Episode 3 An Hour To Save Your Life

'Hello, ambulance service.' 'There's a guy just got 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.

Yes. 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 infra scanner to maybe give us a slightly

clearer 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.

Yep, through the cord. Tube, please. Tube on.

We follow three 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. 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.

60 minutes that will change their lives forever.

You'll constantly be surprised

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

This programme contains scenes which some viewers may find upsetting

At ambulance control in Waterloo,

an emergency call has just been received from north London.

He's making noises?

Consultant Gareth Greer and paramedic Sue Trow

from London's Air Ambulance are on their way to the incident.

'We know very little, apart from someone's been hit by a bus.'

It could be an injury to any part of the body.

It could be that the patient has multiple injuries.

We're kind of ready for any eventuality.

A London ambulance service crew are already on scene,

struggling to assess the patient. HE MOANS

Yeah.

Understood.

HE GROANS

See the damage to the bus? He smashed a light casing. Yeah.

37-year-old Dusan, a fitness instructor,

was walking to the gym when he was hit by the bus.

When the ambulance arrived, he was found highly confused.

We're going to look after you.

'If someone's agitated,'

to me, it signifies it's going to be quite a severe head injury.

Some people appear like they're drunk through having a head injury

like that, but with the injuries that he had around his face,

you have to suspect that he had a bad head injury.

This strange behaviour is a clue

that Dusan's brain is suffering from the impact.

'The knock on the head has damaged all of the connections in his brain.

'He is disorientated, he doesn't know where he is,'

he doesn't know what's happening.

He can't put all of these things together.

HE CRIES We're going to help you.

We're going to help you, all right?

'If there is bleeding in his brain,'

that needs to be sorted very, very quickly

otherwise it could be catastrophic for him.

What I'm going to do is try him with a little bit of sedation.

We'll just have a look at his veins, just to see what...

'We need to get on top of the agitation

'before we can do anything else.'

If you just draw up 4mls for now.

Gareth gives Dusan Midazolam, a powerful sedative.

The impact from the bus may have caused other internal injuries

and he needs to assess him properly.

Yeah, we'll move him up... Once...

Let's just cut the front of his clothes off first.

HE GROANS

Let's start moving him out because we need to start getting

the tube down, because he's not ventilating too well.

Dusan is breathing abnormally and has very low oxygen levels.

To boost them, Gareth gives pure 02 through a mask and prepares

to take control of his airway with a breathing tube,

but, for this procedure, he needs more space.

If the breathing carries on in this abnormal way, that can result in

increasingly bad brain damage...

very, very quickly over a period of minutes rather than hours.

This one has just kinked a little bit.

To take over Dusan's breathing,

Gareth must first anaesthetise him and paralyse his muscles.

OK, guys, so we're going to do the anaesthetic.

This procedure usually takes place in a calm operating theatre...

..but Gareth must act now.

110 miles away in Bristol,

an ambulance control room has just received a call about a man involved

in a serious horse-riding accident.

Great Western Air Ambulance critical care team Dr Greg Cranston

and paramedic John Wood

have been dispatched to a field just north of the M4 near Bristol.

We go to a fair number of riding accidents.

We'll probably go to one every couple of weeks.

The most common injury that a patient would sustain from a fall

from a fall from horse would be a bony-type injury, so a fracture.

They're looking for a 63-year-old man who's been thrown at speed

from his horse.

We were told that the patient had come off,

was conscious but had difficulty in breathing

and couldn't move his limbs,

so that information immediately rang alarm bells.

Straight ahead. Horse tripped on landing. He fell off.

He's got pain in his neck, he can't move his hands,

he is conscious, he is talking.

Breathing is shallow.

My priorities are to establish the range of injuries that he has and to

work out if any of those are likely to be immediately life-threatening.

We just haven't moved him.

We haven't touched him. Excellent.

Covered him up, that's all we've done. Hello, there.

Hello. My name is Dr Cranston, one of the doctors with the Air Ambulance.

What's your name?

George. Hello, George. Are you in any pain?

My neck hurts quite a bit.

OK. Can you open your eyes for me? Yeah.

Open your eyes. Can you look at me?

You can see me OK. Excellent.

Can you move your fingers? No.

Can you give me a squeeze at all here? No. OK.

Falling from a horse is a potentially serious mechanism of

injury and people aren't generally ready for this fall,

so they often don't have time

in order to manipulate themselves or control the way in which they land.

'I'm starting to worry already that this may be a spinal cord injury.'

Can you feel me touching you here?

Yes. You're well tucked in, aren't you?

Yes. Can you feel me touching you here on your chest?

I think a little bit.

A little bit. Can you feel me touching you on your hand? No.

You can break a bone of your neck and your spinal cord

could be completely intact, and it's painful and it gets better.

But a spinal cord injury is a significant injury,

because that's the thing that can cause you paralysis.

The extent of George's spinal injury is not yet known.

Greg can't rule out the impact this might have on his other vital signs.

Don't be scared, OK?

We're going to look after you, all right?

We'll get you sorted bit by bit, slowly,

one bit at a time, and we'll fly you to hospital. OK?

There's no way that we can tell at this point how serious that injury

is until he arrives at hospital.

I'm just wondering how much of this we'll cut off.

Just cut it off so we can see what's going on down the back. Yeah?

Before they can move George,

Greg needs to check the rest of his body for injuries.

We're going to cut some of your clothes off, OK?

We will keep you warm.

It's really important that we get to assess you fully.

It's almost certainly going to be my neck.

I agree with you. I agree with you,

but there is a danger that you could have other injuries that we wouldn't

easily know about.

Stay with us, George.

George, take some deep breaths for me.

Big, deep breath.

His breathing is very shallow.

As I ask him to take deep breaths,

it doesn't appear that he does take any breaths at all.

Deep breaths, George.

He's breathing but it's so shallow that I'm unable to detect that by

either looking or listening with my stethoscope.

The spinal cord is a connection between the brain and the body and,

if you break that connection,

then the muscles of the body are unable to respond.

My main concern is whether George will continue to breathe.

He's breathing now, but will he continue to do that?

Deep breaths, George.

Go on, nice and deep.

Oxygen mask on tight, reservoir moving with ventilation.

In north London, 37-year-old Dusan has been hit by a bus,

suffering a massive head injury, and he's not breathing properly.

Baseline blood pressure seen and monitor set to two minutes. Check.

Despite Gareth's efforts to improve Dusan's oxygen levels,

they're still very low,

a sign he may have significant injury to his lungs.

This could damage other vital organs and his already injured brain.

'What I'm trying to do is to take over Dusan's breathing'

so that we have control of the oxygen levels in his bloodstream.

We're just starting the RSI now and then we'll be...

A rapid sequence induction will take over Dusan's breathing,

enabling Gareth to deliver oxygen down a tube to his lungs.

He is having 4mls of fentanyl.

Just hold his arm for me.

Thank you.

For this, Gareth must anaesthetise him and force his muscles to relax.

Fentanyl's in. Ketamine next.

It's essentially giving someone an anaesthetic, like you would have

if you went in for an operation,

but it's doing it in an emergency situation,

which is a high-risk procedure.

OK, the jaw is nice and floppy.

OK.

The drugs have worked quite quickly,

so we might be able to proceed relatively quickly with this.

Dusan is now completely paralysed.

Gareth has just minutes to manoeuvre a breathing tube

through his vocal cords and into his windpipe.

If you can't get the tube down into the windpipe,

then the patient won't breathe.

OK, grade one view.

Just won't go through the cord.

Sue, just pass me the tube a second. Hmm-hmm.

Thank you.

Yeah, tube's in.

Just deflate the cuff a minute, Sue.

I'm not happy that's in.

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

and it's going to go in again. Nope.

OK.

I can see the tube between the chords.

Can I just borrow your stethoscope for a minute?

Just to listen to his tummy.

Just hold the tube there for me.

Although Gareth is now in full control of Dusan's breathing,

his oxygen levels are still low,

suggesting something is seriously wrong with his lungs.

Air entry.

Pretty grotty.

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

Just keep holding the tube.

'Dusan's heart rate has gone down catastrophically.'

It's gone down to 30 beats a minute.

This is very, very bad.

If that gets any worse,

he'll be in cardiac arrest and his heart will effectively stop.

A normal heart rate would be around 60 beats per minute,

but Dusan's low oxygen levels

are now impacting on his heart's ability to pump.

Gareth must get as much oxygen in as quickly as he can.

I'm ventilating fast on purpose. Yeah.

'I want his heart to be able to fill properly and have enough oxygen to

'allow itself to work properly,'

and I'm hoping his heart will kick in and come back to normal.

OK, heart rate's come back up. That's good.

Just give him a little bit more bagging.

Sue, can you pass me some long suction catheters from the bag?

Yep. Thank you.

So, this is pulmonary oedema.

'Fluid leaks out of the little blood vessels inside the lungs,

'into the air spaces.'

And then, when you put someone on the breathing machine,

you see that fluid coming up.

A bloodstained fluid coming out of the tube suggests

Dusan's lungs have been seriously damaged by the impact of the bus.

This is all pulmonary oedema that you get on the chest. Is it?

But the scale of his injuries is still not clear.

Dusan is critically ill and Gareth must get him to hospital fast.

I just want to have a quick look at the rest of him and then I'll...

'As well as the possibility of a really bad head injury,'

Dusan could have bleeding in other areas

that could also kill him quickly.

The tummy was distended before.

We'll cut these off in a minute.

Nothing obviously there.

Dusan's stomach is worryingly tight.

This could be caused by internal bleeding from yet another injury.

We do need to get moving.

Let's start packing up, getting ready to go.

We need to get him to the hospital to try and work out

if there are any other injuries that we can't see at the moment

that could also kill him very, very quickly.

Ready, steady, go.

SIREN BLARES

Are you aware of us taking your boots off?

No. No, OK.

Near Bristol, rider George has lost all feeling in his body

from the neck down, having been thrown from his horse

while jumping a hedge.

He's unable to move and his breathing has become very shallow.

A high-level spinal cord injury

disconnects your brain from the muscles in your ribcage,

so you can't breathe using those muscles.

There's another nerve, which takes a different pathway,

and it connects directly to the diaphragm.

So the diaphragm can continue to assist in breathing,

but you become very tired very quickly

and you can progress to not being able to breathe at all.

This separate nerve comes out of the spinal cord, high up in the neck,

and might be the only thing keeping George alive.

I'll tell you what we'll do, let's split this,

roll him onto half of it.

George's heart rate is also worryingly slow,

but this, too, has a dedicated nerve,

as well as special cells that keep it beating on its own.

Our heart has an intrinsic ability to keep beating.

Even if it came out of the body,

it would still keep beating for a short period.

However, it would continue at a slow rate only.

With his breathing and heart rate critically low,

it's not clear how long George can survive.

We're going to roll you onto your back, OK?

Is that all right?

I'm going to take good control of your head and neck,

that's going to be my job, OK?

We're going to do everything very slowly.

If anything hurts, just shout out.

I'm listening, OK?

I think the important thing here, guys,

is we do everything very carefully. Very, very carefully.

There's no rush, OK? We'll do things carefully.

What we have to be careful is that we don't worsen the injury,

we don't cause any further damage to the spinal cord.

Therefore, we have to move him as carefully as possible.

So, has everyone got appropriate hands on the position

and knows where...? I've just got his pelvis area, really.

We'll just very slowly go over,

nice and controlled, straightening him out as we go.

OK. We're doing this slowly. OK?

'We need to get George into a neutral alignment,'

perfectly aligned, on his back,

with as little movement as possible to his entire spine.

So, ready, steady, we'll start.

The spinal cord has the consistency of toothpaste.

It's very delicate.

It can be damaged if the bones that surround it are broken

and impinge or push onto the spinal cord.

If anyone's got any problems as we go,

just shout out and we'll pause, OK?

We're doing this slowly, OK?

That came off easily. Good. Just keep him coming.

That's it.

You've got his head, mate? I have his head.

How are you doing?

Is that uncomfortable? There.

Where? In your neck?

I'm delighted to say that pins and needles are now beginning to start.

Pins and needles? They're going down further...

Further down my biceps.

Down your arms? Yeah. OK.

My collar bones are fantastically sensitive.

'What I think is happening here

'is that his brain is unable to process or understand

'the information that it's receiving,

'so it tries to fill in the gaps and imagine what should be there.'

This would probably just be a perception

rather than a genuine sensation.

Is this pain or is it a funny feeling? Pain. Real, real pain.

Pain. And that's pain to your...?

Neck. Neck, OK.

Going down to my collarbone and round to the top of my shoulders.

Yeah.

Christ, it hurts.

With George's pain now rapidly increasing,

Greg gives him intravenous morphine to ease his distress.

It's started going in, George, OK?

So you'll start to feel some effects of that. Yeah.

But I don't want to just blast so much of it in all at once

that you get knocked off, OK?

'Morphine depresses your brain's drive to breathe'

and that's the last thing we wanted to do.

Lift!

With George's breathing a major concern,

Greg must get him to hospital as fast as possible.

His son was also riding with him when he came off his horse.

So, he will have a scan within...

I would give an estimate of ten minutes of walking through the door

and we'll know to quite a degree what the damage is.

It's a bit of an unanswerable question.

What I've said to him is, "Don't lose hope. Don't give up hope."

Things aren't always as bad as they seem straight off.

That's true, but we do have to be prepared for everything.

It's not a great rate, actually, even in here.

George's heart rate is also still worryingly slow.

Greg alerts the nearest major trauma centre.

ETA is probably 15 from now.

1-5.

In Chelmsford, East of England Ambulance Control has received

an emergency call about a man who's fallen from a tall ladder.

Essex and Herts Air Ambulance doctor Sam Sadek

and critical care paramedic Simon Probert

have been called to St Albans.

An ambulance crew already with the patient

are concerned about his condition.

The difficulty with a fall from height

is it really could be anything, sometimes everything.

When a person hits the floor, they decelerate

and you can get a lot of hidden injuries with a fall like that.

Some of the internal organs can be very badly damaged.

23-year-old Seb, a tree surgeon,

was cutting branches with a long pole pruner

when he fell to the ground.

He's now in an ambulance, braced on a stretcher.

It's Seb, isn't it? Seb. Yeah. What were you doing?

You were cutting trees, were you?

Yeah.

And you landed how?

Onto your feet, like this, or onto your side?

Yeah, OK.

We'll cut all your clothes off.

We'll keep you in the ambulance so you're warm for now, OK, buddy?

'My first impression of Seb'

is a man who is in a lot of pain,

is not breathing quite normally -

either because of his injury, or because of his pain -

and a man who is very scared, and that worries me.

Do you mind if, while I do a primary survey...?

'Not everybody looks that scared after they've had an injury,'

so, yeah, it's a sign of something bad going on.

Someone tries to pop in another cannula.

We're going to get you really warmed up now

and give you loads of painkillers, OK, mate?

Sam needs to find the source of Seb's pain

to work out what's going on inside.

I'll have a gentle feel of your tummy.

Does it hurt? Yeah. Everywhere?

Yeah. OK.

When I pressed his tummy, he was desperately tender and rigid,

which can be a sign of a real disaster going on in the abdomen.

If I press here, does that hurt?

It's hurting down there when I'm pressing here?

I'm just undoing your trousers to have a look at your pelvis.

Paramedic Simon Probert is concerned about the risk of internal bleeding.

With all trauma patients that we attend,

we'll always perform an examination of the pelvis.

It's a very strong, rigid structure, but it can be broken.

Because of the amount of blood vessels that sit within your pelvis,

pelvic fractures can be fatal.

They can be life-threatening and you can lose your entire blood volume

within your pelvis without any external bleeding.

Does that hurt your back at all?

OK.

That hurts you where in your back?

Lower back, yeah. OK.

How much morphine has he had? Ten.

Ten. Let's try more morphine and I'll be back in a second.

Time is critical because, every second that the body is bleeding,

your chance of death increases.

I leave to gather probably one of the most important

bits of information for myself and that is to look at the exact scene -

where he fell from and what he landed on.

Yeah.

Oh, really? OK.

Right. From where?

A-frame meaning what? Scaffolding? A great big ladder. A ladder.

Metal, an A-frame ladder that goes like that.

OK, and what branches was he cutting?

Those broken top ones up there? Yep. OK.

'Seeing that tree, seeing the height and what he landed on,'

for me, was the clincher.

I thought, "This is enough.

"I'm not going to take any chances with this man."

Concerned Seb could be bleeding from internal injuries sustained in the

high fall, Sam must get him to hospital fast.

He's fallen a fair old way onto the base of a bush,

so a big deceleration.

I mean, he's extremely tender in his abdomen.

I think we should go to a major trauma centre

because I'm worried he's bleeding. Yeah, yeah. I agree.

In the last 60 minutes,

emergency clinicians have battled to

treat three critically ill patients.

Horse rider George is being

airlifted to hospital

after suffering major damage

to his spinal cord.

Dusan has been anaesthetised

after an accident

has left him with multiple injuries.

And after falling from a tall ladder,

Seb is showing signs of potential internal bleeding.

Dusan has been rushed to the Royal London Hospital

after being hit by a bus while walking to the gym.

Gareth is concerned about his head and chest injuries.

He's also worried he may be bleeding into his abdomen.

I just wanted to let you know there's a trauma patient arriving.

The 40-year-old male pedestrian versus bus.

OK.

Emergency medicine consultant Simon Walsh is preparing

to take over the patient and assess the scale of his injuries.

OK, everyone, this gentleman is approximately 40 years of age.

He was hit by a bus.

I think he's hit the bus with his head.

His saturations where 85% and his last blood pressure was 88 systolic.

OK. Let's start the primary survey, please.

Can we get the...? Is the scoop undone?

Dusan has both critically low oxygen and blood pressure.

As well as his head injury,

the impact of the bus may have damaged his lungs

and Simon is also concerned he's bleeding

from other internal injuries.

'Firstly, why has his blood pressure become so low?'

Is he bleeding?

Do we need to give him some blood to replace blood loss immediately?

So I'm thinking, "Does he have another injury?"

Is there more to this than meets the eye?

Chest X-ray has got a lot of opacification

of the right hemithorax,

so presumed contusion, plus or minus hemothorax.

The X-ray shows what could be severe bruising

to Dusan's right lung, or an area of blood around it,

which could be preventing him from getting enough oxygen.

Sats still reading 84.

If you could do anything with the ventilation to improve that...

Consultant anaesthetist Mit Lahiri is also concerned

about the impact of his damaged lungs on the rest of his body.

The things that were worrying me initially

were that his oxygen levels were low,

despite the fact we were on as much oxygen as we could give him.

So we take a sample of blood from the artery,

and that gives us a huge amount of information.

Got bloods. Thank you.

This blood sample is processed within minutes

and reveals another major problem.

He is very acidotic, got a pH 6.97.

Dusan's body has been starved of oxygen

and is now creating lactic acid in his blood.

A pH of 6.9 is a potentially unsurvivable level of acid

without immediate intervention.

The longer the body is acidic,

the more likely the cells are going to die.

This acidic blood could trigger yet more complications.

Increased levels of acid can cause problems with the blood clotting,

which can cause more bleeding and so it goes on.

In my experience,

you're more likely to die than live with numbers like that.

We're spiralling towards a point

where we're not going to be able to come back,

so we need to do something pretty sharp.

OK, so, obviously, he has got a significant head injury,

but he probably is also bleeding, so we'll request a pack A

and get him to CT and see what else is going on. OK?

Hi, can I request a pack A, please?

Simon rushes Dusan to the CT scanner and requests

an urgent blood transfusion.

He needs to find out exactly what's wrong with Dusan's lungs

and locate the source of his internal bleeding.

Ultimately, the question is, does he need an operation

to stop bleeding in his belly?

Does he need any procedures done to

improve his ventilation function in his chest?

And does he need neurosurgery?

ALARM BEEPS

But as Dusan enters the scanner,

his blood pressure plummets to its lowest yet.

This chap is a code red. Dropped his blood pressure to 71/50.

He's just in CT now.

ALARM CONTINUES

Code red lets key staff know there's a patient bleeding to death,

and makes blood and blood products quickly available.

The team start an urgent transfusion while Simon begins the scan.

Getting a CT scan allows us to see exactly what the brain injury is,

it allows us to see, is he bleeding into his chest?

Is he bleeding into his abdomen?

Any one of those things, in itself, can be life-threatening.

Simon consults neurosurgeon Emma Sillery.

The impact of the bus could have given Dusan

a major bleed in his head.

Your brain is a soft, pliable thing

that you could compress with your fingers,

so it's a delicate and easily damaged.

And heavy bleeding inside the head can push on the brain

and, if things push on the brain, it's only a small step, really,

before life-threatening conditions can develop.

His head doesn't look like it's got any large haematoma

that needs to be evacuated.

He's got an injury and some intracranial air.

The scan reveals an area of air in Dusan's head

which has entered through fractures to his face,

but there's no obvious signs of bleeding.

His brain, serious though it is, wasn't too bad,

and we could then at that point make a quick call

that they could leave this for now.

Simon decides to monitor Dusan's head injury

and continues scanning the rest of his body.

He's got a bit of blood in his right chest, doesn't he?

He's got a chest injury with some bleeding

on the right side of the chest, and some air escaped from both lungs.

The scan reveals Dusan has blood and air trapped around his lungs.

This is affecting his breathing and reducing his oxygen levels.

But before Simon can see to this,

he must find the main source of bleeding.

He's got a lot of blood around his spleen and some around his liver.

Then the scan locates a large area where blood is collecting.

The CT appearance, showing blood within his abdomen,

makes me concerned that he's actually bleeding to death.

Harriet, we're going to need chest drain on each side.

Simon must now drain the blood and air trapped around Dusan's lungs

and, without immediate surgery to stop the bleeding in his abdomen,

Dusan may not survive.

In Bristol, Great Western Air Ambulance

has just landed with horse rider George.

He's a 63-year-old male,

fall from horse, who's got a sensory level of C4 and is in spinal shock.

Emergency department consultant Adam Brown

is preparing to receive a handover.

He needs to rapidly determine the full scale of George's spinal damage

and any hidden injuries he might have from the riding accident.

We, as a medical profession,

quite rightly withhold our prognosis with these sorts of injuries.

But the reality of the fact is that,

if you see a devastating spinal cord injury,

you know, nearly all of the time, it's life-changing.

You all know about trauma calls by now - it's in, assess, stabilise.

If the patient's stable, off to CT.

Any questions? Groovy.

Red bag, please. And can we get the TX8 out but not drawn up?

Just park up.

OK, guys, just listen in for the handover, please.

This is a horse riding incident.

He's come off, he knows he has a neck injury,

neck pain was his only complaint.

I suspect he has a neck injury with probably a C3 for complete level.

Any questions from anyone? OK.

This is what I want to happen, please.

I'd like to undo all this blanket. He's on a yellow scoop.

I'd like people to come around the sides, lift up the scoop,

get out all the orange stuff

and then we'll do the monitor change after that.

Despite George's obvious neck injury,

Adam must be thorough and look for other possible internal injuries.

I know that George has a potentially life-threatening,

life-changing, high-neck injury.

I do not want to be complacent or focused on George's neck injury.

He has fallen, at speed, off a horse.

We need to ensure we do not miss any injuries

because we are so focused on the obvious, devastating,

life-changing injury that he may have.

Got good CO2.

Sats are 96.

What we're going to do then is we're going to get off the scoop,

package for CT, draw up presses, please, and we will go to scan.

11 minutes after arrival to resus,

George is taken for a full body scan to rule out other internal injuries

and look for damage to his spine.

On the word slide. Ready, steady, slide.

Well done.

The CT images actually looked remarkably OK.

It was as if George had injured his neck,

restored his neck back to its normal position,

and you couldn't really see any injury at all.

The CT scan is reassuring from the point of view of

we know there's no other injuries, but we haven't got the answer

to why George can't move his arms and his legs.

With no sign of injury to any of George's organs or bones

on the scan, Adam will need to run further tests.

George, can you try and bring your toes of both feet

back up towards your chin?

OK. And then can you try and push your toes down on both feet?

Try and push your feet down.

OK. So he's going to need an MRI. That's effectively it, isn't it?

He's going to need an MRI scan of his spinal cord

because we found no bone injury at all. The scans were normal.

An MRI scanner will show tissue detail

and any damage to George's spinal cord.

I think the important thing to communicate with George,

who is fully aware,

is to be honest and to be sensitive.

Without a shadow of a doubt, on some level,

I know that George knows what's going on.

And...as George's trauma team leader,

I'd don't really want to say it,

but that doesn't help anybody.

Obviously, you're behaving like somebody who's got an injury

to their spinal cord because you can't move your arms

and can't move your legs, but you can feel certain things.

So what you're going to need is an MRI scan,

which is a much more detailed scan, in a tunnel,

to have a look at detail of the spinal cord

because I think that's where the injury is that's giving you this.

It might be that you've just got bruising of that,

but, either way, we need to know.

And until we know, we need to keep you laying flat like this.

Will it show any damage? It will show, yes.

All right, OK. All right.

So that will show, basically, what the future is for me?

Yes, yes, it will. OK.

Let me go and sort that out now. Thank you. OK.

In St Albans, young tree surgeon Seb

is complaining of severe abdominal pain,

having fallen 30 feet from a ladder.

Concerned his injuries could be life-threatening,

Sam has decided to fly him to the nearest major trauma centre.

I'm looking at Seb, I'm worried about him,

I'm telling everybody and telling myself that he could be bleeding

into his abdomen or his pelvis,

and I know that we're a long way from hospital.

Ready, brace, lift.

Another injury which is very likely from that type of fall

is a spinal injury, particularly as he was complaining

of pain in his lower back as well as his abdomen.

With that always comes the risk of damaging your spinal cord,

even though he can move his legs,

and that could be devastating in the long run.

I know that I can't just chuck him on the helicopter.

He needs his spine to be kept very still

because it could well be broken.

Ready, set, lift.

Claire, we are bringing you a trauma patient by air.

He's a 23-year-old adult male.

He's fallen 25 feet, possibly a pelvic fracture.

It's a 17-minute flight to the Royal London Hospital,

where emergency medicine consultant Ben Clarke and his team

are preparing to receive Seb.

A fall from height is dangerous because, essentially,

you suddenly accelerate and then you very, very suddenly decelerate

and, by that, you come to a very abrupt stop.

And what can happen with that deceleration

is you can tear bits of the bowel, you can tear big blood vessels

and the impact itself can cause

damage to any number of different organs and bones.

Hello, guys. This is Seb.

He's 23 years old.

He fell around about 25-30 feet from the top of a tree.

He's a tree surgeon cutting branches.

'I'm hearing in this handover that Sebastian

'has fallen a great distance.'

He was complaining of very severe lower back pain and abdominal pain,

and those automatically point me to thinking about internal bleeding

and organ injuries, but also, most importantly, a pelvic injury.

Let's get the bed down.

We'll aim to do a primary survey nice and quickly.

Chest X-ray.

Ben decides to do an ultrasound scan to look for internal bleeding.

The purpose of it is to look at certain parts inside the belly

and the heart to see whether there's

any clear signs of internal bleeding.

Let's have a quick look down in his pelvis, if you don't mind.

Negative thus far.

It gives us an indication as to whether Sebastian's path may be

to the theatre, or whether he is stable

and we can go through the Cat scanner.

OK, guys. If we're good and we've got him disconnected,

let's go through to scan, if they're ready.

The ultrasound hasn't revealed any bleeding,

so Ben takes Seb through to the CT scanner

for a more detailed look inside.

The CT is a very sensitive,

very specific tool for showing us everything that is going on,

from his head down to his pelvis,

and see whether there is any clear sites of injury or bleeding.

Just be gentle, just be really gentle.

At the Royal London Hospital,

scans have revealed Dusan has suffered life-threatening injuries

to his chest and abdomen after being hit by a bus.

A build-up of blood and air trapped around his lungs has caused them

to collapse and he's bleeding inside his abdomen.

First priority is to put chest drains in

to allow his lungs to fully reinflate and allow them

to deliver as much oxygen into his circulation as is possible.

Is that drain doing anything? It was bubbling.

Yeah? Still bubbling? Bubbling.

With chest drains releasing the blood and air

trapped around Dusan's lungs,

Simon turns his attention to the abdominal bleeding.

Since the accident, this has been causing Dusan's blood pressure

to fall dangerously low, and they need to operate soon.

So how much blood have we actually given him so far?

240. 240, OK.

That's all we need.

For Dusan to survive long enough for surgery,

Simon has been giving him a blood transfusion.

He also hopes this will help make his blood less acidic

and enable it to clot.

You have a window where they're heading down

a slope of worsening acidosis,

and, if you don't reverse that very quickly,

then death can follow within minutes.

OK, the gas has improved a bit.

Ph 7.11.

Lactate's come down to 4.4.

With his blood gas results and blood pressure improving,

Dusan now has a window of opportunity for surgery.

Simon rushes him to the operating theatre

and hands over to consultant trauma surgeon Wayne Sapsford.

There are a number of areas within the body

which have a huge amount of potential space

in which blood can accumulate

and in the abdomen, in particular,

you can lose most or all of your blood.

Wayne begins the process of locating the source of Dusan's bleed.

When I opened Dusan's abdomen, there was 1-1.5 litres of free blood,

which we removed.

And then I did a thorough examination of all of his abdomen.

Major organs and vessels in the abdomen and pelvis

must be checked meticulously for active bleeding.

When I got to the liver and examined that in more detail,

he had a 6-7cm laceration on the right lobe of the liver

which wasn't actively bleeding.

The impact of the bus has torn part of Dusan's liver,

but this bleeding now appears to have stopped.

The liver is a manufacturer of clotting products

and is very good at stopping bleeding by itself.

However, I left packs around the liver to compress the laceration

in order to try and prevent it from bleeding again

in the ongoing hours and days.

Wayne leaves Dusan with a temporary closure of his abdomen.

The packs will help prevent any further bleeding from his liver

and will be removed at a later date.

But Dusan is not out of danger yet.

We're going to be doing an insertion of a right frontal ICP bolt,

so this is the patient's right,

and it's just going to be a little probe into the brain.

Despite there being no obvious bleed in Dusan's head,

neurosurgeon Emma Sillery is keen to monitor the pressure

around his brain over the coming days.

He does have fractures,

he did have some bleeding and we think he is at the risk of swelling.

The skull is a rigid structure

and Emma is worried that bruising on his brain could create swelling.

This would dangerously increase the pressures in his head.

Your heart has to be able to push blood into your head -

that happens all the time. You have an natural pressure in your head,

and your heart overcomes it and pumps blood into your head.

The pressure on the brain gets too much,

the heart can't pump blood into it,

and you have a brain without blood, and that's...

That doesn't last very long.

This probe will enable Emma to accurately monitor

the pressure in Dusan's head, minute by minute.

You use a small, thin wire that we put inside the brain

to measure the pressure inside the skull.

We have to put a screw into the skull

with a little tunnel through it,

and then we can put our delicate, little probe

through that screw tunnel and into the brain.

When I put the little pressure monitor in,

initially, his pressures were fine.

We could tell that from the scan, we were expecting that.

What we were really doing was to make sure that,

over the coming days, if his brain got big and crowded in there,

that we would pick that up on the monitor.

We can keep a little eye on his brain, 24 hours a day,

while he's in such a critical situation.

Dusan will be kept in a coma

while they monitor for swelling and bleeding.

They must now wait to see how well he recovers.

In Bristol, doctors are trying to figure out why rider George

has lost all control from the neck down after coming off his horse.

His CT scan showed no broken bones,

but the results are now back from a more detailed MRI.

Effectively, George's neck has been thrown forward with force,

backward with force.

So this is George's neck

and what we are seeing

is a possible disruption of three on four,

and that's visible on his CT scan,

but it doesn't give us enough information to say

that's exactly what the problem is,

which is why we moved to the MRI scan.

You can see the grey and the white of the cord in the spinal canal.

The cord should look like this -

pristine, continuous.

And, as you can see,

when you get here, there's a significant amount of disruption.

What has happened to George's spinal cord is it's not severed,

the cord is intact, but it's been stretched rather than torn.

If the injury had been a complete tearing of the cord,

it would be very easy to say, "This is probably not going to get

"any better and that is it."

In George's case, it's very complicated

because it's what we call an incomplete injury

and we just do not know how that is going to improve

over the coming hours, days, weeks and months.

George is unable to move any of his muscles below the neck

apart from his toes.

And relax.

His wife, Sarah, is working with him to regain any possible control.

I think that's enough exercise.

It is exhausting, isn't it?

Very encouragingly, there are one or two muscles

that I can move a tiny amount

and so I'm at that very, very tense stage, at the moment,

when I don't know whether I'll be what I think is called

a tetraplegic - someone who cannot move any of their limbs,

other than their neck.

At the Royal London Hospital, tree surgeon Seb is undergoing

an urgent head-to-toe CT scan to look for the source of his pain.

'Looking at Sebastian's scan,

'I am most worried about excluding injuries.'

I want to make sure I can't see any obvious signs of bleeding,

any very clear fractures.

Otherwise, that looks pretty good, doesn't it?

Full at the top, full at the bottom. Yeah.

He needs a wee. He definitely needs a wee.

He did say that. Yeah, bless him.

The initial scan rules out any life-threatening bleeding

that would require immediate surgery.

For Ben to find the source of Seb's pain,

he must wait for the scan to be fully processed.

Hello, mate. Everything's looking pretty good so far,

so what we're waiting on is

we're waiting on just the formal report of the scan.

There's still just a little bit of pain.

Where is that pain? Stomach. In the stomach, all right.

No worries.

What we'll do is I'm going to go and have a good look through

the scan as well and make sure there is nothing subtle that I can see.

With the full images now available, Ben makes a further assessment.

That explains a lot of his pain then, doesn't it?

The scan reveals Seb's fall has severely crushed one of his vertebra

and this is where his pain is coming from.

We've got all these lucencies,

it's irregular, it's got what looks to be cracks.

We can see that L1, which is this one here,

has been crushed, basically.

It's been fractured. It's been basically squashed down.

Despite the crushed vertebra, Seb's spinal cord is currently intact,

but a sudden movement could cause significant nerve damage.

All right, mate. We've got the results.

So your lumber spine, which is about here in your back,

it looks like one of the bones there has been broken -

and it's called your L1 vertebra.

The way you've fallen,

what's happened is that vertebra has been squashed a bit.

It's what we call unstable.

What we're going to do is get our neurosurgical doctors,

they're going to have a look at you

and then tell you exactly what the plan will be from there.

Simon hands over to consultant neurosurgeon Jonathan Bull,

who takes the decision to operate the next day.

The risk is that, having had it partially fractured,

as he started to walk around on it,

the bone would then further collapse and push fragments

into the spinal canal, which would then squash the spinal cord

and risk, basically, paralysis in his lower limbs.

One option was to treat him in a brace,

so he wouldn't have had an operation.

He would have worn that for around 10-12 weeks.

The alternative was a surgical option,

particularly for trauma patients,

a fixation with screws, but done through the skin.

It's like a scaffolding. It's like a support for the fractured bone.

X-ray.

'Rather than making a large incision,

'we make small sequential incisions at each level and pass a guide wire

'into the vertebral body, and then put a screw into it.'

Have that screw, please?

Jonathan uses the fixation as a scaffold

to support the fractured bone.

This is braced to a healthy vertebrae above and below,

all done through keyhole surgery.

It means the wound is smaller,

there's less damage to the surrounding muscle,

so they can often mobilise more rapidly.

Theoretically, if the fracture heals satisfactory,

you'll have a full range of motion, or near-full range of motion.

He sent me a WhatsApp from the hospital.

It was a little ambulance emoji, so of course I was quite scared.

I knew he had a dangerous job and I didn't know what had happened.

You're with the tree.

When it's windy and raining, you're sort of up there and it's...

Sometimes it's scary, but you...

I was never really scared of heights.

When I saw him in that hospital bed,

he just looked so small and...

he was scared.

Sebastian, I think, was lucky

insofar as the fracture didn't compromise his spinal cord

and he didn't have a deficit or weakness in his limbs from it.

I'm hoping he'll make a good recovery from it.

I'm fortunate for not being paralysed.

It could have been a lot worse.

I'm glad that I'm up and walking.

I just found out I was pregnant.

I told him just the week before.

We have a little boy on the way,

so that's really good.

A new chapter.

He's relying a lot on me,

but we're grateful that we still have each other, alive and walking.

He's doing incredibly well.

From seeing him in the CT scanner, with a blood pressure that low,

I was concerned as to whether he would survive.

Picture the scene, where you're just going about doing your thing,

and then you wake up and it's a month later.

And you're somewhere you've no idea where you are,

looking at somebody and you don't know who they are.

And that's a weird thing, because it affects you as a person.

The natural course of untreated bleeding and acidosis

with a brain injury is quite commonly death...

..but our aim is to intervene, to try and stop that process,

but it has to be done at the very early stage,

otherwise it's too late.

So, if we put your arm in there...

Now that his elbow is held up...

I...

They're quite short ropes.

If they were longer ropes, it would go further, I promise you.

I think, if I had the choice,

I would elect not to have jumped that hedge

in the way that I jumped it.

But I've had such an enjoyable life

and that's partly because of the things I've been able to do.

You look around for the positives

and it's a reminder that this isn't a practice for anything,

this is the real thing, and you only get one...

One go.

Can I have some water?

If you live your life protecting yourself

from every single potential outcome,

you'll never do anything.

So...life is there to be lived,

George was doing that,

and we're there to support the next life George has.

My current efforts, as indeed are this hospital's efforts,

are to make the best of what I've got

and follow the road where it takes me.

We both... Well, I don't know if we both,

I would love it if you could scratch your nose by yourself

and I didn't have to do it.

Thank you.

I'm going to put lots of scratch posts in my house,

so I can go up to them and...

Next time...

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

In central London, a man suddenly collapses at work

with a suspected cardiac arrest.

We are going to anaesthetise him here.

In Newcastle, a mother of three

fights for her life after being stabbed in the chest and neck.

How big was the knife?

And a cyclist in Durham suffers horrific crush injuries to his chest

after being run over by a bus.

Let's get the blood in.

Unparalleled talent, unprecedented access.

BBC Two takes a sneaky peek behind the celebrity curtain.

One piece of advice...

Go out there, grab it with both hands and stick it in your mouth.

Job done!