FASTEN YOUR SEATBELTS: THE TURBULENT JOURNEY TO BECOMing A DOCTOR THE MAGAZINE FOR JUNIOR DOCTORS
Presenting History JuniorDr is a free lifestyle magazine aimed at trainee doctors from their first day at medical school, through their sleepless foundation years and tough specialist training until they become a consultant. It’s proudly produced entirely by junior doctors - right down to every last spelling mistake. Find us quarterly in hospitals throughout the UK and updated daily at JuniorDr.com. Editor Ashley McKimm, firstname.lastname@example.org Editorial Team Michelle Connolly, Anita Sharma, Muhunthan Thillai, Andro Monzon Newsdesk email@example.com Advertising & Production Rob Peterson, firstname.lastname@example.org JuniorDr PO Box 36434, London, EC1M 6WA Tel - +44 (0) 20 7 684 2343 Fax - +44 (0) 87 0 130 6985 email@example.com Health warning JuniorDr is not a publication of the NHS, Gordon Brown (if he is still PM by date of publication), his wife, the medical unions or any other official (or unofficial) body. The views expressed are not necessarily the views of JuniorDr or its editors, and if they are they are likely to be wrong. It is the policy of JuniorDr not to engage in discrimination or harassment against any person on the basis of race, colour, religion, intelligence, sex, lack thereof, national origin, ancestry, incestry, age, marital status, disability, sexual orientation, or unfavourable discharges. JuniorDr does not necessarily endorse or recommend the products and services mentioned in this magazine, especially if they bring you out in a rash. © JuniorDr 2009. All rights reserved. Get involved We’re always looking for keen junior doctors to join the team. Benefits include getting your name in print (handy if you ever forget how to spell it) and free sweets (extra special fizzy ones). Check out JuniorDr.com.
resh into medical school I would have been the first person to dash down the aeroplane aisle if they had asked for a doctor on board. Eager with enthusiasm no stewardess could have stood in my way to attempt a tracheotomy with little more than a drinks straw and an airline napkin. Today, despite being a qualified doctor for five years, I’m pretty confident I wouldn’t. More likely I would be cowering in my seat hoping, that by some luck, there is a trauma consultant on board who could deal with any eventuality. The bad news, as we find out on page 9 (Medical Emergencies at 30,00ft), is that the frequency of hearing that dreaded message over the flight tannoy is likely to rise. With increasing life expectancy more people are flying long-haul in later life taking with them all their co-morbid medical conditions. Costing as much as £125,000 to divert a plane, falling ill in the air is a very serious business. We look at what the airlines are doing to provide medical assistance during a flight and the most likely emergencies you might have to deal with. This all however, is far from the minds of new medical students starting their training this month. That first day at medical school is the beginning of the final chapter in the dream to get that Dr prefix to your name. We offer some advice (Medical School Survival Guide p14) from doctors and medical students who have been there before on how to survive in the land of colonoscopy clinics, cardiology vivas and neuro MCQs. Good luck to everyone starting out on that journey. Just try to hold back that enthusiasm to dash down the aeroplane aisle mid-Atlantic - especially if there is a trauma consultant just behind you.
“No stewardess could have stood in my way to attempt a tracheotomy with little more than a drinks straw and an airline napkin.”
Ashley McKimm JuniorDr Editor-in-Chief ST3 Psychiatry
What’s inside 04 09 14 15 18 20 21
LATEST NEWS Medical Emergencies at 30,000ft StarTing Medical School Guide Weekend Ward Escape SECRET DIARY OF A CARDIOLOGY SPR Dumbo gets a check-up Hospital Confidential
Tell us your news. Email firstname.lastname@example.org or call 020 7684 2343.
Junior doctors “press-ganged” into HIV tests
Manchester chosen as new PLAB centre
unior doctors working at four NHS trusts in England have reported feeling “press-ganged” into HIV tests as part of their pre-employment occupational health checks, says a study published in the Journal of Medical Ethics. New guidance in 2007 from the Department of Health stipulated that all staff should be offered tests for the serious blood-borne viruses hepatitis B and C, HIV and TB. However, the guidance makes it clear that the tests are not mandatory for doctors whose work does not expose them to these viruses, nor are they a prerequisite for employment. “The only discussion I had with somebody about the test was to say: ‘we’re going to test you for HIV. Is that OK?”
The study of 24 junior doctors found they were not given any information about the HIV test or told why they needed to have it. Most of the doctors did not feel they had the option to refuse the test; only four did so. Few were offered any follow up counselling or discussion, which would have been provided had they been ordinary patients. Only three of the doctors were actually asked about behaviour that would have increased their risk of acquiring HIV; none felt they had been at high risk. One doctor said: “The only discussion I had with somebody about the test was to say: ‘we’re going to test you for HIV. Is that OK?’ and then being stabbed.” Another said: “I wonder if they’d have sacked me if it was positive. No one really explained what would happen if it were positive either. Would my bosses have been told about it?” Only two documented HIV patients in the world have been infected by a doctor. Neither was in the UK. jme.bmj.com
anchester has been selected as the new location for national assessment of international medical graduates from 2010. All international medical graduates have to demonstrate their clinical skills and knowledge before they are registered with the GMC and allowed to seek work in the UK. From March 2010 doctors who want to work in the UK but graduated outside the European Economic Area will be assessed at the centre. It is expected that 1,800 will be examined each year which will form the second part of the Professional Linguistics and Assessment Board (PLAB) test. “The move of these facilities to Manchester will ensure that we can continue to provide, and improve upon, a high quality of service. We expect to assess around 1,800 candidates every year,” said Anthony Egerton, Assistant Director of Registration at the GMC. The PLAB test assesses doctors’ skills and knowledge through a variety of exercises across four areas – clinical examination, practical skills, communication skills and history taking. Tested skills include taking blood, examining a mocked-up ‘pregnant’ abdomen and performing simulated examinations of the eye, ears and nervous system. The GMC is moving the Clinical Assessment facilities because it is expanding its remit to take full responsibility for the whole spectrum of medical education, following a merger with the Postgraduate Medical Education and Training Board (PMETB). The centre will also be used by doctors undergoing a performance assessment as part of an investigation into their fitness to practise.
Consultants failing to use portfolios properly in appraisals
onsultants who assess the performance of junior doctors and medical students are failing to use the portfolio-based appraisal systems properly, says new research presented at the British Sociological Association’s Conference. The study found that almost half of consultants simply ignored the trainees’ own portfolios when assessing them and completed the tick-box exercise based on their own assessment. “All [of the appraisers] reported trainees’ portfolios played a highly superficial role in helping them decide what work tasks an appraisee should undertake and be assessed in and form an opinion about the level of technical proficiency possessed by an appraisee,” said Dr Chamberlain and his research team from the University of Chester. Those questionned believed the new portfolio-based performance appraisal systems were ‘box-ticking exercises’ and continued to use the traditional method of day-to-day performance for the assessment The study which looked at 46 UK consultants, surgeons and GP assessors found none fully complied with the appraisal system’s requirements.
“You fill in the forms in a workmanlike ‘dotting the Is and cross the Ts’ fashion. But it’s all for the look of the thing.” Assessor
Portfolio-based performance appraisal systems have been brought into medical training over the last decade as a way of formally logging the progress of junior doctors as a record during their training. They are also used during the annual appraisal of all doctors as part of their NHS contract. www.britsoc.co.uk
New report ignores ‘crippling cost’ of medical education
Romanian Society for Medical Mycology & Mycotoxicology
One doctor questionned described the process as purely a bureaucratic exercise: “You fill in the forms in a workmanlike ‘dotting the Is and cross the Ts’ fashion. But it’s all for the look of the thing. It doesn’t mean that you actually have done what you are meant to have done, or for that matter believe in what you have written past a very superficial level,” he said.
new report aimed at increasing the number of doctors from lower income groups has been branded a missed opportunity by doctor and medical student leaders after it failed to address the full extent of the soaring financial cost of studying medicine in the UK. Unleashing Aspiration, a report by the Panel on Fair Access to the Professions and chaired by former health sec Alan Milburn MP, examined the barriers and pathways to reaching the professions. The BMA is critical of the UK government for restricting the Panel’s remit to allow it to examine fully two of the main barriers blocking wider access to medicine - debt and tuition fees. “Just 4% of medical students currently come from the lowest two socio-economic groups. Ministers have no hope of addressing this poor level of participation without examining the
“I strongly recommend this book to all medical students, clinical microbiology and ŝŶĨĞĐƟŽƵƐĚŝƐĞĂƐĞƌĞƐŝĚĞŶƚƐ as a useful guide for their training.”
crippling and increasing costs of medical education,” said Tim Crocker-Buque, chairman of the BMA’s Medical Student Committee. “The Panel has been undermined from its inception by the government’s refusal to allow it to examine fully two of the main barriers blocking wider access to medicine - debt and tuition fees.” The BMA estimates a graduation debt of £37,000 for those who began their medical degree in 2006. They rejected the idea that tuition fee waivers for those staying at home would have a substantial impact on increasing social mobility in medicine - particularly as most medical students do not live within travelling distance of the 32 medical schools in the UK. www.bma.org.uk
ĂƐĞ^ƚƵĚŝĞƐŝŶ/ŶĨĞĐƟŽƵƐŝƐĞĂƐĞ is an undergraduate textbook ĐŽŶƐŝƐƟŶŐŽĨĨŽƌƚǇĐĂƐĞƐƚƵĚŝĞƐ ŽĨƚŚĞŵŽƐƚŝŵƉŽƌƚĂŶƚŚƵŵĂŶ ŝŶĨĞĐƟŽƵƐĚŝƐĞĂƐĞƐĞŶĐŽƵŶƚĞƌĞĚ ŐůŽďĂůůǇ͘
COMING SOON: INDIVIDUAL CASES FOR PURCHASE AT OUR EBOOKSTORE: www.ebookstore.tandf.co.uk
Cases ϭ͘ Aspergillus fumigates Ϯ͘ Borellia burgdorferi ΘƌĞůĂƚĞĚƐƉĞĐŝĞƐ ϯ͘ Campylobacter jejuni ϰ͘ ŚůĂŵǇĚŝĂƚƌĂĐŚŽŵĂƟƐ ϱ͘ ůŽƐƚƌŝĚŝƵŵĚŝĸ ĐŝůĞ ϲ͘ ŽǆŝĞůůĂďƵƌŶĞƫ ϳ͘ ŽǆƐĂĐŬŝĞǀŝƌƵƐ ϴ͘ EchinococcusƐƉƉ͘ ϵ͘ Epstein-Barr virus ϭϬ͘Escherichia coli ϭϭ͘Giardia lamblia ϭϮ͘Helicobacter pylori ϭϯ͘,ĞƉĂƟƟƐǀŝƌƵƐ ϭϰ͘,ĞƌƉĞƐƐŝŵƉůĞǆǀŝƌƵƐϭ ϭϱ͘,ĞƌƉĞƐƐŝŵƉůĞǆǀŝƌƵƐϮ ϭϲ͘Histoplasma capsulatum ϭϳ͘,ƵŵĂŶŝŵŵƵŶŽĚĞĮĐŝĞŶĐǇǀŝƌƵƐ ϭϴ͘/ŶŇƵĞŶǌĂǀŝƌƵƐ ϭϵ͘Leishmania ƐƉƉ͘ ϮϬ͘Leptospira ƐƉƉ͘ Ϯϭ͘Listeria monocytogenes ϮϮ͘Mycobacterium leprae Ϯϯ͘Mycobacterium tuburculosis Ϯϰ͘Neisseria gonorrhoea Ϯϱ͘EĞŝƐƐĞƌŝĂŵĞŶŝŶŐŝƟĚĞƐ Ϯϲ͘EŽƌŽǀŝƌƵƐ Ϯϳ͘WĂƌǀŽǀŝƌƵƐ Ϯϴ͘Plasmodium ƐƉƉ͘ Ϯϵ͘ZĞƐƉŝƌĂƚŽƌǇƐǇŶĐǇƟĂůǀŝƌƵƐ ϯϬ͘ZŝĐŬĞƩƐŝĂƐƉƉ͘ ϯϭ͘Salmonella typhi ϯϮ͘Schistosoma ƐƉƉ͘ ϯϯ͘Staphlococcus aureus ϯϰ͘^ƚƌĞƉƚŽĐŽĐĐƵƐŵŝƟƐ ϯϱ͘Streptococcus pneumoniae ϯϲ͘Streptococcus pyogenes ϯϳ͘Toxoplasma gondii ϯϴ͘Trypanosoma ƐƉƉ͘ ϯϵ͘sĂƌŝĐĞůůĂŽƐƚĞƌǀŝƌƵƐ ϰϬ͘tƵĐŚĞƌĞƌŝĂďĂŶĐƌŽŌŝ April 2009 z 608 pp z 270 full color illus Paperback: 978-0-8153-4142-0: £30.00
Most surgeons do not report needle stick injuries
hree-quarters of surgeons who experienced one or more sharps injuries in the last year did not report them, according to research by The Royal College of Surgeons. The study at three district general hospitals in the UK found that only 25.8% followed proper procedure and reported all of their sharps injuries - perforations of the skin caused by a needle, scalpel or other sharp instrument. When asked why they didn’t, more than a third of surgeons responded that they did not think it was necessary as they considered the patient to be at a low risk of carrying an infectious virus. A further third said they had no time and almost a quarter simply said they were not concerned. “While the probability of acquiring a blood
borne infection remains low, the potential consequences are severe,” warned John Black, President of the Royal College of Surgeons. “In failing to report sharps injuries, surgeons are missing this opportunity for treatment, and masking the true scale of the problem.” A report published in 2003 by the Senate of Surgery of Great Britain and Ireland – an association of all major surgical bodies – recommended that all sharps injuries should be reported at the earliest possible stage, as early treatment can significantly reduce the chance of acquiring some infections, particularly HIV.
GMC Fees frozen for 2010/11
More chest pain for men John Black President of the Royal College of Surgeons
“In failing to report sharps injuries, surgeons are missing this opportunity for treatment, and masking the true scale of the problem.”
Men with angina are twice as likely to have a cardiac arrest as women, according to a study by the National University of Ireland - the first to link primary and secondary care data with mortality records. The study of 1,785 patients also found that although angioplasty (PTCA) or coronary artery bypass surgery (CABG) was also higher in men neither procedure was associated with significantly improved survival. www.bmj.com/cgi/doi/10.1136/bmj. b3058
Steroids for sore throats
Rise In Homicides By Mentally Ill
A single dose of corticosteroid drugs alongside antibiotics to adults with severe sore throat can relieve pain more quickly and effectively, suggests research published in the BMJ. Metaanalysis showed the average time to pain relief for patients given corticosteroids in addition to antibiotics was reduced by about six hours. The study found no evidence of significant benefit in children.
he number of people killed by individuals with mental health problems has increased between 1997 and 2005, figures from the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness show. The research by the University of Manchester and funded by the National Patient Safety Agency found that there had been an increase in the number of homicides committed by people with mental illness at the time of the offence from 54 in 1997 to over 70 in 2004 and 2005. The rise occurred in people who were not under mental health care and was not found in mental health patients. “It is important to emphasise that the increase has not occurred in mental health patients,” said Professor Louis Appleby, Director of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. “It is also important to keep these findings in perspective. The risk of being a victim of homicide in England and Wales is around 1 in 1,000 and the risk of being killed by
The GMC and PMETB have announced that fees for trainee doctors completing specialty training will be frozen at the current levels for 2010/11. It comes as PMETB is merged with the GMC meaning that for the first time, all stages of medical education and training are the responsibility of a single organisation. The merger is due to be completed by 1 April 2010.
someone with schizophrenia is around 1 in 20,000.” There study found a rise in the number of homicides by people with schizophrenia from 25 in 1997 to 46 in 2004 and an estimated 40 in 2005. The data also shows that the number of patient deaths by suicide has gone down to its lowest level since data collection began in 1997. In 2006, there were 185 fewer deaths than in 2005. The number of in-patient suicides has continued to fall from a high of 219 deaths in 1997 to 141 in 2006. www.npsa.nhs.uk
Not quite an emergency? Call 111 Consultation on a new three-digit number - 111 - to offer advice and information on non-emergency care has been launched by the government. In the long-term, 111 could become the single number to access non-emergency care services in England, including NHS Direct. 999 will remain the number to call in an emergency situation. www.nhsdirect.nhs.uk
Training affected by service reorganisation
ew ways of assessing and reviewing patients can negatively impact junior doctor training, according to a study of acute care at the Royal Liverpool University Hospital. The results, published in the journal Clinical Medicine, show that while waiting times in A&E until assessment by a consultant have improved, restriction of hours prevented junior doctors from being present when the patients they admitted to the wards were reviewed by a consultant. It noted that around half of all diagnoses are changed after assessment by the junior doctor and that the current system has no mechanism “The restriction of junior doctors’ hours means there is less time for consultants to discuss their decisions with the doctors in training.” Dr Solomon Almond Royal Liverpool University Hospital
New BMA Junior Doctor Chair Elected
hree Datta, a Specialist Registrar in obstetrics and gynaecology at Royal Sussex County Hospital, has been elected as the new chair of the BMA’s Junior Doctors Committee. Shree takes over from Andy Thornley when he steps down after a year in the post on 19th September. She says the impact of the EWTD is one of the key challenges for the year ahead. “The introduction of the 48 hour week has left many junior doctors concerned about getting
uture medical students will undertake ‘assistantships’ before entering FY1 as a trainee doctor, according to new guidance issued by the GMC this month. During ‘student assistantship’ blocks they will assist a junior doctor to become familiar with the workplace and undertake supervised procedures. The aim is to help students understand practical
for feedback to the initial assessing team. “The results of our audit highlight the benefits for patients of being seen by consultants soon after admission. However, the restriction of junior doctors’ hours means there is less time for consultants to discuss their decisions with the doctors in training,” said Dr Solomon Almond, one of the study team. “Ideally all emergency admissions would be seen straight away by consultants accompanied by the junior doctors. This would re-establish the link between hands-on clinical medicine, training and experience that was for many years the foundation of post graduate medical education in this country.” The authors noted that hospitals are struggling to balance government targets for waiting times with the new target for reducing junior doctors’ working hours whilst maintaining training. www.rcplondon.ac.uk/pubs/clinicalmedicine/
the training opportunities they need to be the consultants of tomorrow,” says Datta. “It is essential that hospitals, especially those under financial pressures, do not cut back on their obligations to train new doctors in an attempt to deliver services on the cheap. This attitude is short-sighted and threatens our future capacity to provide high quality services to patients.” Shree is joined by Tom Dolphin, Vice Chair of the Junior Doctors Committee, and Johann Malawana, Deputy Chairman with responsibility for education and training issues. A further election will take place on the 19th September 2009 to select a new Deputy Chairman with responsibility for negotiations. www.bma.org.uk
tasks such as filling in a prescription form or ordering a blood sample before their first formal post. The plans are part of a new version of Tomorrow’s Doctors issued by the GMC which provides the framework that UK medical schools use to design their own detailed curricula and schemes of assessment. The report also outlines ‘hard science’ subjects and a standardised list of clinical procedures that students must be competent to undertake before graduation. www.gmc-uk.org
on our selection of detailed, uncomplicated revision guides for junior doctors
rsmpress.co.uk Please quote JuniorDr when ordering
Royal College of Art
mart Pods’ was a two-year study at the Royal College of Art that explored new mobile treatment solutions that would enable healthcare professionals to assess and treat more people in the community, instead of taking them by ambulance to hospital. In the future, urgent response vehicles will not be required to travel at high speeds. The look and feel of such vehicles will reflect a new type of service, which is geared to treating people at home, rather than taking them to hospital at speed. The Shell Concept, by Rui Guo, is a compact and efficient vehicle designed for the delivery of urgent medical capability. The removable ‘shell’ can be deployed to create an expanded treatment space, or left on-scene for extended periods of time. It is equipped with all the kit and consumables required. To accommodate a range of uses the shell is interchangeable: multiple treatment units can be prepared at base ready for immediate deployment. For more information on ‘Smart Pods’ visit: www.rca.ac.uk
Royal College of Art Masters Vehicle Design Project: Shell Concept Designer: Rui Guo Length: 4.4m (6.2m when expanded) Width: 1.7m Height: 1.9m
Medical Emergencies at 30,000ft Settling in for a flight is never the same once you’ve taken the Hippocratic Oath. In the back of your mind is always the fear of hearing the dreaded message asking if there is a doctor on board. But how likely is it that you’ll need to perform an in-flight trachestomy with only a coat hanger? And what assistance can you expect at 30,000ft? JuniorDr’s Ben Chandler finds out.
ramped in a cabin with up to 850 other anxious passengers isn’t the best place to practice medicine. Add in the effects of engine noise, cabin pressure and a limited supply of unfamiliar equipment and it can become your worst nightmare. Unfortunately with an ageing population and greater passenger numbers your chance of facing a medical emergency whilst jetting off on your summer holiday is on the rise. With between 1 and 10 incidents per 40,000 passengers1 it’s a scenario that many doctors will face at some point in their careers.
In-flight emergencies There have been numerous documented medical incidents in the air but perhaps the most famous occurred in 1995 between Hong-Kong and London. A female patient developed chest pain and dyspnoea shortly after take off and was seen by two doctors onboard. Having diagnosed a tension pneumothorax they proceeded to insert a chest drain using brandy as disinfectant, a coat hanger as a trochar and bottle of Evian water as an underwater seal. The flight continued and the patient was eventually seen in a
Commonest Medical Emergencies Inflight
• Syncope • Gastrointestinal disorders • Cardiac conditions • Nausea and Vomiting • Allergy • Accidents • Hypoglycaemia
Federal Aviation Authority, Emergency Medical Equipment Regulations4 • Sphygmomanometer • Stethoscope • Airways, oropharyngeal (3 sizes): 1 pediatric, 1 small adult, 1 large adult or equivalent • Self-inflating manual resuscitation device with 3 masks (1 pediatric, 1 small adult, 1 large adult or equivalent)
• Aspirin tablets, 325 mg
Travelling by commercial airliner exerts various effects on the body that can precipitate medical difficulties. The most immediate is the lower ambient pressure which causes a drop in oxygen saturations to around 90% even in healthy passengers. Airline cabin pressures are usually equivalent to 2000-2400 metres altitude, and passengers with underlying heart or chest disease may require additional oxygen to counter hypoxia. Most people experience the expansion of gas in air filled cavities on take-off manifesting as pain in the ears or sinuses but it also has the potential to convert a simple pneumothorax into a tension pneumothorax. Relative humidity is low in the cabin, causing dehydration, worsened by alcohol. The risks of deep vein thrombosis from limited mobility and dehydration are well recognised as the infamous ‘economy class syndrome’.
• Bronchodilator, inhaled (metered dose inhaler or equivalent)
• CPR mask (3 sizes), 1 pediatric, 1 small adult, 1 large adult, or equivalent • IV Admin Set: Tubing w/ 2 Y connectors • Alcohol sponges • Adhesive tape, 1-inch standard roll adhesive • Tape scissors • Tourniquet • Saline solution, 500 cc • Protective non permeable gloves or equivalent • Needles (2-18 ga., 2-20 ga., 2-22 ga., or sizes necessary to administer required medications) Syringes (1-5 cc, 2-10 cc, or sizes necessary to administer required medications) • Analgesic, non-narcotic, tablets, 325 mg • Antihistamine tablets, 25 mg • Antihistamine injectable, 50 mg, (single dose ampoule or equivalent) • Atropine, 0.5 mg, 5 cc (single dose ampoule or equivalent)
• Dextrose, 50%/50 cc injectable, (single dose ampoule or equivalent) • Epinephrine 1:1000, 1 cc, injectable, (single dose ampoule or equivalent) • Epinephrine 1:10,000, 2 cc, injectable, (single dose ampoule or equivalent) • Lidocaine, 5 cc, 20 mg/ml, injectable (single dose ampoule or equivalent) • Nitroglycerine tablets, 0.4 mg
hospital in the UK where she made an uncomplicated recovery2. But before you start revising chest drain insertion it is useful to know that this is one of the more rare emergencies you are likely to face. Most cases are due to exacerbation of pre-existing medical conditions, either from the aircraft effects such as cabin pressure or the stress of flying, or medication problems such as accidentally packing important medication in the hold. Syncope is by far the commonest, making up around 50% of cases. Gastro-intestinal upset and generalised pains are the next most frequent - possibly related to dehydration, alcohol consumption and disrupted sleep. Fortunately many emergencies will be dealt with by airline staff without the assistance of onboard doctors.
Over recent years the amount and type of emergency equipment carried on aeroplanes has been reviewed with many airlines now carrying automated external defibrillators (AEDs). One person who has benefited from this is MP Paul Keetch. In 2007 Mr Keetch suffered a cardiac arrest whilst on a Virgin Atlantic flight from Heathrow to New York.
He was successfully defibrillated and returned to Heathrow for hospital treatment. In a recently published study one major US airline reported 200 uses of AEDs over a 2 year period, including 13 defibrillations. They found a 40% survival rate for VF or pulseless VT arrests - remarkable when you consider the difficult cabin environment.3
Emergency Landings Many of these medical scenarios can be dealt with in the air avoiding unnecessary emergency landings, however in around 1-2% of cases an emergency diversion is necessary. This is potentially a very expensive decision with the overall cost as much as £125,000 to divert a plane.5 If other passengers are left stranded for any reason, then hotel bills and other expenses can increase dramatically. In 1996 a passenger on a Virgin Atlantic flight had a suspected heart attack, and the flight diverted to a small airport in Eastern Canada. However during the landing one of the aeroplanes’ engines was damaged. Nearly 400 passengers (including pop star Gary Barlow) were left stranded for 15 hours at the local curling rink while other aeroplanes were sent to pick them up.6
Support from the ground If called upon to help you are unlikely to be totally alone. On any flight there is approximately a 6085% chance of there being a doctor as a passenger onboard7 and most flight attendants are trained to deal with common medical emergencies. Many airlines also have access to MedLink, the largest medical support service with experienced emergency doctors on hand to offer advice. “In this scenario the medical volunteer assumes a position of being the eyes and hands, helping in assessing and administering medication” says Dr Paulo Alves, the Vice-President of MedAire, who run the service. “The MedLink Physician will have the experience and emotional detachment to help with situation onboard, and help the captain to make the best decision about landing or not.” Medlink is run from Pheonix USA, and is staffed by emergency
doctors with training in aviation medicine. They deal with nearly 100 cases per day. As well as supplying medical knowledge they also have access to a database of medical resources and details of runways around the globe, so they can advise on the most suitable diversion should it be necessary. Interest is now growing in telemedical devices which will allow vital signs, ECG and other data to be transmitted to staff on the ground. This technology has already been taken up by several airlines.
Good Samaritan Acts Many doctors have concerns that they could potentially be the subject of medico-legal action arising from their decisions during an aeroplane medical emergency. The legal position is complicated as it is different in different countries. Despite this the GMC and BMA stance is that doctors should assist if required. Indemnity against prosecution may be offered by the airline, but this may depend on whether you were asked to help. Both the MPS and MDU cover their members for actions taken while on a plane. The MPS suggest that before getting involved doctors should clearly state their competencies and skills, as well as other factors that may affect their performance, such as alcohol.8 So if you ever hear those dreaded words over the airline tannoy, keep in mind to do simple interventions, recognise your own limits, and in most cases there should be help of some kind available.
References 1. Surgical ad Medical emergencies onboard European aircraft. Sand M, Falk-Georges B, Sand D, Mann B. Critical Care, 2009. 13:1 2. Managing in flight emergencies. Wallace W. BMJ, 1995;311:374-375 3. Use of Automated External Defibrillators by a U.S. Airline. Page R, Joglar JA, Kowal R, Zagrodzky J, et al. NEJM, 2000; 343:12101216 4. Federal Aviation Authority Advisory Circular, 2006. www.rgl.faa.gov 5. How much does an airline diversion cost. Martin G. www.gadling.com 6. Unexpected Arctic stop for Brits, Yanks. Van Rassel J. Nunatsiaq News 1996. 7. Health Issues of air travel. DeHart R. Annual Review of Public Health, 2003; 24: 133-151 8. Flying doctors: is protection plain. Williams S. Casebook 2008; 16: 8-11
Is there a doctor on board? At thirty thousand feet and four thousand miles from the nearest medical support it’s the last place anyone would want to take ill. Over the loudspeakers a call goes out asking for a medical doctor on board. From that point onwards the care of one man with chest pain and the decision to divert four hundred passengers rested with junior doctor Krish Vedavanam.
t all started with a ham sandwich, Dr Vedavanam told JuniorDr. It was November and I was flying from London to Toronto for the wedding of a close friend who had been on my GP training scheme. With me were two other junior doctors - a paediatrician and a general physician. Arriving at Heathrow we found our Air Canada flight delayed by five hours. After some time complimentary food arrived in the form of a ham or egg sandwich. Sitting opposite us in the terminal were a Muslim couple. I could tell as the woman was wearing a hijab. I looked at her, then at the ham sandwich, and said, “Are you sure you ought to be eating that?” She looked back blankly clearly not understanding. “Pork!” I said in a loud voice pointing at the sandwiches. Her husband responded and thanked me with some broken English. I gave them my egg sandwich but not the cereal bar - it was full of sugar and I was sure they were both diabetic. They were really grateful for the sandwich. Later the man came up to me again and asked if he could phone his son in London, which he did. Finally at 9pm we boarded the plane. I was very tired and fell fast asleep just after take-off.
Is there a doctor on board? Three quarters of the way into the journey, still in a daze, I heard the dreaded phrase over the loudspeaker - “If there are any medical doctors on board could they please make themselves known to the cabin crew”. My friend had also heard the message and had got up. I followed her. Towards the back of the plane we found the man who I had given my egg sandwich to before the flight. He was complaining
of central chest pain and looked generally unwell. After my communication problems at Heathrow I was a little concerned about the ability to understand what was happening. Luckily there happened to be an Urdu speaking air stewardess onboard - the only one in Air Canada. The gentleman told us that he was a cardiac patient and had chest pain at rest before starting his journey to Canada. Before stopping in London he had been in Saudi Arabia where he was given low molecular weight heparin and had been told to take another dose when he got off the flight - which I’m sure you’ll agree this was already a little worring. As he was already taking beta-blockers and GTN patches we tried another patch but there was no improvement. With difficulty we laid him down flat behind one of the bulkheads in the plane and gave him highflow oxygen and treatment dose aspirin. His wife was terrified throughout. She was scared he was going to die and, because of the language barrier, there was very
little we personally could do to reassure her. Although his observations were stable the pain was still not improving. The airline medical kit, although containing items like morphine, didn’t have a BM monitor. We had to put an announcement out for any passenger with a BM kit to come forward. Luckily someone did, but rather embarrassingly we had to call them back for a second time to explain how it worked. As he was still in acute pain we decided to obtain IV access and gave him morphine. Dr Krish Vedavanam
“Diverting a jumbo jet is a pretty big decision to make when you know it will affect the other 400 people on board.”
Diverting the plane It was at that point we were asked to make the decision on whether to divert the plane. Diverting a jumbo jet is a pretty big decision to make when you know it will affect the other 400 people on board. We had a working diagnosis of acute coronary syndrome and decided that he needed medical treatment as soon as possible so informed the crew. The cabin crew had been great throughout the flight, efficiently helping in whatever way they could. The plane was diverted to Newfoundland, the most easterly point of Canada. It took a further two hours to reach there. Luckily the gentleman was stable throughout the reminder of the journey. Whilst other passengers and the cabin crew were strapped in on the landing we weren’t. As the plane came into land we were still with the gentleman trying to keep him comfortable - it was a strange experience. On touching down in Newfoundland we were met by paramedics who stretchered the gentleman off the plane. He remained stable and was quite comfortable at this point. His wife went with him. After he had been ‘unloaded’ the pilot thanked us and the passengers applauded. It was a good feeling, not just the appreciation but also the relief of getting him to safety. Although he had remained stable throughout we always had a fear in the back of our minds that he could deteriorate at any time - not something you want to happen when the nearest hospital is
three hours away and you have 400 people watching.
Back in the air Less than two hours later we were back in the air and continuing on our way to Toronto where we landed safely. Looking back the entire incident went smoothly. I do however understand how stressful it must be for doctors when someone takes more seriously ill - especially if they don’t have colleagues to help like we did. After our experience I definitely feel all planes should carry a full doctor’s bag, as the onboard medical kit lacked some key items. Although, I think most doctors wouldn’t hesitate to help in a similar situation, I feel it’s also really important to make sure you’ve got medical indemnity insurance for Good Samaritan acts. As far as I am aware the gentleman recovered. We went on to our wedding slightly late but it was still an amazing day. Fortunately our return flight to London was less eventful with no more dreaded announcements over the speakers. This time I slept soundly throughout.
Flight facts • Medical emergencies are the most common reason for diverting an aircraft. • 75 per cent of medical emergencies among passengers take place whilst still on the ground. • 1 passenger per 40,000 need emergency medical assistance in-flight. • Items falling from overhead lockers represent 6.3 per cent of incidents requiring treatment. Wallace WA. Managing in flight emergencies. BMJ 1995; 311: 1508 Cummings RO, Schubach JA. Frequency and types of medical emergencies among commercial air travelers. JAMA 1989;261:1295-9
Starting medical school guide
Medical school can be a scary place. There’s the dissection room, angry hospital consultants and the student union bar on a Wednesday night. But don’t go running for home just yet. With the help of medical students and doctors who have been there before we’ll tell you how to survive in the land of colonoscopy clinics, cardiac vivas and neuro MCQs. So put on that white coat, swing a stethoscope round your neck and step out into the big bad world of becoming a doctor. We start with the essential induction to your new life. Trust me I’m a doctor
Ask most patients what a ‘medical student’ is and they’ll screw up their eyes in confusion. Patients see you trailing around after the real doctors in your smart white coat and often view you in the same medically qualified club. As such you’ve unwittingly become a privileged member of society’s most trusted profession. As a medical student you’ll spend more time with patients than any other person in the team. You’re in that middle-ground between being a member of the public and a medical professional. Patients won’t find you quite as scary as a proper doctor and you’ll be making an extra special effort to suck up in order to take their medical history. Because of this they’ll tell you things they’ve never told anyone and you’ll witness grown men break down in tears behind that thin, flimsy cubicle curtain. It’s all part of becoming a doctor - and a good one at that. Just don’t abuse it. Patients trust you with this information and you’re legally bound to confidentiality. So no blabbing about it down the pub, it could be the patient’s relatives at the next table. Medical students have been kicked out of medical school on a number of occasions for abusing this - and they’ve no defence.
Whether you like it or not you’re going to be stuck with that big hairy guy who picks his nose for at least the next five years. There’s also a high probability that you’ll end up marrying one of those drunken idiots who vomited over you during freshers week. You need to remember that medicine is a team sport. Refuse to play ball with your colleagues and your performance and experience will suffer. Medical school isn’t a competition, you either pass or fail - and the pass mark has already been set. It’s better to drag your buddies with you when you pass the final exams rather than fall flat on your face when you attempt to go solo.
How to spot a fresher
1 2 3
Can be spotted fighting over free tins of beans at freshers fairs.
They turn up to all lectures - even those that aren’t compulsory.
Conversation over lunch includes topics other than resection of the small bowel. Jump at the chance to sign-up for clinical trials to earn a fiver being injected with the Ebola virus.
Commonly throw up in the tube/taxi on the way back from the union.
Work hard, play hard Unlike those other students studying embroidery or pole dancing, you’re going to have to do some hard studying during the course. You’ve made it to medical school which proves you’ve got a few brain cells - but don’t let this go to that straight-‘A’ head of yours. Medicine is one of those subjects which trumps the ‘A-levels are the hardest exams you’ll ever do’ line - in fact, it rips this theory to shreds, throws it on the ground and stomps all over it. Medicine is tough and there’s no escaping that.
A first year med student can be spotted more easily than a baby with chicken pox. Here’s what gives you away.
Borrow every book on pathology from the library so no ‘proper’ medics can use them to revise for path exams. Appear to drown when trying to do a ‘funnel’.
8 9 10
Clothes are badly stained with fat from the dissection lab. End up on the floor after watching a surgeon make the first incision. Still want to be a doctor because they ‘care deeply about mankind and want to repay their debt to society for their pitiful existence’
Fresher Translation Guide
hought a ‘fresher’ was a kind of fizzy sweet? Or that you only had one ‘mummy and daddy’? Think again. Freshers week is the maddest, most fun, least slept seven days you’ll have at uni. Let’s first start with the basics. Here’s the translation guide you’ll need to get through those first few weeks. Fresher also known as – freshman, ‘fresh’ student Similar to ‘fresh milk’ - innocent, unpolluted and doesn’t mix well with alcohol. Refers to all new first year students. See opposite for a guide on how to spot one. Although technically the nametag ‘fresher’ should only persist for those first few weeks you’ll mostly likely be branded it for the entire first year - or longer if you’re extremely incompetent and uncoordinated. Mummies and daddies also known as - student parents During freshers week you may be allocated a ‘mummy’ and/ or ‘daddy’. This doesn’t mean you’ve unwittingly put yourself up for adoption. They’re ‘student parents’ who are there to guide you through the transition into the big bad world of university life. They’re great for advice on which events to go to, which clubs to join and for borrowing lecture notes and exam papers.
But don’t get disheartened if you only scraped into medical school by the skin of your teeth and the number of zeros on daddy’s cheque to the alumni association - you don’t need to be a whizzkid to pick up a MBBS. A little common sense and good organisation is all you need. Medicine is a practical subject that requires lateral thinking and it’s the straight ‘A’ students who often struggle. The easiest way to fail is to fall behind with the curriculum. Remember that we’re learning about the human body - everything is linked. If you miss that lecture on the science behind gastric acid production then the GORD workshop will leave you with a burning pain in your chest - and you won’t understand why. Keep on top of the work and you’ll be fine. This means occasionally being prepared to ditch drinking games at the union for a night with your head in the books.
Get involved You may not be keen on chasing after a ball on the rugby pitch, or testing your tactics in the chess team but that’s no excuse for not getting involved in uni activities. It’s very unlikely that you won’t find at least one club or society that interests you, and in that rare case you can easily set up your own. Joining a club isn’t just about improving your ball passing ability or checkmating skills, it’s all about making friends and being part of university life. With the team environment of medicine and being away from home you’ll need all the friends you can get. Throughout your career you’ll realize that medicine is as much about who you know as what you know.
Unlike your real mum and dad though, it’s highly unlikely they’ll offer to do your ironing or give you pocket money. Doing a funnel Not exclusive to medical students but we’re the only ones who understand the physiology behind it. A ‘funnel’ is a plastic tube (like a hosepipe) ideally less than 5cm in diameter with a funnel attached to one end. Done properly it involves crouching down, inserting the end of the plastic tube into your mouth while your rugby club buddies pour half a crate of beer into the funnel at the other end. Thanks to the power of gravity you’ll be able to consume the same amount as the entire team in a matter of seconds. Unfortunately on most occasions it all comes pouring out again thanks to projectile vomiting or the stomach pump in your local A&E department. Freshers Fair Nope, it’s not where you get auctioned off to the highest bidder, or a chance to ride on the merry go-round. The fresher fair is your opportunity to find out about which clubs and associations are available in your university. There’ll also be loads of big firms offering you freebies and harassing you to sign-up for bank accounts and credit cards. You’ll end up leaving weighed down with free popcorn makers, CD vouchers and more bank accounts than a major international money laundering operation. Freshers week is the time when you’ll meet more potential doctors than any other. Work the crowds and get involved. Remember that students in the years above will be doctors soon. They’ll be able to bail you out of trouble, not just when you’re an incompetent student, but when you’re an incompetent doctor and they’re your boss.
A little respect While other students will be playing with PCs we medical students get to play with people’s lives. Patients are often scared, in pain and may even be terminally ill. Put yourself in their position, treat them as you would want to be treated and you won’t go wrong. Watch out for the difference between consultants who treat patients like real people and those who think they’re just a piece of meat. Learn from it. By the time you finish medical school you should have a list of doctors who get the respect of both you and the patients, and a list of those who you wouldn’t want to treat a member of your own family. When you reach consultant grade you’ll want medical students to talk about you down the pub as a ‘great doctor’. That’s when you’ll know you’ve finally made it. You’ve got around twenty years to become this fantastic individual so start moulding yourself now.
Practice makes perfect Unlike A-levels your medical exams will test your practical skills and not just your academic knowledge. Sucking up pints down the union when you should be practising sucking up blood may appear the better option at the time but could land you in trouble in a few years.
Starting medical school guide
Sure, it’s difficult trying a new practical procedure, especially when it involves sticking sharp things into little old ladies but unless you force yourself to overcome this fear now you’ll struggle even more in the future - and no-one wants to be a venflon virgin forever. Watch someone experienced first and get them to talk you through the procedure. It doesn’t need to be the head of the anaesthetics department, one of your brave buddies is often a better bet as they can point out the areas where they struggled themselves. Most medical schools and placement hospitals have a clinical skills centre where you can practice procedures. Dummies don’t care if it takes seventeen tries to get an arterial blood gas sample. Ask at the centre for training workshops or times when you can practice by yourself. Always remember that it’s not just getting the needle in the vein
that’s important, there’s going to be a terrified little old lady attached to it. You’ll need to hold a conversation about her granddaughter’s new baby whilst maneuvering that piece of metal in her arm. Just like riding a bike, practical procedures become easier the more you do. You’ll soon be able to simultaneously extract blood and recall all eight grandkids in order without any trouble.
Enjoy it The last and most important point - enjoy it! You’re one of only a few thousand students accepted into medical school each year. With electives, the best student events and an almost guaranteed job at the end, your life’s looking great already. Live it up!
Living in halls You’ve just moved into the thirteenth floor of halls. Your room is the size of a matchbox. The person next door plays music so loud that cracks are forming in the wall and someone’s stealing your milk. Don’t panic! … here’s some advice. Label your food If you have to share a kitchen then get your initials on your grub. There’s nothing more irritating than finding someone has eaten your pack of choccy biccies by mistake. Be open minded You’ll meet a greater diversity of people than ever before. You’ll have to share your living space, the kitchen and even the shower. So what, they might eat Coco Pops for breakfast but the fact that you eat Ricicles isn’t exactly normal either! Don’t hide in your room The hairy guy in room 13 may be frightening but staying in your room isn’t the answer. Get out and meet people. Your first year in halls is the easiest way to meet other medics. If you don’t push yourself to meet new people this term you’ll regret it later. Sort out any problems If you’re slowly going deaf because of the loud music played by your neighbour confront him about it. Don’t shout, yell or throw your dissection scalpel at him. Offer him a cup of coffee, explain calmly the problem and invite him to hear how loud the music is himself. Shower power If one of your floormates spends 45 minutes in the shower each morning shaving his/her legs then here’s a trick to get them out. Most of the water outlets on each floor are connected so turn off and on the hot or cold taps in the sinks or showers. The water going from stifling hot to freezing cold should speed him up.
The clean team Share the laundry load. Team up with a mate and do a mass of laundry at one time. It’ll save you a fortune and you’ll have someone to hang out with while the machine goes round and round and round ... just keep your red boxer shorts out of her whites. Remember to hang your CK pants up right away and you might just escape the need to iron them. Don’t shop till you drop Save yourself the torture of dragging five tons of shopping back from the supermarket by getting it to come to you. Get together with the rest of the guys on your floor and order your beer and pizzas online. Enter you shopping list at Tesco.com or Sainsburys.com and they’ll cope with all the trolley trauma. As long as you request it they’ll bring it right to your floor … so your don’t even have to change out of your PJ’s! Sort problems soon If you do have any problems about living in halls get it sorted straight away. There’s no point letting things get you down. The staff in the student accommodation office have dealt with every conceivable problem so don’t feel embarrassed.
Sucking up with style Soon you’ll be swinging your stethoscope round your neck and venturing into the big bad world of hospital life. Here’s how to look both cool and clever ... Imagine this When your consultant can’t distinguish you from an RTA victim that’s been trailed through an articulated lorry sideways, there’s a problem. “Image is everything,” says Deborra Radcliffe, a professional image consultant. “Looking smart and dressing professionally can actually make you appear more intelligent than you actually are.” Male magic “For men, wear a shirt and tie that complement each other with the same colour shades,” suggests Radcliffe. If you’ve less colour sense than a blind patient without a guide dog, high street chains such as Next and Debenhams sell pre-packaged matching combinations. “Shirts with cufflinks will improve your ranking but only if you wear a jacket or white coat on top.” Pokemon ties are only acceptable if you’re doing paeds … or if your consultant has the mental age of a five-year-old. Winning as a woman If you’re a woman, forget the skirt advises Radcliffe, “Women who power dress are taken more seriously.” For women who
have a soft voice and mild manner, wear darker colours to appear more confident. “Students who ooze confidence should choose paler shades to help you take advantage of your womanly side - it will make you appear more in touch with the patient’s perspective.” Role play Making small talk with a patient about haemorrhoids can often put you in more pain than they are. The fear of talking to someone for the first time is all about being scared of the unexpected suggests Radcliffe. “Having a practised introduction when you meet a new patient can help you through this difficult period,” she advises. “The first 30 seconds of conversion is the most stressful and yet the most important for making a positive impression.” Practise your speech and face expressions in front of a mirror, she suggests. Escaping embarrassment Examining semi-naked patients can be an uncomfortable experience even for the most confident. You need to distance yourself from the reality of the situation suggests Radcliffe. “There’s nothing unnatural about nakedness - it’s just the human emotions we’ve attached to it,” she explains. “Treating the consultation in a purely clinical way is one way to deal with this. Removing the concept of the ‘person’ from the ‘body’ often works.”
MEDICAL PROTECTION SOCIETY PROFESSIONAL SUPPORT AND EXPERT ADVICE
FREE Student Membership MPS is the leading provider of comprehensive professional indemnity and expert advice to doctors, dentists and health professionals around the world. As a medical student member you will have access to: � FREE Worldwide Elective � Casebook – the journal Protection* of MPS � DISCOUNTS and special offers � ONLINE medicolegal resources
� EMERGENCY medicolegal advice 24/7
Find out more Email email@example.com Visit www.mps.org.uk/student Call 0845 900 0022 *special arrangements exist for electives in Australia. The Medical Protection Society Limited. A company limited by guarantee. Registered in England No. 36142 at 33 Cavendish Square, London W1G 0PS.
2973 Student Ad UK A5 Land s2.indd 1
MPS is not an insurance company. All the benefits of membership of MPS are discretionary as set out in the Memorandum and Articles of Association.
Secret Diary of a Cardiology SpR Monday If you’ve been following this column you’ll realise that I had accepted a consultant post and was on the verge of starting work. Douglas, my boss and unofficial mentor, offered me a way of delaying for six months by finding me an interventional fellowship in Australia. I pondered it for a while and then declined. Instead, I found a position myself. In California. Rounds here begin at 6.15am. And the day doesn’t get any smoother than that. After a radiology meeting with two black coffees and a skinny blueberry muffin (not my first choice but I’ve decided to copy everyone else out here) we go to CCU to see what came in over the weekend. Although I don’t have any on call commitments during these six months I’m still expected to act as a senior resident (think final year registrar) on the wards in between my interventional work. By 8.30 I’ve had a third coffee and am now ready, albeit a little shaky from the caffeine, for a day of intervention under the watchful eye of my boss James Kawani, a very slim and very bronzed Hawaiian surfer (I kid you not) with a fantastic technique when it comes to stenting the left main stem. A full day of this, followed by lengthy rounds of the cardiac wards, leaves me shattered and I get back to my apartment around nine. I fall asleep on the sofa in front of the television.
Tuesday The morning is spent teaching at the university. I give a lecture on cardiac anatomy to a hall full of second year medical students who seem to know a surprising amount and ask some proper questions. I then have a bedside teaching session with five final years. I push them hard until I realise that we’re going through it as if they were sitting their MRCP. I bring it down a notch and they visibly relax. Hopefully the rumours of the mad English doctor who cracks the whip haven’t spread too far. I spend the afternoon reviewing patients with my team and teaching a couple of juniors about echos. Again, they prove to be pretty knowledgeable. I wonder if it’s my own prejudices about American (or in fact anyone other than British) graduates that have lowered my expectations. I mention it to James who smiles. He asks me what I’m doing on Thursday afternoon and my reply of ‘doing rounds’ makes him laugh out loud. He tells me to keep it free.
Wednesday The usual start but this time I choose a full fat chocolate chip muffin. This draws a couple of looks from some of my colleagues who are no doubt counting the calories that I gulp down. More time in CCU, this time with a sick patient who needs an angioplasty so we take her straight to the lab. I spend the rest of the day learning to play with a new piece of kit which helps inject the dye into the coronaries a little bit better. Very neat but I’m not sure it’s worth the extra £30k. The afternoon goes by quickly seeing patients and I go home early. It’s a resident’s night out in a local bar so I have a long shower and get changed into something reasonably hot before heading out. I spend the evening downing shots of vodka whilst letting a neurology resident get a little close. It turns out neurologists in this part of the world aren’t as geeky as their counterparts back home. He invites me back to his but I decline and go home alone and a little more than drunk. 18
* Names have been changed to try to keep our cardiology SpR in a job - though she’s doing a pretty good job of trying to lose it without our help!
Thursday A major hangover is compounded by the lack of full fat muffins on the trolley so I settle for two of the skinny variety. We rush through rounds and some more bedside teaching and after a few coffees and a bacon sandwich I start to feel better. After lunch James swings by and asks me if I’m ready. I can’t work out if this is a date or a teaching session but have worn something that would be appropriate for both. We head to his car and he drives ten miles downtown into an area that is as deprived as any I’ve seen. We stop outside a drab and dilapidated building and it is only after we enter that I realise that we’re in some sort of hospital. We’re here to run an inner city clinic. The attendings at the university have set this up and they take it in turns to run two daily sessions. Thursday afternoons is cardiology and it’s James’ turn to pitch in. We take a room each and begin seeing patients. After half an hour I realise that as fantastic as the care uptown is, for those without health insurance it is approaching that of a developing nation. Patient after patient needs an angiogram but can barely afford the Lasix (furosemide for me and you) let alone the procedure. We do what we can and then head out for a drink.
Friday James calls my cell on the way in and tells me not to bother with radiology and rounds. I knew that Friday had a session called ‘wave’ but I assumed this was some sort of new ECG technology. I’ve done a little surfing before and as I get to the beach James hands me an old board and a wetsuit. Much of the team are here, from the portly chief attending to the sprightly young medical students attached to the team. We spend an hour splashing about as the sun comes in over the Pacific. We head back to the beach, shower and get changed before all heading to a breakfast place overlooking the ocean. I wolf down some scrambled eggs with salmon on toasted muffins. An intern presents the patients from the night and we make tentative management decisions before going in to see them. We laugh and joke and James tells the others about our clinic yesterday. I try to defend our own antiquated health system and my stance about all patients getting an angiogram at the expense of hardly anyone getting a cardiac CT or MRI draws a few nods of approval from the older attending who have worked in their system for too long. I sip my orange juice and watch as a young couple meander down the beach towards the surf with a little dog in tow. I could get used to this place.
Weekend Ward Escape to
Ljubljana A city which few can pronounce and even fewer can locate may not sound the ideal location for a few days retreat after MRCPs. Surprisingly though, Ljubljana is the hidden gem of the EU accession states. It’s got more museums per population than anywhere else in Europe and is packed with riverside bars and restaurants – plus, where else can you return to Monday’s ward round having spent the weekend in prison and enjoyed it! Ljubljana is tiny for a capital city. It’s the size of Nottingham, the British city with which it is twinned, but with students making up a staggering fifth of the population it can feel more like a ghost town if you are wandering around in summer. Underneath this emptiness is an enthusiastic attempt to appeal to new European tourists clutching their shiny mauve passports. Ljubljana now has more museums per head than any other city in Europe. There’s also a reported 10,000 concerts per year and 12 international festivals.
Hostel Celica (www.souhostel.com) is a converted prison with each “cell” designed by a different architect. It’s chic and stylish and costs just £20 per person per night. Doubling as an art gallery you’re obliged to let visitors peer through the cell door bars during the day. Breakfast is served outside, there’s a meditation room and free internet access too. The city centre is a 5 minute walk away. If you don’t fancy a short stay behind bars the three-star City Hotel is a good option (web.cityhotel.si) right in the centre. Rooms from around £70 per night.
Key attractions Tromostovje (Triple Bridge) - Marking the centre of Ljubljana this is the feature that appears on postcards. It is literally what it’s called - a ‘triple bridge’ - and an impressive one at that. Moderna Galerija (Museum of Modern Art) - Stunning exhibits with lots of projects based around the past
To date Ljubljana hasn’t been overrun with loud, beer-swilling stag parties. Compared to the new EU cities of Prague, Riga and Bratislava it appears on the surface more upmarket and locals welcome visitors in well spoken English.
conflicts that led to the breakup of Yugoslavia in 1991. Definitely worth a visit.
Nightlife Cafe Galerija, Mestni trg 5 - Definitely the trendiest bar in Ljubljana. Candles light the path to a Middle Eastern style bar with vast couches and adorned with curtains everywhere. Levstik, Levstikov trg 9 - If you’re looking for a more original Slovene experience try Levstik. With broken walls it’s pretty grotty but has great food and beer! Find the full Ljubljana guide at JuniorDr.com.
Key facts • Population - 280,000
Where to stay?
• Language - Slovene
There are nearly a hundred lavish hotels in Ljubljana offering concierge style service with all the latest hi-tech offerings and flatscreen TVs. But don’t stay there - Ljubljana is one of the few cities where you can stay in a prison.
• Currency - Euro • Slovenia has only existed since 1991 • Slovenia has the lowest rate of marriage of all the countries in the EU
Assessed by Gil Myers
e may believe that an elephant can fly but I believe that he may be suffering from a number of different conditions.
Fragile X Syndrome The picture I get of Dumbo’s life is one of psychogenic muteness, repetitive behaviour (the same jump into the bucket of pie filling every night), social anxiety, peer teasing and difficulty with physical feats - most recently the elephant pyramid disaster resulting from poor muscle tone. This, coupled with his appearance, suggests the possibility of Fragile X syndrome - a genetic disorder caused by mutation of the FMR1 gene on the X chromosome. It would also explain why Dumbo’s mother was so secretive about his birth using a stork delivery service rather than a hospital to avoid questions which may have been raised regarding her family history.
Temporal lobe aneurysm
4 The recumbent position (9) 5 Name associated with syndrome of rheumatoid arthritis plus
necrotic lung granulomata (6) 7 Pyrexia (5) 9 Inner longer bone of the forearm (4) 10 Acute confulsional state (8) 11 French surgeon associated with ulcer that develops at the edge of a chronic skin ulcer; usually venous (8) 13 Third stage of mitosis (8) 15 Schisotosomiasis (12) 16 Blind-ended air-sac of microscopic size in lungs (8) Down:
1 Boeck’s disease; characterised by appearance of granulomata (11) 2 Long thin outer bone of the lower leg (6) 3 Commonest type of thyroid neoplasia (9) 6 Gingiva; chewy sweets in variety of flavours (3) 7 Licensed antidepressant for under-18s (10) 8 Ringworm (5) 12 Functional obstruction due to reduced bowel motility (5) 14 First cervical vertebra (5) 15 Name associated with irregularly shaped cells occurring in uraemia; hole in the head (4) 17 Disease caused by Borrelia burghdorferri (4)
You can find the crossword solution by searching for ‘crossword answers’ at www.juniordr.com.
At various points in the documented life of Dumbo he begins to hear others singing rather than speaking to him. Although that could be a purely escapist fantasy to avoid confronting his own mundane dilemmas it would be remiss not to think about the possibility of these being auditory hallucinations (defined as sensory stimuli in the absence of external sensory stimuli). A CT should be requested as a matter of course although it would be a challenge to accommodate him in a scanner.
Vertigo A belief that you can fly is, more often than not, incorrect. Even given his enlarged ears it is near impossible that Dumbo can lift his own body weight off the ground. Add to this the physiological impracticality of “flapping” ones ears and the result is that we must assume that Dumbo cannot actually fly. We are therefore left with an assumption that Dumbo experiences what could be misinterpreted as “flight” - the sensation of swaying while the body is actually stationary with respect to his surroundings. Inner ear problems are often the cause of vertigo as they act to effect the balance mechanisms of the vestibular system - more likely given Dumbo’s distended auricular protuberance.
Schizophrenia All of these symptoms could be brought together in a single diagnosis: schizophrenia. Dumbo reports auditory hallucinations, visual hallucinations and delusional beliefs about flying and his famed destiny. There is a suggested family history of odd behaviour: when Dumbo’s mother assaulted those teasing Dumbo she is judged to be “mad” by the other circus performers (and locked away). There is a strong genetic component to schizophrenia making the diagnosis more likely. A trial of antipsychotics may be in order - I would suggest Seroquelephant.
Writing in the Notes Team American
hear that we’ve Dear Editor, e EU! I’m glad to th r fo rs ee ch e keep patients Thre orking hours to w ith w ss re og merican junior made pr last issue that A ur yo in d te no 80 hours per safe. I ng an average of ki or w ill st e ar s about reducdoctors w making noise no ly on e ar d hours (‘No way week an ep from 30 to 16 sle t ou ith w e ctor hours Iss 13 ing tim in US junior do n io ct of du re r fo to pay’ of the dark ages K is finally out U e t th en e tm lik ar el ep fe the D p5). I ons - hurray for iti nd t ea co gr ng a ki e or at plic poor w Obama can re ly ul ef e th op H of . e lth sid other of Hea e NHS on the th e lik e. em tim st e sy m health es at the sa prove doctor’s liv Atlantic and im
Jay Gurinder y ST1 Psychiatr
Colleges are doin
g their best
Dear Editor, I am writing in response to the anonymous lett criticising the la er ck of support fo r the EWTD by Royal Colleges the (Colleges unrepr esentative Iss 13 I feel it is impo p21). rtant for the au thor to remembe one of the roles r that of the Royal Col leges is to maint and set professio ain nal standards fo r higher training position that th . Th e Royal College e of Surgeons, am others, has taken ong supports the need for trainees to ha adequate experie ve nce to maintain safe practice. I agree that the co di sllege is not repr esenting some of members. I hope their you will realise that they are ta this stance for th king e benefit of the speciality and al members, both l their present and in th e future.
Dr Sajid ST3 Anaest
hesia, Notti ngham
Women worries l?) juxtaposiDear Editor, al (or intentiona nt de ci ac e th ths of women I note les about the pa tic ar o tw e th mmitted to tioning of t docs remain co os (M S H N e come majorthrough th d Women to be an s ar ye 25 r te e discontinuthe NHS af 13 p6). I find th s Is 17 20 r te af e to outnumity of docs women are clos lst hi w at th g one-third of ity worryin still only occupy ey th s or ct do e in the othbering mal despite, as stated is is Th s. st po similar career consultant women follow d an en m at th ress to make. er article, have some prog ill st e w s ar pe paths. It ap ghes Siobhan Hu GP Registrar
‘Writing in the notes’ is our regular letters section. Email us at firstname.lastname@example.org.
hen your hospital food tastes like the remnants of a liposuction procedure and the price bears more resemblance to the cost of a PICU incubator things start to take the biscuit. Here’s our regular column of the best and worse hospital essentials you’ve reported:
Ready salted crisps
Enough to make you choke at:
Chase Farm Hospital, London
Just watch your arteries at this price:
40p Hot chocolate (small)
Woodend Hospital, Aberdeen
Burns your wallet as well as your mouth at:
Royal Free Hospital
Lucky chocolate is good for you at:
Good for your health but not your pocket:
St Marys’s Hospital, London
Barnet General Hospital
Next issue we’re checking the cost of fish and chips, a cup of tea (small) and a jacket potato with cheese. Email prices to email@example.com.
Princess Alexandra, Harlow Sky HD on 42in High Def plasma, wireless 16Mb broadband, leather sofas, lava lamps. 3 computers in separate computer room: 2 for all access broadband. Kitchen with dishwasher, microwave, basic food bread, tea, coffee, biccies etc usually topped up. Separate chill out/quiet room (with a few old sofas!). £10/month.
JuniorDr Score: ★★★★✩
Published on Feb 19, 2010