0:00:03 > 0:00:06Where is he? I don't know. You need to shout for help. Where is he?
0:00:06 > 0:00:08Which way did he go?
0:00:08 > 0:00:10One of London's biggest hospital trusts...
0:00:10 > 0:00:11He's having a heart attack,
0:00:11 > 0:00:14but we'll get him in straightaway, and we'll get him sorted out.
0:00:14 > 0:00:16OK, on three. One, two, three.
0:00:16 > 0:00:20..treating more than 20,000 people every week.
0:00:20 > 0:00:22Flying over the enemy lines.
0:00:22 > 0:00:26This is a place with some of the best specialists in the world...
0:00:26 > 0:00:28I'm amazed he's alive. He had two blocked arteries.
0:00:28 > 0:00:30..where lives are transformed...
0:00:30 > 0:00:32Oh, thank you so much.
0:00:34 > 0:00:36..but it's under intense pressure...
0:00:36 > 0:00:39We have a financial deficit of 41 million.
0:00:39 > 0:00:41..with growing patient numbers...
0:00:41 > 0:00:43We are full. We're always full.
0:00:43 > 0:00:44How long has he been here?
0:00:44 > 0:00:4713 hours and 46 minutes.
0:00:47 > 0:00:49I don't think that's best patient care.
0:00:49 > 0:00:50..and higher expectations...
0:00:50 > 0:00:53There can't be nothing in this day and age.
0:00:53 > 0:00:55I want to look after him.
0:00:55 > 0:00:57First ambulance is on the rack.
0:00:58 > 0:01:02..at a time when the NHS has never been under more scrutiny.
0:01:02 > 0:01:04We are declaring a major incident at the St Mary's site.
0:01:04 > 0:01:07If this was my sister or a friend or anyone,
0:01:07 > 0:01:08this wouldn't be good enough.
0:01:08 > 0:01:13Week by week, we reveal the complex decisions the staff must make...
0:01:13 > 0:01:18Anybody else who hasn't gone knife to skin, they need to be sent home.
0:01:18 > 0:01:20..about who to care for next.
0:01:22 > 0:01:25Do you reach a point where you say enough is enough?
0:01:25 > 0:01:27Yes. The family may not like that,
0:01:27 > 0:01:30but we are stopping, and this is where it ends.
0:01:35 > 0:01:37PAGER BEEPS
0:01:40 > 0:01:44Emergency coming, five minutes, by a London Ambulance Service.
0:01:44 > 0:01:46So, what do we know? Who took the phone?
0:01:46 > 0:01:50Peri arrest, 50, hypotensive, bradycardic.
0:01:52 > 0:01:5556-year-old Edward, OK.
0:01:55 > 0:01:57Called about two o'clock. Yeah.
0:01:57 > 0:01:59He said he had a central chest pain. Yeah.
0:01:59 > 0:02:03He was in peri arrest, bradycardic. Around sort of 30-50.
0:02:03 > 0:02:05OK.
0:02:05 > 0:02:0956-year-old city worker Eddie is suffering a major heart attack.
0:02:12 > 0:02:15Oh, hello. HE GROANS
0:02:15 > 0:02:16All right, Edward?
0:02:16 > 0:02:17You're in hospital. HE GROANS
0:02:17 > 0:02:21After calling 999, Eddie collapsed at home alone.
0:02:21 > 0:02:25His heart is severely unstable and could stop at any time.
0:02:27 > 0:02:30It's all right, we've got some. Need some atropine, please. Quick, quick.
0:02:30 > 0:02:34What do you need? Atropine. Blood pressure, 125.
0:02:34 > 0:02:35What was the last heart rate?
0:02:35 > 0:02:37It's 35. OK, perfect.
0:02:38 > 0:02:41Yeah, atropine's in.
0:02:41 > 0:02:45Hammersmith is one of the UK's foremost heart attack centres,
0:02:45 > 0:02:46or HACs.
0:02:46 > 0:02:49Eddie will receive acute treatment
0:02:49 > 0:02:51only available in specialist hospitals.
0:02:51 > 0:02:53Mind your backs, please.
0:02:59 > 0:03:02The HACs are like a specialised A just for the heart.
0:03:02 > 0:03:04One, two, three.
0:03:04 > 0:03:06London ambulance bring us more and more patients,
0:03:06 > 0:03:09so probably double what we would have seen five years ago
0:03:09 > 0:03:12when we first started.
0:03:12 > 0:03:14Anna, have you got an ECG? Where's the ECG?
0:03:16 > 0:03:19Oh, dear, the ECG's showing that he's having a big heart attack.
0:03:19 > 0:03:23So, the team is going to intubate, cos he's so restless.
0:03:23 > 0:03:26He's got no forward output, really.
0:03:26 > 0:03:30Next stage, which is to get into his arteries and take a picture,
0:03:30 > 0:03:32find the blockage, fix the blockage.
0:03:32 > 0:03:35It's just making sure that he doesn't have a cardiac arrest
0:03:35 > 0:03:37before we get to that point.
0:03:40 > 0:03:41Pressure line on, please.
0:03:43 > 0:03:46The faster you are, the more muscle you save,
0:03:46 > 0:03:49and it's important, when someone's really sick,
0:03:49 > 0:03:52to get that artery open as fast as you can.
0:03:52 > 0:03:56So, we've got to get beyond this tricky leg.
0:03:56 > 0:04:00A catheter wire is inserted through Eddie's groin into his heart.
0:04:00 > 0:04:03Balloons and small mesh tubes called stents
0:04:03 > 0:04:07will then unblock his arteries in a procedure called angioplasty.
0:04:07 > 0:04:09This has got to be a big, big right.
0:04:09 > 0:04:11Must be a huge right. OK, we're in now.
0:04:14 > 0:04:18Yeah, look, a huge, great big clot that's just blown downstream.
0:04:18 > 0:04:20We'll see if we can't suck it out. OK.
0:04:20 > 0:04:22HEART MONITOR BEEPS
0:04:24 > 0:04:27No, I wouldn't call him stable.
0:04:27 > 0:04:29He's on blobs of adrenaline.
0:04:29 > 0:04:32So, let's just see if we've got a clot here.
0:04:32 > 0:04:36I don't have any big clots here. We're going to go back in again.
0:04:36 > 0:04:40We need to get rid of any clot that's sitting in this line.
0:04:40 > 0:04:43No point in taking the clot out of the coronary artery
0:04:43 > 0:04:46and then blowing it into his brain - that would be bad, wouldn't it?
0:04:46 > 0:04:48So...
0:04:48 > 0:04:49Now, that may have trapped something,
0:04:49 > 0:04:51cos that's not coming back.
0:04:51 > 0:04:54Yeah, yeah. Ah, it's opened up. Just leave it.
0:04:54 > 0:04:56This man had... I'm amazed he's alive.
0:04:56 > 0:04:58He had two blocked arteries.
0:04:58 > 0:05:01So, 40% of patients have two ruptured clots,
0:05:01 > 0:05:04but not two ruptured clots causing complete blockages, I have to say.
0:05:06 > 0:05:08OK. Good.
0:05:08 > 0:05:11The heart attack centre is one of seven set up in London
0:05:11 > 0:05:13within the last ten years
0:05:13 > 0:05:17to consolidate specialist skills and resources.
0:05:17 > 0:05:18He decided he wanted to live.
0:05:21 > 0:05:24Since they were established, survival rates in the capital
0:05:24 > 0:05:27for the most serious heart attacks have doubled.
0:05:27 > 0:05:31OK, let's see what we have.
0:05:31 > 0:05:34So, this is a nice story, yes? Yeah.
0:05:34 > 0:05:36Potentially.
0:05:36 > 0:05:39I'm very clear that today he was dead
0:05:39 > 0:05:41if he hadn't ended up with us and had gone to a smaller hospital
0:05:41 > 0:05:43where they didn't have a cath lab.
0:05:43 > 0:05:45Had he had a cardiac arrest in an A department
0:05:45 > 0:05:47without a cath lab facility,
0:05:47 > 0:05:49he would never have stabilised to come over to us
0:05:49 > 0:05:51to open up his arteries.
0:05:51 > 0:05:54There's no debate about it, he would be dead.
0:05:55 > 0:05:57INTERVIEWER: And where are you off to now?
0:05:57 > 0:06:02I'm into the next lab. So, we've just started another hot case -
0:06:02 > 0:06:05not quite as hot as him - this is a gentleman who's in his 80s,
0:06:05 > 0:06:07who's presented with a heart attack.
0:06:16 > 0:06:17Over the past decade,
0:06:17 > 0:06:20there's been a move to centralise NHS services
0:06:20 > 0:06:23in order to offer specialised care to more people
0:06:23 > 0:06:25in fewer, bigger hospitals.
0:06:30 > 0:06:33Charing Cross Hospital is the Trust's specialist centre
0:06:33 > 0:06:36for neurosurgery and the treatment of brain tumours.
0:06:44 > 0:06:47I'm off in to see my oncologist.
0:06:47 > 0:06:50She's asked me to come in quite urgently,
0:06:50 > 0:06:54just to have a chat about my recent MRI scan.
0:06:57 > 0:07:0128-year-old Ben had a brain tumour removed four years ago.
0:07:03 > 0:07:07I've been here a lot, cos this is where I was operated on
0:07:07 > 0:07:10to have my brain tumour taken out,
0:07:10 > 0:07:14and then also to have my follow-up radiotherapy and chemo.
0:07:16 > 0:07:18Since his operation,
0:07:18 > 0:07:23he's been monitored by consultant clinical oncologist Alison Falconer.
0:07:23 > 0:07:27He's been having scans every six months since he finished treatment.
0:07:27 > 0:07:30Over the last year, there's been a progressive change in his scans.
0:07:32 > 0:07:34Dr Falconer's called me in,
0:07:34 > 0:07:36but I don't think it's an official appointment,
0:07:36 > 0:07:38she said come in for 11:30.
0:07:38 > 0:07:41We've got the Grade 3 brain tumours, which Ben has.
0:07:41 > 0:07:45With these tumours, half the patients have died in five years -
0:07:45 > 0:07:47and it's four years since surgery.
0:07:50 > 0:07:52Hello. Hi, Ben. Hi, how are you?
0:07:52 > 0:07:55Good. Nice to meet you. So, I've heard your name a lot.
0:07:55 > 0:07:58Kevin O'Neill. Yeah. Did we meet before?
0:07:58 > 0:07:59I don't think I've ever actually met you,
0:07:59 > 0:08:01I just always hear Kevin O'Neill.
0:08:01 > 0:08:03Do you? That's strange. I think you're famous.
0:08:03 > 0:08:06Basically. So, we've been discussing you in our own big team,
0:08:06 > 0:08:09so we work altogether. Yeah, OK. So, how have you been?
0:08:09 > 0:08:11Have you been...? I've been fine, yeah.
0:08:11 > 0:08:13I've had absolutely no symptoms from my brain.
0:08:13 > 0:08:16No seizures? No seizures since the op.
0:08:16 > 0:08:18There's always a chance that things could change.
0:08:18 > 0:08:21Yeah, which I've always been aware of. Yeah.
0:08:21 > 0:08:23I think, if you look back, you can see a little ring
0:08:23 > 0:08:26that looks like maybe a residual bit of tumour.
0:08:26 > 0:08:28Looks like it's been very well-behaved,
0:08:28 > 0:08:30but in the last scan, it just...
0:08:30 > 0:08:32Part of it... Yeah. ..looks a little bit bigger.
0:08:32 > 0:08:34That would warrant us going in
0:08:34 > 0:08:36to remove that bit that's growing, and...
0:08:36 > 0:08:39Right. ..potentially threatening you. Mm-hm.
0:08:39 > 0:08:43OK. So, you're saying that you feel I should have a procedure...
0:08:43 > 0:08:45another operation.
0:08:45 > 0:08:47Well, we all feel that, you know,
0:08:47 > 0:08:49there is a risk of leaving you alone
0:08:49 > 0:08:53and the risk of treating you is less than the risk of leaving you alone.
0:08:53 > 0:08:57From my understanding of the tumour that I have had, blah, blah, blah,
0:08:57 > 0:09:01it was slow-growing? Relative to the fast ones, unfortunately.
0:09:01 > 0:09:04There's always a spectrum. OK. So there's barely growing,
0:09:04 > 0:09:06which are what we call benign - 1, 2.
0:09:06 > 0:09:08The Grade 3, which is what you had,
0:09:08 > 0:09:11means you can't just sit and watch it and observe it lifelong.
0:09:11 > 0:09:14Yeah, OK. Has to come out, have the chemotherapy, have the radiotherapy,
0:09:14 > 0:09:17as you did. Yeah. And the Grade 4 are the much more aggressive ones.
0:09:17 > 0:09:21In terms of timings, what are your thoughts, then, on...?
0:09:21 > 0:09:23When would it need to...? Probably in the next few weeks.
0:09:23 > 0:09:25Oh. Two or three weeks, we'd need to set it up.
0:09:25 > 0:09:27OK. Have you got plans?
0:09:27 > 0:09:29Well, yeah, I've always got plans, I'm really busy,
0:09:29 > 0:09:33but we have to work around those. Yeah.
0:09:33 > 0:09:37It's not going to be tomorrow. And, yeah, so...
0:09:37 > 0:09:40We've seen it grow, there's no point just sitting here, watching it,
0:09:40 > 0:09:42we need to do something about it. Yeah.
0:09:43 > 0:09:45Mm. Does that make sense?
0:09:45 > 0:09:47Yeah, it's making sense.
0:09:47 > 0:09:49It's just a pain in the arse.
0:09:49 > 0:09:51Basically.
0:09:51 > 0:09:53It's a tricky balance.
0:09:53 > 0:09:55Thanks very much.
0:09:59 > 0:10:03It's just a lot of stress and it's just annoying, isn't it?
0:10:03 > 0:10:05It's just...
0:10:05 > 0:10:07It is annoying. Yeah, it's annoying.
0:10:07 > 0:10:10It's just... That's nothing to what I said when I saw the e-mail.
0:10:10 > 0:10:11It really isn't fair.
0:10:11 > 0:10:14No, it's not fair, but it's happening, so get on with it,
0:10:14 > 0:10:16I guess. Right, so... Yeah.
0:10:18 > 0:10:19Great.
0:10:19 > 0:10:20SHE LAUGHS
0:10:20 > 0:10:23Why don't you get out into the sunshine? Yeah, exactly, exactly.
0:10:23 > 0:10:25It's fine. OK.
0:10:25 > 0:10:27Yeah, thank you very much.
0:10:27 > 0:10:29Oh. I know, what the hell?
0:10:29 > 0:10:33But it was going to happen at some point, I think. It's all right.
0:10:33 > 0:10:36Thank you. Right. Are we going, Ben?
0:10:36 > 0:10:38Yeah. Take care, see you soon.
0:10:38 > 0:10:40Oh, thank you.
0:10:41 > 0:10:45INTERVIEWER: Was it always going to come back? No.
0:10:45 > 0:10:46We always, always hope...
0:10:46 > 0:10:50There are patients whose tumours don't come back.
0:10:50 > 0:10:52He's been the unlucky one.
0:10:53 > 0:10:55So, this is Ben's story, basically.
0:10:55 > 0:10:59So, he had a tumour way back in 2012.
0:10:59 > 0:11:02This is my colleague, who did a very good resection,
0:11:02 > 0:11:05and got a lot of this out. You can see a big resection cavity here,
0:11:05 > 0:11:09but over the last few years, there's been something growing anteriorly.
0:11:09 > 0:11:13If we give it enough time to regrow, it can transform into something...
0:11:13 > 0:11:15high grade that will threaten him.
0:11:15 > 0:11:19It's very, very frustrating treating brain tumour patients like Ben
0:11:19 > 0:11:21where they've had a good surgery
0:11:21 > 0:11:23and, you know, his tumour's come back.
0:11:23 > 0:11:25The biggest problem with brain tumours
0:11:25 > 0:11:26is they have such poor survival rates.
0:11:26 > 0:11:28Many of them are very aggressive.
0:11:28 > 0:11:30For that reason, they cause the greatest reduction
0:11:30 > 0:11:33of life expectancy compared to any other cancer,
0:11:33 > 0:11:36because they can affect any one of us at any age.
0:11:36 > 0:11:39Most of them are fatal and under the age of 40,
0:11:39 > 0:11:40they're the greatest cancer killer.
0:11:40 > 0:11:42You know, you want to solve this problem
0:11:42 > 0:11:44and you want to make things better
0:11:44 > 0:11:47and that's what drives us on to try and research and develop,
0:11:47 > 0:11:50and design new technologies and new treatments.
0:11:51 > 0:11:55Kevin and his team are at the forefront of using new technology
0:11:55 > 0:11:58to understand more about brain tumours like Ben's.
0:11:58 > 0:12:01I didn't know exactly how my story would pan out,
0:12:01 > 0:12:05but I had a Grade 3 brain tumour, which had been treated,
0:12:05 > 0:12:09but there is the history that it does come back...
0:12:11 > 0:12:13..but the thing is, like, I've just got on with my life.
0:12:13 > 0:12:15I've enjoyed...I've enjoyed things
0:12:15 > 0:12:19and I've been, you know, living my life and getting on with it -
0:12:19 > 0:12:22and then, it has happened,
0:12:22 > 0:12:24and I just need to, erm...
0:12:24 > 0:12:26do it again.
0:12:42 > 0:12:45Any change from this morning here?
0:12:45 > 0:12:48It's 24 hours since Eddie arrived at the HAC,
0:12:48 > 0:12:51suffering a major heart attack.
0:12:51 > 0:12:53This came as quite a surprise.
0:12:53 > 0:12:57I would have expected there to be a feeling of panic,
0:12:57 > 0:13:00and something like that.
0:13:00 > 0:13:03For some reason, it was like...
0:13:03 > 0:13:07"I just hope that they get here with that ambulance quickly.
0:13:07 > 0:13:11"If not, then this could be it."
0:13:11 > 0:13:12That's all I felt.
0:13:22 > 0:13:25I hadn't really thought about it that hard up until then.
0:13:25 > 0:13:27So, that's quite...
0:13:29 > 0:13:31..quite heavy.
0:13:34 > 0:13:36But...I'm here.
0:13:38 > 0:13:40He's done pretty well, actually.
0:13:40 > 0:13:42He's come off the ventilator,
0:13:42 > 0:13:45he's come off all the drugs that were supporting the heart yesterday.
0:13:45 > 0:13:47So, for the extreme types of heart attacks that we see,
0:13:47 > 0:13:50that is a speedy recovery -
0:13:50 > 0:13:54and, hopefully, yeah, he'll be back at work within a few weeks.
0:13:54 > 0:13:56Hello, sir. Oh, hi, again.
0:13:56 > 0:13:58Right, how are you feeling compared to this morning?
0:13:58 > 0:14:01Much better. Does anything not make sense to you?
0:14:01 > 0:14:03Cos you've been through a lot in the last 24 hours.
0:14:03 > 0:14:06No. It has been literally 24 hours, this time yesterday.
0:14:06 > 0:14:09Yes, indeed. No, people have explained it very well.
0:14:09 > 0:14:11OK. Your heart tracings are good,
0:14:11 > 0:14:14your monitoring, your blood pressure and everything's been good.
0:14:14 > 0:14:17So, I think we can literally unhook you from all of this,
0:14:17 > 0:14:19make the next step and get you to the ward -
0:14:19 > 0:14:22and you'll find, as days go by, the heart gets stronger and stronger.
0:14:22 > 0:14:25That should make you feel better. Yeah. Cool. OK.
0:14:25 > 0:14:28Great. Thank you. Bye-bye.
0:14:31 > 0:14:33IQBAL: As a front line service for the heart,
0:14:33 > 0:14:35the HAC is incredibly successful.
0:14:35 > 0:14:37London is pretty well served,
0:14:37 > 0:14:39the rest of the country's following suit.
0:14:39 > 0:14:43These heart attack centres mean that there's a concentration of skills,
0:14:43 > 0:14:45a concentration of staff.
0:14:45 > 0:14:47These patients stay in the hospital for less days,
0:14:47 > 0:14:50and therefore not only does their life get saved,
0:14:50 > 0:14:51it's also cost-effective.
0:14:53 > 0:14:55OK, sir. Back in the ward now.
0:14:57 > 0:14:59HE HUMS TO HIMSELF
0:15:01 > 0:15:05Every division in the Trust must make significant cost savings
0:15:05 > 0:15:08to hit efficiency targets set by the Government.
0:15:08 > 0:15:10Morning. Morning.
0:15:10 > 0:15:13It's the job of general manager Steve Hart
0:15:13 > 0:15:15to oversee the Trust's cost saving plan
0:15:15 > 0:15:18for their cardiac services, including the HAC.
0:15:18 > 0:15:24Firstly, a sort of good news story for the team, so last year, '16/'17,
0:15:24 > 0:15:29challenged to deliver a ?2.3 million cost improvement programme.
0:15:29 > 0:15:31We actually achieved ?2.6 million,
0:15:31 > 0:15:34so surpassed what we're expected to do.
0:15:35 > 0:15:38What that doesn't mean is that '17/'18 is going to get any easier,
0:15:38 > 0:15:42unfortunately. So, last year, our challenge is ?2.3 million.
0:15:42 > 0:15:45This year, we've got a new challenge ?3 million.
0:15:45 > 0:15:47The plan is, basically,
0:15:47 > 0:15:49for us to either deliver
0:15:49 > 0:15:51more activity to a higher quality for the same money,
0:15:51 > 0:15:55or to deliver the same activity to a better quality for less money.
0:15:55 > 0:15:57I'm going to go through the plans now
0:15:57 > 0:16:00and, sort of, let's have the honest discussion
0:16:00 > 0:16:02around when are these likely to start?
0:16:02 > 0:16:04Be mindful of the fact that, at some stage,
0:16:04 > 0:16:07we may need to close beds - unless we expand the service.
0:16:07 > 0:16:10Every year, we're asked to make more and more savings,
0:16:10 > 0:16:13and it gets to a point where, actually,
0:16:13 > 0:16:14there is no more meat on the bone.
0:16:14 > 0:16:16What about seven-day working, then?
0:16:16 > 0:16:18Where's that rolling out?
0:16:18 > 0:16:20I think seven-day working is getting discussed
0:16:20 > 0:16:23as part of the chest pain pathway discussions.
0:16:23 > 0:16:24I'm hoping we don't need to do it
0:16:24 > 0:16:27and I'm conscious that we'll all be calling on the same group of staff
0:16:27 > 0:16:31that have already said, "We don't like working Saturdays and Sundays."
0:16:31 > 0:16:35Seven-day working, in principle, is an excellent idea.
0:16:35 > 0:16:39It doesn't matter what day or time you're admitted,
0:16:39 > 0:16:41you should get the same treatment.
0:16:41 > 0:16:43However, we cannot implement something
0:16:43 > 0:16:46when we don't have the infrastructure to do it.
0:16:46 > 0:16:51Is there a demand for a sixth cath lab to support growth
0:16:51 > 0:16:53in private patient activity?
0:16:53 > 0:16:57I'd just like it to be minuted that I am really, really nervous
0:16:57 > 0:17:00about this sixth cath lab that seems to be rolling on.
0:17:00 > 0:17:05It is impossible to have more cath labs than we have CCU beds.
0:17:05 > 0:17:07It cannot happen.
0:17:07 > 0:17:09So, at the minute, I think...
0:17:09 > 0:17:13I think this... The bed discussion is very much a pipeline discussion.
0:17:13 > 0:17:15What you need to do is see it in the business case,
0:17:15 > 0:17:17which is what I intend to allow you, enable you to see.
0:17:17 > 0:17:19PAGER BEEPS
0:17:19 > 0:17:21Heart valves is... Terminally in eight minutes.
0:17:21 > 0:17:24I've got a pericardial coming in with a GCS three.
0:17:24 > 0:17:26ETA's about five minutes.
0:17:29 > 0:17:31It is difficult -
0:17:31 > 0:17:34and it's continuing tension on a day-to-day basis.
0:17:34 > 0:17:36What is important from my perspective
0:17:36 > 0:17:38is the quality of care delivered to our patients
0:17:38 > 0:17:41and our patient safety isn't compromised in any way
0:17:41 > 0:17:44as a consequence of any of the cost-improvement proposals.
0:17:47 > 0:17:51As a specialist centre, in addition to treating heart attacks,
0:17:51 > 0:17:52Hammersmith's cardiologists
0:17:52 > 0:17:55deal with rare and complex heart conditions.
0:18:00 > 0:18:01Sharp scratch.
0:18:06 > 0:18:08I was...I was really, really healthy.
0:18:08 > 0:18:10Like, at the peak of my health.
0:18:10 > 0:18:13I was really into the gym and, like, fitness and everything.
0:18:13 > 0:18:17We might need to keep it in, because you're having the procedure.
0:18:17 > 0:18:2123-year-old teacher Rosa has a life-threatening infection
0:18:21 > 0:18:24on the mitral valve of her heart called endocarditis.
0:18:24 > 0:18:29Great, thank you. All right? That's you done.
0:18:29 > 0:18:31Right.
0:18:31 > 0:18:36Hello. Plan today is echo before lunch, scan this afternoon. Mm-hm.
0:18:38 > 0:18:42She's got an infected heart valve, and that's called endocarditis.
0:18:42 > 0:18:44It's the last thing you want to see in a young person.
0:18:44 > 0:18:47It carries a high mortality.
0:18:47 > 0:18:49Anywhere between 20-40%.
0:18:51 > 0:18:55Though Rosa appears well, infected tissue from her heart is breaking
0:18:55 > 0:18:59off and causing complications in her brain.
0:18:59 > 0:19:01I was just, like, sending a text message
0:19:01 > 0:19:04and then, I just suddenly couldn't...
0:19:04 > 0:19:07couldn't type with my thumb and I was like, "This is weird,"
0:19:07 > 0:19:09and then the next day, that happened again about five times,
0:19:09 > 0:19:13and then, the last few times, it spread to my face and I, like,
0:19:13 > 0:19:17couldn't move the left side of my face, so I couldn't smile.
0:19:17 > 0:19:20They called it, like, mini strokes.
0:19:20 > 0:19:24It's so weird to just sit here and feel completely normal...
0:19:24 > 0:19:28and have major problems in your brain, and in my heart.
0:19:30 > 0:19:33They said, "We need to speak to you,
0:19:33 > 0:19:35"but," you know, "not here."
0:19:35 > 0:19:36So, we knew. We knew.
0:19:36 > 0:19:38We knew there was something very serious.
0:19:38 > 0:19:40Yeah, in fact they phoned us, didn't they?
0:19:40 > 0:19:42They asked us to come in, in fact.
0:19:42 > 0:19:44All right, love. So, I can text you when I'm back.
0:19:44 > 0:19:46Yeah, all right, sweetheart. Well, I'll make sure that I'm back.
0:19:46 > 0:19:50OK. It takes you right back to when she was born, somehow.
0:19:50 > 0:19:54You sort of go back into being needed as a parent,
0:19:54 > 0:19:57whereas we sort of got used to not really being needed!
0:19:57 > 0:20:00No, you just have this horrible feeling in the pit of your stomach
0:20:00 > 0:20:03that you can't shift,
0:20:03 > 0:20:07and it will be there until they tell us that everything's OK, basically.
0:20:08 > 0:20:11I could see the fear in her parents' eyes,
0:20:11 > 0:20:15and I could understand that because, you know, I'm a parent myself.
0:20:15 > 0:20:18I have a young daughter, and isn't it every parent's worst nightmare?
0:20:24 > 0:20:26This echo's from Friday afternoon
0:20:26 > 0:20:28when I saw her in Charing Cross.
0:20:28 > 0:20:31There's a...there's a big blob. Any leak?
0:20:31 > 0:20:32Yeah, it is leaking.
0:20:34 > 0:20:36Oh, yeah.
0:20:36 > 0:20:39Every Wednesday, senior cardiologists and heart surgeons
0:20:39 > 0:20:43come together to discuss their most complex cases.
0:20:43 > 0:20:46Looking to operate as early as possible, I'd have thought, to...
0:20:46 > 0:20:48That's what we were thinking on Friday.
0:20:48 > 0:20:51So, that's why we had so much discussions with the neurology team,
0:20:51 > 0:20:55the stroke team and neuroradiology.
0:20:55 > 0:20:57The valve needs surgery.
0:20:57 > 0:20:59She needs an operation.
0:20:59 > 0:21:02So, it's one of the most challenging things we treat,
0:21:02 > 0:21:06because the timing of surgery is crucial.
0:21:06 > 0:21:09If you don't get the timing of surgery right, the patient will die.
0:21:09 > 0:21:11I saw her on Saturday.
0:21:11 > 0:21:15I explained that we don't know either the risk of spontaneous bleed
0:21:15 > 0:21:18or going on bypass - and before talking to her,
0:21:18 > 0:21:19I'd spoken to the neuroradiologist,
0:21:19 > 0:21:23who actually said there is a very high risk of spontaneous bleed.
0:21:23 > 0:21:25So, personally, I would wait longer. Yeah.
0:21:25 > 0:21:28They did say that they didn't think that it would preclude
0:21:28 > 0:21:30putting someone on bypass, they have written that.
0:21:30 > 0:21:33We're are all strong minded individuals,
0:21:33 > 0:21:35and we don't always agree,
0:21:35 > 0:21:38but usually we can hammer it out.
0:21:38 > 0:21:43There is a reason to just wait and not rush, so I think...
0:21:48 > 0:21:51Is the neuroradiology MDT in Charing Cross?
0:21:51 > 0:21:54Yeah. Yes. Quarter to 12, I can find out where it is.
0:21:54 > 0:21:56Today? Yeah. It would be good if I could go down, wouldn't it?
0:21:56 > 0:21:58OK. So, we got a plan.
0:21:58 > 0:22:00Great. Right. Who's next?
0:22:02 > 0:22:05There is no clear right or wrong here,
0:22:05 > 0:22:09and you have to go on clinical judgment.
0:22:09 > 0:22:13This grey area in medicine - but at the end of the day,
0:22:13 > 0:22:17somebody has to make a decision.
0:22:25 > 0:22:26It hasn't really hit home yet,
0:22:26 > 0:22:29but I know that tomorrow it's, like, surgery time.
0:22:29 > 0:22:3428-year-old Ben is at the neurosurgery centre in Charing Cross
0:22:34 > 0:22:36for his brain tumour operation.
0:22:37 > 0:22:39When this first happened to me, I was 24.
0:22:39 > 0:22:44I moved down here to train in musical theatre,
0:22:44 > 0:22:48which I'd worked in until this happened four years ago.
0:22:48 > 0:22:53Last time, I was having visual problems, dizzy spells,
0:22:53 > 0:22:57a couple of seizures, which I didn't realise were seizures.
0:22:57 > 0:22:58Basically, blurred vision,
0:22:58 > 0:23:03so I was rushed to A and they found the mass from an MRI scan.
0:23:03 > 0:23:05It was found to be Grade 3.
0:23:05 > 0:23:08I lost my left peripheral vision.
0:23:08 > 0:23:10It was all pretty horrific.
0:23:10 > 0:23:14Giving up dancing and going to dancing auditions was hard,
0:23:14 > 0:23:17because that was my career path,
0:23:17 > 0:23:21and I think I went through a sort of grieving process...
0:23:22 > 0:23:25..and now that it's happening again, it's all a bit...
0:23:25 > 0:23:28It's like going back to four years ago,
0:23:28 > 0:23:31like, history repeating and it's bringing everything back.
0:23:32 > 0:23:34Seventh floor.
0:23:36 > 0:23:38To prepare for the operation,
0:23:38 > 0:23:41the team creates a 3D map of Ben's brain.
0:23:48 > 0:23:52This will help Kevin pinpoint Ben's tumour during the surgery.
0:23:54 > 0:23:57These days, as opposed to his previous surgery, four years ago,
0:23:57 > 0:23:59we now have more tools in the box,
0:23:59 > 0:24:03so we now have quite useful intraoperative imaging,
0:24:03 > 0:24:06which tells us where things are,
0:24:06 > 0:24:08despite things moving around -
0:24:08 > 0:24:11but we are also developing new tools.
0:24:11 > 0:24:13Ben has consented for his operation
0:24:13 > 0:24:16to be part of a pioneering research programme
0:24:16 > 0:24:20which aims to change the way cancer is diagnosed and treated.
0:24:22 > 0:24:24INTERVIEWER: Do you need people to, you know, guinea pig this?
0:24:24 > 0:24:26We don't want anybody to be a guinea pig.
0:24:26 > 0:24:28None of us wants to be a guinea pig,
0:24:28 > 0:24:30but I think we are now starting to make advances.
0:24:30 > 0:24:34You know, with innovations, it's going to open up a whole new world
0:24:34 > 0:24:37of research and potential treatment options for these patients.
0:24:37 > 0:24:40It's literally signing your life away, isn't it?
0:24:40 > 0:24:42No. Hope not. All right. We'll see you soon. OK, yeah, yeah.
0:24:42 > 0:24:44Thank you very much.
0:24:50 > 0:24:51Hello, hello.
0:24:51 > 0:24:53How are you doing, then?
0:24:53 > 0:24:55Erm, yeah. You've had a little bit of a shave, there. OK.
0:24:55 > 0:24:58Did you do that or did we do that? No, I didn't do that!
0:24:58 > 0:25:01OK. OK. Well, look, Are you happy about tomorrow?
0:25:01 > 0:25:03Tomorrow. Yes.
0:25:03 > 0:25:06So, what we want to do is try and get you back... Yeah.
0:25:06 > 0:25:08..to a point where you've got very little
0:25:08 > 0:25:11or no discernible tumour on the imaging.
0:25:11 > 0:25:13My main concern is my visual field -
0:25:13 > 0:25:17and I know you can't promise that it won't be affected.
0:25:17 > 0:25:18There is a small chance that...
0:25:18 > 0:25:21There is a small chance that that could be affected.
0:25:21 > 0:25:24How are your visual fields?
0:25:24 > 0:25:27So, I've got no left peripheral from the last operation... Yeah.
0:25:27 > 0:25:30..and a tiny bit hindered in the right.
0:25:30 > 0:25:32Look me straight in the left eye and tell me when you can see my finger
0:25:32 > 0:25:35coming, and I'll do the same. Can you see it coming in? Tell me.
0:25:35 > 0:25:37Now. OK. I can see this way out here.
0:25:37 > 0:25:39You can't see it till we get to... No, now. ..the midline.
0:25:39 > 0:25:42You've got some deficit up there, but it's maybe the lower quadrant,
0:25:42 > 0:25:46isn't it, on that left? Yeah. Is...? Yeah. We can't guarantee...
0:25:46 > 0:25:48The vicinity that it's in is close
0:25:48 > 0:25:51to where the connections from the eyeball
0:25:51 > 0:25:54to where the brain perceives vision. Yeah, yeah.
0:25:54 > 0:25:56Those radiations, it's...
0:25:56 > 0:25:58They're going around that and have been stretched by that,
0:25:58 > 0:26:00and they have been interfered with.
0:26:00 > 0:26:03Obviously, every surgery we do... Yeah. ..has a certain risk to it.
0:26:19 > 0:26:20I wish they'd do surgery sooner,
0:26:20 > 0:26:24because I'm just sat here thinking at any point some of this infection
0:26:24 > 0:26:27could come off again and cause another aneurysm.
0:26:27 > 0:26:31What if an aneurysm happens in my brain and I'll just die?
0:26:31 > 0:26:3523-year-old Rosa needs an operation to remove infected tissue
0:26:35 > 0:26:37from her heart valve.
0:26:37 > 0:26:39Due to complications in her brain,
0:26:39 > 0:26:43the team must first decide if it's safe to go ahead.
0:26:43 > 0:26:46Obviously, there is a risk of stroke for Rosa having surgery.
0:26:46 > 0:26:48We are not risk averse,
0:26:48 > 0:26:51but the right decision about timing is fundamental.
0:26:53 > 0:26:56I went down to the neuro MDT in Charing Cross.
0:26:56 > 0:27:01Her recent imaging from Tuesday hasn't changed,
0:27:01 > 0:27:05and, actually, their concern over bleeding risk has gone down,
0:27:05 > 0:27:08substantially, and they felt if she needed surgery,
0:27:08 > 0:27:11from our point of view - we should just go ahead.
0:27:11 > 0:27:16So, we were going to repeat the CTA brain on Tuesday,
0:27:16 > 0:27:19and the transthoracic echo and we'll come back.
0:27:19 > 0:27:22She's responding to antibiotics. She is. I think she is.
0:27:24 > 0:27:26Yeah, yeah, yeah -
0:27:26 > 0:27:30but if things change on Tuesday and it looks worse, we just regroup.
0:27:33 > 0:27:34Good.
0:27:35 > 0:27:38There are so many consultants involved with the decision,
0:27:38 > 0:27:41but, eventually, there will be one name next to her bed
0:27:41 > 0:27:43that is the name of the surgeon that operates on her,
0:27:43 > 0:27:48and if things go well, it will be a great team effort.
0:27:48 > 0:27:51If things don't go well, obviously,
0:27:51 > 0:27:54the surgeon will be the first name to be on the spot.
0:27:56 > 0:27:58You are a popular young woman.
0:27:58 > 0:28:02So, we have talked and talked and talked. Yeah.
0:28:02 > 0:28:06You have several small aneurysms in your brain.
0:28:06 > 0:28:11These aneurysms are caused by infected material breaking off,
0:28:11 > 0:28:12going up to the brain,
0:28:12 > 0:28:15and it burrows through the wall of the artery.
0:28:15 > 0:28:18So, I don't think we know yet when to operate.
0:28:20 > 0:28:22I don't think we can decide now.
0:28:22 > 0:28:23But, you know, know this -
0:28:23 > 0:28:26we are not going to put you through surgery...
0:28:27 > 0:28:31..that's going to cause you risk if we don't have to. Yeah. Yeah.
0:28:31 > 0:28:33I'm just worried that with leaving it that, like...
0:28:33 > 0:28:36I don't want any more aneurysms, especially in my brain.
0:28:36 > 0:28:38But no new ones have formed. Yeah. Remember that.
0:28:38 > 0:28:43OK. So, it's just a waiting game, in a way. Yeah.
0:28:47 > 0:28:48OK, bye.
0:29:04 > 0:29:0770-year-old retired railway worker Chhotalal
0:29:07 > 0:29:09is waiting for an angioplasty
0:29:09 > 0:29:13after arriving at the HAC complaining of chest pains.
0:29:13 > 0:29:16My dad, he had a heart attack in January.
0:29:16 > 0:29:18Over the weekend, he was just having a few pains
0:29:18 > 0:29:21and, again, he wasn't saying exactly what was going on.
0:29:21 > 0:29:23Because he was saying before it was indigestion,
0:29:23 > 0:29:27and it wasn't indigestion, it was actually having a heart attack.
0:29:27 > 0:29:31You just don't know when it comes to the heart, and men, especially,
0:29:31 > 0:29:35don't like to admit that they might be dying, possibly. Yeah.
0:29:35 > 0:29:38When did you come in here?
0:29:38 > 0:29:41Yesterday, I came on the Tuesday.
0:29:41 > 0:29:45And I've been kept prisoner since then.
0:29:45 > 0:29:48So this lady is a PCI, to come into mine.
0:29:48 > 0:29:51And this chap is the chap on HAC.
0:29:51 > 0:29:53We've had a very busy night.
0:29:53 > 0:29:56We've got lots of inpatients that need procedures,
0:29:56 > 0:29:59we've got a busy elective list,
0:29:59 > 0:30:00and we are going to get more admissions
0:30:00 > 0:30:03and we are going to get more primaries.
0:30:03 > 0:30:06Right, so what have we got now next?
0:30:06 > 0:30:09So this is our...
0:30:09 > 0:30:11Primary. Can we go through this case?
0:30:11 > 0:30:15So, 70-year-old came in as a primary call.
0:30:15 > 0:30:17Hypertensive, hypergastrinemia.
0:30:17 > 0:30:20Just one stent.
0:30:20 > 0:30:22Was rotablated, arm was heavily calcified.
0:30:23 > 0:30:29He's under the care of consultant cardiologist Ghada Mikhail.
0:30:29 > 0:30:32So we need to check the LAD first, don't we?
0:30:32 > 0:30:34He has got ongoing chest pain
0:30:34 > 0:30:37and he's got some disease left in the other arteries,
0:30:37 > 0:30:40so that's what we're going to treat.
0:30:40 > 0:30:44What we are seeing is increasingly patients with more complex coronary
0:30:44 > 0:30:48disease. When I started training, we had what we call type A lesions,
0:30:48 > 0:30:51very simple coronary disease. You put a balloon and a stent.
0:30:51 > 0:30:54Now patients are living longer, they're getting older,
0:30:54 > 0:30:56the disease is more complex.
0:30:56 > 0:30:58Their arteries are calcified and hardened,
0:30:58 > 0:31:00which can make angioplasty more complex.
0:31:00 > 0:31:02BEEPING
0:31:11 > 0:31:13I got a call from LAS about a gentleman -
0:31:13 > 0:31:15and he's arrested in the community.
0:31:15 > 0:31:16Downtown is five minutes.
0:31:16 > 0:31:18He's on his way? He's on his way.
0:31:18 > 0:31:19They're going to put a call out shortly.
0:31:19 > 0:31:23So, you know what, we can't start this case now.
0:31:23 > 0:31:25He's nearby. Let's talk to him, let's talk to him.
0:31:33 > 0:31:36Hello. How are you?
0:31:36 > 0:31:39OK. Listen, I don't have very good news at the moment.
0:31:39 > 0:31:41We were about to start your procedure,
0:31:41 > 0:31:46but we've just had an emergency call of a patient who's really unwell.
0:31:46 > 0:31:48They're first. Quite good.
0:31:48 > 0:31:50We just need to get the other patient done.
0:31:50 > 0:31:51I'm really sorry about that.
0:31:51 > 0:31:52It doesn't matter. I've got ten years to go.
0:31:52 > 0:31:56Ha-ha! Fantastic, thank you so much.
0:31:56 > 0:31:58OK, there's a cardiac arrest coming in.
0:31:58 > 0:32:01We really don't like to do that type of thing,
0:32:01 > 0:32:03but the other cath labs are being used.
0:32:03 > 0:32:07This is a patient coming in in a cardiac arrest situation.
0:32:07 > 0:32:14He's stable, so he can afford to wait, compared to the other patient.
0:32:14 > 0:32:15I'm really sorry about that.
0:32:18 > 0:32:21Any family, any family?
0:32:21 > 0:32:24Hello. Just tell us what's going on.
0:32:24 > 0:32:27Tell us, OK. Are you ready for a handover? Yes, please.
0:32:27 > 0:32:29Just one second, sorry.
0:32:29 > 0:32:32If he's got an output, we should take him to the lab, yeah?
0:32:39 > 0:32:41Every day is unpredictable.
0:32:41 > 0:32:44You plan for the day, but you could have a lot of emergencies
0:32:44 > 0:32:46one after the other in one day,
0:32:46 > 0:32:49or it could be a day where you have a couple of emergencies
0:32:49 > 0:32:51and manage to get all the elective cases done.
0:32:57 > 0:32:59Do you expect to be seen today?
0:32:59 > 0:33:02I don't want to impose nothing.
0:33:02 > 0:33:04I'm quite patient, because I'm retired.
0:33:04 > 0:33:07What the hell am I going to rush it for?
0:33:07 > 0:33:12I rushed enough for more than 50 years in the jobs I've done, so...
0:33:12 > 0:33:14How are you feeling at the moment?
0:33:14 > 0:33:16Oh, fine. Just as good as you.
0:33:16 > 0:33:18It's just that the inside is not happy.
0:33:19 > 0:33:21BEEPING
0:33:21 > 0:33:22All right.
0:33:22 > 0:33:25So this is another one. So it's going to be crazy today.
0:33:29 > 0:33:32That is exactly how it happens.
0:33:32 > 0:33:36You can be pootling along and then within sort of ten, 15 minutes
0:33:36 > 0:33:38you've got two patients coming in.
0:33:57 > 0:34:00I feel like I'm healthy enough to walk.
0:34:03 > 0:34:06I'm going in for this major surgery,
0:34:06 > 0:34:08but I feel fine, and it's really weird.
0:34:08 > 0:34:12Last time, I was having seizures and a few blackouts.
0:34:12 > 0:34:15I was on high medications, I was feeling like shit.
0:34:15 > 0:34:19But this time, I'm feeling really fine, so it doesn't feel right
0:34:19 > 0:34:21for me to be having surgery this morning.
0:34:22 > 0:34:26It's the day of Ben's operation to remove his brain tumour.
0:34:29 > 0:34:32Do we come up? No. No? OK, all right.
0:34:32 > 0:34:36His family is here from Huddersfield to support him.
0:34:36 > 0:34:38See you in a bit. See you in a bit.
0:34:38 > 0:34:40It's just mixed emotions, you know.
0:34:40 > 0:34:43You try to be positive for him and reassure him and everything,
0:34:43 > 0:34:45but it's a bit surreal.
0:34:45 > 0:34:50You just kind of... Can't imagine it.
0:34:50 > 0:34:51Couldn't imagine it for myself.
0:34:51 > 0:34:55What you want is it to be you.
0:34:55 > 0:34:57You want it to be you, not him,
0:34:57 > 0:35:00and that's the feeling I had, that it should have been me, not him.
0:35:02 > 0:35:04Now, we're here today and he's having it done,
0:35:04 > 0:35:09he's going through it all again and... It's just...
0:35:09 > 0:35:12Well, he's going to come through it and he's going to be fine.
0:35:12 > 0:35:15He's got loads of years ahead of him.
0:35:15 > 0:35:19He's still got a lot to do in life. He's still got aims.
0:35:19 > 0:35:22Oh, God, yeah. Always. Yeah.
0:35:27 > 0:35:31We've created a three-dimensional image volume of Ben.
0:35:31 > 0:35:34You can recognise that's Ben. These are the reference points,
0:35:34 > 0:35:35these little markers we've put on his head,
0:35:35 > 0:35:40which we use as reference points to correlate this virtual image
0:35:40 > 0:35:42to the real Ben.
0:35:42 > 0:35:44We can peel away the surface
0:35:44 > 0:35:49and look at all the blood vessels that you need to avoid.
0:35:49 > 0:35:52Years ago, without this sort of equipment,
0:35:52 > 0:35:54it would be a lot harder.
0:35:54 > 0:35:57I remember the days of putting a CT scan up
0:35:57 > 0:36:00and marking on those lines where the tumour was
0:36:00 > 0:36:03on the scout image to see where we would make our craniotomy.
0:36:03 > 0:36:06We'd just had to hold it up and stand back
0:36:06 > 0:36:09and look at the image on the wall.
0:36:09 > 0:36:11Now, look where we are now.
0:36:12 > 0:36:17You can see I'm pointing to this fiducial.
0:36:17 > 0:36:19That machine is telling me where I'm pointing.
0:36:19 > 0:36:22It even shows you my probe, look.
0:36:22 > 0:36:24Beautiful.
0:36:24 > 0:36:28During the operation, Ben could lose more of his peripheral vision.
0:36:28 > 0:36:32There's also a risk of loss of sensation in his left side
0:36:32 > 0:36:34and paralysis.
0:36:34 > 0:36:36It's really that bit that we want take out, there.
0:36:38 > 0:36:42Ultrasound probes will carry out live brain imaging,
0:36:42 > 0:36:45guiding Kevin along the 3D map of Ben's brain,
0:36:45 > 0:36:48helping him safely remove as much tumour as possible.
0:36:48 > 0:36:51On the left-hand screen, you see the grey of the MRI,
0:36:51 > 0:36:53and then on the ultrasound
0:36:53 > 0:36:57you can see that bright signal in the cavity. Very clear cavity.
0:36:57 > 0:37:01I can actually see it. There's the tumour there, look.
0:37:01 > 0:37:04You can actually see it with your naked eye.
0:37:04 > 0:37:06Amazing.
0:37:06 > 0:37:08OK, so we've got to try and get that out.
0:37:08 > 0:37:10That's Ben.
0:37:10 > 0:37:11Emma. And that's Molly.
0:37:13 > 0:37:15Yeah, happy-go-lucky. Yeah, always...
0:37:15 > 0:37:16Bit bossy towards the other two.
0:37:16 > 0:37:19Yeah, bossy. Always liked to have people around him.
0:37:19 > 0:37:22His main thing were musical theatre.
0:37:22 > 0:37:24He wanted to be in the West End.
0:37:24 > 0:37:28Yeah, he wanted to be there. That was his dream. Yeah.
0:37:28 > 0:37:32I just hope from today that they can do what they need to do to get
0:37:32 > 0:37:35all the cancer out, all the tumour.
0:37:35 > 0:37:37So he can move on, then, with his life.
0:37:39 > 0:37:42Ben has agreed to be part of a research programme
0:37:42 > 0:37:44testing a new diagnostic tool, the iKnife,
0:37:44 > 0:37:47which is being pioneered at Imperial.
0:37:48 > 0:37:52This is the iKnife, so you take tissue, you turn it on,
0:37:52 > 0:37:54and it buzzes the tissue, coagulates it.
0:37:54 > 0:37:56And you get some smoke being produced,
0:37:56 > 0:37:59which then gets sucked up into this tube,
0:37:59 > 0:38:02and that tube then goes into that machine.
0:38:02 > 0:38:05And it tells you what the molecular make-up of that vapour is.
0:38:07 > 0:38:09I'm going to get some iKnife samples here
0:38:09 > 0:38:13and then at the boundary... So shall I take an iKnife sample?
0:38:13 > 0:38:16As the iKnife heats and cuts the tissue,
0:38:16 > 0:38:20it generates so-called surgical smoke.
0:38:20 > 0:38:21It's basically like a sniffer knife.
0:38:21 > 0:38:24It's smelling the vapour coming off the tumour.
0:38:24 > 0:38:28Got something? OK, good.
0:38:28 > 0:38:30Healthy tissue gives off a different molecular signature
0:38:30 > 0:38:32to cancerous tissue.
0:38:32 > 0:38:34The iKnife analyses the smoke
0:38:34 > 0:38:37and transfers the data to its computer.
0:38:38 > 0:38:41We've got a very, very early model, which is not...
0:38:41 > 0:38:44We don't have a huge amount of data.
0:38:44 > 0:38:46Usually, if you were going to have a robust database,
0:38:46 > 0:38:49you would want thousands,
0:38:49 > 0:38:52even tens of thousands, of bits of information to build it on.
0:38:52 > 0:38:55So it is very early days.
0:38:56 > 0:38:58The iKnife can already identify
0:38:58 > 0:39:02the margin between healthy tissue and a number of different cancers,
0:39:02 > 0:39:05but it's still in the training phase for brain tumours.
0:39:07 > 0:39:10The thing about this is that it's bringing the lab into surgery,
0:39:10 > 0:39:13giving us information very quickly. Maybe, possibly, in the future,
0:39:13 > 0:39:16we'll have treatments that we can give locally as we're operating,
0:39:16 > 0:39:17rather than then having to be closed up
0:39:17 > 0:39:20and then wait for post-op chemotherapy and radiotherapy,
0:39:20 > 0:39:23we can actually start giving treatments instantly
0:39:23 > 0:39:24alongside surgery.
0:39:24 > 0:39:27Perhaps, if we're lucky,
0:39:27 > 0:39:30it'll give us some answers to a potential cure.
0:39:30 > 0:39:32Let's see. Let's see.
0:39:32 > 0:39:35I know you can see the tumour, and I am just now
0:39:35 > 0:39:37pulling it away from more normal looking brain.
0:39:37 > 0:39:39But it looks kind of greyish
0:39:39 > 0:39:43and potentially a little bit more aggressive than it perhaps was.
0:39:43 > 0:39:45So what I'm going to do is reset now.
0:39:50 > 0:39:51Tumour.
0:39:54 > 0:39:56Ben's tumour is sent to a lab,
0:39:56 > 0:39:58where pathologists will determine
0:39:58 > 0:40:00if it's more aggressive than his original cancer.
0:40:03 > 0:40:05It'll be two weeks before he gets the results.
0:40:08 > 0:40:10That tumour that was down there is all gone.
0:40:12 > 0:40:15If this turns out to be slightly more aggressive,
0:40:15 > 0:40:17then it was the best thing we could have done.
0:40:19 > 0:40:22Right.
0:40:22 > 0:40:23Good.
0:40:38 > 0:40:39Want to check your temperature.
0:40:39 > 0:40:42There was an emergency, they couldn't do it for me,
0:40:42 > 0:40:43so I stayed all night long.
0:40:43 > 0:40:45I couldn't say nothing.
0:40:45 > 0:40:50Somebody might be in more dire trouble so...
0:40:50 > 0:40:51I'm OK, I wasn't bad.
0:40:51 > 0:40:53I wasn't feeling that bad anyway.
0:40:53 > 0:40:5570-year-old Chhotalal
0:40:55 > 0:40:58had his angioplasty cancelled yesterday
0:40:58 > 0:40:59due to an emergency admission.
0:41:01 > 0:41:05He's spent the night on the busy HAC Ward.
0:41:05 > 0:41:09Current bed state is we're nearly at full capacity at the moment.
0:41:11 > 0:41:14As it stands, if we have a primary come in that goes to the lab
0:41:14 > 0:41:16and needs to go to the coronary care unit,
0:41:16 > 0:41:18we don't have a bed to put them in.
0:41:21 > 0:41:23How do you feel about that?
0:41:23 > 0:41:26It makes me nervous. We are the primary service.
0:41:26 > 0:41:30So anyone having a heart attack within north-west London
0:41:30 > 0:41:32will come here via LAS.
0:41:32 > 0:41:34I've got to do this because he's on HAC.
0:41:34 > 0:41:36It needs to be done.
0:41:36 > 0:41:38Yeah, no, do him... and then two coronaries.
0:41:38 > 0:41:41And then whoever takes the other one with the pacemaker. Yeah? OK.
0:41:41 > 0:41:46He got admitted with chest pain and he's been cancelled once.
0:41:46 > 0:41:49So he needs to be done.
0:41:49 > 0:41:52He wasn't on the elective list, he's come in with symptoms.
0:41:52 > 0:41:54So you can't cancel him again
0:41:54 > 0:41:57because patients can become unstable at any time.
0:42:00 > 0:42:02Comfortable?
0:42:02 > 0:42:04All right, happy for me to carry on?
0:42:04 > 0:42:05Good.
0:42:07 > 0:42:12This is Chhotalal's second angioplasty in three months.
0:42:12 > 0:42:16Take a gentle breath in for me, gentle breath in.
0:42:16 > 0:42:19So this is a very small balloon
0:42:19 > 0:42:23that we're just going to use to inflate the narrowing.
0:42:24 > 0:42:26Stents are inserted into his arteries
0:42:26 > 0:42:29in an attempt to prevent him having another heart attack.
0:42:32 > 0:42:34I'll try and crack that artery open.
0:42:34 > 0:42:37Two, four, six, eight, ten.
0:42:37 > 0:42:38BEEPING
0:42:38 > 0:42:41That's better, and down.
0:42:41 > 0:42:43Narrowing was quite resistant to cracking,
0:42:43 > 0:42:45a lot of chalk in it, and calcium,
0:42:45 > 0:42:48but with a small balloon, it's managed to crack it open.
0:42:48 > 0:42:53How do you feel about the future of the HAC, with the current NHS cuts?
0:42:53 > 0:42:56It's actually very frustrating and really quite depressing.
0:42:56 > 0:42:59As a cardiologist, you want to do more for your patients.
0:42:59 > 0:43:03But, you know, we're getting busier and busier, day by day, actually.
0:43:03 > 0:43:05And the staff are extremely stretched,
0:43:05 > 0:43:08but we have to keep going. Because you can't just walk out.
0:43:11 > 0:43:14Fantastic. We're all done here. OK.
0:43:15 > 0:43:16Good, all done.
0:43:16 > 0:43:20All right? You all right? Yeah, it was very nice. You a bit emotional?
0:43:20 > 0:43:23The benefit of having a centralised system for heart attacks
0:43:23 > 0:43:27is well-proven. But the NHS is cost-constrained,
0:43:27 > 0:43:30I think what's going to happen is that the emergency services,
0:43:30 > 0:43:33as ever with the NHS, are going to be fantastic.
0:43:33 > 0:43:36What might take the hit is the elective patients,
0:43:36 > 0:43:39so when you're not acutely acutely unwell, you're going to wait longer.
0:43:39 > 0:43:42And that is a reality of the modern NHS.
0:43:57 > 0:43:59I is brand-new.
0:44:03 > 0:44:06It feels like my life has just been put on hold.
0:44:06 > 0:44:09Rosa is still waiting for major heart surgery
0:44:09 > 0:44:13to remove infected tissue from her mitral valve,
0:44:13 > 0:44:17but her brain aneurysms need to heal before it's safe to operate.
0:44:17 > 0:44:21If I think about it too much, I'll just be, like, scared and miserable.
0:44:28 > 0:44:30I think that's been one of the hardest things for her.
0:44:30 > 0:44:32She looks around the ward,
0:44:32 > 0:44:38and most people on the ward are kind of 60s, 70s, 80s.
0:44:38 > 0:44:42And she... And that causes you to think a bit more, "Why me?"
0:44:42 > 0:44:46I think the injustice of it all has got to her a bit.
0:44:49 > 0:44:53Hi. Amrish, hi. Hi, Susan.
0:44:53 > 0:44:57So, Rosa, the last time we spoke at the Neuro MDT,
0:44:57 > 0:45:01we were down to one with a whiff of a second. Correct.
0:45:01 > 0:45:03So there's just... A hint.
0:45:03 > 0:45:05Only because you know that there was something there.
0:45:05 > 0:45:07Had I not known, if I didn't have any of these,
0:45:07 > 0:45:09I would have called this completely fine.
0:45:09 > 0:45:12Oh. And the right frontal one is really inconspicuous, actually,
0:45:12 > 0:45:14at this stage. That is just great news.
0:45:14 > 0:45:18And I don't believe that there are any other new...
0:45:18 > 0:45:23Lesions. ..lesions or septic foci, which I can't see on here.
0:45:23 > 0:45:27This is a great result, isn't it? Yeah. Thanks very much.
0:45:27 > 0:45:29No probs, thank you. All right.
0:45:29 > 0:45:32Well, a lot happier.
0:45:32 > 0:45:34Even to me, I'm a cardiologist, I can't read brain scans,
0:45:34 > 0:45:37but even I can see that that looks a lot better.
0:45:41 > 0:45:44Hello. Hello. Hi.
0:45:45 > 0:45:47We had a look at your brain scan
0:45:47 > 0:45:49and the brain scan looks a lot better.
0:45:49 > 0:45:51In fact, if you weren't looking for it,
0:45:51 > 0:45:53you probably wouldn't even see it.
0:45:53 > 0:45:55This is a good outcome.
0:45:55 > 0:45:59It doesn't mean the risk of bleeding is zero,
0:45:59 > 0:46:02but I think it's as low as we're going to get.
0:46:02 > 0:46:07So there's a window here, Rosa, and I think we're in it. Yeah, yeah.
0:46:07 > 0:46:09But she's in good hands.
0:46:09 > 0:46:12Yes. Oh, yeah. Yeah. Thank you.
0:46:15 > 0:46:18I hope I'll get some sleep. I don't know if I will.
0:46:40 > 0:46:42Hi, there. Hello.
0:46:42 > 0:46:45How are you doing? You OK?
0:46:45 > 0:46:48Yeah. Relief. Relief it's all over?
0:46:48 > 0:46:52Feeling OK? I'm just relieved that my vision is here still.
0:46:52 > 0:46:58Good. Still got your vision, yeah.
0:46:58 > 0:46:59I was, I was, I was very worried
0:46:59 > 0:47:03that I would wake up with no vision or less vision...
0:47:03 > 0:47:07I just had nightmares that I would wake up to, or not wake up,
0:47:07 > 0:47:09or have blackness... Yeah.
0:47:09 > 0:47:12If I'm honest... It's a big relief, isn't it?
0:47:12 > 0:47:16I'm sorry, I don't really know what to say. Don't worry.
0:47:16 > 0:47:19You're going to have a bad headache because we took some pressure off
0:47:19 > 0:47:22so it's going to be like the worst hangover you've had.
0:47:22 > 0:47:26Very difficult. Of course it was, no. You've done really well.
0:47:26 > 0:47:29You know, you couldn't almost see the tumour with the naked eye,
0:47:29 > 0:47:31but we just confirmed it with everything
0:47:31 > 0:47:35and it all correlated, and it's all gone. Oh!
0:47:35 > 0:47:37What? Yeah. You've got it all out? Yeah, pretty much.
0:47:37 > 0:47:40Oh, wow. Very happy.
0:47:40 > 0:47:42OK? So you can relax now. Thank you.
0:47:42 > 0:47:44You can relax.
0:47:44 > 0:47:48OK? Wow. Thank you, thank you very, very, very, very, very, very much.
0:47:48 > 0:47:50No problem. I'll see you later.
0:47:50 > 0:47:55If anyone wants to ask what relief feels like, get into my body now.
0:47:55 > 0:47:57OK. I'm going to have to go back to the next operation now.
0:47:57 > 0:48:00Thank you. Good luck. See you. Thank you, well done, thank you.
0:48:00 > 0:48:02He's had all that technology thrown at him
0:48:02 > 0:48:06and he's come out the other side really well. So he will benefit,
0:48:06 > 0:48:09but the real benefit will come for patients in the future,
0:48:09 > 0:48:14when that technology is really well-developed and validated.
0:48:14 > 0:48:16But without patients like Ben
0:48:16 > 0:48:19who are willing to donate their tumour for analysis,
0:48:19 > 0:48:21we're not going to make those steps forward.
0:48:32 > 0:48:38This morning, we have got a big case. This young lady, Rosa.
0:48:38 > 0:48:41You take care.
0:48:52 > 0:48:56Up until now she's been incredibly lucky, really, health-wise.
0:48:56 > 0:48:58In every regard.
0:49:02 > 0:49:06She's very lucky to have landed in this hospital
0:49:06 > 0:49:08with the right expertise.
0:49:09 > 0:49:12I can't thank them enough. No, they've been brilliant.
0:49:15 > 0:49:17Knife, please.
0:49:17 > 0:49:20So we make an incision,
0:49:20 > 0:49:22then we go underneath the breast
0:49:22 > 0:49:28and we enter the chest in the fourth intercostal space.
0:49:28 > 0:49:31Roberto is one of the only heart surgeons in the country
0:49:31 > 0:49:33who performs this operation
0:49:33 > 0:49:37using a minimally invasive technique without breaking the breast bone.
0:49:37 > 0:49:40A traditional incision would be from here, the end of the bone,
0:49:40 > 0:49:43to the beginning of the bone, so will cover all this
0:49:43 > 0:49:46and will spread apart and then open it like this.
0:49:46 > 0:49:48Only the noise makes me feel a little bit uneasy.
0:49:48 > 0:49:49SQUEAKING
0:49:49 > 0:49:53It looks like a Spanish Inquisition sort of tool.
0:49:53 > 0:49:59I'm opening the pericardium, which is the sac around the heart.
0:49:59 > 0:50:02You know, this is the heart.
0:50:02 > 0:50:04The pericardium, the heart.
0:50:04 > 0:50:07In order to operate on her mitral valve,
0:50:07 > 0:50:09Rosa's heart must be stopped.
0:50:09 > 0:50:12You happy there? Yes, we've got good line pressure.
0:50:12 > 0:50:16First, her blood is diverted through a bypass machine
0:50:16 > 0:50:18that takes over the work of her heart and lungs.
0:50:21 > 0:50:24Full flow. Yes, that's full flow there.
0:50:24 > 0:50:29Next, a solution of potassium slows then finally stops Rosa's heart.
0:50:31 > 0:50:33Once it stops, the ECG will be flat.
0:50:36 > 0:50:38We can work safely for an hour.
0:50:38 > 0:50:42OK. Now I'm going to open the left atrium.
0:50:42 > 0:50:43You see, there is a lot of blood here.
0:50:45 > 0:50:48Within minutes, Rosa's heart valve is exposed.
0:50:48 > 0:50:52It's not just the vegetation, there's a perforation in the valve.
0:50:52 > 0:50:55Can you see the hole where I am putting my instrument,
0:50:55 > 0:50:56but most of all, it's not just a hole.
0:50:56 > 0:50:59All the valve here is so thin with infection,
0:50:59 > 0:51:01it has to come out.
0:51:01 > 0:51:02We can't compromise on this.
0:51:07 > 0:51:09OK, one bit is coming off on its own.
0:51:10 > 0:51:14At the moment, I just took out the infected part of the valve.
0:51:14 > 0:51:17So I think that the amount of valve tissue left
0:51:17 > 0:51:22is still good enough, with some work, for us to fix it.
0:51:22 > 0:51:24That is really the best scenario.
0:51:24 > 0:51:26Until I saw the valve, I didn't know we were going to be able to do it.
0:51:26 > 0:51:28Can I have some water to test it?
0:51:30 > 0:51:34In a patient like Rosa, who could have a life expectancy
0:51:34 > 0:51:39of many, many decades, so is a long-term result.
0:51:39 > 0:51:44Suction. Now we've got a pretty happy valve.
0:51:44 > 0:51:47Can you see this, what we call the smiley face, yeah?
0:51:47 > 0:51:50Once I'm out of here and we finish,
0:51:50 > 0:51:54closing this incision will take five minutes.
0:51:54 > 0:51:57So this minimally invasive technique has been proven
0:51:57 > 0:52:00to let the patient recover much faster.
0:52:00 > 0:52:03They are likely to be in hospital possibly two days less
0:52:03 > 0:52:06than the normal traditional operation.
0:52:06 > 0:52:09And so we're saving a lot of taxpayer money.
0:52:09 > 0:52:12Now turn the red on, gently.
0:52:14 > 0:52:17With her valve repaired, Rosa's heart is restarted.
0:52:19 > 0:52:21Now let's have the facing.
0:52:21 > 0:52:23The heart has been still for an hour,
0:52:23 > 0:52:27so it is regaining its own rhythm which is becoming better and better,
0:52:27 > 0:52:28now it's silence.
0:52:30 > 0:52:33Rosa's got a normal heart rhythm.
0:52:33 > 0:52:34The valve is looking very good.
0:52:34 > 0:52:38There is no leak. As far as I'm concerned, it has been a success.
0:52:48 > 0:52:51Hello. Good afternoon.
0:52:51 > 0:52:53Hi, again.
0:52:53 > 0:52:55You remember me, yeah? Yes, of course.
0:52:55 > 0:52:57So, all good. All good.
0:52:57 > 0:53:00Everything has been really, really straightforward.
0:53:00 > 0:53:03Good news is that it's working well, and it's her own valve.
0:53:03 > 0:53:06The heart is working on its own without any support.
0:53:06 > 0:53:09Of all scenarios, this is really the best scenario.
0:53:09 > 0:53:12Thank you very much. Thank you.
0:53:12 > 0:53:16But we just have to wait until she wakes up and then assess her.
0:53:52 > 0:53:54I have spoken to the intensive care last night,
0:53:54 > 0:53:56but I haven't seen her since so...
0:53:58 > 0:54:00She's here, behind these curtains.
0:54:00 > 0:54:02Look at that.
0:54:02 > 0:54:04Doesn't look like she went through much, huh?
0:54:04 > 0:54:07Yes, isn't this wonderful?
0:54:07 > 0:54:09Morning. Hello.
0:54:09 > 0:54:11Look at you.
0:54:11 > 0:54:14Hard to believe you had heart surgery yesterday.
0:54:14 > 0:54:17So it went well?
0:54:17 > 0:54:19Yes, absolutely. All perfect.
0:54:19 > 0:54:24Here's the man. All perfect, so the valve looked like infected.
0:54:24 > 0:54:28Yeah. And it looked like several weeks' infection, and it was,
0:54:28 > 0:54:32it managed to produce a hole in the leaflet of the valve,
0:54:32 > 0:54:34so all the tear has been taken out,
0:54:34 > 0:54:37and we have managed to stitch it back in the normal position,
0:54:37 > 0:54:39so we checked with the tube inside
0:54:39 > 0:54:41and the valve looked absolutely perfect.
0:54:41 > 0:54:43So that's my own valve?
0:54:43 > 0:54:44You have got your own valve.
0:54:44 > 0:54:46I think that is really the best scenario.
0:54:46 > 0:54:49Am I going to have to have it replaced in ten years?
0:54:49 > 0:54:51Probably not. With your valve working well now, we don't know,
0:54:51 > 0:54:53we just have to check over the time.
0:54:53 > 0:54:56Obviously, we need to hope that the infection is gone completely.
0:54:56 > 0:54:57Yeah. Good.
0:54:57 > 0:54:59You are happy? Very, very happy.
0:54:59 > 0:55:01Thank you. I am very happy too.
0:55:01 > 0:55:03I'm really delighted. This is just the best outcome
0:55:03 > 0:55:06we could have hoped for, yeah. Yeah, really happy.
0:55:06 > 0:55:10Thank you all so much. Great. I am just in awe of your work.
0:55:10 > 0:55:13No, not at all, Rosa, it's a pleasure.
0:55:13 > 0:55:16Talk soon, all right? All the best, yeah, bye-bye.
0:55:16 > 0:55:18Thank you. Great.
0:55:22 > 0:55:24See you later.
0:55:25 > 0:55:28A thank you card doesn't really cover it, does it?
0:55:31 > 0:55:33Yeah, I know, I'm really happy.
0:55:45 > 0:55:47There has been a drive in the NHS,
0:55:47 > 0:55:49and I think it's been the right one,
0:55:49 > 0:55:54to concentrate services in specialist areas.
0:55:54 > 0:55:56I think Imperial is probably unique,
0:55:56 > 0:55:59in that it's such a large cardiac unit
0:55:59 > 0:56:03but also has a very large neurology, acute stroke unit,
0:56:03 > 0:56:07neurosurgical unit, so you have this confluence of expertise
0:56:07 > 0:56:09which actually, when it came to Rosa's case,
0:56:09 > 0:56:11was absolutely appropriate.
0:56:15 > 0:56:17It's great, well done. This has been a long time coming.
0:56:17 > 0:56:20It really has, you've been brilliant. Yeah.
0:56:20 > 0:56:22OK? Mm-hm.
0:57:09 > 0:57:13So it looks as though we've got a primary angioplasty that's just arrived.
0:57:13 > 0:57:15Anterior hypokinesia, OK.
0:57:15 > 0:57:17Anterior ST elevation and... OK.
0:57:20 > 0:57:22Don't worry about him. He's having a heart attack
0:57:22 > 0:57:25but we'll get him in straightaway and we'll get him sorted out.
0:57:25 > 0:57:28Don't worry about him. You take a seat in the waiting room
0:57:28 > 0:57:30and we'll get him sorted out quickly.
0:57:30 > 0:57:33OK, and we'll come out and let you know. Thank you. All right.
0:57:38 > 0:57:40What choices would you make
0:57:40 > 0:57:42when faced with complex health care decisions?
0:57:42 > 0:57:46Visit our interactive pages to find out how you would respond.
0:57:46 > 0:57:48Go to...
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