0:00:06 > 0:00:09Just move yourselves over to the side for a minute.
0:00:09 > 0:00:12This winter, one of Britain's busiest NHS trusts
0:00:12 > 0:00:14opened its doors...
0:00:14 > 0:00:16We have to look after the patients
0:00:16 > 0:00:19whether they come from Buck Palace or the park bench.
0:00:19 > 0:00:22..to show us what's really happening inside our hospitals.
0:00:22 > 0:00:24We've got lots of patients now competing for
0:00:24 > 0:00:27an unknown number of beds.
0:00:27 > 0:00:31Every week, more than 20,000 people are treated here...
0:00:31 > 0:00:32The pressure's just gone.
0:00:32 > 0:00:35What?! Is it completely gone?
0:00:35 > 0:00:40..and the numbers, as well as our expectations, are rising.
0:00:40 > 0:00:43We just had our worst ten days on record,
0:00:43 > 0:00:45there's nowhere in the hospital to move anybody.
0:00:45 > 0:00:47At some point, somebody will be telling us
0:00:47 > 0:00:49whether we're allowed to do any work.
0:00:49 > 0:00:52This is a place with some of the best specialists in the world...
0:00:52 > 0:00:53Tumour's out, job done.
0:00:53 > 0:00:55..where lives are transformed...
0:00:55 > 0:00:57This is saving his life.
0:00:57 > 0:00:58It has to work.
0:00:58 > 0:01:00..but they are operating in a time when the NHS
0:01:00 > 0:01:02has never been under more pressure...
0:01:02 > 0:01:04- Got any beds?- No.
0:01:04 > 0:01:07- No beds for anyone?- No.- OK.
0:01:07 > 0:01:10It does feel to me like the elastic's a bit nearer
0:01:10 > 0:01:13to breaking now than it ever was.
0:01:15 > 0:01:17..its very future under scrutiny.
0:01:17 > 0:01:19All right, well, I think we will go out on red because we're
0:01:19 > 0:01:21under real pressure in the emergency department.
0:01:21 > 0:01:23We're aware of the problems -
0:01:23 > 0:01:25anybody got a solution?
0:01:25 > 0:01:28Following the patients from the moment they are admitted...
0:01:28 > 0:01:32Anything I've done up to this point means nothing compared to
0:01:32 > 0:01:35when you can literally give a bit of yourself to save someone else.
0:01:36 > 0:01:38..to the moment they leave...
0:01:38 > 0:01:40It's all good news - the cancer has gone.
0:01:40 > 0:01:42You don't need any more treatment.
0:01:42 > 0:01:43Fantastic.
0:01:43 > 0:01:45Thank you so much.
0:01:46 > 0:01:49..week-by-week, we reveal the complex decisions the staff
0:01:49 > 0:01:52must make about who to care for next.
0:01:54 > 0:01:57That patient is coming to me to be operated on,
0:01:57 > 0:02:00and if I don't do it, then there's only one inevitable outcome -
0:02:00 > 0:02:01they're going to die.
0:02:18 > 0:02:21Right, good morning, everybody. Shall we begin?
0:02:21 > 0:02:22I've seen the gang at Charing Cross.
0:02:22 > 0:02:25- Good morning, Charing Cross. - 'Morning.- Good morning.'
0:02:25 > 0:02:27OK, do you want to just talk us through your screen this morning?
0:02:27 > 0:02:30Lesley Powls is the site director at St Mary's,
0:02:30 > 0:02:32the biggest of the five hospitals
0:02:32 > 0:02:35in London's Imperial College Healthcare NHS Trust.
0:02:36 > 0:02:39Every morning, she leads a conference call
0:02:39 > 0:02:41with the other hospitals to plan the day.
0:02:41 > 0:02:43The focus is always the same -
0:02:43 > 0:02:45how many empty beds have they got?
0:02:45 > 0:02:48- CHARING CROSS:- 'There's currently no cubicles anywhere in A&E
0:02:48 > 0:02:49'to see any new patients.'
0:02:49 > 0:02:54OK, so not a great start to a Monday morning for you guys, then?
0:02:56 > 0:02:59'The first call of the day is to kind of take the temperature of
0:02:59 > 0:03:01'what's gone on overnight,'
0:03:01 > 0:03:04and what our beds look like going forward
0:03:04 > 0:03:05for the next couple of hours.
0:03:05 > 0:03:08Let's go to St Mary's. So, as you can see,
0:03:08 > 0:03:10we're in a very similar position to Charing Cross this morning -
0:03:10 > 0:03:12very full and busy ED screen.
0:03:12 > 0:03:15Let's just have a look at the beds.
0:03:15 > 0:03:17It's probably easier for me to say what we've got,
0:03:17 > 0:03:19which is absolutely nothing at the moment.
0:03:19 > 0:03:22So, really, priorities for us this morning are to sort out the
0:03:22 > 0:03:24rest of the unplaced patients in the emergency department
0:03:24 > 0:03:26before we do anything else.
0:03:26 > 0:03:29We'll pick up surgical electives in about ten minutes.
0:03:29 > 0:03:32All right, well, I think we will go out on red this morning, then.
0:03:32 > 0:03:35OK, thank you very much, everybody, we'll speak again at lunchtime.
0:03:38 > 0:03:43St Mary's uses a colour coding system to indicate its bed status.
0:03:43 > 0:03:46Amber means that the hospital is almost at full capacity,
0:03:46 > 0:03:51with only a handful of its 301 adult beds available for new admissions.
0:03:51 > 0:03:53Code red is even more serious.
0:03:53 > 0:03:55It means that, throughout the hospital,
0:03:55 > 0:03:58from the A&E department to the Intensive Care Unit,
0:03:58 > 0:04:02from the High Dependency Unit to the general nursing wards,
0:04:02 > 0:04:04there are not enough beds available
0:04:04 > 0:04:07for the number of patients that need them.
0:04:07 > 0:04:08The hospital is full.
0:04:10 > 0:04:13St Mary's must now put scheduled operations on hold.
0:04:13 > 0:04:16The pressure on beds can only be relieved
0:04:16 > 0:04:18by existing patients leaving the hospital.
0:04:18 > 0:04:21It's one in, one out.
0:04:21 > 0:04:22For the last three weeks,
0:04:22 > 0:04:25we've run at almost completely 100% capacity.
0:04:25 > 0:04:30We are probably on code red every three or four days.
0:04:30 > 0:04:33I'm hoping that, within the next couple of hours, we get
0:04:33 > 0:04:35enough beds that we can at least do
0:04:35 > 0:04:37a couple of our elective patients.
0:04:37 > 0:04:39SIREN BLARES
0:04:42 > 0:04:43That's the trauma patient.
0:04:45 > 0:04:49Which means that we are very likely, shortly, to need another trauma bed.
0:04:49 > 0:04:51So today, we are in trouble.
0:04:54 > 0:04:56So at the moment, there are no beds in the hospital.
0:04:56 > 0:05:01There's a lot of emergencies who will need operating on.
0:05:01 > 0:05:04When St Mary's is on code red, surgical staff must wait
0:05:04 > 0:05:07while site operations look for patients to discharge.
0:05:07 > 0:05:11Today, there are no beds in the Trust at all.
0:05:11 > 0:05:13Right, let's go and postpone things.
0:05:13 > 0:05:15It's the job of the on-call anaesthetist to stop planned
0:05:15 > 0:05:18operations getting underway.
0:05:18 > 0:05:20Until the hospital gets off code red, there won't be enough
0:05:20 > 0:05:24beds for all the patients to recover from their surgery.
0:05:24 > 0:05:27What tends to happen is, people can be a bit naughty,
0:05:27 > 0:05:30and suddenly they just start their patient.
0:05:30 > 0:05:33I mean, after knife's to skin, there's absolutely nothing
0:05:33 > 0:05:35you can do about it.
0:05:35 > 0:05:37There is no bed, 100%.
0:05:39 > 0:05:43There's loads of patients in A&E, there are no beds whatsoever...
0:05:43 > 0:05:44- OK.- ..in the Trust.
0:05:44 > 0:05:47Rex, you know that it's only day cases or inpatients?
0:05:47 > 0:05:50Right, or day care, yeah.
0:05:50 > 0:05:52- I didn't know that, but I do know now.- Yeah.
0:05:54 > 0:05:56They said not to go ahead, and they want to go ahead.
0:05:56 > 0:05:59Well, no, you can't go ahead if we haven't got a bed.
0:05:59 > 0:06:01Even if we don't have a bed,
0:06:01 > 0:06:02if we do any patients that need beds,
0:06:02 > 0:06:05they have to stay in recovery, that's not acceptable.
0:06:05 > 0:06:07No, no, no, they can't go cos we haven't got the
0:06:07 > 0:06:10- recovery staff to look after them. - Exactly, but you're not listening.
0:06:10 > 0:06:12Because I said they have to stay in recovery
0:06:12 > 0:06:14doesn't mean the patient can go to recover -
0:06:14 > 0:06:15it means that it's not acceptable.
0:06:15 > 0:06:17But nobody's listening.
0:06:17 > 0:06:19This is really annoying, isn't it?
0:06:19 > 0:06:22Because many hours are wasted waiting for things,
0:06:22 > 0:06:24which just pisses me off.
0:06:26 > 0:06:27This is a bad Monday morning.
0:06:27 > 0:06:32There's been no frost, there's been no flu, it's not cold, you know?
0:06:32 > 0:06:35And the fact that the hospital's already overwhelmed
0:06:35 > 0:06:36is really quite scary.
0:06:36 > 0:06:39Anyway, so I better have my mango lassi.
0:06:42 > 0:06:45George Reese is one of the surgeons waiting to start work.
0:06:45 > 0:06:48He specialises in keyhole surgery.
0:06:49 > 0:06:50IT support as well.
0:06:51 > 0:06:53We have one operation to do today,
0:06:53 > 0:06:56and that's an anterior section,
0:06:56 > 0:06:59which is an operation for rectal cancer.
0:06:59 > 0:07:01The gentleman's here, my team have seen him,
0:07:01 > 0:07:04but the hospital's on red alert, so we are just going to wait to
0:07:04 > 0:07:08find out to see if we've got permission to start operating.
0:07:08 > 0:07:12George Reese can't begin his patient's surgery until a bed is
0:07:12 > 0:07:15available on the High Dependency Unit for him to recover in.
0:07:15 > 0:07:17Morning.
0:07:17 > 0:07:21Nurses there are currently trying to discharge patients to make space.
0:07:21 > 0:07:24Hello. Can we do a quick brief, please?
0:07:24 > 0:07:27So we don't have permission to start because they don't know if
0:07:27 > 0:07:30there's a bed or not, so we're not allowed to do anything.
0:07:30 > 0:07:33The difficulty is...
0:07:33 > 0:07:36that it's 3.5 hours of surgery.
0:07:36 > 0:07:37- Yeah, and it's cancer. - And it's cancer.
0:07:37 > 0:07:41So if they don't tell us early, we've run out of time.
0:07:41 > 0:07:43But they know that.
0:07:43 > 0:07:47Professor George Hanna is also waiting to start a cancer operation.
0:07:47 > 0:07:48I'll come later on.
0:07:48 > 0:07:52His patient will need a minimum of six hours of surgery,
0:07:52 > 0:07:54followed by a bed in the Intensive Care Unit.
0:07:54 > 0:07:56- Oh, hello.- Hello. - How are you?
0:07:56 > 0:07:57Good morning to you.
0:07:57 > 0:07:59- So let's stand him up. - SHE LAUGHS
0:07:59 > 0:08:01- Hello.- How are you?
0:08:01 > 0:08:03- Good, thank you. - Pretty good, thank you.
0:08:03 > 0:08:06- Are we good to go, or not? - We're just waiting.
0:08:06 > 0:08:08- We're just still waiting? OK. - Yes, still waiting.
0:08:08 > 0:08:10Have you been doing your exercises?
0:08:10 > 0:08:12I have been doing my exercises.
0:08:12 > 0:08:14Very rigorously.
0:08:14 > 0:08:15So once we know, get back to you.
0:08:15 > 0:08:18- We'll let you know.- Yeah. - We'll call you to come in.
0:08:18 > 0:08:19Well, I'll see you shortly.
0:08:19 > 0:08:22- See you again, yes?- OK. Take care.
0:08:22 > 0:08:27The patient has a cancer of the gullet, which is the oesophagus.
0:08:27 > 0:08:29To cure him, he needs to have the operation -
0:08:29 > 0:08:31otherwise, really, he can't survive.
0:08:34 > 0:08:37I was first diagnosed back in April,
0:08:37 > 0:08:40and then I went onto a chemo
0:08:40 > 0:08:43and radiotherapy treatment course,
0:08:43 > 0:08:46which was designed to shrink the tumour.
0:08:46 > 0:08:49Became quite difficult to eat.
0:08:49 > 0:08:52- PRODUCER: Do you feel poorly? - Not now, no. But I did then.
0:08:52 > 0:08:54Oh, my God, I did then.
0:08:54 > 0:08:56And the thing is, you know, he's, what, sort of
0:08:56 > 0:08:59- 13st or whatever normally.- Not now.
0:08:59 > 0:09:01Well, no, but you were.
0:09:01 > 0:09:03I was more like 14st.
0:09:03 > 0:09:05I mean, big, strong, healthy guy, you know?
0:09:05 > 0:09:08Playing golf three times a week or whatever.
0:09:08 > 0:09:11And suddenly, he's not.
0:09:16 > 0:09:19So looking at the scan, it looks actually, he...
0:09:19 > 0:09:23he has a good response to chemotherapy and radiotherapy.
0:09:23 > 0:09:25Here is the oesophagus.
0:09:25 > 0:09:29And this black is the food channel inside the oesophagus.
0:09:29 > 0:09:32And if we go up, you will find it is wide.
0:09:32 > 0:09:35If you go down, you will find it narrow.
0:09:35 > 0:09:38So the tumour and the thickening makes it
0:09:38 > 0:09:40so that inside is small,
0:09:40 > 0:09:44and this is why the patient struggles to eat.
0:09:44 > 0:09:48One of the main aims of the operation is to have a clear
0:09:48 > 0:09:50margin of normal tissue to ensure
0:09:50 > 0:09:53that the tumour is completely removed.
0:09:55 > 0:09:58Simon's surgery has already been cancelled once before.
0:09:58 > 0:10:01Just like today, the Intensive Care Unit was full.
0:10:06 > 0:10:09We've only got 16 intensive care beds at St Mary's,
0:10:09 > 0:10:12and those beds are always needed for our sickest patients
0:10:12 > 0:10:13in the organisation.
0:10:13 > 0:10:15So those coming through our emergency department,
0:10:15 > 0:10:18are major trauma patients and are patients who are going to
0:10:18 > 0:10:20recover from some of the biggest surgery
0:10:20 > 0:10:22that we do in the organisation.
0:10:22 > 0:10:25St Mary's Intensive Care Unit, or ICU,
0:10:25 > 0:10:29contains the most sought-after bed spaces in the hospital.
0:10:29 > 0:10:32Each one provides one-to-one nursing care,
0:10:32 > 0:10:35and the most advanced life support systems.
0:10:35 > 0:10:38There is no capacity to add more beds.
0:10:38 > 0:10:41The team tries to keep at least one of these bed spaces
0:10:41 > 0:10:44in reserve in case of an emergency admission.
0:10:44 > 0:10:46But with patient numbers rising,
0:10:46 > 0:10:48this is proving increasingly difficult.
0:10:48 > 0:10:50Today, all 16 beds are full.
0:10:53 > 0:10:56I need to move patients off intensive care
0:10:56 > 0:10:57and down to the ward.
0:10:57 > 0:11:00But before we move them, I need to go and have a look at them
0:11:00 > 0:11:01and make sure that
0:11:01 > 0:11:04'they're well enough to move and that they'll be safe on the ward.'
0:11:04 > 0:11:06Hi, there. How you getting on?
0:11:06 > 0:11:08How are you doing?
0:11:08 > 0:11:10It's good to see you're all right.
0:11:10 > 0:11:12I think you're doing really well, sir.
0:11:14 > 0:11:16How you going?
0:11:16 > 0:11:18OK, good. All right.
0:11:18 > 0:11:20I think you're improving.
0:11:20 > 0:11:23All right? I think you are.
0:11:23 > 0:11:26Simon Ashworth has identified two patients who could
0:11:26 > 0:11:30potentially be stepped down from the ICU to other wards,
0:11:30 > 0:11:33but only if their conditions improve over the next few hours.
0:11:38 > 0:11:40I have to tell you, it's nine o'clock.
0:11:40 > 0:11:41PRODUCER: And what does that mean?
0:11:41 > 0:11:43It means, at some point, somebody will be telling us
0:11:43 > 0:11:45whether we're allowed to do any work.
0:11:45 > 0:11:47- Nervous?- No, I am not.
0:11:47 > 0:11:49HE LAUGHS
0:11:49 > 0:11:50I am nervous for you.
0:11:50 > 0:11:53You worry too much - you'll get heart attack.
0:11:53 > 0:11:54LAUGHTER
0:11:54 > 0:11:58George Reese's cancer patient Eladio's operation is already
0:11:58 > 0:11:59two hours behind schedule.
0:11:59 > 0:12:01I've decided not to get frustrated.
0:12:01 > 0:12:05There's nothing I can do to fix this problem.
0:12:05 > 0:12:08So...I will trust that the people who are doing it
0:12:08 > 0:12:09are doing their very best.
0:12:13 > 0:12:15- Morning.- Hello.
0:12:15 > 0:12:17How are you?
0:12:17 > 0:12:19- Hello, we didn't get to meet last time.- No, no, we didn't.
0:12:19 > 0:12:24I just want to set the scene of today a bit.
0:12:24 > 0:12:27At the moment, they haven't given us permission
0:12:27 > 0:12:30to start the operation because there isn't a bed in the hospital.
0:12:30 > 0:12:32- Yeah.- But they're working on it.- OK.
0:12:32 > 0:12:35- And when I know, you will know. - OK.- Lovely.
0:12:35 > 0:12:36Is there anything you wanted to ask me?
0:12:36 > 0:12:39- Well...- No, I think...
0:12:39 > 0:12:43- ..I just would like to ask about the parking outside.- The parking?
0:12:43 > 0:12:45The cost to me now is £10.80.
0:12:45 > 0:12:47Please...
0:12:47 > 0:12:49please, because if we're going to be here all day,
0:12:49 > 0:12:52that's going to cost me an arm and a leg.
0:12:52 > 0:12:54I kind of meant, is there anything you wanted
0:12:54 > 0:12:58to ask me about the operation or about the...the surgery today?
0:12:58 > 0:13:01- No, I'm OK.- OK.
0:13:01 > 0:13:05Site director Lesley has received an update on the bed situation
0:13:05 > 0:13:06from the High Dependency Unit.
0:13:06 > 0:13:09So we've managed to get some discharges,
0:13:09 > 0:13:12which means we can start to operate on patients
0:13:12 > 0:13:13who can go into High Dependency,
0:13:13 > 0:13:16but not patients yet who need intensive care.
0:13:16 > 0:13:19Yeah. So, marvellous, and then,
0:13:19 > 0:13:22start the Reese patient needing HDU.
0:13:24 > 0:13:26Miriam?
0:13:26 > 0:13:28- Don't feel any pressure(!) - LAUGHTER
0:13:28 > 0:13:30I'm coming to find out if I'm allowed to start,
0:13:30 > 0:13:33cos if I can't start now, we have to send him home.
0:13:33 > 0:13:36So the cancer patient who needs level two, that can go ahead.
0:13:36 > 0:13:37OK, great - so we can go ahead?
0:13:37 > 0:13:39Thank you.
0:13:39 > 0:13:41So we need to go and tell them.
0:13:43 > 0:13:45Can you hear me? We're coming down to theatre.
0:13:45 > 0:13:46We're allowed to do the case, OK?
0:13:48 > 0:13:49They found a bed.
0:13:49 > 0:13:51PHONE RINGS
0:13:52 > 0:13:54Hello, site office, Lesley speaking.
0:13:54 > 0:13:57Lesley must now deal with a new emergency.
0:13:57 > 0:14:01A patient is on her way from Norfolk with a ruptured aorta.
0:14:01 > 0:14:02SIREN BLARES
0:14:03 > 0:14:06The aorta is the main artery in the body.
0:14:06 > 0:14:09If it bursts en route, the patient will die in the ambulance.
0:14:12 > 0:14:16St Mary's lead vascular surgeon, Richard Gibbs,
0:14:16 > 0:14:19will perform the life-saving operation.
0:14:19 > 0:14:21I've been sent here because we're a specialist centre
0:14:21 > 0:14:23for aortic surgery.
0:14:23 > 0:14:26We feel a real moral responsibility
0:14:26 > 0:14:28for accepting patients like this.
0:14:28 > 0:14:31Without any shadow of a doubt, they
0:14:31 > 0:14:33will need an intensive care bed.
0:14:33 > 0:14:34But, to a certain extent,
0:14:34 > 0:14:36we just have to get on and do the operation.
0:14:36 > 0:14:40So we'll have to worry about the ITU bed at a later stage in the day.
0:14:40 > 0:14:43That patient is coming to me to be operated on.
0:14:43 > 0:14:47If I don't do it, then there's only one inevitable outcome,
0:14:47 > 0:14:49which is they're going to die.
0:14:49 > 0:14:51ITU are uncertain now as to...
0:14:51 > 0:14:55This morning, they were declaring two patients to step down.
0:14:55 > 0:14:57They're now not sure that they have two to step down.
0:14:57 > 0:14:59They think they might just have one bed.
0:14:59 > 0:15:03If they have one bed, that bed will have to be held for
0:15:03 > 0:15:06the ruptured patient coming from Norwich.
0:15:07 > 0:15:10Richard Gibbs goes to discuss the impact of his incoming
0:15:10 > 0:15:13emergency on George Hanna's patient.
0:15:14 > 0:15:15George.
0:15:16 > 0:15:19As things stand, you need an ITU bed,
0:15:19 > 0:15:20we need an ITU bed,
0:15:20 > 0:15:22cos we've got this woman who's in an ambulance
0:15:22 > 0:15:24on the way from Norfolk
0:15:24 > 0:15:27with a ruptured aneurysm, so she needs an open operation.
0:15:27 > 0:15:30So if she arrives alive, which we think and hope she will,
0:15:30 > 0:15:33she's going...we are going to do her in theatre nine
0:15:33 > 0:15:34and not worry about ITU for now.
0:15:34 > 0:15:37We've got to get on with that and sort it out.
0:15:37 > 0:15:38Fine.
0:15:38 > 0:15:40So what are we waiting for now?
0:15:40 > 0:15:45There's...one or maybe two patients in ITU who can step down.
0:15:45 > 0:15:48So we're just waiting for confirmation from them
0:15:48 > 0:15:50that one or both will go. We only need one bed,
0:15:50 > 0:15:52which will free up the ITU bed for you.
0:15:56 > 0:16:00Simon and Patricia, his wife of 36 years, have been waiting for
0:16:00 > 0:16:04three hours to find out if his operation can go ahead.
0:16:04 > 0:16:07You don't quite know whether not hearing something is
0:16:07 > 0:16:09a good sign or a bad sign, do you?
0:16:09 > 0:16:12You're geared up to do nothing, really - just wait.
0:16:12 > 0:16:15When we first embarked on this process,
0:16:15 > 0:16:17we were told that there is...
0:16:17 > 0:16:20a window of,
0:16:20 > 0:16:23I don't know how many weeks - five-to-eight weeks -
0:16:23 > 0:16:25after the chemo and radio stops
0:16:25 > 0:16:28when it is the best time to do the operation.
0:16:31 > 0:16:34I haven't asked the question, "So if you can't do it today...
0:16:38 > 0:16:41"..do I then have to start doing chemo and radio again,
0:16:41 > 0:16:43"or something? Or what actually happens?"
0:16:43 > 0:16:46Cos you don't like to ask those questions. You don't...
0:16:46 > 0:16:49you don't really want to have the answer.
0:16:49 > 0:16:51You just rely on them to do the operation.
0:16:51 > 0:16:54But you reach a point where you just say, "I want it done."
0:16:54 > 0:16:57You know? You just can't keep putting it off forever.
0:16:59 > 0:17:01And I guess it's not just for you,
0:17:01 > 0:17:02it's the impact on family,
0:17:02 > 0:17:05- loved ones, and...- Oh, yes.
0:17:05 > 0:17:06Yeah.
0:17:09 > 0:17:10- ..me... - SHE LAUGHS
0:17:10 > 0:17:12- ..particularly.- Yeah.
0:17:16 > 0:17:17Can you tell me your name?
0:17:17 > 0:17:19- Eladio Pracoyo.- Great.
0:17:19 > 0:17:20And your date of birth?
0:17:20 > 0:17:23January 22, 1941.
0:17:23 > 0:17:24That's a great birthday.
0:17:24 > 0:17:27- It's my birthday as well.- Yeah?
0:17:27 > 0:17:30All right, just open and close that hand a couple of times.
0:17:30 > 0:17:32So it's exactly four weeks after Christmas, isn't it?
0:17:32 > 0:17:35- Mm.- Your birthday?- Yes.
0:17:35 > 0:17:37- From the Philippines?- Yes.- Yeah?
0:17:43 > 0:17:46Surgeon George Reese begins his patient Eladio's operation.
0:17:48 > 0:17:51We're going to do a keyhole operation for him where we
0:17:51 > 0:17:54remove the part of the bowl with the cancer in it,
0:17:54 > 0:17:56and its adjacent blood supply
0:17:56 > 0:17:59so that we can take any lymph glands
0:17:59 > 0:18:01that may or may not be affected by the cancer.
0:18:01 > 0:18:04And then we're going to join it all back together again.
0:18:10 > 0:18:12Four hours later, the tumour is out,
0:18:12 > 0:18:14and the operation is over.
0:18:15 > 0:18:19Why should I feel victorious that I'm actually just allowed to
0:18:19 > 0:18:21do what I should have started doing
0:18:21 > 0:18:23at eight o'clock this morning?
0:18:23 > 0:18:26It's because the beds are so bad at the moment that
0:18:26 > 0:18:28it seems rare to be allowed
0:18:28 > 0:18:30to actually go ahead and do an operation.
0:18:30 > 0:18:33- Very bizarre. - SIREN BLARES
0:18:35 > 0:18:38The emergency patient from Norfolk is an hour away.
0:18:38 > 0:18:41The team doesn't know if she will survive the journey.
0:18:43 > 0:18:46The risk we run here is we're holding a bed for
0:18:46 > 0:18:49a patient who hasn't even made it into the organisation yet,
0:18:49 > 0:18:52and not going ahead with patients who are already here.
0:18:56 > 0:18:58Do you have to do this for people every day?
0:18:58 > 0:19:00- Struggling with socks?- Yeah, yeah. - THEY LAUGH
0:19:03 > 0:19:04- Ah.- Hi, George.
0:19:04 > 0:19:05Hi, thank you.
0:19:05 > 0:19:08The two people I'm kicking out from ICU,
0:19:08 > 0:19:12I-I...one of them I'm not really that comfortable with,
0:19:12 > 0:19:15so I don't have a guaranteed bed for anybody at the moment.
0:19:15 > 0:19:16Right.
0:19:16 > 0:19:19So I might get one or both of them out, but, you know.
0:19:19 > 0:19:21And if your patient leaves,
0:19:21 > 0:19:23do you think you will have a space?
0:19:23 > 0:19:26If this patient doesn't survive from...
0:19:26 > 0:19:28from Norfolk, then, you know.
0:19:28 > 0:19:31But we can't predicate.
0:19:31 > 0:19:35- So shall we wait a bit more time? - The only thing you can do is wait.
0:19:35 > 0:19:37But I don't think the odds are very good.
0:19:37 > 0:19:43We don't have enough slack in our capacity to be able to let
0:19:43 > 0:19:46Prof Hanna go ahead and do the oesophagectomy.
0:19:46 > 0:19:50Um...I mean, what's hard about this is that, you know,
0:19:50 > 0:19:52we're also talking about
0:19:52 > 0:19:55whether we can go ahead and do it...
0:19:57 > 0:20:01..if the patient from Norwich doesn't survive the journey,
0:20:01 > 0:20:04and that's a very hard and callous-sounding thing
0:20:04 > 0:20:08to be talking about, but that's the practical reality.
0:20:08 > 0:20:14They have this patient coming in who might require the I...
0:20:14 > 0:20:15intensive care bed.
0:20:15 > 0:20:20- They might die.- If they die, then the bed is available for me.
0:20:20 > 0:20:22And we can do the operation.
0:20:24 > 0:20:26But if not, they've got the bed.
0:20:26 > 0:20:30- That's the seriousness of... - They've got the bed if they need it.
0:20:30 > 0:20:32How does that make you feel?
0:20:35 > 0:20:37Guilty, actually.
0:20:39 > 0:20:41- Yeah.- In a way, yeah.
0:20:47 > 0:20:50I'm the person that, when someone is really irate and they say,
0:20:50 > 0:20:53"Who made the decision that we're not going to do blah?"
0:20:53 > 0:20:56my team or various other general managers
0:20:56 > 0:21:00will say, "Lesley did that - and here's her number," usually.
0:21:01 > 0:21:03So that's who I am.
0:21:03 > 0:21:06So you're the one that stops things happening sometimes?
0:21:06 > 0:21:09Sometimes I stop things happening, yeah.
0:21:09 > 0:21:11- What's that like?- Horrible.
0:21:11 > 0:21:14It's a horrible feeling because when you stop something...
0:21:14 > 0:21:19You know, I'm a nurse. I've spent my whole working career...
0:21:19 > 0:21:22doing the bit that is about making things right.
0:21:22 > 0:21:24Not always making things better
0:21:24 > 0:21:28but doing the right thing by people all the time.
0:21:28 > 0:21:31And I do the right thing all the time in this job
0:21:31 > 0:21:35but it's not always the right thing for one person.
0:21:35 > 0:21:37I do the right thing for the hospital.
0:21:37 > 0:21:40And that's really difficult because that does mean
0:21:40 > 0:21:45that there will be people who today we haven't done the right thing for.
0:21:52 > 0:21:53- Hello.- Hi.
0:21:53 > 0:21:55Hi, Simon.
0:21:55 > 0:21:58I thought I'd pop up and see what we can do to help.
0:21:58 > 0:22:00I have very few options.
0:22:00 > 0:22:04What worries me is, we've got no slack
0:22:04 > 0:22:07for the...for the unexpected that is the norm here.
0:22:07 > 0:22:10What I don't want to do is put you guys under loads of pressure.
0:22:10 > 0:22:14I think we are asking for trouble if we try and do...
0:22:14 > 0:22:16Yeah, but we are trying to work out...
0:22:16 > 0:22:19George, if you can operate, if you could do it tomorrow,
0:22:19 > 0:22:21I think the chances are better.
0:22:21 > 0:22:22Yeah, but I think...
0:22:26 > 0:22:29We can certainly... Whatever you step down from ITU,
0:22:29 > 0:22:32we will create beds to allow that to happen.
0:22:32 > 0:22:35But Simon is now trying to keep an empty bed
0:22:35 > 0:22:37just as a slack for something to happen.
0:22:37 > 0:22:41- How long do you think you're going to be...?- I will be very late.
0:22:41 > 0:22:44I will take six hours' operating.
0:22:44 > 0:22:47If we go ahead now, we'll finish by midnight.
0:22:47 > 0:22:49I think the safest thing to do is to defer it,
0:22:49 > 0:22:53but, you know, I understand the logistics of that are a disaster.
0:22:53 > 0:22:56It's not just the logistics, there are clinical issues here
0:22:56 > 0:22:58because it's the second cancellation
0:22:58 > 0:23:00with a dedicated time in radiotherapy
0:23:00 > 0:23:03and we're not doing him to keep a slack in the system
0:23:03 > 0:23:04which doesn't have a slack.
0:23:04 > 0:23:08But I've got no ability to manage any other problems.
0:23:08 > 0:23:11If he didn't have a bed, I would have no problems.
0:23:11 > 0:23:13I can understand it.
0:23:13 > 0:23:16But if we are not doing him to keep a slack while we can
0:23:16 > 0:23:20use recovery as an alternative, this is the difficulty I have.
0:23:20 > 0:23:23- We're very close to the limit. - We are close to the limit.
0:23:23 > 0:23:24We're very close to the limit
0:23:24 > 0:23:27and operating absolutely on the limit is unwise.
0:23:27 > 0:23:31The question really, if we wait another week or another time,
0:23:31 > 0:23:35this will not be... I'm not sure how this will get better.
0:23:35 > 0:23:40Cancelling a cancer patient three times is a serious incident, so...
0:23:42 > 0:23:45This is something you need to... to work on it.
0:23:47 > 0:23:50It's your call, Simon. What do you want us to do?
0:23:50 > 0:23:54You know, we don't have the slack at the moment to do this safely.
0:23:54 > 0:23:56We are stuck at that point.
0:23:56 > 0:23:58OK. That's fine.
0:23:58 > 0:24:00So, from my point of view...
0:24:00 > 0:24:04I think you need to get on with her, whatever you do,
0:24:04 > 0:24:08and I'll work on the basis that they will be able to give me a bed.
0:24:08 > 0:24:10SIREN
0:24:13 > 0:24:16The scans from the hospital in Norfolk
0:24:16 > 0:24:18have been received by Richard Gibbs.
0:24:18 > 0:24:21They reveal a huge aneurysm in the main artery
0:24:21 > 0:24:23from the patient's heart.
0:24:23 > 0:24:26OK, shall we just... so, the team brief here...
0:24:26 > 0:24:31this lady has a ruptured aneurysm.
0:24:31 > 0:24:34Her aorta is four times the normal diameter
0:24:34 > 0:24:37so it's very dilated and that's like a balloon.
0:24:37 > 0:24:40It's just stretched and stretched and stretched
0:24:40 > 0:24:43and now it's finally given, so blood's starting to come out of it
0:24:43 > 0:24:45where it's got a small tear in it.
0:24:45 > 0:24:48The surgical plan is to do a left thoracolaparotomy
0:24:48 > 0:24:51and not disturb the abdomen until we've got control
0:24:51 > 0:24:55of the lower thoracic aorta and then we'll obviously open up.
0:24:55 > 0:24:58All right? See you in a few minutes.
0:24:59 > 0:25:02'There are frustrations so the whole team gets assembled
0:25:02 > 0:25:06'and we make a plan and it takes quite a lot of effort
0:25:06 > 0:25:09'and concentration to get everyone pulling together to do it.'
0:25:09 > 0:25:14And so if that plan is preceded by three hours of negotiations about,
0:25:14 > 0:25:17can we slot someone into HDU if they go to Hammersmith
0:25:17 > 0:25:20so the ITU patient can drop down?
0:25:20 > 0:25:22You know, I...I...
0:25:22 > 0:25:26I sometimes feel that I spend as much energy on trying to organise
0:25:26 > 0:25:29and manage beds and the movement and the flow of patients
0:25:29 > 0:25:32within the hospital in order to allow us to do what we
0:25:32 > 0:25:36actually want to just do and get on with, which is to operate.
0:25:36 > 0:25:38SIREN
0:25:43 > 0:25:46Professor Hanna has now been waiting to be given the go-ahead
0:25:46 > 0:25:49for HIS operation for five hours.
0:25:51 > 0:25:53Hi, Lesley. It's George Hanna.
0:25:53 > 0:25:56Hi, Lesley. The aneurysm will come in one hour's time.
0:25:56 > 0:25:58I spoke to Rick.
0:25:58 > 0:26:00So, yeah...
0:26:00 > 0:26:03So now we need to make a decision, really.
0:26:03 > 0:26:06'We had a patient come in who was a self-hanging.'
0:26:06 > 0:26:08OK, just one second, Lesley.
0:26:09 > 0:26:13There is a trauma came in just now. Just now.
0:26:13 > 0:26:14Somebody's hanging,
0:26:14 > 0:26:18so there's an extra case into the equation.
0:26:18 > 0:26:20If this patient goes to ITU,
0:26:20 > 0:26:23then potentially there will be no beds?
0:26:23 > 0:26:26Definitely no?
0:26:27 > 0:26:30Head of intensive care Simon Ashworth must now go to A&E
0:26:30 > 0:26:34to decide if the hanging patient will need an intensive care bed.
0:26:34 > 0:26:37- He didn't have a cardiac arrest? - Correct.
0:26:37 > 0:26:39Have you got him sedated or anything?
0:26:39 > 0:26:42He is on a propofol infusion.
0:26:42 > 0:26:47The patient will need life-support, which only ICU can provide.
0:26:47 > 0:26:49We'll need to find a bed for him.
0:26:51 > 0:26:53I think it'll be possible,
0:26:53 > 0:26:57providing that nobody else here needs to come up.
0:26:57 > 0:27:01But it certainly means that the chances that we would be able to
0:27:01 > 0:27:04do the oesophagectomy is zero now.
0:27:09 > 0:27:13It's just a trauma came in now. Just literally now.
0:27:13 > 0:27:16- Do we all have to go home? - Yes.- OK.
0:27:18 > 0:27:19OK.
0:27:25 > 0:27:27Waste of resources.
0:27:27 > 0:27:30There is anaesthetist, there is a surgeon,
0:27:30 > 0:27:34there is theatre, there is three or four nurses,
0:27:34 > 0:27:37and this is empty - it is not used, not utilised,
0:27:37 > 0:27:40so it is a waste.
0:27:40 > 0:27:42SIREN
0:27:58 > 0:28:01After a four-hour journey from Norfolk,
0:28:01 > 0:28:04the patient with the ruptured aorta, retired school teacher Janice,
0:28:04 > 0:28:06arrives at St Mary's A&E.
0:28:13 > 0:28:16OK, Mrs Metcalf...Medcalf.
0:28:16 > 0:28:18Sorry, is it Mrs or Miss?
0:28:18 > 0:28:20M-E-D.
0:28:20 > 0:28:22What's happened is, the aneurysm has ruptured
0:28:22 > 0:28:26but, luckily, the blood is just sitting in the back of the abdomen
0:28:26 > 0:28:30by the big back muscles, so it hasn't just blown,
0:28:30 > 0:28:32and that means we've got a chance to fix this.
0:28:32 > 0:28:34We've had a look at it on the scans.
0:28:34 > 0:28:37The safest way to do it is, we're going to make a cut
0:28:37 > 0:28:40which is going to go run near your chest and down into your tummy
0:28:40 > 0:28:44and then we can clamp the aorta and hopefully sew a big graft on
0:28:44 > 0:28:46and that will be the end of the problem.
0:28:46 > 0:28:48- It's obviously a bit risky. - SHE LAUGHS
0:28:48 > 0:28:50I'm going to be honest with you.
0:28:50 > 0:28:53And there's a few complications that can happen.
0:28:53 > 0:28:57I mean, you're definitely going to lose quite a bit of blood.
0:28:57 > 0:29:00And there's always the risk of things like a heart attack
0:29:00 > 0:29:03or a stroke or kidney failure, erm, afterwards.
0:29:03 > 0:29:06But the thing is, we haven't got a lot of choice,
0:29:06 > 0:29:10because if we don't do it, then that's the end anyway.
0:29:10 > 0:29:12- OK?- Thank you.
0:29:12 > 0:29:15This case has trumped the patient with cancer
0:29:15 > 0:29:17that was going to get done in the other theatre
0:29:17 > 0:29:19because she's...
0:29:20 > 0:29:25..got a condition which will kill her, erm...
0:29:25 > 0:29:30sometime in the next three, four, five, six hours,
0:29:30 > 0:29:33so if we don't do it now,
0:29:33 > 0:29:36then there is going to be no "five hours' time" for her.
0:29:42 > 0:29:45'Multiple cancellations are something we really try
0:29:45 > 0:29:48'very hard to avoid but, actually, without slack in the system
0:29:48 > 0:29:50'it is impossible.
0:29:50 > 0:29:53'And if you try too hard to avoid them, what you end up doing
0:29:53 > 0:29:57'is prioritising somebody because they've been cancelled'
0:29:57 > 0:30:00'over somebody who is at immediate risk of dying.
0:30:00 > 0:30:03'They are the issues you are juggling.'
0:30:04 > 0:30:07Janice's sons arrived minutes later,
0:30:07 > 0:30:10by which point their mother's operation has already begun.
0:30:12 > 0:30:14'We spoke to her last night, literally.
0:30:14 > 0:30:19'She'd said that she was in some discomfort, got stomach pains,
0:30:19 > 0:30:24'but she decided to go to the out-of-hours surgery
0:30:24 > 0:30:27'and took herself off... drove herself there,
0:30:27 > 0:30:29'but didn't reach -
0:30:29 > 0:30:31'she passed out behind the wheel and crashed the car.
0:30:31 > 0:30:36'I heard about it from the ambulance driver about 4:30am this morning,
0:30:36 > 0:30:39'saying that she had this aneurysm.'
0:30:44 > 0:30:47'Will she survive? Will she pull through or not?
0:30:47 > 0:30:50'There's always significant risks.'
0:30:50 > 0:30:54Mortality is probably about 50-60%.
0:30:58 > 0:31:03We'd like to try and get the aorta dissected out in a nice, clean way
0:31:03 > 0:31:05before it blows.
0:31:05 > 0:31:08I mean, it's already ruptured, but if it starts bleeding freely
0:31:08 > 0:31:10because we're dissecting around it,
0:31:10 > 0:31:13then we're going to have to clamp in a real hurry.
0:31:17 > 0:31:20OK, guys? Thank you.
0:31:21 > 0:31:23Have you got a periosteal elevator?
0:31:23 > 0:31:25Can I have a Wylie?
0:31:25 > 0:31:28So the fish slice just needs to go there.
0:31:28 > 0:31:31We can put the lung down if we want but let's try to avoid it
0:31:31 > 0:31:33because she wouldn't like it.
0:31:33 > 0:31:35So that's the heart...
0:31:35 > 0:31:38and this is the thoracic aorta.
0:31:38 > 0:31:41The problem is actually a bit lower down in the belly.
0:31:42 > 0:31:44So she's got a huge haematoma.
0:31:44 > 0:31:47Don't touch the haematoma, whatever you do.
0:31:47 > 0:31:51I mean, it might blow any minute. It really might, literally.
0:31:51 > 0:31:54That's the blood from the rupture which is tracking round the back
0:31:54 > 0:31:56and coming towards the front.
0:31:56 > 0:31:59That's the aneurysm. Don't press it too hard.
0:31:59 > 0:32:02This is going to go, so we need to get a wiggle on.
0:32:05 > 0:32:06'She...
0:32:06 > 0:32:09'likes to keep herself occupied.
0:32:09 > 0:32:12'Reception-aged children, she used to teach,
0:32:12 > 0:32:15'she does various crafty things, she goes bowling,
0:32:15 > 0:32:17'she plays darts.'
0:32:17 > 0:32:21We would joke that we have to make an appointment to go and see her.
0:32:21 > 0:32:23Keeping our fingers crossed.
0:32:24 > 0:32:25Very nervous.
0:32:28 > 0:32:30OK.
0:32:30 > 0:32:32The difficult bit is just about to start.
0:32:32 > 0:32:35Everyone do it slowly. Take the diaphragm away from us.
0:32:35 > 0:32:39So this...gently. Let me just get this down here.
0:32:39 > 0:32:41It's the last bit and then we're there.
0:32:41 > 0:32:44Relax, let go. Let me just do this.
0:32:44 > 0:32:46Move that up to there.
0:32:47 > 0:32:48Get that.
0:32:50 > 0:32:52Suck, suck, suck, suck, suck.
0:32:52 > 0:32:54OK.
0:32:54 > 0:32:58- The pressure's just gone. - What?! Has it completely gone?
0:32:59 > 0:33:01OK, is the patient all right?
0:33:01 > 0:33:03Guys, give it a minute.
0:33:03 > 0:33:05I can clamp the thoracic aorta any time.
0:33:05 > 0:33:07- She didn't tolerate it.- All right.
0:33:07 > 0:33:10- It's coming up anyway, isn't it? - It's coming up.
0:33:33 > 0:33:36- Hi. I'm Richard Gibbs.- Hello.- Hi.
0:33:37 > 0:33:40I'm just going to tell you this straight,
0:33:40 > 0:33:42the operation was, erm, a success,
0:33:42 > 0:33:46but it was quite challenging at times
0:33:46 > 0:33:49and although she's stable at the moment,
0:33:49 > 0:33:52I won't say anything yet about the prognosis.
0:33:52 > 0:33:55She needs to go to ITU for the next 24 hours
0:33:55 > 0:33:57and they will stabilise her
0:33:57 > 0:34:00and support her in any way that is necessary.
0:34:00 > 0:34:05But at her age, and having a really big operation like this,
0:34:05 > 0:34:08I don't think we can say she's in the clear yet.
0:34:08 > 0:34:10I think we need to give that 72 hours
0:34:10 > 0:34:13and if she starts to get better and better,
0:34:13 > 0:34:15then I'll be really hopeful.
0:34:25 > 0:34:27'We've been full all day.
0:34:27 > 0:34:30'Sadly this has meant we had to cancel George Hanna's patient,
0:34:30 > 0:34:35'but, you know, I'm hopeful that we might be able to do that tomorrow.
0:34:35 > 0:34:38'I think we do need more capacity because we're always under pressure
0:34:38 > 0:34:42'and it does feel to me like the elastic
0:34:42 > 0:34:46'is a bit nearer to breaking now than it ever was.'
0:34:48 > 0:34:52It's wearing, constantly going around, taking bad news to people,
0:34:52 > 0:34:56and, you know, everybody gets a bit irate and it...
0:34:56 > 0:34:59you know, it takes it out of you.
0:35:03 > 0:35:06St Mary's' capacity problems are directly linked
0:35:06 > 0:35:09to its status as a major trauma centre.
0:35:10 > 0:35:13Its A&E department must provide round-the-clock emergency care.
0:35:15 > 0:35:18A 10% increase in patients in the last 12 months
0:35:18 > 0:35:22means that it now handles more than 150 new cases every day.
0:35:24 > 0:35:26A&E has four resuscitation bays
0:35:26 > 0:35:29for patients with life-threatening conditions
0:35:29 > 0:35:32and a further 16 beds for the seriously ill.
0:35:33 > 0:35:37Government regulations stipulate that patients either have to be
0:35:37 > 0:35:40discharged or moved on to another ward within four hours.
0:35:41 > 0:35:44But when the hospital is at full capacity,
0:35:44 > 0:35:47the department quickly fills up with patients waiting for beds
0:35:47 > 0:35:50and the four-hour time limit is regularly breached.
0:35:53 > 0:35:55Hello, I'm Ali, I'm one of the doctors.
0:35:55 > 0:35:58Can you squeeze my hand?
0:35:59 > 0:36:03Alison Sanders, Clinical Director of Emergency Medicine,
0:36:03 > 0:36:05is the consultant on call in A&E.
0:36:05 > 0:36:08'What's happened in the last two years is the whole system,
0:36:08 > 0:36:11'country-wide, seems to have ground to a halt.'
0:36:11 > 0:36:15It just makes us feel as though we are firefighting every single day
0:36:15 > 0:36:17and we're not unique, we're not unique at Imperial,
0:36:17 > 0:36:20we are the same as any other emergency department
0:36:20 > 0:36:23in the country and any other major trauma centre.
0:36:23 > 0:36:27Every day we just feel like we are struggling to just keep afloat.
0:36:27 > 0:36:30That was just another trauma coming in now.
0:36:30 > 0:36:32A fall from six foot. LOC.
0:36:32 > 0:36:34Is the shooting coming to us?
0:36:34 > 0:36:36He's had two lines of cocaine,
0:36:36 > 0:36:39unknown quantities of vodka and beer.
0:36:40 > 0:36:4328-year-old male stabbed three times.
0:36:43 > 0:36:46It's been given as seven men with guns have gone into a building,
0:36:46 > 0:36:47someone's not moving.
0:36:47 > 0:36:49And what about trauma beds?
0:36:49 > 0:36:51Two.
0:36:51 > 0:36:53Hello. What beds have you got for me, please?
0:36:53 > 0:36:57The minute that we have bed problems,
0:36:57 > 0:37:00usually due to patients not being able to leave the hospital
0:37:00 > 0:37:03at the other end, then we end up in this state.
0:37:03 > 0:37:07Erm...we're going to need this man in resus to go to ITU,
0:37:07 > 0:37:11so what have we got that can come out and where can we put it?
0:37:13 > 0:37:16Everyone is already working as hard as they can and I think
0:37:16 > 0:37:20they're fed up of being told to be more efficient all the time.
0:37:21 > 0:37:23There's only so efficient you can be
0:37:23 > 0:37:26and also, when everybody is working so hard, day in, day out,
0:37:26 > 0:37:29then eventually, you know, they get tired.
0:37:29 > 0:37:31You hope they don't get tired and make mistakes,
0:37:31 > 0:37:35you hope you've got enough resilience in the system for that,
0:37:35 > 0:37:37but it certainly doesn't make everyone more efficient.
0:37:43 > 0:37:45With winter approaching,
0:37:45 > 0:37:50the pressure is set to intensify within A&E and across the hospital.
0:37:56 > 0:37:59Good morning, everyone. Who have we got at Hammersmith this morning?
0:37:59 > 0:38:02And Charing Cross, have we got you guys?
0:38:02 > 0:38:05OK, let's look at capacity at St Mary's.
0:38:05 > 0:38:08We've got a completely full resus, very full majors,
0:38:08 > 0:38:10minors is creeping up
0:38:10 > 0:38:13so a big push on anything we've got dischargeable, please.
0:38:13 > 0:38:16St Mary's remains close to capacity.
0:38:16 > 0:38:18However, it is no longer on Code Red.
0:38:18 > 0:38:21From a critical care perspective,
0:38:21 > 0:38:23it's not been the best start to the week.
0:38:23 > 0:38:27Unfortunately, sometimes, being a major trauma centre,
0:38:27 > 0:38:30our demand for very sick patients
0:38:30 > 0:38:33outstrips what we have in capacity and we can't predict that.
0:38:34 > 0:38:38On the high dependency unit, George Reese's patient Eladio
0:38:38 > 0:38:41is awake and stable following surgery yesterday.
0:38:41 > 0:38:43More.
0:38:48 > 0:38:50So you had a nice sleep?
0:38:50 > 0:38:53- About one hour, two hours. - Yeah?- Enough.
0:38:53 > 0:38:55Yeah, I'm waking up.
0:38:56 > 0:39:00He should be well enough to go home by the end of the week.
0:39:03 > 0:39:06In intensive care, Janice is yet to wake up
0:39:06 > 0:39:09following the operation to repair her aorta.
0:39:10 > 0:39:13Squeeze my hand, Janice.
0:39:13 > 0:39:15Janice?
0:39:15 > 0:39:17Janice, squeeze my hand if you can.
0:39:17 > 0:39:20As the nurses reduce her sedation,
0:39:20 > 0:39:22she should begin to regain consciousness.
0:39:22 > 0:39:24Can you open your eyes for me?
0:39:46 > 0:39:49After being forced to postpone Simon's operation yesterday,
0:39:49 > 0:39:52Professor George Hanna is waiting to find out
0:39:52 > 0:39:55if there is a bed available in intensive care this morning.
0:39:57 > 0:39:59There's Dr Ashworth.
0:40:00 > 0:40:02Good morning.
0:40:02 > 0:40:05- Morning. - You all right this morning?- Ish.
0:40:05 > 0:40:08We're still trying to get George's case done.
0:40:08 > 0:40:10It's probably contingent on... Hi.
0:40:10 > 0:40:14on moving one of our patients to Charing Cross.
0:40:14 > 0:40:17- They've still got the bed. - They've still got the bed, OK?
0:40:17 > 0:40:19If the patient is stable enough to go.
0:40:19 > 0:40:22- Are you going to let George know? - I'll let George know.
0:40:22 > 0:40:25- I told him that was the contingency. - He'll be delighted.
0:40:25 > 0:40:26Hi, George.
0:40:26 > 0:40:29Yes, you can start. I've just spoken to Lesley.
0:40:29 > 0:40:31Wonderful.
0:40:31 > 0:40:32Fine.
0:40:34 > 0:40:37Good morning. I've got good news. We have a bed.
0:40:42 > 0:40:46Finally, after weeks of preparation and two cancellations,
0:40:46 > 0:40:50the operation to remove Simon's tumour can go ahead.
0:40:51 > 0:40:53How was he last night?
0:40:53 > 0:40:55Erm, he was OK.
0:40:55 > 0:40:57We had jumbo prawns and noodles.
0:40:57 > 0:41:02Yes, I gave him a great big bowl, as I have been doing,
0:41:02 > 0:41:04with cream lashed onto it for him!
0:41:05 > 0:41:07So we ate and, erm...
0:41:07 > 0:41:10watched a bit of TV and chatted and...
0:41:11 > 0:41:13..he was fine.
0:41:13 > 0:41:17And I knew he probably wouldn't sleep very much but that was OK.
0:41:21 > 0:41:24The operation will take more than six hours.
0:41:31 > 0:41:35An oesophageal tumour, you know, you, you...
0:41:35 > 0:41:38you bombard it with the radiotherapy,
0:41:38 > 0:41:40you bombard it with the chemo, which he had,
0:41:40 > 0:41:43and it has shrunk.
0:41:44 > 0:41:47But if we just carried on with our life,
0:41:47 > 0:41:49it could just grow again
0:41:49 > 0:41:51and so that's...
0:41:52 > 0:41:53You know, there is no...
0:41:53 > 0:41:56there is no choice, you just have to have the surgery.
0:42:00 > 0:42:03So, yes, I do feel relieved...
0:42:04 > 0:42:09..because it's now happening and there's nothing else anyone can do
0:42:09 > 0:42:11except the team, so...
0:42:14 > 0:42:16And waiting is... Sorry.
0:42:16 > 0:42:18Waiting is going to be tricky.
0:42:18 > 0:42:19But it'll be fine.
0:42:21 > 0:42:25It's a privilege to operate on a fellow human.
0:42:25 > 0:42:28The patient will put his life in my hands
0:42:28 > 0:42:31and I have a duty to do the best of my ability
0:42:31 > 0:42:34to give them the best outcome.
0:42:35 > 0:42:38The first stage of the operation is to remove Simon's oesophagus
0:42:38 > 0:42:40and the tumour it contains.
0:42:40 > 0:42:43'You open the chest, you open the abdomen,
0:42:43 > 0:42:47'you dissect along a lot of blood vessels,
0:42:47 > 0:42:50'and that's why, actually, in terms of the impact of the operation,
0:42:50 > 0:42:54'it's one of the biggest operations of the body can take.'
0:42:54 > 0:42:56How is the patient? Is he OK?
0:42:58 > 0:43:02So this is the oesophagus and the tumour which we removed now.
0:43:06 > 0:43:09The oesophagus is taken to the pathology lab
0:43:09 > 0:43:12to see how far his cancer has spread.
0:43:19 > 0:43:22This is the oesophagus at the top, between my fingers,
0:43:22 > 0:43:25this is the stomach here, so we expect to find the tumour
0:43:25 > 0:43:28somewhere at the bottom of the oesophagus,
0:43:28 > 0:43:30just where it goes into the stomach.
0:43:30 > 0:43:32I'm trying to put my finger into the oesophagus
0:43:32 > 0:43:35and I can feel it's thickened and narrowed.
0:43:35 > 0:43:38One thing we want to know is whether all the tumour has been removed.
0:43:38 > 0:43:41The further the tumour has invaded into the wall,
0:43:41 > 0:43:43the worse the prognosis for the patient,
0:43:43 > 0:43:46and if the tumour has spread to the lymph nodes,
0:43:46 > 0:43:48the worse the prognosis for the patient,
0:43:48 > 0:43:51and the more lymph nodes that are involved,
0:43:51 > 0:43:53the worse the prognosis for the patient.
0:43:57 > 0:44:02The most challenging part of the operation can now begin.
0:44:02 > 0:44:04Professor Hanna must create a new food pipe
0:44:04 > 0:44:07in order for Simon to be able to eat.
0:44:07 > 0:44:09We convert the stomach...
0:44:10 > 0:44:14..and we need to reconnect the gastrointestinal tract
0:44:14 > 0:44:18in a way that the patient will be able to eat after that.
0:44:21 > 0:44:23Going well. Really well.
0:44:23 > 0:44:25Operation looks...
0:44:26 > 0:44:29..looks nice, really, and if things look nice
0:44:29 > 0:44:31usually it's worked very well.
0:44:40 > 0:44:43Simon will spend the night in intensive care,
0:44:43 > 0:44:46the same unit as Janice.
0:45:00 > 0:45:03Having finished in theatre in the early hours,
0:45:03 > 0:45:06Professor Hanna heads to the intensive care unit
0:45:06 > 0:45:08to check on Simon's progress.
0:45:08 > 0:45:10All went well. I spoke to your wife yesterday.
0:45:10 > 0:45:13- That's very kind of you. Thank you.- So she's happy.
0:45:13 > 0:45:16They may send you to go to the high dependency unit.
0:45:16 > 0:45:17Tomorrow?
0:45:17 > 0:45:20- No, today.- Today?- Yeah.- Wow.
0:45:20 > 0:45:22- Most likely, yeah.- OK.
0:45:22 > 0:45:25- So it's a promotion to go there. - Absolutely, yes.
0:45:25 > 0:45:27- Heavens, I wasn't expecting that. - Yeah.
0:45:27 > 0:45:31- You obviously need the bed. - No, you look well.
0:45:31 > 0:45:34You look well. You don't need to be here if you don't need to.
0:45:37 > 0:45:40Two days after her emergency operation,
0:45:40 > 0:45:43Janice is stable enough to be taken off life-support.
0:45:43 > 0:45:45A big bold hello.
0:45:45 > 0:45:47- FAINT:- Hello.
0:45:48 > 0:45:49- FAINT:- Hello.
0:45:50 > 0:45:52You'll get there.
0:45:54 > 0:45:56She's not out of the woods by any means,
0:45:56 > 0:45:59so there's still a long road to recovery here,
0:45:59 > 0:46:03but she's been making steady progress all the way through.
0:46:10 > 0:46:13Every week, Lesley and her team meet with senior managers
0:46:13 > 0:46:17to review how they're dealing with the hospital's capacity issues.
0:46:17 > 0:46:20I think things have been getting more and more challenged.
0:46:20 > 0:46:23Certainly the pressure feels much more intense
0:46:23 > 0:46:26and it feels like we are making difficult,
0:46:26 > 0:46:29really difficult decisions much more regularly
0:46:29 > 0:46:33than we had been doing and than we should be doing.
0:46:34 > 0:46:37Chairing today's meeting is Professor Tim Orchard,
0:46:37 > 0:46:40Imperial Trust's Director of Medicine.
0:46:40 > 0:46:43Top of the agenda, the chronic bed shortage.
0:46:43 > 0:46:46If we have a significant flu epidemic,
0:46:46 > 0:46:50we are going to be completely stuffed.
0:46:50 > 0:46:55We have never started winter with so little spare capacity.
0:46:55 > 0:46:59And so I think one of the things that we need to do,
0:46:59 > 0:47:01and we've never had to do it in this Trust before,
0:47:01 > 0:47:03but I think we need to think about
0:47:03 > 0:47:06what we do when we actually run out of beds.
0:47:06 > 0:47:10What do you do in terms of, if we get noro and we lose a ward,
0:47:10 > 0:47:13- organisationally, we are not going to manage.- Exactly.
0:47:13 > 0:47:15We've got nowhere to go to.
0:47:15 > 0:47:19It's felt on many days as though we had the tipping over the edge
0:47:19 > 0:47:22of the cliff phenomenon, where you get to a critical point
0:47:22 > 0:47:25and you can't function for the admitted or non-admitted patients
0:47:25 > 0:47:27because everything is full.
0:47:27 > 0:47:30There is no more capacity on the St Mary's side.
0:47:30 > 0:47:31We know that.
0:47:31 > 0:47:35It looks impractical to move any surgical specialties off this site
0:47:35 > 0:47:39so one possibility is moving the paediatric outpatient department,
0:47:39 > 0:47:42which would potentially allow the creation
0:47:42 > 0:47:45of probably around 15 to 20 beds on the sixth floor.
0:47:45 > 0:47:48But that's obviously going to be quite expensive.
0:47:48 > 0:47:50It might be a really good plan for next year,
0:47:50 > 0:47:53but the reality of getting all of that sorted out by winter, it feels
0:47:53 > 0:47:56like we need to do something sensible and practical now.
0:47:56 > 0:48:00One of the big debates people are having nationally at the moment is,
0:48:00 > 0:48:03in extremis, can adults be nursed alongside children?
0:48:03 > 0:48:06What do you do in terms of, like we've had on this site,
0:48:06 > 0:48:09when you've had ten paediatric beds and you've got ten unplaced adults
0:48:09 > 0:48:12in ED, what decision would you want to make there?
0:48:12 > 0:48:16So the question is, where can we board extra patients on wards?
0:48:17 > 0:48:21How would we nurse that to make sure the patients are safe
0:48:21 > 0:48:24and that the patients have an appropriate level
0:48:24 > 0:48:26of privacy and dignity?
0:48:26 > 0:48:29Other trusts have used places like gyms,
0:48:29 > 0:48:31endoscopy,
0:48:31 > 0:48:33cath lab recovery,
0:48:33 > 0:48:38Erm, so, I think we just need to be clear what...
0:48:38 > 0:48:41what the levels of escalation are.
0:48:41 > 0:48:45What we need to do is to roll out to every single ward and department
0:48:45 > 0:48:49in the Trust a plan that says, we've got to aim to do X, Y or Z.
0:48:49 > 0:48:51Very good. Thank you.
0:48:51 > 0:48:54It is tough and I think people are working incredibly hard,
0:48:54 > 0:48:56which we do appreciate.
0:48:56 > 0:48:59The senior managers have agreed a set of new measures
0:48:59 > 0:49:01called the Full Capacity Protocol.
0:49:02 > 0:49:06I'm still a practising doctor, I still go on the wards regularly,
0:49:06 > 0:49:09so I'm very, very well aware, very in touch with what's going on.
0:49:09 > 0:49:12I think we know that we need to create more capacity.
0:49:12 > 0:49:15I think we have put in place a number of plans
0:49:15 > 0:49:17of what to do with our estate to make things better.
0:49:17 > 0:49:21Every consultant will go around and make sure every patient
0:49:21 > 0:49:24who's in the hospital really needs to be in hospital
0:49:24 > 0:49:27and, obviously, we will then make sure that every single bed
0:49:27 > 0:49:30that can be opened safely is opened.
0:49:30 > 0:49:34There are some wards where there is space that is relatively unused
0:49:34 > 0:49:37and we would be able to fit a bed into that space
0:49:37 > 0:49:40so it's about using every single square inch of space,
0:49:40 > 0:49:43even if it doesn't normally have a bed in it.
0:49:45 > 0:49:49It will be down to Lesley to implement the hospital's new policy.
0:49:49 > 0:49:51Problems definitely aren't easy to solve
0:49:51 > 0:49:55but we've got something that will see us over the next few months.
0:49:55 > 0:49:58It's much better that we have an ability for the whole hospital
0:49:58 > 0:50:01to know that we're in trouble, rather than it just being me
0:50:01 > 0:50:04and my office sitting here with our head in our hands.
0:50:04 > 0:50:08It's better to put out an alert that says to the whole organisation,
0:50:08 > 0:50:10"We need some help today."
0:50:11 > 0:50:13- LESLEY:- Right, good morning, everybody.
0:50:15 > 0:50:17- Morning.- Morning?
0:50:17 > 0:50:20- ALL:- Morning. - That's better! Right.
0:50:20 > 0:50:24Bed-wise, we've got one bed in CDU and two beds on Albert,
0:50:24 > 0:50:28no confirmed discharges and a smattering of queries,
0:50:28 > 0:50:31so we have a really challenging day at St Mary's.
0:50:31 > 0:50:34I think we'll go out on Red this morning.
0:50:34 > 0:50:37We'll keep this line open because it will require people to dial in
0:50:37 > 0:50:40to let us know they are undertaking a new set of actions
0:50:40 > 0:50:42in the Full Capacity Protocol.
0:50:42 > 0:50:44Great. We'll speak later. Thank you.
0:50:45 > 0:50:48'There's a lot of both nervousness and excitement
0:50:48 > 0:50:50'about the Full Capacity Protocol.
0:50:50 > 0:50:54What we want to try and do is get to the point where if we're struggling,
0:50:54 > 0:50:56we take an early set of decisions
0:50:56 > 0:50:58that give departments a bit of breathing space.
0:51:04 > 0:51:07Having been stepped down from intensive care,
0:51:07 > 0:51:10Simon is making steady progress.
0:51:11 > 0:51:13He's doing well.
0:51:13 > 0:51:17There's a lot of work that went into him to be at this stage.
0:51:17 > 0:51:18He's very positive.
0:51:18 > 0:51:22If you ask him to walk a mile, he walks three miles.
0:51:22 > 0:51:24I'm looking forward to going home.
0:51:24 > 0:51:26Erm...
0:51:28 > 0:51:30I've been told to expect to feel very tired
0:51:30 > 0:51:33but to keep exercising...
0:51:33 > 0:51:36by walking once we get home.
0:51:36 > 0:51:37Erm...
0:51:37 > 0:51:40there will be some ups and downs, inevitably.
0:51:40 > 0:51:43So you cope with them and come out the other end of that.
0:51:44 > 0:51:47There will be dips and they are quite severe.
0:51:47 > 0:51:51Anyone who thinks there won't be is kidding themselves, basically.
0:51:55 > 0:51:58Simon must now wait to find out if his cancer has spread.
0:51:58 > 0:52:02The pathology lab results are expected in a week.
0:52:05 > 0:52:08In intensive care, Janice is doing well.
0:52:11 > 0:52:15- We're going to hang on to her tonight.- That's fine. OK.
0:52:15 > 0:52:17I'm not going to send her out today.
0:52:17 > 0:52:19I want you to lean forward
0:52:19 > 0:52:21and we're just going to help you over here.
0:52:21 > 0:52:23Really push with your good leg.
0:52:23 > 0:52:27If her progress continues, she will soon be able to leave intensive care
0:52:27 > 0:52:29and recover on a general ward.
0:52:29 > 0:52:32Tuck your bottom in. Tuck your bottom in.
0:52:33 > 0:52:34Well done.
0:52:34 > 0:52:36So push through your arms.
0:52:36 > 0:52:39Look up. That's it.
0:52:39 > 0:52:41Take a big breath in for me.
0:52:42 > 0:52:44- Well done.- Big breath.
0:52:44 > 0:52:45Hello, world.
0:52:45 > 0:52:47Janice is out to get you.
0:52:49 > 0:52:51Oh, dear.
0:52:51 > 0:52:54Hello, Mrs Medcalf. It's great to see you out of bed.
0:52:54 > 0:52:58You get your chest going again and I think that makes the potential
0:52:58 > 0:53:00for you to be home in a week or two real,
0:53:00 > 0:53:04as opposed to what might be a month or two otherwise.
0:53:04 > 0:53:07- So, really important, OK?- Yes.
0:53:07 > 0:53:09- All right.- Thank you very much.
0:53:09 > 0:53:11Sorry?
0:53:11 > 0:53:13- Thank you so much. - No, it's a pleasure.
0:53:13 > 0:53:17- We'll try and get you right as soon as we can, all right?- Thank you.
0:53:22 > 0:53:26Five days after his operation, George Reese's patient Eladio
0:53:26 > 0:53:28is well enough to go home.
0:53:29 > 0:53:32He doesn't need any further treatment.
0:53:32 > 0:53:35The cancer he has was completely removed
0:53:35 > 0:53:38and there was no sign that it had spread
0:53:38 > 0:53:39anywhere else around his body,
0:53:39 > 0:53:42which is the best result we could have hoped for.
0:53:43 > 0:53:47Some weeks are more emotionally challenging than others
0:53:47 > 0:53:49and I think this week has been one of those weeks,
0:53:49 > 0:53:53that emotionally we've, kind of, put ourselves through the wringer.
0:53:57 > 0:54:01The organisation chose me to do this role because I'm resilient.
0:54:01 > 0:54:04Don't get me wrong, it's not like I don't go home some days,
0:54:04 > 0:54:08walk through the front door, and start crying, because I do.
0:54:08 > 0:54:11I've never done it in the office, I'll always wait until I get home,
0:54:11 > 0:54:15but I do because I've had a day that, sometimes you think,
0:54:15 > 0:54:17that was the day from hell,
0:54:17 > 0:54:20I don't know what went so horribly wrong there,
0:54:20 > 0:54:24but it's gone because I've got to make it right the next day.
0:54:30 > 0:54:34The pathology team has concluded its analysis of Simon's tumour.
0:54:34 > 0:54:38They must now disclose the results to Professor Hanna.
0:54:39 > 0:54:42OK, let's start. The first patient.
0:54:42 > 0:54:44Simon A.
0:54:44 > 0:54:47So here is the lumen, here you can see some normal mucosa,
0:54:47 > 0:54:49but in all the blocks we examined,
0:54:49 > 0:54:52there's just a single focus of cancer, which is here...
0:54:53 > 0:54:55..in the oesophagus.
0:54:55 > 0:54:59- All margins are negative, so...? - I should have said it was.
0:54:59 > 0:55:01It's a very good response.
0:55:06 > 0:55:11I think sometimes it would feel like all we do all day is manage beds.
0:55:11 > 0:55:16Actually, what we manage here are people who need us
0:55:16 > 0:55:18to help them.
0:55:19 > 0:55:21That's what we really do.
0:55:22 > 0:55:27The tumour is only in the inner surface of the oesophagus,
0:55:27 > 0:55:28in the very first layer.
0:55:29 > 0:55:32All the margins are clear so...
0:55:32 > 0:55:34you continue to be a lucky man.
0:55:34 > 0:55:36Thank you.
0:55:36 > 0:55:39So we'll keep an eye on you and see you for the next year
0:55:39 > 0:55:42- every three months. - I can start feeding him again now.
0:55:42 > 0:55:44Shove lots of food into him.
0:55:45 > 0:55:47- Thanks very much for all your help. - Well done.
0:55:47 > 0:55:51- LESLEY:- 'We can never predict what's going to happen to a patient
0:55:51 > 0:55:54'when they've left us on the next part of their journey.
0:55:54 > 0:55:56'We can't see into the future,
0:55:56 > 0:55:59'all we can do is the here and now for people.'
0:56:00 > 0:56:03It really is as if we've been in a thick fog
0:56:03 > 0:56:08and now we can see the sunshine, which is great.
0:56:21 > 0:56:25- LESLEY:- 'We go home knowing that that day
0:56:25 > 0:56:30'we cared and we did everything we could have done for our patients.
0:56:31 > 0:56:35'The heart of what hospitals do is have people in them
0:56:35 > 0:56:39'who have a tremendous respect for life but also an understanding
0:56:39 > 0:56:42'that sometimes we can't always save that life.'
0:56:59 > 0:57:01SIREN
0:57:04 > 0:57:09Next time, a busy A&E must contend with a suspected brain injury.
0:57:11 > 0:57:14You know, he's 21 years of age, he's got a little baby.
0:57:15 > 0:57:18One of the hospital's oldest patients is ready to leave,
0:57:18 > 0:57:22but the problems begin when they try to discharge her.
0:57:22 > 0:57:24It's a farce, really.
0:57:24 > 0:57:26It could be made into a comedy.
0:57:28 > 0:57:31And a specialist team is assembled
0:57:31 > 0:57:33for a complex and challenging operation.
0:57:33 > 0:57:37It's been amazing, the bringing together of all this expertise
0:57:37 > 0:57:39just for Peter.
0:57:43 > 0:57:44What choices would you make
0:57:44 > 0:57:47when faced with complex health care decisions?
0:57:47 > 0:57:51Visit our interactive pages to find out how you would respond.
0:57:51 > 0:57:53Go to...
0:57:53 > 0:57:56and follow the links to the Open University.