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Foo20151013 2023 quzkes?1444774189
5
612

Hello World, I've been to London's Air Ambulance for a bit...

Hi. Or rather, #HelloMyNameIs Adam. I like trauma, emergency medicine, PHEC, #FOAMed, twitter and scuba diving (but only when there's sunshine involved afterwards). I also like teaching and education, and I'm one of the final year medical students here in Edinburgh. But for 2 months I wasn't. I was one of the London's Air Ambulance elective students down in Whitechapel at the Royal London Hospital. So as an opening gambit, and by some way of an introduction I thought you might want to hear about that. After all, they're much more interesting than I am, and I can't host you for your elective… I managed to swindle my way into a 2 month elective with LAA just before Christmas 2014 and in a word it was pretty great. For those of you thinking of doing it, just go, now, and apply. Then you can come back and read the rest of my ramblings. For the rest of you, here’s what happened. LAA electives are a bit different, unsurprisingly. To cover its 1800-odd missions a year, LAA runs both their trauma service in two flavours: a helicopter (G-EHMS, aka “Mike Sierra” or MEDIC 1) by day and a car (DA “Delta Alpha” 77 or MEDIC 1 NIGHT) by night, (because apparently, whilst sporting and enjoyable for the pilots, landing in metropolitan areas in the dark is too risky, especially with comparatively empty roads). Alongside the trauma service, there is also a Physician Response Unit (PRU) which responds locally to cardiac arrests to provide quality CPR (along with some advanced post-arrest care like cooling and delivery to a cath lab), but for the most part does jobs for the London Ambulance Service which have been deemed probably not to require hospital, but might benefit from a doctor. There’s a 5 year waiting list for day-time flying shifts, and not much less for the rest of their work, so you’re not going to spend 4, 6 or 8 weeks in a helicopter flying round London taking names and saving lives, in fact the helicopter schedule is totally off-limits to students. Instead you’ll start off scheduled for a couple of night shifts each month and there will be opportunities to see a lot of London Ambulance Service, from the “control” at the Emergency Operations Centre (EOC), to time spent with road crews, and, off the back of some of the folk you’ll meet, a route in to observing with some more specialist units too. (More on that in the future if I run out of other ideas!) As well as the “live” experience there are 5 very experienced senior registrars from a variety of backgrounds as well as the 4 full-time LAA consultants, and opportunities to learn both practical skills and theoretical knowledge from them abound. As it turned out, the PRU was probably my favourite part of the elective. You can read about all the trauma that LAA goes to elsewhere, its splashed all over their shiny new website for a start, and many things have been written about their work (I might even write some more later on!) and there’s even a (not great) telly program on Channel 5. But the PRU is just really cool. I hate that word but it is. It fits into a strange, but now expanding niche in emergency care. That is, it serves to lighten the load both on the ambulance service and on the Emergency Departments of London by going out to people who have called 999 and asked for an ambulance but might in fact be better managed in the community. The work is incredibly varied, you can see older folk with a nasty UTI who couldn’t get to see their GP, you can go to a school and glue the head of a kid who’s taken a nasty fall in the playground, or you can end up in some sheltered housing talking to a lady who’s having the roughest of times and trying to deal with borderline personality disorder to boot. The PRU is crewed about half the time by a small group of GPs and EM docs who have been doing it for a while, usually about once a week or so, and quite often in their own time (in between the rota is made up with the LAA docs who usually work the trauma service). They’re kept firmly in line by an experienced LAS paramedic who is seconded over to run this unit, 9-5, 5 days a week, usually for about a year. As a team, they have perfected their ability to assess a patient using the minimal resources available to them, and as we are so often reminded, quite rightly, it turns out to be all in the history. Some interventions are available to them that aren’t available to paramedics, prescribing antibiotics or other drugs to leave with the patient, bypassing the ED for referral straight to specialists, and doing urine dipsticks being the most used among them; but mostly it is the team’s experience and advanced clinical judgement which makes this unit tick, and empowers them to safely leave so many of their patients at home, with care delivered, advice given, and a plan arranged should anything deteriorate. This wasn’t my first rodeo, I’ve been lucky enough to spend some time with the Scottish Ambulance Service up here in Edinburgh, and have spent more than my fair share of time in our Emergency Department, but it was still impressive to see how these guys dealt with the delicate balance of who to leave at home and who might need a further investigation in hospital. Firstly, this is something that anyone who aspires to work in an emergency department should aspire to be comfortable to do. There are going to be a huge number of people who don’t need to be admitted coming through it every day, wherever it is. The faster and more confidently you can identify their problems, treat them, and crucially, reassure them with appropriate advice, good follow up and a safety net, the better experience they will have. Of course much of this comes with experience and training, but tagging along with teams like this is a fine way to start getting some. Secondly, and this is a bit of a stab in the dark, but I think this idea really might take off. The media is almost swamped with stories of A&E departments being overwhelmed, ambulance services are operating at or near capacity, and we’re struggling to work out how we get the public to access the right care provider for their problem at that time. So maybe this is a solution. Maybe doctors, have a new role to play in assessing people earlier rather than people going through so many steps down a potentially unsuitable line of care. We’re starting to see consultants running triage at A&Es, we’re starting to see doctors out in cars like this. Get in on the ground floor guys and girls, I think we’re going to start being “first on scene” a little more often than we might be used to, even if you never leave the hospital.  
Adam Collins
over 5 years ago
Foo20151013 2023 86qh1h?1444774193
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570

Thou shalt not doubt oneself in front of the patient

As part as my paediatrics attachment, I was having peripheral nervous system bed side teaching. We had spoken over the examination and I was first up to practice on 4 year old Jake. One consultant and 3 other medical students looked on as I worked my way through the examination. My general inspection and impression of the child got approving nods from my colleagues. Phew! Next up was actual exam “two people can’t resist…” I recalled in my head. First up, tone. I assessed this correctly and nothing had gone majorly wrong yet. Relief. Power was next. “ok, so put out your arms up like this and resist me…ok, no, not like that..erm..oh god…I don’t know how to explain it”. My colleagues looked on. The consultant chipped in “tell him to touch his shoulders”. It did the trick and I was able to get through the rest of the examination without too many hiccups. When we had finished, in classic med school fashion I had to reflect on what had just happened and then say something I did good and something I could have done better. My good thing was “I got through it..I mean I remembered everything”. My bad thing was “I wasn’t good at explaining power to him”. My feedback wasn’t the same as my bad thing though. My feedback was “be more confident. You did everything correctly and didn't forget anything. I think it’s a girl thing. You doubt yourselves more than the boys”. Next up was a male medical student’s turn. He did the examination just fine but there were things that I could pick out that he could have done better and being totally objective my examination was better. But there was a major difference. His confidence. He seemed like he knew what he was doing and when he went wrong or missed something out, he just added it to the end of his examination. If I were his examiner, I would have found it difficult to fault him. He appeared confident and as a patient that inspires confidence and a happy patient makes for a happy examiner and good marks. After the session, I got to thinking: am I really incompetent or am I just underestimating my own ability which is making me lack confidence? The fact that a paediatric consultant and all my colleagues told me that my examination was fine, good even, answers the first part. I am not incompetent. So I must be underestimating my own ability. And if I am, is that something that is unique to me? Or are other medical students doing that too? And more interestingly to me, is this something that the female medical students are doing more than their male colleagues?  
Salma Aslam
over 5 years ago
Foo20151013 2023 13vodzp?1444774194
9
160

Is ADHD a difficult diagnosis?

In a recent article in the BMJ the author wonders about the reasons beyond the rising trend diagnosing Attention Deficit Hyperactivity Disorder (ADHD). The article attempts to infer reasons for this. One possible reason was that the diagnostic criteria especially DSM may seem for some to be more inclusive than ICD-10. The speculation may explain the rise of the diagnosis where DSM is used officially or have an influence. In a rather constructive way, an alternative to rushing to diagnosis is offered and discussed in some details. The tentative deduction that the Diagnostic Statistical Manual (DSM) may be one of the causes of rising diagnosis, due to raising the cut-off of age, and widening the inclusion criteria, as opposed to International Classification of Diseases, 10th revision (ICD-10), captured my attention. On reading the ICD-10 diagnostic criteria for research (DCR) and DSM-5 diagnostic criteria, I found them quite similar in most aspects, even the phraseology that starts with 'Often' in many diagnostic criteria, they seem to differ a bit in age. In a way both classification, are attempting to describe the disorder, however, it sounds as if someone is trying to explain a person's behaviour to you, however, this is not a substitute to direct clinical learning, and observing the behaviour, as if the missing sentence is 'when you see the person, it will be clearer'. El-Islam agrees with the notion that DSM-5 seems to be a bit more inclusive than ICD-10. A colleague of mine who is a child psychiatrist and she is doing her MSc. thesis in ADHD told me, that DSM-5 seems to be a substantial improvement as compared to its predecessor. The criteria - to her - though apparently are more inclusive, they are more descriptive with many examples, and she infers that this will payback in the reliability of the diagnosis. She hopes gene research can yield in biological tests for implicated genes and neurotransmitters in ADHD e.g. DRD4, DAT, gene 5,6,11 etc. One child psychiatrist, regretted the fact that misdiagnosis and under-diagnoses, deprive the patient from one of the most effective treatments in psychiatry. It is hoped the nearest forthcoming diagnostic classification (ICD-11), will address the issue of the diagnosis from a different perspective, or else converge with DSM-5 to provide coherence and a generalised newer standard of practice. The grading of ADHD into mild, moderate, and severe seem to blur the border between disorder and non-disorder, however, this quasi-dimensional approach seems realistic, it does not translate yet directly in differences in treatment approaches as with the case of mild, moderate, severe, and severe depression with psychotic symptoms, or intellectual disability. The author states that one counter argument could be that child psychiatrists are better at diagnosing the disorder. I wonder if this is a reflection of a rising trend of a disorder. If ADHD is compared to catatonia, it is generally agreed that catatonia is less diagnosed now, may be the epidemiology of ADHD is not artefact, and that we may need to look beyond the diagnosis to learn for example from environmental factors. Another issue is that there seems to be significant epidemiological differences in the rates of diagnosis across cultures. This may give rise to whether ADHD can be classified as a culture-bound syndrome, or whether it is influenced by culture like anorexia nervosa, or it may be just because of the raising awareness to such disorders. Historically, it is difficult to attempt to pinpoint what would be the closest predecessor to ADHD. For schizophrenia and mania, older terms may have included insanity, for depression it was probably melancholia, there are other terms that still reside in contemporary culture e.g. hypochondriasis, hysteria, paranoia etc. Though, it would be too simplistic to believe that what is meant by these terms was exactly what ancient cultures meant by them, but, they are not too far. ADHD seems to lack such historical underpinning. Crichton described a disorder he refers to as 'mental restlessness'. Still who is most often credited with the first description of ADHD, in his 1902 address to the Royal College of Physicians. Still describes a number of patients with problems in self-regulation or, as he then termed it, 'moral control' (De Zeeuw et al, 2011). The costs and the risks related to over-diagnosis, ring a warning bell, to enhance scrutiny in the diagnosis, due to subsequent stigma, costs, and lowered societal expectations. They all seem to stem from the consequences of the methodology of diagnosis. The article touches in an important part in the psychiatric diagnosis, and classifications, which is the subjective nature of disorders. The enormous effort done in DSM-5 & ICD-10 reflect the best available evidence, but in order to eliminate the subjective nature of illness, a biological test seems to be the only definitive answer, to ADHD in particular and psychiatry in general. Given that ADHD is an illness and that it is a homogeneous thing; developments in gene studies would seem to hold the key to understanding our current status of diagnosis. The suggested approach for using psychosocial interventions and then administering treatment after making sure that it is a must, seems quite reasonable. El-Islam, agrees that in ADHD caution prior to giving treatment is a recommended course of action. Another consultant child psychiatrist mentioned that one hour might not be enough to reach a comfortable diagnosis of ADHD. It may take up to 90 minutes, to become confident in a clinical diagnosis, in addition to commonly used rating scales. Though on the other hand, families and carers may hypothetically raise the issue of time urgency due to scholastic pressure. In a discussion with Dr Hend Badawy, a colleague child psychiatrist; she stated the following with regards to her own experience, and her opinion about the article. The following is written with her consent. 'ADHD is a clinically based diagnosis that has three core symptoms, inattention, hyperactivity and impulsivity in - at least - two settings. The risk of over-diagnosis in ADHD is one of the potentially problematic, however, the risk of over-diagnosis is not confined to ADHD, it can be present in other psychiatric diagnoses, as they rely on subjective experience of the patient and doctor's interviewing skills. In ADHD in particular the risk of under-diagnosis is even more problematic. An undiagnosed child who has ADHD may suffer various complications as moral stigma of 'lack of conduct' due to impuslivity and hyperactivity, poor scholastic achievement, potential alienation, ostracization and even exclusion by peer due to perceived 'difference', consequent feelings of low self esteem and potential revengeful attitude on the side of the child. An end result, would be development of substance use disorders, or involvement in dissocial behaviours. The answer to the problem of over-diagnosis/under-diagnosis can be helped by an initial step of raising public awareness of people about ADHD, including campaigns to families, carers, teachers and general practitioners. These campaigns would help people identify children with possible ADHD. The only risk is that child psychiatrists may be met with children who their parents believe they might have the disorder while they do not. In a way, raising awareness can serve as a sensitive laboratory investigation. The next step is that the child psychiatrist should scrutinise children carefully. The risk of over-diagnosis can be limited via routine using of checklists, to make sure that the practice is standardised and that every child was diagnosed properly according to the diagnostic criteria. The use of proper scales as Strengths and Difficulties Questionnaire (SDQ) in its two forms (for parents SDQ-P and for teachers SDQ-T) which enables the assessor to learn about the behaviour of the child in two different settings. Conner's scale can help give better understanding of the magnitude of the problem. Though some people may voice criticism as they are mainly filled out by parents and teachers, they are the best tools available at hands. Training on diagnosis, regular auditing and restricting doctors to a standard practice of ensuring that the child and carer have been interviewed thoroughly can help minimise the risk of over-diagnosis. The issue does not stop by diagnosis, follow-up can give a clue whether the child is improving on the management plan or not. The effects and side effects of treatments as methylphenidate should be monitored regularly, including regular measurement height and weight, paying attention to nausea, poor appetite, and even the rare side effects which are usually missed. More restrictions and supervision on the medication may have an indirect effect on enhancing the diagnostic assessment. To summarise, the public advocacy does not increase the risk of over-diagnosis, as asking about suicidal ideas does not increase its risk. The awareness may help people learn more and empower them and will lead to more acceptance of the diagnosed child in the community. Even the potential risk of having more case loads for doctors to assess for ADHD may help give more exposure of cases, and reaching more meaningful epidemiological finding. From my experience, it is quite unlikely to have marked over-representation of children who the families suspect ADHD without sufficient evidence. ADHD remains a clinical diagnosis, and it is unlikely that it will be replaced by a biological marker or an imaging test in the near future. After all, even if there will be objective diagnostic tests, without clinical diagnostic interviewing their value will be doubtful. It is ironic that the two most effective treatments in psychiatry methylphenidate and Electroconvulsive Therapy (ECT) are the two most controversial treatments. May be because both were used prior to having a full understanding of their mechanism of action, may be because, on the outset both seem unusual, electricity through the head, and a stimulant for hyperactive children. Authored by E. Sidhom, H. Badawy DISCLAIMER The original post is on The BMJ doc2doc website at http://doc2doc.bmj.com/blogs/clinicalblog/#plckblogpage=BlogPost&plckpostid=Blog%3A15d27772-5908-4452-9411-8eef67833d66Post%3Acb6e5828-8280-4989-9128-d41789ed76ee BMJ Article: (http://www.bmj.com/content/347/bmj.f6172). Bibliography Badawy, H., personal communication, 2013 El-Islam, M.F., personal communication, 2013 Thomas R, Mitchell GK, B.L., Attention-deficit/hyperactivity disorder: are we helping or harming?, British Medical Journal, 2013, Vol. 5(347) De Zeeuw P., Mandl R.C.W., Hulshoff-Pol H.E., et al., Decreased frontostriatal microstructural organization in ADHD. Human Brain Mapping. DOI: 10.1002/hbm.21335, 2011) Diagnostic Statistical Manual 5, American Psychiatric Association, 2013 Diagnostic Statistical Manual-IV, American Psychiatric Association, 1994 International Classification of Diseases, World Health Organization, 1992  
Dr Emad Sidhom
over 5 years ago
Foo20151013 2023 8occ4b?1444774213
4
135

A taste of someone else's medicine

Choosing a career path is one of the hardest (non-clinical) decisions many doctors will face in their professional lives. With almost 100 specialties and sub-specialties available, settling on any one career can seem pretty daunting, particularly as in the majority of cases the choice will set a path you’re likely to be on for the next 30+ years. But, with only a very small range of these specialties and almost none of the sub-specialties available to undertake as rotations during any one foundation programme, finding out what actually working in different specialties is like can be difficult. It’s likely you’ll have at least identified an area you’re kind of/maybe interested in before starting the foundation programme but, to use a total cliché, you wouldn't buy a car without taking it for a test drive, right? There is good evidence to show that any experience, even if only brief, can be very influential on career choice and this is why all deaneries offer new doctors to undertake a ‘taster week’ at some point during the Foundation Programme. This is usually from 2-5 days, taken as study leave, in a specialty of the doctor’s choosing which they haven’t and won’t work during their foundation programme. Most hospitals will allow doctors to do this at an external hospital or organisation if the desired specialty isn't available locally. Tasters are often organised by the trainee but deaneries are encouraged to provide a list or register of structured taster programmes to its trainees. A timetable split into half-day activities, including time for 1:1 discussion with both consultants and trainees, should be provided or agreed with a supervisor, which gives the doctor as broad an experience of the roles, responsibilities, highlights, challenges and lifestyle of the specialty as possible. This should then give the doctor plenty of food for thought and provide an opportunity for (you guessed it) reflection to confirm or exclude that specialty as a career choice and identify (if the former) what steps they need to take to get there. At the end of the experience the doctor should fill in a feedback form and formally reflect in their portfolio. Taster weeks aren't limited to particular specialties and sub-specialties either; there are plenty of more over-arching opportunities such as experiencing leadership and management roles or getting involved in academia, research or medical education. As long as you can identify and describe what you’ll aim to learn or understand from the experience, almost any taster is possible. So, how do you go about it? Each deanery should have a policy relating to taster weeks, or have an responsible administrator who can provide advice. Talking to your educational supervisor can also be really useful. Considering early on in FY1 which area or specialty you want to explore is important; time runs out scarily quickly and taking time out of rotations needs careful planning and co-ordination to make sure there is enough cover for your day job. You may already know or have identified an appropriate supervisor who will facilitate the experience but if not, your supervisor or administrator will almost certainly be able to point you in the right direction. You’ll never get to experience every possible career path before starting out on one; the specialty or sub-specialty you eventually work in may not even exist yet. But getting an idea of what you’ll definitely consider, or definitely won’t, will give you a better chance of identifying something that will suit you personally and professionally, and, particularly in the more competitive and run-though specialties will give you another example of commitment to specialty. Don’t be afraid to think outside the box or look at something really niche – it may give you a taste for something unexpected that you’ll love for life. References: http://www.foundationprogramme.nhs.uk/download.asp?file=Tasters_guidance_2011_final-2.pdf  
Dr Lydia Spurr
over 5 years ago
Foo20151013 2023 1nftkgk?1444774218
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297

Gin & Tonic Anyone?

It was a Saturday, about tea-time in the quaint village of Athelstaneford, East Lothian. Mrs Alexandria Agutter sat in her cottage, enjoying the delights of the late-summer evening with a glass of gin and tonic. She listlessly sipped from the rather generous pick-me up, no doubt chewing over the happenings of the day. Blast! The taste was much too bitter to her liking. She stood up. And promptly crumpled to the floor in a dizzied heap. It had not been five minutes when a fiery pain gripped her parched throat and in her frenzied turn she watched the bleary room become draped in a gossamery silk. How Dame Agatha would approve. But this is no crime novel, on that fateful day, 24th August 1994, poor Mrs Agutter immortalised herself in the history books of forensic medicine; she was the victim of a revered toxin and a vintage one it was too. She had unwittingly imbibed a G&T laced with a classic poison of antiquity. A clue from the 21st century: do you recall the first Hunger Games film adaption? Those inviting purple-black berries or as Suzanne Collins coined them ‘Nightlock’; a portmanteau of hemlock and Deadly Nightshade. True to the laters’ real life appearance those onscreen fictional fruits played a recurring cameo role. Deadly Nightshade is a perennial shrub of the family Solanaceae and a relative of the humble potato (a member of the Solanus genus). It is a resident of our native woodland and may be found as far afield as Europe, Africa and Western Asia. The 18th century taxonomist, Carl Linnaeus gave the plant an intriguing name in his great Species Plantarum. The genus Atropa is aptly named after one of the three Greek Fates, Atropos. She is portrayed shearing the thread of a mortal’s life so determining the time and manner of its inevitable end. The Italian species name belladona (beautiful woman) refers to the striking mydriatic effect of the plant on the eye. The name pays homage to Pietro Andre Mattioli, a 16th century physician from Sienna, who was allegedly the first to describe the plant’s use among the Venetian glitterati - ladies of fashion favoured the seductive, doe-eyed look. Belladona is poisonous in its entirety. It was from the plant’s roots in 1831, the German apothecary Heinrich F. G. Mein isolated a white, odourless, crystalline powder: it was (surprise, surprise) atropine. Atropine is a chiral molecule. From its natural plant source it exists as a single stereoisomer L-atropine, which also happens to display a chiral potency 50-100 times that of its D-enantiomer. As with many other anaesthetic agents it is administered as a racemic mixture. How strange that atropine now sits among the anaesthetist’s armamentarium, its action as a competitive antimuscarinic to counter vagal stimulation belies its dark history. It was a favourite of Roman housewives seeking retribution against their less than faithful husbands and a staple of the witch’s potion cupboard. Little wonder how belladona became known as the Devil’s plant. Curiouser still it’s also the antidote for other poisons, most notably the organophosphates or nerve gases. On account of its non-selective antagonism, atropine produces a constellation of effects: the inhibition of salivary, lacrimal and sweat glands occurs at low doses; dry mouth and skin are early markers. Pyrexia is a central effect exacerbated by the inability to sweat. Flushing of the face due to skin vessel vasodilatation. Low parasympathetic tone causes a moderate sinus tachycardia. Vision is blurred as the eye becomes dilated, unresponsive to light and accommodation is impaired. Mental disorientation, agitation and ataxia give the impression of drunkedness or a delirium tremens like syndrome. Visual hallucinations, often of butterflies or silk blowing in the wind, are a late feature. It was then that Mr Agutter, seemingly untroubled by the sight of his wife’s problematic situation, proceeded to leave a message with the local practitioner. How fortunate they were to have the vigilant locum check the answering machine and come round to the Agutter’s lodge accompanied by an ambulance crew. The attending paramedic had the presence of mind to pour the remainder of Mrs Agutter’s beverage into a nearby jam jar, while Mr Agutter handed over what he suspected to be the offending ingredient: the bottle of Indian tonic water. As it soon transpired there were seven other casualties in the surrounding countryside of East Lothian – all involving an encounter with tonic water. In fact by some ironic twist of fate, two of the victims were the wife and son of Dr Geoffry Sharwood-Smith, a consultant aneasthetist. Obviously very familiar with the typical toxidrome of anticholinergic agents, he was quick to suspect atropine poisoning. Although for a man of his position with daily access to a sweetshop of drugs, it was not something to draw attention to. Through no small amount of cunning had the poisoner(s) devised the plan. It was elegant; atropine is very bitter. So much so that it can be detected at concentrations of 100 parts per million (0.001%). Those foolish enough to try the berries of belladonna during walks in the woods are often saved by the berry’s sour taste. They are soon spat out. But the quinine in the tonic water was a worthy disguise. The lethal dose for an adult is approximately 90-130mg, however atropine sensitivity is highy variable. In its salt form, atropine sulfate, it is many times more soluble: >100g can be dissolved in 100ml of water. So 1ml may contain roughly tenfold the lethal dose. There ensued a nationwide scare; 50 000 bottles of Safeway branded Indian tonic water were sacrificed. Only six bottles had been contaminated. They had all been purchased, tops unsealed, from the local Safeway in Hunter’s Tryst. Superficially this looked like the handiwork of a psychopath with a certain distaste for the supermarket brand, and amidst the media furore, it did have some verisimilitude: one of the local papers received a letter from 25 year old, Wayne Smith admitting himself as the sole perpetrator. The forensic scientist, Dr Howard Oakley analysed the contents of the bottles. They all contained a non-lethal dose, 11-74mg/litre of atropine except for the Agutter’s, it contained 103mg/litre. The jam jar holding Mrs Agutter’s drink bore even more sinister results, the atropine concentration was 292mg/L. It would appear Mrs Agutter had in some way outstayed her welcome. But she lived. A miscalculation on the part of the person who had added an extra seasoning of atropine to her drink. According to the numbers she would have had to swallow a can’s worth (330ml) to reach the lethal dose. Thankfully she had taken no more than 50mg. The spotlight suddenly fell on Dr Paul Agutter. He was a lecturer of biochemistry at the nearby University of Napier, which housed a research syndicate specialising in toxicology. CCTV footage had revealed his presence at the Safeway in Hunter’s Tryst and there was eye witness evidence of him having placed bottles onto the shelves. Atropine was also detected by the forensic investigators on a cassete case in his car. Within a matter of two weeks he would be arrested for the attempted murder of his wife. Despite the calculated scheme to delay emergency services and to pass the blame onto a non-existent mass poisoner, he had not accomplished the perfect murder. Was there a motive? Allegedly his best laid plans were for the sake of a mistress, a mature student from Napier. He served seven years of a twelve year sentence. Astonishingly, upon his release from Glenochil prison in 2002, he contacted his then former wife proclaiming his innocence and desire to rejoin her in their Scottish home. A proposition she was not very keen on. Dr Agutter was employed by Manchester University as a lecturer of philosophy and medical ethics. He is currently an associate editor of the online journal Theoretical Biology and Medical Modelling. We will never know the true modus operandi as Dr Agutter never confessed to the crime. Perhaps all this story can afford is weak recompense for the brave followers of the Dry January Campaign. Oddly these sort of incidents never appear in their motivational testimonials. Acknowledgements Emsley J. Molecules of Murder. 2008, Cambridge, RSC Publishing, p.46-67. Lee MR. Solanaceae IV: Atropa belladona, deadly nightshade. J R Coll Physicians Edinb. March 2007; 37: 77-84. Illustrator Edward Wong This blog post is a reproduction of an article published in the The Medical Student Newspaper January issue, 2014 http://www.themedicalstudent.co.uk/  
James Wong
over 5 years ago
Foo20151013 2023 e9tc1t?1444774226
5
232

Grand Round: Dos and Don’ts

“To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all.” The words of Sir William Osler, the acclaimed father of modern medicine, are still no less profound. They hark from an age when medicine still retained a sense of ceremony: an amphitheatre filled to the rafters, the clinicians poised in their white coats and ties, all eyes convergent on their quarry or rather the patient seated before them. Any memory of such scenes live out a vestigial existence in black&white photos or histrionic depictions recalling the rise of modern medicine. To think this is how the tradition of grand rounds proceeded in the not so distant past. Today grand rounds have a more tuitional flavour to them. The Socratic dialogue which reportedly took place has been superseded by the much less appetising PowerPoint presentation. It’s a weekly event marked in the calendar. For the ever-busy junior doctor it at least offers the prospect of a free lunch. I gest, they serve a social as well as an educational function. On the other hand medical student grand rounds are purely a learning exercise. They are most importantly not a race to find and present the most ‘interesting’ case in the trust because this is usually interpretted as a vanishingly rare condition, which even your ejudicating consultant has never encountered in a lifetime of experience. It falls short of the primary aim: to learn about the patients who you will be seeing as a junior doctor and as the addage goes - common things are common. What will make your grand round interesting, is not the patient you choose but how you choose to present that patient. Unfortunately, as fair a point Sir Osler makes, the old practice of patient participation in grand rounds has long since faded. You will have to call upon your thespian talents to retell the story to your fellow students. Of course not everyone’s a natural showman, however fortune favours the prepared and in my experience there are only a handful of things to worry about. Structure. This is the back bone of your presentation. Obviously a solid introductory line about the patient with all the salient points goes without saying, it’s no different to presenting to the consultant on ward rounds or in the clinic. Always set the scene. If you clerked your patient on a hectic night oncall down in majors, then say so. It makes the case less one dimensional. The history is your chance to show off - to consider the presenting complaint expressed in the patient’s own words and to form a working differential, which you can encourage your colleagues to reel off at the outset. The quality of the history should guide your audience to the right diagnosis. Equip them with all the information they need, so not just the positive findings. Showing that you have ruled out important red flag symptoms or signs will illustrate good detective work on your part. However you wish to order the relevant past medical/family history, medications, social impact etc is up to you. It’s a subjective thing, you just have to play the game and cater to the consultant’s likes. You can only gage these after a few cases so do the honourable thing and let your colleagues present first. Performance. Never read your slides in front of an audience. Their attention will rapidly wane (especially if they’re postprandial). The slides are an aide-memoire and to treat them as a script is to admit your presence adds nothing more to your presentation. Communicating with the audience requires you to present uncluttered slides, expanding on short headings and obliging your colleagues to listen for the little nuggets of clinical knowledge you have so generously lain in store. Insight. When the consultant asks you the significance of an investigation, always know on what grounds it was ordered and the limitations of the results. The astute student will be aware of its diagnostic or prognostic potential.The same may be said of imaging. Perusing the radiologists report and using it to guide the audience through (anoynmised) CXRs, CTs, US etc is a feather in your cap. Literature reviews of your choosing constitute a mandatory part of the presentation. They are demonstrative of not only your wider reading but your initiative to find the relevant evidence base e.g. the research underlying the management plan of a condition or perhaps its future treatments. Timing. Waffling is only detrimental to the performance. Rehearsing the presentation with a firm mate is a sure way to keep to time constraints. Memorability, for the right reasons, relies on a concise and interactive presentation. A splash of imagination will not go unnoticed. The consultant marking you has seen it all before; surprising titbits of knowledge or amusing quirks in your presentation will hopefully appeal to their curious and humorous side. If anything it might break the tedium grand rounds are renown for. Oratory is a universal skill and is responsible for so much (undue) anxiety. The more timid can take comfort grand rounds aren’t quite the grand occasions they used to be. Illustrator Edward Wong This blog post is a reproduction of an article published in the Medical Student Newspaper, December 2013 issue.  
James Wong
over 5 years ago
Foo20151013 2023 1u6up6r?1444774235
4
130

Keep on Truckin’

Shattered. Third consecutive day of on-calls at the birth centre. I’m afraid I have little to show for it. The logbook hangs limply at my side, the pages where my name is printed await signatures; surrogate markers of new found skills. Half asleep I slump against the wall and cast my mind back to the peripheral attachment from which I have not long returned. The old-school consultant’s mutterings are still fresh: “Medical education was different back then you see....you are dealt a tough hand nowadays.” I quite agree, it is Saturday. Might it be said the clinical apprenticeship we know today is a shadow of its former self? Medical school was more a way of life, students lived in the hospital, they even had their laundry done for them. Incredulous, I could scarcely restrain a chuckle at the consultant’s stories of delivering babies while merely a student and how the dishing out of “character building” grillings by their seniors was de rigeur. Seldom am I plied with any such questions. Teaching is a rare commodity at times. Hours on a busy ward can bear little return. Frequently do I hear students barely a rotation into their clinical years, bemoan a woeful lack of attention. All recollection of the starry-eyed second year, romanced by anything remotely clinical, has evaporated like the morning dew. “Make way, make way!...” cries a thin voice from the far reaches of the centre. A squeal of bed wheels. The newly crowned obs & gynae reg drives past the midwife station executing an impressive Tokyo drift into the corridor where I stand. Through the theatre doors opposite me he vanishes. I follow. Major postpartum haemorrhage. A bevy of scrubs flit across the room in a live performance of the RCOG guidelines for obstetric haemorrhage. They resuscitate the women on the table, her clammy body flat across the carmine blotched sheets. ABC, intravenous access and a rapid two litres of Hartmann’s later, the bleeding can not be arrested by rubbing up contraction. Pharmacological measures: syntocinon and ergometrine preparations do not staunch the flow. Blood pressure still falling, I watch the consciousness slowly ebb from the woman’s eyes. Then in a tone of voice, seemingly beyond his years, the reversely gowned anaesthetist clocks my badge and says, “Fetch me the carboprost.” I could feel an exercise in futility sprout as I gave an empty but ingratiating nod. “It’s hemabate....in the fridge” he continues. In the anaesthetic room I find the fridge and rummage blindly through. Thirty seconds later having discovered nothing but my general inadequacy, I crawl back into theatre. I was as good as useless though to my surprise the anaesthetist disappeared and returned with a vial. Handing me both it and a prepped syringe, he instructs me to inject intramuscularly into the woman’s thigh. The most common cause of postpartum haemorrhage is uterine atony. Prostaglandin analogues like carboprost promote coordinated contractions of the body of the pregnant uterus. Constriction of the vessels by myometrial fibres within the uterine walls achieves postpartum haemostasis. This textbook definition does not quite echo my thoughts as I gingerly approach the operating table. Alarmingly I am unaware that aside from the usual side effects of the drug in my syringe; the nausea and vomiting, should the needle stray into a nearby vessel and its contents escape into the circulation, cardiovascular collapse might be the unfortunate result. Suddenly the anaesthetist’s dour expression as I inject now assumes some meaning. What a relief to see the woman’s vitals begin to stabilise. As we wheel her into the recovery bay, the anaesthetist unleashes an onslaught of questions. Keen to redeem some lost pride, I can to varying degrees, resurrect long buried preclinical knowledge: basic pharmacology, transfusion-related complications, the importance of fresh frozen plasma. Although, the final threat of drawing the clotting cascade from memory is a challenge too far. Before long I am already being demonstrated the techniques of regional analgesia, why you should always aspirate before injecting lidocaine and thrust headlong into managing the most common adverse effects of epidurals. To have thought I had been ready to retire home early on this Saturday morning had serendipity not played its part. A little persistence would have been just as effective. It’s the quality so easily overlooked in these apparently austere times of medical education. And not a single logbook signature gained. Oh the shame! This blog post is a reproduction of an article published in the Medical Student Newspaper, February 2014 issue.  
James Wong
over 5 years ago
Foo20151013 2023 3cqojv?1444774240
3
95

Goodbye fear and ego, hello better patient care

The best doctors in the world still have bad consultation. Sometimes you just start off on the wrong foot. The patient leaving in a floor of tears is usually an indication that this has just occurred. On one of my medical placements I witnessed one such consultation. A young woman in the early stages of her pregnancy had a per vaginal bleed and wanted a scan to see if the pregnancy was still ok. Medically speaking, a scan wasn’t indicated as the pregnancy was too early on to detect any changes. The doctors noted the “agenda” as they later remarked, and was not going to “play the game” and send the young woman for a scan. She was not happy about this. The doctor felt that he couldn’t have done more. Medically there was nothing he could offer to the woman other than advice to go home and wait a little while before repeating a pregnancy test. To me, there was lots that could have been done. This woman was scared and worried and a sympathetic ear and a tissue would have gone some way to making her feel better. The doctor I was with couldn’t see this. They were blind sighted by the repeated requests for a scan and slightly frustrated that the unhelpfulness of this was not being understood. When the young woman began to cry I was waiting for the doctor to hand over a tissue. “Any second now...” I thought, but it never happened. I wanted to give the woman a tissue and put my arm around her but that would have meant physically placing myself between the doctor and the patients and interrupting a consultation I wasn’t really a part of. But the truth is. I was a part of that consultation. I might not have been the doctor in charge but I was another person in that room who could have made that situation easier for that patient and I didn’t. Hours later, on my way home, I was still thinking about this. I felt I had let that woman down. I could see what she needed and I sat there and did nothing. After the consultation I immediately told the doctor what I thought. I felt that the patient had been let down. They took on what I said and mostly agreed with it. All egos were put aside in that frank conversation and the doctor genuinely reflected on how they could have done better in that situation. It wasn’t about me or the doctor. It was about the patient. As a medical student it is easy to feel in the way in the hospital environment or in a busy clinic. When the consultant is running behind, it takes a lot to ask the patients something or butt in and add something you think is relevant that in the end may turn out to be a very trivial thing. But at the end of the day, it is worth it if it means that there is a better out come for the patient because when all is said and done they are the ones we are doing this all for. I regret not handing that patient a tissue and it’s a mistake I hope never to repeat again.  
Salma Aslam
over 5 years ago
Foo20151013 2023 zwf33b?1444774244
5
91

"So are you enjoying it?"

"When did the pain start Mr Smith?" "Ah so do you enjoy it?" 'It' of course refers to your five year medical degree. Patients can be nice can't they. Often it seems that all patients want to talk about is you. I thought the public didn't like students, aren't students lazy drunks who wake up at midday, squander their government hand-outs on designer clothes, and whose prevailing role in society was to keep the nation's budget baked bean industry in the black? Apparently the same isn't thought of medical students, well maybe it is, but god patients are polite. The thing is I have found these questions difficult; it is surprising how they can catch you off guard. Asking if I am enjoying 'it' after I have woken up at dawn, sat on a bus for 40 minutes, and hunted down a clinician who had no idea I was meant to be there, could lead on to a very awkward consultation. But of course it doesn't "yes it is really good thank you". "Do you take any medications, either from your GP or over the counter?" "Are you training to be a GP then?" Medicine is a fascinating topic and indeed career, which surely human nature makes us all interested in. As individuals lucky enough to be studying it, maybe we forget how intriguing the medical profession is? This paired with patients sat in a small formal environment with someone they don’t know could bring out the polite ‘Michael Parkinson’ in anybody. Isn't this just good manners, taking an interest. Well yes. Just because I can be faintly aloof doesn't mean the rest of the world has to me. But perhaps there is a little more to it, we ask difficult personal questions, sometimes without even knowing it, we all know when taking a sexual history to expect the consultation to be awkward or embarrassing, but people can be apprehensive talking about anything, be it their cardiovascular disease, medications, even their date of birth. We often then go on to an examination: inspecting from the end of the bed, exposing a patient, palpating. Given a bit context you can see why a patient may want to shift the attention back to someone like us for a bit, and come on, the medical student is fair game, the best target, asking the consultant whether they enjoys their job, rather you than me. If we can oblige, and make a patient feel a bit more at ease we should, and it certainly won't be doing our student patient relationship any harm. Hopefully next time my answers will be a bit more forthcoming. "Any change in your bowels, blood in any motions?" "How many years do you have left?" It is a good thing we are all polite.  
Joe de Silva
over 5 years ago
Foo20151013 2023 vvr5q9?1444774253
5
182

Clinics - Making the most of it

Commencing the first clinical year is a milestone. Things will now be different as your student career steers straight into the unchartered waters of clinical medicine. New challenges and responsibilities lie ahead and not just in an academic sense. After all this is the awaited moment, the start of the apprenticeship you have so desired and laboured for. It won’t be long before these clinical years like the preclinical years before them, will seem just as distant and insular, so why not make the most of it? The first days hold so much excitation and promise and for many they deliver, however, it would be wise not to be too optimistic. I am afraid your firm head standing abreast the doors in a prophetic splaying of arms is an unlikely sight. In this new clinical environment, it is natural to be a little flummoxed. The quizzical looks of doctors and nurses as you first walk in, a sure sign of your unexpected arrival, is a recurring theme. If the wards are going to be your new hunting ground, proper introductions with the medical team are in order. This might seem like a task of Herculean proportions, particularly in large teaching hospitals. Everyone is busy. Junior doctors scuttling around the ward desks job lists in hand, the registrar probably won’t have noticed you and as luck would have it your consultant firm head is away at a conference. Perseverance during these periods of frustration is a rewarding quality. Winning over the junior doctors with some keenness will help you no end. What I mean to say is that their role in our learning as students extends further than the security of sign-off signatures a week before the end of the rotation. They will give you opportunities. Take them! Although it never feels like it at the time, being a medical student does afford some privileges. The student badge clipped to your new clinic clothes is a license to learn: to embark on undying streaks of false answers, to fail as many skills and clerkings as is required and to do so unabashed. Unfortunately, the junior doctors are not there purely for your benefit, they cannot always spare the time to directly observe a history taking or an examination, instead you must report back. With practice this becomes more of a tick box exercise: gleaning as much information and then reconfiguring it into a structured presentation. However, the performance goes unseen and unheard. I do not need to iterate the inherent dangers of this practice. Possible solutions? Well receiving immediate feedback is more obtainable on GP visits or at outpatient clinics. They provide many opportunities to test your questioning style and bedside manner. Performing under scrutiny recreates OSCE conditions. Due to time pressure and no doubt the diagnostic cogs running overtime, it is fatefully easy to miss emotional cues or derail a conversation in a way which would be deemed insensitive. Often it occurs subconsciously so take full advantage of a GP or a fellow firm mate’s presence when taking a history. Self-directed learning will take on new meaning. The expanse of clinical knowledge has a vertiginous effect. No longer is there a structured timetable of lectures as a guide; for the most part you are alone. Teaching will become a valued commodity, so no matter how sincere the promises, do not rest until the calendars are out and a mutually agreed time is settled. I would not encourage ambuscaded attacks on staff but taking the initiative to arrange dedicated tutorial time with your superiors is best started early. Consigning oneself to the library and ploughing through books might appear the obvious remedy, it has proven effective for the last 2-3 years after all. But unfortunately it can not all be learnt with bookwork. Whether it is taking a psychiatric history, venipuncture or reading a chest X-ray, these are perishable skills and only repeated and refined practice will make them become second nature. Balancing studying with time on the wards is a challenge. Unsurprisingly, after a day spent on your feet, there is wavering incentive to merely open a book. Keeping it varied will prevent staleness taking hold. Attending a different clinic, brushing up on some pathology at a post-mortem or group study sessions adds flavour to the daily routine. During the heated weeks before OSCEs, group study becomes very attractive. While it does cement clinical skills, do not be fooled. Your colleagues tend not to share the same examination findings you would encounter on an oncology ward nor the measured responses of professional patient actors. So ward time is important but little exposure to all this clinical information will be gained by assuming a watchful presence. Attending every ward round, while a laudable achievement, will not secure the knowledge. Senior members of the team operate on another plane. It is a dazzling display of speed whenever a monster list of patients comes gushing out the printer. Before you have even registered each patient’s problem(s), the management plan has been dictated and written down. There is little else to do but feed off scraps of information drawn from the junior doctors on the journey to the next bed. Of course there will be lulls, when the pace falls off and there is ample time to digest a history. Although it is comforting to have the medical notes to check your findings once the round is over, it does diminish any element of mystery. The moment a patient enters the hospital is the best time to cross paths. At this point all the work is before the medical team, your initial guesses might be as good as anyone else’s. Visiting A&E of your own accord or as part of your medical team’s on call rota is well worth the effort. Being handed the initial A&E clerking and gingerly drawing back the curtain incur a chilling sense of responsibility. Embrace it, it will solidify not only clerking skills but also put into practice the explaining of investigations or results as well as treatment options. If you are feeling keen you could present to the consultant on post-take. Experiences like this become etched in your memory because of their proactive approach. You begin to remember conditions associated with patient cases you have seen before rather than their corresponding pages in the Oxford handbook. And there is something about the small thank you by the F1 or perhaps finding your name alongside theirs on the new patient list the following morning, which rekindles your enthusiasm. To be considered part of the medical team is the ideal position and a comforting thought. Good luck. This blog post is a reproduction of an article published in the Medical Student Newspaper, Freshers 2013 issue.  
James Wong
over 5 years ago
Foo20151013 2023 1vzj1mi?1444774262
5
198

Wikipedia - help or hindrance?

It’s quick, it’s easy and we’ve all done it. Don’t blush, whether it’s at our leisure or behind the consultant’s back we can confess to having used the world’s sixth most popular website. You might have seen it, sitting pride of place on the podium of practically any Google result page. Of course, it’s the tell tale sign of one of Web 2.0’s speediest and most successful offspring, Wikipedia. Now for fear of patronizing a generation who have sucked on the teat of this resource since its fledgling years, the formalities will remain delightfully short. Wikipedia is the free, multilingual, online encyclopedia, which harnesses the collective intelligence of the world’s internet users to produce a collaboratively written and openly modifiable body of knowledge. The technology it runs on is a highly flexible web application called wiki. It is open-source software; hence the explosion of wiki sites all united under the banner of combined authorship. Anyone with internet access can edit the content and do so with relative anonymity. It would be unthinkable that a source, which does not prioritize the fidelity of its content, could possibly play a role in medical education. How ironic it seems that medical students can waste hours pondering which textbook to swear their allegiance for the forthcoming rotation, yet not spare a second thought typing their next medical query into Wikipedia. Evidently it has carved itself a niche and not just among medical students, but healthcare professionals as well. According to a small qualitative study published in the International Journal of Medical Informatics, 70% of their sample, which comprised of graduates from London medical schools currently at FY2 and ST1 level, used Wikipedia in a given week for ‘clinical purposes’. These ranged from general background reading to double checking a differential and looking up medications. We are so ensnared by the allure of instantaneous enlightenment; it’s somewhat comparable to relieving an itch. "Just Google it..." is common parlance. We need that quick fix. When the consultant asks about his or her favourite eponymous syndrome or you’re a little short on ammunition before a tutorial, the breadth and ease-of-use offered by a service accessible from our phones is a clandestine escape. The concept of Wikipedia, the idea that its articles are in a way living bodies because of the continual editing process, is its strength. Conversely textbooks are to a degree outmoded by the time they reach their publication date. While I commend the contributors of Wikipedia for at least trying to bolster their pages with references to high impact journals, it does not soften the fact that the authorship is unverifiable. Visitors, lay people, registered members under some less than flattering pseudonyms such as Epicgenius and Mean as custard, don’t impart the sense of credibility students (or for that matter patients)expect from an encyclopedia. Since the prestige of direct authorship if off the cards, it does beg the question of what is their motivation and I’m afraid ‘the pursuit of knowledge and improving humanity’s lot' is the quaint response. There is a distinct lack of transparency. It has become a playground where a contributor can impress his/her particular theory regarding a controversial subject unchallenged. Considering there is no direct ownership of the article, who then has the authority to curate the multiple theories on offer and portray a balanced view? Does an edit war ensue? It is not unheard of for drug representatives to tailor articles detailing their product and erase the less pleasant side-effects. Obviously Wikipedia is not unguarded, defences are in place and there is such a thing as quality control. Recent changes will come under the scrutiny of more established editors, pages that are particularly prone to vandalism are vetted and there are a special breed of editors called administrators, who uphold a custodial post, blocking and banishing rebellious editors. A study featured in the First Monday journal put Wikipedia to the test by deliberately slipping minor errors into the entries of past philosophers. Within 48 hours half of these errors had been addressed. Evidently, the service has the potential to improve over time; provided there is a pool of committed and qualified editors. Wikiproject Medicine is such a group of trusted editors composed primarily of doctors, medical students, nurses, clinical scientists and patients. Since 2004, its two hundred or so participants have graded an excess of 25,000 health-related articles according to quality parameters not dissimilar to peer review. However, the vast majority of articles are in a state of intermediate quality, somewhere between a stub and featured article. Having some degree of professional input towards a service as far reaching as Wikipedia will no doubt have an impact on global health, particularly in developing countries where internet access is considered a luxury. March this year saw the medical pages of the English Wikipedia reach a lofty 249,386,264 hits. Its ubiquity is enviable; it maintains a commanding lead over competing medical websites. The accessibility of this information has catapulted Wikipedia far beyond its scope as a humble encyclopedia and into a medical resource. Patients arrive to clinics armed with the printouts. As future doctors we will have to be just that one step ahead, to recognise the limitations of a source that does not put a premium on provenance but is nevertheless the current public health tool of choice. Illustrator Edward Wong This blog post is a reproduction of an article published in the Medical Student Newspaper, November 2013 issue.  
James Wong
over 5 years ago
Foo20151013 2023 o7es6t?1444774265
16
437

Chronic: How one word can change everything

So, I think its about time I posted another blog post! A few weeks ago I received the results from my most recent scan. I was both nervous and excited to find out my results, after months of tests and being misdiagnosed several times I just wanted to know what was wrong with me. However, as I read through the letter from my consultant I realised that my journey was just beginning. I was diagnosed with a rare stomach condition. Gastroparesis. A chronic illness. There is no known cure, just various treatments with limited success. I didn’t really know how to react to this news. Shouldn’t I be happy that I finally knew what was wrong? I had convinced myself for months that as soon as the doctors found out what was wrong, they could fix it and I’d be better in no time, but this wasn’t to be. I couldn’t understand how this could happen. Slowly the reality began to sink in, I’ll probably be fighting this battle for the rest of my life. I think the mental aspect of chronic conditions is so commonly overlooked. I’ve sat through endless lectures about the pathophysiology of illnesses but I’ve never once stopped to think what it must be like to actually have it. The way it can limit your life, from not being able to go for a drink with friends because you’re in too much pain to the countless hospital appointments that your life seems to revolve around. The thing that hit me the most is the amount of medications I have to take on a daily basis just to make my symptoms bearable. I no longer have full control of my life and that's the worst part. This experience has given me an invaluable insight into how patients with chronic illness feel. It affects almost every aspect of your life and you can never escape. It scares me to think of the future, I never know when I’m going to get my next flare up or how long its going to last. I just have to take one day at a time and hope that when I wake up tomorrow I won’t be too nauseous. After spending a few weeks feeling down about it all, I’ve realised that I just have to enjoy life when I can and be grateful that I can still live a normal-ish life. It doesn’t matter how much I complain, it's not going to go away, and I think I’ve finally accepted that fact. If anything, this experience has made me more determined to achieve my dream of becoming a doctor. I’ve been a lot more motivated to work harder so that one day I can help others like me through some of their toughest times, hopefully bringing them some comfort and relief.  
Nicole Mooney
over 5 years ago
%3fr=0
3
150

Doing more with less: own Pride and Joy.

“There is nothing new under the sun” - Ecclesiastes 1:4-11. If any of you have read one of my blogs before you will have realised that I am a huge fan of books. The blog I am writing today is also about a book, but more than that, it is about an idea. The idea is simple, practical and nothing especially new. It is an idea that many call common sense but few call common practice. It is an idea that has been used in every sort of organisation for over 20 years. It is an idea that needs to be applied on a greater scale to the health service. The idea is not new. How the book is written is not new. But how the book explains the idea and applies it to healthcare is new and it will change how you view the health service. It is a revolutionary book. The book is called “Pride and Joy” by Alex Knight view here. How I came to read this book is a classic story of a Brownian motion (a chance encounter), leading to an altered life trajectory. The summer before starting medical school I was working as a labourer cleaning out a chaps guttering. During a tea break in the hot summer sun he asked me what I was going to study at Uni. As soon as I said “Medicine”, he said “then you need to come see this”. He took me into his office and showed me a presentation he had given the year before about a hospital in Ireland. He was a management consultant and had been applying a management theory he had learned while working in industry. With his help the hospital had managed to reduce waiting times by a huge amount. The management theory he was applying is called "The Theory of Constraints" (TOC). I thought that his presentation was fascinating and I could not understand why it was not more widely applied. I went away and read the books he suggested and promised that I would stay in touch. Four years later and I had been exposed to enough of the clinical environment to realise that something needs to change in how the health service is run. To this end, a couple of colleagues and myself founded the Birmingham Medical Leadership society (BMLS) with help from the Faculty of Medical Leadership and Management (FMLM). The aim of which is to help healthcare students and professionals understand the systems they are working in. The first thing I did after founding the society was contact that friendly management consultant and ask him for his advice on what we should cover. He immediately put me in contact with QFI consulting, @QFIConsulting. This small firm has been working with hospitals all over the world to implement this simple theory called the Theory of Constraints. They were absolutely fantastic and within 2 emails had promised to come to Birmingham to run a completely free workshop for our society’s members. The workshop was on March 8th at Birmingham Medical School. Through our society’s contacts we managed to encourage 15 local students to take a revision break to attend the workshop on a sunny Saturday. We were also able to find 11 local registrars/ consultants who wanted to improve their management knowledge. It just so happens that the chap leading this workshop was Mr Alex Knight. The workshop sparked all of our interests and when he mentioned that he had just written a book, pretty much the whole crowd asked for a copy. When I got my copy, I thought I would leave it to read for after my end of year exams. However, I got very bored a few days before the first written paper and needed a revision break – so I decided that reading a few pages here and there wouldn't hurt. Trouble was that this book was a page turner and I soon couldn't put it down. I won’t spoil the book for all of you out there, who I hope will read it. I shall just say that if you are interested in healthcare, training to work in healthcare, already work in healthcare or just want a riveting book to read by the pool then you really should read it. The basic premise is that healthcare is getting more expensive and yet there appears to be an increase in the number of healthcare crises'. So if more money isn't making healthcare better, then maybe it is time to try a different approach. “Marketing is what you do when your product is no good” – Edward Land, inventor of the Polaroid Camera. Mr Land was a wise man and I can happily say that I have no conflict of interest in writing this blog. I have not been promised anything in return for this glowing review. The only reason that I have written this is because I believe it is important for people to have a greater understanding of how the health service works and what we can do to make it even better! As a very junior healthcare professional, there is not much that we can do on a practical level but that does not mean we are impotent. We can still share best practice and show our enthusiasm for new approaches. Healthcare students and professionals, if you care about how your service works and you want to help make it better. Please find a copy of this book and read it. It won’t take you long and I promise that it will have an impact on you. NB - Note all of the folded down corners. These pages have something insightful that I want to read again... there are a lot of folded pages!  
jacob matthews
over 5 years ago
Foo20151013 2023 thqdyy?1444774274
1
183

Why we need to work to maintain a social life - A Darwinian Medical Training Programme

Book of the week (BotW) = The Darwin Economy by Prof Frank Being a medical student and wanna-be-surgeon, I am naturally very competitive. I know exactly where I want to end up in life. I want to be a surgeon at a major unit doing research, teaching and management, as well as many other things. To reach this goal in a rational way I, and many others like me, need to look at what is required and make sure that we tick the boxes. We must also out-compete every other budding surgeon with a similar interest. Medicine is also a dog-eat-dog world when it comes to getting the job you want. Luckily you can head off into almost any field you find interesting, as long as you have the points on your CV to get access to the training. In recent years, the number of med students has increased, but so has the competition for places. The number of FY1 jobs has increased but so has the competition for good rotations. The number of consultant posts has increased, but so has the competition for the jobs. To even be considered for an interview for a consultant surgeon post these days a candidate (hopefully my future self) will have to demonstrate an excellent knowledge of anatomy, physiology, pathology and demography. They will need to have competent surgical skills and have completed all of the hours and numbers of procedures. To further demonstrate this they will need to have gone on extra-curricular courses and fellowships. They will also need to show that they can teach and have been doing so regularly. They must now also have an understanding of medical leadership and have a portfolio of projects. Finally, they will have had to tick the research box, with posters, publications, oral presentations and research degrees. That’s a long list of tick boxes and guess what? It has been getting longer! I regularly attend a surgical research collaborative meeting in Birmingham. Many of those surgeons didn’t even get taught about research at medical school or publish anything until they were registrars. Now even to get onto a good Core Training post you need to have at the very least some posters in your chosen field and probably a minimum of a publication. That’s a pretty big jump in standards in just 15 years. In two generations the competition has increased exponentially. Why is that? Prof Frank explains economic competition in Darwinian terms. His insights apply equally well to the medical training programme. It’s all about your relative performance compared to your peers and the continual arms race for the best resources (training posts). However, the catch is, if everyone ups their performance by the same amount then you all work harder for no more advantage for anyone, except for the first few people who made the upgrade. The majority do not benefit but are in fact harmed by this continual arms race. I believe that this competition will only get worse as each new year of med students tries to keep up and surpass the previous cohort. This competition will inevitably lead to a greater time commitment from the students with no potential gain. Everything we do is relative to everyone else. If we up our game, we will outperform the competition, until they catch up with us and then relatively we are no better off but are working harder. Why is this relevant? I know everyone will want to select “the best” candidate, but in medicine the “best” candidate doesn’t really exist because we are all almost equally capable of doing the role, once we have had the training. So there is no point us all working ourselves into the ground for a future job, if all our hard work won’t pay off for most of us anyway. But we can’t make these choices as individuals because if one of us says that “I am not going to play the game. I am going to enjoy my free time with my friends and family”, that person won’t get the competitive job because everyone else will out-perform them. We have to tackle this issue as a cohort. How do we ensure that we don’t work ourselves into the ground for nothing? Collectively as medical students and trainees we should ask the BMA and Royal Collages to set out a strict application process that means once candidates have met the minimum requirements, there is no more points for additional effort. For instance, the application form for a surgical consultant post should only have space to include 5 peer-reviewed publications. That way it wouldn’t necessarily matter if you had 5 or 50 publications. This limit may seem counter-intuitive and will possibly work against the highly competitive high achievers, but it will have a positive effect on everyone else’s life. Imagine if you only had to write 5 papers in your career to guarantee a chance at a job, instead of having to write 25. All that extra time you would have had to invest in extra-curricular research can now be used more productively by you to achieve other life goals, like more time with your family or more patient contact or even more time in theatre perfecting your skills. If you were selecting candidates for senior clinicians, would you rather pick an all round doctor who has met all of the requirements and has a balanced work-life balance or a neurotic competitor who hasn’t slept in 8 years and is close to a breakdown? Being a doctor is more than a profession, it is a life-style choice but we should try to prevent it becoming our entire lives.  
jacob matthews
about 5 years ago
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Beating the Bully

I read an article recently that 90% of surgical trainees have experienced bullying of one form or other in their practice. That’s 90%. That’s shocking. Worryingly it is highly likely that this statistic is not purely isolated to surgery. This is evidence of a major problem that needs to be addressed. We don’t accept bullying in schools and in the workplace policies are in place to stop bullying and harassment– so why have 90% of trainees experienced bullying? I can relate to this from personal experience, as I am sure most of us can. Prior to intercalating I had always had the typical med student ambition of joining the big league and taking on surgery. I had a keen interest in anatomy, I had decided to intercalate in anatomy, I did an SSC on surgical robotics, presented at an undergraduate surgical conference and had a small exposure to surgery in my first couple of years that gave me enough drive to take on a competitive career path. I took it upon myself to try and arrange a brief summer attachment where I would learn as a clinical medical student what it is like to scrub in and be in theatre. At the beginning I was so excited. At the end every time someone mentioned surgery I felt sick. It became apparent very quickly that I was an inconvenience. I think medical students all get this feeling – ‘being in the way’ - but this was different. This was being made to feel deliberately uncomfortable. I asked if I could have some guidance on scrubbing in and this was met with a complete huff and annoyance because I didn’t know how to do it properly (thank goodness for a lovely team of theatre nurses!). I even got assigned a pet name for the week – the ‘limpet’ (notable for their clinging on to rocks) that was frequently used as a humiliation tactic in front of colleagues. By the end of the week I dreaded walking into the hospital and felt physically sick every morning. Now some people might say ‘man up’ and get on with it. Fair enough, but I’m a fairly resilient character and it takes a lot to make me feel like I did that week. This experience completely eradicated any ambition I had at the time to go into surgery. Since then I’ve focused elsewhere and generally dreaded surgical rotations until very recently where I managed to meet a wonderful orthopaedic team who were incredibly encouraging. Bullying can be subjective. Just because a consultant asks you a difficult question doesn’t mean they’re bullying you. By and large clinicians want to stretch you and trigger buttons that make you go and look things up. If it drives you to work and develops you as a professional then it’s not bullying, but if it makes you feel rubbish, sick or less about yourself then you should perhaps think twice about the way you’re being treated. Of course bullying doesn’t stop at professionals. Psychological bullying is rife in medical schools. We’ve all been ‘psyched out’ by our peers – how much do you know? How did you know that when I didn’t? Intimidating behaviour can be just as aggressive. Americans dub these people ‘Gunners’ although we’ve been rather nice and adopted the word ‘keen’ instead. Luckily most medical schools have a port of call for this sort of behaviour. But a word of advice – don’t let anyone shrug it off. If it’s a problem, if it’s affecting you – tell someone. Bullying individuals that are trying to learn and develop as professionals is entirely unacceptable. If you would like to share similar experiences, drop them in the comments box below.  
Lucas Brammar
about 5 years ago
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Education for Cardiology Disease Professionals - Radcliffecardiology

Cardiology consultants can find the latest news & information about cardiovascular disease & cardiology conferences by going to Radcliffe cardiology’s website.  
radcliffecardiology.com
over 4 years ago
Static.www.bmj
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Legal system distorts reality by focusing on a single error in untoward incidents, conference hears

“You’re only ever one error away from a manslaughter prosecution,” the consultant surgeon Kenneth Woodburn told doctors at a meeting on medical manslaughter last week. “So often, adverse events in the NHS occur when people are trying to go a little bit further.”  
feeds.bmj.com
over 4 years ago
Static.www.bmj
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Legal system distorts reality by focusing on a single error in untoward incidents, conference hears

“You’re only ever one error away from a manslaughter prosecution,” the consultant surgeon Kenneth Woodburn told doctors at a meeting on medical manslaughter last week. “So often, adverse events in the NHS occur when people are trying to go a little bit further.”  
feeds.bmj.com
over 4 years ago
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Research shows women trying hard to avoid unwanted pregnancy

Most women experiencing unwanted pregnancy report they used a contraceptive at the time they conceived, data released by the British Pregnancy Advisory Service (bpas) shows.  
medicalnewstoday.com
over 4 years ago
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Should surgical training include involvement in a clinical trial?

The next generation of surgical consultants will need research experience to advance the specialty, writes Dion Morton, but Colin Bicknell worries about increasing the time trainees spend away from the operating theatre, where they learn their craft  
feeds.bmj.com
over 4 years ago