My experience of working in AMU
The acute medical unit is a ward where patients are admitted via GP's, the emergency department and ambulatory care.
Patients usually stay here for 24 to 48 hours and then either discharged or transferred to the specialist wards as they need input from teams.
COMMON CASES
CNS:
https://omarsguidelines.blogspot.com/2019/06/my-experience-of-working-in-neurology.html
Meningitis
Headaches
Epilepsy/first fit
Strokes - which can be missed sometimes or if there is no bed on the stroke unit.
Brain tumor
Spinal cord compression
Papilloedema
Myasthenia
Mental health:
Overdoses
Transfer from mental health facilities for management of medical conditions.
Endocrinology:
DKA
HHS
Thyrotoxicosis
CVS:
Myocardial infarction.
Endocarditis
Chest pain with negative troponins and D dimer.
Pericarditis
Respiratory
Asthma exacerbation
COPD exacerbation - infective or non infective.
Pneumonia
Plueral effusion
Pneumothorax
Lung Cancer
GIT :
https://omarsguidelines.blogspot.com/2019/03/my-experience-of-working-in.html
Upper GI bleeds
Lower GI bleeds
Loose stools ? infective /?inflammatory
IBD flare up
Alcohol withdrawal
Spontaneous bacterial peritonitis
Decompensated chronic liver disease
Renal:
https://omarsguidelines.blogspot.com/2018/10/dealing-with-renal-patients.html
AKI
Anuria
Urinary retention
Urosepsis
Complications of renal transplant, haemodialysis, peritoneal dialysis
Acute elderly scenarios:
http://omarsguidelines.blogspot.com/2018/08/managing-elderly-patients.html
Falls
Delirium
Unable to cope at home due to being alone/lack of package of care, etc.
YOUR JOB AS A SHO
SHO ON CLERKING
http://omarsguidelines.blogspot.com/2017/05/guideline-for-on-calls.html
SHO ON AMU REVIEWS
These SHOs are usually based in AMU on a few months' placement ( 3 to 6 months). Their job is to review all the patients on AMU who have been seen by a consultant once they have been clerked ( ie they have been post taked).
Their job is pretty simple:
1. To review any sick patients. Usually the medical registrar on call, the AMU registrar and the consultant on AMU reviews are aware and see them as well. So you are well supported.
2. To ensure the patients who have investigations pending ( ie CT head, CTPA, repeat U and E's, repeat bloods for patients who have infections, etc)
3. To do bloods if they have been requested after the phlebotomists have been, difficult to bleed patients and if the nurses are too busy ( They usually are as there is a high turnover in AMU). Also cannulating patients.
4. Doing procedures like ascitic taps, drains (unless the patient has been taken over by the Gastroenterology team ), lumbar punctures, NGT insertions, ABGs, etc.
5. Doing discharge summaries.
AMBULATORY CLINICS
SHOs on AMU placements may also be asked to do ambulatory clinics where patients who are safe enough to mobilize but need to be seen on the same day by an ambulatory consultant. These patients are usually accepted by the consultant on call for the ambulatory unit.
Cases include:
1. Cellulitis- these patients meet a certain criteria for a single dose of IV antibiotics which varies from trust to trust and then they come the following day for a review, then again the 3rd day for a review and step down to oral antibiotics.
2. DVT and PE- again, these patients meet a certain criteria.
3. Chest pain with negative troponins.
4. Other cases which GPs are concerned about but do not warrant urgent admission.
These clinics are an excellent way to get the mandatory clinic requirement met. You learn a lot and see and present patients to a consultant who has the time to listen to your history and you can even get your other assessments ( like case based discussions, mini CEX, etc signed off).
WHY SHOs SHY AWAY FROM AMU:
After ITU and the RESUS room in the emergency department, AMU has the sickest patients.
It can be highly stressful initially but then it is an excellent learning opportunity once you get used to how the AMU works. It is highly satisfying too as quite a significant proportion of patients get better within 24 to 48 hours and walk out of the AMU.
The SHO is expected to multitask. Because there are more nurses, there are more jobs. You may be asked to cannulate bed 1, ask to review bed 4 who is EWSing at 8, ask to prescribe IV fluids for a patient in bed 8 who is nil by mouth, do a discharge summary for a patient in bed 15 for whom transport has been booked in 30 minutes, catheterize a patient in bed 20 who is retaining 700 ml, discuss the antibiotics regimen with the microbiology team for a patient in bed 30 who is C diff positive and has multiple antibiotic allergies, has an AKI and now has an aspiration pnuemonia. This list keeps going on and on.
Now this seems very challenging, but you learn how to delegate tasks and prioritize tasks.
In the above scenario, this is how I would prioritize my jobs:
1. I would start seeing bed 4 who is EWSing at 8, ask the nurse to bleep the registrar and critical care team. If I do not see/escalate this patient, (s)he will DIE!
2. I would ask the nurse in charge to see if there is any nurse who is free enough to catheterize bed 20. If not, I would request the ACP/PA/clerking doctors to help.
3. I would ask the nurse in charge to call the clerking doctors to help me with jobs - ie cannulate bed 1, prescribe fluids.
4. I would ask the physician associate to start doing the discharge summary for bed 15 and if there are no new medications, I will read through it and sign it off if the PA is new. The ward clerk can post it to the patient.
5. Once I am done, I will call micro and then discuss bed 30 with them.
With the above scenario, all aforementioned tasks can be done within 30 minutes if you :
- Escalate
- Delegate
- Do not loose your cool.
This takes time. You make excellent friends this way. The nurse in charge respects you and helps you. Your hard work starts getting noticed and you develop excellent leadership qualities.
HOWEVER, things do go wrong - when there is no one to help. Even then, you learn to prioritize. The high EWSer in bed 4 should always be your priority. (S)he will die if you do not see him/her- And if you are in court, no one will care how many discharge summaries/cannulas you were asked to do. With prioritizing, you make a list of things to do. When you make a list, you remember what you have to do and what can wait. Even if you are alone, a skilled SHO can manage all of the above within 2 hours.
MY TIPS FOR AMU PLACEMENTS
1. Be proactive. Identify potential discharges and flag them to a consultant. You will learn which ones are medically fit after a few weeks of working in AMU. Prepare their discharge summaries in advance
2. Do not make decisions independently. If you have a sick patient, inform your registrar/consultant immediately. Start requesting the necessary investigations, do an A to E assessment. Also ask the nurses to inform the critical care outreach team - A group of ITU nurses who help support patients on the wards and can help facilitate transfers to ITU. There is always be someone to escalate to- your more senior SHO ( ie CT2 who is about to start his/her ST3 in a few months), registrar on call, AMU consultant, consultant on call, ITU registrar, critical care outreach team, specialty registrars and specialty consultants ( ie if it is a sick gastro patient, the gastro team can help) .
3. Respect your nurses! I cannot stress on this enough. They admit patients, have very thorough admission notes to put in, do MRSA swabs, update families, print out discharge summaries, discuss the discharge summaries with patients. They MAY NOT have time to do cannulas, take bloods. Therefore be kind and help them as a team member.
This blog post might help:
http://omarsguidelines.blogspot.com/2018/01/nurses-in-nhs.html
4. Try to be proactive to do procedures. Observe, assist, do under supervision, do under limited supervision, do independently, then teach others. LPs, ascitic taps, drains, chest drains, plueral taps, NGT placements, difficult ABGs, etc. This is your chance to practice as much as possible.
5. ALWAYS volunteer to do cannulas and bleed difficult patients. This skill will help you everywhere. You CANNOT get good enough. If you think you are good enough, start doing ultrasound guided cannulations rather than bleeping the ITU registrar.
6. Use this opportunity to get as many ACATs, CBDs, mini CEX's, DOPs, etc done.
7. Volunteer to do ambulatory clinics. You will learn how to direct patients ESPECIALLY if you are working as a GP.
8. Do a QIP- AMU is the best place to do it. There is always something you can improve on.
http://omarsguidelines.blogspot.com/2018/02/all-about-quality-improvement-projects.html
9. Give yourself a break. There will always be jobs to do on AMU. Always take time off for lunch and always pee.
10. There are loads of teaching opportunities- some trusts have weekly AMU teaching sessions, grand rounds,etc. There are always medical students and student physician associates who are eager to learn.
11. Love your team like your own family- everyone from domestics, ward clerks, HCAs, student nurses, nurses nurse in charge, critical care team, your colleagues, consultants, ACPs, physician associates, etc . And they will love you back. They will go beyond their comfort zone for you in ways you cannot imagine.
MY PERSONAL EXPERIENCE :
I came to the UK in January, 2016. I started working as a non trainee SHO in medicine. I started my on calls in 3 months after I started and I used to get confused. A consultant suggested that rather than going home and reading books, I should reflect upon the cases I have seen and read upon them from uptodate and NICE guidelines. This way, I quickly started enjoying my on calls as I knew what I was dealing with. I then started volunteering for extra locums on AMU. I became confident in dealing with sick patients.
In my core medical training, I became passionate about acute medicine. I wanted the AMU to be a ward where doctors felt they were learning, enjoying, were not stressed and made friends. I worked really hard on seeing as many patients as possible ( of course, safely. A patient can take anything like 30 minutes to 2 hours to review- PLEASE DO NOT RUSH). I started "acting up" and volunteered to see and manage sick patients. I started enjoying it so much that I decided to do acute internal medicine as my specialty training.
THE IDEAL AMU UNIT:
I have gone into this specialty to make a standard AMU setting across all trusts. This involves money and staff. Both of which are scarce. However there is no harm in dreaming.
REFERRALS:
All referrals from ED are taken by a registrar who is clerking ( there is a separate registrar for ward cover).
All referrals from GPs are taken by the ambulatory care consultant and AMU consultant.
STAFFING
There is a SHO WhatsApp group on which the rota team puts shifts out if there is any sickness. The locum rate is 50 GBP per hour. And this can go upto 60 GBP per hour when it is a bank holiday.
There is one SHO for AMU, 2 SHOs for clerking, one ACP for post take ward round jobs, 1 physician associate to help with cannulas, bloods, discharge summaries, etc and an AMU consultant who post takes patients as soon as they are clerked by a SHO.
TRAINING
SHOs get to discuss the patients they have clerked with the post take consultant - and this way, are able to get CBDs, ACATs, mini-CEXs signed off.
The location of interesting PACES cases are shared on a PACES WhatsApp group and the consultant supervises the candidates examine patients.
PROCEDURES:
There is a dedicated ultrasound machine in AMU which all SHOs are trained on how to use ( the ITU team can arrange sessions) to do USS guided cannulations.
There is a procedures tray with all the necessary equipment for a particular procedure. Ie a lumbar puncture trolley, an ascitic drain trolley.
The AMU SHO does all the procedures. If (s)he cannot do them, (s)he assists. No matter what level they are ( FY2, CT1, GPST1). This way, by the end of their AMU placement they can do all basic procedures.
TEACHING
There is dedicated weekly teaching on acute cases in AMU.
Morbidity and mortality meetings are held every month and the presentations are sent to all SHOs via work email if they are unable to attend them.
The AMU SHO has to teach medical students and physician associates. They have a set timetable.
There is a monthly simulation training on managing the deteriorating patient.
NURSING
There is one nurse per bay.
There is one HCA who can do bloods, cannulate, catheterize and do ECGs.
HANDOVER
There is a handover in the morning and evening. This is the norm. However there should be an AMU handover in which all sick patients, patients who need to be transferred to other wards, potential discharges are discussed. The AMU SHO leads it ( this way, learns leadership skills) and the consultants add in anything they may have missed. It is attended by the AMU MDT.
CLEAR PATHWAYS
There should be clear pathways for all acute emergencies which should be available on the internet. Juniors should be encouraged to print them out and tick off whatever they have followed in order to avoid any mistakes.
GET TOGETHERS
The AMU team ( domestics to consultants) do a monthly night out. These socials bring the team closer.
Overall, AMU is a lovely place to work in. I hope this blog post helps.
USEFUL LINKS:
https://www.uptodate.com/home
https://www.healthcareers.nhs.uk/explore-roles/doctors/roles-doctors/medicine/acute-internal-medicine
https://www.acutemedicine.org.uk/
Patients usually stay here for 24 to 48 hours and then either discharged or transferred to the specialist wards as they need input from teams.
COMMON CASES
CNS:
https://omarsguidelines.blogspot.com/2019/06/my-experience-of-working-in-neurology.html
Meningitis
Headaches
Epilepsy/first fit
Strokes - which can be missed sometimes or if there is no bed on the stroke unit.
Brain tumor
Spinal cord compression
Papilloedema
Myasthenia
Mental health:
Overdoses
Transfer from mental health facilities for management of medical conditions.
Endocrinology:
DKA
HHS
Thyrotoxicosis
CVS:
Myocardial infarction.
Endocarditis
Chest pain with negative troponins and D dimer.
Pericarditis
Respiratory
Asthma exacerbation
COPD exacerbation - infective or non infective.
Pneumonia
Plueral effusion
Pneumothorax
Lung Cancer
GIT :
https://omarsguidelines.blogspot.com/2019/03/my-experience-of-working-in.html
Upper GI bleeds
Lower GI bleeds
Loose stools ? infective /?inflammatory
IBD flare up
Alcohol withdrawal
Spontaneous bacterial peritonitis
Decompensated chronic liver disease
Renal:
https://omarsguidelines.blogspot.com/2018/10/dealing-with-renal-patients.html
AKI
Anuria
Urinary retention
Urosepsis
Complications of renal transplant, haemodialysis, peritoneal dialysis
Acute elderly scenarios:
http://omarsguidelines.blogspot.com/2018/08/managing-elderly-patients.html
Falls
Delirium
Unable to cope at home due to being alone/lack of package of care, etc.
YOUR JOB AS A SHO
SHO ON CLERKING
http://omarsguidelines.blogspot.com/2017/05/guideline-for-on-calls.html
SHO ON AMU REVIEWS
These SHOs are usually based in AMU on a few months' placement ( 3 to 6 months). Their job is to review all the patients on AMU who have been seen by a consultant once they have been clerked ( ie they have been post taked).
Their job is pretty simple:
1. To review any sick patients. Usually the medical registrar on call, the AMU registrar and the consultant on AMU reviews are aware and see them as well. So you are well supported.
2. To ensure the patients who have investigations pending ( ie CT head, CTPA, repeat U and E's, repeat bloods for patients who have infections, etc)
3. To do bloods if they have been requested after the phlebotomists have been, difficult to bleed patients and if the nurses are too busy ( They usually are as there is a high turnover in AMU). Also cannulating patients.
4. Doing procedures like ascitic taps, drains (unless the patient has been taken over by the Gastroenterology team ), lumbar punctures, NGT insertions, ABGs, etc.
5. Doing discharge summaries.
AMBULATORY CLINICS
SHOs on AMU placements may also be asked to do ambulatory clinics where patients who are safe enough to mobilize but need to be seen on the same day by an ambulatory consultant. These patients are usually accepted by the consultant on call for the ambulatory unit.
Cases include:
1. Cellulitis- these patients meet a certain criteria for a single dose of IV antibiotics which varies from trust to trust and then they come the following day for a review, then again the 3rd day for a review and step down to oral antibiotics.
2. DVT and PE- again, these patients meet a certain criteria.
3. Chest pain with negative troponins.
4. Other cases which GPs are concerned about but do not warrant urgent admission.
These clinics are an excellent way to get the mandatory clinic requirement met. You learn a lot and see and present patients to a consultant who has the time to listen to your history and you can even get your other assessments ( like case based discussions, mini CEX, etc signed off).
WHY SHOs SHY AWAY FROM AMU:
After ITU and the RESUS room in the emergency department, AMU has the sickest patients.
It can be highly stressful initially but then it is an excellent learning opportunity once you get used to how the AMU works. It is highly satisfying too as quite a significant proportion of patients get better within 24 to 48 hours and walk out of the AMU.
The SHO is expected to multitask. Because there are more nurses, there are more jobs. You may be asked to cannulate bed 1, ask to review bed 4 who is EWSing at 8, ask to prescribe IV fluids for a patient in bed 8 who is nil by mouth, do a discharge summary for a patient in bed 15 for whom transport has been booked in 30 minutes, catheterize a patient in bed 20 who is retaining 700 ml, discuss the antibiotics regimen with the microbiology team for a patient in bed 30 who is C diff positive and has multiple antibiotic allergies, has an AKI and now has an aspiration pnuemonia. This list keeps going on and on.
Now this seems very challenging, but you learn how to delegate tasks and prioritize tasks.
In the above scenario, this is how I would prioritize my jobs:
1. I would start seeing bed 4 who is EWSing at 8, ask the nurse to bleep the registrar and critical care team. If I do not see/escalate this patient, (s)he will DIE!
2. I would ask the nurse in charge to see if there is any nurse who is free enough to catheterize bed 20. If not, I would request the ACP/PA/clerking doctors to help.
3. I would ask the nurse in charge to call the clerking doctors to help me with jobs - ie cannulate bed 1, prescribe fluids.
4. I would ask the physician associate to start doing the discharge summary for bed 15 and if there are no new medications, I will read through it and sign it off if the PA is new. The ward clerk can post it to the patient.
5. Once I am done, I will call micro and then discuss bed 30 with them.
With the above scenario, all aforementioned tasks can be done within 30 minutes if you :
- Escalate
- Delegate
- Do not loose your cool.
This takes time. You make excellent friends this way. The nurse in charge respects you and helps you. Your hard work starts getting noticed and you develop excellent leadership qualities.
HOWEVER, things do go wrong - when there is no one to help. Even then, you learn to prioritize. The high EWSer in bed 4 should always be your priority. (S)he will die if you do not see him/her- And if you are in court, no one will care how many discharge summaries/cannulas you were asked to do. With prioritizing, you make a list of things to do. When you make a list, you remember what you have to do and what can wait. Even if you are alone, a skilled SHO can manage all of the above within 2 hours.
MY TIPS FOR AMU PLACEMENTS
1. Be proactive. Identify potential discharges and flag them to a consultant. You will learn which ones are medically fit after a few weeks of working in AMU. Prepare their discharge summaries in advance
2. Do not make decisions independently. If you have a sick patient, inform your registrar/consultant immediately. Start requesting the necessary investigations, do an A to E assessment. Also ask the nurses to inform the critical care outreach team - A group of ITU nurses who help support patients on the wards and can help facilitate transfers to ITU. There is always be someone to escalate to- your more senior SHO ( ie CT2 who is about to start his/her ST3 in a few months), registrar on call, AMU consultant, consultant on call, ITU registrar, critical care outreach team, specialty registrars and specialty consultants ( ie if it is a sick gastro patient, the gastro team can help) .
3. Respect your nurses! I cannot stress on this enough. They admit patients, have very thorough admission notes to put in, do MRSA swabs, update families, print out discharge summaries, discuss the discharge summaries with patients. They MAY NOT have time to do cannulas, take bloods. Therefore be kind and help them as a team member.
This blog post might help:
http://omarsguidelines.blogspot.com/2018/01/nurses-in-nhs.html
4. Try to be proactive to do procedures. Observe, assist, do under supervision, do under limited supervision, do independently, then teach others. LPs, ascitic taps, drains, chest drains, plueral taps, NGT placements, difficult ABGs, etc. This is your chance to practice as much as possible.
5. ALWAYS volunteer to do cannulas and bleed difficult patients. This skill will help you everywhere. You CANNOT get good enough. If you think you are good enough, start doing ultrasound guided cannulations rather than bleeping the ITU registrar.
6. Use this opportunity to get as many ACATs, CBDs, mini CEX's, DOPs, etc done.
7. Volunteer to do ambulatory clinics. You will learn how to direct patients ESPECIALLY if you are working as a GP.
8. Do a QIP- AMU is the best place to do it. There is always something you can improve on.
http://omarsguidelines.blogspot.com/2018/02/all-about-quality-improvement-projects.html
9. Give yourself a break. There will always be jobs to do on AMU. Always take time off for lunch and always pee.
10. There are loads of teaching opportunities- some trusts have weekly AMU teaching sessions, grand rounds,etc. There are always medical students and student physician associates who are eager to learn.
11. Love your team like your own family- everyone from domestics, ward clerks, HCAs, student nurses, nurses nurse in charge, critical care team, your colleagues, consultants, ACPs, physician associates, etc . And they will love you back. They will go beyond their comfort zone for you in ways you cannot imagine.
MY PERSONAL EXPERIENCE :
I came to the UK in January, 2016. I started working as a non trainee SHO in medicine. I started my on calls in 3 months after I started and I used to get confused. A consultant suggested that rather than going home and reading books, I should reflect upon the cases I have seen and read upon them from uptodate and NICE guidelines. This way, I quickly started enjoying my on calls as I knew what I was dealing with. I then started volunteering for extra locums on AMU. I became confident in dealing with sick patients.
In my core medical training, I became passionate about acute medicine. I wanted the AMU to be a ward where doctors felt they were learning, enjoying, were not stressed and made friends. I worked really hard on seeing as many patients as possible ( of course, safely. A patient can take anything like 30 minutes to 2 hours to review- PLEASE DO NOT RUSH). I started "acting up" and volunteered to see and manage sick patients. I started enjoying it so much that I decided to do acute internal medicine as my specialty training.
THE IDEAL AMU UNIT:
I have gone into this specialty to make a standard AMU setting across all trusts. This involves money and staff. Both of which are scarce. However there is no harm in dreaming.
REFERRALS:
All referrals from ED are taken by a registrar who is clerking ( there is a separate registrar for ward cover).
All referrals from GPs are taken by the ambulatory care consultant and AMU consultant.
STAFFING
There is a SHO WhatsApp group on which the rota team puts shifts out if there is any sickness. The locum rate is 50 GBP per hour. And this can go upto 60 GBP per hour when it is a bank holiday.
There is one SHO for AMU, 2 SHOs for clerking, one ACP for post take ward round jobs, 1 physician associate to help with cannulas, bloods, discharge summaries, etc and an AMU consultant who post takes patients as soon as they are clerked by a SHO.
TRAINING
SHOs get to discuss the patients they have clerked with the post take consultant - and this way, are able to get CBDs, ACATs, mini-CEXs signed off.
The location of interesting PACES cases are shared on a PACES WhatsApp group and the consultant supervises the candidates examine patients.
PROCEDURES:
There is a dedicated ultrasound machine in AMU which all SHOs are trained on how to use ( the ITU team can arrange sessions) to do USS guided cannulations.
There is a procedures tray with all the necessary equipment for a particular procedure. Ie a lumbar puncture trolley, an ascitic drain trolley.
The AMU SHO does all the procedures. If (s)he cannot do them, (s)he assists. No matter what level they are ( FY2, CT1, GPST1). This way, by the end of their AMU placement they can do all basic procedures.
TEACHING
There is dedicated weekly teaching on acute cases in AMU.
Morbidity and mortality meetings are held every month and the presentations are sent to all SHOs via work email if they are unable to attend them.
The AMU SHO has to teach medical students and physician associates. They have a set timetable.
There is a monthly simulation training on managing the deteriorating patient.
NURSING
There is one nurse per bay.
There is one HCA who can do bloods, cannulate, catheterize and do ECGs.
HANDOVER
There is a handover in the morning and evening. This is the norm. However there should be an AMU handover in which all sick patients, patients who need to be transferred to other wards, potential discharges are discussed. The AMU SHO leads it ( this way, learns leadership skills) and the consultants add in anything they may have missed. It is attended by the AMU MDT.
CLEAR PATHWAYS
There should be clear pathways for all acute emergencies which should be available on the internet. Juniors should be encouraged to print them out and tick off whatever they have followed in order to avoid any mistakes.
GET TOGETHERS
The AMU team ( domestics to consultants) do a monthly night out. These socials bring the team closer.
Overall, AMU is a lovely place to work in. I hope this blog post helps.
USEFUL LINKS:
https://www.uptodate.com/home
https://www.healthcareers.nhs.uk/explore-roles/doctors/roles-doctors/medicine/acute-internal-medicine
https://www.acutemedicine.org.uk/
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