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