Survival Frontline Medicine


Survival

Michael Mosley explores the link between war and medical research. How have medics in Afghanistan achieved the highest survival rate in the history of warfare?


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Transcript


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This programme contains some scenes which some viewers may find upsetting

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This programme contains some strong language

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Five litres of blood in the human body, five litres.

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-It can be gone in three to four minutes.

-Gunshot wound, heavy bleeding.

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Really brilliant surgery. His life was definitely saved this morning.

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The survival rate amongst wounded troops in Afghanistan

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is the highest in the history of warfare.

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War has always driven innovation. And this one is no exception.

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Do you have any evidence that this is effective?

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Just by the level of injuries that people are now surviving.

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Posterior tibial pulse is present to both feet.

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We've got people who are alive

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who, five years ago, would not have survived.

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I want to find out what medics and surgeons have learnt

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from the last ten years of bloodshed.

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What are the advances that are making

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the difference between life and death?

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And how could they help us all?

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It's early in the morning and we're going off to war, to Afghanistan.

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Now, the reason I want to go is because the medics there

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are somehow managing to keep up to 90% of casualties alive

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and that is a truly awesome statistic.

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The highest success rate that has ever been achieved.

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I'm also feeling a little bit apprehensive,

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because I have never been to a war zone before.

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I get a taste of what's to come sooner than I expect.

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Wow, this is not what you see on your average aircraft.

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All these stretchers.

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Now, I trained as a doctor and I've seen a lot of trauma,

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but I suspect nothing like what I'm going to see in Afghanistan.

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I was thinking, as we came on the aeroplane -

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I saw those young men going up the steps -

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I was thinking if the war is as fierce this year as it was

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last year then, statistically speaking at least,

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one of those guys back there is going to be killed

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or severely injured in the next six months

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and, if so, they're going to be coming home on one of these.

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This is Camp Bastion,

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headquarters of the British Forces in Afghanistan.

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It's also home to the main hospital for battlefield casualties.

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And just a few hours after landing, that's where I'm heading.

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I'm told that Camp Bastion is the size of Reading.

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It's certainly an awful lot dustier.

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-Hi, guys, is this the hospital?

-Yes.

-Thank you.

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So...something busy is going on.

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I've arrived outside the hospital and suddenly it's all kicking off.

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They're all heading off in that direction.

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I've only been here a few moments

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and already I'm seeing casualties brought in from the battlefield.

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So I've seen one person being carried off the helicopter

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and it looks serious.

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SIREN WAILS

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Nice and gentle.

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This hospital deals with some of the most severe injuries

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you'll see anywhere in the world.

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In three, two, one. Clear.

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It's run by British military medics.

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When they're not on tour, they work in the NHS.

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They're both described as going in and out of consciousness.

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Colonel Jeremy Henning is the clinical director.

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So what's wrong with this guy?

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So he's been shot through the pelvis.

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He was up doing guard duty in an elevated tower.

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He was shot, he's fallen back. He's Afghan Army.

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Normal expansion chest.

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Is this is a typical sort of injury you'd see?

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Yeah, we see two main types of injuries.

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One is the gunshot wounds. They come in very regularly,

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and the other major one we see are the improvised explosive devices.

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He's moving his right foot.

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He's stable enough. He's now gone for a CT scan.

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That is just over ten minutes and he's in...

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-We've got another four casualties coming in.

-How many?

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-Another four.

-Another four, right.

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Posterior tibia pulse is present.

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What is really impressive, I have to say, is the speed at which

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they're moving because there was a guy who was just over there,

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he came in maybe...ten minutes ago and he's already been dealt with.

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They've begun their investigations and he's off having a CT scan.

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This guy came in about five minutes afterwards

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and he's also just about ready. They've already X-rayed him

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and they're about to whisk him off to CT scan as well.

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He's got blast pants on.

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The commonest cause of death amongst casualties out here

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is massive blood loss.

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But they've recently developed ways of dealing with it

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that's had a huge impact on survival rates.

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-That one's 11.20 that one's 11.30.

-'Lieutenant Colonel Steve Lord

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'is a consultant in the Emergency Department.'

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-So what have you got?

-An IED blast and he's apparently got amputations

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-of both legs.

-So he's stood on a mine

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and it's been big enough to blow off both his feet?

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We generally don't get given the level.

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They may say it's just a foot, but if they say legs,

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it could be anywhere from the ankle up to the groin

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and we will not know till we see him.

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They've called "hot vampire", which means they give him blood

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in-flight, so we make sure we've got blood available.

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'They found that by changing how they replace blood

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'they can cut death rates by up to a half.

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'The NHS are interested

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'because 40% of trauma deaths in the UK are caused by blood loss.'

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Just want to go to the blood lab and find out what's going on.

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Hello. 'There's 20 minutes until the casualty arrives

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'and Chief Petty Officer Andy Murphy is getting blood ready.'

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We've got one guy with a head injury, one with a double amp.

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The double amp is obviously the main concern.

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Effectively, any trauma patients, we assign them universal donor blood.

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And each of those people could need 30, 40 units, or what?

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-And the rest, potentially.

-More?

-In some cases.

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There have been cases of patients having upwards of 150 units.

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You're talking up to 50 litres of blood?

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-I mean, that is a bathful of blood, isn't it?

-Yes.

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'Amazing, considering the average body only holds five litres.

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'As usual, blood for transfusions is separated into different parts.'

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'Red blood cells that carry oxygen,

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'and plasma, a yellowy fluid which helps blood clot.

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'In the past, they'd give four times more red cells than plasma.'

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When they used to give four of these to one of these, they weren't

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giving back enough clotting factors

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for the patient to stop bleeding and that's why they would bleed out.

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'So the military recently increased the amount of plasma they give.'

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They actually now give equal volumes. One of this to one of this.

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And that helps to provide...top up the patient's own clotting factors.

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Do you have any evidence that this is effective?

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Just by the survival rate and the level of injuries that people are now surviving.

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-Number 1891.

-4-5-4-7.

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Four litres of blood are rushed to the Emergency Department.

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The new casualty is only moments away.

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He's been flown in from the frontline by the MERT,

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the Medical Emergency Response Team.

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SIREN WAILS

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United States marine. Mechanism is IED versus foot soldier.

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Injuries are left below knee, right below knee,

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with tissue damage up to the groin.

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Lance Corporal Ronald Barnes is just 20-years-old.

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He's been blown up by an IED.

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-That's ADT two.

-22?

-22.

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Oh, dear, it's really distressing.

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No major obvious wounds on the back.

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One, two, slide. Thank you.

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Although heavily bandaged, he may still be losing a lot of blood.

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4.1.

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High wound to right thigh.

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It's a massive wound on the right thigh, OK?

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You want this down?

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And, as you say, above knee on the right and below knee amputation

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-on the left.

-Can we make room for a chest X-ray?

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In three, two, one.

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-Has he lost a lot of blood?

-Well, we have to assume that he has.

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The fact that he received blood on the ground via MERT

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-would imply that he has significant blood loss.

-Right.

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What they're really worried about is the lethal triad -

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blood loss, a build-up of acid and hypothermia.

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The blue blanket is going on the top to make sure that he stays warm.

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You get cold really quickly.

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Ronald's getting cold because he's lost so much blood.

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Not enough oxygen is reaching his tissues to generate heat.

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That lack of oxygen also causes a build-up of lactic acid.

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The cold and increased acid make his blood less able to clot.

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Untreated, he would bleed to death.

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The new way they give blood, adding more plasma,

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should reduce the risk of this happening.

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He does have a weak radial pulse in the right.

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They've got red cells and they've also got plasma

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and he needs that in order to clot and stop a catastrophic haemorrhage,

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bleeding, that may be going on.

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-And two mils of...

-No blood on blood.

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They've got a line going into his arm

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and they're pumping blood through there,

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but they also want to get to the veins in the neck

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cos then they can really pour it in.

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They want to get as much blood into him as they can.

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Everything here is set up for speed of diagnosis and treatment.

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OK, so what have you got there?

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This is a hand-held ultrasound unit that we use to quickly assess

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the abdomen for free fluid and free fluid equals blood.

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If there's any sign of internal bleeding, he'll be taken straight to surgery.

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If not, they'll do a CT scan to get a clearer idea of his injuries.

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Negative.

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-None that we've found so far.

-No internal bleeding?

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None that we've seen.

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Surgeon Commander Peter Small is waiting in the Emergency Department,

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ready to operate as soon as he can.

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He has a good blood pressure, he's not tachycardic

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he's getting blood transfused. I think he's stable.

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-CT?

-CT.

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Is blood loss a big factor?

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Do you know how many units they poured in?

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He had three and three on the helicopter and we've given him

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some more in here, at least two units.

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They've already replaced all the blood in Ronald's body.

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And he still needs more.

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He needs six units. For theatre, they need six units of blood.

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But first, Ronald is taken to the scanner.

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He's got a femoral fracture just above...

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They're getting together detailed information about his injuries.

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They're also looking for any hidden internal bleeding.

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There's a large soft tissue defect anterior thigh.

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They've had a dedicated radiologist for emergency cases here since 2009.

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It's something very few casualty departments have in the UK.

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Massive tissue disruption. No evidence of solid organ injury -

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liver or spleen or kidney. He's intact.

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-Do a transplant and get that one side?

-'Knowledge is power, really.'

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In the past, there could have been a concern of,

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"Is he bleeding from somewhere else? Do we need to open his abdomen just to be sure that he's OK?"

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So here we can say, categorically, there is no evidence of an injury

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in his abdomen that could cause him to bleed during the surgery.

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The surgical team are ready to operate.

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It's been just over an hour since Ronald was picked up from the frontline.

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IEDs are nasty. They go off in earth,

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and are covered in shit and bolts and that gets blown into the body.

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We try to get all that out.

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'The team's first challenge is to stop Ronald losing a lot more blood while they operate.

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'Peter is going to use a new surgical technique they've developed out here.

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'He will shut down the blood supply to Ronald's legs

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'while they deal with his injuries.'

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They're going for one of the major arteries which supplies the leg.

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They're going to tie that off so the blood supply

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to the shattered limb is cut off, because if they didn't do that

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and they started operating, there's a high risk that that guy

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on there would suffer from further catastrophic blood loss.

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'Peter is a Reservist. He normally works in the NHS in Sunderland.'

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So it's a bit like turning off the water supply in the house before you do the plumbing repair, is it?

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-Interesting way of putting it. But only to the radiator.

-Yeah.

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'Although Ronald's blood is clotting, the clots are fragile.

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'So they're also giving him platelets,

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'another constituent of blood which makes clots stronger.

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'They only started doing this in 2007.

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'While they get his blood loss under control,

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'other members of the team are hard at work.'

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What's unusual is so many people are involved in it,

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and so many different specialties.

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You've got a plastic surgeon, an orthopaedic surgeon,

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a trauma surgeon and a general surgeon,

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all gathered around the bed, all operating at the same time.

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'A priority at this stage is to remove destroyed tissue

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'to prevent infection.'

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How's he doing?

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It's hard because you're chasing vessels back to control a muscle

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that's just blasted with debris.

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He's stable.

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'Once they've finished tying up torn blood vessels

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'and cleaning the wounds, Peter unclamps the main artery

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'to let blood flow back into Ronald's legs.

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'I've seen the full extent of Ronald's horrific injuries

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'and I'm amazed he's still alive.'

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He had absolutely outstanding... I mean, really brilliant surgery.

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The whole thing is just massively impressive from the moment

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they come through the door to the moment they're here.

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He's going to face life as a double amputee

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and that's going to be really rough.

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But his life was undoubtedly saved this morning.

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It went well. First of all, the patient didn't die.

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We managed to get early control of the bleeding

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and we've tidied up his amputations, stabilised him

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and we'll be looking to ship him on to American hospitals

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as soon as we can.

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-Do you find it distressing when you see a man come in like that?

-Yes.

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It's not nice to see a human body mutilated,

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but, at the end of the day, we're here to do what we can,

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to save as much as we can.

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We didn't give them the injuries,

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we're trying to stop the injuries getting worse.

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So if you start with that mindset, then, yeah, you can cope with it.

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Ronald is taken to intensive care

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and will be flown back to America as soon as possible.

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In emergency medicine, there's a category of patients

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whose injuries are so severe they're not expected to live.

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Out here, they are saving a quarter of those

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who would normally be expected to die.

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In civilian medicine, the best they manage is 5%.

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Do you think you are saving people who you wouldn't have ten years ago?

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Yes, without a doubt. We've got people who have gone back

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who are alive who, five years ago, would not have survived

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and I think, even over the last three or four years,

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the things we thought were potentially unsurvivable,

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we would now ask, "Why have they not survived?"

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-Do you learn a lot of stuff here that you take back to the NHS?

-I do.

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Scanning. Virtually everyone who comes through here

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gets a full body scan if they've been involved in an explosion

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and there's a lot of evidence, even in civilian literature, that that is the way ahead.

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We use blood products aggressively here, including clotting factors.

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I think that's something we should consider more of in the NHS.

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Normally, we give them crystalloid fluid, which is salty water,

0:19:280:19:32

and, actually, the body should get used to blood products early on.

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If that's what they're losing, that's what we should give them.

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There's now a clinical trial of the new blood transfusion protocol

0:19:420:19:47

being carried out at five casualty departments in the UK.

0:19:470:19:51

TANNOY: Op minimise, op minimise.

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We've just heard over the tannoy a message - "Op minimise," which means

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that this base is cut off from all communication with the UK.

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And the reason for that is a young British serviceman has just died in action

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and they don't want the news to leak out before the relatives can be told.

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His body was brought here to the hospital

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and the mood is very sombre.

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It's graphic evidence that not everybody can be saved.

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TANNOY: I say again, Op minimise, op minimise, op minimise.

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If casualties do get to the hospital alive then the medical team

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would now expect to save them.

0:21:200:21:23

What surprises me is that so many seriously wounded troops

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make it to the hospital alive in the first place.

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Release!

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I want to find out what they're doing on the frontline

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that is helping to save lives.

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Identify your target!

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When I was training in medicine, we used to talk about the golden hour

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and that was the period, the precious hour you had, in which

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you could hopefully treat the patient and make them better.

0:22:000:22:04

Now they talk about the platinum ten minutes.

0:22:040:22:08

That in just ten minutes, within which,

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if you do not do the right thing,

0:22:100:22:12

then there's a good chance that your friend is going to bleed to death.

0:22:120:22:16

Since 2005, all the troops on the ground have been issued

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with one piece of medical equipment that's made a massive difference

0:22:220:22:26

to survival in that first ten minutes.

0:22:260:22:29

Paramedic Chief Petty Officer Steve Parmenter shows me one.

0:22:290:22:34

We carry them in such a way that we can put them on single-handedly.

0:22:340:22:38

They go up on the arm.

0:22:380:22:40

'It's a new type of tourniquet. Simple but incredibly effective.'

0:22:400:22:47

-As much as we can bear and then one more turn.

-Very neat. OK, you're injured where?

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-If I've got a big bleed here, you want to go onto a single bone.

-I'm going here. Good big biceps, blimey!

0:22:510:22:58

-Yep.

-Now pull it tight.

-OK.

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-Brace it against this bar and pull.

-Blimey!

-And again.

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-Then I just go like that, do I?

-Yep.

-That's very neat.

0:23:040:23:07

So when we train, we train so that we lose the distal pulse.

0:23:070:23:10

-If you were bleeding, that would stop that.

-That would slow it down for you to control it.

0:23:100:23:15

-Right.

-So it's no longer catastrophic.

0:23:150:23:17

Somebody told me that if they'd had this thing in Vietnam

0:23:170:23:21

or other major battles, it could have saved thousands of lives.

0:23:210:23:24

Yeah, probably, a lot more lives. When I started my service in the mid-'80s,

0:23:240:23:29

-if we'd had them in Ireland, I can think of a few people that would still be around.

-Yeah.

0:23:290:23:34

-These are being applied in the ambulance service?

-Yes.

0:23:340:23:37

SWAST, South West Ambulance Service, were the first ambulance service to use them.

0:23:370:23:42

Now HEMS, London Ambulance, are all training their guys on these now.

0:23:420:23:45

It's easy to put on when you're in the back of an ambulance,

0:23:450:23:49

but the troops will have to use it on the battlefield.

0:23:490:23:52

Like everything in the military, it's all about training.

0:23:520:23:56

-Young man, are you happy to be used?

-Yeah.

-Come on up.

0:23:560:24:00

So we're going to strip you down. Are you happy with that?

0:24:000:24:03

-Not really! Take your top off. Have you been working out?

-No.

0:24:030:24:08

Where do you think the prominent junctions of his body lie?

0:24:080:24:13

-Good, yeah, happy with that.

-Down there and around there.

0:24:130:24:17

Draw on him, go on. That's good, yeah. Take your trousers down.

0:24:170:24:21

Oh, this is bad for you!

0:24:210:24:23

There you go. And they're the main areas that we're going to bleed out from which is going to kill us.

0:24:230:24:29

Come on, lie on your back. Right, you get to pick someone now.

0:24:290:24:33

Up you come.

0:24:330:24:36

Oh, dear, your world's about to end!

0:24:360:24:39

I want you to sprint as quickly as you can. Go and then come back.

0:24:390:24:44

Right, why are we doing that?

0:24:440:24:47

"What's happened to me?" "You've been blown up by an IED."

0:24:470:24:50

Get a tourniquet on, quick, quick, quick. Get it on!

0:24:530:24:56

Hose him!

0:24:560:24:58

Get your knee in his groin, get your knee is in his groin!

0:24:580:25:01

Hurry up! As quick as you can! ALL: Oh!

0:25:010:25:04

LAUGHTER

0:25:040:25:06

Still hosing out. Still hosing out.

0:25:060:25:09

Come on, hurry up!

0:25:090:25:12

Hurry up! He's dying, he's fading away from you.

0:25:120:25:15

-Right, tell me how that felt?

-Shit.

-Why?

0:25:150:25:19

-HE PANTS

-Straight into it...

0:25:190:25:22

You see, you can hardly talk as well. It is absolutely, guys...

0:25:220:25:26

One thing I'm going to say to you -

0:25:260:25:29

if this ever does happen to you, what you've just got to remember,

0:25:290:25:33

he's sprinted 100 metres there and back, OK?

0:25:330:25:37

But he's going to be wearing body armour, helmet,

0:25:370:25:41

weapons system, gloves, eye protection,

0:25:410:25:44

and he'll upset cos it's his mate lying there.

0:25:440:25:46

You imagine what his heart rate's doing. It'll be difficult for him.

0:25:460:25:50

It's only natural, guys. You're going to panic, you'll be scared,

0:25:500:25:54

you're going to be worried, your hands are going to be shaking, OK?

0:25:540:25:57

-Give him a clap, everyone.

-The course instructor is Sergeant Lee Melvin.

0:25:570:26:01

We realised that the platinum ten minutes is the most important time for a casualty.

0:26:010:26:05

It's the guys out on the ground, the guy that's treating the injured man and making a big difference.

0:26:050:26:10

Five litres of blood in the human body, five litres.

0:26:100:26:13

And it can be gone in three to four minutes. And what we're trying to do

0:26:130:26:17

is teach these guys that through their interventions

0:26:170:26:20

and doing thing quickly, they will make a massive difference.

0:26:200:26:23

'In each patrol, there's a full-time medic.

0:26:230:26:28

'But they've also started to train one in four of the troops to a more advanced level.

0:26:280:26:34

'Recently, Trooper Keith Allen had to put his newly-acquired medical skills to the test.'

0:26:340:26:40

One of the lads had to go and get something off one of the vehicles,

0:26:400:26:44

and as he left, an RPG struck the vehicle.

0:26:440:26:46

He got hit by a lot of shrapnel and initially, we thought the worst

0:26:460:26:50

cos you could see the gash on his left arm so we treated that.

0:26:500:26:55

Me and another guy were trying to clear his airway as he'd swallowed his tongue.

0:26:550:26:59

One guy was holding his head while I was trying to prise his jaw open to release his tongue

0:26:590:27:04

but we were really struggling with it because his jaw was jammed tight.

0:27:040:27:08

He managed to start coming through and he started breathing on his own.

0:27:090:27:14

I recently got called to see someone who was out, heart stopped,

0:27:140:27:18

and I'm thinking when I'm down there,

0:27:180:27:20

"What I do in the next few minutes is either going to change

0:27:200:27:24

"this person's life, or they're going to die."

0:27:240:27:28

-Are these thoughts going through your brain?

-Yeah.

0:27:280:27:32

To start with I always thought, "If we were to get a casualty,

0:27:320:27:35

"would I be able to remember everything?"

0:27:350:27:38

And as soon as you get the casualty, everything just comes flooding back.

0:27:380:27:42

There was three of us working on this one guy and we all knew exactly what to do.

0:27:420:27:46

How did you feel afterwards?

0:27:460:27:49

One of the lads had to sit with me for five minutes, cos I was a bit emotional,

0:27:490:27:53

trying not to cry, trying to hold it in.

0:27:530:27:55

For a week after, it was just playing on my mind all the time...

0:27:550:28:00

but it's... I'm all right now.

0:28:000:28:02

Fantastic. I like the kit. The kit was very impressive

0:28:080:28:11

and you can see how it can be used in ambulance services in the UK.

0:28:110:28:15

But I think the thing impressed me even more was the training.

0:28:150:28:19

The fact that Keith, who only had a few weeks' training, was able to save his mate's life

0:28:190:28:24

because he, and the other guys there, knew exactly what to do.

0:28:240:28:28

I know what it is like to be in that situation where you

0:28:280:28:31

have immense pressure because you know whatever you do will lead

0:28:310:28:35

to the life or death of the person you've got down there.

0:28:350:28:39

And the fact that Keith, without years of training...

0:28:390:28:43

I've had years of training and I still feel that pressure when it occurs.

0:28:430:28:47

But Keith was able to, bang, click, do this, this, this and this

0:28:470:28:50

and almost certainly save his mate's life.

0:28:500:28:54

That was impressive.

0:28:540:28:55

A call has just come in that two soldiers have been shot.

0:29:030:29:09

The Medical Emergency Response Team, the MERT, rush to pick them up.

0:29:090:29:14

But it's not just about speed.

0:29:200:29:23

It's about the getting the right expertise

0:29:230:29:25

to the casualties as quickly as possible.

0:29:250:29:28

So since 2006, along with two paramedics,

0:29:280:29:33

they also have both a doctor and nurse on board.

0:29:330:29:35

Squadron Leader Charlie Thomson, a specialist nurse,

0:29:400:29:43

is in charge of the MERT.

0:29:430:29:46

There's the adrenalin rush of wanting just to get going

0:29:460:29:50

and pick them up as soon as possible.

0:29:500:29:53

Many of our jobs do involve small arms contact against the aircraft.

0:29:530:29:57

The enemy forces know that as soon as one of our soldiers has been shot,

0:29:570:30:01

they know that we're going to come and get them

0:30:010:30:05

which gives them plenty of time to get their weapons ready.

0:30:050:30:10

We just want to get the casualty on board as quick as possible

0:30:160:30:19

so everybody can get out of there.

0:30:190:30:21

It takes the MERT 15 minutes to reach

0:30:210:30:24

the casualties at a forward operating base.

0:30:240:30:28

OK, gunshot wounds.

0:30:280:30:33

Heavy bleeding from this.

0:30:330:30:35

One of them has been shot in the back.

0:30:350:30:38

The other in the leg.

0:30:380:30:39

With a doctor on board they can do blood transfusions,

0:30:450:30:49

anaesthetise patients and even open up

0:30:490:30:51

the chest to treat internal injuries if they have to.

0:30:510:30:55

'The job can be very emotionally difficult at times.

0:30:570:31:02

'But if we can learn how to deal with these traumas,

0:31:020:31:05

'and then be able to save lives, then that's good news all round.'

0:31:050:31:09

Once they get the casualties to the hospital, the MERT's job is done.

0:31:190:31:23

I catch up with Charlie while the crew wait for their next call.

0:31:320:31:36

What would I see here I wouldn't see on an average ambulance?

0:31:380:31:42

For a start, we carry blood - four units of O neg and four units of plasma.

0:31:420:31:46

What we can do in the back of here is more or less exactly the same as what you can do in the hospital.

0:31:460:31:53

OK, so this is it...

0:31:530:31:54

'The MERT also carries innovative new equipment.

0:31:540:31:58

'Charlie shows me some of it, with the help of a volunteer.'

0:31:580:32:02

Say Chris has got a double amputation to his legs.

0:32:020:32:05

The main reason our casualties die is because they lose their blood.

0:32:050:32:09

They lose their circulation, their oxygen supply, their clotting, that sort of thing.

0:32:090:32:13

So ideally we'd like to find a vein.

0:32:130:32:16

We'd probably find a big vein up here.

0:32:160:32:19

If we can't find those - and often we can't because they're so shut down with loss of blood -

0:32:190:32:24

we may have to use an intraosseous device.

0:32:240:32:27

Basically, we drill. For example, here, into the humeral head -

0:32:270:32:32

-we'll drill that needle in there, like so.

-A needle in the bone,

0:32:320:32:36

-then you can pump blood straight into the bone and then into the circulation.

-Yes.

0:32:360:32:40

'A tiny version of this was originally used on babies,

0:32:400:32:44

'whose veins are hard to find.

0:32:440:32:47

'In 2006, the British military picked the idea up and modified it.'

0:32:470:32:52

Our big infantry guys have big biceps and muscles.

0:32:520:32:56

So they designed this one, which is quite nasty to look at, but it works for us.

0:32:560:33:02

Pretend this is a bag of blood.

0:33:020:33:03

Because the blood is cold and we don't want to give casualties cold blood, we use a warming device.

0:33:030:33:09

You're warming the blood presumably because he's in shock

0:33:090:33:12

-and more cold would be a bad idea.

-Yes, that's right,

0:33:120:33:15

it won't help his clotting mechanism at all.

0:33:150:33:18

The other device we can use if this one doesn't work is something that'll go into his sternum.

0:33:180:33:23

Literally into your sternal notch, here.

0:33:230:33:25

These needles go through the skin and rest on the bone to stop the device moving so much.

0:33:250:33:31

And the centre bit there is basically what shoots into the sternum,

0:33:310:33:34

and again we can give blood, drugs and all sorts through there.

0:33:340:33:39

Each year I come out here, we're learning more.

0:33:390:33:43

BUZZER

0:33:430:33:45

We've got a job. Andrew, we've got a job.

0:33:450:33:48

Charlie and the team head off for their next call.

0:33:550:33:59

At the hospital, another casualty is due to arrive.

0:34:000:34:04

What have you heard?

0:34:050:34:07

-We've got someone coming in with an IED, with a partial amputation to his foot.

-Right.

0:34:070:34:12

-That's all we know at the moment. As far as I understand, he's a US soldier.

-Right.

0:34:120:34:17

All right, we have US marine suffered from an IED blast approximately 45 minutes ago.

0:34:280:34:35

He has a partial amputation of the left foot.

0:34:350:34:38

He has 10 milligrams of IV on board.

0:34:380:34:41

His pain is still about six out of ten.

0:34:410:34:43

MAN GROANS

0:34:450:34:47

He's obviously in a lot of pain at the moment, you can hear him groaning.

0:34:500:34:54

'One of the big challenges with such severe injuries is pain control.

0:34:540:34:59

'It's another area where military medics have recently made real progress.

0:34:590:35:03

-How are you doing, fella, what's your name?

-Chuck.

0:35:030:35:06

-Hi, Chuck.

-You guys going to knock me out?

0:35:060:35:10

Yeah, we'll give you some pain killers.

0:35:100:35:12

-Are you in pain right now?

-Yeah.

-OK, we'll give you something for that.

0:35:120:35:16

They've given me some, but it hasn't really helped.

0:35:160:35:18

He's nice and stable, do this nice and slow time.

0:35:180:35:22

'The anaesthetist is Surgeon Commander Dan Connor.'

0:35:220:35:25

-Can you remember what happened, Chuck?

-Yeah.

0:35:250:35:27

We were walking, doing a patrol and I stepped on a fucking IED.

0:35:270:35:33

OK. Did you get thrown at all?

0:35:330:35:37

-No.

-CHUCK CRIES OUT IN PAIN

0:35:370:35:41

-Do you think that foot is actually attached?

-Don't know until we open.

0:35:410:35:46

-It's more upsetting when they're awake and you're experiencing it.

-Yeah.

0:35:460:35:52

It's really upsetting, really, really upsetting.

0:35:520:35:56

Oh, dear. This guy's so young, he's really young.

0:35:560:35:59

And they treat it as though it's a scratch, and it's actually...

0:35:590:36:02

For them, it's actually not a severe injury, but the thought that,

0:36:020:36:06

you know, he's going to lose his foot, is really upsetting.

0:36:060:36:10

Because he's probably the same age as my son Alex - he's 20.

0:36:120:36:18

I didn't, um...yeah, I didn't think I'd feel like that. It's surprising.

0:36:200:36:26

Mm. Oh!

0:36:260:36:27

Has he got pink toes?

0:36:290:36:32

'Chuck is taken for a CT scan to assess the extent of his injuries.'

0:36:320:36:37

-Well, the calcaneous is in bits.

-Basically, the heel?

-Yeah, heel bone.

-Yeah.

0:36:370:36:42

-I mean, that is a mess, isn't it?

-Yeah.

0:36:420:36:46

-His foot's sort of...

-At 90 degrees.

0:36:460:36:49

-This bit there should be onto there.

-Yeah.

0:36:490:36:52

-His foot is pointing in the wrong direction.

-Absolutely.

0:36:520:36:56

-So do you think it's salvageable or not?

-Probably not.

0:36:560:37:00

-Probably not.

-Probably not. And even so, the amount of tissue disruption he's likely to have

0:37:000:37:06

will leave him with... not a very good foot. It depends.

0:37:060:37:10

Orthopaedic surgeons have pinned Chuck's foot in place.

0:37:130:37:17

It's too soon to say if they'll be able to save it.

0:37:170:37:22

In the past, Chuck's post-operative pain would have been controlled by high doses of morphine.

0:37:250:37:31

But Dan's going to use a very different approach,

0:37:310:37:34

one the military have been refining over the last ten years.

0:37:340:37:38

You're just blocking the bit that hurts.

0:37:380:37:40

You're putting local anaesthetic next to a nerve.

0:37:400:37:43

The catheter allows you to keep the anaesthetic running in, so you're just numbing

0:37:430:37:48

that area of the body.

0:37:480:37:50

We can just block his nerves that go to his ankle

0:37:500:37:53

and make him nice and comfortable for the journey home.

0:37:530:37:58

'Morphine affects the whole body and can cause significant side-effects.

0:37:580:38:03

'This technique acts locally and can block pain from Chuck's damaged foot

0:38:030:38:09

'for up to 40 days.'

0:38:090:38:10

You can see the benefits for this kind of injury,

0:38:120:38:15

so either gunshot wounds, small IED strikes

0:38:150:38:18

or single amputations to an upper limb from shrapnel.

0:38:180:38:22

'Dan is using high-resolution ultrasound,

0:38:220:38:26

'developed with US military-funding,

0:38:260:38:28

'to find the individual nerve that runs to Chuck's foot.'

0:38:280:38:32

You can just see the left hand circle

0:38:320:38:35

and that's the popliteal nerve.

0:38:350:38:38

Just to clarify - the bit I'm looking at is this bit here, yeah?

0:38:380:38:41

-Yeah, that's correct.

-And that's the nerve.

-That's the nerve.

0:38:410:38:45

'Once it's in place, a catheter fed through the needle

0:38:450:38:49

'will continuously supply local anaesthetic to the nerve.'

0:38:490:38:52

That's the needle going in, is it?

0:38:520:38:54

This is just the needle going in.

0:38:540:38:56

Just filling up. So that's ideal.

0:39:040:39:07

'Continuous nerve blocks like this are increasingly being used in civilian hospitals

0:39:090:39:14

'for procedures such as knee replacements.'

0:39:140:39:18

If we can manage to do procedures that the patient can go home afterwards,

0:39:180:39:23

whereas they would have been in hospital for two, three days afterwards

0:39:230:39:27

with poorly-controlled pain,

0:39:270:39:29

it benefits the patient, it benefits the NHS.

0:39:290:39:32

So, all round, there's a good synergy there

0:39:320:39:35

between the military experience and requirement

0:39:350:39:40

and also exactly the same in the NHS.

0:39:400:39:43

I watched my mother-in-law suffer terribly

0:39:490:39:52

while she was in hospital with a terminal illness.

0:39:520:39:56

I feel strongly that the pains she went through could and should have been avoided.

0:39:560:40:01

I hate seeing people in pain.

0:40:010:40:03

I'm a huge fan of the NHS,

0:40:030:40:06

but I think often it's managed pain really badly.

0:40:060:40:10

Studies have shown 30% to 80% of patients after surgery

0:40:100:40:17

are left in moderate or severe pain.

0:40:170:40:19

The military have managed to get the targets down to about 10%

0:40:190:40:23

and I think the NHS should be able to do that too.

0:40:230:40:27

The means of controlling pain are out there, but they're not being used properly.

0:40:270:40:31

That is, in many ways, quite shameful.

0:40:310:40:32

It's the end of a long day

0:40:370:40:40

and I've just heard there are more casualties coming in.

0:40:400:40:44

SIREN WAILS

0:40:500:40:53

I feel really shattered, I feel very shaken.

0:41:060:41:09

I've seen a lot of...

0:41:090:41:13

gruesome stuff today - some amputations - and there's more of them coming through.

0:41:130:41:19

The main thing, I thought, after we'd seen some of this stuff,

0:41:190:41:23

I thought, "I don't know how they cope." I don't know how

0:41:230:41:27

the staff in there cope with more and more of them coming in.

0:41:270:41:30

It was bad enough seeing one, two, three, and now there's just more of them pouring in.

0:41:300:41:35

And you just wonder, "How do you get up every morning and do it?"

0:41:350:41:38

SIRENS WAIL

0:41:450:41:49

It's my last day.

0:42:120:42:15

Before leaving, I want to see how Chuck Donnelly,

0:42:160:42:20

the Marine with the damaged foot, is doing.

0:42:200:42:23

So how is your leg feeling in terms of pain?

0:42:230:42:26

There's no pain right now at all.

0:42:260:42:29

It feels really swollen and numb.

0:42:290:42:32

-So what happened?

-Er...

0:42:320:42:35

So the area we were in, I was point man on patrol, so I was leading.

0:42:350:42:42

And I walked...walked by the IED at first.

0:42:420:42:45

All I remember is screaming, "Aaargh!"

0:42:450:42:48

I took a second look. "Why am I screaming? What happened?"

0:42:480:42:51

And then I realised I got hit by an IED and continued to scream now I knew what was going on.

0:42:510:42:57

It was a real small charge. Er...couldn't have been any more than five or ten pounds.

0:42:570:43:03

But...it was probably old, so it didn't completely go off.

0:43:030:43:08

But I was extremely, extremely lucky.

0:43:080:43:11

-Do you have a wife?

-Yeah, a beautiful wife back home.

0:43:110:43:14

-A beautiful wife.

-Yes. Can't wait to see her again.

-Yes.

0:43:140:43:17

'Chuck will be flown back to America to continue his treatment.'

0:43:170:43:23

The stream of appallingly injured young people I've seen

0:43:300:43:33

is a shocking reminder of the human cost of this war.

0:43:330:43:37

But I do believe there will be an important medical legacy from all this horror,

0:43:390:43:45

not least what we're learning about controlling massive blood loss.

0:43:450:43:49

Yet it's not a single big breakthrough, but rather a series of well thought-through changes

0:43:490:43:55

that are making the difference between life and death.

0:43:550:43:59

One of the other things I learnt in Afghanistan

0:44:100:44:13

is that many military developments have their origins in civilian medicine -

0:44:130:44:19

a bit like a relay race, with a medical research baton

0:44:190:44:22

being passed from civilians to military and back again.

0:44:220:44:25

So I've come to America

0:44:270:44:30

to track down the next generation of radical new ideas

0:44:300:44:34

that are attracting the attention of the military.

0:44:340:44:37

I'm starting in Atlanta,

0:44:480:44:50

where they're doing research which sounds so improbable, I want to find out more.

0:44:500:44:55

It's an approach that could dramatically improve the treatment of brain injury,

0:44:580:45:02

a major killer of troops in Afghanistan.

0:45:020:45:06

OK. That would make sense.

0:45:100:45:12

Dr David Wright works in emergency medicine at the Grady Memorial Hospital.

0:45:120:45:18

We see an enormous amount of head injury.

0:45:200:45:22

We have lots of motor vehicle collisions, assaults...

0:45:220:45:26

Under the age of 45, traumatic brain injury is the leading cause of death

0:45:260:45:30

in this country and in many other places in the world.

0:45:300:45:33

Until the Afghan-Iraq wars,

0:45:330:45:36

where the media became aware of soldiers coming back with TBI,

0:45:360:45:40

it was largely ignored.

0:45:400:45:41

It's considered by many the signature injury of the wars,

0:45:410:45:46

so it certainly put a lens on this topic.

0:45:460:45:49

That's the clinical trial data.

0:45:490:45:52

'David is trialling a drug made from progesterone,

0:45:520:45:55

'a hormone more commonly used in the contraceptive pill.

0:45:550:45:58

'Rats injected with progesterone

0:46:010:46:03

'soon after suffering a brain injury made dramatic recoveries.'

0:46:030:46:07

-I'll show you right here.

-What am I looking at here?

0:46:070:46:11

This is actually a rat. And this is a stroke.

0:46:110:46:17

This is a stroke, very typical, which you would have in a human

0:46:170:46:22

and one side of the brain is basically not getting any blood.

0:46:220:46:26

-This is dead?

-This is essentially dead.

0:46:260:46:29

This animal was not treated with anything

0:46:290:46:31

-and this animal was treated with progesterone.

-Right.

0:46:310:46:34

It could be a very life-changing difference,

0:46:340:46:38

maybe even being able to walk versus not being able to walk.

0:46:380:46:41

'The results were just as impressive in humans.

0:46:410:46:44

'In a small trial, patients with head injuries given progesterone

0:46:440:46:50

'were twice as likely to survive.'

0:46:500:46:52

Why should essentially a female hormone, which I associate with controlling ovulation,

0:46:520:46:57

why should that have anything to do with the brain?

0:46:570:47:00

That's a great question.

0:47:000:47:02

It's a misnomer. We actually believe it's not a female hormone.

0:47:020:47:05

-Progesterone is not a female hormone?

-It's a neuro-steroid.

0:47:050:47:08

It's the only hormone that's actually produced in the brain.

0:47:080:47:12

Oestrogen and all the other types of hormones are produced in different glands of the body,

0:47:120:47:17

but not the brain.

0:47:170:47:18

-You get it in guys too?

-You get it in guys. In fact, in the brain it's in equal quantities.

0:47:180:47:22

'Progesterone is critical for the development of neurons,

0:47:220:47:29

'the cells that carry messages in the brain.'

0:47:290:47:32

The reason it goes very high in the second and third trimester of foetal development

0:47:320:47:36

when you're pregnant is probably to protect the brain

0:47:360:47:39

and some sort of novel thing it has to do with brain growth.

0:47:390:47:44

'When the brain is injured, it releases chemicals that destroy neighbouring cells.

0:47:450:47:51

'Progesterone blocks the production of these chemicals.'

0:47:510:47:54

So this is it.

0:47:540:47:56

'Dr Wright is just starting a new trial of this treatment, involving over 1,000 patients.'

0:47:560:48:01

What do the military make of this?

0:48:030:48:06

They're intrigued because it's a huge problem in the military.

0:48:060:48:09

They've actually funded a study to develop a water soluble version,

0:48:090:48:15

one that potentially could be used by the medics in the field.

0:48:150:48:20

One of their sites in San Antonio called BAMC will be involved.

0:48:200:48:26

It's a military hospital. They're gearing up to get started and join us.

0:48:260:48:30

I thought that was utterly fascinating and I love the idea that progesterone,

0:48:340:48:38

something I associate with the contraceptive pill,

0:48:380:48:41

could have such completely unexpected and incredibly profound beneficial effects.

0:48:410:48:47

I was also struck by something else Dr Wright said,

0:48:470:48:50

which was that it's really the fact that all these young men coming back from the wars

0:48:500:48:56

has raised awareness of the importance and the significance of head injury.

0:48:560:49:01

So in this case, you've got a subtle interplay between civilian medicine and military.

0:49:010:49:08

Emergency medics know you can increase survival rates if you act fast.

0:49:170:49:21

As soon as someone is injured, the clock starts to tick.

0:49:210:49:25

In Pittsburgh, they're trying to slow down the hands of that clock,

0:49:280:49:31

using extreme cold to buy time.

0:49:310:49:35

'Numbness, fingers, face.

0:49:380:49:41

'Profoundly cold. Almost looking like corpses.'

0:49:410:49:45

Ten years ago, I made a programme

0:49:470:49:50

about unexpected survivors in the Falklands War.

0:49:500:49:55

One of the surgeons we interviewed said it was perhaps

0:49:550:49:58

because many of them got left on the hillside in the cold night

0:49:580:50:01

and they got hypothermic

0:50:010:50:04

and that could explain why they didn't die of their injuries.

0:50:040:50:08

I have been intensely interested

0:50:080:50:10

in the effects of cold on the human body ever since.

0:50:100:50:14

Getting cold is bad for trauma patients because it delays clotting.

0:50:140:50:19

But if cooling is rapid and extreme enough,

0:50:190:50:22

the benefits may outweigh the risks,

0:50:220:50:25

or at least that's they're hoping to prove here.

0:50:250:50:28

Traumas in the department.

0:50:280:50:30

24-year-old male, two gunshot wounds to the chest.

0:50:300:50:32

One, two, three, lift.

0:50:320:50:34

Persisting ventilations. Gunshot to the right chest.

0:50:340:50:38

'This patient's been shot. He's lost so much blood his heart has stopped.'

0:50:380:50:43

I don't have a pulse.

0:50:430:50:44

I have no pulse. Medic, can you come and do CPR, please?

0:50:440:50:48

'The ER team are trying everything to get his heart working.

0:50:480:50:52

'But they're getting no response.'

0:50:520:50:55

I'm getting no cardiac activity. Let's initiate EPR.

0:50:550:50:58

'What they do next is extraordinary.'

0:51:000:51:02

Initiate cooling.

0:51:020:51:04

-Start bringing the temperature down.

-Pump's ready to go.

0:51:040:51:08

'They slowly pump the remaining blood from his body

0:51:080:51:11

'and replace it with ice-cold saline solution.

0:51:110:51:15

'This induces a state of severe hypothermia.'

0:51:150:51:19

So lots of almost freezing water about to go into his system?

0:51:190:51:23

-That's right.

-What levels are you trying to get them down to?

0:51:230:51:26

-I want to get the brain temperature down to ten degrees centigrade.

-Ooh.

-That's cold.

-That's cold.

0:51:260:51:31

'This is actually a training exercise,

0:51:310:51:35

'but Dr Sam Tischman and his team are taking it very seriously.'

0:51:350:51:39

There's no blood in the left chest.

0:51:390:51:41

-'They're due to start the first ever human trial in a matter of weeks.'

-How's our temperature doing?

0:51:410:51:47

The temperature's coming down.

0:51:470:51:49

'At such low temperatures, the patient would have no heart beat and almost no brain activity.

0:51:490:51:54

'In this death-like state,

0:51:560:51:58

'the brain and other major organs

0:51:580:52:01

'can survive for far longer than normal without oxygen.'

0:52:010:52:04

We think this is the best way we can buy time to try to save his life.

0:52:040:52:09

If he were at normal temperature and no blood flow,

0:52:090:52:12

more than five minutes and pretty high risk of having some brain damage and not recovering very well.

0:52:120:52:17

In this case, you can get how much time?

0:52:170:52:20

We're hoping up to an hour.

0:52:200:52:21

That gives us enough time to get to the operating room,

0:52:210:52:24

stop the bleeding and then we can resuscitate him.

0:52:240:52:27

'We think it's beneficial, not just in decreasing the tissue's demand for oxygen and blood,'

0:52:300:52:35

but decreasing a lot of the deleterious chemical cascades, all the bad things that happen

0:52:350:52:39

when you don't have blood flow to your vital organs for a period of time.

0:52:390:52:43

Once the emergency surgery is done, the patient will be warmed up again,

0:52:430:52:48

and the blood pumped back into their body.

0:52:480:52:52

What are the risks?

0:52:530:52:55

In the trauma world, there's actually great fear of the cold,

0:52:550:52:58

because the colder you are the less your blood will clot, so you'll bleed more,

0:52:580:53:03

and, in fact, if you look at trauma data,

0:53:030:53:05

the colder patients tend to do worse.

0:53:050:53:07

So this is going against the standard treatment that we do for our trauma patients.

0:53:070:53:12

Does that make you feel a bit nervous about it?

0:53:120:53:14

A little, but not too much.

0:53:140:53:16

I think the problem is we know that less than one in ten patients

0:53:160:53:20

that have a cardiac arrest from trauma,

0:53:200:53:22

that we even try to resuscitate at all, will survive.

0:53:220:53:25

-Less than one in ten will survive?

-Less than one in ten.

-Right.

0:53:250:53:28

So we know what we're doing now doesn't work.

0:53:280:53:30

So something like this is exciting to people.

0:53:300:53:32

We might be able to increase that number substantially.

0:53:320:53:35

-BEEPING

-35 degrees.

0:53:350:53:39

I'm very impressed by the constant drive

0:53:470:53:49

to raise the bar of what is survivable.

0:53:490:53:52

Already the combination of military and civilian medicine

0:53:520:53:56

has been extraordinarily successful

0:53:560:53:58

at keeping people alive against the odds.

0:53:580:54:01

But it does mean an increasing number of survivors are facing

0:54:020:54:06

a future with dreadful injuries.

0:54:060:54:08

Before I leave, I've come to the Walter Reed Medical Centre.

0:54:130:54:17

I'm here to visit the young marine who was brought into hospital

0:54:170:54:22

when I was in Camp Bastion.

0:54:220:54:24

Ronald Barnes had both his legs blown off

0:54:240:54:27

and he nearly bled to death.

0:54:270:54:29

Four months on, CJ, as he' known, is in rehabilitation.

0:54:300:54:36

-This is one video of me walking.

-Very good.

0:54:360:54:41

It's a lot more difficult than it looks.

0:54:410:54:44

-HE LAUGHS

-What's the furthest you've walked?

0:54:440:54:47

The furthest I've walked was about a quarter of a mile.

0:54:470:54:51

-How are you feeling? Generally?

-Er...

0:54:510:54:54

It's on a day-to-day basis.

0:54:560:54:59

Some days, I'll feel all right. My pain levels are relatively low.

0:54:590:55:03

But then there's other days, you know,

0:55:030:55:05

days I can't really sleep with nightmares

0:55:050:55:08

and then the rest of that day

0:55:080:55:10

I'll be in so much pain, it's just hard to function.

0:55:100:55:14

-Does anything relieve it?

-Just the drugs that they have me on.

0:55:140:55:19

-Do you dream about walking and things like that?

-Er...

0:55:190:55:23

Sometimes I do.

0:55:260:55:28

Um...it's hard when, like, I'll go on Facebook or something

0:55:280:55:33

and I see a picture of me with legs, actually doing something.

0:55:330:55:36

I mean, that...

0:55:360:55:39

There are times I just have to walk away from it or roll away from it.

0:55:390:55:44

But I can't...I can't really look at it for too long.

0:55:440:55:48

It just gets to me.

0:55:480:55:49

Do you know others it happened to, other people in your regiment?

0:55:490:55:53

Yes. Actually, my...

0:55:530:55:55

When I got hit, they sent a replacement,

0:55:550:55:58

to get another engineer out there.

0:55:580:56:01

And about a month later, my replacement got hit.

0:56:010:56:06

And he is here as well.

0:56:060:56:08

And I know about four or five other people from my unit that are here.

0:56:080:56:13

I don't want to see another person come here, ever.

0:56:130:56:16

It hurts, you know,

0:56:160:56:18

that people that I was living with on a daily basis, you know,

0:56:180:56:22

their lives and my life's pretty much changed for ever.

0:56:220:56:25

So I think the worst part about it...

0:56:270:56:31

is the mental aspect of it.

0:56:310:56:34

Because, I mean, personally, I fight with so much stuff on a daily basis.

0:56:340:56:40

And...the pain that is in my mind

0:56:400:56:46

is so much worse than the pain that's in my body.

0:56:460:56:49

'CJ is actually'

0:56:550:56:58

almost the first person I've talked to in the situation who was,

0:56:580:57:02

I felt, completely honest about it.

0:57:020:57:05

The tendency is very much a positive psychology.

0:57:050:57:09

"It's marvellous. We're going to get ourselves around this."

0:57:090:57:12

And he was the first person who sort of got up and said,

0:57:120:57:15

"No, it's really tough.

0:57:150:57:17

"It's really, really tough. And I still feel it every day."

0:57:170:57:20

And it's made me eager to find out what medicine is doing

0:57:220:57:25

to help survivors like CJ rebuild their lives.

0:57:250:57:29

Next time I will be looking at advances

0:57:360:57:39

in repair and rehabilitation.

0:57:390:57:41

-Can you imagine yourself back in Afghanistan?

-Yeah, that's my job. That's what I do.

0:57:410:57:45

-Do you think you can keep up?

-You're going so fast!

0:57:450:57:49

'From mind control prosthetics...'

0:57:490:57:51

The wrist rotates in 360 degrees.

0:57:510:57:54

..to growing spare body parts,

0:57:540:57:57

and even face transplants.

0:57:570:58:01

Subtitles by Red Bee Media Ltd

0:58:200:58:23

Email [email protected]

0:58:230:58:26

War drives innovation and in this series, Michael Mosley travels from the frontline of war to the frontline of research to uncover the medical breakthroughs that are coming out of current conflicts.

The first episode takes Michael to Camp Bastion hospital in Afghanistan to find out how medics have achieved the highest survival rate in the history of warfare. And in A&E departments in the USA, he looks at the latest medical advances that could save thousands of lives both on and off the battlefield.


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