0:00:02 > 0:00:03This man's had a previous stroke,
0:00:03 > 0:00:08which makes things a bit more complicated in assessing him.
0:00:08 > 0:00:09In - one, two, three.
0:00:09 > 0:00:11Out - one, two, three.
0:00:11 > 0:00:12Cough, come on, cough.
0:00:12 > 0:00:14HE COUGHS
0:00:14 > 0:00:16I think you brought it up.
0:00:16 > 0:00:19It all started with a pea size
0:00:19 > 0:00:21that lived in my right sinus.
0:00:21 > 0:00:23Then it began to grow
0:00:23 > 0:00:26and it came out almost like half a golf ball on my face.
0:00:28 > 0:00:30'You get trained on how to break bad news...'
0:00:30 > 0:00:32We're in to do the bloods, is that OK?
0:00:32 > 0:00:34'..but sometimes you find yourself getting too close to patients,
0:00:34 > 0:00:37'so it's is about finding that balance.'
0:00:37 > 0:00:39Fat grafting is actually pretty simple.
0:00:39 > 0:00:42This is how we harvest it, with this cannula,
0:00:42 > 0:00:47so we're going to start now and harvest some fat.
0:00:47 > 0:00:50There is a risk of bleeding in your brain.
0:00:50 > 0:00:52- Are you able to understand that? - Help.
0:00:53 > 0:00:56Can we try to get a relative on the phone?
0:01:08 > 0:01:11We've spent a year looking under the skin of the Health Service,
0:01:11 > 0:01:13focusing on the large team of people
0:01:13 > 0:01:16who dedicate their lives to saving ours.
0:01:19 > 0:01:21In the Royal Victoria Hospital,
0:01:21 > 0:01:25Doctor Enda Kerr is treating 67-year-old James McCabe,
0:01:25 > 0:01:28who he suspects has had a stroke.
0:01:28 > 0:01:30My name is Doctor Kerr,
0:01:30 > 0:01:32one of the doctors from the stroke unit.
0:01:32 > 0:01:35This is Maria Kinnaird, our stroke specialist nurse.
0:01:35 > 0:01:37All right, pet?
0:01:37 > 0:01:40T-t-t...
0:01:40 > 0:01:41HE WAILS
0:01:41 > 0:01:43Are you able to lift your arm up?
0:01:45 > 0:01:47Good. Can you keep it up?
0:01:47 > 0:01:48Keep it up for ten seconds.
0:01:48 > 0:01:52Ten, nine, eight, seven,
0:01:52 > 0:01:56six, five, four,
0:01:56 > 0:01:58three, two... Right.
0:01:59 > 0:02:01That is a typical drift.
0:02:01 > 0:02:03Can we try to get a relative on the phone
0:02:03 > 0:02:06to establish what his baseline language was like?
0:02:08 > 0:02:11Mr McCabe, he was already in the hospital,
0:02:11 > 0:02:13he was having a procedure done on his heart
0:02:13 > 0:02:17called a coronary angiogram, or a dye test of his arteries, and...
0:02:17 > 0:02:20not an uncommon complication of that procedure
0:02:20 > 0:02:22would be to develop a small clot
0:02:22 > 0:02:23to go up into the brain
0:02:23 > 0:02:25and present as having a stroke.
0:02:25 > 0:02:28Try to point to the ceiling with your finger.
0:02:33 > 0:02:35Is that...?
0:02:36 > 0:02:39It's hard to understand that one, is it? OK.
0:02:39 > 0:02:41We talk about time as brain,
0:02:41 > 0:02:43the quicker you get to us,
0:02:43 > 0:02:45the quicker we give you the treatment,
0:02:45 > 0:02:46the more likely it's going to be effective
0:02:46 > 0:02:49and, really, you need to get to us within three or four hours.
0:02:49 > 0:02:52We're literally talking about a five to ten-minute assessment
0:02:52 > 0:02:54of the patient to clarify the diagnosis.
0:02:54 > 0:02:55Have any double vision?
0:02:55 > 0:02:57'Figure out how bad the stroke is
0:02:57 > 0:02:59'and then get them urgently to the CT scanner.'
0:02:59 > 0:03:01Don't worry.
0:03:01 > 0:03:05James is showing some of the symptoms associated with a stroke
0:03:05 > 0:03:08but, as he was already in hospital when it began,
0:03:08 > 0:03:10time should hopefully be on his side.
0:03:10 > 0:03:12Are you able to lift that leg at all? Not at all.
0:03:17 > 0:03:21While most of us will only need the care and support of the NHS
0:03:21 > 0:03:23a few times in our lives,
0:03:23 > 0:03:25there are some who will need much more.
0:03:26 > 0:03:28Well, Grace has been coming to the School of Dentistry
0:03:28 > 0:03:31for probably about ten years now
0:03:31 > 0:03:34and has had a variety of treatments done over the years.
0:03:34 > 0:03:36Grace Smith was a keen socialite
0:03:36 > 0:03:39and captain of the local golf club.
0:03:39 > 0:03:41At the age of 46,
0:03:41 > 0:03:42she was struck by cancer.
0:03:43 > 0:03:48It all really started with a pea size
0:03:48 > 0:03:50that lived in my right sinus,
0:03:50 > 0:03:53then it began to grow and it came out
0:03:53 > 0:03:55almost like half a golf ball on my face.
0:03:58 > 0:04:01Grace had an aggressive cancer of the salivary glands.
0:04:01 > 0:04:03She has had to have her upper jaw bone,
0:04:03 > 0:04:05lower eye socket
0:04:05 > 0:04:07and most of the right side of her face removed.
0:04:07 > 0:04:09Over the last 12 years,
0:04:09 > 0:04:12a team of experts have used the latest pioneering technology
0:04:12 > 0:04:15to gradually reconstruct her face.
0:04:16 > 0:04:20I had three very young children at the time.
0:04:20 > 0:04:21I knew that I had no alternative.
0:04:21 > 0:04:23I had to go through with it
0:04:23 > 0:04:25or I wasn't going to be here.
0:04:25 > 0:04:28That was really how I felt.
0:04:28 > 0:04:30Anything I had...
0:04:30 > 0:04:33thought of doing or any plans that I had made
0:04:33 > 0:04:36really all just...
0:04:36 > 0:04:37disappeared
0:04:37 > 0:04:39cos nothing matters any more
0:04:39 > 0:04:41and your main thought is,
0:04:41 > 0:04:45"I have cancer and I have to fight it, and I have to get through."
0:04:45 > 0:04:48I would say, in my own small way,
0:04:48 > 0:04:50I was maybe a little vain in life.
0:04:50 > 0:04:53I wouldn't have gone to work without my make-up on
0:04:53 > 0:04:56and I wouldn't have gone out without make-up and nails done,
0:04:56 > 0:04:58so it really hit hard.
0:04:58 > 0:05:00It hit home very hard that,
0:05:00 > 0:05:01all of a sudden,
0:05:01 > 0:05:03I'd gone from being
0:05:03 > 0:05:05a bubbly, outward-looking person
0:05:05 > 0:05:09to living life behind dark glasses
0:05:09 > 0:05:11for 11, 12 years.
0:05:13 > 0:05:14Scalpel blade.
0:05:16 > 0:05:19I'm just going to cut away a wee bit of this as well.
0:05:19 > 0:05:21Grace lost all of her top teeth and upper jaw bone
0:05:21 > 0:05:24as a result of the cancer.
0:05:24 > 0:05:27But today, specialist dental surgeon Dr Simon Killough
0:05:27 > 0:05:30is taking a mould of her reconstructed hard palate
0:05:30 > 0:05:33so she can be fitted for a permanent bridge.
0:05:33 > 0:05:35Really, to get the teeth back in
0:05:35 > 0:05:37will restore her...
0:05:37 > 0:05:39cosmetic appearance, first of all,
0:05:39 > 0:05:42and then also her function.
0:05:42 > 0:05:46She'll be able to eat and drink much more easily.
0:05:46 > 0:05:50The teeth and the smile is such an important part of who we are
0:05:50 > 0:05:54and that's one of the aspects of head and neck cancer,
0:05:54 > 0:05:55it can take that away.
0:05:55 > 0:05:58And it is such a nice part of the job
0:05:58 > 0:06:00to be able to give that back to the patient,
0:06:00 > 0:06:02to give them back their smile.
0:06:03 > 0:06:06Can't smile really without upper teeth,
0:06:06 > 0:06:08so I'm really looking forward
0:06:08 > 0:06:09to being able to smile.
0:06:09 > 0:06:12Also, I have a granddaughter
0:06:12 > 0:06:15and I can't give her a kiss on the cheek
0:06:15 > 0:06:18because I can't do the kissing
0:06:18 > 0:06:20formation with no teeth.
0:06:22 > 0:06:25It's taken 14 surgeries over 12 years
0:06:25 > 0:06:28to get Grace to where she is today -
0:06:28 > 0:06:32the most complex of which was to replace her entire upper jaw bone.
0:06:34 > 0:06:35In 2014,
0:06:35 > 0:06:37a team of surgeons at the Ulster Hospital
0:06:37 > 0:06:41were able to make use of some cutting-edge technology,
0:06:41 > 0:06:43recently pioneered in Belgium,
0:06:43 > 0:06:47which allowed them to make a precise 3-D representation
0:06:47 > 0:06:49of Grace's original jawbone.
0:06:49 > 0:06:51They then replicated it
0:06:51 > 0:06:53using the fibula from her leg.
0:06:54 > 0:06:57The main difficulties with this reconstruction -
0:06:57 > 0:06:59the fibula bone is used routinely here and elsewhere
0:06:59 > 0:07:02to reconstruct the lower jawbone,
0:07:02 > 0:07:03quite a straight bone in a way,
0:07:03 > 0:07:06but trying to do that with the upper jawbone,
0:07:06 > 0:07:08the maxilla, is much more complex
0:07:08 > 0:07:12and that's where the 3-D planning technology came into play.
0:07:12 > 0:07:16It basically uses the image data on the CT scans
0:07:16 > 0:07:18and you can do the virtual surgical planning,
0:07:18 > 0:07:21pre-plan where you're going to cut the bone,
0:07:21 > 0:07:23and generate a template like this.
0:07:24 > 0:07:26These slots are all appropriately angled
0:07:26 > 0:07:28so that, when you make all those cuts,
0:07:28 > 0:07:30it will all piece together
0:07:30 > 0:07:32in a jigsaw fashion, like that.
0:07:32 > 0:07:34It was very, very precise
0:07:34 > 0:07:36and there's no wastage at all
0:07:36 > 0:07:38because you know exactly
0:07:38 > 0:07:40at what millimetre you have to cut.
0:07:40 > 0:07:42While in the old days, if you wanted to do something similar,
0:07:42 > 0:07:46you'd be guessing that, "I need this to be 7-8 millimetres,
0:07:46 > 0:07:47"I need this to be that angle,"
0:07:47 > 0:07:49and if it doesn't fit, you have to trim a bit.
0:07:52 > 0:07:55The Macmillan Unit is located in the grounds of Antrim Area Hospital.
0:07:55 > 0:07:58It's a specialist palliative care facility
0:07:58 > 0:08:01for those in the advanced stages of progressive illnesses,
0:08:01 > 0:08:05such as cancer, motor neurone disease and heart failure.
0:08:07 > 0:08:1123-year-old junior doctor Conal Corr begins his rounds.
0:08:11 > 0:08:13I'm currently a foundation year one doctor.
0:08:13 > 0:08:16My first rotation is up here, in the Macmillan Unit,
0:08:16 > 0:08:19to start off my first job as a doctor.
0:08:20 > 0:08:21- Hello, Maureen.- Hello.
0:08:21 > 0:08:24- How are you?- Not so bad.
0:08:24 > 0:08:25Are you OK sitting forward?
0:08:25 > 0:08:27You're not sore or anything, are you?
0:08:27 > 0:08:31- My stethoscope might be a wee bit cold, all right?- That's all right.
0:08:31 > 0:08:34Maureen was a really, really fit and healthy individual.
0:08:34 > 0:08:37She was a horse riding trainer
0:08:37 > 0:08:39and a gymnast,
0:08:39 > 0:08:42and I think that's why she's managed to get to the age that she is
0:08:42 > 0:08:44without any problems.
0:08:44 > 0:08:48And I think that's why the cancer that she does have
0:08:48 > 0:08:51has been allowed to grow and to spread
0:08:51 > 0:08:54without her really noticing it until a very late stage, unfortunately.
0:08:54 > 0:08:56That's you, all right?
0:08:56 > 0:08:57SHE COUGHS
0:08:57 > 0:09:00- Is that cough still bothering you, is it?- No, it's not bothering me.
0:09:00 > 0:09:02- Are you sure now? Are you just being a trooper?- No, no.
0:09:02 > 0:09:03THEY LAUGH
0:09:03 > 0:09:05I'll leave you in peace now, anyway.
0:09:05 > 0:09:08- All right?- Thank you very much. - See you soon.
0:09:12 > 0:09:13You have to be a people person.
0:09:13 > 0:09:15You have to be able to talk to people.
0:09:15 > 0:09:16There has to be a relationship.
0:09:16 > 0:09:19And I think that's why I'm interested in palliative care
0:09:19 > 0:09:20and end of life care,
0:09:20 > 0:09:22because there's so much...
0:09:22 > 0:09:23It's SO patient-centred.
0:09:25 > 0:09:26The nurses are brilliant.
0:09:26 > 0:09:29Really, really lovely, lovely nurses -
0:09:29 > 0:09:31every one of them.
0:09:31 > 0:09:34Doctors, everything, staff, the lot.
0:09:34 > 0:09:36Could not get better.
0:09:38 > 0:09:41I have a few, like, non-medical friends,
0:09:41 > 0:09:42and when I started the job,
0:09:42 > 0:09:44I was maybe a month or two in,
0:09:44 > 0:09:47and they'd have said, "Oh, Conal, how many lives have you saved?"
0:09:47 > 0:09:49I sort of said, "Well, none,
0:09:49 > 0:09:51"because I don't work in that setting."
0:09:51 > 0:09:53But psychologically
0:09:53 > 0:09:55that's difficult because you're not actually treating people.
0:09:55 > 0:09:58You're not able to fix things and that has been challenging.
0:09:58 > 0:10:00But, apart from that, I love it.
0:10:00 > 0:10:02I couldn't see myself in any other career.
0:10:08 > 0:10:09In Lurgan hospital,
0:10:09 > 0:10:13the Acute Care at Home Team are having their morning meeting.
0:10:13 > 0:10:15Gentleman came on Friday evening,
0:10:15 > 0:10:17MS man, he's in bed at the minute.
0:10:17 > 0:10:20He remained quite chesty over the weekend.
0:10:20 > 0:10:22What fluids is he having, Ann?
0:10:22 > 0:10:24'This is a very unique team.'
0:10:24 > 0:10:26We're the first team within Northern Ireland
0:10:26 > 0:10:29to actually act within this model.
0:10:29 > 0:10:31You'll hopefully see him this afternoon.
0:10:31 > 0:10:33Paul will start cough assist
0:10:33 > 0:10:34and whatever nurse...
0:10:34 > 0:10:37If you can do a joint visit with the nurse this afternoon.
0:10:37 > 0:10:40So, it's a multidisciplinary team
0:10:40 > 0:10:42made up of specialist nurses, physio,
0:10:42 > 0:10:45pharmacist and our consultant doctors.
0:10:45 > 0:10:47It's hospital at home.
0:10:47 > 0:10:50We're doing all the care and intervention that a hospital can do.
0:10:53 > 0:10:56The idea of our service is to cut out hospital admission,
0:10:56 > 0:10:58where they'll be treated within the home.
0:10:58 > 0:11:00Maybe a doctor has been called out,
0:11:00 > 0:11:02our team will come into play
0:11:02 > 0:11:05and we will go and see them and see if they are appropriate
0:11:05 > 0:11:06for the Acute Care at Home Team.
0:11:08 > 0:11:12The acute care service also has big benefits for patients,
0:11:12 > 0:11:15who can be treated in the comfort of their own homes,
0:11:15 > 0:11:16and their families,
0:11:16 > 0:11:21who can avoid the hassle and expense of repeated hospital visits.
0:11:21 > 0:11:23Anne Graham's husband, Billy, has MS...
0:11:23 > 0:11:25Hello, Anne. Hello.
0:11:25 > 0:11:27..and was referred to the team last week
0:11:27 > 0:11:29as he's currently suffering from pneumonia.
0:11:29 > 0:11:32We'll explain everything to you.
0:11:32 > 0:11:34Take a nice, deep breath when you're ready again.
0:11:34 > 0:11:36- Go, a big one. - HE EXHALES
0:11:38 > 0:11:40BILLY COUGHS
0:11:40 > 0:11:42That's OK. That's OK.
0:11:42 > 0:11:43The team that come out
0:11:43 > 0:11:45are really, really good.
0:11:45 > 0:11:48And there is a nurse comes three times a day,
0:11:48 > 0:11:52and does all the injections and things.
0:11:52 > 0:11:54Breathe in with the machine.
0:11:54 > 0:11:57In - one, two, three. Rest.
0:11:57 > 0:11:59It's great because
0:11:59 > 0:12:01you don't have to be tied to a time
0:12:01 > 0:12:02to go and see him,
0:12:02 > 0:12:04you can see him at any time,
0:12:04 > 0:12:07and you know what's going on all the time,
0:12:07 > 0:12:11instead of going into the hospital and being told.
0:12:11 > 0:12:13You know at the time what's happening.
0:12:13 > 0:12:15It's much better, so it is.
0:12:15 > 0:12:17In - one, two, three.
0:12:17 > 0:12:19Out - one, two, three.
0:12:19 > 0:12:21In - one, two, three. Cough.
0:12:21 > 0:12:22Come on, cough.
0:12:22 > 0:12:24- HE COUGHS - Very good. Very good.
0:12:24 > 0:12:26'Cough assist is one of the best options
0:12:26 > 0:12:28'to help him clear the secretions.'
0:12:28 > 0:12:30Clearing secretions are going to help improve the infection
0:12:30 > 0:12:33- as early as possible. - HE COUGHS
0:12:33 > 0:12:34Good, strong cough there.
0:12:34 > 0:12:36Well done.
0:12:36 > 0:12:38He's quite well this afternoon.
0:12:38 > 0:12:42He will still need quite a few more days of intensive physio
0:12:42 > 0:12:43and intravenous antibiotics.
0:12:43 > 0:12:45We'll also be taking blood samples
0:12:45 > 0:12:48to check the effectiveness of the treatment.
0:12:48 > 0:12:50Well done. Well done.
0:12:50 > 0:12:52We could take most of our pneumonias back into the home
0:12:52 > 0:12:55and we could look after them if we have a good team down.
0:12:55 > 0:12:57Most of the pneumonias can be looked after at home.
0:12:57 > 0:12:59You don't really need hospital admission,
0:12:59 > 0:13:02unless they are critically unwell.
0:13:02 > 0:13:04I haven't been well myself,
0:13:04 > 0:13:06which means I can't drive all the time.
0:13:06 > 0:13:10I couldn't get down to see him if he was in hospital.
0:13:10 > 0:13:13At least, if I have him at home, I can see what's going on.
0:13:13 > 0:13:15It's great.
0:13:15 > 0:13:18They even come out here to the house...
0:13:18 > 0:13:20instead of having me go into hospital,
0:13:20 > 0:13:23in which they are more packed.
0:13:23 > 0:13:24Better for them to come here.
0:13:27 > 0:13:29At Craigavon Area Hospital,
0:13:29 > 0:13:31their always-busy laundry department
0:13:31 > 0:13:33has become a integral part
0:13:33 > 0:13:36of the Southern Trust's domestic services,
0:13:36 > 0:13:38with the staff here managing the laundry
0:13:38 > 0:13:40for eight separate hospitals.
0:13:40 > 0:13:43It opened back in 1972
0:13:43 > 0:13:45and head of linen services, Anne Forbes,
0:13:45 > 0:13:48has been at the helm for the past 15 years.
0:13:48 > 0:13:52That's the Belfast linen being sent out.
0:13:52 > 0:13:54Going out, yeah.
0:13:54 > 0:13:57In this laundry, we employ 52 staff.
0:13:57 > 0:14:01We process about 100,000 pieces of linen a week
0:14:01 > 0:14:05and we service up to 1,600 beds.
0:14:07 > 0:14:09All the linen that comes within the health service
0:14:09 > 0:14:12must be washed at a thermal disinfection temperature
0:14:12 > 0:14:17and that's to ensure that all infections are destroyed
0:14:17 > 0:14:20and the linen is safe, at point of use, for the patient.
0:14:22 > 0:14:24Every delivery of dirty laundry
0:14:24 > 0:14:26must first pass through the sorting room,
0:14:26 > 0:14:28where the team takes special care
0:14:28 > 0:14:30to ensure that no unwanted items
0:14:30 > 0:14:32end up in the wash.
0:14:32 > 0:14:36We get phone calls here to watch out for mobile phones
0:14:36 > 0:14:37and iPods,
0:14:37 > 0:14:39false teeth...
0:14:39 > 0:14:41You're never surprised what you're going to find
0:14:41 > 0:14:44when you open a bag in here, you know? It could be anything.
0:14:44 > 0:14:47The only thing we haven't found is a patient.
0:14:47 > 0:14:50There's times that there's stuff comes in here
0:14:50 > 0:14:52and the smell is overpowering.
0:14:52 > 0:14:55You have to have a really, really strong stomach sometimes, you know?
0:14:55 > 0:14:57But you get used to it in the end, you know.
0:15:03 > 0:15:05Back at the Royal, it's 30 minutes
0:15:05 > 0:15:08since James McCabe's started showing signs of a stroke
0:15:08 > 0:15:11and the team are ready to begin his CT scan.
0:15:13 > 0:15:16We want to see if we can identify any large arteries that are blocked,
0:15:16 > 0:15:18in this man's brain,
0:15:18 > 0:15:20that seem to be causing this sudden speech problem
0:15:20 > 0:15:24and visual problem that he's developed.
0:15:24 > 0:15:25But as the results start coming in,
0:15:25 > 0:15:29a diagnosis could prove trickier than expected.
0:15:29 > 0:15:32This is complicated cos this man's had a previous stroke
0:15:32 > 0:15:33in the right side of his brain,
0:15:33 > 0:15:36causing left-sided weakness,
0:15:36 > 0:15:38which makes things a bit more complicated in assessing him.
0:15:38 > 0:15:40A major riddle...
0:15:40 > 0:15:42'The most exciting treatments
0:15:42 > 0:15:44'that people talk about for acute stroke are...'
0:15:44 > 0:15:47One is an intravenous drug, that we call thrombolysis,
0:15:47 > 0:15:49that helps to dissolve clots.
0:15:49 > 0:15:52There's some risk, with that drug, of causing bleeding -
0:15:52 > 0:15:55so selecting a patient for that treatment is really important.
0:15:55 > 0:15:59The second real major advance in stroke treatment in recent years
0:15:59 > 0:16:01is a thing called clot retrieval,
0:16:01 > 0:16:03where we have colleagues in our hospital here
0:16:03 > 0:16:07who can go into your arteries, in your brain, with little fine tubes,
0:16:07 > 0:16:10find the clot and physically pull it out.
0:16:10 > 0:16:13It's remarkable when you see someone with a dense stroke
0:16:13 > 0:16:15going from unable to speak, unable to move, to -
0:16:15 > 0:16:17within minutes or hours after that treatment -
0:16:17 > 0:16:19standing up and walking out.
0:16:21 > 0:16:22We're trying to figure out
0:16:22 > 0:16:25whether you've had a stroke or not this morning.
0:16:25 > 0:16:27Another stroke.
0:16:27 > 0:16:28OK?
0:16:28 > 0:16:31You're large arteries in your brain are OK.
0:16:32 > 0:16:35It might be that there's a small artery in your brain
0:16:35 > 0:16:39that's blocked by a clot.
0:16:39 > 0:16:41The treatment for that is a clot-busting drug
0:16:41 > 0:16:43that we call thrombolysis,
0:16:43 > 0:16:46but there is some risk with doing that,
0:16:46 > 0:16:48in giving you that treatments.
0:16:49 > 0:16:51It's about one in 50,
0:16:51 > 0:16:542% risk,
0:16:54 > 0:16:56of bleeding in your brain.
0:16:56 > 0:16:58That could make you worse.
0:16:58 > 0:17:00Do you understand that?
0:17:00 > 0:17:02Are you able to understand that?
0:17:02 > 0:17:03Help.
0:17:05 > 0:17:07OK. Oh, it's frustrating,
0:17:07 > 0:17:08it is frustrating.
0:17:08 > 0:17:10OK.
0:17:10 > 0:17:14I think what we'll do is we'll give him thrombolysis.
0:17:14 > 0:17:16I can't exclude that he's not had a stroke
0:17:16 > 0:17:18- and he has severe speech problems.- OK.
0:17:22 > 0:17:25OK, sir, I'm going to give this clot-busting medication now, OK?
0:17:27 > 0:17:28I have some suspicion
0:17:28 > 0:17:31that there may be something else going on other than a stroke
0:17:31 > 0:17:34but, at the moment, it's impossible to tell for sure
0:17:34 > 0:17:36whether it was or was not a stroke.
0:17:36 > 0:17:38I'm just going to flush through a bit of water.
0:17:38 > 0:17:42The scans are good, there's no major artery occlusion,
0:17:42 > 0:17:45so this thing seemed to happen very suddenly.
0:17:45 > 0:17:46It is in keeping with a stroke
0:17:46 > 0:17:49and he seems to have right-sided weakness
0:17:49 > 0:17:50along with a loss of language,
0:17:50 > 0:17:52which is very much in keeping with a stroke.
0:17:52 > 0:17:54Just the way he's behaving.
0:17:54 > 0:17:55He seems a bit frustrated with it
0:17:55 > 0:17:58and that's making me wonder, you know, for sure.
0:17:58 > 0:18:01But, if it is a stroke, then we only one option
0:18:01 > 0:18:03and the option is to get rid of this clot
0:18:03 > 0:18:05and the only way we can do that now
0:18:05 > 0:18:07is by giving him the clot-busting drug.
0:18:08 > 0:18:12Tough calls like these are part of everyday life for doctors.
0:18:12 > 0:18:15Mr McCabe will be kept under close observation
0:18:15 > 0:18:17to see how he responds to the treatment.
0:18:22 > 0:18:23At the Ulster Hospital,
0:18:23 > 0:18:25cancer survivor Grace Smith
0:18:25 > 0:18:27is in for yet another operation.
0:18:27 > 0:18:31Plastic surgeons Chris Hill and Declan Lannon
0:18:31 > 0:18:33want to close a hole in her upper palate
0:18:33 > 0:18:35as well as taking fat from her stomach
0:18:35 > 0:18:38to help rebuild her face.
0:18:38 > 0:18:41Grace, I haven't seen you since we did the last fat grafting,
0:18:41 > 0:18:44so I know that your tummy was quite sore afterwards
0:18:44 > 0:18:48and I'm afraid it probably will be again but,
0:18:48 > 0:18:50just looking, it has added a bit more volume in here,
0:18:50 > 0:18:53but there's still this contour deformity in your cheek
0:18:53 > 0:18:55and we'll really aim to try and fill that out this time.
0:18:57 > 0:19:00..but despite undergoing numerous surgeries,
0:19:00 > 0:19:03it still doesn't get any easier for Grace.
0:19:03 > 0:19:05Apprehensive, nervous,
0:19:05 > 0:19:07but I'm in the very best of hands.
0:19:07 > 0:19:09So, looking forward to getting another stage
0:19:09 > 0:19:13in the journey completed and one more move towards the end.
0:19:19 > 0:19:21There are two parts to today's procedure.
0:19:21 > 0:19:23We're going to do some fat grafting to her cheek
0:19:23 > 0:19:25and we're going to then try to close
0:19:25 > 0:19:28the palatial fistula in her mouth.
0:19:28 > 0:19:31What I'm doing now is I'm just looking at her face,
0:19:31 > 0:19:32at the side that's unaffected,
0:19:32 > 0:19:34and I'm just trying to decide...
0:19:34 > 0:19:36We're looking at the contours here on the right side
0:19:36 > 0:19:41to decide where I'm going to put the most fat.
0:19:41 > 0:19:44The sorest bit of the fat grafting procedure is her abdomen.
0:19:44 > 0:19:46It will feel a bit...
0:19:46 > 0:19:50I tell patients it feels a bit like being punched in the tummy,
0:19:50 > 0:19:53so it's not agony, but it's still uncomfortable.
0:19:55 > 0:19:58Fat grafting is actually pretty simple.
0:19:58 > 0:19:59This is how we harvest it,
0:19:59 > 0:20:01with this cannula.
0:20:01 > 0:20:02When it sucks the fat in,
0:20:02 > 0:20:05the idea is to try and not damage the fat
0:20:05 > 0:20:06cos we want the fat to be viable
0:20:06 > 0:20:09so that it will survive when we transfer it to her face.
0:20:09 > 0:20:13So, we're going to start now and harvest some fat.
0:20:13 > 0:20:15So, I'm just making a little stab incision
0:20:15 > 0:20:18through the skin into the fat here
0:20:18 > 0:20:20and then, that's now sitting in the subcutaneous fat.
0:20:20 > 0:20:23I can feel where the tip of the cannula is
0:20:23 > 0:20:24and I've got the suction now on this
0:20:24 > 0:20:28and you can see the fat starting to come into the syringe.
0:20:28 > 0:20:31It'll be quite watery because of the local anaesthetic.
0:20:31 > 0:20:33It's a bit repetitive, but...
0:20:33 > 0:20:37it's fine when we're not trying to harvest too many syringes,
0:20:37 > 0:20:40but, if you're harvesting 20 or 30 ten-mil syringes,
0:20:40 > 0:20:43it becomes quite hard work.
0:20:43 > 0:20:46So, you can see that's a syringe of harvested fat.
0:20:48 > 0:20:51Once Mr Hill has harvested a sufficient amount of fat,
0:20:51 > 0:20:54it then has to be centrifuged and separated
0:20:54 > 0:20:56before being re-injected into her face.
0:20:56 > 0:20:58OK.
0:20:58 > 0:20:59The centrifuge has stopped
0:20:59 > 0:21:01and we're just going to lift these out...
0:21:01 > 0:21:02You grab the other two, Chris.
0:21:02 > 0:21:05..and you can see, it's quite colourful, actually.
0:21:05 > 0:21:07This is the fluid layer, with the blood.
0:21:07 > 0:21:09There's a little patch at the bottom.
0:21:09 > 0:21:12This is the viable fat and, at the top, you can see the oil.
0:21:12 > 0:21:14Now, clearly here, you need to be careful
0:21:14 > 0:21:17that the fat doesn't actually start to run out.
0:21:17 > 0:21:19It's, sort of, held in by the suction at the minute,
0:21:19 > 0:21:21but it will fall out, eventually.
0:21:21 > 0:21:24And that is the fat that we're going to use.
0:21:24 > 0:21:25And that's it...clean now.
0:21:27 > 0:21:29Just let it slide back down the tube.
0:21:31 > 0:21:33So, we're going to infiltrate the fat now with this.
0:21:33 > 0:21:35This is a blunt cannula,
0:21:35 > 0:21:38so through this tiny, little incision
0:21:38 > 0:21:40I'm just going to advance this cannula under the skin.
0:21:40 > 0:21:43You can see it moving down.
0:21:43 > 0:21:45Now, the idea is to infiltrate the fat
0:21:45 > 0:21:47as you withdraw and you can see, look.
0:21:47 > 0:21:51You can see the little ridge of fat that's been left behind.
0:21:51 > 0:21:54So, you just keep doing that until the area is filled.
0:21:55 > 0:21:57Each layer of fat that's placed
0:21:57 > 0:21:59will be close to her blood supply.
0:21:59 > 0:22:00If you put it all in the same place,
0:22:00 > 0:22:02if you just keep injecting and blow one area up,
0:22:02 > 0:22:04the innermost layer of fat,
0:22:04 > 0:22:05or the inner layers of fat,
0:22:05 > 0:22:08will be too far from the blood supply to actually take as a graft.
0:22:10 > 0:22:12After about four months,
0:22:12 > 0:22:13the fat is felt to be stable,
0:22:13 > 0:22:16so the patient, the volume that they gain
0:22:16 > 0:22:19will remain and really will remain indefinitely.
0:22:19 > 0:22:21So, it's a permanent fix
0:22:21 > 0:22:24and we've certainly significantly improved the contour.
0:22:24 > 0:22:28This fat grafting is only the first part of today's surgery -
0:22:28 > 0:22:31Grace lost most of her upper palate due to the cancer -
0:22:31 > 0:22:33but after this dual operation,
0:22:33 > 0:22:36it should be restored to normal function.
0:22:36 > 0:22:37This lady has a large fistula,
0:22:37 > 0:22:39a large hole in the roof of her mouth,
0:22:39 > 0:22:43connecting into what would have been her sinus and her nose,
0:22:43 > 0:22:45her nasal cavity.
0:22:45 > 0:22:47So, that's giving her nasal speech
0:22:47 > 0:22:50and it can cause a certain amount of nasal regurgitation,
0:22:50 > 0:22:53where food and fluid can pour out of the nose.
0:22:53 > 0:22:55We're trying to close that.
0:22:55 > 0:22:57Declan has raised this oral flap
0:22:57 > 0:23:00and it's going to swing back the way
0:23:00 > 0:23:02and stitch across that, like that.
0:23:02 > 0:23:04We'll be using the front of her palate
0:23:04 > 0:23:07to try to close the back of the palate.
0:23:07 > 0:23:09The front of her palate will then be a raw area.
0:23:09 > 0:23:11It will be a raw, unclosed wound
0:23:11 > 0:23:15that will have to heal itself over the coming weeks.
0:23:21 > 0:23:23Back at the Macmillan Unit...
0:23:23 > 0:23:26We need a blood sample on Jacqueline in room 12.
0:23:26 > 0:23:29..junior doctor Conal Corr is finishing his rounds.
0:23:29 > 0:23:32Unfortunately, it has been tried a few times
0:23:32 > 0:23:34and it's been really difficult to get it,
0:23:34 > 0:23:37so we're going to have another go on her, just to see.
0:23:37 > 0:23:39I will have two goes. Two goes is quite reasonable.
0:23:39 > 0:23:40Three's pushing it.
0:23:43 > 0:23:46Then you might want to just refer on to somebody else who can do it,
0:23:46 > 0:23:47who's maybe more experienced.
0:23:47 > 0:23:50ALARM BEEPS
0:23:53 > 0:23:56'Jacqueline is a new lady that was just brought down to us yesterday.
0:23:56 > 0:23:59'She's a young lady with breast cancer
0:23:59 > 0:24:03'and she's had chemo, she's had the surgery, she's had everything,
0:24:03 > 0:24:06'but unfortunately the disease has come back.
0:24:06 > 0:24:08'So now it is all about supportive measures,
0:24:08 > 0:24:10'but she has a really good family support,
0:24:10 > 0:24:12'which is so lovely to see and it's...
0:24:12 > 0:24:14'It makes our job a lot easier when the family are there,
0:24:14 > 0:24:16'helping them through.' Hello, Jacqueline.
0:24:16 > 0:24:19- Hiya.- Morning.- We're in to do the bloods, is that OK?
0:24:21 > 0:24:24Sometimes you find yourself getting too close to patients.
0:24:24 > 0:24:26You know, you get trained on how to break bad news
0:24:26 > 0:24:29and how to tell somebody that somebody's died.
0:24:29 > 0:24:30But I was on a night shift,
0:24:30 > 0:24:33'and there was a patient of ours recently
0:24:33 > 0:24:35'who I was a very close with, and I thought I'd pop down...'
0:24:35 > 0:24:37That's going to be really tight, OK?
0:24:37 > 0:24:39But it'll help. The tighter, the better.
0:24:39 > 0:24:44I went into the main office and her name wasn't on the board any more,
0:24:44 > 0:24:45and that was how I found out.
0:24:45 > 0:24:47And that...
0:24:47 > 0:24:48You know, that was no-one's fault,
0:24:48 > 0:24:51but that wasn't a nice way to find out.
0:24:51 > 0:24:53And, in that way, it is difficult,
0:24:53 > 0:24:55so it's about finding that balance.
0:24:55 > 0:24:56Stop.
0:24:56 > 0:24:58Sometimes it does that.
0:24:58 > 0:24:59That's what Gordon said.
0:25:03 > 0:25:06Every person that's passed away in this unit
0:25:06 > 0:25:08has done so comfortably,
0:25:08 > 0:25:11peacefully and surrounded by their families, every time.
0:25:13 > 0:25:15That, for me, has been...
0:25:15 > 0:25:17It's really helped me deal with it in my own head and say,
0:25:17 > 0:25:19"Yes, these patients are dying,
0:25:19 > 0:25:21"but it's a successful death."
0:25:21 > 0:25:23We're all going to die someday and I think, if I did,
0:25:23 > 0:25:24that's how I'd want it.
0:25:24 > 0:25:26I'd want to be peaceful and comfortable
0:25:26 > 0:25:28and surrounded by my family, so, you know,
0:25:28 > 0:25:30you can't really ask any more than that.
0:25:39 > 0:25:41At the Royal Victoria Hospital,
0:25:41 > 0:25:4467-year-old James McCabe has responded well
0:25:44 > 0:25:46to his clot-busting medication.
0:25:47 > 0:25:49Mr McCabe has had a fantastic outcome
0:25:49 > 0:25:50after getting the clot-buster drug,
0:25:50 > 0:25:53which was given to him really very quickly
0:25:53 > 0:25:55after onset of the stroke.
0:25:55 > 0:25:57And I suppose that's the thing about stroke,
0:25:57 > 0:25:59it can be really devastating
0:25:59 > 0:26:01and, hopefully, you can see
0:26:01 > 0:26:04that the systems we have set up in our hospitals
0:26:04 > 0:26:08allow us to try to respond to people having a stroke urgently.
0:26:08 > 0:26:11We get there as quickly as we can.
0:26:11 > 0:26:15I can't thank Doctor Kerr and the medical team enough.
0:26:15 > 0:26:19They explained everything, bit by bit,
0:26:19 > 0:26:22because, at the time, it was frightening.
0:26:22 > 0:26:24You couldn't get the words out.
0:26:24 > 0:26:28You had them in your brain, but they wouldn't come out.
0:26:28 > 0:26:31With the care of Doctor Kerr and his team,
0:26:31 > 0:26:33it was bloody marvellous.
0:26:33 > 0:26:37You couldn't be in a better place than it actually happened.
0:26:45 > 0:26:48It's now been seven weeks since Grace's surgery.
0:26:49 > 0:26:52And it's improving the shape of my face,
0:26:52 > 0:26:55and it's giving me the symmetry with the other side
0:26:55 > 0:26:58and I feel that that in itself
0:26:58 > 0:27:01is helping me feel a lot more confident going out and about
0:27:01 > 0:27:02when people aren't just staring at me
0:27:02 > 0:27:04the same as they were in the past.
0:27:06 > 0:27:07Each surgery that has taken place
0:27:07 > 0:27:11has really improved my inner feeling about myself
0:27:11 > 0:27:14and I definitely feel a lot more confident.
0:27:14 > 0:27:17And with her oral surgery now complete...
0:27:17 > 0:27:20We've got your bridge back from the laboratory.
0:27:20 > 0:27:23..Grace is finally able to be fitted with a permanent bridge.
0:27:23 > 0:27:26So, what do you think, Grace? What you think of them?
0:27:26 > 0:27:28I think they're wonderful. Thank you. Yeah.
0:27:28 > 0:27:30- Really pleased with them. - It's looks lovely.
0:27:30 > 0:27:32- I love them.- Yeah?
0:27:32 > 0:27:36It's lovely just to think now that I have permanent teeth.
0:27:36 > 0:27:38They're absolutely wonderful and I'm delighted with them.
0:27:38 > 0:27:40And it's a new smile,
0:27:40 > 0:27:42a new chewing technique
0:27:42 > 0:27:44and everything's great.
0:27:45 > 0:27:49She really thinks it looks really good and I'm really pleased.
0:27:49 > 0:27:52It's very rewarding sort of work, this, and such a good result.
0:27:53 > 0:27:55Everything is moving forward,
0:27:55 > 0:27:59and I'm delighted with it and I feel that I'm really getting there now.
0:27:59 > 0:28:02One thing it's given to me, as I've said before
0:28:02 > 0:28:05and will continue to say for the rest of my days,
0:28:05 > 0:28:08is that they've given me quality of life
0:28:08 > 0:28:10and they've given me my life back
0:28:10 > 0:28:13and I never will be able to thank them enough for that.