Episode 4 Saved: At the Heart of the Health Service

This man's had a previous stroke,

which makes things a bit more complicated in assessing him.

In - one, two, three.

Out - one, two, three.

Cough, come on, cough.

HE COUGHS

I think you brought it up.

It all started with a pea size

that lived in my right sinus.

Then it began to grow

and it came out almost like half a golf ball on my face.

'You get trained on how to break bad news...'

We're in to do the bloods, is that OK?

'..but sometimes you find yourself getting too close to patients,

'so it's is about finding that balance.'

Fat grafting is actually pretty simple.

This is how we harvest it, with this cannula,

so we're going to start now and harvest some fat.

There is a risk of bleeding in your brain.

-Are you able to understand that?

-Help.

Can we try to get a relative on the phone?

We've spent a year looking under the skin of the Health Service,

focusing on the large team of people

who dedicate their lives to saving ours.

In the Royal Victoria Hospital,

Doctor Enda Kerr is treating 67-year-old James McCabe,

who he suspects has had a stroke.

My name is Doctor Kerr,

one of the doctors from the stroke unit.

This is Maria Kinnaird, our stroke specialist nurse.

All right, pet?

T-t-t...

HE WAILS

Are you able to lift your arm up?

Good. Can you keep it up?

Keep it up for ten seconds.

Ten, nine, eight, seven,

six, five, four,

three, two... Right.

That is a typical drift.

Can we try to get a relative on the phone

to establish what his baseline language was like?

Mr McCabe, he was already in the hospital,

he was having a procedure done on his heart

called a coronary angiogram, or a dye test of his arteries, and...

not an uncommon complication of that procedure

would be to develop a small clot

to go up into the brain

and present as having a stroke.

Try to point to the ceiling with your finger.

Is that...?

It's hard to understand that one, is it? OK.

We talk about time as brain,

the quicker you get to us,

the quicker we give you the treatment,

the more likely it's going to be effective

and, really, you need to get to us within three or four hours.

We're literally talking about a five to ten-minute assessment

of the patient to clarify the diagnosis.

Have any double vision?

'Figure out how bad the stroke is

'and then get them urgently to the CT scanner.'

Don't worry.

James is showing some of the symptoms associated with a stroke

but, as he was already in hospital when it began,

time should hopefully be on his side.

Are you able to lift that leg at all? Not at all.

While most of us will only need the care and support of the NHS

a few times in our lives,

there are some who will need much more.

Well, Grace has been coming to the School of Dentistry

for probably about ten years now

and has had a variety of treatments done over the years.

Grace Smith was a keen socialite

and captain of the local golf club.

At the age of 46,

she was struck by cancer.

It all really started with a pea size

that lived in my right sinus,

then it began to grow and it came out

almost like half a golf ball on my face.

Grace had an aggressive cancer of the salivary glands.

She has had to have her upper jaw bone,

lower eye socket

and most of the right side of her face removed.

Over the last 12 years,

a team of experts have used the latest pioneering technology

to gradually reconstruct her face.

I had three very young children at the time.

I knew that I had no alternative.

I had to go through with it

or I wasn't going to be here.

That was really how I felt.

Anything I had...

thought of doing or any plans that I had made

really all just...

disappeared

cos nothing matters any more

and your main thought is,

"I have cancer and I have to fight it, and I have to get through."

I would say, in my own small way,

I was maybe a little vain in life.

I wouldn't have gone to work without my make-up on

and I wouldn't have gone out without make-up and nails done,

so it really hit hard.

It hit home very hard that,

all of a sudden,

I'd gone from being

a bubbly, outward-looking person

to living life behind dark glasses

for 11, 12 years.

Scalpel blade.

I'm just going to cut away a wee bit of this as well.

Grace lost all of her top teeth and upper jaw bone

as a result of the cancer.

But today, specialist dental surgeon Dr Simon Killough

is taking a mould of her reconstructed hard palate

so she can be fitted for a permanent bridge.

Really, to get the teeth back in

will restore her...

cosmetic appearance, first of all,

and then also her function.

She'll be able to eat and drink much more easily.

The teeth and the smile is such an important part of who we are

and that's one of the aspects of head and neck cancer,

it can take that away.

And it is such a nice part of the job

to be able to give that back to the patient,

to give them back their smile.

Can't smile really without upper teeth,

so I'm really looking forward

to being able to smile.

Also, I have a granddaughter

and I can't give her a kiss on the cheek

because I can't do the kissing

formation with no teeth.

It's taken 14 surgeries over 12 years

to get Grace to where she is today -

the most complex of which was to replace her entire upper jaw bone.

In 2014,

a team of surgeons at the Ulster Hospital

were able to make use of some cutting-edge technology,

recently pioneered in Belgium,

which allowed them to make a precise 3-D representation

of Grace's original jawbone.

They then replicated it

using the fibula from her leg.

The main difficulties with this reconstruction -

the fibula bone is used routinely here and elsewhere

to reconstruct the lower jawbone,

quite a straight bone in a way,

but trying to do that with the upper jawbone,

the maxilla, is much more complex

and that's where the 3-D planning technology came into play.

It basically uses the image data on the CT scans

and you can do the virtual surgical planning,

pre-plan where you're going to cut the bone,

and generate a template like this.

These slots are all appropriately angled

so that, when you make all those cuts,

it will all piece together

in a jigsaw fashion, like that.

It was very, very precise

and there's no wastage at all

because you know exactly

at what millimetre you have to cut.

While in the old days, if you wanted to do something similar,

you'd be guessing that, "I need this to be 7-8 millimetres,

"I need this to be that angle,"

and if it doesn't fit, you have to trim a bit.

The Macmillan Unit is located in the grounds of Antrim Area Hospital.

It's a specialist palliative care facility

for those in the advanced stages of progressive illnesses,

such as cancer, motor neurone disease and heart failure.

23-year-old junior doctor Conal Corr begins his rounds.

I'm currently a foundation year one doctor.

My first rotation is up here, in the Macmillan Unit,

to start off my first job as a doctor.

-Hello, Maureen.

-Hello.

-How are you?

-Not so bad.

Are you OK sitting forward?

You're not sore or anything, are you?

-My stethoscope might be a wee bit cold, all right?

-That's all right.

Maureen was a really, really fit and healthy individual.

She was a horse riding trainer

and a gymnast,

and I think that's why she's managed to get to the age that she is

without any problems.

And I think that's why the cancer that she does have

has been allowed to grow and to spread

without her really noticing it until a very late stage, unfortunately.

That's you, all right?

SHE COUGHS

-Is that cough still bothering you, is it?

-No, it's not bothering me.

-Are you sure now? Are you just being a trooper?

-No, no.

THEY LAUGH

I'll leave you in peace now, anyway.

-All right?

-Thank you very much.

-See you soon.

You have to be a people person.

You have to be able to talk to people.

There has to be a relationship.

And I think that's why I'm interested in palliative care

and end of life care,

because there's so much...

It's SO patient-centred.

The nurses are brilliant.

Really, really lovely, lovely nurses -

every one of them.

Doctors, everything, staff, the lot.

Could not get better.

I have a few, like, non-medical friends,

and when I started the job,

I was maybe a month or two in,

and they'd have said, "Oh, Conal, how many lives have you saved?"

I sort of said, "Well, none,

"because I don't work in that setting."

But psychologically

that's difficult because you're not actually treating people.

You're not able to fix things and that has been challenging.

But, apart from that, I love it.

I couldn't see myself in any other career.

In Lurgan hospital,

the Acute Care at Home Team are having their morning meeting.

Gentleman came on Friday evening,

MS man, he's in bed at the minute.

He remained quite chesty over the weekend.

What fluids is he having, Ann?

'This is a very unique team.'

We're the first team within Northern Ireland

to actually act within this model.

You'll hopefully see him this afternoon.

Paul will start cough assist

and whatever nurse...

If you can do a joint visit with the nurse this afternoon.

So, it's a multidisciplinary team

made up of specialist nurses, physio,

pharmacist and our consultant doctors.

It's hospital at home.

We're doing all the care and intervention that a hospital can do.

The idea of our service is to cut out hospital admission,

where they'll be treated within the home.

Maybe a doctor has been called out,

our team will come into play

and we will go and see them and see if they are appropriate

for the Acute Care at Home Team.

The acute care service also has big benefits for patients,

who can be treated in the comfort of their own homes,

and their families,

who can avoid the hassle and expense of repeated hospital visits.

Anne Graham's husband, Billy, has MS...

Hello, Anne. Hello.

..and was referred to the team last week

as he's currently suffering from pneumonia.

We'll explain everything to you.

Take a nice, deep breath when you're ready again.

-Go, a big one.

-HE EXHALES

BILLY COUGHS

That's OK. That's OK.

The team that come out

are really, really good.

And there is a nurse comes three times a day,

and does all the injections and things.

Breathe in with the machine.

In - one, two, three. Rest.

It's great because

you don't have to be tied to a time

to go and see him,

you can see him at any time,

and you know what's going on all the time,

instead of going into the hospital and being told.

You know at the time what's happening.

It's much better, so it is.

In - one, two, three.

Out - one, two, three.

In - one, two, three. Cough.

Come on, cough.

-HE COUGHS

-Very good. Very good.

'Cough assist is one of the best options

'to help him clear the secretions.'

Clearing secretions are going to help improve the infection

-as early as possible.

-HE COUGHS

Good, strong cough there.

Well done.

He's quite well this afternoon.

He will still need quite a few more days of intensive physio

and intravenous antibiotics.

We'll also be taking blood samples

to check the effectiveness of the treatment.

Well done. Well done.

We could take most of our pneumonias back into the home

and we could look after them if we have a good team down.

Most of the pneumonias can be looked after at home.

You don't really need hospital admission,

unless they are critically unwell.

I haven't been well myself,

which means I can't drive all the time.

I couldn't get down to see him if he was in hospital.

At least, if I have him at home, I can see what's going on.

It's great.

They even come out here to the house...

instead of having me go into hospital,

in which they are more packed.

Better for them to come here.

At Craigavon Area Hospital,

their always-busy laundry department

has become a integral part

of the Southern Trust's domestic services,

with the staff here managing the laundry

for eight separate hospitals.

It opened back in 1972

and head of linen services, Anne Forbes,

has been at the helm for the past 15 years.

That's the Belfast linen being sent out.

Going out, yeah.

In this laundry, we employ 52 staff.

We process about 100,000 pieces of linen a week

and we service up to 1,600 beds.

All the linen that comes within the health service

must be washed at a thermal disinfection temperature

and that's to ensure that all infections are destroyed

and the linen is safe, at point of use, for the patient.

Every delivery of dirty laundry

must first pass through the sorting room,

where the team takes special care

to ensure that no unwanted items

end up in the wash.

We get phone calls here to watch out for mobile phones

and iPods,

false teeth...

You're never surprised what you're going to find

when you open a bag in here, you know? It could be anything.

The only thing we haven't found is a patient.

There's times that there's stuff comes in here

and the smell is overpowering.

You have to have a really, really strong stomach sometimes, you know?

But you get used to it in the end, you know.

Back at the Royal, it's 30 minutes

since James McCabe's started showing signs of a stroke

and the team are ready to begin his CT scan.

We want to see if we can identify any large arteries that are blocked,

in this man's brain,

that seem to be causing this sudden speech problem

and visual problem that he's developed.

But as the results start coming in,

a diagnosis could prove trickier than expected.

This is complicated cos this man's had a previous stroke

in the right side of his brain,

causing left-sided weakness,

which makes things a bit more complicated in assessing him.

A major riddle...

'The most exciting treatments

'that people talk about for acute stroke are...'

One is an intravenous drug, that we call thrombolysis,

that helps to dissolve clots.

There's some risk, with that drug, of causing bleeding -

so selecting a patient for that treatment is really important.

The second real major advance in stroke treatment in recent years

is a thing called clot retrieval,

where we have colleagues in our hospital here

who can go into your arteries, in your brain, with little fine tubes,

find the clot and physically pull it out.

It's remarkable when you see someone with a dense stroke

going from unable to speak, unable to move, to -

within minutes or hours after that treatment -

standing up and walking out.

We're trying to figure out

whether you've had a stroke or not this morning.

Another stroke.

OK?

You're large arteries in your brain are OK.

It might be that there's a small artery in your brain

that's blocked by a clot.

The treatment for that is a clot-busting drug

that we call thrombolysis,

but there is some risk with doing that,

in giving you that treatments.

It's about one in 50,

2% risk,

of bleeding in your brain.

That could make you worse.

Do you understand that?

Are you able to understand that?

Help.

OK. Oh, it's frustrating,

it is frustrating.

OK.

I think what we'll do is we'll give him thrombolysis.

I can't exclude that he's not had a stroke

-and he has severe speech problems.

-OK.

OK, sir, I'm going to give this clot-busting medication now, OK?

I have some suspicion

that there may be something else going on other than a stroke

but, at the moment, it's impossible to tell for sure

whether it was or was not a stroke.

I'm just going to flush through a bit of water.

The scans are good, there's no major artery occlusion,

so this thing seemed to happen very suddenly.

It is in keeping with a stroke

and he seems to have right-sided weakness

along with a loss of language,

which is very much in keeping with a stroke.

Just the way he's behaving.

He seems a bit frustrated with it

and that's making me wonder, you know, for sure.

But, if it is a stroke, then we only one option

and the option is to get rid of this clot

and the only way we can do that now

is by giving him the clot-busting drug.

Tough calls like these are part of everyday life for doctors.

Mr McCabe will be kept under close observation

to see how he responds to the treatment.

At the Ulster Hospital,

cancer survivor Grace Smith

is in for yet another operation.

Plastic surgeons Chris Hill and Declan Lannon

want to close a hole in her upper palate

as well as taking fat from her stomach

to help rebuild her face.

Grace, I haven't seen you since we did the last fat grafting,

so I know that your tummy was quite sore afterwards

and I'm afraid it probably will be again but,

just looking, it has added a bit more volume in here,

but there's still this contour deformity in your cheek

and we'll really aim to try and fill that out this time.

..but despite undergoing numerous surgeries,

it still doesn't get any easier for Grace.

Apprehensive, nervous,

but I'm in the very best of hands.

So, looking forward to getting another stage

in the journey completed and one more move towards the end.

There are two parts to today's procedure.

We're going to do some fat grafting to her cheek

and we're going to then try to close

the palatial fistula in her mouth.

What I'm doing now is I'm just looking at her face,

at the side that's unaffected,

and I'm just trying to decide...

We're looking at the contours here on the right side

to decide where I'm going to put the most fat.

The sorest bit of the fat grafting procedure is her abdomen.

It will feel a bit...

I tell patients it feels a bit like being punched in the tummy,

so it's not agony, but it's still uncomfortable.

Fat grafting is actually pretty simple.

This is how we harvest it,

with this cannula.

When it sucks the fat in,

the idea is to try and not damage the fat

cos we want the fat to be viable

so that it will survive when we transfer it to her face.

So, we're going to start now and harvest some fat.

So, I'm just making a little stab incision

through the skin into the fat here

and then, that's now sitting in the subcutaneous fat.

I can feel where the tip of the cannula is

and I've got the suction now on this

and you can see the fat starting to come into the syringe.

It'll be quite watery because of the local anaesthetic.

It's a bit repetitive, but...

it's fine when we're not trying to harvest too many syringes,

but, if you're harvesting 20 or 30 ten-mil syringes,

it becomes quite hard work.

So, you can see that's a syringe of harvested fat.

Once Mr Hill has harvested a sufficient amount of fat,

it then has to be centrifuged and separated

before being re-injected into her face.

OK.

The centrifuge has stopped

and we're just going to lift these out...

You grab the other two, Chris.

..and you can see, it's quite colourful, actually.

This is the fluid layer, with the blood.

There's a little patch at the bottom.

This is the viable fat and, at the top, you can see the oil.

Now, clearly here, you need to be careful

that the fat doesn't actually start to run out.

It's, sort of, held in by the suction at the minute,

but it will fall out, eventually.

And that is the fat that we're going to use.

And that's it...clean now.

Just let it slide back down the tube.

So, we're going to infiltrate the fat now with this.

This is a blunt cannula,

so through this tiny, little incision

I'm just going to advance this cannula under the skin.

You can see it moving down.

Now, the idea is to infiltrate the fat

as you withdraw and you can see, look.

You can see the little ridge of fat that's been left behind.

So, you just keep doing that until the area is filled.

Each layer of fat that's placed

will be close to her blood supply.

If you put it all in the same place,

if you just keep injecting and blow one area up,

the innermost layer of fat,

or the inner layers of fat,

will be too far from the blood supply to actually take as a graft.

After about four months,

the fat is felt to be stable,

so the patient, the volume that they gain

will remain and really will remain indefinitely.

So, it's a permanent fix

and we've certainly significantly improved the contour.

This fat grafting is only the first part of today's surgery -

Grace lost most of her upper palate due to the cancer -

but after this dual operation,

it should be restored to normal function.

This lady has a large fistula,

a large hole in the roof of her mouth,

connecting into what would have been her sinus and her nose,

her nasal cavity.

So, that's giving her nasal speech

and it can cause a certain amount of nasal regurgitation,

where food and fluid can pour out of the nose.

We're trying to close that.

Declan has raised this oral flap

and it's going to swing back the way

and stitch across that, like that.

We'll be using the front of her palate

to try to close the back of the palate.

The front of her palate will then be a raw area.

It will be a raw, unclosed wound

that will have to heal itself over the coming weeks.

Back at the Macmillan Unit...

We need a blood sample on Jacqueline in room 12.

..junior doctor Conal Corr is finishing his rounds.

Unfortunately, it has been tried a few times

and it's been really difficult to get it,

so we're going to have another go on her, just to see.

I will have two goes. Two goes is quite reasonable.

Three's pushing it.

Then you might want to just refer on to somebody else who can do it,

who's maybe more experienced.

ALARM BEEPS

'Jacqueline is a new lady that was just brought down to us yesterday.

'She's a young lady with breast cancer

'and she's had chemo, she's had the surgery, she's had everything,

'but unfortunately the disease has come back.

'So now it is all about supportive measures,

'but she has a really good family support,

'which is so lovely to see and it's...

'It makes our job a lot easier when the family are there,

'helping them through.' Hello, Jacqueline.

-Hiya.

-Morning.

-We're in to do the bloods, is that OK?

Sometimes you find yourself getting too close to patients.

You know, you get trained on how to break bad news

and how to tell somebody that somebody's died.

But I was on a night shift,

'and there was a patient of ours recently

'who I was a very close with, and I thought I'd pop down...'

That's going to be really tight, OK?

But it'll help. The tighter, the better.

I went into the main office and her name wasn't on the board any more,

and that was how I found out.

And that...

You know, that was no-one's fault,

but that wasn't a nice way to find out.

And, in that way, it is difficult,

so it's about finding that balance.

Stop.

Sometimes it does that.

That's what Gordon said.

Every person that's passed away in this unit

has done so comfortably,

peacefully and surrounded by their families, every time.

That, for me, has been...

It's really helped me deal with it in my own head and say,

"Yes, these patients are dying,

"but it's a successful death."

We're all going to die someday and I think, if I did,

that's how I'd want it.

I'd want to be peaceful and comfortable

and surrounded by my family, so, you know,

you can't really ask any more than that.

At the Royal Victoria Hospital,

67-year-old James McCabe has responded well

to his clot-busting medication.

Mr McCabe has had a fantastic outcome

after getting the clot-buster drug,

which was given to him really very quickly

after onset of the stroke.

And I suppose that's the thing about stroke,

it can be really devastating

and, hopefully, you can see

that the systems we have set up in our hospitals

allow us to try to respond to people having a stroke urgently.

We get there as quickly as we can.

I can't thank Doctor Kerr and the medical team enough.

They explained everything, bit by bit,

because, at the time, it was frightening.

You couldn't get the words out.

You had them in your brain, but they wouldn't come out.

With the care of Doctor Kerr and his team,

it was bloody marvellous.

You couldn't be in a better place than it actually happened.

It's now been seven weeks since Grace's surgery.

And it's improving the shape of my face,

and it's giving me the symmetry with the other side

and I feel that that in itself

is helping me feel a lot more confident going out and about

when people aren't just staring at me

the same as they were in the past.

Each surgery that has taken place

has really improved my inner feeling about myself

and I definitely feel a lot more confident.

And with her oral surgery now complete...

We've got your bridge back from the laboratory.

..Grace is finally able to be fitted with a permanent bridge.

So, what do you think, Grace? What you think of them?

I think they're wonderful. Thank you. Yeah.

-Really pleased with them.

-It's looks lovely.

-I love them.

-Yeah?

It's lovely just to think now that I have permanent teeth.

They're absolutely wonderful and I'm delighted with them.

And it's a new smile,

a new chewing technique

and everything's great.

She really thinks it looks really good and I'm really pleased.

It's very rewarding sort of work, this, and such a good result.

Everything is moving forward,

and I'm delighted with it and I feel that I'm really getting there now.

One thing it's given to me, as I've said before

and will continue to say for the rest of my days,

is that they've given me quality of life

and they've given me my life back

and I never will be able to thank them enough for that.