When we think of a hospital, most of us picture a general ward or perhaps the operating theatre. The reality is that there are dozens of different locations within a typical District General Hospital (DGH), some more important than others, that are necessary for high-quality patient care. There are even more specialist areas in major teaching hospitals (regional tertiary referral centres), such as cardiac surgery units, neurosurgical units, major trauma centres, organ transplant units, etc. (In case you were wondering about primary and secondary care units, these are your local general practice and your local DGH respectively.) The following is far from a comprehensive take on how I think key areas of a hospital function.

The Doctors’ Mess

I’ve put the doctors’ mess at the top of my list because it’s the most important part of any hospital. The nerve centre. Mission Control. Or at least it used to be.

Back in the olden days (well, the 1980s do feel like ancient history) when I was a medical student and then a junior hospital doctor, the doctors’ mess really was something. Most newly-qualified house officers and SHOs were single. They lived in the mess, which was usually a substantial building situated in the centre of the hospital campus or part of the main hospital building. The mess comprised living quarters, a kitchen and dining room, a bar, a TV and games room, and often a hall where the legendary doctors’ parties were held. Some messes, like the one at Manchester Royal Infirmary, served freshly cooked food to the junior doctors at mealtimes.

The doctors’ mess was not simply a place for juniors to eat and relax during periods of relative quiet; it was also a place to confer informally with colleagues from different specialities about tricky patients. More of this kind of referral work was accomplished in the doctors’ mess than by going through official channels and filling out lengthy patient referral forms. The doctors’ mess method was much more efficient, too. A busy surgical SHO at the end of yet another long and stressful day would be more far more likely to make the effort to squeeze in a visit to assess a patient with abdominal pain on the chest ward as a favour to a mate he’d been playing pool with the night before than if an impersonal referral form from a doctor he didn’t know had suddenly appeared in his pigeonhole asking him for his opinion.

Of an evening, the mess would often be quite busy with off-duty juniors lounging around, watching TV, supping pints from the bar, and playing pool. If you were on call, it was great to nip down to the mess, if you could manage to break off from saving lives for half an hour, for a chat and to grab something to eat (the staff dining room would now be closed, of course). Even better if the mess was in one of the few remaining enlightened hospitals that didn’t know the cost of everything and the value of nothing, and so still delivered trays full of sandwiches and snacks to the mess every evening to keep the hungry troops’ morale and blood sugar up.

Although my memory must be at fault here, I recall that there was a doctors’ party in the mess most weekends. What riotous occasions they were. The main guests, apart from the junior doctors, were nurses, of course. A motley collection of porters, radiographers and physios would also pitch up to join in the fun, as well as coachloads of people nobody had ever clapped eyes on before. Nobody seemed to mind. The music was loud, the dancing was hot, the booze seemingly never-ending, and the bedrooms above were conveniently available for any party-goers who overdid things and got over-tired. Or whatever.

We did well to party as hard as we did because doctors’ messes, as they existed then, were on their way out. Hospital chief execs, in their droves, decided they needed the buildings for a higher purpose: to house themselves and their managerial underlings. Or the building needed to be demolished to make way for a car park. Doctors’ messes nowadays have been relegated to small, out-of-the-way cubby holes and cupboards under the stairs.

It makes me sad to think about the demise of the doctors’ mess. We juniors had a place to de-stress, socialise, make friends, relax, and party. Yes, we worked a ridiculous number of hours and were sometimes on continuous duty for 48, even 72, hours at a time, but the doctors’ mess provided sanctuary, friendship, solace and support during difficult times. In conjunction with The Firm system, the mess played an essential role in maintaining junior doctors’ mental health. Both the mess and The Firm are long gone, and as far as I can see, nothing satisfactory has replaced them.

Hospital HQ

Hospital HQ is usually located at the hospital’s epicentre, where the doctors’ mess used to be until it was annexed by the chief exec. It’s the place where the executive team and other senior hospital managers work. Hospital HQ is the only carpeted area of a hospital with nice decor. Apparently, a hub of intense cerebral activity during regular working hours, the lights were all switched off by the time I was leaving for home after another hard day in the operating theatre. And the place was entirely abandoned at weekends and during bank holidays.

The Emergency Department (ED)

Aka Accident and Emergency

Aka Casualty

Aka Drop-In Centre for the homeless, the clueless, drunks, down-and-outs, wasters and time-wasters, the bad, the mad and the sad, and anyone else with nothing better to do and nowhere else to go who decide to pop down to their local ED to ask about the headache they’ve had since last Christmas and tonight seems as good a time as any to get it sorted given that there’s sod all on TV.

The ED is the hospital’s front door, and it’s always open. All are welcome. Nobody is ever turned away. This is in sharp contrast to the back door of the hospital, the way through to hospital discharge, which is permanently blocked by legions of frail, elderly patients whose needs are now social or nursing rather than medical but have nowhere else to go because of the dearth of investment in social care and nursing homes over past decades.

Most EDs are like a war zone or a scene from a disaster movie with bodies, dead and alive, lying everywhere – in cubicles, on trolleys, on the floor, in corridors, in cupboards. There are too few doctors and nurses running feverishly hither and thither from one victim to the next, desperately trying to do their best for as many patients as possible. Hopefully, nobody will slip through the cracks on this shift.

As a patient, you are supposed to be triaged (graded as to whether your condition is immediately life-threatening, serious but can wait an hour or two, walking wounded, or trivial), diagnosed and treated, and either discharged home or admitted to the hospital, all within 4 hours. When I was a consultant, I could have counted the number of occasions when the 95% target was met on the fingers of one hand. I remember we generally achieved somewhere between 85% and 95%. Little did we know at the time how stormingly marvellous we were performing. Currently, only about two-thirds of patients meet the 4-hour target, with 10% waiting more than 12 hours. And 3% of elderly, frail, seriously ill patients are waiting longer than 24 hours!

Having entered through the front door and having finally been seen by a doctor (unless you’ve died in the interim or pissed off home because you think you’ll receive better care there), you exit the ED in one of the following ways:

1.      You are kicked back out of the front door with the admonition to consult your GP the next time your piles are itching again.

2.      It’s a bit more serious, and you are taken to the mortuary.

3.      You are transferred directly to the ICU, put on a mechanical ventilator and have tubes, catheters and drains shoved up every natural orifice, as well as a few man-made ones.

4.      You are admitted to the Coronary Care Unit because you’re having a heart attack.

5.      You are rushed up to the operating theatre for emergency surgery to have a buzzing foreign body removed from your rectum.

6.      You are admitted to the Medical or Surgical Assessment Unit for further treatment and stabilisation of your presenting acute illness before being transferred to a hospital ward a day or two later.

The Intensive Care Unit (ICU)

Aka Critical Care Unit; not the same as the High Dependency Unit (HDU).

The ICU is where you’ll normally find the sickest patients in the hospital – at least those with a realistic chance of surviving. One of the main differences between the ICU and the HDU is that most ICU patients depend on mechanical ventilators to breathe for them, whereas HDU patients can manage on their own. The ICU patients are also more seriously ill, as a rule, having a greater number and severity of organ system failures. For these reasons, the nurse-to-patient ratio in the ICU is generally 1-to-1, whereas on the HDU it is usually 1-to-2. We used to say that you were buggered if you ended up on HDU, but if you needed to go to ICU, you were well and truly fucked. We might have been exaggerating, though, because more than 75% of patients admitted to the ICU survive to hospital discharge. I’ll have more to say about what goes on in the ICU and HDU in a later post.

Acute medical and surgical wards

This is where hospital inpatients spend most of their time. Characterised by too few nurses looking after too many patients, it’s surprising that there is no clearly defined recommended minimum standard for safe staffing on acute medical and surgical wards, even though there is evidence that a nurse-to-patient ratio in excess of 1-to-8 is associated with an increased risk of patient harm. Hellishly busy and noisy during the day, pandemonium breaks out as soon as it gets dark, when all the patients who have been in hospital for more than a few days go bonkers. Those that are physically capable run, naked, up and down the ward all night, screaming like banshees, usually trailing their urinary catheter bags behind them, while being chased by a harassed junior doctor with a big syringe full of Valium or some other powerful sedative. Their less physically adept ward companions join in by wailing and howling and falling out of their beds to break their hips. Before the long night is over, the frazzled nurses join in the lupine chorus.

All of this means that when you are admitted to a ward with a nasty bout of double pneumonia, you’ll inevitably suffer from acute sleep deprivation into the bargain, which is not conducive to getting better because it depresses your immune system, stresses you out and finally turns you into a raving lunatic after sunset so that the whole vicious circle is maintained.

Your only chance is to somehow blag yourself a cosy side room, a refuge from the madhouse, where you can hunker down and concentrate on getting better. It’s easier said than done, though, because there is a dearth of side rooms in most NHS hospitals. Patients only enjoy the amenity of the extra privacy and en suite facilities that a side-room affords for one of four reasons:

1.      You’re a private NHS patient (oxymoron alert) and have paid for the privilege.

2.      You receive special treatment because you are a VIP, such as the Duke of Kent, a member of staff, or a relative/personal friend of the consultant.

3.      You’ve got a horribly contagious, deadly, infectious disease.

4.      You’re on your way out, but nobody’s told you (by far the most common reason).

If you aren’t a VIP and you’ve got money to burn, try for 1. Otherwise, 3 is worth a go. You could probably simulate bubonic plague with a red marker pen. Most doctors and nurses are rubbish at diagnosing rashes, so they would probably keep you in the side room just to be on the safe side. If none of the above applies to you and you’ve been given a side room anyway, you might want to consider making those finishing touches to your last will and testament before anything else happens.

Delivery Suite (DS) and the Special Care Baby Unit (SCBU)

These are both very scary places, although for different reasons.

The DS is inhabited by two of the most intimidating groups of people I worked with as an anaesthetist – midwives and labouring women. I only ever went there if it was absolutely necessary. The SCBU is even more terrifying with its tiny little scraps of humanity weighing less than a bag of sugar lying helplessly in their incubators, being mechanically ventilated and fed via nasogastric tubes. Far too small for me. How the neonatologists (paediatricians specialising in the care of neonates, that is, newborn babies in their first month or so of life) managed to cannulate veins I would have needed an electron microscope just to see, I will never know. Thank goodness, I was seldom called down to the SCBU in an emergency.

Operating Theatres

Most people have a pretty good idea about what goes on in theatre, and they are wrong. The bit they get right is that there’s a patient asleep under anaesthetic (usually) being operated on. The surgeon beavers away, his sweaty brow being delicately mopped periodically by one of the theatre nurses. There is dead silence for long periods of time to allow the surgeon to concentrate. Conversation, when permitted, is erudite and professional, relating to how surgery is progressing or perhaps debating the relative merits of a new procedure. Apart from the surgeon, also present in theatre are a scrub nurse, who passes the surgeon instruments, and a circulating nurse (the one who’s always depicted in TV medical dramas picking up used, bloody swabs with a pair of long forceps and hanging them on a metal stand). Last and certainly least, there is an anaesthetist. They don’t usually feature in the action very much, but the TV producer knows they’re there doing something. Together, they make a tight-knit team. Everyone is naturally in awe of the surgeon, including the surgeon, who is definitely in charge. The team is 100% focused on the patient at all times, their every thought and action devoted to saving yet another life.

It might be like that on TV and even in a few real-life operating theatres, but I never worked in one. The first difference between imagination and reality is just how many personnel are routinely required to properly look after a patient going under the knife: the lead surgeon; one, sometimes two, surgical assistants; the scrub nurse; one or two circulating nurses; a consultant anaesthetist and a trainee anaesthetist; an anaesthetic assistant (either an anaesthetic nurse or an Operating Department Practitioner); a theatre orderly (gofer), sometimes two; a radiographer, if X-rays are required during surgery. And that’s before accounting for any medical students, nursing students or paramedics observing proceedings, as well as random people from other theatres sticking their noses in to see what’s going on in between cases. I’ve been to less crowded football grounds than many operating theatres. But then, it’s not called theatre for nothing.

The second thing is that most operating theatres are far from quiet places. Music is usually playing from an ancient, bashed-up radio, at a volume ranging from soft background to an eardrum-rupturing 100 decibels, in genres as diverse as classical, easy-listening, pop, heavy rock, grunge and garage (I’ve no idea what the last two are). For some reason that nobody can explain, the radio’s aerial is always broken or missing entirely, and has been replaced by a pair of Spencer Wells forceps clipped to the aerial base. It’s amazing what sterling reception you get with a pair of Spencer Wells. As well as the melodic strains, there are usually several threads of conversation going on simultaneously, and none of them has anything to do with the patient or their operation. Like any other workplace, you are much more likely to hear about who’s rumoured to be shagging who, whatever was on TV last night, how ugly the patient is and what a wanker the new CEO has turned out to be.

I was an anaesthetist for over 30 years, so I feel reasonably well qualified to tell you what anaesthetists generally get up to while their patients are anaesthetised in theatre. First of all, rest assured that we do stay with you throughout your operation. If we didn’t, you would probably die. Or suffer a catastrophic brain injury from acute oxygen starvation and not wake up at the end of your operation. Or wake up paralysed and in agony during your operation.

When you’re under a general anaesthetic, you are not asleep. You are lying unconscious, eyes closed and unmoving, but the resemblance to natural sleep is superficial. The state of anaesthesia is one of deep, unresponsive coma, in which your brain function is suppressed to a level similar to that associated with brain death. When you are anaesthetised, your life hangs in a delicate balance between this world and the next. Your brain is incapable of carrying out its job of regulating all your vital functions, such as breathing, heartbeat, blood pressure, blood flow, fluid balance, kidney function, blood sugar, core temperature, and many more essential aspects of your body’s physiological control mechanisms.

Which is why your anaesthetist is ever present, watching over you like your guardian angel, keeping you safe. And they do all this while simultaneously completing today’s Telegraph crossword, studying this month’s British Journal of Anaesthesia or Hello! magazine, re-tuning the radio to another station at the surgeon’s request or reattaching the Spencer Wells forceps because it’s pinged off again, answering the theatre phone because nobody else can be arsed, adjusting the operating lights so that the surgeon can see what it they’re cutting out, and eating their lunch in the anaesthetic room because they didn’t have time to eat it at lunchtime – keeping a beady eye on proceedings through the window of the anaesthetic room door between mouthfuls.

You still need to be continuously monitored even if you aren’t under a general anaesthetic. For example, the blood pressure of patients having a hip replacement under a spinal anaesthetic has a dangerous habit of unpredictably disappearing into their boots if nobody is looking. To be honest, it’s harder work for anaesthetists to look after awake patients than it is for them to look after the ones who are asleep.

Doh! Even I’ve fallen into the trap. They’re not asleep; they’re anaesthetised.

If you’re awake, you need talking to – for reassurance, to relieve the tedium and just to be sociable. Plus, if you’re awake, everyone in theatre has to be on their best behaviour and try to act professionally, which is a real ball ache. No slagging off the CEO, for instance. Or you, the patient. And definitely no laughing at the surgeon when he cuts the wrong bit off and blood spurts everywhere. For these reasons, I usually convinced my patients having hip and knee replacements under spinal anaesthesia that they would be much better off being sedated while their new hip or knee was fitted. To be fair, they didn’t usually need much persuasion.

Day Case Unit (DCU)

When I first started out, if you were going to have your hernia (rupture) repaired or your gallbladder taken out, you would be admitted to the hospital at least one day before surgery, have your operation, and be discharged home a few days later. The whole episode could easily last a week or more. Nowadays, you pitch up on the day of surgery itself and have your operation before your husband or wife or whoever it was that brought you to the hospital has even managed to get out of the car park because their car was clamped in the ten minutes it took them to accompany you to the door of the DCU. You are discharged home later that same day. A different person has to come and pick you up because the first person’s car is still clamped.

Not having to stay in hospital for even one night, let alone a week or more, is great news. That’s something we can all agree on. Perhaps. Although if you happen to wake up at three in the morning in agony because the nerve block the anaesthetist gave you has worn off and the strongest painkiller you’ve been supplied with is paracetamol, you might beg to differ. All of a sudden, staying in hospital overnight and having a double dose of morphine doesn’t seem such a bad thing, after all.

The Outpatient Clinic

This is where your GP refers you when your case isn’t an emergency, but they want the advice of a consultant regarding your further clinical management, such as the need for surgery. The waiting areas in outpatient clinics are always jam-packed with desperate, seething masses of humanity, waiting hours on end for their chance to see the great man or woman. It would help if they were not all given the same 09:00 appointment time. Nobody knows why all the appointment times are the same. They just are. Always have been and always will be. I used to find that the situation was usually worse in the medical clinics than in the surgical clinics. Most surgical outpatients attend only two or three times: once before their operation and once or twice afterwards for their routine postoperative review. This is not the case with medical outpatients.

I found out at first hand why this is so at my very first medical outpatient clinic as an SHO working for a chest physician. I read the voluminous notes of the first patient before calling her into the consulting room. The last entry, dated six months previously, had nothing to do with her chest or breathing. Then, she’d been complaining of headaches, a nervous tic affecting her right eye, a painful big toe on her left foot and an itchy rash in her nether regions. Interesting stuff, perhaps, but not remotely respiratory.

I flicked back a page and read the entry from a year ago, thinking that must be when she had been complaining about her chest. However, there was no mention of her breathing except to note it was ‘the same as usual’ and to ‘continue taking her inhalers as prescribed’. There was mention, however, of her sore left elbow, abdominal gripes and flatulence, dizzy spells and a smelly discharge from her nether regions. Presumably, these symptoms from a year ago had all cleared up at her last clinic visit six months earlier, given that they hadn’t been mentioned then.

As I flicked further back through her notes, it transpired that Ethel had been on a six-monthly outpatient review for the past 15 years. Her GP had referred her originally because he had wanted some advice about how best to treat Ethel’s asthma. As far as I could make out, Ethel’s asthma had come under control almost immediately with a change of treatment and she’d not had any trouble with it for years. For some reason, she had never been discharged back to the care of her GP and so had been on six-monthly hospital follow-up ever since. Every time Ethel attended the clinic, she had a fresh constellation of symptoms that were always unrelated to each other. They often led to yet more blood tests and other investigations. These were always normal, and no firm diagnosis was ever made, but it didn’t really matter because all her symptoms would resolve between clinic appointments, to be replaced by a different set.

After hearing at length that Ethel’s latest complaints were a ringing noise in her ears whenever the weather was cold (wear ear muffs), a stabbing pain in her hip if she went dancing (try swimming) and was feeling tired all the time (TATT syndrome is nothing to worry about, we’ve all got it), I decided to take the bull by the horns and discharge her from further follow up. Ethel immediately burst into tears and accused me of being a heartless beast. Apparently, she didn’t get out much and looked forward to her clinic visits. Handing her a tissue, I relented and said we’d see her again in six months.

Nowadays, you’d probably be shot at dawn if you adopted that attitude. For years, hospital managers berated consultants for not discharging more of their outpatients. They tried unsuccessfully to change consultants’ mindset, proposing radical solutions to the problem of crowded outpatient clinics, such as telephone consultations. The consultants were having none of it. It was a dangerous proposition. Your patient needed to be physically present. Subtle abnormalities would be missed with catastrophic consequences. It took the COVID-19 pandemic to effect substantial change. Now you’re more likely to see tumbleweed blowing through the outpatient clinic than a crowd of patients.

The X-Ray Department

Aka Radiology, Diagnostic Imaging

It’s bloody marvellous what goes on in an X-Ray department these days. You can have a good old-fashioned plain X-Ray of your chest, broken arm or arthritic hip, of course. But there’s a whole bunch of other diagnostic investigations you can have, such as ultrasound scans, Computed Tomography (CT) scans, Magnetic Resonance (MR) scans, Positron Emission Tomography (PET) scans (who would have thought antimatter would be useful in diagnostic imaging), radio-isotope scans and fluoroscopic imaging (using continuous pulsed X-Ray beams to produce a real-time moving video) that allows your doctor or nurse to obereve organs and tissues actively functioning, for example, coronary angiography. But X-Ray departments aren’t only places to visit to be diagnosed with something because you are just as likely to be definitively treated for whatever’s wrong with you.

It’s called interventional radiology, a relatively new medical speciality that involves minimally invasive therapeutic procedures performed by inserting needles, catheters, wires, and fibreoptic endoscopes through minor skin incisions or existing bodily orifices under image guidance (X-rays, ultrasound, CT, MR, fluoroscopy, etc.). The medical consultants who do this stuff are radiologists (as opposed to radiographers, who are highly qualified medical technicians and not doctors).

Their menu of procedures is extensive and includes:

1.      Removing gallstones causing a blockage and/or infection in the bile duct.

2.      Inserting stents in the bile duct to bypass an obstruction, eg a tumour.

3.      Inserting stents in the oesophagus (gullet) to provide symptomatic relief to patients with advanced oesophageal cancer.

4.      Insertion of stents into narrowed arteries, such as coronary, carotid, and lower limb arteries. Alternatively, a catheter with a balloon at its tip may be passed down the narrowed artery to the constricted area. When the balloon is inflated, it stretches the narrowed vessel open, after which the balloon is deflated and the catheter removed (balloon angioplasty).

5.      Percutaneous nephrostomy, a bypass procedure that involves passing a drainage catheter through the skin into the collecting system of a kidney whose outflow tract is blocked by a tumour or stone, thereby allowing it to drain freely. It’s a relatively straightforward procedure to preserve kidney function that previously would have necessitated a major open surgical procedure.

6.      Embolisation, a procedure in which either a metal coil or gel foam is positioned within an artery to block the onward flow of blood. There are a variety of applications, such as preventing subarachnoid brain haemorrhage in patients with leaky cerebral aneurysms and cutting off the blood supply to malignant tumours.

7.      Endovascular Aneurysm Repair (EVAR) in which a stent-graft is inserted into a large Abdominal Aortic Aneurysm (AAA) to prevent catastrophic fatal haemorrhage.

The huge advantage of interventional radiology is the avoidance of the otherwise necessary conventional major surgery, which means it requires a shorter hospital length of stay, is less expensive and is less of an ordeal for the patient. Crucially, interventional radiology is inherently safer and has a lower mortality than conventional surgery, meaning it can be offered to patients where surgery would be contraindicated because of the high risk of death.

That’s all for now on the anatomy of a hospital. We’ll continue this thread in the next post.