0:00:05 > 0:00:08'Hello, ambulance service.' 'There's a guy just got hit by a bus.
0:00:08 > 0:00:11'He was on a bike. He's been really badly injured.'
0:00:11 > 0:00:14From the moment an emergency call is made, a clock starts ticking.
0:00:18 > 0:00:20'Female lying on the road, struggling to breathe.'
0:00:20 > 0:00:26The golden hour is the opportunity that we have to save the patient.
0:00:26 > 0:00:28Deep breaths, George.
0:00:28 > 0:00:32The longer the clock ticks, the increased likelihood there is of death.
0:00:36 > 0:00:39In the fight for survival, time is the enemy.
0:00:39 > 0:00:41I'm ventilating fast on purpose.
0:00:41 > 0:00:44Yes. I'm hoping that heart rate will pick up any second.
0:00:44 > 0:00:49Now, new techniques and technology are bringing emergency medicine to the roadside...
0:00:49 > 0:00:51We can use the infra scanner to maybe give us a slightly
0:00:51 > 0:00:54clearer picture of what's going on underneath the skull.
0:00:54 > 0:00:59..breaking new ground and treating patients faster than ever before.
0:00:59 > 0:01:02We can now provide emergency surgery,
0:01:02 > 0:01:05blood transfusions, anaesthesia, at the scene of the accident.
0:01:05 > 0:01:09Yep, through the cord. Tube, please. Tube on.
0:01:12 > 0:01:16We follow three patients through the crucial first hour of care.
0:01:17 > 0:01:21In north London, a man is hit by a bus and fights for his life.
0:01:21 > 0:01:24I'm not happy. I'm just going to pull the tube back a little bit.
0:01:24 > 0:01:27Near Bristol, a rider lies unable to move
0:01:27 > 0:01:29after being thrown from his horse.
0:01:29 > 0:01:30Can you move your fingers?
0:01:30 > 0:01:33No. Can you feel me touching you here? Yes.
0:01:33 > 0:01:37And in St Albans, a tree surgeon falls 30 feet off a ladder
0:01:37 > 0:01:39while cutting branches.
0:01:39 > 0:01:41I'm worried about him. We're a long way from hospital.
0:01:41 > 0:01:44He could be bleeding into his abdomen or his pelvis.
0:01:47 > 0:01:5060 minutes that will change their lives forever.
0:01:50 > 0:01:52You'll constantly be surprised
0:01:52 > 0:01:56just what you can bring back from the jaws of death.
0:01:56 > 0:02:02This programme contains scenes which some viewers may find upsetting
0:02:09 > 0:02:11At ambulance control in Waterloo,
0:02:11 > 0:02:16an emergency call has just been received from north London.
0:02:27 > 0:02:29He's making noises?
0:02:36 > 0:02:39Consultant Gareth Greer and paramedic Sue Trow
0:02:39 > 0:02:42from London's Air Ambulance are on their way to the incident.
0:02:45 > 0:02:49'We know very little, apart from someone's been hit by a bus.'
0:02:49 > 0:02:51It could be an injury to any part of the body.
0:02:51 > 0:02:54It could be that the patient has multiple injuries.
0:02:54 > 0:02:58We're kind of ready for any eventuality.
0:03:01 > 0:03:05A London ambulance service crew are already on scene,
0:03:05 > 0:03:09struggling to assess the patient. HE MOANS
0:03:10 > 0:03:11Yeah.
0:03:13 > 0:03:14Understood.
0:03:14 > 0:03:15HE GROANS
0:03:15 > 0:03:20See the damage to the bus? He smashed a light casing. Yeah.
0:03:22 > 0:03:2537-year-old Dusan, a fitness instructor,
0:03:25 > 0:03:28was walking to the gym when he was hit by the bus.
0:03:28 > 0:03:31When the ambulance arrived, he was found highly confused.
0:03:33 > 0:03:35We're going to look after you.
0:03:35 > 0:03:36'If someone's agitated,'
0:03:36 > 0:03:40to me, it signifies it's going to be quite a severe head injury.
0:03:40 > 0:03:43Some people appear like they're drunk through having a head injury
0:03:43 > 0:03:46like that, but with the injuries that he had around his face,
0:03:46 > 0:03:49you have to suspect that he had a bad head injury.
0:03:49 > 0:03:51This strange behaviour is a clue
0:03:51 > 0:03:54that Dusan's brain is suffering from the impact.
0:03:55 > 0:03:59'The knock on the head has damaged all of the connections in his brain.
0:03:59 > 0:04:01'He is disorientated, he doesn't know where he is,'
0:04:01 > 0:04:03he doesn't know what's happening.
0:04:03 > 0:04:05He can't put all of these things together.
0:04:05 > 0:04:08HE CRIES We're going to help you.
0:04:08 > 0:04:11We're going to help you, all right?
0:04:11 > 0:04:13'If there is bleeding in his brain,'
0:04:13 > 0:04:15that needs to be sorted very, very quickly
0:04:15 > 0:04:20otherwise it could be catastrophic for him.
0:04:20 > 0:04:22What I'm going to do is try him with a little bit of sedation.
0:04:22 > 0:04:25We'll just have a look at his veins, just to see what...
0:04:25 > 0:04:27'We need to get on top of the agitation
0:04:27 > 0:04:29'before we can do anything else.'
0:04:29 > 0:04:31If you just draw up 4mls for now.
0:04:32 > 0:04:36Gareth gives Dusan Midazolam, a powerful sedative.
0:04:37 > 0:04:40The impact from the bus may have caused other internal injuries
0:04:40 > 0:04:42and he needs to assess him properly.
0:04:42 > 0:04:44Yeah, we'll move him up... Once...
0:04:44 > 0:04:46Let's just cut the front of his clothes off first.
0:04:46 > 0:04:48HE GROANS
0:04:48 > 0:04:50Let's start moving him out because we need to start getting
0:04:50 > 0:04:53the tube down, because he's not ventilating too well.
0:04:54 > 0:04:59Dusan is breathing abnormally and has very low oxygen levels.
0:04:59 > 0:05:04To boost them, Gareth gives pure 02 through a mask and prepares
0:05:04 > 0:05:07to take control of his airway with a breathing tube,
0:05:07 > 0:05:09but, for this procedure, he needs more space.
0:05:12 > 0:05:15If the breathing carries on in this abnormal way, that can result in
0:05:15 > 0:05:18increasingly bad brain damage...
0:05:18 > 0:05:21very, very quickly over a period of minutes rather than hours.
0:05:21 > 0:05:23This one has just kinked a little bit.
0:05:23 > 0:05:25To take over Dusan's breathing,
0:05:25 > 0:05:29Gareth must first anaesthetise him and paralyse his muscles.
0:05:29 > 0:05:32OK, guys, so we're going to do the anaesthetic.
0:05:32 > 0:05:36This procedure usually takes place in a calm operating theatre...
0:05:37 > 0:05:38..but Gareth must act now.
0:05:50 > 0:05:52110 miles away in Bristol,
0:05:52 > 0:05:56an ambulance control room has just received a call about a man involved
0:05:56 > 0:05:59in a serious horse-riding accident.
0:06:15 > 0:06:19Great Western Air Ambulance critical care team Dr Greg Cranston
0:06:19 > 0:06:21and paramedic John Wood
0:06:21 > 0:06:25have been dispatched to a field just north of the M4 near Bristol.
0:06:25 > 0:06:29We go to a fair number of riding accidents.
0:06:29 > 0:06:33We'll probably go to one every couple of weeks.
0:06:33 > 0:06:36The most common injury that a patient would sustain from a fall
0:06:36 > 0:06:40from a fall from horse would be a bony-type injury, so a fracture.
0:06:42 > 0:06:45They're looking for a 63-year-old man who's been thrown at speed
0:06:45 > 0:06:47from his horse.
0:06:47 > 0:06:51We were told that the patient had come off,
0:06:51 > 0:06:55was conscious but had difficulty in breathing
0:06:55 > 0:06:58and couldn't move his limbs,
0:06:58 > 0:07:02so that information immediately rang alarm bells.
0:07:06 > 0:07:10Straight ahead. Horse tripped on landing. He fell off.
0:07:10 > 0:07:14He's got pain in his neck, he can't move his hands,
0:07:14 > 0:07:16he is conscious, he is talking.
0:07:16 > 0:07:17Breathing is shallow.
0:07:20 > 0:07:25My priorities are to establish the range of injuries that he has and to
0:07:25 > 0:07:28work out if any of those are likely to be immediately life-threatening.
0:07:28 > 0:07:31We just haven't moved him.
0:07:31 > 0:07:33We haven't touched him. Excellent.
0:07:33 > 0:07:36Covered him up, that's all we've done. Hello, there.
0:07:36 > 0:07:40Hello. My name is Dr Cranston, one of the doctors with the Air Ambulance.
0:07:40 > 0:07:42What's your name?
0:07:42 > 0:07:45George. Hello, George. Are you in any pain?
0:07:45 > 0:07:47My neck hurts quite a bit.
0:07:47 > 0:07:50OK. Can you open your eyes for me? Yeah.
0:07:50 > 0:07:52Open your eyes. Can you look at me?
0:07:52 > 0:07:55You can see me OK. Excellent.
0:07:55 > 0:07:57Can you move your fingers? No.
0:07:57 > 0:08:00Can you give me a squeeze at all here? No. OK.
0:08:01 > 0:08:05Falling from a horse is a potentially serious mechanism of
0:08:05 > 0:08:08injury and people aren't generally ready for this fall,
0:08:08 > 0:08:09so they often don't have time
0:08:09 > 0:08:13in order to manipulate themselves or control the way in which they land.
0:08:14 > 0:08:19'I'm starting to worry already that this may be a spinal cord injury.'
0:08:21 > 0:08:22Can you feel me touching you here?
0:08:22 > 0:08:25Yes. You're well tucked in, aren't you?
0:08:25 > 0:08:28Yes. Can you feel me touching you here on your chest?
0:08:28 > 0:08:29I think a little bit.
0:08:29 > 0:08:31A little bit. Can you feel me touching you on your hand? No.
0:08:31 > 0:08:35You can break a bone of your neck and your spinal cord
0:08:35 > 0:08:38could be completely intact, and it's painful and it gets better.
0:08:38 > 0:08:43But a spinal cord injury is a significant injury,
0:08:43 > 0:08:47because that's the thing that can cause you paralysis.
0:08:47 > 0:08:51The extent of George's spinal injury is not yet known.
0:08:51 > 0:08:55Greg can't rule out the impact this might have on his other vital signs.
0:08:56 > 0:08:58Don't be scared, OK?
0:08:58 > 0:09:00We're going to look after you, all right?
0:09:00 > 0:09:04We'll get you sorted bit by bit, slowly,
0:09:04 > 0:09:07one bit at a time, and we'll fly you to hospital. OK?
0:09:07 > 0:09:11There's no way that we can tell at this point how serious that injury
0:09:11 > 0:09:14is until he arrives at hospital.
0:09:14 > 0:09:16I'm just wondering how much of this we'll cut off.
0:09:16 > 0:09:20Just cut it off so we can see what's going on down the back. Yeah?
0:09:20 > 0:09:22Before they can move George,
0:09:22 > 0:09:25Greg needs to check the rest of his body for injuries.
0:09:25 > 0:09:28We're going to cut some of your clothes off, OK?
0:09:28 > 0:09:30We will keep you warm.
0:09:30 > 0:09:32It's really important that we get to assess you fully.
0:09:32 > 0:09:34It's almost certainly going to be my neck.
0:09:35 > 0:09:38I agree with you. I agree with you,
0:09:38 > 0:09:42but there is a danger that you could have other injuries that we wouldn't
0:09:42 > 0:09:44easily know about.
0:09:46 > 0:09:47Stay with us, George.
0:09:49 > 0:09:52George, take some deep breaths for me.
0:09:53 > 0:09:55Big, deep breath.
0:09:58 > 0:10:00His breathing is very shallow.
0:10:00 > 0:10:03As I ask him to take deep breaths,
0:10:03 > 0:10:06it doesn't appear that he does take any breaths at all.
0:10:09 > 0:10:11Deep breaths, George.
0:10:12 > 0:10:16He's breathing but it's so shallow that I'm unable to detect that by
0:10:16 > 0:10:19either looking or listening with my stethoscope.
0:10:21 > 0:10:25The spinal cord is a connection between the brain and the body and,
0:10:25 > 0:10:27if you break that connection,
0:10:27 > 0:10:29then the muscles of the body are unable to respond.
0:10:30 > 0:10:35My main concern is whether George will continue to breathe.
0:10:35 > 0:10:38He's breathing now, but will he continue to do that?
0:10:38 > 0:10:40Deep breaths, George.
0:10:40 > 0:10:41Go on, nice and deep.
0:10:52 > 0:10:55Oxygen mask on tight, reservoir moving with ventilation.
0:10:56 > 0:11:01In north London, 37-year-old Dusan has been hit by a bus,
0:11:01 > 0:11:04suffering a massive head injury, and he's not breathing properly.
0:11:06 > 0:11:10Baseline blood pressure seen and monitor set to two minutes. Check.
0:11:10 > 0:11:14Despite Gareth's efforts to improve Dusan's oxygen levels,
0:11:14 > 0:11:16they're still very low,
0:11:16 > 0:11:19a sign he may have significant injury to his lungs.
0:11:19 > 0:11:23This could damage other vital organs and his already injured brain.
0:11:23 > 0:11:26'What I'm trying to do is to take over Dusan's breathing'
0:11:26 > 0:11:30so that we have control of the oxygen levels in his bloodstream.
0:11:31 > 0:11:34We're just starting the RSI now and then we'll be...
0:11:34 > 0:11:38A rapid sequence induction will take over Dusan's breathing,
0:11:38 > 0:11:42enabling Gareth to deliver oxygen down a tube to his lungs.
0:11:42 > 0:11:44He is having 4mls of fentanyl.
0:11:46 > 0:11:48Just hold his arm for me.
0:11:49 > 0:11:50Thank you.
0:11:50 > 0:11:55For this, Gareth must anaesthetise him and force his muscles to relax.
0:11:56 > 0:11:59Fentanyl's in. Ketamine next.
0:12:03 > 0:12:06It's essentially giving someone an anaesthetic, like you would have
0:12:06 > 0:12:07if you went in for an operation,
0:12:07 > 0:12:10but it's doing it in an emergency situation,
0:12:10 > 0:12:12which is a high-risk procedure.
0:12:15 > 0:12:17OK, the jaw is nice and floppy.
0:12:17 > 0:12:18OK.
0:12:18 > 0:12:20The drugs have worked quite quickly,
0:12:20 > 0:12:23so we might be able to proceed relatively quickly with this.
0:12:24 > 0:12:27Dusan is now completely paralysed.
0:12:27 > 0:12:30Gareth has just minutes to manoeuvre a breathing tube
0:12:30 > 0:12:32through his vocal cords and into his windpipe.
0:12:34 > 0:12:36If you can't get the tube down into the windpipe,
0:12:36 > 0:12:37then the patient won't breathe.
0:12:42 > 0:12:44OK, grade one view.
0:12:54 > 0:12:55Just won't go through the cord.
0:12:55 > 0:12:57Sue, just pass me the tube a second. Hmm-hmm.
0:12:57 > 0:12:59Thank you.
0:13:06 > 0:13:08Yeah, tube's in.
0:13:09 > 0:13:11Just deflate the cuff a minute, Sue.
0:13:13 > 0:13:15I'm not happy that's in.
0:13:15 > 0:13:17I'm just going to pull the tube back a little bit...
0:13:17 > 0:13:21and it's going to go in again. Nope.
0:13:21 > 0:13:22OK.
0:13:22 > 0:13:24I can see the tube between the chords.
0:13:24 > 0:13:26Can I just borrow your stethoscope for a minute?
0:13:26 > 0:13:28Just to listen to his tummy.
0:13:28 > 0:13:29Just hold the tube there for me.
0:13:29 > 0:13:33Although Gareth is now in full control of Dusan's breathing,
0:13:33 > 0:13:34his oxygen levels are still low,
0:13:34 > 0:13:38suggesting something is seriously wrong with his lungs.
0:13:41 > 0:13:42Air entry.
0:13:48 > 0:13:50Pretty grotty.
0:13:52 > 0:13:55I'm hoping that heart rate will pick up any second.
0:13:55 > 0:13:57Just keep holding the tube.
0:13:57 > 0:14:00'Dusan's heart rate has gone down catastrophically.'
0:14:01 > 0:14:04It's gone down to 30 beats a minute.
0:14:04 > 0:14:06This is very, very bad.
0:14:06 > 0:14:07If that gets any worse,
0:14:07 > 0:14:12he'll be in cardiac arrest and his heart will effectively stop.
0:14:12 > 0:14:15A normal heart rate would be around 60 beats per minute,
0:14:15 > 0:14:17but Dusan's low oxygen levels
0:14:17 > 0:14:20are now impacting on his heart's ability to pump.
0:14:20 > 0:14:25Gareth must get as much oxygen in as quickly as he can.
0:14:25 > 0:14:27I'm ventilating fast on purpose. Yeah.
0:14:29 > 0:14:34'I want his heart to be able to fill properly and have enough oxygen to
0:14:34 > 0:14:35'allow itself to work properly,'
0:14:35 > 0:14:39and I'm hoping his heart will kick in and come back to normal.
0:14:50 > 0:14:52OK, heart rate's come back up. That's good.
0:14:52 > 0:14:54Just give him a little bit more bagging.
0:14:56 > 0:14:59Sue, can you pass me some long suction catheters from the bag?
0:14:59 > 0:15:00Yep. Thank you.
0:15:02 > 0:15:04So, this is pulmonary oedema.
0:15:05 > 0:15:09'Fluid leaks out of the little blood vessels inside the lungs,
0:15:09 > 0:15:12'into the air spaces.'
0:15:12 > 0:15:15And then, when you put someone on the breathing machine,
0:15:15 > 0:15:17you see that fluid coming up.
0:15:17 > 0:15:20A bloodstained fluid coming out of the tube suggests
0:15:20 > 0:15:24Dusan's lungs have been seriously damaged by the impact of the bus.
0:15:24 > 0:15:27This is all pulmonary oedema that you get on the chest. Is it?
0:15:27 > 0:15:30But the scale of his injuries is still not clear.
0:15:30 > 0:15:35Dusan is critically ill and Gareth must get him to hospital fast.
0:15:35 > 0:15:37I just want to have a quick look at the rest of him and then I'll...
0:15:37 > 0:15:41'As well as the possibility of a really bad head injury,'
0:15:41 > 0:15:43Dusan could have bleeding in other areas
0:15:43 > 0:15:45that could also kill him quickly.
0:15:47 > 0:15:49The tummy was distended before.
0:15:49 > 0:15:51We'll cut these off in a minute.
0:15:51 > 0:15:53Nothing obviously there.
0:15:53 > 0:15:55Dusan's stomach is worryingly tight.
0:15:55 > 0:15:59This could be caused by internal bleeding from yet another injury.
0:15:59 > 0:16:01We do need to get moving.
0:16:01 > 0:16:03Let's start packing up, getting ready to go.
0:16:06 > 0:16:08We need to get him to the hospital to try and work out
0:16:08 > 0:16:11if there are any other injuries that we can't see at the moment
0:16:11 > 0:16:14that could also kill him very, very quickly.
0:16:14 > 0:16:16Ready, steady, go.
0:16:16 > 0:16:18SIREN BLARES
0:16:23 > 0:16:26Are you aware of us taking your boots off?
0:16:26 > 0:16:28No. No, OK.
0:16:28 > 0:16:32Near Bristol, rider George has lost all feeling in his body
0:16:32 > 0:16:34from the neck down, having been thrown from his horse
0:16:34 > 0:16:35while jumping a hedge.
0:16:37 > 0:16:40He's unable to move and his breathing has become very shallow.
0:16:40 > 0:16:43A high-level spinal cord injury
0:16:43 > 0:16:47disconnects your brain from the muscles in your ribcage,
0:16:47 > 0:16:50so you can't breathe using those muscles.
0:16:51 > 0:16:55There's another nerve, which takes a different pathway,
0:16:55 > 0:16:59and it connects directly to the diaphragm.
0:16:59 > 0:17:04So the diaphragm can continue to assist in breathing,
0:17:04 > 0:17:06but you become very tired very quickly
0:17:06 > 0:17:09and you can progress to not being able to breathe at all.
0:17:10 > 0:17:14This separate nerve comes out of the spinal cord, high up in the neck,
0:17:14 > 0:17:17and might be the only thing keeping George alive.
0:17:17 > 0:17:19I'll tell you what we'll do, let's split this,
0:17:19 > 0:17:21roll him onto half of it.
0:17:21 > 0:17:24George's heart rate is also worryingly slow,
0:17:24 > 0:17:26but this, too, has a dedicated nerve,
0:17:26 > 0:17:29as well as special cells that keep it beating on its own.
0:17:29 > 0:17:33Our heart has an intrinsic ability to keep beating.
0:17:33 > 0:17:34Even if it came out of the body,
0:17:34 > 0:17:37it would still keep beating for a short period.
0:17:37 > 0:17:40However, it would continue at a slow rate only.
0:17:42 > 0:17:45With his breathing and heart rate critically low,
0:17:45 > 0:17:48it's not clear how long George can survive.
0:17:48 > 0:17:51We're going to roll you onto your back, OK?
0:17:51 > 0:17:53Is that all right?
0:17:53 > 0:17:56I'm going to take good control of your head and neck,
0:17:56 > 0:17:57that's going to be my job, OK?
0:17:57 > 0:17:59We're going to do everything very slowly.
0:17:59 > 0:18:01If anything hurts, just shout out.
0:18:01 > 0:18:02I'm listening, OK?
0:18:03 > 0:18:05I think the important thing here, guys,
0:18:05 > 0:18:08is we do everything very carefully. Very, very carefully.
0:18:08 > 0:18:10There's no rush, OK? We'll do things carefully.
0:18:11 > 0:18:14What we have to be careful is that we don't worsen the injury,
0:18:14 > 0:18:18we don't cause any further damage to the spinal cord.
0:18:18 > 0:18:22Therefore, we have to move him as carefully as possible.
0:18:22 > 0:18:24So, has everyone got appropriate hands on the position
0:18:24 > 0:18:27and knows where...? I've just got his pelvis area, really.
0:18:27 > 0:18:29We'll just very slowly go over,
0:18:29 > 0:18:32nice and controlled, straightening him out as we go.
0:18:32 > 0:18:34OK. We're doing this slowly. OK?
0:18:34 > 0:18:37'We need to get George into a neutral alignment,'
0:18:37 > 0:18:39perfectly aligned, on his back,
0:18:39 > 0:18:43with as little movement as possible to his entire spine.
0:18:43 > 0:18:45So, ready, steady, we'll start.
0:18:47 > 0:18:50The spinal cord has the consistency of toothpaste.
0:18:50 > 0:18:52It's very delicate.
0:18:54 > 0:18:59It can be damaged if the bones that surround it are broken
0:18:59 > 0:19:02and impinge or push onto the spinal cord.
0:19:02 > 0:19:04If anyone's got any problems as we go,
0:19:04 > 0:19:05just shout out and we'll pause, OK?
0:19:05 > 0:19:07We're doing this slowly, OK?
0:19:08 > 0:19:11That came off easily. Good. Just keep him coming.
0:19:13 > 0:19:14That's it.
0:19:14 > 0:19:17You've got his head, mate? I have his head.
0:19:17 > 0:19:18How are you doing?
0:19:18 > 0:19:20Is that uncomfortable? There.
0:19:20 > 0:19:21Where? In your neck?
0:19:22 > 0:19:27I'm delighted to say that pins and needles are now beginning to start.
0:19:27 > 0:19:30Pins and needles? They're going down further...
0:19:30 > 0:19:32Further down my biceps.
0:19:32 > 0:19:33Down your arms? Yeah. OK.
0:19:35 > 0:19:37My collar bones are fantastically sensitive.
0:19:40 > 0:19:42'What I think is happening here
0:19:42 > 0:19:45'is that his brain is unable to process or understand
0:19:45 > 0:19:48'the information that it's receiving,
0:19:48 > 0:19:52'so it tries to fill in the gaps and imagine what should be there.'
0:19:52 > 0:19:55This would probably just be a perception
0:19:55 > 0:19:57rather than a genuine sensation.
0:19:59 > 0:20:02Is this pain or is it a funny feeling? Pain. Real, real pain.
0:20:02 > 0:20:04Pain. And that's pain to your...?
0:20:04 > 0:20:05Neck. Neck, OK.
0:20:05 > 0:20:09Going down to my collarbone and round to the top of my shoulders.
0:20:09 > 0:20:10Yeah.
0:20:13 > 0:20:14Christ, it hurts.
0:20:17 > 0:20:20With George's pain now rapidly increasing,
0:20:20 > 0:20:24Greg gives him intravenous morphine to ease his distress.
0:20:24 > 0:20:25It's started going in, George, OK?
0:20:25 > 0:20:28So you'll start to feel some effects of that. Yeah.
0:20:28 > 0:20:30But I don't want to just blast so much of it in all at once
0:20:30 > 0:20:32that you get knocked off, OK?
0:20:32 > 0:20:35'Morphine depresses your brain's drive to breathe'
0:20:35 > 0:20:37and that's the last thing we wanted to do.
0:20:39 > 0:20:41Lift!
0:20:41 > 0:20:43With George's breathing a major concern,
0:20:43 > 0:20:46Greg must get him to hospital as fast as possible.
0:20:48 > 0:20:51His son was also riding with him when he came off his horse.
0:20:54 > 0:20:56So, he will have a scan within...
0:20:56 > 0:20:59I would give an estimate of ten minutes of walking through the door
0:20:59 > 0:21:02and we'll know to quite a degree what the damage is.
0:21:05 > 0:21:07It's a bit of an unanswerable question.
0:21:07 > 0:21:10What I've said to him is, "Don't lose hope. Don't give up hope."
0:21:10 > 0:21:13Things aren't always as bad as they seem straight off.
0:21:13 > 0:21:17That's true, but we do have to be prepared for everything.
0:21:21 > 0:21:25It's not a great rate, actually, even in here.
0:21:25 > 0:21:29George's heart rate is also still worryingly slow.
0:21:29 > 0:21:32Greg alerts the nearest major trauma centre.
0:21:32 > 0:21:34ETA is probably 15 from now.
0:21:34 > 0:21:361-5.
0:21:49 > 0:21:52In Chelmsford, East of England Ambulance Control has received
0:21:52 > 0:21:56an emergency call about a man who's fallen from a tall ladder.
0:22:08 > 0:22:12Essex and Herts Air Ambulance doctor Sam Sadek
0:22:12 > 0:22:15and critical care paramedic Simon Probert
0:22:15 > 0:22:17have been called to St Albans.
0:22:17 > 0:22:19An ambulance crew already with the patient
0:22:19 > 0:22:22are concerned about his condition.
0:22:23 > 0:22:25The difficulty with a fall from height
0:22:25 > 0:22:27is it really could be anything, sometimes everything.
0:22:27 > 0:22:29When a person hits the floor, they decelerate
0:22:29 > 0:22:33and you can get a lot of hidden injuries with a fall like that.
0:22:33 > 0:22:37Some of the internal organs can be very badly damaged.
0:22:37 > 0:22:3923-year-old Seb, a tree surgeon,
0:22:39 > 0:22:42was cutting branches with a long pole pruner
0:22:42 > 0:22:43when he fell to the ground.
0:22:43 > 0:22:46He's now in an ambulance, braced on a stretcher.
0:22:50 > 0:22:52It's Seb, isn't it? Seb. Yeah. What were you doing?
0:22:52 > 0:22:54You were cutting trees, were you?
0:22:59 > 0:22:59Yeah.
0:23:04 > 0:23:07And you landed how?
0:23:07 > 0:23:09Onto your feet, like this, or onto your side?
0:23:12 > 0:23:14Yeah, OK.
0:23:14 > 0:23:15We'll cut all your clothes off.
0:23:15 > 0:23:18We'll keep you in the ambulance so you're warm for now, OK, buddy?
0:23:18 > 0:23:22'My first impression of Seb'
0:23:22 > 0:23:26is a man who is in a lot of pain,
0:23:26 > 0:23:29is not breathing quite normally -
0:23:29 > 0:23:32either because of his injury, or because of his pain -
0:23:32 > 0:23:36and a man who is very scared, and that worries me.
0:23:36 > 0:23:39Do you mind if, while I do a primary survey...?
0:23:39 > 0:23:42'Not everybody looks that scared after they've had an injury,'
0:23:42 > 0:23:45so, yeah, it's a sign of something bad going on.
0:23:45 > 0:23:48Someone tries to pop in another cannula.
0:23:48 > 0:23:50We're going to get you really warmed up now
0:23:50 > 0:23:52and give you loads of painkillers, OK, mate?
0:23:52 > 0:23:54Sam needs to find the source of Seb's pain
0:23:54 > 0:23:57to work out what's going on inside.
0:23:57 > 0:23:59I'll have a gentle feel of your tummy.
0:24:01 > 0:24:04Does it hurt? Yeah. Everywhere?
0:24:04 > 0:24:05Yeah. OK.
0:24:05 > 0:24:09When I pressed his tummy, he was desperately tender and rigid,
0:24:09 > 0:24:11which can be a sign of a real disaster going on in the abdomen.
0:24:11 > 0:24:13If I press here, does that hurt?
0:24:16 > 0:24:19It's hurting down there when I'm pressing here?
0:24:19 > 0:24:22I'm just undoing your trousers to have a look at your pelvis.
0:24:22 > 0:24:26Paramedic Simon Probert is concerned about the risk of internal bleeding.
0:24:26 > 0:24:28With all trauma patients that we attend,
0:24:28 > 0:24:31we'll always perform an examination of the pelvis.
0:24:31 > 0:24:35It's a very strong, rigid structure, but it can be broken.
0:24:35 > 0:24:38Because of the amount of blood vessels that sit within your pelvis,
0:24:38 > 0:24:40pelvic fractures can be fatal.
0:24:40 > 0:24:44They can be life-threatening and you can lose your entire blood volume
0:24:44 > 0:24:47within your pelvis without any external bleeding.
0:24:47 > 0:24:49Does that hurt your back at all?
0:24:49 > 0:24:50OK.
0:24:53 > 0:24:55That hurts you where in your back?
0:24:55 > 0:24:57Lower back, yeah. OK.
0:24:57 > 0:24:59How much morphine has he had? Ten.
0:24:59 > 0:25:02Ten. Let's try more morphine and I'll be back in a second.
0:25:03 > 0:25:09Time is critical because, every second that the body is bleeding,
0:25:09 > 0:25:11your chance of death increases.
0:25:12 > 0:25:15I leave to gather probably one of the most important
0:25:15 > 0:25:20bits of information for myself and that is to look at the exact scene -
0:25:20 > 0:25:22where he fell from and what he landed on.
0:25:25 > 0:25:26Yeah.
0:25:27 > 0:25:28Oh, really? OK.
0:25:30 > 0:25:32Right. From where?
0:25:35 > 0:25:38A-frame meaning what? Scaffolding? A great big ladder. A ladder.
0:25:38 > 0:25:41Metal, an A-frame ladder that goes like that.
0:25:41 > 0:25:43OK, and what branches was he cutting?
0:25:43 > 0:25:46Those broken top ones up there? Yep. OK.
0:25:49 > 0:25:52'Seeing that tree, seeing the height and what he landed on,'
0:25:52 > 0:25:54for me, was the clincher.
0:25:54 > 0:25:55I thought, "This is enough.
0:25:55 > 0:25:58"I'm not going to take any chances with this man."
0:25:59 > 0:26:02Concerned Seb could be bleeding from internal injuries sustained in the
0:26:02 > 0:26:06high fall, Sam must get him to hospital fast.
0:26:06 > 0:26:09He's fallen a fair old way onto the base of a bush,
0:26:09 > 0:26:10so a big deceleration.
0:26:11 > 0:26:14I mean, he's extremely tender in his abdomen.
0:26:14 > 0:26:16I think we should go to a major trauma centre
0:26:16 > 0:26:19because I'm worried he's bleeding. Yeah, yeah. I agree.
0:26:30 > 0:26:31In the last 60 minutes,
0:26:31 > 0:26:33emergency clinicians have battled to
0:26:33 > 0:26:35treat three critically ill patients.
0:26:36 > 0:26:38Horse rider George is being
0:26:38 > 0:26:39airlifted to hospital
0:26:39 > 0:26:40after suffering major damage
0:26:40 > 0:26:42to his spinal cord.
0:26:43 > 0:26:45Dusan has been anaesthetised
0:26:45 > 0:26:46after an accident
0:26:46 > 0:26:48has left him with multiple injuries.
0:26:48 > 0:26:51And after falling from a tall ladder,
0:26:51 > 0:26:53Seb is showing signs of potential internal bleeding.
0:26:59 > 0:27:02Dusan has been rushed to the Royal London Hospital
0:27:02 > 0:27:04after being hit by a bus while walking to the gym.
0:27:06 > 0:27:10Gareth is concerned about his head and chest injuries.
0:27:10 > 0:27:13He's also worried he may be bleeding into his abdomen.
0:27:13 > 0:27:16I just wanted to let you know there's a trauma patient arriving.
0:27:16 > 0:27:19The 40-year-old male pedestrian versus bus.
0:27:19 > 0:27:20OK.
0:27:20 > 0:27:24Emergency medicine consultant Simon Walsh is preparing
0:27:24 > 0:27:27to take over the patient and assess the scale of his injuries.
0:27:30 > 0:27:34OK, everyone, this gentleman is approximately 40 years of age.
0:27:34 > 0:27:36He was hit by a bus.
0:27:36 > 0:27:38I think he's hit the bus with his head.
0:27:38 > 0:27:42His saturations where 85% and his last blood pressure was 88 systolic.
0:27:42 > 0:27:44OK. Let's start the primary survey, please.
0:27:44 > 0:27:48Can we get the...? Is the scoop undone?
0:27:48 > 0:27:52Dusan has both critically low oxygen and blood pressure.
0:27:52 > 0:27:53As well as his head injury,
0:27:53 > 0:27:56the impact of the bus may have damaged his lungs
0:27:56 > 0:27:58and Simon is also concerned he's bleeding
0:27:58 > 0:28:00from other internal injuries.
0:28:01 > 0:28:05'Firstly, why has his blood pressure become so low?'
0:28:05 > 0:28:06Is he bleeding?
0:28:06 > 0:28:11Do we need to give him some blood to replace blood loss immediately?
0:28:13 > 0:28:16So I'm thinking, "Does he have another injury?"
0:28:16 > 0:28:19Is there more to this than meets the eye?
0:28:19 > 0:28:21Chest X-ray has got a lot of opacification
0:28:21 > 0:28:22of the right hemithorax,
0:28:22 > 0:28:26so presumed contusion, plus or minus hemothorax.
0:28:27 > 0:28:30The X-ray shows what could be severe bruising
0:28:30 > 0:28:33to Dusan's right lung, or an area of blood around it,
0:28:33 > 0:28:37which could be preventing him from getting enough oxygen.
0:28:37 > 0:28:39Sats still reading 84.
0:28:39 > 0:28:42If you could do anything with the ventilation to improve that...
0:28:42 > 0:28:45Consultant anaesthetist Mit Lahiri is also concerned
0:28:45 > 0:28:49about the impact of his damaged lungs on the rest of his body.
0:28:50 > 0:28:52The things that were worrying me initially
0:28:52 > 0:28:55were that his oxygen levels were low,
0:28:55 > 0:28:58despite the fact we were on as much oxygen as we could give him.
0:28:58 > 0:29:01So we take a sample of blood from the artery,
0:29:01 > 0:29:04and that gives us a huge amount of information.
0:29:04 > 0:29:06Got bloods. Thank you.
0:29:06 > 0:29:09This blood sample is processed within minutes
0:29:09 > 0:29:12and reveals another major problem.
0:29:12 > 0:29:15He is very acidotic, got a pH 6.97.
0:29:15 > 0:29:18Dusan's body has been starved of oxygen
0:29:18 > 0:29:21and is now creating lactic acid in his blood.
0:29:21 > 0:29:26A pH of 6.9 is a potentially unsurvivable level of acid
0:29:26 > 0:29:29without immediate intervention.
0:29:29 > 0:29:31The longer the body is acidic,
0:29:31 > 0:29:34the more likely the cells are going to die.
0:29:34 > 0:29:37This acidic blood could trigger yet more complications.
0:29:38 > 0:29:42Increased levels of acid can cause problems with the blood clotting,
0:29:42 > 0:29:46which can cause more bleeding and so it goes on.
0:29:47 > 0:29:49In my experience,
0:29:49 > 0:29:52you're more likely to die than live with numbers like that.
0:29:53 > 0:29:55We're spiralling towards a point
0:29:55 > 0:29:58where we're not going to be able to come back,
0:29:58 > 0:30:02so we need to do something pretty sharp.
0:30:02 > 0:30:06OK, so, obviously, he has got a significant head injury,
0:30:06 > 0:30:11but he probably is also bleeding, so we'll request a pack A
0:30:11 > 0:30:14and get him to CT and see what else is going on. OK?
0:30:15 > 0:30:17Hi, can I request a pack A, please?
0:30:17 > 0:30:21Simon rushes Dusan to the CT scanner and requests
0:30:21 > 0:30:23an urgent blood transfusion.
0:30:25 > 0:30:28He needs to find out exactly what's wrong with Dusan's lungs
0:30:28 > 0:30:30and locate the source of his internal bleeding.
0:30:32 > 0:30:35Ultimately, the question is, does he need an operation
0:30:35 > 0:30:37to stop bleeding in his belly?
0:30:37 > 0:30:40Does he need any procedures done to
0:30:40 > 0:30:43improve his ventilation function in his chest?
0:30:43 > 0:30:44And does he need neurosurgery?
0:30:47 > 0:30:50ALARM BEEPS
0:30:50 > 0:30:52But as Dusan enters the scanner,
0:30:52 > 0:30:56his blood pressure plummets to its lowest yet.
0:30:56 > 0:31:00This chap is a code red. Dropped his blood pressure to 71/50.
0:31:00 > 0:31:01He's just in CT now.
0:31:04 > 0:31:06ALARM CONTINUES
0:31:06 > 0:31:10Code red lets key staff know there's a patient bleeding to death,
0:31:10 > 0:31:15and makes blood and blood products quickly available.
0:31:15 > 0:31:18The team start an urgent transfusion while Simon begins the scan.
0:31:21 > 0:31:26Getting a CT scan allows us to see exactly what the brain injury is,
0:31:26 > 0:31:29it allows us to see, is he bleeding into his chest?
0:31:29 > 0:31:31Is he bleeding into his abdomen?
0:31:31 > 0:31:35Any one of those things, in itself, can be life-threatening.
0:31:36 > 0:31:40Simon consults neurosurgeon Emma Sillery.
0:31:40 > 0:31:43The impact of the bus could have given Dusan
0:31:43 > 0:31:44a major bleed in his head.
0:31:47 > 0:31:50Your brain is a soft, pliable thing
0:31:50 > 0:31:52that you could compress with your fingers,
0:31:52 > 0:31:54so it's a delicate and easily damaged.
0:31:54 > 0:31:57And heavy bleeding inside the head can push on the brain
0:31:57 > 0:32:01and, if things push on the brain, it's only a small step, really,
0:32:01 > 0:32:06before life-threatening conditions can develop.
0:32:06 > 0:32:08His head doesn't look like it's got any large haematoma
0:32:08 > 0:32:09that needs to be evacuated.
0:32:09 > 0:32:13He's got an injury and some intracranial air.
0:32:13 > 0:32:15The scan reveals an area of air in Dusan's head
0:32:15 > 0:32:19which has entered through fractures to his face,
0:32:19 > 0:32:21but there's no obvious signs of bleeding.
0:32:21 > 0:32:24His brain, serious though it is, wasn't too bad,
0:32:24 > 0:32:27and we could then at that point make a quick call
0:32:27 > 0:32:29that they could leave this for now.
0:32:30 > 0:32:33Simon decides to monitor Dusan's head injury
0:32:33 > 0:32:36and continues scanning the rest of his body.
0:32:36 > 0:32:39He's got a bit of blood in his right chest, doesn't he?
0:32:39 > 0:32:42He's got a chest injury with some bleeding
0:32:42 > 0:32:46on the right side of the chest, and some air escaped from both lungs.
0:32:47 > 0:32:52The scan reveals Dusan has blood and air trapped around his lungs.
0:32:52 > 0:32:56This is affecting his breathing and reducing his oxygen levels.
0:32:56 > 0:32:58But before Simon can see to this,
0:32:58 > 0:33:01he must find the main source of bleeding.
0:33:03 > 0:33:06He's got a lot of blood around his spleen and some around his liver.
0:33:07 > 0:33:10Then the scan locates a large area where blood is collecting.
0:33:12 > 0:33:15The CT appearance, showing blood within his abdomen,
0:33:15 > 0:33:18makes me concerned that he's actually bleeding to death.
0:33:21 > 0:33:24Harriet, we're going to need chest drain on each side.
0:33:24 > 0:33:28Simon must now drain the blood and air trapped around Dusan's lungs
0:33:28 > 0:33:32and, without immediate surgery to stop the bleeding in his abdomen,
0:33:32 > 0:33:33Dusan may not survive.
0:33:42 > 0:33:44In Bristol, Great Western Air Ambulance
0:33:44 > 0:33:47has just landed with horse rider George.
0:33:47 > 0:33:48He's a 63-year-old male,
0:33:48 > 0:33:53fall from horse, who's got a sensory level of C4 and is in spinal shock.
0:33:53 > 0:33:55Emergency department consultant Adam Brown
0:33:55 > 0:33:58is preparing to receive a handover.
0:33:58 > 0:34:02He needs to rapidly determine the full scale of George's spinal damage
0:34:02 > 0:34:06and any hidden injuries he might have from the riding accident.
0:34:06 > 0:34:08We, as a medical profession,
0:34:08 > 0:34:12quite rightly withhold our prognosis with these sorts of injuries.
0:34:12 > 0:34:14But the reality of the fact is that,
0:34:14 > 0:34:17if you see a devastating spinal cord injury,
0:34:17 > 0:34:20you know, nearly all of the time, it's life-changing.
0:34:20 > 0:34:23You all know about trauma calls by now - it's in, assess, stabilise.
0:34:23 > 0:34:25If the patient's stable, off to CT.
0:34:25 > 0:34:27Any questions? Groovy.
0:34:27 > 0:34:30Red bag, please. And can we get the TX8 out but not drawn up?
0:34:34 > 0:34:35Just park up.
0:34:35 > 0:34:37OK, guys, just listen in for the handover, please.
0:34:37 > 0:34:39This is a horse riding incident.
0:34:39 > 0:34:42He's come off, he knows he has a neck injury,
0:34:42 > 0:34:45neck pain was his only complaint.
0:34:45 > 0:34:50I suspect he has a neck injury with probably a C3 for complete level.
0:34:50 > 0:34:51Any questions from anyone? OK.
0:34:51 > 0:34:53This is what I want to happen, please.
0:34:53 > 0:34:55I'd like to undo all this blanket. He's on a yellow scoop.
0:34:55 > 0:34:58I'd like people to come around the sides, lift up the scoop,
0:34:58 > 0:35:00get out all the orange stuff
0:35:00 > 0:35:02and then we'll do the monitor change after that.
0:35:02 > 0:35:04Despite George's obvious neck injury,
0:35:04 > 0:35:08Adam must be thorough and look for other possible internal injuries.
0:35:08 > 0:35:13I know that George has a potentially life-threatening,
0:35:13 > 0:35:16life-changing, high-neck injury.
0:35:16 > 0:35:21I do not want to be complacent or focused on George's neck injury.
0:35:21 > 0:35:25He has fallen, at speed, off a horse.
0:35:25 > 0:35:28We need to ensure we do not miss any injuries
0:35:28 > 0:35:31because we are so focused on the obvious, devastating,
0:35:31 > 0:35:34life-changing injury that he may have.
0:35:34 > 0:35:36Got good CO2.
0:35:36 > 0:35:38Sats are 96.
0:35:38 > 0:35:41What we're going to do then is we're going to get off the scoop,
0:35:41 > 0:35:43package for CT, draw up presses, please, and we will go to scan.
0:35:45 > 0:35:4811 minutes after arrival to resus,
0:35:48 > 0:35:52George is taken for a full body scan to rule out other internal injuries
0:35:52 > 0:35:54and look for damage to his spine.
0:35:54 > 0:35:57On the word slide. Ready, steady, slide.
0:35:57 > 0:35:58Well done.
0:36:11 > 0:36:13The CT images actually looked remarkably OK.
0:36:13 > 0:36:17It was as if George had injured his neck,
0:36:17 > 0:36:20restored his neck back to its normal position,
0:36:20 > 0:36:23and you couldn't really see any injury at all.
0:36:23 > 0:36:26The CT scan is reassuring from the point of view of
0:36:26 > 0:36:30we know there's no other injuries, but we haven't got the answer
0:36:30 > 0:36:32to why George can't move his arms and his legs.
0:36:32 > 0:36:35With no sign of injury to any of George's organs or bones
0:36:35 > 0:36:38on the scan, Adam will need to run further tests.
0:36:45 > 0:36:47George, can you try and bring your toes of both feet
0:36:47 > 0:36:49back up towards your chin?
0:36:51 > 0:36:54OK. And then can you try and push your toes down on both feet?
0:36:54 > 0:36:56Try and push your feet down.
0:36:56 > 0:36:59OK. So he's going to need an MRI. That's effectively it, isn't it?
0:36:59 > 0:37:01He's going to need an MRI scan of his spinal cord
0:37:01 > 0:37:05because we found no bone injury at all. The scans were normal.
0:37:05 > 0:37:07An MRI scanner will show tissue detail
0:37:07 > 0:37:10and any damage to George's spinal cord.
0:37:10 > 0:37:14I think the important thing to communicate with George,
0:37:14 > 0:37:18who is fully aware,
0:37:18 > 0:37:22is to be honest and to be sensitive.
0:37:22 > 0:37:24Without a shadow of a doubt, on some level,
0:37:24 > 0:37:27I know that George knows what's going on.
0:37:27 > 0:37:31And...as George's trauma team leader,
0:37:31 > 0:37:34I'd don't really want to say it,
0:37:34 > 0:37:36but that doesn't help anybody.
0:37:36 > 0:37:39Obviously, you're behaving like somebody who's got an injury
0:37:39 > 0:37:41to their spinal cord because you can't move your arms
0:37:41 > 0:37:46and can't move your legs, but you can feel certain things.
0:37:46 > 0:37:48So what you're going to need is an MRI scan,
0:37:48 > 0:37:52which is a much more detailed scan, in a tunnel,
0:37:52 > 0:37:54to have a look at detail of the spinal cord
0:37:54 > 0:37:57because I think that's where the injury is that's giving you this.
0:37:57 > 0:38:00It might be that you've just got bruising of that,
0:38:00 > 0:38:02but, either way, we need to know.
0:38:02 > 0:38:05And until we know, we need to keep you laying flat like this.
0:38:05 > 0:38:07Will it show any damage? It will show, yes.
0:38:07 > 0:38:09All right, OK. All right.
0:38:09 > 0:38:17So that will show, basically, what the future is for me?
0:38:17 > 0:38:19Yes, yes, it will. OK.
0:38:19 > 0:38:22Let me go and sort that out now. Thank you. OK.
0:38:30 > 0:38:32In St Albans, young tree surgeon Seb
0:38:32 > 0:38:35is complaining of severe abdominal pain,
0:38:35 > 0:38:37having fallen 30 feet from a ladder.
0:38:40 > 0:38:42Concerned his injuries could be life-threatening,
0:38:42 > 0:38:46Sam has decided to fly him to the nearest major trauma centre.
0:38:46 > 0:38:49I'm looking at Seb, I'm worried about him,
0:38:49 > 0:38:52I'm telling everybody and telling myself that he could be bleeding
0:38:52 > 0:38:54into his abdomen or his pelvis,
0:38:54 > 0:38:57and I know that we're a long way from hospital.
0:38:57 > 0:38:58Ready, brace, lift.
0:38:59 > 0:39:03Another injury which is very likely from that type of fall
0:39:03 > 0:39:07is a spinal injury, particularly as he was complaining
0:39:07 > 0:39:09of pain in his lower back as well as his abdomen.
0:39:09 > 0:39:12With that always comes the risk of damaging your spinal cord,
0:39:12 > 0:39:14even though he can move his legs,
0:39:14 > 0:39:17and that could be devastating in the long run.
0:39:17 > 0:39:19I know that I can't just chuck him on the helicopter.
0:39:19 > 0:39:22He needs his spine to be kept very still
0:39:22 > 0:39:24because it could well be broken.
0:39:24 > 0:39:25Ready, set, lift.
0:39:27 > 0:39:29Claire, we are bringing you a trauma patient by air.
0:39:29 > 0:39:32He's a 23-year-old adult male.
0:39:32 > 0:39:37He's fallen 25 feet, possibly a pelvic fracture.
0:39:39 > 0:39:42It's a 17-minute flight to the Royal London Hospital,
0:39:42 > 0:39:45where emergency medicine consultant Ben Clarke and his team
0:39:45 > 0:39:47are preparing to receive Seb.
0:39:47 > 0:39:50A fall from height is dangerous because, essentially,
0:39:50 > 0:39:54you suddenly accelerate and then you very, very suddenly decelerate
0:39:54 > 0:39:56and, by that, you come to a very abrupt stop.
0:39:57 > 0:39:59And what can happen with that deceleration
0:39:59 > 0:40:03is you can tear bits of the bowel, you can tear big blood vessels
0:40:03 > 0:40:04and the impact itself can cause
0:40:04 > 0:40:07damage to any number of different organs and bones.
0:40:10 > 0:40:12Hello, guys. This is Seb.
0:40:12 > 0:40:14He's 23 years old.
0:40:14 > 0:40:18He fell around about 25-30 feet from the top of a tree.
0:40:18 > 0:40:20He's a tree surgeon cutting branches.
0:40:20 > 0:40:23'I'm hearing in this handover that Sebastian
0:40:23 > 0:40:24'has fallen a great distance.'
0:40:24 > 0:40:28He was complaining of very severe lower back pain and abdominal pain,
0:40:28 > 0:40:31and those automatically point me to thinking about internal bleeding
0:40:31 > 0:40:35and organ injuries, but also, most importantly, a pelvic injury.
0:40:35 > 0:40:36Let's get the bed down.
0:40:36 > 0:40:39We'll aim to do a primary survey nice and quickly.
0:40:42 > 0:40:43Chest X-ray.
0:40:46 > 0:40:51Ben decides to do an ultrasound scan to look for internal bleeding.
0:40:51 > 0:40:55The purpose of it is to look at certain parts inside the belly
0:40:55 > 0:40:58and the heart to see whether there's
0:40:58 > 0:41:01any clear signs of internal bleeding.
0:41:01 > 0:41:04Let's have a quick look down in his pelvis, if you don't mind.
0:41:05 > 0:41:07Negative thus far.
0:41:07 > 0:41:10It gives us an indication as to whether Sebastian's path may be
0:41:10 > 0:41:12to the theatre, or whether he is stable
0:41:12 > 0:41:14and we can go through the Cat scanner.
0:41:14 > 0:41:16OK, guys. If we're good and we've got him disconnected,
0:41:16 > 0:41:20let's go through to scan, if they're ready.
0:41:20 > 0:41:22The ultrasound hasn't revealed any bleeding,
0:41:22 > 0:41:25so Ben takes Seb through to the CT scanner
0:41:25 > 0:41:27for a more detailed look inside.
0:41:27 > 0:41:30The CT is a very sensitive,
0:41:30 > 0:41:33very specific tool for showing us everything that is going on,
0:41:33 > 0:41:35from his head down to his pelvis,
0:41:35 > 0:41:39and see whether there is any clear sites of injury or bleeding.
0:41:40 > 0:41:42Just be gentle, just be really gentle.
0:41:50 > 0:41:52At the Royal London Hospital,
0:41:52 > 0:41:56scans have revealed Dusan has suffered life-threatening injuries
0:41:56 > 0:41:59to his chest and abdomen after being hit by a bus.
0:41:59 > 0:42:03A build-up of blood and air trapped around his lungs has caused them
0:42:03 > 0:42:05to collapse and he's bleeding inside his abdomen.
0:42:09 > 0:42:11First priority is to put chest drains in
0:42:11 > 0:42:15to allow his lungs to fully reinflate and allow them
0:42:15 > 0:42:19to deliver as much oxygen into his circulation as is possible.
0:42:22 > 0:42:25Is that drain doing anything? It was bubbling.
0:42:25 > 0:42:27Yeah? Still bubbling? Bubbling.
0:42:27 > 0:42:30With chest drains releasing the blood and air
0:42:30 > 0:42:32trapped around Dusan's lungs,
0:42:32 > 0:42:35Simon turns his attention to the abdominal bleeding.
0:42:36 > 0:42:39Since the accident, this has been causing Dusan's blood pressure
0:42:39 > 0:42:44to fall dangerously low, and they need to operate soon.
0:42:44 > 0:42:46So how much blood have we actually given him so far?
0:42:46 > 0:42:48240. 240, OK.
0:42:48 > 0:42:49That's all we need.
0:42:49 > 0:42:52For Dusan to survive long enough for surgery,
0:42:52 > 0:42:55Simon has been giving him a blood transfusion.
0:42:55 > 0:42:58He also hopes this will help make his blood less acidic
0:42:58 > 0:43:00and enable it to clot.
0:43:01 > 0:43:04You have a window where they're heading down
0:43:04 > 0:43:07a slope of worsening acidosis,
0:43:07 > 0:43:10and, if you don't reverse that very quickly,
0:43:10 > 0:43:14then death can follow within minutes.
0:43:16 > 0:43:18OK, the gas has improved a bit.
0:43:18 > 0:43:20Ph 7.11.
0:43:20 > 0:43:23Lactate's come down to 4.4.
0:43:24 > 0:43:27With his blood gas results and blood pressure improving,
0:43:27 > 0:43:30Dusan now has a window of opportunity for surgery.
0:43:32 > 0:43:34Simon rushes him to the operating theatre
0:43:34 > 0:43:37and hands over to consultant trauma surgeon Wayne Sapsford.
0:43:39 > 0:43:41There are a number of areas within the body
0:43:41 > 0:43:45which have a huge amount of potential space
0:43:45 > 0:43:46in which blood can accumulate
0:43:46 > 0:43:48and in the abdomen, in particular,
0:43:48 > 0:43:51you can lose most or all of your blood.
0:43:55 > 0:43:59Wayne begins the process of locating the source of Dusan's bleed.
0:43:59 > 0:44:07When I opened Dusan's abdomen, there was 1-1.5 litres of free blood,
0:44:07 > 0:44:08which we removed.
0:44:11 > 0:44:17And then I did a thorough examination of all of his abdomen.
0:44:17 > 0:44:19Major organs and vessels in the abdomen and pelvis
0:44:19 > 0:44:22must be checked meticulously for active bleeding.
0:44:25 > 0:44:29When I got to the liver and examined that in more detail,
0:44:29 > 0:44:33he had a 6-7cm laceration on the right lobe of the liver
0:44:33 > 0:44:36which wasn't actively bleeding.
0:44:36 > 0:44:40The impact of the bus has torn part of Dusan's liver,
0:44:40 > 0:44:42but this bleeding now appears to have stopped.
0:44:44 > 0:44:47The liver is a manufacturer of clotting products
0:44:47 > 0:44:51and is very good at stopping bleeding by itself.
0:44:51 > 0:44:56However, I left packs around the liver to compress the laceration
0:44:56 > 0:44:58in order to try and prevent it from bleeding again
0:44:58 > 0:44:59in the ongoing hours and days.
0:45:02 > 0:45:06Wayne leaves Dusan with a temporary closure of his abdomen.
0:45:06 > 0:45:09The packs will help prevent any further bleeding from his liver
0:45:09 > 0:45:11and will be removed at a later date.
0:45:12 > 0:45:14But Dusan is not out of danger yet.
0:45:16 > 0:45:20We're going to be doing an insertion of a right frontal ICP bolt,
0:45:20 > 0:45:21so this is the patient's right,
0:45:21 > 0:45:24and it's just going to be a little probe into the brain.
0:45:24 > 0:45:27Despite there being no obvious bleed in Dusan's head,
0:45:27 > 0:45:31neurosurgeon Emma Sillery is keen to monitor the pressure
0:45:31 > 0:45:33around his brain over the coming days.
0:45:34 > 0:45:35He does have fractures,
0:45:35 > 0:45:38he did have some bleeding and we think he is at the risk of swelling.
0:45:38 > 0:45:40The skull is a rigid structure
0:45:40 > 0:45:45and Emma is worried that bruising on his brain could create swelling.
0:45:45 > 0:45:47This would dangerously increase the pressures in his head.
0:45:47 > 0:45:50Your heart has to be able to push blood into your head -
0:45:50 > 0:45:53that happens all the time. You have an natural pressure in your head,
0:45:53 > 0:45:56and your heart overcomes it and pumps blood into your head.
0:45:56 > 0:45:57The pressure on the brain gets too much,
0:45:57 > 0:45:59the heart can't pump blood into it,
0:45:59 > 0:46:03and you have a brain without blood, and that's...
0:46:03 > 0:46:05That doesn't last very long.
0:46:05 > 0:46:08This probe will enable Emma to accurately monitor
0:46:08 > 0:46:11the pressure in Dusan's head, minute by minute.
0:46:11 > 0:46:14You use a small, thin wire that we put inside the brain
0:46:14 > 0:46:17to measure the pressure inside the skull.
0:46:17 > 0:46:19We have to put a screw into the skull
0:46:19 > 0:46:21with a little tunnel through it,
0:46:21 > 0:46:24and then we can put our delicate, little probe
0:46:24 > 0:46:26through that screw tunnel and into the brain.
0:46:26 > 0:46:29When I put the little pressure monitor in,
0:46:29 > 0:46:30initially, his pressures were fine.
0:46:30 > 0:46:34We could tell that from the scan, we were expecting that.
0:46:36 > 0:46:38What we were really doing was to make sure that,
0:46:38 > 0:46:41over the coming days, if his brain got big and crowded in there,
0:46:41 > 0:46:44that we would pick that up on the monitor.
0:46:45 > 0:46:48We can keep a little eye on his brain, 24 hours a day,
0:46:48 > 0:46:51while he's in such a critical situation.
0:46:51 > 0:46:53Dusan will be kept in a coma
0:46:53 > 0:46:56while they monitor for swelling and bleeding.
0:46:56 > 0:46:59They must now wait to see how well he recovers.
0:47:10 > 0:47:14In Bristol, doctors are trying to figure out why rider George
0:47:14 > 0:47:18has lost all control from the neck down after coming off his horse.
0:47:19 > 0:47:22His CT scan showed no broken bones,
0:47:22 > 0:47:25but the results are now back from a more detailed MRI.
0:47:28 > 0:47:32Effectively, George's neck has been thrown forward with force,
0:47:32 > 0:47:33backward with force.
0:47:33 > 0:47:35So this is George's neck
0:47:35 > 0:47:37and what we are seeing
0:47:37 > 0:47:41is a possible disruption of three on four,
0:47:41 > 0:47:43and that's visible on his CT scan,
0:47:43 > 0:47:46but it doesn't give us enough information to say
0:47:46 > 0:47:48that's exactly what the problem is,
0:47:48 > 0:47:51which is why we moved to the MRI scan.
0:47:51 > 0:47:55You can see the grey and the white of the cord in the spinal canal.
0:47:56 > 0:47:58The cord should look like this -
0:47:58 > 0:48:00pristine, continuous.
0:48:00 > 0:48:01And, as you can see,
0:48:01 > 0:48:04when you get here, there's a significant amount of disruption.
0:48:05 > 0:48:09What has happened to George's spinal cord is it's not severed,
0:48:09 > 0:48:13the cord is intact, but it's been stretched rather than torn.
0:48:14 > 0:48:17If the injury had been a complete tearing of the cord,
0:48:17 > 0:48:21it would be very easy to say, "This is probably not going to get
0:48:21 > 0:48:23"any better and that is it."
0:48:23 > 0:48:25In George's case, it's very complicated
0:48:25 > 0:48:28because it's what we call an incomplete injury
0:48:28 > 0:48:32and we just do not know how that is going to improve
0:48:32 > 0:48:35over the coming hours, days, weeks and months.
0:48:37 > 0:48:40George is unable to move any of his muscles below the neck
0:48:40 > 0:48:42apart from his toes.
0:48:43 > 0:48:45And relax.
0:48:47 > 0:48:51His wife, Sarah, is working with him to regain any possible control.
0:48:51 > 0:48:54I think that's enough exercise.
0:48:56 > 0:49:00It is exhausting, isn't it?
0:49:00 > 0:49:04Very encouragingly, there are one or two muscles
0:49:04 > 0:49:07that I can move a tiny amount
0:49:07 > 0:49:12and so I'm at that very, very tense stage, at the moment,
0:49:12 > 0:49:16when I don't know whether I'll be what I think is called
0:49:16 > 0:49:19a tetraplegic - someone who cannot move any of their limbs,
0:49:19 > 0:49:21other than their neck.
0:49:32 > 0:49:36At the Royal London Hospital, tree surgeon Seb is undergoing
0:49:36 > 0:49:40an urgent head-to-toe CT scan to look for the source of his pain.
0:49:42 > 0:49:44'Looking at Sebastian's scan,
0:49:44 > 0:49:48'I am most worried about excluding injuries.'
0:49:48 > 0:49:52I want to make sure I can't see any obvious signs of bleeding,
0:49:52 > 0:49:55any very clear fractures.
0:49:55 > 0:49:57Otherwise, that looks pretty good, doesn't it?
0:49:57 > 0:49:59Full at the top, full at the bottom. Yeah.
0:49:59 > 0:50:02He needs a wee. He definitely needs a wee.
0:50:02 > 0:50:04He did say that. Yeah, bless him.
0:50:04 > 0:50:07The initial scan rules out any life-threatening bleeding
0:50:07 > 0:50:10that would require immediate surgery.
0:50:10 > 0:50:13For Ben to find the source of Seb's pain,
0:50:13 > 0:50:15he must wait for the scan to be fully processed.
0:50:15 > 0:50:18Hello, mate. Everything's looking pretty good so far,
0:50:18 > 0:50:19so what we're waiting on is
0:50:19 > 0:50:22we're waiting on just the formal report of the scan.
0:50:22 > 0:50:24There's still just a little bit of pain.
0:50:24 > 0:50:27Where is that pain? Stomach. In the stomach, all right.
0:50:27 > 0:50:29No worries.
0:50:29 > 0:50:31What we'll do is I'm going to go and have a good look through
0:50:31 > 0:50:34the scan as well and make sure there is nothing subtle that I can see.
0:50:38 > 0:50:42With the full images now available, Ben makes a further assessment.
0:50:49 > 0:50:53That explains a lot of his pain then, doesn't it?
0:50:53 > 0:50:57The scan reveals Seb's fall has severely crushed one of his vertebra
0:50:57 > 0:50:59and this is where his pain is coming from.
0:50:59 > 0:51:01We've got all these lucencies,
0:51:01 > 0:51:04it's irregular, it's got what looks to be cracks.
0:51:04 > 0:51:08We can see that L1, which is this one here,
0:51:08 > 0:51:11has been crushed, basically.
0:51:11 > 0:51:14It's been fractured. It's been basically squashed down.
0:51:14 > 0:51:18Despite the crushed vertebra, Seb's spinal cord is currently intact,
0:51:18 > 0:51:22but a sudden movement could cause significant nerve damage.
0:51:22 > 0:51:25All right, mate. We've got the results.
0:51:25 > 0:51:30So your lumber spine, which is about here in your back,
0:51:30 > 0:51:33it looks like one of the bones there has been broken -
0:51:33 > 0:51:35and it's called your L1 vertebra.
0:51:35 > 0:51:36The way you've fallen,
0:51:36 > 0:51:39what's happened is that vertebra has been squashed a bit.
0:51:39 > 0:51:40It's what we call unstable.
0:51:40 > 0:51:43What we're going to do is get our neurosurgical doctors,
0:51:43 > 0:51:45they're going to have a look at you
0:51:45 > 0:51:49and then tell you exactly what the plan will be from there.
0:51:49 > 0:51:53Simon hands over to consultant neurosurgeon Jonathan Bull,
0:51:53 > 0:51:56who takes the decision to operate the next day.
0:51:58 > 0:52:01The risk is that, having had it partially fractured,
0:52:01 > 0:52:03as he started to walk around on it,
0:52:03 > 0:52:05the bone would then further collapse and push fragments
0:52:05 > 0:52:08into the spinal canal, which would then squash the spinal cord
0:52:08 > 0:52:11and risk, basically, paralysis in his lower limbs.
0:52:13 > 0:52:15One option was to treat him in a brace,
0:52:15 > 0:52:17so he wouldn't have had an operation.
0:52:17 > 0:52:19He would have worn that for around 10-12 weeks.
0:52:19 > 0:52:21The alternative was a surgical option,
0:52:21 > 0:52:23particularly for trauma patients,
0:52:23 > 0:52:25a fixation with screws, but done through the skin.
0:52:28 > 0:52:32It's like a scaffolding. It's like a support for the fractured bone.
0:52:35 > 0:52:36X-ray.
0:52:37 > 0:52:40'Rather than making a large incision,
0:52:40 > 0:52:44'we make small sequential incisions at each level and pass a guide wire
0:52:44 > 0:52:47'into the vertebral body, and then put a screw into it.'
0:52:49 > 0:52:50Have that screw, please?
0:52:50 > 0:52:53Jonathan uses the fixation as a scaffold
0:52:53 > 0:52:55to support the fractured bone.
0:52:55 > 0:52:58This is braced to a healthy vertebrae above and below,
0:52:58 > 0:53:00all done through keyhole surgery.
0:53:02 > 0:53:03It means the wound is smaller,
0:53:03 > 0:53:05there's less damage to the surrounding muscle,
0:53:05 > 0:53:07so they can often mobilise more rapidly.
0:53:07 > 0:53:10Theoretically, if the fracture heals satisfactory,
0:53:10 > 0:53:13you'll have a full range of motion, or near-full range of motion.
0:53:37 > 0:53:41He sent me a WhatsApp from the hospital.
0:53:41 > 0:53:46It was a little ambulance emoji, so of course I was quite scared.
0:53:46 > 0:53:50I knew he had a dangerous job and I didn't know what had happened.
0:53:52 > 0:53:53You're with the tree.
0:53:53 > 0:53:56When it's windy and raining, you're sort of up there and it's...
0:53:56 > 0:53:59Sometimes it's scary, but you...
0:53:59 > 0:54:02I was never really scared of heights.
0:54:02 > 0:54:04When I saw him in that hospital bed,
0:54:04 > 0:54:07he just looked so small and...
0:54:07 > 0:54:08he was scared.
0:54:10 > 0:54:11Sebastian, I think, was lucky
0:54:11 > 0:54:15insofar as the fracture didn't compromise his spinal cord
0:54:15 > 0:54:18and he didn't have a deficit or weakness in his limbs from it.
0:54:18 > 0:54:21I'm hoping he'll make a good recovery from it.
0:54:21 > 0:54:26I'm fortunate for not being paralysed.
0:54:26 > 0:54:29It could have been a lot worse.
0:54:29 > 0:54:33I'm glad that I'm up and walking.
0:54:35 > 0:54:36I just found out I was pregnant.
0:54:37 > 0:54:39I told him just the week before.
0:54:39 > 0:54:43We have a little boy on the way,
0:54:43 > 0:54:45so that's really good.
0:54:45 > 0:54:47A new chapter.
0:54:47 > 0:54:48He's relying a lot on me,
0:54:48 > 0:54:52but we're grateful that we still have each other, alive and walking.
0:55:08 > 0:55:09He's doing incredibly well.
0:55:09 > 0:55:14From seeing him in the CT scanner, with a blood pressure that low,
0:55:14 > 0:55:16I was concerned as to whether he would survive.
0:55:18 > 0:55:20Picture the scene, where you're just going about doing your thing,
0:55:20 > 0:55:23and then you wake up and it's a month later.
0:55:24 > 0:55:26And you're somewhere you've no idea where you are,
0:55:26 > 0:55:29looking at somebody and you don't know who they are.
0:55:29 > 0:55:33And that's a weird thing, because it affects you as a person.
0:55:38 > 0:55:42The natural course of untreated bleeding and acidosis
0:55:42 > 0:55:45with a brain injury is quite commonly death...
0:55:47 > 0:55:51..but our aim is to intervene, to try and stop that process,
0:55:51 > 0:55:54but it has to be done at the very early stage,
0:55:54 > 0:55:55otherwise it's too late.
0:56:04 > 0:56:09So, if we put your arm in there...
0:56:10 > 0:56:13Now that his elbow is held up...
0:56:17 > 0:56:19I...
0:56:21 > 0:56:23They're quite short ropes.
0:56:23 > 0:56:27If they were longer ropes, it would go further, I promise you.
0:56:36 > 0:56:39I think, if I had the choice,
0:56:39 > 0:56:41I would elect not to have jumped that hedge
0:56:41 > 0:56:43in the way that I jumped it.
0:56:45 > 0:56:47But I've had such an enjoyable life
0:56:47 > 0:56:51and that's partly because of the things I've been able to do.
0:56:51 > 0:56:54You look around for the positives
0:56:54 > 0:56:58and it's a reminder that this isn't a practice for anything,
0:56:58 > 0:57:04this is the real thing, and you only get one...
0:57:04 > 0:57:06One go.
0:57:06 > 0:57:07Can I have some water?
0:57:09 > 0:57:11If you live your life protecting yourself
0:57:11 > 0:57:15from every single potential outcome,
0:57:15 > 0:57:17you'll never do anything.
0:57:17 > 0:57:19So...life is there to be lived,
0:57:19 > 0:57:21George was doing that,
0:57:21 > 0:57:25and we're there to support the next life George has.
0:57:26 > 0:57:32My current efforts, as indeed are this hospital's efforts,
0:57:32 > 0:57:35are to make the best of what I've got
0:57:35 > 0:57:38and follow the road where it takes me.
0:57:41 > 0:57:43We both... Well, I don't know if we both,
0:57:43 > 0:57:46I would love it if you could scratch your nose by yourself
0:57:46 > 0:57:48and I didn't have to do it.
0:57:49 > 0:57:50Thank you.
0:57:53 > 0:57:56I'm going to put lots of scratch posts in my house,
0:57:56 > 0:57:58so I can go up to them and...
0:58:00 > 0:58:02Next time...
0:58:02 > 0:58:06We follow three patients through the crucial first hour of care.
0:58:06 > 0:58:09In central London, a man suddenly collapses at work
0:58:09 > 0:58:11with a suspected cardiac arrest.
0:58:11 > 0:58:15We are going to anaesthetise him here.
0:58:15 > 0:58:17In Newcastle, a mother of three
0:58:17 > 0:58:20fights for her life after being stabbed in the chest and neck.
0:58:20 > 0:58:22How big was the knife?
0:58:22 > 0:58:26And a cyclist in Durham suffers horrific crush injuries to his chest
0:58:26 > 0:58:29after being run over by a bus.
0:58:29 > 0:58:30Let's get the blood in.
0:59:01 > 0:59:04Unparalleled talent, unprecedented access.
0:59:04 > 0:59:07BBC Two takes a sneaky peek behind the celebrity curtain.
0:59:07 > 0:59:08One piece of advice...
0:59:08 > 0:59:11Go out there, grab it with both hands and stick it in your mouth.
0:59:11 > 0:59:13Job done!