Working as a Physician Associate in Renal
Tuesday 1st January 2019
Isil Mirzanli - recreated with permission form her website not a doctor
Got an upcoming placement in Renal? Considering a job as a PA in Renal medicine? Then take a read and find out what it's all about. Please bear in mind, my experiences in Renal are from a Tertiary centre with dialysis facilities so it might not be representative of what goes on in non-Tertiary settings.
For those of you who are new to the blog, I'll just set the scene quickly. I am a Physician Associate currently working in Manchester. I qualified in March 2018 and am doing a 1-year preceptorship/internship programme which involves rotations in medicine. I recently finished a rotation in Renal so I thought I would share to give you guys some insight.
I was quite anxious about leaving Cardiology as I had just got to know the staff and the routine of things. I got a taste of what Junior doctors must feel every time they change jobs! I didn't have much experience in Renal, I had done 2 weeks during placement in 1st year so didn't really know what to expect.
My rotation was timed 2 weeks before the junior doctor's changeover in August, which meant I got shown the ropes in time for the new group of doctors. On my first day I was shown the ward and introduced to the team. At my Trust there are 2 renal wards next door to each other, one male and one female. I was placed on the male side as it has double the amount of beds and needed the most help. As in Cardiology everyone was really friendly, welcoming and willing to help. Here's a pic of some lovely members of the Renal team.
As on most wards the daily routine consisted of having a ward round, either led by a Consultant or a Registrar, and then completing the ward jobs alongside the doctors. I learnt quickly that the ward rounds on Renal were longer than the ones I had experienced on Cardiology. This is to do with the types of patients that make up a Renal ward in a Tertiary centre.
Although you often learn about AKI being a renal problem, on a Tertiary renal ward, there are few patients with an AKI unless they are severe/AKI on CKD. Given the dialysis service being on the ward, our patients were mostly haemodialysis patients, peritoneal dialysis patients and patients with end-stage renal failure (pre-dialysis). These patients often have multiple co-morbidities which means their time in hospital is usually longer and more complex than the types of patients I saw in Cardiology.
Below are some things to consider when seeing renal patients on the ward round:
What is the patient's primary renal diagnosis?
When meeting a patient for the first time, this is an important question to know the answer to. Basically, what has caused their kidney disease. I've given you some causes below.
Diabetes (Types 1 and 2) - leading cause of CKD. Poor diabetic control damages the vessels in the kidneys which stops them working efficiently - diabetic nephropathy.
Cardiorenal syndrome - an umbrella term that describes the interaction between heart disease and kidney disease. Acute or chronic dysfunction in one organ can cause acute or chronic dysfunction in the other. An example could be chronic heart failure causing CKD, or vice versa.
Autoimmune causes - examples include IgA nephropathy (build up of IgA deposits in the kidneys), Lupus Nephritis (kidney disease caused by Systemic Lupus Erythematosus) and Anti-glomerular basement membrane (GBM) disease (also known as Goodpasture's syndrome)
Genetic causes - Polycycstic Kidney Disease, Alport syndrome (disorder of the glomerular basement membrane) and Tuberous sclerosis (causes benign tumours to develop in different parts of the body, commonly in the kidneys)
Why are they in hospital?
Some examples of why patients were with us:
Fluid overload - as renal function declines, the kidneys are less able to get rid of waste fluid. For pre-dialysis patients this could be a sign that they were nearing the need for dialysis. For patients already on dialysis, this could mean that they need more ultrafiltration (UF - removal of fluid) on dialysis. Could also mean that patients were not sticking to their fluid restrictions or not compliant with medications.
Line infections/fistula infections/peritonitis - patient who dialyse via a tesio line or fistula are at risk of these getting infected from regular use. Patient who receive peritoneal dialysis are at risk if peritonitis.
Worsening renal function - a patient may be admitted with symptoms such as oliguria, fluid overload, confusion etc. and on inspection of their bloods, reveals worsening renal function. If the patient doesn't have an obvious reason for this and no renal diagnosis, this would prompt further investigations such as special blood tests, renal biopsies etc. to find the cause.
Haemolytic uraemic syndrome (HUS) - often a complication from infection with E. coli 0157, but there are other causes as well. It can lead to acute renal failure which can require dialysis.
What do their bloods show?
U&Es aren't enough on a renal ward, you have to get a 'standard renal profile' which includes bicarbonate and chloride. For pre-dialysis patients we look at their renal function to monitor treatment/if they need dialysis. For dialysis dependent patients, urea, creatinine and GFR is less important because the patient essentially has no kidneys. Anaemia is a common problem so checking haemoglobin is important. Hyperkalaemia is also common and obviously something to avoid so always check potassium!
In terms of clinical skills, patients on dialysis could have bloods taken off their lines whilst on dialysis. This was a super helpful thing because renal patients are difficult to bleed! If they had a fistula then you were already down to one arm and if they were an IVDU it was even more tough.
What is their fluid status?
Since the kidneys are responsible for making urine and getting rid of waste fluid then fluid overload is a common symptom of failing kidneys. Fluid status is an important factor to consider when treating a renal patient. It can lead to changes in treatment, fluid restrictions, and dialysis regimes. So always have a look at the patient's legs for peripheral oedema and have a listen to their chest. Sometimes you don't have to look too closely, oedematous faces can be a tell-tale.
I really enjoyed working in Renal. Not having a Consultant ward round every day meant I was able to go and see some patients on my own. Because of the complexity and comorbidities of the patients, I learnt a lot of medicine outside of renal. Sometimes it felt like an acute medical ward but with dialysis patients. Also, because of the nature of dialysis, I was involved in a few crash calls and peri-arrest patients. It's really scary but you learn something new every time.