0:00:02 > 0:00:07This programme contains scenes which some viewers may find upsetting
0:00:07 > 0:00:11DISPATCHER: 'Emergency ambulance. What's the nature of the emergency?'
0:00:11 > 0:00:13The moment an emergency call is made,
0:00:13 > 0:00:16a battle against time begins.
0:00:16 > 0:00:19- DISPATCHER: 'Is she awake?' - 'No. She looks dead.'
0:00:19 > 0:00:22FAINT DISPATCHER
0:00:23 > 0:00:26The decisions that are made in the first 60 minutes for major trauma patients
0:00:26 > 0:00:28will make the difference between life and death.
0:00:28 > 0:00:33If we can intervene within the first 60 minutes or so, the so-called golden hour,
0:00:33 > 0:00:37then we know we can positively affect your outcome.
0:00:37 > 0:00:39The sooner a doctor can reach their patient,
0:00:39 > 0:00:41the more likely they are to survive.
0:00:41 > 0:00:45We now have the ability to reverse the initial effects of the injury
0:00:45 > 0:00:50if we are given the chance and we are able to act quickly enough.
0:00:50 > 0:00:54In their race against the clock, doctors and paramedics are now
0:00:54 > 0:00:57taking the hospital to those at the very edge of life.
0:00:57 > 0:01:00We're pretty close. SIRENS WAIL
0:01:02 > 0:01:05The more equipment and expertise and knowledge
0:01:05 > 0:01:08we can get out on to the street or the scene of the accident,
0:01:08 > 0:01:10then we will save more people's lives.
0:01:10 > 0:01:12Armed with new treatments and equipment...
0:01:12 > 0:01:15I'll get the AutoPulse ready and we'll get him on it.
0:01:15 > 0:01:17..they're performing surgery on the roadside.
0:01:18 > 0:01:22I could do the operation in the back of the ambulance if necessary.
0:01:22 > 0:01:25Administering powerful drugs.
0:01:25 > 0:01:27Draw us up 200 of tranexamic acid.
0:01:27 > 0:01:29Using innovative techniques.
0:01:29 > 0:01:32If you pull that one and I'll pull this one.
0:01:32 > 0:01:35Pushing the boundaries of science...
0:01:35 > 0:01:37The REBOA is in.
0:01:37 > 0:01:39I'll let you know once the balloon is up.
0:01:39 > 0:01:42..to save time and to save lives.
0:01:42 > 0:01:43We've got to go.
0:01:43 > 0:01:48This series will count down second by second, minute by minute
0:01:48 > 0:01:53the crucial decisions made in the first 60 minutes of emergency care.
0:01:53 > 0:01:56One hour, the difference between life and death.
0:02:18 > 0:02:22London. Home to over 8 million.
0:02:24 > 0:02:27Every hour, eight people will face a life-threatening
0:02:27 > 0:02:30emergency in this sprawling metropolis.
0:02:33 > 0:02:38This film will follow three patients through 60 minutes of care
0:02:38 > 0:02:41that will push the limits of scientific innovation.
0:02:43 > 0:02:48In London, 24-year-old Stanley is stabbed three times in the chest.
0:02:53 > 0:02:55In Kent, a high-speed road accident
0:02:55 > 0:02:58critically injures 27-year-old Michael.
0:02:58 > 0:03:01- Is his blood running?- Yep.- OK.
0:03:01 > 0:03:05And 68-year-old Mick collapses in north London.
0:03:05 > 0:03:08I must admit, I can't feel a cardiac output in this chap.
0:03:08 > 0:03:13From the moment each emergency call is made, the clock starts ticking.
0:03:13 > 0:03:15INCOMING CALL
0:03:15 > 0:03:17Hello.
0:03:17 > 0:03:18Cardiac arrest.
0:03:20 > 0:03:22Hello, there. I've got a job for you.
0:03:22 > 0:03:26Map reference is 32 November Bravo.
0:03:26 > 0:03:30Ambulance control has just received a call about an elderly male
0:03:30 > 0:03:33whose heart has stopped beating in a betting shop.
0:03:42 > 0:03:46Dr Ben Clarke, part of a medical unit specialising in cardiac arrest,
0:03:46 > 0:03:48is tasked to the job.
0:03:50 > 0:03:53As soon as I hear the term cardiac arrest,
0:03:53 > 0:03:56I know the heart isn't pumping blood, the brain isn't getting oxygen,
0:03:56 > 0:03:58the heart isn't getting oxygen,
0:03:58 > 0:04:01the other really vital organs in the body aren't getting oxygen.
0:04:01 > 0:04:03That's totally blocked. How are you meant to...?
0:04:03 > 0:04:05It's completely blocked up.
0:04:05 > 0:04:07SIRENS WAIL Ah, come on!
0:04:07 > 0:04:12Every second counts and time is most definitely of the essence.
0:04:13 > 0:04:16Maybe just pull up around the corner in front.
0:04:16 > 0:04:21First on scene, a paramedic crew has already restarted Mick's heart.
0:04:21 > 0:04:25But as Ben arrives, he goes into cardiac arrest again.
0:04:26 > 0:04:29You're good, mate. Stay as you are.
0:04:33 > 0:04:37We know that that period around when someone's had a cardiac arrest
0:04:37 > 0:04:39and if they get spontaneous circulation,
0:04:39 > 0:04:42it's an incredibly fragile time for the body.
0:04:42 > 0:04:44When he re-arrests, I then think,
0:04:44 > 0:04:47"Right, OK, we need to obviously manage this
0:04:47 > 0:04:50"and we need to get on this and manage it assertively."
0:04:50 > 0:04:55What I saw straightaway was that he was a fairly large gentleman.
0:04:55 > 0:04:56He also looked very dusky.
0:04:56 > 0:05:00And by that, his colour was awful and it indicated to me
0:05:00 > 0:05:03that his cardiac perfusion, or the ability of his heart
0:05:03 > 0:05:06to pump blood around his body was perhaps compromised.
0:05:06 > 0:05:09I must admit, I can't feel a cardiac output in this chap.
0:05:09 > 0:05:12In a patient who's got a cardiac arrest,
0:05:12 > 0:05:14their level of consciousness is essentially zero.
0:05:14 > 0:05:16They're comatose. They're clinically dead.
0:05:16 > 0:05:20- Back in VF. - He's just gone back into VF.
0:05:20 > 0:05:26VF or ventricular fibrillation, is a major cause of cardiac arrest
0:05:26 > 0:05:29and occurs when the muscles inside the heart
0:05:29 > 0:05:31quiver rather than contract,
0:05:31 > 0:05:33meaning Mick's heart is unable to supply
0:05:33 > 0:05:36the rest of his body with oxygen.
0:05:36 > 0:05:40The ambulance crew initiate CPR to try to do the job for him.
0:05:40 > 0:05:42Would I be able to get you to have a quick listen to his chest?
0:05:42 > 0:05:44Do you want to grab my tubes?
0:05:44 > 0:05:47I remember when I was a junior doctor seeing my first cardiac arrest
0:05:47 > 0:05:50and the first time I saw someone getting CPR.
0:05:50 > 0:05:53It looks awful. It looks brutal.
0:05:53 > 0:05:56Um...it looks out of control.
0:05:56 > 0:05:58And for anyone who hasn't seen it before,
0:05:58 > 0:06:01it almost looks like an assault.
0:06:03 > 0:06:06We don't really have any other choice unfortunately.
0:06:07 > 0:06:11Ben is worried that they still can't get a stable heartbeat from Mick
0:06:11 > 0:06:13and that they're starting to lose him.
0:06:13 > 0:06:15We know that chest compressions
0:06:15 > 0:06:17aren't as good as a heart beating for itself.
0:06:17 > 0:06:20So automatically, I know that his brain, his heart,
0:06:20 > 0:06:23his other organs probably have had a lower level of oxygen
0:06:23 > 0:06:26than they normally should have.
0:06:26 > 0:06:29And so for me, the first clinical decision in that phase was,
0:06:29 > 0:06:31let's establish a more definitive airway
0:06:31 > 0:06:35so I can be sure that we're ventilating him appropriately.
0:06:35 > 0:06:38- Now might be an opportune time to get that tube in. What do you think?- Yep.
0:06:38 > 0:06:41The team insert a tube into Mick's airway
0:06:41 > 0:06:45to squeeze oxygen directly into his lungs mechanically with a bag.
0:06:45 > 0:06:47Our priority then is actually
0:06:47 > 0:06:50just making sure we get the breathing tube into the trachea.
0:06:50 > 0:06:53You can see the tube's passed the chords.
0:06:53 > 0:06:56Cool. That means she's out.
0:06:56 > 0:06:59Just make sure, mate, you're not getting too tired with your CPR.
0:06:59 > 0:07:02- He's due for an analyse in a second. - Good.
0:07:02 > 0:07:06- So, are you happy with that tube? - Yep.- It's just a nightmare.
0:07:06 > 0:07:08At the same time, the paramedics
0:07:08 > 0:07:10try to get a normal heart rhythm back for Mick.
0:07:10 > 0:07:13We can administer an electric shock
0:07:13 > 0:07:17and that can often restart the heart into a more appropriate rhythm.
0:07:17 > 0:07:20Yeah. Let's shock that. Shock that.
0:07:20 > 0:07:24- Stand clear!- All clear, guys.
0:07:24 > 0:07:26All right. Is the CPR back on?
0:07:32 > 0:07:34But the electric shock hasn't worked.
0:07:34 > 0:07:38Mick's heart is still not beating correctly and he's fading fast.
0:07:41 > 0:07:44Unless we got things sorted fairly quickly,
0:07:44 > 0:07:48there was a very, very good chance that he would die.
0:07:55 > 0:07:58Ten minutes ago, across London,
0:07:58 > 0:07:59a call came in about a young man
0:07:59 > 0:08:01who's been attacked after an argument.
0:08:13 > 0:08:15London's Air Ambulance is en route
0:08:15 > 0:08:18with an advanced trauma team on board.
0:08:38 > 0:08:42The minute you get a call for a stabbing, you're anxious
0:08:42 > 0:08:45because you know it's really important to get there quickly.
0:08:45 > 0:08:50They can literally bleed to death in a few minutes.
0:08:50 > 0:08:52We know he's been stabbed in the chest.
0:08:52 > 0:08:56You can't help but feel a degree of anxiety.
0:08:56 > 0:09:00For every minute you're sat in the helicopter twiddling your thumbs,
0:09:00 > 0:09:05I imagine a heart that's pouring out blood that I need to stitch.
0:09:11 > 0:09:15It may be something that requires open-heart surgery.
0:09:15 > 0:09:18So we literally have to take the kitchen and the kitchen sink.
0:09:28 > 0:09:32I was dreading opening the doors to see what we were going to see.
0:09:49 > 0:09:51Stanley, my name's Dr Davies.
0:09:51 > 0:09:54Gareth's immediate concern is the exact location
0:09:54 > 0:09:57- of Stanley's stab wounds. - Hold on, hold on.
0:10:03 > 0:10:07Stanley could quite easily trick a causal observer
0:10:07 > 0:10:09or a young doctor or young paramedic.
0:10:09 > 0:10:14Because the wounds are small. They don't bleed.
0:10:14 > 0:10:18And the patient looks big and healthy.
0:10:18 > 0:10:20But right underneath those wounds
0:10:20 > 0:10:24is some of the major clockwork of the body.
0:10:24 > 0:10:25The heart, the aorta,
0:10:25 > 0:10:29are literally only inches from some of those wounds.
0:10:30 > 0:10:33Stanley has three stab wounds to his chest.
0:10:33 > 0:10:36Any one of them could be fatal.
0:10:36 > 0:10:41I was worried by the fact he was so sweaty and clammy,
0:10:41 > 0:10:44which...can be very subtle.
0:10:44 > 0:10:46And you may only pick it up simply by touch.
0:10:46 > 0:10:51You won't see the beads of sweat on someone's forehead.
0:10:51 > 0:10:53And that again is a sign that the body
0:10:53 > 0:10:56is really fighting for survival.
0:10:56 > 0:11:00Stanley, my name's Dr Davies. Can you speak to me?
0:11:03 > 0:11:04Stanley's not speaking
0:11:04 > 0:11:07and his breathing is gradually getting worse.
0:11:07 > 0:11:12Stanley was so silent that day because he knew he was ill.
0:11:12 > 0:11:15He was fighting for, er...for his life.
0:11:15 > 0:11:17His brain was telling him,
0:11:17 > 0:11:20"I can't breathe, I can't oxygenate myself."
0:11:20 > 0:11:25And actually, his way of dealing with that is actually not to talk,
0:11:25 > 0:11:28but to focus and to use hand gestures.
0:11:28 > 0:11:31Does your breathing feel normal or not? No, it's not.
0:11:32 > 0:11:37When I looked at Stanley, there was a key decision to make, which is,
0:11:37 > 0:11:41how far down a dying process is he?
0:11:41 > 0:11:47Young people actually protect themselves to the bitter end.
0:11:47 > 0:11:49And they can stay conscious,
0:11:49 > 0:11:52they can have high heart rates and high blood pressures
0:11:52 > 0:11:57and then eventually, all of their compensatory mechanisms fall apart.
0:11:57 > 0:12:01And they can fall apart in literally a few seconds or minutes.
0:12:01 > 0:12:04So they can look quite well.
0:12:04 > 0:12:05So it's quite difficult to know
0:12:05 > 0:12:10how far Stanley is down that particular line.
0:12:10 > 0:12:12OK. Just bring your neck up.
0:12:12 > 0:12:16Gareth is most concerned about a possible punctured lung,
0:12:16 > 0:12:19or even a wound to Stanley's heart.
0:12:19 > 0:12:22He now faces a dilemma.
0:12:22 > 0:12:27Is he well enough for us to essentially work en route,
0:12:27 > 0:12:31get the ambulance moving and start heading for hospital,
0:12:31 > 0:12:36or is he in such a position that actually, no, we have to stop,
0:12:36 > 0:12:37we have to get out all our equipment,
0:12:37 > 0:12:42we have to start draining collapsed lungs at the roadside,
0:12:42 > 0:12:45or perhaps think about doing open-heart surgery?
0:12:53 > 0:12:56It's a judgment call, it's an experiential call.
0:12:56 > 0:12:59In Stanley's case, it felt prudent
0:12:59 > 0:13:02and best for him actually to get moving.
0:13:02 > 0:13:03Shall we just...?
0:13:08 > 0:13:12Gareth decides to fast-track Stanley to the Royal London Hospital.
0:13:12 > 0:13:13SIRENS WAIL
0:13:28 > 0:13:32In north London, 68-year-old Mick remains critically ill.
0:13:32 > 0:13:34We've got two leads in there.
0:13:34 > 0:13:36Mate, we should, um...ACD and AutoPulse, as well.
0:13:36 > 0:13:39His heart muscles are not beating properly
0:13:39 > 0:13:42and his body isn't getting enough oxygen.
0:13:44 > 0:13:46This was an incredibly challenging environment.
0:13:46 > 0:13:48Not only are we in the shop,
0:13:48 > 0:13:51we have furniture that's banked up around this gentleman.
0:13:51 > 0:13:53Sorry, mate. Excuse me, please.
0:13:53 > 0:13:57For Michael and for us, this was a really difficult scenario.
0:14:00 > 0:14:03His condition couldn't be any more severe. He was essentially dead.
0:14:03 > 0:14:07All right, guys, we're going to chuck him on the AutoPulse machine.
0:14:07 > 0:14:11Ben can't get Mick's heart back into a regular rhythm.
0:14:11 > 0:14:15He decides to continue treatment with an AutoPulse machine.
0:14:17 > 0:14:21The AutoPulse is essentially providing the cardiac output
0:14:21 > 0:14:23that the heart can't do for itself.
0:14:23 > 0:14:26And it's ensuring that the tissues get exactly what they need,
0:14:26 > 0:14:28and that's oxygen, pretty much, in this case.
0:14:28 > 0:14:32Ready, brace, lift. Straight up.
0:14:32 > 0:14:36The reason we use it is because we know it's more effective than us at CPR.
0:14:36 > 0:14:39There have been studies that show it does a better job
0:14:39 > 0:14:42at getting the blood around the body than we do.
0:14:42 > 0:14:43It also doesn't get tired.
0:14:45 > 0:14:47- Good stuff. Happy?- Yep. - All right, guys...
0:14:47 > 0:14:51The AutoPulse is one of only a handful of mechanical CPR machines
0:14:51 > 0:14:53on the streets of London.
0:14:54 > 0:14:58The aesthetics of it are dramatic. How it looks. You've got the noise.
0:14:58 > 0:15:00It all sounds very mechanical.
0:15:00 > 0:15:03Whilst it looks fairly confronting,
0:15:03 > 0:15:07it's actually probably one of the best ways in the pre-hospital
0:15:07 > 0:15:10setting of ensuring that we get the blood around the body.
0:15:12 > 0:15:16If we didn't have the AutoPulse, my inclination would be to
0:15:16 > 0:15:19stay on scene and see if we could get the heart beating by itself.
0:15:19 > 0:15:22If we can, what we might look to do is actually
0:15:22 > 0:15:24we can transport him on the AutoPulse.
0:15:24 > 0:15:28- So, guys, we'll go on lift. - That's all right, don't worry.
0:15:28 > 0:15:32- Everyone got it?- Yeah.- OK, on lift again. Ready? Brace, lift.
0:15:32 > 0:15:33All right.
0:15:35 > 0:15:38Right. Try that. Can we just pull it out?
0:15:38 > 0:15:41- I've got that, I've got that. - If we can just get it out.
0:15:43 > 0:15:46So his entitle is 4.3.
0:15:46 > 0:15:49We're due another rhythm check now, so are you happy just to stop?
0:15:49 > 0:15:53Pause that, yeah. Oh, feel for a pulse.
0:15:53 > 0:15:57- We've got an entitle of 4.3. - I have a pulse.- Excellent.
0:15:57 > 0:16:00All right, guys. Nice job. Really well done.
0:16:00 > 0:16:03He had a cardiac output, so his heart had restarted.
0:16:03 > 0:16:06What that meant then was we could stop the AutoPulse
0:16:06 > 0:16:09'and we could then actually just get going.'
0:16:09 > 0:16:11Really well done, guys.
0:16:11 > 0:16:14Although Mick's heart has returned to a normal rhythm,
0:16:14 > 0:16:17he could re-arrest at any moment.
0:16:17 > 0:16:19The AutoPulse now allows Ben to move Mick to
0:16:19 > 0:16:22hospital as fast as possible.
0:16:22 > 0:16:26'We either stayed until the bitter end in the betting shop,'
0:16:26 > 0:16:31or we take him to hospital, try and get him to the angiography lab
0:16:31 > 0:16:35and see if we can open up a blocked blood vessel.
0:16:35 > 0:16:38He's a 70-year-old bloke who's had a witnessed VF arrest.
0:16:38 > 0:16:41Two shocks, got return of spontaneous circulation,
0:16:41 > 0:16:43then he's had a subsequent VF arrest.
0:16:43 > 0:16:47I rang the cardiologist, who is the heart specialist at London Chest,
0:16:47 > 0:16:52and the purpose of that, essentially, is to prepare them.
0:16:52 > 0:16:54It also allows them
0:16:54 > 0:16:58to provide any distinct advice for this patient to me.
0:16:58 > 0:17:02Appropriate cardiac arrest patients in London are now taken
0:17:02 > 0:17:06directly to specialist cardiac units, bypassing A&E.
0:17:06 > 0:17:10You can have as much expertise as you wish,
0:17:10 > 0:17:12sitting with the patient on scene,
0:17:12 > 0:17:16but unless you actually have the system in place that ensures the
0:17:16 > 0:17:19patient gets from the betting shop and then goes to the place where he's
0:17:19 > 0:17:22going to receive definitive care,
0:17:22 > 0:17:25unless you have that system in place, it's all null and void.
0:17:25 > 0:17:30Perfect. Thanks very much. All right, we'll see you soon. Cheers.
0:17:30 > 0:17:34But before they can leave, Mick crashes again.
0:17:34 > 0:17:38Heart rate's slowing down. We've got a pulse rate of 40 at the moment.
0:17:38 > 0:17:42All right, so... His entitles... He's looking...very ropey, isn't he?
0:17:44 > 0:17:47It looks like, yeah... He's about to arrest.
0:17:47 > 0:17:50No, he is. You're absolutely right.
0:17:50 > 0:17:52Do you want to start the AutoPulse again?
0:17:52 > 0:17:55'The monitoring had changed.'
0:17:55 > 0:17:58Michael's heart wasn't pumping effectively.
0:17:58 > 0:18:00Yeah, stand by, mate. He's just arrested again.
0:18:00 > 0:18:05For the third time, Mick's heart has stopped beating again.
0:18:05 > 0:18:09At that point in time, I was thinking he wasn't going to make it.
0:18:09 > 0:18:11Plain and simple.
0:18:11 > 0:18:14Yeah, mate. Good to go.
0:18:14 > 0:18:17SIREN
0:18:24 > 0:18:26All right, mate. So, London Chest.
0:18:26 > 0:18:30And if you can give me a ten-minute warning, that'd be awesome.
0:18:47 > 0:18:51The Royal London Hospital is one of the UK's leading trauma
0:18:51 > 0:18:53and emergency care centres.
0:18:53 > 0:18:56And across the South East of England, it can be the last
0:18:56 > 0:18:59chance of survival for those on the very edge of life.
0:19:01 > 0:19:0527-year-old Michael has been involved in a catastrophic
0:19:05 > 0:19:08road accident and is being airlifted from Kent,
0:19:08 > 0:19:1252 miles away from central London.
0:19:12 > 0:19:16He has a suspected broken pelvis and severe internal bleeding.
0:19:16 > 0:19:18He's been classed as code red.
0:19:18 > 0:19:22'We received a priority call from the ambulance doctor.
0:19:22 > 0:19:25'The code red trauma call.'
0:19:25 > 0:19:28We only put out code red trauma call for the most severely injured
0:19:28 > 0:19:31patients where we believe that massive haemorrhage is
0:19:31 > 0:19:33an issue for them.
0:19:33 > 0:19:37We've got chest drains? Yeah, two chest drains.
0:19:37 > 0:19:39'The patient that was coming in,'
0:19:39 > 0:19:42from the priority call information, was one of the most severely
0:19:42 > 0:19:45injured people that I'd had to look after for a long time.
0:19:45 > 0:19:47'The heart rate does go up a bit.'
0:19:54 > 0:19:58Michael has already been given a blood transfusion to stop him
0:19:58 > 0:20:00bleeding to death at the roadside.
0:20:00 > 0:20:04But his blood loss is so extreme that the hospital begins
0:20:04 > 0:20:07preparing blood products to treat him with.
0:20:07 > 0:20:09Right, bye.
0:20:09 > 0:20:13We all know we have to make quick decisions
0:20:13 > 0:20:16and we have to make some big decisions.
0:20:16 > 0:20:18We prime ourselves and set things up
0:20:18 > 0:20:21in a certain way to try and facilitate that and to allow
0:20:21 > 0:20:24everything to happen smoothly and quickly.
0:20:24 > 0:20:25Good evening. Hello.
0:20:25 > 0:20:30The air ambulance team prepare to hand Michael over.
0:20:30 > 0:20:33OK, let's get the handover then, please.
0:20:33 > 0:20:3727-year-old male who was riding a motorbike at 60mph
0:20:37 > 0:20:41when he T-boned into a car, pulling out and turning right.
0:20:41 > 0:20:45He fell off the bike sideways, ending up underneath the car
0:20:45 > 0:20:47and the bike skidded out to the right.
0:20:48 > 0:20:52The team need to keep supplying Michael with blood,
0:20:52 > 0:20:56whilst quickly trying to assess the scale of his injuries.
0:21:01 > 0:21:05Percussion that is resonant bilaterally. Bilateral thoracotomy.
0:21:05 > 0:21:07No obvious lung bone injuries.
0:21:07 > 0:21:09OK, has he got central pulse?
0:21:09 > 0:21:13'Despite having four units of blood in a very short period of time
0:21:13 > 0:21:17'when he arrived, his heart rate was very high, 160,'
0:21:17 > 0:21:21his blood pressure was very low, he'd actually had unrecordable
0:21:21 > 0:21:25blood pressures for the last hour or so, from scene to hospital.
0:21:25 > 0:21:29And...essentially, he was bleeding to death.
0:21:29 > 0:21:31Very, very quickly.
0:21:32 > 0:21:34I can see a pulse...
0:21:34 > 0:21:37Bring it right in here now.
0:21:37 > 0:21:39- So he's got a central pulse?- Yeah.
0:21:39 > 0:21:42OK, can you start the blood through the Belmont?
0:21:42 > 0:21:45We need to do it fast as well, don't we?
0:21:45 > 0:21:48Can we just do that now, quickly?
0:21:48 > 0:21:49Thank you.
0:21:49 > 0:21:52Simon orders an ultrasound scan to try
0:21:52 > 0:21:55and identify any large pools of blood collecting in Michael's
0:21:55 > 0:22:00three main cavities - his chest, his abdomen or his pelvis.
0:22:00 > 0:22:04'With blunt trauma, as was the case with this patient,'
0:22:04 > 0:22:07the blood loss is often concealed within the body,
0:22:07 > 0:22:12so although the patient had signs of massive haemorrhage, there
0:22:12 > 0:22:15wasn't blood pouring out all over the floor, all over the trolley.
0:22:15 > 0:22:18It's easier to deal with that because
0:22:18 > 0:22:21if you can see where the blood's coming from, it's easier to stop it.
0:22:21 > 0:22:25It's more of a challenge when the blood is somewhere within
0:22:25 > 0:22:28one of the body cavities and we don't know exactly where.
0:22:32 > 0:22:33So heart rate is very fast.
0:22:35 > 0:22:37Right lung is up.
0:22:37 > 0:22:39- So blood running?- Yeah.
0:22:39 > 0:22:41OK.
0:22:43 > 0:22:46The ultrasound scan has shown that Michael is bleeding into his
0:22:46 > 0:22:50pelvis and is deteriorating rapidly in front of the team.
0:22:57 > 0:23:00He's obviously still badly unstable.
0:23:00 > 0:23:03He's had four units of blood, tranexamic acid.
0:23:03 > 0:23:06I wanted to get him into interventional radiology to
0:23:06 > 0:23:10give the radiologists a chance to try and stop that bleeding.
0:23:10 > 0:23:13But I didn't think he was going to survive the journey.
0:23:19 > 0:23:22SIREN WAILS
0:23:29 > 0:23:32Can I just check that we've got everyone we should have?
0:23:32 > 0:23:36We've got Fiona, anaesthetist... Are you going to do the primary survey?
0:23:39 > 0:23:42- Which bay is this person going to? - That one, there.
0:23:44 > 0:23:4654 minutes after the 999 call,
0:23:46 > 0:23:50Gareth hands Stanley over to the trauma team leader, Helen.
0:23:51 > 0:23:56When we hear that we're receiving a patient who's been stabbed,
0:23:56 > 0:23:59it could be nothing,
0:23:59 > 0:24:01or it could it could be something
0:24:01 > 0:24:03that's imminently life-threatening.
0:24:04 > 0:24:06Good afternoon, everybody.
0:24:06 > 0:24:09This is a gentleman believed to be called Stanley, approximately
0:24:09 > 0:24:1320 years of age, has allegedly been assaulted with a knife.
0:24:13 > 0:24:19'You're trying to compress what is effectively 40-45 minutes'
0:24:19 > 0:24:24of time and history and events and interventions
0:24:24 > 0:24:29into a form that the receiving doctor can handle and process.
0:24:29 > 0:24:33He's got three incisional wounds, all of approximately 0.5 to 1cm
0:24:33 > 0:24:35in length.
0:24:35 > 0:24:39He has been complaining of a lot of pain, he's had morphine...
0:24:40 > 0:24:42OK.
0:24:42 > 0:24:43Hello.
0:24:43 > 0:24:45Stanley?
0:24:47 > 0:24:52'He had relatively innocuous looking wounds,'
0:24:52 > 0:24:56but it's impossible to tell from the outside,
0:24:56 > 0:24:59looking at that wound, what the underlying damage is.
0:25:02 > 0:25:08If you can imagine a knitting needle that's driven straight through
0:25:08 > 0:25:12the chest, it would leave very little signs of external damage,
0:25:12 > 0:25:18but could have pierced any number of vital internal organs.
0:25:18 > 0:25:21Stanley, I'm just going to examine your chest.
0:25:21 > 0:25:24Are you feeling short of breath at all?
0:25:24 > 0:25:26Are you having trouble breathing?
0:25:26 > 0:25:28Of Stanley's three stab wounds,
0:25:28 > 0:25:32Helen is concentrating on the one on the left side of his chest.
0:25:32 > 0:25:33X-rays, please.
0:25:33 > 0:25:37She's worried it's punctured his lung and is stopping him
0:25:37 > 0:25:38from breathing properly.
0:25:39 > 0:25:41Three, two, one... Thank you.
0:25:45 > 0:25:48I've seen the left pneumothorax.
0:25:48 > 0:25:51'His left lung was partially collapsed,'
0:25:51 > 0:25:54so the implement, the knife I think it was,
0:25:54 > 0:25:58had penetrated the surface of the lung and it had popped.
0:25:58 > 0:26:01Saturations are 86. On how much oxygen?
0:26:01 > 0:26:0315 litres.
0:26:03 > 0:26:05OK.
0:26:05 > 0:26:09But Stanley's breathing suddenly deteriorates.
0:26:09 > 0:26:12I'm just going to give you some pain relief, OK?
0:26:12 > 0:26:16If we find a collapsed lung following penetrating trauma,
0:26:16 > 0:26:22we're instantly concerned that that collapsed lung will very rapidly
0:26:22 > 0:26:27collapse down even further and the patient will have a cardiac arrest.
0:26:28 > 0:26:31Have we got all the monitoring on at the moment?
0:26:41 > 0:26:46For the last 60 minutes, frontline medics have fought to keep
0:26:46 > 0:26:48three critically-ill patients alive.
0:26:49 > 0:26:52But the battle is far from over.
0:26:52 > 0:26:56The decisions made for Mick, Stanley and Michael have bought
0:26:56 > 0:26:59doctors more time to now try and save their lives.
0:27:06 > 0:27:08So that's his blood pressure.
0:27:08 > 0:27:11So we'll be aiming for an entitle around 4.5.
0:27:11 > 0:27:15En route to hospital, Mick is still in cardiac arrest and Bern is
0:27:15 > 0:27:19relying on the AutoPulse to protect his brain and vital organs.
0:27:21 > 0:27:26'I don't know what his quality of life is before I turned up on scene.'
0:27:26 > 0:27:32My role is to make sure I do the best for every patient all the time.
0:27:32 > 0:27:35And it's then up to them, it's then up to time.
0:27:35 > 0:27:38Just press the stop button for me.
0:27:42 > 0:27:44He's got an output.
0:27:44 > 0:27:4974 minutes after the 999 call, the physician response unit and the
0:27:49 > 0:27:53paramedics have brought Mick back from the dead for the third time.
0:27:53 > 0:27:56Yeah, yeah. He's got a nice radial pulse.
0:27:59 > 0:28:01The fight to keep him
0:28:01 > 0:28:04alive will continue at the London Chest Hospital,
0:28:04 > 0:28:08where he will be taken to a cath lab, a state-of-the-art facility
0:28:08 > 0:28:13where the team will be able to X-ray Mick's heart in minute detail.
0:28:13 > 0:28:15The best thing for him was to get into that cath lab
0:28:15 > 0:28:19and actually have them have a good look and see what his heart
0:28:19 > 0:28:23was doing, see whether there was a blockage in his blood vessel.
0:28:29 > 0:28:30Excuse me, guys.
0:28:30 > 0:28:33Who knows this guy the best?
0:28:33 > 0:28:35You do. Hi. Andrew.
0:28:35 > 0:28:37Nice to meet you.
0:28:37 > 0:28:41'The survival of cardiac arrest is improving dramatically.'
0:28:41 > 0:28:44Now, if you get resuscitated in good time,
0:28:44 > 0:28:46your prognosis can be excellent.
0:28:46 > 0:28:4865-year-old gentleman, standard CPR,
0:28:48 > 0:28:50when the first crew got there was in VF.
0:28:50 > 0:28:53He's had two shocks, return of spontaneous circulation,
0:28:53 > 0:28:56was making his own respiratory effort at that point.
0:28:56 > 0:28:58How long in total do you think he's been down?
0:28:58 > 0:29:02Total downtime, if you do it as accumulative, is probably
0:29:02 > 0:29:05going to be about 20-25 minutes, but that would be in separate chunks.
0:29:05 > 0:29:08- Past medical history?- Past medical history difficult to ascertain.
0:29:08 > 0:29:12Certainly chronic kidney disease. Yeah. It's tough.
0:29:12 > 0:29:15When I handed Michael over, I must admit, I did feel a bit of relief.
0:29:15 > 0:29:18We'd had quite a tough time with him pre-hospital.
0:29:18 > 0:29:21- Are you happy staying with that tube there?- Yeah.
0:29:23 > 0:29:26Who's ventilating?
0:29:32 > 0:29:35His blood pressure's just going up now.
0:29:41 > 0:29:45I think let's just get an angiogram first.
0:29:45 > 0:29:47Andrew begins by giving an angiogram,
0:29:47 > 0:29:49a digital X-ray with contrast fluid.
0:29:51 > 0:29:55'The overall plan for us is first of all to get pictures'
0:29:55 > 0:29:57of the blood vessels of his heart
0:29:57 > 0:30:00to confirm or exclude the diagnosis of a blocked blood vessel
0:30:00 > 0:30:02causing a heart attack.
0:30:02 > 0:30:05Let's just change over for the Jl4, please.
0:30:05 > 0:30:09The first thing I saw when we got the angiogram pictures
0:30:09 > 0:30:14was one of the main branches of that blood vessel was completely blocked.
0:30:14 > 0:30:17And the main artery itself had a very severe narrowing in.
0:30:17 > 0:30:19It wasn't completely blocked
0:30:19 > 0:30:22but it was effectively almost completely blocked.
0:30:23 > 0:30:27Andrew decides to perform a procedure called angioplasty to try
0:30:27 > 0:30:31and open up Mick's blocked artery and allow the blood to flow again.
0:30:35 > 0:30:40What we first had to do is to pass a small tube called a catheter
0:30:40 > 0:30:43up through a blood vessel in his leg, up to the heart.
0:30:48 > 0:30:50But minutes into the procedure,
0:30:50 > 0:30:53Andrew makes a discovery in Mick's abdomen.
0:30:58 > 0:31:00The arteries feel like chalk.
0:31:05 > 0:31:07He's got a massive aneurysm. Oh, crikey.
0:31:14 > 0:31:15How are we going to get out of it?
0:31:15 > 0:31:21An aneurysm is an abnormal swelling of a blood vessel inside the body.
0:31:22 > 0:31:25The main concern with them is that they can rupture and bleed
0:31:25 > 0:31:28and that technically makes it very difficult for us
0:31:28 > 0:31:31to manoeuvre our wires where we want to get them to.
0:31:32 > 0:31:35If Andrew snags the aneurysm with his wire,
0:31:35 > 0:31:38it could trigger a massive haemorrhage in Mick's abdomen.
0:31:40 > 0:31:44I can't... I'll be amazed if we can tort this.
0:31:46 > 0:31:47Flush, please.
0:32:01 > 0:32:04Stanley, I'm just going to ask you to do this twice.
0:32:04 > 0:32:07Can you open your mouth and take a deep breath in?
0:32:08 > 0:32:10Well done.
0:32:10 > 0:32:13OK. Just one more time.
0:32:13 > 0:32:16At the Royal London's major trauma centre,
0:32:16 > 0:32:1924-year-old Stanley is deteriorating fast.
0:32:19 > 0:32:21He has been stabbed three times
0:32:21 > 0:32:24and has a punctured lung that continues to collapse.
0:32:25 > 0:32:29Left untreated, it could develop into a tension pneumothorax
0:32:29 > 0:32:32and ultimately a cardiac arrest.
0:32:32 > 0:32:38A pneumothorax is a situation when the lining of the lung has popped.
0:32:38 > 0:32:42It's like a balloon. So you pop a balloon and all the air escapes.
0:32:42 > 0:32:44That is exactly what it's like.
0:32:44 > 0:32:48It escapes at a variable and not predictable rate.
0:32:48 > 0:32:52So it can collapse very slowly or it can collapse really fast.
0:32:52 > 0:32:55All that air that is escaping from the balloon, that is the lung,
0:32:55 > 0:32:59is accumulating within the chest wall, can't escape,
0:32:59 > 0:33:02so it just gets bigger and bigger and bigger
0:33:02 > 0:33:06and squashes everything else within the chest cavity.
0:33:06 > 0:33:08Helen must decide whether there is time for a CT scan
0:33:08 > 0:33:11before Stanley's punctured lung gets worse.
0:33:13 > 0:33:16He was going to need a CT scan of his chest and abdomen
0:33:16 > 0:33:20because of the injuries that we had found.
0:33:20 > 0:33:25We can either go to CT now before we put the chest drain in,
0:33:25 > 0:33:28but I think probably it's preferable to put the chest drain in
0:33:28 > 0:33:30so we can check the position with the CT.
0:33:30 > 0:33:33In that sort of situation,
0:33:33 > 0:33:37you have got no idea really how quickly a tension might develop.
0:33:37 > 0:33:42I took the decision that it was safer to put the chest drain in
0:33:42 > 0:33:45before we went to the CT scan.
0:33:49 > 0:33:53The team need to make a surgical incision
0:33:53 > 0:33:56to relieve the pressure in Stanley's chest and re-inflate his lung.
0:34:00 > 0:34:06It can seem strange that we as doctors seem to be inflicting
0:34:06 > 0:34:10yet more trauma on patients who have already suffered enough.
0:34:10 > 0:34:12HE MOANS
0:34:12 > 0:34:15All right, OK. Hang fire.
0:34:15 > 0:34:18But in order to treat their injuries,
0:34:18 > 0:34:23it is necessary to make more holes in the patient.
0:34:37 > 0:34:39HE MOANS
0:34:39 > 0:34:42Stanley's chest cavity is filling up with blood and air,
0:34:42 > 0:34:46which will potentially kill him unless the team can drain it away.
0:34:48 > 0:34:50The surgery is extremely painful
0:34:50 > 0:34:54but the team decide to administer a local anaesthetic
0:34:54 > 0:34:57as they need Stanley to respond to their instructions.
0:34:59 > 0:35:01When the drain is in,
0:35:01 > 0:35:03what I want him to do is take a really keep breath in,
0:35:03 > 0:35:05as pain permits him to,
0:35:05 > 0:35:10to try and push that air out, to expel that air and expand his lung.
0:35:11 > 0:35:15If I can expand his lung, he'll get more oxygen in his blood
0:35:15 > 0:35:19and he will then start to feel better and his pain will go down.
0:35:19 > 0:35:21His lung will fully expand.
0:35:25 > 0:35:29Take a deep breath in and out for me. A really deep breath. Good. And again.
0:35:29 > 0:35:31HE MOANS
0:35:32 > 0:35:34Is that painful?
0:35:37 > 0:35:39Do you understand what we are doing?
0:35:42 > 0:35:47Stanley, when you were stabbed, your lung was popped
0:35:47 > 0:35:51so we're just getting your lung back up to its normal size.
0:35:51 > 0:35:53I'm just going to give you some more pain relief.
0:35:53 > 0:35:55HE MOANS
0:36:11 > 0:36:1527-year-old Michael is bleeding profusely from his pelvis.
0:36:15 > 0:36:18He needs to go to interventional radiology
0:36:18 > 0:36:22to repair the damaged blood vessels and stop any further blood loss.
0:36:22 > 0:36:27But Samy and Simon are worried that he is too unstable to be moved.
0:36:27 > 0:36:29This patient was bleeding to death.
0:36:29 > 0:36:33Uncontrollably and from a place that we couldn't access
0:36:33 > 0:36:36and we couldn't stop immediately.
0:36:36 > 0:36:39We didn't think he was going to survive the journey,
0:36:39 > 0:36:41even the short journey to theatre.
0:36:42 > 0:36:45To try and keep Michael alive long enough,
0:36:45 > 0:36:49Samy and Simon are going to attempt an innovative procedure called REBOA.
0:36:52 > 0:36:59REBOA stands for Resuscitative Endovascular Balloon Occlusion of the Aorta.
0:36:59 > 0:37:03R-E-B-O-A, because that is too long to say.
0:37:03 > 0:37:06The procedure will involve blocking Michael's main artery
0:37:06 > 0:37:08with an inflated latex balloon.
0:37:09 > 0:37:13Effectively, what you are doing is cutting off the blood supply below the waist
0:37:13 > 0:37:17and obviously whilst that will stop the bleeding immediately,
0:37:17 > 0:37:20as soon as you cut off the blood supply to the limbs,
0:37:20 > 0:37:24they start becoming ischaemic and starved of oxygen.
0:37:25 > 0:37:30We should only inflict that on the body if there is absolutely no other solution.
0:37:30 > 0:37:31Just check for a central pulse, please.
0:37:31 > 0:37:34What we need is you to swap places with the ultrasound scanner.
0:37:34 > 0:37:37- You are going to do REBOA, yes? - Yes.- OK, thank you.
0:37:39 > 0:37:41The REBOA procedure will block the aorta,
0:37:41 > 0:37:43the major artery from the heart.
0:37:46 > 0:37:49This will stop blood flow in Michael's lower abdomen
0:37:49 > 0:37:53to the smaller arteries, which supply the lower half of the body with blood,
0:37:53 > 0:37:55including Michael's fractured pelvis.
0:37:57 > 0:38:00This will buy Simon and Samy time to rush him
0:38:00 > 0:38:02to interventional radiology.
0:38:02 > 0:38:05But the procedure is not without risk.
0:38:05 > 0:38:08By blocking that blood vessel and starving half of the body
0:38:08 > 0:38:13of oxygen and blood, it can have catastrophic effects itself.
0:38:13 > 0:38:15Right, we need to make some space.
0:38:15 > 0:38:18Only a handful of critically injured people in the UK have ever
0:38:18 > 0:38:20received this treatment for traumatic bleeding.
0:38:22 > 0:38:24But none are known to have survived.
0:38:25 > 0:38:29There is always an element of angst, I suppose,
0:38:29 > 0:38:32if you are performing a new procedure,
0:38:32 > 0:38:35a procedure that is new to you, new to the hospital,
0:38:35 > 0:38:39that is potentially new to the whole country.
0:38:39 > 0:38:42The procedure has been refined to be minimally invasive.
0:38:42 > 0:38:46Through an incision in Michael's groin, Sam has to carefully
0:38:46 > 0:38:49but quickly feed the deflated balloon up to his aorta
0:38:49 > 0:38:53so he can then inflate it and cut off the blood supply.
0:38:55 > 0:38:59We are blind and we are going by a predetermined set of distances
0:38:59 > 0:39:03and all we have really to guide us is the ultrasound to find entry site
0:39:03 > 0:39:08and from there on in, we're going by a predetermined set of distances
0:39:08 > 0:39:11and we are essentially blind until we get there.
0:39:11 > 0:39:15All the training, all the reading and all the preparation in the world
0:39:15 > 0:39:19are obviously essential, but you still feel a little bit nervous.
0:39:26 > 0:39:29It has migrated down to 30 centimetres and stopped,
0:39:29 > 0:39:32so I am going to leave it there. We're going to fix it down.
0:39:32 > 0:39:34We are going to pass a much longer wire,
0:39:34 > 0:39:37a wire that can go potentially all the way up to the heart
0:39:37 > 0:39:41and then we pass this balloon catheter over that wire.
0:39:44 > 0:39:48The REBOA is in. I will let you know once the balloon is up.
0:39:53 > 0:39:55We are going to block the aorta.
0:39:57 > 0:40:00- Simon, can you mark the time?- Yes.
0:40:01 > 0:40:04We know in trauma patients who have major haemorrhage,
0:40:04 > 0:40:10the major factor that determines their likelihood of surviving
0:40:10 > 0:40:14is the time between the injury and stopping the bleeding.
0:40:15 > 0:40:19The balloon is inflated and Samy has now cut off the blood supply
0:40:19 > 0:40:21to everything below Michael's waist.
0:40:25 > 0:40:27Just to let you know.
0:40:38 > 0:40:41We are going to go up to interventional radiology.
0:40:41 > 0:40:45Secure the lines. Secure the drains. Package him.
0:40:45 > 0:40:49As a result of the REBOA, Michael's muscle tissue below his waist
0:40:49 > 0:40:51is now starting to deteriorate.
0:40:52 > 0:40:56So Simon and Samy need to move quickly.
0:40:56 > 0:41:01Ready? Is everybody ready to move? On the anaesthetist's count.
0:41:15 > 0:41:18At the Royal London, the trauma team have re-inflated Stanley's left lung
0:41:18 > 0:41:22and drained away the excess air and fluid from his chest.
0:41:23 > 0:41:27With the chest drain in, the team send him for a CT scan
0:41:27 > 0:41:30to assess the damage caused by the other two stab wounds.
0:41:30 > 0:41:34It's amazing that little wound has done all that.
0:41:34 > 0:41:38When I examine his abdomen, his abdomen is soft,
0:41:38 > 0:41:42he's got a wound but he's tender in other parts of his belly,
0:41:42 > 0:41:45well away from where his wounds are. For me, that worries me.
0:41:45 > 0:41:48Has he got an abdomen full of blood? Is he bleeding from his liver?
0:41:48 > 0:41:50Is he bleeding from his stomach?
0:41:50 > 0:41:53Is he bleeding from major vessels within his abdomen?
0:42:00 > 0:42:03Trauma is a disease where you have to exclude everything.
0:42:03 > 0:42:05He has wounds to multiple cavities.
0:42:05 > 0:42:08It's important we rule out blood around the heart.
0:42:08 > 0:42:12It's important we rule out injuries to major vessels,
0:42:12 > 0:42:14major organs in his abdomen.
0:42:22 > 0:42:25Breathe in and hold your breath.
0:42:32 > 0:42:36- A tiny one there. - Where the chest drain can go.
0:42:41 > 0:42:43It's over the sternum.
0:42:44 > 0:42:48When I looked at his CT scan and knowing where his wound was,
0:42:48 > 0:42:49you can try and predict a track.
0:42:49 > 0:42:53Knives go in a straight line and looking at his liver, there was a
0:42:53 > 0:42:56suspicion that there was a little bit of bleeding where there shouldn't be.
0:43:00 > 0:43:02He's got one wound that is in the right upper quadrant.
0:43:02 > 0:43:05He's tender in the right.
0:43:05 > 0:43:08It looks like it just could have nicked the capsule of the liver.
0:43:08 > 0:43:11Yes. That makes sense.
0:43:12 > 0:43:16The CT scan has given a clearer picture of Stanley's injuries,
0:43:16 > 0:43:19including his right lung, which has also been punctured.
0:43:21 > 0:43:24It wasn't obvious on the X-ray so the CT scan helps us.
0:43:24 > 0:43:27It gives us more information and obviously it's important
0:43:27 > 0:43:30because he's got this wound that is where the chest meets
0:43:30 > 0:43:33the abdomen in a junctional wound where the knife track has
0:43:33 > 0:43:37potentially injured both his liver, his abdomen,
0:43:37 > 0:43:40abdominal contents and also gone into the chest.
0:43:40 > 0:43:42The drain needs to come back.
0:43:42 > 0:43:45The drain needs to come back a little bit.
0:43:45 > 0:43:47And the other one needs to go in.
0:43:58 > 0:44:01The team now need to drain the other side of Stanley's chest,
0:44:01 > 0:44:04which also has a build-up of blood and air.
0:44:04 > 0:44:07They will then have to re-inflate Stanley's right lung.
0:44:07 > 0:44:11I don't want to wait and assume he will be well.
0:44:11 > 0:44:14He has a build-up of air around his lung. Let's drain it off.
0:44:14 > 0:44:16We can't leave the blood in there.
0:44:16 > 0:44:18It leaves him prone to infections at a later date.
0:44:21 > 0:44:23Come closer to it.
0:44:28 > 0:44:29Stanley, are you OK?
0:44:29 > 0:44:33We've had to give you some painkillers to put some drains in your chest, all right?
0:44:33 > 0:44:36You've got some damage to your lungs.
0:44:36 > 0:44:39That is why you've got these drains in your chest, all right?
0:44:39 > 0:44:41But you'll be fine. OK?
0:44:53 > 0:44:55At the London Chest Hospital,
0:44:55 > 0:44:59Andrew is still battling to save Mick's life.
0:45:00 > 0:45:04To get to the blocked artery, Andrew needs to carefully navigate
0:45:04 > 0:45:08his surgical tools around a swollen blood vessel, or aneurysm,
0:45:08 > 0:45:10that he has just discovered in Mick's abdomen.
0:45:12 > 0:45:16The aneurysm itself is a pretty serious condition and if it ruptures it can cause fatal bleeding.
0:45:19 > 0:45:21Let's go around, please.
0:45:28 > 0:45:32OK. Roadmap that, please. Let's have the long wire back, please.
0:45:34 > 0:45:38When you've got a very tortuous blood vessel that you have to negotiate,
0:45:38 > 0:45:42it means it makes it much more difficult to steer the end of your catheter
0:45:42 > 0:45:46and actually get the support that you need to do to do the operation.
0:45:46 > 0:45:48We actually managed to negotiate the aneurysm
0:45:48 > 0:45:51and we got a clear understanding of what the problems were.
0:45:52 > 0:45:57Andrew thinks he's finally reached the blockage in Mick's artery in his heart.
0:45:59 > 0:46:02The way we treat any artery is that we first have to pass
0:46:02 > 0:46:04a very fine wire down through either the blockage
0:46:04 > 0:46:06or through the narrowed area.
0:46:10 > 0:46:14Essentially, it's a bit like a drinking straw that you put down into the blood vessel
0:46:14 > 0:46:18and then suck out any blood clot within the vessel.
0:46:18 > 0:46:21Can I have the balloon, please? Inflating the balloon.
0:46:21 > 0:46:24We then stretch the blood vessel with the balloon that we blow up
0:46:24 > 0:46:27inside where the blockage was to restore the blood flow.
0:46:27 > 0:46:29It went in quite nicely.
0:46:29 > 0:46:32And once that had been put in position,
0:46:32 > 0:46:34we blew the balloon up inside it.
0:46:38 > 0:46:39Let's have a 3528, please.
0:46:41 > 0:46:46The effect of the balloon is immediate as blood flow in Mick's heart dramatically improves.
0:46:47 > 0:46:49Right. We want to go quite a bit way down, don't we?
0:46:49 > 0:46:53There is some shoulder disease off the end of it as well that we'll cover.
0:46:53 > 0:46:56We got a very nice, what we call angiographic result,
0:46:56 > 0:47:01meaning that the pictures confirm that the blood flow to the heart muscle had been restored.
0:47:01 > 0:47:03OK. That looks really good.
0:47:03 > 0:47:06So the artery at the front of the heart, we're happy with.
0:47:06 > 0:47:09We've not been able to open the side branch,
0:47:09 > 0:47:12but we've certainly preserved the flow in the main artery.
0:47:18 > 0:47:22We've got to a position now where we can at least have a look and see what the heart looks like.
0:47:22 > 0:47:26The heart is contracting but it looks very severely impaired.
0:47:27 > 0:47:31You should be seeing this main pump here, which is the left ventricle,
0:47:31 > 0:47:33contracting much more vigorously.
0:47:33 > 0:47:36So you would be seeing the walls coming close together
0:47:36 > 0:47:39and the muscle would be thickening nicely with each contraction.
0:47:52 > 0:47:5527-year-old Michael has a fractured pelvis
0:47:55 > 0:47:57and is suffering from major internal bleeding.
0:47:59 > 0:48:02To try and keep him alive, the trauma team have cut the blood
0:48:02 > 0:48:06supply to the lower half of his body through a process called REBOA.
0:48:08 > 0:48:11He's now been moved to interventional radiology.
0:48:14 > 0:48:18Using X-ray and contrast fluid, Rob, the radiologist,
0:48:18 > 0:48:20can identify the damaged blood vessels
0:48:20 > 0:48:24and inject a clotting gel to stop them bleeding in his pelvis.
0:48:27 > 0:48:30We knew that he had a pelvic fracture
0:48:30 > 0:48:33but we didn't really know exactly where the bleeding was coming from.
0:48:33 > 0:48:36We suspected it was from somewhere within the pelvis
0:48:36 > 0:48:40but he was never stable enough to get him into the CT scanner.
0:48:40 > 0:48:43We were hoping that Rob would be able to find a bleeding point
0:48:43 > 0:48:48but when we went there, it was a hope and we weren't really sure whether we would be able to do that.
0:48:51 > 0:48:54When we got the patient to interventional radiology,
0:48:54 > 0:48:58Rob inserted a catheter into one of the blood vessels in the groin
0:48:58 > 0:49:02and then through that he was able to insert a wire
0:49:02 > 0:49:06and inject some contrast, which is a dye which shows up on X-rays.
0:49:06 > 0:49:10The aim of that was to look for any ongoing bleeding points
0:49:10 > 0:49:15and identify them and then try and stop the bleeding from those points
0:49:15 > 0:49:21by injecting something which causes blood to clot in those vessels.
0:49:26 > 0:49:30For the last 40 minutes, the REBOA balloon has stopped Michael bleeding to death.
0:49:31 > 0:49:34But as Rob begins, there is a problem.
0:49:41 > 0:49:43I think we may have to let the balloon down.
0:49:45 > 0:49:48I think that is the vessels but I can't see them very well at all.
0:49:50 > 0:49:55Because we had blocked the aorta, he couldn't see the femoral artery.
0:49:55 > 0:49:57He could not see where he needed to go.
0:49:59 > 0:50:03The lack of blood flow means the arteries are now too small to access.
0:50:05 > 0:50:09Simon, Samy and Rob need to take a calculated risk.
0:50:16 > 0:50:18We had to deflate the balloon,
0:50:18 > 0:50:22um...which was necessary to allow blood flow into the vessels
0:50:22 > 0:50:26to give Rob a chance of seeing where the bleeding points were
0:50:26 > 0:50:28and then to try and stop the bleeding from there.
0:50:28 > 0:50:31The lower half of Michael's body
0:50:31 > 0:50:34has been without blood flow for over 40 minutes.
0:50:34 > 0:50:38And deadly toxins are likely to be building up in his legs.
0:50:40 > 0:50:44The worst-case scenario would be on deflating the balloon,
0:50:44 > 0:50:48if these toxins take their toll just a little bit too much
0:50:48 > 0:50:51as they are flushed out of the body.
0:50:51 > 0:50:53They make the heart extremely unstable
0:50:53 > 0:50:55and the patient could have a cardiac arrest.
0:50:58 > 0:51:01The other immediate danger is that you haven't quite controlled
0:51:01 > 0:51:02the bleeding as well as you think.
0:51:02 > 0:51:08You deflate the balloon and the patient bleeds out continuously.
0:51:10 > 0:51:12- The balloon's deflating now, OK?- OK.
0:51:14 > 0:51:17It was the first time we'd all done this particular procedure,
0:51:17 > 0:51:20so none of us really knew exactly what was going to happen.
0:51:25 > 0:51:27BEEPING
0:51:29 > 0:51:31BEEPING
0:51:34 > 0:51:36The balloon is down.
0:51:38 > 0:51:40Michael remains stable.
0:51:40 > 0:51:44Simon and Samy have given Rob a window of opportunity
0:51:44 > 0:51:47to fix the source of the internal bleeding.
0:51:47 > 0:51:51He starts by injecting a clotting gel into the damaged blood vessels.
0:51:58 > 0:52:02OK. You can see it starting to slow down the flow down there,
0:52:02 > 0:52:05so that's hopefully done the trick.
0:52:07 > 0:52:11All right. His gas is really good. He's pretty much back to normal.
0:52:11 > 0:52:15It's as good as you can hope it can be, really.
0:52:15 > 0:52:17It was becoming apparent to me
0:52:17 > 0:52:21and the rest of the team that he seemed to be turning the corner
0:52:21 > 0:52:25and was stabilising and was not continuing to bleed.
0:52:29 > 0:52:31I think one of the beneficial effects of the balloon
0:52:31 > 0:52:35was that it had slowed and stopped the bleeding to such an effect
0:52:35 > 0:52:38that allowed the body to clot to some degree.
0:52:38 > 0:52:41Um...and again, just give us enough time to get in
0:52:41 > 0:52:43with the interventional radiologist
0:52:43 > 0:52:45to find all of the sites of bleeding.
0:52:45 > 0:52:49I've gel foamed both his internal iliac arteries,
0:52:49 > 0:52:53which supply pretty much everything
0:52:53 > 0:52:56in the pelvis on both sides.
0:52:56 > 0:52:58Hopefully, that's temporarily
0:52:58 > 0:53:01at least slowed down the flow in both those vessels.
0:53:01 > 0:53:05His heart rate's come down, so hopefully, that's done enough.
0:53:06 > 0:53:10Michael has stopped bleeding from his pelvis.
0:53:10 > 0:53:12He becomes the first patient in Britain to have survived
0:53:12 > 0:53:15the refined REBOA procedure.
0:53:15 > 0:53:20He will now need extensive surgery to repair his other injuries.
0:53:20 > 0:53:23But for now, Simon, Samy and the trauma team
0:53:23 > 0:53:25have stopped him bleeding to death.
0:53:25 > 0:53:31In some ways, I was...surprised,
0:53:31 > 0:53:34but more relieved that this went so well.
0:53:34 > 0:53:37It's something we've had quite a large build-up to here at the Royal London.
0:53:37 > 0:53:40It is a big...thing to embark on.
0:53:40 > 0:53:42It's a very new and novel procedure.
0:53:42 > 0:53:46So, yeah, um...very relieved and a little bit surprised.
0:53:50 > 0:53:53He doesn't seem to be at the moment, does he?
0:53:53 > 0:53:55No, I know. His blood gas is great.
0:54:14 > 0:54:17OK, Stanley. Can you hear me?
0:54:17 > 0:54:20Stanley, on that day, I think was very lucky.
0:54:20 > 0:54:25There was a huge chain of people involved in his care.
0:54:27 > 0:54:32He's particularly lucky because the system that exists here in London
0:54:32 > 0:54:36can nuance his care in a very bespoke way
0:54:36 > 0:54:39that many systems around the world can't do.
0:54:42 > 0:54:45I remember asking myself if that's how I was going to go.
0:54:45 > 0:54:48Like, if that was my final moment on Earth.
0:54:52 > 0:54:56I believe that if they didn't get there as fast as they did,
0:54:56 > 0:54:58I would not be sitting here today.
0:54:58 > 0:55:01So yes, it was a miracle.
0:55:22 > 0:55:25A month or two ago, before we had REBOA as an option,
0:55:25 > 0:55:27our only option would have been to open his chest
0:55:27 > 0:55:29from one side to the other
0:55:29 > 0:55:33and manually press on the aorta with your hand to stop the bleeding.
0:55:33 > 0:55:38That obviously carries with it lots of complications.
0:55:38 > 0:55:40We would have inflicted a big, big injury
0:55:40 > 0:55:43on top of the injuries he already had.
0:55:43 > 0:55:46So lots of things were aligned, if you like,
0:55:46 > 0:55:49to enable him to survive this, I think.
0:55:49 > 0:55:51So yeah, in that respect, he's very lucky indeed.
0:56:07 > 0:56:11So despite, um...all of these very active treatments that we had
0:56:11 > 0:56:15trying to support almost every aspect of Michael's body,
0:56:15 > 0:56:17he continued to deteriorate
0:56:17 > 0:56:20and unfortunately, he died the next day.
0:56:20 > 0:56:22You wouldn't be in this field
0:56:22 > 0:56:27if you didn't have faces or cases that stick with you.
0:56:27 > 0:56:30At least his family had a chance to see him.
0:56:30 > 0:56:34His mum was at his bedside.
0:56:34 > 0:56:37She could at least come to terms with what had happened
0:56:37 > 0:56:41and she could be there when he did ultimately die.
0:56:41 > 0:56:45Um...and for me, that's, you know,
0:56:45 > 0:56:48that's as good as it could be for Michael, I guess.
0:57:09 > 0:57:14Next time, tree surgeon Ben falls 20 feet onto the pavement.
0:57:14 > 0:57:16- So, he landed more on his side than on his back?- Yeah.
0:57:16 > 0:57:20Grandmother Gudrun collapses in her hotel.
0:57:24 > 0:57:27And Vincent is involved in a high-speed collision.
0:57:27 > 0:57:29Really pale feet.
0:57:29 > 0:57:31You can find out more about trauma
0:57:31 > 0:57:35and emergency care with the Open University's free booklet.