0:00:02 > 0:00:05This programme contains some scenes which some viewers may find upsetting
0:00:05 > 0:00:11This programme contains some strong language
0:00:11 > 0:00:15Five litres of blood in the human body, five litres.
0:00:15 > 0:00:19- It can be gone in three to four minutes. - Gunshot wound, heavy bleeding.
0:00:19 > 0:00:23Really brilliant surgery. His life was definitely saved this morning.
0:00:25 > 0:00:28The survival rate amongst wounded troops in Afghanistan
0:00:28 > 0:00:31is the highest in the history of warfare.
0:00:33 > 0:00:37War has always driven innovation. And this one is no exception.
0:00:38 > 0:00:41Do you have any evidence that this is effective?
0:00:41 > 0:00:44Just by the level of injuries that people are now surviving.
0:00:44 > 0:00:47Posterior tibial pulse is present to both feet.
0:00:47 > 0:00:50We've got people who are alive
0:00:50 > 0:00:53who, five years ago, would not have survived.
0:00:55 > 0:00:58I want to find out what medics and surgeons have learnt
0:00:58 > 0:01:00from the last ten years of bloodshed.
0:01:00 > 0:01:03What are the advances that are making
0:01:03 > 0:01:06the difference between life and death?
0:01:06 > 0:01:08And how could they help us all?
0:01:28 > 0:01:33It's early in the morning and we're going off to war, to Afghanistan.
0:01:33 > 0:01:36Now, the reason I want to go is because the medics there
0:01:36 > 0:01:41are somehow managing to keep up to 90% of casualties alive
0:01:41 > 0:01:44and that is a truly awesome statistic.
0:01:44 > 0:01:46The highest success rate that has ever been achieved.
0:01:48 > 0:01:51I'm also feeling a little bit apprehensive,
0:01:51 > 0:01:54because I have never been to a war zone before.
0:02:04 > 0:02:09I get a taste of what's to come sooner than I expect.
0:02:09 > 0:02:13Wow, this is not what you see on your average aircraft.
0:02:13 > 0:02:15All these stretchers.
0:02:15 > 0:02:19Now, I trained as a doctor and I've seen a lot of trauma,
0:02:19 > 0:02:22but I suspect nothing like what I'm going to see in Afghanistan.
0:02:22 > 0:02:25I was thinking, as we came on the aeroplane -
0:02:25 > 0:02:28I saw those young men going up the steps -
0:02:28 > 0:02:31I was thinking if the war is as fierce this year as it was
0:02:31 > 0:02:35last year then, statistically speaking at least,
0:02:35 > 0:02:38one of those guys back there is going to be killed
0:02:38 > 0:02:40or severely injured in the next six months
0:02:40 > 0:02:44and, if so, they're going to be coming home on one of these.
0:03:00 > 0:03:02This is Camp Bastion,
0:03:02 > 0:03:06headquarters of the British Forces in Afghanistan.
0:03:06 > 0:03:11It's also home to the main hospital for battlefield casualties.
0:03:13 > 0:03:17And just a few hours after landing, that's where I'm heading.
0:03:22 > 0:03:25I'm told that Camp Bastion is the size of Reading.
0:03:25 > 0:03:28It's certainly an awful lot dustier.
0:03:28 > 0:03:30- Hi, guys, is this the hospital? - Yes.- Thank you.
0:03:32 > 0:03:36So...something busy is going on.
0:03:36 > 0:03:41I've arrived outside the hospital and suddenly it's all kicking off.
0:03:41 > 0:03:44They're all heading off in that direction.
0:03:44 > 0:03:47I've only been here a few moments
0:03:47 > 0:03:51and already I'm seeing casualties brought in from the battlefield.
0:03:54 > 0:03:58So I've seen one person being carried off the helicopter
0:03:58 > 0:04:00and it looks serious.
0:04:03 > 0:04:06SIREN WAILS
0:04:18 > 0:04:21Nice and gentle.
0:04:21 > 0:04:25This hospital deals with some of the most severe injuries
0:04:25 > 0:04:28you'll see anywhere in the world.
0:04:28 > 0:04:33In three, two, one. Clear.
0:04:33 > 0:04:36It's run by British military medics.
0:04:36 > 0:04:39When they're not on tour, they work in the NHS.
0:04:39 > 0:04:43They're both described as going in and out of consciousness.
0:04:43 > 0:04:46Colonel Jeremy Henning is the clinical director.
0:04:46 > 0:04:49So what's wrong with this guy?
0:04:49 > 0:04:53So he's been shot through the pelvis.
0:04:53 > 0:04:56He was up doing guard duty in an elevated tower.
0:04:56 > 0:04:59He was shot, he's fallen back. He's Afghan Army.
0:04:59 > 0:05:03Normal expansion chest.
0:05:03 > 0:05:06Is this is a typical sort of injury you'd see?
0:05:06 > 0:05:09Yeah, we see two main types of injuries.
0:05:09 > 0:05:13One is the gunshot wounds. They come in very regularly,
0:05:13 > 0:05:18and the other major one we see are the improvised explosive devices.
0:05:18 > 0:05:20He's moving his right foot.
0:05:20 > 0:05:23He's stable enough. He's now gone for a CT scan.
0:05:23 > 0:05:27That is just over ten minutes and he's in...
0:05:27 > 0:05:30- We've got another four casualties coming in.- How many?
0:05:30 > 0:05:32- Another four.- Another four, right.
0:05:32 > 0:05:34Posterior tibia pulse is present.
0:05:37 > 0:05:41What is really impressive, I have to say, is the speed at which
0:05:41 > 0:05:44they're moving because there was a guy who was just over there,
0:05:44 > 0:05:48he came in maybe...ten minutes ago and he's already been dealt with.
0:05:48 > 0:05:53They've begun their investigations and he's off having a CT scan.
0:05:53 > 0:05:56This guy came in about five minutes afterwards
0:05:56 > 0:05:59and he's also just about ready. They've already X-rayed him
0:05:59 > 0:06:02and they're about to whisk him off to CT scan as well.
0:06:02 > 0:06:05He's got blast pants on.
0:06:13 > 0:06:18The commonest cause of death amongst casualties out here
0:06:18 > 0:06:20is massive blood loss.
0:06:21 > 0:06:24But they've recently developed ways of dealing with it
0:06:24 > 0:06:27that's had a huge impact on survival rates.
0:06:29 > 0:06:32- That one's 11.20 that one's 11.30. - 'Lieutenant Colonel Steve Lord
0:06:32 > 0:06:35'is a consultant in the Emergency Department.'
0:06:35 > 0:06:39- So what have you got?- An IED blast and he's apparently got amputations
0:06:39 > 0:06:42- of both legs. - So he's stood on a mine
0:06:42 > 0:06:44and it's been big enough to blow off both his feet?
0:06:44 > 0:06:47We generally don't get given the level.
0:06:47 > 0:06:51They may say it's just a foot, but if they say legs,
0:06:51 > 0:06:54it could be anywhere from the ankle up to the groin
0:06:54 > 0:06:57and we will not know till we see him.
0:06:57 > 0:07:00They've called "hot vampire", which means they give him blood
0:07:00 > 0:07:02in-flight, so we make sure we've got blood available.
0:07:02 > 0:07:06'They found that by changing how they replace blood
0:07:06 > 0:07:09'they can cut death rates by up to a half.
0:07:09 > 0:07:11'The NHS are interested
0:07:11 > 0:07:16'because 40% of trauma deaths in the UK are caused by blood loss.'
0:07:16 > 0:07:19Just want to go to the blood lab and find out what's going on.
0:07:24 > 0:07:28Hello. 'There's 20 minutes until the casualty arrives
0:07:28 > 0:07:31'and Chief Petty Officer Andy Murphy is getting blood ready.'
0:07:31 > 0:07:34We've got one guy with a head injury, one with a double amp.
0:07:34 > 0:07:37The double amp is obviously the main concern.
0:07:37 > 0:07:43Effectively, any trauma patients, we assign them universal donor blood.
0:07:43 > 0:07:46And each of those people could need 30, 40 units, or what?
0:07:46 > 0:07:50- And the rest, potentially. - More?- In some cases.
0:07:50 > 0:07:54There have been cases of patients having upwards of 150 units.
0:07:54 > 0:07:57You're talking up to 50 litres of blood?
0:07:57 > 0:08:00- I mean, that is a bathful of blood, isn't it?- Yes.
0:08:00 > 0:08:04'Amazing, considering the average body only holds five litres.
0:08:04 > 0:08:09'As usual, blood for transfusions is separated into different parts.'
0:08:09 > 0:08:13'Red blood cells that carry oxygen,
0:08:13 > 0:08:17'and plasma, a yellowy fluid which helps blood clot.
0:08:18 > 0:08:23'In the past, they'd give four times more red cells than plasma.'
0:08:23 > 0:08:27When they used to give four of these to one of these, they weren't
0:08:27 > 0:08:29giving back enough clotting factors
0:08:29 > 0:08:34for the patient to stop bleeding and that's why they would bleed out.
0:08:34 > 0:08:38'So the military recently increased the amount of plasma they give.'
0:08:38 > 0:08:43They actually now give equal volumes. One of this to one of this.
0:08:43 > 0:08:47And that helps to provide...top up the patient's own clotting factors.
0:08:47 > 0:08:50Do you have any evidence that this is effective?
0:08:50 > 0:08:54Just by the survival rate and the level of injuries that people are now surviving.
0:08:54 > 0:08:58- Number 1891.- 4-5-4-7.
0:08:58 > 0:09:03Four litres of blood are rushed to the Emergency Department.
0:09:03 > 0:09:06The new casualty is only moments away.
0:09:06 > 0:09:11He's been flown in from the frontline by the MERT,
0:09:11 > 0:09:13the Medical Emergency Response Team.
0:09:15 > 0:09:19SIREN WAILS
0:09:26 > 0:09:31United States marine. Mechanism is IED versus foot soldier.
0:09:31 > 0:09:34Injuries are left below knee, right below knee,
0:09:34 > 0:09:35with tissue damage up to the groin.
0:09:38 > 0:09:42Lance Corporal Ronald Barnes is just 20-years-old.
0:09:42 > 0:09:45He's been blown up by an IED.
0:09:45 > 0:09:49- That's ADT two.- 22?- 22.
0:09:49 > 0:09:52Oh, dear, it's really distressing.
0:09:53 > 0:09:56No major obvious wounds on the back.
0:09:56 > 0:10:00One, two, slide. Thank you.
0:10:00 > 0:10:05Although heavily bandaged, he may still be losing a lot of blood.
0:10:05 > 0:10:074.1.
0:10:07 > 0:10:10High wound to right thigh.
0:10:10 > 0:10:15It's a massive wound on the right thigh, OK?
0:10:15 > 0:10:18You want this down?
0:10:18 > 0:10:22And, as you say, above knee on the right and below knee amputation
0:10:22 > 0:10:26- on the left.- Can we make room for a chest X-ray?
0:10:26 > 0:10:29In three, two, one.
0:10:29 > 0:10:32- Has he lost a lot of blood? - Well, we have to assume that he has.
0:10:32 > 0:10:35The fact that he received blood on the ground via MERT
0:10:35 > 0:10:38- would imply that he has significant blood loss.- Right.
0:10:39 > 0:10:44What they're really worried about is the lethal triad -
0:10:44 > 0:10:49blood loss, a build-up of acid and hypothermia.
0:10:49 > 0:10:52The blue blanket is going on the top to make sure that he stays warm.
0:10:52 > 0:10:54You get cold really quickly.
0:10:54 > 0:10:58Ronald's getting cold because he's lost so much blood.
0:10:58 > 0:11:02Not enough oxygen is reaching his tissues to generate heat.
0:11:02 > 0:11:07That lack of oxygen also causes a build-up of lactic acid.
0:11:07 > 0:11:11The cold and increased acid make his blood less able to clot.
0:11:11 > 0:11:13Untreated, he would bleed to death.
0:11:13 > 0:11:18The new way they give blood, adding more plasma,
0:11:18 > 0:11:20should reduce the risk of this happening.
0:11:20 > 0:11:25He does have a weak radial pulse in the right.
0:11:25 > 0:11:28They've got red cells and they've also got plasma
0:11:28 > 0:11:32and he needs that in order to clot and stop a catastrophic haemorrhage,
0:11:32 > 0:11:36bleeding, that may be going on.
0:11:36 > 0:11:40- And two mils of... - No blood on blood.
0:11:40 > 0:11:42They've got a line going into his arm
0:11:42 > 0:11:45and they're pumping blood through there,
0:11:45 > 0:11:48but they also want to get to the veins in the neck
0:11:48 > 0:11:50cos then they can really pour it in.
0:11:50 > 0:11:53They want to get as much blood into him as they can.
0:11:55 > 0:12:00Everything here is set up for speed of diagnosis and treatment.
0:12:00 > 0:12:02OK, so what have you got there?
0:12:02 > 0:12:07This is a hand-held ultrasound unit that we use to quickly assess
0:12:07 > 0:12:10the abdomen for free fluid and free fluid equals blood.
0:12:10 > 0:12:17If there's any sign of internal bleeding, he'll be taken straight to surgery.
0:12:17 > 0:12:21If not, they'll do a CT scan to get a clearer idea of his injuries.
0:12:23 > 0:12:25Negative.
0:12:25 > 0:12:28- None that we've found so far. - No internal bleeding?
0:12:28 > 0:12:30None that we've seen.
0:12:32 > 0:12:35Surgeon Commander Peter Small is waiting in the Emergency Department,
0:12:35 > 0:12:39ready to operate as soon as he can.
0:12:39 > 0:12:43He has a good blood pressure, he's not tachycardic
0:12:43 > 0:12:47he's getting blood transfused. I think he's stable.
0:12:47 > 0:12:50- CT?- CT.
0:12:50 > 0:12:54Is blood loss a big factor?
0:12:54 > 0:12:57Do you know how many units they poured in?
0:12:57 > 0:13:01He had three and three on the helicopter and we've given him
0:13:01 > 0:13:03some more in here, at least two units.
0:13:03 > 0:13:07They've already replaced all the blood in Ronald's body.
0:13:07 > 0:13:10And he still needs more.
0:13:10 > 0:13:15He needs six units. For theatre, they need six units of blood.
0:13:19 > 0:13:22But first, Ronald is taken to the scanner.
0:13:26 > 0:13:30He's got a femoral fracture just above...
0:13:30 > 0:13:34They're getting together detailed information about his injuries.
0:13:34 > 0:13:37They're also looking for any hidden internal bleeding.
0:13:37 > 0:13:41There's a large soft tissue defect anterior thigh.
0:13:41 > 0:13:48They've had a dedicated radiologist for emergency cases here since 2009.
0:13:48 > 0:13:53It's something very few casualty departments have in the UK.
0:13:53 > 0:13:56Massive tissue disruption. No evidence of solid organ injury -
0:13:56 > 0:14:01liver or spleen or kidney. He's intact.
0:14:01 > 0:14:05- Do a transplant and get that one side?- 'Knowledge is power, really.'
0:14:05 > 0:14:08In the past, there could have been a concern of,
0:14:08 > 0:14:13"Is he bleeding from somewhere else? Do we need to open his abdomen just to be sure that he's OK?"
0:14:13 > 0:14:17So here we can say, categorically, there is no evidence of an injury
0:14:17 > 0:14:20in his abdomen that could cause him to bleed during the surgery.
0:14:23 > 0:14:28The surgical team are ready to operate.
0:14:28 > 0:14:32It's been just over an hour since Ronald was picked up from the frontline.
0:14:32 > 0:14:36IEDs are nasty. They go off in earth,
0:14:36 > 0:14:40and are covered in shit and bolts and that gets blown into the body.
0:14:40 > 0:14:42We try to get all that out.
0:14:44 > 0:14:49'The team's first challenge is to stop Ronald losing a lot more blood while they operate.
0:14:49 > 0:14:54'Peter is going to use a new surgical technique they've developed out here.
0:14:54 > 0:14:57'He will shut down the blood supply to Ronald's legs
0:14:57 > 0:15:00'while they deal with his injuries.'
0:15:00 > 0:15:04They're going for one of the major arteries which supplies the leg.
0:15:04 > 0:15:08They're going to tie that off so the blood supply
0:15:08 > 0:15:12to the shattered limb is cut off, because if they didn't do that
0:15:12 > 0:15:15and they started operating, there's a high risk that that guy
0:15:15 > 0:15:20on there would suffer from further catastrophic blood loss.
0:15:21 > 0:15:27'Peter is a Reservist. He normally works in the NHS in Sunderland.'
0:15:27 > 0:15:32So it's a bit like turning off the water supply in the house before you do the plumbing repair, is it?
0:15:32 > 0:15:37- Interesting way of putting it. But only to the radiator.- Yeah.
0:15:38 > 0:15:43'Although Ronald's blood is clotting, the clots are fragile.
0:15:43 > 0:15:46'So they're also giving him platelets,
0:15:46 > 0:15:50'another constituent of blood which makes clots stronger.
0:15:51 > 0:15:54'They only started doing this in 2007.
0:16:01 > 0:16:03'While they get his blood loss under control,
0:16:03 > 0:16:05'other members of the team are hard at work.'
0:16:07 > 0:16:10What's unusual is so many people are involved in it,
0:16:10 > 0:16:12and so many different specialties.
0:16:12 > 0:16:15You've got a plastic surgeon, an orthopaedic surgeon,
0:16:15 > 0:16:18a trauma surgeon and a general surgeon,
0:16:18 > 0:16:22all gathered around the bed, all operating at the same time.
0:16:22 > 0:16:26'A priority at this stage is to remove destroyed tissue
0:16:26 > 0:16:28'to prevent infection.'
0:16:30 > 0:16:31How's he doing?
0:16:31 > 0:16:35It's hard because you're chasing vessels back to control a muscle
0:16:35 > 0:16:37that's just blasted with debris.
0:16:41 > 0:16:43He's stable.
0:16:43 > 0:16:46'Once they've finished tying up torn blood vessels
0:16:46 > 0:16:50'and cleaning the wounds, Peter unclamps the main artery
0:16:50 > 0:16:52'to let blood flow back into Ronald's legs.
0:16:57 > 0:17:00'I've seen the full extent of Ronald's horrific injuries
0:17:00 > 0:17:03'and I'm amazed he's still alive.'
0:17:05 > 0:17:10He had absolutely outstanding... I mean, really brilliant surgery.
0:17:10 > 0:17:14The whole thing is just massively impressive from the moment
0:17:14 > 0:17:17they come through the door to the moment they're here.
0:17:17 > 0:17:20He's going to face life as a double amputee
0:17:20 > 0:17:23and that's going to be really rough.
0:17:23 > 0:17:27But his life was undoubtedly saved this morning.
0:17:32 > 0:17:35It went well. First of all, the patient didn't die.
0:17:35 > 0:17:39We managed to get early control of the bleeding
0:17:39 > 0:17:44and we've tidied up his amputations, stabilised him
0:17:44 > 0:17:47and we'll be looking to ship him on to American hospitals
0:17:47 > 0:17:49as soon as we can.
0:17:49 > 0:17:52- Do you find it distressing when you see a man come in like that?- Yes.
0:17:52 > 0:17:56It's not nice to see a human body mutilated,
0:17:56 > 0:18:00but, at the end of the day, we're here to do what we can,
0:18:00 > 0:18:03to save as much as we can.
0:18:03 > 0:18:06We didn't give them the injuries,
0:18:06 > 0:18:09we're trying to stop the injuries getting worse.
0:18:09 > 0:18:13So if you start with that mindset, then, yeah, you can cope with it.
0:18:16 > 0:18:19Ronald is taken to intensive care
0:18:19 > 0:18:22and will be flown back to America as soon as possible.
0:18:25 > 0:18:29In emergency medicine, there's a category of patients
0:18:29 > 0:18:34whose injuries are so severe they're not expected to live.
0:18:34 > 0:18:38Out here, they are saving a quarter of those
0:18:38 > 0:18:41who would normally be expected to die.
0:18:41 > 0:18:45In civilian medicine, the best they manage is 5%.
0:18:45 > 0:18:49Do you think you are saving people who you wouldn't have ten years ago?
0:18:49 > 0:18:53Yes, without a doubt. We've got people who have gone back
0:18:53 > 0:18:57who are alive who, five years ago, would not have survived
0:18:57 > 0:19:00and I think, even over the last three or four years,
0:19:00 > 0:19:03the things we thought were potentially unsurvivable,
0:19:03 > 0:19:06we would now ask, "Why have they not survived?"
0:19:06 > 0:19:10- Do you learn a lot of stuff here that you take back to the NHS?- I do.
0:19:10 > 0:19:13Scanning. Virtually everyone who comes through here
0:19:13 > 0:19:16gets a full body scan if they've been involved in an explosion
0:19:16 > 0:19:21and there's a lot of evidence, even in civilian literature, that that is the way ahead.
0:19:21 > 0:19:25We use blood products aggressively here, including clotting factors.
0:19:25 > 0:19:28I think that's something we should consider more of in the NHS.
0:19:28 > 0:19:32Normally, we give them crystalloid fluid, which is salty water,
0:19:32 > 0:19:36and, actually, the body should get used to blood products early on.
0:19:36 > 0:19:39If that's what they're losing, that's what we should give them.
0:19:42 > 0:19:47There's now a clinical trial of the new blood transfusion protocol
0:19:47 > 0:19:51being carried out at five casualty departments in the UK.
0:19:57 > 0:20:02TANNOY: Op minimise, op minimise.
0:20:09 > 0:20:15We've just heard over the tannoy a message - "Op minimise," which means
0:20:15 > 0:20:20that this base is cut off from all communication with the UK.
0:20:20 > 0:20:25And the reason for that is a young British serviceman has just died in action
0:20:25 > 0:20:30and they don't want the news to leak out before the relatives can be told.
0:20:32 > 0:20:35His body was brought here to the hospital
0:20:35 > 0:20:38and the mood is very sombre.
0:20:40 > 0:20:46It's graphic evidence that not everybody can be saved.
0:20:48 > 0:20:55TANNOY: I say again, Op minimise, op minimise, op minimise.
0:21:16 > 0:21:20If casualties do get to the hospital alive then the medical team
0:21:20 > 0:21:23would now expect to save them.
0:21:23 > 0:21:27What surprises me is that so many seriously wounded troops
0:21:27 > 0:21:32make it to the hospital alive in the first place.
0:21:32 > 0:21:34Release!
0:21:39 > 0:21:43I want to find out what they're doing on the frontline
0:21:43 > 0:21:46that is helping to save lives.
0:21:46 > 0:21:49Identify your target!
0:21:53 > 0:21:57When I was training in medicine, we used to talk about the golden hour
0:21:57 > 0:22:00and that was the period, the precious hour you had, in which
0:22:00 > 0:22:04you could hopefully treat the patient and make them better.
0:22:04 > 0:22:08Now they talk about the platinum ten minutes.
0:22:08 > 0:22:10That in just ten minutes, within which,
0:22:10 > 0:22:12if you do not do the right thing,
0:22:12 > 0:22:16then there's a good chance that your friend is going to bleed to death.
0:22:18 > 0:22:22Since 2005, all the troops on the ground have been issued
0:22:22 > 0:22:26with one piece of medical equipment that's made a massive difference
0:22:26 > 0:22:29to survival in that first ten minutes.
0:22:29 > 0:22:34Paramedic Chief Petty Officer Steve Parmenter shows me one.
0:22:34 > 0:22:38We carry them in such a way that we can put them on single-handedly.
0:22:38 > 0:22:40They go up on the arm.
0:22:40 > 0:22:47'It's a new type of tourniquet. Simple but incredibly effective.'
0:22:47 > 0:22:51- As much as we can bear and then one more turn.- Very neat. OK, you're injured where?
0:22:51 > 0:22:58- If I've got a big bleed here, you want to go onto a single bone.- I'm going here. Good big biceps, blimey!
0:22:58 > 0:23:01- Yep.- Now pull it tight.- OK.
0:23:01 > 0:23:04- Brace it against this bar and pull. - Blimey!- And again.
0:23:04 > 0:23:07- Then I just go like that, do I?- Yep. - That's very neat.
0:23:07 > 0:23:10So when we train, we train so that we lose the distal pulse.
0:23:10 > 0:23:15- If you were bleeding, that would stop that.- That would slow it down for you to control it.
0:23:15 > 0:23:17- Right.- So it's no longer catastrophic.
0:23:17 > 0:23:21Somebody told me that if they'd had this thing in Vietnam
0:23:21 > 0:23:24or other major battles, it could have saved thousands of lives.
0:23:24 > 0:23:29Yeah, probably, a lot more lives. When I started my service in the mid-'80s,
0:23:29 > 0:23:34- if we'd had them in Ireland, I can think of a few people that would still be around.- Yeah.
0:23:34 > 0:23:37- These are being applied in the ambulance service?- Yes.
0:23:37 > 0:23:42SWAST, South West Ambulance Service, were the first ambulance service to use them.
0:23:42 > 0:23:45Now HEMS, London Ambulance, are all training their guys on these now.
0:23:45 > 0:23:49It's easy to put on when you're in the back of an ambulance,
0:23:49 > 0:23:52but the troops will have to use it on the battlefield.
0:23:52 > 0:23:56Like everything in the military, it's all about training.
0:23:56 > 0:24:00- Young man, are you happy to be used? - Yeah.- Come on up.
0:24:00 > 0:24:03So we're going to strip you down. Are you happy with that?
0:24:03 > 0:24:08- Not really! Take your top off. Have you been working out?- No.
0:24:08 > 0:24:13Where do you think the prominent junctions of his body lie?
0:24:13 > 0:24:17- Good, yeah, happy with that. - Down there and around there.
0:24:17 > 0:24:21Draw on him, go on. That's good, yeah. Take your trousers down.
0:24:21 > 0:24:23Oh, this is bad for you!
0:24:23 > 0:24:29There you go. And they're the main areas that we're going to bleed out from which is going to kill us.
0:24:29 > 0:24:33Come on, lie on your back. Right, you get to pick someone now.
0:24:33 > 0:24:36Up you come.
0:24:36 > 0:24:39Oh, dear, your world's about to end!
0:24:39 > 0:24:44I want you to sprint as quickly as you can. Go and then come back.
0:24:44 > 0:24:47Right, why are we doing that?
0:24:47 > 0:24:50"What's happened to me?" "You've been blown up by an IED."
0:24:53 > 0:24:56Get a tourniquet on, quick, quick, quick. Get it on!
0:24:56 > 0:24:58Hose him!
0:24:58 > 0:25:01Get your knee in his groin, get your knee is in his groin!
0:25:01 > 0:25:04Hurry up! As quick as you can! ALL: Oh!
0:25:04 > 0:25:06LAUGHTER
0:25:06 > 0:25:09Still hosing out. Still hosing out.
0:25:09 > 0:25:12Come on, hurry up!
0:25:12 > 0:25:15Hurry up! He's dying, he's fading away from you.
0:25:15 > 0:25:19- Right, tell me how that felt?- Shit. - Why?
0:25:19 > 0:25:22- HE PANTS - Straight into it...
0:25:22 > 0:25:26You see, you can hardly talk as well. It is absolutely, guys...
0:25:26 > 0:25:29One thing I'm going to say to you -
0:25:29 > 0:25:33if this ever does happen to you, what you've just got to remember,
0:25:33 > 0:25:37he's sprinted 100 metres there and back, OK?
0:25:37 > 0:25:41But he's going to be wearing body armour, helmet,
0:25:41 > 0:25:44weapons system, gloves, eye protection,
0:25:44 > 0:25:46and he'll upset cos it's his mate lying there.
0:25:46 > 0:25:50You imagine what his heart rate's doing. It'll be difficult for him.
0:25:50 > 0:25:54It's only natural, guys. You're going to panic, you'll be scared,
0:25:54 > 0:25:57you're going to be worried, your hands are going to be shaking, OK?
0:25:57 > 0:26:01- Give him a clap, everyone. - The course instructor is Sergeant Lee Melvin.
0:26:01 > 0:26:05We realised that the platinum ten minutes is the most important time for a casualty.
0:26:05 > 0:26:10It's the guys out on the ground, the guy that's treating the injured man and making a big difference.
0:26:10 > 0:26:13Five litres of blood in the human body, five litres.
0:26:13 > 0:26:17And it can be gone in three to four minutes. And what we're trying to do
0:26:17 > 0:26:20is teach these guys that through their interventions
0:26:20 > 0:26:23and doing thing quickly, they will make a massive difference.
0:26:23 > 0:26:28'In each patrol, there's a full-time medic.
0:26:28 > 0:26:34'But they've also started to train one in four of the troops to a more advanced level.
0:26:34 > 0:26:40'Recently, Trooper Keith Allen had to put his newly-acquired medical skills to the test.'
0:26:40 > 0:26:44One of the lads had to go and get something off one of the vehicles,
0:26:44 > 0:26:46and as he left, an RPG struck the vehicle.
0:26:46 > 0:26:50He got hit by a lot of shrapnel and initially, we thought the worst
0:26:50 > 0:26:55cos you could see the gash on his left arm so we treated that.
0:26:55 > 0:26:59Me and another guy were trying to clear his airway as he'd swallowed his tongue.
0:26:59 > 0:27:04One guy was holding his head while I was trying to prise his jaw open to release his tongue
0:27:04 > 0:27:08but we were really struggling with it because his jaw was jammed tight.
0:27:09 > 0:27:14He managed to start coming through and he started breathing on his own.
0:27:14 > 0:27:18I recently got called to see someone who was out, heart stopped,
0:27:18 > 0:27:20and I'm thinking when I'm down there,
0:27:20 > 0:27:24"What I do in the next few minutes is either going to change
0:27:24 > 0:27:28"this person's life, or they're going to die."
0:27:28 > 0:27:32- Are these thoughts going through your brain?- Yeah.
0:27:32 > 0:27:35To start with I always thought, "If we were to get a casualty,
0:27:35 > 0:27:38"would I be able to remember everything?"
0:27:38 > 0:27:42And as soon as you get the casualty, everything just comes flooding back.
0:27:42 > 0:27:46There was three of us working on this one guy and we all knew exactly what to do.
0:27:46 > 0:27:49How did you feel afterwards?
0:27:49 > 0:27:53One of the lads had to sit with me for five minutes, cos I was a bit emotional,
0:27:53 > 0:27:55trying not to cry, trying to hold it in.
0:27:55 > 0:28:00For a week after, it was just playing on my mind all the time...
0:28:00 > 0:28:02but it's... I'm all right now.
0:28:08 > 0:28:11Fantastic. I like the kit. The kit was very impressive
0:28:11 > 0:28:15and you can see how it can be used in ambulance services in the UK.
0:28:15 > 0:28:19But I think the thing impressed me even more was the training.
0:28:19 > 0:28:24The fact that Keith, who only had a few weeks' training, was able to save his mate's life
0:28:24 > 0:28:28because he, and the other guys there, knew exactly what to do.
0:28:28 > 0:28:31I know what it is like to be in that situation where you
0:28:31 > 0:28:35have immense pressure because you know whatever you do will lead
0:28:35 > 0:28:39to the life or death of the person you've got down there.
0:28:39 > 0:28:43And the fact that Keith, without years of training...
0:28:43 > 0:28:47I've had years of training and I still feel that pressure when it occurs.
0:28:47 > 0:28:50But Keith was able to, bang, click, do this, this, this and this
0:28:50 > 0:28:54and almost certainly save his mate's life.
0:28:54 > 0:28:55That was impressive.
0:29:03 > 0:29:09A call has just come in that two soldiers have been shot.
0:29:09 > 0:29:14The Medical Emergency Response Team, the MERT, rush to pick them up.
0:29:20 > 0:29:23But it's not just about speed.
0:29:23 > 0:29:25It's about the getting the right expertise
0:29:25 > 0:29:28to the casualties as quickly as possible.
0:29:28 > 0:29:33So since 2006, along with two paramedics,
0:29:33 > 0:29:35they also have both a doctor and nurse on board.
0:29:40 > 0:29:43Squadron Leader Charlie Thomson, a specialist nurse,
0:29:43 > 0:29:46is in charge of the MERT.
0:29:46 > 0:29:50There's the adrenalin rush of wanting just to get going
0:29:50 > 0:29:53and pick them up as soon as possible.
0:29:53 > 0:29:57Many of our jobs do involve small arms contact against the aircraft.
0:29:57 > 0:30:01The enemy forces know that as soon as one of our soldiers has been shot,
0:30:01 > 0:30:05they know that we're going to come and get them
0:30:05 > 0:30:10which gives them plenty of time to get their weapons ready.
0:30:16 > 0:30:19We just want to get the casualty on board as quick as possible
0:30:19 > 0:30:21so everybody can get out of there.
0:30:21 > 0:30:24It takes the MERT 15 minutes to reach
0:30:24 > 0:30:28the casualties at a forward operating base.
0:30:28 > 0:30:33OK, gunshot wounds.
0:30:33 > 0:30:35Heavy bleeding from this.
0:30:35 > 0:30:38One of them has been shot in the back.
0:30:38 > 0:30:39The other in the leg.
0:30:45 > 0:30:49With a doctor on board they can do blood transfusions,
0:30:49 > 0:30:51anaesthetise patients and even open up
0:30:51 > 0:30:55the chest to treat internal injuries if they have to.
0:30:57 > 0:31:02'The job can be very emotionally difficult at times.
0:31:02 > 0:31:05'But if we can learn how to deal with these traumas,
0:31:05 > 0:31:09'and then be able to save lives, then that's good news all round.'
0:31:19 > 0:31:23Once they get the casualties to the hospital, the MERT's job is done.
0:31:32 > 0:31:36I catch up with Charlie while the crew wait for their next call.
0:31:38 > 0:31:42What would I see here I wouldn't see on an average ambulance?
0:31:42 > 0:31:46For a start, we carry blood - four units of O neg and four units of plasma.
0:31:46 > 0:31:53What we can do in the back of here is more or less exactly the same as what you can do in the hospital.
0:31:53 > 0:31:54OK, so this is it...
0:31:54 > 0:31:58'The MERT also carries innovative new equipment.
0:31:58 > 0:32:02'Charlie shows me some of it, with the help of a volunteer.'
0:32:02 > 0:32:05Say Chris has got a double amputation to his legs.
0:32:05 > 0:32:09The main reason our casualties die is because they lose their blood.
0:32:09 > 0:32:13They lose their circulation, their oxygen supply, their clotting, that sort of thing.
0:32:13 > 0:32:16So ideally we'd like to find a vein.
0:32:16 > 0:32:19We'd probably find a big vein up here.
0:32:19 > 0:32:24If we can't find those - and often we can't because they're so shut down with loss of blood -
0:32:24 > 0:32:27we may have to use an intraosseous device.
0:32:27 > 0:32:32Basically, we drill. For example, here, into the humeral head -
0:32:32 > 0:32:36- we'll drill that needle in there, like so.- A needle in the bone,
0:32:36 > 0:32:40- then you can pump blood straight into the bone and then into the circulation.- Yes.
0:32:40 > 0:32:44'A tiny version of this was originally used on babies,
0:32:44 > 0:32:47'whose veins are hard to find.
0:32:47 > 0:32:52'In 2006, the British military picked the idea up and modified it.'
0:32:52 > 0:32:56Our big infantry guys have big biceps and muscles.
0:32:56 > 0:33:02So they designed this one, which is quite nasty to look at, but it works for us.
0:33:02 > 0:33:03Pretend this is a bag of blood.
0:33:03 > 0:33:09Because the blood is cold and we don't want to give casualties cold blood, we use a warming device.
0:33:09 > 0:33:12You're warming the blood presumably because he's in shock
0:33:12 > 0:33:15- and more cold would be a bad idea. - Yes, that's right,
0:33:15 > 0:33:18it won't help his clotting mechanism at all.
0:33:18 > 0:33:23The other device we can use if this one doesn't work is something that'll go into his sternum.
0:33:23 > 0:33:25Literally into your sternal notch, here.
0:33:25 > 0:33:31These needles go through the skin and rest on the bone to stop the device moving so much.
0:33:31 > 0:33:34And the centre bit there is basically what shoots into the sternum,
0:33:34 > 0:33:39and again we can give blood, drugs and all sorts through there.
0:33:39 > 0:33:43Each year I come out here, we're learning more.
0:33:43 > 0:33:45BUZZER
0:33:45 > 0:33:48We've got a job. Andrew, we've got a job.
0:33:55 > 0:33:59Charlie and the team head off for their next call.
0:34:00 > 0:34:04At the hospital, another casualty is due to arrive.
0:34:05 > 0:34:07What have you heard?
0:34:07 > 0:34:12- We've got someone coming in with an IED, with a partial amputation to his foot.- Right.
0:34:12 > 0:34:17- That's all we know at the moment. As far as I understand, he's a US soldier.- Right.
0:34:28 > 0:34:35All right, we have US marine suffered from an IED blast approximately 45 minutes ago.
0:34:35 > 0:34:38He has a partial amputation of the left foot.
0:34:38 > 0:34:41He has 10 milligrams of IV on board.
0:34:41 > 0:34:43His pain is still about six out of ten.
0:34:45 > 0:34:47MAN GROANS
0:34:50 > 0:34:54He's obviously in a lot of pain at the moment, you can hear him groaning.
0:34:54 > 0:34:59'One of the big challenges with such severe injuries is pain control.
0:34:59 > 0:35:03'It's another area where military medics have recently made real progress.
0:35:03 > 0:35:06- How are you doing, fella, what's your name?- Chuck.
0:35:06 > 0:35:10- Hi, Chuck.- You guys going to knock me out?
0:35:10 > 0:35:12Yeah, we'll give you some pain killers.
0:35:12 > 0:35:16- Are you in pain right now?- Yeah.- OK, we'll give you something for that.
0:35:16 > 0:35:18They've given me some, but it hasn't really helped.
0:35:18 > 0:35:22He's nice and stable, do this nice and slow time.
0:35:22 > 0:35:25'The anaesthetist is Surgeon Commander Dan Connor.'
0:35:25 > 0:35:27- Can you remember what happened, Chuck?- Yeah.
0:35:27 > 0:35:33We were walking, doing a patrol and I stepped on a fucking IED.
0:35:33 > 0:35:37OK. Did you get thrown at all?
0:35:37 > 0:35:41- No. - CHUCK CRIES OUT IN PAIN
0:35:41 > 0:35:46- Do you think that foot is actually attached?- Don't know until we open.
0:35:46 > 0:35:52- It's more upsetting when they're awake and you're experiencing it.- Yeah.
0:35:52 > 0:35:56It's really upsetting, really, really upsetting.
0:35:56 > 0:35:59Oh, dear. This guy's so young, he's really young.
0:35:59 > 0:36:02And they treat it as though it's a scratch, and it's actually...
0:36:02 > 0:36:06For them, it's actually not a severe injury, but the thought that,
0:36:06 > 0:36:10you know, he's going to lose his foot, is really upsetting.
0:36:12 > 0:36:18Because he's probably the same age as my son Alex - he's 20.
0:36:20 > 0:36:26I didn't, um...yeah, I didn't think I'd feel like that. It's surprising.
0:36:26 > 0:36:27Mm. Oh!
0:36:29 > 0:36:32Has he got pink toes?
0:36:32 > 0:36:37'Chuck is taken for a CT scan to assess the extent of his injuries.'
0:36:37 > 0:36:42- Well, the calcaneous is in bits. - Basically, the heel? - Yeah, heel bone.- Yeah.
0:36:42 > 0:36:46- I mean, that is a mess, isn't it? - Yeah.
0:36:46 > 0:36:49- His foot's sort of...- At 90 degrees.
0:36:49 > 0:36:52- This bit there should be onto there. - Yeah.
0:36:52 > 0:36:56- His foot is pointing in the wrong direction.- Absolutely.
0:36:56 > 0:37:00- So do you think it's salvageable or not?- Probably not.
0:37:00 > 0:37:06- Probably not.- Probably not. And even so, the amount of tissue disruption he's likely to have
0:37:06 > 0:37:10will leave him with... not a very good foot. It depends.
0:37:13 > 0:37:17Orthopaedic surgeons have pinned Chuck's foot in place.
0:37:17 > 0:37:22It's too soon to say if they'll be able to save it.
0:37:25 > 0:37:31In the past, Chuck's post-operative pain would have been controlled by high doses of morphine.
0:37:31 > 0:37:34But Dan's going to use a very different approach,
0:37:34 > 0:37:38one the military have been refining over the last ten years.
0:37:38 > 0:37:40You're just blocking the bit that hurts.
0:37:40 > 0:37:43You're putting local anaesthetic next to a nerve.
0:37:43 > 0:37:48The catheter allows you to keep the anaesthetic running in, so you're just numbing
0:37:48 > 0:37:50that area of the body.
0:37:50 > 0:37:53We can just block his nerves that go to his ankle
0:37:53 > 0:37:58and make him nice and comfortable for the journey home.
0:37:58 > 0:38:03'Morphine affects the whole body and can cause significant side-effects.
0:38:03 > 0:38:09'This technique acts locally and can block pain from Chuck's damaged foot
0:38:09 > 0:38:10'for up to 40 days.'
0:38:12 > 0:38:15You can see the benefits for this kind of injury,
0:38:15 > 0:38:18so either gunshot wounds, small IED strikes
0:38:18 > 0:38:22or single amputations to an upper limb from shrapnel.
0:38:22 > 0:38:26'Dan is using high-resolution ultrasound,
0:38:26 > 0:38:28'developed with US military-funding,
0:38:28 > 0:38:32'to find the individual nerve that runs to Chuck's foot.'
0:38:32 > 0:38:35You can just see the left hand circle
0:38:35 > 0:38:38and that's the popliteal nerve.
0:38:38 > 0:38:41Just to clarify - the bit I'm looking at is this bit here, yeah?
0:38:41 > 0:38:45- Yeah, that's correct.- And that's the nerve.- That's the nerve.
0:38:45 > 0:38:49'Once it's in place, a catheter fed through the needle
0:38:49 > 0:38:52'will continuously supply local anaesthetic to the nerve.'
0:38:52 > 0:38:54That's the needle going in, is it?
0:38:54 > 0:38:56This is just the needle going in.
0:39:04 > 0:39:07Just filling up. So that's ideal.
0:39:09 > 0:39:14'Continuous nerve blocks like this are increasingly being used in civilian hospitals
0:39:14 > 0:39:18'for procedures such as knee replacements.'
0:39:18 > 0:39:23If we can manage to do procedures that the patient can go home afterwards,
0:39:23 > 0:39:27whereas they would have been in hospital for two, three days afterwards
0:39:27 > 0:39:29with poorly-controlled pain,
0:39:29 > 0:39:32it benefits the patient, it benefits the NHS.
0:39:32 > 0:39:35So, all round, there's a good synergy there
0:39:35 > 0:39:40between the military experience and requirement
0:39:40 > 0:39:43and also exactly the same in the NHS.
0:39:49 > 0:39:52I watched my mother-in-law suffer terribly
0:39:52 > 0:39:56while she was in hospital with a terminal illness.
0:39:56 > 0:40:01I feel strongly that the pains she went through could and should have been avoided.
0:40:01 > 0:40:03I hate seeing people in pain.
0:40:03 > 0:40:06I'm a huge fan of the NHS,
0:40:06 > 0:40:10but I think often it's managed pain really badly.
0:40:10 > 0:40:17Studies have shown 30% to 80% of patients after surgery
0:40:17 > 0:40:19are left in moderate or severe pain.
0:40:19 > 0:40:23The military have managed to get the targets down to about 10%
0:40:23 > 0:40:27and I think the NHS should be able to do that too.
0:40:27 > 0:40:31The means of controlling pain are out there, but they're not being used properly.
0:40:31 > 0:40:32That is, in many ways, quite shameful.
0:40:37 > 0:40:40It's the end of a long day
0:40:40 > 0:40:44and I've just heard there are more casualties coming in.
0:40:50 > 0:40:53SIREN WAILS
0:41:06 > 0:41:09I feel really shattered, I feel very shaken.
0:41:09 > 0:41:13I've seen a lot of...
0:41:13 > 0:41:19gruesome stuff today - some amputations - and there's more of them coming through.
0:41:19 > 0:41:23The main thing, I thought, after we'd seen some of this stuff,
0:41:23 > 0:41:27I thought, "I don't know how they cope." I don't know how
0:41:27 > 0:41:30the staff in there cope with more and more of them coming in.
0:41:30 > 0:41:35It was bad enough seeing one, two, three, and now there's just more of them pouring in.
0:41:35 > 0:41:38And you just wonder, "How do you get up every morning and do it?"
0:41:45 > 0:41:49SIRENS WAIL
0:42:12 > 0:42:15It's my last day.
0:42:16 > 0:42:20Before leaving, I want to see how Chuck Donnelly,
0:42:20 > 0:42:23the Marine with the damaged foot, is doing.
0:42:23 > 0:42:26So how is your leg feeling in terms of pain?
0:42:26 > 0:42:29There's no pain right now at all.
0:42:29 > 0:42:32It feels really swollen and numb.
0:42:32 > 0:42:35- So what happened?- Er...
0:42:35 > 0:42:42So the area we were in, I was point man on patrol, so I was leading.
0:42:42 > 0:42:45And I walked...walked by the IED at first.
0:42:45 > 0:42:48All I remember is screaming, "Aaargh!"
0:42:48 > 0:42:51I took a second look. "Why am I screaming? What happened?"
0:42:51 > 0:42:57And then I realised I got hit by an IED and continued to scream now I knew what was going on.
0:42:57 > 0:43:03It was a real small charge. Er...couldn't have been any more than five or ten pounds.
0:43:03 > 0:43:08But...it was probably old, so it didn't completely go off.
0:43:08 > 0:43:11But I was extremely, extremely lucky.
0:43:11 > 0:43:14- Do you have a wife?- Yeah, a beautiful wife back home.
0:43:14 > 0:43:17- A beautiful wife.- Yes. Can't wait to see her again.- Yes.
0:43:17 > 0:43:23'Chuck will be flown back to America to continue his treatment.'
0:43:30 > 0:43:33The stream of appallingly injured young people I've seen
0:43:33 > 0:43:37is a shocking reminder of the human cost of this war.
0:43:39 > 0:43:45But I do believe there will be an important medical legacy from all this horror,
0:43:45 > 0:43:49not least what we're learning about controlling massive blood loss.
0:43:49 > 0:43:55Yet it's not a single big breakthrough, but rather a series of well thought-through changes
0:43:55 > 0:43:59that are making the difference between life and death.
0:44:10 > 0:44:13One of the other things I learnt in Afghanistan
0:44:13 > 0:44:19is that many military developments have their origins in civilian medicine -
0:44:19 > 0:44:22a bit like a relay race, with a medical research baton
0:44:22 > 0:44:25being passed from civilians to military and back again.
0:44:27 > 0:44:30So I've come to America
0:44:30 > 0:44:34to track down the next generation of radical new ideas
0:44:34 > 0:44:37that are attracting the attention of the military.
0:44:48 > 0:44:50I'm starting in Atlanta,
0:44:50 > 0:44:55where they're doing research which sounds so improbable, I want to find out more.
0:44:58 > 0:45:02It's an approach that could dramatically improve the treatment of brain injury,
0:45:02 > 0:45:06a major killer of troops in Afghanistan.
0:45:10 > 0:45:12OK. That would make sense.
0:45:12 > 0:45:18Dr David Wright works in emergency medicine at the Grady Memorial Hospital.
0:45:20 > 0:45:22We see an enormous amount of head injury.
0:45:22 > 0:45:26We have lots of motor vehicle collisions, assaults...
0:45:26 > 0:45:30Under the age of 45, traumatic brain injury is the leading cause of death
0:45:30 > 0:45:33in this country and in many other places in the world.
0:45:33 > 0:45:36Until the Afghan-Iraq wars,
0:45:36 > 0:45:40where the media became aware of soldiers coming back with TBI,
0:45:40 > 0:45:41it was largely ignored.
0:45:41 > 0:45:46It's considered by many the signature injury of the wars,
0:45:46 > 0:45:49so it certainly put a lens on this topic.
0:45:49 > 0:45:52That's the clinical trial data.
0:45:52 > 0:45:55'David is trialling a drug made from progesterone,
0:45:55 > 0:45:58'a hormone more commonly used in the contraceptive pill.
0:46:01 > 0:46:03'Rats injected with progesterone
0:46:03 > 0:46:07'soon after suffering a brain injury made dramatic recoveries.'
0:46:07 > 0:46:11- I'll show you right here. - What am I looking at here?
0:46:11 > 0:46:17This is actually a rat. And this is a stroke.
0:46:17 > 0:46:22This is a stroke, very typical, which you would have in a human
0:46:22 > 0:46:26and one side of the brain is basically not getting any blood.
0:46:26 > 0:46:29- This is dead? - This is essentially dead.
0:46:29 > 0:46:31This animal was not treated with anything
0:46:31 > 0:46:34- and this animal was treated with progesterone.- Right.
0:46:34 > 0:46:38It could be a very life-changing difference,
0:46:38 > 0:46:41maybe even being able to walk versus not being able to walk.
0:46:41 > 0:46:44'The results were just as impressive in humans.
0:46:44 > 0:46:50'In a small trial, patients with head injuries given progesterone
0:46:50 > 0:46:52'were twice as likely to survive.'
0:46:52 > 0:46:57Why should essentially a female hormone, which I associate with controlling ovulation,
0:46:57 > 0:47:00why should that have anything to do with the brain?
0:47:00 > 0:47:02That's a great question.
0:47:02 > 0:47:05It's a misnomer. We actually believe it's not a female hormone.
0:47:05 > 0:47:08- Progesterone is not a female hormone?- It's a neuro-steroid.
0:47:08 > 0:47:12It's the only hormone that's actually produced in the brain.
0:47:12 > 0:47:17Oestrogen and all the other types of hormones are produced in different glands of the body,
0:47:17 > 0:47:18but not the brain.
0:47:18 > 0:47:22- You get it in guys too?- You get it in guys. In fact, in the brain it's in equal quantities.
0:47:22 > 0:47:29'Progesterone is critical for the development of neurons,
0:47:29 > 0:47:32'the cells that carry messages in the brain.'
0:47:32 > 0:47:36The reason it goes very high in the second and third trimester of foetal development
0:47:36 > 0:47:39when you're pregnant is probably to protect the brain
0:47:39 > 0:47:44and some sort of novel thing it has to do with brain growth.
0:47:45 > 0:47:51'When the brain is injured, it releases chemicals that destroy neighbouring cells.
0:47:51 > 0:47:54'Progesterone blocks the production of these chemicals.'
0:47:54 > 0:47:56So this is it.
0:47:56 > 0:48:01'Dr Wright is just starting a new trial of this treatment, involving over 1,000 patients.'
0:48:03 > 0:48:06What do the military make of this?
0:48:06 > 0:48:09They're intrigued because it's a huge problem in the military.
0:48:09 > 0:48:15They've actually funded a study to develop a water soluble version,
0:48:15 > 0:48:20one that potentially could be used by the medics in the field.
0:48:20 > 0:48:26One of their sites in San Antonio called BAMC will be involved.
0:48:26 > 0:48:30It's a military hospital. They're gearing up to get started and join us.
0:48:34 > 0:48:38I thought that was utterly fascinating and I love the idea that progesterone,
0:48:38 > 0:48:41something I associate with the contraceptive pill,
0:48:41 > 0:48:47could have such completely unexpected and incredibly profound beneficial effects.
0:48:47 > 0:48:50I was also struck by something else Dr Wright said,
0:48:50 > 0:48:56which was that it's really the fact that all these young men coming back from the wars
0:48:56 > 0:49:01has raised awareness of the importance and the significance of head injury.
0:49:01 > 0:49:08So in this case, you've got a subtle interplay between civilian medicine and military.
0:49:17 > 0:49:21Emergency medics know you can increase survival rates if you act fast.
0:49:21 > 0:49:25As soon as someone is injured, the clock starts to tick.
0:49:28 > 0:49:31In Pittsburgh, they're trying to slow down the hands of that clock,
0:49:31 > 0:49:35using extreme cold to buy time.
0:49:38 > 0:49:41'Numbness, fingers, face.
0:49:41 > 0:49:45'Profoundly cold. Almost looking like corpses.'
0:49:47 > 0:49:50Ten years ago, I made a programme
0:49:50 > 0:49:55about unexpected survivors in the Falklands War.
0:49:55 > 0:49:58One of the surgeons we interviewed said it was perhaps
0:49:58 > 0:50:01because many of them got left on the hillside in the cold night
0:50:01 > 0:50:04and they got hypothermic
0:50:04 > 0:50:08and that could explain why they didn't die of their injuries.
0:50:08 > 0:50:10I have been intensely interested
0:50:10 > 0:50:14in the effects of cold on the human body ever since.
0:50:14 > 0:50:19Getting cold is bad for trauma patients because it delays clotting.
0:50:19 > 0:50:22But if cooling is rapid and extreme enough,
0:50:22 > 0:50:25the benefits may outweigh the risks,
0:50:25 > 0:50:28or at least that's they're hoping to prove here.
0:50:28 > 0:50:30Traumas in the department.
0:50:30 > 0:50:3224-year-old male, two gunshot wounds to the chest.
0:50:32 > 0:50:34One, two, three, lift.
0:50:34 > 0:50:38Persisting ventilations. Gunshot to the right chest.
0:50:38 > 0:50:43'This patient's been shot. He's lost so much blood his heart has stopped.'
0:50:43 > 0:50:44I don't have a pulse.
0:50:44 > 0:50:48I have no pulse. Medic, can you come and do CPR, please?
0:50:48 > 0:50:52'The ER team are trying everything to get his heart working.
0:50:52 > 0:50:55'But they're getting no response.'
0:50:55 > 0:50:58I'm getting no cardiac activity. Let's initiate EPR.
0:51:00 > 0:51:02'What they do next is extraordinary.'
0:51:02 > 0:51:04Initiate cooling.
0:51:04 > 0:51:08- Start bringing the temperature down. - Pump's ready to go.
0:51:08 > 0:51:11'They slowly pump the remaining blood from his body
0:51:11 > 0:51:15'and replace it with ice-cold saline solution.
0:51:15 > 0:51:19'This induces a state of severe hypothermia.'
0:51:19 > 0:51:23So lots of almost freezing water about to go into his system?
0:51:23 > 0:51:26- That's right.- What levels are you trying to get them down to?
0:51:26 > 0:51:31- I want to get the brain temperature down to ten degrees centigrade. - Ooh.- That's cold.- That's cold.
0:51:31 > 0:51:35'This is actually a training exercise,
0:51:35 > 0:51:39'but Dr Sam Tischman and his team are taking it very seriously.'
0:51:39 > 0:51:41There's no blood in the left chest.
0:51:41 > 0:51:47- 'They're due to start the first ever human trial in a matter of weeks.' - How's our temperature doing?
0:51:47 > 0:51:49The temperature's coming down.
0:51:49 > 0:51:54'At such low temperatures, the patient would have no heart beat and almost no brain activity.
0:51:56 > 0:51:58'In this death-like state,
0:51:58 > 0:52:01'the brain and other major organs
0:52:01 > 0:52:04'can survive for far longer than normal without oxygen.'
0:52:04 > 0:52:09We think this is the best way we can buy time to try to save his life.
0:52:09 > 0:52:12If he were at normal temperature and no blood flow,
0:52:12 > 0:52:17more than five minutes and pretty high risk of having some brain damage and not recovering very well.
0:52:17 > 0:52:20In this case, you can get how much time?
0:52:20 > 0:52:21We're hoping up to an hour.
0:52:21 > 0:52:24That gives us enough time to get to the operating room,
0:52:24 > 0:52:27stop the bleeding and then we can resuscitate him.
0:52:30 > 0:52:35'We think it's beneficial, not just in decreasing the tissue's demand for oxygen and blood,'
0:52:35 > 0:52:39but decreasing a lot of the deleterious chemical cascades, all the bad things that happen
0:52:39 > 0:52:43when you don't have blood flow to your vital organs for a period of time.
0:52:43 > 0:52:48Once the emergency surgery is done, the patient will be warmed up again,
0:52:48 > 0:52:52and the blood pumped back into their body.
0:52:53 > 0:52:55What are the risks?
0:52:55 > 0:52:58In the trauma world, there's actually great fear of the cold,
0:52:58 > 0:53:03because the colder you are the less your blood will clot, so you'll bleed more,
0:53:03 > 0:53:05and, in fact, if you look at trauma data,
0:53:05 > 0:53:07the colder patients tend to do worse.
0:53:07 > 0:53:12So this is going against the standard treatment that we do for our trauma patients.
0:53:12 > 0:53:14Does that make you feel a bit nervous about it?
0:53:14 > 0:53:16A little, but not too much.
0:53:16 > 0:53:20I think the problem is we know that less than one in ten patients
0:53:20 > 0:53:22that have a cardiac arrest from trauma,
0:53:22 > 0:53:25that we even try to resuscitate at all, will survive.
0:53:25 > 0:53:28- Less than one in ten will survive? - Less than one in ten.- Right.
0:53:28 > 0:53:30So we know what we're doing now doesn't work.
0:53:30 > 0:53:32So something like this is exciting to people.
0:53:32 > 0:53:35We might be able to increase that number substantially.
0:53:35 > 0:53:39- BEEPING - 35 degrees.
0:53:47 > 0:53:49I'm very impressed by the constant drive
0:53:49 > 0:53:52to raise the bar of what is survivable.
0:53:52 > 0:53:56Already the combination of military and civilian medicine
0:53:56 > 0:53:58has been extraordinarily successful
0:53:58 > 0:54:01at keeping people alive against the odds.
0:54:02 > 0:54:06But it does mean an increasing number of survivors are facing
0:54:06 > 0:54:08a future with dreadful injuries.
0:54:13 > 0:54:17Before I leave, I've come to the Walter Reed Medical Centre.
0:54:17 > 0:54:22I'm here to visit the young marine who was brought into hospital
0:54:22 > 0:54:24when I was in Camp Bastion.
0:54:24 > 0:54:27Ronald Barnes had both his legs blown off
0:54:27 > 0:54:29and he nearly bled to death.
0:54:30 > 0:54:36Four months on, CJ, as he' known, is in rehabilitation.
0:54:36 > 0:54:41- This is one video of me walking. - Very good.
0:54:41 > 0:54:44It's a lot more difficult than it looks.
0:54:44 > 0:54:47- HE LAUGHS - What's the furthest you've walked?
0:54:47 > 0:54:51The furthest I've walked was about a quarter of a mile.
0:54:51 > 0:54:54- How are you feeling? Generally? - Er...
0:54:56 > 0:54:59It's on a day-to-day basis.
0:54:59 > 0:55:03Some days, I'll feel all right. My pain levels are relatively low.
0:55:03 > 0:55:05But then there's other days, you know,
0:55:05 > 0:55:08days I can't really sleep with nightmares
0:55:08 > 0:55:10and then the rest of that day
0:55:10 > 0:55:14I'll be in so much pain, it's just hard to function.
0:55:14 > 0:55:19- Does anything relieve it? - Just the drugs that they have me on.
0:55:19 > 0:55:23- Do you dream about walking and things like that?- Er...
0:55:26 > 0:55:28Sometimes I do.
0:55:28 > 0:55:33Um...it's hard when, like, I'll go on Facebook or something
0:55:33 > 0:55:36and I see a picture of me with legs, actually doing something.
0:55:36 > 0:55:39I mean, that...
0:55:39 > 0:55:44There are times I just have to walk away from it or roll away from it.
0:55:44 > 0:55:48But I can't...I can't really look at it for too long.
0:55:48 > 0:55:49It just gets to me.
0:55:49 > 0:55:53Do you know others it happened to, other people in your regiment?
0:55:53 > 0:55:55Yes. Actually, my...
0:55:55 > 0:55:58When I got hit, they sent a replacement,
0:55:58 > 0:56:01to get another engineer out there.
0:56:01 > 0:56:06And about a month later, my replacement got hit.
0:56:06 > 0:56:08And he is here as well.
0:56:08 > 0:56:13And I know about four or five other people from my unit that are here.
0:56:13 > 0:56:16I don't want to see another person come here, ever.
0:56:16 > 0:56:18It hurts, you know,
0:56:18 > 0:56:22that people that I was living with on a daily basis, you know,
0:56:22 > 0:56:25their lives and my life's pretty much changed for ever.
0:56:27 > 0:56:31So I think the worst part about it...
0:56:31 > 0:56:34is the mental aspect of it.
0:56:34 > 0:56:40Because, I mean, personally, I fight with so much stuff on a daily basis.
0:56:40 > 0:56:46And...the pain that is in my mind
0:56:46 > 0:56:49is so much worse than the pain that's in my body.
0:56:55 > 0:56:58'CJ is actually'
0:56:58 > 0:57:02almost the first person I've talked to in the situation who was,
0:57:02 > 0:57:05I felt, completely honest about it.
0:57:05 > 0:57:09The tendency is very much a positive psychology.
0:57:09 > 0:57:12"It's marvellous. We're going to get ourselves around this."
0:57:12 > 0:57:15And he was the first person who sort of got up and said,
0:57:15 > 0:57:17"No, it's really tough.
0:57:17 > 0:57:20"It's really, really tough. And I still feel it every day."
0:57:22 > 0:57:25And it's made me eager to find out what medicine is doing
0:57:25 > 0:57:29to help survivors like CJ rebuild their lives.
0:57:36 > 0:57:39Next time I will be looking at advances
0:57:39 > 0:57:41in repair and rehabilitation.
0:57:41 > 0:57:45- Can you imagine yourself back in Afghanistan?- Yeah, that's my job. That's what I do.
0:57:45 > 0:57:49- Do you think you can keep up? - You're going so fast!
0:57:49 > 0:57:51'From mind control prosthetics...'
0:57:51 > 0:57:54The wrist rotates in 360 degrees.
0:57:54 > 0:57:57..to growing spare body parts,
0:57:57 > 0:58:01and even face transplants.
0:58:20 > 0:58:23Subtitles by Red Bee Media Ltd
0:58:23 > 0:58:26Email subtitling@bbc.co.uk