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Secret Diary Of a cardiology SpR
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Collagen corpses The trade in human tissues
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When doctors are expected to kill
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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.
The NHS cannot treat people without doctors
Editor Ashley McKimm SHO Addiction Psychiatry
editor@juniordr.com Editorial Team Mareeni Raymond London
Michelle Connolly London
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Thanks to Andro Monzon, Rhys Ball, Rhona Atkin, Mun Hong Cheang
Ashley McKimm Editor SHO Addiction Psychiatry, London
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Listen up Professors Crockard and Heard who head the MMC Bevan, the hero of the NHS, offered some advice during the failure of the other great British powerhouse - pay attention to the workers. Just like the miners, banding changes have starved us with paycuts, we’ve been forced to adopt inflexible nightshift patterns and the intensity of work has worsened along with morale. MMC is widely regarded as sensible and essential by junior doctors. We’re not disputing the need for change. We are however vehmently opposed to how it hasbeing implemented. The lack of consultation, sparsity of information and the speed at
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Health warning JuniorDr 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) too. Check out juniordr.com/joinus.
Editorial “The Government has tried everything to solve the problem of the coal industry - semi-starvation, imprisonment, extortion, threats, the supplication of the miner's leaders, and what is the almost omnipotence of Churchill’s oratory. All have failed. The one truth the Government has not yet learned is ... you can get coal without the coal owners, but you can’t get coal without miners.” Aneurin Bevan, Health Minister (1945), widely credited with the formation of the NHS.
Triage
JuniorDr
which MMC has been steamrolled has sent many junior doctors into a ill-informed panic. Fearful of unemployment and being forced to move away from family and friends it’s an unacceptable way to treat ‘partners in healthcare’
“Doctors can contin-
ue to treat people without the NHS, but the NHS can’t treat the people without it’s doctors.” Morale is rock bottom among junior doctors - not just about our jobs but about the future of the NHS. We continue to agree that changes need to be made but it is essential to balance that with taking care of the workforce. Failure of MMC will produce thousands of disillusioned doctors. Many are already planning to quit if they get posted to far-flung parts of the country. Instead our doctors will work in the city travel to Australia. Can we really afford to lose them? Before the national provision of health in the UK does finally collapse maybe it’s time to take heed from Bevan ... doctors can continue to treat people without the NHS, but the NHS cannot treat the people without it’s doctors.
> What’s on the inside When doctors are expected to kill The role of doctors in administering lethal injections on death row. Page 10
The Secret Diary of a Cardiology SpR Page 19
Latest News Page 4
Medicinema The new ‘blockbuster’ prescription Page 14
Collagen corpses The trade in human tissues. Page 17
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JuniorDr The Pulse
News Pulse Tell us your news. Email the team at newsdesk@juniordr.com or call us on 020 7684 2343.
Working Conditions
Clinical disruption feared as MMC recruitment nears > MMC Timetable
> Your viewpoints
“It takes away people’s flexibility in job hunting but does make the whole process more efficient.” Kent Yip SHO Medicine Addenbrooke's Hospital, Cambridge
LONDON 9am on Monday 22nd starts the formal application process for Modernising Medical Careers - the UK’s largest ever junior doctor recruitment and training restructuring program. Over two weeks junior doctors are expected to compete for around 20,000 specialist training posts nationally with applications accepted solely online. A rapid interview process for each speciality over a few days then follows during two rounds of elimination. Widespread disruption
“SHO training needed input - although MMC had promise in concept, it was appalling in execution.” Nathan Borgeaud SHO Anaesthetics Homerton Hospital, London
On average three candidates are expected to be interviewed for every two posts. The absence of both interviewees and senior interviewers from clinical duties have drawn fears of how hospitals will cope. “The number of consultants involved in the process will be considerable,” said David Pring, York consultant in obstetrics and gynaecology. “At the same time, juniors will be trotting around the country being interviewed. The service impact will be huge.”
'Far from Perfect' Modernising Medical Careers has been greeted with widespread panic by junior doctors many of whom feel alienated from the system and fearful of unemployment. The BMA, who campaigned for the process to be delayed by a year, believes the process is ‘far from perfect’ but admits some progress has been made since its conception. “Pressure from the BMA has resulted in vital improvements. For example, knowledge tests - which would have had no basis in evidence - have been dropped from the process,” says Dr Jo Hilborne, chairman of the BMA Junior Doctors’ Committee. “The number of posts doctors can apply for has increased from two to four and the number of overall posts available has been hugely expanded. Doctors will now be asked to rank their four choices in order of preference, which will improve their chance of getting the post they want, and they will be able to submit ‘linked’ applications for posts with partners.”
22 January 2007 Round 1: Opening date for applications 4 February 2007 Round 1: Closing date for applications 5 - 23 February 2007 Applicants (except GPs) offered interviews if they have been short-listed 24 February 2007 GP stage one selection day Early March 2007 GP candidates notified of the outcome of stage one selection 28 February - 13 April 2007 Interviews take place 19 April 2007 Programme offers made to successful applicants 27 April 2007 FTSTAs offered to successful applicants 28 April 2007 Unfilled programme vacancies re-advertised 28 April 2007 Round 2: Opening date for applications 2 May 2007 Unfilled FTSTAs re-advertised 11 May 2007 Round 2: Closing date for applications 14 May - 27 May 2007 Local panels short-list applications 29 May 2007 Applicants offered interviews if they have been short-listed 4 June - 22 June 2007 Interviews take place 23 June 2007 Offers made to successful applicants 23-26 June 2007 Applicants accept/reject offers Reproduced courtesy MMC
JuniorDr Intelligent children may be more likely to be vegetarian as adults, a study published in the BMJ suggests. Raised IQ was found to be statistically significant after adjusting for better education and higher occupational social class. It may also help to explain why children who score higher on intelligence tests tend to have a lower risk of coronary heart disease in later life. http://bmj.bmjjournals.com/cgi/rapidpdf/bmj. 39030.675069.55
Alternative prescriptions Sixty percent of doctors’ surgeries in Scotland prescribe homeopathic or herbal remedies, according to a study of nearly two million patients published in the British Journal of Clinical Pharmacology. The findings have led to a call for a critical review of prescribing in the NHS and to the high levels given to babies and children. http://www.blackwellpublishing.com/bjcp
Heart of hearing A new stethoscope that enables doctors to hear heart sounds in extremely loud situations, such as transporting soldiers in helicopters, has been unveiled in Alabama, USA. The device which uses ultrasound technology enables accurate readings at noise levels up to 120 decibels - similar to that experienced at the front row of a rock concert. It is expected to cost up to £400 when released.
Don’t to bed alone Going to bed lonely can trigger elevated early morning cortisol levels, according to a study by Northwestern University. The hormone, which is linked to depression and obesity when chronically raised, was studied in 156 adults who recorded their ‘loneliness’ feelings the previous evening in diaries. http://www.northwestern.edu
Stay sleepy and safe Feeling tired? Contrary to popular belief you may be less likely to get hurt according to a study published in the Journal of the American Board of Family Medicine. In the study of 2,500 patients those who had slept less than normal in the last 24 hours were found to be at higher risk of injury. The authors suggest that it may be that people change their behaviour when sleepy. http://www.jabfm.org
Working Conditions
Shift rotas linked to risk of traffic accidents LONDON Sixteen percent of specialist medical registrars have been involved in a road traffic accident while commuting to or from work according to a recent survey by the Royal College of Physicians. The study of over 1,600 specialist medical registrars found that 264 of them had been involved in road traffic accidents. Roughly half of those were returning from a shift at work - with these doctors working one night in ten it makes the return from night shift significantly more risky. Nearly half of specialists registrars work seven nights in a row the shift pattern with the highest risk of tiredness and mistakes. “Half of the Specialist Registrars involved in acute medical care are working seven con-
secutive nights, the majority with 13-hour shifts, resulting in a 91hour week!” said Dr Bob Coward, RCP Specialist Registrar Adviser. “It is no surprise therefore that 86 per cent were tired at work with 20 per cent considering switching to a non-acute speciality and a further 15 percent to general practice.” Following the introduction of the European Working Time Directive (EWTD), junior doctors are allowed to work no more than 56 hours per week on average. In 2009 this will be further reduced to 48 hours. While the EWTD was implemented with the intention to improve working conditions many junior doctors are now suffering from poorly designed rotas. The RCP recently recommended a rota with three nine hour shifts to provide 24 hour cover, as opposed to the two thirteen hour
The Pulse
Brainy broccoli
shifts currently used. It is hoped that this change will improve the quality of patient care and reduce the probability of accidents in and outside the hospital. Rachel Brown
Patient Care
A&E departments struggle to cope with pressures LONDON A&E Departments are struggling to sustain the four-hour access target because of a shortage of beds, according to a survey by the BMA and British Association for Emergency Medicine. Just over half (54 percent) of respondents believe the four-hour target is met by their hospital despite official figures setting a 98 per cent target. A third claimed data manipulation was used in order to meet these access targets. Over 500 medical staff of all grades were surveyed. Almost nine out of ten (87 percent) of respondents reported a shortage of available beds as the main reason for not meeting the target. “The report finds that doctors and other staff are working exceptionally hard and putting in extra hours to meet access targets. Working towards the four-hour target on A&E waiting times has been
a fantastic achievement, it has proved good news for patients and the extremely long waits seen in the last decade are now very rare,” said Mr Don MacKechnie, Chairman of the BMA’s Emergency Medicine Committee . “However respondents tell us that despite this success, the level of performance in many departments is proving unsustainable and these departments are finding it difficult to cope on a daily basis.” Respondents were also asked if there were any clinical concerns arising from efforts to meet the access target. Two-thirds (66 percent) of respondents said that some patients may be moved to inappropriate areas or wards and over half (58 percent) reported that patients may be discharged from A&E before they had been adequately assessed or stabilised. Mun Hong Cheang
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JuniorDr The NHS
The Pulse
Docs still the most trusted profession LONDON Doctors continue to top the poll of professionals that the public trust the most, according to the latest annual survey commissioned by the Royal College of Physicians. Ipsos MORI polled over 2,000 people as to whether they trusted different professions to tell the truth. 92 percent of the public stated that they trusted doctors, closely followed by teachers at 88 percent. Only one in five trusted politicians and government ministers, however it was journalists who ranked lowest with just 19 per cent saying they trusted what they read. “I am delighted that once again the public have voted doctors the most trusted professional,” said Professor Ian Gilmore, President of the Royal College of Physicians. “This fits with the work that we have been doing on medical professionalism ‘Doctors in Society’, redefining the doctor/patient relationship in a changing world. With patients
Bleak future
having access to an increasing range of health facts and figures about their health, it is reassuring to know that the doctor/patient relationship is still highly valued.” Doctors have consistently topped the list of most trusted professions in virtually every year since 1983 when the poll began. Hayley McKenzie
“This fits with the work that we have been doing on medical professionalism.” Professor Ian Gilmore President Royal College of Physicians
Sports doc shortage for 2012 Olympics
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Adults living with children eat more saturated fat - the equivalent of nearly an entire small pepperoni pizza each week - than adults who do not live with children, according to research published in the Journal of the American Board of Family Medicine. Compared to adults living without children, adults living with children ate an additional 4.9 grams of fat daily, including 1.7 grams of saturated fat. http://www.jabfm.org
The NHS
LONDON There are insufficient numbers of sports doctors to support the 2012 Olympics in London, according to a report by the Royal College of Physicians. Only three doctors in the UK hold a place on the Specialist Register in Sport and Exercise Medicine - a number which needs to increase ten-fold according to Professor Charles Galasko, Chairman of the Intercollegiate Academic Board for Sport and Academic Medicine (IABSEM). In addition he believes that each PCT should eventually have its own Sports Medicine Specialist. The lack of specialist
Parents get peckish
doctors also has implications for the drive to combat rising obesity levels and to improve the health of the nation says Galasko. The warning came at the launch of a new intercollegiate Faculty of Sport and Exercise Medicine. Professor Ian Gilmore, President of the Royal College of Physicians said, “The work of this specialty will be of wide national relevance in light of the prevalence of obesity in the UK. Increasing numbers of people will require professional guidance in order to exercise effectively to prevent or combat obesity.” Helen Richards
Latest calculations by the WHO and Harvard University suggest that overall life expectancy by 2030 will have increased. Deaths from heart disease and cancer will increase as will HIV/AIDS deaths, however those dying from infectious diseases will decrease. 50 per cent more people are also predicted to die of tobacco-related disease than of HIV/AIDS in 2015. By 2030, the three leading causes of illness are predicted to be HIV/AIDS, depression and ischaemic heart disease. http://dx.doi.org/10.1371/journal.pmed.0030512
Up in smoke The government is to raise the legal minimum age to purchase tobacco from 16 to 18 years from 1st October 2007. It will come soon after the introduction of smoke free public places and workplaces on 1 July. The move will bring England and Wales into line with laws in Canada, Australia, New Zealand and the US. http://www.dh.gov.uk
Poor and accident prone Lansoprazole, the compound found in common antacids, could also be used to fight oral bacteria linked with gum disease, researchers at the University of Rochester Medical Center and Goteborg University in Sweden have found. When the mouth becomes acidic - a sign of bacteria at work - lansoprazole kicks in disabling the bacteria F. nucleatum which produces a toxin allowing other bacteria to attach to the tooth surface and cause decay. If further trials are successful they hope to incorporate similar compounds into toothpastes and mouthwashes http://www.rochester.emu
Journal Review Shock number of sudden unexplained cardiac deaths LONDON More than 500 sudden unexplained deaths occur each year in England - around eight times more than previously thought according to the study published in the journal Heart. Cases from 117 coroners across England between 1997 and 1999 were assessed by an expert to eliminate other identifiable causes of death. The results show that only around a third of cases of SADS (sudden adult death syndrome) were correctly identified.
SADS cases tended to be young with an average age of 32. Almost two-thirds (63 percent) were male. Furthermore, almost one in five (18 percent) had a family history of sudden unexplained deaths before the age of 45. They noted that although only a small number had reported cardiac symptoms in the previous 48 hours, nearly two-thirds had experienced cardiac symptoms at some point in the past. The authors conclude that SADS should be a certifiable cause of death, which should prompt automatic screening of other family members. Sudden adult death syndrome and other non-ischaemic causes of sudden cardiac death. Heart 2006 92: 316-320
The Pulse
JuniorDr
Circumcision reduces HIV risk, study stopped early CHICAGO A study by the University of Illinois has been stopped early due to preliminary results indicating that medical circumcision of men reduces their risk of acquiring HIV during heterosexual intercourse by 53 percent. The study’s independent Data Safety and Monitoring Board met on December 12 and halted the trial recommending that all men enrolled in the study be offered circumcision. Study results show that 22 of the 1,393 circumcised men in the study contracted HIV compared to 47 of the 1,391 uncircumcised men - 53 percent fewer infections. “Circumcision is now a proven, effective prevention strategy to reduce HIV infection in
men,” said Robert Bailey, professor of epidemiology in the UIC School of Public Health. The clinical trial enrolled 2,784 HIV negative, uncircumcised men between 18 and 24 years old in Kisumu, Kenya. Until now public health organisations have not supported circumcision as a method of HIV prevention due to a lack of randomised controlled trials. Opponents of circumcision had speculated that circumcised men may feel they are not at risk of contracting HIV and may be more likely to engage in risky behaviour, something which the Kenya study disproves says Bailey. www.uic.emu
“Circumcision is now a proven, effective prevention strategy to reduce HIV infection in men.” Robert Bailey Professor of Epidemiology UIC School of Public Health
Ecstasy can harm brains of first-time users CHICAGO Even a small amount of MDMA, the psychoactive compound in ecstasy, can be harmful to the brain according to findings presented at the annual meeting of the Radiological Society of North America. The researchers examined 188 volunteers with no history of ecstasy use but at high-risk for firsttime ecstasy use in the near future. After 18 months the volunteers were re-assessed and 59 had been found to have taken on average 6 tablets. They found that low doses of ecstasy did not severely damage the serotonergic neurons or affect
mood. However, there were indications of subtle changes in cell architecture and decreased blood flow in some brain regions, suggesting prolonged effects from the drug, including some cell damage. In addition, the results showed a decrease in verbal memory performance among low-dose ecstasy users compared to non-users. “We do not know if these effects are transient or permanent,” said Dr. de Win, radiological resident. “Therefore we cannot conclude that ecstasy, even in small doses, is safe for the brain, and people should be informed of this risk” www.RSNA.org/press06
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Medical conditions from the journals you just won’t believe! Nuns knee Swelling of the kneecap from repeated kneeling in prayer. (Diseases of occupations, 1975)
Ice-cream frostbite Frostbite on the lips from prolonged contact with ice-cream. (New England Medical Journal, 1982)
Alopecia Walkmania Loss of hair from prolonged use of personal stereo headphones. (Journal of the American Medical Association, 1984)
Hookers Elbow Painful shoulder swelling suffered by fisherman repeatedly jerking upwards on a fishing line. (New England Journal of Medicine, 1981)
Jean folliculitis Irritation of the hair follicles from the waist down to the knees caused by ultra-tight jeans. (New England Medical Journal, 1981)
Label lickers tongue Ulcers in the mouth from sensitivity to licking sticky labels. (Journal of Dangerous Trades, 1902)
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Flip flop dermatitis Skin disease on the feet from wearing flipflops. (BMA Journal, 1965)
Chicken neck wringers finger Partial dislocation and arthritis of the middle finger joint from continued use of this finger to dislocate chickens necks for slaughtering. (BMJ, 1955)
Dog walkers elbow Pain caused by constant tension and tugs from a dog leash. (New England Journal of Medicine, 1979)
Toilet seat folliculitis Skin irritation from spending too much time on the toilet. (Archive of Dermatology, 1933)
Beer drinkers finger Swelling, bluish discolouration and wasting of the finger caused by placing pop-top beer can rings on the finger. (Journal of the American Medical Association, 1968)
Credit carditis Pain over the rear and down the thigh due to pressure on nerve from a wallet stuffed with credit cards. (New England Journal of Medicine, 1966)
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JuniorDr Features
When do are expe At exactly 11pm on the 21st September 2006 forty-eight year old Clarence Hill was strapped to the table at Starke Prison, Florida. The warden gave the signal and a cocktail of lethal drugs was pumped into his veins. At 11.12pm the ECG flatlined and Hill was pronounced dead. Hill’s execution went ahead despite his lawyers arguing that the lethal injection is inhumane. Many doctors in California agree and believe the method of lethal injection, supposedly painfree, does cause the condemned pain and should be banned. September marked a turning point in the debate when the execution of a Californian inmate was postponed indefinitely after the doctors refused to participate. They became opposed after a judge’s ruling stated that doctors would have to physically intervene if the condemned person appeared to be in pain. Doctors would therefore have been expected to tell prison officials whether the prisoner needed more sedation, or possibly even to administer more drugs. “Any such intervention would be medically unethical,” the anaesthetists replied in a statement. “As a result, we have withdrawn from participation.” Lethal injections were suspended as a result. Michelle Connolly looks at the role of for JuniorDr. What’s legal? Lethal injection under United States federal law states that ‘the punishment of death must be inflicted by continuous, intravenous administration of a lethal quantity of an ultrashort-acting barbiturate in combination with a chemical paralytic agent until death is pronounced by a licensed physician according to accepted standards of medical practice.’ In it’s simplicity lethal injection simulates a medical procedure - the
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intravenous induction of general anaesthesia. The procedure Once the prisoner has been strapped to the table the arm is swabbed with alcohol. Two 14gauge catheters, the largest commercially available, are inserted, one in each arm. The second is a backup, in case the primary IV. fails. Both catheters are flushed with heparin to prevent clots forming inside. All condemned prisoners are given the opportunity to make any final statement they wish, and then, on the warden’s signal the drugs are administered. Sodium thiopental (at 14 times the normal dose) is used to induce anaesthesia, pancuronium bromide is the substance used to paralyse the respiratory muscles and potassium chloride is administered to induce ventricular fibrillation. Even without inducing VF death would still follow by
“Even more surprising was that in 43 percent of cases in those four states levels were consistent with consciousness.”
JuniorDr Features
octors ected to kill - administering a lethal injection ‘Inhumane execution’
> Starke Prison, Florida Execution Room Picture: Florida Department of Corrections
The claim of the lethal injection being the most humane form of capital punishment, is disputed by many. Leonidas Koniaris, professor of surgical oncology at the University of Miami, Florida, writing in The Lancet, suggests evidence that judicial execution by these means is not as humane as death penalty proponents have claimed. Researchers obtained postmortem toxicology reports from four of the 36 states killing prisoners via lethal injection. The results indicated that levels of sodium thiopental were lower than those required for surgical anaesthesia. Even more surprising was that in 43 percent of cases levels were consistent with consciousness. Determining consciousness levels in prisoners who are paralysed and who will not be resuscitated is both difficult and debatable. This lack of certainty has however prompted the American Veterinary Medical Association to ban the use of neuromuscular blocking agents, such as pancuronium bromide, when putting animals to sleep. The involvement of doctors
asphyxiation. Death typically takes 8-10 minutes and is pronounced on asystole. A coroner then signs the death certificate and the procedure is complete. With the IV lines, a cardiac monitor and a medical doctor on standby the execution room is not
dissimilar from an acute medical ward. The direct telephone line to the Department of Justice in Washington is perhaps the only giveaway - the President is the sole authority able to grant lastminute clemency.
The involvement of doctors varies considerably with 35 of the 38 death penalty states that rely on lethal injection allowing doctors to participate, and 17 states requiring it. Participating doctors are required to ensure that the Eighth Amendment of the US
> Starke Prison, Florida Death Row Cells A Death Row cell is 6x9x9.5 feet high. Florida State Prison also has Death Watch cells to incarcerate inmates awaiting execution after the Governor signs a death warrant for them. A Death Watch cell is 12x7x8.5 feet high. Last Meal Prior to execution, an inmate may request a last meal. To avoid extravagance, the food to prepare the last meal must cost no more than $40 and must be purchased locally. Contact When a death warrant is signed the inmate is put under Death Watch status and is allowed a legal and social phone call. While on Death Watch, inmates may have radios and televisions positioned outside their cell bars. Florida Department of Corrections
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JuniorDr Features
Constitution, which prohibits ‘cruel and unusual punishment’ is upheld. It was a doctor who pushed the syringe in Illinois's first lethal injection execution and in Nevada, doctors are required to examine the condemned for good venous access and to prescribe the fatal drugs. Some states, such as Illinois and South Dakota, have attempted to de-medicalise the death penalty with laws decreeing that the assistance of death does not constitute medical practice. South Dakota’s death penalty statute states that “any infliction of the penalty of death … may not be construed to be the practice of medicine.”
“The worst toxicology reports were obtained from states that employed teams qualified only at technician level.”
The argument for medical involvement Despite the reluctance of medical professionals to involve themselves many feel their presence is essential for the welfare of the prisoner. Each step of the execution procedure from the dosing of fatal drugs to the pronouncement of death ideally requires a medical practitioner.
Where doctors are unavailable these tasks are performed by trained ‘technicians’ but as Koniaris and his team point out the worst toxicology reports were obtained from states that employed teams qualified only at technician level. Death row inmates often have poor vascular access as a result of intravenous drug use or obesity and it is here that the skills of doctors are particularly useful. In Georgia one of the three doctors present in the execution chamber during procedures is an expert in vascular access. Many also use the argument view that healthcare personnel transform the executions from a terrifying to peaceful environment alleviating pain or giving the illusion that pain is being alleviated.
The president of Georgia’s medical school, in a letter to the prison warden, condemned the involvement of doctors saying their presence in the chamber ‘compromised their relationship with the inmate population.’
The argument against
The American Medical Association (AMA) specifically condemns the involvement of doctors in state-sanctioned executions. It cites eight acts constituting direct involvement: 1. Administering lethal drugs 2. Maintaining injection devices 3. Supervising technicians 4. Prescribing lethal drugs 5. Selecting intravenous access sites 6. Inserting IV lines 7. Monitoring vitals 8. Pronouncing the prisoner dead
Firstly doctors argue that they were not asked whether they agreed with the medicalisation of the death penalty prior to its reintroduction in 1976. Many doctors oppose the execution process on ethical grounds.
More significantly in June 2006, the American Society of Anaesthesiologists sent letters to its 40,000 members urging them to ‘steer clear of any participation in execution.’
One anaesthetist One doctor
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Choosing to participate Despite what appears as widespread reluctance by the medical profession to participate in lethal injections many doctors are still willing to assist in state execution. An American Medical Association survey found that 19 percent would inject lethal drugs and 41 percent said they would perform at least one of the eight acts (see table)2. Many individuals balance their clinical responsibility against their duties to society and agreed to their involvement. Many also wanted to provide a ‘painless’' death and were concerned with the expertise of the technician-level
staff. In a case that caused particular furore among the medical profession, the governor of Kentucky, who is a doctor, signed the death warrant of a prisoner with an IQ of 74. Executive counsel John Roach said Dr Fletcher did not violate the American Medical Association guidelines and that in signing a death warrant, he is in ‘no way participating in the conduct of an execution’. Doctors still refuse to be present in the execution room in California. Their role in administering lethal injections across the United States is still uncertain - but executions continue in the other states.
> References Koniaris LG, Zimmers TA, Lubarsky DA and Sheldon JP (2005). Inadequate anaesthesia in lethal injection for execution. The Lancet. 365: 1412-1414. Groner JI (2002). Lethal injection: a stain on the face of medicine. BMJ 325: 1026-1028. Farber NJ, Aboff BM, Weiner J, Davis EB, Boyer EG, Ubel PA (2001). Physicians' willingness to participate in the process of lethal injection for capital punishment. Ann Intern Med. 135: 884888.
History of the lethal injection Lethal injection was first considered in 1888 by a New York doctor writing in the journal Medico-Legal. Initially this was not for humane reasons but to rob the prisoner of the hero status which was attached to hanging. He suggested the injection of 6g of morphine. The idea didn’t catch on and New York state introduced the electric chair instead. In the UK the British Royal Commission on Capital Punishment looked into lethal injection back in the 1950s but following pressure from the BMA decided against it. Lethal injection in its modern form was the brainchild of Stanley Deutsch, an anaesthesiologist at the University of Oklahoma. In response to the state senator’s 1977 request for a cheaper alternative to repairing the dilapidated oak electric chair, Dr Deutsch recommended barbiturate as a ‘rapid, pleasant way to bring about unconsciousness’ followed by a muscle relaxant to bring about an ‘extremely humane’ death. Texas became the pioneering state for lethal injection as a form of capital punishment. It was doctors who watched as the drugs were pumped into the veins of a 40 year old African-American. He was dead within minutes and the procedure was deemed a success. Since then over over 700 men and women have been executed by lethal injection in the USA alone.
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Missouri officials then sent nearly 300 letters to anaesthetists in the state and in Illinois to ascertain their ‘willingness to participate in execution’. To date not a single recipient has said they would so it seems the Society’s call is being heard. In a further development the following month North Carolina’s state medical board banned doctors from participating in state executions.
JuniorDr Features
Medicinema Big screen therapy For many patients staying in hospital can be a traumatic experience for a few it’s not far off a personal horror movie. Medicinema is a charity that aims to change that bringing therapy via the big screen and changing that horror movie hospital experience into a comedy, romance or in fact any genre of the patients choosing. Shrabani Talukder tells us more. The idea behind MediCinema is extremely simple - install cinemas in hospitals for the sole purpose and enjoyment of the patients. It offers everyone from children visiting ill parents to elderly patients recovering from hip replacements the opportunity for a ‘night out’ at the movies where they are able to watch the latest blockbusters. Each Medicinema shows a wide variety of film genres from big action flicks to comedy - perfect for those who believe laughter is truly the best medicine. The team behind MediCinema recognise the escapist qualities of films and catching a movie in each state of the art cinema can offer patients a welcome relief from what can often be a tedious time in hospital. Medicinema also allows families of the patients to visit the cinema which can give family and friends something to really look forward to. The idea The idea for Medicinema was first devised by Christine Hill MBE at St. Thomas’ Hospital, in London - an idea which came to her while watching patients on a welcome break from the wards. “One hot day I was watching patients being wheeled to the river to watch the boats on the Thames when I noticed how like a cinema screen it was. I thought this was great when it was hot but when it rained there was nothing for the patients to do,” she explained. “I thought of an on-site cinema but with the idea of not having the screen in the wards but away from the medical environment with nurses instead of ushers so that the patients would feel secure in the knowledge that they would still have medical help on hand.”
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Supporters As you might expect each Medicinema isn’t funded by the NHS. MediCinema gets invaluable support from all the film distributors and The Walt Disney Company as well as being the nominated charity of the cinema chain Vue. MediCinema has also been named as the film industry’s charity by BAFTA. Numerous patrons such as Dame Helen Mirren, Ewan McGregor and Kate Winslet also add the glamour of the silver screen. Charity Support Officer for Medicinema at St. Thomas’s Lisa Molson is excited about the future: “We have just finished building a Medicinema at The Royal Hospital for Sick Children Yorkhill, Glasgow and are also fundraising for a MediCinema at the new Children's Centre in Newport South Wales. We have successfully completed a feasibili-
ty study for Stoke Mandeville Hospital for Spinal Injuries and are now commissioning one for the Royal Victoria Infirmary in Newcastle as well as being in discussion with several other hospitals in the UK.” It looks likely that Medicinema will become a blockbuster itself.
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Members of few professions endure such an endless process of examination as do students and practitioners of medicine. Medical finals require assimilation of large tracts of information, combined with the ability to identify from photographic evidence, face oral questioning and patient-centred testing. Literature on the mechanisms of memory tells us that there are no short cuts to the acquisition in memory of this volume of specialised, factual material. To flatten the graph of the 'forgetting curve' however, it seems that there are a few obvious learning techniques to apply. Understanding is the key to remembering Firstly, and unavoidably it seems, understanding is the primary key to remembering, as the speed of forgetting is slowed down by the level of meaning contained in the information. That is to say, the more meaningful the information is to you as a medical student, the easier it will be to remember the details. Mnemonics and the representation of memory Also of significance is how successfully you represent information for yourself, a skill that people possess in varying degrees but which can be developed. Mnemonics are verbal aids to memory, whimsical lists, poems or such which are designed to remind one of the information. This technique is well developed in medicine and there are websites devoted to their furtherance. Related to this is the form of revision where the student takes notes from revision material a minimum of 3 times, resulting in a checklist of
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Undergraduate Finals Revision Courses 2007
The significance of active recall The third point to bear in mind when approaching an important set of examinations, is that active recall is far more efficient than passive review (i.e. reading) of information. When memory is actively stimulated in the learning process, long term memory is consolidated. Therefore, by sitting mock exams or engaging in question and answer sessions, memory is actively strengthened. If repeated often to start with, as long term memory sets in, the length of time between repetitions may be reduced. It is a formidable task facing the student of medicine. To seek assistance from experts is a sensible approach, and available from revision specialists PasTest. PasTest have previously offered their services only to postgraduates but, from 2007, will run Finals Revision Courses for Undergraduates as well.
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An established name in the medical fraternity, PasTest is synonymous with examination preparation and methodology as well as publication of revision textbooks. For 30 years they have assisted medical professionals with preparation for post-graduate medical examinations as well as continuous professional development study. Their lecturers are top quality specialists chosen for familiarity with the examination content and delivery. PasTest and MLP will present Undergraduate Finals Revision Courses in many locations nationally, offering an excellent supplement to your revision schedule: > Expert lecturers, taking you through case-based teaching which covers popular medicine and surgery topics > Interactive electronic voting keypads offer the advantage of immediate feedback, plus an analysis of your areas of weakness or strength > Comprehensive course information including all featured cases plus additional popular scenarios, learning points and mnemonic lists to assist with retention > Access to online content following your course, for last minute preparation. > Save 25% on PasTest's extensive range of books when you book to attend a Finals Revision Course > Choose from 10 dates in 7 locations around the UK and Northern Ireland to fit in with your revision programme > A weekend of concentrated tuition offered for the superb price of ÂŁ98 Co-presenters MLP Private Finance plc specialise in financial planning and wealth management for professionals, and as such their services are tailored to the particular needs of the medical profession. Being independent means that MLP consultants are able to consider the entire marketplace and recommend the products, plans and funds that best fit the specific situation of the client. MLP offer financial solutions for: > > > > > > >
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4. ADE Following major trauma or surgery, increased circulating cortisol produces an increase in gluconeogenesis from non-carbohydrate sources. The breakdown of protein for gluconeogenesis causes a negative balance. Negative potassium balance is caused by cortisol-induced secretion of potassium by the renal tubules and the release of potassium from autolysed cells. Platelet aggregation is enhanced and the tendency for blood clot formation is increased. Third space fluid loss depends on the size of the
2. CDE More than 90% of duodenal ulcers are due to H.Pylori. Serum gastrin levels are high in duodenal ulcer. They are extremely high in Zollinger Ellison syndrome.
geal mucosal erythema, and arthralgia or arthritis. Coronary artery aneurysms result from an acute perivasculitis. Non-cardiovascular complications include CSF pleocytosis, pulmonary infiltrates and hydrops of the gallbladder. There is also a neutrophil leukocytosis, thrombocytosis, sterile pyuria and proteinuria, elevated LFTs, raised ESR, and CRP. The aetiology is unknown.
Answers and Teaching Notes 1. B The lesions of basal cell carcinoma typically have a rolled, pearly edge with a central keratin crater. The lesions are slow growing and tend to be more common in older people. They also tend not to metastasise; the spread is by local invasion and along tissue planes. Treat: Rx excision/radiotherapy.
3. ABDE Kawasaki disease presents clinically with prolonged fever, cervical lymphadenopathy, rash, epidermal peeling on the hands and feet, especially around the fingertips, ocular conjunctivitis, lymphadenopathy, fissured lips, oropharyn-
surgery and may vary from 1-3ml/kg/H for minor surgery to 15/kh/H with major surgery. 5. D The splenic artery gives off branches like short gastrics to supply: - The fundus of the stomach - Part of greater curvature, body and tail of pancreas - The spleen The lesser curvature of stomach and pyloric antrum is supplied by the left gastric-br. coeliac and by right gastric-br. of Hepatic. The superior mesenteric is the artery of the midgut which distributes to an area from D2-beyond the ampulla of vater up to the left half of transverse colon. 6. D Squamous Cell Carcinoma is a malignant tumour of keratinocytes. It usually arises in sun damaged skin, scar tissue. It is more common in
16 transplant recipients, and this is thought to be due to the immunosuppression these patients receive. The lesions are typically hyperkeratotic, ulcerated, expanding nodules; invasion of the dermis allows metastases to local lymph nodes. Treat: excision / radiotherapy. 7. A Pancytopenia may be due to bone marrow failure (aplastic anaemia) or to bone marrow infiltration (leukaemia, lymphoma or nonhaemopoietic malignancy). Aplastic anaemia may be idiopathic or secondary to drugs, paroxysmal nocturnal haemoglobinuria or Fanconi's anaemia. In a child of this age, ALL, AML or aplastic anaemia would be the most likely causes of pancytopenia. B12 deficiency could cause pancytopenia, but would be unlikely in a child of this age. A blood film would help to distinguish between aplastic anaemia and leukaemia as the latter condition may have circulating blasts.
A. There is increased glucose formation from noncarbohydrate sources B. The patient is in nitrogen balance C. Potassium balance tends to be negative because of diminished potassium in the diet D. Platelet aggregation increases E. Third space fluid losses depend on the surgical procedure
Q4
In the first few days following a major traumatic injury or surgical operation -
To activate, please go to www.123doc.com and enter this code: JRDOC20
Get Your £10 Study Grant A. B. C. D. E.
Bone marrow aspirate and trephine Peripheral blood immunophenotyping Bone marrow cytogenetics ANA and rheumatoid factor Serum ferritin
What would be the most helpful investigation? A. Conjuctivitis B. Rash in groin C. Petechiae D. Coronary artery aneurysm E. Prolonged fever
Hb WBC Plts Neutrophils
following may be useful in making a diagnosis Q3 The of Kawasaki's Disease Q7
5.8 g/dl 2.8 x 109/l 35 x 109/l 0.8 x 109/l
A 5 year-old boy is presented to his GP with lethargy and tiredness. A. B. C. D. E.
A. H.Pylori infection is associated in 80% of patients B. Serum gastrin levels fall C. Iron deficiency anaemia may be present D. Misoprotosol neutralises gastric acid E. Laparoscopic HSV may be necessary
Behcet’s disease Stevens-Johnson syndrome Herpes simplex Squamous cell carcinoma Pemphigus vulgaris
Q2 In duodenal ulcer A. B. C. D. E.
Squamous cell carcinoma Basal cell carcinoma Keratoacanthoma Sebaceous hyperplasia Malignant melanoma
likely diagnosis is A 60-year-old male complains of these lesions Q6 developing over the last 8 months. The most
The diagnosis is -
A. B. C. D. E.
Lesser curvature stomach Head of pancreas Jejunum Fundus of stomach Duodenum that is derived from midgut
ing structures will be at risk of ischaemia?
months.
Workshop
is a 73-year-old-male presented with a Following a thrombotic obstruction at the oriQ1 Presented lesion on his nose. It had progressed over the last 8 Q5 gin of the splenic artery, which of the followThink you know the complications of splenic artery thrombosis? Or how to make the diagnosis of Kawasaki’s Disease? This issue, in association with 123Doc, we bring you a selection of self-test questions to check your medical knowledge.
Test yourself JuniorDr
JuniorDr
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. 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 laboratory 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 disclosed that collagen in UK clinics was being 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 however 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.
“Hopefully the forthcoming changes in the regulations will eliminate the fringe clinics offering poor advice and questionable treatments with inferior products.”
> Collagen Facts Collagen has been widely used in cosmetic surgery and certain skin substitutes for burns patients for the past 25 years. It’s use, particularly for cosmetic implants, however is declining for a number of reasons > There is a high rate of allergic reactions causing prolonged redness and requiring inconspicuous patch testing prior to cosmetic use. > Most medical collagen is currently derived from cows which introduces the risk of transmitting prion diseases like variant CJD. > New alternatives which use the patient’s own body fat or hyaluronic acid are becoming readily available.
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Features 18
The Secret Diary of a Cardiology SpR
JuniorDr
* 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!
Monday First things first. That incident (if you’ve been following this column) with the aortic balloon pump blew over. I was vindicated by an internal hospital inquiry and things were left at that. Of course my boss was also vindicated which can’t have been right as I went against his orders to save someone’s life - so we can’t both have been right. But that’s how these things work in the wonderful system that is our NHS. I’m now in (almost) full time research at a nearby hospital. Monday mornings are spent with my supervisor. He’s a bright individual but can be very demanding. He often emails me late at night usually asking me to present something to him. This happened yesterday so I’ve been up most of the night trying to sort things out. This morning he seems to have forgotten about it. When I ask him if he’d like to go over things he tells me that he has changed his mind and wants me to look into another aspect of the work. It would have been nice if he’d told me this six hours ago. The rest of the day is spent in meetings looking over our work and trying to figure things out. I get home early and go out with friends for dinner. We stay out too late and I have too much Californian Merlot to drink. Tuesday I’ve drunk a litre of mango and blueberry smoothie as a prophylaxis against my hangover and it seems to have worked. Except I keep needing to empty my bladder. I spend the entire day in the lab. My current project is looking into cardiac muscle cells and how they respond to a host of different chemical stimuli. It sounds pretty boring and to be honest it mainly is. There’s a billion dollar drug at the end of it but my time here will be up before we get anywhere near that. After lunch I have a meeting with Jackson. He’s a senior researcher here and spends most of his time speaking to the drug companies. He's thirty-five, recently divorced, tall and thin with a few streaks of silver in his hair and a wickedly infectious laugh - plus he actually looks good in a lab coat. He asked me out for a drink a few weeks ago and when I said no I think I seriously dented his con-
fidence. He’s been avoiding direct eye contact since then - which is kind of hard when we meet a couple of times a week. I can’t remember my excuse but it was something about needing time out after my last disastrous relationship. I spend the rest of the day in the lab. There is a problem with one of my cell suspensions and by the time I've sorted it out it's almost ten at night. I get a cab home and collapse in bed. I’ve got real work tomorrow. Wednesday I spend the morning in the cath lab back at my old hospital. I run into a few consultants but not my arch nemeses (the one who tried to get me fired). We have four cases and the last one, a fifty-seven year old man, gets a little complicated. Before I know it I have a problem on my hands. We have a cardiothoracic team on site and I bleep the on call consultant to bail me out. He’s a friendly and straight talking surgeon in the twilight of his career. He takes the man straight to theatre for an emergency CABG. I spend the afternoon in clinic but my mind keeps wandering to my angio. I did nothing wrong and having to proceed to an operation is a known complication and something you consent patients for. But it’s the first time that it has happened to me. As soon as I’m done I go straight to CITU. The patient is awake and talking. I find the surgeon and thank him profusely. He smiles and tells me that it’s the most fun he’s had in weeks and that if not for people like me he’d be out of a job. I go home call my parents for the first time in a long while. They’re in a chatty mood so we talk for a long time before I fall asleep in front of the TV. Thursday Back in the lab today. More of the usual but then my supervisor calls me into his office before lunch. He has an extra ticket to a conference in Milan at the weekend and wonders if I’d like to go. The opportunity is immense but I hesitate before answering. There are five other people in my lab and I’m the only medic. It was hard at first as I tried to grapple with basic scientific techniques. On top of that I got paid a lot more than them as my salary came from outside the uni-
versity. This was reason enough for resentment but I put a good few months into building our relationships. We’ve even been out for drinks a few times. I tried explaining all of this to him but he just smiled. In research, he explained, you had to take whatever opportunities that came your way. It wasn’t about pushing other people down, it was simply about making the most of what was passed in front of you. I told him I’d let him know by tomorrow. I spent the afternoon feeling guilty but by the end of the day word had got round and I received a multitude of snide comments. I tried to brush them off with jokes about shopping for shoes in Italy but this made things worse. I don’t think they realised how hurt I was. Friday The morning was spent in a teleconference with a materials supplier from Texas which sounds a lot more exciting than it was. Friday afternoons are free so I popped back across London to see how my CABG patient was doing. His bed was empty which is usually a bad sign. The SHO on call told me that he had arrested last night and died. He’d been in asystole throughout without a hope of coming back. I left and spent the rest of the day in Starbucks with a novel and a Mocha Latte with cream and caramel sauce (more calories than a double bacon cheeseburger). I don’t normally get upset about deaths, even if I’ve been somehow involved but this had really gotten to me. Perhaps I was better off in research where the worst that could go wrong was a cell line dying. But then that’s not why I went to medical school in the first place. I went to treat people not test tubes. My lab colleagues were right. I was different from them. I called up my supervisor and told him that I’d meet him at the airport tomorrow morning. I finished my coffee and then called James to see if he was free for dinner tonight. He was.
JuniorDr Features
Weekend ward escape to
Madrid With bullfighters, women who dance clapping metal cymbals and huge 30 inch plates of paella there’s no doubt Madrid sees itself as a macho city. Hardly a place for a relaxing weekend away you may think. Wrong. Madrinos also have a strong reputation for enjoying themselves ... you just have to let them take the lead. Where to stay? Like any capital city staying in Madrid is expensive. Visiting at the weekend does let you take advance of reduced rates when all the business travellers have left. Try the centrally located Petit Palace Arenal (Calle Arenal) approx £60 a room. If you’re still waiting for your paycheck you could try the Barbieri Internation Hostel (Calle Barbieri), just a short walk from the centre, which offers double rooms from under £30. Or if you’re planning a really special weekend away you could splash out on Hotel Santo Mauro (Calle Zurbano) - the choice of residence for the Beckhams at £250 per night. Eating Tapas will become addictive whilst in Madrid. Pop into a bar, order a drink and nibble the night away with the locals - it’s how they can stomach drinking until the early hours of the morning. The top tapas treats can be found at Juana la Loca (Plaza Puerta de Moros) or Alhambra (Calle Victoria) which offers a more lively experience with heavy music and a younger crowd. For a more sedate sit-down meal consider La Viuda Blanca (Calle Campomanes) which offers a modern take on Spanish cuisine. Key attractions Palacio Real - Arguably the most impressive building in Madrid with fantastic gardens which are perfect for a spot of lunch. There’s 3,000 rooms to the Royal Palace, many of which you can wander through. El Teleférico de Madrid - This is a 10 minute cable car ride that departs from the park behind the
Royal Palace. It’s a great way to see the city from afar and also ends at a welcome restaurant. Prado Museum - This is Madrid’s most popular tourist attraction and claims to have a higher concentration of masterpieces than anywhere else in the world. At any time there’s 1,500 works of art on display out of an impressive collection of 9,000. Parque del Retiro - Retiro means retreat and is the most popular park in Madrid. With a large lake, monuments and shaded areas it’s the perfect place to relax after stomping around the Prado - which is conveniently situated close to the main entrance. Nightlife Plaza de Toros de Las Ventas Whether you amazed or are appaled by bullfighting it’s certainly a big part of Madrino culture and increasingly popular. Tickets can cost from a few quid to over fifty depending on where you sit in this massive 25,000 seater stadium with the action kicking off from 7pm. Casa Patas (Casa Canizares) Flamenco is the other great Madrino passion and certainly worth an evening’s viewing. Casa Patas offers one of the more authentic experiences. Entrance is approximately £25 and includes a complementary drink. Find the full Madrid guide at JuniorDr.com The pics Key facts > Population - 2,905,100 > Language - Spanish > Currency - Euro
Clockwise from top left Tapas; Bullfighting at Plaza de Toros de Las Ventas; Palacio Real; Madrid city centre
> Madrid is Europe's highest city (2,100 feet)
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JuniorDr
General Practitioner to the Stars
Medical Report - Mr S. Claus Obesity well over 35. Obesity, ‘jolly’. He is obese, with a BMI of Santa isn’t just big-boned. He isn’t factor for ‘Syndrome X’ inant obesity, is an important risk especially central or waist-predom ispose for cardioases and risk factors that heavily pred - the clustering of a number of dise blood cholesterol high , sure etes mellitus, high blood pres vascular disease. These include diab correlated with is ity obes e, rom synd c rt from the metaboli and combined hyperlipidemia. Apa ar scul (CHF) to gaswith TLAs), ranging from cardiova a variety of other complications (all or Die Santa. Diet r: gical (BDD). The answer is clea trointestinal (GoRD) and psycholo Cyclothymia not speaking to anyone world for the majority of the year, Santa locks himself away from the everything and with d ars incredibly happy, overjoye (except for his ‘elves’) and then appe money buying his ds spen ely ssiv doesn’t sleep, exce unable to stop himself laughing. He e dressed in bright vehicle and speeds off - all the whil presents for all and then get in his irritation, recklessness mood is often this is followed by colours. A word of warning, high Rudolf. and sexual disinhibition - watch out Albinism nosis would be white as snow. The most likely diag His head, beard and eyebrows are hair, eyes or skin, an hum in re no pigment is found Albinism, a genetic abnormality whe ain why he is only expl also ld wou It . pale e, and the skin making the eyes blue, the hair whit ing easily from expoprotective pigment in his skin, burn seen at night - he lacks melanin, a photosensitivity. sure to the sun and suffering from
20
Assessed by Gil Myers
Red Face Santa warm’ may out ‘a little glass of whiskey to keep All those years of children leaving the liver. As this of osis g-term alcohol use causes cirrh have left him with a problem. Lon signs. The tiny ic stem ti-sy mul are down and the results stops working and begins to shut cheeks. This would go ing a permanent red face, nose and blood vessels in his face burst leav ain why he always expl gynaecomastia. It would also well with his jaundice, clubbing and empty in the mornys alwa was left and why the glass you wears gloves and baggy clothes ing. Haemorrhoids snow-covered and cosy. Assuming he starts off from Santa’s sleigh doesn’t look very warm of time sitting on a cold, world he must spend an awful lot Lapland and travels all across the Too much pressure much time for toilet breaks either. hard seat. He doesn’t appear to have obesity, sedentary with led coup cle tone or poor posture, on the rectal veins due to poor mus proven to cause haemements (or constipation) has been lifestyle and postponing bowel mov t exactly pop down to cult for Santa to get help - he can’ orrhoids. It must also be very diffi sol. his local chemist for a tube of Anu Sexual Fetishes ren or a red-nosed reinseen in the company of elves, child He is a grown man who is always hing else. I wouldn't anyt ng be reading this I’m not sayi deer. But just in case he happens to want to go on his naughty list ...
It’s tough being a doctor these days. Patients turn-up having researched their ailments on Google. Sometimes a little reassurance that they don’t know everything makes us feel better. We did some spot check-ups outside a London hospital asking the public to tell us about a common condition. Now, just what was it? Describe the symptoms? “Terrible pain. It’s better to sit down. Massages help and I think aspirin is good. You shouldn’t fly either as this condition can get worse and can be deadly.” Paul, Transport Engineer Who gets it? “You get it when you’re old. It only affects women but I don’t know why.” John, IT Can it be fatal? “Hmm. I don’t know anyone who’s died from it. I’m sure you can lose a leg though.” June, Shop assistant Is it contagious? “Yes. I’ve got it. I got it from my mother. I think all our family have it. I’ve had an operation on two of mine last year and they’re much better.” Patricia, Shop assistant Is it preventable? “Walking is good and don’t have a desk job. Wearing stockings helps too. You shouldn’t fly either as it also causes them.” June, Shop assistant How can it be treated? “You can get it cut out which I guess is permanent. A lot of people just cover them up with make-up or clothing and deal with the pain.” Xantham, Driver
Hmm ... sounds like a DVT doesn’t it? Not quite. We asked them about varicose veins which two people think is caused by flying. See, we’re still needed after all.
(B.H.S, M.&.S, R.S.V.P.)
We offered all our interviewees a factsheet about varicose veins and advised John that he could get them too - he wasn’t happy.
Features
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Applied Clinical Ethics (ACE)
ÂŁ95
Medical Updates
6 x 1-Day Professional Training on Saturdays at Imperial College London „ 24 Feb 2007 „ 24 March 2007
„ 21 April 2007 „ 19 May 2007
„ 9 June 2007 „ 30 June 2007
The UK's first part-time course in applied clinical ethics, designed specifically for practising clinicians. Taught by leading authorities in the field, including Prof. Raanan Gillon, and experts in medical law and conflict resolution. Covers key issues in clinical ethics and methods of case analysis. The course is intended for hospital doctors, surgeons, general practitioners, nurses, managers and members of clinical ethics committees. No experience of academic medical ethics necessary. Limited places available. Directed by Dr. Daniel Sokol, Lecturer in Ethics, Keele University, and Honorary Research Associate, Imperial College London.
Details: Ulrika Wernmark +44(0)20 7594 6886; cpd@imperial.ac.uk
www.imperial.ac.uk/cpd/ace
CME/CPD approval sought
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May 2007 @ St Mary’s Hospital London For more information and to register visit -
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Journalism The Medical Journalists’ Association brings together medical writers, the media, health professionals, and health charity workers. > Meetings on major health and medical topics of the day > A forum to meet colleagues > Recognition and cash awards for distinguished work > A website with your own address - visit www.mja-uk.org > Professional advice when you need it Wish to join? For more information visit www.mja-uk.org Next Event - ‘Talking Sex’ on 15 March with presentations by fpa, Relate, the Brook, Sexual Dysfunction Association, and Association of Sexual and Relationship Therapists. Discussion. Buffet supper. Starts: 6.00pm for 6.30pm at Browns Courtrooms, 82-84 St Martins Lane, Covent Garden, WC2. Tickets free. Apply via Rachel Vrettos: rVrettos@rdcomms.com
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Ethical advisor
Flatliners (1990) Kiefer Sutherland, Julia Roberts, Kevin Bacon
Help with the portfolio: consent, assent, and capacity I'm a house officer in London. As part of the FY1 Foundation Learning Portfolio, we need to know the difference between consent, assent, and capacity. Can you clarify? Dr Roland Hettige, St Mary's Hospital, London. Consent Consent is the patient’s voluntary agreement to an examination, treatment or procedure. It can be obtained orally, in writing, or by co-operating (ie. ‘implied’ consent, such as opening your mouth for a tongue inspection). Obtaining consent is typically a process which requires the doctor to establish whether the patient a) is sufficiently informed b) is competent enough to make the decision and c) is acting voluntarily. At the risk of teaching the proverbial grandmother to suck eggs, a signature on a consent form is not sufficient to constitute valid consent if you haven’t properly gone through the a) to c) process. Assent Assent is also a patient’s agreement to treatment, but the patient lacks sufficient capacity to give valid consent. Hence assent is usually applied to situations involving young children. So, whereas a competent patient’s consent can be translated as ‘yeap, thanks for asking doc, go ahead; I understand what this is about, I’ve got enough marbles to appreciate the situation, and no one’s forcing me to have this’, assent is more straightforward: ‘yeap, thanks for asking, go ahead doc’. Assent, in brief, is an agreement to participate which differs from consent in that competence and voluntariness are not required to the same degree. Capacity
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Capacity is the legal term for ‘competence’. Without it, patients
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medical movies
cannot make decisions about their care. Capacity is not an all-ornothing affair, but can be present in degrees and may fluctuate depending on the patient’s mental or physical state. Judging whether someone has enough capacity to make a decision will be based in part on the decision to be made. Generally speaking, the more serious the consequences of the decision, the more stringent the criteria for capacity. A patient may have enough capacity to choose which arm will receive an injection but not to decide whether to have a life-saving operation. To assess capacity, a doctor should also determine whether the patient can understand key aspects of the decision (e.g. the purpose of the treatment, its risks and benefits, etc.), whether the patient has the cognitive ability to believe and assess the information, and whether mental illness (e.g. depression) is not affecting cognitive processes to such an extent that capacity is undermined. Hope that helps! Daniel K. Sokol, Lecturer in Ethics, University of Keele, and Honorary Research Fellow, Imperial College, London. www.medicalethicist.net Any comments, questions or cases? Contact daniel.sokol@talk21.com Medical Ethics and Law - Surviving on the Wards and Passing Exams Sokol and Bergson £14.95 ISBN 0954765710
Five medical students get a little overexcited whilst exploring the mysterious world between life and death. By stopping the heart of one of the group they stimulate a near-death experience and then just pray they’ve been paying enough attention in lectures to resuscitate them again.
Lorenzo’s Oil (1992) Nick Nolte, Susan Sarandon When their 5-year old son develops a nasty form of adrenoleukodystrophy his parents don’t believe their doctors when told it’s terminal. Instead they set out to study the disease, take on the pharmaceutical establishment and the medical profession. As you can imagine for a Hollywood blockbuster they come out on top. Patch Adams (1998) Robin Williams Based on a true-story Robin William gets to clown around as a medical student who attempts to ‘treat the patient, not the disease’ by making them laugh. Often cringe-worthy, occasionally inspiring, it may just make you want to wear a red-nose to ward rounds. Outbreak (1995) Dustin Hoffman, Rene Russo Tense, edge-of-seat thriller as Mr Hoffman and colleagues try to contain a virus that has hitched it’s way into the US on a little monkey. Luckily our heroes manage to avert total annihilation of mankind single-handily - though they can’t save the little monkey who dies in one of the more tearjerking scenes. Awakenings Robert de Niro, Robin Williams Mr Williams graduates to doctor in this impressive flick during which he treats comatosed catatonic patients by administering L-dopa for the first time. The spectacular results of the drug mirror real-life events in New York during the 1960s and are pretty awe-inspiring even with Williams in the lead.
JuniorDr
Walking the corridors
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 -
Sachet of tomato ketchup
While we doctors are puzzling over squiggles on ECG traces, prescribing IV nystatin and ordering MR scans for patients with metal implants there are a bunch of people in the background quietly observing what’s going on. Porters, students, secretaries and canteen staff see the other side of hospital medicine. We’ve asked them to tell all. MRI spine to rule out cord compression at four-thirty on a Friday afternoon - usually on a patient they’ve been sitting on all week. On call can vary from place to place. As I work in quite a big hospital my on calls are unfortunately on site and they can be very busy. You can get into arguments with consultants as well - usually over night scans. We had one radiologist who hadn’t paid for a link to his house (despite all the money he was getting from private scans). This meant that he had to come in to report scans. He would often ask radiographers to look at CT brains when on call. Sure, after twenty years I can tell if there’s a bleed but that’s what they pay him to do. The first time he asked me to do it I said I would but then asked for his GMC number so that next to my report I could write a little paragraph about him asking me to do it. He came in pretty quickly and hasn’t bothered me since. On a normal day I’m supposed to finish by five but I never leave before six, often later. After the consultants go home and the junior doctors finish their shifts we’re still there. I make sure that the paperwork is all filled in and that any urgent scans have been reported. I have my fifth cup of coffee and it’s usually me who turns the lights off on the way out.
Bet it goes all over your shirt too Belfast City Hospital Belfast
WOW!
15p
Squeezelicious Royal Brompton Hospital London
9p
LOW!
Ready salted crisps Enough to make you choke Royal London Hospital London
WOW!
57p
Just watch your arteries at this price Belfast City Hospital Belfast
35p
LOW!
330ml can of Coke/Pepsi Tell them to can it at North Middlesex Hospital London
WOW!
70p
Fizztastic prices at Chase Farm Hospital London
40p
LOW!
Next issue we’re looking for the lowest/highest price of a toothbrush, a chocolate chip muffin and a portion of chips. Email team@juniordr.com.
Which mess is the best?
JANE RADIOGRAPHER (SOUTHAMPTON) You may not realise this but there is currently a national shortage of radiographers. This means that as much as doctors complain about working hours we get it much worse. My day usually starts at 8am. I arrive before most of the consultants. If I’m working in MRI or CT then I fire up the scanners and send a test scan. Our equipment is state of the art so it’s very different from when I trained. These days you have to be more like a software engineer than an xray technician. I have a coffee at my desk and then spend the morning in the scanner. Most of it is standard stuff but you do get the occasional emergency. Most of my entertainment comes from junior doctors getting slapped around by our consultants. There’s such a difference in how they ask for scans. I’ve realised that it is all about confidence. I can usually tell when a radiologist is going to accept a scan. It’s because the young doctor walks in with a respectful yet confident air. They already know that they’re going to get the scan before they’ve started presenting the case. By lunch things have started to quieten down. There is always some paperwork and another coffee to drink. We also try and teach the juniors a little each day. The afternoon can get busy, depending on where you work. For example, there is always a request for an
The Mess
Hospital
> Broomfield Hospital, Chelmsford
What it’s got Permanently in a messy state. No food in the fridge. Out of date microwave meals in the freezer. Toilet blocked more often than not. Two computers with internet that are usually off-line. Stained couch after many nights being slept on by the surgical team. Old television but at least it has Sky TV. In a nutshell, disappointing for a tenner a month. JuniorDr Score - 1/5
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The Informal Consultation by Annmarie McTigue, Writer, MPS After all the years of hard work, you are now a qualified doctor. . . and the hard work seems to get harder. Revision, supervised procedures and exams have been replaced by learning on the job and from experience. And you’re working in the most trusted profession, a status that brings its own challenges. You have probably won new respect in the eyes of friends and family, who may come to you for advice on aches and pains. Although you are qualified, you are very much still learning, so your newfound ‘doctor’ status may lead you to a medicolegal minefield – the informal consultation.
Scenarios 1. You go to your parents’ house for a family lunch. Following a general conversation with your sister-in-law, she says: “I’m so glad you’ve made it today. I was going to book to see my GP, but you can probably help.” She goes on to describe the symptoms of a recurring ailment. What do you do? 2. You bump into a friend of a friend while training at the gym. The last time you saw him he was “as high as a kite” on a night out. You once treated him in A&E after an accident and he confided he was on anti-depressants. He asks if you could write him a character reference for a new job. As an acquaintance you would have qualms about his social drug-taking, but as a doctor, you are also aware of his previous history of depression. What do you do? You may not see a problem with giving somebody some general advice about an illness or writing that reference, and may be happy to do it. Both these scenarios, however, could lead to a complaint or claim if something went wrong.
Getting out of a tricky situation So what would you do in the above scenarios? In the first case, you are dealing with a family member and would naturally wish to help. MPS would advise adopting an empathetic approach to your sister-in-law, but explaining that it would be better for her to see her usual GP. Explain that you would not be able to properly diagnose any condition without being able to review her medical history/notes or conduct the necessary examination or tests. Add that it if you were to offer a diagnosis or advice now on the basis of incomplete information, problems could arise for both of you if a different, and possibly serious, condition came to light in the future. This second case puts you in an awkward position. It would be best to explain that as you once treated him and also know him from nights out, you would not be the best person to provide a reference of the type he is requesting. If he persisted in his request, explain that you would be able to write something in the form of a medical report, which would need to include reference to any relevant past medical history, adding that he would need to see and consent to it being sent.
Better to be safe than sorry If you find yourself in a grey area between professionalism and your social or personal life, contact your protection organisation for advice.
1. GMC recommendations The GMC’s Good Medical Practice does not offer specific advice on dealing with informal consultations. However, there are some general points to follow that should help you make a judgment call.
Providing good clinical care Good clinical care must include: adequately assessing the patient’s conditions, taking account of the history (including the symptoms, and psychological and social factors), the patient’s views, and where necessary examining the patient providing or arranging advice, investigations or treatment where necessary referring a patient to another practitioner, when this is in the patient’s best interests.
Avoid treating those close to you Wherever possible, you should avoid providing medical care to anyone with whom you have a close personal relationship. (the GMC does not specify what constitutes a close relationship.)
Doctor–patient relationship In most successful doctor–patient relationships a professional boundary exists between doctor and patient. If this boundary is breached, this can undermine the patient’s trust in their doctor, as well as the public’s trust in the medical profession.
2. BMA guidance on treating family or friends The BMA advises that treating family and friends should generally be avoided, except in emergencies. It states that in such cases a GP may fail to notice symtoms that a dispassionate observer would note and if seeing somebody outside the surgery, they may not be able to carry out all the tests that would be done in a formal consultation.
Professional support and expert advice Membership Helpline 0845 718 7187 or visit www.mps.org.uk MPS is not an insurance company. All the benefits of membership of MPS are discretionary as set out in the Memorandum and Articles of Association.