Episode 4 An Hour To Save Your Life

RINGING TONE Hello, ambulance service.

There's a guy just got hit by a bus.

He was on a bike. He's been really badly injured.

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

This programme contains scenes which some viewers may find upsetting

Female lying on the road, struggling to breathe.

The golden hour is the opportunity that we have to save the patient.

Deep breaths, George.

'The longer the clock ticks,'

the increased likelihood there is of death.

In the fight for survival, time is the enemy.

I'm ventilating fast on purpose.

Yeah. I'm hoping that heart rate will pick up any second.

Now, new techniques and technology

are bringing emergency medicine to the roadside...

We can use the Infrascanner to give us a slightly clearer picture

of what's going on underneath the skull.

..breaking new ground and treating patients faster than ever before.

We can now provide emergency surgery, blood transfusions,

anaesthesia at the scene of the accident.

Yeah, through the cords. Tube, please. Tube on.

We follow three patients through the crucial first hour of care.

In central London, a man collapses at work

with a suspected cardiac arrest.

We are going to anaesthetise him here.

In Newcastle, a mother of three

fights for her life after being stabbed.

How big was the knife?

And a cyclist in Durham suffers horrific crush injuries,

after being hit by a bus.

Let's get the blood in.

60 minutes that will change their lives for ever.

You will constantly be surprised

just what you can bring back from the jaws of death.

OPERATOR: Emergency ambulance, tell me exactly what's happened.

WOMAN: He's out cold.

Is he awake? He wasn't.

Is he breathing? I don't know,

I think he might be choking.

In central London, an emergency call

has just been received about a man

who has collapsed from

a suspected cardiac arrest at work.

SIREN WAILS

It's near Charterhouse Street. OK, fine, keep going.

On duty in London's Air Ambulance's emergency medical car

are consultant Anne Weaver and paramedic Bill Leaning.

They are only minutes from the scene.

'Cardiac arrest is a time-critical incident.

'It's essential that the patient gets'

immediate care, that can be from a bystander or a professional.

It doesn't really matter,

as long as someone takes action as quickly as possible.

Do you want to just carry the bag for us? Cheers.

Come and hold that for me. Cheers, thank you very much.

62-year-old Michael collapsed in a corridor

and his heart stopped beating.

A London Ambulance Service paramedic is already on the scene.

Michael is now breathing again, but deeply unconscious.

All right sweetheart, hello. You all right, mate?

OK. Someone grab a Guedel, thanks.

Yeah, of course. And some oxygen.

I can see he's got a facial injury, he's got blood coming from his nose,

but the most worrying thing is his breathing is not normal.

He's got a lot of blood in his airway.

We don't know what his facial damage is,

but any damage to the airway

instantly compromises you as a person,

because you've got to breathe.

If you're not breathing, you're in trouble.

Matt, you grab that.

Anne suspects Michael's body is being starved of oxygen,

and needs to act fast

before organs like his brain begin to suffer and die.

One more. OK.

What I need you to do is put a finger behind each jaw, each side,

and just lift it up. Yeah.

We're trying to stop that snoring noise.

I'm going to insert a plastic airway into his nose,

to make sure there is wide-open channels

for the oxygen to be delivered down to his lungs.

Knowing that Michael is deeply unconscious,

Anne urgently needs to find out what happened when he collapsed.

You're all right, mate.

Who was here first, or saw him collapse?

He was following me up the stairs,

I was walking upstairs from the ground floor to the third floor,

and he was sort of running behind me.

He just groaned and fell forward. Onto his face? Yeah. OK.

For someone to say he just went forward, that's quite worrying.

'It sounds as though he's completely lost

'the blood supply to the part of his brain that keeps you awake,'

and he's literally just gone down very, very hard, immediately.

Where's that blood coming from? It that from his nose?

Have we got a bit of gauze to stop it?

One of the first people to help Michael

was co-worker Emily, a trained first-aider.

I very much felt that this person in front of me was about to die.

He started to go slightly darker purple,

perhaps a slightly blue colour.

Did you have to do CPR?

I had to. Did you have to breathe for him?

We tried that, but the man at the 999 on the phone said don't do it.

OK, all right.

We took the decision to go through the resuscitation routine,

which includes CPR and the defibrillator.

Well done, yeah, you've done a good job helping him.

The prompt actions of Michael's co-workers restarted his heart,

but the cause of his arrest is still unclear.

'It's wide open at that point in time, as to what is the cause.

'There's a possibility that Michael's had a bleed'

inside his head, that could be

what we call an intracranial or intracerebral bleed,

or it could be that he's had a cardiac event,

he's had an arrhythmia, or he's had a heart attack.

OK, so we've got a heart rate of 130, sats of 100.

His pupils are equal, he's breathing,

but he's fallen onto his face.

Michael?

Michael?

OK, probably GCS 3.

Yeah. Can we get a 12-lead ECG, please?

Connecting Michael to an electrocardiogram, or ECG,

will allow Anne to look for any changes in heart rhythm

or electrical patterns

that could point to the cause of his cardiac arrest.

Anne, there's your ECG.

OK guys, his ECG isn't entirely normal from a cardiac point of view.

He's got some ST depression, inferiorly and laterally.

But I'm slightly worried it could be a cerebral event as well.

His ECG shows some abnormalities,

but the changes are not diagnostic of an acute heart attack,

but they're not entirely normal.

Those changes could be attributed to a bleed on the brain.

Anne is concerned that Michael may have had a brain haemorrhage

that is affecting the area controlling his lungs and heart.

A further bleed could be life-threatening to him.

Time is critical,

whether or not it's Michael's heart or whether it's his brain,

either way, we need to get a diagnosis as quickly as possible.

16 minutes ago in Northumberland,

emergency services received a call

from a suburban street

on the outskirts of Newcastle.

Ambulance service, can you tell me what the problem is?

Yeah, they put a knife in my wife.

She's been stabbed? Please, I need an ambulance, please!

Sir, you need to tell me what's happened.

Is she breathing?

Yes... Please...

Listen, don't worry, an emergency ambulance has been arranged, OK?

OK, OK.

North East Ambulance Service senior paramedic Gary Shaw

is in one of three ambulances dispatched to the scene.

AMBULANCE RADIO: 'Anyone on the air, got a detail in North Shields.

'A patient, multiple stabbing.'

Yeah, roger, just send it on, thanks.

Multiple stabbings.

I was given information from our control room that we had a female,

possibly stabbed in the neck.

You have major vessels within the neck. If they are damaged,

you bleed really heavily and quickly from those wounds.

Stabbed in the neck and the chest.

Wounds to the chest are obviously very dangerous ones,

you've got your heart within your chest, your lungs,

all of your vital organs.

If that's not dealt with really quickly,

you're then looking at the potential for a fatality at scene.

The stab victim is Gidia, a young mother of three.

Paramedic Phil Blance is rapidly assessing

where the knife has penetrated.

Say again? Chest wound?

Chest wound, deep, possibly full thickness.

In the sternum?

Yes, sternum. Both sides of the neck.

She'd been stabbed in the centre of her chest,

and she had some lacerations to her neck, as well.

OK, 134/106.

Sats are 86.

'It doesn't have to be long or particularly wide,'

anything that penetrates that area, because of the major vessels,

is potentially fatal for the patient.

Right, we're good. Excuse me, honey,

we're going to be going on blue lights and sirens, OK?

We've got access. Yes.

'Pre-hospitally, I can't see, internally,'

if there's any damage, you've just got to suspect the worst.

SIREN WAILS

Phil is rushing Gidia to the nearest major trauma centre

at Newcastle's Royal Victoria Infirmary.

How big was the knife?

Ten inches?

A big one? A kitchen knife?

'I was quite surprised when the lady said it was a ten-inch knife,'

which does have a different impact on your treatment.

'The size does matter.

'We've got to assume it has gone in ten inches,'

that's the main concern for us.

And your date of birth?

01... Yeah? 'Where she was stabbed in the centre of her chest,

'the knife could have punctured the lung. If the lung collapses'

due to the stabbing, you have a build-up of air

in what they call the pleural cavity.

If air is allowed to build up in her chest,

Gidia will struggle to breathe.

'We will place a Russell Chest Seal,

'which acts as a valve that lets the air out

'but doesn't let the air in.'

196, I wonder if you could pre-alert the RVI, please?

Are you ready for the details? Over.

Yes, we have a 36-year-old female who has three stab wounds.

The first stab wound

is in the centre of her chest, in the sternum.

There's a Russell Chest Seal in situ.

Phil phones ahead to Newcastle's RVI Hospital

to alert the major trauma team to prepare for Gidia's arrival.

The second stab wound is to the left side of her neck,

she has a small laceration to the right side of her head.

Gidia's life will be in the hands

of emergency medicine consultant Sohom Maitra.

The sternum and twice in the neck.

GCS 15, blood pressure OK.

I think it'll probably be a question of how deep,

the usual sort of thing.

My current concern is that she has an injury

in two areas of the body, the neck and the chest,

where there are vital organs and vital vessels,

and I am very concerned that she could have active bleeding

in and around her heart, or in and around her lungs,

and also in and around the main vessels of her neck.

SIREN WAILS

Sats are up at 97.

'You are constantly reassessing all the time.'

Reassessing her airway,

looking at the monitor to see if her heart rate is increasing.

Although Gidia appears stable,

her body could be masking a life-threatening injury.

Phil knows she could deteriorate at any time.

Pulse, 82 and regular.

BM is 11.4.

You are always aware that things

can change quite dramatically en route to hospital.

SIRENS DROWN SPEECH

In central London,

62-year-old office worker Michael

is still unconscious after suffering

a suspected cardiac arrest at work.

It may not be his heart, so it's a possibility...

It could be his head. Better off doing... Yeah.

Anne urgently needs to get Michael to a hospital

to diagnose whether the arrest

was caused by a brain haemorrhage or a heart problem.

If he has had an intracerebral bleed,

there may be something that a neurosurgeon can do about it.

'Equally, if he has had a cardiac event, again,

'he may need a time-critical intervention.'

But before she can move him, she needs to address his breathing.

Michael currently isn't breathing normally. He is breathing,

but it is not regular and it is not a normal depth or pattern.

How much O2 have we got left?

Have we got only one O2 bottle up here?

Oh, right. Have we only got that cylinder?

That cylinder at the moment and one on the truck.

Michael's abnormal breathing risks starving his vital organs of oxygen

and could cause brain damage or trigger another cardiac arrest.

You're just going to do a little roll,

just enough for me to get this side of the scoop in.

One, two, three.

Anne decides to anaesthetise Michael and take over his breathing.

Right, if we've got the oxygen, let's pop that between his legs.

We are going to anaesthetise him here, so I need total quiet.

It's really important

that everything is kept strictly cordoned off now.

I have taken a lot of thought about whether Michael needs this.

I have given him some time to see if he recovers

but he is still deeply unconscious.

This procedure will mean that his airway is protected

and, to some extent, we can also control the level of oxygen

to make sure, if he does have a brain injury,

we minimise any further insult to his brain.

OK, straight on to the trolley. Pull that closed. So, people,

we're going to give him some drugs to put him to sleep, OK?

Can I get you to just hold his arm straight for me, please? Thanks.

Michael is given a combination of strong sedative drugs

to relax his airway and paralyse his chest muscles.

Sats are 97, pulse rate is 85.

In simple terms, we are stopping the patient breathing.

Michael is breathing.

We are now going to stop him breathing.

The responsibility that comes with that is massive.

OK, I'm going to get you to stay there for a minute

and I'm just going to get you

to hold his neck while we intubate him, OK?

Can you just hold his head?

Right, there's a lot of blood. Suction?

Now the drugs have taken effect,

Anne has seconds to insert a breathing tube

through Michael's vocal cords and down his windpipe.

Just pop your hand where my finger is, just there.

OK, bougie, please. Bougie in your hand.

'It is a very tense moment.'

Just support the top of it, Phil, the top of the bougie.

'If I can't get that tube through the cords,'

Michael isn't going to breathe.

Someone has to do that for him

and I need a way of getting oxygen down into his lungs.

Yeah, through the cords. Tube, please. Tube on the bougie.

If I fail completely,

I may have to make a hole in the front of his neck,

so I'm hoping I can get the tube down first time.

Tube is through.

OK, bougie out, please. Watch your eyes.

Bougie out. OK, let go of the tube, thanks.

With the tube in place,

Anne must now manually control Michael's breathing.

OK, give me a bag.

And again.

'It's a huge relief when we know that we can ventilate Michael.'

We know we can deliver oxygen effectively.

It's a bit quieter on that side.

'He is in that place now where he needs definitive treatment'

and that can only be delivered by a specialist centre.

What are our sats? Sats are 5 now.

OK, good, let's just get this out of the way.

But without a clear cause for Michael's cardiac arrest,

Anne now faces a difficult decision -

whether to take Michael to a cardiac centre to investigate his heart,

or to a major trauma centre to look at his brain.

I have to decide what I think the top diagnosis is,

which hospital I am going to take him to.

If I take him to the cardiac centre,

they investigate him and treat him for his heart,

that may involve him having anticoagulation drugs,

which will thin his blood.

If he has a brain injury, that could make it worse.

If they anticoagulated him and he had a bleed inside his head,

a further bleed could be life-threatening to him,

so it's important that we rule that out by doing a CT scan.

Guys, just so everyone is clear,

we're going to go to the London and get his head scanned.

So, could we have a lift available, fellas, to go? Thank you.

Anne is taking Michael to the Royal London Hospital

where specialist neurosurgeons will be able to find out

if he has suffered a severe brain haemorrhage.

Excuse us, mate.

Thank you.

There is a big risk, if you go to the London

and there's nothing wrong with his head,

now we are, again, into minutes of his heart dying.

We're going to go to the London. I will put the blue call in.

I've got a feeling it's going to be the wrong hospital

but I think we have to get his head scanned first.

Guys, we're going to do a U-turn and go down...

Right, so, I've got a male.

He has collapsed at work in the City

but has fallen forwards and has got facial injuries.

It's a possible cardiac event,

but I'm coming to you cos I think we need to scan his head

and put him through as a trauma call.

We'll be with you in eight minutes.

All right? Yeah, we're good.

SIREN WAILS

In Newcastle, it's been 42 minutes

since an ambulance was called

to Gidia, a young mother of three,

stabbed multiple times with a knife.

Suspecting internal bleeding, the medical team

are rushing her to the major trauma centre at Newcastle 's RVI.

OK, ladies and gentlemen,

this is a 35-year-old lady who, at around 10 o'clock today,

has suffered multiple stab wounds to the chest and neck.

Injuries sustained.

She has a right central stab wound to the chest,

a deep laceration to the left side of her neck,

blood pressure 120/60,

respiratory 70 and sats are 96.

'It's very difficult to work out,

'just from looking from the outside, what is underneath.'

A stab wound could have gone anywhere,

gone to any depth and involved anything.

Sohom's urgent priority is to decide if any of Gidia's major organs

have been struck by the knife.

OK, we're just having a little look at these wounds, all right?

GIDIA GROANS I know it's quite sore.

We're going to give you something for your pain.

I'm very much worried about the heart and the lungs,

I'm also worried about the vessels in her neck,

which supply oxygen and blood to the brain.

Can I ask you to stick your tongue out?

That is quite a deep wound.

Just to the right of the upper part of the sternum.

Is that sore if I press on your voice box there?

GIDIA MOANS Yeah, OK.

'She was a little tender over the top of her voice box,

'which does create a concern in my mind that there may be damage.

'It can swell up and block the airway

'and stop oxygen going to the brain.

'I am really worried as to how much is she covering

'for what may be going on underneath.'

Does it hurt when you move your tongue?

Although Gidia looks stable,

Sohom is aware that things can change rapidly.

She is a young person and young people, particularly, in trauma

can compensate and hold on to their blood pressure

and heart rate and oxygen levels for an extremely long time,

right up until moments or seconds

before they actually go into cardiac arrest or die.

Do you want to have a little look,

if there's any lung points on ultrasound?

Fearing that Gidia could deteriorate at any minute,

Sohom saves critical time using a portable ultrasound

to check her vital organs.

Ultrasound is fantastic in the resuscitation effort

and it provides answers very timely at the bedside for...

"Is the lung affected?" Yes/no.

"Is the heart affected in a major way?" Yes/no.

That's fine. And on the right.

I think you have got enough of a view to say it looks OK.

OK, Gidia, we are just finishing the ultrasound scan,

we have looked at the lung and it looks OK so far

which is good news, and we're just having a look at your tummy as well.

Whilst Gidia's lungs appear unharmed on the ultrasound,

Sohom is concerned it can't tell the whole story.

We want to know more than just a yes/no answer

as to whether something is affected,

we want detail, we want major detail.

Craig, are you all right giving...?

Would you mind giving them a ring in CT?

The CT scan will reveal whether Gidia is bleeding internally.

After this, we will need to do some scans, called CT scans,

to make sure that there is no injury to anything else.

Is there something underneath that is slowly building,

whether it is a small drip-drip effect

or whether it's something more severe than that,

whereby, actually, we are about to run into problems very, very quickly

but we don't know it yet?

51 minutes ago, at North East Ambulance Service control,

operators received a call about a man in Durham

in critical condition after a serious road accident.

OPERATOR: Hello, ambulance service. Can you tell me what the problem is?

We will get somebody there as quickly as we can.

Code red trauma, 20 minutes.

An air ambulance team are already at the scene and issue a code red alert

to Newcastle's Royal Victoria Hospital

to prepare them to receive a patient suffering from severe blood loss.

He has got pre-hospital blood coming...going

and he's got bilateral thoracotomies.

I think the main thing is to move quickly.

Emergency medicine consultant Bas Sen

is heading up a specialist team

that will be treating 31-year-old Ben.

If you have any blood ready,

he has a cannula in his right antecubital fossa.

He probably needs that attaching as soon as you can. OK.

31-year-old male, injured in Durham about an hour ago.

He is a cyclist, underneath a bus and had to be extricated.

Ben has severe injuries to his chest,

which is deformed, and possible pelvic injury as well,

he has had two units of red cells en route.

His last blood pressure was 110 systolic.

Heart rate is still in the 130s.

So evidence of severe chest injury and bleeding.

OK, thanks, Phil.

The weight of the bus has crushed Ben's chest,

causing major internal bleeding.

The concealed haemorrhage is when you bleed into a body cavity

so you can't see it but it is as serious as external haemorrhage.

To save Ben's life and get him to hospital,

the air ambulance team

have given him two units of blood and anaesthetised him.

But Ben is still bleeding heavily and his levels are dangerously low.

Haemorrhagic shock is a condition where

the patient is losing blood actively

and there isn't enough blood to go around the system.

The major organs start to shut down, like your brain and your heart,

this does mean that Ben is dying if there is no intervention.

But before the team can start to treat Ben's injuries,

Bas must address his massive internal bleeding.

OK, chaps, can we get the blood in and started, please?

That is our priority.

Let's get the blood in. Can I have the blood, please?

In response to the code red call,

blood products such as red blood cells, plasma and platelets,

have been ordered and are ready and waiting for Ben.

Is that blood going?

He will need a combination of all three just to keep him alive.

I knew we had to move very quickly into CT scan

to find out where he was bleeding from.

Airway, are you happy? OK.

But Ben is dangerously unstable

and too ill to be moved to the scanner.

He has got a pretty bad crush to his chest.

'The decision I had to make was whether to wait'

and stabilise his chest further or whether to go straight for CT.

He has bilateral chest movement.

So, at the moment, we are happy from a B point of view.

So, Alan, circulation. Has he got a peripheral pulse?

He does, he has... a very faint radial.

He's got a faint radial? OK.

'We had satisfactory breathing'

but his circulation was worrying me.

Can't really feel his femoral, in fact. Not very good.

Is the blood going, chaps? Yes. All right.

'Ben was losing a significant amount of blood'

and we couldn't get a satisfactory radial pulse.

A weak pulse in Ben's wrist

means there is not enough blood in his system

and he is losing it faster than they can replace it.

If Bas can't increase Ben's blood levels,

it could trigger a cardiac arrest.

Miriam, is the peripheral line not working?

It is not brilliant, we are not getting more than...

OK, go for it. Go for it.

I knew that what I needed to do here was to save his circulation.

I decided to make sure

that we replaced sufficient blood in his system

for him to have time to go through a CT scan.

Have you got a decent pulse there? No, it's very, very...

That is what I need to know from you guys.

Are you happy with the stroke volume or not,

or do you want to transfuse him with more?

We could do with about five minutes of transfusion.

OK, that is fine.

If that is all right.

Bas must now wait for the transfusion to take effect.

Only once Ben has a stable pulse and blood pressure can he go to CT.

Five minutes.

Yeah.

In the last 60 minutes,

emergency clinicians have battled

to deliver medical interventions

to three critically ill patients.

Having survived the cardiac arrest,

Michael has been anaesthetised and his treatment now rests

on doctors determining the exact cause.

Cyclist Ben is being transfused with blood

and doctors now need to locate the source of his internal bleeding.

And after a knife attack

has left mother-of-three Gidia with multiple stab wounds,

the team are using the latest equipment

to look for any injury that could threaten her life.

It has been 20 minutes since cyclist Ben arrived

at Newcastle's major trauma centre after being crushed by a bus.

Blood pressure is 124/88.

Continuous blood transfusions have so far kept Ben alive.

Bas now needs to scan him

to find the source of his internal bleeding as soon as possible.

Marie? No, we don't. OK.

'The longer you leave it,'

the more you are risking

the patient suffering from multi-organ failure.

I have seen patients die within minutes.

Bas is finally able to see

the severity of the injuries Ben has sustained.

What's the state of his lungs? Can you see them?

VARIOUS MUTTERED REPLIES

The bus crushed his chest,

so this is almost like your chest becomes flat

and when that happens, all your ribs break.

Ben's ribs have been severed from his breastbone

and his shattered ribcage has punctured both lungs.

OK. We have got gas under there. Mm-hm.

'Ben's chest showed significant injuries to both his lungs

'and his lungs had collapsed about 50%.'

He had almost every abnormality we could find.

OK, as long as he is not bleeding into his chest.

But despite a life-threatening injury to Ben's chest,

the source of his internal bleeding remains unclear.

As the scan moves down Ben's body,

Bas must look at one organ at a time.

As we went into Ben's abdomen,

it showed that he was bleeding significantly from his spleen

and I could see by looking at the scans

that his spleen was in two bits.

Ben's spleen has been torn into pieces by his shattered ribcage,

causing catastrophic bleeding.

He is bleeding into a cavity called the peritoneal cavity,

which is in the abdomen.

This artery that feeds into the spleen

has to be clamped off and tied because you can lose

your whole blood volume into a cavity like the peritoneum.

I think the priority is to get the drains in.

OK, I will make sure that Steve is primed and ready to go.

It's... We can put the arterial line in any...

That's not a therapeutic intervention.

I am just a bit concerned about his abdominal haemorrhage.

Ben requires immediate surgery on his spleen

to stop his internal bleeding,

but the scans show that Ben's lungs are still collapsed

and air is building in his chest cavity.

When he took a deep breath in, air leaked out of his lungs

and the air was trapped in his body.

If we left the situation as it is, the air would crush his lungs.

Unless Bas can relieve the pressure on Ben's lungs,

he won't survive the operation to stop his bleeding.

OK, chaps, we are going to take him out, take him back,

put his drains in and then he goes to theatre

and it will have to be done fairly quickly.

Bas gains access to Ben's chest cavity

through holes made in his side by the air ambulance team at the scene.

Put your finger in and make sure you are in the pleural cavity, yeah?

Yeah. Can you feel the lung? I can feel the lung, yeah. OK, good.

Tubes are inserted into the holes to keep them open

and allow any build-up of pressure

caused by air or fluids to be released.

OK, done?

With Ben's breathing now under control,

Bas can send him to get the surgery he so desperately needs.

At the Royal London Hospital,

office worker Michael is returning to the ambulance

after undergoing a CT scan of his head.

Michael's head scan looks normal,

we can't see any bleeding in the brain or around the brain,

which is reassuring.

Good to go? Yeah.

How long will it take us to get to Barts from here?

Having ruled out a brain haemorrhage,

Anne now suspects Michael's cardiac arrest

to be the result of a heart problem.

She now urgently needs to get Michael

to Barts Heart Centre for further investigation.

Hello, it is Anne Weaver,

I just rang about a patient we are bringing in,

we will be with you in about four minutes.

If he has got a blocked coronary artery, for example,

or partially blocked, that is still a risk,

we haven't fixed that and we still need to consider

that he could have another cardiac arrest at any time.

Anne is passing over Michael's care to a specialist team, headed up

by consultant interventional cardiologist John Hogan.

62-year-old man, we anaesthetised him at the scene in Holborn,

it could either be cerebral or cardiac.

It has improved, but he has got...

John must think carefully about treating Michael's heart

as any intervention he makes from here

requires the use of drugs that thin the blood.

He could be bleeding slowly within the skull

and that may not be apparent on the first scan

or there may only be a small bleed

but if we were to give him our drugs which interfere with blood clotting,

it may aggravate any tendency to bleed

and if he was to have a brisk bleed into his skull

that would be very threatening.

At the moment, he has got facial fractures

with some blood in his maxillary sinuses.

Having spent the last hour thinking hard about this,

I am more and more convinced that his heart is the problem

so I'm trying to hand that over to my colleagues.

All right.

I think we look, just to look,

cos we have come this far,

and just to turn our backs would not be right.

I think he is a collapse, he needed CPR,

we don't know if he had...

so it really is a bit of a fishing expedition, so we do it, OK? Yeah.

John decides to do the angiogram

to try to find the cause of Michael's collapse.

Ready, steady, slide.

Using detailed X-rays,

John looks for blockages in the arteries supplying Michael's heart.

You inject dye into the heart arteries

and that demonstrates whether they have any narrowing or blockages

that you may need to do something to safeguard their future.

In Michael's case, we do see all three coronary arteries are present,

but we also see hardenings or narrowings within them.

Michael does have what we call triple vessel disease,

so he does have some heart disease

and there is a possibility that he has had a cardiac event today.

Michael was moving up the stairs fairly rapidly

and perhaps the coronary arteries

weren't able to allow the flow of blood and oxygen

that his heart muscle demanded at that time,

so it may have exacerbated an event.

Although the team have found evidence of narrowed arteries,

they are not immediately life-threatening.

None of those narrowings appear to be complete,

so the vessel is not entirely obstructed,

and the blood flow through the narrowings seems to be reasonable.

The decision was to leave things as they were

so that we could reassess the head injury

to make sure that that was not going to be progressive,

and because his cardiac circumstances were stable,

that would allow us to do that.

Michael may need a procedure

to widen the narrowings in his arteries,

but John and his team decide to allow his brain and other injuries

time to recover before any further treatment.

Thank you very much for helping us, that is great.

In Newcastle, Gidia, a young mother-of-three,

has been stabbed multiple times with a knife.

Although her condition has so far remained stable,

Sohom can't be sure Gidia won't suddenly deteriorate.

He needs to get Gidia to CT for an urgent scan.

The journey to CT is one that is very fraught,

the time clock is still ticking,

and we are still not sure what is going on with Gidia,

are there any major injuries that we are not seeing at the moment?

OK, Gidia, we are just doing the CT scan now

and we will look at the neck and chest

and see if there is any injury underneath those wounds.

It will be a bit sore going across.

OK, honey? Ready, steady, slide.

Having a stab wound to the neck

always raises the possibility in my mind

of whether or not there could be major bleeding

that can threaten the windpipe and threaten the airway.

Ten-inch non-serrated knife.

The chances for her having major bleeding,

particularly in the left-hand side of her neck,

is still extremely high.

Gidia has been stabbed in the area occupied by major blood vessels,

including the jugular vein.

Sohom can see from the scans exactly where the knife has penetrated.

The stab wounds were millimetres from her heart,

her great vessels around the heart and the vessels in her neck,

by that, the carotid artery and the jugular vein.

To the amazement of the doctors,

Gidia has narrowly avoided suffering a severe internal bleed.

The knife has missed vital organs like her heart.

Gidia is extremely lucky at the moment.

She has come, really, within millimetres

of the stab wound affecting major vessels and organs

and, really, for her to be clear of this

is an excellent position for her to be in.

But Gidia's wounds are deep and she will need to have

exploratory surgery to assess the damage.

We are looking at about... five inches.

That will need to be explored, won't it?

Give us two seconds.

I can see that it has gone through the top few layers of muscle,

it has gone through the skin,

and it is a good few centimetres deep into her neck,

and I will need a formal look inside, in an operating theatre,

to know exactly what has been damaged

and how deep things have gone.

The main issue I am ringing you for is for a wound

which is over the border of the left sternomastoid.

Sohom pre-alerts the specialist maxillofacial surgeons

who will operate on Gidia.

It is not impossible by any means

that the operating surgeons can find an injury pattern

or bits of bleeding that the scans did not show.

No scan ever reaches 100% accuracy.

Two-and-a-half hours after being crushed by a bus,

cyclist Ben is being rushed to emergency theatre

where consultant general surgeon Peter Coyne

will attempt to tackle the most urgent threat to Ben's survival -

the heavy internal bleeding from his spleen.

How much has he had? He had some on the road, didn't he?

Five and two of platelets. Five of...? Blood, two platelets, OK.

The type of surgery that Ben needs is a damage-control approach,

damage-control surgery,

and essentially, that means opening his abdomen

and dealing with the things that are going to kill him

in the next half an hour to an hour.

The anaesthetist ventilating him is fairly happy

that his chest side of things, at the moment, is stable

and the thing that will kill him quickest

is his spleen that is actively bleeding.

We will get control and then get a proper look at everything.

OK to start? Yeah.

Are you? OK, starting.

To gain access to Ben's spleen, Peter must cut open his abdomen.

Time is critical,

not only to stop the bleed,

but for every minute Ben's abdomen is open,

he is losing heat rapidly.

What you don't want

is to have a patient on the table for a number of hours.

By that point, he has probably got cold,

his acid levels are high

and his blood clotting factors will be low,

and that cascade, which we call a deathly triad,

usually means that his blood doesn't clot

and he starts oozing from everywhere, and that is usually fatal.

The key thing is to fix what needs to be fixed quickly

and then get him back to ITU and get him better.

Peter uses sterile swabs to pack the space in Ben's belly

to absorb the blood that has accumulated.

And the pack, thanks.

And again.

By putting pressure on the vessels and organs in Ben's abdomen,

Peter stems the bleeding temporarily.

This buys him time to search for the fragments of Ben's torn spleen.

The spleen had essentially been squashed.

It is well protected normally by the ribcage, and it sits under the back,

underneath the ribs, and they usually protect,

but as they have been fractured, they have clearly punctured into it.

The spleen is a mop, it is a sponge, and essentially, its main function

is to sponge up all the dead blood cells,

so because of that, the turnover of blood going through it is very high.

He had a spleen that was in multiple fragments

and all of those were actively bleeding.

Half a spleen.

First half.

Ben's spleen is so badly damaged,

Peter has no choice but to remove it completely.

Second half.

'If you don't have a spleen, you are more susceptible to infection.

'It is preferable, if you can, to have it, but in Ben's case,'

that is simply not possible.

Thank you, could you take Lorna's right hand?

That would be great. Could you put a hand over there?

Fab.

Peter now has control of the bleeding artery

that supplies Ben's ruptured spleen.

I've just sutured off, hopefully, the blood supply to it,

and then... That is great, thanks.

Have a look here again.

That is OK, don't go digging down there. That side is fine.

But just as Peter finishes,

he is alerted to a problem with Ben's chest drains.

The increased bubbling of the chest drains

means Ben's punctured lungs are leaking air at an alarming rate.

At that stage, the question

is whether we need to explore his chest.

Peter immediately makes a phone call to a specialist thoracic surgeon.

During the procedure, his left chest drain

has been bubbling quite extensively.

Ben's chest remains badly damaged. He needs a procedure

to look for any injuries to his airway or bleeding in his chest.

But Peter knows another operation could kill him.

We suspect it is a parenchymal lung injury on the left side,

from bony segments. We didn't know whether

you'd want to do anything about that while he is on the table.

If he had complex rib injuries and we were to fix those,

that would take four or five hours.

OK.

The chest guys are happy, they think it might stop,

so they will leave him at the moment rather than doing the operation.

Leave him for the moment, see how he goes in ITU overnight.

The human body is a magnificent thing,

but at some point, it reaches a point of no return.

At this stage, they thought

that going in to explore his chest, inflate his lungs,

would be too big an insult for Ben to get through

given what he had already been through

from his abdomen and blood loss.

The surgeons have no option but to wait to see

if the air leaking out of Ben's punctured lungs reduces.

Ben will now be moved to Intensive Care where, over the coming days,

doctors and nurses will keep a watchful eye on him.

Only if and when he recovers

can they attempt to fix his shattered ribs.

In the operating theatre of Newcastle's RVI,

stab victim Gidia is about to undergo emergency surgery.

Consultant maxillofacial surgeon Matthew Kennedy

needs to explore the wounds by eye

for any injuries that the scans have failed to pick up.

Can we get a couple of skin hooks, please?

'You can only rule out damage to vessels

'once you have seen the full extent of the wound.'

I need to be able to see into the wound

as far as that blade has travelled.

OK, that has obviously just come in here and straight out.

One of these is just an entry and an exit wound.

It has come down very superficially.

If you leave a bit unexplored,

there could be a small artery that has had the end severed

and that could start bleeding again at any moment.

Let's have a look at this one.

Matthew concentrates on the wound to Gidia's chest.

This one is a different kettle of fish.

I'll tell you what. I'll extend it a little bit, just to get more of...

He cuts the skin to open the wound wider

to see and feel how far the knife has penetrated

and what it hit on the way.

I feel there is a little chip of bone

come off the clavicle in there as well.

The blade has skirted straight over the top of the clavicle.

The knife had essentially skimmed over the top of her collarbone.

A centimetre lower and it could have skirted underneath the collarbone,

and then lung, major vessels, would certainly have been injured

and it could have been a very different picture.

Take a little bit of bone off the top.

Matthew removes a fragment of Gidia's collarbone,

chipped off by the knife's blade.

We have to be careful, prodding around right at the back here.

That is ten centimetres deep.

Only when he is satisfied there is no bleeding

does Matthew stitch the wound.

Finally, he tackles the remaining and largest wound,

on the left side of Gidia's neck.

Some more lignocaine...2% with adrenaline, 180,000 going in.

The one on the left side of her neck, towards the back,

is quite obviously deep.

It is the bigger of the wounds, and you can clearly see

that it has gone through the muscle there.

Matthew inserts a drain to siphon any excess blood and fluids

away from the injured area, and stitches the wounds closed.

Can I have a damp swab, as well, please?

Gidia's risk of internal bleeding is now low,

but she will need to return to surgery at a later date

to repair the damage to her muscles.

It has been nine days since office worker Michael

collapsed in cardiac arrest after running up the stairs.

After further tests and heart scans,

doctors have now confirmed that Michael's cardiac arrest

was caused by the narrowings in his arteries.

Sharp scratch in the wrist, it is the anaesthetic.

Now an interventional cardiology team,

led by consultant Roshan Weerackody,

is attempting to widen Michael's arteries with stents

to restore their normal blood flow.

If you have got a tube that is narrowed

and it is interrupting the flow of blood through the tube

when the heart demands more oxygen or nutrients,

it can't deliver that demand

and those narrowings can cause a heart attack.

Roshan wants to tackle the most severe narrowing,

in the main artery at the front of the heart.

In Michael's case, the length of disease is quite long,

over 60 millimetres.

Bit of pushing at your arm, that will be me pushing the tube in.

It might be a bit uncomfortable.

Roshan uses continuous X-rays to help run a tiny guide wire

from Michael's wrist to the blockage in his artery.

Just take a deep breath in, sir.

We have got the tube in the main artery

and we will start taking some pictures.

Before we put the stent in,

we inflate a balloon to expand the narrowing,

which allows us more space for the stent to come in,

because it is slightly bulkier.

The narrowed areas contain fatty deposits that have calcified,

causing them to become rigid.

I can see the calcium's ridge, so bring the fine cross back a bit.

And that's very hard material, and simple ballooning techniques

that we have normally doesn't work.

OK, so you are going to hear a noise now.

It is just my drill, don't worry.

DRILL BUZZES

Come off now, please, so that we can see the distal wire.

Roshan needs to unblock the artery with a drill.

The diamond encrusted head of the drill destroys that calcium

into smaller material, that gets washed away down the artery.

The section where I have to use the drill is probably the most critical

and most dangerous part of the procedure.

The drill head will only follow the path of the guide wire

that is placed inside the artery, and it will only take away

the artery wall where it is hardened with calcium.

So, we are through the lesion.

We're through the narrowing in the artery with the drill, so we will

stretch the artery open with the balloon

and then put a couple of stents in, OK?

So, the stent is like a mesh cylinder made out of cobalt chromium,

a metal scaffold which is left behind, and it'll keep the artery open.

You might get a bit of tightness in the chest, sir.

It's just the balloon going up inside your artery.

Can I have a 275-20 non-compliant, please?

The stent is mounted on a tiny balloon, which Roshan must direct

down the guide wire and position precisely within the artery.

And as you inflate the balloon, the stent gets expanded

and gets deposited within the artery and it doesn't move,

it stays there for ever.

So we've put one stent in.

We're going to put another one in

and, hopefully, that will be it for this artery.

Same artery, yes.

Michael's stent contains a drug which will help the artery

heal correctly and stop it from re-narrowing.

The drug that is embedded in the stent

will disappear after two to three months,

and what is left behind will be covered in the lining of the artery.

The artery, after it's treated, it looks bigger and fatter,

and there is brisker blood flow down the artery.

I'm just going to clean your arm.

So, this is what we started off with.

This was your main artery in front of the heart.

We can see, in several places here, it is severely narrowed, and now...

That is with the stents put in. It's much fatter, the artery. Wow!

You've got the stent... Thanks, guys.

..running from here to here, and that's keeping... All that way?

Yes. Blooming heck, I didn't realise that.

Although Roshan has fixed one of Michael's arteries, he will need

a similar procedure for any other narrowed vessels at a later date.

Thanks so much. Good stuff. OK, sir?

All right?

Gidia was literally millimetres from death.

The scan confirms that the stab wound was millimetres

from her heart, her great vessels around the heart and her neck.

Gidia's injury pattern and her surviving this injury

is only by millimetres.

I think she's doing very well. I'm very hopeful for the future.

With an attack like this, there are physical and emotional scars.

Physical wounds tend to heal quicker than emotional ones,

but everyone's different.

At the moment, she is troubled with stiffness, and I think that is due

to scarring in the muscles, but with time,

I would hope that that would settle and she'll be able to,

before too long, put all this behind her.

Michael has gone on to have intervention,

which, hopefully, will reduce his risk of having any further events,

and I'm glad that he got to the hospital in the end

and that they were able to help him.

I tend to walk fast, very fast, and going up the stairs,

I was walking very fast, and I was just about to go round a corner

and I felt dizzy, and that's all I know, that's all I remember.

I was taking a deep breath and that was it, the lights went out.

Michael was very lucky that he had colleagues at work who were near him

when he collapsed, who immediately jumped into action.

The fact that the ambulance service cycle paramedic was very close,

was there within a couple of minutes,

and then we were literally only about a minute away,

which may have been the difference

between him having a good neurological outcome as he did,

or perhaps he could have been left in a worse state.

The people in work, oh, yes, brilliant,

absolutely fantastic what they did.

I talked to them all afterwards and that was just fantastic,

getting to know what happened and to know that they did that.

We have fixed the mechanical problem,

but the interim weeks and months to come,

that same process that caused the narrowing in the artery

in the first place is not going to go away, so we need to address that

with tablets, lifestyle changes and so on.

I think I had let myself down before because I wasn't going to the gym

and I wasn't probably exercising enough.

I just wanted to live life to the full.

I realise living life to the full can be done better.

A lot of patients we see with that mechanism,

so a heavy weight crushing them,

have injuries that simply cannot be fixed.

Everything was pretty numb.

I remember sort of vaguely realising I was under the bus and thinking,

"This doesn't hurt too much, maybe things aren't so bad."

I remember being told it was very important to not die,

so I did try very hard not to die,

and everybody else tried very hard not to let me die.

Statistically, Ben really should not have survived.

However, I think because everything worked really well that day,

Ben did survive and he is one of our unexpected survivors,

and that is what the team is proud of.

I've got to take antibiotics for the rest of my life

because of the lack of spleen.

That's just a couple of pills each day.

I should make an almost entirely full recovery.

You do realise that things could have been very different.

So, yeah, you step back and think,

"I could very easily have not been here."

It's strange sometimes, you almost feel a little bit like a ghost.

..three, four...

One, two, three, four...

OK, my love, I'm going to tell you how to give him mouth to mouth, OK?

When resources stretch to breaking point,