Alfred the great

I arrived at the Alfred Hospital in Melbourne to find they had just finished filming the latest series of the hit Australian television show Medical Emergency. I knew that I was going to be undertaking my elective in a very special hospital.
 
The Alfred is a major tertiary referral centre situated in the Melbourne suburb of Prahran. For my eight-week elective I would be working in the emergency and trauma centre with some of the best doctors, nurses and surgeons in the country.

Top facilities

The purpose-built centre is designed to accept in excess of 50,000 patients a year and it boasts the following facilities:
Four trauma bays/theatres
Four patient resuscitation bays
 17 acute constantly monitored bays
Two psychiatric emergency assessment rooms
 14 non-life threatening emergency bays
 12 short-stay beds
Eight fast-track bays for minor injuries and surgeries
 A procedure room
 A plaster room

It also contains its own X-ray department, CT scanner and MRI machine - all accessible 24 hours a day.

The entire department is computerised and run from what is termed "the flight deck" situated in the middle of the department. All procedures can be ordered electronically, radiograph images viewed, results analysed and incoming emergency calls received. Communication with different departments all occurs from the flight deck.
 
At any one time the department is supervised by two consultant doctors, with one overseeing the acute bays and the other the trauma centre. Four specialist registrars work each shift and two junior interns also work in the department at any one time.

My consultant supervisor, Dr Mark Santamaria, spoke highly of the department and believed that, although there were still improvements to be made, it was the leading emergency department in all Australia. He had spent a couple of years working in the UK so was very helpful in explaining to me how the system in Australia differs to that of the UK.

Dr Santamaria preferred his students to be self-reliant and organised and believed my best chances of observing good medical conditions and practising my skills was to attach myself each day to a particular registrar. They were always more than willing to teach students.

There were four Australian medical students on the emergency team during the first few weeks of my elective and they were happy to show me the ropes too. I was also introduced to the other consultants, who were grateful for another helping hand on the team. I was invited to all of the meetings and lunches and was even invited along with the other students to the home of one consultant for dinner.

Dispelling the myths

After reading lots of information about electives in many of the medical guide books and on the internet, I was under the impression that most hospitals in Australia saw a different range of medical problems to those seen in the UK. I thought I would witness many presentations of malignant melanomas and all varieties of spider and snake bites.

During my eight weeks, however, I failed to witness any of these. Aside from the couple of patients presenting with cellulitis as a result of infected mosquito bites, many of the patients arrived with presentations often seen in the UK. The acute bays mainly contained patients presenting with episodes of chest pain or shortness of breath, and the protocols for dealing with each patient differed only slightly to those I was familiar with in the UK.
 
Throughout an ordinary day the trauma department received up to 20 cases, many of which were road traffic accidents. The Alfred has a helipad capable of housing four helicopters at one time and receives all trauma cases via air ambulance from the entire state of Victoria.
 
It was a real privilege watching the doctors work on some of the trauma victims and seeing how experienced they were. All members of the team were involved in decision making and the consultant in charge would ask for his or her team's input when required.
 
So, although I did not get to see some of the conditions that I was expecting, I believe I experienced very many real-life scenarios and medical emergencies.

Helping the registrars

A typical day would see me arriving in the department at 9am and meeting the consultant in charge that day. At this time, the trauma bays would often be full due to many road traffic accidents on the morning commute so I would stay by those bays and make myself available to the staff.

I would be allowed to gain venous access and take the bloods for all necessary tests while the doctors continued an ABCDE (airways, breathing, circulation, disability, everything else) approach to ensure the patient was safe. If the patients needed a CT, I would then follow them through to the scanner to observe the images.
 
When the morning trauma list had stabilised I would find a registrar and ask if there were any patients I could help with. The registrars would then often find me a patient on the computer who I then placed in an emergency bay. I would then take a full history, perform an examination and present the case to the registrar. I would form my own list of differential diagnoses and the series of tests to initiate later.

The registrar and I then discussed the case before he ordered the necessary tests. I would then cannulate and take bloods from the patient. I saw several patients throughout the day and followed their treatment through, which exposed me to many of the common presentations such as shortness of breath, chest pain, and headaches.
 
As the weeks progressed, I became more confident with my history taking and began to correctly suggest the next series of tests that were important. It was an amazing place to learn.

Learning not to panic

During one resuscitation I was asked to place a cannula and remove routine bloods for testing. There were some seven staff around the bed at the time, and I was very aware of the need to get venous access. I was also aware that I would be carrying sharps with staff nearby.

This was unfamiliar to me, however I knew there was no point in panicking as if I could not get the access there would be someone on hand to give me support. As it transpired, neither the registrar nor I were able to get venous access.

This was an important lesson to me and one I will not forget: knowing that there are others on hand if needed and that I should not be afraid to ask for help. As the weeks went on I became more and more confident in my abilities and knew I could cope under demanding situations in the future.
 
I was given the opportunity all day to practise cannulation, catheterisation, taking blood pressures, examinations and opthalmoscopy. I became so confident at doing such things that many of them simply became second nature. The fast-track department was an excellent place for this. These eight bays took patients who required minor treatment, presenting with a variety of conditions: lacerations, fractures, and foreign bodies.

Dr Santamaria would not allow me to arrive before 9am, or leave after 10pm, as he wanted to ensure his student found time to socialise. However, I tried to gain as much experience as possible and get to know the staff members.
 
Every Tuesday at 7.30am the registrars had a teaching session until lunch time. The entire postgraduate facility was fitted with top-of-the-range computers. All of the presentations were wirelessly controlled which made the teaching session interactive and flow well. Everyone was included and a quiz at the end of each session showed you how much you had picked up. It was an excellent teaching method and one to suggest to the undergraduate department back home.

Australian lifestyle

The suburb of Prahran was a small but very lively part of town. However, as a developed country much of the Australian lifestyle I experienced was very similar to that of the UK. Had I been in the outback, I would have expected a different variety of emergency medicine brought on by a different way of life.
 
The Alfred's emergency department did though include a hyperbaric chamber, used for patients presenting with extreme pressure disorders requiring high-pressure oxygen therapy, for example decompression sickness (the bends) or an air embolism.
 
This demonstrated the popularity of scuba diving and skydiving in Australia which necessitated such machines. However, I was not allowed to observe patients within this area for insurance reasons. I was also unable to go out with the air ambulance team.
 
I took the opportunity during some of my free time to travel to Adelaide. On another occasion I travelled to Sydney to see the sights, and I explored much of Melbourne's surrounding countryside. I met a few celebrities and travelled down the south coast to Torquay to experience some of the surfing waves of Australia.
 
Many people refer to Melbourne as a city with a "good vibe," and it is widely seen as having a good cultural mix, celebrating a variety of performing arts events, architecture and live music. Perhaps more famously, it is the sporting capital of Australia and is the spiritual home of Australian Rules football. I thoroughly enjoyed exploring some of the interesting buildings, unusual bars and world-famous sports venues.

A memorable elective

In conclusion, I will always remember the time I spent at the Alfred Hospital. The staff were keen to teach and as a result I had a fantastic experience. I increased my knowledge and improved my practical skills. The trauma and resuscitation bays were technologically advanced and it was an invaluable experience to observe it all in action. I hope to see similar equipment shortly in UK hospitals.
 
At the end of my placement Dr Santamaria and I discussed my time in Australia and we both concluded that I had an excellent time here and learnt a lot. From an educational point of view this is an excellent elective for future students. The hospital is one of the best in the world and it is a real privilege to obtain a place there.

I would highly recommend this placement to everyone!

This guidance was correct at publication 22/04/2009. It is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.

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