Spring 2019

THE BLACK BAG

BRISTOL MEDICAL SCHOOL Spring Term Ed., 2019

Editor-in-Chief: J. KONDRATOWICZ Assistant Editor: V. K. MANDAGERE Treasurer: C. HARMER Illustrators: M. ACHANTA Crossword designer: A. CLARKE Contributions: Prof. T. THOMPSON, B. D. GOMPELS, S. SARFARAZ, S.MASOOD

@BlackBagBristol The Black Bag theblack_bag The Black Bag has been the medical school magazine since 1937. Published thrice every year, we are the voice of both students and alumni.

Initially designed by the Faculty of Medicine as a scholastic publication, the Black Bag was taken over by students in the 1970s and replaced with a slightly less-polished perspective on the raucous life of medical students.

Today, our articles range from the informative to the satirical, providing a platform for both thought-provoking discussion and comical musings. We look to reflect on the wide variety of Galenicals sub-societies (sports, music, drama) as well as to evaluate (and lampoon) the current state of the Bristol Medical School and the world of medicine.

The Black Bag are always looking for contributors. If you are interested in writing for us, please email: blackbag@galenicals.org.uk

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THE BLACK BAG EDITORIAL

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Thompson Talks: Why we Sleep? Review and Commentary

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Are YOU getting enough?

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MEDIC TRIBES: A guide to out placement

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Medic lunchboxes

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Nutritank: Bristol sparks a movement

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Revision ready recipe

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Dear Cancer: A letter

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Crossword

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Crossword Solution

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EDITORIAL “It is a common experience that a problem difficult at night is resolved in the morning after the committee of sleep has worked on it.” ― John Steinbeck, Sweet Thursday Yet another term down and one more to go. This means only one thing: exams are looming and medical students all over Bristol are burying their heads in the books (or the sand as the case may be). With this in mind, our fabulous team of writers and illustrators have put together this ‘lifestyle issue’ dedicated to helping getting the most out of yourself and your performance. This might sound a bit daunting, but the good news is that this entails sleeping, eating and being merry (not drinking though- you didn’t think the news would be that good did you?).

So you’ve been burning the candle at both ends and you might be feeling a little sleep deprived right about now. In fact, we know you are, because over 50% of you told us so- turn to page 10 to see the results of a little medical school sleep survey we’ve been busily conducting. But if you think sleep is for the weak, think again. It turns out that old maxim was actually right- early to bed might indeed be the key to making you healthy, wealthy and wise. So if you’ve been rebuffing your non-medic friends’ late-night pub invites in preference for clocking up time in the library perhaps you shouldn’t feel so smug after all. We’ll be hearing from everyone’s favourite Professor in “THOMPSON TALKS” on why hitting the hay instead of the books might be the the best exam revision technique (pagE 7) .For those of you who will be starting our first jobs as doctors(!) in August, take note as Trevor gives us some words of wisdom about surviving those night shifts.

We’ll also be hearing from Nutritank. Born at Bristol Medical School, this team have sparked a nationwide movement. Backed by the likes of Jamie Oliver we hear about their mission to get medical students and doctors talking more about healthy eating. Speaking of which, see page 21 for a ready-made revision fuel recipe.

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We wish you all the best of luck in exams and hope the final years are having a grand time on elective. Hopefully this issue can provide some useful advice as well as a bit of light relief from the textbooks. But if you are reading this at 1am, do put this down and get some sleep!

J. KONDRATOWICZ Editor-in-chief 4th year MB ChB

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Thompson Talks: Why we Sleep? Review and Commentary When I were a lad, newly qualified and sporting the full length white coat (medical students wore shorties), sleep was quite a preoccupation. On my first ever weekend on-call, we clocked in of a Friday morning, and clocked off at 5pm the following Monday. In between times I had, I kid you not, a total of ten hours of fractured sleep, having personally admitted twenty-nine persons to the hospital. By the Monday I was way beyond tired – I had actually gone slightly mad. Only a spell in a major war could have prepared us.

I am so glad Matthew Walker’s book “Why We Sleep” wasn’t written in 1991.

Bad enough to know that sleep deprivation had addled our ability to think and feel. How miserable it would have been to be informed by a Professor of Neuroscience at Berkeley, that deprivation was also a major risk factor for diabetes, heart disease, cancer, mental health problems and infertility. I’m actually surprised most of us are still alive.

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Some physiology. Sleep is an example of a circadian rhythm. It is not principally governed by light, but by an intrinsic pacemaker sitting atop the optic chiasm.

Only by the end of it, will the brain have adapted to the wrecking ball, which is a week of nights. Though at the time I was suspicious or dismissive, I now understand how it was, that in any cohort of junior docs, there was always one who went insane on nights. Caffeine to the rescue! An effective blocker of receptors for adenosine, our endogenous temazepam, it kids the brain into wakefulness with a half-life of six hours (so take care when you imbibe).

From the perspective of the sleeper, sleep is binary – either one is asleep, or one is awake. But science has taught us that in fact sleep has a highly differentiated neural architecture. Have you ever observed someone in REM sleep? It is pretty spooky. The sleeper is deeply asleep (REM sleepers are hardest to wake) but their eyes are doing an absolute fandango – zipping about in all directions. This contrasts with the quietude of NREM sleep which is, if anything, more weird, as it sees the whole brain pulse in self-generated synchrony.

With such a lot to memorise in your medical degree – have you studied how best to learn? A full night of sleep (around eight hours) will give you a 40% recall advantage over someone who has slept five hours or less. Sleep works by shifting memory from short term storage in the hippocampus to long term storage in the cortex. This feat of filing happens during NREM sleep – especially when associated with little explosions of neuronal activity called “sleep spindles”. Sleep spindles occur more towards the end of sleep – the bit of sleep we are most likely to sacrifice after a late night hitting the books or the bottle.

Sadly, spindles have more or less packed in by the age of 50.

Unless you have an actual sleep disorder, as a student your deprivation is most likely self-inflicted. You either go to bed too late or get up too early to allow yourself the necessary eight. Walker quotes research on the impact on reaction times of different intensities of deprivation. Six hours per night for ten days (a duration some of us unwisely consider normal) had the same impact as one night of no sleep at all – a 400% worsening compared with the 8-hour brigade.

A common manifestation of deprivation is “microsleeps” – a second of slumber long enough to drift your car into an adjoining lane. I am ashamed to confess that in my twenties I frequently drove in a state of post on-call exhaustion – chasing a lassie who lived up the M5. I fought microsleeps with an open window, coffee and short naps in service areas. Once I was crawling along the North Circular after a 33 hour shift at Ealing Hospital (including, to be fair, a 8

full four hours of fitful sleep) when I came to an abrupt halt – I’d only rammed into the rear bumper of a police car. It is not illegal to drive whilst exhausted (should it be?), but it is now illegal to make people work dangerously long hours – thanks to those meddling desk-jockeys in Brussels and their “European Working Time Directive”. A colleague called Dr Chris Johnstone won a High Court battle against his employer for making him work ridiculous hours as a junior obstetrician – he too had fallen asleep at the wheel.

So much for how Walker’s message impacts us personally as students and practitioners, but how should we engage with sleep in the clinic and on the ward? I was delighted to see UHBristol was running a campaign to make to the hospital quieter at night. Recovering from the effects of a motorbike crash in my late teens, I experienced the tyranny of two night-nurses who took sadistic pleasure in shouting and clanging their way through the wee small hours.

Please, do what you can to preserve the delicate and healing sleep of in-patients in your vicinity. And in the clinic? In my surgery we practically never issue more than short (7-14d) courses of hypnotics. Why? Because they are habit-forming and side-effect inducing and typically lead to rebound insomnia. Most of all, they don’t create normal sleep. More confessions. About twice a year, I’ve been in the habit of taking 5mg (half a tab), of prescribed Temazepam, when I find myself wide awake in the middle of the night with a big event the following day.

It works, it gets me to sleep. But all the evidence suggests that that druginduced sleep is not equivalent to natural sleep. In particular, it lacks the normal, memory-enhancing, slow-wave, NREM sleep. Likely I get no net benefit from that slightly longer time nominally spent “asleep”.

This is a great book. I’d go so far as to say it is a must-read for medics. The style is a not world-class – at times a little messianic. But by the breadth of its scope, and the depth of its scientific foundations (including many of the author’s own studies) it serves to transform the reader’s appreciation of the genius and the jeopardy of sleep. Guys, we really have got some catch-up to do here, deepening our knowledge of the facts, valuing our own sleep, and learning how to include it in our clinical conversations. Really, sleep history should be part of every clerking consultation.

This summer we run, for the first time, an SSC on sleep. Its title “Sleep: Chief Nourisher” borrows from those famous lines of Shakespeare. Just think, completely natural, 9

free and profoundly effective. Go sleep (eight hours)!

Sleep that knits up the ravell'd sleave of care, the death of each day's life, sore labour's bath, balm of hurt minds, great nature's second course, chief nourisher in life's feast.

[Macbeth Act 2, Scene 2].

PROF. TREVOR THOMPSON, Reader in Healthcare Education, Head of Teaching for Primary Care, Bristol Medical School

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Are YOU getting enough?

Sleep: The results are in‌

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J. KONDRATOWICZ Editor-in-chief 4th year MBChB

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MEDIC TRIBES: A guide to out placement THE ALCOHOLIC Monday comes around once more.

“Well, might as well buy a pack of stubbies then.”

Perpetually bored with the suburban lifestyle of the Tauntonian, Reece spends his evenings drinking cheap Lidl wine in his flat to terminate the endless cycle of clinical medicine. Unable to fathom any sort of fun not involving alcohol, Reece snubs his colleagues who enjoy exploring the local vicinity. Instead he mutters and gurgles obscenities into his glass of “genuine Lidl Whiskey”, while leaning back in his ergonomic chair, fat spilling over his once-chiselled frame.

THE PARASITE Never organising his own clinics or clerkings, Dennis feeds on the academic enthusiasm of his peers. Known to rigorously stalk his colleagues in advance, he casually suggests partnering up with the highest rank student: a move he has been planning for months. Herein lies the parasite. Commonly clad in baggy sweatshirts and signet rings, Dennis spends any time alone searching for the best deals to Columbia so he can escape the hell that is out placement.

It is of great amusement to witness these creatures when their clinical partner has been taken ill: they wander the wards aimlessly, bumping into patients, mislaying every piece of medical equipment they own.

THE NATIVE “I just don’t know why everyone complains about Weston-super-Mare”, she asserted with her fresh West Country accent.

Georgie’s gone native. Seldom seen in the car back to Bristol, Georgie immerses herself in the local culture. As soon as anyone complains about leaving Bristol, she ardently defends her newfound spiritual homeland to the death.

Aggressively calling her nemesis “a reet spuddling”, she enumerates the various ways in which Weston is “Gert Lush”, and that anyone who disagrees should 14

“G’woam to where they’d come”. Conversant in the history of the Grand Pier and a frequent contributor to the Ship Inn skittles team, Georgie, the selfidentified Westoner, ends up requesting to stay in the decaying seaside town: much to the disgust to her colleagues, and for that matter, the wider universe.

THE CONNOISSEUR “Oh you haven't been to Swindon before? You’ll have a great time the teaching is fantastic and I know all the best local spots to eat, I was there for a week on LITHE.” God forbid ever discovering the 3 town attractions for yourself the connoisseur rams local knowledge down your throat before you can even say ‘outplacement’.

Any hope you had of working out where the hospital canteen was is lost within 10 seconds of arriving. ‘The teaching fellows are sooooo lavely” you were promised before being grilled on the origins of the corticospinal tract for 2 hours. Lies, f*****g lies.

RETURN TICKET TO BRISTOL Josh learnt how to drive at the age of 13 and constantly rubs it in people’s faces.

Always the first to rush out of seminars or bedside teaching, this particular medical student maximises his time in Bristol. Never failing to miss a night out on the triangle, Josh purposefully failed to provide the £20 deposit for the Swindon accommodation, because he said “it was a waste of money” -- while simultaneously spending hundreds of pounds hurtling down the M4.

This specimen is often found publicly broadcasting their love for the Bristol grime scene, though more often than not, ends up spending their evenings cuddling a childhood teddy bear with their patagonia PJs on.

THE GHOST No one has ever seen him in the flesh. A slammed door at 6:30am and a lukewarm cup of instant coffee are the only evidence of his existence.

Supposedly he’s offsite on the psychiatric ward but no one can confirm his exact whereabouts. With his CAPs logbook signed off 3 weeks in advance and his clinical portfolio brimming with patients there is no questioning his competence, but who the f**k is the bloke?

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THE PLACEMENT GIRLFRIEND/BOYFRIEND “Oh it’s lovely in Yeovil, you’ll have a fab weekend if you’d come and visit me” were the pack of lies this sorry partner was sold. He/She is immediately underwhelmed by both the size of the town and the size of the bed which would ‘definitely fit two’. What was sold as a budget romantic getaway to the West Country soon transforms into a torrid 2 sleepless nights followed a huge argument over who stole the duvet at 3am. Bleary eyed and with an uncanny resemblance to the walking dead, the commute back to Bristol for this sleepy partner on Monday morning is noticeably less rose tinted than the journey up.

— A True Cynic

Medic lunchboxes

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Black Bag Article Nutritank:Nutritank Bristol sparks a movement

Around 80% of patients who walk into general practice have conditions related

Around 80% of patients who walk into general practice have condition(s) related to poor to poor diet or lifestyle choices. We are living for longer, but spending more diet or lifestyle choices. We are living for longer, but spending more years in ill health years in ill health with stressful ‘on-the-go’ lives, eating increasing portions of with ​stressful ‘on-the-go’ lives, eating increasing portions of nutritionally poor food and nutritionally poor food and lack of physical activity. Obesity and lifestyle-related lack of physical activity. Obesity and lifestyle-related disease is affecting quality of life disease is affecting quality of life and putting the healthcare systems under and putting the healthcare systems strain.causes ​Nutrition and lifestyle are the leading strain. Nutrition and lifestyle areunder the leading of disease but medical causes of disease but are medical students in and doctors are unconfident at To advising students and doctors underconfident advising patients on the matter. patients in the To ​restore the eroded relationship between lifestyle and restore the matter. eroded relationship between food, lifestyle and health infood, the modern healthworld in theand modern equip future doctors withtackle the tools needed equip world futureand doctors with the tools needed these issues,tackle Bristolthese issues, Bristolstudents, medical Ally students, and Iaincreated Broadley created Nutritank… medical Jaffee Ally and Jaffee Iain Broadley Nutritank.

This lifestyle medicine hub, hub, is taking a dual approach to ensuring nutrition is embedded This lifestyle medicine is taking a dual approach to ensuring nutrition is into the medicalinto curriculum, targeting policyNutritank makers as well as ensuring students embedded the medical curriculum. targets policy makersthat as well as ensuring that students are empowered within their university communities are empowered within their university communities via their NutritankSoc. Though all via their NutritankSoc. Though all local our work, maintain our core values:the UK, we our work whether, it be national or at a level we in our 23 branches across maintain our core values:

The past year the national committee has hosted a Sustainable Health and Wellbeing in partnership with College of Medicine, worked with the British Dietetics Association to create a bespoke nutrition course for students as well as collaborating with Dr Hazel Wallace (The Food Medic, check out her 18

Over the past year the national committee has made a lot of progress. Nutritank hosted a Sustainable Health and Wellbeing in partnership with College of Medicine. We have worked with the British Dietetics Association to create a bespoke nutrition course for students. We have even collaborated with Dr Hazel Wallace (The Food Medic, check out her free podcast on iTunes!), Dr Rangan Chatterjee (author of the 4 Pillar Plan) and Dr Rupy Aujla (The Doctor’s Kitchen). Amidst writing a best selling recipe book, working as NHS GP, hosting his podcast amongst other ventures, Rupy has founded Culinary Medicine UK. This RCGP accredited and designed course gives doctors the opportunity to learn the foundations of clinical nutrition and practical cooking skills so they can best motivate their patients to lead healthier lives using food.

In July 2018, Bristol became the first medical school to offer this course to its students over the 4 week eSSC period. The hard work of our founders was noticed by Jamie Oliver’s team, who came to interview the students on the course - for those of you wondering, it was was completely surreal experience for all of us and yes what you see is what you get, he’s exactly like he is on the telly!

Locally the Bristol branch has hosted and been part of a variety of events. We’ve contributed to the Students for Global Short Course (session on the ‘ Food Crisis’), presenting at the the 3rd Year PREVENT! Central Study Day (right) and an eSSC evening on ‘Healthy Diets’; as well as creating community partnerships with business such as Beets and Roots (Nutritank members get exclusive discounts!).

But we’re not done yet...on the 30th of March we’re hosting a lifestyle medicine conference with GPSoc based on the 4 pillar plan. The day will consist of a series of short lectures and workshops on nutrition, physical activity, relaxation and sleep. Come and find out how you can apply these principles to your future practice as well as your own lifestyle; certificates will be provided, so keep your eyes peeled as we have some exclusive speakers lined up!

It may not seem the most appealing or exciting part of your medical training, 19

but it most certainly will be one of the rewarding. Changing patients’ behaviours, is by far one of the most difficult aspects of being a clinician, so much so that most don’t even try. Imagine having the confidence to tackle this, instead of prescribing patients pills, you will be able to work with them to get to the root of their problem: providing sustainable solutions through lifestyle changes alongside their medical care. You’re not simply giving a quick fix for their illness, but empowering them to lead healthier lives, focusing on being ‘well’ instead of just ‘being’.

S. SARFARAZ, 4th year MB ChB Bristol Branch Lead 2018-19

With thanks to Ellen Crisp, Ally Jaffee and Iain Broadly

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Revision ready recipe

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Dear Cancer: A letter Dear Cancer, Your species a product of evolution, taking steps down a new road armed with nothing but your own vision. Look how far you’ve come. The hundreds of thousands of mutated forms you disguise yourself in. You’re familiar to everyone, across all walks of life. Littered across headlines. Labels that can’t be lifted, outperforming many other destructors of life. Your name needn’t be uttered.

Your story doesn’t deserve to be told. But you’re there. Always. Everywhere. In one way or another.

Who planted you within me? How have you spread and grown unwantedly on my soil so quickly? I never fed you, but you fed off me for so long without my knowing. You’re rooted. In me. Why? You somehow concluded that I was the perfect vessel, not only touching me but those I love dearly. No, touch is too soft. You pierced our hearts beyond repair, shattered the remnants of hope and threw me into a war I never thought existed. When will our war be over? Your existence feeds off humanity releasing this violent emanation as you feast, prey.

Strangling every organ, constricting each limb, pervading me entirely. Why aren’t you happy with occupying 10% of me? Who told you it’s all or nothing?

Why can’t you be reasoned with?

I was writing the story of my life, but you came and took the pen. You enslaved me, master. Me being the creation, creator. The biggest battle was understanding your nature. Now I know the anger you leave in your wake, the harm and uncertainty you throw individuals into. You told me not to underestimate your abilities, how significant the consequences were to be.

You’d sewn your purpose to the deepest parts of my vessel. Your body, fluid yet so firm and anchored. I know, I’m just another number you managed to successfully invade.

Clocks, watches, all things time telling, in the house, on family members, littered in hospitals, carried around meaninglessly, glued to everyone but me. I now know of its existence. Time – this relative, irreversible process. The creator, the ager and destroyer of all things. Every tick closer to my terminal date. It’s a countdown that nobody really has any control over, but you. Time isn’t a monster, but ‘the’ monster that cannot be reasoned with.

You changed the world but more importantly people’s worlds. I walk the 22

streets, fighting a hidden battle people know nothing about. With you I felt vulnerable to deterioration, exposed to disease, infected with your filth, a burden to all. They’re trying to eradicate you, you know. You will end when I end. You like everything else have been designed to have flaws. I don’t need you to survive but you need me.

Thank you for giving me an expiry date. I was fearful of you. Fear, forget everything and run. I am still fearful of you. Fear, face everything and rise. I’ve embraced the pain you put me through and burnt it to fuel my shortened stay on earth. Does it have to be the way society perceives it, family and friends saddened by the thought of me leaving ‘maybe’ before them. We all worry about tomorrow as if it’s guaranteed. All that differs between me and them is that my expiry date has been confirmed. People, do something instead of killing time because time is killing you. Everyone dies but not everyone lives and thanks to your presence cancer, you brought life and meaningful purpose back into me for whatever time remains, a constant reminder to fulfil and serve it. It’s not the years in life that count. But the life in your years. Cancer, your education has been second to none, unparalleled. Lesson of gratitude. Having taken life for granted, I’ve concluded it’s the little things in life that matter most. Lesson of kindness. Be kind for people are fighting many hidden battles you know nothing about. Lesson of resilience. Continuously fighting for what you believe in and picking yourself up, again.

This isn’t my story but our story and you seem to edit it quite often. At times I thought that everything was going wrong, but I too late realised you came to me to set everything right. There’s good and evil in all walks of life including you.

You’re a work of art. Not everyone will understand you, but the ones who do will never forget you. I wasn’t ever ashamed of the scars you gave me. It simply meant that I was stronger than whatever tried to hurt me. They’re more like internal tattoos but with better stories. I was given this life because I was strong enough to live it. I have survived 100% of my worst days. I’m doing just fine.

Even in the hardest of times, the longest day is 24 hours. Everything passes, nothing stays. You included. There’s always someone who has it harder than me, fighting a tougher, more brutal battle than me. Every loss is nothing else but a reminder that nothing in this life is permanent. Life has many chapters for us.

One bad chapter doesn’t mean it’s the end of the book.

How peacefully you grew within me, restoration of faith you brought back to me and giving me the courage to begin life again. Blooming so beautifully, you really got under my skin, physically holding my heart in your hands. They tried to rid you from me but that hurt me even more as my leaves fell. We’ll depart 23

this place together. Leave our mark together. You didn’t change me. Instead you revealed me. How have I been hidden for this long? You’ve made me take advantage of life before death. You inspected me, directed me, corrected me, protected me and perfected me. I wake with you, sleep with you, breath with you, walk with you, eat with you, see the beauty in our world with you, bleed with you, cry with you, suffer heartache and misery with you. I am you and you are me. Cancer, in case no one told you today, you’re beautiful, alive for a reason, presence on this earth makes a difference whether you see it or not. You do not discriminate, and I applaud you for that. If you can change the way you look at things, the things you look at change. Sometimes blessings are not in what we receive but taken away. Don’t look back. We’re not going that way.

Love, from your home S. MASOOD

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Crossword

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Crossword Solution

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EDITORS’ AFTERWORD Thank you for reading THE BLACK BAG. It took us blood, sweat and tears, so even if you didn’t enjoy it, keep it to yourself.

Medical Students were once described by Charles Dickens as “a parcel of lazy, idle fellars, that are always smoking and drinking and lounging…”. We hope this issue has you fully convinced that he was right.

If we haven’t just put you off, why not send us an article? We want the whole of the Bristol Medical School community writing for us- students, staff and alumni! All ideas are welcome.

Email us at blackbag@galenicals.org.uk — YEAR REPS: Year 2: T. GREENSLADE Year 3: N. REES Year 4: J. HUTCHINGS Year 5: C. ALBRINES

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Inspired by the wit and lyricism of Bristol Medical School’s literati? Or are you gushing with fury and vitriol at the mere sight of our humble chronicle?

Well‌Why not write for us? Any contributions welcome. Just email blackbag@galenicals.org.uk and pitch your idea for an article!

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THE BLACK BAG Galenicals publication Bristol Medical School, University of Bristol