Episode 3 Life Savers

This programme contains scenes which some viewers may find upsetting

If you suffer a life-threatening injury,

your chances of survival are changing.

There's a revolution going on right now across the United Kingdom

in the way that we treat patients with major trauma.

We've got a head-on collision, with people still trapped in cars.

There's not a lot left of that vehicle.

In the past, hundreds of patients have died

who might otherwise have survived

had there been a more effective chain of survival.

-PHONE RINGS

-Addenbrooke's Major Trauma Centre.

We think she's Triage Tool Positive under the pelvic fracture.

OK, has she had pain relief?

Now, across the country, a new coordinated system

is triggered by the most critical injuries.

She's going straight down. Kate is your team leader.

OK. Quiet!

Medics with advanced life-saving skills rush to the scene.

Can we take over the leadership?

A well-drilled emergency department prepares.

MACHINE BEEPS Pupils are not reactive.

The latest technology is waiting.

I want this patient through the scanner as quickly as possible.

And leading consultants stand by.

We have every specialty under one roof, so we can deal with

any type of injury coming through the front door.

The clock is ticking.

The BBC has followed the first regional Major Trauma Network

to be fully operational, based at Addenbrooke's Hospital in Cambridge.

This is the frontline of emergency medicine.

Just don't keep anything from me.

We have people who arrive at the very limits of life.

SIREN WAILS

And I just thought she'd gone at that point.

OK. Stand clear, everyone. Shocking.

If you suffer a critical injury,

these are the men and women with the best chance of saving your life.

It's 5pm on a Monday evening.

Critical care paramedic Dan Cody

is on call with the East of England Ambulance Trust.

'Just off the junction of the A1301 before the roundabout.'

'There are two vehicles on scene, over.'

Yeah. Roger that. Thank you.

Going to an RTC, involving a motorcycle and a car.

I don't know much more than that.

At Addenbrooke's Hospital, the emergency department

is treating a steady flow of illness and minor injury.

Any difficulty breathing?

Consultant Catherine Hayhurst and Dr Adam Chesters

are just coming on shift.

-If we get on top of that.

-Yeah, as soon as possible.

-Cool.

If it's the big bones - the thigh bone, the femur - that's a big bone.

If there's enough force gone in to break that bone,

there's always the risk of other injuries to go with it.

Emergency medical teams effectively take the emergency department to the roadside

and they actually start the process of treating major trauma

before the patient even gets to the ED.

Two ambulance crews and the police

are already at the scene of the collision,

but they need Dan's expertise and drugs

before they can move the patient.

-What have you got?

-17-year-old lady. She's normally fit and well.

No allergy, no meds. She's come off her bike.

Tenderness around pelvis and right femur, nothing else.

OK. You keep doing that.

-What's your name?

-Molly.

-Molly, I'm Dan. How we doing?

Molly was riding her moped back from college

when a car hit her from the side.

-You got access? Happy with her chest? Happy she's GCS 15?

-Yeah, yeah.

Just pop that on the other finger for me.

Molly's parents were called by the paramedics,

and they rushed from home just a couple of miles away.

Big, deep breath for me.

-Any pain in your chest at all?

-Not really, no.

-Any pain there at all?

-No.

-It's mainly her hip.

-On your hip?

-Yeah. It's very tender.

-OK.

She's come off a motorbike. She's got quite serious injuries, probably to her pelvis and her right leg.

She's completely awake at the moment, she's got no breathing problems -

however, her blood pressure is very low. The bleeding, it appears that there is some.

She's actually potentially quite sick.

So our plan is just to finish off doing a couple of bits there,

give her some fluid to bring her blood pressure up a bit, but not too much,

and then sedate her with some ketamine,

which is a strong painkiller,

which will allow us to pull her leg out to length

and stop hopefully some of that bleeding and splint it properly.

-Molly, I'm going to give you some ketamine. It's a strong painkiller.

-Is it...

-Sorry? It's going to go through this tube in your arm.

-Fine.

When we do that, you're not really going to be aware what is going on.

We're going to work on 60 kilos,

so we're going to give her 30 mg to start with.

She's going to go completely out of it.

The ketamine will numb Molly's pain,

giving Dan enough time to put her broken bones back into position.

Ketamine's there going on, just hold on to her hip.

We're going to get the pelvic splint on, then I'll get the traction splint on.

Then we'll log roll her, get the bubble wrap underneath her

with the scoop, package her up and on our way.

Dan hopes that strapping Molly's leg and hips in place

will stop the sharp pieces of broken bone

cutting her blood vessels and causing more bleeding.

Just give John a bit of countertraction.

OK. Back down when you're ready, mate.

Dan gives the Addenbrooke's Emergency Department early warning.

Got a 17-year-old female. A motorcyclist. An RTC.

Pelvic and femur fractures.

Initially hypotensive, but now stable.

OK, and what was the speed of the RTC?

Liz Hamilton is the sister in charge of the resuscitation room.

Was it bike V car?

Car versus motorbike. Lovely.

We're going to be going into Addenbrooke's...

Liz gathers a six-person trauma team,

ready to assess and stabilise the patient.

The biggest risk to her is if she has damaged her pelvis, then the potential damage that has done.

Inside the pelvis, there's lots of big blood vessels that can bleed.

You can hide bleeding in the pelvis for quite some time

before you actually start to have any physiological response to it.

So, although she may look stable, she may deteriorate quite quickly.

-Can you just tell me the initial BP, please?

-It was 80 systolic.

She's had some ketamine and some morphine without complication.

We'll be with you in about 10 to 15 minutes.

10/15 minutes. So I make it 1805 now, so about 18:15?

Yes, about that.

We'll make resus bay one available for you when you get here,

-so if you want to come straight through to that.

-OK.

-Thanks. Bye.

Adult trauma call, A&E resus.

We've been told they suspect pelvic and long bone fractures,

which is always worrying because you can lose a lot of blood from them.

And the fact that she's quite tachiacardic and her blood pressure's a bit low

suggests that that might be what's happened.

-She's starting to come round now, isn't she?

-Yeah, just ever so slightly.

-Hello, Molly.

-Hello.

-How are you?

I've just given her a bit of morphine. By the time that's working, she'll be coming out, I think.

Trauma documentation.

Ketamine and morphine.

Expected at 6:15pm, which is three minutes or so.

We're here. Just into bay 1, please.

So this is Molly. Molly's a 17-year-old.

At approximately 5pm, she was involved in an RTC.

She was a motorcyclist, hit by a car

on a reasonably fast stretch of road.

Injuries suspected are query pelvis

and obvious angulated mid-shaft right femur.

Molly's mum joins her,

as the trauma team check if she's stable enough for a CT scan.

How is she? Have you spoken to her?

-Very ketamined, but otherwise she's OK. She's responding to me.

-Right.

MOLLY GASPS

-Well done.

-It's all done. She's got the blood, so just relax.

Fantastic.

Catherine gives the go-ahead for the scan.

The priority is to do a top to toe, so we know what injuries there are.

Chest looks good, but we'll have to check that, as well.

She's had a high-impact injury with very little protection if she's on a motorbike.

The team's worried that Molly's still losing blood internally,

and connect her to a blood infuser.

It's really important that we can give blood wherever we need it.

And if that's on route to different scanners then so be it.

Moving into the scanner now.

The CT is a rotating X-ray machine

that produces detailed internal images from head to toe.

It's a crucial tool in the Major Trauma System.

She's got a mid-femoral fracture on the right, and she's got

a nasty-looking pelvis fracture, so those are her major injuries.

If you look at the socket here where it should actually be just there,

it's broken off there. That's where the socket of the femur should be.

If the broken bones have damaged surrounding arteries,

it could put Molly's life in danger.

The radiographer injects dye into an artery

to help the scanner pick up any bleeding.

You can see this bulge here in the back of the vein,

which is the vein running up from the groin up into the abdomen.

And this is the abnormal pouching in the back of the vein here.

What's probably happened is this complex pelvic fracture,

there's a sharp spike of bone that's hit the vein

and made a hole in the vein.

It's not actively bleeding at the moment,

but it's bled and it's at risk of further bleeding.

So when they manipulate - put this pelvic fracture back together -

they might poke another hole in it and make it bleed again.

So, just to be clear, we're going to scoop her off the bubble wrap,

get the board out and then we'll do the traction.

Adam Chesters has joined the team to help move Molly,

so they can replace the temporary splints on her leg and pelvis.

If the bones move too much and it punctures that blood vessel,

we could have a serious bleeding problem on our hands,

so we've got to be really, really careful.

Treat it like a glass bowl - any slight movement could crack it

and cause a catastrophic problem for us.

She's been in a splint both on her pelvis and on her femur

for the last couple of hours since she's been in here and that's stopped the bones moving.

Now we've taken that splint off and we're moving the bones around,

it's going to be excruciating

if those two bones are allowed to grate together.

On scale of 1 to 10 in terms of pain it's probably up there at 9 or 10.

So, I'm giving her some very strong pain relief to essentially

make her unconscious while we're doing this.

The orthopaedic team can now put Molly's legs under tension.

This procedure will hold the sharp, broken ends of her bones apart

and prevent further internal damage.

The bands are wrapped around the legs.

And rope then go over the pulley system down to the weights that hang near the floor.

And that just applies some gentle traction

and pulls the legs out to length.

Didn't even flinch. Very strong painkillers, ketamine.

It's actually one of the common drugs of abuse.

People take it to have a good time in town at parties -

certainly not something we'd recommend.

This is a medicinal dose, and it still does weird things to you.

How was your dream on ketamine this time?

-Weird.

-Weird?

You going to do some art work on it?

Being an artist, you could do some fairly interesting pieces.

You really could.

It's anything from a really, really good dream

to a horrendously scary dream.

But actually this has been a very smooth reaction.

I just saw an image of Asha with an extra set of eyes on her cheeks.

Weird.

Really weird.

I arrived to cars

and two ambulances and flashing lights

and just seeing her lying with her leg at a weird angle.

And keeping her very still, thinking...

Well, all the worst things that go through your head.

You know she's alive, but has she got spinal injury?

Is she going to be paralysed? Is she going to be in a wheelchair

for the rest of her life? What, what, what, how?

The specialists have had a chance to have a look at all of her images

from the CT scans and they're quite comfortable

that there's nothing serious that needs to be fixed tonight.

So she's going to have quite extensive operations

to reconstruct her pelvis, to fix the long bones in her thigh.

And actually that's best done in the cold light of day

when there's a whole team there,

as opposed to being done at midnight when it's just the on-call team

who've got other emergencies to deal with.

It's just before 6am on a Friday morning.

Adam Chesters is back on shift, and, after a quiet night,

he's just had early warning that a serious case is coming in.

As part of the trauma network, we've got a transfer of a patient

from one of the trauma units at King's Lynn.

It's a 37-year-old who's been assaulted this evening.

He came in with a head injury and deteriorated in their department.

The stakes are high with these head-injured patients,

because head injury is the biggest killer of people under the age of 40 in the UK,

and we have to act fast and get the patient to the right place

to have the right treatment.

As soon as King's Lynn Hospital saw the patient was getting worse,

they triggered the Major Trauma Network

to rush him to the head injury specialists at Addenbrooke's.

Adam needs to check the patient's stable

and get him to the CT scanner within 20 minutes.

Theoretically, we shouldn't have to do anything, other than

put him across, check the tube and then go to CT.

The quicker the specialists have an up-to-date scan,

the sooner they can try to stop any damage getting worse still.

Hi, chaps.

We're going to need our scoop and we'll scoop him off.

The police called to the assault say the patient's name is David,

but they're not sure exactly what happened.

Somehow attacked with a hammer,

and he had blows to his head and the side of his face.

So, guys, we'll do a log roll on to the scoop.

Scoop him off their trolley and straight onto ours.

This is always the bit that takes time.

We're four minutes in, we're doing well.

-Bring your end out a little bit more.

-OK. Nice and quick.

-1, 2, 3.

-Very good.

OK, what I'd like to happen now is to go on to our ventilator, OK?

We've found that the patient's remained

as he was when he left King's Lynn, so we've got nothing to do in ED,

other than just get him to CT and really characterise what injuries he has.

So, team, we've got to pick up the pace a little bit.

Can we get the bridge on and get ready for transfer as soon as you can?

Just coming up to 19.5 minutes for our target 20.

-Have we got the transfer bag?

-Yeah.

OK, let's do it.

Very good. 20 minutes and 30 seconds.

This has been a serious assault. It's fairly uncommon

for someone to end up on a life support machine like this.

This has been quite a beating.

We're treating this like a brand-new trauma patient

and we're just going to scan from top to toe.

What we've found so far is that there's quite a lot of blood in the fluid that surrounds the brain,

what we call a subarachnoid haemorrhage. That's causing a blockage to the outflow of fluid.

If the pressure inside the skull spikes,

then actually that could be fatal, that could kill him.

So that's actually an emergency that may well need

an immediate operation to reduce the pressure in the brain.

Adam takes David straight to the Neuro-critical Care Unit,

one of the UK's leading departments for severe head and spinal injuries.

He's 37. He's been hit by a hammer.

-That's it.

-OK. That's all the information?

-That's all I've got.

The specialist on duty is Mark Kotter.

These are his ventricles, the fluid-filled chambers of the brain.

And if you look at the third ventricle,

you can see there's a blood clot.

This prevents fluid from draining from these lateral ventricles

through into this chamber.

And the lack of space around the brain suggests that there's quite some pressure in the brain.

The clot plugging the fluid is too small to be removed by surgery,

so instead Mark prepares to make a hole in his skull

to release the pressure.

The idea's really just to put in a drain from the outside

into the ventricle in order to drain the fluid.

Over the next three days,

the pressure in David's skull drops as the excess fluid drains away,

and he's taken off the breathing machine.

He's regained consciousness

and his mum, dad and sister Emma are here to see him.

-Do you know who it is? Who is it?

-Mummy.

-I'm Mummy!

-Well done, David, well done.

-And who's this here?

-All right, David?

-Your sister.

Mummy!

Don't think he's ever called you Mummy, has he?

Only when he wanted something.

-Are you feeling a bit cooler?

-Better than yesterday.

-Better than yesterday? Oh, that's good.

-That's good.

-You remember yesterday then, do you? Hmm?

-Don't remember all of it.

Don't remember all of it. No, no.

David had gone to Norfolk to see his girlfriend, it was her birthday.

My brother had said that night that he'd felt a bit nervous

and he thought something might happen,

but they carried on celebrating her birthday.

And her ex-partner smashed the window of the back door,

ran in to the house, chased after David

who then had to unlock the front door and run.

And I think then he had a hammer,

and hit him three times over the head with a hammer.

Well, we got the phone call at home, Friday morning,

to say that he was here.

Just those first words, "This is the police," you know, just those first words and you think, "Oh, my God."

He's doing absolutely fine because he's obeying commands,

-and he's moving his legs.

-Good. Yes.

-When he's awake, he's fighting. That's what you're meant to do.

-Yes.

Yeah, he is a bit of a fighter.

Just keep telling him where he is because he won't know where he is.

And he's safe, where he is and what day it is,

and keep everything simple.

We're just waiting for the drain from his brain

to start running a bit clearer,

and then hopefully things will improve a bit.

HE MUMBLES

What?

HE MUMBLES

You're in hospital in Cambridge. All right?

Nobody's going to hurt you. You're safe.

It's six days since Molly was knocked off her moped.

She's had her first operation,

pinning her right thigh bone together.

My art class made me a card.

They've drawn themselves inside, which is the sweetest thing.

And signed it all, which made me laugh a lot.

Art is my everything - it's what I want to do for the rest of my life.

And it's tough to be put in a situation

where I can't be working towards my portfolio.

(Oh, sweetie.)

Thank you. I can do that. I can do that.

Pelvic specialist Julian Owen has discovered her left thigh bone

has shattered her hip joint.

You can tell from this injury, with multiple fragments, that this

was a very high energy fracture. And the high energy will have used

the femoral head as a battering ram to smash the socket.

So, you've got something hitting her from the side - femoral head - bam!

It explodes.

Molly's injury is right at the extreme

of what I would attempt to reconstruct.

But at her age, you have to try.

They leave it a year

and then they'll replace it with a metal hip and ball.

And hopefully that will last her 20 years

before she has to have another one.

But it's quite a big deal for her to take in, aged 17.

Originally they thought it just had a crack in it,

and then they came and told us it was completely smashed.

Originally I thought I was just going to be here for, like, a month...

and now feels like it's a lot longer, and they're considering

how much it's going to affect my college work.

She's eaten something for the first time today.

-Oh, brilliant.

-She had some breakfast.

Two of Molly's best mates have come to see her.

Her first visit from outside the family.

Normally she's so bouncy and happy and springy.

It's going to be a bit strange seeing her.

Love me! SHE LAUGHS

-Oh, my God. Look at you.

-It's so good to see you.

I've missed you. Please don't cry, because I'm going to cry.

-How's college?

-Really boring without you.

I've sat through hours of Spanish without you, just not being able to talk to anyone.

I don't know anyone's names, it turns out, in my class.

It's just not the same, Mol.

She's really frightened.

She's really scared and she's tired and she's hurting

and she's full of drugs which are giving her bad dreams.

-This is morphine!

-Really?

Ketamine... When they put me under to take me in the ambulance,

they put me on ketamine.

Your mum said you were tripping so bad.

I was. You don't want to lift that blanket.

It's hideous down there.

There's a pin going through one of my knees, so they can pull it down.

This is in pieces, this pelvis.

It's just fractures of bone floating around.

-I'll see you really, really soon.

-Goodbye.

The reconstruction of Molly's hip is planned for two days' time.

It's a difficult and dangerous operation.

It will be good to have it over and done with, to be honest,

cos it's hanging over us a bit, this one. And it's - there's more

risk all the time, because there could be floating fragments

that are dangerous because there's lots of arteries and veins in there.

So need to get it sorted.

I need to keep telling myself that it could be a lot worse.

That's what I tell myself - that actually,

there are people who... At least there's no head injury.

It's just before 9pm on a Wednesday evening.

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

'I'm at the scene of a road traffic accident.'

'How many people are injured?'

'Two people injured - one person that has been fitting

'and has now stopped.

'He's breathing OK. And one person unconscious who's still breathing.'

The Major Trauma Network's been triggered again.

Any change in the patient's condition?

James French is the consultant on duty

in the Addenbrooke's Emergency Department.

Ten to 15 minutes. OK. So I'll be waiting at the front door, and basically I'll have

some emergency drugs ready, more anaesthetic drugs,

and a transfer bag, and we'll just go straight to theatre with him, essentially. See you in a bit.

Unfortunately, a very young man was

involved in a high-speed road traffic collision.

Although he was walking around at scene,

he has become critically ill at Peterborough Hospital.

We've done a CT scan in Peterborough which shows he's got a large

bleed around the outside of his brain

and that bleed is expanding and that's absolutely life-threatening.

The network's swung into action to bring the patient to

Addenbrooke's, where there's a neurosurgical

specialist on standby 24 hours a day.

If a patient's coming from a network hospital to us,

they'll send the scans through so we can start planning the surgery

and getting the team ready.

Damian Omato's on duty and assesses the scans sent from Peterborough.

This is the clot making a sort of crescent shape, indenting

the brain, and he's got a couple of little bruises in his brain, as well.

You need to take the side of his head off and then get the clot out.

And that is a simple concept, but obviously quite difficult to do because you're

operating on someone's brain - it's brains surgery.

We can do quite a lot for major trauma in terms of surgery.

The results from the neck down are quite predictable,

but it's a different story from the neck up.

Is this the head injury?

It's 4.5 hours since the patient's collision.

His name is Sam - he's 19 years old.

So, Katie, you're still managing his critical care,

I'm just making sure he gets to the right place.

It looks like the A pillar, which is the front pillar of the car,

I think probably hit the side of his head.

So he's been hit from the side,

and that's actually one of the worst ways to be hit in a car.

A craniotomy on the left side - his scan shows the left side...

Good, OK?

So that's a big safety thing.

They do a time out before the operation, when they say,

"Have we got the right patient, are we doing the right procedure on the right side?"

Because stressed, people can make simple mistakes,

and obviously this guy doesn't need a simple mistake.

Damian first makes a cut in Sam's scalp.

He then cuts an 8cm-wide hole in the skull,

directly over the blood clot that's on the outside of the brain.

It is a big clot,

and the important thing about the clot in a younger person,

is that his brain is well-developed, it hasn't degenerated over time

that happens with age - so there's not a lot of space in his head.

So it's really important to get it out straight away.

With the bone cut away, Damian can reach in and remove the clot.

We'll reconstruct the bone and put the bone back in,

and close his scalp.

So that's the fracture, right over the clot.

That's the burn hole I've made just there,

and then we come round and cut out a craniotomy there.

So what we'll do is put some plates on there to hold that back

together, and then we'll plate it back in.

So we'll take him back down, have another scan after surgery,

see what that looks like...

and then try and wake him up.

After Sam's been given a follow-up scan,

he's taken to the Neurocritical Care Unit.

Sam, wakey-wakey. It's one of the doctors.

Open your eyes for me. Try and open your eyes.

Good boy.

Sam... Get that tube out of your mouth, hold on.

Nice and still.

Well done, well done.

Open, open, that's it, good, well done.

He's got good power in all of his limbs, so that's a good sign.

Damian checks the latest scans to make sure there's no further

damage developing in Sam's brain.

This is my craniotomy here, that's the bone plate that we took out

and beneath it was a clot that went like this before.

So that's all gone now and he did have some

bruising in the brain below that, and I can see that there.

It's a bit bigger than it was pre-operatively,

so we'll just have to see how he goes with that.

David is still on the Neurocritical Care Unit,

nearly two weeks after being attacked with a hammer.

His condition has deteriorated

and he's been put back on a breathing machine.

Can you wiggle your toes?

See if you can wiggle your toes for me.

No, too tired are you?

Too tired.

You just have to take every day at a time, don't you?

There's still hope.

Yep.

Consultant Neurosurgeon Peter Hutchinson has just received

the latest scan of his brain.

There's no doubt that his condition is worse now than it was

a few days ago. You can see a different signal intensity

on the left side of the brain compared to the right side.

So this would fit with the stroke-like syndrome,

where he's not moving the right side of his body.

You know, there is going to be an element of disability as a result

of this injury. The question is how severe that's going to be.

Hi, have you met?

Hi, yeah, I've seen you.

Peter has arranged to give David's family an update.

So we know this has been a very nasty injury that's been inflicted.

The problem is when there's a lot of blood in the spaces around the brain, the vessels

can go into spasm and that restricts the blood flow to the brain.

I think that's what happened, that there

have been parts of the brain that have not had enough blood supply

and I think that's why he's deteriorated.

So can that improve? Will things improve?

Yes, he wasn't in a devastating condition immediately afterwards

and he's been better than he is now and his age, are the positive features.

-I think the concerns are the MRI scan is a concern.

-Hmm.

We are very concerned about his condition,

but in terms of the way forward at the moment, I'm sure the right

thing is to very actively treat him down on the Intensive Care Unit.

The plan over the next few days is to get him breathing better

so we can try and get him breathing by himself

so he's not dependant on the ventilator to do the breathing.

So you think there's, I know you can't say definitely,

but a chance of recovery, some recovery?

Yeah, I'm sure this is the right course, to do the tracheostomy

and treat him actively and try to focus on that, rather than...

in terms of prognosis in the future, you're looking at months.

So is that months that he's going to wake up,

or months that...he's talking?

He needs to start breathing on his own...

So I think the first step within this process is to get him

breathing and get him off the ventilator.

So I don't think there's any difficult decisions to make.

No, no.

I think it's clear what the right thing to do is at the moment

and we're going down that route.

Thanks very much.

Molly's being taken for surgery that will piece her shattered hip joint back together.

It's a highly complicated operation that will determine how well

she'll be able to walk.

She actually has a lot of pieces for someone of her age.

Julian Owen and his colleague Peter Hull both spent

a year in the US learning this operation

and will work together to combine their experience.

It's a very nasty fracture at a very young age

and you can't rebuild them all.

You can see it on the CT 3-D reconstructions here.

The main injury runs across the hip socket, which would be through here,

but there's more fragmentation of the front part of the hip socket.

And then if we look from behind, that is this fragment here,

which has most of the joint surface on it.

This is where everything could either go right or go wrong.

It's going to go right, cos we've got the top people on the job.

Always, you're struggling to get to the hip socket, which is

a very deep structure and there isn't an easy way of exposing

the whole thing to get a perfect fracture realignment.

Nearly there, OK? You'll be asleep very soon.

The other issue here, of course, is the vein.

Especially after an injury like this with the vein damaged so much.

I have seen patients in my time, die of embolism before I've

even had a chance to get to their fractures.

So it's a very, very scary injury. It has to be taken very seriously.

-Have you had your breakfast, boys?

-Yes.

I think it'll be all day.

The risk of operating next to Molly's damaged vein

means Julian and Peter will be joined by a third surgeon.

How many surgeons to fix a bone?

We've got Mr Boyle, the vascular consultant,

because we'll be working very close to the artery and the vein.

So the concern was, early on in the exposure, whether that suddenly might bleed, which is why he's here.

-Well, I thought we might start, is that all right with you?

-Yeah.

Peter and Julian's first job is to create an opening to work on the hip.

The fracture is there, isn't it?

The first view of the hip socket confirms the scans.

It's smashed, isn't it? What have we got here?

It's just totally smashed up.

-I think you're getting quite close to the big vessels there, aren't you?

-I am.

I think we are very close.

So what happens if I hit the vein and then it starts bleeding?

-Then I'll dissect it out...

-But you'd happily do it in that order?

Well...

it's not the easiest bit of the vein to fix where it is.

A fresh tear in the vein would need all of Jon Boyle's skill

to stop the bleeding.

Let's take a long...

Now we're up to fracture.

It's toast, isn't it?

-The roof has gone, poof.

-I can't get at it.

So far we've got the fracture exposed,

but we're starting to work out exactly how to get the reduction manoeuvres to hold it reduced.

If we can't get the jigsaw puzzle back together perfectly,

it increases her chances of arthritis, which are very high.

Can you get a screw in that, at any direction,

-without it going into joint?

-A very short one.

Just to hold it before you put the plate on?

Julian and Peter put a screw into the top of the thigh bone,

hoping to pull it into a more normal position in the socket.

That's the closest you get to getting the head

in the right place so far, isn't it, when that's there?

-It's a good start, it's not perfect yet, but at least...

-No, that's grand.

Just have a look here at this column here, through this window,

-that's now quite good. Oh, hello!

-That's good.

I think that's a good reduction.

Pulling on the thigh bone has also brought the hip fragments into the right place.

They can now be fixed using plates and screws.

And another ball pusher, please.

The more accurately Julian and Peter can re-piece the jigsaw, the

better Molly's chance of avoiding a hip replacement in a year's time.

The best screwdriver on the set, please.

X-ray there...

So this one's beautiful.

That one, you've got the dome tilted back, I'm much happier.

Julian and Peter just need to slot the last fragment

of Molly's hip into place.

They've managed to avoid her damaged vein throughout

the six hours of surgery.

-So that fragment's tilted right back.

-It has, yeah.

I'm really pleased with that.

It's three weeks since David's head was seriously injured

in an attack with a hammer.

His parents and sister visit him every day

on the Neuro Critical Care Unit.

I'm playing him the Match Of The Day theme tune on YouTube.

Because the other night on Wednesday it was the England and Sweden game.

And he woke up as soon as the theme tune came on

and opened his eyes for the whole football game

and moved his arm a bit.

He's a Liverpool supporter,

so we've been playing him You'll Never Walk Alone, as well.

David's chest has improved so much,

he hardly needs the breathing machine,

but he's still not responding.

We just want somebody to say...

you know, when he's going to wake up.

But they can't, really.

Peter Hutchinson has been asked for his opinion and calls a meeting.

-I mean, really, he's not changed at all.

-No, completely static.

No, OK.

The police have been in touch with me this morning about a statement.

So there has been somebody who has been arrested and charged

-and has pleaded guilty.

-Pleaded guilty, is what they said to me.

And is awaiting sentencing. So they want a statement and prognosis.

In terms of the next few months, it's difficult to be sure,

but I don't think this is looking very hopeful.

Deeply comatose, I think it's very bleak.

I can't see the next few months changing.

There's nothing that we can do to make him more awake

-and there's nothing we can do to not support him.

-Yeah.

I mean, I think I've had that conversation with them.

There isn't a major treatment decision in terms

of withdrawal of therapy.

Peter's arranged to update David's family.

We last spoke on...

-Last Friday.

-Friday, it was a week ago, wasn't it?

How do you think he's been over the last week?

-No response, really.

-No.

-No.

I mean, he hasn't really changed.

We would have hoped to have seen more of a response by now.

He has the one eye open, the left one,

but there's no recognition there.

He doesn't even follow you, you know, doesn't even follow you.

I think we should get another scan and I think we should try and get him

-off the ventilator.

-Mmm.

-Then take things from there.

So I don't think there's any big decision to make.

-You know, I think we know what needs to be done.

-Mmm.

But we are very concerned.

Oh, dear.

-Mmm.

-Having said that, we're still relatively early in...

-Mmm?

-You know, from the injury.

-Yeah, yeah.

I don't think we should give up, or lose hope.

Have you got anything you want to ask?

Do you want to say anything, Nicole? Have you got anything, you know?

-We'll make sure that we're keeping you updated.

-OK.

-OK.

-Do you want to stay in here for a bit?

-Yeah.

-Yeah, OK.

-OK.

Does there come a time when they just decide to stop?

Sorry, Sam.

No, that isn't something that we're even thinking about.

-We can only give it a bit of time.

-Yeah.

-Unfortunately, it's time...

-Mmm.

-..to just even out and see where we are.

-Yeah, yeah.

Sam's on the rehabilitation ward,

three weeks after hitting his head in a collision.

Since the operation to remove the blood clot,

he's had more surgery to take away a section of his skull.

We were concerned after Sam's operation that he was not waking up properly,

and therefore he underwent a further scan.

There was bleeding within the brain itself,

causing pressure on the brain.

So we undertook a second operation to remove the bone

and that has enabled the brain to expand under the scalp

to protect the rest of the brain.

Sam's family are visiting.

That's when you arrived in hospital.

-Yeah.

-Swearing.

-I didn't swear.

-You did.

-Oh, OK.

It was just a shock that, you know, it turned out to be so serious.

Erm, obviously upset and, you know, he was on...

..such a high that day, before...

Sorry...

That's straight after the operation.

Oh, no.

-Is that the first operation?

-And boxing gloves.

That's his first operation, I didn't see him after the second one.

Two days later, we had to have surgery again.

Deeper into the brain, because more bruising.

Erm...

and then I was really scared, very scared.

There's a feeling inside that you can't describe.

I don't remember anything like that,

but, erm, pretty cool, to be honest.

-It looks pretty cool now.

-Yeah.

-But it didn't then.

-Yeah, I see.

-And you couldn't move an inch.

Yeah, I can't really remember, apart from the crash.

That's about it, to be honest, I can't remember.

-Where was you going, do you know?

-No.

-Right, because we thought you were perhaps going to visit your brother.

-Maybe.

A long recovery for you, I think. Lots of things to sort out.

-I'll be all right.

-You're not going to be all right yet.

I don't think you really know how bad it is...

or was. I just...

You're in a bit of a dream.

When you get home, you aren't going to do what you think you're going to do.

-Yeah, I'm going to go out...

-You're not, I'll chain you in.

-It isn't going to be like it was for a while.

-Yeah, I suppose.

-Well, no, it just isn't.

-Yeah.

You've got half your head missing.

-You're going to keep moving forward, aren't you?

-Yes.

How are you doing, Sam?

Speech and language therapist, Lisa Robson,

is one of the rehab team helping Sam with his recovery.

How are you feeling today?

-All right, I suppose.

-You suppose.

How are you finding your speaking?

Erm, quite difficult to...say.

I don't know, I don't know.

Is it difficult thinking of the words, or stringing them into a sentence?

-What kind of...

-It wasn't difficult thinking of the word,

but I can't string them, like... to a sentence

-like I usually can.

-OK.

He's totally different. He just seems more polite to people.

He's certainly talking to people a lot more.

Whether that's due to being in here or an operation,

or a change of personality, I don't know.

I think what's going on with your language at the moment

is something they call Aphasia.

Aphasia is a language difficulty.

So we normally store our language about here in your brain

-on your left side.

-Oh, right.

So obviously you've had quite an injury to that bit of your brain.

You're doing really well, from our point of view,

-considering what has happened.

-Yeah.

-RADIO:

-Cambridge 105...

'I think it's time for some more shout-outs.

'First of all, I think we should give a massive shout-out to Molly,

'who's one of our most dedicated listeners.

'Always there.'

It's nearly a month since Molly's hip operation and she's regaining strength on the trauma rehab ward.

-'Yeah, she's in hospital at the moment, which is pretty sad.'

-'Yeah, it's awful.'

'But, apparently, she's getting better, which is wicked!'

'Yeah, so get better as soon as you can, Molly.'

I will.

'We're rooting for you.'

That was so sweet.

I feel all warm inside.

You have this big input of surgical intervention

and then there's a waiting game while the fracture heals,

and it's a frustration for everyone because the patient starts to feel more comfortable,

the wounds are healed, the clips holding the wound together have been removed, so there's just a scar

and the feeling is, "Why can't I get up and start walking on it?"

-Are you recording?

-I am recording.

Erm, so...

The case manager came today and he says that he can ring

the transport and fix a set time for me to come home tomorrow.

So it's all a bit overwhelming

and I'm hoping to go home...

..first thing tomorrow, which is amazing,

because I didn't think I'd be home for Christmas.

MUSIC AND LAUGHTER

MOLLY HUMS TO MUSIC

FRIENDS JOIN IN HUMMING

We should do a three-part harmony.

She's going home!

She's going home.

Who's going to take the high one?

It is hard to convince a patient that it's really important

not to stress that fracture fixation.

The problem is a waiting game to not flex the hip

and not weight bear, and that means a reclining wheelchair

and to convince the patient not to try and cheat.

David shows no sign of regaining consciousness.

To make his care easier in the longer term,

Peter wants to do an operation.

One of the problems that David has had is that the ventricles,

the fluid spaces inside the brain that contain brain fluid,

have become enlarged following the injury.

And it's important that we treat that

and the way we do that is through the shunt operation.

This drain in here is draining the fluid outside into a bag,

so in effect we're going to convert that so the fluid will drain

through from the ventricles through a valve and down a piece of tubing

that we're going to put into his abdomen, where it will get absorbed.

He'll have this shunt in for the rest of his life.

There's nothing we can do about the original injury,

the treatment is there to try and give him

the best possible chance of making the recovery.

But, you know, we're very concerned and we don't know

whether he will ever actually be able to take that opportunity.

This is the tubing that we're going to pass under the skin.

And this is a special sort of valve, in that we can vary

the pressure using a magnet on the outside of the head.

Medical intervention has made major advances

and I think that people are now surviving who used to die.

What I think we need to be really, really conscious of is

the quality of the survival for these patients.

For medical intervention to save life,

but produce a cohort of patients who are in vegetative states

or states of very severe disability is not a good outcome.

You can actually see the fluid is then coming up the brain catheter,

through the valve, and we can see the fluid dropping

out of the bottom end of the abdominal catheter.

The day of the court case was Friday.

We were all a bit stressed that day.

He got sentenced to nine years four months, which is

one of the highest sentences you can get for that offence.

So we are pleased with that outcome

and, yeah, you just have to... That's gone now

and now we just need to concentrate on getting David better.

Fingers crossed he will.

Hi...

-How are you?

-Not too bad.

-In fact, I'm great.

-Good, we need to get you out of here, don't we?

-Yeah, please.

-I would get out of here before somebody stops you going.

-Yeah, OK.

-All right?

-Yeah.

It's interesting if you compare David,

who we know he's very, very unwell at the moment.

He's dependant on nursing staff, he's really still in a coma.

Sam is slightly different in that he has actually done well, we think.

You know, he's been though two operations,

he's made a good recovery, he's discharged and everybody's happy.

So you know, from the outside he appears to have done really, really well,

but, you know, there were potential issues in terms of perhaps more subtle things...

Thanks. Thanks, Rodger.

..in terms of his personality, memory and concentration,

and it will be absolutely fascinating to see him

in a couple of months' time.

I can't believe that I made it.

Two months later, Sam's back for his follow-up.

Sam, why don't you come and sit here?

Right side's my best side.

Good man. It's nice to see you.

How have you been getting on?

Erm, good, apart from the seizures.

-Apart from?

-The seizures.

-Seizures, OK.

My face went droopy... kind of thing,

I thought I was having a stroke.

-Yeah.

-And then my whole right-hand side body went.

-You know, these are to prevent the seizures that you described?

-Yeah.

So, I think what we should do is just build this up, gradually...

..until, you know, we're sure that you've got enough to stop you having these seizures.

How are things otherwise?

-Awesome.

-Awesome, good.

-Sense of smell?

-Yeah.

It's OK.

Hearing? Speech?

Well, my speech is a bit like this.

And what about things like your memory?

Probably not as good as it was, but it's all right.

-Is that my brain?

-That's your brain and you can see how swollen it was

and, in fact, where we removed the bone it's swollen through that defect.

-That's why we took the bone out.

-Yeah.

What we're going to have to do is plan putting the skull back together.

Good.

-We'll get the titanium back in instead.

-That'll be cool.

-Metal head.

-Metal head, yeah.

Do I get to keep my skull?

-If you'd like it, yeah.

-Yeah, I want it. It'll be awesome.

At the end of the day, you've done fantastically well.

We'll get on top of this and it's very, very good.

-I'll be all right?

-Yeah, you'll be fine.

-Thanks for saving my life.

-No, it's...

As I said, we're really pleased with how everything's going. It's great.

Yeah, cool.

-Thank you.

-We'll see you soon, hopefully for the plate.

-Bye, take care, you know where we are if you need us.

-Yes, thank you.

Safe trip back.

The outcome from head injury is a huge spectrum.

We have many patients who don't survive,

we have patients that make a fantastic, really good recovery

and Sam, seeing Sam, who's at the better end of the spectrum

in terms of the nature of his injury,

is very satisfying for us.

From the people who saw him at the scene,

people in the emergency department, through intensive care,

the operating theatre, the neurosurgical ward, the rehabilitation,

doctors, nurses all the therapists and everybody that's been involved,

I think it's sometimes a pity that everybody doesn't see Sam.

It would be nice if we could get more of the nurses to see him like this.

You know, see the impact of their work in terms of his recovery.

So putting it all together, I think, it's good.

It's nearly four months since Molly's accident.

She's on her feet and back at school.

By the end of the surgery, I was feeling an awful lot better

that we'd certainly avoided a hip replacement for a while.

And even if Molly's fracture deteriorates,

she gets arthritis, there's still a solution.

The hip replacement is now established and works

and we will keep her walking, but hopefully, that won't be necessary.

Erm, this goes at the front so...

Everyone who visited me in the hospital said,

"Oh, you're going to have to use this for your artwork,

"this is a real major life experience."

So I looked at Dirk Skreber because he looks at car crashes.

So, yeah, I want to do something similar.

It's something that is super personal to me and so the truth

of that will, hopefully, come across in my work and get me a good mark.

I can't tell whether the red... the red is actually blood, or not.

Are these tendons or something?

-No, these are arteries.

-Oh, my gosh, really?

And that was like, severed.

This is what's in there now, though.

THEY GIGGLE

There was a mixed blessing in this, in that, you know,

Molly and I got very close again

and she had to allow me to care for her.

I did, sort of, say a huge thank you.

I don't think it will ever quite be enough.

Now she's back up in her room, she's back on Twitter,

she's back on Facebook, but there's just a difference, you know.

I think Moll and I will always have a link now,

which maybe we wouldn't have had if this hadn't happened.

Shall I hold this so you can see it?

It's so complicated looking at my X-rays

and thinking, where would you even begin?

I'm lucky that the people who looked after me

were the best at what they do.

Molly, actually, is a good example of an awful lot of specialties

coming together and working together,

and that is a product of the major trauma system.

I keep on using the word "machine", because that's what it feels like, but it's a machine that works.

All in all, I'm a very lucky girl.

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