Episode 1 An Hour To Save Your Life


Episode 1

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Transcript


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This programme contains scenes which some viewers may find disturbing.

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From the moment an emergency call is made,

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a clock starts ticking.

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Female lying on the road struggling to breathe.

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The golden hour is the opportunity that we have

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to save the patient.

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Deep breaths, George.

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'The longer the clock ticks,'

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the increased likelihood there is of death.

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In the fight for survival, time is the enemy.

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I'm ventilating fast on purpose.

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-Yes.

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

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Now, new techniques and technology

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are bringing emergency medicine to the roadside...

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We can use the infrascanner to maybe give us a slightly clearer picture

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of what's going on underneath the skull.

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..breaking new ground

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and treating patients faster than ever before.

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We can now provide emergency surgery,

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blood transfusions, anaesthesia at the scene of the accident.

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Yes, the cord. Tube, please.

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Tube on.

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

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In London, a man is run over by a lorry.

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This is going to be an RSI

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and road to the Royal London.

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A policeman has a cardiac arrest in the gym.

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-Ah.

-I've just giving you some medicine

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that's probably going to help with the chest pain.

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And in the Pennine hills,

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a cyclist is seriously injured after a fall.

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You OK?

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60 minutes that will change their lives forever.

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You will constantly be surprised

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

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In London, ambulance control

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have just received an emergency call

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about a moped rider

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run over by a bin lorry.

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Emergency ambulance,

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what's the address of the emergency?

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Just south of Blackfriars Bridge.

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A bin lorry drove over a guy.

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Do you know whether

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the patient's awake?

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I suspect they're dead -

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I have no idea.

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London's air-ambulance doctor Will Glazebrook

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and paramedic Colin Smith

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have been dispatched to the scene.

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The first that we heard was he was underneath a very heavy lorry

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and trapped by his head and neck area.

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We obviously have great concerns

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about a concurrent head injury and neck injury.

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Anything versus a bin lorry,

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anything tends to come off worse than the bin lorry.

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You're normally be expecting to see quite extensive injuries,

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quite serious injuries.

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London ambulance paramedic Richard Kingham

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was first responder at the scene.

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He's administered oxygen to moped rider Martin.

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I was met by a number of policeman

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who told me he was dead.

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-'He looked dead.'

-Are you going to hold the head?

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His heart wasn't beating.

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'Immediately, I'm thinking, he's broken his neck.'

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So we need to get his helmet off soon as.

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He was very blue, and clearly wasn't getting any oxygen to his brain.

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So we began the resuscitation process.

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The oxygen has enabled Martin to breathe again

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and his heart is now beating.

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Nice pulse there.

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Will must now establish the severity of his injuries.

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The front wheel of the lorry was actually here. On this side.

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OK.

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He's obviously got some bruising here.

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He's got a decent jacket on.

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Due to the mechanism of injury that Martin had,

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being underneath the lorry at a funny angle

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with the tyre on his neck,

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we're obviously worried about a spinal injury,

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'and we quickly established

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'that Martin hadn't moved either his arms or his legs since the injury.'

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Has anybody looked...? Did you look at his pupils?

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Yeah, they were...

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They were quite large and fixed.

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About size seven.

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I had great concerns that he was suffering from a head injury.

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There would have been a period of time

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when he would not have had oxygenated blood going to his brain.

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A lack of oxygen to the brain can lead to brain damage.

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Do you want to do that? We'll put a line there.

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We're going to put him through this.

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It was just going to be a roc only, but we'll RSI him,

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so if we could just set up over there.

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I felt that the most important thing for us to do

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would be to secure his airway,

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to ensure we can give him oxygen.

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To do this, Will and the team need to anaesthetise Martin,

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which will allow them to insert a tube into his windpipe

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and take over his breathing.

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Good to go. We're going to give this gentleman anaesthetic.

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We're going to put him to sleep. First, we're going to run through a checklist

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to make sure that's a safe thing for us to do.

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You're going to hold the head, you can bag. Yeah?

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So we're going to roll, just only about 10 degrees this way.

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OK, on three. One, two...

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He still had a chance of arresting again,

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he still had a chance of not surviving this injury,

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and my thoughts at that time

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certainly were that the injuries that he did sustain

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would be life-changing.

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14 minutes ago, across London,

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ambulance control were alerted

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to another medical emergency.

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In the heart of the city,

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a police officer has collapsed at the gym

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whilst undergoing a fitness test.

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Control, G460.

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G460, we've got a 55-year-old male

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with cardiac arrest.

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An emergency medical car

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carrying London's air-ambulance consultant Anne Weaver

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and paramedic Bill Leaning

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is sent to the scene,

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where the man's colleagues have begun CPR.

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Control - G460, that's all received.

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Check, check.

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The number of people who survive

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an out-of-hospital cardiac arrest is less than 10%.

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You need to get there quickly, because time is of the essence

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with any cardiac arrest. Time is life.

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Watch heads.

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At the scene, London Ambulance paramedics

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are already treating David.

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Can you just tell me what you know?

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Yeah. Police officer doing a fitness test. Collapsed.

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-Yeah.

-Was given two shocks prior to our arrival.

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Is he breathing on his own?

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He's breathing on his own. Yeah.

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David was technically dead during the cardiac arrest.

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His heart was not beating,

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he was having external chest compressions

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to provide some blood flow to his heart and his brain.

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David's colleagues have managed to restart his heart

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with CPR and a defibrillator.

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-DAVID GASPS

-Ooh, hello! All right?

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Hello, sweetheart. Just take it off, just take it off a minute.

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Hello, sweetheart. What's his first name? David.

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-Hello.

-DAVID SIGHS

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All right, sweetheart.

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It's OK, you're in the gym, I'm a doctor.

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You've got some very good people here who've looked after you, OK?

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-Yeah.

-Well done. OK.

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You're doing really well.

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I'm just going to pop a little oxygen mask on your face, OK?

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-Yeah.

-But you're doing really well.

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Can you take a big deep breath for me?

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That's brilliant, well done, absolutely brilliant.

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'So David's breathing isn't quite normal at the moment.'

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It's a little bit slow,

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it's quite deep and laboured.

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I'm not entirely sure how much oxygen he's getting.

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All right. Are you OK there?

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You're doing fine. Can we pop something under his head?

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Have we got anything soft?

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If your brain is starved of oxygen,

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that can have a devastating effect

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and, even if we restart the heart, the brain may never recover.

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So, sats 99, heart rate 105.

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-Let's get that 12-lead.

-Let's get a 12-lead.

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David's heart could stop again.

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Anne decides to run an electrocardiogram, or ECG,

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to understand what is happening in his heart.

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Yeah, fine. OK.

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So, BP of 108/70.

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Heart rate of 93.

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12-lead just coming.

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Heart rate, good.

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He's got quite marked ST depression, naturally.

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-Yeah.

-So he's probably got a posterior.

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-Yeah.

-OK, all right, we've got enough to go on there.

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-But, erm...

-Bart's.

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Yeah.

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'I'm looking at David's ECG'

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and I can see changes, which suggest to me

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that he has a blocked coronary artery in his heart.

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The heart muscle is still ischaemic,

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which means it's still not getting enough oxygen.

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If the muscle doesn't have oxygen restored quickly,

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that heart muscle will start to die.

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He could go back into cardiac arrest.

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He might.

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There's a limited amount we can do on scene.

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We can treat his symptoms,

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but I can't unblock that coronary artery here

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and more heart muscle is dying whilst we are waiting.

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We want to get you to hospital as quick as we can.

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So, in a minute, we're going to help pick you up.

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If you're sick, don't worry, OK? I can give you something to stop you feeling sick.

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But it's part of what's happened, OK?

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We're going to get you on the trolley and in an ambulance.

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All right? I know you don't feel well at all.

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OK? We're going to look after you, I promise you, OK?

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-David?

-Oh...

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-Have you got a chest pain?

-Yeah.

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'David's clutching his chest and is in significant pain.'

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His heart is beating, but from the ECG changes

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and looking at David, he's got chest pain.

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He is having a heart attack in front of us.

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200 miles away,

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North East ambulance control

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have taken a call

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about a cycling accident

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in the remote North Pennine hills.

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He's come off his cycle

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and part of his mouth's all hanging out.

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I just need to check first

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that the patient's fully breathing?

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He is breathing,

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but he's bleeding very badly.

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Has there been a heavy blood loss?

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He's bleeding very badly

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at the moment, yes.

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In freezing conditions,

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the Great Northern Air Ambulance

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is carrying Doctor Dion Arbid and paramedic Andy Mawson

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to the scene of the accident.

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I've been told that

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there's a gentleman come off a pedal cycle

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up in the hills in the snow

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and it sounds like he's got a really nasty facial injury.

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I'm thinking that he could well have

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a significant head injury, and that's our biggest worry.

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After coming off the bike,

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the cyclist managed to ride another three miles to a local pub.

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Thanks very much.

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Hello, mate. What's your name, buddy?

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Julian.

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Julian? OK.

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'A lot of the time, you can have a good guess at what people have done,

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'depending on what the description of the incident is.

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'But you can never take anything for granted.'

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Do you take medicines for anything? Are you allergic to anything?

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-Have you hurt yourself anywhere else apart from your face?

-My hand.

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Your hand?

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'Julian doesn't know how bad his face looks.

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'He had a very nasty cut'

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to his lower lip, which extended down onto his jaw.

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Have you lost any teeth, Julian?

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-Yeah.

-Haven't swallowed any or anything like that,

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-you don't think?

-No.

-OK.

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As well as his facial wounds,

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Dion is worried Julian may have other serious injuries.

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Sit forward a tiny bit for us.

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Good man. Any pain lower down your neck there?

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Nothing at all? Deep breaths in now.

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And out.

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'From the impact itself,

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'he could well have torn vessels'

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inside his head, inside his brain, and caused bleeding.

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-Good man. Have you got any morphine? Do you carry morphine?

-Yes.

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Give me some morphine, if you can draw that up, ready for us.

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-Cheers.

-Yeah, no worries.

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Dion and the team need to prepare Julian

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for the helicopter ride to hospital for a more detailed examination.

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OK, we'll just give you some of this painkiller.

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This might make you feel a tiny bit woozy, OK?

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'We still have to remain vigilant on the ride in.'

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'Things can change very, very quickly.'

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Pop these on you. It'll be cold, I'm afraid.

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If you've got any problems, just wave at me.

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Right, start number one.

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Concerned that there may be injuries he can't see,

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Dion rushes Julian to the nearest major trauma centre in Newcastle,

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a journey of just 15 minutes by helicopter.

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We're looking for, predominantly,

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a change in his level of consciousness,

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whether he becomes drowsy, whether any of his neurology changes,

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if he's bleeding internally, his pulse rate goes up -

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all these things we'll keep an eye on, on the flight.

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You can never take for granted that nothing's going to change.

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Unexpected things do happen,

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and we just have to deal with them as and when.

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In central London,

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moped rider Martin

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is about to be anaesthetised

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after being run over by a bin lorry

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and suffering multiple injuries.

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Yeah, just a scene update.

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This is going to be an RSI and road to the Royal London.

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'Message received.'

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We obviously have great concerns

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about a concurrent head injury and neck injury.

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Checklist. Happy, Colin?

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Will is worried the injuries may be restricting the supply of oxygen

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to Martin's brain.

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He's got equal pupils...

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He decides to perform a critical procedure called an RSI.

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So, oxygen mask on tight.

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All oxygen cylinders are greater than half-full.

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515...

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An RSI is a rapid sequence induction of anaesthesia.

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It is the giving of an anaesthetic drug

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and a paralytic agent.

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It's not a procedure that we take lightly.

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Once you give your drugs and you've paralysed a patient,

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you are on a road to ensure that you take over their breathing.

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So we do 200 of fentanyl.

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-4ml.

-4ml, yeah.

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Ketamine, do 150.

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150, check.

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And the roc,

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we're going to give 70mg.

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-7ml?

-7ml.

-OK.

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So, guys, just a little bit of concentration now.

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This chap's going to go even further asleep than he was.

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It takes about 45 seconds

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for him to stop breathing

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and become 100% paralysed.

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Can somebody just give me the time? The roc is in that...

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-Time is 34.

-34. Thank you.

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'Once you stop a patient breathing,

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'you've got a very short period of time'

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to get a breathing tube down their throat

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and start delivering oxygen to them.

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Can I have the suction, please?

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So, I can't see very much at the moment.

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There's a lot of blood.

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OK, I can see the cords, the cords are apart.

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It's a grade-two view.

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I can see...

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yeah, it going through the cords.

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-So add the tube over.

-Tube over.

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Just have a listen to the chest again for me.

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Sats are 98. Good BP.

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I want you to just hold that tube there.

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Just hold that there. Don't let it move.

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Right, OK, we're going to go by land to the Royal London,

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if you don't know already.

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With the tube in place, vital oxygen is now being delivered

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to Martin's heart and brain.

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But until he reaches hospital for scans,

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there's no way of knowing

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what kind of injuries he's suffered to his head and neck.

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There's still a lot that can go wrong.

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There'll still be repercussions

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from the period where he's been in cardiac arrest.

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So we're going to start moving that way.

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There's potential secondary brain damage

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where his brain's been starved of oxygen,

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and they all need to be addressed.

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SIREN WAILS

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In central London,

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police officer David

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is in the grip of

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an ongoing heart attack.

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Have we got a... Let's just keep the oxygen near him.

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We'll blue this in as post-cardiac arrest with ongoing chest pain.

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Yeah.

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He has a blocked coronary artery.

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I think the blockage

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is a significant obstruction to blood flow

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and, hence, to oxygen to the muscle.

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That's a heart attack.

0:17:270:17:29

Oh...

0:17:290:17:30

He's still got this crushing chest pain,

0:17:310:17:34

because his heart is still struggling to work.

0:17:340:17:36

Whatever's caused his cardiac arrest -

0:17:360:17:39

and we believed it was a blocked artery -

0:17:390:17:41

that is still blocked, we haven't cleared that.

0:17:410:17:43

-Can we get our medical drugs pack now?

-Got it.

0:17:430:17:45

-What would you like?

-Get some GTN.

-GTN it is.

0:17:450:17:48

Yeah, thanks.

0:17:480:17:49

-Oh...

-OK.

0:17:490:17:50

-GTN.

-Right, we're going to give you a little spray under your tongue.

0:17:500:17:54

-Oh, I feel sick.

-OK.

0:17:540:17:55

Don't worry. If you're sick, it's fine - there's a bag here.

0:17:550:17:58

-Good man.

-Aah!

0:17:580:17:59

Good. I've given David a spray under his tongue, it's called GTN,

0:17:590:18:03

or glyceryl trinitrate.

0:18:030:18:05

This is a drug which opens up blood vessels,

0:18:050:18:08

and I'm doing that to try and improve

0:18:080:18:10

the blood flow through his coronary arteries.

0:18:100:18:12

Are you sure?

0:18:120:18:14

If everyone's ready - ready, brace, lift.

0:18:140:18:16

DAVID GROANS

0:18:160:18:18

The drugs will reduce David's pain

0:18:180:18:20

and increase the oxygen to his heart.

0:18:200:18:22

Then the team will take him to hospital.

0:18:220:18:25

Oh! Oh, headache.

0:18:250:18:27

I've just given you some medicine

0:18:270:18:29

that's probably going to help with the chest pain

0:18:290:18:31

-that does give you a bit of a headache, OK?

-Oh!

0:18:310:18:34

Can you just turn your arm out?

0:18:340:18:36

OK. Just turn your arm out for me.

0:18:360:18:38

Anne injects David with morphine to help further reduce his pain.

0:18:380:18:41

Got a headache.

0:18:410:18:43

Yeah, I've just given you something to try and take that away

0:18:430:18:45

and to get rid of your chest pain, OK?

0:18:450:18:48

Cor, flippin' heck!

0:18:480:18:49

I think if you do this job and you don't reflect on your patients,

0:18:510:18:54

there's something a bit wrong with you.

0:18:540:18:57

That patient is someone's father, someone's mother,

0:18:580:19:01

someone's sister, someone's brother.

0:19:010:19:02

It's nothing that can ever be taken lightly.

0:19:040:19:07

OK. I need to just put a little bit of oxygen on your face, OK?

0:19:070:19:10

I know you feel sick, we can take it off quickly,

0:19:100:19:13

but this may help, OK.

0:19:130:19:14

-Oh!

-All right.

0:19:140:19:16

With his heart attack continuing,

0:19:160:19:19

David will be monitored closely, en route to a specialist heart centre.

0:19:190:19:23

In Northumberland,

0:19:280:19:30

cyclist Julian is arriving

0:19:300:19:31

at Newcastle's Major Trauma Centre.

0:19:310:19:33

Emergency doctor Kian Dastoori

0:19:380:19:40

is preparing to receive him.

0:19:400:19:42

His face went into a cattle-grid, apparently.

0:19:440:19:47

Julian, 45, fit and well, no medicines, no allergies.

0:19:510:19:54

Off a pedal bike, face into a cattle-grid.

0:19:540:19:57

And it's done some quite considerable soft-tissue damage

0:19:570:20:00

to his lower lip,

0:20:000:20:02

his dentition on that bottom

0:20:020:20:04

and query fractured mandible as well.

0:20:040:20:05

Right, Julian. Are you all right to be called Julian?

0:20:050:20:08

Yeah, my name's Kian, OK? I'm one of the doctors.

0:20:080:20:11

'On the first seeing Julian come through the resus doors,'

0:20:110:20:14

I could see that he was alert, looking around.

0:20:140:20:17

Right, have you got any blood going down the back of your throat?

0:20:170:20:21

-No.

-No. And you've got no neck pain at all, Julian?

0:20:210:20:23

-No.

-No.

0:20:230:20:24

'But you always have to keep your guard up.'

0:20:240:20:27

He's lost his lower dentition off his palate,

0:20:270:20:30

he's stripped all his mucosa all off his mandible

0:20:300:20:33

and he's got lacerations down both sides,

0:20:330:20:36

so the bottom of his mouth's flapping.

0:20:360:20:38

-Knocked any teeth out?

-Yeah.

0:20:380:20:40

You have knocked some teeth out, yeah?

0:20:400:20:42

-No.

-No tenderness up here?

0:20:420:20:45

Right.

0:20:450:20:46

OK. Fine. So it seems to be mainly isolated to the face.

0:20:460:20:49

He's torn his frenulum on his tongue,

0:20:490:20:51

and he's got a deep laceration to the left side of his lip.

0:20:510:20:54

So we'll get an X-ray of his jaw and we'll go from there.

0:20:540:20:58

Oh, hey, Claire, it's just Kian.

0:20:590:21:01

We've had a chap come in who's come off his bike

0:21:010:21:04

and gone face-planted into a cattle-grid.

0:21:040:21:06

I just wondered if you could come and have a look?

0:21:060:21:08

We're going to get X-rays of his mandible and jaw anyway.

0:21:080:21:11

We'll get you round for your X-ray shortly, OK?

0:21:110:21:13

Let us know if you know more painkillers, OK? OK.

0:21:130:21:17

As Kian waits for Julian to be taken to X-ray,

0:21:200:21:23

he notices a change in his condition.

0:21:230:21:26

-You just went straight over?

-Yeah.

0:21:260:21:28

-Yeah?

-Like that.

-Straight on.

0:21:280:21:30

OK.

0:21:300:21:32

Right. Do you still know where we are?

0:21:320:21:34

-Yeah.

-Where are we?

0:21:340:21:36

-Hospital.

-Yeah, fine, OK.

0:21:360:21:37

Although Julian appeared orientated still

0:21:390:21:42

and I kept asking him, "Do you know where we are?"

0:21:420:21:45

and he could tell me we were in hospital...

0:21:450:21:48

..he'd changed somehow, and I knew that there was something going on.

0:21:500:21:54

Keep him on pretty close neurobs.

0:21:560:21:58

He still knows where he is and stuff,

0:21:580:22:00

he's just got a bit dazed and it's just not quite right.

0:22:000:22:03

I just caught a glimpse of him as he was going out of the room

0:22:050:22:09

and his face appeared to have changed.

0:22:090:22:11

And it was that reason why

0:22:130:22:14

I followed him round to the X-ray department.

0:22:140:22:17

It's your left hand that we're going to X-ray,

0:22:230:22:25

does that sound right?

0:22:250:22:26

And then some images of your face

0:22:260:22:28

and your mandible as well and your chest.

0:22:280:22:30

HE MUMBLES

0:22:300:22:32

Does your hand normally flatten out?

0:22:350:22:37

Yeah.

0:22:370:22:38

Yeah, can you try and uncurl all of your fingers for me, then?

0:22:380:22:42

And turn your hand palm down.

0:22:420:22:44

'At the point when your gut tells you

0:22:450:22:48

'there's something going on here,'

0:22:480:22:51

you do have this sort of internal clock

0:22:510:22:54

that just starts ticking until you find out what the diagnosis is.

0:22:540:22:58

Down there.

0:23:050:23:06

That arm. No.

0:23:080:23:09

Can you bring this arm up here? You're on there.

0:23:090:23:13

Can I have a quick look at him, guys? Sorry.

0:23:130:23:16

Julian, can I see this arm?

0:23:170:23:19

The tone of your muscles, at rest,

0:23:190:23:22

should be nice and relaxed.

0:23:220:23:24

Whereas, when I went in to quickly assess Julian's arms,

0:23:240:23:29

he appeared to be nice and relaxed on his right side.

0:23:290:23:32

Let this arm relax, just relax.

0:23:320:23:33

Can you let this one relax as well?

0:23:360:23:38

But his left side was more rigid.

0:23:380:23:41

His muscles appeared to not be at rest.

0:23:420:23:45

He needs to go for a CT head.

0:23:450:23:47

-CT head.

-Do you want a quick chest?

-CT Head. No, CT head now. OK.

0:23:470:23:51

'Increased tone essentially can be a sign

0:23:510:23:53

'that you're not getting oxygen to that part of your brain.

0:23:530:23:56

'At this point, I'm worried that Julian'

0:23:560:23:59

is showing signs of having a stroke.

0:23:590:24:01

We're going to bring him in for a CT head now, guys, he's...

0:24:080:24:10

-Oh...

-He's got increased tone of his left arm and he's just...

0:24:100:24:13

He's not really using it that well.

0:24:130:24:15

'We need to urgently scan his head

0:24:150:24:17

'to make sure there's no bleed in his brain.'

0:24:170:24:20

That is now time-critical.

0:24:200:24:21

OK?

0:24:250:24:26

Yeah.

0:24:270:24:28

The scan should reveal any blood clots or bleeds.

0:24:390:24:42

But it's clear.

0:24:460:24:48

Fine. Good.

0:24:490:24:50

So, in CT, we don't find anything on the brain...

0:24:510:24:55

That's fine. Yeah, we'll get his X-rays now.

0:24:550:24:57

All we find is a fracture to the skull near his eye.

0:24:570:25:02

But I wasn't reassured.

0:25:020:25:04

My gut was telling me

0:25:040:25:05

there's something going on with this patient.

0:25:050:25:08

We now have a man who was...

0:25:080:25:11

essentially well when he came in,

0:25:110:25:14

despite his facial injuries,

0:25:140:25:16

and is now developing new symptoms

0:25:160:25:20

which seem to be progressing.

0:25:200:25:22

So I had to go looking for something else.

0:25:230:25:26

I had to be looking for something that could explain all of this.

0:25:260:25:30

In the last 60 minutes,

0:25:370:25:39

doctors and paramedics

0:25:390:25:41

have pulled moped rider Martin

0:25:410:25:42

from under a bin lorry,

0:25:420:25:44

and suspect he's suffered

0:25:440:25:45

brain and spinal damage.

0:25:450:25:47

Police Officer David

0:25:490:25:50

is being rushed to hospital

0:25:500:25:51

with an ongoing heat attack.

0:25:510:25:53

And cyclist Julian is showing

0:25:530:25:55

worrying signs of deterioration.

0:25:550:25:57

At the Royal London Hospital,

0:26:000:26:02

a trauma team led by emergency medicine consultant Alistair Wilson

0:26:020:26:06

is on high alert to receive Martin.

0:26:060:26:08

He was pinned underneath the front wheel

0:26:100:26:13

by his left shoulder and head in a funny angle.

0:26:130:26:16

The lorry was reversed,

0:26:160:26:18

he was pulled out in PEA arrest.

0:26:180:26:21

Helmet came off, LMA, oxygen

0:26:210:26:24

and he got a ROSC.

0:26:240:26:25

Our arrival, GCS of 3,

0:26:250:26:28

not been seen to move any of his limbs.

0:26:280:26:30

Let's go for the...

0:26:300:26:33

Let's get the...

0:26:330:26:35

top and bottom off.

0:26:350:26:36

'I like the whole business of actually working out'

0:26:360:26:40

what has caused what.

0:26:400:26:43

There isn't an injury that the patient has

0:26:450:26:48

that cannot be related to what has gone on.

0:26:480:26:51

It's a bit like looking at cars,

0:26:510:26:52

you know, if you have a car that's been in an accident,

0:26:520:26:55

every dent, every bump is caused by something else,

0:26:550:26:58

and you need to piece together all those bits.

0:26:580:27:01

The same thing is true with the body.

0:27:010:27:03

Right, hands over from right to left.

0:27:030:27:05

Alistair's team begin by examining Martin

0:27:070:27:10

for any immediate life-threatening injuries.

0:27:100:27:12

Can you feel the chest for me with your...

0:27:130:27:15

Yes, there's no tenderness...

0:27:150:27:17

Well, no, look, go right the way round the back

0:27:170:27:19

and tell me what it feels like.

0:27:190:27:21

It became abundantly apparent very quickly

0:27:220:27:26

that his wasn't just a head injury.

0:27:260:27:29

He'd got a lot of bruising at the very base of his neck,

0:27:290:27:32

which you could feel.

0:27:320:27:34

So when you're ready, let's get that blood gas off,

0:27:340:27:36

fast as you can.

0:27:360:27:38

So, are we ready for CT? Let's go.

0:27:380:27:40

So the issue was to move Martin as fast as possible

0:27:420:27:45

into the CT scanner

0:27:450:27:47

to review all of these injuries and see exactly what was going on.

0:27:470:27:50

Knowing that Martin's head and neck were dragged under the lorry,

0:27:550:27:59

Alistair is going to CT scan both.

0:27:590:28:01

He's behaving as if he's got quite a bit of cerebra anaemia already.

0:28:010:28:06

We could use facial bones as well.

0:28:060:28:08

Primarily, the left side of his face had been smashed inwards.

0:28:100:28:14

The facial bones were all fractured.

0:28:140:28:16

There was a lot of swelling under the very base of the skull.

0:28:180:28:21

As well as the trauma to Martin's face,

0:28:230:28:26

Alistair is also looking for any injury to the brain.

0:28:260:28:29

His brain looks quite good.

0:28:290:28:31

It does tell me that there's no bleeding

0:28:330:28:35

inside the brain matter itself,

0:28:350:28:37

or contusions or tears in the brain matter.

0:28:370:28:39

I wonder what sort of helmet he was wearing.

0:28:390:28:41

The policeman's got it.

0:28:410:28:43

Oh, excellent, I'll have a look.

0:28:430:28:45

So, it's between the road...

0:28:470:28:49

That's road, and that's...

0:28:490:28:50

-And that's...

-That's him.

0:28:500:28:52

Perfect. Exactly what we would expect.

0:28:520:28:55

Perfect. If Martin hadn't been wearing a helmet,

0:28:550:28:58

I suspect he would probably have had a fatal head injury at scene

0:28:580:29:03

and probably would not have been able to be resuscitated.

0:29:030:29:07

Whilst Alistair is encouraged by the scan,

0:29:080:29:12

it could be days before any damage

0:29:120:29:14

caused by the lack of oxygen begins to show.

0:29:140:29:17

The damage to the brain

0:29:170:29:20

would have been expressed in the cells,

0:29:200:29:24

initially by just not working,

0:29:240:29:26

but with time, the cells die

0:29:260:29:28

and the whole of the brain then becomes oedematous -

0:29:280:29:31

it's got a lot of swelling, a lot of water on it.

0:29:310:29:34

Unfortunately, it does take two days or so

0:29:340:29:37

before that expresses itself.

0:29:370:29:40

So it's a matter of waiting to see what has happened.

0:29:400:29:43

OK.

0:29:430:29:45

Having checked the brain,

0:29:450:29:47

Alistair now focuses his attention on Martin's spine.

0:29:470:29:50

I'm concerned about his C-spine, but we haven't got the recons here.

0:29:500:29:54

That's blood round there.

0:29:540:29:55

When you looked at the spinal cord,

0:29:550:29:58

at the base of the brain,

0:29:580:30:00

just at the bottom of the brain - a little bit into the brain, too -

0:30:000:30:03

but there, pushing the spinal cord across, was blood.

0:30:030:30:07

That's compressed inwards, isn't it?

0:30:070:30:08

So he's got this haematoma,

0:30:080:30:11

-in this area here.

-Yeah.

0:30:110:30:13

The danger to Martin because of this bleeding

0:30:130:30:16

is, if it is compressing the cord,

0:30:160:30:19

then it will be damaging the cord.

0:30:190:30:21

And it would be an emergency then,

0:30:210:30:23

and we would need to go in and let that blood out.

0:30:230:30:25

To decide if Martin requires surgery,

0:30:270:30:30

the trauma team need a more detailed examination of his spinal cord.

0:30:300:30:34

MRI is the next thing to do.

0:30:350:30:37

An MRI lets us see very clearly

0:30:370:30:41

ligaments, soft tissues,

0:30:410:30:43

brain and neural tissue

0:30:430:30:46

in a lot more detail than we ever could with the CT scan.

0:30:460:30:49

The real issue in Martin's case was

0:30:500:30:53

were we going to need to do something with his neck?

0:30:530:30:56

Whether we needed to do an operation

0:30:570:30:59

on the spinal cord, or the spinal column,

0:30:590:31:02

had to be determined by the MRI scans.

0:31:020:31:05

Any significant damage to Martin's spinal cord

0:31:070:31:10

could lead to permanent paralysis.

0:31:100:31:12

He's got these little fractures round the back there.

0:31:120:31:15

C7.

0:31:150:31:17

Um... Hmm.

0:31:170:31:20

All of that looks raised, doesn't it?

0:31:200:31:22

All the way up and down.

0:31:220:31:24

It's this stuff in the centre of the cord that's the issue.

0:31:240:31:27

Yeah.

0:31:270:31:28

After the MRI, it was clear that there was no compressive pressure

0:31:310:31:36

being put on the spinal cord

0:31:360:31:38

and, therefore, there was no requirement

0:31:380:31:41

for any neck surgery, or to let any clot out

0:31:410:31:44

or let any pressure out.

0:31:440:31:46

Although there's no need for surgery,

0:31:470:31:50

Alistair can't tell at this stage

0:31:500:31:52

what the long-term implications of Martin's injuries will be.

0:31:520:31:55

To aid his recovery, Martin will be kept in an induced coma

0:31:550:31:59

until the medical team feel it's safe to wake him.

0:31:590:32:02

Is he going to be able to move his arms and his legs?

0:32:020:32:05

We have to wait and see. He could wake up in two days, three days,

0:32:050:32:08

and his brain might not work at all.

0:32:080:32:11

David is arriving at Barts Heart Centre.

0:32:200:32:24

Anne suspects one of his major coronary arteries is blocked.

0:32:270:32:30

She's given him drugs for the pain.

0:32:300:32:32

Until doctors clear the blockage,

0:32:320:32:35

his heart will be starved of oxygen and nutrients.

0:32:350:32:38

This is David, he's a 57-year-old policeman.

0:32:390:32:42

He was doing the bleep test this morning

0:32:420:32:44

when he dropped to his knees, clasped his chest and fell prone.

0:32:440:32:47

Immediate bystander CPR.

0:32:470:32:49

His 12-lead ECG basically shows a sinus rhythm,

0:32:490:32:53

but he's got some inferior and lateral changes

0:32:530:32:56

and ongoing chest pain. He's taken 10 morphine...

0:32:560:32:59

Within minutes, David goes for an emergency angiogram,

0:32:590:33:03

a specialist heart X-ray,

0:33:030:33:05

under the eye of consultant interventional cardiologist John Hogan.

0:33:050:33:10

We know he's had a cardiac arrest.

0:33:120:33:14

We're not entirely certain why he's had one.

0:33:140:33:17

If he does have a blocked artery, which is recently occluded,

0:33:170:33:20

the longer it is blocked, the more damage it causes to heart muscle.

0:33:200:33:24

You're going to feel a burning sensation of the arm, OK?

0:33:260:33:31

Using dye, John examines

0:33:320:33:35

each of David's three major coronary arteries in turn,

0:33:350:33:38

looking for any narrowing.

0:33:380:33:40

The arteries develop a lining called atherosclerosis

0:33:410:33:43

over a period of time.

0:33:430:33:45

That lining itself is subject to developing cracks.

0:33:450:33:51

Such little cracks are sealed by little blood clots which seal it

0:33:530:33:58

and if you get a big blood clot,

0:33:580:34:00

it can actually block an artery off at the time and that's how you get

0:34:000:34:03

what is typically known as a heart attack.

0:34:030:34:06

Why do people get hardening of the arteries?

0:34:080:34:11

It can be a number of things.

0:34:110:34:12

Do they have hypertension, do they have diabetes,

0:34:120:34:15

do they have high levels of cholesterol?

0:34:150:34:17

And their lifestyle issues. Are they sedentary, do they smoke?

0:34:170:34:20

All of these things contribute to the development of atherosclerosis.

0:34:200:34:25

-He's got collaterals.

-Yeah.

0:34:250:34:27

And so that implies that the vessel has been blocked before

0:34:270:34:31

and he's had these collaterals in the interim period.

0:34:310:34:34

John discovers a drastically reduced flow

0:34:360:34:38

through one of the three main arteries supplying David's heart.

0:34:380:34:42

There's no doubt that David has a blocked artery

0:34:420:34:45

that runs down the front of his heart.

0:34:450:34:46

We just need to have a little MDT about this before we press on.

0:34:460:34:50

John must now make a decision on how to treat David,

0:34:500:34:54

to give him the best chance of survival.

0:34:540:34:56

We've had a look at the angiogram.

0:34:590:35:02

Of your three coronary arteries,

0:35:020:35:04

you've blocked the one that goes down the front of the heart.

0:35:040:35:08

You do not appear to have blocked it off this morning,

0:35:080:35:11

but your exercise may have aggravated matters

0:35:110:35:16

and caused your collapse.

0:35:160:35:17

So we think that your circumstances

0:35:170:35:20

would be best treated in the long term

0:35:200:35:22

by an operation to bypass that blocked artery.

0:35:220:35:25

Until David goes to theatre for emergency surgery the following day,

0:35:280:35:32

he will be closely watched for the smallest of fluctuations

0:35:320:35:35

in his heart activity.

0:35:350:35:36

In Newcastle, over the last four hours,

0:35:480:35:51

Julian has been closely monitored following his accident.

0:35:510:35:55

His head scan has revealed nothing

0:35:550:35:57

to explain his continued deterioration,

0:35:570:35:59

but Kian believes he may have found the answer.

0:35:590:36:02

I'm going to bring Julian back round for a CTA. Are you guys ready?

0:36:020:36:06

The only thing that could explain his symptoms

0:36:060:36:10

were a carotid artery dissection.

0:36:100:36:13

It's one of the most important vessels in your body,

0:36:130:36:16

which carries oxygen to your brain,

0:36:160:36:19

so anything that disrupts that is potentially fatal.

0:36:190:36:23

We need to make sure that when he's fallen, when he's hit the ground,

0:36:240:36:28

he's hyperextended his neck,

0:36:280:36:30

we need to make sure that he's not dissected

0:36:300:36:32

or torn one of the arteries which supplies his brain.

0:36:320:36:35

That wouldn't show up initially on a CT scan.

0:36:350:36:38

Kian sends Julian for a specialised scan called a CT angiogram.

0:36:400:36:45

The one thing that's going through my mind at this stage is

0:36:460:36:49

I need to get this scan fast and find out if this is the diagnosis

0:36:490:36:54

and get the right people involved

0:36:540:36:56

to give him the best chance of a potential recovery.

0:36:560:36:58

There's nothing else that can explain the new acute weakness.

0:37:010:37:06

OK, Julian, we're back in the scan room, OK?

0:37:060:37:09

We're going to move you over again, OK?

0:37:090:37:11

Let's have a look at your eyes, Julian, OK?

0:37:110:37:14

Julian is having a dye injected into his arm.

0:37:140:37:17

It will allow Kian to track the blood flow

0:37:170:37:20

in the artery in his neck.

0:37:200:37:21

Normally you would get the dye just flowing nicely through the vessels.

0:37:210:37:26

With a dissection, you'll see some of that dye moving into places

0:37:260:37:31

that it shouldn't go and, ultimately, if there's a clot there,

0:37:310:37:35

you won't actually get dye advancing past where it should be going.

0:37:350:37:39

Yeah. It's dissected.

0:37:430:37:45

On Julian's CT, it showed that he had what I was suspecting.

0:37:450:37:50

He had a dissection of his neck.

0:37:500:37:52

Right, we'll get him back through.

0:37:550:37:56

As soon as Julian had fallen off his bike and hyperextended his neck,

0:37:560:38:01

he would have sustained that tear in his artery

0:38:010:38:05

and, from that point, he would've had blood going into an area

0:38:050:38:09

where it shouldn't have gone and the body would have been starting

0:38:090:38:12

to form clots the whole time.

0:38:120:38:14

It wasn't until actually parts of a clot started to shoot off

0:38:150:38:19

and go up into his brain, until he would've actually started

0:38:190:38:22

getting symptoms and signs of a stroke.

0:38:220:38:25

Hi, can you put me through to the stroke consultant on call, please?

0:38:250:38:28

Hi, sorry to bother you. My name's Kian, I'm on A&E at the RVI...

0:38:280:38:32

Kian calls in a specialist stroke team.

0:38:320:38:35

They'll try to break down the clots

0:38:350:38:37

which are cutting off the blood supply to Julian's brain.

0:38:370:38:40

'The fact that a big clot was formed in Julian's neck from a tear

0:38:410:38:46

'is incredibly rare.'

0:38:460:38:47

You're coming into the RVI just now? Right.

0:38:490:38:52

You could see it as a bit of a ticking time bomb

0:38:520:38:55

as to when he was actually going to develop symptoms of a stroke.

0:38:550:38:58

-Yeah, we think you have. Yeah, yeah, you have. OK?

-Yeah.

-OK?

0:39:020:39:05

We're going to try and give you some medication

0:39:050:39:09

-to try and break down the clots that are causing the problem, OK?

-OK.

-OK?

0:39:090:39:13

Oh, hey, it's just Kian.

0:39:130:39:15

The stroke consultant's here. They're going to thrombolyse him.

0:39:150:39:19

Doctors give Julian a powerful drug

0:39:190:39:21

to break down the blood clots causing the stroke.

0:39:210:39:24

But it is not without danger.

0:39:240:39:26

Thrombolysis can be a risky procedure.

0:39:260:39:30

It's essentially something that goes in to try to break down clots

0:39:300:39:34

and, as a result of that,

0:39:340:39:36

you can start spontaneously bleeding from anywhere in your body.

0:39:360:39:41

With the extensive injuries to his face, Julian is at risk

0:39:450:39:49

of bleeding into his airway and drowning in his own blood.

0:39:490:39:53

At this point, it was really important to get

0:39:530:39:55

the maxillofacial doctors back down to start putting in some stitches

0:39:550:39:59

into his face to try and do some damage control

0:39:590:40:01

on the potential bleeding that could happen from those wounds.

0:40:010:40:05

If you open as wide as you can for me.

0:40:050:40:07

Even bigger than that.

0:40:070:40:09

Kian must now wait to see how Julian responds.

0:40:090:40:12

Julian, at this stage, was showing signs of quite an extensive stroke.

0:40:120:40:17

This is something that he could potentially die from.

0:40:180:40:21

It's the morning after Julian came off his bike,

0:40:370:40:40

smashing his face into a cattle grid.

0:40:400:40:43

A blood clot in his neck has caused a major stroke in Julian's brain

0:40:440:40:49

so he's been given a powerful drug to try and break it down.

0:40:490:40:52

At the intensive care unit that he's been moved to,

0:40:540:40:56

consultant anaesthetist Hugh McConnell

0:40:560:40:59

and registrar Tom Keans are checking to see if it's worked.

0:40:590:41:03

Morning, Julian. It's Dr McConnell here.

0:41:030:41:05

-I saw you downstairs last night in casualty.

-Yeah.

0:41:050:41:09

How are things...? How are things going?

0:41:090:41:12

'When I saw him on the round that morning, I could tell that he was

0:41:120:41:16

'still very weak down the left-hand side of his body'

0:41:160:41:19

and was concerned that the stroke deficit hadn't improved particularly

0:41:190:41:24

with the clot-busting drug.

0:41:240:41:25

Can I get you to hold your arms out in front of you?

0:41:250:41:29

Can you keep that there? OK.

0:41:290:41:31

Can you put your palms to the ceiling?

0:41:310:41:33

And what about that one?

0:41:330:41:35

Can you squeeze my hand at all, Julian, with this side? OK.

0:41:350:41:39

Do you understand what's happening at the moment? Yeah? OK.

0:41:410:41:45

You've injured one of the blood vessels in your neck

0:41:450:41:50

and that's caused a stroke.

0:41:500:41:52

'At that time, an area of that brain will have been starved

0:41:540:41:56

'of oxygen and nutrients that it requires, and when that happens,'

0:41:560:42:00

those cells begin to die or swell.

0:42:000:42:03

Can I get you to open your eyes for me, Julian?

0:42:070:42:09

'The key problem with brain swelling

0:42:090:42:11

'is that the swelling is occurring in a rigid box -

0:42:110:42:14

'the skull - and if you get a lot of swelling within the skull,

0:42:140:42:18

'the pressure goes up'

0:42:180:42:20

and it pushes over the vital structures

0:42:200:42:23

that exist within the brain

0:42:230:42:25

and that can cause catastrophic and irreversible damage

0:42:250:42:29

to the previously healthy brain tissue

0:42:290:42:33

that's not affected by the initial injury.

0:42:330:42:35

As Julian's brain expands, and with no room to move,

0:42:350:42:39

it will begin to push onto his cranial nerves,

0:42:390:42:42

which control his breathing and his heart.

0:42:420:42:45

We look for signs of these cranial nerves becoming compromised,

0:42:460:42:50

and one of the most easy to identify

0:42:500:42:53

is the pressure effect or traction effect on the third cranial nerve,

0:42:530:42:57

which typically causes inability to open the eyelid

0:42:570:43:02

and dilation of the pupil.

0:43:020:43:04

I'm just going to shine a torch in your eyes there.

0:43:060:43:08

The key change was undoubtedly when Julian's pupil reactions changed.

0:43:080:43:13

'That is a very black and white transition that he went through.'

0:43:130:43:18

And, in this setting,

0:43:200:43:22

a dilated pupil always means

0:43:220:43:25

'very high pressure in the skull

0:43:250:43:27

'and so that prompted me to get another scan.'

0:43:270:43:30

OK.

0:43:300:43:31

-Bless him. He's not had the easiest of rides, has he?

-He's not, no.

0:43:400:43:45

There's a concept known as coning, which is where

0:43:480:43:50

the brain swells and swells and has got nowhere else to go

0:43:500:43:53

so pressure goes down toward the brainstem,

0:43:530:43:56

which is the most important part of the brain,

0:43:560:43:58

relating to you being aware and conscious and breathing.

0:43:580:44:02

So, if you press enough on that,

0:44:020:44:04

then ultimately the patient will die.

0:44:040:44:06

The dark shading on Julian's scan

0:44:080:44:10

confirms the swelling to his brain has reached a critical level.

0:44:100:44:14

-We're going to theatre one.

-Yes.

0:44:160:44:18

There's a very, very fine line between a brain that's just managing

0:44:180:44:22

and one that doesn't manage at all

0:44:220:44:24

and he's fallen off a precipice, really,

0:44:240:44:26

in terms of his brain's ability to manage what was going on up there.

0:44:260:44:31

Time is absolutely critical here.

0:44:310:44:33

We need to reduce the pressure in his skull.

0:44:330:44:36

-I mean, I'm ready to go.

-I'll go and get somebody to come and collect.

0:44:360:44:40

To reduce the pressure,

0:44:400:44:42

the only option left is an emergency operation called a craniectomy.

0:44:420:44:46

Decompressive craniectomy is actually as simple as removing

0:44:480:44:51

a fairly large plate of bone,

0:44:510:44:52

which allows the injured brain to swell out the way

0:44:520:44:56

rather than pushing in on the healthy areas of brains.

0:44:560:45:00

The operation won't reverse the stroke,

0:45:010:45:04

but it might stop further damage to Julian's brain,

0:45:040:45:07

and it may save his life.

0:45:070:45:09

In London, just 24 hours after his cardiac arrest,

0:45:180:45:22

police officer David is also in theatre,

0:45:220:45:25

having urgent heart surgery.

0:45:250:45:28

Consultant cardiothoracic surgeon Wael Awad

0:45:280:45:31

is about to tackle the dangerous blockage in David's coronary artery.

0:45:310:45:36

What we have to do is restore the blood flow

0:45:360:45:39

to that area of the heart, which is in jeopardy

0:45:390:45:43

and to do that, we have to bypass blood beyond the blockage.

0:45:430:45:47

OK, starting.

0:45:480:45:49

Wael needs to take an artery from David's chest wall and sew it past

0:45:540:45:58

the blockage, creating a new path for blood to feed his heart muscle.

0:45:580:46:03

-Table up, please.

-Table up?

0:46:030:46:05

But, as the operation begins, David's heart suddenly deteriorates.

0:46:080:46:12

'His blood pressure dropped, his heart is beginning to struggle'

0:46:120:46:16

by the added stress of the general anaesthetic

0:46:160:46:20

and the opening of the chest.

0:46:200:46:22

-Full dose?

-Yeah.

0:46:220:46:25

At this point, I decided to do the operation by stopping the heart.

0:46:250:46:30

-Yeah, we will be going on bypass, please.

-OK.

0:46:320:46:36

Pericardium coming up.

0:46:360:46:39

The team connect David's heart vessels

0:46:390:46:41

to a cardiopulmonary bypass pump...

0:46:410:46:44

Give one litre of cardioplegia, please.

0:46:440:46:46

..which will circulate oxygenated blood around his body.

0:46:460:46:50

Happy?

0:46:520:46:54

Yes?

0:46:540:46:55

Now Wael can begin work on David's blocked artery.

0:46:560:47:00

This is delicate surgery.

0:47:030:47:05

The arteries are very small

0:47:050:47:08

and I think that one does have to be a good technician

0:47:080:47:12

to be able to do this well.

0:47:120:47:14

We're harvesting an artery from the inside of the chest wall

0:47:140:47:18

and stitching that to his coronary artery.

0:47:180:47:21

The arteries Wael needs to stitch together

0:47:230:47:25

are just two millimetres wide.

0:47:250:47:27

It's looking quite good at the moment.

0:47:280:47:31

Once the stitching is complete,

0:47:320:47:34

Wael needs to take David off the heart-lung machine

0:47:340:47:37

and get his heart beating again.

0:47:370:47:40

Ventilate, please.

0:47:400:47:41

Ventilating normally?

0:47:410:47:43

-Yes, good ventilation.

-Potassium and gases normal?

0:47:430:47:45

-Yep.

-Off bypass, please.

0:47:450:47:48

As soon as the blood flow to the heart is restored,

0:47:500:47:53

the heart should work on its own.

0:47:530:47:56

Yeah, it's working now.

0:47:560:47:57

'We see that the heart, first of all, is beating spontaneously'

0:47:590:48:03

and the ECG is normal and the blood pressure is stable.

0:48:030:48:07

In that corner, please.

0:48:090:48:11

The team will now monitor David closely

0:48:110:48:13

as he recovers in intensive care.

0:48:130:48:16

In Newcastle, doctors have one last chance to save Julian's life.

0:48:260:48:30

Ready, steady, slide.

0:48:300:48:32

OK. OK, right shoulder.

0:48:340:48:35

Specialist neurosurgeon Shuaibu Dambatta

0:48:350:48:38

is about to remove a large section of Julian's skull

0:48:380:48:41

to ease the pressure on his brain.

0:48:410:48:43

This is Julian's scan of his brain.

0:48:430:48:46

This part of the brain is darker

0:48:460:48:49

and this is the part that has had the stroke.

0:48:490:48:52

This area there is supposed to be right in the middle,

0:48:520:48:55

so this line should be going through here,

0:48:550:48:57

and you can see that the middle of his brain has been shifted

0:48:570:49:00

by about more than a centimetre to the other side

0:49:000:49:02

and so the operation we're planning to do

0:49:020:49:04

is going to be taking this bone out as much as possible, so that,

0:49:040:49:09

instead of this brain swelling to push the normal brain

0:49:090:49:12

and causes more damage on the side that doesn't have the stroke,

0:49:120:49:15

it can now push upward and swell upward because there's no bone there

0:49:150:49:18

so the skin is softer and it can just distend it.

0:49:180:49:21

First, Shuaibu marks out where he's going to cut.

0:49:240:49:27

A centimetre too far could cause catastrophic bleeding.

0:49:290:49:32

There are certain areas within the skull or just underneath the skull

0:49:320:49:37

where you have big blood vessels within the brain

0:49:370:49:39

and we have to make sure that we don't damage those areas.

0:49:390:49:43

It's a balance between trying to take as much bone as possible

0:49:430:49:47

and also knowing the limit of how far you can go.

0:49:470:49:51

OK, everyone nearly there?

0:49:530:49:55

-Yes.

-Happy starting?

0:49:550:49:57

OK.

0:49:570:49:58

Every minute the swelling continues,

0:49:580:50:00

it risks damaging the unaffected areas of Julian's brain,

0:50:000:50:04

so Shuaibu needs to act quickly.

0:50:040:50:06

It's difficult to say exactly how much time we've got because,

0:50:130:50:16

if those brain cells are not dead but they've been stunned,

0:50:160:50:20

as in shocked...

0:50:200:50:22

..if you act quickly enough, you might be able to revive them

0:50:230:50:26

but, really, time is of the essence and every minute counts.

0:50:260:50:31

OK, so I'll make another hole.

0:50:310:50:35

Painstakingly, Shuaibu cuts around the section of the skull

0:50:350:50:39

that needs to be removed.

0:50:390:50:40

OK.

0:50:420:50:43

So the recommendation is to take about 13 by 6 millimetres,

0:50:510:50:55

minimum, and we've got about at least 16 centimetres here.

0:50:550:51:00

'It's probably the most amount of skull I've had to take

0:51:000:51:03

'in doing this type of operation.'

0:51:030:51:06

We've got about...

0:51:060:51:08

11.5 centimetres across, here.

0:51:080:51:12

I can tell that Julian's brain is damaged by its appearance,

0:51:120:51:18

because it didn't look normal.

0:51:180:51:20

However, even though it looked damaged,

0:51:200:51:23

I can't tell if there's still a part of that brain

0:51:230:51:27

or there are some cells within that brain that are still alive.

0:51:270:51:31

And my aim, really, is to provide Julian's brain,

0:51:310:51:36

even though it looked dead, with all the support it needs,

0:51:360:51:40

as if it were alive

0:51:400:51:42

in the hope that there might be a part of that brain

0:51:420:51:45

which may survive

0:51:450:51:47

and that part may have some use to Julian in the future.

0:51:470:51:53

INDISTINCT

0:51:550:51:57

..and come back next time.

0:51:570:51:59

Without the skull to protect it, Julian's brain is open to infection.

0:52:000:52:05

Shuaibu uses a special collagen membrane to cover it.

0:52:050:52:09

OK. Let's get ready to start closing, please.

0:52:100:52:13

Now the skin will be closed up without the skull underneath.

0:52:130:52:17

Get an artery, please. Let me just have an artery.

0:52:170:52:21

I think that is all.

0:52:210:52:22

We've written on that, "No bone flap."

0:52:220:52:24

That means that the nurses and whoever is looking after him

0:52:240:52:28

know that he hasn't got a bone there and directly under his skin

0:52:280:52:31

is his brain, so that means you don't press it

0:52:310:52:33

and, if they lie on that side,

0:52:330:52:35

they don't lie directly on the brain,

0:52:350:52:36

so that's why we've put that sign there.

0:52:360:52:39

A scan shows how much Julian's brain has swelled

0:52:460:52:49

beyond the confines of his skull.

0:52:490:52:52

Shuaibu's operation has done its job.

0:52:520:52:55

We haven't allowed the pressure inside his head

0:52:550:52:58

to raise to a level where it had caused him to lose his life.

0:52:580:53:02

On the longer term,

0:53:020:53:04

he will need another operation to reconstruct that skull

0:53:040:53:08

and that also carries its own risk, which is why we have to balance

0:53:080:53:14

the risk of having the operation

0:53:140:53:17

against the risk of not doing anything at all.

0:53:170:53:21

Julian will stay in intensive care

0:53:240:53:26

and be kept unconscious until the swelling of his brain has stopped.

0:53:260:53:30

Only time will tell what recovery he'll make.

0:53:300:53:33

You don't believe it's happened.

0:53:480:53:50

You hear of people who don't come round from that,

0:53:500:53:53

don't come back from that.

0:53:530:53:54

I think, for David,

0:54:000:54:01

the most significant thing that saved his life

0:54:010:54:03

was that he was in the presence of his colleagues

0:54:030:54:05

who recognised he was in cardiac arrest

0:54:050:54:08

and they did immediate chest compressions and phoned 999.

0:54:080:54:11

I look at my life. Obviously, I've got my second chance.

0:54:150:54:18

At the moment, I'm actually doing

0:54:200:54:23

a minimum of 30 minutes' walk a day, five days a week.

0:54:230:54:26

Once a week, I'm going up to the cardio rehab at the hospital.

0:54:300:54:35

No pain or anything. Hardly out of breath.

0:54:350:54:37

I feel I can achieve anything, I can do anything.

0:54:390:54:42

You know, it's... I possibly can't

0:54:420:54:45

but up here I'm thinking, "Yep, it's given me a new lease of life."

0:54:450:54:51

It could have been such a totally different story that day.

0:54:520:54:56

He was able to receive the treatment that he did so quickly.

0:54:560:54:59

A split second and it'd be a different story.

0:54:590:55:02

'He was a very lucky man.'

0:55:040:55:06

-THEY LAUGH

-It looks like a mole.

0:55:060:55:08

One thing that I had to learn after the collision,

0:55:270:55:31

after the accident, was actually just the sheer power of time

0:55:310:55:36

in terms of how your body recovers

0:55:360:55:39

and what it will do in that recovery period.

0:55:390:55:42

If the Ambulance Service had got to him two or three minutes later,

0:55:470:55:50

pulled him out and done exactly the same thing,

0:55:500:55:52

his brain would have been hypoxic for two or three more minutes

0:55:520:55:55

and his outcome would have been very different.

0:55:550:55:57

It's almost overwhelming...

0:55:590:56:01

..and I consider myself to be lucky in how I got away with things.

0:56:030:56:08

The effect of the stroke in Julian's case

0:56:140:56:18

is, because it's the right side of his brain that is affected,

0:56:180:56:22

he's got a weakness on the left side of his body.

0:56:220:56:25

It is challenging and frustrating that you cannot say to Julian that,

0:56:250:56:30

"Two years down the line, you might be able to lift your arm again."

0:56:300:56:34

But, at the same time, you don't lose hope.

0:56:340:56:38

I'm absolutely amazed by, when you're fit and well and able-bodied,

0:56:440:56:48

how much you take for granted.

0:56:480:56:49

You don't assume that standing is going to be particularly difficult.

0:56:490:56:53

The first time I could stand, it felt like a great achievement.

0:56:530:56:57

Lovely. Well done.

0:56:590:57:01

Julian's incredibly strong and very, very determined.

0:57:010:57:05

He's got a very good positive mental attitude.

0:57:050:57:08

Good, Julian. Well done.

0:57:080:57:09

One of the goals I've set is I want to be able to walk

0:57:090:57:12

before I leave here.

0:57:120:57:14

That's something we've been working on in physiotherapy today -

0:57:150:57:19

standing and taking a step.

0:57:190:57:20

Where my head's...

0:57:310:57:33

Where there's no skull, there's very little protection,

0:57:330:57:36

so I run the risk,

0:57:360:57:37

if I banged my head again, it could be very, very serious

0:57:370:57:42

cos I've got no bone.

0:57:420:57:43

Ultimately, Julian will need to come back and have a plate put back on

0:57:450:57:50

and that operation itself isn't without some degree of risk.

0:57:500:57:55

Obviously, it's been a very difficult time for my family,

0:57:560:57:59

but I'm of the opinion that far worse things happen to other people.

0:57:590:58:03

Next time, we follow three more patients

0:58:050:58:07

through the crucial first hour of care.

0:58:070:58:10

In Bristol, a woman suffers a life-threatening brain injury

0:58:100:58:13

after being hit by a car...

0:58:130:58:15

She's got a big lump to the left side of her head.

0:58:150:58:18

Just get her on the ambulance then and go from there.

0:58:180:58:20

..in Gloucester, a man has his legs crushed by a forklift truck...

0:58:200:58:24

-Which bit of you is hurting?

-All of me.

-All of you.

0:58:240:58:27

..and, in central London,

0:58:270:58:29

a collision leaves a young woman with a severe head injury.

0:58:290:58:33

So you give her nasal oxygen.

0:58:330:58:35

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