Episode 2 An Hour To Save Your Life

This programme contains scenes which some viewers may find upsetting

Ambulance service? There's a guy hit by a bus. He was on a bike. He's been really badly injured.

From the moment an emergency call is made,

a clock starts ticking.

Female lying on the road, struggling to breathe.

The golden hour is the opportunity that we have to save the patient.

Deep breaths, George.

The longer the clock ticks,

the increased likelihood there is of death.

In the fight for survival, time is the enemy.

I'm ventilating fast on purpose. Yeah.

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

Now, new techniques and technology

are bringing emergency medicine to the roadside.

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

of what's going on underneath the skull.

Breaking new ground

and treating patients faster than ever before.

We can now provide emergency surgery, blood transfusions,

anaesthesia at the scene of the accident.

Through the cord, tube, please.

Tube on.

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

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

after being hit by a car.

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

Let's just get on the ambulance, then, and go from there.

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

Which bit of you is hurting? All of me. All of you.

And in central London,

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

We'll give her nasal oxygen...

Right. ..at quite a high level.

60 minutes that will change their lives forever.

You will constantly be surprised

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

Across Britain, medical teams are on call 24 hours

to deliver critical care to those most seriously injured.

At night, when the helicopters are unable to fly,

the air ambulance teams travel in specially equipped cars,

able to respond at a moment's notice.

Ambulance service, what city are you in?

Bristol.

OK, can you tell me exactly what's happened?

Basically, I've just pulled up and there's a fellow on the floor.

At Bristol South Western Ambulance,

handlers receive a call about a young girl

who's been hit by a car.

Is she breathing? Yes, she's breathing. She's breathing.

Is she awake?

No, she's not awake. She's not awake? No.

I'm organising that help for you now.

Great Western Air Ambulance critical care team

Dr Greg Cranston and paramedic Vicky Brown are dispatched by car

to the scene.

Thanks for the update, 15.

Left here.

Knew we were going to a incident where someone had been hit by a car.

Female lying on the road.

Struggling to breathe, I think.

If there are serious injuries,

we'll need to intervene with anything life-threatening

as soon as possible.

We're probably about three minutes from the scene.

We know that every minute that passes,

things could be slipping away, things could be getting worse.

Here we are.

1015 on scene.

I'll get the blood.

Ambulance teams, including critical care paramedic Neil,

are already on the scene.

Seemed to go up, hit the deck.

Apparently originally sort of GCS three, then combative... Like this.

She's now localising, no eye opening,

and voice is incomprehensible sounds at the moment.

18-year-old Christy has been hit whilst crossing the road

and is struggling to regain consciousness.

Chest actually looks OK, feels OK,

belly feels OK, pelvis feels OK.

Long bones feel OK.

Just had a BM.

I think it's head only at the moment.

So my impression would be in and have a look,

cos I don't think there's a DCA assess. Fine. Cool.

'Christy is lying on the floor.

'She had been hit by a car,'

thrown up into the air and then landing on the ground,

though not clearly known exactly how she would have landed.

There's no airway compromise.

My immediate observations were that we were dealing with a patient who

was severely neurologically impaired.

Have you got her covered?

She's not settled, she is anxious,

she's agitated, she's fighting out, pushing people away.

We'll swap these blankets in a minute once we're off.

This indicates to me that is a strong likelihood

of there being a serious brain injury involved in this accident.

OK, fine, let's just get her on the ambulance then and go from there.

That's fine. And a warming blanket.

The team want to get Christy out of the cold and the dark

and into the ambulance so they can assess her fully.

It's impossible to actually determine whether there's bleeding,

bruising and swelling to the brain.

But people with severe brain injuries die.

They die at the time of impact.

They die very shortly afterwards.

I haven't had a listen to the chest yet. OK. Let's just get her in.

Although the injury's happened now and we're just at the start,

things are likely to get worse from this situation on.

Shut the door, please.

40 miles away in Gloucester,

Great Western Air Ambulance critical care team Dr James Tooley

and paramedic Peter Sadler

are responding to another emergency call.

RADIO CRACKLES

13 minutes ago,

call handlers were alerted to a serious incident

at an industrial site.

Ambulance service, what's the address of the emergency?

Right, is he able to respond to you at all?

He's not responding?

Are there any obvious injuries that you're aware of?

OK, I'm organising help for you.

We know that severe injuries using industrial machinery

can lead to a death really quite quickly

if certain things aren't addressed.

So my main concern is to make sure that he hasn't had

a massive haemorrhage.

That his airway is under control, that his breathing is OK,

and that he hasn't lost lots of blood, either externally or internally.

We'll be with you in approximately 15 minutes, over.

Is there massive internal haemorrhage

that we may not be able to deal with on the scene?

In which case he needs to go to hospital quickly

to have an operation and to resolve that.

1015, go ahead?

1015 on scene.

Roger, on scene.

First response technicians immediately update the team

on truck driver Peter's condition.

This is Pete. Yup.

He's been crushed by that against there. Yeah.

Not being able to move from the waist down is a very suspicious,

worrying feature that he may have some spinal cord damage.

If you truly have severed your spinal cord,

you may not be able to move your lower limbs

for the rest of your life.

Fearing Peter may be paralysed,

James must find out what sensation he has in his legs.

Hey, mate, I'm a doctor with the air ambulance.

Which bit of you is hurting?

Can you feel your knees?

OK, mate, we'll get you all sorted out.

Mate, the worst pain you can ever imagine is 10 out of 10,

nought is nought, what yours?

Once he was less scared and less fearful

and able to confirm that he could feel his legs and move them,

I was much less worried that there was any spinal injury.

What we might end up doing is giving you some painkillers that make you

a bit woozy and a bit confused.

I don't want too much.

Are you allergic to anything? No. Aspirin, no aspirin.

OK. All right, mate.

Although now less concerned about a spinal injury,

James fears that Peter has been crushed

and he needs to look for signs of bleeding.

Do you mind if I have a quick look under here to see what's going on?

Not a really good opportunity to get him assessed here. Shall we just...?

Just get him scooped, get him in the truck, I think.

He says his pain's 10 out of 10, he's in a lot of pain.

His pelvis was hurting, his legs were hurting.

So if the pelvis and the two femurs have been broken,

you can lose a significant amount of blood into that area and can die

because the blood is in the wrong part of your body.

Which are the worst bits for pain at the moment?

All right, mate.

We're just going to put these warming blankets under you, mate.

Is his skin cold because he's lying out in the cold,

or is his skin cold because he's lost a significant amount of blood

and needs to be topped up with blood or get to an operation very, very quickly?

What we're going to do, Pete,

is just gets you scooped up now and into the ambulance,

so we'll warm you up and then we can have a proper look at you

and work out what's going on with you, mate.

The team want to get Peter onto the ambulance

so they can fully assess him for signs of bleeding.

But Peter needs to be turned on to his back and moving injured patients

carries risk.

My concern at this stage is that by rolling him over,

any clots that might be forming within the pelvic area,

that might just be holding off some bleeding, may be disrupted.

So, let's just get that out of the way there.

So, what we need you to do is to roll this way

onto that stretcher there, mate.

I've still got in the back of my mind that there could be an unseen

haemorrhage, and I can recall many occasions where I've been talking to

patients one minute,

only to find that they have died within an hour or two.

Are we ready?

Me knees!

All right, Pete.

PETE GROANS

All right.

Stay square on, stay square on.

Well done, mate.

Worst is over, mate, we'll get you in the warm.

18 minutes ago,

police in central London triggered an emergency medical alert

following a serious road accident.

From medic two.

Travelling to this scene are London's air ambulance,

consultant Gareth Davies and paramedic Nick Hardy,

who are now only minutes away.

Straight across here.

We know that it's some form of crash involving a car,

and one of the occupants, and that's it.

On the way there, you forever have a ticking clock

in the back of your head.

You know time is everything.

Red base from medic two, just to let you know we're on scene.

Female in the ambulance on the left has got a head injury.

A head injury.

My first impression is this is a serious accident.

There seems to be two cars involved

and we really need to establish just how many patients there are.

Whilst Nick checks the condition of the other occupant,

Gareth is directed to where London Ambulance Service paramedic

Katie Edwards is treating 24-year-old Jacqueline.

She was screaming at me, shouting about the pain in her arm.

It was only quite a short period of time

that she was actually quite lucid and speaking to me.

JACQUELINE GROANS

We need this arm. Jacqueline, it's Katie.

I was able to walk her to the ambulance.

At which point her conscious levels started dropping quite substantially

and quite quickly.

I'm cold! I know, my darling, I'll pop the blankets on you.

You just need to try and stay nice and calm.

Jacqueline's head has taken the full force of the impact,

leaving her with an open skull fracture.

I could tell she was seriously injured.

The fractured skull had been forced into her brain matter

and, literally, like toothpaste out of a tube,

that brain matter had been forced past the cracks in the bones

and come out through the wound.

She's sort of obeying commands, she's not vocalising at all. OK.

she's not opened her eyes any more so her GCS is falling.

Is that better?

The team monitoring Jacqueline had been assessing her level

of consciousness using the Glasgow coma score.

We have a scale which is split into three.

You're looking at the eye movements,

their verbal response and their motor movements.

Three is the worst you can score and 15 is the best you can score.

What was facing us now was someone who had deteriorated

to a score of 10 or 11, or something of that region.

You just need to let the doctors help you, OK?

Now she was just speaking in simple one word sentences,

sometimes incomprehensible sounds.

And that shows that the brain is becoming dysfunctional,

it's not working.

I'm cold! I know, I know, darling.

Guys, can you just get some Medaz ready as well?

Gareth believes Jacqueline is starting to show signs

of a serious brain injury.

Was it her brain that was swelling?

Was it a blood clot that was growing inside her skull that was causing her to deteriorate?

And that's when medicine needs to step in.

We could potentially turn that around.

Jacqueline? Jacqueline?

Gareth fears Jacqueline's head injury could soon start

to compromise her ability to breathe.

Well done, darling.

You're doing so well.

In order to protect Jacqueline's breathing,

Gareth wants to anaesthetise her at the roadside using a process called

rapid sequence induction, or RSI.

Flush here as well. OK, thanks.

If we can do the breathing,

we can guarantee that the right levels of carbon dioxide in her blood are there

and that will minimise any pressure within the skull.

How are we doing? We're good, I'm ready.

We'll go with this position here, I think.

To anaesthetise Jacqueline,

Gareth uses a combination of powerful sedative drugs

which he must administer in precise quantities.

So we've got fentanyl.

50 micrograms, one mil of fentanyl.

When you have a serious head injury,

the last thing you need is a low blood pressure

and the drugs that we give can lower blood pressure

so we had to get the dosing absolutely right

to make sure that her brain wasn't further damaged by that process.

Suction please. Suction.

A lot of blood.

Once they have inserted a breathing tube into Jacqueline's windpipe,

Nick is able to finally control the levels of oxygen and carbon dioxide

in the blood going to her brain.

Sats 100.

You can carry on, probably a little bit faster.

There's a number here, it says 4.9. Can you see that purple number?

Ideally we're trying to get that down a little to about four.

'Unfortunately, there's very little that we can do about wound

'and the fractures on scene.'

Our focus is on keeping Jacqueline alive so she gets to hospital.

We can probably go a little bit faster.

120 miles away in Bristol,

18-year-old Christy is in a critical condition

after being hit by a car.

Greg, Neil and Vicky fear she has a severe brain injury

and are moving fast to assess for any other threats to her life.

Can you open your eyes for me?

To be honest she's saturated 100, so it's not huge.

I didn't find any other signs of serious injury.

We can't exclude that for certain,

but it reassured ourselves that we didn't need to do anything

immediately before dealing with the primary problem

that we knew we had, and that was the brain injury.

She's either hit her head on the vehicle that's hit her,

or she's hit her head as she's fallen back onto the road.

You're going to get bruising,

then you get swelling just like you can in any other part of the body.

But the brain is within a rigid box so it can only swell so much.

Without being able to see the damage in Christy's head,

Vicky's only way to assess her is by the size of her pupils.

I'm not seeing signs at the moment with the pupils,

but if the pupils become unequal,

or not reacting to the light,

that's a big sign for us to say that the brain is now starting

to herniate, and this is very life-threatening.

With Christy showing no signs of improvement,

the team now need to act fast to keep her stable.

At the time of the accident,

the brain sustains an impact injury,

that's called the primary brain injury.

We can't do anything about that, that's already happened.

What we can do is prevent any secondary brain injury.

And that's all about optimising the conditions

that the brain is living within.

If the brain is starting to be compromised due to lack of oxygen,

then it can be a matter of minutes before the brain starts to become

damaged because of that.

Right, guys, we're going to pop her off to sleep.

To prevent further damage to Christy's brain

from lack of oxygen,

the team want to anaesthetise her

in order to take control of her breathing.

Vicky, Greg - happy?

Happy.

So, ketamine is going in now.

We want to control her breathing so that we can control her gases

within her blood that have effects on how well blood gets to the brain.

With the drugs administered,

Vicky must wait one minute for the paralysis to take effect

so she can insert the breathing tube.

OK, that's coming up for a minute.

That's 55 seconds.

OK, and there's your minute.

Tube.

Got it.

With the tube inserted,

Greg quickly connects Christy to a ventilator to ensure her breathing

rate is kept at a constant level.

What rate's she on at the moment?

About 18 at the moment, we've got it down to 4.3.

The only way to determine how badly her brain is injured

is to get Christy to a CT scan.

Pressure's at 21.

Ventilating OK.

Looks all right, doesn't it?

What we've done up to this point is purely

just controlling things as best we can,

stabilising her so that she can be transferred safely to hospital.

I need to have a listen to the chest.

It may well be that there is something

that needs immediate operation to relieve that pressure or swelling

in order to increase her chances.

Guys, how long do you reckon?

That's brilliant. No more than 15.

In Gloucester,

doctors and paramedics are still trying to assess truck driver

Peter's injuries after he was run over by a forklift.

Where's your pain now, fella?

Yeah, I bet, horrible laying on that concrete all that time.

Can you feel pain, Pete?

So have you had morphine before? No.

Have five of it, mate, it's quite a small dose for a big lad like you.

To relieve his severe pain,

James gives Peter intravenous morphine.

What's the worst bit that's in pain at the moment?

So it's mainly around your groin and then the bottom of your legs.

In my legs it just feels like a golf ball.

His legs are hurting round there, Pete, that's the bit that's hurting.

The pain in Peter's groin suggests

he's damaged the bones in his pelvis.

So, the pelvis, if it loses integrity, if it loses its shell,

becomes a floppy sack and your disrupted blood vessels,

if they are damaged by this crush injury,

can just leak blood at a fast rate.

We need to take all the clothes out from underneath you and we're going

to put something around your pelvis.

Right. Pelvic binder.

To help control any bleeding,

Peter and James decide to bind Peter's pelvis.

HE MOANS

All right, all right, OK.

My legs, my legs! All right, I'm sorry, I'm really, really sorry.

The pelvic binder is a really good way of turning that potential space

into a more restricted space.

So the binder goes around the broken pelvis,

you pull the binder tight and if blood is leaking into that area,

it stops once it's reached the pressure around the binder.

OK, have you got that one, then?

There we go.

With Peter's pelvis bound,

James can continue looking for other signs of injury.

Squeeze my fingers really, really tight.

OK. That's it. Hold your arm still.

Don't let me move them, all right? Don't let me move them.

Before I arrived, I was incredibly worried that he was going to have

either life-threatening or life-changing injuries.

Can you feel me touching you? Yeah.

The further through the assessment I could get,

the chances of that were diminishing but I was still concerned enough

that he had major pelvic injury and needed to go to Southmead Hospital.

Any pain in your chest up here at all, mate? Anything at all? Nothing.

No, these bits weren't injured, is that right?

Fine.

Fine. Pelvis we're worried about.

And then I think soft-tissue injury around the legs.

I can't see any obvious fractures, no.

So the question... He certainly might have a lot of soft-tissue injury

around his legs and things like that, so I think Southmead seems

the most appropriate place for him to go. I agree.

Only detailed scans and X-rays at a major trauma centre will reveal

the exact nature of Peter's injuries.

What's that pain score now, Peter?

About seven. It's about a seven?

So earlier on it was ten, was it?

In the last 60 minutes,

emergency clinicians have battled to deliver interventions

and medical care to three critically ill patients.

After being hit by a car,

Christy is being rushed into hospital

in order to assess the damage to her brain.

Jacqueline has been anaesthetised following a car crash that left her

with an open-skull fracture.

And after being run over by a forklift truck,

Peter's lower body has been badly damaged and doctors suspect he may

be bleeding internally.

In central London, medical teams are on the scene treating Jacqueline

after she was involved in a serious road collision.

She's a female, looks to be in her 20s.

She's got an obvious skull fracture

in the forehead and facial lacerations

and she's been intubated and ventilated.

Right. Can you shout out some numbers for me?

Yep. We've got...

..sats are 100%.

Heart rate is 120.

You've got end tidal 4.2 and a good waveform.

Although they've taken control of her breathing,

Gareth is worried that the huge impact to Jacqueline's head has

caused bleeding within her skull.

My real concern was for what was going on

underneath those broken bones,

blood vessels within the skull may have been lacerated and start to

produce blood clots that themselves threaten the brain tissue.

To detect signs of bleeding,

London's air ambulance teams are using a pioneering new device called

an infrascanner.

I've got the scanner down here, Gareth and it's turning on.

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

picture of what's going on underneath the skull.

The device uses infrared light to detect the presence of blood

in or around the brain.

The infrascanner is very simple.

Where it believes there is a blood clot, it shines up red.

Where it believes there isn't a blood clot, it shines up green.

OK. And we can't do, obviously, the...

It's saying... Yes, it's suggesting haematoma on the right-hand side.

We got a quite clear indication that there were blood clots deep within

the skull itself and perhaps the brain matter.

What we need to know is the extent of that bleeding,

whether it's getting worse.

That means that we need to get Jacqueline as quickly as we can

to a major trauma centre

to have a scan to give us a much better idea of what's

going on underneath her skull.

Gareth is transporting Jacqueline to the Royal London Hospital,

where she may need the help of specialist neurosurgeons

to remove any blood clots from in and around her brain.

I'll put a blue call in, yeah? OK.

Hi, it's Gareth here.

Just to let you know I am bringing you a patient.

She is a 25-year-old

young girl, she's got a big skull fracture with some brain tissue on

the surface of her skin. We're leaving the scene now,

so I guess we're going to be about 12 to 15 minutes.

Bye.

Let's hope the infrascanner is wrong.

In Bristol,

18-year-old pedestrian Christy is being rushed into Southmead Hospital

so they can assess her brain injury.

Waiting in the emergency department is consultant Nicola Morgan.

My concern at this point is that she has had a significant injury,

a significant impact with a car.

We know she's got a head injury and we know that could get worse if we

don't look after her properly.

But I'm also suspicious of trying to find any other injuries that might

be there before she becomes more unwell from them.

So let's get the patient across and then we'll take handover.

Doctors have given Christy a general anaesthetic at the roadside

and are breathing for her using a ventilator.

So this is a young female, approximately 20 years old,

seemed to go over something into the air.

We think she's got an isolated head injury,

she has swelling to her left head.

We haven't found any other specific injury anywhere else.

Her pupils were fine.

OK, she's had an RSI.

321 fentanyl ketamine rock.

I think that completes for now. Over to you, I'll be available.

Lovely, thank you so much.

So let's start with a primary survey.

She's young, and it's always difficult,

it doesn't matter who the patient is or what age they are,

it's always difficult to look after someone who you know could be

significantly injured and could...

Their life is likely to change from this point.

Airway secure. Lovely.

Good air entry bilaterally.

Lovely, thank you.

No obvious pelvic injury.

OK, the plan is - as soon as we've got access and blood sent off,

we'll take the scoop out, we'll check her temperature,

we'll keep her warm and get her round to scan.

I'm feeling quite uncomfortable at this point.

We're gathering information but we still don't really know what

happened, we don't really know

how unwell she's going to be.

We suspected she's got a head injury but we don't really know exactly

the extent of that.

Nicky's hope is that a CT scan will reveal vital

information about the extent of the injuries.

OK, we're all ready to go from a button-pushing point of view.

What I can see is there's some bruising to the left side of her head,

sort of near the back, but the bruising to her brain is near the front,

so I'm suspecting now that she's had maybe two lots of impact.

Where she's hit her head once on the side and then the brain shunted

itself forward and injured the front of the brain.

So I'm suspicious that there might be two areas of injury to her brain,

which obviously is worse than one.

Any bruising to Christy's brain could be a sign

of permanent brain damage.

This is particularly worrying for me because the front part of the brain

controls so many things,

it's so important not only to things like voluntary movement and how we

move around but particularly it's really involved in personality and

in emotion and in behaviour and how people react and how they speak.

Christy's scan also reveals a fracture of the bone

at the back of her skull.

All of the nerves and blood vessels that control the rest of your body

come from your brain through the bottom of your skull

and into your body.

So having a break in the bottom of the skull can affect those nerves

and those blood vessels.

Best motor score is withdrawing of pain to both arms

before she was RSI'd.

Nicky has further concerns that

Christy's injured brain is now swelling.

I can see that the spaces around Christy's brain look smaller than

I would expect them to be, so I'm already concerned that there is an

increase in pressure inside of her skull.

And because the skull is fixed,

there's nowhere for that pressure to go.

So we need to really keep a close eye on what effect that's having on

her. I'm really worried for Christy at the moment.

This is a significant injury to her brain.

OK.

Nicky fears that the swelling to Christy's brain will continue to

get worse over the coming hours.

Secondary survey shows nothing other than the traumatic brain injury.

If the swelling in her brain continues to increase,

the worst-case scenario really is that the nerves and the blood supply

that controls how she breathes and

how her heart functions could be affected

and if those things get interrupted then her heart could stop and she

could stop breathing.

Straight to theatre.

Truck driver Peter is arriving at Southmead Hospital where emergency

department consultant Leilah Dare has assembled a specialist trauma

team to deal with his injuries.

When someone's been run over by a forklift truck,

that immediately makes me worried that they've got some serious

injuries that I need to worry about and act on quickly.

Doctors fear the weight of the forklift has damaged his internal organs.

It's a 40-minute journey to get Peter to me and he could be bleeding

or his injuries could be getting worse in that time and I need to be

prepared for that. What I want to do is just have a quick primary survey.

Then split the scoop, get some bloods and go to scan.

Peter needs a CT scan but doctors must first make sure

he's stable enough to go.

OK, yes, so airway intact.

Good air entry throughout.

Any signs of bruising or anything on the chest?

No. Blood pressure of 119/75.

Right, let's keep him covered up and then let's go to scan.

So my concerns are that he may have pelvic fractures and if he does have

a pelvic fracture he may have other

injuries in the abdomen or the pelvis.

And they can bleed catastrophically

and you can bleed to death from pelvic injuries

and it's really important that we find them and treat them as

quickly as possible.

One, two, three, across.

To try to prevent any excessive blood loss,

Peter had his legs and pelvis bound on scene.

Only when we know exactly what fracture we're dealing with,

when I know exactly the nature of it will I then decide whether

the pelvic binder can come off.

Treatment he's had on scene is I think about 15 milligrams of morphine.

Pelvic binder, legs tied together.

And transported, final transport, GCS is 15.

Peter is undergoing a full-body scan to look for any broken bones,

bleeding or organ damage that will need immediate treatment.

He's got a tiny fracture to the front of his pelvis

but actually everything else looks OK.

I'm very surprised at what I see.

I really think that Peter should have some nasty injuries and

actually I'm quite amazed that I can't see anything on the scans.

And then I really worry - "Right, if that's not injured,

"then where else is he injured?"

Cos he must have done something, having been run over by a forklift truck.

Until a radiologist can look at Peter's scans in more detail,

Leilah can't be sure that there aren't more serious injuries.

In Whitechapel, Jacqueline has been rushed to the Royal London Hospital

after a car accident left her with serious injuries

including an open-skull fracture.

Evening, everyone. Or morning, I should say.

Morning. So this is Jacqueline.

She's got a severe head injury,

she's got an obvious deformity to her frontal bone,

she's got a ten-centimetre laceration.

With some evidence of brain matter in that wound.

Pupils are small and reactive and the infrascanner suggests she's got

a right sided haematoma.

Thank you.

A mobile scan made of Jacqueline's head at the scene indicates she may

be bleeding within her skull.

It's now up to emergency medicine consultant Malik Ramadhan to locate

the bleeding and determine the next course of action.

We're going to run through a quick check to make sure that nothing is

changed since Gareth handed her over.

Stable.

She's got an obvious injury to her face.

If there's a threat to her life,

it will be bleeding inside her head, which I can't see by looking at her.

The CT scan will allow me to decide how quickly we need to operate on

her. Given that she seems pretty solid,

I'm quite keen to get her head scanned.

Ready, steady, go.

The images of Jacqueline's head reveal the full extent of the damage.

This is all fractures. Fracture.

Most, if not all, of the impact has been taken through the forehead.

This is her forehead, that should be in continuity.

The bone's been driven into her head.

That's brain, the white is blood.

She has some bleeding inside her brain, which is from the force and

possibly from a fragment of bone that's damaged her brain.

She's got some bleeding on the surface of her brain.

Even a small amount of bleeding will cause pressure on the brain.

Malik's priority is to look for any bleeding or swelling that will

require Jacqueline to have immediate neurosurgery.

It doesn't look like she needs an operation this second to remove

blood from inside her skull.

If she stopped bleeding and I'm looking at a clot,

then we've got time to wait.

If she's still bleeding inside her head,

potentially it will get bigger and bigger and she still might

need to have an operation.

To monitor the pressure from any

bleeding or swelling in Jacqueline's brain,

neurosurgeons attach an intracranial pressure bolt to her skull.

So now the bolt's working,

I can see that the pressure inside her head is normal.

Which means that she doesn't need an operation and that when she's on

the intensive care unit, they can monitor that pressure

and be reassured that she's not still bleeding inside her head.

The reconstructed 3-D CT scans

give Malik the ability to fully visualise

the extent of the fractures to Jacqueline's skull and facial bones.

Essentially, that's the fracture.

And it extends down into both her

eye sockets and then there are fractures

in the floor of the eye as well.

She clearly has a huge skull and facial injury

and a soft-tissue injury

that will need to be fixed and it's likely

to require multiple specialties to fix it successfully.

Once we're happy that the brain injury isn't developing

and that she's had her best chance of her brain recovering,

we would then look to operate to fix the fractures to her face.

Can we just quickly catch up with things that need to happen?

Yes. So we're going to do a central line. Yup.

Do an arterial line. Yup. Once we've got access,

we're going to give some phenytoin for seizure prophylaxis.

To protect Jacqueline's brain whilst she recovers,

the team close the wound on her forehead.

We can't leave someone with their brain exposed.

There's a massive risk of infection.

The sutures will allow the brain to be protected whilst we wait for

the operation to happen.

Jacqueline is now moved to intensive care where her brain injury can be

monitored closely round the clock.

She's now unlikely to die in the next 20 to 30 minutes.

But the risk of infection is huge and anyone with an injury like this

that goes to intensive care is absolutely not out of the woods.

It's been three-and-a-half hours since Christy was hit by a car,

leaving her with a traumatic brain injury.

The bruising to her brain is causing it to swell,

increasing the pressure in her skull.

She now requires neurosurgery and has been taken to theatre,

supervised by neurosurgeon specialist registrar Adam Williams.

With Christy, the brain swelling is happening very rapidly indeed,

so if we didn't intervene and the swelling continued,

then we would expect her to exhaust her own body's ability

to cope with that change in pressure.

And then inevitably the brain would start to herniate,

to move to different parts of the skull,

causing pressure on critical structures.

And there is every chance that that would be life-threatening.

To manage the pressure in her skull,

Christy is having an operation to remove the fluid in her brain.

The aim to remove the brain fluid is to give more space within the skull,

so that the brain, which is swelling, can fill that space.

Neurosurgical clinical fellow Asli Aziz must drill a precise hole

through Christy's skull and insert the drain or catheter

deep within the fluid spaces in her brain.

This particular anatomical location is being used because we want to

avoid a very important structure which we call the motor cortex.

If Asli accidentally damages the motor cortex,

he could permanently affect Christy's ability

to control the muscles in her body.

You'll lose that for a second.

Oh, right, OK. Can you suck a little bit?

Very small ventricles. Yes, very small.

There you go.

Well done. OK. OK.

Whenever you're ready.

In order to get an accurate reading of the pressure

in Christy's skull,

Asli also fits a thin wire monitoring device into her brain.

OK, can we have the ICP?

So the depth we're talking about there, that's five.

We don't need...

Yeah.

The device has a sensor which picks up intracranial pressure, or ICP,

and feeds it to a monitor.

With having the wire into the brain tissue,

we are able to measure the pressure and if the pressure is high then we

use the second catheter to divert the flow out.

Safe ICP levels range between 5 and 20.

Yup, back to you.

And the team hope that the measures put in place will be

enough to keep her levels at a safe range.

At the moment this is extremely early days and her life still is

in grave danger at present.

Yeah, dressings.

Brain swelling tends to crescendo and we would normally say

days three and four are where it's at its maximum.

We've got every expectation that the coming hours and days are going to

prove difficult to control her intracranial pressure.

From now on, Christy will be kept under sedation where they hope to

control the swelling in her brain using a combination of drugs,

oxygen and fluid levels.

If her ICP spikes,

they will have to act immediately.

In Bristol, doctors are trying to figure out the extent of Peter's

crush injuries.

Although a major bleed has been ruled out,

a CT scan has revealed a fracture to Peter's pelvis and there is still

concern about the damage to his legs.

Yeah. So, right and left upper limbs abnormality.

That's really sore, isn't it?

Has he got femoral fractures? Has he got fractures of his lower legs?

I'm just worrying that he may have injuries that aren't related to his

pelvis from what we know of what's happened.

Has he actually been run over in a different part of his body?

Sorry.

Where's that sore? Back of the calf, underneath...

OK. He's got abrasions over that right leg.

He's got a tiny bit of an abrasion or an imprint on his calf that makes

me wonder whether he has been

run over by the forklift truck on that calf.

So, we need X-rays of...

right and left feet.

And ankles and feet.

Leilah is worried that Peter may have significantly

damaged the soft tissue of his lower legs.

This tissue swells up and that causes compression and pressure on

the nerves and the blood vessels and

it gives you large amounts of pain and

can cause pressure and death to the tissues within that lower leg over

a matter of hours.

They're pretty swollen so we'll get him rolled, get him round...

They want to get round to X-ray to do that, to take the binder off.

Peter is sent to X-ray so Leilah can look for any damage to his bones.

Remarkably, Peter's X-rays confirm

no critical damage to his lower legs.

I was convinced he was going to have some injury to his foot,

but his X-rays all look normal,

he doesn't have any fractures to his feet,

his ankles, his lower leg.

So he was just in a lot of pain from what looked like some

significant soft-tissue injuries.

The X-rays are able to confirm Peter's pelvic fracture.

So I think you can see the fractures through there.

So not particularly visible.

Although much less severe than expected,

Peter's pelvic fracture will need time to heal.

Any injury to the pelvis is significant,

it means that you've had a significant blow to it,

because you don't fracture your pelvis lightly.

Peter will now remain in hospital until doctors can fully assess

the mobility of his legs.

Less than 24 hours after her accident,

Christy had to be rushed back into surgery.

Christy, I'm just going to shine a light in your eyes a minute.

Despite the medical team's best efforts,

her brain continued to swell.

The only way for doctors to relieve the pressure was to do a procedure

called a craniectomy and remove part of her skull.

The brain is held within a fixed box

and when it swells, it has nowhere to go.

And so really, the aim of this procedure is to open the box.

And we do that by taking off a large proportion of the skull that

extends really low down from one ear up over the top to the other ear

and right down low on the front of the forehead.

By allowing the brain to expand outside the confines of her skull,

doctors have kept Christy alive, but it's not without its risks.

Even with the craniectomy,

there is a real risk of her surviving but with no return

of Christy as we remember her.

The surgical technique can relieve the pressure inside the head

but it can't undo the original injury.

Christy is now on an intensive care unit where nurses are monitoring her

around the clock and assessing the extent of her brain damage.

Christy.

Hello, lovely, it's Hannah.

We're going to come to the edge of the bed towards me.

OK? Can you start moving your legs towards me?

It takes quite a long time, often,

for patients who've had a brain injury to start waking up.

That's it. Fantastic. Good. And this one.

Often we have families say, "Is this normal?

"Is this normal for this person?" "You want to know?

"OK, in five days' time they're going to be awake,

"they're going to be doing this." So roll towards me, Christy.

All the way over.

Well done, Christy.

BEEPING

Can you put that hand on the bed for me?

That's it. Good.

And the thing with brain injuries is that it doesn't happen like that.

Everybody is so individual

because everybody's injury is completely different.

You're doing really well, Christy. She's doing so well.

Good. We need to wiggle her bottom forwards a bit more.

Brilliant, well done.

Christy's brain damage is in the areas governing motor skills

and personality.

Over time there are parts of the brain

that have been irreversibly injured from the original injury

which will ultimately die.

There are areas of the brain that were salvageable

that we've been lucky enough to salvage

and we hope they will return a normal level of function.

Christy, keep your eyes open for me, lovely.

Look at me.

Good, well done.

We hope that we can achieve a good enough resolution to bring back

the people that everybody remembers before the injuries.

But we can't always guarantee it.

Well done.

In London, medical teams have been closely monitoring Jacqueline

in intensive care following an accident that left her

with multiple fractures to her face and skull.

Her brain injury has been managed without the need for surgery.

Now that Jacqueline has regained consciousness,

a team led by consultant maxillofacial surgeon Simon Holmes

are attempting to reconstruct her face and skull.

My feeling is the force would have hit Jacqueline something like

that direction up here. And then the force would have dissipated

and there's a starburst fracture above her forehead.

And that force then went down into the nose,

across the upper cheekbones, through into the palate

and split the palate down the middle.

The width of the nose is completely gone and you can get a sense

of how far in the nose is pushed in.

'I want Jacqueline to look incredible.'

One of my greatest sources of satisfaction is seeing patients

return to normal life.

Start work, go out with partners, get married, have children.

And one of my parts of my collection is wedding photos.

To start rebuilding her face,

Simon first wires Jacqueline's lower jaw to her upper jaw.

So we're just using the teeth as surrogate bone pins, in essence,

to attach wires to.

'You know the bottom jaw is good.'

If we then wire the top jaw, which is broken, to the bottom jaw,

from that point, if you link the fragments together

so they meet perfectly, you know you've got it right.

Don't forget to stabilise it when you pull

because it's loose.

OK. That's good. Hold that, see? It locks, doesn't it?

With Jacqueline's jaw aligned,

Simon needs to remove her scalp

so he can fix the fractures in her skull around her forehead.

We need some cat's paws when you've made the first cut.

To minimise any visible scars,

the team make the cut at the top of Jacqueline's head,

hidden behind her hairline.

We zigzag the incision so that when the patient goes swimming

or has a shower, the hair doesn't part and look like an Alice band.

We should be able to sweep our fingers in there.

'So we then peel the scalp forward.

'Essentially, we scalp the patient.'

And we can get this to align through the pupils so that we can get access

to all the nose, top of the nose, and forehead, and also the brain.

Shall we just see where we are, John?

Better. It's all coming now, isn't it?

Can you start to see the fracture now?

Yeah. Just there.

But uncovering the impact site,

Simon is finally able to see the extent of the injuries

to Jacqueline's forehead.

Screws are carefully attached to each piece of the skull

to help manipulate the fractures.

Simon then starts to free up the individual fragments

of Jacqueline's skull.

'If they are impacted tight and you simply pull, they won't move.'

So you have to encourage them gently to move apart.

Anything Simon does from here on in

is highly risky to Jacqueline's brain

and could be critical to her future.

In order to continue,

Simon must enlist the help of consultant neurosurgeon Chris Uff.

Another clip, please.

'He is the one that protects the big veins of the brain and ultimately

'is the one that moves the forehead fragments around in a safe manner.'

You got it? Yeah, I've got that.

If you remove the section of bone and put it to one side,

you can then trim the sharp bits of bone

so that everything meets more cleanly.

With the fractures no free to move,

Simon must attempt to lift Jacqueline's nose

back out of her face.

So what we're going to do is,

you're going to lift the scalp up

and I'm going to get the nasal prongs

and lift the whole nose out.

That's the plan.

A retractor, please.

Could I have the nasal forceps, please?

'You know which way it went in

'so you literally have to reverse the force,'

lift all that weight up. It's quite a lot.

'As you feel the face move,'

you hear a very gentle but satisfying crunch

as all the bits locate in the right place.

Having reset Jacqueline's nose,

Simon and Chris are able to replace all the skull fragments

in their correct position.

Now they must make sure they remain in place by inserting metal plates.

'The plates in Jacqueline's case, they're titanium,'

and they literally hold the fragments together.

But they only hold them together, Jacqueline does the rest -

she fills in the gaps of bone and heals it.

After about three to four weeks, the plates are superfluous.

Jacqueline is in surgery for 5 1/2 hours.

In total, Simon used more than 15 plates and 50 screws

to reconstruct Jacqueline's skull.

Jacqueline's right eye was particularly a problem.

The roof of the eye socket had caved in which had essentially,

we thought, torn through her eyelid muscle, which opens her eye.

So we had to reconstruct the floor of the eye socket.

This is the plate here.

Can you see the orbital plate?

It'll be a few weeks before the surgical team can assess

just how successful the operation has been.

You know, one minute you're working

and the next you see a forklift on top of you and then that's it.

I thought I would be paralysed from the waist down.

I just didn't feel anything except for the sheer pain.

I never want to feel pain like that in my life again.

If I'd have been worse off in the accident, be in a wheelchair,

it's just not my life that's altered, it's Paula's, my kids.

I've been off work now weeks.

I'm off the painkillers now,

up and downstairs just various exercises,

and a few walks out with Paula on my crutches for a meal now and then.

One of the doctors said, "He's Iron Man

"for what we've seen and what he's been put through.

"And the injuries he's got is just unbelievable."

I would imagine Peter should make a full recovery.

I think he's got off incredibly lightly.

Most bones take about six to eight weeks to heal

and usually they heal on their own and don't need any other treatment.

I feel like I'm one of the luckiest men alive.

I was astounded.

The surgeons had done an amazing job.

It's really reassuring that Jacqueline shows

no long-standing signs of any brain damage.

Jacqueline's been very lucky to get the care that she needed

at the roadside, not die on the roadside

and then survive the surgery.

When my surgeon removed the plasters from my face...

..I did cry, because I didn't know what I looked like.

And then he showed me my skull before and after.

It's like, look at me know.

I'm quite proud of myself, how far I've come.

Obviously people's loss of identity through disfigurement

or a change in their face can be huge,

so really important that the surgery

is timely and as effective as possible.

She does of course have a scar on her forehead,

but it's still very early days. That will continue to heal.

My scar tells the story and I'm not embarrassed of it.

Personally I think Jacqueline looks great.

There's great satisfaction to see that she is happy

and you get her how she was as near as possible before the injury.

That for me is the essence of why I do the job.

That's what makes an old man happy.

The doctors - I'm so, so grateful.

If I could give them the world,

I would.

My brain has been affected...

..in a way so now I have really...

..quite poor short-term memory.

And I don't know what the last thing I remember is either

because my brain doesn't really work in chronological order.

I've just got random flashes of memories.

Christy's eight weeks into rehabilitation.

She is doing remarkably well

but there are issues, there are problems,

and at this point in time we don't know how those problems

are going to turn out.

Recovery after these is always a bit of a stormy process

and we don't expect a uniform, comfortable improvement over time.

However, when we see patients responding as quickly

and as well as Christy has done, then we're hugely encouraged.

I've got every hope that we will return her to independent living.

I think that for someone who was hit by a car,

I'm probably in the very, very, very best...

..condition that I could be at this point.

I'm lucky that I didn't die when I was hit,

and then again, I was saved a second time by the doctors.

So eternally grateful.

Next time, we follow three more patients

through the crucial first hour of care.

In north London, a man is hit by a bus and fights for his life.

I'm not happy that's in, OK,

I'm just going to pull the tube back a little bit.

Near Bristol, a rider lies unable to move

after being thrown from his horse.

Can you move your fingers? No.

Can you feel me touching you here? Yes.

And in St Albans,

a tree surgeon falls 30 feet off a ladder while cutting branches.

I'm worried about him. We're a long way from hospital,

he could be bleeding into his abdomen or his pelvis.