Over Easter, 2015 I spent four days on a Stroke Care Unit at Epsom Hospital, under the supervision of consultant Doctor Jha. The ward consisted of 19 beds: 15 of which were occupied by stroke patients and 3 medical patients who presented the most complex cases with multiple diseases and symptoms. Although, the majority of the work I encountered was observational-which is appropriate due to my lack of qualifications-I gained a significant insight into working in a hospital. The main thing that I noticed was the high amount of cooperation and teamwork needed in this setting. If you want a solitary job, this is definitely not the one for you. I was also surprised to find that by the end of the week, many acronyms and medical jargon had become so familiar to me.
The typical day in the ward for the junior doctors consisted of an early start to update medical notes on all the patients on the wards, in preparation for a departmental meeting and a review of each patient. The discussion involves a progress update from the night before and any changes to the social circumstances of the patients. After the departmental meeting, the hectic and busy ward round could begin. I was kindly advised by the junior doctors to have a large breakfast as this process can go on until 1pm.
Although the mental state of most of the patients on the ward was impaired due to conditions such as Dementia and Alzheimer’s, the consultant would try to communicate with them to assess their pain levels. The consultant would listen to the breathing of the patients and tap their back to assess their respiratory functioning and predict possible infections. For new patients a more thorough investigation must take place. For example, to identify whether a stroke has taken place the consultant may request CT scans or for more refined search, an MRI. They may also look into their cognitive functioning by asking simple questions such as “who is the Queen?”, “Who is the current British Prime Minister?” , and cross checking date of births with the age the patients claim they are. This was all done to help assess the damage to memory from a stroke. In order to identify tremors, which can indicate damage to the cerebellum, the consultant would get the patient to touch their nose and his finger. Junior doctors would rapidly assess the vital signs of the patient. These included the blood pressure, heart rate, body temperature, respiratory rate and oxygen saturation. I learnt that vital signs are a good indicator of the ‘wellness’ of the patients, especially for those who were unable to convey this verbally. Notes were profusely scribbled down in a characteristic doctor’s handwriting during the ward round. Junior doctors noted down the alterations to drugs and the scans to be ordered.
After a brief lunch break, it was the duty of the junior doctors to compile and complete the jobs for the day. The doctors would check the blood counts that had been taken by a phlebotomist on a previous day to examine kidney and liver functioning. Inflammatory markers such as the level of C-reactive proteins and white blood cells can indicate infection. The level of C-reactive protein should be less than 5 in a normal well person; however, as most the patients on the ward had multiple complications, often including cancer, it is essential for the doctors to work within their abilities to fight the constant infection. These infections could be verified by microbiological tests such as mid-stream urinalysis which can be cultured and identify the specific bacterial pathogen. Therefore, the infection can be targeted with specific antibiotics more effectively. Likewise, when we encountered a patient with very low haemoglobin levels in the red blood cell, blood transfusions could be requested to help reduce the patient’s fatigue. Whilst the majority of the doctors’ tasks consisted of paperwork there were occasional practical elements such as inserting cannulas and taking blood with an arterial stab. I observed that an arterial stab is a harder procedure than simply taking blood from the veins. As the arteries are located deeper within the body the doctors work from touch rather than visible directions. However, due to the pain caused and importance of the major blood vessels, it is usually less advocated by doctors.
What became apparent very quickly to me is the mountain of forms and paperwork which the doctors had to rapidly complete and that the actual everyday care of the patients was largely under the control of the nursing staff.
The support team
As I said before, the work experience highlighted to me the necessity for cooperation between professionals in this busy environment. I would describe the nursing staff as the backbone of the hospital, getting to know the patients better than the doctors. They play an essential role in minor practical tasks and deal with the patients immediate requirements.
The role of the occupational therapist is to restore the patient’s functional ability according to their varying levels of capability and required independence. On the stroke ward at Epsom hospital the patients are encouraged to make their own breakfast when capable. This is so that the journey from a passive GM tube to making and eating their own breakfast in the common room is a recognisable improvement in their functioning and increases the morale of patients. I attended a swallowing tutorial lead by an occupational therapist and I hadn’t appreciated that swallowing is one of the most complex tasks performed by the nervous system.
The junior doctors emphasized the importance of maintaining a good relationship with the Ward Clark. This essential communicator for the ward liaises with different parts of the hospital, often to chase up those critical scans or test results.
I thoroughly enjoyed my session with the speech therapist. We met with an old lady who was trying to regain her speech. I couldn’t help being amused when testing her cognitive functioning, she mistook a banana for a telephone. However, it was impossible not to feel sympathy towards the woman, as she was obviously frustrated by her inability to produce coherent words. The speech therapist tried many techniques such as singing ‘Happy Birthday’ and showing the woman photos of her family and loved ones to help trigger memories.
The other professionals I met included Physiotherapists, Pharmacists, Stroke care coordinators, Dieticians and a Discharge manager.
I encountered several thought-provoking events during my visit. Firstly, the ward was confronted with an issue where a man with dementia couldn’t be discharged because he had been rejected by several nursing homes, due to his aggressive behaviour and poor prognosis. This meant that he was taking up valuable room in stroke care unit. The question that arose is: should nursing homes be able to reject patients and exert further pressure on a strained NHS? Understandably the nursing homes wished to avoid taking in patients with a bad prognosis as it can demoralize staff and possibly lead to investigations into death records of patients. However, this delay in discharge presented a crisis in the understaffed hospital stroke ward.
Secondly, the most emotionally challenging encounter I witnessed during my work experience, was the death of a cancer patient. As a result of the circumstances, I was the only person available to console her only living relative, a spinster older sister. On my first day, the doctors explained to the patient’s sister that it was the ‘end of the road’ and that they were moving into a more palliative care plan. On the third day when I returned to the ward, there was an empty bed and a distraught sister. Although it was difficult to console her, I identified with her, as I myself am the oldest of three sisters. A cup of tea and someone holding her hand seemed futile when I knew she would have to return to her home that she had shared with her dead sister. The doctor’s detached approach seemed harsh but I realised that it was important for him to remain professional in order to deal effectively with such draining events on an everyday basis.
Disturbing sounds were everyday occurrence on the ward. For example, a woman was continually crying out in German and was not being understood as she had forgotten all her English due to her stroke.
My final impression
After talking with the consultant I have gathered that whilst there are long, hard hours working in a hospital and it seems there are a lot less emotionally challenging routes to gaining the same economic rewards, this altruistic profession can be incredibly fulfilling. That is, there are a lot easier ways to earn a living! Also, although not every case ends in success you get to deal with people on a daily basis and the job has a social and practical application of science, that can really make a difference to people’s lives.
Stroke information summary:
There are two types of strokes:
1) Ischemic. These are due to a blood clot, which causes a loss of blood supply to the brain. Without oxygen the death of cerebral cells occurs at a rate of 2 million per minute. This is the type of stroke most commonly encountered (85% of stroke patients). Blood clots are formed from the build-up of an atheroma, in a disease known as atherosclerosis. The atheroma can block an artery or break down producing fragments, causing a thrombus. If the clot develops in the heart it is known as an embolus. The brain cells could also be deprived of oxygen from an extremely low blood pressure.
2) Haemorrhagic. This type of stroke is also known as a brain bleed, and the symptoms presented can be more complex. The arteries near the brain burst causing an aneurysm , the leakage of blood into the brain. Bleeds are caused from the build-up of too much pressure in the blood vessels. High pressure can be a result of inflammation or infection and certain drugs that narrow the lumen of the heart.
During the time I spent with the consultant he discussed the potential risk factors for strokes which we can identify within the community. Number one, (no surprises here) was smoking, but also too high levels of red meat containing cholesterol and high blood pressure also have been recognised as a risk factor. After further research I found that genetic factors such as being male, over 55 years old, of African-American ethnicity and having a family history can also increase the risk.
The symptoms of strokes include: Loss of sensation, weakness, impaired vision, slurred speech, imbalance, loss of recognition and cognitive functioning. Damage from a stroke is viewed physically on the opposite side of the body to the location within the brain, apart from a stroke that has occurred in the cerebellum, where the symptoms would present on the same side as the infarction.
The diagnosis of a stroke can be confirmed usually from a CT or more sensitive MRI scan. The prognosis for stroke sufferers is not overwhelmingly positive, as around 20% of patient die in hospital. However, many patients can be rehabilitated at least to a level where they can regain the independence to live in a nursing home or with a full time carer. Some of the luckier ones return to their previous job. In Epsom hospital there is no onsite rehabilitation centre however, the patients are often referred to a smaller NEECH hospital once they are stable for transfer. The main role of the hospital is to provide medical assistance in life functions such as feeding through a GM tube and supplying oxygen to patients. Stroke care is a slow and gradual process, and it focuses on small improvements such as an increase in the thickness of the food a patient can tolerate.
Terms I have learnt:
Hyperkalaemia: a too high potassium level, which can have an effect on the heart rate.
Hypokalaemia: a too low potassium level. This may be due to loss of potassium from bodily fluids especially if the patient is being treated with diuretics. Potassium is essential for correct functioning of nerve and muscle cells.
Atrial fibrillation: an irregular or too fast heartbeat due to a lack of coordination of the ventricles of the heart, and can cause poor blood flow around the body.
- Tachycardia: a fast heart rate more than 100bpm
- Bradycardia: a slow heart rate less than 60bpm
- Dysphasia: difficulty or discomfort in swallowing.
- Endocarditis: swelling of the inner heart, or inflammation of the endocardium.
- Ascites: excess fluid in the abdomen, due to the accumulation of fluid in the peritoneal cavity.
- Pleural effusion: an infection in the pleural cavity, the space around the lungs. This build-up of fluid can impair breathing by limiting the expansion of the thorax.
- Refeeding Syndrome: Potentially fatal shifts in fluids and electrolytes that can occur in malnourished patients after receiving artificial refeeding.
- Thrombolysis: The treatment following a stroke to dissolve dangerous clots in the blood vessels to improve blood flow and prevent further damage to organs.
- Emetic: the adjective of causing vomiting.
- Beta blocker: a class of drugs which can control heart rhythm and reduce high blood pressure.