IMGs work experience in Acute Medicine (AMU)

¬By Abeera Khan

Acute Medicine is a specialty concerned with the assessment, diagnosis and treatment of adult patients with urgent medical needs. Acute Medicine is distinct from Emergency Medicine (A&E), although specialist acute physicians often work in close collaboration with specialists in Emergency Medicine. In the NHS hospitals, both departments work side by side.

There can be different names of Acute Medical Unit in different hospitals like CDU (Clinical Decision Unit) or AAU (Acute Assessment Unit). AMU is a short stay unit where patients stay for a maximum of 72 hours. They are then transferred to respective wards (Gastro/Respiratory/Care of Elderly or else) depending upon their line of management, transferred out of Trust if needed or discharged home direct from AMU.

If you have worked in the NHS, you must be familiar with the breech time in A&E. The NHS Constitution sets out that a minimum of 95% of patients attending an A&E department should be admitted, transferred or discharged within 4 hours of their arrival. However, on the floor, it’s not practically possible many a times due to number of reasons (huge influx of patients, understaffing in A&E at various shift times, blood tests and other results, shortage of beds in the hospital especially during winters/weekends and many more). However, trusts do their best to reach this target.

When the patient comes to the A&E, he/she is stabilised and then transferred over to the Acute Medical unit (if the patient is undergoing medics). The AMU is a team led by Consultants, on call Registrar, on-call SHOs (CMTs, GPSTs, Trust grade, FY1/FY2), Advanced Nurse Practitioners and the base team of AMU. In my previous Trust, we had 3 SHOs who were AMU based. The Consultant can be an Acute Physician or from a sub-specialty.

AMU also receives urgent admissions from GPs, patients from chemotherapy unit for suspected neutropenic sepsis, from Ambulatory care and Outpatient department.

Aim/Purpose of AMU:

The basic aim of AMU is to assess the clinical condition of the patient, follow up pending blood and Radiology results, start appropriate line of treatment, request further tests if required, refer to sub-specialties for review, make a diagnosis and then transfer to ward/discharge home.

My experience:

I have worked as AMU based doctor for 06 months. Around 80-90% of admissions are from A&E (roughly my statistics). The AMU team (SHOs/Reg) will review the patient, clerk, follow the pending investigations, do further tests (depending what the patient is coming in with), make a management plan and discuss with the Registrar and patient is then reviewed by the Consultant.

AMU ward rounds start at 08:00. This is called post-take ward round (PTWR) when the consultant reviews the patients admitted overnight. As there is constant influx of patients, so Consultants try to move patients to the ward if they need to stay in the hospital for few more days or discharge them home from AMU.

Example:

If the patient is admitted overnight with a mild/moderate acute attack of Asthma, had baseline investigations, CXR, ABGs, Nebulisers, steroids, antibiotics (if needed) and is now clinically stable, maintaining saturations on air and not needing Nebs, peak flow within normal range, he can be discharged home from AMU with a prescription.

After the ward round there is a handover in which the team goes through the patients and you write up on the board what further investigations need to be requested for each patient, any referrals to be made to specific teams or subspecialties within the hospital, TTOs( discharge letters) to be done, any investigations to chase up or expedite, mostly with Radiology like CT scans/MR/Ultrasound. If any discussion need to be done with Consultant Microbiologist on call or any out of hospital referrals.

It is best to work as a team in AMU. After the ward round, we used to divide work like half of SHOs used to do the jobs mentioned above and 1-2 SHOs keep clerking new patients coming in. If at times there was a bed blockage and no movement is happening from AMU to the wards, we used to finish the jobs at AMU and 2 of us (SHOs) used to go to A&E with the on-call registrar and start clerking patients there in ED who are definite admission. This helps your night team if you are working on days as staffing at night is less as compared to full day team. The same we used to do at night shifts too.

Common cases encountered in AMU:

There is a broad spectrum of clinical work in AMU. The range of clinical problems encountered is very wide, which gives the work a great deal of variability and that’s what I like best, mixture of medicine and blended work.  AMU routine is tough on everyday basis, but I like continuity of work, so I thoroughly enjoyed my rotation. You would commonly see,

Headache (Rule out Subarachnoid haemorrhage). Would have had their CT Brain from ED and would get LP in AMU.

Asthma

Acute exacerbation of COPD

Chest infection/ Pneumonia

Acute Kidney injury

Overdose (most common- Paracetamol)

GI Bleeding

Acute flare up of Inflammatory Bowel disease (Crohns/Ulcerative Colitis)

Chronic pancreatitis

UTI in elderly causing delirium

Diabetic Ketoacidosis

Cellulitis

Suspected Pulmonary embolism

Neutropenic Sepsis

Suspected cauda equina (in my previous trust, it used to come under medics)

Anaemia requiring blood transfusion

CLD patients

Sometimes patients come in for pain management, social admissions

 

What I learnt:

  • Best place to work as a team, constant support from fellow colleagues and Consultants
  • Clerk patients every day, make your own plan of management, discuss it with your Reg/Consultant and then mark it off as a CBD (case base discussion) and mini-CEX (Clinical evaluation exercise)
  • Do ACATs (Acute Care Assessment Tools)
  • Opportunity to do various procedures (Lumbar puncture, ascitic drain, pleural taps)
  • Good mix of cases keep you up to date

Overall, it’s a good learning opportunity and make the most of it when you are working in AMU (Well, that holds true for every rotation). Hope it helps.

My A&E Experience as Starting IMG

¬ By Abeera Khan

A&E is the front door of the hospital. A lot of IMGs think about picking up A&E as their first job as ED is on shortage occupation list and there are lot of vacancies in different trusts. It is commonly heard that ED job is very hectic at SHO level, and some people might tell you not to join ED as a first job. However, I can assure you that many IMGs have started it as their first job and they settled well with time. No matter where you start from, it would be difficult at first as this would be your first NHS experience.

I had many job rotations offers but I opted for A&E and AMU rotation for a year (06 months each). I worked in one of the busiest A&E departments in the North region which covers a very large population. We had an 8 bedded Resus, 15 bedded Majors with 4 Rapid Assessment Rooms, 6 in Minors/urgent care and a separate Paediatric area, fracture/plasters room and GP consultation room.

Yes, it is very overwhelming especially during winter months, but you need to understand that if its busy in ED, its busy in the medical and surgical departments too.

Watch this video to see how winter pressures affect NHS. BBC was given free access to the A&E of Royal Blackburn Hospital while I was working there last winters (2016-2017).

The best thing I like about working in A&E is a good mix of cases you see ranging from trauma (if the ED department is a trauma centre), acute medical and surgical conditions, orthopaedic emergencies (fractures), managing paediatric conditions, gynae cases to assess and then refer and common illness seen in minor area.

As a starter, it is the best place to practise ABCDE protocol. From the moment you start taking your history, you try to rule out differentials. If you have been out of practise, you will get hands on doing cannulations, blood sampling, ABGs, urinary catheters, suturing. As ED is constantly busy with rapid influx of patients, you can’t just sit and wait for the Nurses to come over and do everything for you.

There is a lot of senior support on the floor and they would always listen to you and guide you.

In urgent care/minor area, you can see, manage and discharge patients on your own if you are confident. If you are not, always consult with the Registrar.

Be very clear in your documentation. If you are not sure about reading X-rays (especially for fractures), don’t make your assumptive diagnosis. Always ask your seniors.

You can easily get your foundation competencies signed off if you are working well.

Yes, the job is hectic because it is constant brain storming. You see one patient, plan and then move on to the next. We could have a 20-minute break after 4 hours in an 8-hour shift. And two 20-minute breaks in 10-12 hours every 04 hours.

You develop good communication and referral skills when you deal with other specialties. Remember you are the one who has seen the patient and you know if patient is stable to be discharged or not. Treat the patient, not the Numbers.

Just to quote an example, I have had 5-year-old with extradural hematoma and midline shift (prompt History, examination, knowing NICE guidelines for CT scan, speaking to radiology Registrar and referring to Manchester Royal Infirmary all done in an hour) and then followed up with that patient post-surgery, reflected upon it on my portfolio.

The only thing I found hard was my Rota as there is a constantly changing pattern of shifts. You would do Standard days, long days, then twilight shifts (18:00 to 02:00, 18:00 to 04:00, 16:00 to 04:00, 12:00 to 00:00), night shifts. Be prepared for this as the ED rotas may be a bit maniac.

You can even follow up your patients in AMU/Surgical assessment Unit/Paediatrics later, as in ED you would manage the acute condition and stabilise the patient.

Another thing IMGs worry about is the portfolio. I would say that,

  • There is a lot of experience you can reflect upon in your portfolio while working in A&E.
  • You can get MSF from colleagues working at different grades.
  • You can get your CBDs and mini-CEXs signed off.
  • You can do audits while working in A&E.
  • You can get your foundation competencies signed off (I did after 04 months)

All the above things I have mentioned, I have got them all in 06 months rotation.

Only drawback I found was there is less of teaching as due to rotas, you tend to miss the teaching sessions. But then you can ask for a teaching presentation to deliver. You can always email the undergrad/postgrad department in your trust and they are always very helpful.

IMGs worry if working in A&E would help them in future or not especially when applying for training. The UK foundation trainees do get to rotate in A&E in their training as it is very essential. I applied for my CMT and GP training while in A&E and got offer for both.

I believe every work you do helps you and gives you experience and knowledge. I have a variety of background experience of working in general medicine, neurology, radiology, A&E, acute medicine, undergrad teaching and I have never regretted anything I have done so far as I feel I have learnt a lot from everywhere I have worked.

 

NHS Junior Doctor Working hours – What TCS 2016 bring

Lately there has been a reshuffle of terms and conditions as TCS 2002 have moved to TCS 2016 and got implemented across England by mid 2017 (yeah we envy you lot in Wales, Ireland and Scotland!) , though, new contract has been applicable to new junior doctors  joining NHS  and those who were already in NHS by mid 2016, have been given protection till 2nd August 2022 , then new TCS will be implemented across the board.

Some bullet points about TCS 2016 , in addition, to the requirement for all trusts, to have an assigned role of guardian of working hours for junior doctor, are following:

  • Max average of 48 hours work per week  –  Max weekly average across a rota reference period (up to 26 weeks).
  • Max 72 hours work in any 7 consecutive calendar
    days
  • 30 minute break for 5 hours work & a second 30 minute break for more than 9 hours (taken
    individually, or combined as close to the middle of
    the shift)

When it comes to Shifts duration and Rest:

  • Max 13 hour shift length Maximum individual shift length
  • Max 5 consecutive long shifts, at least 48 hours rest on conclusion of the fifth shift ( a shift means longer than 10 hours here) when you finish before 11:00 PM
  • Max 4 consecutive long daytime/evening shifts,at least 48 hours rest on conclusion of the fourth shift (thats when you finish after 11:00 PM but before 2:00 AM)
  • Max 4 consecutive night shifts, at least 46 hours rest on conclusion of the third or fourth shift
  • Max 8 consecutive shifts , NOT CALLS i.e less than 10 hours i.e normal working day length   (except low intensity on-call), at least 48 hours rest on conclusion of the final shift
  • If your on-call on a Saturday & Sunday contains less than 3 hours of work and no more than 3 episodes of work per day, up to 12 consecutive shifts can be worked
  • At least 11 hours continuous rest betweenrostered shifts

When it comes to weekend work, please note following:

  • Max frequency of 1 in 2 weekends can be worked across the rota cycle (thing of note here is ACROSS ROTA CYCLE meaning upto 26 weeks block, so you can be asked to do conscecutive weekends as long as its 1 in 2 across your rotation when averaged)

Please refer to following links for details and exception report violations and get to know who is the guardian of safe working hours in your trust. hope this helps

References:

 

https://www.bma.org.uk/-/media/files/pdfs/employment%20advice/contracts/junior%20doctor%20contract/junior-doctor-rota-rules-ataglance-guide-feb2017.pdf?la=en

https://www.bma.org.uk/-/media/files/pdfs/practical%20advice%20at%20work/contracts/jdrestreqs.pdf?la=en

http://www.nhsemployers.org/~/media/Employers/Documents/Need%20to%20know/TCS%202016_June%202016.pdf