Just as a bit of an intro, my name is Conrad Hayes, I'm a 4th year medical student studying in Staffordshire. My medical school are quite big on getting us into the habit of writing down reflections. It's something I feel I do subconsciously whilst I'm with patients or in teaching sessions, but frankly I suck at the written bit and I feel on the whole it's probably because there's nobody discussing this with us or telling me I'm an idiot for some of the things I may think/say!
So I think if I'm going to attempt to complete a blog then I am going to do it in a reflective style and I do look forward to peoples feedback and discussions. I'll try to do it daily and see if that works out well, or weekly. But hopefully even if it doesn't get much response it can just be a store for me to look back on things! (Providing I keep up with it).
So I'll start now, with a short reflection on my career aspirations which have been pretty much firmed up, but today I gave a presentation that I felt really galvanised me into this. So I want to do Emergency Medicine and Expedition Medicine (on the side more than as my main job). Emergency Medicine appeals to me as I love primary care and being the first to see patients, but I want to see them when they're ill and have a role in the puzzle solving, as it were, that is their issues. Possibly more to the point I want to do this in a high pressure environment where acutely ill individuals come in, and I feel (having done placements in A&E and GP and AMU) A&E is the place for me to be.
Expedition Medicine on the other hand is something I accidentally stumbled upon really. In 2nd year I was part of a podcast group MedHeads that we tried to set up at my medical school. I interviewed Dr Amy Hughes of Expedition & Wilderness Medicine, a UK company, and I got really excited about the concepts she was talking about. Practicing medicine in the middle of nowhere, limited resources and sometimes only personal accumen and ingenuity to help you through. It sounded perfect! And since then I've wanted to do it, particularly being interested in Mountain Medicine and getting involved with some research groups.
Today in front of my group I gave a presentation on the effects of altitude on the brain (I'm on Neurology at the moment and we had to pick a topic that interested us). I spoke for 15 minutes, a concept that usually terrifies me truth be told, and I thoroughly enjoyed myself. Now I've given a fair number of presentations but this was the first time I was actively excited and really happy about talking! It seems to me that if that isn't the definition of why you should go for a job, then I need to talk to a careers advisor. This experience has definitely ensured I pursue this course with every resource I have available to me!
I would be interested in hearing how other people feel about their careers panning out and what got them into it so feel free to leave a comment!!
Maybe it’s just me, but I cannot get my head around pharmacology and antibiotics are certainly doing their best to finish me off! My group at uni decided that this was one area that we needed to revise, and the task fell on my hands to provide the material for a revision session. So, the night before the session I began to panic about how to come up with any useful tips for my group, or indeed anyone at all, to try to remember anything useful about antibiotics at all. If only Paracetamoxyfrusebendroneomycin was a real drug, it would make our lives so much easier. Come on Adam Kay and Suman Biswas, get the trials started and create your wonderful super drug. For the mean time I guess I will just have to keep blissfully singing along to your song. However, that is not going to help me with my task in hand.
After a lot of research that even took me beyond the realms of Wikipedia (something I do not often like to do), I found various sources suggesting remembering these Top 10 Rules (and their exceptions)
All cell wall inhibitors are ?-lactams (except vancomycin)
All penicillins are water soluble (nafcillin)
All protein synthesis inhibitors are bacteriostatic (aminoglycosides)
All cocci are Gram positive (Neisseria spp.)
All bacilli are Gram negative (anthrax, tetanus, botulism, diptheria)
All spirochetes are Gram negative
Tetracyclines and macrolides are used for intracellular bacteria
Pregnant women should not take tetracyclines, aminoglycosides,
fluroquinolones, or sulfonamides
Antibiotics beginning with a ‘C’ are particularly associated with
While the penicillins are the most famous for causing allergies, people may also react to cephalosporins
If those work for you, then I guess you can stop reading now… If they don’t, I can’t promise that I have anything better, but give these other tips that I found a whirl… Alternatively, I have created a Page on my own blog called Rang and Dale’s answer to Antibiotics, which summarises their information, so please take a look at that.
Most people will suggest that you can categorise antibiotics in three ways, and it’s best to pick one and learn examples of them.
Mode of action:
bacteriostatic (stop multiplying)
2 mnemonics to potentially help you remember examples:
We’re ECSTaTiC about bacteriostatics?
Erythromycin Clindamycin Sulphonamides Tetracyclines Trimethoprim
Very Finely Proficient At Cell Murder (bactericidal) - Vancomycin Fluroquinolones Penicillins Aminoglycosides Cephalosporins
Spectrum of activity:
broad-spectrum (gram positive AND negative)
narrow (gram positive OR negative)
Mechanism of action
Inhibit cell wall synthesis
Inhibit nucleic acid synthesis
Inhibit protein synthesis
Inhibit cell membrane synthesis
If you have any more weird and wonderful ways to remember antibiotics, let me
know and I will add them! As always, thank you for reading.
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.
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
The book of the week this week has been Chris Patten’s “Not quite the diplomat” – part autobiography, half recent history and a third political philosophy text. It is a fascinating insight into the international community of the last 3 decades. The book has really challenged some of my political beliefs – which I thought were pretty unshakeable – and one above all others, the EU. I read this book to help me decide who I should vote for in the upcoming MEP elections.
I have to make a confession, my political views are on the right of the centre and I have always been quite a strong “Eurosceptic”. Although recently, I have found myself drifting further and further into the camp of “we must pull out of Europe at all costs” but Mr Patten’s arguments and insights have definitely made me question this stance.
With the European Parliamentary elections coming up, I thought it might be an interesting time to put some ideas out there for discussion.
From a young age, I have always been of the opinion that Great Britain is a world leading country, a still great power, one of the best countries in the world - democratic, tolerant, fair, sensible - and that we don’t need anyone else’s “help” or interference in how our country is run. I believe that British voters should have a democratic input on the rules that govern them.
To borrow an American phrase “No taxation without representation!”
I believe that democracy is not perfect but that it is the best system of government that humans have been able to develop. For all of its faults, voters normally swing back to the centre ground eventually and any silly policies can be undone. This system has inherently more checks and balances than any meritocracy, oligarchy or bureaucracy (taking it literally to mean being ruled by unelected officials).
This is one of my major objections to how the European Union currently works. For all intents and purposes, it is not democratic. Institutions of the EU include the European Commission, the Council of the European Union, the European Council, the Court of Justice of the European Union, the European Central Bank, the Court of Auditors, and the European Parliament. Only one of these institutions is elected by the European demos (the parliament) and that institution doesn’t really make any changes to any policies – “the rubber stamp brigade”. The European Council is made up of the President of the European Council (Unelected), President of the European commission (Unelected) and the heads of the member states (elected) and is where quite a lot of the "major" policies come from but not all of the read tape (the European Commission and Parliament).
I am happy to be proved wrong but it just seems that the EU, as a whole, is made up of unelected officials who increasing try to make rules that apply to all 28 member states without any consent from the voters in those states – it looks like the rule of “b-euro-crats” (bureaucrats – this version has far too many vowels for a dyslexic person to use).
A beurocratic rule which many of us do not agree with but seemingly have to succumb to, a good example for medics is the European Working Time Directive (EWTD) which means that junior doctors only get paid for working 48h a week when they may spend many, many more hours in work. The EWTD has also made training a lot more difficult for many junior doctors and has many implications for how the health service is now run. Is it right that this law was imposed on us without our consent? If we imposed a treatment on a patient without their consent then we would be in very big trouble indeed!
I cannot deny that the EU has done some good in the world and I cannot deny that Britain has benefited from being a member. I just wish that we could pay to have access to the markets, while retaining control over the laws in our lands. I want us to be in Europe, as a partner but not as a vassal. In short, I would like us to stay within the EU but with major reforms.
I know that any reforms I suggest will not be read by anyone in power and I know they are probably unrealistic but I thought I would put it out there just to see what people think.
I would like to see a NICE’er European Union.
The National Institute for Clinical Excellence is a Non Departmental Public Body (NDPB), part of the UK Department of Health but a separate organisation (http://www.nice.org.uk/aboutnice/whoweare/who_we_are.jsp). NICE’s role is to advise the UK health service and social services. It does this by assessing the available evidence for treatments/ therapies/ policies etc and then by producing guidelines outlining the evidence and the suggested best course of action.
None of these guidelines are enforced by law, for example, as a doctor you do not have to follow the NICE recommendations but if you ignore them and your patient suffers as a consequence then you are likely to be in big trouble with the General Medical Council.
So, here would be my recommendations for EU reform:
First, we all pay pretty much the same as we do now for access to the European market. We continue with free movement and we keep the European Council but elect the President. This way all the member states can meet up and decide if they want to share any major policies. We all benefit from free movement and we all benefit from a larger free trade area.
Second, we get rid of most of the rest of the EU institutions and replace them with an institute a bit like NICE. The European Institute for Policy Excellence (EIPE) would be (hopefully) quite a small department that looks at the best available evidence and then produces guidance on the policy.
A shorter executive summary would hopefully also be available for everyday people to read and understand what the policy is about - just like how patients can read NICE executive summaries to understand their condition better.
Then any member state could choose to adopt the policy if their parliaments think it worthwhile. This voluntary opt-in system would mean that states retain control of their laws, would probably adopt the policies voluntarily (eventually) and that the European citizens might actually grow to like the EU laws if they can be shown to be evidence based, in the public’s best interests, in the control of the public and not just a law/red tape imposed from above.
The European Union should be a place where our elected officials go to debate and agree policies in the best interests of their electorates. There should therefore be an opt-out of any policy for any member state that does not think it will benefit from a policy.
This looser union that I would like to see will probably not happen and I do worry that one day we will wake up in the undemocratic united federal states of Europe but this worry should not force us to make an irrational choice now. We should not be voting to "leave the EU at all costs" but we should be voting for reform and a better more co-operative international community.
I would not dare suggest who any of you should vote for but I hope you use your vote for change and reform and not more of the same.