2010 2 by Galenicals

the

Black Bag

The University of Bristol Medical Studentsâ&#x20AC;&#x2122; Magazine

The University of Bristol Medical Students’ Magazine VOL. I

SUMMER TERM, 2010

NO. 3

EDITORS: R. A. F. Pellatt & D. R. A. Cox SUB EDITORS: F. McCurdie & P. Barnes CONTRIBUTORS: James Cundell, Jo Davies, Eoin Dinneen, Jess Hawksley, Steve Lindley, Liz McKiernan, Hannah Nazri, Harriet O’Neill, Piers Osborne, Dr Trevor Thompson, William Maclean

‘In nothing do men more nearly approach the gods than in giving health to men.’ — CICERO

Black Bag the

Summer 2010

Contents Editorial .

Page .

A Year on the Galenicals Committee .

. 12

The Black Bag: a 111 Year Legacy

. 17

My PS3 SSC

An Interview with Professor Barr

. 21

Black Bags from the Past .

. 23

Anatomy of a Firm

. 25

Sonnet 147

. 29

White Lies

. 31

Sick Notes .

. 33

Educational Crypticities .

. 36

On Reflection .

. 38

Coffee Break

. 43

Book Reviews .

. 45

Editorial

s we sit down to write the third and final editorial of this academic year’s magazine, a storm rages outside following several days of glorious sunshine. We cannot help but reflect in this change of weather our own experiences as editors of The Black Bag. For so long we basked in glimmering success like lizards on the Lounge floor: notoriety and fame were ours. Then the storm came. Scandal! Censorship! We had overstepped the mark – drunk with editorial power and jugs of Agent Orange – pages of The Black Bag fell like torrents of rain, torn from the bindings of our second edition. Disgraced we retreated to the safety and comfort of cigarettes and Alanis Morissette. Our final edition of the year is a penance, an effort at redemption through which we hope to amuse and entertain the medical school populace. From a coveted interview with a memorable intellectual, Professor and general surgeon, to musings on the social structure of medical firms; from one 5th year student’s PS3 orientated SSC to the outgoing Vice Presidents’ take on a year on the Galenicals Committee, we have tried once more to be servants to humour and mirth. As the storm tumbles on, so shall this black book. ‘Blow, winds, and crack your cheeks! rage! blow!’

D. R. A. Cox & R. A. F. Pellatt

An Interview with

PROFESSOR BARR

Left to right: Daniel Cox, Prof. Barr, Richard Pellatt, Cathy Powell (Prof. Barr’s secretary), Kirsty Kendall (Mr Vipond’s secretary)

D. Cox: Professor Barr, could you tell us a bit about your

background? Prof. Barr: My father was in the RAF during the war and afterwards he went to medical school; everyone in my family has been medical since. I trained in Liverpool. After qualifying I spent time in London, then in Oxford. I did research in North America and came back to complete my training in Oxford. After initially training as a gastrointestinal surgeon I became interested in Barrett’s oesophagus and started undertaking some research in photodynamic therapy of the alimentary tract. DC: Could you tell us something about your current research? PB: Essentially building devices: the two main groups are in Raman spectroscopy, that is, using optics for early diagnosis, irradiating tissue with light to give a molecular fingerprint. We do that predominantly in the oesophagus. I’m also very interested in volatile analysis, that is, ‘smelling things’ – so we’ve been smelling people for early diagnosis; we’ve smelt for helicobacter… renal disease… for fungi and also for liver disease. The biggest thing is to smell cancer – that’s a bit harder though! But my main interest is in smelling infection: clostridium, TB, fungi and the response to bacteria [with electronic sensors]. With endoscopies you put a lot of air in and blow it out — why not analyse the air you get out? We can smell cancer cell lines — trying to understand whether they liberate the volatile while they’re still dead. We’ve also teamed up with local artists looking at the mood altering effect of smells. We did an art/science piece up in London with George Taylor looking at mood alteration and at human pheromones. DC: Do they [pheromones] really exist?

PB: This is the big problem. No human pheromones have been isolated, but hopefully we’ll get one from the armpit of a female soon. But as you know pheromones are wide-spread in nature. The piece of work we did in London was mostly around trying to sense the female orgasm, which I’m not an expert in of course! ‘Le Petit Mort’ it [the project] was called, ‘The Little Death’, a metaphor for the female orgasm. We had to try and understand the huge physiology that occurs at these events and try to sense these ‘transformative experiences’. We’re also interested in the passage of the soul at death – the ‘smell’ of death. As you know people can develop an odour at death. With ‘Le Petit Mort’ we were trying to sense sweat… we had to, of course, have volunteers to help us analyse… we got some young post-docs who fortunately were trying for a baby and we asked their wives if they’d be good enough to tell us whether his performance was substantial or not! We put pads on people and we were also able to then look through the female cycle. This was with mainly artists and it was essentially a conceptual piece. R. Pellatt: Did you develop this interest in research as a student? PB: No, no, not at all. I concentrated on the usual stuff that medical students do: I was in the archery team, I loved rugby but was not good enough… but it was always at the back of my mind that I’d do research. I didn’t really peak at medical school; when it got really competitive taking the Fellowship exams in surgery then I devoted myself to studying and did very well. Then I got into the technical aspects of surgery – surgery’s very addictive, once you start doing it you can’t give it up. I got a bit interested in these very technical tumours, particularly pancreatic and oesophageal and the Barrett’s oesophagus.

DC: What were your first jobs when you qualified? PB: My first job was as a houseman in Ormskirk District General Hospital. It was wonderful - we had a very tight team, we had a little cottage we all lived in and a mess there. Some of the gentler aspects of the firm structure in surgery were there: we all had lunch together, all had tea together, we had a lady knock on our door in the morning and ask if you wanted one cup of tea or two – in my case it was always one! Since I’m a seriously ugly boy! You virtually spent your whole life in that hospital. We did hospital revues, we ran hospital parties, you could go into the mess and there’d be someone around to talk to. The informal structures to support you through the difficult problems in medicine were good, when you thought maybe something was going very bad on the ward and you’re not coping very well, someone would sit you down – you don’t have to have a weeping session but you have to have an informal support network. Lovely job. RP: Today, a lot of the informal care structure you had would be

an ‘incident report form’ and endless levels of bureaucracy. What do you think about this situation? PB: I’m a bit old-fogeyish about this: I believe it takes away the informality… I used to get invited to the Housemans’ weddings! We do try to persevere a room here where consultants can bump into each other and say ‘Heck, I’ve seen this…’ and they’d come down and help you. The juniors have a bit of a formalised assessment and can feel a little isolated. Having said that, I think that docs coming through such as you guys are really good and usually they build up a little network.

RP: There’s an increasing number of people aiming to go part-

time these days: will this have a negative impact on surgery? PB: We’ll work round that. I’m not averse to people having good time off. People used to be over committed, they were over-experienced and under-trained; now they’re over-trained and under-experienced. People should have a life, I don’t want to see any bad personal things happen to people. These days relationships are more complex than in my day… I’m an ugly boy, I see a girl who likes me and I get the kids and settle down! Now its all breakups and ‘Oooooh’ and all this sort of stuff; its important because people work well if their personal lives are good. Often there’s two people working; in my day my wife gave up her job – she was an actress – when I started working. I was out all the time; she was bringing up the kids. She was fantastic. Now there’s often two professionals and they both have to work so we have to cut people more slack. If your personal life is a mess you don’t work well. DC: What do you think of the medical students coming

through? PB: I think they’re bright; all ladies! I would prefer they were attached to a firm like I was. I did weekends on call with the houseman: got up, did the drips, the catheterisations. They’re not picking up the ambiance, the mood, they’re not learning to joke and laugh at themselves: ‘Bad things will happen, but we’ll get on, have a cup of tea’ – a bit more relaxed. It would be nice for medical students to be part of the firm structure rather than being here, there and everywhere. But hey, that’s the way it is! You’re all a lot brighter than me! DC: Do students seem more career orientated? These days

medicine is very much ‘tick the boxes’, follow the pathway… PB: I’d like students to have more choice; I don’t like to see people categorised too early. I think you get too focused on the career. My big worry is that you won’t do research. I’d like you to do a heck of a lot of research! Once you get people into research they love it! A different lifestyle: international meetings, bonding with scientists, working in the lab; you get to think a bit. [Medicine] is too protocol-ised. I like people to be able to come in and out of research, not just to tick the box, but to really embrace it. Like my pheromone research – how cool is that?! The big problem with medicine is that after 20 or 30 years you’ll get bored, angry at the system. The system wants you down at the coalface digging coal. ‘See more patients, see more patients!’, ‘Do, do, do!’ But you’re the brightest people on the planet, and you’re not going to tolerate this ‘coalface’ work without another interest. Research gives you that. Some people go into education but that gets a bit protocol-ish. Some people go into management, and some people concentrate on big private practice, which is fine. You need another interest, or you’ll get pissed off, start chasing different girls, you know! DC: Can you be a part time surgeon? PB: Oh yes. DC: A good one? PB: Yes – but not as good as me! We’ll have to accommodate, that’s the way it is.

Professor Barr is a Consultant General Surgeon at Gloucestershire Royal Hospital 10

A Year on the Galenicals Committee: The Making of Two Medics

round this time last year, something rather extraordinary happened. A pair of star-crossed bohemian nobodies, brought together by Weston academy and a penchant for peace, love and clothes that resemble your gran’s wallpaper, both managed to sneak onto the Galenicals committee. Needless to say, eyebrows were raised; even the new president was overheard muttering ‘Who are these grubby hippies?!’ More likely to be found in the sweaty depths of Thekla than Lounge and as medically orientated as box of colouring pencils, we weren’t the obvious choice. No one was more surprised than we were. Out went the daisy chains and fairy cakes and in came Googlemail, countless meetings and endless ‘chat’ (accompanied by protected Galenicals free tea breaks to preserve our dwindling sanity). Work didn’t take a back seat: it was

thrown in the boot. There was always an email (or twenty) that needed responding to or another meeting to attend. Ah, meetings with the faculty. The frequent experience of sitting in a sweaty board room for hours with a crowd of sincere grandfather types, the plate of biscuits always just out of reach and their proposals always too sluggish to ever come into fruition. Our utopian ideas, chipped black nail polish and vociferous whinging provoked plenty of awkward silences and perplexed faces. The thing is, the faculty aren’t all bad. There’s Cahill: new programme director, all round Irish LAD and shiny beacon of hope. We liked him. But there were so many ‘broken record’ moments. Watching them scratch their heads repeatedly as the medical school slumped into the National Student Survey cesspit whilst we screeched about

feedback and pastoral care until we were positively cyanotic. The small victories – ‘Amazing, they’ve actually given the 4th years a full break down of their unit marks’ were all too often accompanied by set backs – ‘Oh… no wait... they still managed to balls it up.’ Of course, it wasn’t all doom and bureaucratic gloom. We quickly discovered there was a far more hedonistic and riotous side to being on the Galenicals committee. We were shocked. It all began with that initiations trip. What started as a polite Enid Blyton-esque outing to the seaside with ice cream and touch rugby quickly deteriorated into full on bollocksmashing beach nudity, forced mayo + beer + mustard consumption (thanks Jack) and Mr Stoneham terrorising the local boat owners. The night concluded with an epic slice of welfare / Black Bag four-way spooning in a muddy tent perfumed by the piquant odour of Jess’ beeriod. The welfairies had finally become fledgling medics.

September rolled in and we merrily welcomed the returning clinical years.* Then October arrived and with it, the freshers of ‘09, the nailbitingly good Spoof Lecture and the guilty pleasure of scaring them shitless (we felt those sweaty palms). It was then, as ‘Milky’ and ‘that Violin girl’, we stepped forward to take the freshers under our warm, welfairy wings. ** With unparalleled enthusiasm we implemented ‘Mums and Dads version 2009’: the overly ambitious idea of trying to match years 1, 2 and 4 by hobbies and interests. The consequence of this? Several long weekends in a dark room with a spreadsheet, hundreds of scraps of paper and a distinct lack of human interaction. We definitely knew far too much about hundreds of people we didn’t actually know. This became all too apparent on the medic’s bar crawl when I (that’s me, Jo - I can’t really tar Jess with the weirdo brush on this occasion) could proudly name the hometown and hobbies of any fresher that

crossed our boozy path. In hindsight, this was probably a little unnerving, yes? *** Ah, the bar crawl. Having been cruelly pennyed at 6.30pm (cheeky bloody freshers) we knew we were headed for the floor, face first. The experience of bran flakes making an unwelcome reappearance the following Monday morning whilst we perspired actual vodka made us feel, admittedly, a tad unprofessional. We were in 4th year, why were we suddenly so reckless? Where had this new enthusiasm for medicy-styled merriment come from? The thing is, when you surrender to your inner medic as late as we did (after all, we shunned it for so long), you need to make up for lost time. Suddenly we found ourselves running down Whiteladies Road dressed as a banana and a crayon, prancing around in our slinky knickers for CLICendales and trying to evade the pages of Black Bag. We dealt with the existential crisis of becoming the sort of irritating

goons who held focus groups with other medical schools to discuss ‘careers’ and ‘professionalism’, the sort of people who might go to Lounge twice in one week. So, as we reluctantly choked down our handover pints of beer/wine/detergent/ onions/saliva (probably) we also breathed a sigh of relief. Will we miss being on the Galenicals committee? Of course. Because beyond the socials, the agendas, the fancy dress, the meetings, the action points, the dirty pints, the focus groups, the queue jumps, the Cahill, the e-mails, the flirting, the fraternising, the feedback, the stripping, the committee camaraderie and the conferences, we did care, we promise. And now? Well, it’s time for us to retire to our caravan in Stokes Croft - back to our knitting, scone baking and dreams of a quiet, floral life in GP land. We’ll be around though. J. Davies & J. Hawksley

*As Clinical Welfare, Jess took particular delight in welcoming back the

finalists and, more recently, waving them off too. ** Jo interpreted Preclinical Welfare as an ALL encompassing role. *** We lament the fact that we never found the 1st year author of the piece of paper that cited ‘BOOZE, BIRDS, BANTER’ as his only interests. Anonymous LAD.

We welcome comments on any of the articles published (excluding complaints). Please address correspondence, including submissions, to The Editors at: blackbag2009@googlemail.com

Jack Wills Rep

Tiddlywinks Rep

Lizard Lounge Rep

Wine Stains Rep

Assorted Highlighters Rep

â&#x20AC;&#x2DC;It is with great pride that I present to you, Galenicals Committee, our long awaited and entirely indispensable 112th member: the new World of Warcraft Rep. â&#x20AC;&#x2122; F. McCurdie

The Black Bag: a 111 Year Legacy M

any are surprised to hear that the origins of The Black Bag magazine date back to 1899. Then a ‘proper’ journal, The Stethoscope, as it was called, featured mainly serious medical articles and appraisals of issues that affect the medical students of the then University College Bristol. Thankfully, The Stethoscope contained more light-hearted elements as well, including discussions about the best sisters to drink tea with on the wards (definitely still applicable today!). We know little of what happened to the journal until 1937, when it took its current name, The Black Bag, in the same year that the Galenicals Society was formed. Fully half of the magazine was made up of adverts for drugs, bookshops and medical equipment. It was certainly a long way

from political correctness, as this BB report on questions and answers, from a (fake) nursing exam shows: Examiner: Name three types

of haemorrhage, nurse. Nurse: Um, capillary... artillery and… venereal? The magazine was printed throughout World War Two, although editors were forced to abandon previous professional printing arrangements, instead printing a limited number of copies on postcardsized pages due to rationing. Life seems to have been rather more exciting (as well as more frightening and tragic) for medical students during ‘The War Years’. The three War Utility Black Bags from 1945 describe a world in which the Bristol Royal Infirmary was being run with a skeleton crew

The Black Bag Archive is now on display in the Dolphin House Bar as doctors were conscripted to battle. After the war, the professional feel of the journal was resumed. Many interesting articles which were topical at the time, such as the distribution of penicillin in the mid to late 1940s, are ever more fascinating today. Other articles of note include the construction of the medical school building in 1963 and a discussion about whether Bristol should begin water supply fluoridation. BB kept its tone of demure until editors of the Spring

1965 edition announced that â&#x20AC;&#x2DC;The stolid, reactionary image people had of BLACK DRAG has now, we cross ears, gone for good. You have something worth writing for.â&#x20AC;&#x2122; And to this day, that outlook is still true; we have yet to return to writing a serious journal. Instead, The Black Bag takes the role of an official document, satirically referencing the way we live as students during our journey though Bristol Medical School. Although a satirical tone links all BB editions since 1965, many aspects of the

journal have seen change. Long gone are the days when Guinness strategically targeted medical students with bespoke BB adverts. The Wills family also used to sponsor the magazine, in exchange for the printing of large, full-page Castella Pamatella Cigar adverts (see page 32)! Rivalling these, in terms of 21st century unacceptability, are pictures of medics in 1980 dressed as Robertson’s jam mascots. As well as BB being a permanent fixture of the

medical school, other ‘pieces of furniture’, so to speak, are serially referenced in historic issues. One of the first CLICendales posters can be found in the Easter 1995 edition. Pre-clinical and Clinical reviews are examined and culprits of ‘The Freshers Spoof Lecture’ fondly reflect on well orchestrated pranks. I hear you ask, how on earth do we know all of this? Well, for the past couple of months, a group of medics have been scanning in old

editions of BB held in the library, with the aim of making them accessible for you all to read on the Galenicals website. The Galenicals committee has also managed to secure funding to build a museum-style archive of old copies and printing stamps, which can be found in the seminar room of the Dolphin House Bar. There is little doubt that the quality of The Black Bag has fluctuated over the years, but nostalgically this matters very little. The levels of nudity

may have increased, and the serious case reports may have all but disappeared, but the magazine maintains its captivated medical audience. Most importantly, this antique institution still has the knack to inspire authors to celebrate our experiences at Bristol Medical School. S. Lindley & L. McKiernan

My PS3 SSC

uring my 4 week Student Selected Component earlier this year, I feel that I learnt many of the necessary skills required to become a less-than competent F1doctor. I decided early on that I would research the Playstation 3 games console for my project, and further narrowed this down by selecting the Call of Duty series as a topic of particular interest. The month-long attachment took me to a number of exotic and interesting locations, including the poppy fields of Afghanistan, the windy roof tops of New York skyscrapers and the decaying battlefields of World War Two. I was able to take away a number of points from my experience that will benefit my future practice and improve the standard of care my patients receive. For the bulk of the attachment, when I was not waiting idly in the online lobby, I was

able to work on practical skills such as improving my decision -making ability (Deathmatch, Ground War or Free-for-all?). I was able to practise team working over the intercom with ten year-old geeky Americans and improve my manual dexterity, for example tapping the L2 button quickly to throw a flash-bang to stun enemies. When asked to see a very sick patient, a careful and structured plan of assault should be carried out. Should I encounter very sick patients dressed in camouflage gear with M4A1 assault rifles, or Nazi zombies crawling through the windows of the BRI, I have learnt that the best course of action is to take the ABC approach:

A - Airway

- preferably sever with commando knife using Melee Attack.

B - Breathing

- Be sure to

use Ninja Pro so that you are quiet enough to hear nearby enemies breathing, as well as using Bullet Penetration to shoot claymore mines through the wall.

C - Circulation

- always aim for a head-shot for an instant kill. Alternatively the heart and chest will give maximal haemorrhage. Although my project was extremely enjoyable, my body did undertake a great deal of physical stress, undoubtedly due to the enormous levels of concentration and exertion required. I suffered medical problems throughout my journey along the PS3 network, most notably an uncomfortable episode of acute urinary retention due to the diuretic effects of a sedentary (sentry gun) lifestyle. My housemate also fell victim to a pilonidal sinus from spending too much time sitting on the sofa watching my research (play). Towards the end of the attachment I began to suffer

more degenerative changes, and was left with bilateral repetitive strain injuries to my thumbs, as well as trigger fingers in my other digits. I also noticed degeneration in my eye muscles from looking at a screen two metres away for over twelve hours a day. When the project was over, it was time for me to leave my quilted three-piece work station. It had been an emotional journey. Rehabilitation has been gruelling but I’m now happy to report that ten weeks in Yeovil has all but extinguished the memory of those heady days, controller in one hand, Domino’s pizza in the other. Even so, a pang of longing returns every time I walk past the TV remote. One day, perhaps in the wake of a divorce, I will return to the virtual world. For now, I’m just trying to pass Finals.

J. Cundell

Anatomy of a Firm

f you’re reading this you probably fall into one of a number of categories. You could be a 1st/2nd year medical student hungover, listening to someone ‘on the spectrum’ talking about the Krebs Cycle. To answer your questions: No, you will never need to know about it in the future and Yes, it does get better. You could be a poor unfortunate arts student who has just stumbled into the Medical School, God forbid. My words to you are ‘piss off’ and buy a map, us privileged few in here aren’t retards. Finally, you might well be my target audience; those of us experiencing clinical medicine and the joy of ‘firms’. The dictionary defines a firm as ‘a partnership of two or more persons’, aka the randoms you are stuck with in Yeovil to survive a particular unit of study. The most obvious differentiation is the number of female members. As a general rule, the more girls in a firm, the worse it is. That is fact and something no one can change. Generally if the number of girls is > half firm size, get ready for ten weeks of pain. Both girls and boys prefer to have more boys in a firm. Unfortunately, due to Bristol’s insane admission policy, this is unlikely to occur, with girls now making up 70% of intake. If you look around your firm and see lots of boys, be assured that someone will always be later than you, always

have done less work than you and is probably thinking or saying something even more stupid than you. The next obvious distinction is people in the firm who ‘get you’. Bear with me; I’m not turning into one of the panellists from Loose Women. By this, I mean people who are broadly on your wavelength. To explain it’s easier to give you some scenarios. For ease I will assume the person in the scenarios is an easygoing player with a good sense of humour.

1. The person taking your next tutorial is late and has cancelled. You have two hours until your next teaching. People on your wavelength are already deciding whether to just sack the whole day off, or get a newspaper and have an extended coffee break, possibly in the common room watching Jeremy Kyle. Those who don’t ‘get you’ will cry, run off and clerk or perform an autopsy or something equally keen.

You are in a tutorial, the girl sitting in front of you is sitting forward, exposing her arse crack and a cheeky g-string (red in case you were wondering). People who get you will instantly dare you to try and drop a pen in there or even better try and squeeze the words ‘red’, ‘ass’, ‘g-string’ or ‘crack’ into the next hour’s teaching. Whoever gets the most references will leave the tutorial with the ultimate prize, respect for having the best banter and being the best lad (or ladette). Those not on your wavelength will ignore this entirely or inform the girl that she is exposed. Having people on your wavelength will make your firm and unit more bearable. They provide moments of

escape and allow you to be comforted in the fact that although you know embarrassingly little, you at least have fun and are human. Next is more of a warning. Sexual politics. As a rule of thumb, never get involved with anyone on your firm. You will always regret it. The strip fluorescent lighting of the BRI burning your retinas will make anyone look attractive after enough time. If you do ‘interact’, the best you can look forward to is a number of weeks of awkward encounters and permanent jokes at your expense. Instead, I recommend heavy flirting with the occasional dose of physical contact. The right target can provide you with excuses for being late, clerkings to copy and notes to steal (that’s right, steal). N.B. If you are in an academy and single, ignore all the above. Take what you can get, man-up and take all banter in your stride. On the other hand, avoid being towed along or you’ll end up one of the biggest bitches in Friendsville. Finally, know your place. If people want to work hard and do really well, let them. Don’t get your red g-string in a twist. And one thing I really can’t stand is stereotypes. I think it’s best to list some here so you don’t believe them:    

 

Mature students work hard. Get over it and stay out of their way. Also don’t trust them. Girls have always done four times more work than they admit. Boys have either done twice as much work as they admit, or half as much. Do the reading before the tutorial and you will sound like a genius. The downside is people won’t trust you and think you’re a wanker. It’s always safer not to do it. Every firm has at least one Christian. Every firm has at least one slut.



  

There is a maximum of one state school educated person per firm, anymore and it would drag the whole firm down. There is always one person you will find more attractive everyday. Every firm has someone you suspect of being a paedo/rapist/autistic. If you’re still reading up to this point, you agree with everything I’ve said and promise not to sue.

I hope this arms you with the weapons you’ll need to survive clinical medicine. Unfortunately, there is no guarantee that you will ever get a good firm or a good placement. That’s life. If you blame God, and I do, why not engage the Christian in your firm in endless discussion about why bad things happen to good people. That’ll keep you entertained… P. Osborne

Sonnet 147 My love is as a fever, longing still For that which longer nurseth the disease, Feeding on that which doth preserve the ill, Th' uncertain sickly appetite to please: My reason, the physician to my love, Angry that his prescriptions are not kept, Hath left me, and I desperate now approve Desire is death, which physic did except. Past cure I am, now reason is past care, And frantic mad with ever more unrest; My thoughts and my discourse as madmen's are, At random from the truth vainly expressed: For I have sworn thee fair, and thought thee bright, Who art as black as hell, as dark as night. William Shakespeare 29

he definitive Elizabethan playwright William Shakespeare is equally famed for the lyric poetry of his sonnets. This example, which at number 147 brings up the rear of the opus that comprised 154 poems, is speculated to have been written about the poet’s mistress. Here, the author’s love for the woman is symbolised as a fever raging through his body. Logical reason, which he seems to have lost, is portrayed as the physician or a pharmaceutical remedy which could potentially cure his condition. The pyrexial nature of the metaphorical disease, and the allusions to mental instability and psychosis - ‘…frantic mad with ever more unrest’ – hint to an initial differential of sepsis. However, we can also identify the theme of mental illness; in the juxtaposition of the final couplet, what was wrongly thought to be ‘fair’ and ‘bright’ is in actual fact ‘black as hell,’ indicating a transient delusional state in which the boundaries of reality are so drastically warped as to invert perception. There is also an element of hunger to this disease, with its ‘sickly appetite’, ‘feeding’ on the sonnet’s subject: the mistress. The irrational desire to remain in the throes of the love-malady is well documented throughout the verse, introduced in the first line as a ‘longing’ for the mistress. The conflict between reason and desire highlights the disparity of heart and head, or body and mind, and emphasises the delusional state in which the author finds himself: contradicting his reason and denying a cure. Indeed, this sonnet examines one of the intrinsic paradoxes of human nature: the insatiable desire to do certain things which we know are bad for us. In a modern context, this could be applied to masochistic practices such as the compulsion to drink copious quantities of alcohol despite knowledge of its inevitably healthdamaging properties. Yet even four centuries since these words were written, we can identify with Shakespeare’s original subject matter: the acute mania of lust and its irresistible intoxication. H. O’Neill

White Lies A

s a youngster, my cousin looked uncannily like Bart Simpson’s friend, Millhouse. Short, bespectacled and with a face that gave the impression he was carrying the weight of the world on his shoulders; actually, the only time his life got stressful was when he was losing Championship Manager. When he was at Primary School, there was an assembly in which the pupils were specifically told not to swing on a new set of fire doors as they had already caused several injuries. With this in mind, my cousin went about his business as an average nine year old: writing about what he did at the weekend, trading Pokémon cards and swinging on fire doors… until he broke his finger. Rather than face being told off for swinging on the doors, when asked how he broke his finger, he claimed he had got it caught in the gap between the

bricks on the corridor walls. Essentially, he told a little white lie. He told the same white lie to his parents, including his father (my uncle) who was at the time a prominent member of the school’s PTA. He decided to bring the issue of the dangerous corridor walls to the next PTA meeting. After all… he was a caring father and the wall had broken his son’s finger (apparently). After much campaigning by my uncle and many of the other parents on the PTA who were also just as concerned about their children’s fingers, the school (which was in financial trouble at the time) filled in all of the gaps between all of the bricks in all of their corridors, at considerable cost. There was an article in the local newspaper about the event. My cousin was photographed and there was even a small plaque put in place commemorating what a fine

young man he was for making the school a much safer place. The whole time, my cousin had to maintain his now quite prominent white lie. I imagine the concerned look behind his Mickey Mouse glasses during this period of time was due to a lot more than his performance at Championship Manager. I also imagine that he was much more careful around fire doors for the rest

of his time at school. It was only when he was 18 that he told his father as well as the family the truth as to what actually happened to his finger. And the moral of the story is? Telling lies wonâ&#x20AC;&#x2122;t get you eaten by a wolf: it may, however, bankrupt your school. P. Barnes

H. Oâ&#x20AC;&#x2122;Neill

Educational_Crypticities_ Each set of pictures amounts to a medical condition. Answers in Coffee Break. example

ein

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On Reflection... M

ary was thirty five, intelligent, beautiful and desperate - for six months her work as a dental nurse had been disrupted by severe exertional palpitations. I met her in my practice for the first time a few days after her treadmill ECG and blood tests were reviewed in out-patients. Sheâ&#x20AC;&#x2122;d received reassurance that all was well. I too could find nothing amiss on couch examination but was perplexed by a sinus tachycardia of 140 after mild exertion. Mary was deeply concerned about what was happening in her body, but unlike her I was reassured by the cardiology report, though I did expedite an echo-

cardiogram. Two days later one of my partners called me at home with the news that Mary was dead. She had had a cardiac arrest and a later post mortem showed the cause to be a massive pulmonary embolism. Mary was terribly unlucky. Her symptoms were so prolonged and atypical of PE that every doctor who saw her was led off the scent. No haemoptysis, no chest pain, no obvious risk factors. Though I was not criticised by the coroner, and though paradoxically the family in their grief thought I was the only doctor to take her symptoms seriously, her death was the single most

upsetting event of my medical career. Why didn’t I check her oxygen saturation? Why didn’t I respond to the clearly ‘organic’ feel of her presentation with an urgent referral back to hospital? There are few occasions when a GP gets to save a life and it bites hard that I missed this one. This is one of those events for which our medical education leaves us ill prepared. And pretty much every doctor has a story to tell about a patient who died when they might have lived, of making a clinical error, of having to respond to an aggressive and litigious complaint. These events are, mercifully, rare but how we deal with them can have a disproportionate impact. For instance being sued may render a doctor unduly investigative or lacking in clinical confidence. In the case of Mary I was fortunate to be able to talk it through with my family and my partners who helped exorcise my guilt and get things in perspective. Thinking about these important things that happen,

attending to our emotional responses and learning lessons for the future – that is reflective practice. Though I enjoyed being a student I enjoyed medicine a lot more after qualification when important things seemed to happen on a regular basis, with me in the thick of it. A Black Bag-esque example. When I was a GP registrar a woman consulted with her young son. She was willowy and, I have to admit, pretty damn gorgeous, with an understated elegance, in clothing and accessories that seemed to have walked off the pages of Marie Claire. A couple of days later I was gobsmacked to received a hand-written letter in which she said she had found me very attractive and had intuited that I had felt the same about her and would I like to meet up? This brings up a very interesting point worthy of reflection by any student with blood in their veins. Unless there is something quite seriously wrong with you, you will find yourself sometimes attracted to

your patients, as they will to you. This is down to a simple matter of biology and is not in my book a moral issue whatsoever. The moral questions hang over where you go with it if it comes up and what, if anything, you do to provoke it. Observing myself over several years I have noted that when someone is suffering, the attraction element seems, blessedly, to go out the window. In the example above the woman was not sick and was not even technically a patient, hence I may have been a little over-friendly. I showed the letter to my GP trainer and my intrigued wife and of course wrote a friendly and carefully worded letter ‘letting her down gently’ as my trainer had recommended. I never saw her again. In reading Black Bag and attending pre-clinical and clinical reviews it is obvious that sex and sexual innuendo is bubbling up all over the place; but I wonder does the community value what I might call ‘sexual intelligence’ – the ability to experience and enjoy

one’s sexuality without harming self or others in the process (or getting mired in guilt)? Authentic talk of sexuality in the clinical context is virtually taboo. This is a pity because being comfortable with one’s own sexuality is the first step in being able to reach out to those far from comfortable with theirs. I am consistently surprised by how much sexual dysfunction there is out there and how candidly folk will talk about it if lent a sympathetic and unshockable ear. How to practice reflectively? There are many mirrors. When I was an SHO in the frantic world of A&E at St James’s Hospital, Leeds, I kept a note all the interesting things I learned, a journal I still dip into. For bigger issues, that involve emotions, talking certainly helps, as can the Arts. The Spring 2010 BB contains a triptych of Limericks by Sion Williams, decrying the placement of creative initiatives in the curriculum at the expense of core clinical learning. Sion is a diligent student with a reflective pedigree, having

been privileged to spend his intercalation year immersed in literary, historical and philosophical reflections on the medical enterprise. But his humour presents a false dichotomy. We think about what happened after the event, rarely during and never instead of getting on with the job. The www.outofourheads.net website contains nearly three hundred examples of works by students who have responded to clinical situations through the Arts. Type ‘Igwe’ to read and hear that famous rap about the plight of a single mum, ‘Caithness’ for an immaculate prose portrait of a tricky home visit, ‘touching’ for reflections on the power of professional touch or ‘David’ on the trials loving the unlovable. Reflection mustn’t replace action but it can inspire it. When I was a junior doctor it bugged me that recently anginal patients had to

traipse through the hospital following signs for ‘cardiac stress test’ and campaigned for rebranding the clinic ‘heart fitness assessment’. Type ‘snowman’ to find out what Thomas Scharzgruber did for a hospice patient. The Foundation Programme folk are moving toward the idea of students completing their MTAS forms in exam conditions. Contrary to Sion’s view, the curriculum provides us with few opportunities to hone our thinking on the deeper, ambiguous and paradoxical aspects of medical life. If you can’t imagine yourself writing responses to ten scenarios such as ‘tell us about the last time you faced an ethical dilemma in the ward environment?’ then you may get time to reflect whilst on call in Scunthorpe. Dr T. Thompson

Kidney Flower H. Nazri

From www.outofourheads.net, a collection of creative works by Bristol Medics

Educational Crypticities answers: 1) Unipolar Mania (UNI + POLAR + MANE + EAR); 2) Renal Cell Carcinoma (REN + AL + CAR + SIN + O + MAN - N); 3) Obesity (O + BEE + CITY)

Pills of Wisdom

Bedside Banter Doctor: You’re in good health,

‘Did God who gave us flowers and trees, Also provide the allergies?’

E. Y. Harburg A doctor must work eighteen hours a day and seven days a week. If you cannot console yourself to this, get out of the profession.

Martin H. Fischer ‘Nothing is more fatal to health than over care of it.’

Benjamin Franklin ‘The art of medicine cannot be inherited, nor can it be copied from books.’

Paracelsus Failure to examine the throat is a glaring sin of omission, especially in children. One finger in the throat and one in the rectum makes a good diagnostician.

William Osler

you’ll live to be 80.

Patient: But I’m 80 right now. Doctor: See, what did I tell you.

***** ‘Doctor Doctor, I think I’m God.’ ‘How did that start?’ ‘In the beginning, there was darkness...’

Willy’s Cryptic Conundrum

First correct answers to wm5583@bris.ac.uk to win a bottle of wine!

Across

Down

1. An Italian red wine with iodine in it could calm you down. (10) 4. Protein shakes a mouldy Infiltration. (7) 6. A backwards pair of fish might shock. One mixed papa could cause fatties to turn blue while dreaming. (5,6) 7. A damn poet turned Kussmaul in his grave. (9) 8 & 9 Down. A timely vasculitis might rustle up a rite stir. (8, 7) 10. White blood cells stuck at the Longmont Emergency Unit priced between a sibling. (11) 12. A drink at this bar might give you a fit. (8) 14. First do no harm or swear not to caper. Shit op reassessed by physician. (11) 17. The fine Alps reveal how long you will live. (8) 20. Dirty Shit! Orbiting Jupiter’s moon might leave these women fat and constipated. (11) 21. Aerobatic lice make me piss razor blades if they’ve crept out of my gut. (1, 4, 8) 21. Improving stamina earns the ability to catalyse reactions (12)

1. A six pack stops short as it is filled with Staphylococci. (7) 2. Is 1 lite enough to illuminate this small abdominal problem? (7) 3. A pod belongs to me and stops me producing milk? (8) 4. Smarten the cole nicely so it is well received by strong smokers? (13) 5. Has trouble to articulate a pseudobulbar palsy. (10) 9. (See 8 across) 11. It takes less than 2 seconds for the ref to get stuck in his sick hat. (3,6) 13. Abscise, try not to pick at this burrowing infestation! (7) 15. My Heater will turn you red. (7) 16. Bra use without ecstasy might stiffen your joint. (5) 18. Can I mix in? I’m a good honey making nutrient. (6) 19. Two heads can point you to the beach. (6)

Book Reviews Oxford Handbook of Clinical Medicine (8th Edition), Oxford Further superlatives regarding this text are unnecessary; if you are a medical student in any year of study and you do not own it, buy it. More pertinent is whether those of us who have a copy of the nearflawless 7th edition should bother upgrading to the 8th. Of course, there is the obligatory minor overhaul of colour-scheme — the orange boxes are now blue — but the changes are far from superficial. The new edition is narrower (good for pockets) and the colour-coded chapters stand out more than those of the 7th. There is a dedicated history and examination chapter that distinctly outshines the snippets included in the 7th. One notices that nearly all pictures larger, especially the chest radiographs. Many of the black and white images are now full colour and there are new prints throughout. If your wallet is tight for cash, your dog-eared 7th edition will do just fine, but it is certainly worth investing in this new and, dare we say, improved copy. Macleod’s Clinical Examination (12th Edition), Elsevier Another indispensible guide that has recently undergone the upgrade. Another student ‘classic’ that simply isn’t worth doing without. The new colour scheme is more sombre in tone than the rainbow 11th edition; while this does neaten things up, this editor laments the easily recognisable ‘blue’ respiratory or ‘red’ cardiovascular chapters of edition 11. The textboxes, tables and figures are more detailed but new icons make things feel a little overcrowded. Positives? Existing images are sharper and there are a spattering of new ones improves the overall aesthetic. Plus points for the expanded introductory chapters: skin, endocrine and visual systems are now independent sections, no longer a lazy lump-’em-together is in the 11th. The best addition is the DVD containing videos of each individual examination, useful for OSCE and OSLER practice.

since 1937; free to those who can afford it.