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CASE NOTES
Tuesday 13 April 2004 9.00-9.30pm
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CASE NOTES 2: ACCIDENT AND EMERGENCY

RADIO 4

TUESDAY 13/04/04 2100-2130

PRESENTER: MARK PORTER

CONTRIBUTORS:

DAVID CHEESMAN
FRANCES STELLING
NANCY FONTEYN
PAUL DAVIS

PRODUCER: HELEN SHARP

PORTER
Hello. Accident and emergency is the busiest department in most hospitals and the one most of us have had first hand experience of. A&E staff have to deal with everything, from minor cuts and grazes to cardiac arrests and the results of major traffic accidents, you can never be sure what's coming in next. But you have to be prepared for everything.

I'm standing outside the A&E department at Whipps Cross University Hospital in London and over the next half hour I'll be taking a behind the scenes look at what really happens in a field of medicine glorified by the likes of Casualty and ER. And as I discover sometimes truth is stranger than fiction.

RECEPTIONIST
We have had people who bring their pets in to A&E and that can be a bit comical.

PORTER
What requesting treatment?

RECEPTIONIST
Oh yes, yes, we've had a snake brought in to us before now.

AMBULANCE DRIVER
We'll bring in anything from serious road accidents and also we bring in very minor injuries from toothaches that don't warrant an ambulance at all.

ACTUALITY

CHARLIE
My name is Charlie and I'm one of the nurse practitioners. Right what's been the problem?

PATIENT
Well I was wiping a dish this morning, a cereal dish, and in the process it broke and the other bit shot into the back of my hand.

CHARLIE
Right.

PATIENT
And it poured blood on the floor but I wasn't sure what damage I'd done. And just to be safe really I thought I'd better come and check out whether - I don't know I think I've just skimmed the top, I don't know whether …

CHARLIE
Don't worry I'll have a look at it for you in a few minutes okay. Now how old are you?

PATIENT
Thirty six [LAUGHTER], sixty eight.

CHARLIE
Sixty eight, okay.

PORTER
Eighteen months ago the A&E department here didn't have the best of reputations, with one of the worst records for waiting times in the country. Today, thanks to a number of initiatives, like the state of the art triage assessment system and screens displaying estimated wait, it's a very different story. With me is David Cheesman, he's director of emergency care at the hospital. David, how many patients do you see here?

CHEESMAN
We see about a hundred thousand patients every year, which represents - actually it's a 20% increase on the previous year, so we're a busy A&E department within the walk-in centre on the same site.

PORTER
And what sort of staff do you need to support that?

CHEESMAN
We've got a mixed team of consultant staff, nurses, emergency nurse practitioners who are nurse practitioners, who can see patients independently, as well as all the support staff, cleaners, admin staff, receptionists.

PORTER
It's 11 o'clock in the morning now and we're sitting in reception here and it's actually quite quiet. What's your busiest time?

CHEESMAN
Our busiest times tend to be traditionally Monday afternoons when patients have been seen in GP practices on a Monday morning, Thursday afternoons when some of the practices locally close and also the traditional times of Friday and Saturday evenings.

PORTER
It can be chaos on a Friday and Saturday night can't it. How long would someone expect to wait on a bad time?

CHEESMAN
Our maximum wait time, if you like, should be four hours, that's the sort of national target, at the moment we're about 95% compliant with that, so there are patients who wait a bit longer, in the past patients have waited a lot longer, in fact we had some of the worst waiting times in the country.

PORTER
What was the longest someone would have to wait?

CHEESMAN
We'd have patients waiting over 12 hours.

PORTER
Over 12 hours. I presume it makes a big difference, depending on what type of injury you've got, if you come in with a splinter in your finger you're going to be put to the bottom of the queue. Has triage or working out the priority of patients made a big difference?

CHEESMAN
It has done. Clearly we will treat the sickest patient first but what you don't want to have is obviously the patient with a minor injury waiting and waiting and waiting while the sicker patients are treated, so therefore we stream patients direct to the minor stream where emergency nurse practitioners can treat people with minor injuries and ailments, they don't wait a long time while the sick patients are treated.

PORTER
There must be quite a few patients who actually depend on the local accident and emergency department for all aspects of their medical care, people perhaps who are not registered with a GP?

CHEESMAN
We do have a number of local people - refugees, people with chaotic lifestyles - who won't be registered with a GP and those patients can tend to reattend many times in an A&E department. What we actually do is refer those patients on to the walk-in centre where they can actually be registered with a local practice and be treated then, so if you like they taken them off our hands and make sure they have adequate provision in primary care and that works very well

ACTUALITY

CHARLIE
Let's have a look? Cor your husband put a pressure bandage on. It's doing the job but it's not keeping the circulation away. A lot of people come in, they don't even bother putting anything on and just bleed away, so it's good that he has done a little bit of first aid.

PATIENT
He does yeah.

CHARLIE
He looks after you does he?

PATIENT
He's got a St. John's Ambulance certificate. [LAUGHTER]

CHARLIE
That's not too bad is it?

PATIENT
No, it's alright now actually isn't it.

CHARLIE
Well see you put the pressure on it to stop the bleeding.

PATIENT
All I was worried about was whether I'd caught a vein or anything.

CHARLIE
Yeah, well we will put some stitches in.

PATIENT
Will you?

CHARLIE
Yeah, let me just check your pulse. Don't worry we're very gentle.

PORTER
Well I've slipped down the corridor into the plaster room, which is empty at the moment, for a quiet chat with consultant nurse Nancy Fonteyn. Nancy, one of the things I want to talk to you about was this whole system of triage, of prioritising patients as they come into the unit, how does it work?

FONTEYN
In the past patients have been either eyeballed by untrained staff and then we saw something called Manchester triage, which was just a series of coloured diamonds fitting patients into 52 sub-headings, well that really didn't fit patients or clinical assessment. So what we do here at Whipps Cross is we do initial assessment, but in order to stream patients to the appropriate place to see the appropriate professional. And they are prioritised from - in a colour code - from a red to a blue, all indicating levels of severity, i.e. patients who need to be seen immediately, have life threatening or potentially life threatening problems are seen immediately and patients who warrant investigations within 10 minutes are given a priority of 10 minutes and that...

PORTER
What sort of condition might fit that?

FONTEYN
Something like chest pain, always seen and assessed within 10 minutes at Whipps Cross to fulfil the national service frameworks for coronary heart disease.

PORTER
What happens if I come in with something like a sprained ankle?

FONTEYN
Well interestingly a sprained ankle would be thoroughly assessed and you will be given analgesia here, on arrival, if you require that and you'll be given an x-ray, if you require one, according to appropriate guidelines and although these patients have - are not life or limb threatening, because that's assessed, they are invariably seen very quickly by our minor injury service.

PORTER
You don't always have to be seen by a doctor do you, I think that people think that they go to A&E to be seen by the doctor but nurses, physios are doing a lot of the work.

FONTEYN
Healthcare's now multi-professional and we've actually trained nurses, senior nurses here, to see minor injury and illness cases and the plan is for Whipps Cross is that physiotherapists will be doing the same job, so we have a senior house officer, junior doctors, nurses and physios all working on the front line together.

PORTER
Do you get many people turning up with things that obviously aren't appropriate? My tetanus jab ran out 10 years ago and I'm going to Malaysia on holiday tomorrow can I have one please?

FONTEYN
Well healthcare access is a problem nationally and there is no such thing as the inappropriate patient, so what we have across country is developing walk-in centres and at Whipps Cross we have one on site and so patients are assessed and then if deemed appropriate for the walk-in centre are sent to a primary care centre next door and given the appropriate advice and then they get the right treatment from the right professional.

PORTER
And if you're seeing things during the triage that are - fall into the domain of the general practitioner would you then send them around to the walk-in clinic as well?

FONTEYN
Yes we do that because obviously doing a full initial assessment we can pick up and exclude any medical emergencies and therefore once we've excluded these things and done appropriate interventions and observations we can then send it to the GPs.

PORTER
Now at Whipps Cross who's actually doing the triage, who makes those decisions initially?

FONTEYN
Well in fact what we do here is we actually use nurse-led triage. We employ two trained nurses and a healthcare support worker to work on every shift because we have a hundred thousand patients through here per annum. But they all follow a set training and they actually have to go through assessment by me, so it is nurse-led but it's actually got a very stringent and rigorous competency.

PORTER
I mean it's quite a change since I did A&E, it's back nearly 20 years ago now, and basically the receptionist was the person doing the triage, she was or he was the person who looked at the patient and said doctor there's someone pretty poorly out there.

FONTEYN
Well I have to say that does - that's still your first line, even in the walk-in centre and even - our receptionist in emergency care - they will spot somebody immediately they come through the door and it may be that they get immediately put on a trolley before they're registered. So in fact that still goes on as your very first line.

ACTUALITY

RECEPTIONIST
Can I help you?

PATIENT
Yes my name is Elizabeth, I was here on Monday and on Monday I was told by the doctor that if the condition should get any worse in fact I was to come back.

RECEPTIONIST
Okay.

PATIENT
And it's still present and I believe it has got worse in my right leg.

RECEPTIONIST
Okay, so we need to re-register you first, as a first step, and then - what is your date of birth please?

PATIENT
It's 23rd of the 10th '44.

PORTER
Well I'm now in the busy reception and the manager here is Frances Stelling. Frances, you're the front line of the A&E department, what's it like?

STELLING
Very busy, hectic, can be stressful at times. We have comical moments, we have very sad moments. We cover a whole multitude of emotions here.

PORTER
Well give me an example of a comical moment.

STELLING
Comical moments - you have - we have had people who bring their pets in to A&E and that can be a bit comical.

PORTER
What requesting treatment?

STELLING
Oh yes, yes, yes, we've had a snake brought into us before now.

PORTER
My heart always goes out to receptionists because I think they're much aligned. I mean you're the front line aren't you between the clinical staff and the waiting room that's full of tired, poorly, injured, sometimes drunk, often people who've been waiting for a long, long time, do they take their aggression out on you - their frustration?

STELLING
They do, yeah. But I've got a lot of very experienced caring staff who are very good at talking down a patient. The people who are drunk are probably the hardest and they can be difficult but we're probably safer now, as far away from physical violence, than we ever have been in A&E - it's not very user friendly.

PORTER
Well I notice - it's a nice reception here but you're sitting here behind glass screens - is that for your protection?

STELLING
It is yes. We have a very good relationship I think with the general public and it is only the odd few that can be abusive. And a lot of those are abusive because they are worried about somebody they care for or they're worried about themselves. So providing you understand that right from the start you can normally get through to them and calm the situation.

PORTER
Well another thing that's changed dramatically since I was a young doctor in A&E is that you've got the screen that shows them how long they've got to wait and when they came and saw me - I used to work in Hereford - they had no idea how long they were going to have to be waiting. What's a typical wait during the day here?

STELLING
Now at Whipps Cross our waiting times are extremely good. I mean at the moment they're showing one to two hours but two hours I think would be quite a long time for our children and our minor injuries. The majors sometimes can be a bit longer because of the nature of the treatment that they're getting.

PORTER
And what do you actually mean by the waiting time - is that from when they arrive and start checking in with you?

STELLING
No, the waiting time, we would say, is from the time they arrive to the most important time for them, when they see a doctor and that is - of course we're measured on the door-to-door time, so we're measured on the time they walk in the door and the time they walk out. But I think once a patient gets to see a doctor they relax and think well I've made it, this is the important time to them, not so much to the association but to them.

PORTER
Are there things that patients can do to help you do your job?

STELLING
The most important thing is information for my reception staff, the more information about a patient the better we are, for their journey through the department. If their end is that they need to come back and we have to phone them we need as much information on that patient as we possibly can, it may be to such an extent that we need to contact a next of kin while they're in the department, so we need that information and so if they're elderly bring the telephone numbers of their relatives because that's always very useful and can be a headache. But please make sure, before you come, that A&E is the place that you're looking for and that you're not - you know it would be more appropriate for you to go to a walk-in centre or a GP unit instead. But no we'll see anyone.

ACTUALITY

PATIENT
I saw the nurse quite quickly.

RECEPTIONIST
If you want to go and sit over there just for a few minutes we are getting your records out and the nurse will call you into triage and then they will tell you what needs to be done.

PATIENT
Alright thanks, yeah.

ELIZABETH
It was only a very short while, prior to seeing the nurse and then I waited about an hour to see the doctor. So for Whipps Cross that wasn't bad to be candid.

PORTER
Elizabeth was referred to A&E by her GP with a suspected deep vein thrombosis or DVT, a potentially life threatening clot in the veins of the leg which is linked to, among other things, long haul flights.

ELIZABETH
I flew back from South Africa over Friday night, arriving into London Heathrow on Saturday morning and on the taxi coming back from Heathrow I noticed that my legs were uncomfortable, I think no stronger than that. And over the weekend it seemed to get worse. I saw the nurse, who I have to say very thorough - blood pressure, everything else - and then I waited to see the doctor and the doctor when she examined my legs didn't think it was DVT and she said I'd have red swelling and very unusual that both legs hurt. So I could understand that and it made sense. But she said if it get any worse I was to come back. And the pain hasn't gone away since that time and the right leg has got worse, I was actually in bed last night and it felt like it was pulsating.

PORTER
Any swelling at all?

ELIZABETH
Not, not vastly so no, no. So I'm hoping it isn't that naturally but if it isn't what is it? Tingling in the toes last night and all sorts. So I'm back.

ACTUALITY

TRIAGE NURSE
Take your sleeve out of your jacket from me, I'm just going to check your blood pressure.

PORTER
The triage nurse assesses Elizabeth to see what needs to be done and who would be best to do it.

ACTUALITY

TRIAGE NURSE
I'm just going to measure your legs.

ELIZABETH
Of course.

TRIAGE NURSE
Okay, if you just put them down. But it's this leg that's troubling you?

ELIZABETH
More so yes.

TRIAGE NURSE
Yes and has the pain in this leg?

ELIZABETH
It's still there, it's like a dull sort of ache.

TRIAGE NURSE
Yeah.

PORTER
The triage nurse has assessed Elizabeth's leg and wants a second opinion, so Nancy, the consultant nurse, is coming in to see whether Elizabeth needs to be admitted for further investigations.

ACTUALITY

NANCY
Mrs Ellison?

ELIZABETH
Yes that's me.

NANCY
Hello, I'm the consultant nurse.

ELIZABETH
Hello pleased to meet you.

NANCY
Would you like to just come through for me?

ELIZABETH
Yes of course.

NANCY
Is somebody with you?

ELIZABETH
My husband, I've left outside.

NANCY
Do take a seat.

ELIZABETH
Thank you.

NANCY
I understand that you were here...

ELIZABETH
Monday morning, yes.

NANCY
...on Monday. Are you normally fit and well?

ELIZABETH
Yes pretty well.

NANCY
And where does it hurt the most for you?

ELIZABETH
In the calf.

NANCY
Okay.

ELIZABETH
I mean they told me they'd be red and swollen if it was DVT.

NANCY
Not necessarily. What we're going to do, you have a risk factor because you've taken a long flight, okay, and it hasn't gone away, even though we've seen you already. So what I'm going to do today I'm going to get a scan of this leg and we're also going to take some blood tests from you. So I'd do the blood test first and then we'll send you off to scanning and then we'll know for sure.

ELIZABETH
Thank you very much I'm relieved.

NANCY
And what will happen, whether it's positive or negative, we will see you here. If it's negative we'll give you discharge advice back to the community, if it's positive we'll treat the deep vein thrombosis.

ELIZABETH
Alright, thanks for your help.

NANCY
Pleasure.

PORTER
I'm just passing back through the A&E reception here at Whipps Cross in London. You're listening to Case Notes on Radio 4 and I'm Dr Mark Porter.

AMBULANCE SIREN

Well many of the patients who arrive here in casualty do so in an ambulance. Ambulance control in London gets 3,500 calls a day, 700 of which are inappropriate. Alan Tokley's duty station officer here at Whipps Cross.

Alan, what sort of patients are you and the other paramedics bringing in to Whipps Cross in a typical day?

ALAN
We bring in anything from serious road accidents to children with scolds and also we bring in very minor injuries that - from toothaches that don't warrant an ambulance at all.

PORTER
Why is someone with a toothache calling an ambulance?

ALAN
It's a case of - people don't really understand what is available to them through the NHS and they see the ambulance service as a front door into the NHS and also they believe that they will be seen quicker by coming into an ambulance, which is not true.

PORTER
But I mean you've got more important things to be doing than transporting people around with toothache haven't you.

ALAN
Yes we have and since December last year we are the first ambulance service in the country to actually introduce a no send policy, where we actually refuse to send an ambulance.

PORTER
You can do that can you?

ALAN
We can yes.

PORTER
The role of ambulance crews has changed tremendously over the last 20 or 30 years, I mean you're now very highly trained members as paramedics of the emergency care team, what sort of things are you doing?

ALAN
In the vehicles we are doing [indistinct words] ECGs.

PORTER
That's checking the heart - the heart rhythm.

ALAN
We measure the heart trace, it can show up injury or damage to the heart muscle. We are also doing defibrillation, using cardiac drugs.

PORTER
That's the paddles that we see on ER and Casualty - shocking people.

ALAN
Yes.

PORTER
And you're actually administering drugs in cardiac arrest as well.

ALAN
Yes we use adrenaline, we're placing tubes into the throat to maintain airways.

PORTER
This is all advanced life support that before wasn't done - do a bit of first aid originally, when I was a medical student people - ambulance crews would do first aid and get the patient as quickly as possible to hospital but it must have transformed some patients survival.

ALAN
Oh without a doubt, yes and our crews now are really highly thought of within the health service profession.

PORTER
What advice would you give to people who are listening about when perhaps they should and when they shouldn't call an ambulance?

ALAN
Well certainly when they should call an ambulance is obviously if anybody's unconscious, when they're not responding, they want talk to the person that's with them, any severe or heavy blood loss, where they think that there is possibly broken bones, deep wounds including stab wounds, anything that penetrates into the body they should be considering calling 999. Heart attacks definitely, anything with severe crushing chest pain for at least 15 minutes definitely dial 999, we would rather come to that and find it's nothing than to just let it go and the public need to be aware if the crushing chest pain is serious, call 999. There are other things - severe burns, any difficulty in breathing at all and the severe allergic reaction. And that really is the category where 999 should be used.

PORTER
Just remind us of some of the inappropriate things that you've been called for - you said toothache earlier on, what other things do you get called for?

ALAN
Period pains, we get called to flu-like symptoms where again people just aren't aware of what is available to them through the NHS system. There are lots of other ones but obviously at the time the person who called thought they were genuinely ill so we do have to consider their feelings as well.

PORTER
I've got to ask you, is it like it is on Casualty?

ALAN
There are similarities - we use blue lights. There has to be poetic licence in television, we understand that. Some things are almost real.

PORTER
Although ambulances bring in the worst casualties most of the patients seen in A&E have more mundane problems. I'm in reception with one stoic woman who didn't need an ambulance, she made it here under her own steam, albeit sometime after she injured herself. What have you done?

PATIENT
I fell over on Sunday and hurt my ankle.

PORTER
It looks quite swollen.

PATIENT
Yes it is, I mean I don't know how I actually - I don't know, I'm just kind of amazed at how it's swollen up, it wasn't - it was swollen round the ankle Sunday morning when I came in, I had my boots on and I think what happened is because I was on my way out and I didn't come home and I didn't think it was that bad so I was trying to bop around on this leg and when I got home and couldn't get the boot off, it was a big struggle, I realised the damage I'd done but I just thought I'd...

PORTER
Was it not painful?

PATIENT
...sprain. Well yeah it is, I had some painkillers this morning, so that's what's kind of done it but yeah it just looks really puffy and not very nice.

PORTER
Well we'll find out in a minute.

PATIENT
Yes we will.

PORTER
I've left the Accident and Emergency department now and right next door is a walk-in clinic and I'm sitting with Paul Davis, who's medical director of the clinic. Paul, I practise in a sort of semi-rural area and we don't have walk-in clinics, what are they?

DAVIS
Well they're a necessity here in our part of London because we find there are so many patients who haven't been registered and so many patients that have come from overseas, perhaps from South Africa or from Poland, where they go to the hospital for their basic primary care. Having arrived at the hospital they don't really need an accident and emergency department so they're sent next door to us. We're trying to even prevent them from getting into A&E in the first place, so there's two elements to it, one is to relieve the pressure on A&E and we're taking something like 16,000 patients a year out of A&E …

PORTER
That's nearly one in five.

DAVIS
That's right. And we're also trying to avoid them ever getting there in the first place, so that we're building up the walk-in element so they can just come in here and get their basic primary care.

PORTER
So if I lived in the Whipps Cross area and wasn't registered with a GP or even if I was I could still just walk in here, as I can walk in next door …

DAVIS
Absolutely. Yeah, we don't turn anyone away, we treat everybody.

PORTER
And who will see me? Now you're a GP aren't you.

DAVIS
I am, I'm a GP by training, we have GPs here but we also have nurses here and so whoever might be the most appropriate clinician would be the person that saw you. If it's something simple like removal of sutures or something like that one of our basic nurses would see you and we will have the emergency nurse practitioners and we've got GPs, so that we can actually see quite a wide range of patients.

PORTER
What happens if it's a problem that needs ongoing care? I come in I'm feeling a bit low and you find that I've got mild diabetes for instance.

DAVIS
We would encourage you to try and register with one of the local GPs and we have arrangements through the primary care trust that we can get you registered with a local practice for the ongoing care. We try not to get involved in long-term care.

PORTER
And what sort of patients are you seeing here?

DAVIS
We see anything and everything. Minor injuries, we see anxious mums with their babies, we see patients who've been unwell, patients that can't get an appointment with their GP, patients who are travelling around the world and become unwell while they're here. We'll see almost anything that would normally go to a GP's surgery.

PORTER
And what are the hours of the clinic?

DAVIS
We're open 24 hours a day seven days a week, we don't turn away at any time.

PORTER
And what sort of wait - we've been hearing that in the A&E next door an average wait might be one to two hours, it's very unusual to go for more than four. What happens here?

DAVIS
I would say between half an hour and two hours, depending on the time of day and the pressure that's going on but certainly not a long wait.

PORTER
What about continuity of care - one of the advantages of being a GP is when a patient comes in to see me I've got - hopefully all of their medical records from the day they were born in front of me, you don't have that do you.

DAVIS
No, and that makes it a very different sort of consultation because we have to start from absolute scratch with every patient. We have to find all the basic information from them, we have to rely on what they tell us. It's one of the weaknesses of the system and we're hoping that as IT develops we will actually be able to plug back into the patient's home record, pick up some information there and to be able to look after them rather better.

PORTER
We don't have a model like this in my area and I'd like to think that it probably wouldn't work because the patients seem to want to come back and see their own GP, in fact we have problems persuading them to call an ambulance when they get chest pains and things because they want their GP's opinion first. But it's obviously a much needed model, can you see it spreading around the country?

DAVIS
I think it is more likely to be in cities and large towns that it's likely to be useful or commuter areas where patients find it a bit difficult to get to their GPs when the GP is open. I think patients in rural areas often behave very differently to the ones that we get and I guess not one size fitting all but the opportunity to use these various - various different models in different places.

PORTER
You must be very popular with the local GPs, I'd love to have a centre like yours down the road where my patients could just turn up if they wanted to.

DAVIS
Yeah it is quite popular. We thought at first they might think we were pinching all their patients but actually taking the pressure of them at certain times is quite popular with them.

PORTER
Trust me, general practice is not a competitive industry.

DAVIS
No, no longer.

PORTER
There's room for plenty more.

Back in A&E the stoic lady with the bad ankle has lost the bet.

ACTUALITY

NURSE
What did we say earlier?

PATIENT
I said that I was sprained.

NURSE
And I felt your foot and ankle and I decided that it was fractured and we were going to lay a bet.

PATIENT
Yes.

NURSE
And I won. I'm afraid. So although you've been very stoic since Sunday and you haven't left your bedroom. Right, that is your big shinbone and that is the bone on the outside and do you remember when I touched you here and you went ooo and that's exactly the ooo bit because it's broken there. So if you want …

PATIENT
So is that where it's what?

NURSE
You see where it doesn't fit, it's sort of a fragment out of here.

PATIENT
Okay yeah.

PORTER
You're too stoic for your own good aren't you.

PATIENT
Well I don't know what to say, I just can't believe I've done so much damage.

NURSE
Well you actually have a displaced spiral fracture of your distal fibula - if you want the long term.

PORTER
That's medical for painful. You're allowed to wince.

NURSE
Which is sore and swollen and you need a plaster.

PATIENT
Oh no. So when am I going to be able to go back to work?

NURSE
Well not this week anyway. It's going to take about four to six weeks to heal, that's up to about six weeks you're going to be in plaster. No I'm going to put you in half plaster because it's still very swollen and very warm and we're going to refer you to the orthopaedics - the bone doctors - and they're going to see you in clinic.

PATIENT
Okay, what clinic? The clinic here?

NURSE
Yes the clinic here. It's only marginally displaced so I don't think there'll need to do anything.

PATIENT
That's not too bad then.

PORTER
How did you get to the hospital?

PATIENT
My partner brought me down here in the car.

PORTER
I thought you were going to say you drove for a moment there.

PATIENT
No, no. It looks like a little baby foot doesn't it.

NURSE
It does. And we'll measure you up - I just need to check your crutches are the right height and put the plaster on you and then we'll get you to see the orthopaedics tomorrow in clinic.

PORTER
Have you ever been in plaster before?

PATIENT
No.

PORTER
They're itchy.

PATIENT
Is it?

NURSE
We'll do a very beautifully designer one for you.

PATIENT
Thank you, yeah because I've got to think of my street cred.

NURSE
Oh absolutely. I'm afraid we don't do multiple colours here, it's bog standard ..

PATIENT
Six weeks!

PORTER
Thank you very much I hope you make a speedy recovery, thank you very much.

PATIENT
So do I.

PORTER
That's all we have time for I'm afraid. Thank you to all the staff and patients here at Whipps Cross University Hospitals. Next week I'll be back in the studio for a programme on fertility - I'll be finding out what couples can do to improve their chances of conceiving and what recent changes mean for those seeking help on the NHS.

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