- 'Hello, ambulance service.'
- 'There's a guy just got hit by a bus.
'He was on a bike. He's
been really badly injured.'
From the moment an emergency call
is made, a clock starts ticking.
'Female lying on the road,
struggling to breathe.'
The golden hour is the opportunity
that we have to save the patient.
Deep breaths, George.
The longer the clock ticks, the
increased likelihood there is of death.
In the fight for survival,
time is the enemy.
I'm ventilating fast on purpose.
- Yes. - I'm hoping that heart
rate will pick up any second.
Now, new techniques and technology are
bringing emergency medicine to the roadside...
We can use the infra scanner
to maybe give us a slightly
clearer picture of what's
going on underneath the skull.
.. breaking new ground and treating
patients faster than ever before.
We can now provide emergency surgery,
blood transfusions, anaesthesia,
at the scene of the accident.
- Yep, through the cord.
Tube, please. - Tube on.
We follow three patients through
the crucial first hour of care.
In north London, a man is hit by
a bus and fights for his life.
I'm not happy. I'm just going to
pull the tube back a little bit.
Near Bristol, a rider lies unable to move
after being thrown from his horse.
Can you move your fingers?
- No. - Can you feel me
touching you here? - Yes.
And in St Albans, a tree surgeon
falls feet off a ladder
while cutting branches.
I'm worried about him. We're
a long way from hospital.
He could be bleeding into
his abdomen or his pelvis.
minutes that will
change their lives forever.
You'll constantly be surprised
just what you can bring
back from the jaws of death.
At ambulance control in Waterloo,
an emergency call has just been
received from north London.
He's making noises?
Consultant Gareth Greer
and paramedic Sue Trow
from London's Air Ambulance are
on their way to the incident.
'We know very little, apart from
someone's been hit by a bus.'
It could be an injury
to any part of the body.
It could be that the patient
has multiple injuries.
We're kind of ready for any eventuality.
A London ambulance service
crew are already on scene,
struggling to assess the patient.
Yeah.
Understood.
- See the damage to the bus? He
smashed a light casing. - Yeah.
-year-old Dusan, a fitness instructor,
was walking to the gym
when he was hit by the bus.
When the ambulance arrived,
he was found highly confused.
We're going to look after you.
'If someone's agitated,'
to me, it signifies it's going
to be quite a severe head injury.
Some people appear like they're
drunk through having a head injury
like that, but with the injuries
that he had around his face,
you have to suspect that
he had a bad head injury.
This strange behaviour is a clue
that Dusan's brain is
suffering from the impact.
'The knock on the head has damaged
all of the connections in his brain.
'He is disorientated, he
doesn't know where he is,'
he doesn't know what's happening.
He can't put all of these things together.
We're going to help you.
We're going to help you, all right?
'If there is bleeding in his brain,'
that needs to be sorted very, very quickly
otherwise it could be
catastrophic for him.
What I'm going to do is try him
with a little bit of sedation.
We'll just have a look at his
veins, just to see what...
'We need to get on top of the agitation
'before we can do anything else.'
If you just draw up mls for now.
Gareth gives Dusan Midazolam,
a powerful sedative.
The impact from the bus may have
caused other internal injuries
and he needs to assess him properly.
Yeah, we'll move him up... Once...
Let's just cut the front
of his clothes off first.
Let's start moving him out
because we need to start getting
the tube down, because he's
not ventilating too well.
Dusan is breathing abnormally
and has very low oxygen levels.
To boost them, Gareth gives pure
through a mask and prepares
to take control of his
airway with a breathing tube,
but, for this procedure,
he needs more space.
If the breathing carries on in this
abnormal way, that can result in
increasingly bad brain damage...
very, very quickly over a period
of minutes rather than hours.
This one has just kinked a little bit.
To take over Dusan's breathing,
Gareth must first anaesthetise
him and paralyse his muscles.
OK, guys, so we're going
to do the anaesthetic.
This procedure usually takes place
in a calm operating theatre...
.. but Gareth must act now.
miles away in Bristol,
an ambulance control room has just
received a call about a man involved
in a serious horse-riding accident.
Great Western Air Ambulance
critical care team Dr Greg Cranston
and paramedic John Wood
have been dispatched to a field
just north of the M near Bristol.
We go to a fair number
of riding accidents.
We'll probably go to one
every couple of weeks.
The most common injury that a
patient would sustain from a fall
from a fall from horse would be a
bony-type injury, so a fracture.
They're looking for a -year-old
man who's been thrown at speed
from his horse.
We were told that the
patient had come off,
was conscious but had
difficulty in breathing
and couldn't move his limbs,
so that information
immediately rang alarm bells.
Straight ahead. Horse tripped
on landing. He fell off.
He's got pain in his neck,
he can't move his hands,
he is conscious, he is talking.
Breathing is shallow.
My priorities are to establish the
range of injuries that he has and to
work out if any of those are likely
to be immediately life-threatening.
We just haven't moved him.
- We haven't touched him.
- Excellent.
- Covered him up, that's all we've done.
- Hello, there.
Hello. My name is Dr Cranston, one
of the doctors with the Air Ambulance.
What's your name?
- George. - Hello, George.
Are you in any pain?
My neck hurts quite a bit.
- OK. Can you open your
eyes for me? - Yeah.
Open your eyes. Can you look at me?
You can see me OK. Excellent.
- Can you move your fingers?
- No.
- Can you give me a squeeze
at all here? - No. - OK.
Falling from a horse is a
potentially serious mechanism of
injury and people aren't
generally ready for this fall,
so they often don't have time
in order to manipulate themselves or
control the way in which they land.
'I'm starting to worry already that
this may be a spinal cord injury.'
Can you feel me touching you here?
- Yes. - You're well
tucked in, aren't you?
- Yes. - Can you feel me
touching you here on your chest?
I think a little bit.
- A little bit. Can you feel me
touching you on your hand? - No.
You can break a bone of your
neck and your spinal cord
could be completely intact, and
it's painful and it gets better.
But a spinal cord injury
is a significant injury,
because that's the thing
that can cause you paralysis.
The extent of George's spinal
injury is not yet known.
Greg can't rule out the impact this
might have on his other vital signs.
Don't be scared, OK?
We're going to look after you, all right?
We'll get you sorted bit by bit, slowly,
one bit at a time, and we'll
fly you to hospital. OK?
There's no way that we can tell at
this point how serious that injury
is until he arrives at hospital.
I'm just wondering how
much of this we'll cut off.
Just cut it off so we can see
what's going on down the back. Yeah?
Before they can move George,
Greg needs to check the rest
of his body for injuries.
We're going to cut some
of your clothes off, OK?
We will keep you warm.
It's really important that
we get to assess you fully.
It's almost certainly going to be my neck.
I agree with you. I agree with you,
but there is a danger that you could
have other injuries that we wouldn't
easily know about.
Stay with us, George.
George, take some deep breaths for me.
Big, deep breath.
His breathing is very shallow.
As I ask him to take deep breaths,
it doesn't appear that he
does take any breaths at all.
Deep breaths, George.
He's breathing but it's so shallow
that I'm unable to detect that by
either looking or listening
with my stethoscope.
The spinal cord is a connection
between the brain and the body and,
if you break that connection,
then the muscles of the
body are unable to respond.
My main concern is whether
George will continue to breathe.
He's breathing now, but
will he continue to do that?
Deep breaths, George.
Go on, nice and deep.
Oxygen mask on tight, reservoir
moving with ventilation.
In north London, -year-old
Dusan has been hit by a bus,
suffering a massive head injury,
and he's not breathing properly.
- Baseline blood pressure seen and
monitor set to two minutes. - Check.
Despite Gareth's efforts to
improve Dusan's oxygen levels,
they're still very low,
a sign he may have significant
injury to his lungs.
This could damage other vital organs
and his already injured brain.
'What I'm trying to do is to
take over Dusan's breathing'
so that we have control of the
oxygen levels in his bloodstream.
We're just starting the RSI
now and then we'll be...
A rapid sequence induction will
take over Dusan's breathing,
enabling Gareth to deliver
oxygen down a tube to his lungs.
He is having mls of fentanyl.
Just hold his arm for me.
Thank you.
For this, Gareth must anaesthetise
him and force his muscles to relax.
Fentanyl's in. Ketamine next.
It's essentially giving someone an
anaesthetic, like you would have
if you went in for an operation,
but it's doing it in
an emergency situation,
which is a high-risk procedure.
OK, the jaw is nice and floppy.
OK.
The dr*gs have worked quite quickly,
so we might be able to proceed
relatively quickly with this.
Dusan is now completely paralysed.
Gareth has just minutes to
manoeuvre a breathing tube
through his vocal cords
and into his windpipe.
If you can't get the tube
down into the windpipe,
then the patient won't breathe.
OK, grade one view.
Just won't go through the cord.
- Sue, just pass me the
tube a second. - Hmm-hmm.
Thank you.
Yeah, tube's in.
Just deflate the cuff a minute, Sue.
I'm not happy that's in.
I'm just going to pull the
tube back a little bit...
and it's going to go in again. Nope.
OK.
I can see the tube between the chords.
Can I just borrow your
stethoscope for a minute?
Just to listen to his tummy.
Just hold the tube there for me.
Although Gareth is now in full
control of Dusan's breathing,
his oxygen levels are still low,
suggesting something is
seriously wrong with his lungs.
Air entry.
Pretty grotty.
I'm hoping that heart rate
will pick up any second.
Just keep holding the tube.
'Dusan's heart rate has
gone down catastrophically.'
It's gone down to beats a minute.
This is very, very bad.
If that gets any worse,
he'll be in cardiac arrest and
his heart will effectively stop.
A normal heart rate would be
around beats per minute,
but Dusan's low oxygen levels
are now impacting on his
heart's ability to pump.
Gareth must get as much oxygen
in as quickly as he can.
- I'm ventilating fast
on purpose. - Yeah.
'I want his heart to be able to fill
properly and have enough oxygen to
'allow itself to work properly,'
and I'm hoping his heart will
kick in and come back to normal.
OK, heart rate's come
back up. That's good.
Just give him a little bit more bagging.
Sue, can you pass me some long
suction catheters from the bag?
- Yep.
- Thank you.
So, this is pulmonary oedema.
'Fluid leaks out of the little
blood vessels inside the lungs,
'into the air spaces.'
And then, when you put someone
on the breathing machine,
you see that fluid coming up.
A bloodstained fluid coming
out of the tube suggests
Dusan's lungs have been seriously
damaged by the impact of the bus.
- This is all pulmonary oedema
that you get on the chest. - Is it?
But the scale of his
injuries is still not clear.
Dusan is critically ill and Gareth
must get him to hospital fast.
I just want to have a quick look
at the rest of him and then I'll...
'As well as the possibility
of a really bad head injury,'
Dusan could have bleeding in other areas
that could also k*ll him quickly.
The tummy was distended before.
We'll cut these off in a minute.
Nothing obviously there.
Dusan's stomach is worryingly tight.
This could be caused by internal
bleeding from yet another injury.
We do need to get moving.
Let's start packing up,
getting ready to go.
We need to get him to the
hospital to try and work out
if there are any other injuries
that we can't see at the moment
that could also k*ll
him very, very quickly.
Ready, steady, go.
Are you aware of us taking your boots off?
- No.
- No, OK.
Near Bristol, rider George has
lost all feeling in his body
from the neck down, having
been thrown from his horse
while jumping a hedge.
He's unable to move and his
breathing has become very shallow.
A high-level spinal cord injury
disconnects your brain from
the muscles in your ribcage,
so you can't breathe using those muscles.
There's another nerve, which
takes a different pathway,
and it connects directly to the diaphragm.
So the diaphragm can continue
to assist in breathing,
but you become very tired very quickly
and you can progress to not
being able to breathe at all.
This separate nerve comes out of the
spinal cord, high up in the neck,
and might be the only
thing keeping George alive.
I'll tell you what we'll
do, let's split this,
roll him onto half of it.
George's heart rate is
also worryingly slow,
but this, too, has a dedicated nerve,
as well as special cells that
keep it b*ating on its own.
Our heart has an intrinsic
ability to keep b*ating.
Even if it came out of the body,
it would still keep b*ating
for a short period.
However, it would continue
at a slow rate only.
With his breathing and
heart rate critically low,
it's not clear how long
George can survive.
We're going to roll you
onto your back, OK?
Is that all right?
I'm going to take good
control of your head and neck,
that's going to be my job, OK?
We're going to do everything very slowly.
If anything hurts, just shout out.
I'm listening, OK?
I think the important thing here, guys,
is we do everything very
carefully. Very, very carefully.
There's no rush, OK? We'll
do things carefully.
What we have to be careful is
that we don't worsen the injury,
we don't cause any further
damage to the spinal cord.
Therefore, we have to move
him as carefully as possible.
So, has everyone got appropriate
hands on the position
- and knows where...?
- I've just got his pelvis area, really.
We'll just very slowly go over,
nice and controlled,
straightening him out as we go.
OK. We're doing this slowly. OK?
'We need to get George
into a neutral alignment,'
perfectly aligned, on his back,
with as little movement as
possible to his entire spine.
So, ready, steady, we'll start.
The spinal cord has the
consistency of toothpaste.
It's very delicate.
It can be damaged if the bones
that surround it are broken
and impinge or push onto the spinal cord.
If anyone's got any problems as we go,
just shout out and we'll pause, OK?
We're doing this slowly, OK?
- That came off easily. Good.
- Just keep him coming.
That's it.
- You've got his head, mate?
- I have his head.
How are you doing?
- Is that uncomfortable?
- There.
Where? In your neck?
I'm delighted to say that pins and
needles are now beginning to start.
- Pins and needles?
- They're going down further...
Further down my biceps.
- Down your arms? - Yeah. - OK.
My collar bones are
fantastically sensitive.
'What I think is happening here
'is that his brain is unable
to process or understand
'the information that it's receiving,
'so it tries to fill in the gaps
and imagine what should be there.'
This would probably just be a perception
rather than a genuine sensation.
- Is this pain or is it a funny feeling?
- Pain. Real, real pain.
Pain. And that's pain to your...?
- Neck.
- Neck, OK.
Going down to my collarbone and
round to the top of my shoulders.
Yeah.
Christ, it hurts.
With George's pain now rapidly increasing,
Greg gives him intravenous
morphine to ease his distress.
It's started going in, George, OK?
- So you'll start to feel
some effects of that. - Yeah.
But I don't want to just blast
so much of it in all at once
that you get knocked off, OK?
'Morphine depresses your
brain's drive to breathe'
and that's the last thing we wanted to do.
Lift!
With George's breathing a major concern,
Greg must get him to
hospital as fast as possible.
His son was also riding with
him when he came off his horse.
So, he will have a scan within...
I would give an estimate of ten
minutes of walking through the door
and we'll know to quite a
degree what the damage is.
It's a bit of an unanswerable question.
What I've said to him is, "Don't
lose hope. Don't give up hope."
Things aren't always as bad
as they seem straight off.
That's true, but we do have
to be prepared for everything.
It's not a great rate,
actually, even in here.
George's heart rate is
also still worryingly slow.
Greg alerts the nearest
major trauma centre.
ETA is probably from now.
- .
In Chelmsford, East of England
Ambulance Control has received
an emergency call about a man
who's fallen from a tall ladder.
Essex and Herts Air
Ambulance doctor Sam Sadek
and critical care paramedic Simon Probert
have been called to St Albans.
An ambulance crew already with the patient
are concerned about his condition.
The difficulty with a fall from height
is it really could be
anything, sometimes everything.
When a person hits the
floor, they decelerate
and you can get a lot of hidden
injuries with a fall like that.
Some of the internal organs
can be very badly damaged.
-year-old Seb, a tree surgeon,
was cutting branches
with a long pole pruner
when he fell to the ground.
He's now in an ambulance,
braced on a stretcher.
- It's Seb, isn't it? - Seb.
- Yeah. What were you doing?
You were cutting trees, were you?
Yeah.
And you landed how?
Onto your feet, like
this, or onto your side?
Yeah, OK.
We'll cut all your clothes off.
We'll keep you in the ambulance
so you're warm for now, OK, buddy?
'My first impression of Seb'
is a man who is in a lot of pain,
is not breathing quite normally --
either because of his injury,
or because of his pain --
and a man who is very
scared, and that worries me.
Do you mind if, while I
do a primary survey...?
'Not everybody looks that scared
after they've had an injury,'
so, yeah, it's a sign of
something bad going on.
Someone tries to pop in another cannula.
We're going to get you
really warmed up now
and give you loads of
painkillers, OK, mate?
Sam needs to find the source of Seb's pain
to work out what's going on inside.
I'll have a gentle feel of your tummy.
- Does it hurt? - Yeah. - Everywhere?
- Yeah.
- OK.
When I pressed his tummy, he was
desperately tender and rigid,
which can be a sign of a real
disaster going on in the abdomen.
If I press here, does that hurt?
It's hurting down there
when I'm pressing here?
I'm just undoing your trousers
to have a look at your pelvis.
Paramedic Simon Probert is concerned
about the risk of internal bleeding.
With all trauma patients that we attend,
we'll always perform an
examination of the pelvis.
It's a very strong, rigid
structure, but it can be broken.
Because of the amount of blood
vessels that sit within your pelvis,
pelvic fractures can be fatal.
They can be life-threatening and you
can lose your entire blood volume
within your pelvis without
any external bleeding.
Does that hurt your back at all?
OK.
That hurts you where in your back?
Lower back, yeah. OK.
- How much morphine has he had?
- Ten.
Ten. Let's try more morphine
and I'll be back in a second.
Time is critical because, every
second that the body is bleeding,
your chance of death increases.
I leave to gather probably
one of the most important
bits of information for myself and
that is to look at the exact scene --
where he fell from and what he landed on.
Yeah.
Oh, really? OK.
Right. From where?
- A-frame meaning what? Scaffolding?
- A great big ladder. - A ladder.
Metal, an A-frame ladder
that goes like that.
OK, and what branches was he cutting?
- Those broken top ones
up there? - Yep. - OK.
'Seeing that tree, seeing the
height and what he landed on,'
for me, was the clincher.
I thought, "This is enough.
"I'm not going to take any
chances with this man."
Concerned Seb could be bleeding from
internal injuries sustained in the
high fall, Sam must get
him to hospital fast.
He's fallen a fair old way
onto the base of a bush,
so a big deceleration.
I mean, he's extremely
tender in his abdomen.
I think we should go
to a major trauma centre
- because I'm worried he's bleeding.
- Yeah, yeah. I agree.
In the last minutes,
emergency clinicians have battled to
treat three critically ill patients.
Horse rider George is being
airlifted to hospital
after suffering major damage
to his spinal cord.
Dusan has been anaesthetised
after an accident
has left him with multiple injuries.
And after falling from a tall ladder,
Seb is showing signs of
potential internal bleeding.
Dusan has been rushed to
the Royal London Hospital
after being hit by a bus
while walking to the gym.
Gareth is concerned about
his head and chest injuries.
He's also worried he may be
bleeding into his abdomen.
I just wanted to let you know
there's a trauma patient arriving.
The -year-old male
pedestrian versus bus.
OK.
Emergency medicine consultant
Simon Walsh is preparing
to take over the patient and
assess the scale of his injuries.
OK, everyone, this gentleman is
approximately years of age.
He was hit by a bus.
I think he's hit the bus with his head.
His saturations where % and his
last blood pressure was systolic.
OK. Let's start the
primary survey, please.
Can we get the...? Is the scoop undone?
Dusan has both critically low
oxygen and blood pressure.
As well as his head injury,
the impact of the bus may
have damaged his lungs
and Simon is also concerned he's bleeding
from other internal injuries.
'Firstly, why has his blood
pressure become so low?'
Is he bleeding?
Do we need to give him some blood
to replace blood loss immediately?
So I'm thinking, "Does
he have another injury?"
Is there more to this than meets the eye?
Chest X-ray has got a lot of opacification
of the right hemithorax,
so presumed contusion,
plus or minus hemothorax.
The X-ray shows what
could be severe bruising
to Dusan's right lung, or
an area of blood around it,
which could be preventing him
from getting enough oxygen.
Sats still reading .
If you could do anything with the
ventilation to improve that...
Consultant anaesthetist Mit
Lahiri is also concerned
about the impact of his damaged
lungs on the rest of his body.
The things that were worrying me initially
were that his oxygen levels were low,
despite the fact we were on as
much oxygen as we could give him.
So we take a sample of
blood from the artery,
and that gives us a huge
amount of information.
Got bloods. Thank you.
This blood sample is
processed within minutes
and reveals another major problem.
He is very acidotic, got a pH . .
Dusan's body has been starved of oxygen
and is now creating
lactic acid in his blood.
A pH of . is a potentially
unsurvivable level of acid
without immediate intervention.
The longer the body is acidic,
the more likely the
cells are going to die.
This acidic blood could trigger
yet more complications.
Increased levels of acid can cause
problems with the blood clotting,
which can cause more
bleeding and so it goes on.
In my experience,
you're more likely to die than
live with numbers like that.
We're spiralling towards a point
where we're not going
to be able to come back,
so we need to do something pretty sharp.
OK, so, obviously, he has got
a significant head injury,
but he probably is also bleeding,
so we'll request a pack A
and get him to CT and see
what else is going on. OK?
Hi, can I request a pack A, please?
Simon rushes Dusan to the
CT scanner and requests
an urgent blood transfusion.
He needs to find out exactly
what's wrong with Dusan's lungs
and locate the source of
his internal bleeding.
Ultimately, the question is,
does he need an operation
to stop bleeding in his belly?
Does he need any procedures done to
improve his ventilation
function in his chest?
And does he need neurosurgery?
But as Dusan enters the scanner,
his blood pressure
plummets to its lowest yet.
This chap is a code red. Dropped
his blood pressure to / .
He's just in CT now.
Code red lets key staff know
there's a patient bleeding to death,
and makes blood and blood
products quickly available.
The team start an urgent transfusion
while Simon begins the scan.
Getting a CT scan allows us to see
exactly what the brain injury is,
it allows us to see, is he
bleeding into his chest?
Is he bleeding into his abdomen?
Any one of those things, in
itself, can be life-threatening.
Simon consults neurosurgeon Emma Sillery.
The impact of the bus
could have given Dusan
a major bleed in his head.
Your brain is a soft, pliable thing
that you could compress with your fingers,
so it's a delicate and easily damaged.
And heavy bleeding inside the
head can push on the brain
and, if things push on the brain,
it's only a small step, really,
before life-threatening
conditions can develop.
His head doesn't look like
it's got any large haematoma
that needs to be evacuated.
He's got an injury and
some intracranial air.
The scan reveals an area
of air in Dusan's head
which has entered through
fractures to his face,
but there's no obvious signs of bleeding.
His brain, serious though
it is, wasn't too bad,
and we could then at that
point make a quick call
that they could leave this for now.
Simon decides to monitor
Dusan's head injury
and continues scanning
the rest of his body.
He's got a bit of blood in
his right chest, doesn't he?
He's got a chest injury with some bleeding
on the right side of the chest, and
some air escaped from both lungs.
The scan reveals Dusan has blood
and air trapped around his lungs.
This is affecting his breathing
and reducing his oxygen levels.
But before Simon can see to this,
he must find the main source of bleeding.
He's got a lot of blood around his
spleen and some around his liver.
Then the scan locates a large
area where blood is collecting.
The CT appearance, showing
blood within his abdomen,
makes me concerned that he's
actually bleeding to death.
Harriet, we're going to need
chest drain on each side.
Simon must now drain the blood and
air trapped around Dusan's lungs
and, without immediate surgery to
stop the bleeding in his abdomen,
Dusan may not survive.
In Bristol, Great Western Air Ambulance
has just landed with horse rider George.
He's a -year-old male,
fall from horse, who's got a sensory
level of C and is in spinal shock.
Emergency department consultant Adam Brown
is preparing to receive a handover.
He needs to rapidly determine the
full scale of George's spinal damage
and any hidden injuries he might
have from the riding accident.
We, as a medical profession,
quite rightly withhold our prognosis
with these sorts of injuries.
But the reality of the fact is that,
if you see a devastating
spinal cord injury,
you know, nearly all of the
time, it's life-changing.
You all know about trauma calls by
now -- it's in, assess, stabilise.
If the patient's stable, off to CT.
Any questions? Groovy.
Red bag, please. And can we get
the TX out but not drawn up?
Just park up.
OK, guys, just listen in
for the handover, please.
This is a horse riding incident.
He's come off, he knows
he has a neck injury,
neck pain was his only complaint.
I suspect he has a neck injury with
probably a C for complete level.
Any questions from anyone? OK.
This is what I want to happen, please.
I'd like to undo all this
blanket. He's on a yellow scoop.
I'd like people to come around
the sides, lift up the scoop,
get out all the orange stuff
and then we'll do the
monitor change after that.
Despite George's obvious neck injury,
Adam must be thorough and look for
other possible internal injuries.
I know that George has a
potentially life-threatening,
life-changing, high-neck injury.
I do not want to be complacent or
focused on George's neck injury.
He has fallen, at speed, off a horse.
We need to ensure we
do not miss any injuries
because we are so focused
on the obvious, devastating,
life-changing injury that he may have.
Got good CO .
Sats are .
What we're going to do then is
we're going to get off the scoop,
package for CT, draw up presses,
please, and we will go to scan.
minutes after arrival to resus,
George is taken for a full body scan
to rule out other internal injuries
and look for damage to his spine.
On the word slide. Ready, steady, slide.
Well done.
The CT images actually
looked remarkably OK.
It was as if George had injured his neck,
restored his neck back
to its normal position,
and you couldn't really
see any injury at all.
The CT scan is reassuring
from the point of view of
we know there's no other injuries,
but we haven't got the answer
to why George can't move
his arms and his legs.
With no sign of injury to any
of George's organs or bones
on the scan, Adam will
need to run further tests.
George, can you try and
bring your toes of both feet
back up towards your chin?
OK. And then can you try and
push your toes down on both feet?
Try and push your feet down.
OK. So he's going to need an MRI.
That's effectively it, isn't it?
He's going to need an MRI
scan of his spinal cord
because we found no bone injury
at all. The scans were normal.
An MRI scanner will show tissue detail
and any damage to George's spinal cord.
I think the important thing
to communicate with George,
who is fully aware,
is to be honest and to be sensitive.
Without a shadow of a
doubt, on some level,
I know that George knows what's going on.
And... as George's trauma team leader,
I'd don't really want to say it,
but that doesn't help anybody.
Obviously, you're behaving like
somebody who's got an injury
to their spinal cord because
you can't move your arms
and can't move your legs, but
you can feel certain things.
So what you're going
to need is an MRI scan,
which is a much more
detailed scan, in a tunnel,
to have a look at detail
of the spinal cord
because I think that's where the
injury is that's giving you this.
It might be that you've
just got bruising of that,
but, either way, we need to know.
And until we know, we need to
keep you laying flat like this.
- Will it show any damage?
- It will show, yes.
- All right, OK.
- All right.
So that will show, basically,
what the future is for me?
- Yes, yes, it will.
- OK.
- Let me go and sort that
out now. - Thank you. - OK.
In St Albans, young tree surgeon Seb
is complaining of severe abdominal pain,
having fallen feet from a ladder.
Concerned his injuries
could be life-threatening,
Sam has decided to fly him to
the nearest major trauma centre.
I'm looking at Seb, I'm worried about him,
I'm telling everybody and telling
myself that he could be bleeding
into his abdomen or his pelvis,
and I know that we're a
long way from hospital.
Ready, brace, lift.
Another injury which is very
likely from that type of fall
is a spinal injury, particularly
as he was complaining
of pain in his lower back
as well as his abdomen.
With that always comes the risk
of damaging your spinal cord,
even though he can move his legs,
and that could be
devastating in the long run.
I know that I can't just
chuck him on the helicopter.
He needs his spine to be kept very still
because it could well be broken.
Ready, set, lift.
Claire, we are bringing you
a trauma patient by air.
He's a -year-old adult male.
He's fallen feet,
possibly a pelvic fracture.
It's a -minute flight to
the Royal London Hospital,
where emergency medicine
consultant Ben Clarke and his team
are preparing to receive Seb.
A fall from height is
dangerous because, essentially,
you suddenly accelerate and then
you very, very suddenly decelerate
and, by that, you come
to a very abrupt stop.
And what can happen with that deceleration
is you can tear bits of the bowel,
you can tear big blood vessels
and the impact itself can cause
damage to any number of
different organs and bones.
Hello, guys. This is Seb.
He's years old.
He fell around about -
feet from the top of a tree.
He's a tree surgeon cutting branches.
'I'm hearing in this
handover that Sebastian
'has fallen a great distance.'
He was complaining of very severe
lower back pain and abdominal pain,
and those automatically point me
to thinking about internal bleeding
and organ injuries, but also,
most importantly, a pelvic injury.
Let's get the bed down.
We'll aim to do a primary
survey nice and quickly.
Chest X-ray.
Ben decides to do an ultrasound
scan to look for internal bleeding.
The purpose of it is to look at
certain parts inside the belly
and the heart to see whether there's
any clear signs of internal bleeding.
Let's have a quick look down in
his pelvis, if you don't mind.
Negative thus far.
It gives us an indication as to
whether Sebastian's path may be
to the theatre, or whether he is stable
and we can go through the Cat scanner.
OK, guys. If we're good and
we've got him disconnected,
let's go through to
scan, if they're ready.
The ultrasound hasn't
revealed any bleeding,
so Ben takes Seb through to the CT scanner
for a more detailed look inside.
The CT is a very sensitive,
very specific tool for showing
us everything that is going on,
from his head down to his pelvis,
and see whether there is any clear
sites of injury or bleeding.
Just be gentle, just be really gentle.
At the Royal London Hospital,
scans have revealed Dusan has
suffered life-threatening injuries
to his chest and abdomen
after being hit by a bus.
A build-up of blood and air trapped
around his lungs has caused them
to collapse and he's
bleeding inside his abdomen.
First priority is to put chest drains in
to allow his lungs to fully
reinflate and allow them
to deliver as much oxygen into
his circulation as is possible.
- Is that drain doing anything?
- It was bubbling.
- Yeah? Still bubbling?
- Bubbling.
With chest drains
releasing the blood and air
trapped around Dusan's lungs,
Simon turns his attention
to the abdominal bleeding.
Since the accident, this has been
causing Dusan's blood pressure
to fall dangerously low, and
they need to operate soon.
So how much blood have we
actually given him so far?
- .
- , OK.
That's all we need.
For Dusan to survive
long enough for surgery,
Simon has been giving
him a blood transfusion.
He also hopes this will help
make his blood less acidic
and enable it to clot.
You have a window where
they're heading down
a slope of worsening acidosis,
and, if you don't reverse
that very quickly,
then death can follow within minutes.
OK, the gas has improved a bit.
Ph . .
Lactate's come down to . .
With his blood gas results
and blood pressure improving,
Dusan now has a window of
opportunity for surgery.
Simon rushes him to the operating theatre
and hands over to consultant
trauma surgeon Wayne Sapsford.
There are a number of
areas within the body
which have a huge amount
of potential space
in which blood can accumulate
and in the abdomen, in particular,
you can lose most or all of your blood.
Wayne begins the process of
locating the source of Dusan's bleed.
When I opened Dusan's abdomen, there
was - . litres of free blood,
which we removed.
And then I did a thorough
examination of all of his abdomen.
Major organs and vessels
in the abdomen and pelvis
must be checked meticulously
for active bleeding.
When I got to the liver and
examined that in more detail,
he had a - cm laceration on
the right lobe of the liver
which wasn't actively bleeding.
The impact of the bus has
torn part of Dusan's liver,
but this bleeding now
appears to have stopped.
The liver is a manufacturer
of clotting products
and is very good at
stopping bleeding by itself.
However, I left packs around the
liver to compress the laceration
in order to try and prevent
it from bleeding again
in the ongoing hours and days.
Wayne leaves Dusan with a
temporary closure of his abdomen.
The packs will help prevent any
further bleeding from his liver
and will be removed at a later date.
But Dusan is not out of danger yet.
We're going to be doing an insertion
of a right frontal ICP bolt,
so this is the patient's right,
and it's just going to be a
little probe into the brain.
Despite there being no
obvious bleed in Dusan's head,
neurosurgeon Emma Sillery is
keen to monitor the pressure
around his brain over the coming days.
He does have fractures,
he did have some bleeding and we
think he is at the risk of swelling.
The skull is a rigid structure
and Emma is worried that bruising
on his brain could create swelling.
This would dangerously increase
the pressures in his head.
Your heart has to be able to
push blood into your head --
that happens all the time. You have
an natural pressure in your head,
and your heart overcomes it and
pumps blood into your head.
The pressure on the brain gets too much,
the heart can't pump blood into it,
and you have a brain
without blood, and that's...
That doesn't last very long.
This probe will enable
Emma to accurately monitor
the pressure in Dusan's
head, minute by minute.
You use a small, thin wire
that we put inside the brain
to measure the pressure inside the skull.
We have to put a screw into the skull
with a little tunnel through it,
and then we can put our
delicate, little probe
through that screw
tunnel and into the brain.
When I put the little pressure monitor in,
initially, his pressures were fine.
We could tell that from the
scan, we were expecting that.
What we were really doing
was to make sure that,
over the coming days, if his brain
got big and crowded in there,
that we would pick that up on the monitor.
We can keep a little eye on
his brain, hours a day,
while he's in such a critical situation.
Dusan will be kept in a coma
while they monitor for
swelling and bleeding.
They must now wait to see
how well he recovers.
In Bristol, doctors are trying
to figure out why rider George
has lost all control from the neck
down after coming off his horse.
His CT scan showed no broken bones,
but the results are now back
from a more detailed MRI.
Effectively, George's neck has
been thrown forward with force,
backward with force.
So this is George's neck
and what we are seeing
is a possible disruption of three on four,
and that's visible on his CT scan,
but it doesn't give us
enough information to say
that's exactly what the problem is,
which is why we moved to the MRI scan.
You can see the grey and the white
of the cord in the spinal canal.
The cord should look like this --
pristine, continuous.
And, as you can see,
when you get here, there's a
significant amount of disruption.
What has happened to George's
spinal cord is it's not severed,
the cord is intact, but it's
been stretched rather than torn.
If the injury had been a
complete tearing of the cord,
it would be very easy to say,
"This is probably not going to get
"any better and that is it."
In George's case, it's very complicated
because it's what we
call an incomplete injury
and we just do not know how
that is going to improve
over the coming hours,
days, weeks and months.
George is unable to move any
of his muscles below the neck
apart from his toes.
And relax.
His wife, Sarah, is working with
him to regain any possible control.
I think that's enough exercise.
It is exhausting, isn't it?
Very encouragingly, there
are one or two muscles
that I can move a tiny amount
and so I'm at that very, very
tense stage, at the moment,
when I don't know whether
I'll be what I think is called
a tetraplegic -- someone who
cannot move any of their limbs,
other than their neck.
At the Royal London Hospital,
tree surgeon Seb is undergoing
an urgent head-to-toe CT scan to
look for the source of his pain.
'Looking at Sebastian's scan,
'I am most worried about
excluding injuries.'
I want to make sure I can't see
any obvious signs of bleeding,
any very clear fractures.
Otherwise, that looks
pretty good, doesn't it?
- Full at the top, full
at the bottom. - Yeah.
- He needs a wee.
- He definitely needs a wee.
- He did say that.
- Yeah, bless him.
The initial scan rules out
any life-threatening bleeding
that would require immediate surgery.
For Ben to find the source of Seb's pain,
he must wait for the scan
to be fully processed.
Hello, mate. Everything's
looking pretty good so far,
so what we're waiting on is
we're waiting on just the
formal report of the scan.
There's still just a little bit of pain.
- Where is that pain? - Stomach.
- In the stomach, all right.
No worries.
What we'll do is I'm going to
go and have a good look through
the scan as well and make sure there
is nothing subtle that I can see.
With the full images now available,
Ben makes a further assessment.
That explains a lot of
his pain then, doesn't it?
The scan reveals Seb's fall has
severely crushed one of his vertebra
and this is where his pain is coming from.
We've got all these lucencies,
it's irregular, it's got
what looks to be cracks.
We can see that L ,
which is this one here,
has been crushed, basically.
It's been fractured. It's
been basically squashed down.
Despite the crushed vertebra, Seb's
spinal cord is currently intact,
but a sudden movement could
cause significant nerve damage.
All right, mate. We've got the results.
So your lumber spine, which
is about here in your back,
it looks like one of the bones
there has been broken --
and it's called your L vertebra.
The way you've fallen,
what's happened is that
vertebra has been squashed a bit.
It's what we call unstable.
What we're going to do is get
our neurosurgical doctors,
they're going to have a look at you
and then tell you exactly what
the plan will be from there.
Simon hands over to consultant
neurosurgeon Jonathan Bull,
who takes the decision
to operate the next day.
The risk is that, having
had it partially fractured,
as he started to walk around on it,
the bone would then further
collapse and push fragments
into the spinal canal, which
would then squash the spinal cord
and risk, basically,
paralysis in his lower limbs.
One option was to treat him in a brace,
so he wouldn't have had an operation.
He would have worn that
for around - weeks.
The alternative was a surgical option,
particularly for trauma patients,
a fixation with screws,
but done through the skin.
It's like a scaffolding. It's like
a support for the fractured bone.
X-ray.
'Rather than making a large incision,
'we make small sequential incisions
at each level and pass a guide wire
'into the vertebral body, and
then put a screw into it.'
Have that screw, please?
Jonathan uses the fixation as a scaffold
to support the fractured bone.
This is braced to a healthy
vertebrae above and below,
all done through keyhole surgery.
It means the wound is smaller,
there's less damage to
the surrounding muscle,
so they can often mobilise more rapidly.
Theoretically, if the
fracture heals satisfactory,
you'll have a full range of motion,
or near-full range of motion.
He sent me a WhatsApp from the hospital.
It was a little ambulance emoji,
so of course I was quite scared.
I knew he had a dangerous job and
I didn't know what had happened.
You're with the tree.
When it's windy and raining,
you're sort of up there and it's...
Sometimes it's scary, but you...
I was never really scared of heights.
When I saw him in that hospital bed,
he just looked so small and...
he was scared.
Sebastian, I think, was lucky
insofar as the fracture didn't
compromise his spinal cord
and he didn't have a deficit or
weakness in his limbs from it.
I'm hoping he'll make a
good recovery from it.
I'm fortunate for not being paralysed.
It could have been a lot worse.
I'm glad that I'm up and walking.
I just found out I was pregnant.
I told him just the week before.
We have a little boy on the way,
so that's really good.
A new chapter.
He's relying a lot on me,
but we're grateful that we still
have each other, alive and walking.
He's doing incredibly well.
From seeing him in the CT scanner,
with a blood pressure that low,
I was concerned as to
whether he would survive.
Picture the scene, where you're
just going about doing your thing,
and then you wake up
and it's a month later.
And you're somewhere you've
no idea where you are,
looking at somebody and you
don't know who they are.
And that's a weird thing, because
it affects you as a person.
The natural course of
untreated bleeding and acidosis
with a brain injury is
quite commonly death...
.. but our aim is to intervene,
to try and stop that process,
but it has to be done
at the very early stage,
otherwise it's too late.
So, if we put your arm in there...
Now that his elbow is held up...
I...
They're quite short ropes.
If they were longer ropes, it
would go further, I promise you.
I think, if I had the choice,
I would elect not to
have jumped that hedge
in the way that I jumped it.
But I've had such an enjoyable life
and that's partly because of
the things I've been able to do.
You look around for the positives
and it's a reminder that this
isn't a practice for anything,
this is the real thing,
and you only get one...
One go.
Can I have some water?
If you live your life protecting yourself
from every single potential outcome,
you'll never do anything.
So... life is there to be lived,
George was doing that,
and we're there to support
the next life George has.
My current efforts, as indeed
are this hospital's efforts,
are to make the best of what I've got
and follow the road where it takes me.
We both... Well, I don't know if we both,
I would love it if you could
scratch your nose by yourself
and I didn't have to do it.
Thank you.
I'm going to put lots of
scratch posts in my house,
so I can go up to them and...
Next time...
We follow three patients through
the crucial first hour of care.
In central London, a man
suddenly collapses at work
with a suspected cardiac arrest.
We are going to anaesthetise him here.
In Newcastle, a mother of three
fights for her life after being
stabbed in the chest and neck.
How big was the Kn*fe?
And a cyclist in Durham suffers
horrific crush injuries to his chest
after being run over by a bus.
Let's get the blood in.
03x03 - Episode 3
"An Hour to Save Your Life" is a medical science series exploring the life or death decisions facing doctors in the first critical hour of emergency care.