An Hour To Save Your Life (2014) s02e01 Episode Script
Between Life and Death
WOMAN: 'Hello, Ambulance.
' MAN SLURS 'Hello?' 'Quick!' 'Why do you need the ambulance?' 'I'm dying.
' From the moment an emergency call is made, a clock starts ticking.
SIRENS WAIL 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, come on! There's no blood pressure.
Come on.
This series will count down 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.
ALARM SOUNDS 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.
SIRENS WAIL We are always trying to push the limits of what's possible.
Let's go! From open-heart surgery in the street All right, no pulse.
Carry on, we're doing a thoracotomy.
We're going to open the chest, we're going to fill it up with blood.
.
.
to the intubation of newborn babies.
Many more babies are surviving conditions nowadays that five or ten years ago would've been impossible to imagine.
We can give some surfactant to try and minimise lung trauma.
These are the medics using cutting-edge science to save time We're really struggling here.
.
.
and to save lives.
~ BABY CRIES ~ 'You can't give up.
' There's always a chance this patient might survive.
Never give up.
In Britain, an emergency call is made every three seconds.
For the most seriously injured, survival will depend not just on how quickly treatment begins, but who gives it.
Today, highly-trained doctors and paramedics can perform surgery at the roadside and in dedicated hospitals, teams of specialists are ready to intervene the moment a patient arrives.
This film follows these medical pioneers battling to save three people caught between life and death.
In London, cyclist Janina goes into cardiac arrest after colliding with a lorry.
OK, heart is pretty empty still, so keep filling with the blood.
Can we squeeze that blood in? In Yorkshire, doctors have just minutes to stop Tony bleeding to death.
We need to rush you to theatre and if we don't do anything, it is a risk to your life.
And on a suburban street, 11-year-old Blake is showing signs of a brain injury after being hit by a car.
BLAKE SCREAMS ~ What can you see? ~ Nothing.
PHONE RINGING 'Thank you, caller, go ahead.
Tell me exactly what's happened.
' 'A lorry has run over a cyclist.
' In Central London, an emergency call is received about a seriously injured young woman.
'Is she awake?' 'Yes, she's moving, but in desperate need of help.
' Base, minute one - we're mobile.
ETA six minutes, over.
RADIO: 'Mobile, six minutes, all received, thank you.
SIRENS WAIL London's Air Ambulance clinicians Dr Simon Walsh and paramedic Tony Montebello are dispatched by car to the nearby scene, where 26-year-old Janina has collided with a lorry.
Continue straight 500 metres to the major junction 'When you hear that a cyclist has gone under a HGV,' they may not still be alive by the time we get to the scene.
'But if they are, they're likely to have' crush injuries to the chest, abdomen or pelvis and their life is likely to be in danger.
200 metres.
'We need to be there within a few minutes 'to have a chance of saving someone's life.
' OK.
Excuse me, mate, can you just grab this bag for us? Can one of you grab that bag? Cheers.
'Police, fire crew and London ambulance paramedics 'have cordoned off the scene after pulling Janina from the road 'and are performing CPR.
' 'When you see chest compressions in progress, 'it's obvious that you haven't got any time to play with.
' 'Just minutes ago, Janina went into cardiac arrest 'and is no longer breathing.
' Hey, guys.
With that wheel? OK.
Er 'Within a few seconds it's apparent that this patient has been 'crushed by the wheels of the vehicle to the point where she'd had' catastrophic haemorrhage, very quickly leading to cardiac arrest.
Yeah, we've got fluid and stuff going on down here.
'Massive internal bleeding has drained Janina's heart of blood, 'causing it to stop beating.
' ~ I don't know what all this is but ~ OK.
~ Came out of her mouth.
~ OK.
'Effectively, the heart had nothing left to pump around to her brain' and other organs.
'Unless we can do something to reverse that process rapidly,' then that is the end of life.
We're going to intubate.
Have we got some access? 'Once Janina's in cardiac arrest,' she isn't making any effort to breathe herself 'and so we have to get oxygen into her lungs.
' And the best and most effective way to do that is to put a tube down into the windpipe and ventilate her with a bag.
~ Tony? ~ Yes.
~ Are you happy to intubate? ~ Yes.
~ Thank you.
Can you just pass the tube over the bougie for me? OK, I've got the tube.
Hold the bougie.
Squeeze the bag.
~ That's fine, that's fine.
~ Carry on.
OK, secure the tube.
The next priority is blood, please.
'Now they have taken over Janina's breathing, 'Simon wants to refill her heart with blood 'in the hope it will begin pumping again.
'London's Air Ambulance is one of a select few services in the UK 'to carry blood to a trauma scene.
' Let's start running some blood in there.
We've got access.
Left arm, yeah.
'While Janina has no blood circulating, 'her vital organs are being starved of oxygen.
' The brain will only survive for a few minutes without good circulation 'so we have to get the blood transfusion into the patient 'within those few minutes.
All the time she's in cardiac arrest,' the clock's ticking and her brain is dying.
Right, just stop and check for any output for a second.
Is there any pulse? ~ We haven't got anything at all, Simon.
~ OK, carry on.
'Despite her blood transfusion and continuous CPR, 'Janina's heart is still not beating.
' 'Your hope when you perform these interventions is that' any one of them will reverse the cardiac arrest.
'If there had been a return of the pulse, then we've got 'a whole load of other options available to us.
' In the absence of that, we were still in a very desperate situation.
OK.
OK.
OK.
In Britain, road traffic accidents are the leading cause of major trauma, and those involving children can be a challenge for the emergency services.
14 minutes ago in Yorkshire, ambulance control received a 999 call about a child hit by a car.
WOMAN: 'Ambulance service.
' BOY CRIES IN BACKGROUND WOMAN: 'A little boy's just run out in front of my car.
' BOY SCREAMS 'Right, where's your pain? Ask him where his pain is.
~ 'His leg.
' ~ 'His leg.
'We're coming as quickly as we can.
' Yorkshire Air Ambulance paramedics Darrell Cullen and Pete Valance are dispatched to the scene.
Any child trauma is quite difficult, because the smaller you are, the more vulnerable you're going to be, even at a slow-speed impact, you could sustain life-threatening injuries.
BOY SCREAMS Hearing his cries from their home nearby, 11-year-old Blake's mother and grandparents have rushed to his side.
When we got to Blake he was in a lot of pain, he was really agitated.
BLAKE SCREAMS First response paramedics immediately update Darrell on Blake's condition.
Yep.
~ He can't see anything? ~ No.
~ Oh, right, OK.
Blake appears to have a broken leg but Darrell is more worried about his sight loss.
'He didn't have any vision at all, he was in complete darkness.
' That was telling me straightaway that he'd got a potentially got a brain injury.
Does he look to have any visible injuries to his head? Although Blake's leg is causing him extreme pain, Darrell's immediate priority is to protect his brain.
~ Blake, we're just going to put this mask over your face.
~ OK.
~ All right.
Brain cells need a continuous supply of oxygen to survive and if it's taken a blow to the head then it means the oxygen has been disrupted so we need to supplement the brain to re-establish a normal level of oxygen.
A nice and steady lift.
To reduce distress and provide pain relief, Darrell gives Blake intravenous morphine.
~ Just here, yeah? Don't move.
~ It's to stop your leg hurting, all right? My arm hurts! 'We were all scratching our heads on the scene, 'it was something that we'd not seen before.
' ~ Can you see that? ~ What? ~ You can't see anything? 'With Blake's blindness showing no sign of improvement, 'Darrell fears he could deteriorate quickly.
' 'Time is critical in head injury cases,' there can be underlying bleeds, there can be swelling and whilst all these are ongoing, it could cost the person their life.
Back in Central London, German student Janina is in a critical condition.
After an accident with a HGV, she's suffered huge internal blood loss, causing her heart to stop.
Can you grab that red bag? Bring it over here So far, Simon and the team have ventilated Janina and given a blood transfusion, but her heart has failed to restart.
If you can just The main pouch, I think.
'I felt 'that there was a young person' who was dying in front of me and I wanted to do everything that I could, even if there was a tiniest chance to reverse the process.
Check the blood afterwards and get that going.
~ Cut at the top, Jane.
~ OK, I think Right, the question is whether we just open the chest now cos we're short of time.
There was one other intervention we could try which was something called a thoracotomy.
We can't do that as she's not got a pulse so let's just open the chest.
~ OK.
~ OK.
We're going to open the chest, we're going to fill it up with blood, see if we can get aortic compression.
After just five minutes on scene, Simon decides he has no option but to cut open Janina's chest and gain direct access to her heart to pump it manually.
Just check before we Definitely don't have a pulse.
Right, no pulse.
Right, carry on.
We're doing a thoracotomy.
OK.
'Probably five years ago we would've just stopped 'and pronounced her life extinct at that point.
' It's major open-chest surgery in the street.
You don't do that if there's anything else you could possibly do to reverse the situation.
Lovely.
Right 'The aim of a thoracotomy in this situation 'is to get the heart pumping again.
' We perform open internal cardiac massage and try and stop the blood loss by pressing on the main blood vessel, the aorta.
OK, the curved mayos and the mosquito forceps, please.
Thank you.
Curved mayo scissors.
OK, heart is pretty empty still, so keep filling with the blood.
Can we squeeze that blood in? Until the aorta is compressed, any blood being given to Janina is bleeding out through her damaged pelvis.
I'm going to get you to do aortic compression afterwards, OK? ~ If you can get your hand in behind here.
~ Yeah.
Onto the front of the spine, fingers down that way, ~ to press down onto the spine.
~ OK.
Feel the soft structure in front, then just compress the aorta.
~ OK? ~ Yeah.
Simon asks emergency technician Adrian Lee to squeeze Janina's aorta with his hand, stopping the blood from flowing out from her lower body and allowing her heart to be refilled.
'Suddenly, I've got my hand inside her chest 'and then finding her aorta and just putting my hand on there' and then he said, "Do not let go whatever you do.
" And then suddenly I realised this was unbelievable.
Keep filling, please.
I just want to get some massage going here, see if we can get any output at all.
Simon simulates the heart's natural pumping rhythm, restoring blood supply into the coronary arteries.
~ OK, how much blood's in? ~ One unit.
~ First bag nearly gone.
If we get an output back, we're going to need to load and go to the Royal London very quickly.
~ Have we got an ambulance that's accessible? ~ Ours is up there.
~ OK.
I've got some activity now.
Hang on a second.
It's slow.
Rhythm But we can see any pulse with that.
At first there were just a few little flickers of attempted movement.
I knew that if I could get enough blood round through the heart muscle that ineffective movement might develop into effective, normal pumping of the heart again.
It's started to look a bit better.
So we're getting some activity back.
I'm hoping that with a bit of filling, we're going to be able to load her and move her.
So have we've got a trolley and a scoot ready to go? That's looking a bit more forceful now.
Have we got a pulse? Sharps again, sharps away.
I was surprised and absolutely elated, really, to see that her heart actually started beating for itself.
Yeah, so when we get her onto the scoot 'It was the first point where I thought, ' "Actually, there's some hope here and if we can sustain that' "and support it, then we could actually get her to hospital alive.
" Keep filling with blood and go.
'With her heart now beating again, Janina has a chance of survival.
' That's looking much better now, better rate.
OK, we've got good vitals now.
~ So we've got a pulse.
~ Good work, Simon.
Good work.
Hi, it's Simon, London Hems, just giving you a code red priority call.
Adult female, code red, I'll phone back with the details.
We've done a thoracotomy.
We're going to be there quite soon - in about ten minutes.
OK, bye.
OK, we want to get her in the scoot and in the ambulance in two minutes, please, guys.
Simon has a small window of time to get her to hospital.
Janina's heart may have suffered muscle damage from lack of oxygen and could arrest again en route.
Ready? Ready? One, two, three, lift.
Nine minutes.
Can you grab a set of the code red check list? At the nearest major trauma centre, a team of at least 15 specialists are gathering, led by emergency department consultant, Dr Samy Sadek.
Everybody nice and quiet, just for a second.
So, we have the resus nurse and ED consultant are here.
~ Level one, is it set up and ready to go? ~ Ready to go, yeah.
~ Fantastic.
~ Theatres know? ~ Theatres know, yep.
~ Great.
'Blood cells and plasma are being prepared for Janina's transfusion.
' So the term "code red" refers to a patient that the team think is bleeding to death.
That person at that particular time is probably the most severely injured patient in the whole of London.
So you're in charge of the blood.
Has FFP been requested? Yes So, let's get going.
Everyone happy? OK.
Right.
Let's go.
SIRENS WAIL OK, guys, right, this is as good as we'll get it.
'The things that I don't know are the extent of her pelvic injury, 'the extent of her abdominal injury and what effect the period' of cardiac arrest has had on her brain and her other vital organs.
The only thing preventing Janina from bleeding to death is Adrian's hand pressed firmly on her aorta.
I knew her life depended on it.
And so I wasn't letting go for anything.
200 miles north, the Leeds General Infirmary treats critically ill patients from across Yorkshire.
A specialist vascular centre, its staff are experts in diseases of the blood vessels.
PHONE RINGING 29 minutes ago, the team in resus were alerted to receive a 61-year-old man, who suddenly collapsed with severe back pain while getting ready for work.
Everybody ready? On slide.
Ready, steady, slide.
With signs he may be bleeding internally, Tony has been fast-tracked to the Leeds General Infirmary to receive expert vascular care.
Within seconds, A & E consultant Dr John Jones conducts a primary survey.
When Tony arrived I was immediately struck by how ill he looked.
Tony's pulse was weak and difficult to feel, which meant that his blood pressure was very, very low and then the body isn't getting enough blood to a variety of critical organs and if that process was allowed to continue, he would either die or suffer the effects of multiple organ failure.
~ Tony, can you hear me? ~ Yeah.
~ Is the pain still really bad? ~ Yeah.
Whereabouts? Quite low down.
OK.
His abdomen and his lower legs were mottled which is a fairly classic sign blood flow simply isn't getting to the extremities.
I'm just going to be doing a scan of your belly, we're also getting a drip into your arm on that side as well, OK? John decides to use ultrasound to see if he can find the source of Tony's bleeding.
An abdominal aortic aneurysm - or triple A - is when the aorta, which is the main blood vessel running through the body, has started to balloon outwards.
In Tony's case, the aneurysm had ruptured and was bleeding copiously into his abdominal cavity, which meant there wasn't enough blood circulating in his body to keep him alive.
My worry here is that there's a problem with the blood vessel in your stomach here, so we're going to be moving pretty fast and trying to get things sorted out.
Only a gentle feel there.
~ Is that sore, there? ~ Yeah.
~ OK, well, I'll stop doing that, then.
A large triple A is extremely dangerous.
If it ruptures, you've got pretty much a 50/50 chance of surviving the immediate event and making it to hospital.
Even if you do make it to hospital, there's a very significant chance that you won't survive the surgery to repair it.
Right, so we've spoken to vascular and they're coming, yes? We just need blood for transfusion.
At that point Tony was going into shock, his body was beginning to shut down.
We really had to act fast and by fast, I mean in minutes.
~ Ah, Shankar, hi.
~ Hi.
~ That's the picture.
There's a flap moving around in it.
John calls for vascular surgeon Kiruba Shankar.
~ 95 was the last one we had but I can't feel good pulses.
~ OK.
We need to rush you to theatre.
Do you understand this? And if we don't do anything, it is a risk to your life.
We really didn't have any time to do any tests or especially a CT scan.
I felt that immediate surgery was the only way that we could stop the bleeding and potentially save Tony's life.
~ Good stuff.
~ We're going to move you to the theatre now.
Just 12 minutes after Tony's arrival, he's taken to theatre for surgery that could save his life.
'I didn't want to wait for a porter, I just wanted to get him upstairs' to the operating theatre because an operation was the only thing that was going to keep him alive.
Blake, open your eyes.
In Yorkshire, paramedic Darrell is still anxious to discover why Blake has lost his sight after being knocked down by a car.
~ So, minimal damage to the vehicle.
~ Perhaps he's hit it on the kerb edge.
Blake landed quite near to the kerb edge so, potentially, he'd hit his head or the back of his head on the kerb and that caused the sight loss cos the area that controls sight is to the back of the head.
With fears Blake may have a significant head injury, trauma doctor Andy Pountney has rushed to the scene.
'Children do behave differently' so they may not necessarily have the same changes in their pulse rate and blood pressure and so on which you would see in an adult and because of that, the extent of the injury can be masked until quite late on when the body just gives up compensating and then things deteriorate very rapidly.
Yeah, Andy, just here.
~ Just going to give Leeds a quick call just to check in.
~ Sure.
Hi, there.
Yeah, it's the Yorkshire Air Ambulance.
Erm, we've been called to an 11-year-old boy We needed to get him to a neuro centre as quickly and as timely as possible.
And that was Leeds General Infirmary.
If he did have an underlying brain injury, then that's the place he needed to be.
He's just had a head injury and he's lost complete vision.
Ready, steady, lift.
But before Blake can be flown to hospital, Andy must be confident he's stable enough to survive the journey.
Blake, how you doing? ~ Have you got any pain anywhere? ~ In my right leg.
~ In your right leg.
Can you open your eyes for me? ~ Yeah.
~ Brilliant.
~ What can you see? ~ You.
~ You can see me.
Not a pretty sight, is it(?) 'When I asked him what he could see, he said he could see me.
' ~ Good.
How many fingers am I holding up? ~ Two.
~ Two.
That's brilliant.
He was able to count how many fingers I was holding up in front of him so that was quite reassuring.
OK, so I'm going to leave you with my friend here, Pete 'But it didn't mean there wasn't anything significant going on,' there was still the potential that he had a serious brain injury.
Darrell knows the only way to understand the severity of Blake's injuries is to get him to hospital for a CT scan.
Primary aim is to make sure that the aorta is compressed and we're controlling haemorrhage.
Second to that is to go to theatre.
Simple as that.
Cyclist Janina is arriving at the Royal London where Simon will hand over to trauma team leader Samy.
'We were told that she'd already had her chest opened on the scene 'which meant she was as sick' as you can possibly get.
A thoracotomy at the roadside has restarted Janina's heart and blood flow to her upper body is being maintained by a hand pressed on her aorta.
'I just want to know that the work that they have done 'to keep this girl alive' doesn't go wrong and she gets what she needs as quickly as possible.
OK, guys, our patient is here, so everybody completely quiet.
The only person speaking will be me or Martin and the person doing a primary survey, if needs be.
OK? Thank you.
So, guys, everybody completely over to the left.
Thank you.
She was witnessed going under the rear wheels of the HGV, proceeded to do a thoracotomy, aortic compression and she regained a cardiac output after approximately eight to ten minutes.
Mm-hm.
Consultant trauma surgeon Martin Griffiths is in charge of tackling the most immediate threat to Janina's survival - her blood loss.
A cyclist versus a HGV is pretty much a worst-case scenario.
'I could see that she had a great big hole in her diaphragm, 'a hand on her aorta,' so my initial movement was to get that hand off and put a clamp into the aorta to allow that pressure to be maintained without need for a person being there.
Lovely.
So, immediate pelvic X-ray.
Pelvic X-ray, bay seven, in five, four, three, two, one.
~ Martin, as expected, she's got a bad pelvis.
~ Yeah, we need to make a move.
Yep.
All right.
'Her pelvic X-ray looked awful.
The pelvis is a very, very strong bone' and the force taken to shatter it like that is huge, so that in itself has a devastating effect.
The pelvis is sitting close to very big blood vessels, veins and arteries.
When you disrupt your pelvic ring, your pelvic fracture, then you bleed out torrentially from that area.
So, guys, our priority now is to go to theatre so anybody who's not doing that, step out.
OK, everybody out the way, we're going to move now.
Janina needs emergency surgery to stem the bleeding in her pelvis before Martin can remove the clamp on her aorta and restore blood flow to the whole of her body.
Good, just everything calm and coordinated and whatever we do, don't displace the clamp.
'We're very, very mindful that we have not fixed the problem.
' This was all about damage control and doing the least necessary to just keep this girl alive.
At Leeds General Infirmary, A & E consultant Jonathan Thornley assembles a specialist paediatric trauma team to receive 11-year-old Blake, who is accompanied by his grandmother.
I understand he has a head injury.
And a lower limb injury and there's a lot of Blake in between the two.
I'm always questioning what's going on in between.
Although Blake's vision has now returned, doctors fear underlying brain damage.
Nice and steady, nice and steady.
Good, drop it down.
~ OK, is it sore on your toes? ~ No.
'But before he can be scanned, consultant paediatrician Abi Hoyle 'must carry out a primary survey to identify his visible injuries.
' ~ Is it sore down here? ~ No.
~ OK.
Is that bit sore there? I'm just going to look in those ears.
Right ear normal, tympanic membrane normal.
Left ear, blood visible.
When I looked in his left ear, there was nothing to see there but blood.
I couldn't see beyond the blood.
Which is obviously quite significant.
Is there bleeding in his brain? 'Is there some sort of fracture around that injury?' We're going to take a little ride round the corner, not too far.
And we're going to do a special scan.
I'm concerned about head injuries.
A rapidly expanding brain injury, bleeding in or around the brain, could lead to urgent surgical intervention.
For the last 60 minutes, front-line clinicians have fought to stop three critically ill patients from losing their lives.
Janina, Blake and Tony have all been rushed to specialist hospitals to receive urgent treatment.
Now trauma doctors, neurologists and vascular surgeons must try to repair the damage and use cutting-edge procedures to keep them alive.
On "move" - ready, steady, move.
In Leeds, 61-year-old Tony has been diagnosed with a ruptured aorta.
For vascular surgeon Shankar, it is now a race against time to stop him from bleeding to death.
At this point, Tony is bleeding from his major blood vessel in the tummy.
It's dropping his blood pressure, reducing the blood flow to heart, kidneys, lungs and brain.
Once you've lost a couple of litres of blood, you're in real trouble.
Beyond that, if the bleeding doesn't stop, you have a short period of time to live.
The priority now is to stop the bleeding.
And the best way is to put a clamp across this aorta as it enters the abdomen, so that we can proceed to fix the ruptured part of the aorta.
'With so little blood left in his body, 'Tony has only minutes to live.
' Shankar needs to cut open Tony's abdomen to place the clamp on his aorta as soon as possible.
'With blood supply now maintained to Tony's vital organs 'above the clamp, Shankar can begin to repair his ruptured aorta.
' What we do here is replace this ruptured part of the abdominal aorta with a tube which is made out of a specialised fabric material.
We suture it with plastics.
And then, in fact, it is advanced plumbing, in simple terms.
Can we get some rifampicin and soak it in? Please, quickly? I don't have a long time on this, because if they leave the clamp longer than say, half an hour to an hour, then interruption of blood flow to the bowel and to the limbs will be significant.
The aortic clamp is starving Tony's lower abdomen and legs of an oxygen supply.
And if it's left on too long, his lower body will start to die.
It's going to take some time.
I'll get on with this.
These are all risky procedures.
Complications can happen after a surgery of this nature.
Including heart attack, stroke, kidney failure.
We still have to hope for the best and to keep our fingers crossed whether the patient survives this.
So, guys - plan.
Laparotomy, pelvic pack, repair diaphragm, thoracotomy, OK? We've got to move fairly quickly, OK? After being crushed by a lorry, student Janina has been rushed to emergency theatre, where surgeon Martin will try to stop the catastrophic haemorrhage in her pelvis.
~ Can I start? ~ Yes, you can start.
~ Thank you.
I can hear a clock ticking in my head, ticking down.
I've got to get this thing done.
If you're going to save her life, what you're going to need to do is an operation that addresses her life-threatening issues now.
Nothing else matters.
If you spend too long, you've lost your window of opportunity and the patient will die.
I'm just going to get into her pelvis.
It's a real, real mess here.
Medium soft, please - do not unfold them.
Do not unfold them.
'Martin packs sterile gauzes between the bones 'and the organs to compress the blood vessels and stem the bleeding.
'Only then can blood flow be restored to her lower body.
' Packing the pelvis, guys.
Big swab, please, in my hand.
Big swab, please.
Heike, how are we? We're just keeping stable and pushing fluids.
Any surgery is a trauma to the body.
And what we do in anaesthesia is often trying to minimise the effect it has.
'Consultant anaesthetist Dr Heike Bojahr must keep a constant vigil, 'monitoring Janina's vital signs and reacting to any changes.
' Can we just crank the heat up, please? 'One of Heike's biggest concerns is Janina's body temperature.
' Janina was very cold when she arrived in theatre.
There is a vicious circle - the more blood you lose, the colder you'll get, and coldness affects the blood's ability to clot.
So one also causes the other.
If somebody is bleeding anyway, on top of having a problem of clotting as well, it can be devastating.
It's a common phenomenon in major haemorrhage in trauma, called a "trial of death".
You get into a horrible spiral to where you're cold and you're bleeding, and everything just falls apart.
Can we have a second warmer? We need to cover up Let's have fluids, let's push the fluids.
We use warming blankets, we use fluid warmers.
Just increasing the ambient temperature in theatre.
Really, really trying to prevent this heat loss.
Go on, good man.
Well done.
The diaphragm is gone here, isn't it? 'With bleeding controlled and her body temperature monitored, 'Martin now begins to repair Janina's diaphragm.
' So we are about 40 minutes in.
OK, fine - we're halfway through, potentially.
OK, fine.
ALARM TONE ~ We're dropping here.
~ Heart's still going.
We're not on the heart.
We're really struggling here.
'Suddenly, Janina begins to rapidly deteriorate.
' 'Her blood pressure was dropping quite dramatically.
' We could see that her heart was starting to tire.
The heart's very full.
It's very full and it's not moving.
And it's stopped.
I'm going to have to conduct CPR.
Janina has gone into cardiac arrest for a second time.
Stop, stop, stop - adrenaline, please.
Martin begins cardiac massage in an attempt to restart Janina's heart.
'When you're operating on somebody for trauma and the heart just stops,' you think to yourself, "What's going on?" But then the training kicks in.
There is a feeling of despair in the theatre when an arrest happens.
Give me a chance here, guys.
'It's a bit of a reality check, really.
' Just showing what we're dealing with.
~ One minute left.
~ OK, they're conducting CPR.
Hand in.
I'm not really able to press it.
She's trying a bit.
~ Why do you think Why has that happened? ~ She's just a bit tired.
~ She's just had to work really hard for the past hour.
~ OK.
Had a clamp on her aorta for quite a long time.
'The woman is a young, fit girl who, an hour ago, was cycling her bike' across London.
Her heart's taken a terrible beating.
And even though she's young and fit, she's probably run two marathons already that day.
She's lost a lot.
She's trying quite hard though.
ALARM TONE What you got now? Is she back? ~ Her heart's going.
~ OK.
Yeah, it's fine, actually.
She's holding, she's holding.
OK, so she's back.
All right, fine - let's hold a second.
When her heart started beating again, of course there is a big relief, and a big sigh.
But then all your efforts are towards preventing the same thing happening again.
What I'm going to do is finish repairing her diaphragm, inspect her abdomen, pack her out, wash out her chest, close it, ~ and then we're done for now, yeah? ~ Fine.
I've packed her pelvis, I've stopped the overt haemorrhage.
When the clamp comes off you'll find out whether or not your surgical stitching is good.
Because there'll be more bleeding, or not.
OK, take the clamp away.
Under direct vision.
Out of her chest.
Wash, please.
Are we intact? Are we intact? We're intact, OK, fine.
The clamp came off unremarkably.
There was no obvious bleeding, and no obvious response to her heart function, so I was comfortable to proceed.
Diaphragm, I think, is closed, Heike.
'With her diaphragm repaired and the aortic clamp removed, 'Martin has bought Janina more time 'and given her a greater chance of survival.
' OK, guys, can we talk? OK, I'm out.
Please bear in mind she's still very unwell, we haven't cleared any injuries yet, we can't relax now.
We've got to keep moving and get her warm, OK? 'Once the surgery has been completed, 'what we're going to do now is take stock and regain ground, 'normalise her situation, get her heart beating more regularly.
' And then at that point in time, make our next step.
The team now try to stabilise Janina, continuing to warm her, give blood and administer drugs while monitoring her closely.
You're anxious for her future, because you have to sit on your hands for a while.
Because it's over to her.
And what happens next depends on how she responds to the treatment she received.
'In Leeds, Blake is undergoing a full body and head CT scan, 'to check for any internal injuries.
' This is Blake that we spoke about.
He's 11 years old.
Low-speed road traffic accident.
He's got a right-sided tib-fib, and an occipital head injury with blood also coming out of his left auditory meatus.
Members of the trauma team stand and try and look, but we can't see anything that quickly.
You have to have a radiologist, a specialist, who looks at the scan to see if there's any sign of blood, any sign of injury that we haven't seen.
How you getting on, Blake? 'A major bleed in Blake's brain has been ruled out.
'But Jonathan must wait to discover the exact damage to his skull 'and the cause of his temporary blindness as his scan is 'closely examined by neurosurgeons.
' Once we've seen the CT scans I'm reassured that Blake hasn't got any imminently life-threatening injuries.
Do you want to sit up now, Blake? 'The CT scan also confirms no damage to Blake's neck or spine, 'allowing Jonathan to remove his collar and blocks.
' Right then, Blake, big, deep breath for me.
Big, deep breath.
Ow! Ow! 'Blake's leg is placed in a cast for protection 'until he can have surgery to realign his broken bone.
' We're always concerned with more significant injuries in childhood as children have their whole lives to live, and this can lead to significant loss of function through later life.
Ow! You're doing really well.
'Blake's brain scans have been analysed, 'revealing vital information about his head injury.
' Thank you so much for that.
Good luck, bye-bye.
Blake has a basal skull fracture - a broken bone that runs along the base of the brain.
Blake must have suffered a significant head injury to do this.
It's possible that the force has stunned the back part of his brain - the sight centre of his brain - and that's led on to this period of loss of vision.
Blake will remain in hospital under careful observation.
Only time will tell how he will recover from his head injury.
The basal skull fracture can be managed with a watchful, waiting approach.
But it might lead to pranging of the nerves that supply the sight, the smell, the taste or the hearing.
Bruising and swelling to the childhood brain It's often very difficult to predict what the final outcome will be.
Right, let's have a pack for me, please.
'It's been over an hour 'since Tony arrived at Leeds General Infirmary, where surgeon Shankar 'is trying to repair his ruptured aorta with specialised tubing.
' It looks a bit dry.
That's good news.
'Once you have fixed the damaged aorta we can release the clamp 'and re-establish the blood flow to the legs.
' 'But Shankar knows this operation is fraught with danger.
'The longer Tony's lower body is deprived of blood, 'the higher the chance of major complications.
' ~ Ready? ~ I'm ready.
~ I have it ready to open.
~ Open then.
~ Yeah.
~ Good.
The important thing to see is whether there is a pulse in the groin, or going to that leg, and the colour of the foot.
Is there a pulse? ~ 95, 94.
~ Yeah.
'A pulse confirms blood flow has been restored to Tony's left leg.
' One leg down.
'Shankar must now check for the same in Tony's right leg.
' Quick look at the leg for a second.
It looks a bit more pink than this one.
Isn't it? On the right side, I couldn't feel a pulse, and the foot also looked a bit pale and white.
This confirmed to me that the blood vessel is blocked.
~ Right side, we may have to do something.
~ OK.
Revascularise.
'Unable to find a pulse in Tony's right leg, Shankar suspects 'there's a blood clot in the artery.
' There's no way of saying when this artery might have blocked.
It could have happened at the time of rupture, er 'or while we were trying to fix this aneurysm.
' Knife here, please.
Thanks.
'There's no time to waste here.
'If you don't service the blood flow quickly, 'then Tony could lose his leg.
' Removing the clot, physically, is the only option left in this case.
Can I have a Fogarty, please? 'I opened the artery on the right side and I passed a 'specialised Fogarty catheter into the artery.
' And there is a balloon at the end of it, you inflate the balloon.
And then as you take it out, this balloon collects all the clot - 'this is called embolectomy.
' Very good, just relax a bit.
'As he removes the balloon, blood suddenly flows again.
' Good.
'With the clot removed, Shankar must check to see if blood 'is now flowing to Tony's leg.
' Yeah, there's a pulse.
It wasn't there before.
Good.
'With emergency surgery complete '.
.
Tony will be transferred to intensive care.
'But the strain on his body has been severe.
' 'Tony is not safe.
' We have seen patients who are doing really well by the time we've finished the surgery, still develop heart and lung and kidney diseases, leading to a poor outcome.
So, they are never out of danger, even after surgery.
In London, 26-year-old Janina is being monitored after extensive surgery at the roadside and in theatre to stop catastrophic internal bleeding.
Her heart has been restarted twice, and she's still too unwell to have her injuries fully assessed with a CT scan.
After surgery was finished, my main concern was her lung function, because I could see that the oxygen levels in her blood had dropped.
'And despite all the measures that I took to improve them,' nothing had a lasting effect.
'Janina's brain may already have suffered damage from her 'two cardiac arrests.
'A further lack of oxygen could make things even worse.
' OK, fine If she can't move, she can't move.
'I was really conflicted at that moment,' because on the one hand, I realised she needs the scan, but on the other hand I felt this is something that might tip her over the edge.
Her life was really balanced on a knife's edge at that moment.
'As well as her low oxygen levels, Heike is worried Janina 'may still be bleeding internally.
' If I open her pelvis Open her belly again, I'll probably kill her doing it.
I can't If I open her belly now, after the vein's packed out to get to Get to her arteries And she would probably not do.
HEIKE SIGHS 'Martin knows that at this point, 'Janina would not survive more surgery.
' It was clear to me that there was no bleeding in her abdomen or her chest.
But she wasn't stable enough, she wasn't well enough to tolerate even being moved around, let alone having further investigations done.
There's a severe amount of head scratching going on at that point in time, because we're facing something as experienced traumatologists we see all the time, but in a situation She's not responding in the way we expected her to behave, and that's unsettling.
You're constantly aware that this is a beautiful young woman with a life, with a family, and .
.
it's heartbreaking.
'Too fragile either for more surgery or to be moved to CT, 'Janina continues to deteriorate.
'A specialist ventilator is brought to theatre in the hope it 'might improve her breathing.
' I think it makes me acutely aware that we do not have all the answers here.
We can do an amazing amount of resuscitation, but there's only a certain amount that is in my power.
Nature has to take its course, and either her lung improves, or it doesn't.
And we have to accept that.
My baby sister had just been born the day before.
So I had been excited and then I went to go run and tell my mates and I ran straight into the road.
When I think about what happened that day - how quickly things can change within a few seconds - it scares me to let him go out now.
It will take about 12 months for his bone to be fully healed, cos he's still walking with a bit of a limp.
He's lost a bit of hearing in his left ear - I think they said 40%.
It is a possibility that his hearing damage is permanent.
No, it was a knock-on.
'Road traffic accidents are the leading cause of childhood injury 'and long-term damage.
' I think Blake is a very lucky young man.
His injuries could have been so much worse.
SHE SNIFFLES Good shot.
No warning - I was just carrying on with normal day-to-day life, just getting ready to go to work.
Four month on now, I'm just trying to recover and get my life back together.
For a 61-year-old with no previous history to present with a ruptured aneurysm was quite unusual.
For Tony, the timing was absolutely critical.
If he'd reached hospital maybe 15, 20 minutes later, I'm not so sure he would have survived.
I think I were probably minutes away from death.
We see so many cyclists.
We see so many cyclists! It feels so futile, it feels so unnecessary.
You're doing the right thing for yourself, you're doing the right thing for the environment but then this happens.
It makes me feel so helpless.
I was very hopeful that she would survive and that she would recover.
So it was quite difficult then to accept that that didn't happen.
But we did get her heart pumping, we got her to hospital alive, and her family were able to come and see her and be with her at the end.
THEY SPEAK IN GERMAN HE SPEAKS IN GERMAN SHE SPEAKS IN GERMAN ~ SIREN WAILS ~ Next time we meet the doctors and midwives making critical decisions in the first minutes of life She's nasal flaring.
.
.
as they battle to save three babies who are struggling to survive birth.
BABY CRIES She's got worse over the last five to ten minutes.
' MAN SLURS 'Hello?' 'Quick!' 'Why do you need the ambulance?' 'I'm dying.
' From the moment an emergency call is made, a clock starts ticking.
SIRENS WAIL 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, come on! There's no blood pressure.
Come on.
This series will count down 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.
ALARM SOUNDS 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.
SIRENS WAIL We are always trying to push the limits of what's possible.
Let's go! From open-heart surgery in the street All right, no pulse.
Carry on, we're doing a thoracotomy.
We're going to open the chest, we're going to fill it up with blood.
.
.
to the intubation of newborn babies.
Many more babies are surviving conditions nowadays that five or ten years ago would've been impossible to imagine.
We can give some surfactant to try and minimise lung trauma.
These are the medics using cutting-edge science to save time We're really struggling here.
.
.
and to save lives.
~ BABY CRIES ~ 'You can't give up.
' There's always a chance this patient might survive.
Never give up.
In Britain, an emergency call is made every three seconds.
For the most seriously injured, survival will depend not just on how quickly treatment begins, but who gives it.
Today, highly-trained doctors and paramedics can perform surgery at the roadside and in dedicated hospitals, teams of specialists are ready to intervene the moment a patient arrives.
This film follows these medical pioneers battling to save three people caught between life and death.
In London, cyclist Janina goes into cardiac arrest after colliding with a lorry.
OK, heart is pretty empty still, so keep filling with the blood.
Can we squeeze that blood in? In Yorkshire, doctors have just minutes to stop Tony bleeding to death.
We need to rush you to theatre and if we don't do anything, it is a risk to your life.
And on a suburban street, 11-year-old Blake is showing signs of a brain injury after being hit by a car.
BLAKE SCREAMS ~ What can you see? ~ Nothing.
PHONE RINGING 'Thank you, caller, go ahead.
Tell me exactly what's happened.
' 'A lorry has run over a cyclist.
' In Central London, an emergency call is received about a seriously injured young woman.
'Is she awake?' 'Yes, she's moving, but in desperate need of help.
' Base, minute one - we're mobile.
ETA six minutes, over.
RADIO: 'Mobile, six minutes, all received, thank you.
SIRENS WAIL London's Air Ambulance clinicians Dr Simon Walsh and paramedic Tony Montebello are dispatched by car to the nearby scene, where 26-year-old Janina has collided with a lorry.
Continue straight 500 metres to the major junction 'When you hear that a cyclist has gone under a HGV,' they may not still be alive by the time we get to the scene.
'But if they are, they're likely to have' crush injuries to the chest, abdomen or pelvis and their life is likely to be in danger.
200 metres.
'We need to be there within a few minutes 'to have a chance of saving someone's life.
' OK.
Excuse me, mate, can you just grab this bag for us? Can one of you grab that bag? Cheers.
'Police, fire crew and London ambulance paramedics 'have cordoned off the scene after pulling Janina from the road 'and are performing CPR.
' 'When you see chest compressions in progress, 'it's obvious that you haven't got any time to play with.
' 'Just minutes ago, Janina went into cardiac arrest 'and is no longer breathing.
' Hey, guys.
With that wheel? OK.
Er 'Within a few seconds it's apparent that this patient has been 'crushed by the wheels of the vehicle to the point where she'd had' catastrophic haemorrhage, very quickly leading to cardiac arrest.
Yeah, we've got fluid and stuff going on down here.
'Massive internal bleeding has drained Janina's heart of blood, 'causing it to stop beating.
' ~ I don't know what all this is but ~ OK.
~ Came out of her mouth.
~ OK.
'Effectively, the heart had nothing left to pump around to her brain' and other organs.
'Unless we can do something to reverse that process rapidly,' then that is the end of life.
We're going to intubate.
Have we got some access? 'Once Janina's in cardiac arrest,' she isn't making any effort to breathe herself 'and so we have to get oxygen into her lungs.
' And the best and most effective way to do that is to put a tube down into the windpipe and ventilate her with a bag.
~ Tony? ~ Yes.
~ Are you happy to intubate? ~ Yes.
~ Thank you.
Can you just pass the tube over the bougie for me? OK, I've got the tube.
Hold the bougie.
Squeeze the bag.
~ That's fine, that's fine.
~ Carry on.
OK, secure the tube.
The next priority is blood, please.
'Now they have taken over Janina's breathing, 'Simon wants to refill her heart with blood 'in the hope it will begin pumping again.
'London's Air Ambulance is one of a select few services in the UK 'to carry blood to a trauma scene.
' Let's start running some blood in there.
We've got access.
Left arm, yeah.
'While Janina has no blood circulating, 'her vital organs are being starved of oxygen.
' The brain will only survive for a few minutes without good circulation 'so we have to get the blood transfusion into the patient 'within those few minutes.
All the time she's in cardiac arrest,' the clock's ticking and her brain is dying.
Right, just stop and check for any output for a second.
Is there any pulse? ~ We haven't got anything at all, Simon.
~ OK, carry on.
'Despite her blood transfusion and continuous CPR, 'Janina's heart is still not beating.
' 'Your hope when you perform these interventions is that' any one of them will reverse the cardiac arrest.
'If there had been a return of the pulse, then we've got 'a whole load of other options available to us.
' In the absence of that, we were still in a very desperate situation.
OK.
OK.
OK.
In Britain, road traffic accidents are the leading cause of major trauma, and those involving children can be a challenge for the emergency services.
14 minutes ago in Yorkshire, ambulance control received a 999 call about a child hit by a car.
WOMAN: 'Ambulance service.
' BOY CRIES IN BACKGROUND WOMAN: 'A little boy's just run out in front of my car.
' BOY SCREAMS 'Right, where's your pain? Ask him where his pain is.
~ 'His leg.
' ~ 'His leg.
'We're coming as quickly as we can.
' Yorkshire Air Ambulance paramedics Darrell Cullen and Pete Valance are dispatched to the scene.
Any child trauma is quite difficult, because the smaller you are, the more vulnerable you're going to be, even at a slow-speed impact, you could sustain life-threatening injuries.
BOY SCREAMS Hearing his cries from their home nearby, 11-year-old Blake's mother and grandparents have rushed to his side.
When we got to Blake he was in a lot of pain, he was really agitated.
BLAKE SCREAMS First response paramedics immediately update Darrell on Blake's condition.
Yep.
~ He can't see anything? ~ No.
~ Oh, right, OK.
Blake appears to have a broken leg but Darrell is more worried about his sight loss.
'He didn't have any vision at all, he was in complete darkness.
' That was telling me straightaway that he'd got a potentially got a brain injury.
Does he look to have any visible injuries to his head? Although Blake's leg is causing him extreme pain, Darrell's immediate priority is to protect his brain.
~ Blake, we're just going to put this mask over your face.
~ OK.
~ All right.
Brain cells need a continuous supply of oxygen to survive and if it's taken a blow to the head then it means the oxygen has been disrupted so we need to supplement the brain to re-establish a normal level of oxygen.
A nice and steady lift.
To reduce distress and provide pain relief, Darrell gives Blake intravenous morphine.
~ Just here, yeah? Don't move.
~ It's to stop your leg hurting, all right? My arm hurts! 'We were all scratching our heads on the scene, 'it was something that we'd not seen before.
' ~ Can you see that? ~ What? ~ You can't see anything? 'With Blake's blindness showing no sign of improvement, 'Darrell fears he could deteriorate quickly.
' 'Time is critical in head injury cases,' there can be underlying bleeds, there can be swelling and whilst all these are ongoing, it could cost the person their life.
Back in Central London, German student Janina is in a critical condition.
After an accident with a HGV, she's suffered huge internal blood loss, causing her heart to stop.
Can you grab that red bag? Bring it over here So far, Simon and the team have ventilated Janina and given a blood transfusion, but her heart has failed to restart.
If you can just The main pouch, I think.
'I felt 'that there was a young person' who was dying in front of me and I wanted to do everything that I could, even if there was a tiniest chance to reverse the process.
Check the blood afterwards and get that going.
~ Cut at the top, Jane.
~ OK, I think Right, the question is whether we just open the chest now cos we're short of time.
There was one other intervention we could try which was something called a thoracotomy.
We can't do that as she's not got a pulse so let's just open the chest.
~ OK.
~ OK.
We're going to open the chest, we're going to fill it up with blood, see if we can get aortic compression.
After just five minutes on scene, Simon decides he has no option but to cut open Janina's chest and gain direct access to her heart to pump it manually.
Just check before we Definitely don't have a pulse.
Right, no pulse.
Right, carry on.
We're doing a thoracotomy.
OK.
'Probably five years ago we would've just stopped 'and pronounced her life extinct at that point.
' It's major open-chest surgery in the street.
You don't do that if there's anything else you could possibly do to reverse the situation.
Lovely.
Right 'The aim of a thoracotomy in this situation 'is to get the heart pumping again.
' We perform open internal cardiac massage and try and stop the blood loss by pressing on the main blood vessel, the aorta.
OK, the curved mayos and the mosquito forceps, please.
Thank you.
Curved mayo scissors.
OK, heart is pretty empty still, so keep filling with the blood.
Can we squeeze that blood in? Until the aorta is compressed, any blood being given to Janina is bleeding out through her damaged pelvis.
I'm going to get you to do aortic compression afterwards, OK? ~ If you can get your hand in behind here.
~ Yeah.
Onto the front of the spine, fingers down that way, ~ to press down onto the spine.
~ OK.
Feel the soft structure in front, then just compress the aorta.
~ OK? ~ Yeah.
Simon asks emergency technician Adrian Lee to squeeze Janina's aorta with his hand, stopping the blood from flowing out from her lower body and allowing her heart to be refilled.
'Suddenly, I've got my hand inside her chest 'and then finding her aorta and just putting my hand on there' and then he said, "Do not let go whatever you do.
" And then suddenly I realised this was unbelievable.
Keep filling, please.
I just want to get some massage going here, see if we can get any output at all.
Simon simulates the heart's natural pumping rhythm, restoring blood supply into the coronary arteries.
~ OK, how much blood's in? ~ One unit.
~ First bag nearly gone.
If we get an output back, we're going to need to load and go to the Royal London very quickly.
~ Have we got an ambulance that's accessible? ~ Ours is up there.
~ OK.
I've got some activity now.
Hang on a second.
It's slow.
Rhythm But we can see any pulse with that.
At first there were just a few little flickers of attempted movement.
I knew that if I could get enough blood round through the heart muscle that ineffective movement might develop into effective, normal pumping of the heart again.
It's started to look a bit better.
So we're getting some activity back.
I'm hoping that with a bit of filling, we're going to be able to load her and move her.
So have we've got a trolley and a scoot ready to go? That's looking a bit more forceful now.
Have we got a pulse? Sharps again, sharps away.
I was surprised and absolutely elated, really, to see that her heart actually started beating for itself.
Yeah, so when we get her onto the scoot 'It was the first point where I thought, ' "Actually, there's some hope here and if we can sustain that' "and support it, then we could actually get her to hospital alive.
" Keep filling with blood and go.
'With her heart now beating again, Janina has a chance of survival.
' That's looking much better now, better rate.
OK, we've got good vitals now.
~ So we've got a pulse.
~ Good work, Simon.
Good work.
Hi, it's Simon, London Hems, just giving you a code red priority call.
Adult female, code red, I'll phone back with the details.
We've done a thoracotomy.
We're going to be there quite soon - in about ten minutes.
OK, bye.
OK, we want to get her in the scoot and in the ambulance in two minutes, please, guys.
Simon has a small window of time to get her to hospital.
Janina's heart may have suffered muscle damage from lack of oxygen and could arrest again en route.
Ready? Ready? One, two, three, lift.
Nine minutes.
Can you grab a set of the code red check list? At the nearest major trauma centre, a team of at least 15 specialists are gathering, led by emergency department consultant, Dr Samy Sadek.
Everybody nice and quiet, just for a second.
So, we have the resus nurse and ED consultant are here.
~ Level one, is it set up and ready to go? ~ Ready to go, yeah.
~ Fantastic.
~ Theatres know? ~ Theatres know, yep.
~ Great.
'Blood cells and plasma are being prepared for Janina's transfusion.
' So the term "code red" refers to a patient that the team think is bleeding to death.
That person at that particular time is probably the most severely injured patient in the whole of London.
So you're in charge of the blood.
Has FFP been requested? Yes So, let's get going.
Everyone happy? OK.
Right.
Let's go.
SIRENS WAIL OK, guys, right, this is as good as we'll get it.
'The things that I don't know are the extent of her pelvic injury, 'the extent of her abdominal injury and what effect the period' of cardiac arrest has had on her brain and her other vital organs.
The only thing preventing Janina from bleeding to death is Adrian's hand pressed firmly on her aorta.
I knew her life depended on it.
And so I wasn't letting go for anything.
200 miles north, the Leeds General Infirmary treats critically ill patients from across Yorkshire.
A specialist vascular centre, its staff are experts in diseases of the blood vessels.
PHONE RINGING 29 minutes ago, the team in resus were alerted to receive a 61-year-old man, who suddenly collapsed with severe back pain while getting ready for work.
Everybody ready? On slide.
Ready, steady, slide.
With signs he may be bleeding internally, Tony has been fast-tracked to the Leeds General Infirmary to receive expert vascular care.
Within seconds, A & E consultant Dr John Jones conducts a primary survey.
When Tony arrived I was immediately struck by how ill he looked.
Tony's pulse was weak and difficult to feel, which meant that his blood pressure was very, very low and then the body isn't getting enough blood to a variety of critical organs and if that process was allowed to continue, he would either die or suffer the effects of multiple organ failure.
~ Tony, can you hear me? ~ Yeah.
~ Is the pain still really bad? ~ Yeah.
Whereabouts? Quite low down.
OK.
His abdomen and his lower legs were mottled which is a fairly classic sign blood flow simply isn't getting to the extremities.
I'm just going to be doing a scan of your belly, we're also getting a drip into your arm on that side as well, OK? John decides to use ultrasound to see if he can find the source of Tony's bleeding.
An abdominal aortic aneurysm - or triple A - is when the aorta, which is the main blood vessel running through the body, has started to balloon outwards.
In Tony's case, the aneurysm had ruptured and was bleeding copiously into his abdominal cavity, which meant there wasn't enough blood circulating in his body to keep him alive.
My worry here is that there's a problem with the blood vessel in your stomach here, so we're going to be moving pretty fast and trying to get things sorted out.
Only a gentle feel there.
~ Is that sore, there? ~ Yeah.
~ OK, well, I'll stop doing that, then.
A large triple A is extremely dangerous.
If it ruptures, you've got pretty much a 50/50 chance of surviving the immediate event and making it to hospital.
Even if you do make it to hospital, there's a very significant chance that you won't survive the surgery to repair it.
Right, so we've spoken to vascular and they're coming, yes? We just need blood for transfusion.
At that point Tony was going into shock, his body was beginning to shut down.
We really had to act fast and by fast, I mean in minutes.
~ Ah, Shankar, hi.
~ Hi.
~ That's the picture.
There's a flap moving around in it.
John calls for vascular surgeon Kiruba Shankar.
~ 95 was the last one we had but I can't feel good pulses.
~ OK.
We need to rush you to theatre.
Do you understand this? And if we don't do anything, it is a risk to your life.
We really didn't have any time to do any tests or especially a CT scan.
I felt that immediate surgery was the only way that we could stop the bleeding and potentially save Tony's life.
~ Good stuff.
~ We're going to move you to the theatre now.
Just 12 minutes after Tony's arrival, he's taken to theatre for surgery that could save his life.
'I didn't want to wait for a porter, I just wanted to get him upstairs' to the operating theatre because an operation was the only thing that was going to keep him alive.
Blake, open your eyes.
In Yorkshire, paramedic Darrell is still anxious to discover why Blake has lost his sight after being knocked down by a car.
~ So, minimal damage to the vehicle.
~ Perhaps he's hit it on the kerb edge.
Blake landed quite near to the kerb edge so, potentially, he'd hit his head or the back of his head on the kerb and that caused the sight loss cos the area that controls sight is to the back of the head.
With fears Blake may have a significant head injury, trauma doctor Andy Pountney has rushed to the scene.
'Children do behave differently' so they may not necessarily have the same changes in their pulse rate and blood pressure and so on which you would see in an adult and because of that, the extent of the injury can be masked until quite late on when the body just gives up compensating and then things deteriorate very rapidly.
Yeah, Andy, just here.
~ Just going to give Leeds a quick call just to check in.
~ Sure.
Hi, there.
Yeah, it's the Yorkshire Air Ambulance.
Erm, we've been called to an 11-year-old boy We needed to get him to a neuro centre as quickly and as timely as possible.
And that was Leeds General Infirmary.
If he did have an underlying brain injury, then that's the place he needed to be.
He's just had a head injury and he's lost complete vision.
Ready, steady, lift.
But before Blake can be flown to hospital, Andy must be confident he's stable enough to survive the journey.
Blake, how you doing? ~ Have you got any pain anywhere? ~ In my right leg.
~ In your right leg.
Can you open your eyes for me? ~ Yeah.
~ Brilliant.
~ What can you see? ~ You.
~ You can see me.
Not a pretty sight, is it(?) 'When I asked him what he could see, he said he could see me.
' ~ Good.
How many fingers am I holding up? ~ Two.
~ Two.
That's brilliant.
He was able to count how many fingers I was holding up in front of him so that was quite reassuring.
OK, so I'm going to leave you with my friend here, Pete 'But it didn't mean there wasn't anything significant going on,' there was still the potential that he had a serious brain injury.
Darrell knows the only way to understand the severity of Blake's injuries is to get him to hospital for a CT scan.
Primary aim is to make sure that the aorta is compressed and we're controlling haemorrhage.
Second to that is to go to theatre.
Simple as that.
Cyclist Janina is arriving at the Royal London where Simon will hand over to trauma team leader Samy.
'We were told that she'd already had her chest opened on the scene 'which meant she was as sick' as you can possibly get.
A thoracotomy at the roadside has restarted Janina's heart and blood flow to her upper body is being maintained by a hand pressed on her aorta.
'I just want to know that the work that they have done 'to keep this girl alive' doesn't go wrong and she gets what she needs as quickly as possible.
OK, guys, our patient is here, so everybody completely quiet.
The only person speaking will be me or Martin and the person doing a primary survey, if needs be.
OK? Thank you.
So, guys, everybody completely over to the left.
Thank you.
She was witnessed going under the rear wheels of the HGV, proceeded to do a thoracotomy, aortic compression and she regained a cardiac output after approximately eight to ten minutes.
Mm-hm.
Consultant trauma surgeon Martin Griffiths is in charge of tackling the most immediate threat to Janina's survival - her blood loss.
A cyclist versus a HGV is pretty much a worst-case scenario.
'I could see that she had a great big hole in her diaphragm, 'a hand on her aorta,' so my initial movement was to get that hand off and put a clamp into the aorta to allow that pressure to be maintained without need for a person being there.
Lovely.
So, immediate pelvic X-ray.
Pelvic X-ray, bay seven, in five, four, three, two, one.
~ Martin, as expected, she's got a bad pelvis.
~ Yeah, we need to make a move.
Yep.
All right.
'Her pelvic X-ray looked awful.
The pelvis is a very, very strong bone' and the force taken to shatter it like that is huge, so that in itself has a devastating effect.
The pelvis is sitting close to very big blood vessels, veins and arteries.
When you disrupt your pelvic ring, your pelvic fracture, then you bleed out torrentially from that area.
So, guys, our priority now is to go to theatre so anybody who's not doing that, step out.
OK, everybody out the way, we're going to move now.
Janina needs emergency surgery to stem the bleeding in her pelvis before Martin can remove the clamp on her aorta and restore blood flow to the whole of her body.
Good, just everything calm and coordinated and whatever we do, don't displace the clamp.
'We're very, very mindful that we have not fixed the problem.
' This was all about damage control and doing the least necessary to just keep this girl alive.
At Leeds General Infirmary, A & E consultant Jonathan Thornley assembles a specialist paediatric trauma team to receive 11-year-old Blake, who is accompanied by his grandmother.
I understand he has a head injury.
And a lower limb injury and there's a lot of Blake in between the two.
I'm always questioning what's going on in between.
Although Blake's vision has now returned, doctors fear underlying brain damage.
Nice and steady, nice and steady.
Good, drop it down.
~ OK, is it sore on your toes? ~ No.
'But before he can be scanned, consultant paediatrician Abi Hoyle 'must carry out a primary survey to identify his visible injuries.
' ~ Is it sore down here? ~ No.
~ OK.
Is that bit sore there? I'm just going to look in those ears.
Right ear normal, tympanic membrane normal.
Left ear, blood visible.
When I looked in his left ear, there was nothing to see there but blood.
I couldn't see beyond the blood.
Which is obviously quite significant.
Is there bleeding in his brain? 'Is there some sort of fracture around that injury?' We're going to take a little ride round the corner, not too far.
And we're going to do a special scan.
I'm concerned about head injuries.
A rapidly expanding brain injury, bleeding in or around the brain, could lead to urgent surgical intervention.
For the last 60 minutes, front-line clinicians have fought to stop three critically ill patients from losing their lives.
Janina, Blake and Tony have all been rushed to specialist hospitals to receive urgent treatment.
Now trauma doctors, neurologists and vascular surgeons must try to repair the damage and use cutting-edge procedures to keep them alive.
On "move" - ready, steady, move.
In Leeds, 61-year-old Tony has been diagnosed with a ruptured aorta.
For vascular surgeon Shankar, it is now a race against time to stop him from bleeding to death.
At this point, Tony is bleeding from his major blood vessel in the tummy.
It's dropping his blood pressure, reducing the blood flow to heart, kidneys, lungs and brain.
Once you've lost a couple of litres of blood, you're in real trouble.
Beyond that, if the bleeding doesn't stop, you have a short period of time to live.
The priority now is to stop the bleeding.
And the best way is to put a clamp across this aorta as it enters the abdomen, so that we can proceed to fix the ruptured part of the aorta.
'With so little blood left in his body, 'Tony has only minutes to live.
' Shankar needs to cut open Tony's abdomen to place the clamp on his aorta as soon as possible.
'With blood supply now maintained to Tony's vital organs 'above the clamp, Shankar can begin to repair his ruptured aorta.
' What we do here is replace this ruptured part of the abdominal aorta with a tube which is made out of a specialised fabric material.
We suture it with plastics.
And then, in fact, it is advanced plumbing, in simple terms.
Can we get some rifampicin and soak it in? Please, quickly? I don't have a long time on this, because if they leave the clamp longer than say, half an hour to an hour, then interruption of blood flow to the bowel and to the limbs will be significant.
The aortic clamp is starving Tony's lower abdomen and legs of an oxygen supply.
And if it's left on too long, his lower body will start to die.
It's going to take some time.
I'll get on with this.
These are all risky procedures.
Complications can happen after a surgery of this nature.
Including heart attack, stroke, kidney failure.
We still have to hope for the best and to keep our fingers crossed whether the patient survives this.
So, guys - plan.
Laparotomy, pelvic pack, repair diaphragm, thoracotomy, OK? We've got to move fairly quickly, OK? After being crushed by a lorry, student Janina has been rushed to emergency theatre, where surgeon Martin will try to stop the catastrophic haemorrhage in her pelvis.
~ Can I start? ~ Yes, you can start.
~ Thank you.
I can hear a clock ticking in my head, ticking down.
I've got to get this thing done.
If you're going to save her life, what you're going to need to do is an operation that addresses her life-threatening issues now.
Nothing else matters.
If you spend too long, you've lost your window of opportunity and the patient will die.
I'm just going to get into her pelvis.
It's a real, real mess here.
Medium soft, please - do not unfold them.
Do not unfold them.
'Martin packs sterile gauzes between the bones 'and the organs to compress the blood vessels and stem the bleeding.
'Only then can blood flow be restored to her lower body.
' Packing the pelvis, guys.
Big swab, please, in my hand.
Big swab, please.
Heike, how are we? We're just keeping stable and pushing fluids.
Any surgery is a trauma to the body.
And what we do in anaesthesia is often trying to minimise the effect it has.
'Consultant anaesthetist Dr Heike Bojahr must keep a constant vigil, 'monitoring Janina's vital signs and reacting to any changes.
' Can we just crank the heat up, please? 'One of Heike's biggest concerns is Janina's body temperature.
' Janina was very cold when she arrived in theatre.
There is a vicious circle - the more blood you lose, the colder you'll get, and coldness affects the blood's ability to clot.
So one also causes the other.
If somebody is bleeding anyway, on top of having a problem of clotting as well, it can be devastating.
It's a common phenomenon in major haemorrhage in trauma, called a "trial of death".
You get into a horrible spiral to where you're cold and you're bleeding, and everything just falls apart.
Can we have a second warmer? We need to cover up Let's have fluids, let's push the fluids.
We use warming blankets, we use fluid warmers.
Just increasing the ambient temperature in theatre.
Really, really trying to prevent this heat loss.
Go on, good man.
Well done.
The diaphragm is gone here, isn't it? 'With bleeding controlled and her body temperature monitored, 'Martin now begins to repair Janina's diaphragm.
' So we are about 40 minutes in.
OK, fine - we're halfway through, potentially.
OK, fine.
ALARM TONE ~ We're dropping here.
~ Heart's still going.
We're not on the heart.
We're really struggling here.
'Suddenly, Janina begins to rapidly deteriorate.
' 'Her blood pressure was dropping quite dramatically.
' We could see that her heart was starting to tire.
The heart's very full.
It's very full and it's not moving.
And it's stopped.
I'm going to have to conduct CPR.
Janina has gone into cardiac arrest for a second time.
Stop, stop, stop - adrenaline, please.
Martin begins cardiac massage in an attempt to restart Janina's heart.
'When you're operating on somebody for trauma and the heart just stops,' you think to yourself, "What's going on?" But then the training kicks in.
There is a feeling of despair in the theatre when an arrest happens.
Give me a chance here, guys.
'It's a bit of a reality check, really.
' Just showing what we're dealing with.
~ One minute left.
~ OK, they're conducting CPR.
Hand in.
I'm not really able to press it.
She's trying a bit.
~ Why do you think Why has that happened? ~ She's just a bit tired.
~ She's just had to work really hard for the past hour.
~ OK.
Had a clamp on her aorta for quite a long time.
'The woman is a young, fit girl who, an hour ago, was cycling her bike' across London.
Her heart's taken a terrible beating.
And even though she's young and fit, she's probably run two marathons already that day.
She's lost a lot.
She's trying quite hard though.
ALARM TONE What you got now? Is she back? ~ Her heart's going.
~ OK.
Yeah, it's fine, actually.
She's holding, she's holding.
OK, so she's back.
All right, fine - let's hold a second.
When her heart started beating again, of course there is a big relief, and a big sigh.
But then all your efforts are towards preventing the same thing happening again.
What I'm going to do is finish repairing her diaphragm, inspect her abdomen, pack her out, wash out her chest, close it, ~ and then we're done for now, yeah? ~ Fine.
I've packed her pelvis, I've stopped the overt haemorrhage.
When the clamp comes off you'll find out whether or not your surgical stitching is good.
Because there'll be more bleeding, or not.
OK, take the clamp away.
Under direct vision.
Out of her chest.
Wash, please.
Are we intact? Are we intact? We're intact, OK, fine.
The clamp came off unremarkably.
There was no obvious bleeding, and no obvious response to her heart function, so I was comfortable to proceed.
Diaphragm, I think, is closed, Heike.
'With her diaphragm repaired and the aortic clamp removed, 'Martin has bought Janina more time 'and given her a greater chance of survival.
' OK, guys, can we talk? OK, I'm out.
Please bear in mind she's still very unwell, we haven't cleared any injuries yet, we can't relax now.
We've got to keep moving and get her warm, OK? 'Once the surgery has been completed, 'what we're going to do now is take stock and regain ground, 'normalise her situation, get her heart beating more regularly.
' And then at that point in time, make our next step.
The team now try to stabilise Janina, continuing to warm her, give blood and administer drugs while monitoring her closely.
You're anxious for her future, because you have to sit on your hands for a while.
Because it's over to her.
And what happens next depends on how she responds to the treatment she received.
'In Leeds, Blake is undergoing a full body and head CT scan, 'to check for any internal injuries.
' This is Blake that we spoke about.
He's 11 years old.
Low-speed road traffic accident.
He's got a right-sided tib-fib, and an occipital head injury with blood also coming out of his left auditory meatus.
Members of the trauma team stand and try and look, but we can't see anything that quickly.
You have to have a radiologist, a specialist, who looks at the scan to see if there's any sign of blood, any sign of injury that we haven't seen.
How you getting on, Blake? 'A major bleed in Blake's brain has been ruled out.
'But Jonathan must wait to discover the exact damage to his skull 'and the cause of his temporary blindness as his scan is 'closely examined by neurosurgeons.
' Once we've seen the CT scans I'm reassured that Blake hasn't got any imminently life-threatening injuries.
Do you want to sit up now, Blake? 'The CT scan also confirms no damage to Blake's neck or spine, 'allowing Jonathan to remove his collar and blocks.
' Right then, Blake, big, deep breath for me.
Big, deep breath.
Ow! Ow! 'Blake's leg is placed in a cast for protection 'until he can have surgery to realign his broken bone.
' We're always concerned with more significant injuries in childhood as children have their whole lives to live, and this can lead to significant loss of function through later life.
Ow! You're doing really well.
'Blake's brain scans have been analysed, 'revealing vital information about his head injury.
' Thank you so much for that.
Good luck, bye-bye.
Blake has a basal skull fracture - a broken bone that runs along the base of the brain.
Blake must have suffered a significant head injury to do this.
It's possible that the force has stunned the back part of his brain - the sight centre of his brain - and that's led on to this period of loss of vision.
Blake will remain in hospital under careful observation.
Only time will tell how he will recover from his head injury.
The basal skull fracture can be managed with a watchful, waiting approach.
But it might lead to pranging of the nerves that supply the sight, the smell, the taste or the hearing.
Bruising and swelling to the childhood brain It's often very difficult to predict what the final outcome will be.
Right, let's have a pack for me, please.
'It's been over an hour 'since Tony arrived at Leeds General Infirmary, where surgeon Shankar 'is trying to repair his ruptured aorta with specialised tubing.
' It looks a bit dry.
That's good news.
'Once you have fixed the damaged aorta we can release the clamp 'and re-establish the blood flow to the legs.
' 'But Shankar knows this operation is fraught with danger.
'The longer Tony's lower body is deprived of blood, 'the higher the chance of major complications.
' ~ Ready? ~ I'm ready.
~ I have it ready to open.
~ Open then.
~ Yeah.
~ Good.
The important thing to see is whether there is a pulse in the groin, or going to that leg, and the colour of the foot.
Is there a pulse? ~ 95, 94.
~ Yeah.
'A pulse confirms blood flow has been restored to Tony's left leg.
' One leg down.
'Shankar must now check for the same in Tony's right leg.
' Quick look at the leg for a second.
It looks a bit more pink than this one.
Isn't it? On the right side, I couldn't feel a pulse, and the foot also looked a bit pale and white.
This confirmed to me that the blood vessel is blocked.
~ Right side, we may have to do something.
~ OK.
Revascularise.
'Unable to find a pulse in Tony's right leg, Shankar suspects 'there's a blood clot in the artery.
' There's no way of saying when this artery might have blocked.
It could have happened at the time of rupture, er 'or while we were trying to fix this aneurysm.
' Knife here, please.
Thanks.
'There's no time to waste here.
'If you don't service the blood flow quickly, 'then Tony could lose his leg.
' Removing the clot, physically, is the only option left in this case.
Can I have a Fogarty, please? 'I opened the artery on the right side and I passed a 'specialised Fogarty catheter into the artery.
' And there is a balloon at the end of it, you inflate the balloon.
And then as you take it out, this balloon collects all the clot - 'this is called embolectomy.
' Very good, just relax a bit.
'As he removes the balloon, blood suddenly flows again.
' Good.
'With the clot removed, Shankar must check to see if blood 'is now flowing to Tony's leg.
' Yeah, there's a pulse.
It wasn't there before.
Good.
'With emergency surgery complete '.
.
Tony will be transferred to intensive care.
'But the strain on his body has been severe.
' 'Tony is not safe.
' We have seen patients who are doing really well by the time we've finished the surgery, still develop heart and lung and kidney diseases, leading to a poor outcome.
So, they are never out of danger, even after surgery.
In London, 26-year-old Janina is being monitored after extensive surgery at the roadside and in theatre to stop catastrophic internal bleeding.
Her heart has been restarted twice, and she's still too unwell to have her injuries fully assessed with a CT scan.
After surgery was finished, my main concern was her lung function, because I could see that the oxygen levels in her blood had dropped.
'And despite all the measures that I took to improve them,' nothing had a lasting effect.
'Janina's brain may already have suffered damage from her 'two cardiac arrests.
'A further lack of oxygen could make things even worse.
' OK, fine If she can't move, she can't move.
'I was really conflicted at that moment,' because on the one hand, I realised she needs the scan, but on the other hand I felt this is something that might tip her over the edge.
Her life was really balanced on a knife's edge at that moment.
'As well as her low oxygen levels, Heike is worried Janina 'may still be bleeding internally.
' If I open her pelvis Open her belly again, I'll probably kill her doing it.
I can't If I open her belly now, after the vein's packed out to get to Get to her arteries And she would probably not do.
HEIKE SIGHS 'Martin knows that at this point, 'Janina would not survive more surgery.
' It was clear to me that there was no bleeding in her abdomen or her chest.
But she wasn't stable enough, she wasn't well enough to tolerate even being moved around, let alone having further investigations done.
There's a severe amount of head scratching going on at that point in time, because we're facing something as experienced traumatologists we see all the time, but in a situation She's not responding in the way we expected her to behave, and that's unsettling.
You're constantly aware that this is a beautiful young woman with a life, with a family, and .
.
it's heartbreaking.
'Too fragile either for more surgery or to be moved to CT, 'Janina continues to deteriorate.
'A specialist ventilator is brought to theatre in the hope it 'might improve her breathing.
' I think it makes me acutely aware that we do not have all the answers here.
We can do an amazing amount of resuscitation, but there's only a certain amount that is in my power.
Nature has to take its course, and either her lung improves, or it doesn't.
And we have to accept that.
My baby sister had just been born the day before.
So I had been excited and then I went to go run and tell my mates and I ran straight into the road.
When I think about what happened that day - how quickly things can change within a few seconds - it scares me to let him go out now.
It will take about 12 months for his bone to be fully healed, cos he's still walking with a bit of a limp.
He's lost a bit of hearing in his left ear - I think they said 40%.
It is a possibility that his hearing damage is permanent.
No, it was a knock-on.
'Road traffic accidents are the leading cause of childhood injury 'and long-term damage.
' I think Blake is a very lucky young man.
His injuries could have been so much worse.
SHE SNIFFLES Good shot.
No warning - I was just carrying on with normal day-to-day life, just getting ready to go to work.
Four month on now, I'm just trying to recover and get my life back together.
For a 61-year-old with no previous history to present with a ruptured aneurysm was quite unusual.
For Tony, the timing was absolutely critical.
If he'd reached hospital maybe 15, 20 minutes later, I'm not so sure he would have survived.
I think I were probably minutes away from death.
We see so many cyclists.
We see so many cyclists! It feels so futile, it feels so unnecessary.
You're doing the right thing for yourself, you're doing the right thing for the environment but then this happens.
It makes me feel so helpless.
I was very hopeful that she would survive and that she would recover.
So it was quite difficult then to accept that that didn't happen.
But we did get her heart pumping, we got her to hospital alive, and her family were able to come and see her and be with her at the end.
THEY SPEAK IN GERMAN HE SPEAKS IN GERMAN SHE SPEAKS IN GERMAN ~ SIREN WAILS ~ Next time we meet the doctors and midwives making critical decisions in the first minutes of life She's nasal flaring.
.
.
as they battle to save three babies who are struggling to survive birth.
BABY CRIES She's got worse over the last five to ten minutes.