03x01 - Series 3, Episode 1

[bunniefuu]

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 infrascanner 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.

Yes, see the cord. Tube, please.

Tube on.

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

In London, a man is run over by a lorry.

This is going to be an RSI and road to the Royal London.

A policeman has a cardiac arrest in the gym.

Ah.

I've just giving you some medicine that's probably going to help with the chest pain.

And in the Pennine hills, a cyclist is seriously injured after a fall.

You OK?

60 minutes that will change their lives forever.

You will constantly be surprised just what you can bring back from the jaws of death.

In London, ambulance control have just received an emergency call about a moped rider run over by a bin lorry.

Emergency ambulance, what's the address of the emergency?

Just south of Blackfriars Bridge.

A bin lorry drove over a guy.

Do you know whether the patient's awake?

I suspect they're dead --

I have no idea.

London's air-ambulance doctor Will Glazebrook and paramedic Colin Smith have been dispatched to the scene.

The first that we heard was he was underneath a very heavy lorry and trapped by his head and neck area.

We obviously have great concerns about a concurrent head injury and neck injury.

Anything versus a bin lorry, anything tends to come off worse than the bin lorry.

You're normally be expecting to see quite extensive injuries, quite serious injuries.

London ambulance paramedic Richard Kingham was first responder at the scene.

He's administered oxygen to moped rider Martin.

I was met by a number of policeman who told me he was dead.

'He looked dead.'

Are you going to hold the head?

His heart wasn't b*ating.

'Immediately, I'm thinking, he's broken his neck.'

So we need to get his helmet off soon as.

He was very blue, and clearly wasn't getting any oxygen to his brain.

So we began the resuscitation process.

The oxygen has enabled Martin to breathe again and his heart is now b*ating.

Nice pulse there.

Will must now establish the severity of his injuries.

The front wheel of the lorry was actually here. On this side.

OK.

He's obviously got some bruising here.

He's got a decent jacket on.

Due to the mechanism of injury that Martin had, being underneath the lorry at a funny angle with the tyre on his neck, we're obviously worried about a spinal injury, 'and we quickly established that Martin hadn't moved either his arms or his legs since the injury.'

Has anybody looked...? Did you look at his pupils?

Yeah, they were...

They were quite large and fixed.

About size seven.

I had great concerns that he was suffering from a head injury.

There would have been a period of time when he would not have had oxygenated blood going to his brain.

A lack of oxygen to the brain can lead to brain damage.

Do you want to do that? We'll put a line there.

We're going to put him through this.

It was just going to be a roc only, but we'll RSI him, so if we could just set up over there.

I felt that the most important thing for us to do would be to secure his airway, to ensure we can give him oxygen.

To do this, Will and the team need to anaesthetise Martin, which will allow them to insert a tube into his windpipe and take over his breathing.

Good to go. We're going to give this gentleman anaesthetic.

We're going to put him to sleep. First, we're going to run through a checklist to make sure that's a safe thing for us to do.

You're going to hold the head, you can bag. Yeah?

So we're going to roll, just only about 10 degrees this way.

OK, on three. One, two...

He still had a chance of arresting again, he still had a chance of not surviving this injury, and my thoughts at that time certainly were that the injuries that he did sustain would be life-changing.

14 minutes ago, across London, ambulance control were alerted to another medical emergency.

In the heart of the city, a police officer has collapsed at the gym whilst undergoing a fitness test.

Control, G460.

G460, we've got a 55-year-old male with cardiac arrest.

An emergency medical car carrying London's air-ambulance consultant Anne Weaver and paramedic Bill Leaning is sent to the scene, where the man's colleagues have begun CPR.

Control -- G460, that's all received.

Check, check.

The number of people who survive an out-of-hospital cardiac arrest is less than 10%.

You need to get there quickly, because time is of the essence with any cardiac arrest. Time is life.

Watch heads.

At the scene, London Ambulance paramedics are already treating David.

Can you just tell me what you know?

Yeah. Police officer doing a fitness test. Collapsed.

Yeah.

Was given two shocks prior to our arrival.

Is he breathing on his own?

He's breathing on his own. Yeah.

David was technically dead during the cardiac arrest.

His heart was not b*ating, he was having external chest compressions to provide some blood flow to his heart and his brain.

David's colleagues have managed to restart his heart with CPR and a defibrillator.

Ooh, hello! All right?

Hello, sweetheart. Just take it off, just take it off a minute.

Hello, sweetheart. What's his first name? David.

Hello.

All right, sweetheart.

It's OK, you're in the gym, I'm a doctor.

You've got some very good people here who've looked after you, OK?

Yeah.

Well done. OK.

You're doing really well.

I'm just going to pop a little oxygen mask on your face, OK?

Yeah.

But you're doing really well.

Can you take a big deep breath for me?

That's brilliant, well done, absolutely brilliant.

'So David's breathing isn't quite normal at the moment.'

It's a little bit slow, it's quite deep and laboured.

I'm not entirely sure how much oxygen he's getting.

All right. Are you OK there?

You're doing fine. Can we pop something under his head?

Have we got anything soft?

If your brain is starved of oxygen, that can have a devastating effect and, even if we restart the heart, the brain may never recover.

So, sats 99, heart rate 105.

Let's get that 12-lead.

Let's get a 12-lead.

David's heart could stop again.

Anne decides to run an electrocardiogram, or ECG, to understand what is happening in his heart.

Yeah, fine. OK.

So, BP of 108/70.

Heart rate of 93.

12-lead just coming.

Heart rate, good.

He's got quite marked ST depression, naturally.

Yeah.

So he's probably got a posterior.

Yeah.

OK, all right, we've got enough to go on there.

But, erm...

Bart's.

Yeah.

'I'm looking at David's ECG' and I can see changes, which suggest to me that he has a blocked coronary artery in his heart.

The heart muscle is still ischaemic, which means it's still not getting enough oxygen.

If the muscle doesn't have oxygen restored quickly, that heart muscle will start to die.

He could go back into cardiac arrest.

He might.

There's a limited amount we can do on scene.

We can treat his symptoms, but I can't unblock that coronary artery here and more heart muscle is dying whilst we are waiting.

We want to get you to hospital as quick as we can.

So, in a minute, we're going to help pick you up.

If you're sick, don't worry, OK? I can give you something to stop you feeling sick.

But it's part of what's happened, OK?

We're going to get you on the trolley and in an ambulance.

All right? I know you don't feel well at all.

OK? We're going to look after you, I promise you, OK?

David?

Oh...

Have you got a chest pain?

Yeah.

'David's clutching his chest and is in significant pain.'

His heart is b*ating, but from the ECG changes and looking at David, he's got chest pain.

He is having a heart att*ck in front of us.

200 miles away, North East ambulance control have taken a call about a cycling accident in the remote North Pennine hills.

He's come off his cycle and part of his mouth's all hanging out.

I just need to check first that the patient's fully breathing?

He is breathing, but he's bleeding very badly.

Has there been a heavy blood loss?

He's bleeding very badly at the moment, yes.

In freezing conditions, the Great Northern Air Ambulance is carrying Doctor Dion Arbid and paramedic Andy Mawson to the scene of the accident.

I've been told that there's a gentleman come off a pedal cycle up in the hills in the snow and it sounds like he's got a really nasty facial injury.

I'm thinking that he could well have a significant head injury, and that's our biggest worry.

After coming off the bike, the cyclist managed to ride another three miles to a local pub.

Thanks very much.

Hello, mate. What's your name, buddy?

Julian.

Julian? OK.

'A lot of the time, you can have a good guess at what people have done, depending on what the description of the incident is. But you can never take anything for granted.'

Do you take medicines for anything? Are you allergic to anything?

Have you hurt yourself anywhere else apart from your face?

My hand.

Your hand?

'Julian doesn't know how bad his face looks.

'He had a very nasty cut' to his lower lip, which extended down onto his jaw.

Have you lost any teeth, Julian?

Yeah. Have you swallowed any or anything like that, you don't think?

No.

OK.

As well as his facial wounds, Dion is worried Julian may have other serious injuries.

Sit forward a tiny bit for us.

Good man. Any pain lower down your neck there?

Nothing at all? Deep breaths in now.

And out.

'From the impact itself, he could well have torn vessels' inside his head, inside his brain, and caused bleeding.

Good man. Have you got any morphine? Do you carry morphine?

Yes.

Give me some morphine, if you can draw that up, ready for us.

Cheers.

Yeah, no worries.

Dion and the team need to prepare Julian for the helicopter ride to hospital for a more detailed examination.

OK, we'll just give you some of this painkiller.

This might make you feel a tiny bit woozy, OK?

'We still have to remain vigilant on the ride in.'

'Things can change very, very quickly.'

Pop these on you. It'll be cold, I'm afraid.

If you've got any problems, just wave at me.

Right, start number one.

Concerned that there may be injuries he can't see, Dion rushes Julian to the nearest major trauma centre in Newcastle, a journey of just 15 minutes by helicopter.

We're looking for, predominantly, a change in his level of consciousness, whether he becomes drowsy, whether any of his neurology changes, if he's bleeding internally, his pulse rate goes up -- all these things we'll keep an eye on, on the flight.

You can never take for granted that nothing's going to change.

Unexpected things do happen, and we just have to deal with them as and when.

In central London, moped rider Martin is about to be anaesthetised after being run over by a bin lorry and suffering multiple injuries.

Yeah, just a scene update.

This is going to be an RSI and road to the Royal London.

'Message received.'

We obviously have great concerns about a concurrent head injury and neck injury.

Checklist. Happy, Colin?

Will is worried the injuries may be restricting the supply of oxygen to Martin's brain.

He's got equal pupils...

He decides to perform a critical procedure called an RSI.

So, oxygen mask on tight.

All oxygen cylinders are greater than half-full.

515...

An RSI is a rapid sequence induction of anaesthesia.

It is the giving of an anaesthetic drug and a paralytic agent.

It's not a procedure that we take lightly.

Once you give your dr*gs and you've paralysed a patient, you are on a road to ensure that you take over their breathing.

So we do 200 of fentanyl.

4ml.

4ml, yeah.

Ketamine, do 150.

150, check.

And the roc, we're going to give 70mg.

7ml?

7ml.

OK.

So, guys, just a little bit of concentration now.

This chap's going to go even further asleep than he was.

It takes about 45 seconds for him to stop breathing and become 100% paralysed.

Can somebody just give me the time? The roc is in that...

Time is 34.

34. Thank you.

'Once you stop a patient breathing, you've got a very short period of time' to get a breathing tube down their throat and start delivering oxygen to them.

Can I have the suction, please?

So, I can't see very much at the moment.

There's a lot of blood.

OK, I can see the cords, the cords are apart.

It's a grade-two view.

I can see... yeah, it going through the cords.

So add the tube over.

Tube over.

Just have a listen to the chest again for me.

Sats are 98. Good BP.

I want you to just hold that tube there.

Just hold that there. Don't let it move.

Right, OK, we're going to go by land to the Royal London, if you don't know already.

With the tube in place, vital oxygen is now being delivered to Martin's heart and brain.

But until he reaches hospital for scans, there's no way of knowing what kind of injuries he's suffered to his head and neck.

There's still a lot that can go wrong.

There'll still be repercussions from the period where he's been in cardiac arrest.

So we're going to start moving that way.

There's potential secondary brain damage where his brain's been starved of oxygen, and they all need to be addressed.

In central London, police officer David is in the grip of an ongoing heart att*ck.

Have we got a... Let's just keep the oxygen near him.

We'll blue this in as post-cardiac arrest with ongoing chest pain.

Yeah.

He has a blocked coronary artery.

I think the blockage is a significant obstruction to blood flow and, hence, to oxygen to the muscle.

That's a heart att*ck.

Oh...

He's still got this crushing chest pain, because his heart is still struggling to work.

Whatever's caused his cardiac arrest -- and we believed it was a blocked artery -- that is still blocked, we haven't cleared that.

Can we get our medical dr*gs pack now?

Got it.

What would you like?

Get some GTN.

GTN it is.

Yeah, thanks.

Oh...

OK.

GTN.

Right, we're going to give you a little spray under your tongue.

Oh, I feel sick.

OK.

Don't worry. If you're sick, it's fine -- there's a bag here.

Good man.

Aah!

Good. I've given David a spray under his tongue, it's called GTN, or glyceryl trinitrate.

This is a drug which opens up blood vessels, and I'm doing that to try and improve the blood flow through his coronary arteries.

Are you sure?

If everyone's ready -- ready, brace, lift.

The dr*gs will reduce David's pain and increase the oxygen to his heart.

Then the team will take him to hospital.

Oh! Oh, headache.

I've just given you some medicine that's probably going to help with the chest pain that does give you a bit of a headache, OK?

Oh!

Can you just turn your arm out?

OK. Just turn your arm out for me.

Anne injects David with morphine to help further reduce his pain.

Got a headache.

Yeah, I've just given you something to try and take that away and to get rid of your chest pain, OK?

Cor, flippin' heck!

I think if you do this job and you don't reflect on your patients, there's something a bit wrong with you.

That patient is someone's father, someone's mother, someone's sister, someone's brother.

It's nothing that can ever be taken lightly.

OK. I need to just put a little bit of oxygen on your face, OK?

I know you feel sick, we can take it off quickly, but this may help, OK.

Oh!

All right.

With his heart att*ck continuing, David will be monitored closely, en route to a specialist heart centre.

In Northumberland, cyclist Julian is arriving at Newcastle's Major Trauma Centre.

Emergency doctor Kian Dastoori is preparing to receive him.

His face went into a cattle-grid, apparently.

Julian, 45, fit and well, no medicines, no allergies.

Off a pedal bike, face into a cattle-grid.

And it's done some quite considerable soft-tissue damage to his lower lip, his dentition on that bottom and query fractured mandible as well.

Right, Julian. Are you all right to be called Julian?

Yeah, my name's Kian, OK? I'm one of the doctors.

'On the first seeing Julian come through the resus doors,'

I could see that he was alert, looking around.

Right, have you got any blood going down the back of your throat?

No.

No. And you've got no neck pain at all, Julian?

No.

No.

'But you always have to keep your guard up.'

He's lost his lower dentition off his palate, he's stripped all his mucosa all off his mandible and he's got lacerations down both sides, so the bottom of his mouth's flapping.

Knocked any teeth out?

Yeah.

You have knocked some teeth out, yeah?

No.

No tenderness up here?

Right.

OK. Fine. So it seems to be mainly isolated to the face.

He's torn his frenulum on his tongue, and he's got a deep laceration to the left side of his lip.

So we'll get an X-ray of his jaw and we'll go from there.

Oh, hey, Claire, it's just Kian.

We've had a chap come in who's come off his bike and gone face-planted into a cattle-grid.

I just wondered if you could come and have a look?

We're going to get X-rays of his mandible and jaw anyway.

We'll get you round for your X-ray shortly, OK?

Let us know if you know more painkillers, OK? OK.

As Kian waits for Julian to be taken to X-ray, he notices a change in his condition.

You just went straight over?

Yeah.

Yeah?

Like that.

Straight on.

OK.

Right. Do you still know where we are?

Yeah.

Where are we?

Hospital.

Yeah, fine, OK.

Although Julian appeared orientated still and I kept asking him, "Do you know where we are?" and he could tell me we were in hospital... he'd changed somehow, and I knew that there was something going on.

Keep him on pretty close neurobs.

He still knows where he is and stuff, he's just got a bit dazed and it's just not quite right.

I just caught a glimpse of him as he was going out of the room and his face appeared to have changed.

And it was that reason why I followed him round to the X-ray department.

It's your left hand that we're going to X-ray, does that sound right?

And then some images of your face and your mandible as well and your chest.

Does your hand normally flatten out?

Yeah.

Yeah, can you try and uncurl all of your fingers for me, then?

And turn your hand palm down.

'At the point when your gut tells you there's something going on here,' you do have this sort of internal clock that just starts ticking until you find out what the diagnosis is.

Down there.

That arm. No.

Can you bring this arm up here? You're on there.

Can I have a quick look at him, guys? Sorry.

Julian, can I see this arm?

The tone of your muscles, at rest, should be nice and relaxed.

Whereas, when I went in to quickly assess Julian's arms, he appeared to be nice and relaxed on his right side.

Let this arm relax, just relax.

Can you let this one relax as well?

But his left side was more rigid.

His muscles appeared to not be at rest.

He needs to go for a CT head.

CT head.

Do you want a quick chest?

CT Head. No, CT head now. OK.

'Increased tone essentially can be a sign that you're not getting oxygen to that part of your brain. At this point, I'm worried that Julian' is showing signs of having a stroke.

We're going to bring him in for a CT head now, guys, he's...

Oh...

He's got increased tone of his left arm and he's just...

He's not really using it that well.

'We need to urgently scan his head to make sure there's no bleed in his brain.'

That is now time-critical.

OK?

Yeah.

The scan should reveal any blood clots or bleeds.

But it's clear.

Fine. Good.

So, in CT, we don't find anything on the brain...

That's fine. Yeah, we'll get his X-rays now.

All we find is a fracture to the skull near his eye.

But I wasn't reassured.

My gut was telling me there's something going on with this patient.

We now have a man who was... essentially well when he came in, despite his facial injuries, and is now developing new symptoms which seem to be progressing.

So I had to go looking for something else.

I had to be looking for something that could explain all of this.

In the last 60 minutes, doctors and paramedics have pulled moped rider Martin from under a bin lorry, and suspect he's suffered brain and spinal damage.

Police Officer David is being rushed to hospital with an ongoing heat att*ck.

And cyclist Julian is showing worrying signs of deterioration.

At the Royal London Hospital, a trauma team led by emergency medicine consultant Alistair Wilson is on high alert to receive Martin.

He was pinned underneath the front wheel by his left shoulder and head in a funny angle.

The lorry was reversed, he was pulled out in PEA arrest.

Helmet came off, LMA, oxygen and he got a ROSC.

Our arrival, GCS of 3, not been seen to move any of his limbs.

Let's go for the...

Let's get the... top and bottom off.

'I like the whole business of actually working out' what has caused what.

There isn't an injury that the patient has that cannot be related to what has gone on.

It's a bit like looking at cars, you know, if you have a car that's been in an accident, every dent, every bump is caused by something else, and you need to piece together all those bits.

The same thing is true with the body.

Right, hands over from right to left.

Alistair's team begin by examining Martin for any immediate life-threatening injuries.

Can you feel the chest for me with your...

Yes, there's no tenderness...

Well, no, look, go right the way round the back and tell me what it feels like.

It became abundantly apparent very quickly that his wasn't just a head injury.

He'd got a lot of bruising at the very base of his neck, which you could feel.

So when you're ready, let's get that blood gas off, fast as you can.

So, are we ready for CT? Let's go.

So the issue was to move Martin as fast as possible into the CT scanner to review all of these injuries and see exactly what was going on.

Knowing that Martin's head and neck were dragged under the lorry, Alistair is going to CT-scan both.

He's behaving as if he's got quite a bit of cerebra anaemia already.

We could use facial bones as well.

Primarily, the left side of his face had been smashed inwards.

The facial bones were all fractured.

There was a lot of swelling under the very base of the skull.

As well as the trauma to Martin's face, Alistair is also looking for any injury to the brain.

His brain looks quite good.

It does tell me that there's no bleeding inside the brain matter itself, or contusions or tears in the brain matter.

I wonder what sort of helmet he was wearing.

The policeman's got it.

Oh, excellent, I'll have a look.

So, it's between the road...

That's road, and that's...

And that's...

That's him.

Perfect. Exactly what we would expect.

Perfect. If Martin hadn't been wearing a helmet, I suspect he would probably have had a fatal head injury at scene and probably would not have been able to be resuscitated.

Whilst Alistair is encouraged by the scan, it could be days before any damage caused by the lack of oxygen begins to show.

The damage to the brain would have been expressed in the cells, initially by just not working, but with time, the cells die and the whole of the brain then becomes oedematous -- it's got a lot of swelling, a lot of water on it.

Unfortunately, it does take two days or so before that expresses itself.

So it's a matter of waiting to see what has happened.

OK.

Having checked the brain, Alistair now focuses his attention on Martin's spine.

I'm concerned about his C-spine, but we haven't got the recons here.

That's blood round there.

When you looked at the spinal cord, at the base of the brain, just at the bottom of the brain -- a little bit into the brain, too -- but there, pushing the spinal cord across, was blood.

That's compressed inwards, isn't it?

So he's got this haematoma, in this area here.

Yeah.

The danger to Martin because of this bleeding is, if it is compressing the cord, then it will be damaging the cord.

And it would be an emergency then, and we would need to go in and let that blood out.

To decide if Martin requires surgery, the trauma team need a more detailed examination of his spinal cord.

MRI is the next thing to do.

An MRI lets us see very clearly ligaments, soft tissues, brain and neural tissue in a lot more detail than we ever could with the CT scan.

The real issue in Martin's case was were we going to need to do something with his neck?

Whether we needed to do an operation on the spinal cord, or the spinal column, had to be determined by the MRI scans.

Any significant damage to Martin's spinal cord could lead to permanent paralysis.

He's got these little fractures round the back there.

C7.

Um... Hmm.

All of that looks raised, doesn't it?

All the way up and down.

It's this stuff in the centre of the cord that's the issue.

Yeah.

After the MRI, it was clear that there was no compressive pressure being put on the spinal cord and, therefore, there was no requirement for any neck surgery, or to let any clot out or let any pressure out.

Although there's no need for surgery, Alistair can't tell at this stage what the long-term implications of Martin's injuries will be.

To aid his recovery, Martin will be kept in an induced coma until the medical team feel it's safe to wake him.

Is he going to be able to move his arms and his legs?

We have to wait and see. He could wake up in two days, three days, and his brain might not work at all.

David is arriving at Barts Heart Centre.

Anne suspects one of his major coronary arteries is blocked.

She's given him dr*gs for the pain.

Until doctors clear the blockage, his heart will be starved of oxygen and nutrients.

This is David, he's a 57-year-old policeman.

He was doing the bleep test this morning when he dropped to his knees, clasped his chest and fell prone.

Immediate bystander CPR.

His 12-lead ECG basically shows a sinus rhythm, but he's got some inferior and lateral changes and ongoing chest pain. He's taken 10 morphine...

Within minutes, David goes for an emergency angiogram, a specialist heart X-ray, under the eye of consultant interventional cardiologist John Hogan.

We know he's had a cardiac arrest.

We're not entirely certain why he's had one.

If he does have a blocked artery, which is recently occluded, the longer it is blocked, the more damage it causes to heart muscle.

You're going to feel a burning sensation of the arm, OK?

Using dye, John examines each of David's three major coronary arteries in turn, looking for any narrowing.

The arteries develop a lining called atherosclerosis over a period of time.

That lining itself is subject to developing cracks.

Such little cracks are sealed by little blood clots which seal it and if you get a big blood clot, it can actually block an artery off at the time and that's how you get what is typically known as a heart att*ck.

Why do people get hardening of the arteries?

It can be a number of things.

Do they have hypertension, do they have diabetes, do they have high levels of cholesterol?

And their lifestyle issues. Are they sedentary, do they smoke?

All of these things contribute to the development of atherosclerosis.

He's got collaterals.

Yeah.

And so that implies that the vessel has been blocked before and he's had these collaterals in the interim period.

John discovers a drastically reduced flow through one of the three main arteries supplying David's heart.

There's no doubt that David has a blocked artery that runs down the front of his heart.

We just need to have a little MDT about this before we press on.

John must now make a decision on how to treat David, to give him the best chance of survival.

We've had a look at the angiogram.

Of your three coronary arteries, you've blocked the one that goes down the front of the heart.

You do not appear to have blocked it off this morning, but your exercise may have aggravated matters and caused your collapse.

So we think that your circumstances would be best treated in the long term by an operation to bypass that blocked artery.

Until David goes to theatre for emergency surgery the following day, he will be closely watched for the smallest of fluctuations in his heart activity.

In Newcastle, over the last four hours, Julian has been closely monitored following his accident.

His head scan has revealed nothing to explain his continued deterioration, but Kian believes he may have found the answer.

I'm going to bring Julian back round for a CTA. Are you guys ready?

The only thing that could explain his symptoms were a carotid artery dissection.

It's one of the most important vessels in your body, which carries oxygen to your brain, so anything that disrupts that is potentially fatal.

We need to make sure that when he's fallen, when he's hit the ground, he's hyperextended his neck, we need to make sure that he's not dissected or torn one of the arteries which supplies his brain.

That wouldn't show up initially on a CT scan.

Kian sends Julian for a specialised scan called a CT angiogram.

The one thing that's going through my mind at this stage is I need to get this scan fast and find out if this is the diagnosis and get the right people involved to give him the best chance of a potential recovery.

There's nothing else that can explain the new acute weakness.

OK, Julian, we're back in the scan room, OK?

We're going to move you over again, OK?

Let's have a look at your eyes, Julian, OK?

Julian is having a dye injected into his arm.

It will allow Kian to track the blood flow in the artery in his neck.

Normally you would get the dye just flowing nicely through the vessels.

With a dissection, you'll see some of that dye moving into places that it shouldn't go and, ultimately, if there's a clot there, you won't actually get dye advancing past where it should be going.

Yeah. It's dissected.

On Julian's CT, it showed that he had what I was suspecting.

He had a dissection of his neck.

Right, we'll get him back through.

As soon as Julian had fallen off his bike and hyperextended his neck, he would have sustained that tear in his artery and, from that point, he would've had blood going into an area where it shouldn't have gone and the body would have been starting to form clots the whole time.

It wasn't until actually parts of a clot started to sh**t off and go up into his brain, until he would've actually started getting symptoms and signs of a stroke.

Hi, can you put me through to the stroke consultant on call, please?

Hi, sorry to bother you. My name's Kian, I'm on A&E at the RVI...

Kian calls in a specialist stroke team.

They'll try to break down the clots which are cutting off the blood supply to Julian's brain.

'The fact that a big clot was formed in Julian's neck from a tear is incredibly rare.'

You're coming into the RVI just now? Right.

You could seer it as a bit of a ticking time b*mb as to when he was actually going to develop symptoms of a stroke.

Yeah, we think you have. Yeah, yeah, you have. OK?

Yeah.

OK?

We're going to try and give you some medication to try and break down the clots that are causing the problem, OK?

OK.

OK?

Oh, hey, it's just Kian.

The stroke consultant's here. They're going to thrombolyse him.

Doctors give Julian a powerful drug to break down the blood clots causing the stroke.

But it is not without danger.

Thrombolysis can be a risky procedure.

It's essentially something that goes in to try to break down clots and, as a result of that, you can start spontaneously bleeding from anywhere in your body.

With the extensive injuries to his face, Julian is at risk of bleeding into his airway and drowning in his own blood.

At this point, it was really important to get the maxillofacial doctors back down to start putting in some stitches into his face to try and do some damage control on the potential bleeding that could happen from those wounds.

If you open as wide as you can for me.

Even bigger than that.

Kian must now wait to see how Julian responds.

Julian, at this stage, was showing signs of quite an extensive stroke.

This is something that he could potentially die from.

It's the morning after Julian came off his bike, smashing his face into a cattle grid.

A blood clot in his neck has caused a major stroke in Julian's brain so he's been given a powerful drug to try and break it down.

At the intensive care unit that he's been moved to, consultant anaesthetist Hugh McConnell and registrar Tom Keans are checking to see if it's worked.

Morning, Julian. It's Dr McConnell here.

I saw you downstairs last night in casualty.

Yeah.

How are things...? How are things going?

'When I saw him on the round that morning, I could tell that he was still very weak down the left-hand side of his body' and was concerned that the stroke deficit hadn't improved particularly with the clot-busting drug.

Can I get you to hold your arms out in front of you?

Can you keep that there? OK.

Can you put your palms to the ceiling?

And what about that one?

Can you squeeze my hand at all, Julian, with this side? OK.

Do you understand what's happening at the moment? Yeah? OK.

You've injured one of the blood vessels in your neck and that's caused a stroke.

'At that time, an area of that brain will have been starved of oxygen and nutrients that it requires, and when that happens,' those cells begin to die or swell.

Can I get you to open your eyes for me, Julian?

'The key problem with brain swelling is that the swelling is occurring in a rigid box -- the skull -- and if you get a lot of swelling within the skull, the pressure goes up' and it pushes over the vital structures that exist within the brain and that can cause catastrophic and irreversible damage to the previously healthy brain tissue that's not affected by the initial injury.

As Julian's brain expands, and with no room to move, it will begin to push onto his cranial nerves, which control his breathing and his heart.

We look for signs of these cranial nerves becoming compromised, and one of the most easy to identify is the pressure effect of traction effect on the third cranial nerve, which typically causes inability to open the eyelid and dilation of the pupil.

I'm just going to shine a torch in your eyes there.

The key change was undoubtedly when Julian's pupil reactions changed.

'That is a very black and white transition that he went through.'

And, in this setting, a dilated pupil always means 'very high pressure in the skull and so that prompted me to get another scan.'

OK.

Bless him. He's not had the easiest of rides, has he?

He's not, no.

There's a concept known as coning, which is where the brain swells and swells and has got nowhere else to go so pressure goes down toward the brainstem, which is the most important part of the brain, relating to you being aware and conscious and breathing.

So, if you press enough on that, then ultimately the patient will die.

The dark shading on Julian's scan confirms the swelling to his brain has reached a critical level.

We're going to theatre one.

Yes.

There's a very, very fine line between a brain that's just managing and one that doesn't manage at all and he's fallen off a precipice, really, in terms of his brain's ability to manage what was going on up there.

Time is absolutely critical here.

We need to reduce the pressure in his skull.

I mean, I'm ready to go.

I'll go and get somebody to come and collect.

To reduce the pressure, the only option left is an emergency operation called a craniectomy.

Decompressive craniectomy is actually as simple as removing a fairly large plate of bone, which allows the injured brain to swell out the way rather than pushing in on the healthy areas of brains.

The operation won't reverse the stroke, but it might stop further damage to Julian's brain, and it may save his life.

In London, just 24 hours after his cardiac arrest, police officer David is also in theatre, having urgent heart surgery.

Consultant cardiothoracic surgeon Wael Awad is about to tackle the dangerous blockage in David's coronary artery.

What we have to do is restore the blood flow to that area of the heart, which is in jeopardy and to do that, we have to bypass blood beyond the blockage.

OK, starting.

Wael needs to take an artery from David's chest wall and sew it past the blockage, creating a new path for blood to feed his heart muscle.

Table up, please.

Table up?

But, as the operation begins, David's heart suddenly deteriorates.

'His blood pressure dropped, his heart is beginning to struggle' by the added stress of the general anaesthetic and the opening of the chest.

Full dose?

Yeah.

At this point, I decided to do the operation by stopping the heart.

Yeah, we will be going on bypass, please.

OK.

Pericardium coming up.

The team connect David's heart vessels to a cardiopulmonary bypass pump...

Give one litre of cardioplegia, please.

.. which will circulate oxygenated blood around his body.

Happy?

Yes?

Now Wael can begin work on David's blocked artery.

This is delicate surgery.

The arteries are very small and I think that one does have to be a good technician to be able to do this well.

We're harvesting an artery from the inside of the chest wall and stitching that to his coronary artery.

The arteries Wael needs to stitch together are just two millimetres wide.

It's looking quite good at the moment.

Once the stitching is complete, Wael needs to take David off the heart-lung machine and get his heart b*ating again.

Ventilate, please.

Ventilating normally?

Yes, good ventilation.

Potassium and gases normal?

Yep.

Off bypass, please.

As soon as the blood flow to the heart is restored, the heart should work on its own.

Yeah, it's working now.

'We see that the heart, first of all, is b*ating spontaneously' and the ECG is normal and the blood pressure is stable.

In that corner, please.

The team will now monitor David closely as he recovers in intensive care.

In Newcastle, doctors have one last chance to save Julian's life.

Ready, steady, slide.

OK. OK, right shoulder.

Specialist neurosurgeon Shuaibu Dambatta is about to remove a large section of Julian's skull to ease the pressure on his brain.

This is Julian's scan of his brain.

This part of the brain is darker and this is the part that has had the stroke.

This area there is supposed to be right in the middle, so this line should be going through here, and you can see that the middle of his brain has been shifted by about more than a centimetre to the other side and so the operation we're planning to do is going to be taking this bone out as much as possible, so that, instead of this brain swelling to push the normal brain and causes more damage on the side that doesn't have the stroke, it can now push upward and swell upward because there's no bone there so the skin is softer and it can just distend it.

First, Shuaibu marks out where he's going to cut.

A centimetre too far could cause catastrophic bleeding.

There are certain areas within the skull or just underneath the skull where you have big blood vessels within the brain and we have to make sure that we don't damage those areas.

It's a balance between trying to take as much bone as possible and also knowing the limit of how far you can go.

OK, everyone nearly there?

Yes.

Happy starting?

OK.

Every minute the swelling continues, it risks damaging the unaffected areas of Julian's brain, so Shuaibu needs to act quickly.

It's difficult to say exactly how much time we've got because, if those brain cells are not dead but they've been stunned, as in shocked... if you act quickly enough, you might be able to revive them but, really, time is of the essence and every minute counts.

OK, so I'll make another hole.

Painstakingly, Shuaibu cuts around the section of the skull that needs to be removed.

OK.

So the recommendation is to take about 13 by 6 millimetres, minimum, and we've got about at least 16 centimetres here.

'It's probably the most amount of skull I've had to take in doing this type of operation.'

We've got about... 11.5 centimetres across, yeah?

I can tell that Julian's brain is damaged by its appearance, because it didn't look normal.

However, even though it looked damaged, I can't tell if there's still a part of that brain or there are some cells within that brain that are still alive.

And my aim, really, is to provide Julian's brain, even though it looked dead, with all the support it needs, as if it were alive in the hope that there might be a part of that brain which may survive and that part may have some use to Julian in the future.

.. and come back next time.

Without the skull to protect it, Julian's brain is open to infection.

Shuaibu uses a special collagen membrane to cover it.

OK. Let's get ready to start closing, please.

Now the skin will be closed up without the skull underneath.

Get an artery, please. Let me just have an artery.

I think that is all.

We've written on that, "No bone flap."

That means that the nurses and whoever is looking after him know that he hasn't got a bone there and directly under his skin is his brain, so that means you don't press it and, if they lie on that side, they don't lie directly on the brain, so that's why we've put that sign there.

A scan shows how much Julian's brain has swelled beyond the confines of his skull.

Shuaibu's operation has done its job.

We haven't allowed the pressure inside his head to raise to a level where it had caused him to lose his life.

On the longer term, he will need another operation to reconstruct that skull and that also carries its own risk, which is why we have to balance the risk of having the operation against the risk of not doing anything at all.

Julian will stay in intensive care and be kept unconscious until the swelling of his brain has stopped.

Only time will tell what recovery he'll make.

You don't believe it's happened.

You hear of people who don't come round from that, don't come back from that.

I think, for David, the most significant thing that saved his life was that he was in the presence of his colleagues who recognised he was in cardiac arrest and they did immediate chest compressions and phoned 999.

I look at my life. Obviously, I've got my second chance.

At the moment, I'm actually doing a minimum of 30 minutes' walk a day, five days a week.

Once a week, I'm going up to the cardio rehab at the hospital.

No pain or anything. Hardly out of breath.

I feel I can achieve anything, I can do anything.

You know, it's... I possibly can't but up here I'm thinking, "Yep, it's given me a new lease of life."

It could have been such a totally different story that day.

He was able to receive the treatment that he did so quickly.

A split second and it'd be a different story.

'He was a very lucky man.'

It looks like a mole.

One thing that I had to learn after the collision, after the accident, was actually just the sheer power of time in terms of how your body recovers and what it will do in that recovery period.

If the Ambulance Service had got to him two or three minutes later, pulled him out and done exactly the same thing, his brain would have been hypoxic for two or three more minutes and his outcome would have been very different.

It's almost overwhelming... and I consider myself to be lucky in how I got away with things.

The effect of the stroke in Julian's case is, because it's the right side of his brain that is affected, he's got a weakness on the left side of his body.

It is challenging and frustrating that you cannot say to Julian that, "Two years down the line, you might be able to lift your arm again."

But, at the same time, you don't lose hope.

I'm absolutely amazed by, when you're fit and well and able-bodied, how much you take for granted.

You don't assume that standing is going to be particularly difficult.

The first time I could stand, it felt like a great achievement.

Lovely. Well done.

Julian's incredibly strong and very, very determined.

He's got a very good positive mental attitude.

Good, Julian. Well done.

One of the goals I've set is I want to be able to walk before I leave here.

That's something we've been working on in physiotherapy today -- standing and taking a step.

Where my head's...

Where there's no skull, there's very little protection, so I run the risk, if I banged my head again, it could be very, very serious cos I've got no bone.

Ultimately, Julian will need to come back and have a plate put back on and that operation itself isn't without some degree of risk.

Obviously, it's been a very difficult time for my family, but I'm of the opinion that far worse things happen to other people.

Next time, we follow three more patients through the crucial first hour of care.

In Bristol, a woman suffers a life-threatening brain injury after being hit by a car...

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

Just get her on the ambulance then and go from there.

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

Which bit of you is hurting?

All of me.

All of you.

.. and, in central London, a collision leaves a young woman with a severe head injury.

So you give her nasal oxygen.