JuniorDr Magazine - Issue 08

JuniorDrJuniorDr.com

The magazine for

JuniorDrs

Issue 8

Return of the body snatchersThe shortage of body donors

Saving lives in SudanDoctors on the front line

Blood, glorious bloodThe history of the red stuff

Please le

ave for

others

to e

njoy

La

st

of

sto

ck

Wa

rnin

g

Patients often think they are

entitled to treatment despite their

attacks. They’re not. When one in

ten doctors have been physically

attacked in the last year it’s a

situation that has become

untenable.

We will always have patients

who are physically or verbally

abusive secondary to their

physical or mental health - it

comes with the job. However we

need the resources to deal with

them. Currently only one in ten

doctors has access to a secure

facility to treat these difficult

patients.

As doctors we make a

commitment to treat patients with

respect - they must do also or

should be refused access.

JuniorDr

3

Tri

ag

e

Presenting History

JuniorDr is a free distribution

magazine produced quarterly for

the UK’s junior doctors. You can

find us in hospitals throughout

England, Scotland, Wales and

Northern Ireland, and online at

JuniorDr.com.

EditorAshley McKimmST2 Psychiatry

[email protected]

Editorial TeamMareeni RaymondLondon

Michelle ConnollyLondon

Hi Wu-LingNottingham

Muhunthan ThillaiChelmsford

Thanks toAndro Monzon, Gil Myers, Mun

Hong Cheang, Rhona Atkin

Newsdesk

[email protected]

Printing partners

Witherbys, UK

Advertising & Production

Rob Peterson

[email protected]

JuniorDr

PO Box 36434

London

EC1M 6WA

Tel - 020 7684 2343

Fax - 0870 130 6985

[email protected]

Health warningJuniorDr is not a publication of the NHS,

Tony Blair, 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. 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.

Going to work each day as a

doctor is a pretty safe event.

Despite the odd patient-acquired

chest infection it’s reasonable to

expect we’ll be home safely at

the end of a long day.

We used to revel in our

position near the top of the UK’s

drink and alcohol abuse charts, and

being at the pinnacle of the suicide

ranking - it showed just how tough

a career in medicine was.

But no longer. We’re doing

pretty well in the health stakes

these days - the city boys are

outdrinking us and we’re less

likely to take our own lives than

housewives.

In fact, if you ignore the mess

the Department of Health has

made with our careers, we’ve

never had it better - expect in one

area - more patients are fighting

back at us.

In our main news story we

report on a BMA poll that showed

almost a third of doctors had been

a victim of a physical or verbal

attack in the last year.

This continued abuse of other

patients and staff is tolerated

because ‘it has always happened’

and the expectation that drunk and

disorderly patients deserve

treatment whatever the situation.

When patients start

to fight backEditorial

> What’s on the insideSaving lives in SudanA look at the work of MSF

in southern Sudan

Page 10

Blood, glorious blood

The story behind the

red stuff

Page 12

The Secret Diary of a

Cardiology SpR

Page 17

Return of the body

snatchersThe shortage of

body donors

Page 14

Latest News

Page 4

Ashley McKimm

Editor-in-Chief

ST2 Psychiatry

“Patients often think

they are entitled to

treatment despite their

attacks. They’re not.

When one in ten

doctors have been

physically attacked in

the last year it’s a

situation that has

become untenable.”

Th

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JuniorDr

News PulseTell us your news. Email the team at [email protected]

or call us on 020 7684 2343.

NHS

One in three doctors has

been a victim of a physical or

verbal attack in the past year

but most do not report it,

according to a poll by the BMA.

The most frequently stated

reason for workplace violence was

dissatisfaction with the service,

including frustration with waiting

times and refusal to prescribe

medication. This has doubled as a

cause of violence since 2003.

Junior doctors are the most

likely to experience violence on

the job.

“Ministers have repeatedly

stated that there should be zero

tolerance to violence of any sort in

the NHS. We heartily agree,” says

Dr Hamish Meldrum, Chairman of

Council at the BMA.

“The mechanisms must be

there to minimise the likelihood of

attacks, to support staff who

experience them, and to ensure

that anyone who commits an act of

violence is dealt with

Violence against doctors

going unreportedLONDON

appropriately.”

Approximately 600 doctors

responded to a BMA survey on

their experiences of violence in the

workplace in the past year. A third

had experienced some form of

violence - including threats and

verbal abuse - and one in ten had

been physically attacked. Of these,

one in three received minor

injuries, and one in 20 was

seriously injured.

Aggression tolerated

Ben, a London GP trainee who

is currently working in A&E feels

there’s an institutional tolerance to

aggression in the NHS:

“At the the start of my post I

was shocked at how verbally

abusive patients are tolerated in

our department - particularly drunk

or intoxicated patients” he told

JuniorDr.

“There’s a common conception

that patients should be treated no

matter what their behaviour ... it’s

not just intimidating for the staff

it’s also upsetting for many of the

other patients too.”

Results of the survey showed

higher rates of violence against

4

Dr Hamish Meldrum

BMA Chairman

“Ministers haverepeatedly statedthat there should bezero tolerance toviolence of any sortin the NHS. Weheartily agree.”

female doctors and psychiatrists.

Over half of physicians polled

report witnessing violence against

other staff members, including

nurses and receptionists.http://www.bma.org.uk/ap.nsf/content/violence08?OpenDocument&Login

Training

The annual retention fee for

full registration on the GMC

medical register will rise to £390

per year, taking effect April

2008.

The annual retention fee is the

main source of income for the

GMC, and is regularly reviewed to

ensure that it remains at an

appropriate level. It has been

frozen at £290 for the past six

years, since 2002.

Professor Sir Graeme Catto,

President of the General Medical

Council said: “It is six years since

the GMC put up the ARF. We have

LONDON

GMC to raise registrationfees by £100

been able to maintain the fee at

that level by a combination of

rigorous measures to ensure that

we have been operating as

efficiently, economically and

effectively as possible ... This rise

is to ensure that the costs of

regulation to doctors and to the

health service are maintained at an

appropriate level.”

Although the fee is set to rise,

the GMC will continue to offer a

50 percent discount for doctors on

lower incomes.www.bma.org.uk/ap.nsf/content/studentfinsurvey17?OpenDocument&Login

> Half of doctors said violence

in the workplace is a problem

> More than half had witnessed

violence against other staff,

such as nurses and receptionists

> Female doctors are more

likely to experience violence in

the workplace than males (37%

compared to 27%)

> Junior doctors are the most

likely to experience violence,

followed by GPs

> Almost two thirds of

psychiatrists report that violence

in their workplace is a problem,

compared with a fifth of

surgeons

> Most doctors have not

received any training in dealing

with violent patients

> Only one in ten doctors has

access to a secure facility in

which to treat violent patients

> Key findings

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Docs have no confidence

in new NHS databaseMost doctors say they have

no confidence in the

government’s ability to handle

confidential patient information

safely, according to a poll

conducted by BMA News.

Over 90 percent of those who

responded to the survey said they

were not confident the data on the

proposed new NHS patient

database would be secure.

The poll follows recent high-

profile data losses, including CDs

from HM Revenue and Customs

containing details of 25 million

child benefit claimants and

security breaches during last

year’s online training recruitment

fiasco for junior doctors.

Trainee cardiologist Dr Sally

Simmons says she has no faith in

security of government

information after her personal

details became publicly available

during the MTAS breach last year:

“I have received no apology

from the Department of Health

despite writing to the former

health secretary [Patricia Hewitt].

I was also affected by the loss of

the two child benefit CDs with my

bank details on them. Not

surprisingly, I have no faith in any

form of IT security that this

government proposes,” she said.

Over 200 doctors replied to

the Doctors Decide poll with nine

out of ten (93 percent) reporting

that they did not feel in a position

to assure patients that their data

would be safe.

LONDON

NHS

The cost of being a junior

doctor has increased by 80

percent over the last seven years,

according to figures published

by the BMA.

Over the same period, junior

doctors’ basic salaries have

increased by little more than 20

percent, and supplements paid for

antisocial hours have fallen.

Research by the BMA looked

at the minimum essential costs

borne by junior doctors as they

progress through their training.

This includes the compulsory

membership of organisations such

as the General Medical Council -

the cost of which has more than

doubled to £290 for second year

junior doctors.

It also includes the costs of

sitting exams - essential if doctors

are to progress in their training.

The fee for receiving a certificate

of completion of training (CCT)

Cost of being junior doctor

soars, salaries remain lowLONDON

Working Conditions

has trebled since 2000 to over

£750.

“In other professions, the

employer pays for the benefits of a

well trained workforce. In the

NHS, junior doctors pay for it

themselves. We’ve seen the cost of

our training soar over the past

seven years, but this hasn't been

matched by an increase in our pay,

or funding for study leave,” says

Ram Moorthy, Chairman of the

BMA Junior Doctors Committee.

The BMA is concerned that

trainees may soon face additional

fees for membership of new

bodies overseeing training. It

should also be noted that take-

home pay has fallen for many

junior doctors because of Working

Time Directive limits on hours.

The BMA has submitted the

figures to the Doctors and Dentists

Review Body, which makes

recommendations on doctors' pay.www.bma.org/uk

JuniorDr

“In other

professions, the

employer pays for

the benefits of a well

trained workforce. In

the NHS, junior

doctors pay for it

themselves.”

Dr Ram Moorthy

Chairman

BMA Junior Doctors Committee

BMA Announces Grants

for International

Humanitarian WorkUp to £45,000 in grants will be

dispensed by the BMA for

international humanitarian work in

2008. Individual NHS teams can

apply for up to £3,000 each. “This

fund is a reflection of the fact that

healthcare is a global issue and

provides an opportunity for NHS

clinicians to access financial

support to undertake work in

partnership with health

professionals overseas,” says Dr

Peter Carter, RCN General

Secretary. NHS staff seeking

funding for projects should apply

to the BMA’s International

Department.www.bma.org.uk/ap.nsf/Content/HumanitarianFun

d07

BMJ Group acquires

OnExamination.comThe BMJ Group announced

that it has acquired

OnExamination.com, the UK

market leader in online exam

preparation for doctors, medical

students and other healthcare

professionals. Since its launch in

2000, OnExamination.com has

expanded to cover the principal

post-graduate exams run by the

UK Royal Colleges in medicine,

surgery and primary care. It has

recently expanded with exam

preparation for medical students

and nurses and is about to launch a

resource for school leavers aiming

for a career in medicine.www.bmjgroup.bmj.com

BMA warns of risks with

Internet drug purchasesA warning to patients about

the dangers of buying prescription

drugs via the Internet was issued

recently from the BMA. The

Association wants to work with

the government and the World

Health Organisation to control

Internet sales of medicines. Dr.

Hamish Meldrum, Chairman of

the BMA Council, said the

problem with buying medications

via the internet is that patients may

not be getting the same drugs, but

instead an inactive or dangerous

substance. Drugs for the treatment

of erectile dysfunction are among

those most frequently purchased

from Internet sites. Dr Meldrum

said: “One of the messages we are

trying to get over to the public is of

the dangers of [self-prescribing

medication without seeing a

doctor].”www.bma.org.uk

A further eight out of ten (81

per cent) said they would not want

their surgery data stored on the

national NHS ‘spine’.

However, Berkshire GP and

consultant in family planning Dr

Meg Thomas argued the benefits:

“This will help with continuity

of care and communication

between primary and secondary

care … There may be a risk but

paper records are also going

astray. We need to join the 21st

century and quick,” she said.www.nhs.uk

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GMC Collects Race

Data on UK doctors

Working Conditions Training

JuniorDr

procedures are free from

discrimination,” says Dr Hamish

Meldrum, Chairman of Council at

the BMA.

No single organisation holds

accurate ethnicity data about the

UK’s 40,000 doctors. As the

regulator, the GMC needs this

information to fulfil specific

statutory duties under the Race

Relations Act.http://www.gmc-uk.org

LONDONThe GMC is attempting to

collect ethnicity data on all

doctors practising in the UK.

With the support of leading

medical organisations, it is calling

on doctors to provide their details

to help the GMC ensure that its

processes are fair and transparent.

The data will be analysed to

help provide answers to long

standing questions, including why

international medical graduates

are comparatively over-

represented in referrals to the

GMC from public bodies (as

opposed to individuals).

“We would encourage doctors

to provide their details because

without such co-operation the

GMC cannot ensure and

demonstrate that its processes and

NHS

Approximately 17,000

unnecessary deaths occur per

year in the UK, according to a

recently released report by the

TaxPayers’ Alliance.

“Wasting Lives: A statistical

analysis of NHS performance in a

European context since 1981”

analyses data from the WHO to

estimate the number of deaths that

could plausibly have been averted

by the NHS since the 1980s. The

measure used is known as

“mortality amenable to

healthcare”. The calculations

compare the UK performance to

that of Germany, France, the

Netherlands and Spain.

If the UK were to achieve the

same level of “mortality amenable

to healthcare” as the average of the

other European countries studied,

there would have been 17,157

fewer deaths in 2004, the most

recent year for which data is

available.

“Thousands are dying every

year thanks to Britain’s health

service not delivering the

standards people expect and

receive in other European

countries,” said Matthew Sinclair,

author of the report and a Policy

Analyst at the TaxPayers’

Alliance. “Billions of pounds have

been thrown at the NHS but the

additional spending has made no

discernable difference to the long-

term pattern of falling mortality.”

Improvements in mortality

rates, relative to European peers,

have been made at almost exactly

the same rate throughout the

Thatcher, Major and Blair

governments despite huge

increases in spending from 1999 to

date. http://tpa.typepad.com/bettergovernment/2008/01/

major-study-on.html

LONDON

High rate of avoidabledeaths, despite increasedhealthcare spending

Electronic Prescription

Transfer Hopes to Save

Time, MoneyA trial of electronic transfer of

repeat prescriptions between

general practices and pharmacies

is currently being rolled out across

the UK. Developers hope it will

streamline the system making it

faster and more convenient for

patients - as well as cutting down

on prescription errors. The new

prescription transfer scheme is to

be studied by academics at The

University of Nottingham with a

research grant from NHS

Connecting for Health.

Researchers will analyse the

program to determine if it benefits

patients and the NHS.www.nottingham.ac.uk

Prostate Cancer linked to

FatherhoodChildless men have a lower

risk of developing prostate cancer

than fathers, according to an article

in the journal Cancer.

Paradoxically, the study also

showed that the more children a

father has, the lower the risk of the

disease. The study found men

without children were 16 percent

less likely than those with children

to be diagnosed with prostate

cancer during 35-years of follow

up. The analysis also showed that

among fathers, there was a

gradually reduced prostate cancer

risk with increasing number of

children.http://www3.interscience.wiley.com/journal/28741/

home

Circumcision not linked

to decreased sexual

satisfactionOver 98 per cent of

circumcised men report the same

levels of sexual satisfaction and

performance as uncircumcised

men, according to an article

published in BJU International.

Circumcision is recommended as

an efficient way to reduce HIV

transmission, but previous trials

found conflicting results. “Other

studies have already shown that

being able to reassure men that the

procedure won't affect sexual

satisfaction or performance makes

them much more likely to be

circumcised,” says co-author

Professor Ronald Gray from the

Bloomberg School of Health at

Johns Hopkins University,

Baltimore, USA.http://www.blackwell-

synergy.com/doi/abs/10.1111/j.1464-

410X.2007.07369.x

Professor Karol Sikora

Doctors for Reform, Report Foreword

“The NHS should notbe a religion, withits structure set intablets of stone.”

The BMA criticised

proposals from the Postgraduate

Medical Education and Training

Board (PMETB) to increase its

fees by up to 48 percent.

Under the proposals, fees for a

Certificate of Eligibility would be

increased 48 percent for doctors in

non-training posts. The fee for

junior doctors applying for a

Certificate of Completion of

Training (CCT) would rise in line

with inflation.

“It's hard to see how these

rises can possibly be justified,”

says Dr Hamish Meldrum, the

BMA’s Chairman of Council. www.bma.org.uk/

LONDON

PMETB 48%

fee increase

criticised

RSMtrainees

RSM Young Fellows/Trainee Membership -

The RSM has a graduated membership for Young Fellows, depending on the date of your qualification, starting at just £65 pa.

We also offer a 50% discount on your subscription rate if you are temporarily out of work, enabling you to continue using the RSM training, networking and library to further your career at a lower rate.

Visit www.rsmmembership.orgfor more information.

Meetings

for Trainees

23 FebruarySociety CourseInteractive ST interviewworkshop

28 FebruaryYoung FellowsWin the publication game

Prizes open

to Trainees

Oncology Section Sylvia Lawler PrizeSubmission Deadline:

26 March 2008

Prize: Two prizes of £500

Young FellowsThe John Glyn Audit PrizeSubmission Deadline:

28 April 2008

Prize: £300

Cardiology Section President's MedalSubmission Deadline:

9 May 2008

Prize: Commemoration

Medal and £1000

For full details, please visit www.rsm.ac.uk/awards

The Royal Society of Medicine is happy to announce the launch of two new services that will help trainee doctors beat the intense competition for posts this year. Collaborating with the experienced team at Maximize YOUR Medical Career, who helped over 2000 doctors apply for ST posts last year, the RSM is offering the following two new services:

1. ST Application Adviser – an online ST application form evaluation service where trainees can submit their application form online to be appraised and improved within 72 hours • Improve your chances of getting shortlisted • Help in identifying your ‘Unique Selling Points’ • Advice on selection of scenarios that best demonstrate required competencies

2. Interactive ST Interview Workshops – Commencing in February day courses and intensive evening courses • Perfect YOUR interview performance • Approach to common interview questions and effective answers • Interview do’s and don’ts • Each of the key competencies for ST training specifically addressed • Practical interview demonstrations and ample opportunities to improve your own performance

For more information on either the ST Application Adviser or Interactive ST Interview Workshops visit www.rsm.ac.uk/STsupport, or phone 020 7290 3856

Need support in applying for a Specialty

training post in 2008?

05 MarchSociety CourseInteractive ST interview workshop



20 MarchYoung FellowsHistopathology training day


31 MarchVascular Medicine SectionPresenting and writing up your research

05 AprilYoung FellowsInterview Intelligencetraining day

For a full list of meetings visit www.rsm.ac.uk/diary

Visit www.rsm.ac.uk

or call 020 7290 2991

JournalReview

NEW YORK

Simulated resuscitationtraining more effectivethan traditional means

Senior doctors who are

trained in critical resuscitation

skills on patient simulators

become more skilled than those

who undergo traditional

training, according to an article

in the journal Chest.

Although prior studies have

already shown that simulation

training is effective in imparting

such skills, this study sought to

demonstrate the superiority of

simulation training over traditional

methods.

In doing so, researchers found

that simulation-trained doctors

out-performed their traditionally

trained counterparts in 8 of the 11

steps of initial airway management

during a simulated scenario of

respiratory arrest.

“We weren’t surprised by the

skills demonstrated in the

simulation-trained residents,

although we were quite surprised

to see how poorly the traditionally

trained residents performed,” said

study author Pierre Kory.

“This finding was quite

alarming because traditional

training or ‘learning by doing’ is

how doctors have historically been

trained and continue to be trained,

around the world.”

Dr. Kory and his colleagues

from Beth Israel Medical Centre,

USA compared two groups of

third-year internal medicine

residents; one group received

training in initial airway

management skills using a

computerised patient simulator

during the first year of residency

while the other group received

NEW YORK

Futurepsychosispredicted byabnormalbehavioursin youth

Young people who are likely

to develop psychosis can be

identified in 65 to 80 percent of

cases if they have specific

combinations of risk factors,

according to a study published

in the Archives of General

Psychiatry.

Predictors of psychosis

included deteriorating social

function, family history of

psychosis combined with a decline

in functional ability, unusual

thoughts, paranoia, and drug

abuse. The team outlined specific

survey criteria for each category.

Research shows that

intervention during the early

stages of psychosis improves

outcomes, but it is not yet clear if

even earlier intervention before a

psychotic illness develops is

effective.http://archpsyc.ama-assn.org/

traditional “hands on” training.

Researchers found that 38

percent of the simulation-trained

residents, compared with zero

percent of the traditionally trained

residents, successfully resuscitated

the mannequin. In addition, the

simulation-trained residents

performed significantly better in

eight of the 11 tasks of initial

airway management.

“Patients should have the

peace of mind of knowing that

their treating physician could save

their life, should they suddenly

stop breathing,” said Alvin V.

Thomas, Jr., President of the

American College of Chest

Physicians.

“Simulation training can

provide efficient and effective

learning in not only airway

management, but in a number of

areas where critical skill is

required.”http://www.chestjournal.org/

JuniorDr

8

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Dr Pierre Kory

Beth Israel Medical Centre

“This finding wasquite alarming

because traditionaltraining or 'learning

by doing' is howdoctors have

historically beentrained and continueto be trained, around

the world.”

JuniorDr

digits; in women, these fingers

tend to be about equal in length.

Researchers at The University

of Nottingham conducted a case-

control study of over 2,000

patients to assess the relationship

between the 2D:4D ratio and the

risk of knee and hip OA. Their

findings suggest that having a

relatively low index finger to ring

finger ratio raises the risk for

People whose index finger is

shorter than their ring finger are

at higher risk of osteoarthritis

(OA), according to a study

published in the journal

Arthritis and Rheumatism.

The results suggest that people

whose index finger is shorter than

their ring finger are up to twice as

likely to suffer from the condition,

which is the most common form of

arthritis.

“The underlying mechanism

of the risk is unclear and merits

further exploration,” said

Professor Michael Doherty, lead

researcher.

Index to ring finger length

ratio (referred to as 2D:4D) is a

trait known for its differences

between the sexes. Men typically

have shorter second than fourth

NOTTINGHAM

Suppressed anger linked

to early deathCouples in which both

partners suppress their anger

during conflicts die earlier than

members of couples where

partners express their anger,

according to a University of

Michigan study. Researchers

looked at 192 couples over 17

years. When both spouses

suppressed their anger at the other

when unfairly attacked, earlier

death was twice as likely as in all

other types. “If you bury your

anger ... and you don't try to

resolve the problem, then you’re in

trouble,” says Ernest Harburg, lead

author.

http://www.sph.umich.edu/

Healthy lifestyle adds

fourteen years to

lifespanPeople who adopt four healthy

behaviours - smoking cessation,

exercise, moderate alcohol intake,

and a diet high in fruits and

vegetables - live on average an

additional fourteen years of life

compared with people who adopt

none of these behaviours. The

study, published in the open access

journal PLoS Medicine, is based

on a lifestyle survey and death

rates of 20,000 men and women.

The increased longevity was

unrelated to body mass index or

social class. medicine.plosjournals.org/perlserv/?request=getdoc

ument&doi=10.1371/journal.pmed.0050015

Meat-heavy diet

increases risk of

metabolic syndromeHealthy adults who eat two or

more servings of meat a day

increase their risk of developing

metabolic syndrome by 25 percent

compared with those who eat meat

twice a week, according to

research published in Circulation:

Journal of the American Heart

Association. Fried food is also to

blame, says to Lyn M. Steffen, co-

author of the study. Dairy

products appear to offer some

protection against metabolic

syndrome. The findings emerged

from an analysis of dietary intake

by 9,514 participants in the

Atherosclerosis Risk In

Communities (ARIC) study of

which nearly 40 percent had three

or more risk factors for metabolic

syndrome.http://circ.ahajournals.org

Finger length ratio maypredict osteoarthritis

HIV Subtype DeterminesVirulence

People infected with HIV in

Thailand die from the disease

significantly sooner than those

with HIV living in other parts of

the world, according to two

studies published in the journal

AIDS.

According to the researchers,

the shorter survival time measured

in the studies suggests that HIV

subtype E, which is the most

common HIV subtype in Thailand,

may be more virulent than other

subtypes of the virus.

The median time from HIV

infection to death for the Thai men

was 7.8 years compared to 11

years for HIV positive men living

in North America and Europe.

The survival rate for the Thai

men was also lower than studies of

similar populations living in low-

and middle-income countries in

sub-Saharan Africa where

subtypes A, C, D and G circulate.

However, the shorter survival after

HIV infection among persons in

Africa infected with subtype D

was similar to the survival among

the Thai men.

LONDON

“The fact that [patients] in

Thailand had similarly shortened

survival compared to persons in

the U.S. and Africa-except those

infected with subtype D viruses-

suggests that viral subtypes D and

E may be more virulent than many

other viral subtypes,” said Kenrad

E. Nelson, MD, a senior author of

both studies and professor in the

departments of Epidemiology and

International Health at the Johns

Hopkins Bloomberg School of

Public Health.

“If we could understand better

the virulence characteristics of

these viruses, we might learn

something more about why those

with HIV infection progress to

AIDS, usually many years after

they are infected.”www.thelancet.com/journals/lancet/article/P

IIS014067360761232X/

developing OA of the knee,

independent of other risk factors

and particularly among women.

“The 2D:4D length ratio

appears to be a new risk factor for

the development of OA,” said

Professor Doherty. “Specifically,

women with the ‘male’ pattern of

2D:4D length ratio - that is, ring

finger relatively longer than the

index finger - are more likely to

develop knee OA.”

Smaller 2D:4D ratios have

intriguing hormonal connections,

including higher prenatal

testosterone levels, lower

oestrogen concentrations, and

higher sperm counts. Reduction in

this ratio has also been linked to

athletic and sexual prowess.http://www.interscience.wiley.com/journal/a

rthritis

Dr Kenrad Nelson

Senior study author

“ Viral subtypes Dand E may be morevirulent than manyother viralsubtypes.”

9

Th

e P

uls

e

I first went on mission with

the medical humanitarian aid

agency MSF in 1999. Nine years

later, and having worked in

Somalia, southern Sudan and

Congo, I am now back in

southern Sudan, working with

MSF for nine months as a

“flying doctor”.

In over twenty years of brutal

warfare between Sudan’s southern

states and the government in

Khartoum, an estimated two

million people died. Ground and

aerial attacks on towns and

villages killed people directly,

while others perished from

exposure, thirst, malnutrition,

epidemics and a host of

preventable diseases. Since a 2005

peace agreement, tens of

thousands of Southern Sudanese

people are returning to their homes

after decades in exile, hoping that

their suffering can finally draw to

a close.

But this is one of the least

developed places on Earth;

southern Sudan is more than twice

the size of Great Britain and has

virtually no roads - and those that

exist are mostly rutted tracks that

become impassable in the rainy

season. There is virtually no health

care and in most of the region

walking for days is the only way to

get to the precious few health posts

that actually exist.

The job

I have a great job, in part

because I do not have a typical

day. My day to day work is

alongside the clinical staff, helping

them to gain new skills and

provide some insights into the

cultural aspects and as to what is

feasible in southern Sudan. There

is very little infrastructure and the

majority of the population we

work with has had little or no

education. It can be difficult for

staff to manage stock in the

pharmacy or to work out the

proportion of an injectable drug to

be given.

My job involves providing

support to the international

medical staff (doctors, nurses,

midwives) and the national staff

teams in four of the projects that

MSF runs in southern Sudan.

These four projects, provide

primary health care to around half

a million people. This "primary"

health care not only covers

outpatients, immunisation,

antenatal care but also inpatient

care, tuberculosis, feeding of

malnourished children (both

inpatient and ambulatory), kala

Saving lives in

MSF has been operating in southern Sudan since 1983

working in hospitals, clinics and through mobile

teams. Here GP Simon Burling who has been

positioned as a "flying doctor" in southern Sudan

talks about his role.

JuniorDr

Fea

ture

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10

In hospitals, clinics and

through mobile teams, MSF

staff provide basic health care,

in-and-outpatient services,

surgery, nutritional, maternity

and ante-natal care. Our teams

also provide treatment for

HIV-AIDS, tuberculosis, kala

azar and sleeping sickness.

In addition to providing

primary and secondary

healthcare, MSF teams in

southern Sudan are on hand to

respond to disease outbreaks

and natural disasters. 2007 saw

MSF launch a large-scale

response to a meningitis

outbreak, as well as treating

people for cholera and

measles.

> Role of MSF in Sudan

azar, maternity care and in one

site, surgery.

Each project has one doctor,

although there is also a general

surgeon in the surgical site. This

means that we need someone with

a wide range of skills which is

increasingly difficult to find in the

West. We do not want specialists,

but someone who can treat

malnourished children, a case of

cerebral malaria, stabilise trauma

cases prior to referral (which

depends on having two dry

landable airstrips in the wet season

and may mean a patient dies

awaiting transport), deal with

obstructive labour (normal

deliveries tend to happen at home

and we only see the problems), run

a TB programme, a routine OPD

and deal with the occasional

hysterical patient. All this in an

environment of 40 plus degrees

heat, living in mud and thatch

huts, with basic food and with a

bunch of other international staff

that you have probably never met

before

I also do assessments and help

set up new aspects of the

programme, for example,

investigating reports of a kala azar

outbreak, working with our water

and sanitation department for a

hepatitis E intervention, restarting

a TB programme and establishing

VCT and STI clinics.

Ongoing conflict

Although there is a peace

agreement, the border areas are

disputed and are scenes of ongoing

conflict. The division of the oil

revenues is not transparent and

withdrawal of troops is behind

schedule. Although none of these

were the trigger for this

evacuation; this time it was a local

revenge shooting between two

different subclans of the

population we work with. One

man was killed and three were

injured, including one of our

senior clinical staff. He was

brought in when I was on call on

New Year's Day. He had been

carried for 6 hours, having been

shot twelve hours previously.

There are no ambulances and it

was too dangerous for people to go

and collect him until the gunman

had left. Although the bullet

transversed his pelvis, he seems to

be only left with a foot drop and

no visceral damage.

Over the last few weeks

tensions have built up with more

shootings and revenge attacks.

Some of our other senior clinical

staff have had to disappear for a

time as they are high valve

revenge targets. Indeed the first

day after the first shooting we had

lost three quarters of our OPD

staff and that is not a pleasant

situation with a full OPD after the

holidays. Triage, innovation and

high frustration tolerance are a

must.

Meningitis

Other plans include training

some of the national staff in

anaesthetics in the newly opened

surgical site. We are also entering

the meningitis season and a large

epidemic is "overdue". Small

outbreaks occur each year but

there was a significant increase in

2007, with 12,570 cases and a

CFR of 6%. We have emergency

preparedness plans and stocks for

this, as well as for the other

outbreaks we see, particularly

measles (a major killer) and

cholera. We also expect that there

will be an increase in

malnourished children this year, as

large amounts of sorghum (the

staple crop) was destroyed by

flooding. There will be a longer

hunger gap and already some staff

are asking for payment in the form

Saving lives in SudanJuniorDr

Fea

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11

of food as opposed to money.

It can be exhausting with long

hours and on call duties with

incredibly sick people and a heavy

reliance on your clinical skills

without fancy investigations - eg

no blood chemistry, no X-rays, but

the work is incredibly satisfying. It

is very clear that we work in some

of the most neglected parts of the

world, away from media attention

and that if MSF was not there,

there would be no health care at

all. However, it is the most

stimulating and satisfying job and

the ability to help the person in

front of you and make a real

difference to their life, even saving

it, is immensely rewarding. I have

and you can truly say that you

make a difference.

You can find out more about

the work of MSF in Dafur and

other projects around the world at

www.msf.org/unitedkingdom

A woman has a

one in eight

chance of dying

during childbirth.

JuniorDr

Fea

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s

12

After William Harvey demonstrated his theory of the circulation of blood

in 1620 scientists struggled for nearly 300 years to perfect the

transfusion of blood to humans. Today the national blood service

collects 2.5 million blood donations each year. Professor Pete Moore,

author of ‘Blood and Justice’, takes us on a journey back to the origins of

blood transfusion.

Fifteen years ago I taught

physiology. One of the more

memorable practical classes

involved a couple of buckets of

ox blood. Laced with heparin, it

was subjected to a series of

‘experiments’ by often pale-

faced undergraduates.

But they were great

experiments. Blood gave us an

opportunity to play with a living

organ, with a fluid that displayed

many different properties, some

simple some complex.

While some students were

squeamish, few attributed this to a

belief that they were handling the

very life of the slaughtered animal.

Wind back a few centuries and the

situation would have been very

different.

First established in pre-

Christian Greece, life was seen by

some to contain blood, by others

to be the very stuff of life itself.

There was a simple observation

that proved the case - let it out and

the person’s life left their body.

This was so well established that

trying to bleed a person became

one of the main criteria for

determining death - cut into a

vessel and if no blood comes out,

there is no life left inside.

The Circulation of Blood

The seventeenth century saw

the first glimpse of a new concept

of blood. Arguably it started

with William

Harvey’s 1620s

realisation that

b l o o d

m u s t

circulate around the body. He

made a few rough and ready

calculations of the blood flow

through the heart and realised that

this was too great to be sustained

by a one-way passage from the

heart to the extremities.

Looking for inspiration he

turned to Aristotle who had come

to similar conclusions from his

local river. The water must be part

of some great cyclic activity,

Aristotle reasoned, otherwise such

was the flow that the mountains

would soon run out of their supply.

Like the presumed water

cycle, Harvey reasoned that blood

flowed to the extremities in the

arteries, and in some way

‘condensed’ into the veins before

returning to the heart. He was also

convinced that a circular system

was in operation as he saw this

sort of motion in the stars of the

heavens. The God who created

had obviously ordained that

circles were good.

His reasoning may have been

flawed, but the conclusion was

correct.

The 1650s then saw anatomist

and astronomer Christopher Wren

inject solutions into this

circulating stream of fluid.

Maybe, he surmised, this would

be a good way of distributing

medication through the body. His

one attempt in a human, involved

borrowing a friend’s servant and

injecting opium into him. The man

slumped to the floor. Wren was

disappointed, as he felt he had

only just started the experiment,

and was fairly sure the wretched

servant was feigning his faint in

order to go home early.

Robert Boyle and colleagues

then took up the trail, investigated

the physical properties of blood

and searched for any medical

benefits that could come from

manipulating it.

Jean Baptise Denis

Into this steady progress of

early scientific endeavour, stepped

a 26 year old Frenchman. Jean

Baptise Denis was keen make a

name for himself and thought that

pioneering a cure-all treatment

would be a good way to achieve it.

Transfusing blood seemed a pretty

good possibility.

His theory was confused, but

incorporated the idea that if a

person was unwell, then their life-

blood was damaged. Draining this

diseased fluid and replacing it with

blood from some healthy donor

should restore health.

He borrowed some ideas from

the English workers, made a few

attempts at transfusing blood

between animals and then launched

into medical applications. On 15

June 1667 Denis connected a sick

teenage boy to a lamb. While Denis

was thrilled that the boy made a

rapid recovery to good health, this

was probably due to the fact that

the boy’s physicians abandoned

him and no performed the standard

treatment of blood letting.

All the same, Denis was

convinced that the technique was a

success and transfused sheep’s

blood into a paid volunteer – again

with apparent success. His next

two patients however died, and

Denis found himself in court

accused of murder.

Not having to go through at

21st century ethical approval

system may have meant that he

could stride ahead rapidly, but

when things went wrong it left him

distinctly exposed.

It would be 250 years until

science caught up and anyone

made a concerted effort to

transfuse blood again. We may

have moved away from believing

in the mystical properties of blood,

but in one aspect Denis was right -

transfusing it can indeed support

sick and injured people and as such

restore their health.

Blood, gloriousblood

> William harvey first demonstrated thecirculation of blood using a deer

> The first successful human to humandidn’t take place until 1818

(Courtesy - Library of Medicine, USA)

(Courtesy - Library of Medicine, USA)

Pete Moore’s ‘Blood and

Justice’ is published by

John Wiley.

ISBN 0470848421.

Over the last five years the

number of bodies donated in

England and Wales has fallen

from 670 to 600. In contrast, the

number of medical schools has

increased by eight, and 15 new

postgraduate anatomy

departments have opened to

improve the anatomy training of

surgeons. In this time the

number of new medical students

has increased to over six

thousand a year.

JuniorDr spoke to Dr Jeremy

Metters, HM Inspector of

Anatomy, about this threat to our

anatomy teaching.

Why do you think there has

been a fall in the number of

cadaveric donors to medical

schools?

Since 2000, the number of

offers of cadaveric donation has

fallen, mainly for three reasons:

firstly, Alder Hey and Bristol

played a role. In light of those

scandals, many people withdrew

their intention to donate their

bodies, directly citing these

scandals. Secondly, from 2001

onwards, if a person was

diagnosed with dementia, their

body could no longer be used for

teaching purposes. Thirdly, if

people had MRSA, they could no

longer donate their bodies.

Annually, 600 people wish to

donate their bodies to medical

science and considering that each

year some 260,000 people die in

the United Kingdom, this isn’t a

great deal. The percentage of

people donating their bodies to

anatomy teaching would be

greater if the public knew how to

donate.

The office of the Inspector of

Anatomy has to be particular in

what type of cadaver is accepted.

Donations below 60 years of age

are declined, unless the patient is

ill and likely to die soon, because

it’s not worth the bureaucracy.

Demand for cadavers has also

risen since 2000 because the

number of medical schools and the

number of students at those

schools has increased by 20

percent. Demand will increase

even further because surgical

reconstruction procedures which

were banned as part of the

Anatomy Act 1984 are now lawful

under the Human Tissue Act 2006.

It was ok for trainee orthopaedic

surgeons to excavate the upper end

of the femur in a cadaver but it was

unlawful for the trainee to insert a

prosthesis. It took 22 years for this

bizarre caveat to be addressed,

simply because it’s very difficult

to obtain parliamentary time.

Do you believe anatomy is still

best taught on cadavers?

Yes. All medical schools with

the exception of Peninsula say that

cadavers are the best means by

which anatomy should be taught.

The use of cadavers is very

expensive. Does the cost-benefit

ratio of anatomy teaching on

cadavers still warrants its

continuation?

Yes, and it is actually not that

expensive. At each of the

thanksgiving services, students are

incredibly grateful for their 'silent

teachers', who provide them with

the most incredible textbook.

Indeed, some medical students

recently wrote “our silent teachers

provided us with a text that no

book can duplicate, no lectures can

match and no computer could

simulate”.

Would you donate your body?Yes, in due course but being on

the National Organ Donor Register

is more important. One cannot be

on both registers, since the

maintenance of life is more

pertinent. A lady today stipulated

that her body be used only for

research purposes, and not for

teaching. But her wishes cannot be

guaranteed, as we cannot forsee

what type of research will be

conducted at the time of death and

whether her body will be of use.

We also cannot guarantee

intending donors that medical

schools will accept the body.

Schools must run checks that can

preclude donation, which is very

distressing for the family,

particularly if it was “Granny's last

wish”.

What are the motives

commonly cited when people

wish to donate their bodies?

People often donate if they

benefited in some way from

medical care. There is also a strong

desire to help future generations.

There are about 600 donations per

year; there would be more but

many cadavers are lost via post

mortems.

What happens to donated

bodies?

Provided there is a consent

form, or a donation request in the

Will, the person in possession of

the body - usually the next of kin,

will contact the medical school,

The recent expansion of

medical training in England

has resulted in a shortage of

bodies for the education of

medical students and for

research.

While the numbers of people

donating body organs has

increased, the number of

people leaving their whole

bodies for medical science

has fallen since 2000.

Michelle Connolly finds out

more from Dr Jeremy

Metters, HM Inspector of

Anatomy.

Return of thebody

snatchers

Fea

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14

JuniorDr

who will then ask questions about

the death. This is to ensure there

are no conditions which preclude

donation (post-mortem

examination, severe deformity,

hepatitis or dementia). The school

will then accept the body for

“anatomical examination or

research” but by law for no longer

than a period of three years. Body

parts are allowed to be separated

but they must be brought together

when the body is cremated or

buried within three years of death.

The donor is free to withdraw their

consent at any time. Under the

Anatomy Act 1984, the next of kin

was allowed to halt donation. This

will no longer be lawful under the

Human Tissue Act 2006. Most

donors take the view: “I don’t mind

what you do with my body after

I’ve gone”, and express this in their

donation forms.

A brief history of body donation

Before the Anatomy Act 1832,

the only bodies available for

anatomy teaching were those of

executed criminals. The shortage

of bodies in the early 19th century

led to the practice of “grave

robbing” - in those days medical

schools asked no questions. The

most infamous grave robbers were

Burke and Hare, who committed

murder to meet demand for

cadavers at Edinburgh medical

school.

Similar events in London led

to the Anatomy Act 1832, which

allowed the use of bodies of

paupers or of unclaimed bodies to

be used in the dissection room.

Until after World War II, most of

the bodies were from those who

had no relatives to pay for the

funeral. It wasn't until the 1960s

when people actually started

bequeathing their bodies to

medical science. The Anatomy

Act 1984 tightened the legal

controls on body donation.

However, Section 4(3) continued

to allow the “person in possession”

to permit donation, where there

was no evidence that the deceased

objected.

There followed a decline the

the willingness of medical schools

to accept bodies when the

deceased had not expressed a wish

to donate. By 1990, all donations

followed the written consent of the

donor. Since 2000, all anatomy

departments in UK medical

schools have refused to accept

bodies unless it was the expressed

wish of the deceased during life.

JuniorDr

Fea

ture

s

In the constant pursuit of

‘forever youth’ collagen

injections have become the

UK’s treatment of choice,

second only to botox.

Collagen itself is a

compound found in

abundance in skin, bone and

muscles and serves as

scaffolding to strengthen and

support these organs. In the beauty

industry it is used to smooth out

wrinkles and bolster lips but

unfortunately treatments have to

be repeated as the effects are

not permanent.

The collagen used

in the UK is originally

sourced from cows,

pig and human skin

and these samples

are grown for up

to ten years in

l a b o r a t o r y

conditions. In all

cases the collagen

is highly purified

and sterilised

before being

converted into an

injectable form ready for use

in humans.

Collagen crime

Last year however, The

Guardian newspaper uncovered

that collagen in some UK clinics

had been sourced from a Chinese

firm which has been extracting

collagen direct from the skin of

executed Chinese prisoners.

Shockingly, according to reports

from agents at the company this

practice is quite ‘normal’.

Bar the ethical concerns of

this collagen, there are also

major health risks to

consider. Transmission of disease

especially blood-borne viruses,

such as hepatitis and vCJD, are

possible - although there are no

records of this happening. An

inquiry by the Department of

Health has reported cases of acute

allergic reactions to contaminated

collagen injections causing

scarring and disfigurement.

Regulation

As collagen products are not

strictly classed as either medicines

or cosmetics they bypass any

current regulations. This anomaly

is being reviewed at present by the

European Commission but any

legislation is several years away.

Mr Douglas McGeorge,

president of the British

Association of Aesthetic Plastic

Surgeons (BAAPS) emphasised

the importance of consumer

awareness:

“Stories like these only

reinforce the advice given by

BAAPS that patients should

always see reputable surgeons

who have a proper training in

aesthetic procedures and who are

properly qualified to give good

and appropriate advice,” he said.

“The hope is that the

forthcoming changes in the

regulations will eliminate the

fringe clinics offering poor advice

and questionable treatments with

inferior products.”

They also hope that patients

will be more proactive in

questioning where and how the

constituents used in their

procedures have been obtained.www.guardian.co.uk/science/2005/sep/13/med

icineandhealth.china

Collagen corpses

In today's celebrity culture, where looks are becoming more and more

central to a person’s confidence, the desire to fit into a set mould is ever

increasing.

But how far will the beauty and medical industries go to fulfil the

demands of such an image conscious public? Sinem Ayman highlights

how fears have been raised about the origins of collagen for implants.

15

Maggots- Taking the bite outof wounds

Chronic wounds and skin

ulcers have always been difficult

to treat. One important example

is that of diabetic foot ulcers that

frequently result in amputation.

Numerous observations of

soldiers at war in past centuries

have shown that wounds

accidentally infested with maggots

not only healed quicker but also

appeared to protect the host from

acquiring septicaemia. Since the

late eighteenth century, studies of

controlled, sterile management of

infected wounds, abscesses and

osteomyelitis with MDT had been

successful and popular until the

introduction of antibiotics and

aseptic techniques in 1940’s,

where it was used only as a last

resort. Interest in the little

creatures has once again grown

recently because of the emergence

of antibiotic resistant

microorganisms - MDT can reduce

the risk of acquiring an MRSA-

related illness.

Certain species of larvae,

particularly the green bottle

blowfly (lucilla sericata), feed on

necrotic tissue only and don’t

invade internal organs or break

away from each other. They

provide a useful method of

removing necrotic tissue that

would normally impede new tissue

formation. They also release

exudates containing certain

proteolytic enzymes and

chemicals such as allantoin,

ammonia and calcium carbonate

that act as antimicrobial agents and

possibly as growth factors to

encourage wound healing. Some

believe that the physical effects of

the crawling maggots and sucking

of debris and bacteria also assist in

these processes.

It is recommended that

between five and ten maggots are

used per centimetre squared of

wound and up to 1000 maggots

can be introduced into the wound

at any one time. They are kept in

place via hydrocolloid dressings

(double layered and designed to

allow oxygen in and exudates and

debris out) and are usually left for

three days. A number of

applications may be needed

depending on severity of the

wound and the amount of necrotic

tissue removal desired. MDT is

mostly used on chronic, external,

non life-threatening wounds,

where other interventions have

failed, and has even been

successfully used for necrotising

fasciitis and other situations where

surgery would have been risky.

Candidates should be chosen

with care. Those with a purulent,

sloughy, skin lesion that is resistant

or not completely responsive to

treatment will benefit from MDT.

It can be used alone (important

when costs need to be kept

minimal) or supplementary to

medical or surgical treatment.

Although studies are difficult to

accurately evaluate and compare, it

has been observed that in 80-95 per

cent of cases most or all

debridment is removed via MDT.

There is substantial evidence to

advocate the use of larval therapy

in chronic leg/pressure/venous

stasis ulcers, diabetic foot wounds,

traumatic and post-surgical

wounds and even burns or necrotic

tumours. MDT is simple, cost-

efficient, effective and rapid,

without any known side effects

aside from itching/tickling

sensations felt by some patients. It

is becoming more and more

popular in hospitals across the

globe, and as our knowledge

increases, will probably open the

doorway to more unconventional

forms of medical treatment.

(1) "Myiasis: The Rise and Fall of

Maggot Therapy", D. Morgan, Journal of

Tissue Viability , 1995, 43-51, 5(2)

Pros

• Simple and fast.

• Cost-effective, especially in

third world countries.

• Decreases chronic wound

healing time and efficiency

• Eliminates odour of necrotic

tissue.

• Reduces morbidity and

mortality by preventing

infection of the wound.

• An alternative to

medical/surgical methods that

have failed or are unsuitable

for the patient.

• No side effects reported

apart from slight physical

discomfort.

Cons

• Disgust/revulsion/other

psychological distress.

• Pain/tickling/itchiness.

• Fear of maggots escaping/

burrowing into skin/maturing

into flies (in fact, this is not

true as mature larvae need to

leave the wound to turn into

pupae and then adult flies).

• Potential allergic risk

(although none has been

reported thus far).

• Require an experienced

clinician to select and sterilise

the right species of maggots.

Most people, with the exception of fishermen and extreme animal lovers, will be disgusted by the thought of maggots crawling onto their skin. You

can instantaneously conjure up an image of a rotting body plagued with flesh-sucking creepy crawlies. In fact, myiasis is the very term given to the

‘infestation of live humans and animals with dipterous larvae which feed on the host’s dead or living tissue, liquid body substances or ingested

food’. But as Amilia Youkhana explains, despite its ickiness, maggot debridement therapy (MDT) could be a significant part of the management of

chronic inflammatory processes such as wounds, ulcers, burns and even necrotic tumours.

“The latest

technological

instrument in the

surgeon’s tray can be

bought from your local

angling shop.”

JuniorDr

16

Fea

ture

s

Fea

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s

17

After telling him off several times

in my nicest voice I give up and

tell him to take a break. He doesn't

understand the sarcasm in my

voice and so thanks me gratefully

before promptly disappearing.

I spend the evening working at

home as I need to hand in my MD

thesis this month.

Wednesday

I have my angio list this

morning. Actually, it’s a list for

Douglas who is my nice

consultant. A near retirement

gentleman with white hair and a

quiet voice, it was he who

encouraged me to go for the MD.

He usually hangs around

somewhere in the department but

generally lets me get on with it. I

perform four procedures during

the session, one of which is a stent

which is placed in perfectly. I wrap

up and meet a colleague for a

leisurely lunch.

The afternoon is spent

reviewing a few inpatient echos

and I leave early enough to have a

shower, change and be at a bar

with some friends by seven. I

drink a little too much and we

spend the evening complaining

about the men (or ex-men) in our

lives. I get a taxi home and

collapse into a bed a little after one

am.

Thursday

Unusually for me I have a

slight headache and feel

reasonably grotty by the time our

ward round starts. This is the once

a week shame game led by my

other boss, the nasty one. He

particularly delights in making

Foundation One squirm. He used

to go for me too but the good thing

about my recent research is that I

think he’s a little scared of me -

especially since last week when I

quoted a New England paper on

cell death after cardioversion to

prove that he was wrong about a

patient. Anyway, I try to help

Foundation One out as much as

possible but some of the holes he’s

dug for himself mean he’s on his

own at times. Afterwards I try to

give him an encouraging word and

even Foundation Two

chips in but he

remains glum.

I spend the

afternoon reviewing

jobs from earlier in

the week and then

find myself at a loss

with nothing to do. I

Monday

If you’ve been following this

column then you’ll know that I had

a dilemma last time - well two

dilemmas actually. The first

involved the job offer for a year in

Montreal to convert my MD into a

PhD and continue the research that

I had been doing into cardiac

myocytes. This was actually more

tempting than you would think - a

year of skiing would have been

perfect. The other dilemma

involved James, the cardiac

surgeon that I had been seeing for

four months. He wanted me to

move in with him.

I thought long and hard about

it over the course of a weekend

(and a few glasses of Merlot) and

decided it was time to change my

life around. I wasn’t getting any

younger (as my mother kept

reminding me) and didn’t want to

keep from doing the things that

mattered to me most. And so I

declined the offer of a PhD,

finished my MD and returned to

clinical medicine. And I dumped

James as he was a bit of a sissy.

Monday involved a clinic and

some paperwork before going

home for an early night.

Tuesday

Another clinic this morning

where I saw post MI patients. I

love explaining the things they can

and can’t do and get most fun

from explaining how long they

should abstain from sex. To be

honest, looking at some of my

chain-smoking overweight cardiac

patients I often feel they should

abstain for a bit longer - for

everyone’s sake. The bad thing

about research is that you lose

touch with clinical work. Aside

from a weekly angio list I hadn’t

done any acute takes and so even

looking at a clinic chest x-ray I

have to spend a few extra seconds

before coming to a decision.

I have a quick lunch and

partake in the joys of a ward round

in the afternoon. The inpatients are

pretty light for some reason and

we move round the beds swiftly. I

have two Foundations who keep

insisting on referring to me as a

Specialist Trainee. I have

reminded them more than once

that I like to be called a registrar.

Foundation Two is a quiet Asian

girl with long black hair and soft

voice. Foundation One is a large

rugby playing Welsh boy who

seems to know nothing at all about

medicine let alone cardiology.

decide to leave early again and

spend the rest of the afternoon

looking for a new handbag. It’s the

first shopping I’ve indulged in for

over a month and it feels pretty

good. I get through a big chunk of

my thesis by nine and then call it a

night as I settle into bed with a

glass of Merlot and a book about

Afghanistan that I never seem to

be able to finish.

Friday

I’m on call today (but

thankfully not at the weekend) so

start early. The good thing about

the system here is that my team are

with me and although Foundation

Two is diligently seeing patients

from the box, Foundation One has

called in sick. I wonder how much

of yesterday’s humiliation got to

him but luckily we have enough

juniors to cope with the workload.

I spend the morning putting in a

chest drain on a palliative lung

cancer patient, excluding

meningitis with an LP and making

an elderly pneumonia comfortable.

Shortly after two I get a fast

bleep from resus. I walk in and

find the casualty middle grade

over the bed of a large white male.

He tells me that it’s a junior doctor

with a suspected overdose and his

GCS is dropping. I walk over to

the bed and for a second the I think

it’s Foundation One. It wasn’t.

I calm myself and then start

work. His airway starts to occlude

and I tube him. An anaesthetist

turns up and takes over. The head

of ICU turns up and the two of us

spend an hour stabilising him

before transferring him upstairs.

Later, I finish my shift and go up

to see him. Around the bed are two

people who I presume are his

parents. Nasty and nice bosses are

here too, deep in conversation with

the ICU consultant as they pour

over his charts. I look over and see

that his blood pressure is dipping

despite the aggressive inotropes

going in through multiple lines.

Back home I call Foundation

One just to check how he’s doing.

He’s fine.

Th

e S

ec

ret

Dia

ry o

f a

Ca

rdio

log

y S

pR

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!

JuniorDr

Edu

ca

tion

18

ISC Medical offer a wide range of products to help you

with your ST interview, including:

Frequent courses with small numbers

Comprehensive ST interview guide (downloadable)

One-to-one coaching

20% OFF for MDU members

How can you make an impact in your interview? Some candidates have

an innate ability to sell themselves well, but many find it more difficult

and are in search of a magic formula that will give them the job they

seek. Forget the miracle cure; there is only one recipe for success:

preparation.

Nurses are not just evil people who bleep you in the middle of the night

to sign a chart - they are also friendly, thoughtful and have lots of

chocolate. A nurse should be your best friend as a junior doctor. Nurse

Tracey Maher tells us why.

www.iscmedical.co.uk

0845 226 9487

in association with

What makes a good candidate?

Good candidates display a wide

range of attributes, but they always

have 3 things in common:

A good structure

Many candidates have good

content; they say all the right

words but they fail to impress the

panel because the information is

not structured. As a result, the

interviewers fail to follow the

arguments presented and good

scoring opportunities are missed.

Make sure that your answers

contain three or four distinct points

which you can develop in turn, and

not a long rambling novel.

A personal approach

Candidates have a tendency to

waffle or "theorise" about topics.

Questions on leadership contain a

lot of buzzwords such as "vision",

questions on governance get

answers discussing "frameworks",

etc. This sounds very theoretical

and does not allow the candidate to

demonstrate that he/she

understands these concepts on a

practical day-to-day level. Rather

than theorise and focus on

buzzwords, bring examples from

your daily experience.

Lateral thinking and maturity

Think about the range of issues

that each question addresses. For

example, dealing with a difficult

ST INTERVIEWS

EFFECTIVE PREPARATION

colleague does not just mean

reporting the issue to a senior

colleague; there is also a human

and communication side to it.

When you describe your teaching

experience, do not limit yourself to

the letter of the question; as well as

your formal and informal

experience of teaching, you can

talk about the methods that you

have used, courses you have

attended, feedback that you have

received and your future plans for

teaching.

How to prepare

It is crucial that you do not rush

into mock interviews too early.

There are hundreds of possible

questions, but they all boil down to

10 or 15 themes. Take four or five

questions from each theme

(teaching, difficult colleague, etc)

and brainstorm them. Then see

how you can structure your answer

using 3 or 4 bullet points. Look at

what you do every day and see

how your experience can be used

to enrich your answers. Take your

time! Once you have done all that,

then you can start practicing.

Attending a course can also help,

but make sure that it has a small

number of participants. With a

small number of participants, you

can discuss good and bad answers

and obtain personal feedback on

your own technique.

SURVIVAL

GUIDE

to ST interviews

You may be familiar with the

creatures who scuttle up and down

the wards, some smiling, others

snarling. The younger ones as a

rule are slim and attractive, the

older variety tend to be haggard

and curvaceous. There is even a

male variety these days, commonly

referred to as the ‘failed medic’.

Junior doctors are generally

fearful of them and rightly so. The

wrath of the consultant can be

nothing compared to the stares and

sniggers of an army of these

creatures. Unless treated with care,

you’ll never find that cannula, or

those notes - you will be running

around like a headless chicken to

the amusement of everyone.

This curious species can

usually be identified by their

uniform and their harassed manner.

They are often found clutching a

bed pan, eating biscuits and

chocolates or gossiping in the

corner of the ward.

‘They’, ladies and gentlemen,

are nurses. So what is their

problem? Quite simply - you!

The history

History has not always been

kind to nurses, they are greatly

misunderstood. In the nineteenth

century they were referred to as

‘attendance’, who kept the ward in

order, the patients clean and

obeyed the doctor’s orders. Today,

nurses are a profession in their own

right, yet you lot often get

confused thinking they are a

subservient branch of medicine.

This mistake on your behalf causes

a few noses to be put out of joint.

Wound care, infection control

and manual handling are just a few

nursing specialities which seem to

make medical students smirk. If

you are guilty of sniggering at this

list then perhaps you have never

seen a patient die from pressure

sores, or MRSA.

On a less drastic note, you will

appreciate the manual handling

skills of a nursing team when

faced with an obese patient who

needs to be turned, or rolled, or

stood up in order to be examined.

As well as having their own

realms of expertise, nurses are also

the people who can keep you out

of trouble and ensure your path to

consultancy is smooth. That

wrongly written dose, or that

missed vital sign could equal

disaster if not spotted.

We’re nice ... really!

Nurses are actually quite nice

too - treat them well and with

respect and you’ll be offered the

odd chocolate, have a shoulder to

cry on when medical life is not a

bed of roses, and when you hang

up your white coat at the end of the

day, have some drinking partners.

But old habits die hard.

Despite this invaluable lesson,

things will not change overnight.

Nurses will continue to think of

you as an arrogant bunch, and

enjoy paging you in the middle of

the night to write up a bag of

fluids, and you will continue to

reprimand nurses for sloppy care,

and find it funny that they have to

wipe bottoms.

But amidst the traditional

conflicts, remember, they are your

comrades. A successful

relationship with the nursing team

can not only save lives, but make

ward life a lot more fun!

“Nurses are also the

people who can ensure

your path to

consultancy is smooth.”

Secret guide tonurses

JuniorDr

Weekend ward escape to the

Getting there

Despite being a Spanish island

Lanzarote lies closer to Africa

situated just 100 miles off the

Moroccan coast on the same

latitude as the Sahara desert.

Flying time is a little over 4 hours

from London.

For flights check out

ThomsonFly, Monarch or the

other package operators for cheap

lastminute deals. Alternatively BA

offer direct flights from many UK

airports with Easyjet are

launching an new route from

Gatwick this March.

Car hire is highly

recommended to allow you to

experience the extreme island

landscape and visit the more

remote villages. Alternatively,

taxi’s on the island are cheap and

coach tours to the main attractions

operate from the major resorts

towns year-round.

Where to stay?

The two main tourist resorts on

the island are the low-rise

developments of Puerto del

Carmen and Playa Blanca on the

south coast. Both are relatively

inoffensive with only a splattering

of ‘all-day English breakfast’ cafes

and beer guzzling Brits making

them a good base for those without

a car.

Try the cheap and cheerful

Atalaya Apartments in Puerto del

Carmen for a good location and

access to the beach at £50 per

apartment per night (+34 902 50

53 50). For a more luxurious 5-star

experience the Princesa Yaiza

Suite Resort Hotel in Playa

Blanca at £140 per night offers a

spa and uncrowded beach

(www.princesayaiza.com).

For a more exclusive and

individual experience try the very

private Lagomar guesthouse with

seaviews over lava craters and

access to an eccentric underground

There’s a myth that the Lanzarote locals coined the slang “Lanza-grotty”

to keep rowdy tourists away from this year-round sunshine island.

Lanzarote however, is more ‘art’ than ‘all-day English breakfast’ and an

ideal choice for a long relaxing weekend ward getaway.

JuniorDr

Key facts

> Population - 130,000

> Language - Spanish

> Currency - 1£ = 1.31 Euros

The pics

Clockwise from top left -

Satellite view of Canaries with

Africa to the left; Jameos del

Agua; Timanfaya National

Park; Lanzarote’s volcanic

coast; Tapas

cave bar (www.lag-o-mar.com).

Eating

Lanzarote cuisine is similar to

that on the Spanish mainland but

you’ll find excellent fresh seafood

most commonly served grilled.

There’s a small number of local

dishes including salted potatoes in

a hot local ‘mojo’ sauce.

Try Caserio de Mozaga

(www.caseriodemozaga.com) in

San Bartolomé which is

recommended for perfect Canarian

grilled fish and local produce.

Another great Canarian

restaurant with a modern twist is

La Tegala in Mácher (+34 928

524 524). Here you can sample

Tapas style dishes and enjoy a

fantastic panoramic view of the

volcanic landscape.

Key attractions

Timanfaya National Park - This

massive 20-square-mile site of

lava and volcanic craters is

spectacular and the island’s top

attraction. After the tour you can

refuel the with food cooked

directly off the volcanic surface.

Jameos del Agua - Designed by

the islands most famous architect,

sculptor and resident, César

Manrique, this site contains a

subterranean garden, restaurant,

pool and concert hall built into a

network of volcanic caves.

Reserve a table in advance.

Fundación César Manrique -

Understand the island’s world

famous artist, architect and

sculptor who worked with the likes

of Andy Warhol.

Find the full Lanzarote guide at

JuniorDr.com.

Lanzarote Fea

ture

s

19

The UK's first part-time course in applied clinical ethics, designed specifically

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The course is intended for hospital doctors, surgeons, general practitioners,

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of academic medical ethics necessary. Limited places available.

Directed by Dr. Daniel Sokol, Lecturer in Medical Ethics and Law, St George’s,

University of London and Honorary Research Associate, Imperial College

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6 x 1-Day Professional Training on Saturdays at Imperial College London

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on (+44) 020 7290 3846 or [email protected]

Meetingsfor Trainees

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05 AprilYoung FellowsInterview Intelli-gence training day

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Beat theWinter Blues

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9LHZ�YDFDQFLHV�RQOLQH�DW�

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Dr Fairytale

General Practitioner to the Stars

(B.H.S, M.&.S, R.S.V.P.)

Medical Report - Mr Peter Pan

Antisocial personality disorder

An ASPD is recognisable by Mr Pan’s disregard for social

rules and norms, impulsive behaviour and indifference to the

rights and feelings of others. Mr Pan claims, when talking

about previous violent actions, “I forget ‘em after I kill ‘em”.

This statement is worrying enough by itself but coupled with

his immature and narcissistic behaviour he should really be

investigated by a forensic psychiatry team. Should he be

allowed to remain at large in the community he may well put

the lives of all his “Lost boys” in danger.

Dwarfism

Described as “The boy who would not grow up”, Mr Pan is

accused of having control over his stature but most forms of

human dwarfism are caused by genetic disorders of cartilage

or bone development. The accusation is a clear example of the

social prejudice which exists against extreme shortness. It

may reduce social and marital opportunities, employment

options and is associated with low self-esteem. This may

explain why Mr Pan is keen to spend time with children in a

fantasy world where he is respected and considered mature

and all-powerful.

"Accidentally" Poisoned

Mr. Pan reports he is the only known person who is able to

speak the Fairy language of “Bells”. He claims to have the

ability to “Imagine things into existence” and create “doors to

place people in Nowhereland”. Mr. Pan is described as: “clad

in skeleton leaves and the juices that flow from trees”. It is

well known that certain naturally occurring substances, when

applied to the skin, or inhaled, cause powerful entheogenic

experiences including intense visual hallucinations, euphoria

and true hallucinations (perceived extensions of reality). It is

not known if any of these grow in “Neverland” but some

likely plants include: Salva divinorum, also known as Magic

Mint, a Mexican plant used by Mazatec shamans; psilocybin

mushrooms, commonly called “magic mushrooms”; or

Anadenanthera peregrina, a native South American tree which

contains DMT.

An unresolved Oedipal Complex leading to Paraphilia

Mr Pan desires for a mother figure. He has conflicting feelings

for Wendy, Tiger Lily, and Tinker Bell, who could be said to

each represent different female archetypes - which could all

possibly hint at a Freudian interpretation. When Mr Pan is

introduced to the adult Wendy, now married with a daughter,

he breaks down and cries. Mr Pan claims Jane, Wendy’s

daughter, asked him to take her with him to Neverland and to

let her “be his new mother” which he joyfully accepted. What

followed in his description was: “we fly off together with

Wendy sorrowfully looking off after us”. Another

interpretation would be a kidnapping, child endangerment and

grooming. Ass

esse

d b

y D

r G

il M

yer

s

Ethicaladvisor

As junior doctors keen to push the boundaries of medical knowledge

and further your careers, you may want to publish in peer-reviewed

journals.

A blank ‘publications’ box on

that Specialty Training application

form can be disheartening. No

doubt many of you have tried - and

some succeeded - in getting audits

or case reports published. The

harsh truth is that most will be

rejected, either because of poor

quality or insufficient contribution

to the field. The writing tends to be

clumsy, error-ridden, and my

medical statistician colleague

assures me the statistics are

generally shaky. In brief, if you’re

going to do it, do it properly.

If you’re new to the

publication game, get an able team

together. Have a literate friend on

board and, if statistics are

involved, seek a statistician. It is

also wise to team up with someone

with a long list of publications in

the same or similar field.

They will know the required

standard and can also help with the

presentation of the manuscript,

including the all-important cover

letter explaining why the journal

should bother considering the

manuscript at all. As a reviewer, I

take a very dim view of sloppily

prepared manuscripts. No matter

how much one protests that it is the

content that matters, these

imperfections will not put

reviewers in a good mood.

My own advice is to offer

potential helpers co-authorship

rather than asking them for a

favour. They will review the

manuscript more meticulously. At

least, they should. If your

Getting an article published in a peer-reviewed

journal

Dr Daniel Sokol is a Lecturer in

Medical Ethics at St George’s, University

of London, and Director of the Applied

Clinical Ethics (ACE) course at Imperial

College, London.

There are four MPS bursaries for

junior doctors to attend ACE 2008,

starting in March. E-mail

[email protected] for details.

JuniorDr

22

Th

e M

es

s

Medical Ethics and

Law - Surviving on

the Wards and

Passing Exams

Sokol and Bergson

£14.95

ISBN 0954765710

“My own advice is to

offer potential helpers

co-authorship rather

than asking them for a

favour. They will review

the manuscript more

meticulously.”

consultant or senior colleague’s

name will appear on the final

submission, they must justify co-

authorship by contributing

significantly. There are criteria for

authorship and these must be met.

Do not let yourself be exploited.

Similarly, if you feel you have

contributed sufficiently to warrant

authorship, then speak up. I know

of one junior doctor who, as a

medical student, was left out of a

research paper in Nature despite

conducting much of the empirical

work. She regrets her silence to

this day.

Finally, I encourage you to

write articles about your own

ethical experiences as junior

doctors. Do not restrict yourself to

audits and case reports. There is a

real need for junior doctors'

perspectives on ethical issues.

Many medical and medical ethics

journals would be delighted to

receive insightful and well-written

pieces on the ethical challenges of

being a junior doctor. These can be

first-person accounts of a moral

dilemma or more formal

examinations of an ethical issue.

For example, I am currently

working with an F2 on how to deal

with racist patients. So think about

your own experiences in the last

few weeks, and put pen to paper.

Suicide Rates Ranked by Country

factfileSuicide

JuniorDr

Hospital

When 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 -

Wh

ich

me

ss

is t

he

be

st?

What it’s got -

“The Doctors’ Mess is in the Education Centre near the canteen

- it’s a bit tiny, but there are comfy seats, a nice big TV,

newspapers and a kitchenette with a toaster, a fridge and a

microwave. Tea and coffee are provided, but don't use the

Education Centres green crockery unless, for whatever reason,

you want to wind them up. A small room off the mess has at least

two computers that can check e-mail and another that can run

various CAL programmes. They’ll insist on teaching you how to

use CAL.”

JuniorDr Score - 2/5

> Papworth Hospital, Cambridgeshire

Small hot chocolate (takeaway)

Burns your wallet as well as your mouth at -

£1.80WOW!Royal Free Hospital

London

Remember, chocolate is good for you at -

80pLOW!Newham General Hospital

London

Toasted cheese sandwich

It’s not just the cheese causing nightmares at -

£2.15WOW!St Thomas' Hospital

London

Cheap enough you can discard the crusts at -

£1.45LOW!Bronglais Hospital

Aberystwyth

Banana

Shop staff are bananas at -

55pWOW!Royal Free Hospital

London

Let the monkeys know about -

35pLOW!University Hospital Of North

Durham

Next issue we’re checking the cost of photocopying one A4 sheet, a

Mars bar (64g) and a can of Sprite. Email prices to [email protected].

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Data from the World Health Organisation (1996-2007)

2. Belarus

(35.1 per 100,000)

3. Russia

(34.3 per 100,000)

9. Japan

(24.0 per 100,000)

11. Sri Lanka

(21.6 per 100,000)

13. Finland

(31.7 per 100,000)

18. Cuba

(18.3 per 100,000)

28. China

(13.9 per 100,000)

45. United States

(11.0 per 100,000)

60. UK

(7.0 per 100,000)

93. Jamaica

(0.1 per 100,000)

1. Lithuania (38.6 per 100,000)

Lithuania has maintained it’s morbid ranking

at the top of world suicide rates since the fall of

Soviet rule in 1990. More people kill

themselves each day in this tiny Baltic county

with a population of less than 4 million than

die in road traffic accidents.

Lithuania’s rise to the top has been blamed on

the rapid increase in alcohol consumption

during the 1980s - a similar trend to that seen

in Finland. Researchers also suggest that the

increase may have followed changes in law

which make it is possible for each citizen to

obtain a handgun legally for self-protection.

Suicide by firearm is now one of the most

common methods.

Trends in suicide in a Lithuanian urban population over the period 1984–2003

Abdonas Tamosiunas , Regina Reklaitiene , Dalia Virviciute and Diana Sopagiene

BMC Public Health 2006, 6:184doi:10.1186/1471-2458-6-184

Documents

JuniorDr Magazine - Issue 08