've got fluids going in.

If he's got a decent blood pressure, this is the time to go

quickly to CT and come back

You can do it fast, if needed...

Jitender urgently needs to find the source

of Vincent's internal bleeding,

but he also wants to do everything he can to try

and save Vincent's leg.

We were suspecting that he may have an injury to one of the major

arteries of his leg because we couldn't feel

the pulses in his foot.

Jitender is worried that the damaged arteries in Vincent's

pelvis could be stopping the blood flow to his leg.

Time is an important factor in management of any

poly trauma patient, especially patients like Vincent who

have multiple systems involvements.

What we are historically told that what kills first,

what kills second, what kills third.

The first clinical decision was to see if we can get him

to CT as soon as possible.

His breathing pattern is slightly altered.

It's just becoming slightly altered, where he's doing very deep...

HE GROANS

But just before they can move him, Vincent crashes.

His blood pressure drops dangerously low.

BEEPING

Vincent is bleeding to death

and the team only have minutes to try keep him alive.

At the moment, we need to get his BP stabilised.

Can we put the rapid infuser on to the grey canula?

It's quite high potential,

so we have to get him stabilised before we go anywhere.

77-year-old Gudrun is in the midst of a stroke.

But she's been given a groundbreaking emergency

procedure, which doctors hope will stop

the stroke by breaking down the blood clot in her brain.

How are you feeling now?

Good.

Can I get you to lift both your arms up for me now?

-This is all...

-That's wonderful.

Oh, look at that.

Fantastic. Brilliant.

And if I get you just to bring your hands back to me.

Can you squeeze my hands?

-Yeah, I can squeeze them.

-SHE LAUGHS

It's working.

Oh, my word.

You want to try and walk.

Not yet. Not yet.

We have to keep you on the bed for just a little bit because the drug

we're giving...we want to make sure you have all of it first.

But that's pretty impressive. That's brilliant. Well done.

I'm happy.

'The type of stroke that Gudrun's having is where

'she is quite fluctuant.'

And even though she's got slightly better,

when I'm seeing her, I know that she could easily slip all the way

back again without much warning.

If... If she gets worse, give me a call.

Good. Thank you.

The way that she's fluctuating is the likely

location of where the stroke is.

It's likely to be in a particularly part of the brain

where we commonly see paralysis

of one side of the body, and people do often have these fluctuations.

Perhaps we've dissolved the clot partially

and there's still some clot there, or it's moved slightly downstream,

allowing a little bit of blood flow but still causing problems.

Motorcyclist Vincent has suffered

a sudden catastrophic haemorrhage.

The team still don't know exactly where his internal

bleeding is coming from and

they haven't been able to find a pulse in his leg.

They are now fighting to keep him alive.

The head of trauma medicine

Professor Porter is called down to resus.

As you continue to lose blood, your blood pressure falls.

You don't deliver effectively oxygen to the vital organs,

including the brain, so you will lose consciousness.

Your heart can't pump effectively

because there's no blood left in the circulation.

Your kidneys can't make urine, and it very much

is a short pause before that patient is going to die.

You OK there, sir?

Vincent did actually say, "I feel like I'm bleeding inside."

That's something I've heard before.

And I've also heard patients say, "I feel I'm dying."

And again, that's quite often seen in someone who's actually

very actively bleeding and getting progressively shocked.

It's almost a feeling of, you know, impending death or impending doom.

-What's GCS...?

-GCS has been 15.

The only time it went to 14 was because he had some ketamine.

Vincent needs to be stabilised before he can be moved.

The team begin a rapid blood transfusion to try and control

the haemorrhage before the source of the bleeding

can be fixed in surgery.

The blood transfusion has improved Vincent's blood pressure,

but Professor Porter is now worried about his breathing.

As the patient deteriorates,

his level of consciousness will become compromised.

He's then at risk of obstructive his airway or,

indeed, of potentially vomiting, and there's no protection to stop

the vomit going in to his lungs.

And therefore one has to do a sort of risk benefit

analysis between continuing to managing without intubation

or to actually intubate him and secure his airway.

We need to get you to the ct scanner,

-so that we can scan all your injuries that are going on. OK?

-OK.

The safest way for us to do this is we have to put you off to sleep.

Doctors are now controlling Vincent's breathing to ensure

he gets a steady supply of oxygen.

The team have bought just enough time to get Vincent

scanned and rushed into surgery.

At the Royal London hospital,

Helen is looking at the results of Ben's CT scan.

He did have four consecutive vertebral fractures

in his lower back.

They weren't unstable, so he wasn't in danger of damaging his chord,

but really painful.

Ben has multiple fractures of his vertebrae, ribs and pelvis,

and severely bruised lungs...

..but Helen suspects there may be other hidden injuries.

Something wasn't quite right.

I couldn't quite believe that this could have happened

without any damage to the head.

I think what's crucial is that

if something doesn't fit, you need to have the courage

and the confidence and the back up to look into it,

and not be rushed on to the next thing.

If something doesn't fit, there's a reason it doesn't fit.

I kept asking Ben whether he could remember what had happened

because I wanted to get some idea whether he had a head injury.

How far did you fall?

'Falling from 20 feet onto concrete,

if you've hit your head, you'd expect there to be some sign,

either a bruise or some bleeding, but we couldn't see any.

So I wasn't quite certain of the story, not certain enough to take

the decision not to do a CT of his head, which I'm glad I did.

HE MUMBLES

HE COUGHS

It's been 15 minutes since Rachel checked how Gudrun's stroke

is responding to the thrombolysis treatment.

You all right there, my darling?

How are you feeling now?

It's not your fault it's not quite working again.

This sometimes happens.

So...shall we have a look? Can we lift this arm again now?

Do you think we can try?

-So the movement's gone again, hasn't it?

-Yes.

We were starting to see fluctuations in her symptoms,

in her stroke symptoms.

Unfortunately, this is quite common.

Can you squeeze my hand?

No. OK.

Don't worry. Don't worry.

Yeah, it's a bit frustrating, isn't it?

All right, my darling.

It's got worse and then it started improving a little bit again,

so there's a lot of fluctuation.

There are two main reasons why a clot-busting drug may not work

One is it does dissolve the clot, but the brain has

already suffered enough damage that the stroke still occurs.

The other reason is that the clot may be just too

big for the clot-busting treatment to dissolve.

CT are free and ready, and they're getting drugs

ready for a CTA. I've already spoke to them.

All right, Gudrun, we're just going to take you for a scan.

Don decides to order a more sophisticated CTA scan,

which combines the CT scan image with a contrast dye,

to try and highlight the actual clot in Gudrun's brain.

What we're looking for is are the blood vessels all filling with

dye, apart from in one area where the blood clot is stopping the dye?

In theory, we could have done the scan with dye at the first

stage, but that would have probably added ten or 20 minutes to her

scan time and we didn't want to take that long.

If the dye can reveal the location of the clot,

there's one last emergency surgical procedure Don can try.

It's actually about going in and physically removing

the clot that's causing the stroke,

and that's done through a small cut at the top of the leg and

feeding a catheter up to the brain to try and snag it and take it out.

But the results are inconclusive.

Don still can't see the clot.

Nothing big and obvious clot-wise, even in any of small vessels.

'There isn't a clot visible any longer,'

which means that it's probably dissolved by the clot-busting

treatment or it might just be too small to see.

Nothing retrievable on the CTA, nothing you can pull out.

Complete the lysis, as we have done,

then she can go up to the stroke ward

and we will continue conventional stroke care.

There's nothing more Don can do.

Gudrun is admitted to the stroke ward whilst

they wait to see what kind of recovery she will make.

-Get some rest, OK? All right.

-Thank you.

Pleasure. Pleasure.

Just get some rest, sweetie.

At the Royal London Hospital,

Helen and her team are waiting for the radiologists report

of Ben's CT scan.

'Injuries to the brain itself, I would say, are the most'

dangerous and they have long term consequences.

Although they're less likely to kill you very quickly than a burst

lung or severe haemorrhage, it's possible to live

for a very long time, but that life may not be worth living.

We've got some unexpected findings.

-Here.

-Look at that.

-So they're talking about this, aren't they?

-They're talking about that.

The CT's reported showing fractures through petrus temporal bone.

The fracture line through the base of the skull ran very close

to one of the holes in the skull where some quite important

blood vessels travel.

Ben has fractured his skull.

The question now is whether this has caused any damage

to the nerves in his brain.

Yeah. Yeah, exactly.

Have you looked in his left ear?

Ben, can you hear me?

We've got the results of the scan back.

They think you might have a fracture of your skull, just down here.

Is it sore when I touch there?

-Yeah.

-There. It is painful.

-Yeah.

OK. We won't push too hard then.

I think we're going to have to look in your ear.

-Since the accident?

-Yeah.

-OK.

'It started to ring alarm bells for me'

because it could indicate that there was damage

to one of the nerves leading to the brain

that's responsible for hearing.

And there are other nerves that supply our other senses -

sight, smell and taste.

Can you screw your eyes up tightly for me?

Stop me opening them.

Good. Does anything smell funny?

No, I don't think so.

-We've given you water, haven't we?

-A little bit.

Did it...? I know this sounds like a really stupid question,

but did it taste like water?

-It didn't have any funny...

-I didn't notice any...

Not weird. OK, good.

I'm just going to have a quick look in your ear.

Don't move your head.

I just want to make sure there was no blood behind your eardrum.

No, that's fine.

The hearing may not be great because nerves that supply your ear,

help you to hear, are running near to where this fracture is.

It explains why your hearing is a bit disturbed.

It doesn't mean it's always going to be.

It's unclear what long-term effects

the damage to Ben's head will have on his hearing.

After a CT scan has revealed multiple fractures,

Vincent is about to undergo surgery to fix the bleed in his pelvis.

An injured patient lying on a trolley with drips going in.

The smell of the road and the smell of blood...

it's never very...

It's never a very uplifting scenario.

Your heart goes out to the poor chap who's injured

because they're in for a hard time.

OK. Right, there you go.

Right. Could we have the fence, please?

'You always know, in a trauma situation,

'that your access to the vessels is going to be more difficult.'

It's like going into a dark room...

and you can get nasty surprises.

Malcolm is exploring the blood vessels in Vincent's abdomen

to find the precise location of the bleed in his pelvis.

We need more room down below, don't we?

'You've got to rapidly find a bit of normal vessel you can recognise,'

and then go along the vessel and find the point of injury.

Can I have a long clamp and a tie?

That's fine.

HE MUMBLES

Oh, there it is. There it is. Got it.

Whey!

Malcolm's found the source of Vincent's bleeding.

We've got a vein hole, which I'm trying to define so I can repair it.

It is controlled. There is some ongoing bleeding from internal iliac,

which is not so bad.

Actually, give me the scissors again for a minute.

I just want to try and get this fluff off and define that hole.

For the first time since his accident,

Vincent's internal bleeding is finally under control.

Malcolm must now see if anything can be done about Vincent's leg,

which has been without a pulse for over four hours.

I'm going open his groin and get some blood flow back to the leg.

Forceps, please.

He starts to explore the main artery that supplies blood to the leg.

HE MUMBLES

But he quickly makes a discovery.

What have we got there?

We found unexpectedly severe arterial disease.

Vincent's artery is blocked by fatty deposits.

'When you have an accident'

and have a severe blunt injury to an artery,

a young elastic injury will just recoil and survive,

and nothing much will happen.

But if you've got arterial disease,

then the arterial lining is detachable.

We found that the internal lining of the artery had come

adrift and so it had caused blockage down towards the groin.

The impact of Vincent's crash

on his arteries has dislodged the fatty material.

Flush, please. I think we've got it

We had to take out the dissected fatty material from the

inside of the artery to make sure we had flow going down to the leg.

The leg's flowing again now, we think.

Ooh!

The leg's flowing now.

It may not be flowing that well, but there's a pulse in his artery anyway.

Time will tell if Vincent's leg will survive being starved of blood

and oxygen for so long.

SHE SPEAKS GERMAN

At the moment I'm not cured.

I still have a lot of problems, physically.

My left side, my arm and my leg are lame and...

they don't work.

But all the other parts of my body are still normal.

Gudrun will recover by effectively relearning how to do

the tasks that that part of the brain used to do.

So the damaged tissue has gone,

but that doesn't mean your recovery can't continue.

Inside I'm still the person I was.

Life is really a gift and you have to be careful with it.

Life is still worth living.

The muscles had swollen up and gone rock hard,

and it was obvious that the muscles had gone beyond

the point of no return.

You have to take some difficult decisions.

Saving life comes first. Saving limb comes second.

Things had deteriorated much more rapidly than I'd expected.

We thought we were going as fast as we could, but it wasn't fast enough.

To have fallen from that height

and not to have sustained life-changing injuries

was...almost not possible.

The scariest bit being told about my ear, actually.

That it was... The deafness in my ear was permanent fixture.

He did have some potentially nasty injuries that some people wouldn't

have been able to cope with as well as he has.

I mean, the fact he's back in a harness swinging out of trees

is pretty remarkable, really.

Being deaf in one ear compared to being wheelchair bound or

having brain damage is...

I think I got off pretty lightly.

You can find out more about trauma

and emergency care with The Open University's free booklet.