These are 2 flowcharts that I made to help me understand the basic blood supply to the brain and drainage via the venous sinus system. They don't go into huge detail, but rather give a general overview and schematic. Enjoy :P
The registrar's face was taking on a testy look. So enduring was the silence our furtive glances had developed a nystagmic quality. “Galactosaemia” came her peremptory reply. Right on queue the disjointed chorus of ahs and head nods did little to hide our mental whiteboard of differentials being wiped clean. At the time conjugated bilirubinaemia in children only meant one thing: biliary atresia. A fair assumption; we were sitting in one of three specialist centres in the country equipped to treat these patients. Ironically the condition has become the unwieldy yardstick I now measure the incidence of paediatric disease.
Biliary atresia is the most common surgical cause of neonatal jaundice with a reported incidence of 1 in 14-16ooo live births in the West. It is described as a progressive inflammatory obliteration of the extrahapatic bile duct. And Dr Charles West, the founder of Great Ormond Street Hospital, offers an eloquent description of the presenting triad of prolonged jaundice, pale acholic stools and dark yellow urine:
‘Case 18...It was born at full term, though small, apparently healthy. At 3 days however, it began to get yellow and at the end of 3 weeks was very yellow. Her motions at no time after the second day appeared natural on examination, but were white, like cream, and her urine was very high coloured.’
1855 was the year of Dr West's hospital note. An almost universally fatal diagnosis and it would remain so for the next 100 years. The time's primordial classification of biliary atresia afforded children with the 'noncorrectable' type, a complete absence of patent extrahepatic bile duct, an unfortunate label; they were beyond saving. Having discovered the extent of disease at laparatomy, the surgeons would normally close the wound. The venerable Harvardian surgeon, Robert E. Gross saved an enigmatic observation: “In most instances death followed a downhill course…”
K-A-S-A-I read the ward’s board. It was scrawled under half the children's names. I dismissed it as just another devilishly hard acronym to forget. The thought of an eponymous procedure had escaped me and in biliary atresia circles, it's the name everyone should know: Dr Morio Kasai.
Originating from Aomori prefecture, Honshu, Japan, Dr Kasai graduated from the National Tohoku University School of Medicine in 1947. His ascension was rapid, having joined the 2nd department of Surgery as a general surgeon, he would assume the role of Assistant Professor in 1953. The department, under the tenure of Professor Shigetsugu Katsura, shared a healthy interest in research.
1955 was the landmark year. Katsura and Kasai operated on their first case: a 72 day old infant. Due to bleeding at the incised porta hepatis, Katsura is said to have 'placed' the duodenum over the site in order to staunch the flow. She made a spectacular postoperative recovery, the jaundice had faded and there was bile pigment in her stool. During the second case, Katsura elected to join the unopened duodenum to the porta hepatis. Sadly the patient's jaundice did not recover, but the post-mortem conducted by Kasai confirmed the development of a spontaneous internal biliary fistula connecting the internal hepatic ducts to the duodenum. Histological inspection of removed extrahepatic duct showed the existence of microscopic biliary channels, hundreds of microns in diameter. Kasai made a pivotal assertion: the transection of the fibrous cord of the obliterated duct must contain these channels before anastomosis with the jejunal limb Roux-en-Y loop. This would ensure communication between the porta hepatis and the intrahepatic biliary system. The operation, entitled hepatic portoenterostomy, was first performed as a planned procedure for the third case at Tohoku. Bile flow was restored and Kasai published the details of the new technique in the Japanese journal Shujutsu in 1959. However, news of this development did not dawn on the West until 1968 in the Journal of Pediatric Surgery. The success of the operation and its refined iterations were eventually recognized and adopted in the 1970s. The operation was and is not without its dangers. Cholangitis, portal hypertension, malnutrition and hepatopulmonary syndrome are the cardinal complications. While diagnosing and operating early (<8 weeks) are essential to the outcome, antibiotic prophylaxis and nutritional support are invaluable prognostic factors.
Post operatively, the early clearance of jaundice (within 3 months) and absence of liver cirrhosis on biopsy, are promising signs. At UK centres the survival after a successful procedure is 80%. The concurrent development of liver transplantation boosts this percentage to 90%. Among children, biliary atresia is the commonest indication for transplantation; by five years post-Kasai, 45% will have undergone the procedure.
On the 6th December 2008, Dr Kasai passed away. He was 86 years old and had been battling the complications of a stroke he suffered in 1999. His contemporaries and disciples paint a humble and colourful character. A keen skier and mountaineer, Dr Kasai lead the Tohoku University mountain-climbing team to the top of the Nyainquntanglha Mountains, the highest peaks of the Tibetan highlands. It was the first successful expedition of its kind in the world. He carried through this pioneering spirit into his professional life. Paediatric surgery was not a recognized specialty in Japan. By founding and chairing multiple associations including the Japanese Society of Pediatric Surgeons, Dr Kasai gave his specialty and biliary atresia, the attention it deserved.
Despite numerous accolades of international acclaim for his contributions to paediatric surgery, Dr Kasai insisted his department refer to his operation as the hepatic portoenterostomy; the rest of the world paid its originator the respect of calling it the ‘Kasia’. Upon completion of their training, he would give each of his surgeons a hand-written form of the word ‘Soshin’ [simple mind], as he believed a modest surgeon was a good one.
At 5 foot 2, Kasai cut a more diminutive figure one might expect for an Emeritus Professor and Hospital Director of a university hospital. During the course of his lifetime he had developed the procedure and lived to see its fruition. The Kasia remains the gold standard treatment for biliary atresia; it has been the shinning light for what Willis J. Potts called the darkest chapter in paediatric surgery. It earned Dr Kasai an affectionate but apt name among his peers, the small giant.
Miyano T. Morio Kasai, MD, 1922–2008. Pediatr Surg Int. 2009;25(4):307–308.
Garcia A V, Cowles RA, Kato T, Hardy MA. Morio Kasai: a remarkable impact beyond the Kasai procedure. J Pediatr Surg. 2012;47(5):1023–1027.
Mowat AP. Biliary atresia into the 21st century: A historical perspective. Hepatology. 1996;23(6):1693–1695.
Ohi R. A history of the Kasai operation: Hepatic portoenterostomy for biliary atresia. World J Surg. 1988;12(6):871–874.
Ohi R. Morio Kasai, MD 1922-2008. J Pediatr Surg. 2009;44(3):481–482.
Lewis N, Millar A. Biliary atresia. Surg. 2007;25(7):291–294.
This blog post is a reproduction of an article published in the Medical Student Newspaper, April 2014 issue.
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.
Easy glycolysis mnemonic for beginning students. You may need to pause/watch it more than once - and there's a self-paced FLASHCARD TUTORIAL at:
All cellular respiration tutorials can be found in our playlist:
This tutorial introduces simplified intermediates structures/ ATP/NADH steps - the next part of our tutorial has the full structures/enzyme names. Please SUBSCRIBE for new videos: more cool stuff coming as we get more Hippo Helpers!
This explanation also explains the difference between the investment and pay-off stages of glycolysis, as well as the important regulatory step, the "committed" step of phosphofructokinase-1.
http://www.helphippo.com - for more video tutorials organized by topic/year.
A resource made to accompany an RLO on peri-arrest arrhythmias I designed as part of my Doctors as Teachers project at Peninsula. It describes the assessment and management of peri-arrest arrhythmias as well as pharmacology of certain drugs used in their management. Hope you find it useful x
“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!
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.
Anatomy and pathology of the nervous system is understood by directly visualizing it. This is best accomplished by handling the brain (or model of the brain as the case may be) and dissecting or taking it apart for direct examination. The purpose (for the clinician) of understanding neuroanatomy and neurophysiology is to be able to use that knowledge to solve clinical problems. The first step in solving a clinical problem is anatomical localization. So, if one cannot directly inspect the patient's brain, how is this localization accomplished? The "window" to the patient's brain is the neurological examination. The neuro exam is a series of tests and observations that reflects the function of various parts of the brain. If the exam is approached in a systematic and logical fashion that is organized in terms of anatomical levels and systems then the clinician is lead to the anatomical location of the patient's problem.