Episode 5 Hospital

ALARMS BLARE

Just move yourselves over to the side for a minute.

This winter, one of Britain's busiest NHS Trusts opened its doors...

We have to look after the patients

whether they come from Buck Palace or the park bench.

..to show us what's really happening inside our hospitals.

We've got lots of patients now,

competing for an unknown number of beds.

Every week, more than 20,000 people are treated here.

-The pressure's just gone.

-What?! Has it completely gone?

And the numbers, as well as our expectations, are rising.

We just had our worst ten days on record.

There's nowhere in the hospital to move anybody.

At some point, somebody will be telling us whether we're allowed to do any work.

This is a place with some of the best specialists in the world...

The tumour's out. Job done.

..where lives are transformed.

This is saving his life. It has to work.

But they are operating at a time when the NHS

has never been under more pressure.

-Any beds?

-No.

-No beds for anyone?

-No.

It does feel to me like the elastic's

a bit nearer to breaking now than it ever was.

Its very future under scrutiny.

All right, I think we will go out on red,

because we're under real pressure in the emergency department.

We're aware of the problems. Anybody got a solution(?)

Following the patients from the moment they are admitted...

Anything I've done up to this point means nothing

compared to when you can literally give a bit of yourself

to save someone else.

..to the moment they leave.

It's all good news. The cancer's gone.

You don't need any more treatment.

-Fantastic!

-Thank you so much.

Week by week, we reveal the complex decisions the staff must make

about who to care for next.

That patient is coming to me to be operated on, and if I don't do it,

then there's only one inevitable outcome - they're going to die.

Just been brought in by ambulance. Onset of stroke symptoms.

Gerry? Just look at me.

Keep your eyes open nice and wide.

Look at me, look at me, look at me.

Gerry? Look at me? Can you see me all right?

87-year-old Gerry has been brought into Charing Cross Hospital

after suffering a stroke.

Gerry, can you see my hand waving?

A medical emergency that occurs when the blood supply

to part of the brain is cut off.

Gerry, open your eyes and look at me.

Family just suddenly saw him go.

I got a telephone call from my son to say

Dad wasn't well, come home quickly.

Just one look, and I knew what was happening.

Gerry, same on the right.

Gerry is being looked after by doctors from the hospital's

acute stroke unit.

70% of their patients are over 65.

The longer you wait to try and restore blood flow

to a part of the brain that's been affected, the more brain cells,

or neurons, will die.

Hi, there. Are you family? Wife, OK.

-He's never had a stroke as far as you're aware?

-No.

-He's never had any brain surgery.

-No, no.

-He's never had a brain haemorrhage before?

-No.

We need to rush, and the first thing we need to do is to do a brain scan.

This has all been quite slow. Let's speed up a bit.

We want to get treatment into Gerry as quickly as possible.

Rydell, do you want to run ahead and tell CC we're coming.

Well done, Gerry. You're doing OK.

We're going to do a quick scan of your head, which is quite important.

Sorry, guys.

I've a stroke.

We called up, they said come up.

OK, what do you want to do?

-It's going to take about five minutes.

-That's fine, then.

-Yep.

All right, let's get this done. One, two, three...

As a stroke patient, Gerry has priority for the CT scanner,

so doctors can quickly decide if he's suitable

for an emergency treatment known as thrombolysis.

He's late eighties, he's got no neurological history.

We really need to look at the scan, and then we'll make a decision.

There are no contraindications,

so we should just go ahead and give thrombosic therapy.

I'm going to go downstairs to make sure the family are happy.

Gerry is a candidate for thrombolysis,

which is a medical injection that is aimed to break down the blood clot.

Giving thrombolysis to the wrong patients

can cause haemorrhage, or bleeding.

And that haemorrhage can be life-threatening,

and can even cause death.

Em, Rydell, can you get the thrombolysis ready?

I've prepped it already.

Come and sit down for a while. OK.

Gerry's just having the last few scans.

There's no bleeding into the head as far as we can tell, so it looks like

this is a stroke that's been caused by a blood clot,

and the best course would be to give him this clot-busting treatment.

However, it's also important to know it's not a miracle cure, at all.

And one of its most serious side-effects is bleeding.

And that bleeding could potentially be life-threatening.

-You know, we've got to understand that all treatments can go wrong.

-Yes.

-I trust you.

-Sure.

-And he's then... As far as I'm concerned, he's in safe hands.

-Sure.

All right, I'll be with you soon.

Would you time two minutes for me? And just give her 30-second updates.

-That's one minute.

-OK, well done.

It's just such a shock.

But, he's 87, and we know...

that it's inevitable that something's going to happen

at some point.

Age is a very strong risk factor for strokes,

so with an ageing population, you'd expect the incidence of stroke to rise.

Every year that goes by, we're feeling incredibly stretched.

We don't want standards to drop, and it feel like standards are slipping.

OK. Well done.

It will be several hours before Gerry's wife, Margaret,

knows how well he's responding to treatment.

Along with Charing Cross, Hammersmith is one of

the five hospitals that make up Imperial College Healthcare NHS Trust.

Retired carpenter John requires an operation

to replace a valve in his heart.

If you're on the top floor, you might have a nice view.

John's procedure, known as a TAVI,

a transcatheter aortic valve importation,

will be conducted by consultant cardiologist Iqbal Malick.

A TAVI is a way of deploying a new valve inside the heart

without cutting the patient too much.

It's an insane thing to even consider, isn't it?

A squashed valve goes into an artery while the patient's awake.

You track back to the heart and pop the new valve into position.

The patient goes home the next day.

That's something that would have been

ludicrous to consider ten years ago.

-So, you're 98.

-And a half.

-And a half! You've never had a stroke?

-No.

-You don't have diabetes?

-No.

-You don't look 98.

-Thank you.

-Age is just a number, you see.

-Yeah.

At 98, John will be the oldest patient ever operated on

by the TAVI team.

Some of the team is nervous that we'll be seen as lunatics

doing a 98-year-old.

I don't think so. I'm going to lead a team.

I don't think so, I think they can do what they like.

I bet you when it's their granny they'll be asking for

a 98-year-old to have their TAVI done.

Have you done any other 98-year-olds?

That would be a no, I think. I think we're...

We're not far off it, I think we've done 95, but, em... Yeah.

They did, yeah.

Let's go through the case. So, he's 98.

We know his creatinine's 200. It hasn't changed.

Renal team's seen him, don't want to do anything in particular.

The average age for TAVI is 80,

so these are patients who can't have open-heart surgery,

and a number of years ago we couldn't offer patients anything.

So, now we're in a privileged position of offering TAVI

to these elderly patients.

He's got so much more in him. He's still so full of life.

My grandparents are my favourite people in the entire world, so...

I'm sure it's the same for everyone.

How many times have you been to hospital before in your life?

I had some varicose veins out...

Em...

Oh, when I was...

About 50 years ago, now.

That was the last time you've been?

Yeah.

He's incredible. At the age of 87, he walked up Vesuvius.

I think he only stopped running races against

me and my brother around the age of 90,

and he would try and win, as well,

this wasn't like he was trying to let us win.

She says they haven't done anybody my age before.

But it's not about age, that's what we were saying to you before,

it's not just about age, it's about how fit you are, otherwise.

You'll be running out of here.

HE LAUGHS

"Three choices.

"Give up, give in,

"or give it your all."

Is now a good time to ask you what you'd like for Christmas?

I'd like to be alive.

Mr Rowland? Hi, Dr Malik.

-Hi.

-Nice to see you.

-And you.

OK, so...

-Can you hear me OK?

-Yeah.

You've been through the risks before.

-Yeah.

-You know what we're talking about,

but I will double check that you do understand.

Just as a short memory test, what is the problem

that you had with your heart?

Well, I get out of breath very quickly and couldn't walk very far.

Yeah, OK.

-In terms of risk...

-Yeah.

..if we did 100 cases, OK,

then about five of them would have a bad problem.

-One in 20?

-Yeah. And that problem...

When you say they have a problem, will it mean they would be dead?

Death, stroke, bleeding, heart attack.

OK?

Is that an acceptable level of risk for you?

-Yeah, well, I haven't much alternative.

-OK.

What's your date of birth, John?

March 1918.

1918, my goodness.

OK, and can I just get you to sign on the dotted line, John?

If you're up for having this procedure done.

It's a miraculous treatment for the older patients that we

couldn't treat before, that we are now treating.

Every cardiologist would hope to have one really important

step that has suddenly changed in their lifetime that they can

experience and I think for me, at the age of 50 now, it's TAVI.

Demand for heart valve procedure TAVI

has tripled at Hammersmith in the last three years.

What, the old valve, the other valve?

John is the second of these patients on Iqbal's list today.

The first is a patient in their 80s.

Is that pressure...

-Who are you calling?

-Rex.

-It's bleeding too much, so he thinks he might want to open.

-OK.

OK, so this is an unexpected complication in the first procedure.

MONITOR BEEPS

The first case hasn't gone according to plan,

because there's been some bleeding internally.

TAVIs, you can't quite predict what's going on.

Normally, they are very straightforward and this is

the first for the year where we've had a major complication.

It's now likely that the patient will need

a post-operative intensive-care bed.

But that means one won't be available for 98-year-old John,

if his operation runs into trouble.

I'm trying to find another bed.

Sometimes, if they've got an incapacity here,

we can use one of their intensive-care beds

as a backup fallback. For the next case.

-Hello, are you the boss?

-I am today, yes.

You may have heard, we had a bit of an emergency

-in the first procedure today.

-Yes.

We have therefore lost our ICU bed.

-But we have a second TAVI.

-Yeah.

We need a fallback critical-care bed, because he's...he's 98.

-Yeah.

-Otherwise quite well, no previous surgeries.

We are full at the moment.

16 inpatients and 16 bed spaces.

Two of the patients were going to go and I think one

was a cardiology patient.

So, the deal is, we have to take one back?

-Yeah, there will be a degree of swapping, but...

-OK.

PHONE RINGS

We are in some difficulty in there.

The bleeding has restarted and therefore,

we can't really think about other cases.

We have a senior surgeon operating, but I think the rest of the day in

this particular lab is not going to be working out.

I think we are going to have to cancel the TAVI.

This is not just realistic. We're not even ready now

and by the time he gets on, it will be four.

By the time we finish it, six. If something goes wrong at six,

we are much less coverage, so... I think it's safety first.

HE SIGHS

Operating out of hours on elective cases that are high-risk

is not clever. I think if it all went well, I'd be finished by five.

You know, I think that's fine.

But actually, if it didn't go so well,

then the complication is being managed out of hours, with,

you know, less team around.

'I think it's unfortunate.'

So, old Father Time has defeated us.

-My luck.

-Exactly, just your luck.

But the thing that has destabilised us is a very rare eventuality,

so, sorry about today. OK?

I'm going to get them to give you a cup of tea,

give you some food, because we've kept you starved all day.

-OK?

-Thank you very much.

-OK.

OK, so I'm just coming down now.

Yeah.

Something he wasn't expecting and we were quite certain that it

was going to happen today.

And...

But what can you do?

We know that there is a risk to doing the procedure,

but we were told by the cardiologist,

without this operation, he has a 50% chance of sudden death.

John will have to come back next week

for another attempt at the procedure.

Boring!

I like shows like Casualty, Holby City, House.

Grey's Anatomy. I like stuff like that.

Because I'd like to be a children's nurse,

and help...people like me.

-How are you doing?

-OK.

-Good.

The Trust's paediatric centre offers pioneering treatments

for patients up to 19 years old.

Just lift that up for me a little bit.

Debbie was diagnosed with sickle cell disease when she was three.

'Sickle cell, it's like a blood disorder.

'It causes pain in the joints, and your arms, and your knees

'and your legs, but it can affect any part of the body, really.'

-Can I pop this here?

-Yeah.

'But more severely, your brain.

'It can cause strokes and neurological problems,

'and that's what happened to me.'

That's when they considered that I need a transplant,

so that I don't get any more damage to my brain.

-Thank you.

-NURSE LAUGHS

The only cure for sickle cell disease is a bone marrow transplant,

which 18-year-old Debbie has been waiting for since 2009.

Yeah.

A standard bone marrow transplant requires

the donor's tissue type to be a 100% match.

Doctors have been unable to find Debbie a suitable donor.

But a new treatment is offering her a lifeline.

-Sally, how is Deborah today?

-Not feeling very well.

Would you mind giving me her chart, so I can have a look at it.

In normal circumstances,

were you to do a 50% mismatched transplant,

that would almost certainly

lead to the patient dying,

from the new bone marrow attacking the body of the patient.

But we now have a method which will enable this new bone marrow,

which is only 50% match, not to be rejected by her body.

-AUTOMATED VOICE:

-Doors opening.

This new method allows Debbie's 22-year-old brother Sam

to be her donor, even though his tissue type

is only a 50% match with hers.

I'm here to see Debbie.

Deborah. Erm, 13.

What way, that way or...?

'Bless her, because the illness,

'she hasn't had that 18-year-old life at all,'

so if I can give her a chance, a fighting chance,

to obviously never have to be in that condition again,

or go through all the crises she's been going through again...

Because she's got SO much to catch up on and so much more to do.

'And I remember when we used to go to the same primary school,

'me always looking out for her, going into the younger playground

'to see if she's all right.

'So, luckily enough, I was a close match.'

Debbie.

-Aww.

-Have you been worrying about things?

-No.

-Because all that worry is for us, OK?

She's worried, OK.

Yeah.

ALL LAUGH

At the moment,

this type of transplant for sickle cell disease is only funded

for children and young adolescents

up to the age of 19.

And then you have some more of the mesna,

which is a kidney protection, running afterwards.

-INTERVIEWER:

-Is there a risk of death

with this type of bone marrow transplant?

Yes, there is a risk of death,

and the risk does goes up with the degree of mismatch of the donor.

However, as current situation stands,

this is Debbie's last chance to get her bone marrow transplant.

They said it will come with loads of risks,

but I just want to have it, so that I can continue with my life.

Gerry? Hello. How are you feeling now?

HE ATTEMPTS TO SPEAK

It's two-and-a-half hours since stroke patient Gerry

was brought into A&E.

..better view. Gerry, what year is it now?

Oh...

INDISTINCT

-Don't worry about that, that's fine.

-I don't know.

Touch my finger.

See my finger? Gerry, can you see my finger there? Touch your nose.

Perfect.

How old are you?

Do you know what day it is today?

Good.

Lift up your leg.

OK, five seconds. One, two, three..

They have saved us here.

They've got Gerry moving again, they've got him talking again.

The change is remarkable in such a short space of time.

How are you feeling, Gerry?

Oh, that's good.

Yeah, it's VERY good.

I think you're going to do fine,

but we need to keep you in hospital for a few days.

OK.

-We'll pop in a bit later on, OK?

-OK.

-Nice to see you.

-Thank you.

-All the best.

-Thank you very much.

Gerry will recover at Charing Cross Hospital's Hyper-Acute Stroke Unit,

or HASU, one of eight specialist stroke centres in London.

The thing that everyone worries about

with someone who's had a stroke is,

they're at risk of having another stroke.

So he's not out of the woods at all, we're going to have to

closely monitor him, he's got very powerful medication on the board.

Things look promising, let's keep our fingers crossed.

SIREN WAILS

I'm going to put it over the top,

because it will be finished before that, probably.

18-year-old Debbie is preparing for her bone marrow transplant

by receiving chemotherapy to deplete her immune system.

Chemotherapy just makes you feel completely lifeless.

You don't want to eat, it makes you feel so sick.

You've got no energy whatsoever

and you just can't do anything.

Ohh.

Hey, Dad.

How is she?

Ohh. It's horrible seeing her like this, though.

I know. I'm here.

How are you feeling?

I don't feel good.

Aww. I didn't realise it was to this extent.

-Yeah.

-Debbie.

HE BLOWS HER A KISS

Don't worry.

I'll see you soon, yeah?

That was, er, very difficult to see.

Never seen her like that, ever.

Ever. And I've never really heard her say she feels not good.

Even if she don't feel good,

she'll say she feels all right, know what I mean?

She was always very optimistic, but obviously the chemo

has rendered her into that sort of state, hasn't it? So...

It's very hard. Very hard to see.

Debbie is travelling to Hammersmith Hospital,

where she will receive a high dose of radiation.

Are they on their way? Right, great. Thanks, bye.

It's the last stage of treatment before her transplant.

Hi, Deborah, my name's Faye, I'm one of the radiographers

doing your treatment today.

We're going to be putting some little measuring devices

onto your skin.

Just do a small little dose first, and then once we're happy,

we'll then do the main part of the treatment.

You OK? Do you want some water?

Headache.

Would you like to have the lights down?

-LEENA:

-The whole thing is a bit like a Trojan horse.

We're trying to get past the guards.

See you in a bit, Deborah.

If we don't do it, then there will be a lot of reaction between

the two immune systems, one of Debbie's

and one of the new bone marrow.

We've got a gantry of 270, colls of zero,

and the Y, 25 on the Xs.

We've checked we're all covered.

-Yep.

-They're ready.

We're good to go here.

CLICKING

She doesn't seem very well at all, has she been like this today or...?

About a week now.

She's very nervous about today.

It's the not knowing, isn't it?

Right lateral.

All finished.

Deborah, how are you?

-How are you, darling?

-WEAKLY:

-Not well.

You have pain in your eyes when you look at me?

Debbie's immune system is now so depleted,

even a mild virus could kill her.

Would you mind if I quickly touch your tummy? Would that be OK?

You can see that though it is fantastic that we are now

able to carry a transplant,

the truth is that the treatment itself is very tough.

Sorry, I have a little bit of cold hands.

The doses we use in transplantation are far higher than we would

use usually in the treatment of cancer.

So the number of side-effects these children suffer,

and these young people suffer, is substantial.

OK. It's a difficult time. We'll leave you in peace.

-FATHER:

-All right, thank you.

SIREN WAILS

So we are going to attend the TAVI multi-disciplinary team meeting.

Which is a meeting we have every week, essentially,

to discuss all cases that we are considering for the TAVI procedure.

For a second time, consultant cardiologist Ghada Mikhail

is preparing for 98-year-old John's heart valve procedure.

So it's the multi-disciplinary, it's attended by cardiologists,

surgeons, echo imaging doctors, CT doctors - all the TAVI team.

OK, good morning. So, the first case is Mr John Rowland, 98.

This case was the case we were supposed to do last week

and it got cancelled, so we're just rediscussing him cos he's booked...

-Can I just answer first?

-Yes.

-So, 98?

-98.

You need to persuade me that there is no frailty.

Can we just re-review the echo?

Do you want to take us through the echo?

In many ways, we are - and the NHS is - a victim of its own success.

So we have so many elderly patients now,

and we are getting into discussions about life expectancy

when patients are already in their nineties.

But the PA pressure was up as well, with a good ventricle,

how do you explain that?

Overall LV function looks preserved.

'With the TAVI MDT, it's particularly difficult,

'because this is a high-risk group of patients. Cost does come into it.

'I have a responsibility to manage resources effectively.'

But actually, we try and pick the winners on clinical grounds,

and we have to decide,

does he have enough reserve to come through the procedure?

Because I'm afraid it is the case that you can have an outcome

which is a fate worse than death.

So it is quite challenging.

Is that a recent change or...?

He's had increasing shortness of breath over the past six months.

Six months ago, apparently, he was walking about four miles,

and now he can only walk about 200 metres.

He's never smoked, he's got good lung function,

-with severe...

-THUMP

..and slightly raised pulmonary artery pressures.

He's got a very supportive family as well who are all

sort of onboard with TAVI.

He's just very keen to have something done.

He wants to continue living and have a good quality of life,

and wants to be less symptomatic, but he's not low-risk.

At 98, he's not going to be low-risk.

I'd want a clear statement that he understands that as well.

The last conversation we had with him,

he will accept risk just to feel better.

OK? Fantastic.

So he's all set.

'We can't be ageist.

'We are dealing with an ageing population,'

and he wants a better quality of life.

We can't deny a patient that, no matter what their age is.

Don't rush.

No, you don't need to go quickly, we can just take our time.

Enjoy the sense of deja vu.

A week after he was first cancelled,

John is back at Hammersmith Hospital.

You couldn't possibly say anything about quantity of life -

how long we'll make him live - but he's a very active 98

and his quality of life has really got worse.

It's very important that he's up for it,

his family is up for it and the team is up for it.

Can you just look up John Rowland's blood results?

If any of the team had dissented, then we'd think again.

Yes?

-Do you want to sit on the chair, Grandad?

-Thank you.

Are you happy to be having the operation?

I'm not happy to be having it but what's the alternative?

Because I'm getting worse all the time recently.

I can only walk about...

I used to walk miles and now I can only walk a couple of hundred yards

and I'm out of wind.

I am genuinely terrified that something might happen to him

because I can't...

honestly can't bear the thought of life without my grandad in it.

It's just about waiting now, isn't it?

I am very, very, very nervous,

because at the end of the day it's just got to work.

22-year-old Sam is donating his bone marrow in an attempt to cure

his 18-year-old sister Debbie of sickle cell disease.

So he's consented for mobilisation with G-CSF injections

for stem cells and to undergo a bone-marrow harvest

under sedation on theatre.

All right, Sam, do you know why you're here today?

-To donate bone marrow to my little sister.

-OK. We're good to go.

I'm starting with something, it's not the anaesthesia yet

but it's just something to relax you a bit.

What are you thinking about, Sam?

I don't know. I'm just scared,

like, all these machines and... I just want it to go well.

Anything I've done up to this point means nothing

compared to when you can literally give a bit of yourself

to save someone else.

Now, THAT'S doing something, that's responsibility.

OK. Ladies, are you ready?

The harvesting of bone marrow from Sam's hips is being conducted

by an expert team at Hammersmith Hospital's centre for haematology.

Ready, steady, move!

When we do the bone-marrow harvest,

the areas that we need are the posterior iliac crest,

which are just the bones that you will feel

on the bottom of your back.

That is the exact place where we have to put the needle through

and extract the marrow.

The whole process will last less than two hours.

So with his white-cell count of 58, we have to collect 700ml.

So we are taking 5ml per syringe.

At the end of the day it is the gift of hope.

Just the gift of life.

It's quite similar to blood.

So you wouldn't be able to distinguish.

Before Sam's bone marrow can be transplanted into Debbie,

it must be tested in the haematology lab.

One of the big requirements of the whole process is that the product

is sterile and free of contamination.

So before we do any processing with the harvest we take

some blood cultures, just to make sure that the product that we've got

from Sam is harvested in a sterile way

and then that there's no microbial contamination.

Hi, Deborah. Are you all set?

Uh...yeah.

15 years after being diagnosed with sickle cell disease,

Debbie is receiving the new bone marrow that could cure her.

So these are your cells.

-Can I take a picture of it?

-Yeah, you can.

-It's all your brother's bone marrow.

-Cool.

It's just like a blood transfusion.

Debbie's half-match transplant has the risk of rejection,

so the body rejects literally the new tissue.

-So you're going to have 15 drops in 15 seconds.

-OK.

However, 90% of the children not only survive the transplant

but also are cured of the underlying disease.

How long will it be?

It will be about three and a half hours.

But unfortunately,

some complications can never be completely prevented.

It will be a few weeks before doctors know

if the bone-marrow transplant is a success.

-It's a rather large box.

-It is!

What's inside, Angela?

It's going to be John's new heart valve.

John's new heart valve has been shipped to Hammersmith

from the United States.

Comes with lots of important kit to try and help us make it

small enough to fit inside the body.

So that's the actual valve itself.

I'll check we've got the right size.

26 valve, and it's the correct size we've got there.

The valve itself is the most expensive part.

These TAVI valves cost anywhere between £12,000 and £18,000.

And then there's the time taken for the procedure,

and so I think if you wrapped up all of that,

you probably wouldn't get much change from 30K, I would think.

But it's cost-effective, because if he came in with heart failure

he's likely to stay two weeks on the first admission,

probably ten days on the second admission, and if he makes it

to a third admission that's probably another two weeks.

You can see that very quickly we've got to beyond 30 days

at £1,000 a day, and we are then going to be in credit,

so we're not spending £30,000 on a patient because we fancy it.

We are spending £30,000 not only to help him and his symptoms,

but I would have a very strong argument that that

is actually going to save the NHS money in the long run.

OK, Iqbal the operator, the other operator.

Dani, anaesthetic nurse. Julie, anaesthetic fellow.

OK, fantastic, so there's a large team around.

Very good team. Thank goodness!

Lot of brains, exactly.

Some of them working as well.

So we've got your name sorted out, the procedure,

it's a transfemoral TAVI, right leg is the main access.

26mm S3 valve, we just checked that all.

So, John, you're part of the team,

so we need to keep you nice and still.

John will be awake throughout the procedure.

Ready?

OK, that's that pipe in,

so, John, we're just making a track for our big pipe to go in.

Hopefully it's not too uncomfortable.

Pair of forceps.

Basically what we're doing is we're going through the right

femoral artery, which will lead us up into the heart.

Once the big pipe is in, we're pretty much committed to the valve,

so that's the time we take the valve.

It's prepped over on the other table.

So that's what the valve looks like, that's the three cusps.

We've squashed the valve into something the size of a Bic biro.

And then as soon as we're ready to go they'll hand it over to us,

we can put it in.

Can I have the wire?

-The clip.

-Just take the clip from there.

So a bit of pushing now, John.

Bit of pushing.

It's quite a tough push, the valve is a bit like a boa constrictor.

It's expanding as we go.

All right, John?

You're doing very well.

OK, so everyone quiet, ready. Casing on.

Balloon up, slowly, slowly, slowly.

Balloon down. Casing off.

And the pressure back.

Let him recover.

So there's the new valve here.

Looks in a very good position, which is good.

We're going to put some colour on that.

Look at that.

Amazing flow, going forwards without turbulence,

-no leak coming backwards that we can see.

-Well done.

We've done this more than 300 times so it's like

a Formula One pit stop, isn't it?

Hello. It's all done! We are all finished!

It's all gone very well. All right?

Do you want to look to the right?

Just a bit slow to respond.

Very slow.

John? John?

John?

Still with us, John? John? John!

Hello, there! Hi, John.

John, just repeat your name for me, can you do that?

Tell me your name.

John?

Squeeze my fingers. Squeeze my fingers, John.

John, move your toes.

Can you feel that?

All right, John.

There's been no improvement at all since the TAVI finished,

so unfortunately it looks... that he's had a neurological event.

We've done all the tests to try and minimise the risk

and we didn't really think his risk of stroke was going to be

any higher than any other patient.

Hi, it's Dr Malik here in the cath lab.

I need to be put through to 999 London Ambulance

to get a critical-care transfer.

Time is of the essence.

If there's going to be any recovery,

a complication has to be dealt with quickly.

They've had a stroke, we need to transfer with critical-care transfer

to the HASU at Charing Cross.

We have a critical transfer

from Hammersmith Hospital to Charing Cross.

We have a 98-year-old male

who had a stroke during a procedure.

Oh, hi, it's Dr Malik here from the Hammersmith Hospital.

Unfortunately, there has been a complication during the procedure.

Are you in a position to talk about that? OK. He's still with us.

The problem is we think there's a stroke, so our only hope

is that he's in that one third that recover completely and not

the one third that do very, very badly,

and we can't tell really at this very early stage

which group he's going to be in.

All right, sorry the news is not better.

No problem, all the best now. Bye now. Bye.

Hmm.

All right, John. We're at a different hospital now.

John has been brought to the trust's hyper-acute stroke unit

at Charing Cross hospital.

Lift this right arm for me, please.

John, your right arm.

I know you're trying. Your right arm. Try your best.

That one, can you lift it up?

Just going to extend your right leg to prevent any bleeding.

Sorry, sir, I'm just trying to check.

You've probably had a stroke, we think.

-Right side?

-Right side weakness.

-There's the artery.

So just here, this is the middle cerebral artery,

which supplies most of the left side of the brain.

You can see here there's a bright spot which indicates a thrombus,

a clot inside a blood vessel,

and that would explain his right-side symptoms.

It's actually a very important part of the brain.

So losing that part of the brain would give him

a significant neurological deficit.

What does that part of the brain do?

It's certainly his more complex neurological functions,

his power sensation to the right side of his body.

I think this would certainly be a candidate for thrombectomy.

Just two hours after his heart procedure,

98-year-old John must now undergo an operation on his brain.

We're planning to do a thrombectomy,

which is where we go up through the blood vessels in the groin,

up past the heart, through the neck,

into the blood vessels of the brain,

and the plan is to try and grab that clot, fish it out

and hopefully restore the flow of blood to that part of John's brain.

I've heard people describe thrombectomy

-as a kind of miracle cure to stroke?

-Yeah.

It is occasions where the stroke is severe.

At the moment it's only Monday to Friday, nine to five?

-Absolutely, yes.

-So what happens outside of those hours?

Well, these patients are going to do, as they have been doing

up to now, badly, unfortunately.

OK, John, you're doing really well.

So we've got a stent deployed where the clot it,

to try and grab it, and we've also got

a big suction catheter to try and suck it at the same time.

The older the patient, the more twisted the vessels,

certainly in someone who's 98.

It's very difficult to get all the equipment up there.

John, you're doing really well.

OK.

If we see the stent, it's a very fine structure.

It's like a cylindrical mesh.

So that's going into his brain?

So that's going into his brain, into the blood vessel

where the blockage is.

And by pulling it back you're hoping that's going to catch the clot.

Nice and still, you're doing well, sir.

So we're quite deep now into the vessels.

Close to the limits of how far we can go.

Really still, John.

The clot has migrated from the major trunk of the artery

much deeper into one of the branches.

The blockage starts about there.

However, the clot probably goes beyond that.

It may not come back, we'll see what it's like.

There's, like, some hard stuff there.

This may well be clotting hard

and be much harder to pull out.

Fingers crossed.

JOHN GROANS

You're doing very well, sir.

OK, John.

We've got the clot out.

Hopefully you'll feel better in a few minutes. OK.

We have some clot stuck at the end of that stent.

If you see here at the end of the tubing.

I don't know if you can zoom in.

There's a black bit that's just come off there,

a very dark bit. It's obviously blocked a major blood vessel

that's supplying the left side of his brain.

So now you can see that that area of brain

before that wasn't filling is now filling.

It's amazing you can take that out.

Yeah, I mean, when it works, it works very well.

It often does. It usually does.

All right, sir, all the best. I'll see you upstairs.

Hopefully, that makes a significant difference.

All right?

There's another stroke just coming in.

-Really?

-Yes.

-So...

-Another stroke.

One in, one out.

Can I ask you, let's just have a look at your arms, first, Gerry.

Can I ask you just to squeeze my fingers as hard as you can.

That's it.

It's six days since Gerry had his stroke.

Lovely. Hard as you can, Gerry. Go on.

That's it.

OK, keep going down, we're going to head straight for the doors.

-To the door?

-Yeah, just to the doors and have a touch

-and we're going to turn around and go back.

-OK.

All right?

What is it like seeing Gerry walk like that

after what's happened to him?

Sorry.

Gerry is recovering well.

It was last Thursday...

But further tests reveal a narrowing of one of the blood vessels

that supplies his brain, putting him at risk of another stroke.

So we're having a multi-disciplinary team meeting

with the vascular surgeons and also the stroke team

and we're having to make a decision on what we think

the best treatment is for Gerry.

Is there any indication for carotid endarterectomy?

I think we have to look at the benefits.

Certain people can benefit from an operation to clear out the narrowing

to prevent further strokes.

I personally don't think he should have his carotid done.

From my viewpoint, I don't think he is clear-cut at all

as to whether we should offer him surgery or not.

I'd quite like to see the patient and then I'll make a judgment.

-Yeah.

-So I'll go and see him this afternoon.

We're weighing up the risks because the purpose of doing the operation

is to reduce his stroke risk.

He could possibly die having the operation.

Doctors will let Gerry decide whether he wants surgery or not.

Hello, sir.

I'm Professor Davies and we've just had our meeting to discuss

whether you should have an operation to reduce the risk of having

a stroke, or whether we should just carry on with various medicines.

I personally think your risks of going on to have an operation

are such that it's a very difficult balance.

My advice would be that you would be better off having

the appropriate medicines and see how you get on.

Now, do you have any immediate thoughts about what I've said?

OK. We will tell them that that's what is your preference.

So, all in all, I can only say "cheerio"

because there's nothing for me to do

and I will, um, get Dr Halse to come back and see you and go from there.

Nice to see you. OK.

Nice to see you again.

Take care.

I think there are quite a lot of people who have decided,

particularly as they get older,

that they do not want to have a surgical intervention.

It's a known surgical intervention that comes with a given risk

and therefore feel that they would like nature to take its course.

You've got to sort of weigh up the pros and cons and I think...

There are a lot of risks, regardless in what way you look at it

but I think having an operation, the risk is much bigger.

I think that, anyway.

I tend to agree with Gerry.

For once.

THEY LAUGH

Have you been sleeping?

-Hmm?

-Yeah.

-OK.

-Yeah.

Since her bone-marrow transplant,

Debbie's blood samples have been sent to the lab every day to see if

her brother's cells have taken hold, a process known as engraftment.

Carrie calling from Grand Union ward, we've got some urgent

bloods to be collected, please.

So far the results have yet to show conclusive evidence it's working.

I'm just logging on so that I can look at the results of her

blood tests today.

The finishing of engraftment is a neutrophil count of more than 0.5

on three consecutive days.

If today is also over 0.5

then...

..she's winning.

Hello, Debbie.

Do you know what's been happening with your blood counts?

Do you know what they are today?

No.

I'll give you the news.

-Yes.

-Yeah.

-It's 1.8 today.

-OK.

Which means it's a third day in a row that it's been more than 0.5,

-which means you have engrafted.

-Yeah.

So your new bone marrow is working.

-Yeah.

-Yes, that's right.

-So...

-Congratulations.

-Yeah...

So you and your team, Team Debbie,

are doing really well.

-That's good.

-That is good.

It's like a little bit of magic, isn't it?

-Yeah.

-Yeah.

From a patient's point of view,

being able to establish normal reaction is a key moment.

The transplant has worked

and it has been cured.

Look at that smile.

-I'm excited.

-Of course.

-The first step is that you can go out for a little walk.

-Yeah.

OK.

Is it nice doing that bit of the job?

Always the best bit.

Overall, in the UK, care of sickle cell in childhood is

absolutely excellent and it's world-class.

You came here alive and you're going back alive.

-That's God for you.

-Yeah.

She's very fond of me and I'm fond of her.

I don't think we can...

..live...

..a day apart.

What does it feel like to be outside?

Good.

I like it.

It's a bit cold.

I was worried and I was considering that perhaps I had, um...

..been a little bit too positive in terms of the way

I presented things to him.

That maybe it would have been better if he hadn't had the TAVI.

-Hello.

-Hello.

How are you?

-How are you?

-Getting there.

Good.

How has your day been?

It's been all right.

He's actually doing remarkably well, I have to say.

He has had some initial problems with his speech

and a little bit of his memory and actually all those things

seem to be more or less resolved now.

He seems to be back to his usual self.

He is interested in the world again.

We were having conversations about who his favourite prime minister was

and who he thought was the worst prime minister he's ever witnessed in his lifetime.

You're doing really well.

-Thank you.

-You're welcome.

SHE CHUCKLES

When I was training, 65 was the cut-off at older age.

That's a young man these days.

Yes, it's getting busier and the patients are getting older

because they're surviving longer,

which is a success story for the UK and the NHS.

We've got all these amazing, pioneering techniques

such as TAVI,

but as the population ages, how sustainable is all of this

within the current structure of the NHS?

It was so worth it

because I get to give her

another fighting chance.

Which is beyond something I could ever dream of doing.

It's like a major beginning for me and my family.

So...I'm very excited for the future.

I think we did make the right decision, and his heart, apparently,

is working beautifully.

So...I think he has every chance now that he's had the TAVI of getting

to 100, and if he does, my goodness, the party we'll have at that point.

I can't wait.

So, we've got a bit of a problem now.

Next time...

I've finished here at Charing Cross so I'm coming over.

With more patients than theatres,

surgeons struggle to get their operations started.

We will talk about it when I've calmed down.

-SIGHS

-OK, um...

I'll going to have to go and tell him.

There's a drive to get obese patients treated.

So that's ten cancellations on the list tomorrow already.

I think there is a stigmatisation against obesity.

I completely disagree with the opinion that

obesity is self-inflicted.

And the hospital joins forces with others across the country

for a live kidney swap.

Everything has to happen at the same time.

One mistake can screw up the whole thing.

Can we please all be quiet,

just let me think a second.

What choices would you make

when faced with complex health-care decisions?

Visit our interactive pages to find out how you would respond.

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