On the Edge An Hour To Save Your Life

This programme contains scenes which some viewers may find upsetting

DISPATCHER: 'Emergency ambulance. What's the nature of the emergency?'

The moment an emergency call is made,

a battle against time begins.

-DISPATCHER: 'Is she awake?'

-'No. She looks dead.'

FAINT DISPATCHER

The decisions that are made in the first 60 minutes for major trauma patients

will make the difference between life and death.

If we can intervene within the first 60 minutes or so, the so-called golden hour,

then we know we can positively affect your outcome.

The sooner a doctor can reach their patient,

the more likely they are to survive.

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

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

In their race against the clock, doctors and paramedics are now

taking the hospital to those at the very edge of life.

We're pretty close. SIRENS WAIL

The more equipment and expertise and knowledge

we can get out on to the street or the scene of the accident,

then we will save more people's lives.

Armed with new treatments and equipment...

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

..they're performing surgery on the roadside.

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

Administering powerful drugs.

Draw us up 200 of tranexamic acid.

Using innovative techniques.

If you pull that one and I'll pull this one.

Pushing the boundaries of science...

The REBOA is in.

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

..to save time and to save lives.

We've got to go.

This series will count down second by second, minute by minute

the crucial decisions made in the first 60 minutes of emergency care.

One hour, the difference between life and death.

London. Home to over 8 million.

Every hour, eight people will face a life-threatening

emergency in this sprawling metropolis.

This film will follow three patients through 60 minutes of care

that will push the limits of scientific innovation.

In London, 24-year-old Stanley is stabbed three times in the chest.

In Kent, a high-speed road accident

critically injures 27-year-old Michael.

-Is his blood running?

-Yep.

-OK.

And 68-year-old Mick collapses in north London.

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

From the moment each emergency call is made, the clock starts ticking.

INCOMING CALL

Hello.

Cardiac arrest.

Hello, there. I've got a job for you.

Map reference is 32 November Bravo.

Ambulance control has just received a call about an elderly male

whose heart has stopped beating in a betting shop.

Dr Ben Clarke, part of a medical unit specialising in cardiac arrest,

is tasked to the job.

As soon as I hear the term cardiac arrest,

I know the heart isn't pumping blood, the brain isn't getting oxygen,

the heart isn't getting oxygen,

the other really vital organs in the body aren't getting oxygen.

That's totally blocked. How are you meant to...?

It's completely blocked up.

SIRENS WAIL Ah, come on!

Every second counts and time is most definitely of the essence.

Maybe just pull up around the corner in front.

First on scene, a paramedic crew has already restarted Mick's heart.

But as Ben arrives, he goes into cardiac arrest again.

You're good, mate. Stay as you are.

We know that that period around when someone's had a cardiac arrest

and if they get spontaneous circulation,

it's an incredibly fragile time for the body.

When he re-arrests, I then think,

"Right, OK, we need to obviously manage this

"and we need to get on this and manage it assertively."

What I saw straightaway was that he was a fairly large gentleman.

He also looked very dusky.

And by that, his colour was awful and it indicated to me

that his cardiac perfusion, or the ability of his heart

to pump blood around his body was perhaps compromised.

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

In a patient who's got a cardiac arrest,

their level of consciousness is essentially zero.

They're comatose. They're clinically dead.

-Back in VF.

-He's just gone back into VF.

VF or ventricular fibrillation, is a major cause of cardiac arrest

and occurs when the muscles inside the heart

quiver rather than contract,

meaning Mick's heart is unable to supply

the rest of his body with oxygen.

The ambulance crew initiate CPR to try to do the job for him.

Would I be able to get you to have a quick listen to his chest?

Do you want to grab my tubes?

I remember when I was a junior doctor seeing my first cardiac arrest

and the first time I saw someone getting CPR.

It looks awful. It looks brutal.

Um...it looks out of control.

And for anyone who hasn't seen it before,

it almost looks like an assault.

We don't really have any other choice unfortunately.

Ben is worried that they still can't get a stable heartbeat from Mick

and that they're starting to lose him.

We know that chest compressions

aren't as good as a heart beating for itself.

So automatically, I know that his brain, his heart,

his other organs probably have had a lower level of oxygen

than they normally should have.

And so for me, the first clinical decision in that phase was,

let's establish a more definitive airway

so I can be sure that we're ventilating him appropriately.

-Now might be an opportune time to get that tube in. What do you think?

-Yep.

The team insert a tube into Mick's airway

to squeeze oxygen directly into his lungs mechanically with a bag.

Our priority then is actually

just making sure we get the breathing tube into the trachea.

You can see the tube's passed the chords.

Cool. That means she's out.

Just make sure, mate, you're not getting too tired with your CPR.

-He's due for an analyse in a second.

-Good.

-So, are you happy with that tube?

-Yep.

-It's just a nightmare.

At the same time, the paramedics

try to get a normal heart rhythm back for Mick.

We can administer an electric shock

and that can often restart the heart into a more appropriate rhythm.

Yeah. Let's shock that. Shock that.

-Stand clear!

-All clear, guys.

All right. Is the CPR back on?

But the electric shock hasn't worked.

Mick's heart is still not beating correctly and he's fading fast.

Unless we got things sorted fairly quickly,

there was a very, very good chance that he would die.

Ten minutes ago, across London,

a call came in about a young man

who's been attacked after an argument.

London's Air Ambulance is en route

with an advanced trauma team on board.

The minute you get a call for a stabbing, you're anxious

because you know it's really important to get there quickly.

They can literally bleed to death in a few minutes.

We know he's been stabbed in the chest.

You can't help but feel a degree of anxiety.

For every minute you're sat in the helicopter twiddling your thumbs,

I imagine a heart that's pouring out blood that I need to stitch.

It may be something that requires open-heart surgery.

So we literally have to take the kitchen and the kitchen sink.

I was dreading opening the doors to see what we were going to see.

Stanley, my name's Dr Davies.

Gareth's immediate concern is the exact location

-of Stanley's stab wounds.

-Hold on, hold on.

Stanley could quite easily trick a causal observer

or a young doctor or young paramedic.

Because the wounds are small. They don't bleed.

And the patient looks big and healthy.

But right underneath those wounds

is some of the major clockwork of the body.

The heart, the aorta,

are literally only inches from some of those wounds.

Stanley has three stab wounds to his chest.

Any one of them could be fatal.

I was worried by the fact he was so sweaty and clammy,

which...can be very subtle.

And you may only pick it up simply by touch.

You won't see the beads of sweat on someone's forehead.

And that again is a sign that the body

is really fighting for survival.

Stanley, my name's Dr Davies. Can you speak to me?

Stanley's not speaking

and his breathing is gradually getting worse.

Stanley was so silent that day because he knew he was ill.

He was fighting for, er...for his life.

His brain was telling him,

"I can't breathe, I can't oxygenate myself."

And actually, his way of dealing with that is actually not to talk,

but to focus and to use hand gestures.

Does your breathing feel normal or not? No, it's not.

When I looked at Stanley, there was a key decision to make, which is,

how far down a dying process is he?

Young people actually protect themselves to the bitter end.

And they can stay conscious,

they can have high heart rates and high blood pressures

and then eventually, all of their compensatory mechanisms fall apart.

And they can fall apart in literally a few seconds or minutes.

So they can look quite well.

So it's quite difficult to know

how far Stanley is down that particular line.

OK. Just bring your neck up.

Gareth is most concerned about a possible punctured lung,

or even a wound to Stanley's heart.

He now faces a dilemma.

Is he well enough for us to essentially work en route,

get the ambulance moving and start heading for hospital,

or is he in such a position that actually, no, we have to stop,

we have to get out all our equipment,

we have to start draining collapsed lungs at the roadside,

or perhaps think about doing open-heart surgery?

It's a judgment call, it's an experiential call.

In Stanley's case, it felt prudent

and best for him actually to get moving.

Shall we just...?

Gareth decides to fast-track Stanley to the Royal London Hospital.

SIRENS WAIL

In north London, 68-year-old Mick remains critically ill.

We've got two leads in there.

Mate, we should, um...ACD and AutoPulse, as well.

His heart muscles are not beating properly

and his body isn't getting enough oxygen.

This was an incredibly challenging environment.

Not only are we in the shop,

we have furniture that's banked up around this gentleman.

Sorry, mate. Excuse me, please.

For Michael and for us, this was a really difficult scenario.

His condition couldn't be any more severe. He was essentially dead.

All right, guys, we're going to chuck him on the AutoPulse machine.

Ben can't get Mick's heart back into a regular rhythm.

He decides to continue treatment with an AutoPulse machine.

The AutoPulse is essentially providing the cardiac output

that the heart can't do for itself.

And it's ensuring that the tissues get exactly what they need,

and that's oxygen, pretty much, in this case.

Ready, brace, lift. Straight up.

The reason we use it is because we know it's more effective than us at CPR.

There have been studies that show it does a better job

at getting the blood around the body than we do.

It also doesn't get tired.

-Good stuff. Happy?

-Yep.

-All right, guys...

The AutoPulse is one of only a handful of mechanical CPR machines

on the streets of London.

The aesthetics of it are dramatic. How it looks. You've got the noise.

It all sounds very mechanical.

Whilst it looks fairly confronting,

it's actually probably one of the best ways in the pre-hospital

setting of ensuring that we get the blood around the body.

If we didn't have the AutoPulse, my inclination would be to

stay on scene and see if we could get the heart beating by itself.

If we can, what we might look to do is actually

we can transport him on the AutoPulse.

-So, guys, we'll go on lift.

-That's all right, don't worry.

-Everyone got it?

-Yeah.

-OK, on lift again. Ready? Brace, lift.

All right.

Right. Try that. Can we just pull it out?

-I've got that, I've got that.

-If we can just get it out.

So his entitle is 4.3.

We're due another rhythm check now, so are you happy just to stop?

Pause that, yeah. Oh, feel for a pulse.

-We've got an entitle of 4.3.

-I have a pulse.

-Excellent.

All right, guys. Nice job. Really well done.

He had a cardiac output, so his heart had restarted.

What that meant then was we could stop the AutoPulse

'and we could then actually just get going.'

Really well done, guys.

Although Mick's heart has returned to a normal rhythm,

he could re-arrest at any moment.

The AutoPulse now allows Ben to move Mick to

hospital as fast as possible.

'We either stayed until the bitter end in the betting shop,'

or we take him to hospital, try and get him to the angiography lab

and see if we can open up a blocked blood vessel.

He's a 70-year-old bloke who's had a witnessed VF arrest.

Two shocks, got return of spontaneous circulation,

then he's had a subsequent VF arrest.

I rang the cardiologist, who is the heart specialist at London Chest,

and the purpose of that, essentially, is to prepare them.

It also allows them

to provide any distinct advice for this patient to me.

Appropriate cardiac arrest patients in London are now taken

directly to specialist cardiac units, bypassing A&E.

You can have as much expertise as you wish,

sitting with the patient on scene,

but unless you actually have the system in place that ensures the

patient gets from the betting shop and then goes to the place where he's

going to receive definitive care,

unless you have that system in place, it's all null and void.

Perfect. Thanks very much. All right, we'll see you soon. Cheers.

But before they can leave, Mick crashes again.

Heart rate's slowing down. We've got a pulse rate of 40 at the moment.

All right, so... His entitles... He's looking...very ropey, isn't he?

It looks like, yeah... He's about to arrest.

No, he is. You're absolutely right.

Do you want to start the AutoPulse again?

'The monitoring had changed.'

Michael's heart wasn't pumping effectively.

Yeah, stand by, mate. He's just arrested again.

For the third time, Mick's heart has stopped beating again.

At that point in time, I was thinking he wasn't going to make it.

Plain and simple.

Yeah, mate. Good to go.

SIREN

All right, mate. So, London Chest.

And if you can give me a ten-minute warning, that'd be awesome.

The Royal London Hospital is one of the UK's leading trauma

and emergency care centres.

And across the South East of England, it can be the last

chance of survival for those on the very edge of life.

27-year-old Michael has been involved in a catastrophic

road accident and is being airlifted from Kent,

52 miles away from central London.

He has a suspected broken pelvis and severe internal bleeding.

He's been classed as code red.

'We received a priority call from the ambulance doctor.

'The code red trauma call.'

We only put out code red trauma call for the most severely injured

patients where we believe that massive haemorrhage is

an issue for them.

We've got chest drains? Yeah, two chest drains.

'The patient that was coming in,'

from the priority call information, was one of the most severely

injured people that I'd had to look after for a long time.

'The heart rate does go up a bit.'

Michael has already been given a blood transfusion to stop him

bleeding to death at the roadside.

But his blood loss is so extreme that the hospital begins

preparing blood products to treat him with.

Right, bye.

We all know we have to make quick decisions

and we have to make some big decisions.

We prime ourselves and set things up

in a certain way to try and facilitate that and to allow

everything to happen smoothly and quickly.

Good evening. Hello.

The air ambulance team prepare to hand Michael over.

OK, let's get the handover then, please.

27-year-old male who was riding a motorbike at 60mph

when he T-boned into a car, pulling out and turning right.

He fell off the bike sideways, ending up underneath the car

and the bike skidded out to the right.

The team need to keep supplying Michael with blood,

whilst quickly trying to assess the scale of his injuries.

Percussion that is resonant bilaterally. Bilateral thoracotomy.

No obvious lung bone injuries.

OK, has he got central pulse?

'Despite having four units of blood in a very short period of time

'when he arrived, his heart rate was very high, 160,'

his blood pressure was very low, he'd actually had unrecordable

blood pressures for the last hour or so, from scene to hospital.

And...essentially, he was bleeding to death.

Very, very quickly.

I can see a pulse...

Bring it right in here now.

-So he's got a central pulse?

-Yeah.

OK, can you start the blood through the Belmont?

We need to do it fast as well, don't we?

Can we just do that now, quickly?

Thank you.

Simon orders an ultrasound scan to try

and identify any large pools of blood collecting in Michael's

three main cavities - his chest, his abdomen or his pelvis.

'With blunt trauma, as was the case with this patient,'

the blood loss is often concealed within the body,

so although the patient had signs of massive haemorrhage, there

wasn't blood pouring out all over the floor, all over the trolley.

It's easier to deal with that because

if you can see where the blood's coming from, it's easier to stop it.

It's more of a challenge when the blood is somewhere within

one of the body cavities and we don't know exactly where.

So heart rate is very fast.

Right lung is up.

-So blood running?

-Yeah.

OK.

The ultrasound scan has shown that Michael is bleeding into his

pelvis and is deteriorating rapidly in front of the team.

He's obviously still badly unstable.

He's had four units of blood, tranexamic acid.

I wanted to get him into interventional radiology to

give the radiologists a chance to try and stop that bleeding.

But I didn't think he was going to survive the journey.

SIREN WAILS

Can I just check that we've got everyone we should have?

We've got Fiona, anaesthetist... Are you going to do the primary survey?

-Which bay is this person going to?

-That one, there.

54 minutes after the 999 call,

Gareth hands Stanley over to the trauma team leader, Helen.

When we hear that we're receiving a patient who's been stabbed,

it could be nothing,

or it could it could be something

that's imminently life-threatening.

Good afternoon, everybody.

This is a gentleman believed to be called Stanley, approximately

20 years of age, has allegedly been assaulted with a knife.

'You're trying to compress what is effectively 40-45 minutes'

of time and history and events and interventions

into a form that the receiving doctor can handle and process.

He's got three incisional wounds, all of approximately 0.5 to 1cm

in length.

He has been complaining of a lot of pain, he's had morphine...

OK.

Hello.

Stanley?

'He had relatively innocuous looking wounds,'

but it's impossible to tell from the outside,

looking at that wound, what the underlying damage is.

If you can imagine a knitting needle that's driven straight through

the chest, it would leave very little signs of external damage,

but could have pierced any number of vital internal organs.

Stanley, I'm just going to examine your chest.

Are you feeling short of breath at all?

Are you having trouble breathing?

Of Stanley's three stab wounds,

Helen is concentrating on the one on the left side of his chest.

X-rays, please.

She's worried it's punctured his lung and is stopping him

from breathing properly.

Three, two, one... Thank you.

I've seen the left pneumothorax.

'His left lung was partially collapsed,'

so the implement, the knife I think it was,

had penetrated the surface of the lung and it had popped.

Saturations are 86. On how much oxygen?

15 litres.

OK.

But Stanley's breathing suddenly deteriorates.

I'm just going to give you some pain relief, OK?

If we find a collapsed lung following penetrating trauma,

we're instantly concerned that that collapsed lung will very rapidly

collapse down even further and the patient will have a cardiac arrest.

Have we got all the monitoring on at the moment?

For the last 60 minutes, frontline medics have fought to keep

three critically-ill patients alive.

But the battle is far from over.

The decisions made for Mick, Stanley and Michael have bought

doctors more time to now try and save their lives.

So that's his blood pressure.

So we'll be aiming for an entitle around 4.5.

En route to hospital, Mick is still in cardiac arrest and Bern is

relying on the AutoPulse to protect his brain and vital organs.

'I don't know what his quality of life is before I turned up on scene.'

My role is to make sure I do the best for every patient all the time.

And it's then up to them, it's then up to time.

Just press the stop button for me.

He's got an output.

74 minutes after the 999 call, the physician response unit and the

paramedics have brought Mick back from the dead for the third time.

Yeah, yeah. He's got a nice radial pulse.

The fight to keep him

alive will continue at the London Chest Hospital,

where he will be taken to a cath lab, a state-of-the-art facility

where the team will be able to X-ray Mick's heart in minute detail.

The best thing for him was to get into that cath lab

and actually have them have a good look and see what his heart

was doing, see whether there was a blockage in his blood vessel.

Excuse me, guys.

Who knows this guy the best?

You do. Hi. Andrew.

Nice to meet you.

'The survival of cardiac arrest is improving dramatically.'

Now, if you get resuscitated in good time,

your prognosis can be excellent.

65-year-old gentleman, standard CPR,

when the first crew got there was in VF.

He's had two shocks, return of spontaneous circulation,

was making his own respiratory effort at that point.

How long in total do you think he's been down?

Total downtime, if you do it as accumulative, is probably

going to be about 20-25 minutes, but that would be in separate chunks.

-Past medical history?

-Past medical history difficult to ascertain.

Certainly chronic kidney disease. Yeah. It's tough.

When I handed Michael over, I must admit, I did feel a bit of relief.

We'd had quite a tough time with him pre-hospital.

-Are you happy staying with that tube there?

-Yeah.

Who's ventilating?

His blood pressure's just going up now.

I think let's just get an angiogram first.

Andrew begins by giving an angiogram,

a digital X-ray with contrast fluid.

'The overall plan for us is first of all to get pictures'

of the blood vessels of his heart

to confirm or exclude the diagnosis of a blocked blood vessel

causing a heart attack.

Let's just change over for the Jl4, please.

The first thing I saw when we got the angiogram pictures

was one of the main branches of that blood vessel was completely blocked.

And the main artery itself had a very severe narrowing in.

It wasn't completely blocked

but it was effectively almost completely blocked.

Andrew decides to perform a procedure called angioplasty to try

and open up Mick's blocked artery and allow the blood to flow again.

What we first had to do is to pass a small tube called a catheter

up through a blood vessel in his leg, up to the heart.

But minutes into the procedure,

Andrew makes a discovery in Mick's abdomen.

The arteries feel like chalk.

He's got a massive aneurysm. Oh, crikey.

How are we going to get out of it?

An aneurysm is an abnormal swelling of a blood vessel inside the body.

The main concern with them is that they can rupture and bleed

and that technically makes it very difficult for us

to manoeuvre our wires where we want to get them to.

If Andrew snags the aneurysm with his wire,

it could trigger a massive haemorrhage in Mick's abdomen.

I can't... I'll be amazed if we can tort this.

Flush, please.

Stanley, I'm just going to ask you to do this twice.

Can you open your mouth and take a deep breath in?

Well done.

OK. Just one more time.

At the Royal London's major trauma centre,

24-year-old Stanley is deteriorating fast.

He has been stabbed three times

and has a punctured lung that continues to collapse.

Left untreated, it could develop into a tension pneumothorax

and ultimately a cardiac arrest.

A pneumothorax is a situation when the lining of the lung has popped.

It's like a balloon. So you pop a balloon and all the air escapes.

That is exactly what it's like.

It escapes at a variable and not predictable rate.

So it can collapse very slowly or it can collapse really fast.

All that air that is escaping from the balloon, that is the lung,

is accumulating within the chest wall, can't escape,

so it just gets bigger and bigger and bigger

and squashes everything else within the chest cavity.

Helen must decide whether there is time for a CT scan

before Stanley's punctured lung gets worse.

He was going to need a CT scan of his chest and abdomen

because of the injuries that we had found.

We can either go to CT now before we put the chest drain in,

but I think probably it's preferable to put the chest drain in

so we can check the position with the CT.

In that sort of situation,

you have got no idea really how quickly a tension might develop.

I took the decision that it was safer to put the chest drain in

before we went to the CT scan.

The team need to make a surgical incision

to relieve the pressure in Stanley's chest and re-inflate his lung.

It can seem strange that we as doctors seem to be inflicting

yet more trauma on patients who have already suffered enough.

HE MOANS

All right, OK. Hang fire.

But in order to treat their injuries,

it is necessary to make more holes in the patient.

HE MOANS

Stanley's chest cavity is filling up with blood and air,

which will potentially kill him unless the team can drain it away.

The surgery is extremely painful

but the team decide to administer a local anaesthetic

as they need Stanley to respond to their instructions.

When the drain is in,

what I want him to do is take a really keep breath in,

as pain permits him to,

to try and push that air out, to expel that air and expand his lung.

If I can expand his lung, he'll get more oxygen in his blood

and he will then start to feel better and his pain will go down.

His lung will fully expand.

Take a deep breath in and out for me. A really deep breath. Good. And again.

HE MOANS

Is that painful?

Do you understand what we are doing?

Stanley, when you were stabbed, your lung was popped

so we're just getting your lung back up to its normal size.

I'm just going to give you some more pain relief.

HE MOANS

27-year-old Michael is bleeding profusely from his pelvis.

He needs to go to interventional radiology

to repair the damaged blood vessels and stop any further blood loss.

But Samy and Simon are worried that he is too unstable to be moved.

This patient was bleeding to death.

Uncontrollably and from a place that we couldn't access

and we couldn't stop immediately.

We didn't think he was going to survive the journey,

even the short journey to theatre.

To try and keep Michael alive long enough,

Samy and Simon are going to attempt an innovative procedure called REBOA.

REBOA stands for Resuscitative Endovascular Balloon Occlusion of the Aorta.

R-E-B-O-A, because that is too long to say.

The procedure will involve blocking Michael's main artery

with an inflated latex balloon.

Effectively, what you are doing is cutting off the blood supply below the waist

and obviously whilst that will stop the bleeding immediately,

as soon as you cut off the blood supply to the limbs,

they start becoming ischaemic and starved of oxygen.

We should only inflict that on the body if there is absolutely no other solution.

Just check for a central pulse, please.

What we need is you to swap places with the ultrasound scanner.

-You are going to do REBOA, yes?

-Yes.

-OK, thank you.

The REBOA procedure will block the aorta,

the major artery from the heart.

This will stop blood flow in Michael's lower abdomen

to the smaller arteries, which supply the lower half of the body with blood,

including Michael's fractured pelvis.

This will buy Simon and Samy time to rush him

to interventional radiology.

But the procedure is not without risk.

By blocking that blood vessel and starving half of the body

of oxygen and blood, it can have catastrophic effects itself.

Right, we need to make some space.

Only a handful of critically injured people in the UK have ever

received this treatment for traumatic bleeding.

But none are known to have survived.

There is always an element of angst, I suppose,

if you are performing a new procedure,

a procedure that is new to you, new to the hospital,

that is potentially new to the whole country.

The procedure has been refined to be minimally invasive.

Through an incision in Michael's groin, Sam has to carefully

but quickly feed the deflated balloon up to his aorta

so he can then inflate it and cut off the blood supply.

We are blind and we are going by a predetermined set of distances

and all we have really to guide us is the ultrasound to find entry site

and from there on in, we're going by a predetermined set of distances

and we are essentially blind until we get there.

All the training, all the reading and all the preparation in the world

are obviously essential, but you still feel a little bit nervous.

It has migrated down to 30 centimetres and stopped,

so I am going to leave it there. We're going to fix it down.

We are going to pass a much longer wire,

a wire that can go potentially all the way up to the heart

and then we pass this balloon catheter over that wire.

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

We are going to block the aorta.

-Simon, can you mark the time?

-Yes.

We know in trauma patients who have major haemorrhage,

the major factor that determines their likelihood of surviving

is the time between the injury and stopping the bleeding.

The balloon is inflated and Samy has now cut off the blood supply

to everything below Michael's waist.

Just to let you know.

We are going to go up to interventional radiology.

Secure the lines. Secure the drains. Package him.

As a result of the REBOA, Michael's muscle tissue below his waist

is now starting to deteriorate.

So Simon and Samy need to move quickly.

Ready? Is everybody ready to move? On the anaesthetist's count.

At the Royal London, the trauma team have re-inflated Stanley's left lung

and drained away the excess air and fluid from his chest.

With the chest drain in, the team send him for a CT scan

to assess the damage caused by the other two stab wounds.

It's amazing that little wound has done all that.

When I examine his abdomen, his abdomen is soft,

he's got a wound but he's tender in other parts of his belly,

well away from where his wounds are. For me, that worries me.

Has he got an abdomen full of blood? Is he bleeding from his liver?

Is he bleeding from his stomach?

Is he bleeding from major vessels within his abdomen?

Trauma is a disease where you have to exclude everything.

He has wounds to multiple cavities.

It's important we rule out blood around the heart.

It's important we rule out injuries to major vessels,

major organs in his abdomen.

Breathe in and hold your breath.

-A tiny one there.

-Where the chest drain can go.

It's over the sternum.

When I looked at his CT scan and knowing where his wound was,

you can try and predict a track.

Knives go in a straight line and looking at his liver, there was a

suspicion that there was a little bit of bleeding where there shouldn't be.

He's got one wound that is in the right upper quadrant.

He's tender in the right.

It looks like it just could have nicked the capsule of the liver.

Yes. That makes sense.

The CT scan has given a clearer picture of Stanley's injuries,

including his right lung, which has also been punctured.

It wasn't obvious on the X-ray so the CT scan helps us.

It gives us more information and obviously it's important

because he's got this wound that is where the chest meets

the abdomen in a junctional wound where the knife track has

potentially injured both his liver, his abdomen,

abdominal contents and also gone into the chest.

The drain needs to come back.

The drain needs to come back a little bit.

And the other one needs to go in.

The team now need to drain the other side of Stanley's chest,

which also has a build-up of blood and air.

They will then have to re-inflate Stanley's right lung.

I don't want to wait and assume he will be well.

He has a build-up of air around his lung. Let's drain it off.

We can't leave the blood in there.

It leaves him prone to infections at a later date.

Come closer to it.

Stanley, are you OK?

We've had to give you some painkillers to put some drains in your chest, all right?

You've got some damage to your lungs.

That is why you've got these drains in your chest, all right?

But you'll be fine. OK?

At the London Chest Hospital,

Andrew is still battling to save Mick's life.

To get to the blocked artery, Andrew needs to carefully navigate

his surgical tools around a swollen blood vessel, or aneurysm,

that he has just discovered in Mick's abdomen.

The aneurysm itself is a pretty serious condition and if it ruptures it can cause fatal bleeding.

Let's go around, please.

OK. Roadmap that, please. Let's have the long wire back, please.

When you've got a very tortuous blood vessel that you have to negotiate,

it means it makes it much more difficult to steer the end of your catheter

and actually get the support that you need to do to do the operation.

We actually managed to negotiate the aneurysm

and we got a clear understanding of what the problems were.

Andrew thinks he's finally reached the blockage in Mick's artery in his heart.

The way we treat any artery is that we first have to pass

a very fine wire down through either the blockage

or through the narrowed area.

Essentially, it's a bit like a drinking straw that you put down into the blood vessel

and then suck out any blood clot within the vessel.

Can I have the balloon, please? Inflating the balloon.

We then stretch the blood vessel with the balloon that we blow up

inside where the blockage was to restore the blood flow.

It went in quite nicely.

And once that had been put in position,

we blew the balloon up inside it.

Let's have a 3528, please.

The effect of the balloon is immediate as blood flow in Mick's heart dramatically improves.

Right. We want to go quite a bit way down, don't we?

There is some shoulder disease off the end of it as well that we'll cover.

We got a very nice, what we call angiographic result,

meaning that the pictures confirm that the blood flow to the heart muscle had been restored.

OK. That looks really good.

So the artery at the front of the heart, we're happy with.

We've not been able to open the side branch,

but we've certainly preserved the flow in the main artery.

We've got to a position now where we can at least have a look and see what the heart looks like.

The heart is contracting but it looks very severely impaired.

You should be seeing this main pump here, which is the left ventricle,

contracting much more vigorously.

So you would be seeing the walls coming close together

and the muscle would be thickening nicely with each contraction.

27-year-old Michael has a fractured pelvis

and is suffering from major internal bleeding.

To try and keep him alive, the trauma team have cut the blood

supply to the lower half of his body through a process called REBOA.

He's now been moved to interventional radiology.

Using X-ray and contrast fluid, Rob, the radiologist,

can identify the damaged blood vessels

and inject a clotting gel to stop them bleeding in his pelvis.

We knew that he had a pelvic fracture

but we didn't really know exactly where the bleeding was coming from.

We suspected it was from somewhere within the pelvis

but he was never stable enough to get him into the CT scanner.

We were hoping that Rob would be able to find a bleeding point

but when we went there, it was a hope and we weren't really sure whether we would be able to do that.

When we got the patient to interventional radiology,

Rob inserted a catheter into one of the blood vessels in the groin

and then through that he was able to insert a wire

and inject some contrast, which is a dye which shows up on X-rays.

The aim of that was to look for any ongoing bleeding points

and identify them and then try and stop the bleeding from those points

by injecting something which causes blood to clot in those vessels.

For the last 40 minutes, the REBOA balloon has stopped Michael bleeding to death.

But as Rob begins, there is a problem.

I think we may have to let the balloon down.

I think that is the vessels but I can't see them very well at all.

Because we had blocked the aorta, he couldn't see the femoral artery.

He could not see where he needed to go.

The lack of blood flow means the arteries are now too small to access.

Simon, Samy and Rob need to take a calculated risk.

We had to deflate the balloon,

um...which was necessary to allow blood flow into the vessels

to give Rob a chance of seeing where the bleeding points were

and then to try and stop the bleeding from there.

The lower half of Michael's body

has been without blood flow for over 40 minutes.

And deadly toxins are likely to be building up in his legs.

The worst-case scenario would be on deflating the balloon,

if these toxins take their toll just a little bit too much

as they are flushed out of the body.

They make the heart extremely unstable

and the patient could have a cardiac arrest.

The other immediate danger is that you haven't quite controlled

the bleeding as well as you think.

You deflate the balloon and the patient bleeds out continuously.

-The balloon's deflating now, OK?

-OK.

It was the first time we'd all done this particular procedure,

so none of us really knew exactly what was going to happen.

BEEPING

BEEPING

The balloon is down.

Michael remains stable.

Simon and Samy have given Rob a window of opportunity

to fix the source of the internal bleeding.

He starts by injecting a clotting gel into the damaged blood vessels.

OK. You can see it starting to slow down the flow down there,

so that's hopefully done the trick.

All right. His gas is really good. He's pretty much back to normal.

It's as good as you can hope it can be, really.

It was becoming apparent to me

and the rest of the team that he seemed to be turning the corner

and was stabilising and was not continuing to bleed.

I think one of the beneficial effects of the balloon

was that it had slowed and stopped the bleeding to such an effect

that allowed the body to clot to some degree.

Um...and again, just give us enough time to get in

with the interventional radiologist

to find all of the sites of bleeding.

I've gel foamed both his internal iliac arteries,

which supply pretty much everything

in the pelvis on both sides.

Hopefully, that's temporarily

at least slowed down the flow in both those vessels.

His heart rate's come down, so hopefully, that's done enough.

Michael has stopped bleeding from his pelvis.

He becomes the first patient in Britain to have survived

the refined REBOA procedure.

He will now need extensive surgery to repair his other injuries.

But for now, Simon, Samy and the trauma team

have stopped him bleeding to death.

In some ways, I was...surprised,

but more relieved that this went so well.

It's something we've had quite a large build-up to here at the Royal London.

It is a big...thing to embark on.

It's a very new and novel procedure.

So, yeah, um...very relieved and a little bit surprised.

He doesn't seem to be at the moment, does he?

No, I know. His blood gas is great.

OK, Stanley. Can you hear me?

Stanley, on that day, I think was very lucky.

There was a huge chain of people involved in his care.

He's particularly lucky because the system that exists here in London

can nuance his care in a very bespoke way

that many systems around the world can't do.

I remember asking myself if that's how I was going to go.

Like, if that was my final moment on Earth.

I believe that if they didn't get there as fast as they did,

I would not be sitting here today.

So yes, it was a miracle.

A month or two ago, before we had REBOA as an option,

our only option would have been to open his chest

from one side to the other

and manually press on the aorta with your hand to stop the bleeding.

That obviously carries with it lots of complications.

We would have inflicted a big, big injury

on top of the injuries he already had.

So lots of things were aligned, if you like,

to enable him to survive this, I think.

So yeah, in that respect, he's very lucky indeed.

So despite, um...all of these very active treatments that we had

trying to support almost every aspect of Michael's body,

he continued to deteriorate

and unfortunately, he died the next day.

You wouldn't be in this field

if you didn't have faces or cases that stick with you.

At least his family had a chance to see him.

His mum was at his bedside.

She could at least come to terms with what had happened

and she could be there when he did ultimately die.

Um...and for me, that's, you know,

that's as good as it could be for Michael, I guess.

Next time, tree surgeon Ben falls 20 feet onto the pavement.

-So, he landed more on his side than on his back?

-Yeah.

Grandmother Gudrun collapses in her hotel.

And Vincent is involved in a high-speed collision.

Really pale feet.

You can find out more about trauma

and emergency care with the Open University's free booklet.