Sunday afternoon and the agency triage nurse asked me to look at a patient she had in her exam room.
Sitting slumped on a chair and in obvious pain was a distressed and exhausted looking 66-year old lady...shabbily dressed...thin...grey hair untidily scrapped up and held in place by an elastic band.
She looked like she had just been through a famine.Her husband,sitting next to her, looked like he had caused the famine...very well fed and smartly dressed with that patina of insouciance that comes from years of selfishness and disinterest in anything except beer and football.
The triage nurse explained that the patient had been medically boarded from her work as a cleaner 2 years ago when she developed osteo-arthritis in several joints;and that in an effort to stay mobile that she went for a brisk walk most days.
One month ago,crossing the road,she had turned her ankle inwards,-inverting it-, and had fallen.
The triage nurse was concerned that despite the injury being 4 weeks old, that the ankle was still swollen and was getting increasingly painful;and that her calf was tense and tender and still freshly bruised.
The patient had also seen her own doctor 2 weeks ago,who did not think the ankle was broken.
Now there is a rule in the Strategic Health Authority in which I work that states that only doctors may order an x-ray for injuries that are older than 2 weeks.
Nurses are able to exercise some professional discretion ,if we feel that we can justify the x-ray to a jury of our clinical peers...this basically means that there had better be a beeeeeeeeeeeeeeeeg freaking fracture visible on the x-ray...and that failure to see and treat it would have an unpleasant outcome for the patient.
I put the patient into a wheelchair and took her to my room...her husband opted to go and sit outside in "his" car...the patient explaining that her husband doesn't like hospitals.
"Why didn't you come into hospital earlier?"
Well...I didn't want to trouble anyone...
"it must have been painful though...clinically your ankle is broken?"
Well...it was painful but my husband doesn't believe in doctors...so he told me to soak my foot and ankle in a bucket of cold water...
He did take me to see the doctor 2 weeks ago though...
"And what did your doctor say?"
Well...she lifted up my trouser leg and looked at the ankle...and said that if I lost 10 pounds in weight,that it would be easier to walk on my ankle...
*Lordy Lordy...the patient is already so thin that she needs to run around under the shower to get wet*
"Did your doctor examine you at all?"
"So what have you been doing for the past 2 weeks then?"
Well I tried the bucket of cold water again...but it really didn't help...
"So what made you come into hospital today?"
Well I was cooking his dinner and I said to him that I couldn't stand any more...so he brought me down to the hospital in his car...
So I x-rayed her ankle...she had broken both bones in the ankle with marked displacement.
This is the front view of the ankle with the break just above the red line...the fibula (outside ankle) is actually broken in 3 places
This is the side view, again with the break just above the red line
I called her husband back into the Unit.
"Right Ma'am...Sir...what we are going to do now is put you into a below-knee plaster-of-paris cast and give you a zimmer frame...and then the radiographer is going to email the x-rays up to St Vulva's hospital and I will speak to the on-call orthopaedic surgeon and discuss your fracture with the ortho team..."
Okay ...said the husband...is that going to take long?
"About 45 minutes in total probably..."
Okay....I'll wait outside then...
Julian took the patient away to do the PoP.
He returned about 10 minutes later and wheeled the lady into the waiting room so that she could wait with her husband...but he was nowhere to be found...I called him on his cell phone and he told me that he had 'popped home for a cup of tea' and would be back later...since there was,-after all-,nothing for him to do...
...true love...its always a wonderful thing to see...
So I phoned the orhtopod who agreed that they would see the patient in fracture clinic during the week...
...the call was more about covering my arse to be honest than in actually expecting that they would see the patient on Sunday...we find as ENP's that whilst we have the diagnostic responsibility of a doctor...but are paid like nurses...that we only have the legal protection of a newt!
I gave the news to the patient and phoned her husband to ask him to come and fetch her.
She again apologised that her husband had gone home because he didn't like hospitals.
"I can understand that Ma'am...but doesn't he like you?"
My ex wife always used to say...Before marriage, a man declares that he would lay down his life to serve you; after marriage, he won’t even lay down his newspaper to talk to you.