0:00:02 > 0:00:05This programme contains scenes which some viewers may find upsetting
0:00:05 > 0:00:09Ambulance service? There's a guy hit by a bus. He was on a bike. He's been really badly injured.
0:00:09 > 0:00:12From the moment an emergency call is made,
0:00:12 > 0:00:14a clock starts ticking.
0:00:17 > 0:00:19Female lying on the road, struggling to breathe.
0:00:19 > 0:00:25The golden hour is the opportunity that we have to save the patient.
0:00:25 > 0:00:27Deep breaths, George.
0:00:27 > 0:00:29The longer the clock ticks,
0:00:29 > 0:00:32the increased likelihood there is of death.
0:00:34 > 0:00:38In the fight for survival, time is the enemy.
0:00:38 > 0:00:40I'm ventilating fast on purpose. Yeah.
0:00:40 > 0:00:43I'm hoping that heart rate will pick up any second.
0:00:43 > 0:00:45Now, new techniques and technology
0:00:45 > 0:00:48are bringing emergency medicine to the roadside.
0:00:48 > 0:00:51We can use the infrascanner to maybe give us a slightly cleaner picture
0:00:51 > 0:00:53of what's going on underneath the skull.
0:00:53 > 0:00:55Breaking new ground
0:00:55 > 0:00:58and treating patients faster than ever before.
0:00:58 > 0:01:02We can now provide emergency surgery, blood transfusions,
0:01:02 > 0:01:05anaesthesia at the scene of the accident.
0:01:05 > 0:01:07Through 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.
0:01:15 > 0:01:18In Bristol, a woman suffers a life-threatening brain injury
0:01:18 > 0:01:20after being hit by a car.
0:01:20 > 0:01:23She's got a big lump to the left side of her head.
0:01:23 > 0:01:25Let's just get on the ambulance, then, and go from there.
0:01:25 > 0:01:30In Gloucester, a man has his legs crushed by a forklift truck.
0:01:30 > 0:01:33Which bit of you is hurting? All of me. All of you.
0:01:33 > 0:01:34And in central London,
0:01:34 > 0:01:38a collision leaves a young woman with a severe head injury.
0:01:38 > 0:01:40We'll give her nasal oxygen...
0:01:40 > 0:01:41Right. ..at quite a high level.
0:01:43 > 0:01:4660 minutes that will change their lives forever.
0:01:46 > 0:01:48You will constantly be surprised
0:01:48 > 0:01:51just what you can bring back from the jaws of death.
0:02:03 > 0:02:07Across Britain, medical teams are on call 24 hours
0:02:07 > 0:02:10to deliver critical care to those most seriously injured.
0:02:12 > 0:02:14At night, when the helicopters are unable to fly,
0:02:14 > 0:02:18the air ambulance teams travel in specially equipped cars,
0:02:18 > 0:02:20able to respond at a moment's notice.
0:02:22 > 0:02:25Ambulance service, what city are you in?
0:02:25 > 0:02:26Bristol.
0:02:28 > 0:02:30OK, can you tell me exactly what's happened?
0:02:30 > 0:02:33Basically, I've just pulled up and there's a fellow on the floor.
0:02:33 > 0:02:36At Bristol South Western Ambulance,
0:02:36 > 0:02:38handlers receive a call about a young girl
0:02:38 > 0:02:40who's been hit by a car.
0:02:40 > 0:02:43Is she breathing? Yes, she's breathing. She's breathing.
0:02:43 > 0:02:45Is she awake?
0:02:45 > 0:02:48No, she's not awake. She's not awake? No.
0:02:48 > 0:02:50I'm organising that help for you now.
0:02:52 > 0:02:54Great Western Air Ambulance critical care team
0:02:54 > 0:02:58Dr Greg Cranston and paramedic Vicky Brown are dispatched by car
0:02:58 > 0:03:00to the scene.
0:03:09 > 0:03:12Thanks for the update, 15.
0:03:12 > 0:03:13Left here.
0:03:14 > 0:03:18Knew we were going to a incident where someone had been hit by a car.
0:03:18 > 0:03:20Female lying on the road.
0:03:20 > 0:03:22Struggling to breathe, I think.
0:03:22 > 0:03:23If there are serious injuries,
0:03:23 > 0:03:25we'll need to intervene with anything life-threatening
0:03:25 > 0:03:27as soon as possible.
0:03:27 > 0:03:29We're probably about three minutes from the scene.
0:03:29 > 0:03:31We know that every minute that passes,
0:03:31 > 0:03:34things could be slipping away, things could be getting worse.
0:03:34 > 0:03:36Here we are.
0:03:36 > 0:03:371015 on scene.
0:03:41 > 0:03:43I'll get the blood.
0:03:43 > 0:03:46Ambulance teams, including critical care paramedic Neil,
0:03:46 > 0:03:49are already on the scene.
0:03:49 > 0:03:50Seemed to go up, hit the deck.
0:03:50 > 0:03:54Apparently originally sort of GCS three, then combative... Like this.
0:03:54 > 0:03:56She's now localising, no eye opening,
0:03:56 > 0:04:00and voice is incomprehensible sounds at the moment.
0:04:00 > 0:04:0318-year-old Christy has been hit whilst crossing the road
0:04:03 > 0:04:06and is struggling to regain consciousness.
0:04:06 > 0:04:08Chest actually looks OK, feels OK,
0:04:08 > 0:04:10belly feels OK, pelvis feels OK.
0:04:10 > 0:04:12Long bones feel OK.
0:04:12 > 0:04:13Just had a BM.
0:04:13 > 0:04:15I think it's head only at the moment.
0:04:15 > 0:04:18So my impression would be in and have a look,
0:04:18 > 0:04:21cos I don't think there's a DCA assess. Fine. Cool.
0:04:21 > 0:04:23'Christy is lying on the floor.
0:04:23 > 0:04:25'She had been hit by a car,'
0:04:25 > 0:04:27thrown up into the air and then landing on the ground,
0:04:27 > 0:04:31though not clearly known exactly how she would have landed.
0:04:31 > 0:04:33There's no airway compromise.
0:04:33 > 0:04:36My immediate observations were that we were dealing with a patient who
0:04:36 > 0:04:39was severely neurologically impaired.
0:04:39 > 0:04:41Have you got her covered?
0:04:43 > 0:04:46She's not settled, she is anxious,
0:04:46 > 0:04:50she's agitated, she's fighting out, pushing people away.
0:04:50 > 0:04:52We'll swap these blankets in a minute once we're off.
0:04:52 > 0:04:55This indicates to me that is a strong likelihood
0:04:55 > 0:04:58of there being a serious brain injury involved in this accident.
0:04:58 > 0:05:01OK, fine, let's just get her on the ambulance then and go from there.
0:05:01 > 0:05:03That's fine. And a warming blanket.
0:05:03 > 0:05:06The team want to get Christy out of the cold and the dark
0:05:06 > 0:05:09and into the ambulance so they can assess her fully.
0:05:09 > 0:05:13It's impossible to actually determine whether there's bleeding,
0:05:13 > 0:05:15bruising and swelling to the brain.
0:05:18 > 0:05:21But people with severe brain injuries die.
0:05:21 > 0:05:24They die at the time of impact.
0:05:24 > 0:05:26They die very shortly afterwards.
0:05:26 > 0:05:29I haven't had a listen to the chest yet. OK. Let's just get her in.
0:05:29 > 0:05:32Although the injury's happened now and we're just at the start,
0:05:32 > 0:05:35things are likely to get worse from this situation on.
0:05:36 > 0:05:38Shut the door, please.
0:05:47 > 0:05:4940 miles away in Gloucester,
0:05:49 > 0:05:53Great Western Air Ambulance critical care team Dr James Tooley
0:05:53 > 0:05:54and paramedic Peter Sadler
0:05:54 > 0:05:57are responding to another emergency call.
0:05:57 > 0:05:58RADIO CRACKLES
0:05:59 > 0:06:0113 minutes ago,
0:06:01 > 0:06:03call handlers were alerted to a serious incident
0:06:03 > 0:06:05at an industrial site.
0:06:05 > 0:06:08Ambulance service, what's the address of the emergency?
0:06:12 > 0:06:16Right, is he able to respond to you at all?
0:06:16 > 0:06:18He's not responding?
0:06:18 > 0:06:22Are there any obvious injuries that you're aware of?
0:06:23 > 0:06:25OK, I'm organising help for you.
0:06:32 > 0:06:35We know that severe injuries using industrial machinery
0:06:35 > 0:06:38can lead to a death really quite quickly
0:06:38 > 0:06:40if certain things aren't addressed.
0:06:40 > 0:06:43So my main concern is to make sure that he hasn't had
0:06:43 > 0:06:45a massive haemorrhage.
0:06:45 > 0:06:48That his airway is under control, that his breathing is OK,
0:06:48 > 0:06:51and that he hasn't lost lots of blood, either externally or internally.
0:06:51 > 0:06:54We'll be with you in approximately 15 minutes, over.
0:06:55 > 0:06:58Is there massive internal haemorrhage
0:06:58 > 0:07:00that we may not be able to deal with on the scene?
0:07:00 > 0:07:02In which case he needs to go to hospital quickly
0:07:02 > 0:07:05to have an operation and to resolve that.
0:07:05 > 0:07:081015, go ahead?
0:07:08 > 0:07:101015 on scene.
0:07:10 > 0:07:11Roger, on scene.
0:07:11 > 0:07:14First response technicians immediately update the team
0:07:14 > 0:07:16on truck driver Peter's condition.
0:07:16 > 0:07:18This is Pete. Yup.
0:07:18 > 0:07:21He's been crushed by that against there. Yeah.
0:07:28 > 0:07:33Not being able to move from the waist down is a very suspicious,
0:07:33 > 0:07:36worrying feature that he may have some spinal cord damage.
0:07:37 > 0:07:39If you truly have severed your spinal cord,
0:07:39 > 0:07:42you may not be able to move your lower limbs
0:07:42 > 0:07:43for the rest of your life.
0:07:43 > 0:07:46Fearing Peter may be paralysed,
0:07:46 > 0:07:49James must find out what sensation he has in his legs.
0:07:49 > 0:07:51Hey, mate, I'm a doctor with the air ambulance.
0:07:51 > 0:07:52Which bit of you is hurting?
0:07:55 > 0:07:56Can you feel your knees?
0:07:58 > 0:08:00OK, mate, we'll get you all sorted out.
0:08:00 > 0:08:02Mate, the worst pain you can ever imagine is 10 out of 10,
0:08:02 > 0:08:04nought is nought, what yours?
0:08:04 > 0:08:07Once he was less scared and less fearful
0:08:07 > 0:08:09and able to confirm that he could feel his legs and move them,
0:08:09 > 0:08:12I was much less worried that there was any spinal injury.
0:08:12 > 0:08:15What we might end up doing is giving you some painkillers that make you
0:08:15 > 0:08:16a bit woozy and a bit confused.
0:08:16 > 0:08:17I don't want too much.
0:08:17 > 0:08:21Are you allergic to anything? No. Aspirin, no aspirin.
0:08:21 > 0:08:23OK. All right, mate.
0:08:23 > 0:08:26Although now less concerned about a spinal injury,
0:08:26 > 0:08:28James fears that Peter has been crushed
0:08:28 > 0:08:30and he needs to look for signs of bleeding.
0:08:30 > 0:08:34Do you mind if I have a quick look under here to see what's going on?
0:08:34 > 0:08:37Not a really good opportunity to get him assessed here. Shall we just...?
0:08:37 > 0:08:39Just get him scooped, get him in the truck, I think.
0:08:39 > 0:08:41He says his pain's 10 out of 10, he's in a lot of pain.
0:08:41 > 0:08:43His pelvis was hurting, his legs were hurting.
0:08:43 > 0:08:46So if the pelvis and the two femurs have been broken,
0:08:46 > 0:08:49you can lose a significant amount of blood into that area and can die
0:08:49 > 0:08:51because the blood is in the wrong part of your body.
0:08:51 > 0:08:53Which are the worst bits for pain at the moment?
0:08:55 > 0:08:56All right, mate.
0:08:56 > 0:08:59We're just going to put these warming blankets under you, mate.
0:08:59 > 0:09:01Is his skin cold because he's lying out in the cold,
0:09:01 > 0:09:04or is his skin cold because he's lost a significant amount of blood
0:09:04 > 0:09:07and needs to be topped up with blood or get to an operation very, very quickly?
0:09:07 > 0:09:09What we're going to do, Pete,
0:09:09 > 0:09:12is just gets you scooped up now and into the ambulance,
0:09:12 > 0:09:14so we'll warm you up and then we can have a proper look at you
0:09:14 > 0:09:17and work out what's going on with you, mate.
0:09:17 > 0:09:19The team want to get Peter onto the ambulance
0:09:19 > 0:09:22so they can fully assess him for signs of bleeding.
0:09:22 > 0:09:26But Peter needs to be turned on to his back and moving injured patients
0:09:26 > 0:09:27carries risk.
0:09:27 > 0:09:31My concern at this stage is that by rolling him over,
0:09:31 > 0:09:35any clots that might be forming within the pelvic area,
0:09:35 > 0:09:39that might just be holding off some bleeding, may be disrupted.
0:09:39 > 0:09:42So, let's just get that out of the way there.
0:09:42 > 0:09:45So, what we need you to do is to roll this way
0:09:45 > 0:09:47onto that stretcher there, mate.
0:09:48 > 0:09:52I've still got in the back of my mind that there could be an unseen
0:09:52 > 0:09:56haemorrhage, and I can recall many occasions where I've been talking to
0:09:56 > 0:09:57patients one minute,
0:09:57 > 0:10:01only to find that they have died within an hour or two.
0:10:01 > 0:10:03Are we ready?
0:10:03 > 0:10:04Me knees!
0:10:04 > 0:10:05All right, Pete.
0:10:05 > 0:10:07PETE GROANS
0:10:10 > 0:10:12All right.
0:10:12 > 0:10:14Stay square on, stay square on.
0:10:14 > 0:10:16Well done, mate.
0:10:16 > 0:10:18Worst is over, mate, we'll get you in the warm.
0:10:31 > 0:10:3318 minutes ago,
0:10:33 > 0:10:36police in central London triggered an emergency medical alert
0:10:36 > 0:10:38following a serious road accident.
0:10:38 > 0:10:40From medic two.
0:10:43 > 0:10:46Travelling to this scene are London's air ambulance,
0:10:46 > 0:10:49consultant Gareth Davies and paramedic Nick Hardy,
0:10:49 > 0:10:51who are now only minutes away.
0:10:53 > 0:10:54Straight across here.
0:10:54 > 0:10:59We know that it's some form of crash involving a car,
0:10:59 > 0:11:02and one of the occupants, and that's it.
0:11:02 > 0:11:05On the way there, you forever have a ticking clock
0:11:05 > 0:11:07in the back of your head.
0:11:07 > 0:11:09You know time is everything.
0:11:09 > 0:11:12Red base from medic two, just to let you know we're on scene.
0:11:14 > 0:11:19Female in the ambulance on the left has got a head injury.
0:11:19 > 0:11:20A head injury.
0:11:21 > 0:11:25My first impression is this is a serious accident.
0:11:25 > 0:11:27There seems to be two cars involved
0:11:27 > 0:11:32and we really need to establish just how many patients there are.
0:11:32 > 0:11:35Whilst Nick checks the condition of the other occupant,
0:11:35 > 0:11:38Gareth is directed to where London Ambulance Service paramedic
0:11:38 > 0:11:42Katie Edwards is treating 24-year-old Jacqueline.
0:11:42 > 0:11:46She was screaming at me, shouting about the pain in her arm.
0:11:46 > 0:11:48It was only quite a short period of time
0:11:48 > 0:11:51that she was actually quite lucid and speaking to me.
0:11:51 > 0:11:52JACQUELINE GROANS
0:11:52 > 0:11:56We need this arm. Jacqueline, it's Katie.
0:11:56 > 0:11:59I was able to walk her to the ambulance.
0:11:59 > 0:12:02At which point her conscious levels started dropping quite substantially
0:12:02 > 0:12:04and quite quickly.
0:12:04 > 0:12:07I'm cold! I know, my darling, I'll pop the blankets on you.
0:12:07 > 0:12:09You just need to try and stay nice and calm.
0:12:09 > 0:12:12Jacqueline's head has taken the full force of the impact,
0:12:12 > 0:12:15leaving her with an open skull fracture.
0:12:15 > 0:12:18I could tell she was seriously injured.
0:12:18 > 0:12:23The fractured skull had been forced into her brain matter
0:12:23 > 0:12:26and, literally, like toothpaste out of a tube,
0:12:26 > 0:12:30that brain matter had been forced past the cracks in the bones
0:12:30 > 0:12:32and come out through the wound.
0:12:32 > 0:12:35She's sort of obeying commands, she's not vocalising at all. OK.
0:12:35 > 0:12:37she's not opened her eyes any more so her GCS is falling.
0:12:37 > 0:12:38Is that better?
0:12:38 > 0:12:41The team monitoring Jacqueline had been assessing her level
0:12:41 > 0:12:44of consciousness using the Glasgow coma score.
0:12:45 > 0:12:47We have a scale which is split into three.
0:12:47 > 0:12:50You're looking at the eye movements,
0:12:50 > 0:12:53their verbal response and their motor movements.
0:12:53 > 0:12:56Three is the worst you can score and 15 is the best you can score.
0:12:58 > 0:13:01What was facing us now was someone who had deteriorated
0:13:01 > 0:13:05to a score of 10 or 11, or something of that region.
0:13:05 > 0:13:08You just need to let the doctors help you, OK?
0:13:08 > 0:13:12Now she was just speaking in simple one word sentences,
0:13:12 > 0:13:15sometimes incomprehensible sounds.
0:13:15 > 0:13:19And that shows that the brain is becoming dysfunctional,
0:13:19 > 0:13:20it's not working.
0:13:20 > 0:13:23I'm cold! I know, I know, darling.
0:13:23 > 0:13:25Guys, can you just get some Medaz ready as well?
0:13:25 > 0:13:28Gareth believes Jacqueline is starting to show signs
0:13:28 > 0:13:29of a serious brain injury.
0:13:29 > 0:13:32Was it her brain that was swelling?
0:13:32 > 0:13:37Was it a blood clot that was growing inside her skull that was causing her to deteriorate?
0:13:37 > 0:13:40And that's when medicine needs to step in.
0:13:40 > 0:13:42We could potentially turn that around.
0:13:42 > 0:13:44Jacqueline? Jacqueline?
0:13:44 > 0:13:48Gareth fears Jacqueline's head injury could soon start
0:13:48 > 0:13:51to compromise her ability to breathe.
0:13:51 > 0:13:52Well done, darling.
0:13:52 > 0:13:53You're doing so well.
0:13:53 > 0:13:56In order to protect Jacqueline's breathing,
0:13:56 > 0:13:59Gareth wants to anaesthetise her at the roadside using a process called
0:13:59 > 0:14:03rapid sequence induction, or RSI.
0:14:03 > 0:14:04Flush here as well. OK, thanks.
0:14:04 > 0:14:06If we can do the breathing,
0:14:06 > 0:14:11we can guarantee that the right levels of carbon dioxide in her blood are there
0:14:11 > 0:14:14and that will minimise any pressure within the skull.
0:14:14 > 0:14:17How are we doing? We're good, I'm ready.
0:14:17 > 0:14:20We'll go with this position here, I think.
0:14:20 > 0:14:22To anaesthetise Jacqueline,
0:14:22 > 0:14:25Gareth uses a combination of powerful sedative drugs
0:14:25 > 0:14:28which he must administer in precise quantities.
0:14:28 > 0:14:29So we've got fentanyl.
0:14:31 > 0:14:3450 micrograms, one mil of fentanyl.
0:14:35 > 0:14:37When you have a serious head injury,
0:14:37 > 0:14:40the last thing you need is a low blood pressure
0:14:40 > 0:14:43and the drugs that we give can lower blood pressure
0:14:43 > 0:14:47so we had to get the dosing absolutely right
0:14:47 > 0:14:51to make sure that her brain wasn't further damaged by that process.
0:14:51 > 0:14:52Suction please. Suction.
0:14:56 > 0:14:57A lot of blood.
0:15:01 > 0:15:05Once they have inserted a breathing tube into Jacqueline's windpipe,
0:15:05 > 0:15:09Nick is able to finally control the levels of oxygen and carbon dioxide
0:15:09 > 0:15:11in the blood going to her brain.
0:15:11 > 0:15:12Sats 100.
0:15:12 > 0:15:14You can carry on, probably a little bit faster.
0:15:14 > 0:15:19There's a number here, it says 4.9. Can you see that purple number?
0:15:19 > 0:15:21Ideally we're trying to get that down a little to about four.
0:15:21 > 0:15:25'Unfortunately, there's very little that we can do about wound
0:15:25 > 0:15:27'and the fractures on scene.'
0:15:27 > 0:15:31Our focus is on keeping Jacqueline alive so she gets to hospital.
0:15:31 > 0:15:34We can probably go a little bit faster.
0:15:43 > 0:15:46120 miles away in Bristol,
0:15:46 > 0:15:4918-year-old Christy is in a critical condition
0:15:49 > 0:15:50after being hit by a car.
0:15:52 > 0:15:55Greg, Neil and Vicky fear she has a severe brain injury
0:15:55 > 0:15:59and are moving fast to assess for any other threats to her life.
0:15:59 > 0:16:01Can you open your eyes for me?
0:16:01 > 0:16:04To be honest she's saturated 100, so it's not huge.
0:16:04 > 0:16:06I didn't find any other signs of serious injury.
0:16:06 > 0:16:09We can't exclude that for certain,
0:16:09 > 0:16:12but it reassured ourselves that we didn't need to do anything
0:16:12 > 0:16:15immediately before dealing with the primary problem
0:16:15 > 0:16:18that we knew we had, and that was the brain injury.
0:16:18 > 0:16:22She's either hit her head on the vehicle that's hit her,
0:16:22 > 0:16:25or she's hit her head as she's fallen back onto the road.
0:16:25 > 0:16:26You're going to get bruising,
0:16:26 > 0:16:30then you get swelling just like you can in any other part of the body.
0:16:30 > 0:16:35But the brain is within a rigid box so it can only swell so much.
0:16:35 > 0:16:38Without being able to see the damage in Christy's head,
0:16:38 > 0:16:42Vicky's only way to assess her is by the size of her pupils.
0:16:42 > 0:16:45I'm not seeing signs at the moment with the pupils,
0:16:45 > 0:16:47but if the pupils become unequal,
0:16:47 > 0:16:49or not reacting to the light,
0:16:49 > 0:16:52that's a big sign for us to say that the brain is now starting
0:16:52 > 0:16:55to herniate, and this is very life-threatening.
0:16:56 > 0:16:58With Christy showing no signs of improvement,
0:16:58 > 0:17:02the team now need to act fast to keep her stable.
0:17:02 > 0:17:04At the time of the accident,
0:17:04 > 0:17:07the brain sustains an impact injury,
0:17:07 > 0:17:10that's called the primary brain injury.
0:17:10 > 0:17:13We can't do anything about that, that's already happened.
0:17:13 > 0:17:17What we can do is prevent any secondary brain injury.
0:17:17 > 0:17:20And that's all about optimising the conditions
0:17:20 > 0:17:22that the brain is living within.
0:17:23 > 0:17:28If the brain is starting to be compromised due to lack of oxygen,
0:17:28 > 0:17:32then it can be a matter of minutes before the brain starts to become
0:17:32 > 0:17:33damaged because of that.
0:17:33 > 0:17:36Right, guys, we're going to pop her off to sleep.
0:17:36 > 0:17:38To prevent further damage to Christy's brain
0:17:38 > 0:17:40from lack of oxygen,
0:17:40 > 0:17:41the team want to anaesthetise her
0:17:41 > 0:17:44in order to take control of her breathing.
0:17:44 > 0:17:45Vicky, Greg - happy?
0:17:45 > 0:17:46Happy.
0:17:46 > 0:17:48So, ketamine is going in now.
0:17:48 > 0:17:53We want to control her breathing so that we can control her gases
0:17:53 > 0:17:57within her blood that have effects on how well blood gets to the brain.
0:17:59 > 0:18:01With the drugs administered,
0:18:01 > 0:18:04Vicky must wait one minute for the paralysis to take effect
0:18:04 > 0:18:06so she can insert the breathing tube.
0:18:06 > 0:18:09OK, that's coming up for a minute.
0:18:09 > 0:18:10That's 55 seconds.
0:18:13 > 0:18:14OK, and there's your minute.
0:18:17 > 0:18:19Tube.
0:18:21 > 0:18:22Got it.
0:18:23 > 0:18:25With the tube inserted,
0:18:25 > 0:18:28Greg quickly connects Christy to a ventilator to ensure her breathing
0:18:28 > 0:18:31rate is kept at a constant level.
0:18:31 > 0:18:33What rate's she on at the moment?
0:18:33 > 0:18:37About 18 at the moment, we've got it down to 4.3.
0:18:37 > 0:18:40The only way to determine how badly her brain is injured
0:18:40 > 0:18:42is to get Christy to a CT scan.
0:18:42 > 0:18:44Pressure's at 21.
0:18:44 > 0:18:46Ventilating OK.
0:18:46 > 0:18:47Looks all right, doesn't it?
0:18:47 > 0:18:50What we've done up to this point is purely
0:18:50 > 0:18:52just controlling things as best we can,
0:18:52 > 0:18:56stabilising her so that she can be transferred safely to hospital.
0:18:57 > 0:18:59I need to have a listen to the chest.
0:19:01 > 0:19:03It may well be that there is something
0:19:03 > 0:19:06that needs immediate operation to relieve that pressure or swelling
0:19:06 > 0:19:08in order to increase her chances.
0:19:10 > 0:19:13Guys, how long do you reckon?
0:19:15 > 0:19:18That's brilliant. No more than 15.
0:19:27 > 0:19:29In Gloucester,
0:19:29 > 0:19:32doctors and paramedics are still trying to assess truck driver
0:19:32 > 0:19:35Peter's injuries after he was run over by a forklift.
0:19:37 > 0:19:39Where's your pain now, fella?
0:19:40 > 0:19:43Yeah, I bet, horrible laying on that concrete all that time.
0:19:43 > 0:19:45Can you feel pain, Pete?
0:19:45 > 0:19:47So have you had morphine before? No.
0:19:47 > 0:19:50Have five of it, mate, it's quite a small dose for a big lad like you.
0:19:52 > 0:19:53To relieve his severe pain,
0:19:53 > 0:19:56James gives Peter intravenous morphine.
0:19:56 > 0:19:59What's the worst bit that's in pain at the moment?
0:20:02 > 0:20:06So it's mainly around your groin and then the bottom of your legs.
0:20:06 > 0:20:08In my legs it just feels like a golf ball.
0:20:08 > 0:20:12His legs are hurting round there, Pete, that's the bit that's hurting.
0:20:12 > 0:20:14The pain in Peter's groin suggests
0:20:14 > 0:20:16he's damaged the bones in his pelvis.
0:20:18 > 0:20:22So, the pelvis, if it loses integrity, if it loses its shell,
0:20:22 > 0:20:27becomes a floppy sack and your disrupted blood vessels,
0:20:27 > 0:20:29if they are damaged by this crush injury,
0:20:29 > 0:20:31can just leak blood at a fast rate.
0:20:31 > 0:20:35We need to take all the clothes out from underneath you and we're going
0:20:35 > 0:20:37to put something around your pelvis.
0:20:37 > 0:20:39Right. Pelvic binder.
0:20:39 > 0:20:40To help control any bleeding,
0:20:40 > 0:20:43Peter and James decide to bind Peter's pelvis.
0:20:43 > 0:20:46HE MOANS
0:20:46 > 0:20:47All right, all right, OK.
0:20:47 > 0:20:51My legs, my legs! All right, I'm sorry, I'm really, really sorry.
0:20:51 > 0:20:57The pelvic binder is a really good way of turning that potential space
0:20:57 > 0:20:59into a more restricted space.
0:20:59 > 0:21:02So the binder goes around the broken pelvis,
0:21:02 > 0:21:05you pull the binder tight and if blood is leaking into that area,
0:21:05 > 0:21:08it stops once it's reached the pressure around the binder.
0:21:08 > 0:21:11OK, have you got that one, then?
0:21:12 > 0:21:13There we go.
0:21:15 > 0:21:16With Peter's pelvis bound,
0:21:16 > 0:21:19James can continue looking for other signs of injury.
0:21:19 > 0:21:21Squeeze my fingers really, really tight.
0:21:21 > 0:21:23OK. That's it. Hold your arm still.
0:21:23 > 0:21:26Don't let me move them, all right? Don't let me move them.
0:21:26 > 0:21:30Before I arrived, I was incredibly worried that he was going to have
0:21:30 > 0:21:33either life-threatening or life-changing injuries.
0:21:33 > 0:21:37Can you feel me touching you? Yeah.
0:21:37 > 0:21:39The further through the assessment I could get,
0:21:39 > 0:21:42the chances of that were diminishing but I was still concerned enough
0:21:42 > 0:21:45that he had major pelvic injury and needed to go to Southmead Hospital.
0:21:45 > 0:21:48Any pain in your chest up here at all, mate? Anything at all? Nothing.
0:21:48 > 0:21:51No, these bits weren't injured, is that right?
0:21:51 > 0:21:52Fine.
0:21:52 > 0:21:54Fine. Pelvis we're worried about.
0:21:54 > 0:21:57And then I think soft-tissue injury around the legs.
0:21:57 > 0:21:59I can't see any obvious fractures, no.
0:21:59 > 0:22:02So the question... He certainly might have a lot of soft-tissue injury
0:22:02 > 0:22:05around his legs and things like that, so I think Southmead seems
0:22:05 > 0:22:07the most appropriate place for him to go. I agree.
0:22:07 > 0:22:10Only detailed scans and X-rays at a major trauma centre will reveal
0:22:10 > 0:22:13the exact nature of Peter's injuries.
0:22:13 > 0:22:15What's that pain score now, Peter?
0:22:15 > 0:22:17About seven. It's about a seven?
0:22:17 > 0:22:19So earlier on it was ten, was it?
0:22:33 > 0:22:35In the last 60 minutes,
0:22:35 > 0:22:38emergency clinicians have battled to deliver interventions
0:22:38 > 0:22:41and medical care to three critically ill patients.
0:22:42 > 0:22:44After being hit by a car,
0:22:44 > 0:22:46Christy is being rushed into hospital
0:22:46 > 0:22:49in order to assess the damage to her brain.
0:22:50 > 0:22:54Jacqueline has been anaesthetised following a car crash that left her
0:22:54 > 0:22:55with an open-skull fracture.
0:22:57 > 0:22:59And after being run over by a forklift truck,
0:22:59 > 0:23:03Peter's lower body has been badly damaged and doctors suspect he may
0:23:03 > 0:23:05be bleeding internally.
0:23:09 > 0:23:13In central London, medical teams are on the scene treating Jacqueline
0:23:13 > 0:23:16after she was involved in a serious road collision.
0:23:18 > 0:23:21She's a female, looks to be in her 20s.
0:23:21 > 0:23:23She's got an obvious skull fracture
0:23:23 > 0:23:26in the forehead and facial lacerations
0:23:26 > 0:23:29and she's been intubated and ventilated.
0:23:29 > 0:23:31Right. Can you shout out some numbers for me?
0:23:31 > 0:23:32Yep. We've got...
0:23:33 > 0:23:35..sats are 100%.
0:23:35 > 0:23:36Heart rate is 120.
0:23:36 > 0:23:38You've got end tidal 4.2 and a good waveform.
0:23:38 > 0:23:41Although they've taken control of her breathing,
0:23:41 > 0:23:44Gareth is worried that the huge impact to Jacqueline's head has
0:23:44 > 0:23:46caused bleeding within her skull.
0:23:46 > 0:23:49My real concern was for what was going on
0:23:49 > 0:23:51underneath those broken bones,
0:23:51 > 0:23:56blood vessels within the skull may have been lacerated and start to
0:23:56 > 0:24:01produce blood clots that themselves threaten the brain tissue.
0:24:02 > 0:24:04To detect signs of bleeding,
0:24:04 > 0:24:08London's air ambulance teams are using a pioneering new device called
0:24:08 > 0:24:09an infrascanner.
0:24:09 > 0:24:12I've got the scanner down here, Gareth and it's turning on.
0:24:12 > 0:24:15We can use the infrascanner to maybe give us a slightly clearer
0:24:15 > 0:24:17picture of what's going on underneath the skull.
0:24:17 > 0:24:21The device uses infrared light to detect the presence of blood
0:24:21 > 0:24:22in or around the brain.
0:24:24 > 0:24:26The infrascanner is very simple.
0:24:26 > 0:24:29Where it believes there is a blood clot, it shines up red.
0:24:29 > 0:24:33Where it believes there isn't a blood clot, it shines up green.
0:24:33 > 0:24:37OK. And we can't do, obviously, the...
0:24:37 > 0:24:41It's saying... Yes, it's suggesting haematoma on the right-hand side.
0:24:41 > 0:24:46We got a quite clear indication that there were blood clots deep within
0:24:46 > 0:24:49the skull itself and perhaps the brain matter.
0:24:50 > 0:24:53What we need to know is the extent of that bleeding,
0:24:53 > 0:24:55whether it's getting worse.
0:24:55 > 0:24:59That means that we need to get Jacqueline as quickly as we can
0:24:59 > 0:25:00to a major trauma centre
0:25:00 > 0:25:03to have a scan to give us a much better idea of what's
0:25:03 > 0:25:05going on underneath her skull.
0:25:07 > 0:25:11Gareth is transporting Jacqueline to the Royal London Hospital,
0:25:11 > 0:25:14where she may need the help of specialist neurosurgeons
0:25:14 > 0:25:17to remove any blood clots from in and around her brain.
0:25:18 > 0:25:20I'll put a blue call in, yeah? OK.
0:25:22 > 0:25:24Hi, it's Gareth here.
0:25:24 > 0:25:27Just to let you know I am bringing you a patient.
0:25:27 > 0:25:30She is a 25-year-old
0:25:30 > 0:25:34young girl, she's got a big skull fracture with some brain tissue on
0:25:34 > 0:25:37the surface of her skin. We're leaving the scene now,
0:25:37 > 0:25:40so I guess we're going to be about 12 to 15 minutes.
0:25:40 > 0:25:41Bye.
0:25:44 > 0:25:45Let's hope the infrascanner is wrong.
0:25:53 > 0:25:54In Bristol,
0:25:54 > 0:25:5918-year-old pedestrian Christy is being rushed into Southmead Hospital
0:25:59 > 0:26:01so they can assess her brain injury.
0:26:02 > 0:26:06Waiting in the emergency department is consultant Nicola Morgan.
0:26:08 > 0:26:11My concern at this point is that she has had a significant injury,
0:26:11 > 0:26:13a significant impact with a car.
0:26:13 > 0:26:16We know she's got a head injury and we know that could get worse if we
0:26:16 > 0:26:18don't look after her properly.
0:26:18 > 0:26:22But I'm also suspicious of trying to find any other injuries that might
0:26:22 > 0:26:24be there before she becomes more unwell from them.
0:26:24 > 0:26:28So let's get the patient across and then we'll take handover.
0:26:28 > 0:26:32Doctors have given Christy a general anaesthetic at the roadside
0:26:32 > 0:26:35and are breathing for her using a ventilator.
0:26:35 > 0:26:38So this is a young female, approximately 20 years old,
0:26:38 > 0:26:41seemed to go over something into the air.
0:26:41 > 0:26:43We think she's got an isolated head injury,
0:26:43 > 0:26:45she has swelling to her left head.
0:26:45 > 0:26:48We haven't found any other specific injury anywhere else.
0:26:48 > 0:26:50Her pupils were fine.
0:26:50 > 0:26:51OK, she's had an RSI.
0:26:51 > 0:26:53321 fentanyl ketamine rock.
0:26:53 > 0:26:56I think that completes for now. Over to you, I'll be available.
0:26:56 > 0:26:57Lovely, thank you so much.
0:26:57 > 0:26:59So let's start with a primary survey.
0:26:59 > 0:27:01She's young, and it's always difficult,
0:27:01 > 0:27:04it doesn't matter who the patient is or what age they are,
0:27:04 > 0:27:07it's always difficult to look after someone who you know could be
0:27:07 > 0:27:09significantly injured and could...
0:27:09 > 0:27:12Their life is likely to change from this point.
0:27:12 > 0:27:14Airway secure. Lovely.
0:27:14 > 0:27:16Good air entry bilaterally.
0:27:16 > 0:27:17Lovely, thank you.
0:27:17 > 0:27:19No obvious pelvic injury.
0:27:19 > 0:27:22OK, the plan is - as soon as we've got access and blood sent off,
0:27:22 > 0:27:24we'll take the scoop out, we'll check her temperature,
0:27:24 > 0:27:27we'll keep her warm and get her round to scan.
0:27:27 > 0:27:29I'm feeling quite uncomfortable at this point.
0:27:29 > 0:27:33We're gathering information but we still don't really know what
0:27:33 > 0:27:35happened, we don't really know
0:27:35 > 0:27:36how unwell she's going to be.
0:27:36 > 0:27:40We suspected she's got a head injury but we don't really know exactly
0:27:40 > 0:27:42the extent of that.
0:27:42 > 0:27:45Nicky's hope is that a CT scan will reveal vital
0:27:45 > 0:27:47information about the extent of the injuries.
0:27:50 > 0:27:53OK, we're all ready to go from a button-pushing point of view.
0:27:58 > 0:28:01What I can see is there's some bruising to the left side of her head,
0:28:01 > 0:28:04sort of near the back, but the bruising to her brain is near the front,
0:28:04 > 0:28:08so I'm suspecting now that she's had maybe two lots of impact.
0:28:08 > 0:28:11Where she's hit her head once on the side and then the brain shunted
0:28:11 > 0:28:13itself forward and injured the front of the brain.
0:28:13 > 0:28:16So I'm suspicious that there might be two areas of injury to her brain,
0:28:16 > 0:28:18which obviously is worse than one.
0:28:20 > 0:28:23Any bruising to Christy's brain could be a sign
0:28:23 > 0:28:25of permanent brain damage.
0:28:27 > 0:28:31This is particularly worrying for me because the front part of the brain
0:28:31 > 0:28:33controls so many things,
0:28:33 > 0:28:37it's so important not only to things like voluntary movement and how we
0:28:37 > 0:28:41move around but particularly it's really involved in personality and
0:28:41 > 0:28:46in emotion and in behaviour and how people react and how they speak.
0:28:48 > 0:28:51Christy's scan also reveals a fracture of the bone
0:28:51 > 0:28:53at the back of her skull.
0:28:53 > 0:28:57All of the nerves and blood vessels that control the rest of your body
0:28:57 > 0:28:59come from your brain through the bottom of your skull
0:28:59 > 0:29:00and into your body.
0:29:00 > 0:29:04So having a break in the bottom of the skull can affect those nerves
0:29:04 > 0:29:05and those blood vessels.
0:29:05 > 0:29:09Best motor score is withdrawing of pain to both arms
0:29:09 > 0:29:11before she was RSI'd.
0:29:14 > 0:29:16Nicky has further concerns that
0:29:16 > 0:29:18Christy's injured brain is now swelling.
0:29:20 > 0:29:24I can see that the spaces around Christy's brain look smaller than
0:29:24 > 0:29:27I would expect them to be, so I'm already concerned that there is an
0:29:27 > 0:29:29increase in pressure inside of her skull.
0:29:29 > 0:29:31And because the skull is fixed,
0:29:31 > 0:29:33there's nowhere for that pressure to go.
0:29:33 > 0:29:36So we need to really keep a close eye on what effect that's having on
0:29:36 > 0:29:39her. I'm really worried for Christy at the moment.
0:29:39 > 0:29:41This is a significant injury to her brain.
0:29:43 > 0:29:45OK.
0:29:45 > 0:29:48Nicky fears that the swelling to Christy's brain will continue to
0:29:48 > 0:29:50get worse over the coming hours.
0:29:50 > 0:29:54Secondary survey shows nothing other than the traumatic brain injury.
0:29:56 > 0:29:59If the swelling in her brain continues to increase,
0:29:59 > 0:30:03the worst-case scenario really is that the nerves and the blood supply
0:30:03 > 0:30:05that controls how she breathes and
0:30:05 > 0:30:07how her heart functions could be affected
0:30:07 > 0:30:10and if those things get interrupted then her heart could stop and she
0:30:10 > 0:30:11could stop breathing.
0:30:12 > 0:30:13Straight to theatre.
0:30:23 > 0:30:27Truck driver Peter is arriving at Southmead Hospital where emergency
0:30:27 > 0:30:31department consultant Leilah Dare has assembled a specialist trauma
0:30:31 > 0:30:32team to deal with his injuries.
0:30:32 > 0:30:35When someone's been run over by a forklift truck,
0:30:35 > 0:30:38that immediately makes me worried that they've got some serious
0:30:38 > 0:30:41injuries that I need to worry about and act on quickly.
0:30:41 > 0:30:45Doctors fear the weight of the forklift has damaged his internal organs.
0:30:45 > 0:30:51It's a 40-minute journey to get Peter to me and he could be bleeding
0:30:51 > 0:30:54or his injuries could be getting worse in that time and I need to be
0:30:54 > 0:30:58prepared for that. What I want to do is just have a quick primary survey.
0:30:58 > 0:31:01Then split the scoop, get some bloods and go to scan.
0:31:03 > 0:31:06Peter needs a CT scan but doctors must first make sure
0:31:06 > 0:31:09he's stable enough to go.
0:31:09 > 0:31:10OK, yes, so airway intact.
0:31:10 > 0:31:12Good air entry throughout.
0:31:12 > 0:31:15Any signs of bruising or anything on the chest?
0:31:15 > 0:31:17No. Blood pressure of 119/75.
0:31:18 > 0:31:21Right, let's keep him covered up and then let's go to scan.
0:31:22 > 0:31:26So my concerns are that he may have pelvic fractures and if he does have
0:31:26 > 0:31:27a pelvic fracture he may have other
0:31:27 > 0:31:29injuries in the abdomen or the pelvis.
0:31:30 > 0:31:32And they can bleed catastrophically
0:31:32 > 0:31:34and you can bleed to death from pelvic injuries
0:31:34 > 0:31:37and it's really important that we find them and treat them as
0:31:37 > 0:31:38quickly as possible.
0:31:38 > 0:31:40One, two, three, across.
0:31:43 > 0:31:45To try to prevent any excessive blood loss,
0:31:45 > 0:31:49Peter had his legs and pelvis bound on scene.
0:31:49 > 0:31:52Only when we know exactly what fracture we're dealing with,
0:31:52 > 0:31:55when I know exactly the nature of it will I then decide whether
0:31:55 > 0:31:57the pelvic binder can come off.
0:31:58 > 0:32:01Treatment he's had on scene is I think about 15 milligrams of morphine.
0:32:01 > 0:32:03Pelvic binder, legs tied together.
0:32:03 > 0:32:06And transported, final transport, GCS is 15.
0:32:08 > 0:32:12Peter is undergoing a full-body scan to look for any broken bones,
0:32:12 > 0:32:15bleeding or organ damage that will need immediate treatment.
0:32:16 > 0:32:18He's got a tiny fracture to the front of his pelvis
0:32:18 > 0:32:22but actually everything else looks OK.
0:32:22 > 0:32:25I'm very surprised at what I see.
0:32:25 > 0:32:28I really think that Peter should have some nasty injuries and
0:32:28 > 0:32:31actually I'm quite amazed that I can't see anything on the scans.
0:32:31 > 0:32:34And then I really worry - "Right, if that's not injured,
0:32:34 > 0:32:35"then where else is he injured?"
0:32:35 > 0:32:39Cos he must have done something, having been run over by a forklift truck.
0:32:39 > 0:32:43Until a radiologist can look at Peter's scans in more detail,
0:32:43 > 0:32:46Leilah can't be sure that there aren't more serious injuries.
0:32:56 > 0:33:00In Whitechapel, Jacqueline has been rushed to the Royal London Hospital
0:33:00 > 0:33:03after a car accident left her with serious injuries
0:33:03 > 0:33:04including an open-skull fracture.
0:33:04 > 0:33:06Evening, everyone. Or morning, I should say.
0:33:06 > 0:33:09Morning. So this is Jacqueline.
0:33:09 > 0:33:11She's got a severe head injury,
0:33:11 > 0:33:14she's got an obvious deformity to her frontal bone,
0:33:14 > 0:33:16she's got a ten-centimetre laceration.
0:33:17 > 0:33:20With some evidence of brain matter in that wound.
0:33:20 > 0:33:24Pupils are small and reactive and the infrascanner suggests she's got
0:33:24 > 0:33:26a right sided haematoma.
0:33:26 > 0:33:28Thank you.
0:33:28 > 0:33:32A mobile scan made of Jacqueline's head at the scene indicates she may
0:33:32 > 0:33:34be bleeding within her skull.
0:33:36 > 0:33:41It's now up to emergency medicine consultant Malik Ramadhan to locate
0:33:41 > 0:33:43the bleeding and determine the next course of action.
0:33:44 > 0:33:47We're going to run through a quick check to make sure that nothing is
0:33:47 > 0:33:50changed since Gareth handed her over.
0:33:50 > 0:33:51Stable.
0:33:54 > 0:33:57She's got an obvious injury to her face.
0:33:57 > 0:33:58If there's a threat to her life,
0:33:58 > 0:34:03it will be bleeding inside her head, which I can't see by looking at her.
0:34:03 > 0:34:08The CT scan will allow me to decide how quickly we need to operate on
0:34:08 > 0:34:10her. Given that she seems pretty solid,
0:34:10 > 0:34:13I'm quite keen to get her head scanned.
0:34:23 > 0:34:25Ready, steady, go.
0:34:27 > 0:34:30The images of Jacqueline's head reveal the full extent of the damage.
0:34:34 > 0:34:35This is all fractures. Fracture.
0:34:36 > 0:34:40Most, if not all, of the impact has been taken through the forehead.
0:34:40 > 0:34:43This is her forehead, that should be in continuity.
0:34:44 > 0:34:46The bone's been driven into her head.
0:34:50 > 0:34:53That's brain, the white is blood.
0:34:53 > 0:34:57She has some bleeding inside her brain, which is from the force and
0:34:57 > 0:35:01possibly from a fragment of bone that's damaged her brain.
0:35:01 > 0:35:04She's got some bleeding on the surface of her brain.
0:35:04 > 0:35:08Even a small amount of bleeding will cause pressure on the brain.
0:35:08 > 0:35:12Malik's priority is to look for any bleeding or swelling that will
0:35:12 > 0:35:15require Jacqueline to have immediate neurosurgery.
0:35:16 > 0:35:21It doesn't look like she needs an operation this second to remove
0:35:21 > 0:35:23blood from inside her skull.
0:35:24 > 0:35:27If she stopped bleeding and I'm looking at a clot,
0:35:27 > 0:35:29then we've got time to wait.
0:35:29 > 0:35:31If she's still bleeding inside her head,
0:35:31 > 0:35:34potentially it will get bigger and bigger and she still might
0:35:34 > 0:35:35need to have an operation.
0:35:37 > 0:35:39To monitor the pressure from any
0:35:39 > 0:35:41bleeding or swelling in Jacqueline's brain,
0:35:41 > 0:35:45neurosurgeons attach an intracranial pressure bolt to her skull.
0:35:47 > 0:35:49So now the bolt's working,
0:35:49 > 0:35:51I can see that the pressure inside her head is normal.
0:35:51 > 0:35:56Which means that she doesn't need an operation and that when she's on
0:35:56 > 0:35:59the intensive care unit, they can monitor that pressure
0:35:59 > 0:36:02and be reassured that she's not still bleeding inside her head.
0:36:02 > 0:36:04The reconstructed 3-D CT scans
0:36:04 > 0:36:07give Malik the ability to fully visualise
0:36:07 > 0:36:11the extent of the fractures to Jacqueline's skull and facial bones.
0:36:11 > 0:36:13Essentially, that's the fracture.
0:36:13 > 0:36:15And it extends down into both her
0:36:15 > 0:36:18eye sockets and then there are fractures
0:36:18 > 0:36:20in the floor of the eye as well.
0:36:20 > 0:36:23She clearly has a huge skull and facial injury
0:36:23 > 0:36:25and a soft-tissue injury
0:36:25 > 0:36:28that will need to be fixed and it's likely
0:36:28 > 0:36:31to require multiple specialties to fix it successfully.
0:36:33 > 0:36:37Once we're happy that the brain injury isn't developing
0:36:37 > 0:36:41and that she's had her best chance of her brain recovering,
0:36:41 > 0:36:45we would then look to operate to fix the fractures to her face.
0:36:49 > 0:36:51Can we just quickly catch up with things that need to happen?
0:36:51 > 0:36:53Yes. So we're going to do a central line. Yup.
0:36:53 > 0:36:55Do an arterial line. Yup. Once we've got access,
0:36:55 > 0:36:58we're going to give some phenytoin for seizure prophylaxis.
0:37:00 > 0:37:03To protect Jacqueline's brain whilst she recovers,
0:37:03 > 0:37:05the team close the wound on her forehead.
0:37:05 > 0:37:08We can't leave someone with their brain exposed.
0:37:08 > 0:37:10There's a massive risk of infection.
0:37:10 > 0:37:13The sutures will allow the brain to be protected whilst we wait for
0:37:13 > 0:37:14the operation to happen.
0:37:18 > 0:37:22Jacqueline is now moved to intensive care where her brain injury can be
0:37:22 > 0:37:25monitored closely round the clock.
0:37:25 > 0:37:29She's now unlikely to die in the next 20 to 30 minutes.
0:37:29 > 0:37:34But the risk of infection is huge and anyone with an injury like this
0:37:34 > 0:37:37that goes to intensive care is absolutely not out of the woods.
0:37:55 > 0:37:59It's been three-and-a-half hours since Christy was hit by a car,
0:37:59 > 0:38:01leaving her with a traumatic brain injury.
0:38:03 > 0:38:06The bruising to her brain is causing it to swell,
0:38:06 > 0:38:07increasing the pressure in her skull.
0:38:09 > 0:38:13She now requires neurosurgery and has been taken to theatre,
0:38:13 > 0:38:18supervised by neurosurgeon specialist registrar Adam Williams.
0:38:18 > 0:38:22With Christy, the brain swelling is happening very rapidly indeed,
0:38:22 > 0:38:26so if we didn't intervene and the swelling continued,
0:38:26 > 0:38:30then we would expect her to exhaust her own body's ability
0:38:30 > 0:38:32to cope with that change in pressure.
0:38:33 > 0:38:37And then inevitably the brain would start to herniate,
0:38:37 > 0:38:39to move to different parts of the skull,
0:38:39 > 0:38:42causing pressure on critical structures.
0:38:43 > 0:38:46And there is every chance that that would be life-threatening.
0:38:47 > 0:38:49To manage the pressure in her skull,
0:38:49 > 0:38:53Christy is having an operation to remove the fluid in her brain.
0:38:53 > 0:38:59The aim to remove the brain fluid is to give more space within the skull,
0:38:59 > 0:39:03so that the brain, which is swelling, can fill that space.
0:39:03 > 0:39:08Neurosurgical clinical fellow Asli Aziz must drill a precise hole
0:39:08 > 0:39:11through Christy's skull and insert the drain or catheter
0:39:11 > 0:39:15deep within the fluid spaces in her brain.
0:39:15 > 0:39:21This particular anatomical location is being used because we want to
0:39:21 > 0:39:26avoid a very important structure which we call the motor cortex.
0:39:26 > 0:39:29If Asli accidentally damages the motor cortex,
0:39:29 > 0:39:31he could permanently affect Christy's ability
0:39:31 > 0:39:33to control the muscles in her body.
0:39:33 > 0:39:35You'll lose that for a second.
0:39:35 > 0:39:38Oh, right, OK. Can you suck a little bit?
0:39:40 > 0:39:42Very small ventricles. Yes, very small.
0:39:45 > 0:39:47There you go.
0:39:47 > 0:39:49Well done. OK. OK.
0:39:50 > 0:39:51Whenever you're ready.
0:39:51 > 0:39:54In order to get an accurate reading of the pressure
0:39:54 > 0:39:55in Christy's skull,
0:39:55 > 0:40:00Asli also fits a thin wire monitoring device into her brain.
0:40:00 > 0:40:02OK, can we have the ICP?
0:40:02 > 0:40:04So the depth we're talking about there, that's five.
0:40:04 > 0:40:06We don't need...
0:40:06 > 0:40:07Yeah.
0:40:07 > 0:40:12The device has a sensor which picks up intracranial pressure, or ICP,
0:40:12 > 0:40:13and feeds it to a monitor.
0:40:15 > 0:40:18With having the wire into the brain tissue,
0:40:18 > 0:40:23we are able to measure the pressure and if the pressure is high then we
0:40:23 > 0:40:29use the second catheter to divert the flow out.
0:40:29 > 0:40:33Safe ICP levels range between 5 and 20.
0:40:33 > 0:40:35Yup, back to you.
0:40:35 > 0:40:37And the team hope that the measures put in place will be
0:40:37 > 0:40:40enough to keep her levels at a safe range.
0:40:41 > 0:40:46At the moment this is extremely early days and her life still is
0:40:46 > 0:40:47in grave danger at present.
0:40:50 > 0:40:51Yeah, dressings.
0:40:53 > 0:40:58Brain swelling tends to crescendo and we would normally say
0:40:58 > 0:41:02days three and four are where it's at its maximum.
0:41:04 > 0:41:09We've got every expectation that the coming hours and days are going to
0:41:09 > 0:41:12prove difficult to control her intracranial pressure.
0:41:14 > 0:41:17From now on, Christy will be kept under sedation where they hope to
0:41:17 > 0:41:21control the swelling in her brain using a combination of drugs,
0:41:21 > 0:41:22oxygen and fluid levels.
0:41:25 > 0:41:26If her ICP spikes,
0:41:26 > 0:41:29they will have to act immediately.
0:41:38 > 0:41:42In Bristol, doctors are trying to figure out the extent of Peter's
0:41:42 > 0:41:44crush injuries.
0:41:44 > 0:41:46Although a major bleed has been ruled out,
0:41:46 > 0:41:51a CT scan has revealed a fracture to Peter's pelvis and there is still
0:41:51 > 0:41:53concern about the damage to his legs.
0:41:53 > 0:41:57Yeah. So, right and left upper limbs abnormality.
0:41:57 > 0:41:58That's really sore, isn't it?
0:41:58 > 0:42:01Has he got femoral fractures? Has he got fractures of his lower legs?
0:42:01 > 0:42:04I'm just worrying that he may have injuries that aren't related to his
0:42:04 > 0:42:06pelvis from what we know of what's happened.
0:42:06 > 0:42:09Has he actually been run over in a different part of his body?
0:42:09 > 0:42:10Sorry.
0:42:10 > 0:42:14Where's that sore? Back of the calf, underneath...
0:42:14 > 0:42:17OK. He's got abrasions over that right leg.
0:42:18 > 0:42:24He's got a tiny bit of an abrasion or an imprint on his calf that makes
0:42:24 > 0:42:25me wonder whether he has been
0:42:25 > 0:42:27run over by the forklift truck on that calf.
0:42:27 > 0:42:30So, we need X-rays of...
0:42:30 > 0:42:32right and left feet.
0:42:32 > 0:42:33And ankles and feet.
0:42:33 > 0:42:36Leilah is worried that Peter may have significantly
0:42:36 > 0:42:38damaged the soft tissue of his lower legs.
0:42:38 > 0:42:41This tissue swells up and that causes compression and pressure on
0:42:41 > 0:42:43the nerves and the blood vessels and
0:42:43 > 0:42:45it gives you large amounts of pain and
0:42:45 > 0:42:50can cause pressure and death to the tissues within that lower leg over
0:42:50 > 0:42:51a matter of hours.
0:42:52 > 0:42:55They're pretty swollen so we'll get him rolled, get him round...
0:42:55 > 0:42:58They want to get round to X-ray to do that, to take the binder off.
0:42:58 > 0:43:03Peter is sent to X-ray so Leilah can look for any damage to his bones.
0:43:04 > 0:43:07Remarkably, Peter's X-rays confirm
0:43:07 > 0:43:09no critical damage to his lower legs.
0:43:11 > 0:43:14I was convinced he was going to have some injury to his foot,
0:43:14 > 0:43:15but his X-rays all look normal,
0:43:15 > 0:43:18he doesn't have any fractures to his feet,
0:43:18 > 0:43:19his ankles, his lower leg.
0:43:20 > 0:43:23So he was just in a lot of pain from what looked like some
0:43:23 > 0:43:26significant soft-tissue injuries.
0:43:26 > 0:43:29The X-rays are able to confirm Peter's pelvic fracture.
0:43:29 > 0:43:31So I think you can see the fractures through there.
0:43:33 > 0:43:35So not particularly visible.
0:43:37 > 0:43:40Although much less severe than expected,
0:43:40 > 0:43:43Peter's pelvic fracture will need time to heal.
0:43:43 > 0:43:45Any injury to the pelvis is significant,
0:43:45 > 0:43:47it means that you've had a significant blow to it,
0:43:47 > 0:43:50because you don't fracture your pelvis lightly.
0:43:51 > 0:43:54Peter will now remain in hospital until doctors can fully assess
0:43:54 > 0:43:56the mobility of his legs.
0:44:09 > 0:44:11Less than 24 hours after her accident,
0:44:11 > 0:44:15Christy had to be rushed back into surgery.
0:44:15 > 0:44:18Christy, I'm just going to shine a light in your eyes a minute.
0:44:18 > 0:44:20Despite the medical team's best efforts,
0:44:20 > 0:44:22her brain continued to swell.
0:44:23 > 0:44:27The only way for doctors to relieve the pressure was to do a procedure
0:44:27 > 0:44:31called a craniectomy and remove part of her skull.
0:44:31 > 0:44:34The brain is held within a fixed box
0:44:34 > 0:44:37and when it swells, it has nowhere to go.
0:44:37 > 0:44:41And so really, the aim of this procedure is to open the box.
0:44:41 > 0:44:46And we do that by taking off a large proportion of the skull that
0:44:46 > 0:44:51extends really low down from one ear up over the top to the other ear
0:44:51 > 0:44:54and right down low on the front of the forehead.
0:44:54 > 0:44:59By allowing the brain to expand outside the confines of her skull,
0:44:59 > 0:45:03doctors have kept Christy alive, but it's not without its risks.
0:45:03 > 0:45:05Even with the craniectomy,
0:45:05 > 0:45:11there is a real risk of her surviving but with no return
0:45:11 > 0:45:14of Christy as we remember her.
0:45:15 > 0:45:20The surgical technique can relieve the pressure inside the head
0:45:20 > 0:45:22but it can't undo the original injury.
0:45:24 > 0:45:28Christy is now on an intensive care unit where nurses are monitoring her
0:45:28 > 0:45:31around the clock and assessing the extent of her brain damage.
0:45:31 > 0:45:33Christy.
0:45:33 > 0:45:35Hello, lovely, it's Hannah.
0:45:35 > 0:45:38We're going to come to the edge of the bed towards me.
0:45:38 > 0:45:43OK? Can you start moving your legs towards me?
0:45:43 > 0:45:45It takes quite a long time, often,
0:45:45 > 0:45:48for patients who've had a brain injury to start waking up.
0:45:48 > 0:45:52That's it. Fantastic. Good. And this one.
0:45:52 > 0:45:54Often we have families say, "Is this normal?
0:45:54 > 0:45:56"Is this normal for this person?" "You want to know?
0:45:56 > 0:45:59"OK, in five days' time they're going to be awake,
0:45:59 > 0:46:02"they're going to be doing this." So roll towards me, Christy.
0:46:02 > 0:46:03All the way over.
0:46:07 > 0:46:09Well done, Christy.
0:46:09 > 0:46:11BEEPING
0:46:11 > 0:46:14Can you put that hand on the bed for me?
0:46:14 > 0:46:16That's it. Good.
0:46:16 > 0:46:19And the thing with brain injuries is that it doesn't happen like that.
0:46:19 > 0:46:21Everybody is so individual
0:46:21 > 0:46:23because everybody's injury is completely different.
0:46:23 > 0:46:26You're doing really well, Christy. She's doing so well.
0:46:26 > 0:46:29Good. We need to wiggle her bottom forwards a bit more.
0:46:30 > 0:46:32Brilliant, well done.
0:46:32 > 0:46:35Christy's brain damage is in the areas governing motor skills
0:46:35 > 0:46:37and personality.
0:46:38 > 0:46:40Over time there are parts of the brain
0:46:40 > 0:46:47that have been irreversibly injured from the original injury
0:46:47 > 0:46:50which will ultimately die.
0:46:50 > 0:46:52There are areas of the brain that were salvageable
0:46:52 > 0:46:55that we've been lucky enough to salvage
0:46:55 > 0:46:58and we hope they will return a normal level of function.
0:46:58 > 0:47:01Christy, keep your eyes open for me, lovely.
0:47:01 > 0:47:03Look at me.
0:47:03 > 0:47:05Good, well done.
0:47:05 > 0:47:10We hope that we can achieve a good enough resolution to bring back
0:47:10 > 0:47:13the people that everybody remembers before the injuries.
0:47:14 > 0:47:16But we can't always guarantee it.
0:47:23 > 0:47:24Well done.
0:47:32 > 0:47:36In London, medical teams have been closely monitoring Jacqueline
0:47:36 > 0:47:39in intensive care following an accident that left her
0:47:39 > 0:47:42with multiple fractures to her face and skull.
0:47:46 > 0:47:49Her brain injury has been managed without the need for surgery.
0:47:50 > 0:47:53Now that Jacqueline has regained consciousness,
0:47:53 > 0:47:57a team led by consultant maxillofacial surgeon Simon Holmes
0:47:57 > 0:48:00are attempting to reconstruct her face and skull.
0:48:02 > 0:48:05My feeling is the force would have hit Jacqueline something like
0:48:05 > 0:48:08that direction up here. And then the force would have dissipated
0:48:08 > 0:48:11and there's a starburst fracture above her forehead.
0:48:11 > 0:48:13And that force then went down into the nose,
0:48:13 > 0:48:18across the upper cheekbones, through into the palate
0:48:18 > 0:48:20and split the palate down the middle.
0:48:20 > 0:48:24The width of the nose is completely gone and you can get a sense
0:48:24 > 0:48:26of how far in the nose is pushed in.
0:48:26 > 0:48:28'I want Jacqueline to look incredible.'
0:48:28 > 0:48:31One of my greatest sources of satisfaction is seeing patients
0:48:31 > 0:48:32return to normal life.
0:48:32 > 0:48:36Start work, go out with partners, get married, have children.
0:48:36 > 0:48:41And one of my parts of my collection is wedding photos.
0:48:41 > 0:48:43To start rebuilding her face,
0:48:43 > 0:48:46Simon first wires Jacqueline's lower jaw to her upper jaw.
0:48:48 > 0:48:52So we're just using the teeth as surrogate bone pins, in essence,
0:48:52 > 0:48:54to attach wires to.
0:48:54 > 0:48:56'You know the bottom jaw is good.'
0:48:56 > 0:49:00If we then wire the top jaw, which is broken, to the bottom jaw,
0:49:00 > 0:49:03from that point, if you link the fragments together
0:49:03 > 0:49:05so they meet perfectly, you know you've got it right.
0:49:05 > 0:49:08Don't forget to stabilise it when you pull
0:49:08 > 0:49:10because it's loose.
0:49:10 > 0:49:13OK. That's good. Hold that, see? It locks, doesn't it?
0:49:14 > 0:49:16With Jacqueline's jaw aligned,
0:49:16 > 0:49:18Simon needs to remove her scalp
0:49:18 > 0:49:21so he can fix the fractures in her skull around her forehead.
0:49:23 > 0:49:25We need some cat's paws when you've made the first cut.
0:49:27 > 0:49:29To minimise any visible scars,
0:49:29 > 0:49:31the team make the cut at the top of Jacqueline's head,
0:49:31 > 0:49:33hidden behind her hairline.
0:49:34 > 0:49:37We zigzag the incision so that when the patient goes swimming
0:49:37 > 0:49:42or has a shower, the hair doesn't part and look like an Alice band.
0:49:42 > 0:49:45We should be able to sweep our fingers in there.
0:49:50 > 0:49:53'So we then peel the scalp forward.
0:49:53 > 0:49:55'Essentially, we scalp the patient.'
0:49:55 > 0:50:00And we can get this to align through the pupils so that we can get access
0:50:00 > 0:50:04to all the nose, top of the nose, and forehead, and also the brain.
0:50:04 > 0:50:07Shall we just see where we are, John?
0:50:13 > 0:50:16Better. It's all coming now, isn't it?
0:50:16 > 0:50:17Can you start to see the fracture now?
0:50:17 > 0:50:19Yeah. Just there.
0:50:21 > 0:50:23But uncovering the impact site,
0:50:23 > 0:50:26Simon is finally able to see the extent of the injuries
0:50:26 > 0:50:28to Jacqueline's forehead.
0:50:30 > 0:50:33Screws are carefully attached to each piece of the skull
0:50:33 > 0:50:35to help manipulate the fractures.
0:50:39 > 0:50:42Simon then starts to free up the individual fragments
0:50:42 > 0:50:44of Jacqueline's skull.
0:50:44 > 0:50:48'If they are impacted tight and you simply pull, they won't move.'
0:50:48 > 0:50:52So you have to encourage them gently to move apart.
0:50:53 > 0:50:55Anything Simon does from here on in
0:50:55 > 0:50:58is highly risky to Jacqueline's brain
0:50:58 > 0:51:00and could be critical to her future.
0:51:01 > 0:51:02In order to continue,
0:51:02 > 0:51:07Simon must enlist the help of consultant neurosurgeon Chris Uff.
0:51:07 > 0:51:09Another clip, please.
0:51:10 > 0:51:15'He is the one that protects the big veins of the brain and ultimately
0:51:15 > 0:51:19'is the one that moves the forehead fragments around in a safe manner.'
0:51:19 > 0:51:22You got it? Yeah, I've got that.
0:51:22 > 0:51:25If you remove the section of bone and put it to one side,
0:51:25 > 0:51:27you can then trim the sharp bits of bone
0:51:27 > 0:51:30so that everything meets more cleanly.
0:51:30 > 0:51:32With the fractures no free to move,
0:51:32 > 0:51:35Simon must attempt to lift Jacqueline's nose
0:51:35 > 0:51:37back out of her face.
0:51:39 > 0:51:41So what we're going to do is,
0:51:41 > 0:51:42you're going to lift the scalp up
0:51:42 > 0:51:44and I'm going to get the nasal prongs
0:51:44 > 0:51:46and lift the whole nose out.
0:51:46 > 0:51:47That's the plan.
0:51:47 > 0:51:50A retractor, please.
0:51:50 > 0:51:52Could I have the nasal forceps, please?
0:51:52 > 0:51:55'You know which way it went in
0:51:55 > 0:51:58'so you literally have to reverse the force,'
0:51:58 > 0:52:01lift all that weight up. It's quite a lot.
0:52:04 > 0:52:06'As you feel the face move,'
0:52:06 > 0:52:08you hear a very gentle but satisfying crunch
0:52:08 > 0:52:11as all the bits locate in the right place.
0:52:11 > 0:52:13Having reset Jacqueline's nose,
0:52:13 > 0:52:17Simon and Chris are able to replace all the skull fragments
0:52:17 > 0:52:19in their correct position.
0:52:19 > 0:52:23Now they must make sure they remain in place by inserting metal plates.
0:52:23 > 0:52:25'The plates in Jacqueline's case, they're titanium,'
0:52:25 > 0:52:28and they literally hold the fragments together.
0:52:28 > 0:52:30But they only hold them together, Jacqueline does the rest -
0:52:30 > 0:52:33she fills in the gaps of bone and heals it.
0:52:33 > 0:52:35After about three to four weeks, the plates are superfluous.
0:52:39 > 0:52:42Jacqueline is in surgery for 5 1/2 hours.
0:52:44 > 0:52:48In total, Simon used more than 15 plates and 50 screws
0:52:48 > 0:52:51to reconstruct Jacqueline's skull.
0:52:51 > 0:52:55Jacqueline's right eye was particularly a problem.
0:52:55 > 0:52:58The roof of the eye socket had caved in which had essentially,
0:52:58 > 0:53:02we thought, torn through her eyelid muscle, which opens her eye.
0:53:02 > 0:53:05So we had to reconstruct the floor of the eye socket.
0:53:05 > 0:53:07This is the plate here.
0:53:07 > 0:53:09Can you see the orbital plate?
0:53:09 > 0:53:13It'll be a few weeks before the surgical team can assess
0:53:13 > 0:53:16just how successful the operation has been.
0:53:27 > 0:53:29You know, one minute you're working
0:53:29 > 0:53:32and the next you see a forklift on top of you and then that's it.
0:53:32 > 0:53:35I thought I would be paralysed from the waist down.
0:53:35 > 0:53:38I just didn't feel anything except for the sheer pain.
0:53:38 > 0:53:41I never want to feel pain like that in my life again.
0:53:41 > 0:53:44If I'd have been worse off in the accident, be in a wheelchair,
0:53:44 > 0:53:48it's just not my life that's altered, it's Paula's, my kids.
0:53:49 > 0:53:51I've been off work now weeks.
0:53:51 > 0:53:52I'm off the painkillers now,
0:53:52 > 0:53:55up and downstairs just various exercises,
0:53:55 > 0:53:59and a few walks out with Paula on my crutches for a meal now and then.
0:53:59 > 0:54:01One of the doctors said, "He's Iron Man
0:54:01 > 0:54:04"for what we've seen and what he's been put through.
0:54:04 > 0:54:06"And the injuries he's got is just unbelievable."
0:54:08 > 0:54:10I would imagine Peter should make a full recovery.
0:54:10 > 0:54:13I think he's got off incredibly lightly.
0:54:13 > 0:54:15Most bones take about six to eight weeks to heal
0:54:15 > 0:54:19and usually they heal on their own and don't need any other treatment.
0:54:19 > 0:54:21I feel like I'm one of the luckiest men alive.
0:54:34 > 0:54:35I was astounded.
0:54:35 > 0:54:38The surgeons had done an amazing job.
0:54:38 > 0:54:41It's really reassuring that Jacqueline shows
0:54:41 > 0:54:45no long-standing signs of any brain damage.
0:54:45 > 0:54:48Jacqueline's been very lucky to get the care that she needed
0:54:48 > 0:54:50at the roadside, not die on the roadside
0:54:50 > 0:54:52and then survive the surgery.
0:54:52 > 0:54:56When my surgeon removed the plasters from my face...
0:54:57 > 0:55:00..I did cry, because I didn't know what I looked like.
0:55:00 > 0:55:04And then he showed me my skull before and after.
0:55:04 > 0:55:06It's like, look at me know.
0:55:06 > 0:55:10I'm quite proud of myself, how far I've come.
0:55:10 > 0:55:13Obviously people's loss of identity through disfigurement
0:55:13 > 0:55:16or a change in their face can be huge,
0:55:16 > 0:55:19so really important that the surgery
0:55:19 > 0:55:22is timely and as effective as possible.
0:55:22 > 0:55:25She does of course have a scar on her forehead,
0:55:25 > 0:55:29but it's still very early days. That will continue to heal.
0:55:29 > 0:55:33My scar tells the story and I'm not embarrassed of it.
0:55:33 > 0:55:35Personally I think Jacqueline looks great.
0:55:35 > 0:55:38There's great satisfaction to see that she is happy
0:55:38 > 0:55:42and you get her how she was as near as possible before the injury.
0:55:42 > 0:55:44That for me is the essence of why I do the job.
0:55:44 > 0:55:46That's what makes an old man happy.
0:55:47 > 0:55:50The doctors - I'm so, so grateful.
0:55:50 > 0:55:52If I could give them the world,
0:55:52 > 0:55:53I would.
0:56:20 > 0:56:22My brain has been affected...
0:56:24 > 0:56:28..in a way so now I have really...
0:56:29 > 0:56:31..quite poor short-term memory.
0:56:35 > 0:56:38And I don't know what the last thing I remember is either
0:56:38 > 0:56:44because my brain doesn't really work in chronological order.
0:56:44 > 0:56:47I've just got random flashes of memories.
0:56:49 > 0:56:52Christy's eight weeks into rehabilitation.
0:56:52 > 0:56:55She is doing remarkably well
0:56:55 > 0:56:57but there are issues, there are problems,
0:56:57 > 0:57:01and at this point in time we don't know how those problems
0:57:01 > 0:57:02are going to turn out.
0:57:02 > 0:57:08Recovery after these is always a bit of a stormy process
0:57:08 > 0:57:13and we don't expect a uniform, comfortable improvement over time.
0:57:16 > 0:57:20However, when we see patients responding as quickly
0:57:20 > 0:57:25and as well as Christy has done, then we're hugely encouraged.
0:57:25 > 0:57:28I've got every hope that we will return her to independent living.
0:57:28 > 0:57:32I think that for someone who was hit by a car,
0:57:32 > 0:57:35I'm probably in the very, very, very best...
0:57:36 > 0:57:39..condition that I could be at this point.
0:57:39 > 0:57:44I'm lucky that I didn't die when I was hit,
0:57:44 > 0:57:48and then again, I was saved a second time by the doctors.
0:57:50 > 0:57:52So eternally grateful.
0:57:56 > 0:57:58Next time, we follow three more patients
0:57:58 > 0:58:01through the crucial first hour of care.
0:58:01 > 0:58:05In north London, a man is hit by a bus and fights for his life.
0:58:05 > 0:58:06I'm not happy that's in, OK,
0:58:06 > 0:58:08I'm just going to pull the tube back a little bit.
0:58:08 > 0:58:10Near Bristol, a rider lies unable to move
0:58:10 > 0:58:12after being thrown from his horse.
0:58:12 > 0:58:14Can you move your fingers? No.
0:58:14 > 0:58:16Can you feel me touching you here? Yes.
0:58:16 > 0:58:18And in St Albans,
0:58:18 > 0:58:22a tree surgeon falls 30 feet off a ladder while cutting branches.
0:58:22 > 0:58:24I'm worried about him. We're a long way from hospital,
0:58:24 > 0:58:27he could be bleeding into his abdomen or his pelvis.