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CASE NOTES
Tuesday 3 October 2006, 9.00-9.30pm
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BRITISH BROADCASTING CORPORATION


RADIO SCIENCE UNIT



CASE NOTES

Programme 2. - ICU



RADIO 4



TUESDAY 26/09/06 2100-2130



PRESENTER:

MARK PORTER



CONTRIBUTORS:

CARL WALDMAN

EILEEN MILES

DIPANJALI BEDI
MELANIE GRANGER

BARRY WILLIAMS



PRODUCER:
KATIE HICKMAN


NOT CHECKED AS BROADCAST





PORTER

Hello. For today's programme I have been granted access to the inner sanctum of the world of intensive care. An alien environment that few people are familiar with, and one that can be very intimidating - particularly if your mind is addled by sedatives and painkillers.



CLIP
They put that many drugs into me that I'm tripping, like hallucinating things and I don't know what's what. I think people are trying to break in the ward to kill me and the nurse, she's telling me I'm in intensive care, I nearly died twice and I just didn't believe it - I said no. But I realise I can't move, I've got tubes in my leg, mouth, head where there's anywhere to put tubes there's tubes. And then I'm frightened, thinking ooh wonder what's happening here.



PORTER
I am standing outside the door to the intensive care unit here at The Royal Berkshire Hospital in Reading and about to go in to be shown around by consultant anaesthetist Carl Waldman.



WALDMAN
We've got 11 bed spaces but in reality we can usually only staff eight or nine of the beds at any one time.



PORTER
And where are your patients coming from?



WALDMAN
There's a mixture. A lot of them come post-surgery and that can either be as an elective procedure, where we know they're coming from theatre or it may be patient comes in for emergency surgery and then will come to intensive care afterwards.



PORTER
And if they're not coming as a result of having had an operation, either planned or emergency, presumably they're coming from accident and emergency unit?



WALDMAN
They can either be medical patients with anything, such as heart failure, problems with diabetes - diabetic coma, they may have taken an overdose, they may have a diagnosis that we just don't know but very commonly we see patients who develop pneumonia. And then of course we see road traffic accidents, trauma.



PORTER
Carl, can we pop over to one of the stations, you've got an empty station here, and this is all the technology, it's been 15 years since I worked in an intensive care unit but it looks very similar, I expect the machines are a bit better than the ones that I had. But could you talk us through what we find round the bed here?



WALDMAN
Well a typical bed space here you'd have the basic monitor which on that monitor you can record every patient's heartbeat, we also record their blood pressure - not through the ordinary cuff that you would get in the general practitioner's surgery but we usually have a line in the radial artery and that gives you a signal all the time which is very accurate. So you've got beat to beat, ECG, heart rate and we do other things like measure the saturation of oxygen reaching their finger, which is a good indicator that we're giving them enough oxygen.



PORTER
And underneath that is another familiar sight - a ventilator.



WALDMAN
The ventilator really takes over the work of breathing.



PORTER
Most patients on a ventilator will have an endotracheal tube in, a tube going from the mouth down into the lungs.



WALDMAN
If they're going to be on intensive care unit for any length of time on a ventilator we do try and change to a tracheostomy tube which is much more comfortable and then we can wean them off more gradually without the discomfort of a tube in their mouth.



PORTER
And that's the tube that goes directly through a hole in the neck, so there's no tube needed in the mouth.



WALDMAN
Exactly.



PORTER
Now on the other side of the bed here we've got - well what looks like a massive drip stand with all sorts of different devices on there, what's that?



WALDMAN
Well in the old days we used to put fluids in and we used to have to watch and count with a watch how much we were giving - that was very inaccurate. And the drugs we're giving today, which are called vasoactive drugs, that means they get the blood pressure up when it's low, very strong drugs, they're sort of based on adrenaline and we want to give that as accurately as possible, so we have to use what we call these infusion pumps. And that ensures that we give them exactly what we mean to give them.



PORTER
Of course the other thing about many patients in intensive care if they're being ventilated, if they're not eating and drinking either, so how do you replace their fluid?



WALDMAN
Well we try at all costs to try and feed them through their stomach. There was a vogue a few years ago to always go to artificial feeding through a vein but a lot of complications with that.



PORTER
So how do you access the stomach?



WALDMAN
So what we do is we have a tube going via their nose into the stomach called a nasal gastric tube and when we're sure that's in the right position we use another infusion pump with special nutrition that goes down it.



PORTER
Now the set up of the unit is that we've got a big central desk here in the middle and all of the beds around, how do the staff apportion - do the patients have individual staff?



WALDMAN
Yes, it depends on what we call the dependency of the patient, if the patient's on a breathing machine and a kidney machine, very dependent, they have usually one nurse and sometimes two nurses, then one nurse could divide their time between two patients, if they're not too seriously ill, so we can be a bit flexible with the number of patients we take depending on their dependency score.



MILES
My name is staff nurse Eileen Miles and I am a staff nurse in the intensive care unit.



PORTER
I just noticed you over there calming a patient down, now how difficult is it to communicate with people who are perhaps ventilated or under the influence of sedative drugs?



MILES
It's frustrating because they're not aware sometimes of where they are, what time of day it is or how long they've been in the environment or who we are. They can't talk...



PORTER
Of course they can't make any noise because of the voice box.



MILES
They can cough and they can show frustration with arms and leg movements, we can use a picture board - a word board - a letter board - or give them a pen and paper or lip reading.



PORTER
Good lip reading?



MILES
It does come over the years.



PORTER
But it means you have to be very observant, you have to sort of watch to make sure ...



MILES
You're at the bedside all the time with them, that's why we have one-to-one nursing.



PORTER
And I suppose you get to learn what's normal for the patient and what's not.



MILES
You do and everything's different for each patient because they're all individuals, so they have different needs.



PORTER
Eileen you can get back to your job, thank you very much.



Carl, a lot of people might be surprised to know that the sort of hardcore of doctors in intensive care are actually anaesthetists.



WALDMAN
It's probably historical because if you go back 30 years, 35 years, when intensive care was in its infancy, the people that understood the breathing machines of course were the anaesthetists because they were using them everyday in theatre, they're also the people used to keeping patients alive - they know about resuscitation, they know about putting lines - what we call lines or special drips - into the neck to give all the drugs, they know all about sedation. So it seemed right that those were the doctors best suited. But gradually over the last few years more and more physicians and more doctors who've worked in emergency departments have got very interested and there's a lot of crossover between those departments and that's great because what you do need is a multidisciplinary team.



BEDI
I'm Dipanjali Bedi and I'm the senior physiotherapist in the IC and surgical wards at the Royal Berkshire Hospital. This patient has had an accident, he fell off a motorcycle, about six days ago. He's had a lot of fractures in the different parts of his body, including his pelvis, his legs and his hands and his ribs have been fractured as well. He's ventilated and completely sedated at the moment to be able to take him through to surgery. We, as physiotherapists, treat his lungs and once he wakes up [indistinct words] tonight we will be starting to make him sit up and mobilise him and getting him to stand over the next few weeks.



PORTER
And by treating his lungs you mean?



BEDI
When a person is unable to breath on his own and the ventilator breathes for him there's a lot of mucus collection within the lungs and he is unable to take a deep breath and clear and cough and remove all that phlegm himself. So we help in loosening all that - all the secretions and then suction it all out.



PORTER
Can you show us what you do with his chest then?



BEDI
We just have to put these pinnies on. Alright just going to give your chest a few shakes. These shakes and a little bit of clapping is what we call percussions, basically help in loosening the phlegm from around the walls that the mucus is attached to.



PORTER
So you're literally vibrating the outside of his chest to shakes things free. Which isn't pleasant presumably if you've got fractured ribs, I mean this gentleman is sedated.



BEDI
Yes we do worry about how much pain we must be causing them.



PORTER
So this gentleman's got an endotracheal tube in which goes into his windpipe - his trachea and that's what you're going to pass the suction down.



BEDI
Right, I'm going to pass the suction catheter through there.



PORTER
Through the middle of it.



BEDI
Right, it would go right down to the end of the windpipe into both the left bronchus and the right bronchus and just suction whatever I can out.



Big cough sir. Well done, well done. Just going to clean the back of your throat, well done. Alright, try and relax for me, well done.



Wasn't too much there but that's a good thing.



PORTER
How do patients when they're lying in a situation like this, they're often - they're uncomfortable, they're feeling unwell, they're in an intensive care unit and they see you arrive at the foot of the bed and you're making them work and do things that perhaps they don't want to.



BEDI
Most of the time the reaction is oh no here comes the physio terrorist but then they do know that they have to start getting going at some point.



PORTER
It's all for your own good sir.



BEDI
It is, it is. We just have to keep telling them that and just be as stubborn as we can be really.



PORTER
Patients, Sarah and John both required extensive physio during their stays on ICU. Sarah was on the unit for five weeks with pneumonia, and John for nearly seven weeks after he developed an infection in his blood. And, like most patients, he didn't look forward to the physio's visits.



JOHN
Anybody who's been in physio in hospital will tell you they hate them at first. I don't want to get out of bed, but they hoisted me out of bed. I just call them horrible people but honestly they're brilliant. I used to go ow no [indistinct words] what are they doing this to my leg for, what they doing this to my arms for? But you have to go through pain, if you didn't you wouldn't move again.



SARAH
I had physio every day where they came in, they would pound on my chest and move the mucus to get it moving. I would slowly sit on the edge of the bed to try and build up my strength. I'd sit in the chair, I found I was so tired all the time. The physio really encouraged me to take a couple of steps but it was really hard.



PORTER
Apart from the whirring and beeping of the various machines and alarms, ICU has a much calmer and quieter atmosphere than a normal ward. Not least because most of the patients are sedated to help with their care - Carl, and follow-up nurse, Melanie Granger:



WALDMAN
There's two arms to sedation, there's treating the anxiety and secondly, if they have things happening to them that maybe extremely painful. So we tend to use a combination of drugs, one we call the hypnotic and one the analgesic. So, for instance, one drug would be medazalan which is a bit like valium to keep them asleep and the other one would be fentanyl or morphine for the pain. So we tend to use combinations of that. But increasingly we're trying to do what we call goal directed analgesia, so we're trying to give less of these drugs, such as medazalan, which incidentally can cause some addiction, and we're trying to use less of drugs such as probathol [phon.] which are not only expensive but do have effects on the immune system and we're trying in certain circumstances to just use strong analgesics - derivatives of morphine and fentanyl - which we find often do the trick and do have some hypnotic activity or sleep activity as well.



PORTER
Presumably some of these patients because of the nature of their injuries will be confused and they're thrashing around, I mean that in itself could prevent a danger if they're being ventilated - do you ever use physical constraints?



GRANGER
At the moment our tact is really that we use chemical restraint as a first option and I think probably this is a cultural thing, I think in the UK we're very at ease with seeing a patient sedated ...



PORTER
Sedated rather than ... yeah.



GRANGER
However there is a shift towards lighter sedation and sometimes that gives you a window where you need to reduce the sedation but actually keep them safe, so that i.e. you're not pulling out the necessary tubes and intravenous infusions. So there is a place and I think to be fair the thinking is shifting slightly towards physical restraint. Interestingly in Europe they tend to physically restrain first off, whereas in the UK that isn't the case.



PORTER
We've mentioned sedation but one thing we haven't mentioned is sleep, you know natural - natural sleep, I mean it's very difficult enough to sleep in hospital and it must be nigh on impossible to get proper sleep in an intensive care unit, is that important?



WALDMAN
We think it is important. The sort of thing we try and do is try and restore day/night variation, for instance in this unit now we have loads and loads of windows, when we first came here there was one window. So getting the day/night orientation is very important. The other thing is having clocks at the end of the bed because patients didn't know what time of day was and then when we got clocks they said we need 24 hour clocks because they didn't know whether it was 12 in the morning or 12 in the evening. Those are all sorts of issues that are very important. On top of that we try and have other things, like there's a tendency for relatives not to touch their loved ones because they're frightened of disturbing the monitoring and the treatment, so we're trying to encourage them and we've been very keen to have an aromatherapist come in and she helps other nurses and relatives apply these lovely smelling oils and massage the patients so they have some contact.



PORTER
Melanie, we've come into the family room here which is quiet away from the unit. What's it's main function?



GRANGER
Well interestingly this area and the waiting area down the end have just been recently redecorated by a family member who recognised that actually you do spend a lot of time as a relative waiting and so she invested a lot of energy and effort into sort of recreating a calm atmosphere, one where you were near the unit and near to be got but also where you can relax as well.



PORTER
Because it's very difficult - it's a very alien environment, I'd assume very few people have first hand experience and you go in there and your relative may well be sedative, on a ventilator, not talking, it's very difficult to assess whether they're doing well or badly.



GRANGER
Yeah and again I think this goes back to what previous relatives have said is this need for information but not just information but timely information as well. And we work in very close relationship with our consultants here and that's one of their key things is making sure that the relatives are up to date and told honestly about the condition of their loved one.



PORTER
Barry Williams is chairman of the Intensive Care Society's patient liaison committee here at the Royal Berkshire - a post he took up after his wife Cathy had been seriously ill on the unit.



WILLIAMS
I remember three years ago when I was here, when my wife was desperately ill, she was in for 49 nights and was very seriously ill and did arrest and I spent three sessions each day sitting by her bedside. The staff were exceptionally good, they do communicate with you, they do tell you what's going on, the full team involves you in the treatment. They were very straight and honest with me, there were three occasions when we thought we were going to lose my wife and they had I think the courage the talk to me about that, so I was well warned and briefed and prepared. With my previous background of health service management I was fairly familiar with a lot of things but the sight and sounds of actually being involved in intensive care with my wife was quite a distressing experience, far more distressing than I ever thought it would be.



GRANGER
A critically ill patient's condition can change from one hour to the next and on admission to intensive care relatives are actually informed that this is almost like a roller coaster and whilst one of their big needs is to have hope and we have to promote that hope, we have to be realistic.



PORTER
One of the most hopeful signs is when a patient gets well enough to be discharged from the unit but that can be a difficult time as well can't it.



WILLIAMS
The unit itself was extremely well staffed, well proportioned but then when she was transferred from there to the general wards it really was quite a shock because the level of care plummeted considerably. There were no nurses on the ward where she went who seemed to be tuned into the high level of illness that she was still suffering, she was much sicker than patients on the general ward. There were two major things that I noticed in any patient who comes out of intensive care are firstly, that they suffer from incredible physical deficit because they've been lying in bed for so long, there's an incredible amount of muscle wastage and then they also suffer from psychological problems. And this is well known, it's well documented, but yet nobody seems to pick this up at a level outside the intensive care. And this was particularly clear with my wife on the general ward - she was disorientated, she was physically incapable of doing things for herself.



PORTER
Disorientation and confusion are common in patients on ICU - particularly in those who have no recollection of how they got there. Emma came too on the unit after developing severe pneumonia - it was the start of a three week stay in intensive care - but at first she had no idea where she was.



EMMA
Couldn't move at all. [indistinct words] and I knew that I had a pipe into my throat, a thick pipe and I could feel the wires, I could see all the wires up my arms and my legs. I just didn't know what had happened. And I thought: I've been kidnapped and I'm in a clinic, I'm somewhere like Dubai or somewhere like that. And I was thinking: How am I getting out, how am I going to ... I can't move they've got me drugged up so I can't move. I can't speak. And they kept on saying to me: Your husband's coming in, your husband's coming in. And I was thinking like I know he's not, I know he's not.



PORTER
Carl, one of the things you often hear from patients who spend a long time in intensive care is they don't really remember that much about what happened.



WALDMAN
The majority of patients we see in our follow-up clinic remember very little. What they do remember can be very unpleasant, they remember the tube being sucked, they may remember being turned. But a lot of them actually explain their memories in terms of nightmares and dreams and part of it can be real, you know, and it's not dissimilar to the hostage syndrome. When the Lebanese hostages, including Terry Waite, were released the syndrome they had has proven to be very similar to the syndrome a lot of our ICU patients have, so we call it hostage syndrome.



PORTER
In what way?



WALDMAN
Because they can't move and they have tubes and they can't go anywhere, they feel they just can't get away and they want to get away. And the body copes by I suppose imagining all sorts of things, very commonly they think staff/relatives are trying to kill them and a lot of the nightmares are sort of near death experiences. One lady we had said she was in a bed on a stage with a shoot going down to a row of coffins and she was waiting for her turn. So it can be very, very unpleasant.



PORTER
Presumably that's one of the advantages of minimising sedation and analgesia to reduce this sort of - this long twilight zone where people don't know whether they're one thing or t'other.



WALDMAN
There is emergent evidence that if you remember absolutely nothing of your intensive care stay it's not good for you in the long run, a lot of people say well what's the harm in not knowing, just as well you didn't know, that would be the impression - if you have some knowledge of what happened to you in intensive care you're more likely to adapt to the rehabilitation and you're less likely to get post-traumatic stress. So there's now a tendency for all patients who are on ITU to have the sedation if possible, if it's not deleterious to them to be lightened once a day until such a time as we feel they need to sedated in an attempt to try and make them aware of their surroundings.



PORTER
What do we mean by post-traumatic stress?



GRANGER
Patients might display in their recovery flashbacks to being critically ill and their hallucinations and nightmares might be triggered by watching a medical programme on the television, they might recall a lot of the incidences and situations here and that stays with them in their recovery. An estimate is probably about 25% of our patients get post-traumatic stress disorder.



EMMA
I have flashbacks inside the hospital and stuff. I was at the school dropping my sons off and there was a woman about my age and I've seen her loads of times but this day she came to the school she had that uniform on that they wear in intensive care, I nearly dropped on the spot, I couldn't take my eyes off that uniform, it flashed me back to it. I've been over and over, hundreds of times, some points of like while I was ill, so I think people should really talk it over even to the point where you've just exhausted it now, just don't try and bottle it up because you think things, they play on your mind and they alter as well in your mind, you don't remember them exactly how they were, you'd have your own little slant on them.



GRANGER
What we're trying to do is often the patient has no memory or recollection of their illness and to return some of that ownership is we invite them back to the unit and actually see the bed space they were in and make them meet some of the nurses that nursed them and listen to some of the alarms and sometimes that triggers memory recall which is good and that does demonstrate that it prevents post-traumatic stress disorder occurring.



PORTER
Putting those cues in context really.



GRANGER
Yeah.



PORTER
Explaining what happened to them so they can see it first hand. Some units use diaries as well, what do you think of those?



GRANGER
Yeah well I think we're probably one of the first units to do that and when patients were coming back to the unit they were seeing the environment but they still said that's lovely but - and there was always a but and the reason is that they wanted to know a factual account of exactly what treatments they had, who delivered it and how they responded. And we do encourage relatives to keep diaries and just to track down, for their own benefit, often it's quite good to offload at the end of the shift and also because they have so much information that it's best to log it as you're going along. But from our point of view we found that for patients they really needed to know exactly what happened and so what we have done in the past is log that and give them a diary of their stay. But unfortunately because we've had cutbacks that's one of the services we had to withdraw.



PORTER
But you encourage the relatives to do it.



GRANGER
Yes but obviously the only thing with relatives doing it is obviously they impart their emotions and often that leads to the patients feeling quite guilty - guilty for being ill, guilty for putting their family through what they've put them through. So whereas the diary that we do it's very factual, very explicit and it's very honest and that is what the patients are seeking.



PORTER
Michelle ended up spending two weeks on the unit when she developed breathing problems after routine surgery.



MICHELLE
I had a diary which I didn't understand properly but I knew there was this group of people were writing in. The nurse consultant read it to me on the day I was discharged and it was the first time I cried and I didn't cry while I was in hospital, while I was having the treatment or whatever but the things that people had written - that the family had written - really got to me and I realised how hard it must have been because I was out of it for a lot of the time and when they were sent for and told that I might not make it and they spent whole nights with me and watching me and waiting for progress reports that must have been awful for them. And so it sort of made me aware and also friends who'd come to see me who'd written little messages in that were very poignant I think. I just made me see what it was like for other people which I don't think I'd considered, you're very self-centred when you're in hospital, it's because everything revolves around you and nurses - and they're all caring - how are you - your visitors come in and ask how you are and they don't [indistinct words] themselves. And so you tend to think there's only you that's affected. And it made me see that this had affected everyone.



PORTER
Carl, at the moment unusually you've got a spare bed or two in the unit but a lot of the time you must be under intense pressure, you need more beds?



WALDMAN
Yeah, it's a sad fact that in the UK the number of beds that we classify as critical care beds in proportion to the rest of the hospital beds is much lower than the other countries such as Denmark, Germany, Holland. So we're starting off with less intensive care beds than we would like.



PORTER
But what happens then you must be full - a lot of the times you are full, you get a phone call from a consultant surgeon who's got a very poorly patient and needs intensive care and you've got to look at that patient either remove someone from your own unit or say no.



WALDMAN
It can be an absolute nightmare - you can have a patient in theatre that expects to come to intensive care afterwards, your intensive care unit is full, there's no one you feel is easy to transfer and then you have a patient arriving in casualty, there may be another patient actually in the CT scanner and some nights are like that and you feel the whole world's imploded because you haven't got enough beds.



PORTER
Well how do you - and who prioritises those patients?



WALDMAN
Now when we get to a point where we're full and there's obviously one or two patients more that need to come in then we have to make a difficult decision about who to transfer. And the actually idea of being sent 50, 100 miles in an ambulance in the middle of the night doesn't sit well with anyone but occasionally that's what we have to do.



PORTER
Presumably they're in a better condition than the person who's acutely ill in hospital that needs their bed?



WALDMAN
Exactly but it puts the nurses and the doctors under extreme pressure.



PORTER
A lot of patients that come through your unit, like all intensive care units, won't survive and overall what sort of proportion of patients don't make it?



WALDMAN
It's about 20% don't leave the intensive care unit - they die here. About another 5-10% will die on the ward before discharge, either because of an unexpected event or more usually because they've got out of intensive care, then they've deteriorated again and it's felt inappropriate to readmit them to intensive care.



PORTER
Is it hard as a clinician, either as a doctor or a nurse, working in an environment where as many as one in three patients won't make it home?



WALDMAN
It is very difficult but it's also very rewarding because the two out of three that do survive may otherwise not have survived. So I think there's two angles to that question really.



PORTER
What's special about the job for you?



WALDMAN
When I was a houseman in London the one thing I always looked at the anaesthetists and the intensive care doctors because those were the ones that seemed to be able to achieve things in a very short time and they seemed to have all the skills in order to resuscitate and I thought whatever I do in medicine it would be good to do at least a year's anaesthetics in intensive care but having gone into it, it's so interesting, you know you're involved in every other speciality - transplants, neurosurgery, cardiac surgery, paediatric surgery - so many things of interest that it just seemed that I didn't really want to leave and try another speciality. And when you get good results it's a great achievement.



PORTER
Consultant anaesthetist Carl Waldman - who has an infectious enthusiasm for his job - talking to me at the busy intensive care unit at the Royal Berkshire Hospital in Reading. But perhaps we should leave the last word to ICU patient Sally and her partner Ian. Sally's stay on the unit changed their outlook for ever, and has helped put life's other challenges in perspective.



SALLY
I do think it has definitely changed me. When I get a bit down there were people who didn't come out of intensive care, there was a lady who was next to me who lost both her legs - amputated.



IAN
We haven't changed things dramatically, we haven't like taken up bungee jumping or anything like that but I'm talking about the little things [indistinct words] enjoy things and enjoy life a bit more.



SALLY
In work and you get an e-mail, so and so has missed this deadline for this very important meeting, I think oh it isn't that important.




ENDS

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