*taps mic*
Is this thing on?
My name’s Zack and I’m one of the new takeAIM fellows this year. This is the first of what I hope will be many blogs about life on the Acute Medical Unit (AMU). I’m hoping they’ll give those of you interested in a career in Acute Medicine an insight into what it’s like to work in what every acute physician considers the best specialty going.
If you’ve ever worked with a career acute medic, I hope you were struck by their boundless enthusiasm for a field that is often poorly understood. Juniors are sometimes puzzled by my decision to pursue a career on AMU. I think that’s because of the (sadly very common) misconception that Acute Medicine is all about being on-call: a frantic cocktail of endless bleeps and anuric ward cover that no one would enjoy.
And that’s just not true!
So this first blog is about what an ordinary (non on call) day shift looks like for me. I currently work as an ST5 registrar at a friendly DGH in West London. We have a reasonably big unit – with over 60 beds – but are usually reasonably well-staffed with consultants and junior doctors. My colleagues are supportive, laid back and good fun to be around. Most days, I look forward to going to work.
Our day begins at 08:30 with morning handover. The night reg will run through patients admitted over the last 248 hours and flag up anyone who’s been unwell overnight. I hate an unfriendly handover – no one likes being grilled about whether they sent paired osmolalities at 3am. Thankfully, our handovers are all about ensuring the night team have handed over everything they need to and that they go home ASAP with a clear head.
Once handover is complete, we’ll divide and conquer for the ward round. I’ll often be assigned to our Enhanced Care Area (ECA), the section of our AMU where we keep out sickest patients. This will include patients with severe sepsis, diabetic ketoacidosis or decompensated type 2 respiratory failure requiring NIV. The consultant and I covering this area split the patients between us.
It’s become a bit of a cliche (I’ve certainly said it enough in job interviews over the years), but the variety we see on an average AMU ward round is one of the real selling points of the specialty. Everything from bilateral pulmonary emboli with right heart strain to an unexplained acute confusional state; from a severe kidney injury in an otherwise healthy patient to a frail patient approaching the end of their life. The fast pace of the work we do means I’ll be meeting many of these patients for the first time. That rarely makes for a straightforward ward round, but why would I want to be bored?
It’ll take a few hours for us to see all the patients and come up with plans for the day ahead. If there is a particularly sick patient on ECA, they will be my priority. That often means bringing in other specialties: respiratory for the patient with the large pleural effusion, cardiology for the patient with pauses on their telemetry, gastroenterology for the sick liver patient, ITU for the patient on BiPAP whose gasses are getting worse… By this time in the year, I’ve made friends with almost all of the other registrars and that always helps.
At lunch time, we’ll have our board round. As with any acute hospital in 2024, our three priorities are discharges, discharges and discharges. We’ve got other pathways we can make use of, including our Ambulatory Care Unit and virtual ward. Many of our older, frailer patients may have issues we need to discuss with our therapies teams and this is a good opportunity to talk about that too.
After lunch, there are often procedures that need to be done: maybe a lumbar puncture or an ascitic drain. I’ll do these if I have to, but I’d much rather supervise one of our juniors. Seeing someone nail their first LP is just the best feeling.
I’ll also need to make time to update patients’ relatives. Sometimes this means having some really challenging conversations about patients who we’ve recognised as dying. These conversations can be tough, but getting them right can make a huge difference.
If I have some time in the afternoon, I’ll use it to develop one of my special skills: Medical Education and Point-of-Care Ultrasound (POCUS). For example, this year I ran the teaching program for third year medical students. So I might spend a chunk of my afternoon running a tutorial or supervising our students seeing patients on the unit.
Now that our students have finished placement for the year, I’ll more often use this time for my ultrasound logbook. I’ve completed my FAMUS accreditation (which is compulsory for acute med training) but enjoyed it so much I am now working toward my echo qualification. So if there are any patients on the unit in need of an echo, I’ll wheel our machine round, get some images and save them for my supervisor to review.
Obviously, the time to pursue these interests is a luxury. On a busy clinical day, it isn’t always available. We’re supposed to have time built into our schedules to pursue our special skill and my current bosses are brilliant at ensuring we get this. But it’s nice to integrate teaching and ultrasound into my clinical work too.
Toward the end of the afternoon, I like to find a quiet spot to sit and go through patients’ results and the events of the day in detail, to make sure I’ve not missed anything. Then, I tend to take a quick walk around the unit to make sure everyone’s on track to go home on time. As an SHO, I remember my threshold to phone the reg was a lot higher than my threshold to ask an opportunistic question when I saw them strolling by. I don’t like to go home unless I’m happy no one is struggling or on track to go home three hours late.
Once the day is done, I’ll jump in the car and dash off to collect my daughter from nursery. That’s when the real hard work starts…
Now that’s not every day. I have my on-calls and my days in Ambulatory Care, not to mention nights and weekends. But this is the kind of day I really like: variety, teaching, ultrasound… AMU always has a buzz to it and there’s always someone to have a laugh with. I’ve always liked that.
Hopefully that gives a little bit of insight into what our day job looks like, and why I still love it so much several years into my Acute Medicine journey. The truth is that no day is the same, but no day is ever boring.
What else can you ask for?