Paediatrics - Hospital Placement Reviews

I am back with another hospital placement review! I am a third year student now and we have to do five weeks of out-of-ambulance placement this year, which includes paediatrics! I was placed in the children's assessment unit at my local hospital, here is what I saw, found and learnt!

Background
I contacted my placement provider two or three months before I was due to start placement, about a month in advance, the lady who is the student coordinator sent me the dates that she was working that week so that I would definitely be placed with her. She gave me Monday, Wednesday and Saturday which was a little odd as I am used to working consecutive days, however it was actually really helpful as on those days off I was able to work and catch up on life things (and sleep as I had just come off Scout camp and was completely exhausted). I arranged for my boyfriend to take me in on his way to work because hospital parking is always a total nightmare for staff, and really expensive for patients.

The Children's Assessment Unit (CAU) is a short stay unit where paediatrics can be referred to by A&E or their GP, and some acute and chronic patient's can have open access (for a few days or the whole time they are receiving treatment for their condition) where they can call the nurse to discuss their concerns, and if appropriate, can be accepted onto the unit. The point of this is so that patient's can be seen quickly and and have a decision made so that less children are kept in hospital when they do not need to be, the staff try to effectively treat paeds in the community where they are less stressed and scared (traumatised) and the parent's can live more normally around work and other children (especially those who have children with chronic conditions as they are constantly in and out of hospital).

At the particular hospital I was in, CAU works very closely with elective care where paeds come in for elective operations (eg tonsillectomies) or treatments (eg blood transfusions). Through the next set of doors was the children's ward so it was not far to transfer patients into the ward if necessary. A&E also work really closely with CAU as they refer patients into the unit, and they can share staff, so if one is really busy the other will send staff across to support to ensure the best patient care. The nurses and doctors based in paeds respond to cardiac arrest calls and trauma calls to support the staff either in CAU, the ward or in A&E.

Day 1
I, a very tired student paramedic, woke up at 5am to get to my hospital placement for 6.30am to give myself time to get stuck in the staff traffic (hospitals are always really busy on changeover as there are lots of doctors, nurses and HCAs all coming and going!) and to find where I was going as I had never been to the ward before (and this hospital does not seem to have an online map). I found the department and rang the buzzer (I was let in immediately due to being in uniform) and found a nurse at the nurses station who showed me the locker room and staff room. As it is a far smaller department than the other ones I have been placed on or worked on, handover was on the ward rather than a big, generic one in the handover room. The night nurse discussed the patients who had been brought in overnight and any patient's who had called for advice or said they were coming in.

I met my supervisor, a junior sister with over 13 years of experience in paeds. She was really lovely and gave me a tour of the whole unit (CAU, elective care and inpatients) and we also went down to A&E whilst it was slow so I could meet the staff down there (which was good as it is the hospital that I normally bring my patients into, so it was nice to properly meet them). We went back to our unit and I watched her do some of her managerial work and speak with parents on the phone, either accepting them to the unit or signposting to the correct services.

There was a safeguarding problem with a young baby who had been sent home 12 hours before our shift started which arose just after we started our shift, so we spent a long time discussing paediatric safeguarding in general, and this patient in particular. I watched the process where my mentor contacted and discussed the situation with the relevant teams on a need-to-know basis and saw what they put in place to protect the family.

We had a patient brought in with glucose in their urine after presenting to the GP with tiredness, recent rapid weight-loss, increased thirst and urine output. We took some capillary bloods for this patient (reducing the number of patient's we subject to venepuncture) and I was tested on levels of different things found in the blood by my mentor, where I was able to diagnose diabetes (which was not surprising by the patient's presentation). This was quite emotional as the family had an idea of what the diagnosis could be, but did not want to believe it without adequate evidence, and once we had done that the rest of their day was very overwhelming, including a stay on the children's ward, and a long time with the specialist diabetic nurses who were teaching him how to test, read, calculate and inject. Fortunately for this patient, their diabetes had been picked up early so concerns that he could be in diabetic ketoacidosis (DKA) were ruled out by the blood results. I learnt that early diagnosis and treatment of diabetes can save them from longer stays in hospital and more damage to their body.

The rest of the day was spent taking and recording observations on babies who were referred to the unit and watching history taking from the nurses. I had a really interesting first day and was looking forward to the second day! The whole unit were really friendly, including the doctors, and I was able to observe and learn quite a lot from this day including paediatric distraction tactics, normal observation ranges and more specifically about fluids, paeds and DKA.

Day 2

I had a day off between day 1 and day 2 which was appreciated as 12.5 hour shifts are especially tiring when you are out of your comfort zone. I have no issue with 12 hour (plus overtime) ambulance shifts but hospital placements seem to be a lot more full on (or mind-numbingly dull) which make them much more tiring. The days in CAU generally start out quite slow as patients are generally referred in my GP and most GPs are closed overnight, so there are a lack of patients from 7am to 11am, when it then starts to pick up. Whilst it was slow, we went down to paediatric A&E because a trauma call came through to the doctors on our unit. The call was for a young girl who was hit by a car on the way to school, she hit and rolled off the bonnet, closely missing the windscreen and banging her head on the floor. I wrote up the necessary information on the board before she arrived, including all information in case of cardiac arrest which is protocol for the department, which helps to reduce human error if the worst occurs. The ambulance crew boarded her and brought her in, and after some checks the doctors were able to remove immobilisation. After helping with checks, we went back to our unit to help find her some pjs due her school uniform getting wet due to the rain and left her for final checks in resus before she was moved into the paediatric ward for observations due to her head injury.

By the time we got back to CAU, a few patient's had been referred in by their GPs. When they arrived I did observations and started filling out history taking, which includes who they live with and social services involvement. Most of these patient's were those fighting infection which is what a lot of CAU's workload involves over winter. We saw quite a few babies and young children which chronic conditions including different cancers, hepatic impairment and cardiac/respiratory problems. We also saw a few premature babies who are more susceptible to malaise than full-term babies. I watched the nurses suction mucous from the babies noses, after giving nebulised salbutamol to loosen it, which really helps to improve their breathing. We saw two babies who had high infection markers and were clearly very unhappy with chesty coughs. After the assessment from the doctors I helped to take them down to x-ray where their mum's helped to position them for imaging. It was quite difficult as these babies were already immuno-compromised before developing an infection, so the nurses had to time taking them down to x-ray so they were around the least amount of sick people as possible. Both x-rays showed pneumonia so the babies were put on IV antibiotics quickly and were admitted onto the ward for further observations.

I also went down to paediatric A&E to see a baby who had been dropped on their head (on concrete) the previous day. The parents noticed the swelling to the head, including the fontanelle. I followed this baby through to the CT scanner, where there was some cranial swelling however it was hard to establish the extent of the swelling. The baby did get admitted into the paediatric ward after some further observations and actually ended up in the high dependency unit.

What is quite good about this placement is that because the units are so close together you can see the transfer of patients into the wards and see if they go home or if they stay in and what happens to them. Unfortunately because my shifts were quite spread out, I did not always get to see what happens but I got to see most of their journey. Again, another interesting day learning about immuno-compromised children, respiratory infections and head injuries in different ages of paediatrics.

Day 3

Again, today started out quite slow especially as it was a Saturday and the huge flaw of the NHS is the lack of doctors appointments at the weekend. This can be noticed as early on Monday's there are normally an influx of children in the unit either in the early hours, when parents cannot wait any longer for the doctors to open on Monday morning, or as soon at GPs open and start referring patients through the doors.

Paeds A&E called up to the unit asking for some support from the CAU staff as they had premature twins brought in, one with a bit of a cold. They were concerned as there was only one nurse working and if any other patient's were brought in then it could become problematic. When ambulances bring paeds in, there is a warning as nurses can know what they are being brought in with, or if they are critical then they will be pre-alerted in. When paeds are brought through the front doors by parents, this can really change the game as triaging can identify a very sick baby, and the nurses do not have any warning. This is what happened with these twins.

Twin 2 was quite unwell, with extended periods of apnea (stopping breathing) especially when he relaxed. The baby was apneic for up to 30 seconds at a time and was mottling alongside this. The baby was not rousing during cannulation either causing quite some concern, and we moved them into resus. Twin 2 was put onto babytherm and it was decided that rather than intubating in resus, he would be moved up to high dependancy and onto humidified oxygen. During this time, Twin 1 was being checked over, and though he was showing some signs of infection he was not as sick as Twin 2.

Once the baby was put onto the humidified oxygen, he just gave up with his breathing. This happened because he was not having to work for the oxygenation, so the apneic events were happening a lot more frequently. As he was not having to breath for the oxygen, this also meant he was not breathing out, causing increased CO2 levels and other complications. The baby was diagnosed with bronchiolitis, where the peak of the illness is normally day 5, and he was on day 2, so was going to continue going downhill before getting better. We then transferred the baby from the ward, up to intensive care (another trek across the hospital) where he was intubated. The intubation process involves a lot more hands on deck that when we are on the road! There were consultants, registrars, anaesthetists, adult ITU nurses, paediatric nurses and the crash team (for really sick patients who help to manage cardiac arrests). Once the baby had been intubated, the Children's Acute Transport Service (CATS) were booked as the hospital I was at do not have the capacity to care for an intubated baby for extended periods of time. ITU do not have paediatric nurses, so my mentor was tied up in ITU until CATS arrived (which only took 2 hours, but can normally take a lot longer), and as the equipment in ITU is different to that in other wards, a trained ITU nurse had to be with the patient at all times alongside the paediatric nurse. The nurses have to prepare all the drugs ready for CATS, so for the couple of hours after intubation, we did not stop until we handed over to the team. The team were great, very knowledgeable, calm and interesting to talk to. Once we handed over, they would then spend an hour or two swapping all of the syringe drivers with their own and putting the baby onto their equipment.

We went back to the ward and had our lunch. We started with the baby at about 8am and left ITU at 3pm, so most of my day was tied up with this. After lunch, I worked alongside a doctor, assessing a child with history of coeliac disease with new onset stomach pain and vomiting. The doctor was great to work alongside, he discussed abdominal assessment and tests with me, and we identified potential diagnoses using test results to rule in or out. He was probably one of the best doctors that I worked alongside on my placement, he had respect for me (as I did for him) and we discussed things thoroughly, with him explaining anything that I did not understand in more depth. Over my three days on CAU, the doctors that I worked alongside were so much more open to working with me and educating me than any doctors I had worked with on adult wards. This was also my first time on wards at this hospital, and I am aware that morale is higher here and the staff get on better than other hospitals and wards I have worked on.

As I had plans in the evening with my Scout Group (no crazy nights out!) and the day had been quite slow, I was able to leave early which was agreed by my mentor. My third and final day was tiring, but very interesting, emotional and rewarding!

Conclusion

I had a great week on placement in Paeds. I was really lucky with my supervisor who was a gem (especially after other hospital supervisors I have had)! It is really easy to get involved with patient care in paeds, getting stuck in, smiling and speaking to patient's and their parents/carers is the best way to go! If you are worried about parents not wanting you to observe you can change this by showing that you are helping, by taking observations and generally helping out. I always stepped out on anything sensitive (for example I saw a patient who had ?testicular torsion) because as a scout leader and swimming instructor in the area, I do not want to awkwardly end up with one of these children. Obviously if I was on the road this was different, however if it is unnecessary then I offered to step out to stop any parents feeling awkward (and myself in future situations). The paediatric nurses seem much more proactive than any adult nurses out there, and really know their stuff!

Other things to consider: bring a thermal cup with proper lid! It makes lots of sense but I did not think about it until I got there as you are not allowed normal mugs on the ward (parents are not either). Pick up leaflets about paediatric conditions, or ask your supervisor for their suggested reading: kids are different to adults, take any free learning opportunities available! Take your JRCALC, nurses know all the normal and abnormal observation ranges off the top of their head, you probably do not so you can check them, especially if left to your own devices when history and observation taking! Finally, enjoy it and try to make the most of it - the more you get involved, the more the staff are going to want to help you. I think this is a really valuable and there is a lot to take away from it!

Read the others in this Hospital Placement series!
Acute Medical Unit
Maternity
Community Mental Health Placement - Prosthetics
Cardiac Intensive Care
Paediatrics


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