Galway University Hospital - Ireland
Jeremiah Eisenschenk, Spring 2011
Galway University Hospital Emergency Department
I choose to complete an emergency medicine elective in Galway, Ireland for a few reasons. Foremost, I'm of Irish descent and have long had a desire to explore my Celtic roots. My grandfather, a retired internist and my inspiration for choosing to study medicine, is a descendent of farmers whom once roamed the mountainous Connemara region of west Ireland. Part of my Ireland experience included tracing my ancestor's footsteps by hiking the Connemara highlands. Second, while I'm going to be a rural family medicine physician, I plan to include emergency medicine responsibilities in my future practice. Galway University Hospital A&E is the busiest emergency department in Ireland – the perfect place to maximize my exposure to emergency physical and social pathology. Additionally, I am interested in organic and sustainable agriculture. A one- week volunteer experience on organic farm on the Aran Island of Inis Mor was the ideal setting to expand my knowledge of this trade. Finally, since attending a Benedictine Prep School in Collegeville, MN I've been drawn to the simplicity and peaceful way of Benedictine monastic life. A visit to Glenstal Abbey will allow me to meditate and pray with monastic brothers, necessary time for introspection before the chaos of residency begins.
I began planning this rotation 6 months before it began. If you are seriously interested in this rotation, I advise planning early this as well. Please see Pearls To An Excellent Galway Experience at the end of this essay for advice and planning tips.
Reflection on my GMER Ireland experience
The morning after Match Day I hopped a flight to Shannon International Airport. A two- hour bus ride took me to my host family in Galway. After exploring the city for the weekend I was set to begin my UGH A&E rotation. (Oh yes, UGH = University Hospital Galway and, A&E = Accident & Emergency, equivalent to our Emergency Department). I first met Mr. Martin, senior physician and director the A&E, the morning I arrived to the Galway University Hospital A&E. After introductions, I began with many questions central to the objectives of my month-long rotation, "What is my shift schedule? How many patients would you like me to see? What weekends should I work? Who runs the codes? Can I draw my own labs?" A jolly, casual man with sharp sense of humor, Mr. Martin replied, "Lad, this is Ireland, not America. We are more laid back here. Slow your heart rate, we want you to have fun. Just put in your time and you hunger for emergency medicine will be fulfilled." Mr. Martin's wisdom could not have been truer. My goals of this rotation included exposure to emergency musculoskeletal cases (soft tissue injuries, fractures), assessment and treatment of eye emergencies (infections, foreign bodies), practice with reading radiographs (extremities, chest, spine), practice with venous and arterial blood draws, and, most importantly, a deeper understanding for and appreciation of the physical exam. Over the next four weeks these goals were accomplished as this elective evolved into one of my best medical school rotations.
Nestled in Galway County, Galway has a population of approximately 74,000 people, most descended from the native Gaelic peoples, with large immigrant populations from across Europe. UGH is the primary referral hospital for the western half of the country. UGH A&E, one of two emergency departments, and the only public A&E in Galway, is known for its ever-full waiting rooms and hallways packed with patients sleeping on trollies (small hospital beds) as they await placement on inpatient wards. The etiology of this multitude of patients is not rooted in the A&E Department itself, rather, less than appropriate government funding, especially amidst the recent Irish recession, has lead to the closure of multiple wards of inpatient beds. Less space in the hospital means that those needing admission from the A&E wait longer and thus those waiting to be seen in the A&E wait as well. Sometime during my first week in the A&E an intern approached me and said, half-jokingly, "if you get sick while you are in Galway, go to the private A&E across town because you'll wait days to be seen here."
While the long waits and chaotic lack of space are constant topics of conversation inside and outside the hospital, the quality of care and expertise of the A&E physicians are admired just as much. I was more than impressed by the intelligence, empathy, bedside presence, and confidence demonstrated by senior residents (referred to as registrars) and attending physicians (referred to as consultants). Taking full advantage of the teaching potential that lie within these excellent A&E physicians required me to be confident, persistent, competent, and independent. Thankfully these characteristics are now second nature as result of my RPAP experience. Starting on day 1 of this rotation I thought of myself as an intern rather than 4th year medical student. This mindset and opened doors to new learning opportunities, adding to the quality of my experience. Had I failed to present myself in this manner, I may have easily been lost amongst the chaos that is the UGH A&E.
My usual day began at 8:30 am. After tea with the A&E physicians I'd present to the A&E floor. Most of my time was spent in the "minors" area. Here my goal was to see at least ten patients a day. The A&E is spilt into "minors" and "majors" areas. Patients assessed as likely to be admitted by the triage nurse are sent to major while less severe complaints are funneled to minors. Minors, I discovered, is a garden rich with musculoskeletal, skin, and eye injuries. I'd typically interview and examine the patients, present them to the attending registrar or consultant, then order the appropriate labs and imaging. As often as possible I'd drawn blood samples from my patients. In fact, there is only one phlebotomist for the department, thus all interns and residents drawn there own bloods – while this is great practice, it adds to the inefficiency of the A&E system. I'd then review the results and imaging with the attending, provide my treatment plan, and write a brief note.
I attended noon A&E lectures with the UGH medical students. These lectures included excellent discussions ranging from head trauma, to acute chest pain, to burns. I was continually fielding questions on, "how is this done in the U.S.?" from medical students and staff so I decided to give a morning lecture to the department on "Physician Training in the United States." This was well received and appreciated by all.
I'd return to the A&E for the afternoon before heading off to an evening lecture with the UGH 5th year medical students. Medical school in Ireland is 5 ½ years, the last 3 years being primarily clinical. A few months prior to graduation all students have to pass the Clinical Exam. This daylong exam focuses on observed histories and examinations of multiple ward patients by senior physicians, and accounts for over half of one's overall grade for the year. I was lucky to be at UGH just prior to the Clinical Exam when the 5th year students were in full study mode. I read their Physical Exam and Clinical Diagnosis textbook then spent a few afternoons roaming the wards with them in search of interesting, and potentially testable, cases. We'd take turns conducting physical exams as physical exams should be conducted, sometime examining one patient's lungs for up to 30 minutes. As the U.S. medical system relies more on labs and imaging, the art of the physical exam, I feel, is gradually being lost. The emphasis placed on the physical exam at the University of Minnesota and other U.S. medical schools is pitiful compared how it remains honored in the British medical training system. I am grateful for the re- established respect and appreciation I have for the physical examination after my time at NUG.
A unique aspect of the UGH A&E is it's Minors Follow-Up Clinic. A&E physicians see patients with sprains, chronic wounds, eye injuries, lacerations, etc., 5-10 days after initial presentation. This provides an interesting setting for continuity of care not common to U.S. emergency departments. It was rewarding to see some patients three and four times over the course of my rotation. The unfortunate side to Minors Follow-Up Clinic may already appear obvious – it adds more patients to an already taxed UGH A&E system. The underlying need for this Clinic, I learned, is twofold. Most patents don't have Primary Care physicians and even if they do most General Practice physicians aren't trained in basic office procedures.
All major trauma and acute medical cases are announced over the loudspeakers. I was given free rein to attend these cases whenever they came in and did just that. I saw over 200 cases during my 4-week rotation, including: DVT, pulmonary embolus, human bite, dog bite, abducens nerve palsy, scaphoid fracture, median plantar nerve neuropraxia, acute blindness, displaced tib-fib fracture, thumb amputation, ASA overdose, major head trauma, acute MI, and status epilepticus.
In addition to friendly Irish medical students, the hospital is rich with other international medical students. I was invited to dinners, parties, and happy hours weekly. Irish hospitality is second to none. This was most evident on the last day of my rotation when Dr. Meehan, a veteran A&E consultant, prepared a homemade Irish to celebrate my last day. All A&E staff attended. It was truly memorable.
Overall, this is an excellent rotation. I feel much more confident with musculoskeletal and eye injuries, reading radiographs, and drawing bloods heading into my Family Medicine intern year. The UGH A&E has a lot to offer, if as Mr. Martin says, Just put in your time and you hunger for emergency medicine will be fulfilled."
Beyond the NUG A&E, I utilized weekends and two weeks of travel time to explore in interests in Irish history, culture, and religion, while leaving ample time for adventurous mountain hikes in the lands of my forefathers. On the Aran Islands I learned to make crab and seaweed salad, in Connemara I hiked one of the highest peaks in Ireland, Craugh Patrick, on Easter Sunday, and at Glenstal Abbey I concluded my Ireland experience with a few days of prayer and meditated with the Benedictine monastics.
Pearls to an excellent Galway experience:
1. Start planning early:
- Contact GMER office/Shannon Benson
- Meet with Dr. Quie, GMER Dept.
- A native Irishman, Dr. David Power, UMN Dept of Family Medicine, is an excellent resource
2. Evaluate your budget:
- Ireland is not a cheap place to fly to, live in, and travel within
- Don't expect financial assistance from GMER itself as these funds are reserved for "third-world nations."
- If living frugally, assume at least $1200 total living expenses/month
- Check current exchange rates (dollar:euro)
- Let your bank/credit card company know when/where your going
- Have a backup check/credit card in case you loose one (as I did)
3. Housing in Galway:
- I stayed with Dolores Tierney (Dolores.email@example.com), retired Anatomy Administrator. She has a beautiful house in Fort Lorenzo – 10 min bike, 25 min walk to Hospital.
- I also advise checking the "Galway Advertiser" online newspaper website for "accommodations to let"
- Airport to Galway – whether arriving to Dublin or Shannon airports, take the Bus Eireann, the government run bus service. After arriving to Galway, you can get pretty much anywhere in town on foot, taxis of course are everywhere
- I was given a bike by one of the ER docs – saved me tons of travel time. You can rent bikes for 50 euro/month – I highly advise this.
- Plenty of grocery stores around town, excellent pubs downtown, hospital food is actually tasty. Again – all pricey
6. Emergency medicine:
"Don't show up asking for interesting cases, put in the time and you'll discover them" ~ Mr. Martin.
- Show confidence from the start and the reins are yours. Like any rotation you make of it what you want.
- Other than seeing patients in "minors" and "majors," I advise practicing blood draws and trying your hand at casting – spend a day with the phlebotomist and fracture nurse.
- Attend all major trauma cases
- Daily noon ER lectures with Galway med students are excellent.
- Top-notch Grand Rounds Friday's at 1pm (free lunch).
7. Outside the hospital:
- Visit Cliffs of Moher on a sunny day (buses from Galway daily)
- Hike in the Burren (buses daily from Galway)
- Climb a mountain in Connemara (check Galway Walking Club website)
- Tour Guinness and Jameson in Dublin and have a beer on Galway's Quay Street
- Walk along beach from Galway to Salthill
- Visit Aran Islands (ferries daily from Rosseveal)
- Hike the famed Crough Patrick (barefoot if your really tough)
- Listen to Irish music at a local pub
- Go to a rugby game
- Go deep-sea fishing
- Research your ancestry (if your Irish, of course)
- Eat seaweed
- Visit Moran's Oyster Cottage (best seafood on the west coast)
- Check hostelworld.com for cheap accommodations throughout Ireland. If you're really looking to stay cheap, try couchsurfing.org
- Renting a car or taking the train are spendy. I advise bus traveling by bus: check Bus Eriann or CityLink
- Doing touristy stuff on the weekends
- Watch the weather for rain
- Use caution when walking/biking throughout Galway and Ireland in general – streets are narrow, shoulders are minimal.
- Wi-fi at most coffee shops, pubs, and in Galway Medical School.
- Purchase an Irish cell phone (roughly 40 euro)
- Don't forget Skype!
10. Things I wish I'd done:
- Bring a waterproof jacket!
- Invest in a quality lock: useful for hostel stays, hospital lockers