[siren wailing]
[dispatcher] Emergency ambulance.
-What's the emergency?-[woman] We need help.
[narrator] The momentan emergency call is made,
a battle against time begins.
-[dispatcher] And is she awake?-[man] No, she looks dead.
-[patient groaning]-[indistinct radio chatter]
The decisions that are made
in the first minutesfor major trauma patients
will make the differencebetween life and death.
If we can intervenewithin the first minutes or so,
the so-called "golden hour,"
then we know we can positively affectyour outcome.
[narrator] The sooner a doctorcan reach their patient,
the more likely they are to survive.
We now have the ability to reversethe initial effects of the injury,
if we are given the chanceand we are able to act quickly enough.
[narrator] In their raceagainst the clock,
doctors and paramedicsare now taking the hospital
-to those at the very edge of life.-[siren wailing]
[Gareth] We're pretty close.They can bring it if we need it.
[patient groans]
The more equipment and expertiseand knowledge we can get out
onto the street or scene of the accident,then we will save more people's lives.
[narrator] Armed with new treatmentsand equipment...
[doctor] I'll get the AutoPulse readyand we'll get him on.
[narrator] ...they're performing surgeryon the roadside.
I could do the operation in the backof the ambulance, if necessary.
[narrator] Administering powerful dr*gs...
[Roger] Draw up two ampoulesof tranexamic acid.
[narrator] Using innovative techniques.
[doctor] You pull that oneand I'll pull this one.
[narrator] And pushingthe boundaries of science...
The REBOA is in,I'll let you know once the balloon is up.
[narrator] ...to save timeand to save lives.
We've got to go.
[narrator] This series will count down,second by second, minute by minute,
the crucial decisions madein the first minutes of emergency care.
One hour,the difference between life and death.
London, home to over eight million.
Every hour, eight peoplewill face a life-threatening emergency
in this sprawling metropolis.
This film will follow three patientsthrough minutes of care
that will push the limitsof scientific innovation.
In London, -year-old Stanleyis stabbed three times in the chest.
[man] He has a few s*ab wounds.
[woman] He's been stabbed?
[man] Yes.
[narrator] In Kent,
a high-speed road accidentcritically injures -year-old Michael.
-[doctor] So, is blood running?-Yeah.
[doctor] Okay.
[narrator] And -year-old Mickcollapses in North London.
I must admit, I can't feela cardiac output in this chap.
[narrator] From the momenteach emergency call is made...
-[alarm ringing]-...the clock starts ticking.
-[telephone rings]-Hello, HEMS desk?
Cardiac arrest.
Hello there, got a job for you.
Map reference is , November Bravo.
[narrator] Ambulance Control has justreceived a call about an elderly male
whose heart has stopped beatingin a betting shop.
[woman] The customer, he's just fell.
All we know is he fell down and went out.He's out on his back.
Hundred metres, right turn.
[narrator] Dr Ben Clarke,
part of a medical unitspecializing in cardiac arrest,
is tasked to the job.
[siren wailing]
As soon as I hear the term"cardiac arrest,"
I know the heart isn't pumping blood,
the brain isn't getting oxygen,the heart isn't getting oxygen,
the other really vital organs in the bodyaren't getting oxygen.
[doctor] That's all totally blocked in.
-How are you...?-[Ben] That is completely blocked in.
Oh, come on.
[Ben] Every second counts.
And timeis most definitely of the essence.
Uh, maybe you just pull uparound the corner in front.
[narrator] First on scene,
a paramedic crewhas already restarted Mick's heart.
But as Ben arrives,he goes into cardiac arrest again.
[Ben] Hi, boss. You're good.Stay as you are.
[medic] When we arrived, he wasin cardiac arrest; his name's Mick.
[Ben] Alright.
We know that that period aroundwhen someone's had a cardiac arrest,
and if they get spontaneous circulation,
uh, it's an incredibly fragile timefor the body.
When he re-arrests,I then think, right, okay,
we need to obviously manage thisand we need to get on this
and manage it assertively.
What I saw straight awaywas that he was a fairly large gentleman.
He also looked very dusky,and by that his colour was awful,
and it indicated to methat his cardiac perfusion,
or the ability of his heartto pump blood around his body,
was perhaps compromised.
I must admit,I can't feel a cardiac output.
In a patient who's got a cardiac arrest,
the level of consciousnessis essentially zero, they're comatose,
they're clinically dead.
[medic] Uh, back in VF.
[Ben] He's just gone back into VF.
[narrator] VF,or ventricular fibrillation,
is a major cause of cardiac arrest
and occurs when the musclesinside the heart quiver
rather than contract,
meaning Mick's heart is unable to supplythe rest of his body with oxygen.
The ambulance crew initiate CPRto try to do the job for him.
[Ben] Would you have a quick listento his chest?
Do you want to grab my tubes?
I remember when I was a junior doctor,seeing my first cardiac arrest,
and the first timeI saw someone getting CPR,
it looks, uh, awful and it looks brutal,
um, it looks out of control.
And for anyone who hasn't seen it before,uh, it almost looks like an as*ault.
We don't really haveany other choice, unfortunately.
[narrator] Ben is worried that they stillcan't get a stable heartbeat from Mick
and that they're starting to lose him.
We know that chest compressions
aren't as goodas a heart b*ating for itself,
so automatically, I know that his brain,his heart, his other organs,
probably have had a lower level of oxygenthan they normally should have.
And so for me, the first clinical decisionin that phase was,
let's establish a more definitive airway
so I can be surethat we're ventilating him appropriately.
Now might be an opportune timeto get that tube in.
-What do you think?-[doctor] Yep.
[narrator] The team insert a tubeinto Mick's airway
to squeeze oxygen directly into his lungs,mechanically with a bag.
Our priority thenis actually just making sure
we get the breathing tubeinto the trachea.
[doctor] I can see the tube's past cords.
[Ben] Cool. Get this out.
Alright, just make sure, mate, you're notgetting too tired with your CPR.
-It's due for an analyse in a second.-[Ben] Good.
-Sorry, dude, you happy with that tube?-[doctor] Yeah.
[Ben] Just nightmarish.
[narrator] At the same time,the paramedics
try to get a normal heart rhythmback for Mick.
We can administer an electric shock,
and that can often restart the heartinto a more appropriate rhythm.
-[doctor] Pulse.-Yeah, no, let's shock that. Shock that.
-[Ben] Capnography up.-[medic] Yeah.
-[medic ] Stand clear.-[Ben] All clear, guys.
-[defibrillator zaps]-Alright. CPR back on.
[medic] Can't find a pulse.
-Yeah.-[indistinct dialogue]
[narrator] But the electric shockhasn't worked.
Mick's heartis still not b*ating correctly
and he's fading fast.
Unless we got things sortedfairly quickly,
um, that there was a very,very good chance that he would die.
[narrator] Ten minutes ago, across London,
a call came in about a young manwho's been att*cked after an argument.
[woman] Outside, this guyis bleeding at the moment.
I think he needs attention urgently.
[narrator] London's Air Ambulanceis en route
with an advance trauma team on board.
[woman] What happened?
[man] Um, it's near his lungs, you know.
[woman] Sorry?
[man] It's near his lungs.
He has a few s*ab wounds, um...
[woman] He's been stabbed?
[man] Yeah.
-[woman] He's been stabbed in the chest?-[man] He can't breathe.
[woman] Is he bleeding still?
[man] Yeah.
The minute you get a callfor a stabbing, you're anxious,
because you know it's really importantto get there quickly.
They can literally bleed to deathin a few minutes.
You know he's been stabbed in the chest,
you know, you can't helpbut feel a degree of anxiety,
'cause for every minute you're satin the helicopter twiddling your thumbs,
you know, I imagine a heart that's pouringout blood that I need to stitch.
It may be somethingthat requires open heart surgery,
so we literally have to take the kitchenand the kitchen sink.
[medic] He's in an ambulance.
[Gareth] I was sort of dreadingopening the doors
to see what we're gonna see.
[knock on door]
So, what have we got?
[medic] Three s*ab woundsin the chest.
He's sweaty.His abs are alright.
-His sats were .-[Gareth] What's his name?
[medic] Stanley.He's not spoken to us.
We don't know what he'sbeen stabbed with.
[Gareth] Stanley, my name's Dr Davies.
[narrator] Gareth's immediate concern
is the exact locationof Stanley's s*ab wounds.
Hold on, hold on.
Where's your pain, fella?Can you point to it?
[Gareth] Stanley could quite easily trick
a casual observer or young doctoror young paramedic,
because the wounds are small,they don't bleed,
and, uh, the patient looksbig and healthy.
But right underneath those wounds,
is some of the major clockworkof the body, the heart,
the aorta are literally only inchesfrom some of those wounds.
[narrator] Stanley has three s*ab woundsto his chest.
[indistinct dialogue]
Any one of them could be fatal.
I was quite worriedby the fact he was so sweaty and clammy,
which can be very subtle.
And you may only pick it upsimply by touch.
You won't see the beads of sweaton someone's, uh, forehead,
and that again is a sign that the bodyis really fighting for survival.
Stanley, my name's Dr Davies.
Can you speak to me?
Alright.
[narrator] Stanley's not speaking
and his breathingis gradually getting worse.
Stanley was so silent that daybecause he... he knew he was ill.
He was fighting for, uh, for his life.
His brain was telling him, "I can'tbreathe, I can't oxygenate myself,"
and actually his way of dealing with thatis, actually, not to talk,
but to focus and to use hand gestures.
Does your breathing feel normal or not?No, it's not.
It's not.
When I looked at Stanley,there was a key decision to make,
which is, how far downa dying process is he?
Young people actually protect themselvesto the bitter end,
and they can stay conscious,
they can have high heart ratesand high blood pressures,
and then eventually, all of theircompensatory mechanisms fall apart,
and they can fall apartin literally a few seconds or minutes.
So they can look quite well.
So it's quite difficult to knowhow far Stanley is
down that particular line.
[Gareth] Okay, just bring your neck up.
[narrator] Gareth is most concernedabout a possible punctured lung.
Or even a wound to Stanley's heart.
He now faces a dilemma.
Is he well enoughfor us to essentially work en route,
get the ambulance movingand start heading for hospital?
Or is he in such a positionthat actually, no, we have to stop,
we have to get out all of our equipment,
we have to start draining collapsed lungsat the roadside,
or perhaps think about doingopen heart surgery?
[Gareth] How long are we till London?
-About minutes.-[medic] We're ready when you are.
[Gareth] It's a judgement call,it's an experiential call.
In Stanley's case,
it felt prudent and best for him,actually, to get moving.
Shall we just go?
-Yeah, we're good to go.-[Gareth] Let's just hit the road.
[Gareth] Making our way to hospital.
[narrator] Gareth decides to fast trackStanley to the Royal London Hospital.
[siren wailing]
-[Gareth] Say again, fella.-[Stanley] I can't breathe.
[Gareth] You feel you can't breathe?
All right, fella.
[narrator] In North London, -year-old Mick remains critically ill.
[doctor] We've got two litres in there.
[Ben] Mate, we should, um,ACD and AutoPulse as well. Alright.
[narrator] His heart musclesare not b*ating properly
and his body isn't getting enough oxygen.
This was an incrediblychallenging environment.
Not only are we in the shop,
we have furniture that's banked uparound this gentleman.
-[Ben] Sorry, mate. Excuse me.-[woman] That's alright.
For Michael and for us,this was a really difficult scenario.
His condition couldn't be any more severe,he was essentially dead.
Alright, what we're gonna, we're gonnachuck him on the, uh, AutoPulse machine.
[narrator] Ben can't get Mick's heartback into a regular rhythm.
He decides to continue treatmentwith an AutoPulse machine.
[Ben] The AutoPulse is essentiallyproviding the cardiac output
that the heart can't do for itself.
And it's ensuring that the tissuesget exactly what they need,
and that's oxygen, pretty much,in this case.
Ready, brace, lift. Straight up.
[Ben] The reason we use it is becausewe know it's more effective
than us, than CPR.
There's been studiesthat just show it does a better job
at getting the blood around the bodythan we do.
It also doesn't get tired.
-I'm sorry.-[Ben] Good stuff.
-[Ben] Happy?-Yeah.
[narrator] The AutoPulse is one of onlya handful of mechanical CPR machines
on the streets of London.
[Ben] The aesthetics of it are dramatic,
how it looks, you've got the noise,it all sounds very mechanical.
Whilst it looks fairly confronting,
it's actually probablyone of the best ways,
in the pre-hospital setting,
uh, of ensuring that we getthe blood around the body.
If we didn't have the AutoPulse,
my inclination would be,actually, to stay on scene
and see if we could getthe heart b*ating by itself.
If we can, what we might do
is, actually, we can transport himon the AutoPulse.
So, guys, we'll go on lift.
-[medic] That's alright. Don't worry.-[Ben] Everyone got a bit of the scoop?
-[medics] Yeah.-[Ben] On lift again. Ready, brace, lift.
Alright.
[medic] Right.
-Can we pull it out?-[Ben] Yep. I've got that.
Yeah. Let's get it all out, if we can.
So, his end-tidal is . .
We're due another rhythm check,are you happy just to stop?
Pause that, yeah.
Oh, feel for a pulse.
We've got an end-tidal of . .
-We've got an output.-I have a pulse.
Excellent. Alright, guys, nice job.Really well done.
He had a cardiac output,so his heart had restarted.
What that meant thenwas we could stop the AutoPulse
and we could then actually just get going.
[heart monitor beeping]
[Ben] Really well done, guys.
[narrator] Although Mick's hearthas returned to a normal rhythm,
he could re-arrest at any moment.
The AutoPulse now allows Ben
to move Mick to hospitalas fast as possible.
[Ben] We either stayeduntil the bitter end in the betting shop,
or we take him to hospital,try and get him into the angiography lab,
and see if we can open upa blocked blood vessel.
He's a -year-old blokewho's had a witnessed VF arrest.
That's two shocks, he's got a returnof spontaneous circulation,
then, uh, has had a subsequent VF arrest.
I rang the cardiologist,
who's the heart specialistat London Chest.
And the purpose of that, essentially,is to, A, prepare them.
It also allows them to provide anydistinct advice for this patient to me.
[narrator] Appropriatecardiac arrest patients in London
are now taken directlyto specialist cardiac units,
bypassing A&E.
You can have as much expertiseas you wish,
uh, sitting with the patient on scene,
but unless you actually havethe system in place
that ensures the patientgets from the betting shop,
and then goes to the place wherehe's going to receive definitive care,
unless you have that system in place,it's all null and void.
-[indistinct chattering]-Perfect, thanks so much.
Alright, we'll see you soon. Cheers.
Alright.
[narrator] But before they can leave,Mick crashes again.
Heart rate's slowing down, actually,we've got a pulse rate of , Ben.
Alright, so it's just...And his end-tidals, yeah.
-The end-tidals are...-[Ben] He's looking very ropey, isn't he?
It looks like he's,yeah, he's about to arrest.
-[medic] So we've got...-No, now he is.
Ooh. You're absolutely right.Do you want to start the AutoPulse again?
The monitoring had changed.
And Michael's heartwasn't pumping effectively.
Yeah, stand by, mate,he's just arrested again.
[narrator] For the third time,Mick's heart has stopped b*ating again.
At that point in time, I was thinkinghe wasn't gonna make it.
Plain and simple.
Yeah, mate, we're good to go.
[siren wailing]
Alright, mate, so London Chest.
If you can give me a ten-minute warning,that would be awesome.
[narrator] The Royal London Hospital
is one of the UK's leading traumaand emergency care centres.
And across the south east of England,
it can be the last chance of survivalfor those on the very edge of life.
[telephone ringing]
Twenty-seven-year-old Michaelhas been involved
in a catastrophic road accident
and is being airlifted from Kent, miles away from Central London.
He has a suspected broken pelvisand severe internal bleeding.
He's been classed as "code red."
[Simon] We received a priority callfrom the ambulance doctor,
a code red trauma call.
We only put out a code red trauma callfor the most severely injured patients,
where, uh, we believe that massivehaemorrhage is an issue for them.
Have we got chest drains? Yeah?
[medic] There are two chest drains ready.
[Simon] The patient that was coming in,from the priority call information,
was one of the mostseverely injured people
that I'd had to look afterfor a long time.
I mean, the heart rate does go up a bit.
[narrator] Michael has already been givena blood transfusion
to stop him bleeding to deathat the roadside,
but his blood loss is so extreme,
that the hospital begins preparingblood products to treat him with.
Alright, bye.
We all know we have to makesome quick decisions
and we have to make some big decisions.
We prime ourselves
and set things up in a certain wayto try and facilitate that,
and to allow everythingto happen smoothly and quickly.
[Simon] Good evening, hello. Hello.
[narrator] The Air Ambulance teamprepare to hand Michael over.
[Simon] Okay, let's getthe handover then, please.
[nurse] Twenty-seven-year-old male whowas riding a motorbike at miles an hour
when he T-boned into a car,pulling out and turning right.
He fell off the bike sideways,ending up underneath the car,
and the bike skidded out to the right.
[monitor beeping]
[Simon] Okay, scoop out the other side.
[narrator] The team needto keep supplying Michael with blood,
whilst quickly trying to assessthe scale of his injuries.
Patient's intubated.
Percussion that is resonant bilaterally,bilateral thoracotomies.
No obvious lung bone injuries.
[Simon] Okay, has he got a central pulse?
[Samy] Despite having four units of bloodin a short period of time when he arrived,
his heart rate was very high, .
His blood pressure was very low.
He'd actually hadunrecordable blood pressures
for the last hour or sofrom scene to hospital, um,
and, uh, essentially,he was bleeding to death
very, very quickly.
I can see a pulse at R femoral.
[medic] Bring it right in here now.
-[Simon] He's got a central pulse?-[medic] Yeah.
[Simon] Okay, right, can you starttwo units of blood?
We need to do it fast as well,Samy, don't we?
-Can we just do that now, quickly?-Right, so, fast.
Thank you.
[narrator] Simon orders an ultrasound scan
to try and identifyany large pools of blood
collecting in Michael'sthree main cavities:
his chest, his abdomen or his pelvis.
With blunt trauma,as was the case with this patient,
um, the blood lossis often concealed within the body.
So, although the patient had signsof massive haemorrhage,
there wasn't blood pouring outall over the floor, all over the trolley.
Um, and, yeah,it's easier to deal with that,
because if you see where the blood'scoming from, it's easier to stop it.
It's more of a challengewhen the blood is somewhere
within one of the body cavities,um, we don't know exactly where.
[monitor beeping]
[Simon] So, heart rate is very fast.
Right lung is up.
-[Simon] So, is blood running?-Yeah.
[Simon] Okay.
[narrator] The ultrasound scan has shownthat Michael is bleeding into his pelvis
and is deteriorating rapidlyin front of the team.
He's obviouslystill badly hemodynamically unstable,
he's had four units of bloodand tranexamic acid.
I wanted to get himto interventional radiology,
uh, to give the radiologists a chanceto try and stop that bleeding.
Um, but I didn't thinkhe was gonna survive the journey.
[siren wailing]
Can I check that we've got everyone,we've got Fiona, anaesthetist.
Right, are you gonna dothe primary survey?
[medic] Obviously,he'll come in here, so...
Which bay is this person going to?
-That's gonna go to that one there.-Okay.
[narrator] Fifty-four minutesafter the call,
Gareth hands Stanley overto the trauma team leader, Helen.
When we hear that we're receivinga patient who's been stabbed,
it could be nothing,
or it could be somethingthat's imminently life-threatening.
[Gareth] Good afternoon, everybody.
Uh, this is a gentlemanbelieved to be called Stanley,
approximately years of age.
Uh, has allegedly been assaultedwith a Kn*fe.
You're trying to compresswhat is effectively , minutes of time
and history and events and interventions,
into a form that the receiving doctorcan handle and process.
He's got three incisional wounds,
all approximately . to one centimetre in length.
But he has been complaining of a lotof pain, and he's had morphine, uh...
-Thanks.-Okay.
-Okay.-Hello?
Stanley?
[indistinct conversation]
[Helen] He had relativelyinnocuous looking wounds.
But it's impossible to tellfrom the outside, looking at that wound,
what the underlying damage is.
[medic] Groin's clear on s*ab check.
If you can imagine a knitting needlethat's driven straight through the chest,
it would leave very little signsof external damage,
but could have pierced, um, any numberof vital internal organs.
Stanley, I'm just gonna examineyour chest.
[medic] Are you feeling short of breath?Are you having trouble breathing?
[narrator] Of Stanley's three s*ab wounds,
Helen is concentrating on the oneon the left side of his chest.
X-rays, please.
[narrator] She's worriedit's punctured his lung
and is stopping himfrom breathing properly.
[medic] In five, four, three, two, one.Thank you.
[Helen] I've seen the left pneumothorax.
His left lung was partially collapsed,
so the implement,the Kn*fe I think it was,
had penetrated the surface of the lungand it had popped.
Saturations are on how much oxygen?
litres. Okay.
[narrator] But Stanley's breathingsuddenly deteriorates.
[nurse] We're just gonna give yousome pain relief, okay?
If we find a collapsed lungfollowing penetrating trauma,
we're instantly concernedthat that collapsed lung
will very rapidly collapse downeven further
and the patientwill have a cardiac arrest.
[Helen] Have we got all the monitoringon at the moment?
[narrator] For the last minutes,
frontline medics have fought to keepthree critically ill patients alive.
But the battle is far from over.
The decisions madefor Mick, Stanley and Michael
have bought doctors more timeto now try and save their lives.
[Ben] That's his blood pressure,
so we'll be aiming for an end-tidalof around four to . .
[narrator] En route to hospital,Mick is still in cardiac arrest
and Ben is relying on the AutoPulseto protect his brain and vital organs.
[Ben] I don't know what his qualityof life is before I turned up on scene.
My role is to make sure I do the bestfor every patient, all the time.
Uh, and it's then up to them,it's then up to time.
Now, just press the stop button for me.
He's got an output.
[narrator] Seventy-four minutesafter the call,
the physician response unitand the paramedics
have brought Mick back from the deadfor the third time.
Yeah, yeah,he's got a nice radial pulse. Alright.
[siren wailing]
[narrator] The fight to keep him alivewill continue
at the London Chest Hospital,
where he will be taken to a cath lab,
a state-of-the-art facility
where the team will be ableto X-ray Mick's heart in minute detail.
I knew the best thing for himwas to get into that cath lab
and have them have a good lookand see what his heart was doing,
see whether there's a blockagein his blood vessel.
-[medics chattering]-[machine] Three, two, one, ventilate.
[Andrew] Uh...
Excuse me, guys, uh,who knows this guy the best then?
-You do. Hi, Andrew, clinic consultant.-[Ben] Nice to meet you.
[Andrew] The survival of cardiac arrestis improving dramatically.
Uh, now, uh, if you get,uh, resuscitated in good time,
your prognosis can be excellent.
[Ben] Sixty-five-year-old gentleman,
bystander CPR, when the first crewgot there, he was in VF.
He's had two shocksand return of spontaneous circulation
was making his own nativerespiratory effort at that point.
-How long do you think he's been down?-Total down time,
if you do it as accumulative,is probably gonna be about , minutes,
-but that would be in separate chunks.-Okay, and the past medical history?
Past medical history,difficult to ascertain,
but certainly chronic kidney disease.
-A CKD of some sort will answer.-Yeah, I know. Yeah, it's tough.
When I handed Michael over,I did feel a bit of relief.
We'd had quite a tough timewith him, pre-hospital.
Are you happy stayingwith that tube there?
-[medic] Yes.-Okay, alright. No, you're good.
[Ben] Is that on a ventilator?Who's ventilating?
[nurse] His blood pressureis just going up now.
[Andrew] Let's just focusto get an angiogram in first.
[narrator] Andrew beginsby doing an angiogram,
a digital X-ray with contrast fluid.
[Andrew] The overall plan for us
is, first of all, to get picturesof the blood vessels of his heart,
uh, to confirm or exclude the diagnosis
of a blocked blood vesselcausing a heart att*ck.
[Andrew] Let's just change overfor, um, the JR- , please.
The first thing I sawwhen we got the angiogram pictures
was one of the main branchesoff that blood vessel
was completely blocked,
and the main artery itselfhad a very severe narrowing in.
It wasn't completely blocked,
but it was effectivelyalmost completely blocked.
[narrator] Andrew decides to performa procedure called angioplasty,
to try and open up Mick's blocked arteryand allow the blood to flow again.
What we first have to dois to pass a small tube called a catheter
up through a blood vessel in his leg,uh, up to the heart.
Just hold it there.
[narrator] But minutes into the procedure,
Andrew makes a discoveryin Mick's abdomen.
[Andrew] Arteries feel like chalk.
He's got a massive aneurysm. Oh, crikey.
Whoo!
[exhales]
How are we gonna get out of it?
An aneurysm is an abnormal swellingof a blood vessel inside the body.
The main concern with them, um,is that they can rupture and bleed,
and that technicallymakes it very difficult
for us to manoeuvre our wireswhere we want to get them to.
Alright, now try.
[narrator] If Andrew snagsthe aneurysm with his wire,
it could trigger a massive haemorrhagein Mick's abdomen.
I can't...I'll be amazed if we can torque this.
-[inaudible dialogue]-Yep, flush, please.
Stanley, I'm just gonna ask youto do this twice.
Can you open your mouthand take a deep breath in.
Well done.
Okay. Just, uh, one-- just one more time.
[narrator] At the Royal London'smajor trauma centre,
-year-old Stanley is deteriorating fast.
He has been stabbed three times
and has a punctured lungthat continues to collapse.
Left untreated, it could developinto a tension pneumothorax
and ultimately, a cardiac arrest.
A pneumothorax is a situationwhen the lining of the lung has popped.
It's like a balloon.
So you pop a balloonand all the air escapes.
So that's exactly what it's like.
It escapes at a variableand not predictable rate,
so it can collapse very, very slowly,or it can collapse really fast.
All that air that's escapingfrom the balloon, that is the lung,
is accumulating within the chest wall.
Can't escape, so it just gets biggerand bigger and bigger
and squashes everything elsewithin the chest cavity.
[narrator] Helen must decidewhether there's time for a CT scan
before Stanley's punctured lunggets worse.
[Helen] He was going to need a CT scanof his chest and abdomen,
because of the injuries that we'd found.
So we can either go to CT now,before we put the chest drain in,
but I think, probably, it's preferableto put the chest drain in
so we can check the position with the CT.
In that sort of situation,
when you've got no idea, really,how quickly a tension might develop,
then I took the decision that it was safer
to put the chest drain inbefore we went to the CT scan.
[narrator] The team need to makea surgical incision
to relieve the pressure in Stanley's chestand re-inflate his lung.
[Helen] It can seem strange
that we, as doctors,seem to be inflicting yet more trauma
on patientswho have already suffered enough.
-[Stanley groaning]-[doctor] Alright, okay, fine.
[doctor] Let's give him milligrams.
But, in order to treat their injuries,
it is necessary to, um,make more holes in the patient.
[Stanley groaning]
[narrator] Stanley's chest cavityis filling up with blood and air,
which will potentially k*ll himunless the team can drain it away.
The surgery is extremely painful,
but the team decide to administera local anaesthetic,
as they need Stanley to respondto their instructions.
[Tom] When the drain is in,
what I want him to dois take a really deep breath in,
as pain permits him to,to try and push that air out,
to expel that air and expand his lung.
And if I can expand his lung,
he'll get more oxygen in his bloodand he will then start to feel better
and his pain will go down,his lung will fully expand.
Take a deep breath in and out,a really deep breath.
Good, and again.
[Stanley groaning]
[Helen] Is that-- Is that painful?
-[Stanley groaning]-[Helen] Okay, okay.
Do you understand what we're doing?
So, Stanley, when you were stabbed,your lung was popped,
so we're just getting your lungback up to its normal size.
[nurse] I'm just gonna give yousome more pain relief.
[Stanley groaning]
[narrator] Twenty-seven-year-old Michaelis bleeding profusely from his pelvis.
He needs to go to interventional radiologyto repair the damaged blood vessels
and stop any further blood loss.
But Samy and Simon are worriedthat he is too unstable to be moved.
This patient was bleeding to death,
uncontrollably, um, and from a placethat we couldn't access
and we couldn't stop immediately.
We didn't thinkhe was gonna survive the journey,
even the short journey to theatre.
[narrator] To try and keep Michael alivelong enough,
Samy and Simon are going to attemptan innovative procedure called REBOA.
REBOA stands for
Resuscitative EndovascularBalloon Occlusion of the Aorta.
R-E-B-O-A, 'cause that's too long to say.
[narrator] The procedure will involveblocking Michael's main artery
with an inflated latex balloon.
Effectively, what you're doing,
is cutting off the blood supplybelow the waist,
and obviously, whilst that will stopthe bleeding immediately,
as soon as you cut offblood supply to the limbs,
they start, um, becoming ischemicand becoming starved of oxygen.
[Samy] We should only inflict thaton the body
if there is absolutely no other solution.
Check for essential pulse.
What I need is you to swap placeswith the ultrasound scanner.
-Samy, you're gonna do REBOA, yeah?-Yeah.
Okay. Thank you.
[narrator] The REBOA procedurewill block the aorta,
the major artery from the heart.
This will stop blood flowin Michael's lower abdomen
to the smaller arteries which supplythe lower half of the body with blood,
including Michael's fractured pelvis.
This will buy Simon and Samy timeto rush him to interventional radiology,
but the procedure isn't without risk.
By blocking that blood vessel
and starving half of the bodyof oxygen and blood,
um, it can havecatastrophic effects itself.
[Simon] We need to make some space.
[narrator] Only a handfulof critically injured people in the UK
have ever received this treatmentfor traumatic bleeding,
but none are known to have survived.
There's always an element of angst,I suppose,
if you're performing a new procedure,
a procedure that's new to you,that's new to the hospital,
that's potentially newto the whole country.
[narrator] The procedure has been refinedto be minimally invasive.
Through an incision in Michael's groin,
Samy has to carefully but quickly feedthe deflated balloon up to his aorta
so he can then inflate itand cut off the blood supply.
[Samy] We're blind, and we're goingby a pre-determined set of distances,
and all we have really to guide us,is the ultrasound to find entry site,
and from there on in, we are goingby a pre-determined set of distances,
and... we are essentially blinduntil we get there.
All the training and all the reading
and all the preparation in the worldare obviously essential,
but you still feel a little bit nervous.
Okay.
It's migrated down to centimetresand stopped,
so I'm gonna leave it there,we're gonna fix it down.
[Samy] We then pass a longer wire,
a wire that can gopotentially all the way up to the heart.
And then we passthis, uh, balloon catheter over that wire.
The REBOA is in.I'll let you know once the balloon is up.
We're gonna block the aorta.
-Simon, can you mark the time?-Yeah.
[Simon] We know, in trauma patientswho have major haemorrhage,
the major factor that determinestheir, um, likelihood of surviving
is the time between the injuryand stopping the bleeding.
[narrator] The balloon is inflated
and Samy has now cut off the blood supplyto everything below Michael's waist.
[indistinct chattering]
-[Samy] Just to let you know...-[medic] Yeah.
The blood pressures are highonly because of this balloon,
so it's still a dire emergency,and the longer it's inflated,
the more he'll sufferfrom the occlusion. Thank you.
We're gonna go upto interventional radiology,
secure the lines,secure the drains, package him.
[narrator] As a result of the REBOA,
Michael's muscle tissue below his waistis now starting to deteriorate.
So Simon and Samy need to move quickly.
-We ready?-Right, let's go.
-We're ready.-Everybody ready to move?
-[medics] Yes.-So, on the anaesthetist count...
-[anaesthetist] Okay, we'll move now.-[medic] Come on, then.
[narrator] At the Royal London,
the trauma team have re-inflatedStanley's left lung
and drained away the excess airand fluid from his chest.
With the chest drain in,the team send him for a CT scan,
to assess the damagecaused by the other two s*ab wounds.
It's amazing that... It's amazingwhat that little wound has done.
Yeah.
So, when I examined his abdomen,his abdomen is soft, he's got a wound,
but he's tenderin other parts of his belly,
well away from where his wounds are.
And for me, that worries me.Has he got an abdomen full of blood?
Is he bleeding from his liver?Is he bleeding from his stomach?
Is he bleeding from major vesselswithin his abdomen?
[machine beeping]
Trauma is a diseasewhere you have to exclude everything.
He has wounds to multiple cavities.
It's important that we rule outblood around the heart,
and it's important that we rule outinjuries to major vessels,
major organs in his abdomen.
[electronic scanner] Breathe inand hold your breath.
[Tom] Right. Yeah, no pneumothorax.
[radiologist] Wait for a second,that one is gonna be pretty crap.
-Right.-[radiologist] Wait for a second.
-Right into his left side...-[radiologist] Tiny one there.
-...where the chest drain will go, yeah.-[radiologist] Yeah. There.
-[Tom] Yeah.-[radiologist] Or there.
[Tom] There, there.
-Over the sternum, isn't it?-[radiologist] Sternum, yeah.
When I looked at his CT scanand knowing where his wound was,
you can try and predict a track.
Knives go in a straight line.
Looking at his liver,there was a suspicion
that there's a little bit of bleedingwhere there shouldn't be.
-He's got no pericardial effusion.-No. No pericardial free air either.
He's got one woundthat's in the right upper quadrant
and he's tender in the right high area.
It just looks like it could have nickedthe capsule of the liver.
Yep.
-So...-Makes sense.
[narrator] The CT scan has givena clearer picture of Stanley's injuries,
including his right lung,which has also been punctured.
That wasn't obvious on the X-ray,so the CT scan helps us,
it gives us more information,
and obviously, it's importantbecause he's got this wound
that is where the chest meets theabdomen, a junctional wound,
where the Kn*fe trackhas potentially injured both his liver,
his abdomen, abdominal contents,and also gone into the chest.
And the drain just needs to come back.
-So the drain needs to come back a bit.-Yeah.
-And the other one needs to go in.-We'll just go across.
[narrator] The team now need to drainthe other side of Stanley's chest,
which also has a build-upof blood and air.
They will then have to re-inflateStanley's right lung.
I don't want to waitand assume he will be well.
He has a build-up of air around his lung,let's drain it off.
We can't leave the blood in there,
it leaves him prone to infectionsat a later date.
And then come closer to it,so this side back.
-[Tom] Stanley, are you okay?-[Stanley groaning]
[Tom] We've had to give you painkillersto put some drains in your chest. Alright?
You've got some damage to your lungs,
that's why you've got these drainsin your chest.
Alright?
But you'll be fine, okay?
Good stuff. Alright.
[narrator] At the London Chest Hospital,
Andrew is still battlingto save Mick's life.
To get to the blocked artery,
Andrew needs to carefully navigatehis surgical tools
around a swollen blood vessel,or aneurysm,
that he has just discoveredin Mick's abdomen.
The aneurysm itselfis a pretty serious condition,
and if it ruptures,can cause fatal bleeding.
[machine beeps]
Let's go round please.
Helio cranial.
Precordial.
Okay, roadmap that, please.
Okay, let's havethe long wire back, please.
When you've gota very tortuous blood vessel
that you have to negotiate,
it means it makes it more difficultto steer the end of your catheter
and actually get the, uh, supportthat you need to do, to do the operation.
We actually managedto negotiate the aneurysm,
and we got a clear understandingof what the problems were.
[narrator] Andrew thinkshe's finally reached the blockage
in Mick's artery in his heart.
[Andrew] The way we treat any artery,is that we first have to pass a fine wire
down through either the blockageor through the narrowed area.
Essentially, it's a bitlike a drinking straw
you put down into the blood vessel,
um, and then suck outany blood clot within the vessel.
[Andrew] Can I have the balloon please?Inflate the balloon.
We then stretchedthe blood vessel with a balloon
that we blew up insidewhere the blockage was,
to restore the blood flow.
It went in quite nicely
um, and, once that had been,uh, put in position,
and, uh, we blew the balloon up inside it.
Let's have a / please.
[narrator] The effect of the balloonis immediate,
as blood flow in Mick's heartdramatically improves.
Right, we want to go way down, don't we?
-Yeah.-Let's just make sure we cover--
there's some shoulder diseaseoff the end that we'll cover.
We got a very nice, uh,what we call angiographic result,
meaning, that the pictures confirmed
that the blood flow to the heart musclehad been restored.
-Okay, well, that looks really good.-Yeah.
The artery in the front of the heart,we're happy with.
We've not been ableto open the side branch, but, um...
we've certainly preservedthe flow in the main artery.
We've got to position, we can havea look, see what the heart looks like.
The heart is contracting,but, uh, it looks very severely impaired.
Um, you should be seeing,uh, this main pump here,
which is the left ventricle,contracting much more vigorously.
So you would be seeing the wallscome in close together.
and the muscle would be thickening nicelywith each contraction.
[narrator] Twenty-seven-year-old Michaelhas a fractured pelvis
and is sufferingfrom major internal bleeding.
To try and keep him alive,
the trauma team have cut the blood supplyto the lower half of his body
through a process called REBOA.
He's now been movedto interventional radiology.
Using X-ray and contrast fluid,
Rob, the radiologist,can identify the damaged blood vessels
and inject a clotting gelto stop them bleeding in his pelvis.
We, uh, knew that he hada pelvic fracture,
but we didn't really know exactlywhere the bleeding was coming from.
We suspected it was from somewherewithin the pelvis,
but he was never stable enoughto get him into the CT scanner.
We were hoping that Rob would be ableto find a bleeding point,
um, but when we wentthere, it was a hope.
We weren't surewhether he'd be able to do that.
-[machine beeping]-Thank you.
[Simon] When we got the patientto interventional radiology,
um, Rob inserted a catheter intoone of the blood vessels in the groin.
And then through that,he was able to, uh, insert a wire
and inject some contrast,which is a dye which shows up on X-rays.
And the aim of that was to lookfor any, uh, ongoing bleeding points,
um, and identify them and then tryand stop the bleeding from those points
by injecting somethingwhich causes, uh, blood to clot
in the, um, in those vessels.
[narrator] For the last minutes,
the REBOA balloonhas stopped Michael bleeding to death.
But as Rob begins, there's a problem.
[inhales]
[exhales]
[Rob] We have to let the balloon down.
Just let it down, 'cause at the moment,I think that's the vessels,
but I can't see them very well at all.
Because we'd blocked the aorta,he couldn't see the femoral artery.
He couldn't see where he needed to go.
[narrator] The lack of blood flow meansthe arteries are now too small to access.
Simon, Samy, and Robneed to take a calculated risk.
We're going to temporarily deflatethe balloon.
[Simon] We had to deflate the balloon,
um, which was necessaryto allow blood flow into the vessels
to give Rob a chance of seeingwhere the bleeding points were,
and then to tryand stop the bleeding from there.
[narrator] The lower halfof Michael's body
has been without blood flowfor over minutes,
and deadly toxinsare likely to be building up in his legs.
[Samy] The worst case scenario would be,on deflating the balloon,
if these toxins take their tolljust a little bit too much,
as they are flushed out of the body,
they make the heart extremely unstable,
and the patient could havea cardiac arrest.
The other immediate danger is that
you haven't quite controlledthe bleeding as well as you think.
You deflate the balloonand the patient bleeds out continuously.
-The balloon's deflating now, okay?-[medic] Okay.
[Samy] It was the first timewe'd all done this particular procedure,
so none of us really knewexactly what was gonna happen.
[machine beeping]
[monitor beeping]
[indistinct dialogue]
Balloon is down.
[narrator] Michael remains stable.
Simon and Samy have given Roba window of opportunity
to fix the sourceof the internal bleeding.
He starts by injecting a clotting gelinto the damaged blood vessels.
[Rob] Okay, you can see it startingto slow down the flow down there,
so that's hopefully done the trick.
Alright. Well, his gas is really good.He's pretty much back to normal.
This is as goodas you could hope it could be.
It was becoming apparent to meand the rest of the team
that he seemed to be turning the corner
and was stabilizingand was not continuing to bleed.
I think that oneof the beneficial effects of the balloon
was that it had slowed and stoppedthe bleeding to such an effect
that allowed the bodyto clot to some degree.
Um, and again, just give usenough time to get in
and for the interventional radiologistto find all of the sites of bleeding.
I've gel foamedboth his internal iliac arteries,
which are the arteries which supplypretty much everything in the pelvis,
in both-- on both sides.
Hopefully, that's temporarily slowed downthe flow in both those vessels.
His heart rate's come down,so hopefully, that's done enough.
[narrator] Michael has stopped bleedingfrom his pelvis.
He becomes the first patient in Britain
to have survivedthe refined REBOA procedure.
He will now need extensive surgeryto repair his other injuries,
but for now, Simon, Samy,and the trauma team
have stopped him bleeding to death.
In some ways, I was... surprised,
but more relieved that this went so well.
It's somethingthat we've had a large build-up to
here at Royal London,it is a big thing to embark on.
It's a very new and novel procedure.
So, yeah, um, very relievedand a little bit surprised.
[Rob] Hopefully he doesn't sufferthe consequences of the balloon.
He doesn't seem to be,at the moment, does he?
No, I know, his blood gas is great.[chuckles]
[Helen] Okay, Stanley. Can you hear me?
Stanley on that day,I think, was very lucky.
There was a huge chain of peopleinvolved in his care.
He's particularly lucky
because the systemthat exists here in London
can nuance his care in a very bespoke way
that many systemsaround the world can't do.
I remember asking myselfif that's how I was gonna go,
like, if that was my final momenton Earth.
I believe that if they didn't get thereas fast as they did,
I would not be sitting here today.
So, yes, it was a miracle.
[Samy] A month or two ago,before we had REBOA as an option,
our only option would have been to openhis chest from one side to the other,
and manually press on the aortawith your hand to stop the bleeding.
That obviously carries with itlots of complications.
We would have inflicted a big, big injuryon top of the injuries he already had.
So lots of things were aligned,if you like,
to enable him to survive this, I think.
So, yeah, in that respect,he's very lucky indeed.
So despite, um, all of thesevery active treatments that we had,
trying to support, um,almost every aspect of Michael's body,
um, he continued to deteriorate,and unfortunately, he d*ed the next day.
You wouldn't be in this fieldif you didn't have faces
or cases that stick with you.
At least his familyhad a chance to see him.
His mum was at his bedside.
Uh, she could at least come to termswith what had happened,
uh, and she could be therewhen he did ultimately die.
Um, and for me, that's, you know,
that's as good as it could befor Michael, I guess.
[radio chatter]
[narrator] Next time...
Tree surgeon Benfalls feet onto the pavement.
-He landed more on his side than his back.-More on his side.
[narrator] Grandmother Gudruncollapses in her hotel.
-[woman ] Is she conscious andbreathing? -[woman ] I don't know.
[narrator] And Vincent is involvedin a high-speed collision.
[medic] Really pale feet.
01x02 - On the Edge
"An Hour to Save Your Life" is a medical science series exploring the life or death decisions facing doctors in the first critical hour of emergency care.