The Decision Brain Doctors

This programme contains scenes which some viewers may find upsetting

It's a fantastic lump of blancmange.

The human brain has a hundred billion neurons,

which makes it the most powerful learning tool in the world.

Your entire person is encapsulated in that little blob of blancmange.

Jay Jayamohan is a senior paediatric neurosurgeon

at the John Radcliffe Hospital, in Oxford.

He's part of an almost hundred-strong team of consultants

who deal with every conceivable problem of the brain.

We are making life and death decisions.

One split second decides everything.

Each year, they perform almost 4,500 operations.

You're concentrating constantly.

Is it in the right place? Stop any bleeding...

So you're already in that mindset of think, think, think, think, think.

Cutting-edge procedures that carry high risk.

It can be a bit like walking on a tightrope in very high winds.

You could fall off and die.

Their interventions can mean the difference between life and death.

You've got to respect the organ.

You've got to respect the fact that what you do to it

can have huge implications for the patient.

Jay's been at the John Radcliff for nine years.

He's dealt with thousands of children's brains and spines,

from those approaching adulthood to others not yet born.

Imagine if you were preggers in this heat. Man alive.

Can't be a lot of fun.

Today, he's off to the Obstetrics Unit to see Nicola.

She's seven and a half months into an unexpected pregnancy

and there are complications.

When we went for our 20-week scan and the lady who was scanning,

she was just really silent the whole time

and then, she kept saying, "I'm going to have to get my colleagues."

So I think you know in your heart of hearts as soon as that happens.

It's one of them moments when you just think, "Oh, my God."

Her unborn baby's been diagnosed with spina bifida.

Is this your first baby?

-It's number four.

-Number four.

So she's a bit of an expert.

Jay and obstetrics consultant Lawrence Impey

are giving Nicola an ultrasound.

-Do you see it there?

-Yeah.

I think that's what it is, yeah.

There is splaying of the vertebrae above L5.

That's exactly what I was wondering.

They think they may have seen a tumour on the baby's spine.

The ultrasound scans that we've got today do show

that there is an abnormality at the bottom of your baby's spine.

-Baby's spine actually looks widened compared to what we'd expect.

-Right.

-And that we don't tend to see in spina bifida.

-OK.

But we do tend to see it more if there's tumour,

cos it actually physically expands out the space.

How similar is it if you did continue to their life?

-Well, it can be cancerous.

-Yeah.

So, um...

-Yeah, it can be life-threatening.

-It's really bad.

-OK.

-So I think we need to get the MRI scan.

Because if I give you a different type of potential outcome for baby

if it was going to make a difference

to what you want to do,

then, that's final.

Yeah, termination was the really hard bit.

Although Nicola is 30 weeks into her pregnancy,

it's not too late to terminate.

Well, the law says, beyond 24 weeks,

you can terminate the pregnancy

if there is a substantial risk of the baby being handicapped.

Now, the law does not define handicapped or substantial

and so, there are grey areas,

but, essentially, it's not uncommon,

for people with a serious abnormality,

to request termination beyond 24 weeks

and, in this country, it's legal.

I don't know what to think.

It's horrible.

'If it's up to, like, 16 weeks,

'if you lost the baby by miscarriage, it's awful,

'but when it's a big baby and you've bonded with it...

'Just to terminate him.

'That's my worst nightmare.'

The decision about whether you're prepared to have a child,

it's not for us to do that.

Lots of people have completely fit and well children

and treat them terribly.

Now, does that mean you can go and sterilize those people

to stop them having more children?

It's not for us to do that,

so if the parents understand

what the child is going to go through,

I haven't yet found one

where I've thought they've made the wrong decision.

You want a decision from them.

You want a final decision, a yes or a no.

But, in the back of your mind, you don't really want to hear it.

Looking at the scan,

I think there's less evidence

that there's a malignant tumour going on.

It is a big spina bifida, though.

If you want to go ahead with pregnancy,

the chances are baby will have an element

of difficulties and disabilities.

Yeah, he's got quite a few more risks now

than we previously thought.

It's likely the baby will have problems with legs,

with balance, with walking.

I suspect they'll be on the more severe end.

I mean, my job is not to, you know, decide for you,

but, obviously, our job is to help you make a decision

by telling you what may, what may not be required for the baby.

If Nicola has her baby,

it will need lifelong medical care.

It'll be with me for 18 years.

A lifetime involvement for Mum as well.

You know, these guys are always closer to their parents

cos they need a lot more attention and help.

But um...yeah, you know when you take these kids on,

they're going to be for your entire life.

Jack is a lifelong patient at the hospital.

He's now 19 and should be on the adult ward,

but he feels more at home on the children's unit under Jay's care.

Hi, Jack!

'I've been looking after Jack for eight or nine years

'since I started here.

'And you do feel a bond with those patients

'that you've had for a long time.'

Jack has a genetic disease, Crouzon syndrome,

that's caused his skull to fuse too early, damaging his brain.

'There aren't that many cases

'of Jack's age with his condition.

'His face doesn't develop properly,'

the bones of his face

and he's clearly got a different way of his brain functioning.

He's got a developmental level

that's way below 19 in many ways

and he's very interested in childish stuff.

It's actually quite a round shape now,

but he's had lots of operations on his head

to try and get him to that shape.

And part of the problem is that these kids

30 years ago didn't used to survive.

So a lot of the problems that we're facing now

are, as they're becoming adults,

we're starting to find what problems they're getting now

because it's a new phenomenon that they're actually living that long.

Jack's had 27 operations

and has spent most of his childhood in hospital.

His mum, Karen, has always been there for him.

You just get institutionalized though, don't you?

You just get so used to being in here.

Is it tough being Jack's mum?

It is sometimes when you've seen him suffer and that,

but, other times, he's just a joy to have.

He's just such a sweet, calm little boy.

He's so loving and he enjoys so much in life, you know,

He's just... He's just so easy to please.

But when you've got to see him suffering, that is really hard.

Jack.

Jack.

You're going to have to have an operation.

Is that all right?

Good boy.

Jack needs more space at the back of his skull

so that his cerebrospinal fluid can flow freely.

I want to operate here.

These are all abnormal blood vessels that are draining the brain,

but coming through the skull, which is what they shouldn't do.

So I don't want to damage those, cos if I damage those,

I'm damaging the drainage of the brain.

So it could give him a stroke.

So it's going to be a bit of a ruddy nightmare.

I mean, last time was so difficult

and I didn't really want to go back in again,

but he's getting worse.

And he's getting worse progressively

where, at the end, it may be a point

where he starts to lose the ability

to stand, to walk, to use his hands

and then, maybe to swallow

and then, he's really stuffed.

Whenever you do something to these kids who have such a complex set-up,

you're never quite sure of the repercussions.

And, you know, it's a bit like this idea

of butterflies wafting in South America

and causing hurricanes elsewhere.

You've got to remember they don't work the same way everyone else does.

Turn the bi-polar down to two. I'll take some micro scissors, please.

You can see that as you buzz the arachnoid...

..the outer layer covering the brain,

it shrinks.

With Jack, if you do something to his jaw or his teeth,

it may completely change his swallowing,

it may change his breathing,

it may affect so many other things.

And some of it you can predict and plan for,

but some of it just comes out of the blue.

Waking up, Jack.

Wiggle your hands for me.

Ah, perfect.

Can you wiggle your toes?

Let's see if you can wiggle your toes.

If he was a private patient, he'd be asleep for hours.

-He's on the expensive drugs today.

-Oh, is he?

-Yeah...

Oh!

Mm, that'll be the end of my list for the next two months then.

Pay for it.

'As regards resources,'

I don't care how much things cost.

If I think it's right for my patient, I want to do it.

Hi, Jack.

All right?

The one thing we have to watch out for is to make sure

there's no leak of fluid from the back of his head.

I think it's unlikely,

but that's the most important thing we have to keep an eye on.

You never know with Jack, do you?

No. You lost weight...

No, my Mrs told me I have to lose weight, said you're getting too fat.

Start to lose weight.

Yeah, I have to eat beans and...stuff

and I go to the gym.

And I'm not allowed to eat chocolates

and I'm only allowed to drink once a week

and even that's kind of frowned upon.

So my life's really cheery.

THEY LAUGH

All right, guys, see you later.

As Jay clocks off,

the night staff take over on the Neuroscience Department.

The Senior Registrar on call is Tim Lawrence.

Yeah, OK. I'm scrubbed at the moment.

So I'll come as soon as I finish the case.

Tim's been called to the children's critical care unit.

A two-and-a-half-year-old boy has collapsed.

A scan shows a blood clot on Raj's brain.

Pupils are reacting all the time.

Yes, they're small but reactive.

There's a large haemorrhage on the scan,

but it's not a particularly normal-looking haemorrhage,

so I wonder if there's something underlying it.

Then, I'll take him to theatre.

Take the clot out and see what's underneath it.

It's critical they remove the blood clot straight away.

Fiona, it's Tim, the neurosurgical reg.

I've got to take a case to theatre right now.

I will come and speak to them

but I need to do this case before I come down,

so I'll be about an hour.

Tim will operate on Raj.

Thanks.

As Senior Paediatric Consultant on call, Jay comes in to supervise.

They suspect that the clot might be caused by a tumour.

The blood clot was fairly straightforward to take out,

but there was abnormal-looking bits around the edges,

so we biopsied a few of those and sent them off.

We're going to send those off for smears now.

They came back as showing tumour.

We don't know enough about brain tumours yet

to understand what pre-disposes people to brain tumours,

other than in a few rare conditions, but, um...

We see brain tumours in fit healthy kids.

It seems very random.

The best option for dealing with Raj's tumour

is discussed at the daily handover meeting.

Right, let's start with Rajvi Rhana.

So this is a two-and-a-half-year-old child,

previously fit and well except for two convulsions.

So went to theatre and had it evacuated.

That's the post-op scan?

He has no movement in his left side post op,

but he's now moving his arm and leg well.

Jay favours surgery

and the physical removal of the tumour as the best option.

Then, I think it probably does warrant it at some stage.

Probably late six weeks was when I was thinking.

This is tumour.

There was two options for what the tumour is.

The first, which hopefully it isn't, is a highly-malignant tumour,

called a glioblastoma.

And if it is that,

there's, there's no benefit in doing more surgery.

Essentially, his outcome is universally bleak.

He's going to die from it.

But the other option is it's a slightly less malignant tumour

known as ependymoma.

Now, if it's that, if we can get it all out,

if I can remove all of this tumour that we can physically see

and then, we give him chemotherapy

and then, maybe radiotherapy,

we've kind of got a 30 to 40%

five-year survival for him.

But it may leave him paralysed down the left side of his body.

HE LAUGHS

Several weeks after the operation to remove his blood clot,

Raj is back on his feet again.

The family return to the hospital to find out what the options are.

It's all down to what kind of tumour Raj has.

If it is a glioblastoma,

then, there is pretty much nothing we can do to

that's going to enable us to lengthen his quantity of life.

So then, we have to very much concentrate on his quality of life.

-Do you want to have a story in the playroom?

-Yes.

Yeah, you're going to have a story.

My personal view is we should assume that it is the more treatable one.

His best outcome is, by me, getting rid of all of the tumour,

which, I would say, may leave him paralysed.

He's up against it any which way.

I think that Mum and Dad need more time to decide

whether they want to go for surgery

with the attendant risks of disability for him.

I've explained again to parents

that we will support them fully whatever their view.

They will contact us as soon as they've made their decision.

Yours sincerely.

I can't find it here.

Ah, bags of poo!

You can't even spell, that's an R, you dimwit.

Brain surgeons, they're all idiots.

Um...

Tiring day.

I was giving spectacularly bad news to two families.

Is there a chance that by operating on this two-and-a-half-year-old,

I could cure him?

Small.

Very small.

I could extend his life by a few years,

but I'll have to leave him quite severely disabled.

Or they can keep him in the current good condition he's in,

but accept that he's probably just got a few months,

which is a very difficult decision for them to make

and they're understandably having a real hard time

working out which way to go.

Just a really, really rubbish position to be in.

You do what's best for the patient.

You've got to do what's best for them.

You've got to give them all the options

and then recommend what you think you need to do.

Usually, when I go home,

I like to sit quietly somewhere

and just um...just kind of contemplate stuff a bit more.

Right, I'm going to go and get my girls and give them a kiss

and be ready for the next day.

Nicola and her husband, Stephen, have come to a decision

back home in Northamptonshire.

We've decided to keep the baby.

I'm glad I kept all the baby stuff as well.

Which is a bonus.

We haven't had to buy as much stuff,

cos it's another little boy,

and, obviously, I've got Brandon, so I've got loads of stuff still.

When we found out, it was the worst week of my life

cos you don't know what to do.

One minute they're telling us that it's these syndromes.

That he wouldn't be able to survive anything.

Then, you go to Oxford and you find out he's got spina bifida

and I didn't know a lot about it.

-Go!

-Brandon.

-Go!

In a few days, they'll be back in hospital for Nicola's caesarean,

leaving their teenage kids and toddler Brandon at home.

I try to get myself ready for it,

but, I think, the closer it's getting...

Scary, isn't it?

It's getting a bit scary.

'The lady at the hospital told me the baby might not survive birth

'and I think just something triggered inside me

'that something like that could happen.

'He deserves a chance.

'It's going to be hard,

'but life is hard.'

Do you want to sit up a bit?

Complications are common in patients with rare genetic disorders

and Jack's had more than his fair share of bad luck.

Right. Do you want Pat and Jess?

The wound from Jack's last operation

is leaking cerebrospinal fluid, or CSF, and won't heal.

'"Well, I'll be a ding, dong, dang!", said the driver.'

He is in a lot of pain, you can see, cos he can't move his neck.

I mean, this morning I did know he was in a lot of pain

cos he was crying and Jack never cries.

It's a bit of a setback cos we were due to go home on Saturday.

So now, we've got to stay until, well, another five days.

But there's always usually setbacks with Jack

and it just, unfortunately, it happened today.

Hello, Jack.

It's Tim, one of the doctors here. How you doing?

Jack, how are you feeling?

Jack, where do you hurt?

Is your head hurting as well?

Jack, I'm just going to take the dressing off.

'The wound is not keeping the CSF inside,'

so the CSF that normally bathes the brain

is leaking out through the wound.

The problem is if you're leaking CSF,

then, it's very, very difficult to get the wound to heal.

And while he's leaking CSF out,

infection can get back up through the same path.

So we can't leave him leaking CSF, it needs to be stopped.

Hello, it's Tim, the neurosurgical reg.

Can you put me through to Mr Jayamohan, please?

Jay, it's Tim.

So Jack, he is leaking decent amounts. He's dripping away.

I can probably do a stealth scan off the image they've got.

See you in a bit. Bye.

We're going to do a small operation for you.

See if we can make your neck feel a bit better.

All right?

It takes 16 years of training

to become a fully-fledged neuro consultant like Jay.

Tim's still got two years to go.

I was in Toronto recently at the hospital for sick kids

and they employ a radiologist or radiographer rather,

just to look after this system in theatre.

So we do all this, look after it.

Set this up, sort it out when it goes wrong,

get everything ready for the patient.

They employ someone just to come and do that.

So the surgeon walks in,

these guys can set up with someone there to set it all up

and they just come in, get on with the operating.

It's a different world.

Tim's hoping to relieve the pressure of excess CS fluid in Jack's brain,

by putting in yet another drain.

The difficulty with patients like Jack is you make operative decisions

based on what you think is the best thing

to try and manage the condition they have.

But a lot of those operative decisions

you're exposing them to huge risk.

So, just with this operation, there's a risk of stroke,

there's a risk of causing seizures and there's a risk to life.

It's a decision that you think very carefully about

and the aim is always to try and make him better.

It's quite difficult to justify those decisions all the time,

but that's why you have to justify those decisions all the time.

And I think that's a big responsibility.

And it's even harder with the kids,

cos they can't make those decisions themselves really.

Jack is taken to the adult Neuro Intensive Care Unit

to recover from his operation.

Nicola's full-term

and has come in for her Caesarean.

Really nervous this morning.

-Are you?

-Yeah, I'm nervous.

Oh, obviously, and about meeting the baby, so...

Bit nervous.

Don't know what to expect there.

-Probably pass out.

-Oh, please don't.

The day after Nicola gives birth,

Jay will operate on her baby

to remove the dangerous spina bifida sac.

The lower back has a spina bifida,

with a big sac coming out from her back,

um...which is fine,

cos the size of the sac doesn't matter

from the closure point of view.

It makes it more difficult for me, but we can close it.

But the other bit we're looking at

is at the bottom of the brain, top of the neck

where the brain can be jammed down into the spine

and can cause problems with breathing and swallowing.

And that's important because it can be very difficult

to get baby breathing and swallowing after baby's born.

A natural birth isn't an option.

It could rupture the baby's sac and kill him.

-Instruments correct and sterile?

-Yes.

-No equipment issues?

-No.

-Are you all right?

-Yeah.

Everyone happy to proceed? Thank you.

Senior obstetrician Lawrence Impey is performing Nicola's Caesarean.

I'm actually really happy.

We'll have to do a good job then, won't we?

SHE LAUGHS

It is quite a large sac.

What we don't want to do

is rupture that sac.

BABY CRIES

BABY CRIES

A seven-pound baby boy, Jensen Ashby,

arrives safely into the world.

Hello.

Tomorrow, Jay will have to perform major surgery on this tiny baby.

It's the first time

that 19-year-old Jack has been treated on an adult ward.

He said he couldn't go to PDHU.

He was better off on the intensive care of the adult side of it,

because he's older now.

So that was a bit trau...traumatic,

cos we didn't expect it.

And it's completely different to what we're used to.

But, actually, it was pretty good...

Jay's come to see how he's doing.

We're just going to wave at Jack, all right?

Hey, Jack, can you sit up for me?

Will you lift him up, Sue?

Sit up for us, Jack, good boy.

Oh, good work!

Looking good.

Looking good, Jack.

He's going to go back to, yeah, Mel's.

I think we'll try and keep him as a Mel's patient at the moment.

All right, Jack. See you later. Good work.

I'll come back to see you later, are you all right?

Can you ask... The nurse who was looking after him yesterday

was going to speak to Mel's and see if we can bring his telly up.

-It was all ready to come.

-It'd be really good if we can bring it up

cos that will make him a lot happier.

-Keep him here today?

-Yeah, absolutely.

I just need to speak to the management about where he would go.

Cos I'd like him to go back to Mel's,

but it may be that he needs to go back to the adult ward.

-All right.

-But I'll talk to them

-and I'll confirm with you guys where he's going to go.

-OK.

Do you think you'll keep him overnight?

-Yeah, definitely.

-Yeah, OK.

So far, he's done well.

No, he is, really doing well, actually.

Beautiful. Thanks very much, guys.

-Get a chance to clear with management...

-Yeah.

-Jack should come back here, as per the plan.

-Yeah.

He's still under me anyway.

Well, no, I mean, I think, you know, he should come back.

Jay wants to keep Jack's continuity of care.

Who are we going to give that kid to

and get proper, organised care?

On the adult NICU,

Karen can't be with Jack 24/7,

as she can on the children's ward.

You can't come up and visit him.

I think it's a bit worrying for Jack because he doesn't know

when we're going to turn up or not.

Jay wants him to go back on Mel's Ward

because that's where he started off.

It just depends what the powers which be say.

Want to try some Ready Brek?

No? OK.

It's mentally exhausting rather than physically exhausting.

You can't let your guard down, you know.

I cry at night when I'm alone.

I don't or I try not to cry in front of Jack,

because I don't want him to feel frightened.

We both try and hold it together, really,

without him seeing us get upset.

He just means the world to...

Well, you know, all children

mean the world to everybody, don't they, their parents,

but we've just been through so much together, we just...

You know, I just pray every day that he's going to improve.

As one of Jay's patients reaches adulthood,

another child's care under him

is just beginning.

BABY CRIES

Baby, baby.

Trussed him up like a kipper.

What've they done here?

What have they...? Here.

Have you used one of those machines at the airport

that you wrap your luggage in?

Today, Jay will separate the network

of nerves in Jensen's spinal cord

from the cushion of fatty tissue

that's grown outside his body.

It's closed. It's not leaking spinal fluid.

So that's great, because if it's leaking spinal fluid

from now until we can operate,

that would increase the risks of an infection occurring.

The sac, the bag is very, very thin, it's almost translucent,

so it's not something that's going to thicken up over time if we leave it,

so we have to close it.

Um...

PHONE RINGS

Never answer a phone if you're not on the ward.

Hello...

Hang on a minute, hang on, you... Wait, hang on.

You've got a confused neurosurgeon.

I'll find someone who knows what's going on.

See, that's why you should never answer the phone

when you're not on the ward.

Did you see him afterwards?

-Yeah, very quickly, yeah.

-OK.

You know, he's got... Well, we knew he was going to have it.

The big spina bifida, the big sac at the back.

The skin overlying it is really thin.

-So it's not something that we can leave, we'll have to fix it.

-Yeah.

-He hasn't peed yet.

-OK.

And the end of his penis

-is not formed quite right.

-Uh-huh.

On his left side, his foot is turned in,

in what, you know, you will know as...we call a club foot.

As regards to his head and his brain,

I've got quite good hopes that we won't need to do anything.

So that all looks good. All right?

-Yeah, that's great.

-OK.

-See you guys later on. I'll bring him round, OK?

-Lovely.

Baby Jensen's at the top of a busy theatre list.

Jay has three operations today

and, with most cases averaging six hours, it'll be a long day.

Good morning, good morning!

We'll do a cell count this morning.

-If it all looks good, late afternoon or even early evening.

-OK.

Jay's won the battle to keep Jack as his patient.

He's now well enough to have his shunt replaced.

Jack, do you like to be here?

You like hospital, don't you?

Do you want to go home?

No.

Where do you like more?

Adult ward or kids ward?

Yeah, children's ward.

Can you think of any more questions or anything else?

No, no, it's fine.

-OK. I'll see you later on, OK?

-See you.

-See you.

I trust Dr Jay so much.

He's really put my mind at ease,

so I know he's safe and well

and he'll be fine.

An operation as delicate as this,

on such a tiny baby,

will demand all Jay's expertise and dexterity.

-It's squashing his weenie a bit, is it?

-Yes.

But if I use this,

then his jewels can go in the gap.

Try putting them down there.

Jay must put the nerves of Jensen's spinal cord back into place

inside his body without further damaging his mobility.

Where the spinal cord would normally separate off from the skin

and become separate tissue, it's stayed joined in.

So all of this clear, not very good tissue needs to come off,

but I need to be very careful

I don't damage

the spine tissue underneath.

Once I open this up,

if infection gets in there,

it could be meningitis.

Meningitis and paralysis.

It's amazing, isn't it, what parents have to put up with?

Let's try it and see if it gives us a better view.

Makes you look like a rhino, Jay.

Some people would say with my conk

I was already there,

but thanks for not saying it.

It's the source of my power, my nose, you know.

I might go round my mates' house when it's dark

and just look in through the window like that...

THEY LAUGH

Thank you.

All of this is going to have to come off,

but what I'm going to want to do now

is to look at the anatomy inside the sac

and work out where we are.

We're finding nerve tissue pretty much straight away.

Come look down here.

See that pink strawberry?

That's the nerve tissue.

So now we know we can relatively safely take this away...

..because we've kind of found the area

that we need to protect and concentrate on.

We've taken the cap off the mushroom.

It's like taking an excess bit of fat off someone.

Doing a fatectomy.

But this is the sort of the stalk of the mushroom.

What would be ideal is

if we could get this nerve tissue back in through that hole

and then close that fissure up to give it as many layers as possible.

It is going in...

..with a little bit of discussion.

Jay covers the nerves

with as much skin and muscle as possible to act as protection

as there's no vertebrae at the base

of Jensen's spine to encase it.

It means that there's less tension on the wound.

It's called a dog ear.

It's satisfying because you've got

such an obvious appearance change

and difference for the family.

This is the first part of a long, long family of operations

that he's going to need.

You know, he's going to be with me until he's 18.

He's likely to need more surgery.

He's likely to need regular follow-ups and scans and stuff,

so it's quite a long process for him

and for us.

What else is on the list?

Jay's next patient,

six-year-old Ollie,

is having a lumbar puncture.

Why am I saying sorry? You bumped into me.

Right, James, it's all lining up

for you to really get a chance to do this, isn't it?

Jay has many trainee neurosurgeons

under his eye

and he's a hard task master.

I think I encourage them in a nice family way and I'm very gentle.

They probably think I'm an absolute git.

They know I'm going to abuse them if they haven't done their work

and they know they're going to get a hard time if they don't do

100% efforts for the patients.

It's people like you that make me want to retire.

THEY CHUCKLE

I don't scream at anyone. I scream generally.

Do I shout?

Sister's saying I shout and I bully and I scream...

Yes, you are a bully.

SHE LAUGHS

Can you believe that?

I did say earlier on you can always tell when you're coming in the ward

cos you've got that distinctive voice, haven't you?

-You're not helping, Karen.

-Oh, all right.

THEY LAUGH

Actually, a lot of people probably say I'm a bit of an arse,

but you start becoming a bit of a pompous arse about it.

You think that because you do such an amazing job,

it makes you an amazing person.

End up a bit of a weirdo.

What would I say to James?

You know, standard advice like try not to steal from work.

And if you do steal, don't leave fingerprints.

Don't drop equipment.

As long as you do all those,

'then, we're all happy.'

-There you go.

-Well done.

I'm going to leave, I'm quitting because of Sunshine.

Not me!

That's a lie, man.

SHE LAUGHS

That's terrible. Can you believe that?

I think I might be fairly demanding.

My wife says I'm very high-maintenance.

But, you know, all I want is for everyone to do their job perfectly.

We'll all get along great.

It's not like this on bloody ER, is it?

Last patient in is Jack.

He's having his shunt replaced.

A regular procedure for him.

-Are we good to go?

-Yeah.

It's his seventh major operation in the last six weeks.

I'm going home to play on the PlayStation.

Someone's going to get it tonight online.

'Jack, he'll be under our care, really, I think until we retire.'

I can't imagine we're going to be discharging him ever.

'My wife always says that patients come first

'and, in a funny way, I guess they do.

'But not because I don't love my family completely,

'but it's because if anything happens to one of my patients,

'I need to be there to help them.'

Poing, poing!

I'm not going to bump my head.

No, you move that twig out the way.

So it's not in the way.

MURMURING IN THE BACKGROUND

What are those two saying?

They're crazy, man.

There's a boat and look, there's duckies living on that little island.

'Even if you're not at work, you spend a lot of time

'thinking about stuff

'and contemplating things that've happened.'

Sometimes you feel absolutely rubbish.

You've then got to think,

"Oh, actually, imagine being that kid or that parent

"and what must it be like," and that's what drives you on.

HE LAUGHS

That was the longest story I've ever heard.

For me, having kids hasn't weakened my resolve or drive

or whatever you want to call it to do my job, it's strengthened it.

Daddy, you've got a little cut on your shoulder.

-I've got a little cut on my shoulder?

-Yeah, that one.

Ah, that's old.

They always get better, honey.

Yeah, they can.

You can get a sense of what it must feel like for these families.

I mean it's just... It's unfathomable

what they go through with a flip of a coin.

Are they nice? Are they yummy?

You do for your patients what you would want if it was one of your children.

And if one of my children was sick,

I would want somebody who put 100% in for them.

Look, look up there!

-Oh! There's people going on holiday. Wave bye!

-Bye!

Turkey...

Turkey.

Turkey pork. Turkey pork.

THEY CHUCKLE

Turkey pork.

It's been three months since Raj had his blood clot removed.

-How was your break?

-Good.

Where did you go?

His parents have spent time thinking and talking to family

and they've come to a decision.

At the time, you thought

you definitely wanted to have something done,

but you weren't sure

whether you were in agreement about doing the more aggressive operation

that could leave him virtually paralysed,

but which was really the only operation

that had any long-term potential for him.

Now that you've had a chance to think, have you made your mind up?

Or do you want to talk about it more?

I think we're looking at going...

With the operation.

With the operation - total removal will give him the best prognosis eventually.

The outcome of any brain surgery is uncertain,

so Jay must prepare Raj's parents for the worst.

It's a big operation,

so there's a risk to his life

-that he won't make it through the operation...

-Yeah.

-..or not wake up afterwards.

-OK.

But we will take every care with him

and give him the same care that we would want for one of our kids.

OK?

THEY SIGH

There's no way, unlike adults,

there's no way we can prepare him

for not being able to use his arm and legs.

No good telling him today,

cos that's going to make no sense to him whatsoever.

So that initial period when things don't work properly,

he's going to be quite distressed

and we just have to talk him through it and just keep him calm.

When you're around him afterwards,

as much as possible,

-just choke it down.

-Uh-huh.

Because if he senses that you guys are really stressed and upset,

especially if he doesn't know what's going on,

-he'll just think, "Right, I'm getting stressed out," you know.

-Yeah.

But if you need to get upset, that's fine.

-But, generally, we find that kids pick up on their parents a lot.

-OK.

HE SOBS

Hurt.

Does it hurt?

It's better.

It's better now, that's good.

'Doing nothing for me wasn't an option.

'If there's some hope, then it's worth going for it.'

There's that chance that, you know, he could have...

you know, some time left, basically.

He knows his way around now, so he thinks he can do what he likes.

SHE CHUCKLES

Cos he's quite energetic and all over the place,

that's probably part of his personality

I think I'm going to miss.

HE LAUGHS

You do start doing things like watching how he moves

and watching how he runs around and...

..you know, you find yourself thinking, "Oh, gosh,

"he might not be able to do that afterwards" or "he won't be able to do that."

And that's the hardest part, but...

I think it's the best thing for him.

That's why we're doing it, it's the best thing for him, really.

He's going to be fine...

SHE CRIES

Catch her! Go catch her!

Oh!

SHE LAUGHS

Bye, buddy!

Love you!

Just hold him really tight. OK.

If you can just support his bottom for me.

-Lawrence has got his head.

-I've got my cardigan there.

OK, sorry.

That's it.

He's asleep, we're going to give him a little bit of oxygen.

OK.

Well done.

Do you want to give him a kiss?

I love you, baby.

It's emotionally very hard.

That was all I could do to stop myself from wailing

in the conversation I've just had.

But you have to fight it back, chuck it down your throat.

Cos you can't, you need to be the strong one for the parents

and even if you're choking up, you have to just keep it hidden.

And you can't let it influence your decision.

MUSIC PLAYS

If Raj has the more aggressive GBM tumour,

Jay will stop the operation.

If it's the less invasive ependymoma,

he'll try to take it all out,

without damaging too much limb function.

Jay's first task is to send tissue off for biopsy.

That's all tumour there.

It's just kind of stuck onto the dura there.

Raj's dura, the protective membrane around the brain,

is riddled with cancer cells.

Generally, we find that tumours that invade the dura are more aggressive.

I don't think there's going to be any dura left here.

I think this dura's coming off.

So we're going to throw this dura away. Take it out.

Can the dura grow again?

Um...

Yes, it can, but it won't matter.

It doesn't matter.

Why not?

Because that's not going to be what's important for him.

Fighting the tumour, that's going to be important,

so whether dura grows back or not, we don't care.

We want to get rid of as much tumour as we can.

If we had a choice, I'd put it back.

But we must, must get this tumour out.

Now, we can remove that.

That's a specimen.

That needs to be labelled

"dura over tumour", please.

It takes the lab just under an hour to process the biopsy

and call the results through to Jay.

Sure, Emily, if you were going to come back to me now

and say it's definitively GBM, I was going to stop.

Well, I think if there's any chance that this is a malignant ependymoma,

I'm going to reset it plus normal brain around it,

that's his only chance.

I am, but we've all decided to give him

the benefit of the doubt on this one.

We're in an optimistic mood today, mate.

HE LAUGHS

OK, thanks a lot. Cheers.

Thank you.

Right, some ependymoma components.

Still could be a GBM,

but certainly some things that look like ependymoma,

so we'll get it all out.

By hook or by crook, this is all coming out.

So there's still, there's still hope.

And we live on it.

You happy for me to take it from there?

Looks all right there, doesn't it?

Anything that's definitively tumour down there.

It's distinctly tumour.

We've gutted out

the centre of the tumour

and what we've found now

is the fingers of the tumour

that are going frontwards into the motor strip,

the movement part of the brain,

so what we've done is mapped out

where tumour looks

and, then given it another few millimetres

of what looks like normal brain

to take into account those fingers

that will have gone in

and we're essentially going to have

to remove all that bit of brain and tumour together

and then try and take it out.

Is it all in one piece?

Retractor, please.

Sorry, hold off, because we'll see if we can take it out.

Although Jay's removed healthy brain tissue from Raj's motor area,

it's impossible to say

what the consequence will be.

That doesn't look so much like tumour there, does it?

So what is it, then?

Is it tumour or is it grey matter?

It's not all nicely coloured like on a text book,

where you've got yellow bits and green bits and purple bits.

It all looks the same.

So you're having to work out from your memory, this should be this,

but the way everyone's brain develops is different.

So although it should be this in him, it may not be.

I think that's grey matter.

OK.

I think we probably are done, aren't we?

That looks pretty good, doesn't it?

Beauty.

Raj has been in theatre for six hours.

His family will have to wait to find out how much movement he has left.

Hello, you!

Hello.

Rajvi, wakey-wakey.

HE CRIES

Oh, mate, I'm sorry, fella.

OK.

All right, sorry, big man.

Definitely there.

OK, whenever he's ready to go, good.

I'll go and catch up with Mum.

Hiya. All done.

He is moving his leg.

-OK.

-That's a good sign.

-Not moving his arm.

We took out the tumour, it looked fairly clear from what we could see,

so we couldn't see any tumour left there at all.

All right? So, so far, pretty good

and we'll see how he does.

-So you're happy with everything?

-Yeah.

-Thank you.

All right? I'll see you later on, OK?

-Take care, man, appreciate it lots.

-No problem.

I would love to say it's because of my brilliance and my skill,

but it's not, really, is it?

Most of it is you do as much as you can safely and carefully

and then, at the end of the day,

it is down to luck in a lot of these cases.

HE CRIES

-It's all right.

-All right, darling.

HE CRIES

-That's his left side.

-Yep.

His arms are moving, his legs are moving. It's good.

It's a brilliant sign.

It's been the worst roller-coaster ride ever

and now, it's just the best thing.

Just relieved, really.

And the fact that he's moving

his left side is just amazing.

Good, really good.

Let him rest up overnight, all right?

-If I don't see you later, I'll see you tomorrow morning.

-Thank you.

-Cheers.

-Take care, mate.

Kiss this hairy arse goodbye!

HE LAUGHS

Jensen's making good progress

and is going home with Mum and Dad today.

Good boy!

He is eight days old today.

You're doing very well, aren't you?

Special boy, aren't you. You, chubby chups.

You are gorgeous.

Jack hopes he'll soon be discharged too.

That yellow one, I think is dying, Jack.

It's swinging on its side.

After an 11-week stay in hospital,

Karen is counting the days.

Jay knows he'll see both patients again.

I'm not going to do any work tonight.

I'll do a little bit, I suppose.

Hopefully, we'll put ourselves out of business

in many parts of our job and we won't ever have to do it for a brain tumour

and hopefully never have to treat somebody

with lots of the congenital diseases that we have to do...

again. It'd be great.

Retire early!

Fantastic!

HE BABBLES

Raj now has full use of all of is limbs

and is responding well to chemotherapy.

HE LAUGHS

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