Internship and Work Experience

@
Queen Elizabeth Hospital
UK National Health System (NHS)
Birmingham, UK

25-29 June 2018

Joseph Farroha
Glenelg Country School

My Queen Elizabeth Hospital Internship

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 As an aspiring Biomedical Engineer and Surgeon, late in 2017 I applied for an
opportunity to gain work experience at the Queen Elizabeth Hospital in Birmingham, UK the
summer of 2018 between my Junior and Senior year of high school. This internship program
introduces ambitious students to the healthcare environment. It specifically guided me in making
decisions on my career path and helped me build on my strengths and interests while also raising
my self-esteem, skills and knowledge. This paper is the culmination of my expedition to the UK,
documenting my timeline, what I experienced, what I learned, and more importantly, how it
influenced my future aspirations!

Figure 1 Queen Elizabeth Hospital in Birmingham, UK [1]

In April 2018, I was notified that I was accepted in the Queen Elizabeth’s internship
program. I was very excited! So on 24 June 2018, I arrived in Birmingham, UK and spent 25-29
June 2018 interning at the Queen Elizabeth Hospital. My host family, coordinated by me and
arranged by my mentor, Dr. Azzam, provided me with room and board for my stay. I was
required to arrange for my transportation to and from my host family’s home and my hours were
generally 8am to 5pm every day. My work experience in the Queen Elizabeth hospital was an
amazing opportunity to witness the medical arts and sciences working together to heal human
suffering. My internship was focused on the reconstructive surgery department where patients of

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burn and skin cancer unit were patients from all ages suffering various degrees of injuries and
diseases.

Figure 2 My Mentor, Dr. Azzam, in front of the Queen Elizabeth Hospital

The Queen Elizabeth Hospital is a beautifully architected facility that serves the
community of Birmingham and beyond helping more than 500,000 patients a year. It is well
known for having the largest solid organ transplantation program in Europe. Patients are
admitted at the Queen Elizabeth Hospital for many reasons including accidents, sickness and
self-inflicted injuries. This internship experience helped me frame my life and career goals to
become a physician and a surgeon to treat people and alleviate their suffering. I used much of
my recent knowledge from biology, anatomy, and physiology to understand the cases and the
severity of the patient's condition.

I spent a significant amount of time with the senior physician and my mentor, Dr. Azzam,
to learn the concepts of diagnosis and determining the best approach to try and alleviate the
suffering and heal the patient. Dr. Azzam is a highly qualified surgeon specializing in Cancer
Care, Cosmetic surgery, Dermatology, Oral and maxillofacial surgery, and Plastic surgery. He
holds several degrees including MBChB, MSc, PGDip(Laser), FICMS(Plast), PhD, FRCS,
FEBOPRAS and is a consulting plastic surgeon in the UK and EU.

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 The junior doctors were in charge of the day-to-day monitoring, observing and adjusting
the treatment; while the nurses were in charge of the hands-on care before and after the surgeries
and caring for the wounds and stitches and skin-grafts. Before, during, and after my residency I
was performing research on the cases and diseases that I encountered. Skin cancer is one of the
most prevalent cancers and is responsible for many deaths in the UK, US and other parts of the
world. The cancer itself is very treatable if caught early and treatment is started immediately;
however, if it goes undiagnosed or ignored the results can be fatal. The melanoma itself spreads
to other parts of the body causing many complications including brain and organ tumors. Jimmy
Carter, former President of the United States, was treated for melanoma that spread to his brain
[2]

Anatomy of the Skin

The skin is the largest organ in the human body and is composed of three major layers
from the outside in are Epidermis, Dermis and Hypodermis. Overall it serves as a protective
barrier prohibiting bacteria and foreign objects from entering the human body. The dermis also
hosts connective tissue, nerve ending, hair roots and sweat glands to control temperature through
sweat and sense through feeling and touching. The most inner layer is made of fat and
connective tissue; which helps conserve the body's heat and pads the body from blunt injuries by
acting as a energy absorber. Damage to skin will result in varying levels of pain and harm to
human body depending on severity, depth and type of injury. Figure 3 illustrates the human skin
anatomy and layers.

Figure 3 Anatomy of the human Skin [3]

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Types of Injuries to the Skin
Skin can be injured by many factors like cuts, burns, allergies, exposure, disease and
genetic reasons. During my internship at the Queen Elizabeth hospital burns unit, the main areas
that the department dealt with were injuries to the supportive tissues as a result of burns, allergies
and exposure. The two main outcomes were various levels of burns and skin cancer
(melanoma).

Melanoma
Melanoma is the most common malignant skin cancer in the world and claims the most
number of lives. When I was researching melanoma, I was expecting to see that most of the
cases were in the southern areas where there is an abundance of sunshine, however, I was
surprised to find out the cases in the US are not distributed according to the common thoughts
where more sunshine equals more cases. The figure show the actual case distribution in 2017.

Figure 3 Actual case distribution of skin melanoma[4]

Melanoma Risk Factors:

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 Melanoma is skin cancer where anybody is at risk of acquiring it, however, people that
are at higher risk for developing malignant melanoma have the following risk factors:

● Increasing Age
● Previous Skin Cancer
● Family History of Melanoma
● Multiple Atypical Moles
● Fair Skin
● Symptoms
Melanoma can appear anywhere on the body, but many cases it shows up to areas that are
usually exposed to sunlight. The first signs or melanoma symptoms are usually an unusual
looking mole. A good way to remember what spots should be suspected is to use the mnemonic
ABCDE [5]:

● A-asymmetry
● B-border irregularity
● C-color variation
● D-diameter -6mm
● E-evolving (enlarging, color changes)

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 Figure 4 illustration of malignant and benign melanoma in human skin [6]

Why do we care?

Here are few statistics that shows the reason why everybody should be aware of
melanoma and should be vigilant when a new growth or discoloration happens to their skin:

Figure 4 Human Melanoma Impact statistics[7]

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Burns
Classifications of level/severity of burns [8]:
● First-degree (superficial) burns. First-degree burns affect only the epidermis, or outer

layer of skin. The burn site is red, painful, dry, but usually does not have blisters. As far

as prognosis, permanent tissue damage is rare but could result in an increase or decrease

in the skin color.

● Second-degree (partial thickness) burns involve the epidermis and part of the dermis

layer of skin. Here the burn site appears red, blistered, swollen and painful.

● Third-degree (full thickness) burns. The burn destroys the epidermis and dermis. There is

no feeling in the area since the nerve endings are destroyed

● Fourth degree burns penetrate entirely through the skin and begin to burn the underlying

muscle, tendons and ligaments. The burn site appears white or charred.

● Fifth degree burns penetrate the muscle and begin to burn bone

● Sixth degree burns are the most severe burns which have charred bone.

Figure 5 shows an illustration of the layers of skin affected in the most common types of burns.

to be able and determine the severity, you need to pay attention to the color, shape, feeling, and

ans size/depth of the impacted area.

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 Figure 5 Burn severity and damage to human skin and tissue [9]

Common Causes of Burns [10]

Although being exposed to open flames is one of the most common reasons that people get

burned, however, there are many other causes that include:

Friction burns: When a hard object rubs off layers of skin of a patient is called a friction burn.

The outcome is both an abrasion (scrape) and a heat burn. These are common in bicycle, skating,

and motorcycle accidents. Carpet burn is another type of friction burn that is more common and

usually is less severe.

Cold burns: This is also called “frostbite,” where damage to skin happens due to freezing. Some

cases of frostbite happen as a result of being outside in freezing temperatures, while others can

happen by direct contact with very cold objects for a prolonged period of time.

Thermal burn: Touching a very hot object raises the skin temperature to the point that your skin

cells start dying. Some cases include very hot metals, scalding liquids, Steam, and flames.

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Radiation burn: Some sources of radiation burn include sun (Sunburn), X-rays or radiation

therapy to treat cancer.

Chemical burns. The chemical reaction with skin can damage it including strong acids, solvents

or detergents resulting in symptoms of skin burn.

Electrical burns: If a person gets in contact with a strong electrical current, the heat and energy

will cause the skin to burn, before more damage to other organs and potentially death.

My Internship Journal

My internship was composed of five full day sessions that span the burn unit in Queen

Elizabeth's main hospital in Birmingham and several of the satellite hospitals in the area. I also

participated in a regional consultation conference in England where the senior consultants met to

discuss the most severe cases, burn stormed solutions and used cross-county/cross-hospital

capabilities to provide the best care possible. I was engaged with the following activities on each

of the days of my internship:

● Shadowed a senior consultant

● Collaborated with many junior doctors

● Worked with/Observed many nurses

● Interacted with many administrators

● Attending Patient Consultations sessions

● Attending Senior Consultant conference

Some highlights of my days at my internship are documented below.

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Day 1 (June 25, 2018):

My first day started with the very early arrival of 7:30am, via public bus transportation that I

arranged via the internet the night before (I purchased a week’s bus pass as this was most cost

effective), to complete the administrative attachment paperwork and receive an issued

identification badge. I was also informed of the rules, procedures and prohibitions. My senior

mentor took me around and introduced me to the staff physicians, nurses and healthcare workers.

My mentor was one of the consulting surgeons in the burn ward dealing with healing and

reconstructive surgeries to the patients. Our first task was to go around the burn ward to check

the status, chemistry and the progression of treatment on all the patients. One of the major

pledges that I had to give is that I could not reveal the identity of the patients or the very minute

details of the case outside the Queen Elizabeth Hospital community. However, I was granted

permission to prepare this report and give talks on exemplar cases, causes, and treatments.

I also observed dressing being changed for numerous patients.

One of our most severe cases was a male patient that had over 70% of his body burned because

of a water heater explosion. The burns varied between 1st and 2nd degree burns. He was in

agony and could not even speak normally. The patient had a feeding tube and he was wrapped

from head to toe with dressing and had to use large amount of anesthetics to keep him semi-

comfortable when changing the dressing. The other patient had 15% of his body burned 2nd

degree and 3rd degree burns. The patient was using fireworks where several exploded next to

him. The burns were severe on his leg and he was in really bad shape. The burned skin and

flesh were red white and some charred black and were oozing. He had been enjoying backyard

fun using high powered explosives when the accident happened. The patient needed to go to

surgery to remove damaged cells and get a skin graft on exposed wounds. The prognosis was

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that he would live with visible scars for the rest of his life. The next patient was a woman that

had 5% burns of her body of 2nd degree severity. The injuries were on her legs after the curling

iron fell on her legs while she was sitting. One of the factors here was that the lady was

intoxicated and responded very slowly compared to the average person resulting in expanded

damage to her body.

Some of the other cases included a patient that that had a stab cauterize wound. The patient was

working on an exterior gate where he encountered a jammed lock. He proceeded to hit it real

hard with his palm. The protruding part of the lock stabbed him in the middle of his palm. His

friend convinced him that the way to stop the bleeding and get rid of the pain is to cauterize the

wound with a hot knife just like it was done in the renaissance age. This middle-aged man who

was partially intoxicated with his friends proceeded to use a torched kitchen knife to cauterize

the wound. Early next morning, his pain became intolerable, got blisters, and he started to lose

functionality of his hand and got scared. He arrived at the ER in the morning where they

stabilized him and sent him to the burn ward for proper treatment. He underwent a procedure

that removed the blisters cleaned and was evaluated. Since the burn was so severe, he needed a

skin graft. The palm skin is somewhat different from other parts of the body and only

interchangeable with the other palm of his hand or the heel of the foot, so there a need for more

treatment for this patient.

I also went to the surgery theater with the senior consultant where he was prepping a patient for

surgery, explaining the procedure and expectations. After answering all questions by the patient,

the anesthesiologist proceeded to administer the medication, and the surgery staff took their

positions. The procedure took 4 hours, then the patient was rolled out to the recovery room.

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That day, I also went with other staff doctors observing checking on patients, assessing care

procedures and consultations among the physician and surgeon to ensure proper care is given. I

also observed other hospital duties with other doctors including educating staff and learning

about newest medications.

Day 2 (June 26, 2018):

The second day I accompanied my mentor to an auxiliary hospital and clinic where he was

scheduled for duty. Again, after introductions to the medical and surgical staff, I was guided to

the consultants office where he was going over the cases, and he took time to explain to me the

patients background and the recommendations from their physicians on what surgery is

recommended; and his evaluation of the case based on the expected outcome and the level of risk

the patient will be subject to. Soon after, the patient was brought in and the physical

examination was performed, followed by an honest and clear discussion with the patient on the

risks, expected outcome and the surgeon recommendations. The physical examinations were of

different types, some were first seen by the surgeon to evaluate the potential for surgery, other

patients were seen that underwent previous surgeries and were examined to see if there is a need

for a second surgery, or if they are ready to be released, and the final type of exam were on

recovering cancer patients that are back because signs of cancer were detected.

They day included observation of over 25 patients in the morning, and about the same for the

afternoon. Many of the observed patients needed to have surgeries.

One of the patients was a middle-aged lady that had third degree burns on her arm because of a

kitchen accident. She had her first surgery few weeks before and is there to be seen to be

evaluated for a skin graft surgery that she needs. After examining the old surgery and the open

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wounds, he confirmed the need for the skin graph to continue the healing process. I started to

learn the process of healing the most urgent aspect of the injury and then coming back for

multiple procedures to make sure that the body is ready to accept the next stage of the treatment.

The procedure was to extract some of the skin of her right thigh and prepare it and place it on her

left forearm to help it heal from the severe burn.

There was an elderly gentleman that came over many years after his melanoma was extracted by

surgery. The patient and his daughter were there for evaluation because the father has new

regions of suspected melanoma and wanted the surgeon to evaluate. There was another

complication where the patient has Alzheimer’s and was not well enough to make up his mind on

what he should do. The evaluation confirmed the suspicion of recurrence of melanoma and the

recommendation was to go for a second surgery. The case was discussed with the daughter in

the presence of the father and she agreed that they would do the second surgery to prohibit the

spread to more skin or internal organs. The patient and his daughter were guided to schedule the

surgery. There were multiple other patients with suspected skin cancer that were there for

confirmation and for treatment for either the first time, or recurrent cancer. Some patients had

small lesions on their face, eyelid, back, legs and neck. The patient that were confirmed, they

were scheduled to come back for surgery.

The evening included a visit to his private clinic where patients were awaiting his evaluation for

further work. There were three patients that were there for cosmetic surgeries to deal with old

injuries or ailments and two that were three for additional surgeries to deal with cancer and one

for a burn. Other were there for consultations and for second opinion before going into surgery.

Day 3 (June 27, 2018):

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My third day was another special day where I accompanied my mentor to the Regional

conference of consulting surgeons and doctors from the midland area of England. The

conference is a quarterly conference event that is focused on learning, sharing of data, and

collaborating on best approaches and ways forward to treat patients.

The conference format was made up of talks by each of the consulting physicians presenting the

complicated cases that they and their staff saw in their respective hospitals. The discussions

included the treatment methods and the degree of the success and the expediency of recover of

the patients. The consultant made recommendations based on their expertise of new or

improved methods to treat such cases if they were to present again. Some of the discussions

were about cases that failed to achieve the desired outcome due to complications or sensitivities

to certain elements. Others are hard cases that required multiple procedures to correct the injury

and bring the patient to a place as close as possible to pre-injury.

There was another segment of the conference where the surgeons discussed different

technologies and medications that can help with alleviating pain, and reconstruction of injuries.

The technologies included diagnoses of cancer, potential better way to deal with dressing

patients wounds and burns and ways to help disinfecting burn.

Day 4 (June 28, 2018):

The fourth day started like day one, with the rounds on all the patients in the burn ward. I was

with a second consulting physician and several junior doctors that were working with patients. I

Observed multiple operations including first triage functions to assess and clean the wounds and

witnessed several reconstructive surgeries. The skin grafts procedure was being prepared by

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cleaning the areas of skin where the skin grafts will be removed and the areas where the skin will

be applied to heal a stubborn wound.

One of the patients that came back today was the Middle-aged man stab wound from my day 1.

He came in for checkup, replacing the dressing, picking up additional medicated dressing and

getting additional pan killer. His wound was looking better but still needed healing time before

the doctors can perform a successful skin graft to help him in the healing process.

There was another Lady in her early 30s with severe sunburn over much of her body; but more

concentrated in her legs and thigh. The doctors took her to the operating theater to help remove

the blistering and remove the dead skin. They also covered her skin with cool wrapping and

exterior warp to reduce pain in legs. She was advised to keep all wound clean and change the

dressing and come back for re-assessment.

Day 5 (June 29, 2018):

This day started the usual way with doing the rounds checking on all the patients in the burn

ward. The teenaged girl came in with 1st and 2nd degree burn and blisters from spilling hot water

on her hands and legs. The burn was evaluated and treated with cleaning and dressing. The

assessment was to determine if there will be any permanent scarring and what bets course of

action to minimize that possibility. After treatment, the patient was prescribed a course of action

to keep the burn clean, moist and ventilated. She was advised to come back for check up again

in a couple of days.

One of the other cases that was different from any that I saw was a case of bad skin reaction to

chemicals. The case here was the whole patients body was covered with rashes and blisters due

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to allergy to medication. Since most of the patient’s body was covered with painful blisters, the

staff checked on him and gave him medications to alleviate the pain. They proceeded to take him

to a special room to remove the blisters and place him in a warm and humid isolation

environment to preserve the integrity of the inner layers of skin since the outer layers were dead.

The treatment was to include measures to ensure inner layers of skin can stay alive after

exposures and because they lost the usual external barriers that they had. The patient was kept in

the specially equipped room for recovery. The rest of the day was filled with many other cases

where I observed operation and observed dressings being changed. I also was part of consulting

sessions where the physicians and surgeons discussed cases and complications. One of the most

important things that I learned is that the physicians and surgeons face different cases every day

that are totally different than what they studied in books. They build their expertise and consult

with each other to give every patient the best potential outcome. However, the patients are all

different and the cases are never straight forward, many complications, allergies and

physiologies that makes every case a unique scenario.

Conclusions

My experience at the Queen Elizabeth Hospital in Birmingham, UK interning with Dr.

Azzam and his skilled medical staff gave me an amazing real-world view into the day-in-the-life

of a highly accomplished and talented reconstruction surgeon. This opportunity has allowed me

to reflect on my goals and objective of my life. Through this experience, I confirmed my desire

to help people in need. I also realized that being a surgeon requires a variety of expertise not just

in human anatomy and medical techniques but excellent communication skills, compassionate

views, and a firm understanding of technology. As a surgeon you must listen, think quickly,

exhibit empathy, caring, and concern and act precisely. A surgeon also needs to be able to

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communicate well with both patients and colleagues to give the best possible patient care. I also

learned that research keeps on extending the boundaries of healing the human body. For

example a few decades ago, burns covering 50% of the human body resulted in fatality;

however, thanks to research today people with burns covering 90% of their bodies can survive,

although they often have permanent impairments and scars [11].

Although I see the next generation of medicine will use the latests technologies to aid the

physician and surgeon to diagnose diseases, patient recovery, and even recommend a course of

treatment; however, for the foreseeable future, the human role continues to be essential. During

and after surgeries, robots can also play an important role under the supervision and control of

medically astute humans. Finally, within the field of artificial intelligence, internal medication

dispensing, life support and limbs, I see technology can be very useful to improve the quality of

life and lifespan for patients while the physician, surgeons, engineers and programmers are

developing new methods and procedures to further improve these technologies.

My internship at Queen Elizabeth Hospital was a rewarding and life affirming experience

for me; and I would never have been more sure of my desired path without this valuable

experience. My sincere gratitude and appreciation to the work experience team, Dr. Azzam, and

their most impressive medical staff at the Queen Elizabeth Hospital!

Cited References

[1] https://en.wikipedia.org/wiki/Queen_Elizabeth_Hospital_Birmingham
[2] https://abcnews.go.com/US/jimmy-carter-due-treatment-melanoma-brain/story?id=33198223
[3] https://integumentarytava.weebly.com/anatomy.html
[4] https://www.epa.gov/sites/production/files/sunwise/images/melanoma_incidence_usmap.gif

[5] https://www.brintonlakedermatology.com/melanomaskin-cancer/

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[6] https://uvderm.com/melignant-melanoma/
[7] https://i.pinimg.com/564x/28/6a/76/286a761d37d9a8edae7d645f2978c86f.jpg
[8] https://www.hopkinsmedicine.org/healthlibrary/conditions/dermatology/burns_85,P01146

[9] US national Laboratory for medicine: https://medlineplus.gov/ency/imagepages/1078.htm

[10] webMD: https://www.webmd.com/first-aid/types-degrees-burns#1
[11] https://www.nigms.nih.gov/education/pages/factsheet_burns.aspx

Other Recommended References

[12] https://www.webmd.com/skin-problems-and-treatments/picture-of-the-skin#1 (Web MD)
[13] https://www.hopkinsmedicine.org/dermatology/index.html (Johns Hopkins University)
[14] https://scholars.duke.edu/display/pub681047 (Duke University)
[15] https://www.ncbi.nlm.nih.gov/pubmed/9300196 (Columbia University)
[16] https://www.health.harvard.edu/topics/skin-cancer (Harvard University)
[17] https://www.keckmedicine.org/these-innovative-technologies-are-tackling-skin-cancer-in-new-ways/
(University of Southern Califirnia)
[18] http://news.cornell.edu/stories/2017/10/new-findings-explain-how-uv-rays-trigger-skin-cancer
(Cornell University)
[19] https://www.cancer.gov/types/skin/hp
[20] https://www.nigms.nih.gov/education/pages/factsheet_burns.aspx

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