Southampton Hospital: Acute Medical Unit
Monday 8th June 2015
I arrived at Southampton General Hospital to start my week of work experience in the Acute Medical Unit. I was paired up with a Health Care Assistant and I spent the rest of the day with her. Firstly, she taught me how to properly make a bed; folding over the corners, pulling out the sides and wrapping them over like a parcel. It was a simple task to start with and it made me feel useful, being able to use my hands.
We then visited a man who was going to need help escorting to the bathroom for a shower but he was in too much pain to leave the bed so the health care assistants had to wash him in the bed. I learned that all the patients are washed with HiBi scrub for 5 days after they are admitted in order to reduce the risk of spreading MRSA. All patients are swabbed to test for MRSA upon arrival but it can take days for results to come through. Therefore, HiBi scrub is a good preventative measure. If patients arrive at the hospital presenting with diarrhoea and vomiting, they are immediately placed into a side room.
MRSA (meticillin-resistant Staphylococcus aureus) is a type of bacteria that is resistant to a number of widely used antibiotics. They can be more difficult to treat than any other bacterial infections. Staphylococcus aureus (staph) is a common type of bacteria that is held on the skin, inside nostrils and throat. It can cause mild infections such as boils but if it enters a break in the skin, it can cause life threatening infections such as blood poisoning and endocarditis (a rare and potentially fatal infection of the inner lining of the heart).
MRSA bacteria are spread by skin-to-skin contact between people who already have an MRSA infection or have the bacteria living on their skin. It can also spread through contact with contaminated objects and because people are more vulnerable when they are in hospital, they are more at risk of becoming infected with MRSA. Therefore, the HiBi scrub and the swab can be very important in preventing the spread of the bacteria.
The man suffered from obesity and had sores under his arms, under his belly and around his testicles. It took two people to be able to move him just to be able to wash his back and the whole time he was making jokes and had a smile on his face. As much as he must have felt uncomfortable, he didn’t seem to show it.
Later on that day, I learnt that the AMU was the only area that shared the doctors and nurses notes and I was able to find out that the man was suffering from brain tumours. That was very shocking as he acted as though he was fine. Treating the patients with the nurses before finding out what was wrong from the doctors really showed me just how strong people can be- it gave me a whole new perspective on how I viewed the patients. However, it also showed me that I personally would prefer working in the place of the doctor as I was really curious about what was wrong with them.
Whilst at the hospital I learnt more about patient’s rights to privacy and confidentiality as when I asked to sit in with a patient, he refused as he did not feel comfortable. This did not faze me as I wanted him to be comfortable and instead, I spent some time with another HCA. She spent her time trying to persuade an elderly woman that it was not her lunchtime (at 11am) and that she was not able to leave the ward to go to the dining room. The woman was suffering from dementia and she was increasingly becoming more argumentative and even a little aggressive. I was pulled away to observe something else but later that day I saw her calmly talk about how she was feeling with a young male doctor.
When it was lunchtime, I helped to give a lady her soup in a mug instead of a bowl which made the patient very happy and she seemed very grateful even though I had not done very much for her.
The health care assistant then tried to take me to see an MRI scan but they would not let me in as I am under 18 which was very annoying (understandable, but still annoying as I would have found it very interesting). Just as we were about to escort a lady to CT, the fire alarm went off. Everyone was shocked at first and didn’t seem to move but someone, somehow, managed to find out that it was coming from ‘door 59’. We all looked absolutely everywhere for a door 59 but as we found door 58, any others seemed to vanish. It was very baffling. Somehow it was all sorted and there was no fire- someone thought it could have been the patient that kept wandering off as she was missing from her bed in AMU 1 (which was very worrying) but fortunately someone found her safely in AMU 3. It showed me just how much responsibility they all have for the patients- what would have happened if there was a fire and they couldn’t get everyone out? The fire alarm had been continuous in the area where the fire supposedly was and was intermittent in AMU 1 and AMU 3 (in areas around the area of the fire) – it was a very clever system.
After it had all calmed down, the health care assistant and I finally were able to escort the patient to the CT scan of her head. For this, we had to transport her (with help from a porter) down to neuro radiology. The health care assistant told me it was her least favourite area of the hospital as it was an old wing and people always seem to get forgotten down there. There was quite a long wait and it gave me an opportunity to get to know more about the health care assistant who was planning to go to University to become a nurse instead of a HCA. At that point, I hadn’t been told that she was a HCA and I didn’t know the difference between who was who as they seemed to do very similar jobs.
Light (pale) blue uniform: HCA
Dark blue with white strips: Sister
Dark blue with red strips: Senior Sister
We went into the room with the scanner and it was a lot bigger than I thought. I walked into the small adjacent room and watched as they lay the patient in the scanner. I watched as the scan came on the screen and I remember feeling as though I wanted nothing more than to be able to understand what the CT was showing. We then transported the patient back to the waiting room in neuro to wait for the porter. As we were talking, the lady started to choke up and cry and she kept saying that it was difficult to express herself but she loved everything very deeply. It was a very emotional moment and I felt helpless not being able to do more than grab the lady a tissue. However, the next moment the lady was laughing hysterically and it was clear that she was suffering from some emotional instability.
One thing I noticed from today was just how much everyone else could affect how you worked. If one person was rude then it could affect the whole atmosphere and also could affect the way some people interacted with the patients, even if they didn’t mean it to.
Tuesday 9th June 2015
Today I worked in the Acute Assessment Unit (AAU) of AMU which everyone seemed to call ‘GP’. It was similar to a mini GP surgery for patients who would be admitted and would later on be transferred to a ward or could go home at the end of the day.
As I walked in, I sat with a nurse and a student nurse in her final year at Uni and on her final placement before she could become a registered nurse. The first patient was an elderly lady who had been brought in from her nursing home. The nurse had to fill out a questionnaire of her important information including next of kin etc… and they also have to ask if they are a British citizen and have lived in the UK for the last 6 months- if not, then the patient has to pay for their care.
We also had to give the patients basic examinations- ‘obs’. We measured the lady’s blood pressure, heart rate, temperature and oxygen saturation. These needed to also be checked later on in the day. This needed to be done with every patient that came into the AAU and we also gave them an ECG as they arrived. As this lady arrived, another pregnant lady came in and she presented with a pain in her chest which worsened upon coughing. Although I spent the day with the nurse and we were checking to see if the patients remained stable, I found myself very curious about what was actually wrong. Therefore, I asked if I would be able to sit in with the doctor as she was talking to the pregnant woman. The doctor was a GP ST1 specialising in elderly care but she treated this patient nonetheless. She told me that they had to make sure that the woman was not suffering from a pulmonary embolism as this could be very dangerous during pregnancy. The doctor asked about her pain and it was worse at night and although there was a history of aneurysms in the family, there was no history of blood clots. The patient thought this was the same thing but the doctor explained that an aneurysm is the widening of the blood vessel.
I was able to sit with the doctor as she was writing up her notes and I was curious to know whether all PEs start in the legs as during the examination, she seemed to pay close attention to the patient’s leg. She explained that this is not always the case, even though it is very common but the reason why it ends in the lungs is because as the veins get closer to the heart, they get wider and the vessels in the lungs are the first places where they get thinner so a blood clot is more likely to block blood flow. As soon as the doctor had written her notes, she seemed to run away which sort of made my heart sink- I had really wanted to spend more time with her, following her around.
I then went back to observing the nurse and student nurse as a couple more patients came in. We had to take blood from some of them and different coloured tubes were testing for different things.
Orange/gold: kidney function
Lilac: full blood count
We took the bloods to the ‘pod room’ where we put them in a cylindrical tube and sent them to Chem pathology in a large pod through what looked like a large vacuum cleaner. We then went back and another, younger, patient was there and she gave us a urine sample which we analysed in a room around the corner. We did a pregnancy test which came back negative and a dip which only showed traces of blood which seemed to be normal. We also did a urine test on the pregnant woman and she had traces of protein and ketones present and a very high concentration of glucose in the urine. This seemed to surprise the doctor and we tested her blood-glucose levels which came back normal which seemed even more surprising.
Another reason why a PE can be more common in pregnant women is because the blood of a pregnant woman is thicker than that of a normal adult.
What I noticed from spending time with the nurses after spending 5 minutes with the doctor was that I could not stop thinking about what the doctors were doing and what they thought could be wrong with the patient. I was intrigued by looking over their shoulders at the woman’s chest x-ray and that was when I realised for certain that I wanted to be a doctor.
Wednesday 10th June 2015
Today I asked if I could work with and shadow a doctor but they all seemed to be busy when I arrived and therefore I observed a nurse to start with. She was sorting out which drugs a patient needed and we started with a lady that was clearly suffering from Parkinson’s disease. She had rather violent tremors and the nurse explained that her drug for Parkinson’s was time sensitive but due to the demands of working on the ward, the lady was receiving her medication an hour later than she should be. The nurse had to rush off to deal with another job and I was left with the drug trolley and the patient who still had not had any of her medication (she must have had at least 15 pills to take). I found it very difficult to understand what the patient was trying to say even though I could tell that she was very aware of her surroundings. I felt awful just smiling at her and only being able to answer the question of ‘whether I was training’ as I knew it must have just been a side effect of the Parkinson’s. The nurse eventually came back and had to place the pills into the lady’s mouth as she did not have complete control over her hands.
We then went around to other patients and finally took the “obs” of the patients. The nurse let me write them in the patient’s notes as she read them out. She explained how they have a scoring system so that if the patient is not under normal readings, this can clearly be seen by a Junior Doctor. She said that it helps with communication between Jr Doctors and Jr Nurses. I wrote the blood pressure with two arrows and lines going between them. Temperature was recorded as an ‘x’ and heart rate as an ‘o’. There was a separate place to write oxygen saturation and other observable features.
We went to check the “obs” of a patient that came in with leg pain when a doctor and a medical student came in. After we had recorded the readings, the nurse let me stay to listen to what the doctor had to stay. For this, she would never know just how grateful I really am. We spent almost an hour with this patient. The doctor was an ST3 neurologist who thoroughly examined the patient. He asked her why she had come in and she explained that she couldn’t move and felt very dizzy every time she did- even sitting up in bed made her feel lightheaded. She also had a history of pain in her legs and at one stage she had lost all feeling in them for months at a time. I had missed the session before they saw the patient when they were examining her x-rays or CT scans and therefore I was quite confused about what was really wrong with her but the doctor explained everything he was looking at in as much detail as he could.
The doctor examined her neck and saw that the monotonous beat in the carotid artery was clear and the beat in the jugular was lower than it should have been. He then looked at her legs and noticed that she was missing a big toe on one foot as it had to be removed as a complication of a surgery she had on her legs- the patient said that she had thought that she might have had to lose her whole foot. The neurologist noticed that there was darker pigmentation around her scar area on her foot and then examined her palms where he also noticed the same, darker pigmentation (hyperpigmentation) in the lines on her palms. He explained to us that this was a clear symptom of Addison’s disease and told us that if we had not heard of Thomas Addison, then we needed to research him. To further add evidence to his predicted diagnosis, he ‘tickled’ the patient’s feet and her toes moved backwards, towards her body. The doctor explained that if a person did not have Addison’s disease, then their toes would curl over, away from the body.
The doctor also explained to us the difference between spasticity and rigidity; spasticity is affected by the rate of movement and is the increased resistance to passive movement which varies due to speed causing an involuntary muscular contraction. Rigidity is the stiffness or inflexibility of a muscle or joint and is the increased resistance to the passive movement which is constant.
As we left the patient, the neurologist told us that the lady was more sick than he had anticipated and as he looked at her notes, he was surprised that she had only been given antibiotics where she should have been given cortisol as Addison’s disease is a rare disease of the adrenal glands which affects the production of the hormone cortisol.
I then had a chance to talk to the medical student who told me that she was in year 2 of the graduate programme after having studied pharmacology. She said that the hardest part of the course, for her, was immunology as there was so much you had to know and because she did the extra degree beforehand, she couldn’t quite remember the basics that she had been taught at A level.
After that, I asked and was able to continue shadowing the neurologist which I was extremely excited about. I followed him into the Acute Assessment Unit in Ambulatory Care where we talked to a patient who could not seem to control all of her muscles. She was always moving and her legs and arms couldn’t stay still, she was always squinting her eyes and seemed to smack her lips together a lot. This had happened overnight and the patient seemed to suffer a lot of distress. As the doctor was examining her, she asked whether some pain in her neck could be related but the neurologist said that this could not be the case as it was affecting her facial features as well which was able to rule out that it was a spinal problem. After we left the patient, the doctor said that she could possibly be suffering from tardive dyskinesia which could have been brought about by a change in her medications however it could also be something else.
After that, the doctor decided to go for his lunch and I was instantly worried that I wouldn’t be able to shadow him for any more time; I had already learned so much and I was having so much fun that I didn’t want it to end! The medical student said she had a meeting at 13.30 and the doctor said it was going to be very interesting and he was also going to go. I was then very surprised that he also invited me along and told me to meet them at 13.30 in neuro radiology, downstairs. I had to get a porter to help direct me but I eventually found the medical student who took me to the room where the doctor was waiting. The meeting consisted of 3 consultant neurologists and a radiologist who were talking about their different cases from that day or a couple of days previously. They showed the MRI scans of the patients on a large screen for the entire room to see. They showed the lady with suspected Addison’s disease and it was fascinating to see the science and anatomy behind what was wrong with her. The doctors shared their cases and expressed their own opinions to help each other.
After the meeting ended, I headed back to the AMU which was very busy. I found a nurse to shadow and she was very busy and didn’t seem to have very much time to explain what she was doing. She put in a ‘didge’ or ‘dig’ (I didn’t want to disrupt her working and ask what it stood for) in a patient and gave an alcoholic treatment that would make their urine and sweat turn orange.
All in all, it had been my favourite day so far and I had learned so much just by spending a short time with the doctor; it was fascinating to see all aspects of that one patient- including spending time with her when I was shadowing the nurse.
Thursday 11th June
Today I worked with the coordinator’s assistant in the discharge lounge. Obviously, at the very beginning of the day, no one was ready to go home so the CA explained to me how people had always thought that working in the discharge lounge was slacking off so she came up with a system that encouraged you to record most of what you did during the day, in a folder. We then walked up to the ward with a wheelchair to collect a patient that was going home. When we arrived on the ward, the occupational therapist was leaving the patient’s room so I carried her bag back down to the discharge lounge.
Most of the day was spent talking to the patients and I spent a surprising amount of time helping them to work their phones so they could call family members.
Friday 12th June
From my work experience at SGH, I can certainly say that I saved the best ‘til last! Today was amazing.
Because it was my last day, I thought I had nothing to lose by asking to spend time with a doctor. Because they seemed really busy to start with, I walked around with the sister coordinator who seemed really nice. She explained how the system worked and how they can lose thousands of pounds if they make patients wait too long without a bed- they have a green, amber, red system that lets them know how they are doing.
The sister then took me into the doctor’s meeting where she said she would pair me up with a doctor. They also seemed really busy and she didn’t think it was very appropriate at that time. We looked around the wards to see if we could find a free doctor but there didn’t seem to be anyone so we went back to the office. One doctor, who said she was a registrar, said that she wouldn’t mind me shadowing her but because of her position she has a lot of referrals and would therefore be spending quite a bit of time on the phone. I sat with her anyway and she explained that she had just seen a patient and was now writing up her notes. She showed me the chest x-ray which seemed to look quite normal but because the patient’s speech was ‘bubbly’, the patient was supposedly aspirating. This was all very interesting but the doctor said that she didn’t have very much else to show me so she paired me up with another doctor who came in the office.
This doctor was a first year Junior Doctor and I learnt more from her in 5 minutes than I felt I had in the entire week. She was incredible but she was also an excellent teacher. She asked me what I wanted from the experience and she quizzed me as we went along- it was so much fun. She was about to see a patient who had fast AF and she gave me the patient’s notes to read; she then asked me what I thought might be strange and I asked whether the oedema in her legs was caused by the fast atrial fibrillation. This was correct and she explained to me why that was the case by drawing a little sketch of the two circulations (systemic and pulmonary). Because AF reduces the heart’s pumping capacity, fluid can build up in the legs.
We then went to go and see the patient and the doctor examined her thoroughly. She asked the patient if she wouldn’t mind me listening to her heart and the patient said it was fine so I was able to listen to her fast AF using the stethoscope; it was amazing!
We then went back to the office so the doctor could write up her notes and because it took her quite a while, she gave me the BNF and told me to read up about warfarin. I read that it is an anticoagulant that prevents the blood from clotting and is commonly prescribed to those who suffer from DVT, PE and AF. I also read that patients with a mechanical prosthetic heart valve are also given warfarin. Later in the day, the doctor tested me on what I had read and I asked her why it was that they were given the anticoagulant. She explained that because it is essentially a foreign object in the body, the patients are at an increased risk of an emboli and the warfarin therefore works to prevent this from occurring.
We then visited another patient who needed an ABG (arterial blood gas). The doctor asked me why I thought these were done instead of just taking blood from the cannula and I suggested that it was because there was a higher concentration of oxygen in the blood in the arteries. This was correct and she explained that it tests the concentration before the oxygen enters the body tissues- it is a more accurate indication. After it was taken, I had to hold the patient’s artery with pressure and the results showed she had low oxygen levels so we increased the concentration of her oxygen mask.
Afterwards, we went to lunch and for the first time I was able to sit in the doctor’s mess. Everyone else in there was a Junior Doctor and they spoke to me about what I wanted to do in terms of University and what I had done as work experience. There was such a variety as one doctor went to Cambridge, another to Nottingham and another to Peninsula. It just showed me that the University doesn’t matter as much as the person and their interest in the course; if they are willing to work hard and become a great doctor, then nothing can get in the way. One doctor did tell me that she went to Nottingham and found that the BMedSci course (which I did not know a lot about) was useful for her when acquiring an FY1 placement. It was really interesting and I still stand by my view that for an aspiring medical student, Junior Doctors are the best people to shadow!
As we were walking out of the mess, the doctor was speaking to me about how she found medicine as a career and she said that every single little thing that they do as doctors, no matter how insignificant it is to them, can affect the patient in a massive way. She said this as, in the mess, one doctor said that she sometimes fed her patients when it looked like they needed it and the doctor I was shadowing agreed with her whereas others thought that was strange. Personally, I would like to think that I would be the kind of doctor to feed my patients when they needed it or even talk to them if it looked like they needed someone to talk to.
After lunch, the last thing I did on my placement was attend a Mortality and Morbidity meeting. This was a meeting of a few of the doctors and senior sister who were involved with the AMU and they were discussing why some of the patients had died in the last month or so and what they thought, if anything, they could do or could have done to prevent this. It was very interesting and the whole team worked efficiently together to try and find any faults in their system to see if they could improve it in any way.
The entire week was an amazing experience and I am so glad that I applied for work experience there; it gave me an insight into many of the different areas of the hospital and confirmed to me that I am certain that I want a career in medicine.