Hospital Episode 1 Documentary Our Stories

This winter, one of Britain's busiest NHS trusts opened its doors. To show us what's really happening inside our hospitals. Every week, more than 20,000 people are treated here. And the numbers, as well as our expectations, are rising. This is a place with some of the best specialists in the world. Where lives are transformed. But they are operating at a time when the NHS has never been under more pressure. It does feel to me like the elastic's a bit nearer to breaking now than it ever was. It's very future under scrutiny. Following the patients from the moment they are admitted. To the moment they leave. Week by week, we reveal the complex decisions the staff must make about who to care for next. That patient is coming to me to be operated on. And if I don't do it, then there's only one inevitable outcome. They're going to die. Right, good morning everybody. Shall we begin? I've seen the gang at Charing Cross. Good morning, Charing Cross. Morning, good morning. OK, do you want to just talk us through your screen this morning? Leslie Powles is the site director at St Mary's. The biggest of the five hospitals in London's Imperial College Healthcare NHS Trust. Every morning, she leads a conference call with the other hospitals to plan the day. The focus is always the same. How many empty beds have they got? There's currently no cubicles anywhere in A&E to see any new patients. OK, so not a great start to a Monday morning for you guys then. The first call of the day is to kind of take the temperature of what's gone on overnight. And what our beds look like going forward for the next couple of hours. Let's go to St Mary's. So as you can see, we're in a very similar position to Charing Cross this morning. Very full and busy ED screen. Let's just have a look at the beds. It's probably easier for me to say what we've got, which is absolutely nothing at the moment. So really priorities for us this morning are to sort out the rest of the unplaced patients in the emergency department before we do anything else. We'll pick up surgical electives in about 10 minutes. All right, and I think we will go out on red this morning then. OK, thank you very much. Everybody will speak again at lunchtime. St Mary's uses a colour coding system to indicate its bed status. Amber means that the hospital is almost at full capacity with only a handful of its 301 adult beds available for new admissions. Code red is even more serious. It means that throughout the hospital, from the A&E department to the intensive care unit, from the high dependency unit to the general nursing wards, there are not enough beds available for the number of patients that need them. The hospital is full. St Mary's must now put scheduled operations on hold. The pressure on beds can only be relieved by existing patients leaving the hospital. It's one in, one out. The last three weeks we've run at almost completely 100% capacity. We're probably on code red every three or four days. I'm hoping that within the next couple of hours we get enough beds that we can at least do a couple of our elective patients. That's a trauma patient, which means that we are very likely shortly to need another trauma bed. So today we are in trouble. So at the moment there are no beds in the hospital. There's a lot of emergencies who will need operating on. When St Mary's is on code red, surgical staff must wait while site operations look for patients to discharge. Today there are no beds in the trust at all. Right, let's go and postpone things. It's the job of the on-call anaesthetist to stop planned operations getting underway. Until the hospital gets off code red, there won't be enough beds for all the patients to recover from their surgery. What tends to happen is that people can be a bit naughty and suddenly they just start their patient. I mean after knives to skin, there's absolutely nothing you can do about it. There is no bed, 100%. There's loads of patients in A&E, there are no beds whatsoever in the trust. Rex, you know that it's only day cases or inpatients. Oh yeah, I didn't know that, but I do know now. They've said not to go ahead and they want to go ahead. Well no, you can't go ahead if we haven't got a bed and they can't stay in recovery. Yeah, we don't have a bed. If we do any patients, they have to stay in recovery. That's not acceptable. No, no, no, they can't go because we haven't got the recovery staff. Exactly, but they're not listening. Because I said they have to stay in recovery doesn't mean the patient can go to recovery. It means that it's not acceptable, but nobody's listening. This is really annoying, isn't it? Because so many hours are wasted waiting for things, which just pisses me off. This is a bad Monday morning. There's been no frost, there's been no flu, it's not cold. And the fact that the hospital's already overwhelmed is really quite scary. Anyway, so I better have my mango lassi. George Rees is one of the surgeons waiting to start work. He specialises in keyhole surgery. IT support as well. We have one operation to do today and that's an anterior section, which is an operation for rectal cancer. The gentleman's here, my team have seen him, but the hospital's on red alert. So we are just going to wait to find out if we've got permission to start operating. George Rees can't begin his patient's surgery until a bed is available on the high dependency unit for him to recover in. Morning. Nurses there are currently trying to discharge patients to make space. Hello, can we do a quick brief please? So we don't have permission to start because they don't know if there's a bed or not. So we're not allowed to do anything. The difficulty is that it's three and a half hours of surgery. And it's cancer. And it's cancer, so if they don't tell us early, we'll run out of time. But they know that. Professor George Hanna is also waiting to start a cancer operation. His patient will need a minimum of six hours of surgery followed by a bed in the intensive care unit. Oh, hello. Hello. How are you? Good morning to you. Yes, I always stand up. Hello. How are you? Thank you. Pretty good, thank you. I'll be good to go or not? We are still waiting. We're just still waiting, OK. Yes, still waiting. Have you been doing your exercises? Yes, I'm doing my exercises. Very rigorously. So once we know about the IT, I will let you know. Yeah. We'll call you to come in. Good. Well, I'll see you shortly. See you again, yes. OK, thank you. The patient has a cancer of the gallbladder, the esophagus. To cure him, he needs to have the operation. Otherwise, really, he can't survive. I was first diagnosed back in April. And then I went on to a chemo and radiotherapy treatment course, which was designed to shrink the tumour. It became quite difficult to eat. Do you feel poorly? Not now, no. But I did then. Oh, my God, I did then. And the thing is, you know, he's, what, sort of 13 stone or whatever normally. Not now. Well, no, but you were. I was more like 14 stone. I mean, big, strong, healthy guy, you know, playing golf three times a week or whatever. And suddenly, he's not. So, looking at the scan, it looks, actually, he has a good response to chemotherapy and radiotherapy. Here, the esophagus, and this black is the food channel inside the esophagus. And if we go up, you'll find it is wide. If you go down, you'll find it narrow. So, the tumour and the thickening makes the inside small, and that's why patients struggle to eat. One of the main aims of the operation is to have a clear margin of normal tissue to ensure that the tumour is completely removed. Simon's surgery has already been cancelled once before. Just like today, the intensive care unit was full. We've only got 16 intensive care beds at St Mary's, and those beds are always needed for our sickest patients in the organisation, so those coming through our emergency department, our major trauma patients, and our patients who are going to recover from some of the biggest surgery that we do in the organisation. St Mary's intensive care unit, or ICU, contains the most sought-after bed spaces in the hospital. Each one provides one-to-one nursing care and the most advanced life support systems. There is no capacity to add more beds. The team tries to keep at least one of these bed spaces in reserve in case of an emergency admission. But with patient numbers rising, this is proving increasingly difficult. Today, all 16 beds are full. I need to move patients off intensive care and down to the ward. But before we move them, I need to go and have a look at them and make sure that they're well enough to move and that they'll be safe on the ward. Hi there. How are you getting on? How are you doing? It's good to see you awake. I think you're doing really well, sir. How are you going? OK, good. All right. I think you're improving. All right, I think you are. Simon Ashworth has identified two patients who could potentially be stepped down from the ICU to other wards, but only if their conditions improve over the next few hours. I have to tell you, it's 9 o'clock. What does that mean? It means at some point somebody will be telling us whether we're allowed to do any work. Nervous? No, I'm not. I'm nervous for you. You worry too much, you'll get a heart attack. George Rees' cancer patient, Eladio's operation, is already two hours behind schedule. I've decided not to get frustrated. There's nothing I can do to fix this problem. So I will trust that the people who are doing it are doing their very best. Morning. How are you? Hello. We didn't get to meet last time. No, no, we didn't. I just wanted to set the scene of today a bit. At the moment, they haven't given us permission to start the operation because there isn't a bed in the hospital. But they're working on it. And when I know you will know. Yeah, lovely. Is there anything you wanted to ask me? Well, I just would like to, because I'm parking outside. It costs me now £10.80, please. Because if we're going to be here all day, that's going to cost me an arm and a leg. I kind of meant, is there anything you wanted to ask me about the operation or about the surgery today? No, that's all right. OK. Site director Leslie has received an update on the bed situation from the high dependency unit. So we've managed to get some discharges, which means we can start to operate on patients who can go into high dependency, but not patients yet who need intensive care. Yeah, so marvellous. And then start the Rhys patient needing HDU. Miriam, don't feel any pressure. I'm coming to find out if I'm allowed to start, because if we can't start now, we have to send him home. So the cancer patient who needs level two, that can go ahead. OK, great. So we can go ahead. Thank you. So we need to go and tell them. Can you hear me? Lisa, can you hear me? We're coming down to see others. We're allowed to do the case, OK? They found a bed. Hello, site office. Leslie speaking. Leslie must now deal with a new emergency. A patient is on her way from Norfolk with a ruptured aorta. The aorta is the main artery in the body. If it bursts en route, the patient will die in the ambulance. St Mary's lead vascular surgeon, Richard Gibbs, will perform the life-saving operation. I've been sent here because we're a specialist centre for aortic surgery. We feel a real moral responsibility for accepting patients like this. Without any shadow of a doubt, they will need an intensive care bed, but to a certain extent, we just have to get on doing the operation. So we'll have to worry about the ITU bed at a later stage in the day. That patient is coming to me to be operated on. If I don't do it, then there's only one inevitable outcome, which is they're going to die. ITU are uncertain now. So this morning they were declaring two patients to step down. They're now not sure that they have two to step down. They think they might just have one bed. If they have one bed, that bed will have to be held for the ruptured patient coming from Norwich. Richard Gibbs goes to discuss the impact of his incoming emergency on George Hanna's patient. George, as things stand, you need an ITU bed, we need an ITU bed, because we've got this woman who's in an ambulance on the way from Norfolk with a ruptured aneurysm, so she needs an open operation. So if she arrives alive, which we think and hope she will, we're going to do her in theatre nine and not worry about ITU for now. We've just got to get on with that and sort it out. Fine. So what are we waiting for now? There's one or maybe two patients in ITU that can step down. So we're just waiting for confirmation from them that one or both will go. We only need one bed, which will free up the ITU bed for you. Simon and Patricia, his wife of 36 years, have been waiting for three hours to find out if his operation can go ahead. You don't quite know whether not hearing something is a good sign or a bad sign, do you? You're geared up to do nothing, really, just wait. When we first embarked on this process, we were told that there is a window of, I don't know how many weeks, five to eight weeks after the chemo and radio stops, when it is the best time to do the operation. I haven't asked the question, so if you can't do it today, do I then have to start doing chemo and radio again or something? Or what actually happens? Because you don't like to ask those questions, quite, and you don't really want to have the answers. You just rely on them to do the operation. But you reach a point where you just say, I want it done. You just can't keep putting it off forever. And I guess it's not just for you, it's the impact on family, loved ones and... Yeah. Me, particularly. Can you tell me your name? Eladio Paguyo. Great. And your date of birth? January 22, 1949. That's a great birthday. It's my birthday as well. Yeah? Yeah. Just open and close that hand a couple of times. So it's exactly four weeks after Christmas, isn't it? Mm-hm. Your birthday. Yes. From the Philippines? Yes. Yeah? Surgeon George Rees begins his patient Eladio's operation. We're going to do a keyhole operation for him where we remove the part of the bowel with the cancer in and its adjacent blood supply so that we can take any lymph glands that may or may not be affected by the cancer. And then we're going to join it all back together again. Four hours later, the tumour is out and the operation is over. Why should I feel victorious that I'm actually just allowed to do what I should have started doing at 8 o'clock this morning? It's because the beds are so bad at the moment that it seems rare to be allowed to actually go ahead and do an operation. Very bizarre. The emergency patient from Norfolk is an hour away. The team doesn't know if she will survive the journey. The risk we run here is we're holding a bed for a patient who hasn't even made it into the organisation yet and not going ahead with patients who are already here. Do you have to do this for people every day? Struggling with stocks? Ah. Hi, George. Hi. Thank you. The two people I'm kicking out from ICU, one of them I'm not really that comfortable with, so I don't have a guaranteed bed for anybody at the moment. Right. So I might get one or both of them out, but, you know... And if your patient leaves, do you think you'll have a space? If this patient doesn't survive from Norfolk, then, you know, we can't predicate. So shall we wait a bit more time? The only thing you can do is wait. But I don't think the odds are very good. We don't have enough slack in our capacity to be able to let Prof Hannah go ahead and do the esophagectomy. I mean, what's hard about this is that, you know, we're also talking about, well, we can go ahead and do it if the patient from Norwich doesn't survive the journey, and that's a very hard and callous-sounding thing to be talking about, but that's the practical reality. They have this patient coming in who might require the intensive care bed. They might die. If they die, then the bed is available for me. Then we can do the operation. But if not, they've got the bed. That's the seriousness of it. They've got the bed if they need it. How does that make you feel? Guilty, actually. In a way. Yeah. I'm the person that when someone's really irate and they say, who made the decision that we're not going to do blah, my team or various other general managers will say, oh, Leslie did that. And here's her number, usually. So that's who I am. So you're the one that stops things happening sometimes? Sometimes I stop things happening, yeah. What's that like? Horrible. It's a horrible feeling because when you stop something happening, you know, I'm a nurse. I've spent my whole working career doing the bit that is about making things right. Not always making things better, but doing the right thing by people all the time. And I do the right thing all the time in this job, but it's not always the right thing for one person. I do the right thing for the hospital, and that's really difficult because that does mean that there will be people who today we haven't done the right thing for. Hi. Hello. Hi, Simon. It's all right. I thought I'd pop up and see what we can do to help. I have very few options. Yeah. And what worries me is we've got no slack for the unexpected that is the norm here. What I don't want to do, Simon, is put you guys under loads of pressure. I think we're asking for trouble if we try and do... Yeah, but we are trying to work out. George, if you can operate, if you could do it tomorrow, I think the chances are better. Yeah, but I think... I mean, we can certainly, whatever you step down from ITU, we will create beds to allow that to happen. But Simon now is trying to keep an empty bed just as a slack for something to happen. How long do you think you're going to be with your associate? I'll be very late. What's that mean? I will take six hours operating. If we go ahead now, we'll finish by midnight. I think the safest thing to do is to defer it, but I understand the logistics of that. It's not just the logistics. There is a clinical issue here, because there's a second cancellation with a dedicated time-keen radiotherapy, and we are not doing him to keep a slack in a system who doesn't have a slack. All I'm saying is I've got no ability to manage any other problems. If he didn't have a bed, I would have no problems. I can understand it. But if we are not doing him to keep a slack, and while we can use a recovery as an alternative, this is the difficulty I have. Well, we're very close to the limit. We are close to the limit. We're very close to the limit. I think operating absolutely on the limit is unwise. The question, really, if we wait another week or another time, this will not be... I'm not sure how this will get better. Cancelling a cancer patient three times is a serious instance, so this is something you need to work on. It's your call, Simon. What do you want us to do? You know, we don't have the slack at the moment, I don't think, to do this safely. We are stuck at that point. OK, that's fine. So just so, from my point of view, if the rupture one gets here, we'll do it anyway and we are what we are. And I'll work on the basis that they will be able to give me a bed. The scans from the hospital in Norfolk have been received by Richard Gibbs. They reveal a huge aneurysm in the main artery from the patient's heart. OK, so shall we just... So the team brief here, so this lady has a ruptured aneurysm. Her aorta is four times the normal diameter, so it's very dilated and that's like a balloon, it's just stretched and stretched and stretched and now it's finally given, so blood's starting to come out of it where it's got a small tear in it. My surgical plan is to do a left thoracolaparotomy and not disturb the abdomen until we've got control of the lower thoracic aorta and then we'll obviously open up. All right, see you in a few minutes. There are frustrations, so the whole team gets assembled and we make a plan and it takes quite a lot of effort and concentration to get everyone pulling together to do it. And so if that plan is preceded by three hours of negotiations about can we slot someone into HDU, if they go to the Hammersmith so the ITU patient can drop down, I sometimes feel that I spend as much energy on trying to organise and manage beds and the movements, the flow of patients within the hospital in order to allow us to do what we actually want to just do and get on with, which is to operate. Professor Hanna has now been waiting to be given the go-ahead for his operation for five hours. Hi, Leslie, it's George Hanna. Hi, Leslie, the aneurysm will come in one hour's time. I spoke to Rick. So now we need to make a decision, really. OK, just one second, Leslie. There is a trauma came intubated now, just now. Somebody is hanging, so there is an extra case into the equation. If this patient go to ITU, then potentially there will be no beds. Definitely now. Head of intensive care, Simon Ashworth, must now go to A&E to decide if the hanging patient will need an intensive care bed. And he didn't have a cardiac arrest? Correct. You got him sedated or anything? He is on a prophylaxis infusion and he's getting antidepressant infusion. The patient will need life support, which only ICU can provide. We'll need to find a bed for him. I think it will be possible, providing that nobody else here needs to come up. But it certainly means that the chances that we'll be able to do the esophagectomy are zero now. There is just a trauma came now, just literally now. Do we all have to go home? Yes. Waste of resources. There is an oesophagist, there is a surgeon, there is a theatre, there are three or four nurses. And this is empty, it's not used, not utilised. So it is a waste. After a four-hour journey from Norfolk, the patient with the ruptured aorta, retired schoolteacher Janice, arrives at St Mary's A&E. Mrs Metcalfe, sorry, is it Mrs or Miss? M-E-D. What's happened is that the aneurysm has ruptured, but luckily the blood is just sitting in the back of the abdomen by the big back muscles, so it hasn't just blown. That means we've got a chance to fix this. We've had a look at it on scans, I think the safest way to do it is to make a cut which is going to run in your chest and then down into your tummy. Then we can clamp the aorta and hopefully sew a big graft on, and that will be the end of the problem. It's obviously a bit risky, OK, I'm going to be honest with you. And there's a few complications that can happen. I mean, you're definitely going to lose quite a bit of blood and there's always the risk of things like a heart attack or a stroke or kidney failure afterwards. But I think the thing is we haven't got a lot of choice because if we don't do it then that's kind of the end anyway. OK? This case has trumped the patient with cancer that was going to get done in the other theatre because she's got a condition which will kill her sometime in the next three, four, five, six hours. So if we don't do it now, then there is going to be no five hours' time for her. Multiple cancellations are something we really try very hard to avoid, but actually without slack in the system, it's impossible. And if you try too hard to avoid them, what you end up doing is prioritising somebody because they've been cancelled over somebody who is at immediate risk of dying. They're the issues that you're juggling. Janice's sons arrive minutes later, by which point their mother's operation has already begun. We spoke to her last night, literally. She'd said that she was in some discomfort, got stomach pains, but she decided to go to the out-of-hours surgery and took herself off, drove herself there, but didn't reach. She passed out behind the wheel and crashed the car. I heard about it from the ambulance driver about half four this morning, saying that she had this aneurysm. Will she survive? Will she pull through or not? There's always significant risks. Mortality is probably about 50%, 60%. We'd like to try and get the aorta dissected out in a nice, clean way before it blows. I mean, it's already ruptured, but if it starts bleeding freely because we're dissecting around it, then we're going to have to clamp in a real hurry. Is that it, guys? Thank you. Have you got a periosteal elevator? Trevor Wiley. So the fish slice just needs to go there. We can put the lung down if we want, but let's try to avoid it because I think she won't like it. So that's the heart, and this is the thoracic aorta. The problem's actually a bit lower down in the belly. So she's got a huge haematoma here. Don't touch the haematoma, whatever you do. What I mean is, it might blow any minute. I mean, it really might, literally. And that's the blood from the rupture, which is tracking around the back and coming forward to the front. That's the aneurysm. Don't press it too hard. This is going to go, so we need to get a wiggle on. Yeah. She likes to keep herself occupied. Reception age children she used to teach. She does various crafty things. She goes bowling, she plays darts. We sort of joke that we have to make an appointment to go and see her. Very nervous. OK. The difficult bit's just about to start. Everyone do it slowly. Take the diaphragm away from her. So this, just gently, let me just get this down here. The last bit, and then we're there. Relax, let go. Let me just do this. Move that up to there. Get that. Suck, suck, suck, suck, suck, suck. OK. The pressure's just gone. What? Is it completely gone? Yeah. OK. Is the patient all right? Guys. Just give it a minute. I can clamp the thoracic aorta any time, Ros. She didn't tolerate the... It's coming up anyway, isn't it? Hi, I'm Richard Gibbs. Hello. Hi. I'm just going to tell you this straight. The operation was a success, but it was quite challenging at times, and although she's stable at the moment, I won't say anything yet about the prognosis. She needs to go to ITU for the next 24 hours, and they will stabilise her and support her in any way that's necessary. But at her age, and having a really big operation like this, I don't think we can say she's in the clear yet. I think we need to give that 72 hours, and if she starts to get better and better, then I'll be really hopeful. We've been full all day. Sadly, this has meant we had to cancel George Hanna's patient, but I'm hopeful that we might be able to do that tomorrow. I think we do need more capacity because we're always under pressure, and it does feel to me like the elastic's a bit nearer to breaking now than it ever was. It's wearing, constantly going round, taking bad news to people, and everybody gets a bit irate, and it takes it out of you. St Mary's capacity problems are directly linked to its status as a major trauma centre. Its A&E department must provide round-the-clock emergency care. A 10% increase in patients in the last 12 months means that it now handles more than 150 new cases every day. A&E has four resuscitation bays for patients with life-threatening conditions and a further 16 beds for the seriously ill. Government regulations stipulate that patients either have to be discharged or moved on to another ward within four hours. But when the hospital is at full capacity, the department quickly fills up with patients waiting for beds, and the four-hour time limit is regularly breached. Hello, I'm Ali, I'm one of the doctors. Can you squeeze my hand? Alison Sanders, Clinical Director of Emergency Medicine, is the consultant on call in A&E. What's happened in the last two years is the whole system, countrywide, seems to have ground to a halt. It just makes us feel as though we are firefighting every single day, and we're not unique, we're not unique at Imperial. We are the same as any other emergency department in the country and any other major trauma centre. Every day we just feel like we are struggling to just keep afloat. There's just another trauma coming in now. Fall from six foot, LOC. Is the shooting coming to us? So he's had two lines of cocaine, unknown quantities of vodka and beer. 28-year-old male stabbed three times. Seven men with guns. It's been given that seven men with guns have gone into a building, someone's not moving. And what about trauma beds? What beds have you got for me, please? The minute that we have bed problems, usually due to patients not being able to leave the hospital at the other end, then we end up in this state. This man in week's last two is going to need to go to ITU. So what have we got that can come out and where have we got that we can put it? I think everyone's already working as hard as they can and I think they're fed up of being told to be more efficient all the time. It's only so efficient you can be. And also I think when everybody's working so hard day in, day out, then eventually, you know, they get tired. You hope they don't get tired and make mistakes, you hope that you've got enough resilience in the system for that, but it certainly doesn't make everyone more efficient. With winter approaching, the pressure is set to intensify within A&E and across the hospital. Good morning, everyone. Who have we got at Hammersmith this morning? And Charing Cross, have we got you guys? OK, let's look at capacity at St Mary's. We've got a completely full recess, very full majors, minors is creeping up, so big push on anything we've got dischargeable, please. St Mary's remains close to capacity. However, it is no longer on code red. From a critical care perspective, it's not been the best start to the week. Unfortunately, sometimes being a major trauma centre our demand for very sick patients outstrips what we have in capacity, and we can't predict that. On the high-dependency unit, George Reese's patient, Eladio, is awake and stable, following surgery yesterday. So you had a nice sleep? He should be well enough to go home by the end of the week. In intensive care, Janice is yet to wake up, following the operation to repair her aorta. Squeeze my hand, Janice. Janice? Janice, squeeze my hand if you can. As the nurses reduce her sedation, she should begin to regain consciousness. Can you open your eyes for me? After being forced to postpone Simon's operation yesterday, Professor George Hanna is waiting to find out if there is a bed available in intensive care this morning. There's Dr Ashworth. Good morning. Morning. We're still trying to get George's case done. It's probably contingent on moving one of our patients to... They've still got the bed. If the patient's stable enough to go. Are you going to let George know? Yeah, I'll let George know. I've already told him that was the contingency. He'll be delighted. Hi, George. Yes, you can start. I've just spoken to Lesley. Wonderful. Fine. Good morning. I've got good news. We have a bed. Finally, after weeks of preparation and two cancellations, the operation to remove Simon's tumour can go ahead. How was he last night? He was OK. We had jumbo prawns and noodles and, yes, I gave him a great big bowl full of, as I have been doing, with cream lashed onto it for him. So we ate and watched a bit of TV and chatted and he was fine. And I knew he probably wouldn't sleep very much, but that was OK. The operation will take more than six hours. An insufferable tumour, you can't, you know, you bombard it with the radiotherapy, you bombard it with the chemo, which he had, and it has shrunk. But if we just carried on with our life, it could just grow again. So that's, you know, there is no choice. You just have to have the surgery. So, yes, I do feel relieved because it's now happening and there's nothing else anyone can do except deems. And waiting is going to be tricky, but it will be fine. It's a privilege to operate on a fellow human. The patient will put his life in my hands and I have a duty to do the best of my ability to give them the best outcome. The first stage of the operation is to remove Simon's esophagus and the tumour it contains. You open the chest, you open the abdomen, you dissect along a lot of blood vessels, and that's why, actually, in terms of an impact of the operation, it's one of the biggest operations the body can take. How's the patient? Is he OK? So this is the esophagus and the tumour which we remove now. The esophagus is taken to the pathology lab to see how far his cancer has spread. This is the esophagus here at the top, between my fingers. This is the stomach here. So we expect to find the tumour somewhere at the bottom of the esophagus, just where it goes into the stomach. I'm trying to put my finger into the esophagus and I can feel it's thickened and narrowed. One of the things we want to know is whether all the tumour has been removed or not. The further the tumour has invaded into the wall, the worse the prognosis for the patient. And if the tumour has spread to the lymph nodes, the worse the prognosis for the patient. And the more lymph nodes that are involved, the worse the prognosis for the patient. The most challenging part of the operation can now begin. Professor Hanna must create a new food pipe in order for Simon to be able to eat. We convert the stomach. And we need to reconnect the gastrointestinal tract in a way that the patient will be able to eat after that. Going well. Really well. Operation looks nice, really. And if things look nice, it usually works very well. Simon will spend the night in intensive care, the same unit as Janice. Having finished in theatre in the early hours, Professor Hanna heads to the intensive care unit to check on Simon's progress. All went well. I spoke to your wife yesterday. Oh, that's very kind of you. Thank you. She's happy. They may send you to go to the high-dependence unit. Tomorrow? No, today. Today? Yeah, most likely, yeah. OK. So it's a promotion to go there. Absolutely, yes. I wasn't expecting that. Yeah. You obviously need to pay. No, you look well. You look well. You don't need to be here if you don't need to. Two days after her emergency operation, Janice is stable enough to be taken off life support. That's it. Big bowls below. You'll get there. She's not out of the woods by any means, so we know there's still a long road to recovery here, but she's been making steady progress all the way through. Every week, Leslie and her team meet with senior managers to review how they're dealing with the hospital's capacity issues. I think things have been getting more and more challenged. I mean, certainly the pressure feels much more intense and it feels like we are making difficult, really difficult decisions much more regularly than we had been doing and than we should be doing. Chairing today's meeting is Professor Tim Orchard, Imperial Trust's Director of Medicine. Top of the agenda, the chronic bed shortage. If we have a significant flu epidemic, we are going to be completely stuffed. We have never started winter with so little spare capacity, and so I think one of the things that we need to do, and we've never had to do it in this trust before, but I think we need to think about is what we do when we actually run out of beds. What do you do in terms of if we get an orro and we lose a ward, organisationally we are not going to manage at the moment. We've got nowhere to go to. I think that it's felt on many days as though we had the tipping over the edge of the cliff phenomenon where you get to a critical point and you can't function for the admitted or the non-admitted patients because everything is full. There is no more capacity on the Samarie site. We know that. It looks like it's going to be impractical to move any surgical specialties off this site, so one possibility is moving the paediatric outpatient department, which would potentially allow the creation of probably around 15 to 20 beds on the sixth floor. But that's obviously going to be quite expensive. It might be a really good plan for next year, but the reality of getting all of that sorted out by winter feels like we need to do something sensible and practical now. One of the big debates people need to have that people are having nationally at the moment is in extremis, can adults be nursed alongside children? What do you do in terms of, like we've had on this site where you've had 10 paediatric beds and you've got 10 unplaced adults in ED, what decision would you want to make there? So the question is, where can we board extra patients on wards? How would we nurse that to make sure the patients are safe and that the patients have an appropriate level of privacy and dignity? Other trusts have used places like gyms, endoscopy, HathLab recovery. So I think we just need to be clear what the levels of escalation are. Because what we need to do is to roll out to every single ward and department in the trust a plan that says we've got to aim to do X, Y or Z. Very good. Thank you. It is tough. And I think people are working incredibly hard, which we do appreciate. The senior managers have agreed a set of new measures called the full capacity protocol. I'm still a practising doctor. I still go on the wards regularly. So I'm very, very well aware, very in touch with what's going on. I think we know that we need to create more capacity. I think we have put in place a number of plans what to do with our estate to make things better. Every consultant will go around and make sure that every patient who's in the hospital really needs to be in hospital. And obviously we will then make sure that every single bed that can be open safely is open. There are some wards where there is space that is relatively unused and we would be able to fit a bed into that space. So it's about using every single square inch of space even if it doesn't normally have a bed in it. It will be down to Lesley to implement the hospital's new policy. Problems definitely aren't easy to solve, but we've got something that will see us over the next few months. It's much better that we have an ability for the whole hospital to know that we're in trouble rather than just being me and my office, us all sitting here with our head in our hands. It's much better to be able to put out an alert that says to the whole of the organisation, we need some help today. Right, good morning everybody. Morning. That's better, right. Bed wise, so we've got one bed in CDU and two beds on Albert. No confirmed discharges and a smattering of queries. So we have a really challenging day at St Mary's. I think we will go out on red this morning. We'll keep this line open because it will require people to dial in to let us know that they're undertaking their new set of actions in the full capacity protocol. OK, great, we'll speak later. Thank you. There's a lot of both nervousness and excitement about the full capacity protocol. What we want to try and do is get to the point where if we are struggling, we take an early set of decisions that give departments a bit of breathing space. Having been stepped down from intensive care, Simon is making steady progress. He's doing well. There is a lot of work that went into him to be at this stage. He's very positive. You do ask him to walk a mile, he walks three miles. I'm looking forward to going home. I've been told to expect to feel very tired, but to keep exercising by walking once we get home. There will be some ups and downs, inevitably. So you cope with them, you come out the other end of that. There will be dips and they're quite severe. Anyone who thinks there won't be is kidding themselves, basically. Simon must now wait to find out if his cancer has spread. The pathology lab results are expected in a week. In intensive care, Janice is doing well. We're going to hang on to her tonight. No, that's fine. I'm not going to send her out today. I want you to lean forward. We're just going to help you over here. Really push with your good leg. If her progress continues, she will soon be able to leave intensive care and recover on a general ward. Tuck your bottom in. Well done. So push through your arms. Look up. That's it. Take a big breath in for me. Well done. Big breath. Hello, world. Janice is out to get you. Oh, dear. Hello, Mrs Mercar. It's great to see you out of bed. You get your chest going again and I think that makes the potential for you to be home in a week or two real as opposed to what might be a month or two otherwise. So really important. OK? Yeah. We're all right. Thank you very much indeed. Sorry? Thank you so much. No, it's a pleasure. We'll try and get you right as soon as we can. All right. Thank you. Five days after his operation, George Reese's patient, Eladio, is well enough to go home. He doesn't need any further treatment. The cancer he has was completely removed and there was no sign that it had spread anywhere else around his body, which is the best result we could have hoped for. Some weeks are more emotionally challenging than others and I think this week's been one of those weeks that emotionally we've kind of put ourselves through the wringer. The organisation chose me to do this role because I'm resilient. Don't get me wrong, it's not like I don't go home some days, walk through the front door and start crying, because I do. I've never done it in the office. I'll always work till I get home, but, I mean, I do, because I've had a day that, you know, sometimes you think, oh, God, that was just like the day from, you know, hell, I don't know what went so horribly wrong there, but it's gone because I've got to make it right the next day. The pathology team has concluded its analysis of Simon's tumour. They must now disclose the results to Professor Hanna. OK, let's start. First patient. Simon A. So here is the lumen. Here you can see some normal mucosa, but in all the blocks we examined, there's just a single focus of cancer, which is here in the esophagus. All margins are negative. I should have said it wasn't. It's a very good response. I think sometimes it would feel like all we do all day is manage beds. Actually, what we manage here are people who need us to help them. That's what we really do. The tumour is only on the inner surface of the esophagus, in the very first layer. All the margins are clear, so you continue to be a lucky man. Oh, thank you. So we'll keep an eye on you. I'll see you for the next year, every three months. I can start feeding him again. Very nice. You should have lots of food interim. Thanks very much for all your help. Well done. We can never predict what's going to happen to a patient when they've left us on the next part of their journey. We can't see into the future. All we can do is the here and now for people. It really is like as if we've been in a thick fog, and now we can see the sunshine, which is great. We go home knowing that that day we cared and we did everything we could have done for our patients. The heart of what hospitals do is have people in them who have a tremendous respect for life, but also an understanding that sometimes we can't always save that life.