01x03 - Making the Invisible Visible

[bunniefuu]

[siren wailing]


[dispatcher] Emergency ambulance. What's the address?


-[woman] We need help. -[dispatcher] What's your emergency?


[narrator] The moment an emergency call is made,


a battle against time begins.


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


-[patient groaning] -[clamouring]


The decisions that are made in the first minutes for major trauma patients


will make the difference between life and death.


If we can intervene within the first minutes or so,


the so-called "golden hour,"


then we know we can positively affect your outcome.


[narrator] The sooner a doctor can reach their patient,


the more likely they are to survive.


We now have the ability to reverse the initial effects of the injury,


if we are given the chance and we are able to act quickly enough.


[narrator] In their race against the clock,


doctors and paramedics are 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 groaning]


The more equipment and expertise and knowledge we can get out


onto the street or the scene of the accident,


then we will save more people's lives.


[narrator] Armed with new treatments and equipment...


I'll get the AutoPulse ready and we'll get him on.


[narrator] ...they're performing surgery on the roadside.


I could do the operation in the back of the ambulance if necessary.


[narrator] Administering powerful dr*gs...


[medic] Draw us up two ampoules of tranexamic acid.


[narrator] ...using innovative techniques.


You pull that one, and I'll pull this one.


[narrator] And pushing the boundaries of science...


The REBOA is in. I'll let you know once the balloon is up.


[narrator] ...to save time...


-...and to save lives. -We've got to go.


-[siren wailing] -[narrator] This series will count down


second by second, minute by minute,


the crucial decisions made in the first minutes of emergency care.


[indistinct radio chatter]


[narrator] One hour, the difference between life and death.


-[lambs bleating] -[birds chirping]


[narrator] million people live in Britain.


Whether at home or at work,


in the city or in the countryside,


every hour over of us will face a life threatening emergency.


This film will follow three stories,


through minutes of care,


that will push the limits of scientific innovation.


[siren wailing]


[narrator] In Birmingham, Gudrun collapses in a hotel room.


[woman] She's a -year-old woman. She's had a stroke.


[narrator] In a leafy suburb of London,


tree surgeon Ben falls feet onto the pavement.


He landed more on his side


-than his back? -More on his side.


[man] Don't move him, don't move him.


[medic] Don't move him. Do not move him unless he's in danger.


[narrator] And in Shropshire,


a road accident leaves -year-old Vincent with life threatening injuries.


He's had a head-on collision.


His motorbike is in the hedge there, in numerous pieces.


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


-[buzzes] -...the clock starts ticking.


[dispatcher] We've got a motorcycle


and the cyclist is not responding at the moment.


[narrator] West Midlands Ambulance Control


has just received an emergency call from the police.


There's been a high speed collision between a motorbike


and a car on a remote country lane in Shropshire.


Its location and severity triggers an Air Ambulance,


carrying a trauma team on board.


You're always trying to imagine what the scene might be like.


We knew it was a warm sunny day,


so it might be quite a high speed impact.


It makes you concerned that there may be major injuries


you'll be faced with when you arrive on scene.


[narrator] Local ambulance staff are already treating the patient.


[officer] A motorcyclist,


his motorbike was in the hedge there, in numerous pieces.


[medic] Oh, blimey, Colette!


[officer] We can't find the number plate.


-[Colette] Wow! -[officer] He's then travelled


an additional yards up the road.


[Colette] No, he has travelled!


When we arrived on scene and looked at the severity of the damage to the bike,


it suggested that the mechanism of injury was quite significant.


He'd also travelled a fair distance from his bike.


Hi, Vince, I'm Colette, one of the doctors here.


He was quite sweaty, he was clammy, he looked very ashen in colour,


all of which can suggest signs of shock.


[narrator] Colette is worried that Vincent is going into shock,


meaning the organs and tissues in his body


aren't receiving an adequate supply of blood.


[Colette] He had quite a weak pulse,


which suggested that his blood pressure was on the low side,


and also his heart rate was fast as well, which made us concerned


that there may be an element of internal bleeding.


They were saying, the main pain, a funny sensation in your pelvis and leg,


is that the main issue?



-[Vincent] My hips. -Your hips.


-Is there any pain in your tummy? -I don't know.


You don't know. If I have a quick feel there, is there anything?


-I'm not sure, it just feels funny. -Just feels funny.


[Colette] When I assessed Vincent's leg, there was an obvious open fracture,


so I could see the bones exposed through the skin of Vincent's lower leg.


However, there wasn't a huge amount of blood loss occurring from the wound


and the bones didn't look overly deformed.


[Colette] Vince, I'm just having a feel of your foot, mate.


[Vince] My boots feel ever so tight.


[doctor] Vince, you actually haven't got any boots on,


we've got some splints that are holding it,


because we think you broke your leg. But your foot is very, very pale.


They look a horrible colour. Really pale feet.


[Colette] One of our concerns


was that maybe he wasn't getting blood supply to that right foot.


[narrator] Although concerned about Vincent's foot,


Colette has to deal with any potentially life threatening injuries first.


[Colette] The problem that we face is that you can't see what's going on


within Vincent's body, so although we could anticipate


that there was some internal bleeding,


we had no idea where the source of the bleeding was.


What we might do is just get a splinter on his pelvis.


[narrator] Colette is worried that a fractured pelvis might be causing


massive internal bleeding inside Vincent's body.


[Colette] Pull that one and I'll pull this one.


[man] That's splint they're putting on.


[Colette] That's it. Right.


[narrator] She hopes the splint will keep the pelvis stable,


reducing any internal blood loss.


[Colette] If you can't prevent bleeding,


or you can't keep up with the blood loss, then eventually your patient would die.


I decided that we'd give him some tranexamic acid


and essentially that's a drug that encourages clot formation


if there's a bleeding point that we can't see externally.


[narrator] Having taken steps to control Vincent's internal bleeding,


Colette must now decide whether she has time at the roadside to treat his leg.


Every minute is vital in deciding what interventions you do,


how many interventions you do,


and at what point you decide to package your patient


for transfer to your hospital.


[phone beeping]


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


[man] Hi.I'm on Handy Road.


I've got a guy who was cutting a tree, he's fallen.


He's conscious. He was wearing a helmet...


but he's not in good shape.


[narrator] Ten minutes ago, Ambulance Control in London


received a call about a man who's fallen feet from a tree.


[man] Don't move him. Don't move him.


[dispatcher] Do not move unless he's in danger.


Got a job for you, map reference is , November, Bravo.


Call connect is . and dispatched at . .


[narrator] Falls from heights are the number one cause of death at work.


In London, any fall over feet triggers the despatch of the Air Ambulance.


[Gareth] Patients that fall from a height can do a myriad of injuries.


If they land on their head, obviously that can cause head injuries.


They can damage their chest, they can break ribs,


they can collapse lungs, they can damage their spine,


um, and if they fall from a very high height,


they can damage the pelvis, one of the biggest bones in the body.


[pilot] We're landing in a playing field,


which on the map is just to the south of the scene.


Time is really important, not just in getting them to hospital,


but getting to the scene,


correcting as many of these issues as quickly as possible.


Speed is part of the deal.


I suppose the things I was worried about fall into two groups,


one of which is very difficult: spinal injuries.


-[Gareth pants] Left here. -[doctor] Yeah.


But the others are injuries that may actually k*ll him,


but we know we can treat, that we can save him from,


we can repair him and we can get him back into a normal life.


[Gareth] Just watch safety here, mate.


[narrator] Nineteen minutes after the call,


Gareth arrives in the leafy suburban street.


London Ambulance Service are already treating the tree surgeon.


[Gareth] He was in a position that he'd obviously fallen,


and that's never a good sign,


because the natural reaction when you've fallen is to get up,


dust yourself down and hobble away from the scene.


Yeah.


[medic] He's fallen from there, landed onto his back.


[Gareth] Yeah.


-[medic] He's been in this position since. -[Gareth] Yeah.


-[Gareth] What's his name? -[medic] Getting this harness off.


[medic] What's your first name?


-[Ben] Ben. -[Gareth] Hello, Ben. Can you hear me?


-[Ben] Yes. -[Gareth] My name's Dr Davies.


-[Ben] Yeah. -[Gareth] Hi, mate.


[Gareth] I'm the consultant with the Air Ambulance. Alright?


[Ben] Air Ambulance?


[Gareth] Yeah, the helicopter ambulance, Alright?


You're gonna be fine,


I just need to find out exactly what damage you've done yourself, alright?


[medic] He said the pain is right in his back.


-and he rates it about out of . -Yeah. Okay, alright.


I was worried that he might have broken his back and not been able to move.


[Gareth] Can I ask you to just move your legs?


[Gareth] I wanted to see that he wasn't paralyzed.



-Your arms and legs feel normal, do they? -[Ben] Yeah, yeah, I think so, yeah.


Yeah. Okay, fella.


[narrator] Ben can move his limbs,


meaning there's no damage to his spinal cord,


but Gareth thinks that some of Ben's vertebrae or bones


around his spinal cord could be fractured.


He may also have other injuries to his head and internal organs.


-[Gareth] Your pain, where is it? -[Ben coughs]


-[Ben] Here. -[medic] If you need me to cut, I can cut.


[Gareth] Lower back?


[Gareth] When I looked at Ben, he did look quite unwell.


He looked very pale, he looked very sweaty.


All of those are signs that he might be bleeding and in shock.


Can you just describe how he landed?


He landed on his side, his right side, so sort of his right arm,


his hip and he was sort of covering his head with his right arm.


He landed more on his side, than his back?


More on his side.


The awkward thing is, you can't see that bleeding.


You have to predict it, you have to assess the fall,


look how high he's come, try and examine his pelvis


and look for other signs of bleeding.


[narrator] If Ben is bleeding internally, his life is at risk.


But the full extent of his injuries can't be diagnosed at the roadside.


Gareth needs to move him to a major trauma centre as soon as possible,


but any movement could make Ben's condition worse.


So, where are we near?


Um, N , the London it's going to be.


How long to drive there?


I'd say , but, yeah.


I was really concerned for Ben.


He had symptoms that suggested a fracture of his lower back or his pelvis,


which is often associated with bleeding and has a very high mortality rate.


[narrator] Having treated Vincent for suspected internal bleeding,


Colette turns her attention to the open wound on his leg.


[Colette] It's very common that an open fracture


can cause compression of the blood vessels


and therefore prevent blood flow to the lower leg.


I was quite confident that that could be a possible source


for the paleness and the mottled colour of his foot.


[narrator] If left for too long without blood,


the muscles will die and the limb may not survive.


Before treating his leg,


Colette decides to give Vincent an analgesic, or pain k*ller.


-[Vince groans] -[Colette] Vince,


one of your feet's gone a funny colour.


-We're gonna give you... -[Vince] Do it.


[Colette] We're gonna give you something to relax you


-and then we're gonna pull it. -[Vince] Do it.


One of the things that you can do is try and straighten the bones,


which not only helps with analgesia, it helps with blood loss,


but it also would regain blood flow to the lower limb.


It can be a very painful procedure, so I administered some ketamine,


which not only is an analgesic in its own right,


it's also a sedative medication.


-You might have to give me a heave ho. -[doctor] Alright, okay.


[Colette] Ben, it's just some pulling, mate.


It didn't do anything.


[Colette sighs]


[paramedics speaking indistinctly]


[Colette] Unfortunately, it didn't have the desired effect


and there wasn't much dislocation of the fractured bones really.


-[doctor] Strange, isn't it? -[Colette] Yeah.


I think that's as good as it's going to get. Yeah.


[sighs] It's just still oozing.


[Colette] So again, it makes you think is there something going on


within his body that's preventing blood flow to his lower limbs?


-[Colette] How are you doing there, Vince? -Oh, I just, my legs.


[Colette] Yeah, we're going to sort that out, sweetheart.


[narrator] There's nothing more Colette can do for Vincent at the scene.


[Colette] I think the most difficult decision was deciding when to stop


performing any interventions at the roadside,


because delaying time on scene would delay any further interventions


that he could receive in hospital.


[medic] Vince?


-He wasn't breathing. -Go.


-[line dialling] -[Colette] Right.


[dispatcher] Emergency, which service?"], index , start , end }


[woman] She's a -year-old woman, she's had a stroke.


[dispatcher] Um, is she conscious and breathing?


[woman] I don't know.


[narrator] Thirty-three minutes ago,


a call was made when Gudrun, a holiday-maker from Germany,


collapsed in her hotel room.


She's lost all feeling down the left side of her body


and is having trouble speaking.


She's rushed into the Queen Elizabeth Hospital in Birmingham.


So tell me, how were you feeling when you first woke up this morning?


[Gudrun] This morning, I was okay.


Yes.


There was nothing wrong.


Then suddenly, it was oh, I feel funny.


I want to run through an assessment,


and it allows me to see how your brain is working


-at the moment, is that alright? -Yes.


Can I get you to shut your eyes tightly for me?


-[Gudrun] What? -Shut your eyes really tightly.


Open them really wide.


Give me a really big smile. Show me your teeth. Lovely.


It's really clear to me that she's got a facial droop



and she's not moving the left side of her body,


which is a really good indication that it is probably stroke.


[narrator] A stroke is caused by a lack of oxygen to the brain,


due to a bleed or blockage in the blood vessels.


Rachael begins by assessing Gudrun's reactions.


[beeping]


[doctor] Look that way for me.


The assessment was important, because it showed me


that Gudrun could follow basic commands and that she did understand


what I was saying, because it allowed me to see that her cognition was not damaged,


so she understood what was going on


and it was likely that that part of the brain


wasn't affected from the stroke.


Can you lift this leg up for me?


And hold it there. One, two, three.


[Rachel] When someone's experiencing a stroke,


it's really vital that we get someone to scan,


so we know what's happening, so we can give that treatment


and potentially save the brain cells from dying.


[narrator] During a stroke,


almost million brain cells can die every minute.


So, Rachael needs to establish quickly,


exactly what kind of stroke Gudrun is having.


[Rachel] There are two types of stroke.


There's ischemic stroke, which is basically a clot,


which forms in the blood vessel in the brain,


and there's also a haemorrhagic stroke,


which is when bleeding occurs in the brain.


And they're both treated very differently.


There we go, lovely.


[narrator] Gudrun needs to have a CT scan as fast as possible,


so the team can see what's going on inside her brain.


We're just going to wheel you round for a scan now, okay?


Would someone be able to just give me a hand guiding through?


[doctor] So complaining of lower back pain and right shoulder blade.


[medic] Okay, I'm ready to roll his...


This is a complete set for you.


[narrator] On a quiet residential street in North London,


Gareth and the paramedics are treating Ben,


who has fallen feet from a tree.


...in all four limbs, possible spinal fractures


and rib fractures on the left side.


Ben?


Okay, we're gonna roll you on to a stretcher now. It's a bit cold.


We're gonna give you morphine just to help with this roll, okay.


We need to get Ben moved to hospital and we're not going to do that


if every time we move him, he cries out.


That will delay his transport from the scene.


Right, ready, brace, roll.


-Okay, roll away. -[Ben groans]


-Well done, mate. -Okay, all the way, all the way.


That's the worst bit over with, mate.


-[groans] -[medic] One...


[narrator] As well as back, chest and head injuries,


Gareth also suspects Ben may be bleeding internally from a broken pelvis.


Okay, ready, brace, lift.


[doctor] We're just gonna get you off the road and into the ambulance.


In my mind's eye, I'm inside his pelvis,


and inside his pelvis are lots of broken bones


and around those bones are blood clots.


And I know that every time I move him or roll him,


those bones pull apart or squash together


and those blood clots disappear, and when they disappear, bleeding ensues.


[Ben groans]


[Gareth] Yeah, alright.


[Ben groans]


He's in pain, he's asking for some more analgesic.


What do you want to give?


Just give him midaz and ket, shall we?


-Yes. Do you want to go up to ketamine? -Yeah, yeah.


[Gareth] Alright, matey.


I'm just a little worried that you might have broken your back there,


or you may have a couple of fractured ribs.


Alright? Let's give him that pain relief.


-I'm gonna give you some pain relief. -Okay?


[Gareth] Just give him ten of ketamine to begin with and then...


[siren wailing]


[narrator] In Birmingham,


Gudrun started suffering from a stroke around minutes ago


and is about to have a CT scan.


Stroke consultant Don Sims needs to decide whether her stroke


is being caused by a clot or a bleed inside her brain.


The time pressure in stroke is much more acute


than in many other conditions, even a heart att*ck.


Uh, we know brain tissue is exquisitely sensitive


to losing its blood supply and the damage is happening right from the start.


[narrator] A stroke caused by a clot can be treated effectively


by administering a blood-thinning drug,


but if Gudrun's stroke is being caused by a haemorrhage,


then the drug will intensify the bleeding, which could k*ll her.


[Don] Brain scans really don't diagnose blood clot type of strokes.


The brain scans are really there only to rule out the bleeding type of stroke.


So the diagnosis of stroke is then based on my assessment of the patient.


[narrator] If Gudrun's stroke is being caused by a clot,


then the affected area of her brain may not appear on the CT scan


until several hours after the onset of her stroke.


But if she has a bleed on her brain, it will show up straight away.


[Don] There's absolutely no blood in it at all.


So, it has to be a clot.


Okay. That's fine, we can get her off.



-[medic] Happy to get back to resus? -[Don] Yeah.


Once I'm happy that there's no bleeding on the brain scan,


the priority is to get her straight back to the emergency department


and deliver the clot-busting treatment without any further hesitation.


Steady, smile!


We target ourselves with trying to get the treatment delivered


within half an hour of their arrival to the emergency department.


Gudrun, hello.


My name's Don Sims,


I'm one of the stroke doctors. Can you squeeze my hand for me?


Can you shut your eyes? Can you show me all your teeth?


Hold that one up for me, just keep it up, just keep it up.


That's absolutely fine. Can you do this one at all for me?


-It's more difficult. -It's difficult.


Gudrun, we think that you're having a stroke.


The brain scan doesn't show any bleeding,


so it means it's a small blood clot that's caused the stroke.


Because you're here quickly enough,


what we would like to do is give you the clot-busting treatment,


which breaks down the blood clot.


[narrator] Don has decided to treat Gudrun using a process called thrombolysis.


Through an injection,


the treatment dissolves blood clots using a powerful drug.


Suddenly, there was a treatment,


which actually seemed to be really very effective,


and before thrombolysis, there was really no acute stroke treatment,


so this is all quite new and novel.


[narrator] But to stop the clot doing permanent damage to Gudrun's brain,


it must be given within four and a half hours of the onset of her symptoms.


Alright.


-There is a small risk with it. -Uh-huh.


About two to three percent of people we give it to


have a significant amount of bleeding, that can be in the brain as well.


-Oh. -And then the outcome


is obviously much worse for them.


But the majority of people, overwhelming majority of people,


either get better or it doesn't affect them in any way for good or bad,


they just have the same symptoms that they were going to have anyway.


I would like to be helped.


-Is that okay? -[Gudrun] Yes.


Yeah?


A little fear stays, but I think I will try it.


[Don] I think it's right. Okay. Okay.


It did. Brilliant, thank you. Okay, yeah, just go for it.


[bell rings]


The clot-busting treatment dissolves the protein strands,


it breaks down the mesh of the blood clot, and then your body helps clear the rest.


And so . .


[Don] And then hopefully blood flow


then continues through where the blood clot was.


So what it is, it's one injection and then we give you continuously,


over the next minutes, and then it's all done.


[Rachel] We're gonna be giving you some medications.


We have to make sure we've got lots of access to your veins, okay?


[siren wailing]


[narrator] In Shropshire,


the team are preparing to fly motorcyclist Vincent to hospital.


[doctor] We've tried to realign his lower leg


and his foot was exceptionally pale.


-He had of morphine, of ket. -Okay.


[doctor] Right is the open tib/fib, left is the ankle.


Okay, that's great. The ETA is still the same?


-Say half past. -[medic] Thank you.


See you soon, bye.


[medic] Alright. Vincent, you're ready to go, mate.


I've got some more updated observations on the patient.


[indistinct conversations]


[siren wailing]


[narrator] Over the last hour,


emergency doctors have battled to keep three critically ill patients alive.


[pilot] Base, we're airborne from scene and with patient.


[narrator] For Ben, Vincent and Gudrun,


the crucial decisions made by the frontline medics


in the first hour have given them a greater chance of survival.


But the fight is not over.


As the race continues, hospital clinicians will build on these decisions


and uncover the full extent of their injuries.


The discoveries they make will determine what type of recovery,


if any, they will make.


Some oxygen, okay. Hi, Ron.


-You okay? -Yeah, I'm good.


[narrator] At the Royal London Hospital,


Gareth is about to hand over Ben to the waiting trauma team leader.


The information that we had pre-hospitally


was concerned that he had an unstable spinal injury.


So, we had to make sure that we didn't allow his spine to move at all.


[Gareth] So, this is Ben Brown,


a gentleman in his s that works as a tree surgeon


and has been working on a tree today,


and fallen approximately feet onto concrete.


Witnessed by a colleague, no loss of consciousness.


Has been GCS throughout and has been moving all four limbs.


He's had milligrams of morphine,


milligrams of ketamine and two milligrams of midazolam.


No further interventions.


-Did he fall on his back? -He landed on his left.


On his left side. Okay, thank you.


So can you start the primary survey and find out where it's hurting him?


Very few patients come in


with a big thing stamped on their forehead saying what's wrong with them.



What I was trying to do with Ben is potentially make the invisible visible.


[doctor] I'm gonna have a listen to your breathing.


Which side is it hurting the most on?


-[Ben] Left side. -[doctor] Left side.


Deep breaths in and out.


[medic] Okay, chest X-ray in three, two, one.


[narrator] An X-ray machine above the bed allows Helen


to check for fractures immediately.


[doctor] It's painful on the left side of the chest?


-[Ben] Yeah. -Any pain when I press here?


The other really serious injury that people who've fallen from a height


can sustain is a pelvic fracture,


which can be associated with massive bleeding.


Okay, pelvis X-ray in three, two, one.


Okay, I'm just looking at the chest X-ray.


The chest X-ray and the pelvic X-ray are important things to do,


because if they are abnormal,


they tell us what we're dealing with early on.


-[doctor] It looks okay. -Yeah, and the chest.


[clicking]


[Helen] Chest and pelvic X-rays look pretty normal.


[Helen] I was surprised about that.


He was complaining of pain in his lower back when he took a deep breath in,


but if they're normal, it doesn't necessarily rule out,


um, a serious underlying injury.


Hello, my name's Helen, I'm another one of the doctors.


[Ben] Hiya.


Okay. Is your pain getting better?


[Ben] I wouldn't say it's getting better.


[narrator] The X-ray won't give a complete picture of Ben's injuries,


as it does not pick up enough fine detail.


Pain X-rays are not very good at showing soft tissue injuries.


They're good at showing bone injuries, but not the internal bleeding.


[Helen] Whereabouts in your back, Ben?


[Ben] Lower left-hand side.


What, at this level where my hand is?


-[Ben] No, right down. -Bit lower?


-Down here? -[Ben] Yeah, right in there.


So, you've got pain in your back about that, about there?


[Ben] On that level, further round.


-[Ben] It's very painful. -Further, behind there, yeah, okay.


Can you feel me touching your feet like this?


[Ben] Yeah.


-And this side? -[Ben] Yeah.


Your toes are wiggling.


-[Ben] Are they? -That's a good sign.


[Helen] We'll go through to CT, so can you request head...?


-Neck. -Neck.


-Whole spine. -Whole spine.


Pelvis, okay?


[Helen] Well, it looks OK, but I think we need to get the whole spine.


[Helen] There is a sense that you need to think quickly.


Things need to happen quickly.


[narrator] Eighty-one minutes after his call,


Vincent arrives at the Queen Elizabeth Hospital.


[Colette] This is Vince, he's .


He's been involved in a motorcycle accident.


Tummy's tender, pelvis was tender.


He's got an open tib/fib on the right.


I've tried to reduce it,


because it's looking very pale and pulse is, we just couldn't,


it looked quite straight and I just couldn't do anything with that.


He's been GCS on arrival.


[doctor] BP?


[Colette] BP has been, last one was over .


So, treatment wise, he's had of ketamine?


-He's had of ketamine. - of fluid?


He had of morphine with the crew. He's had a gram of tranexamic acid.


ml of normal saline and of an....


Let's cr*ck on with the primary survey then.


[narrator] Vincent is suffering from internal bleeding


and a severe leg injury.


Trauma lead Jitender must decide which to treat first.


[medic] I've got questions, are you allergic to anything you know of?


He was driving the bike at a very high speed and had a big crash.


And the pre-hospital team did tell us that there was major damage


to the car and Vincent's bike.


So, you do start to imagine that he must have multi-system injuries.


-[medic] What's your first name, sir? -Vincent.


[medic] Vincent, okay. Do you prefer to be called Vincent or Vince?


-Vince. -Vince.


[Jitender] When you see his observations,


you look at his colour and you think, "Yes, he's...


There is some sort of major blood loss happening inside his body."


-[medic] We've got fluids going. -If he's got a decent blood pressure,


this is the time to go quickly to CT and come back.


[medic] Are we going to do a scan of his belly?


We can do it fast, if needed.


What I want you to do is look at the feet quickly,


make sure we don't need to manipulate before you go to CT.


It looks a bit pale.


[narrator] Jitender urgently needs to find the source of Vincent's internal bleeding.


But he also wants to do everything he can to try and save Vincent's leg.


[doctor] Fluid's in.


-And you can't feel anything on here? -[Vincent] Nothing.


But this side also, he's got no pulses in his foot.


[Jitender] Yeah.


We are suspecting he may have an injury


to one of the major arteries of his leg,


because we couldn't feel the pulses in his foot.



[narrator] Jitender is worried that the damaged arteries


in Vincent's pelvis could be stopping the blood flow to his leg.


Time is the important factor, it's management of any polytrauma patient,


especially patients like Vincent, who have a multi-system involvement.


What we are historically told that,


what kills first, what kills second, what kills third.


So, the first clinical decision was to see


if we can get him to CT as soon as possible.


Can we get ready for CT, then?


[medic] His breathing pattern has slightly altered.


It's just becoming slightly altered where he's doing very deep.


[Vincent groans]


[narrator] But just before they can move him, Vincent crashes.


His blood pressure drops dangerously low.


-[monitor beeping rapidly] -[indistinct chatter]


[narrator] Vincent is bleeding to death.


And the team only have minutes to try and keep him alive.


[Jitender] Because we're not going to the scanner now,


we need to get his BP stabilized.


Can we put the rapid infuser on to the grey cannula, please?


He's got airway flow.


It's quite hypotensive,


so we have to get him stabilized before we go anywhere.


[narrator] Seventy-seven-year-old Gudrun is in the midst of a stroke.


She's been given a ground-breaking emergency procedure,


which doctors hope will stop the stroke


by breaking down the blood clot in her brain.


How are you feeling now?


-Okay. -Good.


I could see you moving your arm, can I get you to lift both your arms up?


-Yes, I can, this is all this. -Yeah, look at that, that's wonderful.


Oh, look at that. Fantastic.


Brilliant. [chuckles]


And bring your hands back to me. Can you squeeze my hands now?


-Yeah, I can squeeze it now! [chuckles] -You can squeeze. [chuckles]


-It's working again. -That's brilliant. It's working.


Yeah. [chuckles]


-This leg is going up. -My word!


[chuckles]


-I would like to try to walk now. -You want to walk?


-I couldn't walk. -Not yet, not yet.


We have to keep you on the bed because of the drug we're giving.


We want to make sure that you have all of it first.


[giggles]


But that's pretty impressive, that's brilliant, well done.


I'm so glad.


[sighs]


I'm happy.


I hope it will last.


I hope it won't come back.


[Don] The stroke that Gudrun is having is a stroke where she's quite fluctuant


and even though she's got slightly better, when I'm seeing her,


I know that she could easily slip all the way back again without much warning.


-If she gets worse, give me a call. -Okay, sir, yeah.


Good, thank you.


The way that she's fluctuating


is the likely location of where the stroke is,


it's likely to be in a particular part of the brain


where we commonly see paralysis of one side of the body,


and people do often have these fluctuations.


Perhaps we've dissolved the clot partially,


and there's still some clot there, or it's moved slightly downstream,


allowing a little bit of blood flow, but still causing problems.


[narrator] Motorcyclist Vincent


has suffered a sudden catastrophic haemorrhage.


The team still don't know exactly where his internal bleeding is coming from


and they haven't been able to find a pulse in his leg.


They are now fighting to keep him alive.


The head of trauma medicine, Professor Porter, is called down to resus.


As you continue to lose blood, your blood pressure falls,


you don't deliver effectively oxygen to the vital organs, including the brain.


So, you will lose consciousness.


Your heart can't pump effectively,


'cause there's no blood left in the circulation.


Your kidneys can't make urine.


And it very much is a short pause before that patient is going to die.


-[medic] Are you okay there, sir? -I feel like I'm bleeding in my belly.


Vincent did actually say, "I feel like I'm bleeding inside."


That's something I've heard before,


and I've also heard patients say, "I feel I'm dying."


And again, that's quite often seen in someone


who's actually very actively bleeding and getting progressively shocked.


It's almost a feeling of impending death or impending doom.


-What's GCS we've seen? ... -[Jitender] GCS has been .


It went to because he had ketamine.


-So he's got a big C problem, yeah. -We medically examined him.


[narrator] Vincent needs to be stabilized before he can be moved.


The team begin a rapid blood transfusion to try and control the haemorrhage


before the source of the bleeding can be fixed in surgery.


[medic] We'll start the blood.


[indistinct chatter]


His radial is slightly better.


His BP is a bit decent now, but we'll see if it holds on.


[narrator] The blood transfusion has improved Vincent's blood pressure,


but Professor Porter is now worried about his breathing.


As the patient deteriorates, his level of consciousness


will become compromised,


he is then at risk of obstructing his airway,


or indeed of potentially vomiting


and there's no protection to stop the vomit going into a lung, his lungs.



And therefore, one has to do a sort of risk benefit analysis


between continuing to manage him without intubation


or to actually intubate him and secure his airway.


We need to get you to the CT scanner, so we can scan all your injuries.


-[Vincent] Okay. -Now, the safest way for us to do this,


is to give you an anaesthetic and put you off to sleep.


[Vincent]


[narrator] Doctors are now controlling Vincent's breathing


to ensure he gets a steady supply of oxygen.


The team have bought just enough time


to get Vincent scanned and rushed into surgery.


[narrator] At the Royal London Hospital,


Helen is looking at the results of Ben's CT scan.


[Helen] He did have four consecutive vertebral fractures in his lower back.


They weren't unstable, so they weren't, [stammers]


he wasn't in danger of damaging his cord


as a consequence of them, but really painful.


[narrator] Ben has multiple fractures of his vertebrae


ribs and pelvis and severely bruised lungs.


But Helen suspects there may be other hidden injuries.


Something wasn't quite right, I couldn't quite believe


that this could have happened without any damage to the head.


I think what's crucial is that if something doesn't fit,


you need to have the courage and the confidence and the back-up


to look into it and not constantly be rushed on


and rushed onto the next thing.


If something doesn't fit, there's a reason it doesn't fit.


[Helen] Just requiring morphine for pain.


I kept asking Ben whether he could remember what had happened,


because I wanted to get some idea about whether or not he had a head injury.


How far did you fall?


I'd say probably between... more than feet...


[Helen] Obviously, falling from feet onto concrete,


if you've hit your head, you'd expect there to be some sign,


either a bruise or some bleeding. But we couldn't see any.


So, I wasn't quite certain of the story, not certain enough to make,


take the decision not to do a CT of his head, which I'm glad I did.


[Ben] My colleague James was up in that tree.


[coughs, clears throat]


[narrator] It's been minutes since Rachael checked how Gudrun's stroke


is responding to the thrombolysis treatment.


Are you all right there, my darling? How are you feeling now?


I'm worrying about my arm


because it doesn't move.


It... Now it's not your fault that it's not quite working again, okay.


This sometimes happens.


So shall we have a look, can we lift this arm again now?


Do you think we can try?


-So, the movement's gone again, hasn't it? -Yes.


We were starting to see fluctuation in her symptoms,


in her stroke symptoms. Unfortunately, this is quite common.


Can you squeeze my hand?


No, okay.


Don't worry, don't worry.


Yeah, it's a bit frustrating, isn't it? A bit frustrating.


All right, my darling.


It's got worse and then it started to improve again,


so there's a lot of fluctuation.


[Don] There are two main reasons why a clot-busting drug may not work.


One is it does dissolve the clot,


but the brain has already suffered enough damage that the stroke still occurs.


The other reason is that the clot may be just too big


for the clot-busting treatment to dissolve.


CT are free and ready and they're getting the dr*gs ready for CTA,


-I've spoke to them. -It's what we need to do.


[Don] We're just gonna take you down for another scan, all right.


[narrator] Don decides to order a more sophisticated CTA scan,


which combines the CT scan image with a contrast dye,


to try and highlight the actual clot in Gudrun's brain.


What we're looking for is, are the blood vessels


all filling with dye, apart from in one area


where the blood clot is stopping the dye.


In theory, we could have done this scan with dye at the first stage,


but that would have added or minutes to her scan time,


and we didn't want to take that long.


[narrator] If the dye can reveal the location of the clot,


there's one last emergency surgical procedure Don can try.


It's actually about going in and physically removing the clot


that's causing the stroke,


that's done through a small cut at the top of the leg


and feeding a catheter up to the brain to try and snag it and take it out.


[narrator] But the results are inconclusive.


Don still can't see the clot.


There's nothing big and obvious clot-wise. Even in any of the small vessels.


There isn't a clot visible any longer, which means that it's probably dissolved


by the clot-busting treatment, or it may just be too small to see.


[indistinct chatter]


[Don] Nothing retrievable on CTA, nothing that you can pull out,


so complete the lysis, as we have done,


and then she can go up to the stroke ward, continue conventional stroke unit care.


[narrator] There's nothing more Don can do.


Gudrun is admitted to the stroke ward whilst they wait to see


what kind of recovery she will make.


-Get some rest, okay. All right. -Thank you.


Hmm. Pleasure. Pleasure.


Okay? Just get some rest, sweetie.


-[beeps] -[narrator] At The Royal London Hospital,


Helen and her team are waiting


for the radiologist's report of Ben's CT scan.


-He's got a... -What have you got?



He's got a skull fracture.


-Do the neurosurgeons need to see him? -Yeah.


[Helen] Injuries to the brain itself,


I would say, are the most dangerous, and they have long-term consequences.


So although they may...


They're less likely to k*ll you very quickly


than a burst lung or severe haemorrhage,


it's possible to live with a really nasty brain injury for a very long time,


but that life may not really be worth living.


We've got some unexpected findings.


Here.


[radiologist] If you look at that, that is one side to the other.


They said it's on the left side.


So, they're talking about this, aren't they?


[radiologist] Yes, they are talking about that.


[Helen] The CT has been reported of showing fractures


through the petrous temporal bone.


And close to the vertebral foramen.


The fracture line through the base of the skull,


ran very close to one of the holes in the skull


where some quite important blood vessels travel.


[narrator] Ben has fractured his skull.


The question now is whether this has caused any damage


to the nerves in his brain.


-It almost looks like one globule. -Yeah, exactly.


But...


-Have you looked in his left ear? -[doctor] No.


[Helen] Right, okay, there you go.


Ben, can you hear me?


So, we've got the results of the scan back and they think that you might have


a fracture of your skull just down here.


Is it sore when I touch there?


-Yeah, there. -There. It is painful?


Yeah.


Okay, I won't push too hard then.


We're going to have to look in your ear and I also want you to do...


It's weird, 'cause the hearing's bad in the left ear.


Since the accident?


-Yeah. -Okay.


[Helen] It started to ring alarm bells for me,


because it could indicate that there was damage to one of the nerves


leading to the brain, that's a supply, was responsible for hearing.


And there are other nerves that supply our other senses,


so, sight and smell and taste.


Okay, can you screw your eyes up tightly for me and stop me opening them.


Good. And now does anything smell funny?


[sniffs] No, I don't think so.


[Helen] We've given you some water, haven't we?


-Yeah, a little bit. -[Helen] And did it...


[Helen] This sounds like a really stupid question, but did it taste like water?


-[Helen] It didn't have any funny... -I didn't notice it tasting.


[Helen] Not weird? Okay, good.


I'm just gonna have a quick look in your ear.


Don't move your head.


I just want to make sure that there's no blood behind your ear drum


or something like that.


No, that's fine.


The hearing may not be great because the nerves


that supply your ear and help you to hear are running near where this fracture is.


Um, so, it explains why your hearing is a bit disturbed.


It doesn't mean to say it's always going to be.


[narrator] It's unclear what long-term effects the damage to Ben's head


will have on his hearing.


[narrator] After a CT scan has revealed multiple fractures,


Vincent is about to undergo surgery to fix the bleed in his pelvis.


[Malcolm] An injured patient lying on a trolley with drips going in.


The smell of the road and the smell of blood,


hmm, it's never very,


it's never a very uplifting scenario,


and your heart goes out to the poor chap who's injured,


because they're in for a hard time.


[Malcolm] Okay, right, there you go.


Right, could we have the fence, please?


[Malcolm] You always know in a trauma situation,


that your access to the vessels is going to be more difficult.


It's like going into a dark room and you can get nasty surprises.


[narrator] Malcolm is exploring the blood vessels in Vincent's abdomen


to find the precise location of the bleed in his pelvis.


[Malcolm] We need more room down below, don't we?


[Malcolm] You've got to rapidly find a bit of normal vessel


that you can recognize and then go along the vessel and find the point of injury.


[Malcolm] Let's have a long clamp and a tie.


I can't quite make that out.


If there's a and a or something would be good.


Oh there it is, there it is, hurray, got it. Hurray!


[narrator] Malcolm's found the source of Vincent's bleeding.


[Malcolm] We've got a vein hole,


which I'm trying to define, so I can repair it. It is controlled.


There's some ongoing bleeding from the internal iliac,


which is not so bad.


[medic] , half...


[Malcolm] Give me the scissors again for a minute,


I want to try and get this fluff off and define that hole.


[narrator] For the first time since his accident,


Vincent's internal bleeding is finally under control.


[whirrs]


[narrator] Malcolm must now see if anything can be done about Vincent's leg,


which has been without a pulse for over four hours.


[Malcolm] I'm just going to open his groin and get some flow to his leg.


Forceps please, ordinary length.



[narrator] He starts to explore the main artery


that supplies blood to the leg.


-[whirrs] -[Malcolm] Hmm. Right, again please.


[narrator] But he quickly makes a discovery.


[Malcolm] Hmm, what have we got there?


We found severe, unexpectedly severe arterial disease.


Can I have a scratch, please?


[narrator] Vincent's artery is blocked by fatty deposits.


[Malcolm] There you go.


When you have an accident and you have a severe blunt injury to an artery,


um, a young elastic artery will just recoil and survive


and nothing much will happen.


But if you've got arterial disease, then the arterial lining is detachable.


We found that the internal lining of the artery had come adrift,


and so it had caused blockage down towards the groin.


[narrator] The impact of Vincent's crash on his arteries


has dislodged the fatty material.


[Malcolm] Flush, please. We've got it.


So we had to take out the dissected fatty material from inside of the artery,


to make sure we'd got flow going down to the leg.


[Malcolm] Basically, we've now got it all out now.


His leg's flowing again now, we think.


Ooh!


The leg's flowing now.


It may not be flowing that well,


but there's a pulse down his artery anyway.


[narrator] Time will tell if Vincent's leg will survive being starved of blood


and oxygen for so long.


[indistinct chatter]


[Gudrun] At the moment I am, I know I am not cured,


I have still a lot of problems, physically.


My left side and my arm and my leg


are lame and... [sighs] they don't work.


But, all the other parts of my body are still normal.


[indistinct chattering]


[Don] Gudrun will recover by effectively relearning how to do the tasks


that that part of the brain used to do.


So the damaged tissue is gone,


but that doesn't mean your recovery can't continue.


[Gudrun] Inside, I am still the person I was.


Life is really a gift and we have to be careful with it.


Life is still worth living.


The muscles had swollen up and gone rock hard


and it was obvious that the muscles had gone beyond the point of no return.


You have to take some difficult decisions, um...


saving life comes first, saving limbs comes second.


Things had deteriorated much more rapidly than I'd expected.


We thought we were going as fast as we could, but it wasn't fast enough.


[Ben] To have fallen from that height and not to have sustained


life-changing injuries was, you know, almost not possible.


The scariest bit was being told about my ear, actually,


I think, um, that was that, the deafness in my ear was a permanent fixture.


He did have some potentially nasty injuries


that some people wouldn't have been able to cope with as well as he has.


The fact that he's back in a harness swinging out of trees


is pretty remarkable really.


[whirrs]


Being deaf in one ear compared to being wheelchair bound


or having brain damage is, you know, I think I've got off pretty lightly.