01x01 - At the Scene

[bunniefuu]

[sirens wailing]


[dispatcher] Emergency ambulance,


-what's the address?-[woman] We need help.


[narrator] The momentan emergency call is made,


a battle against time begins.


-[dispatcher] And is she awake?-[man] No, she looks dead.


-[patient groaning]-[indistinct radio chatter]


The decisions that are made


in the first minutesfor major trauma patients


will make the differencebetween life and death.


If we can intervenewithin the first minutes or so,


the so-called "golden hour,"


then we know we can positively affectyour outcome.


[narrator] The sooner a doctorcan reach their patient,


the more likely they are to survive.


We now have the ability to reversethe initial effects of the injury


if we are given the chanceand we are able to act quickly enough.


[narrator] In their raceagainst the clock,


doctors and paramedicsare now taking the hospital


-to those at the very edge of life.-[siren wailing]


[doctor] We're pretty close.They can bring it if we need it.


[patient groans]


The more equipment and expertiseand knowledge we can get out


onto the street or scene of the accident,then we will save more people's lives.


[narrator] Armed with new treatmentsand equipment...


[doctor] I'll get the AutoPulse readyand we'll get him on.


[narrator] ...they're performing surgeryon the roadside.


I could do the operation in the backof the ambulance, if necessary.


[narrator] Administering powerful dr*gs...


[medic] Draw us two ampoulesof tranexamic acid.


[narrator] ...using innovative techniques.


[doctor] You pull that one,and I'll pull this one.


[narrator] And pushingthe boundaries of science...


[doctor] Okay,let's get the cold fluids going.


[narrator] ...to save timeandto save lives.


[doctor] We've got to go.


[siren wailing]


[narrator] This series will count down,second by second, minute by minute,


the crucial decisions madein the first minutes of emergency care.


One hour,the difference between life and death.


-[sheep bleating]-[birds chirping]


[narrator] Sixty-two million peoplelive in Britain.


Whether at home or at work,


in the city or in the countryside,


today, over of uswill face a life-threatening emergency.


This film will follow three patientsthrough minutes of care


that will push the limitsof scientific innovation.


[siren wailing]


[narrator] In Central London, -year-oldZoe collapses on Oxford Street.


[dispatcher] Is she awake?


[man] No, she's unconscious.She looks dead.


[narrator] A farming accidentin rural Lincolnshire


leaves -year-old Billwith life-threatening injuries.


[doctor] He's been crushedby a -kilogram cow.


[patient groaning]


[narrator] And in North London, -year-old Rumen is hit by a car.


[woman] He flew up in the air.


[narrator] From the moment each oneof these emergency calls is made...


[buzzes]


...the clock starts ticking.


[helicopter blades whirring]


-[woman speaking indistinctly]-[phone ringing]


[dispatcher] Emergency ambulance,what's the emergency?


[woman stuttering]One member of the car accident...


[dispatcher] OK, calm down.


[woman] I think it's twisted in him,I don't know.


[dispatcher] His body looks twisted,does it?


[woman] Yeah.


[narrator] In London,ambulance control receives a call


about a serious road accident.


A specialist paramedic scans thethousands of calls that come in each day,


looking for the most critical emergencies.


[medic] We're quick enoughto listen to a call,


then we can dispatch the teamin less than a minute.


[beeps]


[Steve] Mr Jeffers,we have a job for you.


And you're going to White Hart Lane, N .


And you're going to a -year-old male,car versus pedestrian.


[alarm blares]


[narrator] Paramedic Stevetasks London's Air Ambulance.


This elite medical service can get to anypatient inside the M within minutes.


[MJ] Our helicopter serviceis a dedicated trauma service,


and as such, we only get sent


to the most seriousand severely injured patients.


The co-pilot comes up,he hands me a piece of paper,


it said "pedestrian versus car."


And as soon as I hear that,I immediately start thinking,


what could the potential problems be?


[pilot] Overhead in two minutes.


[dispatcher] Is he breathingat the moment?


[woman] Is he breathing?I can't see.


[dispatcher] OK, that is fine.


[woman] He's lying down now.No, no.


If you're gonna get hit by somethingthat's pretty hard, at speed, potentially,


you know, you will have some injuries.


And my mind starts going throughwhat I could expect when I arrive.


-[officer] Through the gate, left.-[medic] Thank you.


[narrator] Police and a Londonambulance crew are already at the scene.


[MJ] Sorry, guys,give us a bit of space. Sorry.


[officer] Move out of the way.



[MJ] Okay, he looks pretty sick.


Hi, you guys alright?


-[siren wailing]-[people clamouring]


[MJ] Hi, I'm MJ, this is Graham.


-[medic] This is Rumen.-[MJ] Is it Rumen? Hi, Rumen.


[Rumen groans]


[narrator] Within seconds of arriving,


MJ needs to assess Rumenfor life-threatening injuries.


I'm gonna have a quick primary survey,if that's alright.


[Rumen groans]


-[medic] He's years old.-[Graham] Alright.


He's been bull's-eyedby that car over there.


I'm just gonna havea quick look at you, sir.


-Is it Rumen? Is that sore? Okay.-[Rumen groaning]


Rumen had lots of injuries to his faceand he was lying awkwardly,


half-way on the roadand half-way on the pavement.


So, all of these things are cluesthat already gets my mind going.


-Sorry, Rumen.-[man] Come again?


-[MJ] Say again?-[Rumen] My back side.


-[medic ] Your back side.-[medic ] So, back side.


-Is your tummy sore?-Now, try and stay nice and still.


-Rumen, try and stay nice and still.-Is that sore?


When I press, is that painful?


-[Graham] We're getting a loved one now.-[medic] Ninety-seven, .


[MJ] Yeah. Can you squeeze my hand,Rumen?


Squeeze my hand.


Okay, I want to have a quick lookat your face and teeth.


-[Graham] / , blood pressure.-[MJ] Okay, alright. Okay.


[MJ] And then bilateral ankles.


It's most likely that Rumen's legstook the initial impact,


right direct forcethat really broke the two legs.


Um, then the next impactwas on the bonnet,


where I think probably his ribsstarted hitting that.


And then the windscreen,


which was most likely his arms,possibly his head.


I could see, just by getting close to him,


that he had lots and lots of cutson his arms and on his face.


It was quite evident.


And then, also, just being flungover the top of the car


made me concerned about spinal injuries,


um, and further injuries to his ribs,rib cage and his abdomen.


[medic] Can you feel the doctortouching your foot?


-[medic] Brilliant.-[MJ] Good.


[police officer] We're just gettinga loved one now.


Okay, guys, I think what we haveis someone with a minor head injury,


possible fractured ribs,possible pelvis, possible abdomen,


-definite bi-lateral tib-fib fractures.-[Rumen groans]


[medic] You're okay Rumen, okay.Good man.


[MJ] I was concernedthat there is possible bleeding,


possibly in his abdomen,possible in his pelvis.


So in my mind, there is a good chancethat he might deteriorate.


-[MJ] Can you feel me touching?-[medic] Can you feel your feet?


[narrator] MJ must decidewhich of Rumen's injuries to treat first.


[MJ] The fact that Rumencan't feel his feet,


it could show that he's gota potential spinal fracture.


But it could also show that there might bea lack of blood supply to his lower legs.


If you leave it too long,there's always a risk


that, uh, he could lose his legs.


[MJ] So, we'll need to straighten these.


[MJ] It was clear that both his legswere badly, badly fractured.


[MJ] ...ankle, before we cover it up.


[narrator] MJ is concernedabout all of Rumen's injuries


but decides to prioritize his legs.


-[Rumen groans]-It's okay.


[MJ] Just by putting itin the correct position,


you can actually improvea lot of the blood supply


and prevent long-term damage.


[medic] We have to pull it,


get it back into line,cover it the best we can.


[narrator] The paramedic crewcan administer pain K*llers like morphine,


and have already given Rumenten milligrams, but it's not enough.


[MJ] Any movementwould cause absolute agony to him.


He definitely needed good pain killersjust to anatomically realign his feet.


[narrator] Because MJ is a doctor,she can give pain relief such as ketamine,


more powerful than morphine.


Everything's fine.You're very, very safe. Okay?


-[Rumen groans]-[MJ] Alright, Rumen.


I don't want to put someonein a helicopter


if I'm not percent surethey are stable


and they're in the bestpossible condition.


[Rumen groans]


Is that his family over there?Are you family?


-[MJ] He's okay.-[man interpreting]


Problems [sobs]


[MJ] Is he your husband?


-[man] Yes, yes.-[MJ] Okay. He broke his legs.


-[man interpreting]-[MJ] He broke both his legs.


[MJ] We are gonna dosome more medicine on him...


[man interpreting]


[MJ] ...to make him niceand without pain, alright?


[medic] One, two, three, roll.


[narrator] Having straightenedRumen's legs,


MJ turns her attention to his abdomen


and the possibilityof major internal bleeding.


[MJ] We'll just gently slide it in.Okay, everyone ready?


[Rumen groans]


You're doing really well, Rumen.You're okay.


Rumen needs to get to hospital,


and we have to rememberthat the clock is ticking.


[Rumen groaning]



[intense music playing]


[dispatcher] Emergency ambulance,what's the address of the emergency?


[narrator] Eight minutes ago,another emergency call was made


on one of London's busiestshopping streets.


A young woman called Zoe has collapsed.


[man] It's Oxford Street.We think we've got somebody having a fit.


Think she's had a heart att*ck,yeah, could you go down there quick?


-[dispatcher] And is she awake?-[man] No, she's unconscious.


-[dispatcher] Is she breathing?-[man] No.


[dispatcher] I've got three unitson their way, keep an eye out.


make sure there's someone thereto flag them down.


It might be one of our bicycle responderscoming to you, on the pedal bike, okay?


[man] Be really quick.


[dispatcher] Yeah, they'renot too far away.


[narrator] A cycle-mounted paramedicarrives on the scene.


[Eoin] She was, uh, motionless.


[clicks tongue] Um, she was, uh, pale.


Um, her eyes were opened.


Um, and she was receiving CPR,


um, with an absence of a pulse.


[Eoin] I yelled at people initiallyjust to move on


because this is a very undignified placeto have a cardiac arrest.


But is there any dignity in death?


[dispatcher] Just to let you know,I've got no other info,


apart from the fact that I do believeit is a cardiac arrest.


-Roger, uh, that's all copied.-[ambulance siren wailing]


[dispatcher speaking indistinctly]


[narrator] Across the city,


the call has also triggeredLondon's only response car


specializing in cardiac arrest.


It delivers lifesaving medical equipment,dr*gs, and expertise.


It is very rare, not just within the UK,but around the world,


to have a team that really is just focusedon cardiac arrest.


We should be absolutely head onfor Oxford Street now.


[honks]


Basically, the heart has stoppedfunctioning, for whatever reason.


Either it's not b*ating at all


or it's trying to b*at


and it just can't eject the bloodout of the... the ventricles.


And of course, for the rest of the body,that's a catastrophe,


because the rest of the bodysimply isn't getting the oxygen


and glucose that it needs for life.


[Gareth] Right, set of traffic lightsat the bottom here, straight across again.


-[ambulance siren wailing]-[car horn honking]


[Gareth] Although we're goingon blue lights and sirens,


you know for every minute or few secondsat a junction you're delayed,


there is literally brain tissuethat could be paying the price,


and ultimately, a patient may either beseverely disabled because of that,


or may not live.


Uh, we're estimatingabout, uh, two minutes now.


[dispatcher speaking indistinctly]


That's Oxford Street ahead of us.


[narrator] After battling throughthe traffic, Gareth arrives on scene.


-Where's the patient?-Oh, just there.


-[honks]-[siren stops]


[medic] Hello, mate, cheers. Thanks.


[men speaking indistinctly]


[narrator] After CPRand an electric shock,


paramedics have restarted Zoe's heart,


but her pulse is weakand it could stop again at any moment.


-[machine beeping]-[ventilator buzzing]


[Eoin] She just collapsed.


She's probably hadabout ten minutes of CPR.


Uh, we checked the pulsesafter about ten minutes.


-[Gareth] Okay, good.-She had a... she had a pulse.


-Okay. Okay.-She's got a good respiratory rate.


They've managed to restart the heartand there is some activity now.


I was always worried that she would gointo cardiac arrest again.


Whatever had precipitated itbefore we got there


was an ever present risk.


-She looks very young, doesn't she?-Yeah.


I noticed she had an engagement ring onand a wedding ring on.


Um, and I think that is...


hard not to bea little bit emotional about that.


You realize someone's got a life,


so, she's got a husbandor recently... recently married.


-And this is her blood pressure, isn't it?-[Nick] Yeah, just taken that.


When I saw she was so young,your mind goes into a bit of a spin.


What's actually caused this?


Most patients that we go toin cardiac arrest


are at least in their middle agesor elderly.


[narrator] But Zoe is not respondingin the way she should,


and is still in terrible danger.


[Gareth] It would be greatif she'd just simply woken up


the minute her heart started.


But we're in a different situation now.She wasn't waking up at all.


Pupils are big, aren't they?


[Gareth] When I looked into her eyes,


her pupils were massively dilatedand fixed.


Um, just like you see in dead people.


It was obvious that she had sustainedsome brain damage.


And that is the shocker.That's what's worrying me at that point.


[narrator] Minutes after a cardiac arrest,


brain cells begin to diefrom lack of oxygen.


Yeah, that'd be brave.


[narrator] The sooner Garethstarts treating her, the better.


He must act now, or Zoe may sufferirreparable brain damage.


[indistinct radio chatter]


[narrator] Outside an urban centrelike London,


the challenges of delivering medical carein the first critical hour



are even greater.


A hundred and fifty miles away,


a specialist trauma team are en routeto a remote farm in Lincolnshire.


Thirty-three minutes ago,


a call came in about an injured farmerfighting for his life.


As the nearest major trauma centreis over an hour's drive away,


the helicopter is his only hope.


[monitor beeping]


Hi, guys, my name's Dr Topham.


[narrator] A local ambulance crewis already on scene,


but Bill now needsthe interventions of a doctor.


-[medic] Bill, -year-old male.-[Topham] Yes.


-[medic ] Today, Bill's been crushed.-[medic ] Relax, Bill.


-[medic ] ...against a wall from a cow.[Topham] Yeah.


-Not lost any consciousness at all.-Okay.


-He's made his way to here.-Yeah.


He was crushed a bit further away.


When we arrived,he was conscious and breathing.


We cannulated, he's got equal air entry.


He's complaining of pain,right side abdomen.


Okay.


And around the lower right of his chest.


[Topham] Hi, Bill.Hi, it's Dr Topham here.


I'm one of the doctorswith the Air Ambulance.


-Okay?-[Bill groans]


It sounds like you're havingan interesting day.


[groans]


I think there was every chance


that this could have proveda life-threatening injury.


Um, or at the very least,a life-changing injury.


How are you feelingwith your breathing just now?


[Bill] Not too bad.


[Topham] There's noparticular difficulty


-in breathing just at the moment?-No.


Okay.


[narrator] Bill's already hadten milligrams of morphine,


but he's still in severe pain,and Simon needs to work out why.


I'm just gonna have a little feelround this tummy now, okay?


You just let me knowif it's too uncomfortable.


-[Bill groans]-Where's that?


How heavy was the cow?I know it's hard to estimate.


-Was it a big one? Baby one?-[woman] About kilos.


-Alright.-Six-fifty kilos.


-[Bill groans]-Right.


[Topham] This is, uh,a significant beast.


Um, kilograms,


well, that's probably about sevenor eight fairly standard humans


squashing one personagainst, uh, a concrete wall.


[Topham] What does that feel like?


-[Bill groans]-Okay.


[narrator] But Bill's symptomsare causing Simon some confusion.


[Bill groans]


Is it aorta, is it liver, is it spleen?


My concern, given the mechanism of injury,


was that he was going to havesome internal organ damage in hisabdomen.


I expected to see that his blood pressurewas dropping due to blood loss,


and I expected to seethat his heart rate was increasing


as his heart tried to compensatefor the, uh... the loss of blood.


But those things weren't there.


But my gut feeling still


was that there was something going onin the abdomen.


Having had the morphine,and this degree of pain,


it didn't seem right to thinkthere was nothing happening there.


[narrator] Simon doesn't knowexactly how Bill was crushed by the cow,


or which part of his body is injured.


Where's that hurting you?


[Topham] What does thatfeel like down there?


He could bleed to death.


He might only have a small ruptureto a liver or an internal organ,


but basically, you know, it might bea trickle, it could burst at any moment.


You just don't know,you haven't got X-ray eyes.


Pain's still ten out of ten.


[narrator] If Bill has internal bleeding,


they need to try and stem the blood lossbefore they put him on the helicopter.


There was a degree of conflictgoing on at the scene


between a need to get himto the trauma centre,


but the need to ensure


that he wasn't going to deterioratebefore he got there.


[Bill groaning]


[MJ] No, get him onto the scoop.


[narrator] In London,


MJ and the paramedicshave straightened Rumen's broken legs


in the hope of restoring blood flow.


She now has to thinkabout getting him to hospital.


But given the forceof Rumen's impact with the car,


she's worried about moving him.


Everybody bleedsonce you've been hit by something,


and you start forming blood clotsto stop that bleeding.


If I don't care for him in a careful wayand I disturb his clot...


We always say the first clotis the best clot.


Um, then there is always a chanceof him bleeding more.


-Three.-[monitor beeping]


Four.


Five.


Just flash it for us.


Squeeze that in, concentrate,don't look anywhere else.


Sorry, it's very important.


Rocuronium.


[narrator] Any sudden physical movementcould dislodge Rumen's clots.


MJ decides to give hima drug called rocuronium.



It will paralyze all the musclesin his body,


including those in his chest.


[MJ] The effect of a druglike rocuronium


is that it stopsthe intercostal muscles working,


it stops the diaphragm working,he will stop breathing.


/ .


[narrator] Over the next seconds,


Rumen will become unableto breathe for himself.


So this bag just makes the dr*gs kick in.


It takes a bit of time,it takes about seconds.


[medic] Everything's good, sats, .


-[MJ] Excellent.-[medic] Pulse, .


You have to remember not to rush.


I always try and tell the paramedics,"It's medicine, not magic."


It's about seconds.


That seconds or secondsyou have to wait


can feel like an eternity,


when all you're thinking aboutis momentum, momentum, momentum.


[monitor beeping]


[MJ] Okay, let's feel how his jaw feels.


It feels good.


[narrator] MJ now only has seconds to act.


Through a procedurecalled "rapid sequence intubation,"


she will insert a tubeinto Rumen's windpipe


and start breathing for him.


[MJ] See, epiglottis...


It's still quite a scary procedureto perform,


especially next to the roadside,in someone who's bleeding,


who potentially has blood in their airway,who has got a high risk of vomiting.


Yep. So, put your handsover my hands, here. Perfect.


It is risky.


Anything that can go wronghas gone wrong at some point.


Everybody concentrate here now.


Anything as bad as death, brain damage,


someone's blood pressurecompletely dropping.


You've got your windpiperunning essentially from your mouth


all the way down into your lungs,


but right behind it is the food pipe,


which goes from your mouth again,but straight into your stomach.


You don't want to putthe breathing tube in that


'cause no air will go into the lung.


[medic] Okay, bilge is on, tube's on.


What we want to seeis when we squeeze air into the lung,


that the little monitor that we haveat the end of the breathing circuit


turns from purple to yellow.


That's the indication that carbon dioxideis coming out of the lungs


and we are in the right place.


-Yellow.-Perfect.


Okay, lovely.You're doing an excellent job.


Can I have one of the paramedicslisten to his chest?


-[MJ] Great job.-Okay, air entry.


[narrator] Rumen is now intubated,paralyzed and sedated.


With suspected multiple internal injuries,


MJ has done all she can for himat the roadside.


Excellent job, guys.


So next, we're gonna get the blocks,we're gonna put the blocks on,


tape, collar back on,


and then we're going to trolley pushto the aircraft.


[indistinct radio chatter]


[narrator] In the heartof London's West End,


-year-old Zoe is still unconscious.


[Gareth] Okay,let's get the cold fluids going


and see if we can pre-oxygenate heras much as we can.


[narrator] Gareth is worried that Zoe'sbrain is suffering irreparable damage.


I knew I needed to act,uh, and I needed to act fast


by infusing some cold fluidsto try and drop the brain temperature,


which actually stops some of the reallydeleterious effects of oxygen starvation,


which startto literally eat into the brain


in the ensuing hoursand days after a cardiac arrest.


The cooling actually stops those processesand protects the brain


from it literally sort of digesting itselffrom within.


[narrator] Evidence suggeststhe sooner Zoe is cooled,


the slower her brain cells will dieand the less brain damage she will suffer.


Gareth wants to bringher core body temperature down


from a normal degrees to degrees,


putting her into a state of hypothermia.


Have we got a saturation on?


Once that fluid gets into Zoe's body,eventually it gets to the brain,


and it's the brainthat's the most important bit.


The cells of the brainstart to lower their temperature,


and as that temperature falls,


they need less oxygen,they need less glucose.


[narrator] Zoe's metabolismwill slow down,


reducing the speedat which her brain cells die.


Pioneered in London,


this pre-hospital cooling is only offeredby a handful of services in Britain.


Most patients in the world,most patients in the UK,


don't have that cooling processinitiated in the pre-hospital phase.


They have to waituntil their heart is stable,


they have to be transportedto the hospital.


So this is quite innovative,to have that cooling process started


literally as close to the pointof cardiac arrest as Zoe's was.


[Gareth] An extensive pulse rate,it's a good sign.


Every one degree dropin Zoe's temperature


will slow the processof brain cells dying.


But as her temperature drops,


there is a riskthat she will start to shiver.


[Gareth] I knew I had to stopthe patient's body from shivering


because that muscle activityis what keeps the temperature up,


and we're trying to lower the temperature.



So, by giving herthe dr*gs of the anaesthetic,


we stop her shivering,


and that means all of our cold fluidswill have a maximum effect.


[narrator] Whilst under anaesthetic,


Zoe will be paralyzed,blocking her shivering reflex.


This will also stop herbreathing by herself.


Gareth needs to insert a tubeinto her windpipe to breathe for her.


[Gareth] It's a balance of risk,


and I felt that doing thiswas far more in her interests,


compared to the risks of her brain damage.


If we can't pass the tubethrough her mouth and into her lungs,


that could ultimately be fatal for her.


-[machine beeps]-Okay.


If we could just get readywith the suction.


-[machine buzzing]-Okay, tube please.


Right. Two seconds, mate.


Hold on, it's just stuck there. Right.


[Bill groaning]


Bill? Bill?


[indistinct chatter]


-[medic] Okay. Big one.-Bill?


Hello there, you were away therefor a minute. Now then.


[narrator] In Lincolnshire,


Simon is concerned that Bill could beharbouring life-threatening injuries.


Okay, right.


Just a bit worried that you've crushedone of your internal organs


and you may be bleeding,


so we're gonna tryand give you some medication


which will help protect that.


[narrator] Bill could bleed to deathbefore he gets to hospital,


so Simon decidesto give him a clotting drug.


[Roger] Can you draw uptwo ampoules of tranexamic acid?


-[medic] Yeah, no worries. In here?-In a ml syringe.


[Roger] We did give hima drug called TXA, or tranexamic acid.


Initially, it was used for heavymenstrual bleeding and in child birth.


And basically, it's a drug that makes...It sort of binds the clots together.


[Topham] Okay, Bill, thisis the painkiller that's gonna go in now,


you might feel a bit strange.


[Roger] Just gonna give ten milligrams,okay, just starting now.


[Roger] So when someone is actually...stops bleeding from a clot,


the tranexamic acidactually stops that clot breaking down,


so hopefully reducing bleeding


and making the patient sort of stabilizeprior to getting to A and E.


-[monitor beeping]-Thirty-nine.


[narrator] Since ,


this drug is being introducedto all Britain's roadside trauma teams.


Simon now hopes it will buy himenough time to get Bill to hospital.


I'm just gonna havea little feel round here.


Can you just give me another scorefor your pain out of ten?


If ten's the worst you've ever known.


-[Bill] Yeah, nine.-Nine or ten, okay.


I think we have to give yousomething stronger


for the pain to try and help with that.


When I arrived, he'd already hadten milligrams of morphine,


which for most people of his age and size,should give very good pain control,


yet he was still in pain.


[groans]


Okay, so we're talking minutesand he's still got a nine out of ten.


-[medic] You want the morphine?-No, we're gonna give him some ketamine.


[narrator] Bill's pain levelsare still worryingly high


and might cause him to strugglewhen they try to move him.


[Bill groaning]


[narrator] Pre-hospital trauma teamsnow have access to ketamine,


a drug that until a few years ago,outside London,


was only given on arrival at hospital.


[Roger] Want to check that for me?I've got four ml.


-Yes.-To milligrams.


Yes, yep.


It's a horse tranquilizer,it's a very strong drug,


uh, but I think it has been usedby vets for many years.


[Roger] It is quite strong stuff,but his pain scale's like a nine or a ten.


He's had morphine,it's not really subsiding.


This is the best stuff that he can have.


[narrator] Simon hopes the ketaminewill sedate Bill enough


to keep him still on the journeyto hospital,


reducing the risk that he will disturbvital clots inside his body.


[Roger] I'll start offwith ten milligrams over one minute...


and then two-minute.


[Topham] Just keep givinga bit more at a time.


[Roger] Gonna give ten milligrams,okay, I'm just starting now.


[Topham] The medicine we're goingto give you can make you feel strange.


Make you see things, okay?


-Bill?-[groans]


-Can you hear me, Bill?-[groans]


Bill? What is it that's bothering you?


Just relax the left armfor a minute, just relax.


-[groans]-[Topham] It's difficult to know


whether that's the emergenceof the ketamine


-or he's actually in pain.-[Roger] Bill, where's the pain, Bill?


It's really a great drugfor what we need it to do


but it dissociates the patientfrom their environment.


And frequently, you see peoplehaving hallucinations.


They can also appear to still be in pain,


um, probably because of that dissociation.


Give him more tranexamicand then we'll get him on the...


Yeah.


It's whether he's gonna beadequately analgesed for shifting,


but we need to get him moved,really, don't we?


[Bill groaning] Help me.


[narrator] Simon can't tellwhether Bill's reaction



is just the effect of the ketamineor due to organ damage.


He decides to take one last precaution.


[medic] He's had milligrams.


[medic ] Try not to moveyour head, Bill.


[Bill groans]


[Simon] What we're gonna do is we'regoing to put a splinter round your pelvis.


It's just like a very wide band,a very wide belt,


and that will support your pelvisin case there's any bleeding in there.


[Topham] You happy with that, buddy?


[Roger] Alright, Bill,you're gonna feel this get tight


round your pelvic area, alright?


[Topham] The whole pointof putting on a pelvic binder


is to stabilize the pelvisif there is a fracture within it.


Um, and by stabilizing it,reduce blood loss further,


but also, so that we know he's going to bephysically stable through the journey.


Nine forty-five.


[narrator] Out here,there's nothing more Simon can do.


Only a CT scan will revealthe full extent of Bill's injuries.


Back in North London,MJ has fully anaesthetized Rumen.


Only now does she decidehe's stable enough


to be transferredto a major trauma centre.


[phone ringing]


When you stand in resus,there's a moment where that phone rings,


it makes a very distinct noise.


[phone ringing]


-[rings]-[nurse] Hello, Royal London.


Hello, we're bringing inan adult male patient.


[MJ] Pedestrian versus car.


[Johann] It just goes a little bit quieterfor a few seconds


and people tend to look to the phoneand to the person writing down the notes.


He has been RSI'd.


[MJ] He's a potential polytrauma,


and our ETA with you guysis about minutes.


-Good to go.-[woman speaking indistinctly]


[Johann] It was obvious from MJ's callthat Rumen was badly injured


and this could still get worse.


[woman keying]


[narrator] On Oxford Street,Gareth is taking over Zoe's breathing.


Big breaths, that's good.So yes, for yellow, we're good. Right.


In the trachea, that's fine.


-Happy? Feels good, your side?-[Nick] Yep.


Okay, let's just... two seconds.Slowly, slowly, slowly.


Well done.


-Are you okay to do that tie?-[medic] Yeah.


You're a star.


Okay, that's great,so we can control her ventilation,


it's in normal parameters now.


She's well and truly oxygenated.


Just do it again.


-[air hissing]-[monitor beeping]


Okay, that's good air entry, both sides.


-You can slow that down a bit. Right.-[medic] Yeah.


[narrator] Paralyzed and unable to shiver,Zoe's body temperature finally drops.


Bless her.


Okay, right, okay. We've got a control.


[narrator] Her brain is protectedand she's getting enough oxygen.


After minutes of roadside treatment,


Gareth decides Zoe is stable enoughto travel to hospital.


-How long do you reckon it'll take us?-About six, we've got police escort.


-Good, brilliant. Six minutes.-They've stopped the road for us.


It's a lady,approximately to years of age,


who's had a sudden collapseon Oxford Street.


[Gareth] Well, the bottom line is, uh,she looks pretty pink.


-[Nick] She does, doesn't she?-Yeah.


[siren wailing]


[Gareth] I felt the next pressurewas really to take Zoe


to the most appropriate hospital.


[narrator] Zoe is en routeto St Mary's Hospital,


where she will be kept in an induced coma


to try and let her bodyand brain recuperate.


Only time will tell what kind of recovery,if any, she will make.


I can't do any more,this is all medicine can do for Zoe now.


It's Mother Nature needs to do the rest.


[siren wailing]


[indistinct chatter]


-[Roger] One, two, three, lift.-[Bill groans]


[medic] Alright, sweetheart.


-[Bill groans]-[medic] Well done, Bill.


-[Bill groaning]-[Topham] On our way with the patient.


If aircraft's prepared for us, buddy,we'll be there in a couple of minutes.


[Bill groans]


-[Bill groans]-Straight in, mate. Ta, yeah.


[Bill groans]


[Topham] One, two, three, lift.


[phone ringing]


[rings]


He's a -year-old gentlemanwho's been crushed by a -kilogramcow,


uh, between the cow and a concrete wall.


Um, he's sustainedblunt abdominal trauma.


[medic] Can you ring uswhen you've landed?


Okay, thank you. See you shortly. Bye.


Okay, cheers, bye-bye.


Can we ring him when we've landed?


Crushed by a cow.


[siren wailing]


[narrator] For the last minutes,


doctors and paramedics have fought tokeep three critically injured patients alive.


[pilot] Airborne from the scenewith the patient.


[narrator] For Zoe, Rumen and Bill,


the decisions madein this first hour of care



have given thema greater chance of survival.


But the fight is not over.


Now, new hospital teamswill race against the clock


to uncover the full extentof their injuries.


The discoveries they makeand the decisions they take


will determinewhether each of them lives or dies.


-[radio beeping]-[indistinct chatter over radio]


-[Bill groans]-[Roger] Okay.


[narrator] In Nottingham,trauma surgeon Adam Brooks is standingby


to try and find the causeof Bill's extreme pain.


This is, uh, Bill,he's a -year-old gentleman


who was crushed by a -kilogram cowbetween the cow and a concrete wall.


[Adam] When Bill came,he had a significant amount of pain


in his abdomen, predominantly,


especially as he'd had quitea lot of pain relief,


morphine and ketamine,two very powerful dr*gs,


to try and, um, help him with his pain.


What it suggested to mewas there was some pathology,


there was some issue going on,an injury in his abdomen.


[Topham] Right, he started off withfive milligrams of morphine by the crew,


-which didn't give him relief.-Okay, right.


It was still ten out of ten,so we've given him ketamine,


-titrated in ten-milligram.-[doctor] Okay.


-So he's had a total of .-[doctor] Fifty.


[doctor] Isabelle?


[doctor] Open your eyes for me, Bill.


[Adam] Very early on, I make the callthat he needs to get a CT scan.


[narrator] In Nottingham,


the trauma team aims to get patientsscanned within minutes of arrival


to diagnose injuriesas quickly as possible.


Shall we just do a quick check-upbefore we leave for a CT?


Anaesthetics, you are happywith your airway?


-[doctor] Do you need any dr*gs?-[medic] Yes.


[groans]


[Bill groaning]


Okay, injection starting.


[beeps]


[Adam] CT scanning does give usthe opportunity within minutes


of gettinga complete picture of the injuries.


[groans]


[narrator] Adam is looking for signsof internal bleeding


but the answers aren't immediatelyapparent on the CT scan.


It's always a concernwhen the investigations we have


and the clinical picture don't marry up,


as they just don't seem to fit together.


And that sets us outon more of a detective story.


What is the issue here?What are we missing?


[radio beeping]


[pilot] Base, airbornefrom the scene with the patient.


The time . and we'll be on the roofin about two minutes.


[indistinct chatter]


[narrator] MJ is preparingto hand over severely injured Rumen


to the trauma teamat the Royal London Hospital.


There was a chance that he could still diein our department seconds after arriving.


So there's a degree of anticipation,


and you think, anything can still happen.


[Johann] Patient's here.


Everybody keep quiet.


Can we hand over the airwayand then get the hand over?


[MJ] Okay, guys, this is Rumen,we think he's in his 's,


he was a pedestrian hit by a car.


Bull's-eyed the windscreen,completely cracked it,


was found on the opposite side of the car,


half-way on the pavement,half-way on the road.


They didn't see the scene,they didn't see the car,


they didn't see the windscreen,they didn't see the bump.


They didn't see how Rumen lookedwhen I arrived.


Injuries top to toewith multiple facial lacerations.


No boggy swelling,pupils equal and reactive.


[Johann] The handover from MJ is crucial.


In those few seconds,she gives us a picture,


a little snapshot of the preceding hour.


He's not had any fluid with usand he's got bilateral cannulas.


Brilliant, thank you very much.


That handover defines what we doin the next few minutes.


Stephen, on your count, we'll move him.


-[Stephen] Yeah, okay.-[scanner beeps]


[Johann] Having just flown in a chopper,the paramedics and the doctors


have just hada very emotional, involved experience.


And it's good then for a second personto come back


and look at everything that they've done.


-[beeps]-[indistinct chatter]


And sometimes a fresh pair of eyes...


can see smaller things nowin the brighter light of resus,


that they may have not picked uppre-hospitally.


[medic] Five, four, three, two, one.


[narrator] Because Rumenwas anaesthetized at the roadside


and delivered in a stable condition,


he's ready for any operationalintervention that Johann thinks he needs.


[Johann] Can we have three peopleon each side?


We're gonna move him acrossonto the centre of the trolley,


And then take the scoop out.


Three people on the patient's right,scoop on the left to come out first.


[Johann] I was primarily concerned that hemay still be bleeding from somewhere.


He had bad injuries to his legs


and possibly to his pelvisand his abdomen.


So, we were worried that there may besomething going on inside him


that we haven't discovered yet.


We wanted to make sure he was stable,


and get him into the CT scanneras soon as possible,



to see if there's anything else going oninside that we can't see from the outside.


[medic] Okay, pupils are two millimetres,equal and non-reactive.


[narrator] But before they can get himto the CT scan,


Johann is concerned about Rumen's legs.


Intubation.


He'd obviously fracturedboth his lower legs,


and we were worried that the bloodwas not getting into his feet.


If the pulses were not there,that means that he may lose his feet.


No surgical emphysema.


Equal chest wall movement, bilaterally.


-Anything?-He's got a pulse on the left.


Okay.So he's got pulses in his left ankle.


He's got bilateral pulses present.


[narrator] After a few worrying seconds,


the team find a stable pulsein both of Rumen's legs


and can now focuson his suspected pelvic injuries.


Alright, folks, everybody just listen up.As a summary, our primary survey is okay.


He's obviously badly injured.


We're gonna take him now for a CT,head down to pelvis.


[indistinct chatter]


On slideready, steady, slide.


Nicely done.


[Johann] The whole hospitalhas been designed


around the emergency department,around resus.


The CT scanner is right next to him.


All the equipment that we needhas been designed to be right there,


right next to him,available whenever necessary.


The team itself,they all know where to go.


Alright.


[computer]Breathe in and hold your breath.


-[phone ringing]-[Johann] His pelvis looks okay.


Alright, let's get him off.


[Johann] His injuries,especially the ones we are worried about,


are not there, especiallythe life-threatening ones are not there.


I think Rumen can consider himselflucky to be alive.


And after Rumen left the emergencydepartment, he went to intensive care.


And the primary concern thenwas with his legs,


to make sure that they can repair themto a point where he can walk again.


If MJ hadn't put his feet backinto a straight position pre-hospitally,


they would have been without bloodor nerve supply


for a prolonged period of time.


I think it would definitely have madehis chance of walking a lot less.


[narrator] In Nottingham,


Adam is still trying to work outthe root cause of Bill's pain.


[Adam] Always look at the patient,


listen to the patient,examine the patient,


and that really, you know, has got to be,have primacy in your decision making.


So, his pain was out of proportionand then we had nothing on the scan,


and that didn't sit comfortably.


[groaning]


[Adam] Alright, let me haveanother look at your scan.


I think for anybody involved in medicine,and certainly major trauma,


to get the balance between, you know,new technologies, your instinct,


your experience,is actually quite difficult.


It makes you suspiciousthere's something happening


and we've just not yet spotted iton the CT scan.


The new scanners are very accurate,but we still miss things on them,


such as injury to the small bowel.


You don't see free air all the time,injuries to the pancreas.


Even on the new scanners,you don't necessarily pick that up early.


So nothing's definitive,nothing in medicine is percent.


-I think he's perf'd somewhere.-[Bill groaning]


[monitor beeping]


[Adam] I think there's somethinggoing on here, there's some fluid here.


[narrator] After radiologistsexamine the scan in more detail,


they alert Adam to a potential injury.


When I went back and looked at the scan,


I saw a little bit of subtle fluidunderneath the liver,


and that's fluid that shouldn't be there.


And also where he was markedly tender.


[narrator] Adam thinks he's finallydetected the cause of Bill's extreme pain.


[indistinct chatter]


[Bill groaning]


[Adam] If he's been trapped,two things happen,


one of which is, he's going to squashan organ against the bones,


split it and make it bleed.


The other is, you increase the pressurein the bowel where the air is,


and you'll get a blowout somewhere.


And at the moment,my money is on the latter,


that we'll find he's got a small bowelor duodenal perforation.


[narrator] A ruptured bowelcan lead to blood poisoning.


Hey. Are you okay?


How's your pain?


Have you still got pain in your tummy?


-Yeah?-[Bill] Not too bad, not too bad.


Not too bad.


[Bill] What's happening?


I think that you've gota little bit of fluid in your tummy


and maybe a little loop of bowelhas popped and leaked some fluid out.


And that's why you've gotquite so much pain there.


It looks like it's squashedagainst your lower ribs


-in your upper part of your tummy.-Yup.


[Adam] And the pain,there's fluid where it shouldn't be


-on the CT scan.-Yeah.


[Adam] That's probablywhat's causing that pain.


-It's quite sore in your tummy, isn't it?-Painful.


-Painful.-[groans]


I think what we need to dois pop to the operating room


and have a look inside, okay?


-[Bill] My wife?-Yes?



-[Bill] My wife.-We'll let your wife know, don't worry.


Okay, mate. Okay, don't worry.


We were best off doing an operation,have a look inside, look at the injuries,


um, as the ultimate investigation.


Um, but also, it gives us an opportunityto, uh, treat any injuries that we find.


-Can we start?-[medic] Yes, please do, thank you.


[monitor beeping]


[narrator] Bill is takento the operating theatre for surgery.


You want to force me?Where are we gonna start?


What we do is look round the wholeof the abdomen,


we look at all the organs internally,in a sequential fashion,


looking for injuries.


I can't see anything at the moment.


-Have you spied anything yet?-[medic] No.


[Adam] Good, small bowel, lots of it.


His bowel was fine,which was good, that was a relief.


If it had been the bowel leaking,


then that would need,um, more extensive work,


to make sure it was repairedand didn't leak again.


But he had some ongoing bleeding.


It's around his liver, we'll look at that.It's not bleeding much by our standards.


Colon, bit of fluid.


[narrator] Having discounteda bowel injury,


Adam continues to checkall Bill's major organs for bleeding.


Oh, look, here's his liver injury.


So, he's just got a little liver injury,which is bleeding.


Uh, there's a little bridge there,he's torn.


That'll stop.


He had some ongoing bleedingfrom a fairly subtle liver injury,


right at the back of his liver,


um, tucked awaynear one of the big blood vessels.


So, although thisis a pretty small liver injury,


by the scale of things,it's actively bleeding,


it's under my finger there.


So exactly what he's done,he's been squashed at the front


and where his liveroverlies his spinal column,


he's got a couple of little tearsin his liver, and they've caused his pain.


So, Mark, I'm gonna put stitchesand things around the liver.


Good, okay, we're, uh...We're gonna close and get out of here.


-Mark, are you happy?-[Mark] Yeah. All good.


-The team are just gonna close, okay?-[Mark] Okay.


[birds chirping]


[Bill] I kept going through my mind."Am I dead? Is this the end or not?"


I wouldn't wish it on no one,but they did good.


Marvellous, what they did for me.Else, I shouldn't be here today.


[groans]


-[medic] Want the rest of the morphine?-No, we're gonna give him some ketamine.


Bill did very well,he's made a full recovery.


And I think a lot of that


is because we madethe right decisions at the right time.


In that first golden hour,in the first minutes of his care,


we made the right decisions.


-[Bill groans]-[Topham] Right, Bill. Bill?


[Bill groaning]


[exhales]


Yeah, I thought I was dying, to be honest.


I didn't want to leave anybody behind.Just, it's not easy.


-[medic] This is Rumen.-[MJ] Is it Rumen? Hi, Rumen.


[Johann] Rumen's injuries to his legswere quite devastating.


And it's gonna take months, if not years,of intensive physiotherapy.


Learning how to walk again,learning how to live with his injuries.


Where it hit me,


it tossed me in the air.


I was in intensive carefor about three or four days.


I am grateful for this.


To the Royal London for bringing meback to life.


I'm grateful to the doctorswho saved me.


Yellow, we're good, right.


[Gareth] Simple fact is that most patientsdon't survive a cardiac arrest,


perhaps less than ten percent,


and some of those that do surviveare blighted by brain damage.


[nurse] What I'm gonna dois pop stickers on,


just to monitor your heartwhile I'm checking.


[Zoe] My husband's told methat he was holding my hand.


And, um, as I startedto come round he said,


"If you love me, squeeze my hand."


And I squeezed his hand, and, um...


Sorry.


He said, um...


"Squeeze it tighter. If you love me,squeeze my hand really tight."


And so I squeezed it really tight,and they knew then that I was in there.


[narrator] Zoe's cardiac arrestwas caused by a rare heart condition.


Doctors hope they can prevent another.


[nurse] And the good thingis your device is wireless, so...


-Yeah.-Yup.


[Zoe] I've had an ICD fitted,


an ImplantableCardiovascular Defibrillator.


So, if my heart needs to be paced,


it will kick in and try and pace it outof a rhythm, an arrhythmia.


And if it needsto try and give me a shock,


um, to get my heart working properly,


then it will be ableto administer a shock as well.


I don't know if I expected it to be heavy.


-Yeah.-It feels quite light, actually.


[Gareth] It's the ultimate.


It's taking someone whose lifehas just gone, literally stopped,


and rekindling itthrough some very complex diseases


to a point where she's not just alive,but she's alive like she was.


She hasn't got any disabilities.


She can go on and leada completely normal family life.
[ … ]


That's one thing I really want to know.


Can you skydive if you have an ICD?


-[laughs]-You know what I'm saying?


[indistinct radio chatter]


[siren wailing]


[indistinct phone conversation]


[man] He have a few s*ab wounds.


-[man ] He's been stabbed?-[man] Yes.


[narrator] Next time,


a high-speed road accidentcritically injures Michael.


-[doctor] So is blood running?-Yeah.


[doctor] Okay.


[narrator] And in North London, -year-old Mick collapses.


I must admit, I can't feela cardiac output in this chap.