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BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CASE NOTES Programme no. 8 - Emergency Services
RADIO 4
TX DATE: TUESDAY 17TH FEBRUARY 2009 2100-2130
PRESENTER: MARK PORTER
CONTRIBUTORS: CHRIS TURNER
BECKY WILSON
JIM HANCOCKS
SIMON BURROWS
CERI SMART
PRODUCER: HELEN SHARP
NOT CHECKED AS BROADCAST
PORTER
It's now 8 o'clock in the morning, we're in the back of an ambulance, heading out from the ambulance station at Gloucester to stand-by in Cheltenham. It's treacherous weather out there, it's probably about minus five, there's ice all over the roads, there's already been a major incident involving vehicles, including a coach, that's crashed. So a number of ambulances have gone out to that. We're actually going to go and be on stand-by ready for the next emergency and we'll be based in Cheltenham awaiting a call.
I am spending a day with the Great Western Ambulance Service to gain an insight into the type of emergency care it provides. Like all ambulance services its resources have to be carefully placed around the catchment area so they can reach callers from any quarter as rapidly as possible. I am starting off with paramedic Chris Turner and technician Becky Wilson. Chris has been in the job for 13 years, Becky for five and they are based at the main depot just outside Gloucester, but we have been deployed to stand by in a car park five miles down the road in Cheltenham. Giving us time for a quick tour of their state of the art ambulance.
TURNER
Right. Start off with the two bits that are closest to the door. So when you open the door you've got your oxygen and your snatch bag ready, which has got all your life saving equipment, so those are the two things we grab straightaway when we go into jobs because we don't always know or get the right information about what we're going to. So we've got all the stuff in those bags that we need to keep someone alive for a short period of time, in the time it takes to come back and get other pieces.
PORTER
Right, so you literally open the door, grab those ...
TURNER
Grab those two yeah.
PORTER
... and assess the situation?
TURNER
Yeah, yeah.
PORTER
And then if you need to bring people back in here, I mean what can you actually do in the ambulance, it looks pretty well equipped?
TURNER
Yeah we've got everything that we need to keep airway [indistinct word], we've got suction unit, that box there, that'll breathe for the patient so it leaves our hands free to do the rest ...
PORTER
The little ventilator?
TURNER
Yeah small ventilator. Oxygen run. Then on to the monitor which has got four lead and 12 lead ECG capabilities. Blood pressure, pulse oximetry and some of them have got capnography as well.
PORTER
So pulse oximetry, that's measuring oxygen levels in the blood ... and capnography measuring carbon dioxide in their breath. It's the sort of machinery that if somebody watches Casualty or ER that you'd have by the bed there.
TURNER
Yeah, yeah.
PORTER
You've got here in the ambulance and including the defibrillator as well, the thing for shocking them.
TURNER
Shocking them, yeah. Spare batteries because we do get through the batteries with the amount of patients we deal with. Moving down this [indistinct words] which is vacuum splints for immobilising limbs. And we've got a full body cushion as well if they've injured their back ....
PORTER
So these are the special splints that are soft until you suck the air out of them?
TURNER
Yeah that's the ones.
PORTER
So you mould - mould them to ...
TURNER
Yeah, rather than the old rigid box ones which weren't as good.
PORTER
What's happened in terms of emphasis, I mean is your role now - obviously it depends on what sort of case you're going out to see - but is it to stabilise the casualty at the scene in the ambulance or is it a sort of scoop and run and get them back to the hospital as quickly as possible?
TURNER
That's part of the dynamic assessment that you have to do with each patient, you have to make that decision, if they're that serious we can stabilise on route, rather than staying on scene. Obviously if they're trapped at RTCs and stuff then we have to do stabilisation on scene and then move them. But if they are moveable we can do - we can put IV access in, put fluids up - all that sort of thing - en route rather than staying on scene and doing it.
PORTER
There's two of you so one of you would drive and one of you would be in the back here working ...
TURNER
Yeah and then the next job we'll swap round and Becky will drive and I'll go in the back.
PORTER
And what about letting the hospital know what's coming in? Presumably the minute you set off you're talking to the casualty or wherever you're going saying look I've got so and so in the back of my ambulance.
TURNER
If we deem it necessary that we're going to need a resus team or some specialist doctor - paediatrics for example - we'll phone the accident unit ahead and tell them what we've got, give them an update and a pre-alert and run in from that, we don't do it with every patient unless we deem it necessary that they've got something specialist that's going to be required.
PORTER
And can you get advice as well, I mean if you're with a case that you're not sure about you can ring in and get advice?
TURNER
Yeah, particularly with things like overdoses, they've got a tox base at the minor injuries unit, so we can say they've overdosed on - accidentally taken too many of these pill, rather than taking them all the way to hospital and for the hospital to say actually that's not a life threatening overdose, they're okay, we can get advice like that.
PORTER
And it wasn't long before ambulance control was on the radio and we were on the move to our first emergency of the day.
WILSON
Heading towards an RTC - road traffic collision. It's a car apparently on fire, so we need to obviously ask the team whether or not the fire services have run into it, the police will be run into as well. And this will give you an idea of what it's like to run....
TURNER
Well yeah I mean this is Gloucester rush hour.
WILSON
And he's got to ring control.
PORTER
Well we're on our way to the traffic accident but we're having to fight our way through queues and queues and queues of traffic, it's rush hour here between Gloucester and Cheltenham, tens of thousands of people trying to get to and from work and literally the ambulance is trying to squeeze its way down the middle of the road, it's only designed for two people and it's not making very fast progress at the moment, despite Chris's best efforts.
WILSON
And this is your rush hour.
PORTER
So even with the siren they still ...
TURNER
They still put in front of it yeah. [Indistinct words]
PORTER
It's very interesting seeing it from this perspective because people aren't always that helpful are they?
WILSON
They don't hear us and they're on their phones a lot of the time.
TURNER
You've seen the width of the traffic, they stop right opposite and then sit there looking.
PORTER
They'd be better off just putting their foot down and getting ...
TURNER
Yeah, cars are supposed to pull in.
WILSON
Basically we've got three tones. What we tend to do is if we alternate them people are more likely to hear us, because they'll think there's more than one coming so they actually look for us. We've got another tone, it's ... and then the third one - we use that one on motorways and dual carriageways because it throws the sound forwards so you'll hear it from further afield. But if we rotate through the sounds it gives them a heads up that we're coming through.
PORTER
So we've been guided to the accident by the Sat Nav and we've got to where it should be but no sign of a car on fire, so we're just turning round in the road now.
TURNER
I say something up a side street that looks like it might have been something.
PORTER
Presumably the Sat Nav just gives you an approximate position as to where it is?
TURNER
Well it plots where the call's come from and where they say it is but sometimes people get confused if they don't [indistinct word] to the area. So there was something up - on a right hand turn up here so we'll have a look ...
PORTER
Can always stop and ask.
TURNER
Yeah if it's not at that location that we saw we'll then get on to control.
PORTER
After a frustrating 10 minutes driving around a few local black spots - well known to Chris and Becky - we finally found the accident, but only after passing two others. An empty van that had spun through a hedge. And a hatchback that had slid off the road, with a sheepish but uninjured driver standing alongside. The accident to which we had been called was a bit more dramatic - a four by four carrying three people had skidded on ice, gone through a fence and a hedge, and hit a large tree head on.
So tell me what happened - you were driving along.
RTC WOMAN
Just driving along and I actually had it in the four wheel drive as well, so I assumed I was absolutely fine and I think my back wheels must have hit some black ice or something, the next minute I know I'm starting to spin and I was heading on to the other side of the road and I thought oh my god something's going to hit me from the other side, turned the wheel and ended up over there. I have absolutely no idea how my car got in that position because ...
PORTER
In the tree.
RTC WOMAN
Yeah, I know - I just hit the tree and then the bags burst, I've never even seen one of those bags burst before actually, that was quite exciting. And that was it. I actually have no idea how the car got in that position.
PORTER
So you had your boys in the back, taking them to school were you?
RTC WOMAN
Yeah, yeah.
PORTER
Both fine. And so you - except you've hurt your knee.
RTC WOMAN
I've hurt my knee and it's bruised and rather swollen. I've just taken a couple of paracetamol. It's fine. I mean I walked from there to there, I'm not dying, I'm going to be fine.
PORTER
Considering what the front of the car looks like you've got off quite lightly haven't you.
RTC WOMAN
I think I got incredibly light - yeah I was, I was very lucky. I think when the car filled up with smoke that worried me, it filled up with smoke, and so I just yelled at the boys to jump out and it was fine, they'll be fine.
PORTER
Good, well I'm glad you're in one piece.
WILSON
There's obviously been some impact on your knee, okay, it might be - it's going to be best to get it x-rayed just to make sure you haven't chipped anything.
RTC WOMAN
I ought to take a couple of paracetamol and if it's sore go later.
WILSON
That's entirely up to you. Obviously I've advised you to, so ....
RTC WOMAN
Honestly I think it is fine, I think it's just incredibly bruised and painful....
WILSON
That's fine, that's your choice, okay. What we need to do is we'll get you to fill out a form just to say that given what's happened it's possibly an impact injury on the dashboard.
RTC WOMAN
Yeah I think that's exactly what I did.
WILSON
Okay and obviously that I've advised you to get it looked at, an x-ray, if you want to take yourselves down there later ....
PORTER
Chris, Becky's in the ambulance attending to the casualty and you've come straight over to the car, so what are you looking for here?
TURNER
Part of the training that we do is to try and gain as much information from the scene as we can. So we come to the car, because this can tell us a lot about the sorts of injuries that we'd expect to find and injuries that might be hidden, for example that they quite often slide down under the steering wheel and impact with their knees on to the under trays on the dashboard and that can lead to fractures of the legs and fractures of the pelvis and things. There's none of that, it's a fairly low impact RTC, it's just cosmetic damage really to the vehicle and they've got out and walked away with no serious injuries.
PORTER
I suppose the other thing is you need to check there's nobody - nobody left in there?
TURNER
Yeah, yeah as with that van on the way here, that might have just occurred and there could have been someone in there, so we always stop and have a look first. And there have been incidents in the past where there have been crashes like this and the people in the front have been unconscious and with all the stuff thrown around in the back we've found people later on in the back of the car under carpets and clothes and things. So we do a little sweep of the area because people do get dazed and wander off. Luckily we've got snow today so it's really easy to find them.
PORTER
On the way here we passed that van that we stopped at to check that had gone through the hedge that was empty, we also passed another car that had spun - everyone had got out of and looked like they were fine. What would happen if we'd have found somebody in the van, we'd obviously have to stop and attend to them and yet you're on your way here to another call, how do you deal with that?
TURNER
Yeah we'd - well we'd assess how serious the patient at the van was and then we'd get in touch with control and say that we'd found another incident and because they've already got fire service here they can phone them and have a chat with the patients here and we can get a better picture of how the patient is here and who's the most serious of the two and we can treat the most serious.
PORTER
Not a good day to be out on the roads of Gloucestershire.
TURNER
Not a good day to be out on the roads of Gloucester - I think we're going to have a busy one today.
PORTER
Everyone accounted for, and no serious injuries, so we were on our way back to our stand at Cheltenham when another call came in.
AMBULANCE CONTROL
Okay you're going to Cannock Road, Park End.
TURNER
It's a long run down the middle of the Forest of Dean. Is that Park End? Bloody hell.
PORTER
Park End is right across the other side of the county in the Forest of Dean - and the memory of the ensuing 40 minute dash will remain with me for a while. Suffice to say that I have felt better! And to cap it all, just as we were closing in on the accident control called us off and redirected us to a man with a suspected heart attack. The highest priority category A call that requires an ambulance to be on a scene in less than eight minutes. The 999 call had come from a GP's surgery.
TURNER
... previous MI. Looks like he's got a bunder block going on at the moment, so medics are awaiting him at Gloucester Royal.
PORTER
So a bunder block, that's a problem with the conductivity of the heart, he's in a funny rhythm is he, yeah?
TURNER
He's got a 12 lead, he's got a line in, he's had some aspirin.
PORTER
So he came into his GP complaining of chest pain did he?
TURNER
Yeah. So I'll just take a chair in and we'll get him in.
PORTER
Ah a good place to get it in your GP's surgery. Do you get many calls to GPs' surgeries with patients who ....?
TURNER
Yeah because patients - whereas the old, what we like to call the old breed, who don't like to go and see their doctors and don't want to trouble anybody and it's all right I've just got a bit of chest pain radiating into my arm and neck for a week but I won't tell anybody and they come and see their GPs and you know the old stories - they're having heart attacks and things.
PORTER
Because you'd prefer them to call 999 from home presumably if they're developing chest pain?
TURNER
Any chest pain, yeah, we don't mind going out ....
PORTER
But this gentleman's gone into his doctor to check it out before he's bothered you.
TURNER
For a few days.
PORTER
So you went into the surgery today to find out what the chest pain was?
PATIENT
Because of my past experience I thought I'd go and get - ask for an ECG at the surgery and I went in like I've been mob handed, ended up in here.
PORTER
Everybody leapt on you. Did you think about calling for help last night?
PATIENT
No, perhaps I should have done but I didn't. And it was late, it was icy and I thought if I can be alright till the morning that'll be ...
PORTER
Didn't want to put anyone out.
PATIENT
Well no I didn't want to call people out, rushing out.
WILSON
The one thing with the ambulance service is, is we never, never not attend a chest pain. If you've got chest pain we'd rather you call us and it be indigestion.
PATIENT
Well you see it didn't feel like it did when I had a heart attack.
WILSON
No but it doesn't necessarily have to feel the same, all heart attacks can be different.
PATIENT
But it got very uncomfortable.
WILSON
Yeah.
PATIENT
In the night.
WILSON
Yeah. But we don't have a problem coming out, even if it's icy okay? We'd rather come out and it be indigestion and you be fine, alright?
PORTER
Our destination was the accident and emergency department at Gloucestershire Royal Hospital, but thanks to the sheer number of traffic accidents that morning, all beds were occupied meaning Chris and Becky had to continue looking after their patient until one became free. At least they had managed to get him out of the ambulance and in to a warm corridor.
TURNER
The problem is that there's only a finite amount of beds, so when they get filled obviously ...
PORTER
This is actually in the unit itself?
TURNER
Yeah in the unit, in the casualty, they'll come in here and then they'll go from here either to a ward or to an assessment unit. Now if there's no beds on there they have to wait here until there's a bed free there. So we've got bed managers frantically rushing round the hospital at the moment trying to free up beds but we'll just have to wait until they've actually freed the beds up before we go anywhere. Patients used to stay on the ambulances, what we can do now is bring them in and sit them on - we've got two trolleys here, so they'll come in and they'll sit on the trolleys here.
PORTER
So we're actually in a corridor waiting and they're still your responsibility at that stage?
TURNER
Yeah, yeah what we can do is if another ambulance comes in and they need to free up, we can watch both patients and that leaves the ambulance then free to respond, so that's why we've got two in here. But once these two are filled then it's on the ambulances again.
PORTER
And you don't actually know how long you're going to be here for.
TURNER
No, that's the worst sort of - up to an hour maybe, hour and a half sometimes, that's - we have had a major incident, you know, a coach load with 30 people on or another minibus, so it doesn't happen that often that you get a long wait but certainly fairly rare to wait anymore than an hour.
PORTER
As it was we were only waiting for 20 minutes or so, but that was enough time for me to wander over to the air ambulance sitting on the heli-pad outside and have a few words with paramedics Jim Hancocks and Simon Burrows.
Hi guys, Mark Porter, Radio 4. The crew this morning ...yeah, do you mind if I have a quick chat about what you do and what you've been up to? Been up to anything busy this morning?
HANCOCKS
We have yeah been out and busy this morning, we've been up three times this morning, only made it to one patient so far.
PORTER
And what were you called out to this morning?
HANCOCKS
Road traffic accident, given the weather it's not really surprising with the ice and what have you around, so yeah.
PORTER
Two paramedics?
BURROWS
Two paramedics and obviously the pilot. Some crews run a doctor as well but we're the double paramedic crew today.
PORTER
And it's a big helicopter but it's not that big, where does the patient go? How do you get them in and out just on the stretcher?
HANCOCKS
This stretcher here, yeah, it slides out to the side, obviously load the patient on and slide back in. So quite a restricted area, as you can see, goes under the bulkhead. We get to the main head and shoulders of the patient there.
PORTER
And you're carrying the same sort of equipment that you would find on a normal ambulance in terms of ...
HANCOCKS
Yeah a few extra pieces of kit but nothing super duper - just a flying ambulance really.
PORTER
And what sort of jobs are you likely to be called out as first line?
BURROWS
The work we do is about 50% road traffic accidents and we also do a lot of sporting injuries - horse riders - and the other thing that we can do that is particularly tricky when you're on a land ambulance is get to people in very remote areas and we've been known to go into the Brecon Beacons and quite some distances away just because there are certain places you cannot drive an ambulance to.
PORTER
And is also a case of people who need to get in quickly?
HANCOCKS
Yeah I mean that's the beauty, especially in the area that we work in, with it being very rural, sometimes I mean if you get into the deepest darkest depths of Herefordshire and Gloucestershire by land it can be anything up to an hour by land to hospital and we're able to fly in a straight line at 150 miles an hour, so we're normally sort of within 20 minutes of a recognised regional trauma centre or 10 minutes of a local district hospital with a fully equipped A&E department.
PORTER
You say you've been up three times today, how would that compare to a normal day, what would be a typical shift for you?
BURROWS
We average two to three jobs really. Some are obviously more, more people out and about doing various activities, and winter you can do to sort of one maybe two.
PORTER
So you've done your day's worth, you're hoping for a quiet afternoon.
BURROWS
Oh I can't see that happening with the weather at the moment but as long as we get time to have a cup of tea here now we'll be fine.
PORTER
And I see you're wearing flying suits basically, I mean they look much smarter than your average paramedic, much cooler.
HANCOCKS
You may say that but they're the most uncomfortable thing to wear practically - they're cold in the winter, they're ridiculously hot in the summer.
PORTER
But you look like Tom Cruise, so...
HANCOCKS
I wouldn't go as far as to say that at all.
BURROWS
The fog's come down again.
PORTER
Yes I must get my eyes checked.
Despite all the flattery I couldn't blag a lift and, once they'd had their tea break, they were soon on their way again.
Helicopters may be worth their weight in gold in counties like Gloucestershire, but there are not the only alternative way of providing cover across large rural areas. Rapid response cars staffed by Emergency Care Practitioners - a type of enhanced paramedic - are a relatively new addition to the Great Western Ambulance Service, but one that is already proving its worth - both in getting to emergencies quickly and providing medical care in the home where appropriate, so reducing unnecessary trips to hospital.
Ceri Smart leads a team of ECPs at their base in the Forest of Dean, half an hour from the nearest major casualty department. He started by showing me his car.
So I mean it's a pretty conventional one, I suppose people would call a small people carrier.
SMART
Yeah a small people carrier - a Vauxhall Safira. Obviously had some conversion work done to allow our equipment to be stowed correctly.
PORTER
So the boot's all compartmentalised - that's just to keep it all stowed properly.
SMART
Yeah, yeah we've got various compartments for our primary response bag.
PORTER
And basically you're carrying exactly the same sort of kit as an ambulance?
SMART
Yeah when a car turns up people will need to be rest assured that we are carrying the full range of drugs, the full range of medical gases, the full range of life saving equipment and the only things that we don't carry are obviously stretchers and spinal boards.
PORTER
Can we have a look at your drug bag to see what sort of things that you're carrying?
SMART
Yeah certainly.
PORTER
Well it's freezing cold here, let's take the bags inside and we'll have a look through them in your office.
Now this is something that's changed tremendously since I started working in medicine where basically ambulance crew wouldn't be administering anything.
SMART
This is actually - the first bag I've got here is my emergency care practitioner - my ECP drugs. These are drugs that I carry additionally because of my role. These aren't carried by the normal ambulance crews. And in this bag contains a whole wide range of antibiotics, additional pain relief - morphine ...
PORTER
I mean this looks - I mean, well it is, it's identical to my bag. You've got antihistamines, anti-sickness injections and a collection of antibiotics. Exactly what we'd carry.
SMART
Yeah absolutely.
PORTER
Well looking at this I mean you can treat everything from a urinary tract infection or a chest infection through to pain relief for a heart attack through to - or someone having seizures because they're having epilepsy.
SMART
Yeah we attend a wide range of emergencies.
PORTER
Can we have a look at what a paramedic would carry?
SMART
Certainly. So this is the more standard [indistinct words] paramedic drug kit. Okay, heavily based around - I mean this section here are more around cardiac arrest drugs and serious sort of ...
PORTER
Sort of adrenaline and atrophine - something to raise the heart rate there.
SMART
Exactly and you've got neloxone for obviously the side effects of morphine or the side effects of heroine overdoses. And then you've got glucagon and hypostop in our diabetic emergency section. And then we've got our convulsions - diazemuls and diazepam. And then you've got just further range of asthma type nebulisation type drugs.
PORTER
Something for pregnant women who might be bleeding after giving birth.
SMART
Absolutely.
PORTER
Water tablets. Strong - [talking over]
SMART
Yeah we obviously - people in pain present regularly to the 999 system, such things as - right from simple paracetamol and we can use various types of painkillers.
PORTER
This last one here's got salbutamol, that's ventolin for asthma. Now whereas a paramedic might be able to administer ventolin to somebody who's having an asthma attack, the difference perhaps with an ECP is that you go along and say well are you on the right type of inhalers and perhaps alter or advise them and/or indeed give them steroids on top, so you're actually much more like a doctor in situations like that.
SMART
The view of our patient is more broader, it's more holistic, and what I mean by that is we go to patients, very often, a number of times and sometimes an ECP can pick up a small problem that actually calls five or six repeated 999 calls and sometimes it can be just the enhanced knowledge of the pharmacology that they're on. You can then speak to the GP, say actually do you realise that if we did this and we can assist the GP because sometimes we are the eyes and ears very often of either the emergency department of the GP. Very often the GP will only see the patient in surgery where we're seeing people in their home.
PORTER
Which is exactly what we did next. Ceri wanted to review someone he had attended earlier in the day after her worried husband had dialled 999.
SMART
Yeah we're going to see a 65 year old female who presented to the 999 system feeling generally unwell. When I arrived she was laying in bed and just feeling pretty unwell. She's been suffering sort of a four or five day episode of gastroenteritis type symptoms.
PORTER
So diarrhoea and vomiting.
SMART
Yeah, I mean she hasn't had diarrhoea or vomiting for 48 hours but basically hasn't really eaten for the last four or five days, so is feeling pretty weak. And although she's drinking what she thought was adequate fluids I've certainly emphasised that she really needs to push her fluids. I've also told her to start taking some paracetamol because she still had a reasonably high temperature but she'd not really been taking anything for it. So I'm expecting hopefully an improvement now in how she feels, obviously I've given her advice to phone us back if there was any deterioration, which is very important and I'm sure yourself, as a GP, when you put things in place expecting patients to improve is how you safety net those patients. So ...
PORTER
Ceri, I'm asking you this with my GP hat on very much now but if I had somebody like you working in my home town I can imagine my patients quite liking the service and coming back and wanting some more, is that an issue for you, do you find that people are perhaps using you instead of their GP?
SMART
It's certainly a danger that I think that we're all well aware of. However, patient safety is always of paramount to both myself and my colleague, so I would never stop doing follow ups for that reason. However, you do have to make it part of your interaction with your patient, you have to make them understand that actually we're not here to replace the GPs ... we are an emergency service and the key in my job title is emergency care practitioner and I'm certainly not here to replace the GPs.
Well we're here now at the address for the follow up visit. Obviously I'm still available for emergencies, we never take ourselves off the running board to do these follow up visits, they're always fitted in in between our work load because it's clearly important to be available at all times. This lady's already had me as an emergency once and I've already made the decision that she's safe enough to leave. So this is just really a follow up and a welfare check.
Just wanted obviously to check on you Jackie, alright, just obviously with what we discussed this morning. Have you managed to take anymore food etc., and are you drinking plenty?
JACKIE
I haven't had much to eat, I've had a bit more to drink yeah.
SMART
Okay, you look as though - you're a bit more, you've got more colour in your cheeks etc. What I'll do is I'll just check your temperature again. Alright, just to make sure your temperature's come down....
PORTER
And while I was watching Ceri go through his checks, I was struck by how blurred the boundaries have now become between the various parts of the NHS and how paramedics and ECPs are taking on roles more traditionally associated with casualty departments and GPs. And doing a pretty good job too. My only concern would be that their workload is bound to increase as more and more people catch on and are tempted to dial 999 before considering all the other options. Even if their problem isn't that urgent.
Ceri already has enough customers - and this one seems very satisfied.
SMART
Alright? We'll leave you be. So if you just keep drinking plenty and you're going to have to try and push this food a little bit, alright? But I'm really pleased actually that certainly the colour and everything in your cheeks is back. How's your partner making as a nurse?
JACKIE
He's not very good.
SMART
Not very good, no. Okay. Alright, okay. Thanks then Jackie, cheers.
ENDS
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