0:00:02 > 0:00:07This programme contains scenes which some viewers may find disturbing.
0:00:09 > 0:00:11From the moment an emergency call is made,
0:00:11 > 0:00:13a clock starts ticking.
0:00:16 > 0:00:19Female lying on the road struggling to breathe.
0:00:19 > 0:00:22The golden hour is the opportunity that we have
0:00:22 > 0:00:24to save the patient.
0:00:24 > 0:00:25Deep breaths, George.
0:00:26 > 0:00:29'The longer the clock ticks,'
0:00:29 > 0:00:31the increased likelihood there is of death.
0:00:34 > 0:00:37In the fight for survival, time is the enemy.
0:00:37 > 0:00:40I'm ventilating fast on purpose.
0:00:40 > 0:00:42- Yes.- I'm hoping that heart rate will pick up any second.
0:00:42 > 0:00:45Now, new techniques and technology
0:00:45 > 0:00:47are bringing emergency medicine to the roadside...
0:00:47 > 0:00:51We can use the infrascanner to maybe give us a slightly clearer picture
0:00:51 > 0:00:53of what's going on underneath the skull.
0:00:53 > 0:00:54..breaking new ground
0:00:54 > 0:00:57and treating patients faster than ever before.
0:00:57 > 0:01:01We can now provide emergency surgery,
0:01:01 > 0:01:04blood transfusions, anaesthesia at the scene of the accident.
0:01:04 > 0:01:06Yes, the cord. Tube, please.
0:01:07 > 0:01:08Tube on.
0:01:11 > 0:01:15We follow three patients through the crucial first hour of care.
0:01:16 > 0:01:20In London, a man is run over by a lorry.
0:01:20 > 0:01:22This is going to be an RSI
0:01:22 > 0:01:24and road to the Royal London.
0:01:24 > 0:01:27A policeman has a cardiac arrest in the gym.
0:01:27 > 0:01:28- Ah.- I've just giving you some medicine
0:01:28 > 0:01:31that's probably going to help with the chest pain.
0:01:31 > 0:01:32And in the Pennine hills,
0:01:32 > 0:01:35a cyclist is seriously injured after a fall.
0:01:35 > 0:01:36You OK?
0:01:39 > 0:01:4260 minutes that will change their lives forever.
0:01:42 > 0:01:45You will constantly be surprised
0:01:45 > 0:01:48just what you can bring back from the jaws of death.
0:01:59 > 0:02:01In London, ambulance control
0:02:01 > 0:02:04have just received an emergency call
0:02:04 > 0:02:05about a moped rider
0:02:05 > 0:02:06run over by a bin lorry.
0:02:07 > 0:02:09Emergency ambulance,
0:02:09 > 0:02:10what's the address of the emergency?
0:02:10 > 0:02:12Just south of Blackfriars Bridge.
0:02:14 > 0:02:16A bin lorry drove over a guy.
0:02:16 > 0:02:18Do you know whether
0:02:18 > 0:02:19the patient's awake?
0:02:19 > 0:02:20I suspect they're dead -
0:02:20 > 0:02:21I have no idea.
0:02:25 > 0:02:28London's air-ambulance doctor Will Glazebrook
0:02:28 > 0:02:30and paramedic Colin Smith
0:02:30 > 0:02:32have been dispatched to the scene.
0:02:34 > 0:02:38The first that we heard was he was underneath a very heavy lorry
0:02:38 > 0:02:41and trapped by his head and neck area.
0:02:41 > 0:02:43We obviously have great concerns
0:02:43 > 0:02:46about a concurrent head injury and neck injury.
0:02:51 > 0:02:52Anything versus a bin lorry,
0:02:52 > 0:02:55anything tends to come off worse than the bin lorry.
0:02:56 > 0:02:59You're normally be expecting to see quite extensive injuries,
0:02:59 > 0:03:01quite serious injuries.
0:03:02 > 0:03:05London ambulance paramedic Richard Kingham
0:03:05 > 0:03:07was first responder at the scene.
0:03:07 > 0:03:10He's administered oxygen to moped rider Martin.
0:03:19 > 0:03:22I was met by a number of policeman
0:03:22 > 0:03:24who told me he was dead.
0:03:24 > 0:03:26- 'He looked dead.' - Are you going to hold the head?
0:03:26 > 0:03:27His heart wasn't beating.
0:03:27 > 0:03:30'Immediately, I'm thinking, he's broken his neck.'
0:03:30 > 0:03:33So we need to get his helmet off soon as.
0:03:33 > 0:03:37He was very blue, and clearly wasn't getting any oxygen to his brain.
0:03:37 > 0:03:40So we began the resuscitation process.
0:03:42 > 0:03:45The oxygen has enabled Martin to breathe again
0:03:45 > 0:03:46and his heart is now beating.
0:03:49 > 0:03:50Nice pulse there.
0:03:50 > 0:03:52Will must now establish the severity of his injuries.
0:03:52 > 0:03:56The front wheel of the lorry was actually here. On this side.
0:03:56 > 0:03:57OK.
0:04:01 > 0:04:03He's obviously got some bruising here.
0:04:03 > 0:04:05He's got a decent jacket on.
0:04:06 > 0:04:09Due to the mechanism of injury that Martin had,
0:04:09 > 0:04:11being underneath the lorry at a funny angle
0:04:11 > 0:04:13with the tyre on his neck,
0:04:13 > 0:04:16we're obviously worried about a spinal injury,
0:04:16 > 0:04:18'and we quickly established
0:04:18 > 0:04:22'that Martin hadn't moved either his arms or his legs since the injury.'
0:04:22 > 0:04:24Has anybody looked...? Did you look at his pupils?
0:04:24 > 0:04:26Yeah, they were...
0:04:26 > 0:04:29They were quite large and fixed.
0:04:29 > 0:04:30About size seven.
0:04:30 > 0:04:34I had great concerns that he was suffering from a head injury.
0:04:34 > 0:04:36There would have been a period of time
0:04:36 > 0:04:39when he would not have had oxygenated blood going to his brain.
0:04:40 > 0:04:44A lack of oxygen to the brain can lead to brain damage.
0:04:44 > 0:04:46Do you want to do that? We'll put a line there.
0:04:46 > 0:04:47We're going to put him through this.
0:04:47 > 0:04:50It was just going to be a roc only, but we'll RSI him,
0:04:50 > 0:04:52so if we could just set up over there.
0:04:53 > 0:04:57I felt that the most important thing for us to do
0:04:57 > 0:05:00would be to secure his airway,
0:05:00 > 0:05:02to ensure we can give him oxygen.
0:05:03 > 0:05:06To do this, Will and the team need to anaesthetise Martin,
0:05:06 > 0:05:09which will allow them to insert a tube into his windpipe
0:05:09 > 0:05:11and take over his breathing.
0:05:12 > 0:05:15Good to go. We're going to give this gentleman anaesthetic.
0:05:15 > 0:05:18We're going to put him to sleep. First, we're going to run through a checklist
0:05:18 > 0:05:20to make sure that's a safe thing for us to do.
0:05:20 > 0:05:23You're going to hold the head, you can bag. Yeah?
0:05:23 > 0:05:26So we're going to roll, just only about 10 degrees this way.
0:05:26 > 0:05:28OK, on three. One, two...
0:05:29 > 0:05:32He still had a chance of arresting again,
0:05:32 > 0:05:35he still had a chance of not surviving this injury,
0:05:35 > 0:05:37and my thoughts at that time
0:05:37 > 0:05:40certainly were that the injuries that he did sustain
0:05:40 > 0:05:42would be life-changing.
0:05:48 > 0:05:5114 minutes ago, across London,
0:05:51 > 0:05:52ambulance control were alerted
0:05:52 > 0:05:54to another medical emergency.
0:05:56 > 0:05:57In the heart of the city,
0:05:57 > 0:06:00a police officer has collapsed at the gym
0:06:00 > 0:06:01whilst undergoing a fitness test.
0:06:01 > 0:06:03Control, G460.
0:06:03 > 0:06:06G460, we've got a 55-year-old male
0:06:06 > 0:06:07with cardiac arrest.
0:06:07 > 0:06:09An emergency medical car
0:06:09 > 0:06:13carrying London's air-ambulance consultant Anne Weaver
0:06:13 > 0:06:15and paramedic Bill Leaning
0:06:15 > 0:06:16is sent to the scene,
0:06:16 > 0:06:18where the man's colleagues have begun CPR.
0:06:18 > 0:06:20Control - G460, that's all received.
0:06:22 > 0:06:24Check, check.
0:06:24 > 0:06:26The number of people who survive
0:06:26 > 0:06:28an out-of-hospital cardiac arrest is less than 10%.
0:06:29 > 0:06:32You need to get there quickly, because time is of the essence
0:06:32 > 0:06:34with any cardiac arrest. Time is life.
0:06:34 > 0:06:36Watch heads.
0:06:37 > 0:06:39At the scene, London Ambulance paramedics
0:06:39 > 0:06:41are already treating David.
0:06:44 > 0:06:45Can you just tell me what you know?
0:06:45 > 0:06:49Yeah. Police officer doing a fitness test. Collapsed.
0:06:49 > 0:06:51- Yeah.- Was given two shocks prior to our arrival.
0:06:51 > 0:06:53Is he breathing on his own?
0:06:53 > 0:06:54He's breathing on his own. Yeah.
0:06:56 > 0:06:59David was technically dead during the cardiac arrest.
0:06:59 > 0:07:00His heart was not beating,
0:07:00 > 0:07:03he was having external chest compressions
0:07:03 > 0:07:06to provide some blood flow to his heart and his brain.
0:07:08 > 0:07:11David's colleagues have managed to restart his heart
0:07:11 > 0:07:12with CPR and a defibrillator.
0:07:14 > 0:07:17- DAVID GASPS - Ooh, hello! All right?
0:07:17 > 0:07:20Hello, sweetheart. Just take it off, just take it off a minute.
0:07:20 > 0:07:23Hello, sweetheart. What's his first name? David.
0:07:23 > 0:07:24- Hello. - DAVID SIGHS
0:07:24 > 0:07:26All right, sweetheart.
0:07:26 > 0:07:29It's OK, you're in the gym, I'm a doctor.
0:07:29 > 0:07:32You've got some very good people here who've looked after you, OK?
0:07:32 > 0:07:34- Yeah.- Well done. OK.
0:07:34 > 0:07:35You're doing really well.
0:07:35 > 0:07:38I'm just going to pop a little oxygen mask on your face, OK?
0:07:38 > 0:07:40- Yeah.- But you're doing really well.
0:07:40 > 0:07:41Can you take a big deep breath for me?
0:07:41 > 0:07:44That's brilliant, well done, absolutely brilliant.
0:07:44 > 0:07:46'So David's breathing isn't quite normal at the moment.'
0:07:46 > 0:07:48It's a little bit slow,
0:07:48 > 0:07:50it's quite deep and laboured.
0:07:50 > 0:07:53I'm not entirely sure how much oxygen he's getting.
0:07:55 > 0:07:57All right. Are you OK there?
0:07:57 > 0:07:59You're doing fine. Can we pop something under his head?
0:07:59 > 0:08:00Have we got anything soft?
0:08:00 > 0:08:03If your brain is starved of oxygen,
0:08:03 > 0:08:05that can have a devastating effect
0:08:05 > 0:08:08and, even if we restart the heart, the brain may never recover.
0:08:10 > 0:08:12So, sats 99, heart rate 105.
0:08:12 > 0:08:14- Let's get that 12-lead. - Let's get a 12-lead.
0:08:14 > 0:08:17David's heart could stop again.
0:08:17 > 0:08:20Anne decides to run an electrocardiogram, or ECG,
0:08:20 > 0:08:23to understand what is happening in his heart.
0:08:23 > 0:08:25Yeah, fine. OK.
0:08:25 > 0:08:27So, BP of 108/70.
0:08:29 > 0:08:31Heart rate of 93.
0:08:31 > 0:08:3312-lead just coming.
0:08:34 > 0:08:36Heart rate, good.
0:08:37 > 0:08:40He's got quite marked ST depression, naturally.
0:08:40 > 0:08:42- Yeah.- So he's probably got a posterior.
0:08:42 > 0:08:46- Yeah.- OK, all right, we've got enough to go on there.
0:08:46 > 0:08:48- But, erm...- Bart's.
0:08:48 > 0:08:50Yeah.
0:08:50 > 0:08:51'I'm looking at David's ECG'
0:08:51 > 0:08:54and I can see changes, which suggest to me
0:08:54 > 0:08:57that he has a blocked coronary artery in his heart.
0:08:57 > 0:09:00The heart muscle is still ischaemic,
0:09:00 > 0:09:02which means it's still not getting enough oxygen.
0:09:03 > 0:09:06If the muscle doesn't have oxygen restored quickly,
0:09:06 > 0:09:08that heart muscle will start to die.
0:09:10 > 0:09:12He could go back into cardiac arrest.
0:09:13 > 0:09:14He might.
0:09:14 > 0:09:17There's a limited amount we can do on scene.
0:09:17 > 0:09:18We can treat his symptoms,
0:09:18 > 0:09:21but I can't unblock that coronary artery here
0:09:21 > 0:09:25and more heart muscle is dying whilst we are waiting.
0:09:25 > 0:09:28We want to get you to hospital as quick as we can.
0:09:28 > 0:09:30So, in a minute, we're going to help pick you up.
0:09:30 > 0:09:34If you're sick, don't worry, OK? I can give you something to stop you feeling sick.
0:09:34 > 0:09:36But it's part of what's happened, OK?
0:09:36 > 0:09:39We're going to get you on the trolley and in an ambulance.
0:09:39 > 0:09:41All right? I know you don't feel well at all.
0:09:41 > 0:09:44OK? We're going to look after you, I promise you, OK?
0:09:45 > 0:09:47- David?- Oh...
0:09:47 > 0:09:48- Have you got a chest pain?- Yeah.
0:09:48 > 0:09:51'David's clutching his chest and is in significant pain.'
0:09:51 > 0:09:54His heart is beating, but from the ECG changes
0:09:54 > 0:09:57and looking at David, he's got chest pain.
0:09:57 > 0:09:59He is having a heart attack in front of us.
0:10:05 > 0:10:06200 miles away,
0:10:06 > 0:10:08North East ambulance control
0:10:08 > 0:10:09have taken a call
0:10:09 > 0:10:11about a cycling accident
0:10:11 > 0:10:13in the remote North Pennine hills.
0:10:16 > 0:10:18He's come off his cycle
0:10:18 > 0:10:21and part of his mouth's all hanging out.
0:10:21 > 0:10:24I just need to check first
0:10:24 > 0:10:26that the patient's fully breathing?
0:10:26 > 0:10:27He is breathing,
0:10:27 > 0:10:29but he's bleeding very badly.
0:10:30 > 0:10:33Has there been a heavy blood loss?
0:10:33 > 0:10:34He's bleeding very badly
0:10:34 > 0:10:35at the moment, yes.
0:10:41 > 0:10:43In freezing conditions,
0:10:43 > 0:10:45the Great Northern Air Ambulance
0:10:45 > 0:10:48is carrying Doctor Dion Arbid and paramedic Andy Mawson
0:10:48 > 0:10:50to the scene of the accident.
0:11:04 > 0:11:05I've been told that
0:11:05 > 0:11:08there's a gentleman come off a pedal cycle
0:11:08 > 0:11:10up in the hills in the snow
0:11:10 > 0:11:13and it sounds like he's got a really nasty facial injury.
0:11:22 > 0:11:25I'm thinking that he could well have
0:11:25 > 0:11:28a significant head injury, and that's our biggest worry.
0:11:33 > 0:11:34After coming off the bike,
0:11:34 > 0:11:37the cyclist managed to ride another three miles to a local pub.
0:11:41 > 0:11:42Thanks very much.
0:11:42 > 0:11:45Hello, mate. What's your name, buddy?
0:11:45 > 0:11:46Julian.
0:11:46 > 0:11:48Julian? OK.
0:11:48 > 0:11:51'A lot of the time, you can have a good guess at what people have done,
0:11:51 > 0:11:54'depending on what the description of the incident is.
0:11:54 > 0:11:56'But you can never take anything for granted.'
0:11:56 > 0:11:59Do you take medicines for anything? Are you allergic to anything?
0:11:59 > 0:12:02- Have you hurt yourself anywhere else apart from your face?- My hand.
0:12:02 > 0:12:03Your hand?
0:12:03 > 0:12:06'Julian doesn't know how bad his face looks.
0:12:06 > 0:12:08'He had a very nasty cut'
0:12:08 > 0:12:10to his lower lip, which extended down onto his jaw.
0:12:10 > 0:12:12Have you lost any teeth, Julian?
0:12:12 > 0:12:14- Yeah.- Haven't swallowed any or anything like that,
0:12:14 > 0:12:16- you don't think?- No.- OK.
0:12:18 > 0:12:19As well as his facial wounds,
0:12:19 > 0:12:22Dion is worried Julian may have other serious injuries.
0:12:24 > 0:12:26Sit forward a tiny bit for us.
0:12:26 > 0:12:28Good man. Any pain lower down your neck there?
0:12:28 > 0:12:30Nothing at all? Deep breaths in now.
0:12:30 > 0:12:32And out.
0:12:32 > 0:12:34'From the impact itself,
0:12:34 > 0:12:36'he could well have torn vessels'
0:12:36 > 0:12:38inside his head, inside his brain, and caused bleeding.
0:12:38 > 0:12:42- Good man. Have you got any morphine? Do you carry morphine?- Yes.
0:12:42 > 0:12:45Give me some morphine, if you can draw that up, ready for us.
0:12:45 > 0:12:46- Cheers.- Yeah, no worries.
0:12:46 > 0:12:48Dion and the team need to prepare Julian
0:12:48 > 0:12:52for the helicopter ride to hospital for a more detailed examination.
0:12:52 > 0:12:55OK, we'll just give you some of this painkiller.
0:12:55 > 0:12:58This might make you feel a tiny bit woozy, OK?
0:12:58 > 0:13:01'We still have to remain vigilant on the ride in.'
0:13:02 > 0:13:04'Things can change very, very quickly.'
0:13:04 > 0:13:07Pop these on you. It'll be cold, I'm afraid.
0:13:08 > 0:13:10If you've got any problems, just wave at me.
0:13:10 > 0:13:12Right, start number one.
0:13:15 > 0:13:18Concerned that there may be injuries he can't see,
0:13:18 > 0:13:22Dion rushes Julian to the nearest major trauma centre in Newcastle,
0:13:22 > 0:13:25a journey of just 15 minutes by helicopter.
0:13:27 > 0:13:29We're looking for, predominantly,
0:13:29 > 0:13:31a change in his level of consciousness,
0:13:31 > 0:13:35whether he becomes drowsy, whether any of his neurology changes,
0:13:35 > 0:13:38if he's bleeding internally, his pulse rate goes up -
0:13:38 > 0:13:41all these things we'll keep an eye on, on the flight.
0:13:43 > 0:13:47You can never take for granted that nothing's going to change.
0:13:47 > 0:13:48Unexpected things do happen,
0:13:48 > 0:13:51and we just have to deal with them as and when.
0:13:59 > 0:14:00In central London,
0:14:00 > 0:14:01moped rider Martin
0:14:01 > 0:14:03is about to be anaesthetised
0:14:03 > 0:14:05after being run over by a bin lorry
0:14:05 > 0:14:07and suffering multiple injuries.
0:14:11 > 0:14:13Yeah, just a scene update.
0:14:13 > 0:14:15This is going to be an RSI and road to the Royal London.
0:14:15 > 0:14:17'Message received.'
0:14:19 > 0:14:22We obviously have great concerns
0:14:22 > 0:14:25about a concurrent head injury and neck injury.
0:14:25 > 0:14:27Checklist. Happy, Colin?
0:14:27 > 0:14:31Will is worried the injuries may be restricting the supply of oxygen
0:14:31 > 0:14:32to Martin's brain.
0:14:32 > 0:14:34He's got equal pupils...
0:14:34 > 0:14:37He decides to perform a critical procedure called an RSI.
0:14:39 > 0:14:40So, oxygen mask on tight.
0:14:40 > 0:14:43All oxygen cylinders are greater than half-full.
0:14:43 > 0:14:44515...
0:14:44 > 0:14:49An RSI is a rapid sequence induction of anaesthesia.
0:14:49 > 0:14:53It is the giving of an anaesthetic drug
0:14:53 > 0:14:56and a paralytic agent.
0:14:56 > 0:14:58It's not a procedure that we take lightly.
0:14:58 > 0:15:01Once you give your drugs and you've paralysed a patient,
0:15:01 > 0:15:04you are on a road to ensure that you take over their breathing.
0:15:04 > 0:15:08So we do 200 of fentanyl.
0:15:08 > 0:15:09- 4ml.- 4ml, yeah.
0:15:09 > 0:15:11Ketamine, do 150.
0:15:11 > 0:15:13150, check.
0:15:13 > 0:15:15And the roc,
0:15:15 > 0:15:18we're going to give 70mg.
0:15:18 > 0:15:20- 7ml?- 7ml.- OK.
0:15:20 > 0:15:24So, guys, just a little bit of concentration now.
0:15:24 > 0:15:28This chap's going to go even further asleep than he was.
0:15:31 > 0:15:33It takes about 45 seconds
0:15:33 > 0:15:34for him to stop breathing
0:15:34 > 0:15:37and become 100% paralysed.
0:15:39 > 0:15:41Can somebody just give me the time? The roc is in that...
0:15:41 > 0:15:44- Time is 34.- 34. Thank you.
0:15:44 > 0:15:46'Once you stop a patient breathing,
0:15:46 > 0:15:48'you've got a very short period of time'
0:15:48 > 0:15:50to get a breathing tube down their throat
0:15:50 > 0:15:51and start delivering oxygen to them.
0:15:53 > 0:15:55Can I have the suction, please?
0:15:58 > 0:16:00So, I can't see very much at the moment.
0:16:00 > 0:16:01There's a lot of blood.
0:16:01 > 0:16:04OK, I can see the cords, the cords are apart.
0:16:04 > 0:16:06It's a grade-two view.
0:16:06 > 0:16:07I can see...
0:16:07 > 0:16:09yeah, it going through the cords.
0:16:09 > 0:16:12- So add the tube over.- Tube over.
0:16:15 > 0:16:17Just have a listen to the chest again for me.
0:16:17 > 0:16:19Sats are 98. Good BP.
0:16:19 > 0:16:21I want you to just hold that tube there.
0:16:21 > 0:16:23Just hold that there. Don't let it move.
0:16:23 > 0:16:25Right, OK, we're going to go by land to the Royal London,
0:16:25 > 0:16:26if you don't know already.
0:16:26 > 0:16:29With the tube in place, vital oxygen is now being delivered
0:16:29 > 0:16:31to Martin's heart and brain.
0:16:33 > 0:16:35But until he reaches hospital for scans,
0:16:35 > 0:16:37there's no way of knowing
0:16:37 > 0:16:40what kind of injuries he's suffered to his head and neck.
0:16:40 > 0:16:42There's still a lot that can go wrong.
0:16:42 > 0:16:43There'll still be repercussions
0:16:43 > 0:16:45from the period where he's been in cardiac arrest.
0:16:45 > 0:16:48So we're going to start moving that way.
0:16:49 > 0:16:52There's potential secondary brain damage
0:16:52 > 0:16:54where his brain's been starved of oxygen,
0:16:54 > 0:16:56and they all need to be addressed.
0:16:56 > 0:16:58SIREN WAILS
0:17:02 > 0:17:03In central London,
0:17:03 > 0:17:05police officer David
0:17:05 > 0:17:06is in the grip of
0:17:06 > 0:17:07an ongoing heart attack.
0:17:08 > 0:17:12Have we got a... Let's just keep the oxygen near him.
0:17:12 > 0:17:16We'll blue this in as post-cardiac arrest with ongoing chest pain.
0:17:16 > 0:17:17Yeah.
0:17:17 > 0:17:19He has a blocked coronary artery.
0:17:19 > 0:17:21I think the blockage
0:17:21 > 0:17:25is a significant obstruction to blood flow
0:17:25 > 0:17:27and, hence, to oxygen to the muscle.
0:17:27 > 0:17:29That's a heart attack.
0:17:29 > 0:17:30Oh...
0:17:31 > 0:17:34He's still got this crushing chest pain,
0:17:34 > 0:17:36because his heart is still struggling to work.
0:17:36 > 0:17:39Whatever's caused his cardiac arrest -
0:17:39 > 0:17:41and we believed it was a blocked artery -
0:17:41 > 0:17:43that is still blocked, we haven't cleared that.
0:17:43 > 0:17:45- Can we get our medical drugs pack now?- Got it.
0:17:45 > 0:17:48- What would you like? - Get some GTN.- GTN it is.
0:17:48 > 0:17:49Yeah, thanks.
0:17:49 > 0:17:50- Oh...- OK.
0:17:50 > 0:17:54- GTN.- Right, we're going to give you a little spray under your tongue.
0:17:54 > 0:17:55- Oh, I feel sick.- OK.
0:17:55 > 0:17:58Don't worry. If you're sick, it's fine - there's a bag here.
0:17:58 > 0:17:59- Good man.- Aah!
0:17:59 > 0:18:03Good. I've given David a spray under his tongue, it's called GTN,
0:18:03 > 0:18:05or glyceryl trinitrate.
0:18:05 > 0:18:08This is a drug which opens up blood vessels,
0:18:08 > 0:18:10and I'm doing that to try and improve
0:18:10 > 0:18:12the blood flow through his coronary arteries.
0:18:12 > 0:18:14Are you sure?
0:18:14 > 0:18:16If everyone's ready - ready, brace, lift.
0:18:16 > 0:18:18DAVID GROANS
0:18:18 > 0:18:20The drugs will reduce David's pain
0:18:20 > 0:18:22and increase the oxygen to his heart.
0:18:22 > 0:18:25Then the team will take him to hospital.
0:18:25 > 0:18:27Oh! Oh, headache.
0:18:27 > 0:18:29I've just given you some medicine
0:18:29 > 0:18:31that's probably going to help with the chest pain
0:18:31 > 0:18:34- that does give you a bit of a headache, OK?- Oh!
0:18:34 > 0:18:36Can you just turn your arm out?
0:18:36 > 0:18:38OK. Just turn your arm out for me.
0:18:38 > 0:18:41Anne injects David with morphine to help further reduce his pain.
0:18:41 > 0:18:43Got a headache.
0:18:43 > 0:18:45Yeah, I've just given you something to try and take that away
0:18:45 > 0:18:48and to get rid of your chest pain, OK?
0:18:48 > 0:18:49Cor, flippin' heck!
0:18:51 > 0:18:54I think if you do this job and you don't reflect on your patients,
0:18:54 > 0:18:57there's something a bit wrong with you.
0:18:58 > 0:19:01That patient is someone's father, someone's mother,
0:19:01 > 0:19:02someone's sister, someone's brother.
0:19:04 > 0:19:07It's nothing that can ever be taken lightly.
0:19:07 > 0:19:10OK. I need to just put a little bit of oxygen on your face, OK?
0:19:10 > 0:19:13I know you feel sick, we can take it off quickly,
0:19:13 > 0:19:14but this may help, OK.
0:19:14 > 0:19:16- Oh!- All right.
0:19:16 > 0:19:19With his heart attack continuing,
0:19:19 > 0:19:23David will be monitored closely, en route to a specialist heart centre.
0:19:28 > 0:19:30In Northumberland,
0:19:30 > 0:19:31cyclist Julian is arriving
0:19:31 > 0:19:33at Newcastle's Major Trauma Centre.
0:19:38 > 0:19:40Emergency doctor Kian Dastoori
0:19:40 > 0:19:42is preparing to receive him.
0:19:44 > 0:19:47His face went into a cattle-grid, apparently.
0:19:51 > 0:19:54Julian, 45, fit and well, no medicines, no allergies.
0:19:54 > 0:19:57Off a pedal bike, face into a cattle-grid.
0:19:57 > 0:20:00And it's done some quite considerable soft-tissue damage
0:20:00 > 0:20:02to his lower lip,
0:20:02 > 0:20:04his dentition on that bottom
0:20:04 > 0:20:05and query fractured mandible as well.
0:20:05 > 0:20:08Right, Julian. Are you all right to be called Julian?
0:20:08 > 0:20:11Yeah, my name's Kian, OK? I'm one of the doctors.
0:20:11 > 0:20:14'On the first seeing Julian come through the resus doors,'
0:20:14 > 0:20:17I could see that he was alert, looking around.
0:20:17 > 0:20:21Right, have you got any blood going down the back of your throat?
0:20:21 > 0:20:23- No.- No. And you've got no neck pain at all, Julian?
0:20:23 > 0:20:24- No.- No.
0:20:24 > 0:20:27'But you always have to keep your guard up.'
0:20:27 > 0:20:30He's lost his lower dentition off his palate,
0:20:30 > 0:20:33he's stripped all his mucosa all off his mandible
0:20:33 > 0:20:36and he's got lacerations down both sides,
0:20:36 > 0:20:38so the bottom of his mouth's flapping.
0:20:38 > 0:20:40- Knocked any teeth out?- Yeah.
0:20:40 > 0:20:42You have knocked some teeth out, yeah?
0:20:42 > 0:20:45- No.- No tenderness up here?
0:20:45 > 0:20:46Right.
0:20:46 > 0:20:49OK. Fine. So it seems to be mainly isolated to the face.
0:20:49 > 0:20:51He's torn his frenulum on his tongue,
0:20:51 > 0:20:54and he's got a deep laceration to the left side of his lip.
0:20:54 > 0:20:58So we'll get an X-ray of his jaw and we'll go from there.
0:20:59 > 0:21:01Oh, hey, Claire, it's just Kian.
0:21:01 > 0:21:04We've had a chap come in who's come off his bike
0:21:04 > 0:21:06and gone face-planted into a cattle-grid.
0:21:06 > 0:21:08I just wondered if you could come and have a look?
0:21:08 > 0:21:11We're going to get X-rays of his mandible and jaw anyway.
0:21:11 > 0:21:13We'll get you round for your X-ray shortly, OK?
0:21:13 > 0:21:17Let us know if you know more painkillers, OK? OK.
0:21:20 > 0:21:23As Kian waits for Julian to be taken to X-ray,
0:21:23 > 0:21:26he notices a change in his condition.
0:21:26 > 0:21:28- You just went straight over?- Yeah.
0:21:28 > 0:21:30- Yeah?- Like that.- Straight on.
0:21:30 > 0:21:32OK.
0:21:32 > 0:21:34Right. Do you still know where we are?
0:21:34 > 0:21:36- Yeah.- Where are we?
0:21:36 > 0:21:37- Hospital.- Yeah, fine, OK.
0:21:39 > 0:21:42Although Julian appeared orientated still
0:21:42 > 0:21:45and I kept asking him, "Do you know where we are?"
0:21:45 > 0:21:48and he could tell me we were in hospital...
0:21:50 > 0:21:54..he'd changed somehow, and I knew that there was something going on.
0:21:56 > 0:21:58Keep him on pretty close neurobs.
0:21:58 > 0:22:00He still knows where he is and stuff,
0:22:00 > 0:22:03he's just got a bit dazed and it's just not quite right.
0:22:05 > 0:22:09I just caught a glimpse of him as he was going out of the room
0:22:09 > 0:22:11and his face appeared to have changed.
0:22:13 > 0:22:14And it was that reason why
0:22:14 > 0:22:17I followed him round to the X-ray department.
0:22:23 > 0:22:25It's your left hand that we're going to X-ray,
0:22:25 > 0:22:26does that sound right?
0:22:26 > 0:22:28And then some images of your face
0:22:28 > 0:22:30and your mandible as well and your chest.
0:22:30 > 0:22:32HE MUMBLES
0:22:35 > 0:22:37Does your hand normally flatten out?
0:22:37 > 0:22:38Yeah.
0:22:38 > 0:22:42Yeah, can you try and uncurl all of your fingers for me, then?
0:22:42 > 0:22:44And turn your hand palm down.
0:22:45 > 0:22:48'At the point when your gut tells you
0:22:48 > 0:22:51'there's something going on here,'
0:22:51 > 0:22:54you do have this sort of internal clock
0:22:54 > 0:22:58that just starts ticking until you find out what the diagnosis is.
0:23:05 > 0:23:06Down there.
0:23:08 > 0:23:09That arm. No.
0:23:09 > 0:23:13Can you bring this arm up here? You're on there.
0:23:13 > 0:23:16Can I have a quick look at him, guys? Sorry.
0:23:17 > 0:23:19Julian, can I see this arm?
0:23:19 > 0:23:22The tone of your muscles, at rest,
0:23:22 > 0:23:24should be nice and relaxed.
0:23:24 > 0:23:29Whereas, when I went in to quickly assess Julian's arms,
0:23:29 > 0:23:32he appeared to be nice and relaxed on his right side.
0:23:32 > 0:23:33Let this arm relax, just relax.
0:23:36 > 0:23:38Can you let this one relax as well?
0:23:38 > 0:23:41But his left side was more rigid.
0:23:42 > 0:23:45His muscles appeared to not be at rest.
0:23:45 > 0:23:47He needs to go for a CT head.
0:23:47 > 0:23:51- CT head.- Do you want a quick chest? - CT Head. No, CT head now. OK.
0:23:51 > 0:23:53'Increased tone essentially can be a sign
0:23:53 > 0:23:56'that you're not getting oxygen to that part of your brain.
0:23:56 > 0:23:59'At this point, I'm worried that Julian'
0:23:59 > 0:24:01is showing signs of having a stroke.
0:24:08 > 0:24:10We're going to bring him in for a CT head now, guys, he's...
0:24:10 > 0:24:13- Oh...- He's got increased tone of his left arm and he's just...
0:24:13 > 0:24:15He's not really using it that well.
0:24:15 > 0:24:17'We need to urgently scan his head
0:24:17 > 0:24:20'to make sure there's no bleed in his brain.'
0:24:20 > 0:24:21That is now time-critical.
0:24:25 > 0:24:26OK?
0:24:27 > 0:24:28Yeah.
0:24:39 > 0:24:42The scan should reveal any blood clots or bleeds.
0:24:46 > 0:24:48But it's clear.
0:24:49 > 0:24:50Fine. Good.
0:24:51 > 0:24:55So, in CT, we don't find anything on the brain...
0:24:55 > 0:24:57That's fine. Yeah, we'll get his X-rays now.
0:24:57 > 0:25:02All we find is a fracture to the skull near his eye.
0:25:02 > 0:25:04But I wasn't reassured.
0:25:04 > 0:25:05My gut was telling me
0:25:05 > 0:25:08there's something going on with this patient.
0:25:08 > 0:25:11We now have a man who was...
0:25:11 > 0:25:14essentially well when he came in,
0:25:14 > 0:25:16despite his facial injuries,
0:25:16 > 0:25:20and is now developing new symptoms
0:25:20 > 0:25:22which seem to be progressing.
0:25:23 > 0:25:26So I had to go looking for something else.
0:25:26 > 0:25:30I had to be looking for something that could explain all of this.
0:25:37 > 0:25:39In the last 60 minutes,
0:25:39 > 0:25:41doctors and paramedics
0:25:41 > 0:25:42have pulled moped rider Martin
0:25:42 > 0:25:44from under a bin lorry,
0:25:44 > 0:25:45and suspect he's suffered
0:25:45 > 0:25:47brain and spinal damage.
0:25:49 > 0:25:50Police Officer David
0:25:50 > 0:25:51is being rushed to hospital
0:25:51 > 0:25:53with an ongoing heat attack.
0:25:53 > 0:25:55And cyclist Julian is showing
0:25:55 > 0:25:57worrying signs of deterioration.
0:26:00 > 0:26:02At the Royal London Hospital,
0:26:02 > 0:26:06a trauma team led by emergency medicine consultant Alistair Wilson
0:26:06 > 0:26:08is on high alert to receive Martin.
0:26:10 > 0:26:13He was pinned underneath the front wheel
0:26:13 > 0:26:16by his left shoulder and head in a funny angle.
0:26:16 > 0:26:18The lorry was reversed,
0:26:18 > 0:26:21he was pulled out in PEA arrest.
0:26:21 > 0:26:24Helmet came off, LMA, oxygen
0:26:24 > 0:26:25and he got a ROSC.
0:26:25 > 0:26:28Our arrival, GCS of 3,
0:26:28 > 0:26:30not been seen to move any of his limbs.
0:26:30 > 0:26:33Let's go for the...
0:26:33 > 0:26:35Let's get the...
0:26:35 > 0:26:36top and bottom off.
0:26:36 > 0:26:40'I like the whole business of actually working out'
0:26:40 > 0:26:43what has caused what.
0:26:45 > 0:26:48There isn't an injury that the patient has
0:26:48 > 0:26:51that cannot be related to what has gone on.
0:26:51 > 0:26:52It's a bit like looking at cars,
0:26:52 > 0:26:55you know, if you have a car that's been in an accident,
0:26:55 > 0:26:58every dent, every bump is caused by something else,
0:26:58 > 0:27:01and you need to piece together all those bits.
0:27:01 > 0:27:03The same thing is true with the body.
0:27:03 > 0:27:05Right, hands over from right to left.
0:27:07 > 0:27:10Alistair's team begin by examining Martin
0:27:10 > 0:27:12for any immediate life-threatening injuries.
0:27:13 > 0:27:15Can you feel the chest for me with your...
0:27:15 > 0:27:17Yes, there's no tenderness...
0:27:17 > 0:27:19Well, no, look, go right the way round the back
0:27:19 > 0:27:21and tell me what it feels like.
0:27:22 > 0:27:26It became abundantly apparent very quickly
0:27:26 > 0:27:29that his wasn't just a head injury.
0:27:29 > 0:27:32He'd got a lot of bruising at the very base of his neck,
0:27:32 > 0:27:34which you could feel.
0:27:34 > 0:27:36So when you're ready, let's get that blood gas off,
0:27:36 > 0:27:38fast as you can.
0:27:38 > 0:27:40So, are we ready for CT? Let's go.
0:27:42 > 0:27:45So the issue was to move Martin as fast as possible
0:27:45 > 0:27:47into the CT scanner
0:27:47 > 0:27:50to review all of these injuries and see exactly what was going on.
0:27:55 > 0:27:59Knowing that Martin's head and neck were dragged under the lorry,
0:27:59 > 0:28:01Alistair is going to CT scan both.
0:28:01 > 0:28:06He's behaving as if he's got quite a bit of cerebra anaemia already.
0:28:06 > 0:28:08We could use facial bones as well.
0:28:10 > 0:28:14Primarily, the left side of his face had been smashed inwards.
0:28:14 > 0:28:16The facial bones were all fractured.
0:28:18 > 0:28:21There was a lot of swelling under the very base of the skull.
0:28:23 > 0:28:26As well as the trauma to Martin's face,
0:28:26 > 0:28:29Alistair is also looking for any injury to the brain.
0:28:29 > 0:28:31His brain looks quite good.
0:28:33 > 0:28:35It does tell me that there's no bleeding
0:28:35 > 0:28:37inside the brain matter itself,
0:28:37 > 0:28:39or contusions or tears in the brain matter.
0:28:39 > 0:28:41I wonder what sort of helmet he was wearing.
0:28:41 > 0:28:43The policeman's got it.
0:28:43 > 0:28:45Oh, excellent, I'll have a look.
0:28:47 > 0:28:49So, it's between the road...
0:28:49 > 0:28:50That's road, and that's...
0:28:50 > 0:28:52- And that's...- That's him.
0:28:52 > 0:28:55Perfect. Exactly what we would expect.
0:28:55 > 0:28:58Perfect. If Martin hadn't been wearing a helmet,
0:28:58 > 0:29:03I suspect he would probably have had a fatal head injury at scene
0:29:03 > 0:29:07and probably would not have been able to be resuscitated.
0:29:08 > 0:29:12Whilst Alistair is encouraged by the scan,
0:29:12 > 0:29:14it could be days before any damage
0:29:14 > 0:29:17caused by the lack of oxygen begins to show.
0:29:17 > 0:29:20The damage to the brain
0:29:20 > 0:29:24would have been expressed in the cells,
0:29:24 > 0:29:26initially by just not working,
0:29:26 > 0:29:28but with time, the cells die
0:29:28 > 0:29:31and the whole of the brain then becomes oedematous -
0:29:31 > 0:29:34it's got a lot of swelling, a lot of water on it.
0:29:34 > 0:29:37Unfortunately, it does take two days or so
0:29:37 > 0:29:40before that expresses itself.
0:29:40 > 0:29:43So it's a matter of waiting to see what has happened.
0:29:43 > 0:29:45OK.
0:29:45 > 0:29:47Having checked the brain,
0:29:47 > 0:29:50Alistair now focuses his attention on Martin's spine.
0:29:50 > 0:29:54I'm concerned about his C-spine, but we haven't got the recons here.
0:29:54 > 0:29:55That's blood round there.
0:29:55 > 0:29:58When you looked at the spinal cord,
0:29:58 > 0:30:00at the base of the brain,
0:30:00 > 0:30:03just at the bottom of the brain - a little bit into the brain, too -
0:30:03 > 0:30:07but there, pushing the spinal cord across, was blood.
0:30:07 > 0:30:08That's compressed inwards, isn't it?
0:30:08 > 0:30:11So he's got this haematoma,
0:30:11 > 0:30:13- in this area here.- Yeah.
0:30:13 > 0:30:16The danger to Martin because of this bleeding
0:30:16 > 0:30:19is, if it is compressing the cord,
0:30:19 > 0:30:21then it will be damaging the cord.
0:30:21 > 0:30:23And it would be an emergency then,
0:30:23 > 0:30:25and we would need to go in and let that blood out.
0:30:27 > 0:30:30To decide if Martin requires surgery,
0:30:30 > 0:30:34the trauma team need a more detailed examination of his spinal cord.
0:30:35 > 0:30:37MRI is the next thing to do.
0:30:37 > 0:30:41An MRI lets us see very clearly
0:30:41 > 0:30:43ligaments, soft tissues,
0:30:43 > 0:30:46brain and neural tissue
0:30:46 > 0:30:49in a lot more detail than we ever could with the CT scan.
0:30:50 > 0:30:53The real issue in Martin's case was
0:30:53 > 0:30:56were we going to need to do something with his neck?
0:30:57 > 0:30:59Whether we needed to do an operation
0:30:59 > 0:31:02on the spinal cord, or the spinal column,
0:31:02 > 0:31:05had to be determined by the MRI scans.
0:31:07 > 0:31:10Any significant damage to Martin's spinal cord
0:31:10 > 0:31:12could lead to permanent paralysis.
0:31:12 > 0:31:15He's got these little fractures round the back there.
0:31:15 > 0:31:17C7.
0:31:17 > 0:31:20Um... Hmm.
0:31:20 > 0:31:22All of that looks raised, doesn't it?
0:31:22 > 0:31:24All the way up and down.
0:31:24 > 0:31:27It's this stuff in the centre of the cord that's the issue.
0:31:27 > 0:31:28Yeah.
0:31:31 > 0:31:36After the MRI, it was clear that there was no compressive pressure
0:31:36 > 0:31:38being put on the spinal cord
0:31:38 > 0:31:41and, therefore, there was no requirement
0:31:41 > 0:31:44for any neck surgery, or to let any clot out
0:31:44 > 0:31:46or let any pressure out.
0:31:47 > 0:31:50Although there's no need for surgery,
0:31:50 > 0:31:52Alistair can't tell at this stage
0:31:52 > 0:31:55what the long-term implications of Martin's injuries will be.
0:31:55 > 0:31:59To aid his recovery, Martin will be kept in an induced coma
0:31:59 > 0:32:02until the medical team feel it's safe to wake him.
0:32:02 > 0:32:05Is he going to be able to move his arms and his legs?
0:32:05 > 0:32:08We have to wait and see. He could wake up in two days, three days,
0:32:08 > 0:32:11and his brain might not work at all.
0:32:20 > 0:32:24David is arriving at Barts Heart Centre.
0:32:27 > 0:32:30Anne suspects one of his major coronary arteries is blocked.
0:32:30 > 0:32:32She's given him drugs for the pain.
0:32:32 > 0:32:35Until doctors clear the blockage,
0:32:35 > 0:32:38his heart will be starved of oxygen and nutrients.
0:32:39 > 0:32:42This is David, he's a 57-year-old policeman.
0:32:42 > 0:32:44He was doing the bleep test this morning
0:32:44 > 0:32:47when he dropped to his knees, clasped his chest and fell prone.
0:32:47 > 0:32:49Immediate bystander CPR.
0:32:49 > 0:32:53His 12-lead ECG basically shows a sinus rhythm,
0:32:53 > 0:32:56but he's got some inferior and lateral changes
0:32:56 > 0:32:59and ongoing chest pain. He's taken 10 morphine...
0:32:59 > 0:33:03Within minutes, David goes for an emergency angiogram,
0:33:03 > 0:33:05a specialist heart X-ray,
0:33:05 > 0:33:10under the eye of consultant interventional cardiologist John Hogan.
0:33:12 > 0:33:14We know he's had a cardiac arrest.
0:33:14 > 0:33:17We're not entirely certain why he's had one.
0:33:17 > 0:33:20If he does have a blocked artery, which is recently occluded,
0:33:20 > 0:33:24the longer it is blocked, the more damage it causes to heart muscle.
0:33:26 > 0:33:31You're going to feel a burning sensation of the arm, OK?
0:33:32 > 0:33:35Using dye, John examines
0:33:35 > 0:33:38each of David's three major coronary arteries in turn,
0:33:38 > 0:33:40looking for any narrowing.
0:33:41 > 0:33:43The arteries develop a lining called atherosclerosis
0:33:43 > 0:33:45over a period of time.
0:33:45 > 0:33:51That lining itself is subject to developing cracks.
0:33:53 > 0:33:58Such little cracks are sealed by little blood clots which seal it
0:33:58 > 0:34:00and if you get a big blood clot,
0:34:00 > 0:34:03it can actually block an artery off at the time and that's how you get
0:34:03 > 0:34:06what is typically known as a heart attack.
0:34:08 > 0:34:11Why do people get hardening of the arteries?
0:34:11 > 0:34:12It can be a number of things.
0:34:12 > 0:34:15Do they have hypertension, do they have diabetes,
0:34:15 > 0:34:17do they have high levels of cholesterol?
0:34:17 > 0:34:20And their lifestyle issues. Are they sedentary, do they smoke?
0:34:20 > 0:34:25All of these things contribute to the development of atherosclerosis.
0:34:25 > 0:34:27- He's got collaterals.- Yeah.
0:34:27 > 0:34:31And so that implies that the vessel has been blocked before
0:34:31 > 0:34:34and he's had these collaterals in the interim period.
0:34:36 > 0:34:38John discovers a drastically reduced flow
0:34:38 > 0:34:42through one of the three main arteries supplying David's heart.
0:34:42 > 0:34:45There's no doubt that David has a blocked artery
0:34:45 > 0:34:46that runs down the front of his heart.
0:34:46 > 0:34:50We just need to have a little MDT about this before we press on.
0:34:50 > 0:34:54John must now make a decision on how to treat David,
0:34:54 > 0:34:56to give him the best chance of survival.
0:34:59 > 0:35:02We've had a look at the angiogram.
0:35:02 > 0:35:04Of your three coronary arteries,
0:35:04 > 0:35:08you've blocked the one that goes down the front of the heart.
0:35:08 > 0:35:11You do not appear to have blocked it off this morning,
0:35:11 > 0:35:16but your exercise may have aggravated matters
0:35:16 > 0:35:17and caused your collapse.
0:35:17 > 0:35:20So we think that your circumstances
0:35:20 > 0:35:22would be best treated in the long term
0:35:22 > 0:35:25by an operation to bypass that blocked artery.
0:35:28 > 0:35:32Until David goes to theatre for emergency surgery the following day,
0:35:32 > 0:35:35he will be closely watched for the smallest of fluctuations
0:35:35 > 0:35:36in his heart activity.
0:35:48 > 0:35:51In Newcastle, over the last four hours,
0:35:51 > 0:35:55Julian has been closely monitored following his accident.
0:35:55 > 0:35:57His head scan has revealed nothing
0:35:57 > 0:35:59to explain his continued deterioration,
0:35:59 > 0:36:02but Kian believes he may have found the answer.
0:36:02 > 0:36:06I'm going to bring Julian back round for a CTA. Are you guys ready?
0:36:06 > 0:36:10The only thing that could explain his symptoms
0:36:10 > 0:36:13were a carotid artery dissection.
0:36:13 > 0:36:16It's one of the most important vessels in your body,
0:36:16 > 0:36:19which carries oxygen to your brain,
0:36:19 > 0:36:23so anything that disrupts that is potentially fatal.
0:36:24 > 0:36:28We need to make sure that when he's fallen, when he's hit the ground,
0:36:28 > 0:36:30he's hyperextended his neck,
0:36:30 > 0:36:32we need to make sure that he's not dissected
0:36:32 > 0:36:35or torn one of the arteries which supplies his brain.
0:36:35 > 0:36:38That wouldn't show up initially on a CT scan.
0:36:40 > 0:36:45Kian sends Julian for a specialised scan called a CT angiogram.
0:36:46 > 0:36:49The one thing that's going through my mind at this stage is
0:36:49 > 0:36:54I need to get this scan fast and find out if this is the diagnosis
0:36:54 > 0:36:56and get the right people involved
0:36:56 > 0:36:58to give him the best chance of a potential recovery.
0:37:01 > 0:37:06There's nothing else that can explain the new acute weakness.
0:37:06 > 0:37:09OK, Julian, we're back in the scan room, OK?
0:37:09 > 0:37:11We're going to move you over again, OK?
0:37:11 > 0:37:14Let's have a look at your eyes, Julian, OK?
0:37:14 > 0:37:17Julian is having a dye injected into his arm.
0:37:17 > 0:37:20It will allow Kian to track the blood flow
0:37:20 > 0:37:21in the artery in his neck.
0:37:21 > 0:37:26Normally you would get the dye just flowing nicely through the vessels.
0:37:26 > 0:37:31With a dissection, you'll see some of that dye moving into places
0:37:31 > 0:37:35that it shouldn't go and, ultimately, if there's a clot there,
0:37:35 > 0:37:39you won't actually get dye advancing past where it should be going.
0:37:43 > 0:37:45Yeah. It's dissected.
0:37:45 > 0:37:50On Julian's CT, it showed that he had what I was suspecting.
0:37:50 > 0:37:52He had a dissection of his neck.
0:37:55 > 0:37:56Right, we'll get him back through.
0:37:56 > 0:38:01As soon as Julian had fallen off his bike and hyperextended his neck,
0:38:01 > 0:38:05he would have sustained that tear in his artery
0:38:05 > 0:38:09and, from that point, he would've had blood going into an area
0:38:09 > 0:38:12where it shouldn't have gone and the body would have been starting
0:38:12 > 0:38:14to form clots the whole time.
0:38:15 > 0:38:19It wasn't until actually parts of a clot started to shoot off
0:38:19 > 0:38:22and go up into his brain, until he would've actually started
0:38:22 > 0:38:25getting symptoms and signs of a stroke.
0:38:25 > 0:38:28Hi, can you put me through to the stroke consultant on call, please?
0:38:28 > 0:38:32Hi, sorry to bother you. My name's Kian, I'm on A&E at the RVI...
0:38:32 > 0:38:35Kian calls in a specialist stroke team.
0:38:35 > 0:38:37They'll try to break down the clots
0:38:37 > 0:38:40which are cutting off the blood supply to Julian's brain.
0:38:41 > 0:38:46'The fact that a big clot was formed in Julian's neck from a tear
0:38:46 > 0:38:47'is incredibly rare.'
0:38:49 > 0:38:52You're coming into the RVI just now? Right.
0:38:52 > 0:38:55You could see it as a bit of a ticking time bomb
0:38:55 > 0:38:58as to when he was actually going to develop symptoms of a stroke.
0:39:02 > 0:39:05- Yeah, we think you have. Yeah, yeah, you have. OK?- Yeah.- OK?
0:39:05 > 0:39:09We're going to try and give you some medication
0:39:09 > 0:39:13- to try and break down the clots that are causing the problem, OK?- OK.- OK?
0:39:13 > 0:39:15Oh, hey, it's just Kian.
0:39:15 > 0:39:19The stroke consultant's here. They're going to thrombolyse him.
0:39:19 > 0:39:21Doctors give Julian a powerful drug
0:39:21 > 0:39:24to break down the blood clots causing the stroke.
0:39:24 > 0:39:26But it is not without danger.
0:39:26 > 0:39:30Thrombolysis can be a risky procedure.
0:39:30 > 0:39:34It's essentially something that goes in to try to break down clots
0:39:34 > 0:39:36and, as a result of that,
0:39:36 > 0:39:41you can start spontaneously bleeding from anywhere in your body.
0:39:45 > 0:39:49With the extensive injuries to his face, Julian is at risk
0:39:49 > 0:39:53of bleeding into his airway and drowning in his own blood.
0:39:53 > 0:39:55At this point, it was really important to get
0:39:55 > 0:39:59the maxillofacial doctors back down to start putting in some stitches
0:39:59 > 0:40:01into his face to try and do some damage control
0:40:01 > 0:40:05on the potential bleeding that could happen from those wounds.
0:40:05 > 0:40:07If you open as wide as you can for me.
0:40:07 > 0:40:09Even bigger than that.
0:40:09 > 0:40:12Kian must now wait to see how Julian responds.
0:40:12 > 0:40:17Julian, at this stage, was showing signs of quite an extensive stroke.
0:40:18 > 0:40:21This is something that he could potentially die from.
0:40:37 > 0:40:40It's the morning after Julian came off his bike,
0:40:40 > 0:40:43smashing his face into a cattle grid.
0:40:44 > 0:40:49A blood clot in his neck has caused a major stroke in Julian's brain
0:40:49 > 0:40:52so he's been given a powerful drug to try and break it down.
0:40:54 > 0:40:56At the intensive care unit that he's been moved to,
0:40:56 > 0:40:59consultant anaesthetist Hugh McConnell
0:40:59 > 0:41:03and registrar Tom Keans are checking to see if it's worked.
0:41:03 > 0:41:05Morning, Julian. It's Dr McConnell here.
0:41:05 > 0:41:09- I saw you downstairs last night in casualty.- Yeah.
0:41:09 > 0:41:12How are things...? How are things going?
0:41:12 > 0:41:16'When I saw him on the round that morning, I could tell that he was
0:41:16 > 0:41:19'still very weak down the left-hand side of his body'
0:41:19 > 0:41:24and was concerned that the stroke deficit hadn't improved particularly
0:41:24 > 0:41:25with the clot-busting drug.
0:41:25 > 0:41:29Can I get you to hold your arms out in front of you?
0:41:29 > 0:41:31Can you keep that there? OK.
0:41:31 > 0:41:33Can you put your palms to the ceiling?
0:41:33 > 0:41:35And what about that one?
0:41:35 > 0:41:39Can you squeeze my hand at all, Julian, with this side? OK.
0:41:41 > 0:41:45Do you understand what's happening at the moment? Yeah? OK.
0:41:45 > 0:41:50You've injured one of the blood vessels in your neck
0:41:50 > 0:41:52and that's caused a stroke.
0:41:54 > 0:41:56'At that time, an area of that brain will have been starved
0:41:56 > 0:42:00'of oxygen and nutrients that it requires, and when that happens,'
0:42:00 > 0:42:03those cells begin to die or swell.
0:42:07 > 0:42:09Can I get you to open your eyes for me, Julian?
0:42:09 > 0:42:11'The key problem with brain swelling
0:42:11 > 0:42:14'is that the swelling is occurring in a rigid box -
0:42:14 > 0:42:18'the skull - and if you get a lot of swelling within the skull,
0:42:18 > 0:42:20'the pressure goes up'
0:42:20 > 0:42:23and it pushes over the vital structures
0:42:23 > 0:42:25that exist within the brain
0:42:25 > 0:42:29and that can cause catastrophic and irreversible damage
0:42:29 > 0:42:33to the previously healthy brain tissue
0:42:33 > 0:42:35that's not affected by the initial injury.
0:42:35 > 0:42:39As Julian's brain expands, and with no room to move,
0:42:39 > 0:42:42it will begin to push onto his cranial nerves,
0:42:42 > 0:42:45which control his breathing and his heart.
0:42:46 > 0:42:50We look for signs of these cranial nerves becoming compromised,
0:42:50 > 0:42:53and one of the most easy to identify
0:42:53 > 0:42:57is the pressure effect or traction effect on the third cranial nerve,
0:42:57 > 0:43:02which typically causes inability to open the eyelid
0:43:02 > 0:43:04and dilation of the pupil.
0:43:06 > 0:43:08I'm just going to shine a torch in your eyes there.
0:43:08 > 0:43:13The key change was undoubtedly when Julian's pupil reactions changed.
0:43:13 > 0:43:18'That is a very black and white transition that he went through.'
0:43:20 > 0:43:22And, in this setting,
0:43:22 > 0:43:25a dilated pupil always means
0:43:25 > 0:43:27'very high pressure in the skull
0:43:27 > 0:43:30'and so that prompted me to get another scan.'
0:43:30 > 0:43:31OK.
0:43:40 > 0:43:45- Bless him. He's not had the easiest of rides, has he?- He's not, no.
0:43:48 > 0:43:50There's a concept known as coning, which is where
0:43:50 > 0:43:53the brain swells and swells and has got nowhere else to go
0:43:53 > 0:43:56so pressure goes down toward the brainstem,
0:43:56 > 0:43:58which is the most important part of the brain,
0:43:58 > 0:44:02relating to you being aware and conscious and breathing.
0:44:02 > 0:44:04So, if you press enough on that,
0:44:04 > 0:44:06then ultimately the patient will die.
0:44:08 > 0:44:10The dark shading on Julian's scan
0:44:10 > 0:44:14confirms the swelling to his brain has reached a critical level.
0:44:16 > 0:44:18- We're going to theatre one.- Yes.
0:44:18 > 0:44:22There's a very, very fine line between a brain that's just managing
0:44:22 > 0:44:24and one that doesn't manage at all
0:44:24 > 0:44:26and he's fallen off a precipice, really,
0:44:26 > 0:44:31in terms of his brain's ability to manage what was going on up there.
0:44:31 > 0:44:33Time is absolutely critical here.
0:44:33 > 0:44:36We need to reduce the pressure in his skull.
0:44:36 > 0:44:40- I mean, I'm ready to go.- I'll go and get somebody to come and collect.
0:44:40 > 0:44:42To reduce the pressure,
0:44:42 > 0:44:46the only option left is an emergency operation called a craniectomy.
0:44:48 > 0:44:51Decompressive craniectomy is actually as simple as removing
0:44:51 > 0:44:52a fairly large plate of bone,
0:44:52 > 0:44:56which allows the injured brain to swell out the way
0:44:56 > 0:45:00rather than pushing in on the healthy areas of brains.
0:45:01 > 0:45:04The operation won't reverse the stroke,
0:45:04 > 0:45:07but it might stop further damage to Julian's brain,
0:45:07 > 0:45:09and it may save his life.
0:45:18 > 0:45:22In London, just 24 hours after his cardiac arrest,
0:45:22 > 0:45:25police officer David is also in theatre,
0:45:25 > 0:45:28having urgent heart surgery.
0:45:28 > 0:45:31Consultant cardiothoracic surgeon Wael Awad
0:45:31 > 0:45:36is about to tackle the dangerous blockage in David's coronary artery.
0:45:36 > 0:45:39What we have to do is restore the blood flow
0:45:39 > 0:45:43to that area of the heart, which is in jeopardy
0:45:43 > 0:45:47and to do that, we have to bypass blood beyond the blockage.
0:45:48 > 0:45:49OK, starting.
0:45:54 > 0:45:58Wael needs to take an artery from David's chest wall and sew it past
0:45:58 > 0:46:03the blockage, creating a new path for blood to feed his heart muscle.
0:46:03 > 0:46:05- Table up, please.- Table up?
0:46:08 > 0:46:12But, as the operation begins, David's heart suddenly deteriorates.
0:46:12 > 0:46:16'His blood pressure dropped, his heart is beginning to struggle'
0:46:16 > 0:46:20by the added stress of the general anaesthetic
0:46:20 > 0:46:22and the opening of the chest.
0:46:22 > 0:46:25- Full dose?- Yeah.
0:46:25 > 0:46:30At this point, I decided to do the operation by stopping the heart.
0:46:32 > 0:46:36- Yeah, we will be going on bypass, please.- OK.
0:46:36 > 0:46:39Pericardium coming up.
0:46:39 > 0:46:41The team connect David's heart vessels
0:46:41 > 0:46:44to a cardiopulmonary bypass pump...
0:46:44 > 0:46:46Give one litre of cardioplegia, please.
0:46:46 > 0:46:50..which will circulate oxygenated blood around his body.
0:46:52 > 0:46:54Happy?
0:46:54 > 0:46:55Yes?
0:46:56 > 0:47:00Now Wael can begin work on David's blocked artery.
0:47:03 > 0:47:05This is delicate surgery.
0:47:05 > 0:47:08The arteries are very small
0:47:08 > 0:47:12and I think that one does have to be a good technician
0:47:12 > 0:47:14to be able to do this well.
0:47:14 > 0:47:18We're harvesting an artery from the inside of the chest wall
0:47:18 > 0:47:21and stitching that to his coronary artery.
0:47:23 > 0:47:25The arteries Wael needs to stitch together
0:47:25 > 0:47:27are just two millimetres wide.
0:47:28 > 0:47:31It's looking quite good at the moment.
0:47:32 > 0:47:34Once the stitching is complete,
0:47:34 > 0:47:37Wael needs to take David off the heart-lung machine
0:47:37 > 0:47:40and get his heart beating again.
0:47:40 > 0:47:41Ventilate, please.
0:47:41 > 0:47:43Ventilating normally?
0:47:43 > 0:47:45- Yes, good ventilation. - Potassium and gases normal?
0:47:45 > 0:47:48- Yep.- Off bypass, please.
0:47:50 > 0:47:53As soon as the blood flow to the heart is restored,
0:47:53 > 0:47:56the heart should work on its own.
0:47:56 > 0:47:57Yeah, it's working now.
0:47:59 > 0:48:03'We see that the heart, first of all, is beating spontaneously'
0:48:03 > 0:48:07and the ECG is normal and the blood pressure is stable.
0:48:09 > 0:48:11In that corner, please.
0:48:11 > 0:48:13The team will now monitor David closely
0:48:13 > 0:48:16as he recovers in intensive care.
0:48:26 > 0:48:30In Newcastle, doctors have one last chance to save Julian's life.
0:48:30 > 0:48:32Ready, steady, slide.
0:48:34 > 0:48:35OK. OK, right shoulder.
0:48:35 > 0:48:38Specialist neurosurgeon Shuaibu Dambatta
0:48:38 > 0:48:41is about to remove a large section of Julian's skull
0:48:41 > 0:48:43to ease the pressure on his brain.
0:48:43 > 0:48:46This is Julian's scan of his brain.
0:48:46 > 0:48:49This part of the brain is darker
0:48:49 > 0:48:52and this is the part that has had the stroke.
0:48:52 > 0:48:55This area there is supposed to be right in the middle,
0:48:55 > 0:48:57so this line should be going through here,
0:48:57 > 0:49:00and you can see that the middle of his brain has been shifted
0:49:00 > 0:49:02by about more than a centimetre to the other side
0:49:02 > 0:49:04and so the operation we're planning to do
0:49:04 > 0:49:09is going to be taking this bone out as much as possible, so that,
0:49:09 > 0:49:12instead of this brain swelling to push the normal brain
0:49:12 > 0:49:15and causes more damage on the side that doesn't have the stroke,
0:49:15 > 0:49:18it can now push upward and swell upward because there's no bone there
0:49:18 > 0:49:21so the skin is softer and it can just distend it.
0:49:24 > 0:49:27First, Shuaibu marks out where he's going to cut.
0:49:29 > 0:49:32A centimetre too far could cause catastrophic bleeding.
0:49:32 > 0:49:37There are certain areas within the skull or just underneath the skull
0:49:37 > 0:49:39where you have big blood vessels within the brain
0:49:39 > 0:49:43and we have to make sure that we don't damage those areas.
0:49:43 > 0:49:47It's a balance between trying to take as much bone as possible
0:49:47 > 0:49:51and also knowing the limit of how far you can go.
0:49:53 > 0:49:55OK, everyone nearly there?
0:49:55 > 0:49:57- Yes.- Happy starting?
0:49:57 > 0:49:58OK.
0:49:58 > 0:50:00Every minute the swelling continues,
0:50:00 > 0:50:04it risks damaging the unaffected areas of Julian's brain,
0:50:04 > 0:50:06so Shuaibu needs to act quickly.
0:50:13 > 0:50:16It's difficult to say exactly how much time we've got because,
0:50:16 > 0:50:20if those brain cells are not dead but they've been stunned,
0:50:20 > 0:50:22as in shocked...
0:50:23 > 0:50:26..if you act quickly enough, you might be able to revive them
0:50:26 > 0:50:31but, really, time is of the essence and every minute counts.
0:50:31 > 0:50:35OK, so I'll make another hole.
0:50:35 > 0:50:39Painstakingly, Shuaibu cuts around the section of the skull
0:50:39 > 0:50:40that needs to be removed.
0:50:42 > 0:50:43OK.
0:50:51 > 0:50:55So the recommendation is to take about 13 by 6 millimetres,
0:50:55 > 0:51:00minimum, and we've got about at least 16 centimetres here.
0:51:00 > 0:51:03'It's probably the most amount of skull I've had to take
0:51:03 > 0:51:06'in doing this type of operation.'
0:51:06 > 0:51:08We've got about...
0:51:08 > 0:51:1211.5 centimetres across, here.
0:51:12 > 0:51:18I can tell that Julian's brain is damaged by its appearance,
0:51:18 > 0:51:20because it didn't look normal.
0:51:20 > 0:51:23However, even though it looked damaged,
0:51:23 > 0:51:27I can't tell if there's still a part of that brain
0:51:27 > 0:51:31or there are some cells within that brain that are still alive.
0:51:31 > 0:51:36And my aim, really, is to provide Julian's brain,
0:51:36 > 0:51:40even though it looked dead, with all the support it needs,
0:51:40 > 0:51:42as if it were alive
0:51:42 > 0:51:45in the hope that there might be a part of that brain
0:51:45 > 0:51:47which may survive
0:51:47 > 0:51:53and that part may have some use to Julian in the future.
0:51:55 > 0:51:57INDISTINCT
0:51:57 > 0:51:59..and come back next time.
0:52:00 > 0:52:05Without the skull to protect it, Julian's brain is open to infection.
0:52:05 > 0:52:09Shuaibu uses a special collagen membrane to cover it.
0:52:10 > 0:52:13OK. Let's get ready to start closing, please.
0:52:13 > 0:52:17Now the skin will be closed up without the skull underneath.
0:52:17 > 0:52:21Get an artery, please. Let me just have an artery.
0:52:21 > 0:52:22I think that is all.
0:52:22 > 0:52:24We've written on that, "No bone flap."
0:52:24 > 0:52:28That means that the nurses and whoever is looking after him
0:52:28 > 0:52:31know that he hasn't got a bone there and directly under his skin
0:52:31 > 0:52:33is his brain, so that means you don't press it
0:52:33 > 0:52:35and, if they lie on that side,
0:52:35 > 0:52:36they don't lie directly on the brain,
0:52:36 > 0:52:39so that's why we've put that sign there.
0:52:46 > 0:52:49A scan shows how much Julian's brain has swelled
0:52:49 > 0:52:52beyond the confines of his skull.
0:52:52 > 0:52:55Shuaibu's operation has done its job.
0:52:55 > 0:52:58We haven't allowed the pressure inside his head
0:52:58 > 0:53:02to raise to a level where it had caused him to lose his life.
0:53:02 > 0:53:04On the longer term,
0:53:04 > 0:53:08he will need another operation to reconstruct that skull
0:53:08 > 0:53:14and that also carries its own risk, which is why we have to balance
0:53:14 > 0:53:17the risk of having the operation
0:53:17 > 0:53:21against the risk of not doing anything at all.
0:53:24 > 0:53:26Julian will stay in intensive care
0:53:26 > 0:53:30and be kept unconscious until the swelling of his brain has stopped.
0:53:30 > 0:53:33Only time will tell what recovery he'll make.
0:53:48 > 0:53:50You don't believe it's happened.
0:53:50 > 0:53:53You hear of people who don't come round from that,
0:53:53 > 0:53:54don't come back from that.
0:54:00 > 0:54:01I think, for David,
0:54:01 > 0:54:03the most significant thing that saved his life
0:54:03 > 0:54:05was that he was in the presence of his colleagues
0:54:05 > 0:54:08who recognised he was in cardiac arrest
0:54:08 > 0:54:11and they did immediate chest compressions and phoned 999.
0:54:15 > 0:54:18I look at my life. Obviously, I've got my second chance.
0:54:20 > 0:54:23At the moment, I'm actually doing
0:54:23 > 0:54:26a minimum of 30 minutes' walk a day, five days a week.
0:54:30 > 0:54:35Once a week, I'm going up to the cardio rehab at the hospital.
0:54:35 > 0:54:37No pain or anything. Hardly out of breath.
0:54:39 > 0:54:42I feel I can achieve anything, I can do anything.
0:54:42 > 0:54:45You know, it's... I possibly can't
0:54:45 > 0:54:51but up here I'm thinking, "Yep, it's given me a new lease of life."
0:54:52 > 0:54:56It could have been such a totally different story that day.
0:54:56 > 0:54:59He was able to receive the treatment that he did so quickly.
0:54:59 > 0:55:02A split second and it'd be a different story.
0:55:04 > 0:55:06'He was a very lucky man.'
0:55:06 > 0:55:08- THEY LAUGH - It looks like a mole.
0:55:27 > 0:55:31One thing that I had to learn after the collision,
0:55:31 > 0:55:36after the accident, was actually just the sheer power of time
0:55:36 > 0:55:39in terms of how your body recovers
0:55:39 > 0:55:42and what it will do in that recovery period.
0:55:47 > 0:55:50If the Ambulance Service had got to him two or three minutes later,
0:55:50 > 0:55:52pulled him out and done exactly the same thing,
0:55:52 > 0:55:55his brain would have been hypoxic for two or three more minutes
0:55:55 > 0:55:57and his outcome would have been very different.
0:55:59 > 0:56:01It's almost overwhelming...
0:56:03 > 0:56:08..and I consider myself to be lucky in how I got away with things.
0:56:14 > 0:56:18The effect of the stroke in Julian's case
0:56:18 > 0:56:22is, because it's the right side of his brain that is affected,
0:56:22 > 0:56:25he's got a weakness on the left side of his body.
0:56:25 > 0:56:30It is challenging and frustrating that you cannot say to Julian that,
0:56:30 > 0:56:34"Two years down the line, you might be able to lift your arm again."
0:56:34 > 0:56:38But, at the same time, you don't lose hope.
0:56:44 > 0:56:48I'm absolutely amazed by, when you're fit and well and able-bodied,
0:56:48 > 0:56:49how much you take for granted.
0:56:49 > 0:56:53You don't assume that standing is going to be particularly difficult.
0:56:53 > 0:56:57The first time I could stand, it felt like a great achievement.
0:56:59 > 0:57:01Lovely. Well done.
0:57:01 > 0:57:05Julian's incredibly strong and very, very determined.
0:57:05 > 0:57:08He's got a very good positive mental attitude.
0:57:08 > 0:57:09Good, Julian. Well done.
0:57:09 > 0:57:12One of the goals I've set is I want to be able to walk
0:57:12 > 0:57:14before I leave here.
0:57:15 > 0:57:19That's something we've been working on in physiotherapy today -
0:57:19 > 0:57:20standing and taking a step.
0:57:31 > 0:57:33Where my head's...
0:57:33 > 0:57:36Where there's no skull, there's very little protection,
0:57:36 > 0:57:37so I run the risk,
0:57:37 > 0:57:42if I banged my head again, it could be very, very serious
0:57:42 > 0:57:43cos I've got no bone.
0:57:45 > 0:57:50Ultimately, Julian will need to come back and have a plate put back on
0:57:50 > 0:57:55and that operation itself isn't without some degree of risk.
0:57:56 > 0:57:59Obviously, it's been a very difficult time for my family,
0:57:59 > 0:58:03but I'm of the opinion that far worse things happen to other people.
0:58:05 > 0:58:07Next time, we follow three more patients
0:58:07 > 0:58:10through the crucial first hour of care.
0:58:10 > 0:58:13In Bristol, a woman suffers a life-threatening brain injury
0:58:13 > 0:58:15after being hit by a car...
0:58:15 > 0:58:18She's got a big lump to the left side of her head.
0:58:18 > 0:58:20Just get her on the ambulance then and go from there.
0:58:20 > 0:58:24..in Gloucester, a man has his legs crushed by a forklift truck...
0:58:24 > 0:58:27- Which bit of you is hurting? - All of me.- All of you.
0:58:27 > 0:58:29..and, in central London,
0:58:29 > 0:58:33a collision leaves a young woman with a severe head injury.
0:58:33 > 0:58:35So you give her nasal oxygen.