02x03 - Minutes From Death

[bunniefuu]

Hello, ambulance.

Eh...

Hello?

Quick!

Why do you need the ambulance?

I'm dying.

From the moment an emergency call is made, a clock starts ticking Doctors and paramedics are in a race against time.

Continue straight 500 metres.

When you're looking after critically ill patients, people talk about the golden hour when the interventions you make and the treatment you start can make the difference between whether someone lives or dies.

Guys, priority now is to go to theatre.

Come on, there's no blood pressure. Come on, let's have a Kn*fe.

This series will countdown minute by minute, second by second, the life-saving decisions made in the first hour of critical care.

It's vital we get there quickly and we try and reverse that dying process.

Some babies are born in very poor condition and it could take seconds or minutes for them to die unless somebody intervened.

Emergency medicine is changing.

Every day, those on the front line are breaking new ground.

We are always trying to push the limits of what is possible.

From open heart surgery in the street...

Right, no pulse. Carry on, we're doing a thoracotomy.

We're going to open her chest, fill her up with blood.

.. to the intubation of newborn babies.

Many more babies are surviving conditions nowadays that five or ten years ago would have been impossible to imagine.

We can give her surfactant to try to minimise lung trauma.

These are the medics using cutting-edge science to save time...

We're really struggling here.

.. and to save lives.

You can't give up.

There's always a chance this patient might survive.

Never give up.

Every hour in Britain, there are more than 200 life-threatening emergency calls.

For the most critically injured, doctors and paramedics have only moments to intervene before it is too late.

(Sirens blare)

This film follows emergency teams pushing the boundaries of medical science to save three people who are minutes from death.

In Leeds, a man fights for his life after a car crash.

He's kind of localising to pain and no eye opening.

In London, a mother is found collapsed in the street with no heartbeat.

Can we just quickly roll her? Just to make sure we're not dealing with a stabbing. Cos we just don't know what we've got here.

And a young cyclist has gone under the wheels of a lorry.

She's obviously a code red - she needs REBOA and blood.

For all three, the medical decisions in the first few minutes of care will make the difference between life and death.

In the heart of London, emergency services have been alerted to a serious road accident.

Emergency ambulance, what is your emergency, please?

It's a cyclist on the ground, run over by a lorry.

She's in shock and she's... not good.

(Sirens blare)

Continue straight for 1km, take the first exit...

Emergency doctor Simon Walsh and paramedic Bill Leaning are two miles away and immediately diverted to the scene.

Base call 460, go ahead.

We are 30 seconds away. Over.

It was given as a cyclist vs HGV, so we're going to a patient that's... potentially dying.

And when we get there, we are going to need to deliver some really speedy interventions to save their life.

Watch your heads, guys.

Police and London Ambulance paramedics are already on scene and have cordoned off the area.

My name is Simon, I'm a doctor. Can you tell me your name?

What's your name?

OK. Chest is good, belly's not too bad, so it's pelvis and... Which leg?

So that femur's gone.

Yeah.

And this one... OK.

24-year-old Victoria was on her way to work when she was involved in a collision with a lorry.

If we can get the rest of the clothing off, get some more access on this side...

She was lying in an abnormal position with her right leg twisted over the left leg.

There was also what looked liked tyre marks across the pelvis, so it was pretty clear that the wheels had gone over her pelvis and legs.

Right, so in terms of circulation, we've got no radial.

She's pretty shocked.

She was really pale. She was gasping in an abnormal way.

We couldn't measure a blood pressure, we could barely feel a central pulse.

The whole picture looked as though she was bleeding to death from a major pelvic fracture.

OK, so we'll call her 60 kilos.

I'm going to give her up to 30mg of ketamine just to get her onto the scoop.

If the major blood vessels that go through the pelvis into the legs are injured and disrupted, then there is a large space in the pelvis and not much to stop the whole blood volume coming out into that area.

It's quite possible for the bleeding to be so quick and so severe that it will lead to a cardiac arrest within a few minutes.

She's obviously a code red. She's got an unstable pelvic fracture.

We're just going to continue packaging her.

Can we get a second line in on this side?

I had a dilemma with Victoria -

I knew what she needed, but I didn't have those things with me.

I'm just thinking if we can get the team to us with the REBOA kit or whether we go to the Royal London.

Can you get on to the team to see if the team are available? Cos she needs it now.

Victoria is so close to death that Simon's only hope of saving her is to get her a blood transfusion and to perform an extremely rare procedure called REBOA.

But time is running out.

I had to quickly think through the logistics of getting blood and REBOA to her versus loading her onto the ambulance and taking her to hospital.

What it came down to was the fact that I didn't think she was going to survive the journey to hospital.

Simon instructs the helicopter, carrying trauma doctor Sam Sadek, to rush to the scene with blood and equipment for the life-saving REBOA procedure.

This procedure is inserting a balloon into the aorta, the main blood vessel that leads to your pelvis to block it, to stop the blood flow and stop the patient bleeding to death.

London's Air Ambulance is the only service in the world to attempt this extreme procedure at the roadside.

We've refined the equipment that has been used in hospital We've shrunk it down to a small piece of kit and take it out by the roadside.

That's never been done before. And the reason we're doing that is because we're desperately trying to save these patients that just won't survive to hospital.

11 minutes ago, another emergency call was made - this time from a quiet residential street in the North of London.

(Phone rings)

Emergency ambulance, can you tell me exactly what's happening?

There's a young lady lying on the ground.

I think she's been hit by a car.

Just try and ask her what's happened to her. Just try that for me.

Hello. Can you hear me?

Hello?

No, she's not responding at all.

We're now mobile to the incident and estimating seven to eight minutes.

Dr Gareth Davies and paramedic Tony Montebello are on their way to the scene.

Stay on this main road.

As one of Britain's leading trauma specialists, Gareth heads an elite medical service sent to the capital's most life-threatening emergencies.

The control room told us that the patient was lying in the street and was unconscious.

That's all we knew.

Right, straight across if safe.

The woman was found by medical student John Reidy on his way to work.

As I got closer, I realised I could see it was a young woman, and there didn't seem to be any signs of life from her.

I guess I just went into autopilot and I started doing CPR.

After the paramedics arrived, they took over and I stepped back.

Red Base, Medic 1 on scene.

When we pulled up in the car, I could just see out of the windscreen that the ambulance crew were doing CPR.

Her heart had stopped.

And if people weren't doing that, she'd be dead.

No-one knows how long Francita - a young mother of four - was in cardiac arrest before she was found.

Time is absolutely everything for someone who's in cardiac arrest.

All the tissues of the body are dying, and certain tissues, like the brain, are really sensitive to being starved of oxygen.

The longer she is without a heartbeat, the less chance she has of survival.

She's breathing, isn't she?

She had just had a defibrillation, an electric shock, and it wasn't quite clear whether that shock had worked and whether the breathing that she was doing was literally because of CPR or the fact that she now had a pulse.

So, are you OK just to stop a second?

We needed to feel a pulse.

She's got an output?

Yeah.

All right, shall we just get a monitor on to check that rhythm?

When Francita's pulse came back, all of us on scene were hoping that she'd start to wake up.

But she was not talking, she wasn't opening her eyes she wasn't moving.

Gareth suspects that Francita's brain has been damaged and needs to act fast.

Her breaths were not normal.

They were not good enough.

We didn't want more brain damage simply because she wasn't breathing properly.

Shall we just prepare to convert that tube?

To convert her to a tube, then, yeah?

The sooner he can take over her breathing, the sooner he can make sure her brain is not starved of oxygen.

But without knowing what caused Francita's heart to stop, he can't prevent it from happening again.

So no collateral history at all, just found...

Just found, yeah.

.. in a collapsed state.

And when you got to her, you were first on?

Have you seen...? There's no s*ab wounds or anything that we can see?

OK. Can we just quickly roll her?

Just to make sure we're not dealing with a stabbing.

There is literally a myriad of potential causes of a cardiac arrest, which is a big challenge. Our job is to sieve it all out and try and get to the root cause.

Anything?

Can't feel nothing, no.

OK, let's go back.

There were no injuries here that would cause this.

I was really worried that whatever had caused her heart to stop could just do it again.

Across Britain, front-line medics are battling against the clock to diagnose life-threatening conditions at the roadside.

At Yorkshire Ambulance Control, paramedics on the major trauma desk liaise with those at scene and major trauma centres.

They want to make sure that the most critically injured patients get specialist intervention as fast as possible.

OK, tell me exactly what's happened.

He's gone, skidded, totally smashed up the railings, hit a tree, scrambled around, 360 again.

Is he conscious?

No.

He's got severe injuries to his head.

15 minutes ago, paramedics alerted the Leeds Major Trauma Centre to a serious car accident.

A young man has crashed into metal railings after his car spun out of control.

I've checked the laryngoscope, I've got a size 8.5 ET tube, I've checked the balloon.

A & E Consultant Andy Webster is heading up the trauma team that will be treating 26-year-old Kyle.

OK, in here, please.

Can we have the patient's head to the end of the bed?

26-year-old male driver, front impact RTC.

Blood, left pupil. Sluggish reaction, right pupil.

And a scalp wound.

OK.

I was aware from the pre-hospital information that he had a dilated left pupil, which always makes us concerned that there might be raised pressure inside his brain.

There may be a significant bleed in his brain or pressure that needs to be relieved, so we had to get him to the scanner straightaway to see if there's any urgent surgical treatment required.

Can you start the primary survey, please?

But before Andy can take Kyle to the CT scanner, he must assess if there are any other immediate threats to his life.

He's got some blood on the back of the collar, so he might have an injury to the head.

Looks like he might have fractured his right arm.

Yeah, he has fractured his right arm.

Kyle, can you open your mouth, please?

Open your mouth. Kyle, can you open your eyes?

He's kind of localising to pain, probably, incomprehensible sounds and no eye opening.

The fact that Kyle is not responding shows that he has a dangerously low consciousness level.

So let's grab it into the chest.

Airway, he's grumbling but probably not completely patent.

The first thing that could k*ll Kyle is the lack of oxygen going to his brain.

When you're unconscious, you don't breathe adequately, you don't take deep enough breaths and you don't breathe at the right rate.

Moving Kyle to the CT scanner in such an unstable state could be catastrophic.

I had to make that critical decision - should we take him to the CT scanner straightaway or should we take the extra ten minutes intubating and ventilating him to take control of his breathing?

(Kyle moans)

I'm really aware of how important each minute is.

Every minute he's not breathing properly means he's not getting enough oxygen to his brain and there's brain cells dying.

With the danger of oxygen starvation so high, Andy decides to intubate Kyle.

On this occasion, the risks of taking him round to the scanner without his airway being protected was too great.

Andy uses a drug called suxamethonium to paralyse Kyle's breathing muscles.

Sux is in.

And a tube is inserted into his windpipe.

From now on, Kyle's oxygen intake is dependent on a ventilator, which is breathing for him.

When I'm in the resus room with someone with a bad brain injury, I just can't predict their outcome.

I had really grave concerns that this injury was so severe he may not survive.

In Central London, Simon and Bill are about to anaesthetise Victoria on the street.

The young cyclist is bleeding to death after her pelvis was crushed in a traffic accident 26 minutes ago.

OK, so if we get her on the trolley and then we're going to move over to the spot over there where we can RSI...

Victoria's survival now depends on getting a blood transfusion and an emergency procedure called REBOA before it's too late.

We would only consider using REBOA in patients where they're bleeding to death at the scene and we think they're going to be in cardiac arrest before we get to hospital.

The procedure can only be done on patients who still have a pulse, but Victoria is close to losing hers.

I knew that if we were going to use an intervention like REBOA, it needed to be within the next few minutes.

To try to save her, Simon has called on Sam Sadek to fly equipment in to perform the procedure at the roadside.

When someone's bleeding to death from a pelvic injury, every second does count.

Sometimes, the devastating side of it is very hidden. And actually everything on the outside looks intact.

Meanwhile, on the inside, they're catastrophically bleeding.

These patients are sometimes referred to as patients that talk and die.

So their brain appears fine - they sit there and they talk to you.

And then five minutes down the line, they're dead.

Can you hear me?

Tell me your name if you can hear me.

Vicky.

What's your name?

Vicky.

Vicky.

What we're going to do is give you an anaesthetic so that you don't feel any pain any more.

When you're about to give an anaesthetic to someone who's that severely injured, you're conscious that they may not survive this accident and your voice might be the sort of last voice they hear.

Vicky...

I know. This is going to take all the pain away, OK?

I know, so we're going to take that pain away for you, OK?

We're going to look after you, don't worry.

Circuit filter.

Check.

Alternate tube size.

Six, check.

OK, bivalve mask...

Simon wants to anaesthetise Victoria before performing REBOA.

The procedure has only been carried out twice before outside a hospital - with one survivor.

Hi, Sammy. So she's a cyclist. Wheels have gone over her pelvis and right femur fracture. No radial but palpable central pulse.

Blood pressure, not been able to record one.

If you want to anaesthetise, we'll do REBOA and give blood.

Yeah, that's perfect. ~ Sound good?

Yeah. ~ Cool.

OK.

OK.

Can we have silence now, please?

Sam uses a portable ultrasound machine to find the right place to insert the REBOA balloon.

It needs to be fed into Victoria's femoral artery, into her aorta, where it can block blood flow to the pelvis.

OK, so...

It can be very, very difficult to get into the blood vessels of someone who is bleeding to death because your blood vessels tend to constrict and become very, very hard to see and to access.

In that area, there is a big artery and there's a vein.

If you go into the vein, you then feed up into entirely the wrong vessel.

You want to save this girl's life, and you know that it can go wrong so easily.

A millimetre of movement either way and it goes wrong, and that might be your only chance.

OK, the long wire is in.

Can I have the balloon, Sam?

Yep.

When this balloon goes in, it's going to stop all the blood flow below her distil aorta, so we really need to get her into the ambulance and to the Royal London as quick as we can.

OK, balloon's up, Simon.

Balloon's up.

Hi, it's Simon with PRU and London HEMS.

I think we'll be with you in about ten minutes. OK.

Simon's phone call triggers a code red alert at the nearest major trauma centre - at the Royal London Hospital.

So they said the wheels have gone over the pelvis.

She's now been RSI'd and the REBOA was 29-52 when started.

With balloon up. OK.

Trauma specialists are being called and blood is being prepared for Victoria's ongoing need for transfusion.

That's the blood.

Let's go. On you.

She's got a sats reading now that she didn't have before.

OK, good.

97-64.

For the first time since emergency teams arrived on scene, Victoria is now recording a blood pressure.

Once the balloon was inflated, there was an immediate change in physiology, which confirmed to us that the balloon was doing what we wanted it to do.

We've definitely occluded flow.

OK, great.

Using ultrasound, Sam confirms that the REBOA is stopping blood flow.

But it comes at a cost.

You may improve things for the brain and the heart and you may keep that patient alive, which of course is most important, but you are essentially k*lling the rest of the body, cos you're starving it of blood.

We've done something that will save her long enough to get to hospital, and we desperately need to get the balloon down so that she survives beyond that.

All right, let's cr*ck on.

Let's get her onto the scoop stretcher.

In North London, Francita is still unconscious after going into cardiac arrest 30 minutes ago.

Gareth fears that her heart could stop again at any minute.

You're thinking, "Why has a young woman just collapsed on the pavement on the way to work?"

Is she still breathing OK?

Yeah.

As there are no signs of trauma to her body, Gareth has to explore all the other reasons why her heart could have stopped.

We were now left with all the medical causes of a cardiac arrest, such as a brain haemorrhage or a heart att*ck.

Are you all right if I take over the airway from there?

You've done a fantastic job.

I don't know if you heard that, Doctor, but they've got in touch with the family. She's got no medical history, no medical conditions...

OK, all right.

Without hospital scanners, Gareth must glean as much as he can by examining Francita and studying her heart trace.

Can you just hold that for me, please?

So...

It's not a normal ECG.

The ECG tell us a little bit about what has happened to the heart.

When we saw Francita's ECG, I was looking for ST segments that had risen and would indicate that she was having a heart att*ck.

So there's no... OK.

Lovely, thank you.

So there's no ST pattern on her ECG.

OK.

Her ECG was abnormal, but it didn't show signs of a heart att*ck.

Until the cause of Francita's cardiac arrest can be established, nothing can be done to stop it from happening again.

Shall we just note this as a primary collapse?

Nothing else on it, really.

No.

I think it's neurological, to be honest.

Hm, OK.

What are her pupils doing?

Gosh, pupils are...

Can you just check those for me?

About size two, three?

We've got one line here.

Are they reacting or not?

They don't look like they are.

No, OK.

When I looked into Francita's eyes to see her pupils and how they were reacting, I could see that they were very small.

It was suggestive that she had had a problem with her brain that had caused this collapse.

OK, can I have a big breath?

And again.

And again.

Pulse rate is 97. Saturation is 100.

End-tidals coming up at 4.3 now.

You happy to load?

Yeah. If you could... You guys cr*ck on and load.

Just stay on that tube, if you would.

Francita has been anaesthetised and intubated to protect her brain and keep her alive.

The big decision for Francita now is where do we go?

There were signs that Francita had had a problem inside her head, but there were also signs on her ECG that suggested her heart was the problem.

If we don't accurately identify why Francita has gone into cardiac arrest, it may mean that we take her to completely the wrong hospital, and that's why we asked for help.

We're with a lady who's 20 to 30 years of age, who's been found collapsed.

Gareth calls a senior cardiologist for a second opinion.

Her ECG looks to have a sinus rate of about 80 to 90.

Together, they must decide whether to rush Francita to a specialist cardiac centre, like the London Chest, or to a hospital with neurosurgery, like the Royal London.

Post-arrest, she was GCS 3, so she's been intubated and ventilated.

We can find no injuries on this lady at all.

Francita's survival is fundamentally dependent on what the cause of her cardiac arrest is - is it her head, is it her heart?

And still, we don't know that.

Making the wrong decision could cost time and, ultimately, Francita's life.

OK. All right. Cheers now. Thanks. Bye.

OK, people, we're going to the Royal London.

To the London?

Royal London, yep.

On balance, I think we all felt that actually the priority would be Francita's head and try and establish whether there was a problem going on with brain haemorrhage.

One kind of haemorrhage - or bleed - can cause blood clots to form in the brain.

As that blot clot gets bigger and bigger and bigger, it compresses the parts of the brain that are responsible for your heartbeat.

And eventually, if the clot is big enough, it will compress that bit of the brain and stop the heart.

Just letting you know we're bringing you in a patient, a 31-year-old female.

We've spoken with the Chest, who don't feel she needs a PCI, so we're coming to you.

And we'll be with you in about, what, four minutes?

All right. Bye.

I'm just hoping to God that it isn't related to her head, which, unfortunately, is a bit of a possibility.

In a patient that has had a massive bleed inside of their skull that has caused the cardiac arrest, the prognosis is really grim.

It means that absolutely vital areas of the brain have been badly damaged.

Time is of the essence.

(Sirens blare)

That's great.

In Leeds, Andy strongly suspects Kyle's brain has been critically injured after his car spun out of control and crashed into railings.

He has brought him into the CT scanner to find out how serious the damage is.

There are some contusions anyway.

Yeah.

There's blood in his left temporal lateral horn. Isn't it?

It looks quite swollen there.

He's a bit rotated as well, which I think is...

We can tell from the scan that when he hit the railings, his brain just came to a stop and everything just shook up inside, and that caused tearing and bruising inside the brain.

I'm going to give neurosurgery a call.

The bruising is causing a dangerous amount of swelling inside Kyle's brain.

Yeah, hi, it's Andy Webster, one of the consultants in the Emergency Department. I've got a referral for you, please.

Just in when you bruise your leg, that bruise gets worse over a number of days, the same thing happens to the brain.

So although we've got a snapshot of Kyle's injuries, I know that that brain is just going to swell over the next hours to days.

OK, so we'll get him up to ICU if there's no other major injuries.

To try to control the swelling in his brain, Andy is sending Kyle for neurosurgery.

The skull is a tight box which doesn't expand, so when the brain has extra things in there like blood or swelling due to fluid, there's nowhere for it to expand.

If the brain swells too much, it pushes down onto where the brain stem lies inside the skull.

If that happens, the brain stem gets crushed, and you just can't survive from that.

Ready. Steady. Slide.

So, he's got an intracranial haemorrhage. He's got some possible diffuse axonal injury. Ventricles are looking a bit tight.

They've tubed him. Grade 1.

In the first hour, front-line clinicians have battled to stop Victoria, Kyle and Francita from dying.

But their lives are still hanging in the balance.

Now hospital teams must do all they can to diagnose and reverse the damage.

The ongoing survival of all three patients now depends on getting the right specialist interventions... at the right time.

Victoria has been rushed to the Royal London Hospital after a cycling accident left her with catastrophic internal injuries.

Simon needs to get her to the trauma team as quickly as possible.

We've got two nurses.

We've got two anaesthetists.

We've got an ODP, two surgeons, two orthopaedic doctors, trauma research.

Retain focused and remember everybody's roles.

Ready. Brace. Move.

So, if everyone can listen up, please, this is Vicky.

She's had one unit of blood, just finished now.

Since REBOA, she has had blood pressures from 90-95, systolic.

The main issue is her circulatory issue with a suspected massive haemorrhage from a pelvic fracture and right femoral fracture.

The only thing stopping Victoria bleeding to death is a balloon inflated in her aorta.

But it can't keep her alive forever.

78, systolic.

It's 78 over 48.

Consultant anaesthetist Dan Nevin can see she's deteriorating again.

Within minutes of her arrival, her blood pressure started to fall.

Which means that despite the balloon in the aorta, despite the resuscitation processes that are ongoing around her, she is actually still not able to maintain a blood pressure.

Now, that means she's actively bleeding.

Danny, can we put up some more blood and catch up with her FFP, please?

Yep.

Thank you.

It's like a bucket with a hole in the bottom.

And the water is just continuing to pour out.

And no matter what you pouring in at the top, you can't maintain the volume.

OK, teams, so listen up.

She's dropped her pressure again, she's got a REBOA in situ, a CT is not going to show us that much, but plan to go to the operating room.

The only way to stop Victoria dying is for consultant trauma surgeon Tom Konig to find the damaged arteries and repair them... before it's too late.

Drapes, please.

When a lorry, a tipper truck, drives over your pelvis, it's going to break everything.

She's got injuries to the arteries. She's no doubt got injuries to the multitude of veins that move through the pelvis.

She doesn't have time on her side. We need to be as quick as we can to control this bleeding.

So, the balloon's been up an hour...

Yeah, yeah.

.. at the bifurcation, with good effect.

But we need to get it down.

Tom is under intense pressure to find and fix Victoria's damaged blood vessels so he can remove the REBOA balloon.

Suction ready, please.

Whilst the device is life-saving, if left in too long, it can be come life-threatening.

The REBOA process means that you are stopping bleeding but you're also stopping blood flow to tissue.

The longer the balloon remains up, the longer the tissue remains starved of oxygen.

And the tissue starts to die.

There was bleeding, and we want to find it again.

To find which blood vessels are haemorrhaging, Tom momentarily deflates the balloon, letting blood flow again to the damaged area.

So, balloon coming down.

(Gurgling, air hissing)

It's filling that side, isn't it?

That's less, significantly less. Let it go.

I think we ligate that one and pack this down here and come back...

What did reveal itself was that she was bleeding predominantly from the internal iliac arteries, which come off the artery to the limb and go deep down into the pelvis.

Dan we're going to ligate the left internal.

The balloon is down, so you'll be getting a reperfusion.

I'm ready for it.

By sort of ligating that artery, by tying it off, I've stopped her bleeding.

And at that stage, her bleeding is controlled with the balloon down.

All right, wire. That is coming out.

Wire out. Right.

Temperature... Is she cold now?

She's freezing.

Yeah, OK.

With the REBOA balloon removed, Victoria is still alive.

But her temperature has dropped to a dangerous level.

33.5 is extremely cold. It's trending towards significant and profound hypothermia.

To the point that it can be difficult to keep you alive.

Not only was she cold, but she was getting colder. And essentially, there was nothing I could do about it until he finished the operation.

Let's stop.

Dan, we're going to stop, OK?

Until Tom finishes surgery and closes Victoria's body, Dan cannot get her temperature up to safe levels.

Any further surgery to fix her pelvis will have to wait.

The team must now focus on warming Victoria with specialised blankets and checking if blood flow has returned to her legs.

(Beeping)

Right side is lovely and warm.

Yeah.

Right the way up the leg.

And she's pink now.

And she's pink. Yeah.

We may need to explore the left.

Her right leg at the end of the operation was nice and warm and pink and her left foot... wasn't as warm and pink as the right leg.

I can't feel a pulse in her left leg.

The worst case scenario with a leg that isn't as pink and warm as the other one is, does she got an arterial injury?

Has she got a clot in an artery?

Is the artery actually damaged?

It just kind of stops right there.

My concern is that she is at risk of losing that leg.

In the Emergency Department of the Royal London...

Patient's here.

.. Gareth is rushing Francita in for an urgent brain scan.

Just over an hour ago, the mother of four was found collapsed in the street with no heartbeat.

Gareth suspects she has suffered a significant brain haemorrhage.

But her ECG trace also suggests problems with her heart.

Francita got up this morning to go to work perfectly well.

Then, at approximately 07.08, was found in a collapsed state on the pavement by a member of the public.

Her downtime with CPR for that period was approximately 15-18 minutes.

Excellent. Thank you very much, Gareth.

Right.

Right, are you happy with the airway?

OK, break the scoop at top and the bottom, please, and brace from the patient's right.

Ready. Steady. Roll.

The sooner Emergency Department consultant Johann Grundlingh can find the exact cause of her cardiac arrest, the greater his chance of saving her.

I often deal with puzzles in the emergency department, but especially in a case like this, with Francita, it's difficult to say whether it's the head or the heart.

From the evidence so far, investigating Francita's brain takes priority over her heart.

I guess the next step, let's get to a CT. Thank you.

If Francita had sustained a cardiac arrest from a bleed on the brain, that bleed would have been catastrophic, and there was a very real chance it could still k*ll her.

Nice and slowly. Ready. Steady. Slide.

We needed to get her into the scanner very quickly.

Good.

Within minutes, Johann gets the results of the scan.

Francita's CT scan looked completely normal to me.

I couldn't see any signs of any bleed inside her brain.

My focus then shifted to her heart.

We needed to figure out whether she had a heart att*ck or an arrhythmia that caused her to have the cardiac arrest.

Looking globally, it seems to be functioning OK.

And the capillary muscles seem intact, for what it's worth.

Johann uses ultrasound to look for problems with Francita's heart.

You can see the architecture quite well - you've got the aortic valve over here.

LV. Mitral valve.

Look at how arrhythmic she is.

She actually slows down and speeds up.

Slows down, speeds up.

There were signs suggestive of an abnormal rhythm, and that abnormal rhythm can cause you to have a cardiac arrest.

Abnormal rhythms can indicate a problem with the electrical impulses in the heart.

A heart is a bit like your car engine - it keeps your car going, you need electricity running to it. If that electricity is interrupted or goes awry, the engine will stop working or will malfunction.

Some magnesium?

It's there.

If it was an abnormal rhythm that caused her to have her cardiac arrest, there was a very real chance it could reoccur again, at any point in time.

Good morning, Jo Grundlingh, A & E consultant.

I would like a critical transfer for a 31-year-old lady who has had an out-of-hospital VF cardiac arrest.

Having excluded a brain haemorrhage, Johann arranges an emergency transfer to rush Francita to a specialist cardiac centre.

The ambulance crew should be here in the next few minutes for the transfer.

Let's get her ready to go.

The quicker I get her to a place where they can look at her heart the quicker I can prevent her from having another cardiac arrest.

In Leeds, it's been five hours since Kyle's car crashed into railings, leaving him with a severe head injury.

Is this the monitor we're going to use, yeah?

The damage is causing Kyle's brain to swell and pressure to build inside his skull.

Neurosurgeon Souymo Mukerjee is preparing to operate on him.

If the pressure in brain is too high, then something in this rigid box has to give, and so what gives, unfortunately, is the blood supply and the oxygen going to the brain.

The brain eventually loses its blood supply and it loses its oxygen, and it dies.

That can happen very quickly, over the space of a couple of hours.

If we can save time, we can save brain.

The only way for Souymo to get an accurate reading of the rising pressure is to insert a probe into a specific part of Kyle's brain.

I want to be in the frontal lobe, that's where the damage is.

You know, so I have to be there, but I don't want to be there, in the motor cortex, which is the part of the brain that controls his movement.

It's only a matter of millimetres.

So it's easy to get wrong.

So we are going to thread that tube in now and we start to zero it.

The probe has a sensor which converts intracranial pressure - or ICP - into an electrical signal.

Because the probe is giving a minute-to-minute reading of his pressure, we can react to it, essentially, on a minute-to-minute basis.

Yeah.

Yeah. And then we turn it on.

So it tells us what the state of his brain is and also guides our treatment and the Intensive Care treatment.

A normal ICP reading is between seven and 15.

From now on, the Intensive Care team must keep him in an induced coma and monitor his ICP around the clock.

They'll need to react immediately to every surge in pressure by adjusting his levels of fluids, sedation and ventilation.

We know from experience that the brain may well swell significantly in the coming hours to couple of days, so we still consider him and treat him in every sense as still in a life-threatening situation.

In London, it's been over 24 hours since Victoria underwent a pioneering new procedure at the roadside to stop her bleeding to death.

Having survived the night, her temperature and blood pressure are now at safe levels, but surgeon Tom has grave concerns about her leg.

When I see her the next morning, the foot is cold, it's slightly mottled, it's purplish in colour and it's not as warm as the other side. That ticks all the warning signs of a foot that's without a blood supply, that she's got irreversibly dying tissue.

A CT scan has revealed that a clot at the top of her leg is building and has started to obstruct blood flow.

There is a realistic risk that that clot got larger and is now completely occluding the blood vessel, so we make a decision to operate on her that morning.

Tom passes a wire with a balloon into the femoral artery to draw out the clot.

Just pull the vessel towards you.

When the clot comes out of the artery, and you restore blood supply, everything should be running and up and working, but I think the fact that it didn't improve meant that the injury to her foot was more significant than I think we had anticipated.

Although her life was saved with REBOA and surgery, Victoria's leg muscles have become so swollen after her accident, that they are squeezing the blood vessels, cutting off the blood supply to her foot.

Tom decides his only option is an operation called a fasciotomy.

A fasciotomy is an incision through the skin, the fat and the fascial layer, which is a layer which encloses a muscle.

So by opening the skin, opening the fascia, it allows the muscle to swell and not compromise its own blood supply.

So the blood continues to flow.

You optimise the blood flow to the muscle.

I'm mindful that this is a young girl who's...

Young girls want to have legs that are without scars.

But if we didn't perform the procedure, then we wouldn't be giving her the best chance of keeping her leg.

It's one thing to survive being run over by a lorry, it's another to have a normal life afterwards.

Our goal as surgeons, our goal as trauma doctors is not just to save life but also fix people, to restore life and get them back to their normal life that they had before they were injured.

Across London, Francita is still at risk of a sudden cardiac arrest.

She has been transferred to a specialist cardiology unit for a life-saving procedure.

Have we got some of the diamorphine in already, have we?

After tests revealed no blockages in her arteries, a heart att*ck was excluded and consultant cardiologist Ross Hunter has now diagnosed Francita with an electrical abnormality of the heart.

The heart is an electrical organ.

It's electricity passing round it, telling it to b*at.

And it's that same electricity that can become confused and stop working as it should do. And that's what's happened in Francita's case.

If we discharged her and she and another one of these episodes, then the same thing would happen all over again.

And if she were extremely lucky, she might be resuscitated again, come back into hospital.

But the chances are that would not happen, and she would probably pass away.

OK, so that's the two wires right down into the heart.

To protect Francita's life, Ross is surgically implanting an ICD in her body.

An ICD is an implantable cardioverter defibrillator.

There's a couple of floppy wires that go down through the vein, down to the heart inside.

They're attached to a small computer that's buried deep under the skin, up here.

Quick tug test to make sure they're firmly attached, and they are.

If ever you have a dangerous heart rhythm, it will be sensed through the wires and the ICD will give you a small shock directly into the heart.

The shock, or defibrillation, terminates the heart rhythm that you're in and it resets the clock for the heart, if you like.

So the normal heart rhythm then has a chance to ensue again afterwards.

6.8, 7...

You tell us when you're ready and we'll go.

So we'll go on with a burst.

I can count if you let me know when you want me to pull off.

OK, yeah.

Wait for the second.

The only way for Ross to check if the device will save Francita is to force her heart into the same dangerous rhythm that caused her cardiac arrest.

We do that by stimulating her heart very, very quickly through the device, much faster than the heart could realistically sustain.

Once it's in this fast and dangerous heart rhythm, we can then check that it shocks Francita out of that rhythm, back into a normal heart rhythm.

Are you going to go ten under max output, then max output, and then onto external?

30, 40 and then external, yeah.

Great.

If there was going to be a problem with the device, I'd much rather find out here, in this very controlled environment, than have her find out out in the real world, where there's no safety net.

So ready to press and hold if you are.

OK.

One, two, three, four, five, six...

Within moments, Francita goes into cardiac arrest.

.. seven, eight, nine, ten.

That's the shock being delivered.

OK? And a good look at the monitor now...

Thanks to the ICD device, Francita's heart is shocked back into a normal rhythm again.

So, the last layer of sutures and we're all finished.

Doctors have now done all they can to protect her future when she's back home with her family.

In Leeds, Kyle's future is less secure.

It's been a week since the 26 year old's car crash left him with a severe brain injury.

He is being kept sedated in a coma until his brain swelling goes down.

His third and fourth ventricles are more easily seen now.

He has got a significant diffuse axonal injury, as we discussed, so what his neurological prognosis will be, it's too early to say.

Intensive Care consultant John Adams is checking Kyle's brain scan to see whether treatment is working.

Kyle's scan looked to be a little bit better in that the swelling was starting to go down inside the brain, but it's very difficult to tell what damage has been done just by the scans alone.

The scans can give us some useful information, but they don't tell us the whole picture. And really what we need to do is take the patient off the sedation dr*gs and see how they respond to us once the sedation dr*gs are out of their system.

With Kyle off sedation, the Intensive Care team can now see if he will wake up from his coma.

OK, I'm just going to have a little look in your eyes there.

His consciousness levels are tested every hour using a scoring system called the Glasgow Coma Scale, or GCS.

Kyle, open your eyes wide for me.

Kyle, open your eyes wide.

Intensive Care nurse Carla Smith assesses Kyle's condition.

We start by testing the patient's higher functions, so we speak to the patient to see whether they are able to respond to us and obey commands.

Kyle, can you squeeze my hand?

Squeeze my hand, Kyle.

Kyle this is very important.

Squeeze my hand if you can hear me.

Kyle, squeeze my hand.

He was unable to respond, so I then went on to testing his basic functions.

Basic functions are what you're born with.

Kyle, I'm just going to press on your head here.

Push me away when it starts to hurt you.

Push me away, stop me doing this.

Reacting to pain is a normal response, so if somebody inflicts pain, you're normal response is stopping them doing that.

Push me away, Kyle. Push me away.

You want to move towards the painful stimuli.

But in Kyle's case, he moved away from the painful stimuli, which is a very abnormal reaction.

Just going pinch your finger there, Kyle.

Kyle's consciousness is graded on the GCS spectrum, with 15 being the highest possible score for full consciousness.

His GCS was only four at that time, which is really very poor.

And it indicated that he was still deeply unconscious.

All right, darling, all finished.

I think the hardest thing for us is to give accurate information to families about how patients are going to be long term.

We know with the type of brain injury that he's got and how he's starting to respond to us, that his recovery may not be complete and he may be left with a permanent disability, which may be severe.

Less than 10% of patients who have a cardiac arrest survive, so Francita is incredibly lucky not just to survive, but to survive in such a good state.

Slowly.

Wheee!

Oh, you're a cheater.

When I look back, it's quite emotional and... quite sad in the same time as well.

It's a lot to take... a lot to take in.

Time is one of the crucial elements of Francita's care.

How quickly the bystanders called for help, how quickly they established CPR, how quickly the defibrillator was applied.

All of these things improved Francita's chance of survival.

I actually touched death's door and will appreciate life now even more.

I feel like I've been given, like, a second heart.

And I think that without that, who knows if I would be here today with my kids?

We just don't know.

There were signs that his neurological recovery was starting to speed up a little bit.

Gradually, over time, he started to recognise people, to eat and drink more normally, and do sort of normal type of things.

I just want to get back to a normal life now - spending time with friends and family, going back to work, not ending up in hospital.

Just being happy.

Kyle's made an absolutely fantastic recovery.

And I think it's testament to the treatment he had when he was... when he was first in hospital.

It's that attention to detail in the first sort of hours and days after injury which I think can really make a difference to someone like Kyle months or years down the line.

I just feel, um, really, really grateful to the doctors because if it wasn't for them, then I wouldn't be here.

So that's something I'm really grateful for, I think.

As well, you know, just being able to do an operation on the roadside like that is just incredible.

And if they hadn't done that, then I wouldn't be alive.

I've treated lots of people like Victoria, who have had exactly the same injury, who have not survived.

I don't think she would have made it to hospital without what we did.

There were a couple of weeks which were quite hard to kind of take in the fact that I'd lost my leg.

My short-term goal is really to be, you know, up and walking.

And in the future, I'd like to be cycling again, if possible.

I'm not going to be running any marathons, I don't think.

Is that good?

Yes.

Yeah?

It was a very unlucky thing to have happened, but I'm lucky to be alive.