trauma Magazine - Issue 19

The world’s community for trainee doctors

trauma

UK Edition traumaroom.com Issue 19 - Free!

Too Fat to Fix? Banning obese patients from hip replacements Also ... Maggots, Sex Offenders & Ig Nobel Awards

trauma

The world’s community for trainee doctors

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“Six years of hard study for what?”

Editor Michelle Connolly 3rd Year Medical Student GKT

ukeditor@traumaroom.com Editorial Team Assistant Editor Sinem Aymen News Editor Natasha Murray Editorial Team Nicole Chiang Fiona Kenny Richard Partridge Muhunthan Thillai Design Team Nabil Quraishi Distribution Kirstin Daley Printing Partners Witherbys, UK Managing Editor Ashley McKimm Tel - 020 7684 2343 editor@traumaroom.com

Michelle Connolly, trauma Editor

“One thing keeps coming up again and again: it’s nothing short of a lottery.”

“Six years of hard study for what?” was one student’s understandably bitter response to what has become known as the ‘MDAP [Multi-Deanery Application Programme] Farce 2006’.

MDAP is the new online application system for Foundation Programme posts and as expected London was oversubscribed - what wasn’t expected were some 600 UK trained medics left jobless.

Angers rose when it was revealed in ‘The Times’ that 208 overseas-trained students landed jobs. Sixty doctors also failed to meet minimum standards of medical competence and more than half of these could not even speak English adequately. How on earth are these candidates deemed to be suitable to work in our hospitals?

What’s on the inside Sex offenders Are sex offenders hiding in our hospitals?

Page 8

trauma PO Box 36434 London EC1M 6WA Tel - 020 7684 2343 Fax - 087 0 130 6985

Too fat to fix?

Should obese patients be denied hip operations Page 10

Health warning trauma is not a publication of the medical school, Tony Blair, his wife, the student unions or any other official (or unofficial) body. The views expressed are not necessarily the views of trauma or its editors, and if they are they are likely to be wrong. It is the policy of trauma 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. trauma 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.

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In response to the shambles, eighty of Britain’s top doctors have written a scathing letter to The Times newspaper (see page 4), demanding the system be scrapped, and rightly so, as flaws in the application process mean academic excellence is given exactly the same weighting as extra-curricular activities. Face-toface interviews have also been done away with.

Of the correspondence we’ve received and that which is traded on the numerous blogs of incensed finalists one thing keeps coming up again and again: it’s nothing short of a lottery.

When scientists get bored The Ig Nobel Awards Page 16

UK Reps Sandra Acton, Leicester Nishant Pandey, Leeds Derek Mackenzie, GKT Sarah Bennett, UCL/ RF Leigh Bissett, East Anglia Wendy Brown, Dundee Kate Brunskill, UCL/ RF Alison Bryson, Cardiff Paula Funnell, B+L Matt Rowland, Leeds Thomas Chivers, Oxford Jennifer Collie, Dundee

Christine Cowan, Newcastle Charlotte, Imperial Simon Donald, Aberdeen Sandra Dye, St. Andrews Danny McGuiness, IC Sarah Fadden, Cambridge Sheila Fisken, Edinburgh Martin Gill, Leeds Sheraz Younas, Manchester Paddy Wilkinson, B+L Rameen Shakur, Edinburgh Fran Hazelton, Bristol Vicky Holmes, Birmingham Alison Howarth, Glasgow Peter Hutchinson, Cambridge

Susan Isaac, GKT Chris Jackson, Leeds Frances Jones, Leeds Sandra Jones, UCL/ RF Morven Reid, Oxford Karen Lubarr, Cambridge Derek Mackenzie, GKT A McKay, Aberdeen Ambereen Khan, Birmingham Margaret Moir, Aberdeen Abdul Siddiky, Sheffield Khalid Ali, Newcastle Mark Nicholls, Cambridge Ami Nwosu, Liverpool Donald Orrock, Dundee

Walking on all fours A look at the family that has courted controversy in the scientific world.

Page 12

Ian Pickering, Liverpool Paula Purchase, Southampton Jennifer Randall, Imperial Richard Rhys Davies, Oxford Guy Schofield, GKT Sushma Shankar, Oxford Jane Smethurst, Leeds Simon Rees, Southampton Katherine Smith, Oxford Richard Smith, Leicester Elizabeth Spalding, Oxford Wendy Stanton, Nottingham Michael Livingstone, UEA Irene Wells, Aberdeen William Start, Brighton

We’ve got a team at medical schools throughout the country to make sure you get your copy. Want to join our team? Know how we can get better involved in your medical school? Email us at reps@traumaroom.com.

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trauma

News Pulse Tell us your news. Email the team at news@traumaroom.com or call us on 020 7684 2343

Foundation Programme

New online application system risks medical students’ futures > Your viewpoints

“Everyone, even those who got jobs in the first allocation round, are unhappy with the process. We all hope that there will be significant changes next year.”

Liang-Kim Ong Medical Student GKT

LONDON Eighty medical professionals from all over Britain have written to The Times newspaper to express their distrust in the Modernising Medical Careers selection process which came into force last year.

They believe the careers of many medical students could be at risk as a result of the failures in the new online application system, which were reported in the last issue of trauma.

Only days later the BBC discovered that it was possible to hack the MMC website and amend the applications of final year medical students applying through the MMC website.

The new computer system which has borne the most intense criticism uses a computer programme to allocate ‘appropriate’ candidates to first house jobs, and was meant to allow students to apply to any medical school within the UK regardless of where they studied.

The application process puts equal emphasis on leadership skills and team-working abilities as academic excellence. The concept, although deemed as laudable by many, has worried clinical tutors that it may not be the best way to chose future consultants.

Unfair System?

Doctors have described how the system has forced them to employ substandard doctors as there is no vetting of applicants through interviews, and that some of the brightest students are being passed over.

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Charles McCollum, Professor of Surgery at South Manchester University Hospital, who organised the letter to The Times, told trauma that 60 out of 360 medical students in Manchester failed to get a job in the first round of selection.

“Most consultant physicians and surgeons throughout the UK appear to agree. I think the MMC system should be scrapped and that there should be regional systems for selection developed by the regional postgraduate dean,” he said.

Petition The new system has enraged final year medics prompting two students to start a petition to be presented to the MMC. In the first week it received over 500 signatures.

Another frustrated student, who is remaining anonymous so as not to damage his employment prospects, has set up a website on which students can voice their concerns. He says that he “along with

hundreds of others have literally had their dreams dashed through this year's unfair allocation system”.

“If you went for a job at your local Tesco, you would get an interview, but apply to work as a doctor in the NHS? An interview?

Don't be silly! We'll let the doctor lottery experiment decide your fate,” he said.

The situation has been compounded as the number of medical students applying for training jobs has begun to outweigh the number of posts available. Many of these training posts had been phased out as part of the new Modernising Medical Careers training structure.

To sign up to the petition visit: http://www.ipetitions.com/campaigns/Thedoctorlottery/ Or to air your view visit: http://mdap2006farce.blogspot.co m

trauma News in Brief Birmingham celebrates 180 years of medical excellence Birmingham University Medical School has celebrated 180 years of providing medical education in the city.

William Sands Cox began teaching his ‘Anatomical Demonstrations with Surgical and Physiological Observations’ to 19 students from his father’s house in Birmingham on 1 December 1825.

The occasion was marked with the opening of the new 450seat Leonard Deacon lecture theatre, a social space with cyber café, new catering facilities and food court.

Peninsula Medical School wins funding The south-west’s Peninsula Medical School (PMS) has been awarded Government money to fund an extra 33 undergraduate places a year.

The school also received cash to build a new dental school allied to PMS, which it is hoped, will help alleviate the region’s NHS dentist shortages.

The Dean Prof John Tooke said: “A major driver for many of us involved in the PMS project has been the uplift in local healthcare that follows the development of an undergraduate medical school.”

PMS’s main teaching hospitals, the Royal Cornwall Hospital in Truro, and Plymouth's Derriford Hospital have recently announced 500 job cuts, due to deficits of £8m and £22m respectively.

Naps are “back in fashion” says The Lancet Short naps are “indispensable” for junior doctors on long night shifts to enable optimal patient care, according to an editorial in The Lancet.

The article comes after the Royal College of Physicians published guidelines advising that napping for as little as 20 to 45 minutes has been shown to be beneficial to shift workers.

The European Working Time Directive means that most junior doctors now work night shifts, and many hospitals have used the directive to ban access to on-call rooms for those working through the night. Some junior doctors have reported napping on doctors’ lounge sofas. The cutbacks have been opposed by the BMA.

Medical School Life

Med students turn alcohol advisors SOUTHAMPTON A website which calculates the risk posed by alcohol consumption has been created by Southampton medical students.

The ‘Drinkulator’ (www.drinkulator.org) uses brief questions about health and lifestyle to calculate your risk of liver damage and addiction, as well as your risk of stupidity or nastiness, putting your sexual health at risk, and even how likely you are to kill someone when drunk.

Fourth-year medical students Joanne Lavers and Marianne Davies are soon to publish their paper on student drinking, on which the ‘Drinkulator’ was based.

It is estimated that the amount of alcohol drunk in the UK has doubled since the 1960s, with women now drinking more than ever before.

Consequently, deaths from liver disease have increased eightfold in 20 years and medical students particularly, whose ‘work hard, play hard’ mantra leads to particularly high alcohol intake,

should be advised to curb their drinking.

It is however not something all students agree with, one Cardiff medical student told trauma: “We have five years of hard work, exams and being told how much responsibility we will inherit. It’s not surprising that sometimes things seem rosier through the mist of a few vodka lemonades. If that means spending the odd night passed out in a pile of boxes, then there you go!”

Dr Nick Sheron, who supervised the Alcohol Education and Research Council sponsored project said: “The aim of the site is to inform and not to shock. All the ‘predictions’ are based on hard data from research studies. It is absolutely possible to enjoy a drink and to stay entirely healthy.

The key is to respect the fact that alcohol is a highly addictive, toxic substance that can leave you in a very vulnerable state if you are not careful.”

When asked whether the

recent 24-hour drinking laws would affect the amount of alcohol consumed in the UK, Dr Sheron said: “The UK habit of binge drinking was first described by the Venerable Bede in 726AD. It probably took thousands of years to develop, and seems unlikely to change just because the pubs are open longer.”

Medical School Life

HYMS applicants at record low HULL Applications made to the Hull York Medical School (HYMS) fell by 39 per cent compared to last year, according to UCAS. The surprising figures represent the greatest drop in application numbers of any of the colleges associated with UCAS. Connie Cullen, Director of Admissions at HYMS, said: “It is last year’s figures that should really be seen as the blip. The funding changes for 2006 encouraged more mature students to apply in 2005 and we saw a sharp increase in mature student application numbers.”

Most medical schools experienced some inflation in application numbers in 2004/2005 as students

rushed to avoid the £3,000 top-up fees which are to be implemented this year. Overall, applications for pre-clinical medicine courses were actually up by 0.3 per cent on last year.

HYMS's typical offer has this year been raised to AAB, falling in line with those of most medical schools.

Ms Cullen said: “Last year HYMS was one of only two English medical schools to have a typical A-level offer of ABB rather than AAB which attracted a large number of applicants who were uncertain of achieving higher grades.”

HYMS opened its doors in 2003, and takes 130 students a year, whose lectures are carried out by video-link between the Hull and

York campuses. The course is the only in the country in which students undergo equal proportions of primary and hospital placements, and a large proportion of the course is based around the controversial Problem-Based Learning method.

One ex-HYMS student, who transferred to Peninsula for personal reasons said: “The thought of spending five years holed up in places like Scunthorpe and Grimsby puts a lot of students off.

But the support network is very good at HYMS and students and tutors are generally on first name terms.”

Application numbers in the UK were generally down by 3.4 per cent. Nursing applications were up by 15.4 per cent.

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trauma Growing up smart It's the way the brain develops - not it's size - that makes people smart, according to the US National Institute of Mental Health. Clever kids tended to have a thin frontal cortex that thickened more slowly than their normal colleagues. The scientists believe that the longer ‘maturation’ time may lead to more complex neural connections and greater intellect.

Scotland sees better All residents in Scotland are now entitled to free eye tests thanks to a new initiative by the Scottish Executive. The aim is to reduce preventable eye disease which many feel has risen since the abolition of free examinations under the NHS in the early 1980s.

Does my brain look big in this?

A paper published in the journal NeuroImage suggests that obese people also have fat brains.

The research conducted in the US found that when the brains of obese people were compared to ‘lean’ people, a smaller percentage of grey matter was found. These changes were found specifically in the putamen, post-central and middle frontal gyri, and frontal operculum - areas associated with regulation of taste, reward and behavioural control.

Young Brits won’t wait so get sick 42 per cent of young Brits would forego a trip to the doctor simply because they can’t bear waiting for an appointment, according to a study by easyMoney.com. The survey of 18-29 year olds found that 16 per cent became more unwell as a result. It also found one-third risked tooth decay because they “didn't have time” to get to the dentist.

The computer says you’re bored of me Scientists at the Massachusetts Institute of Technology have developed a sensor capable of showing if someone is interested in your conversation, or not. The device aimed at helping autism sufferers was unveiled in New Scientist magazine. A camera fixed on the users glasses analyses the emotional reactions of the listener and translates this to the wearer. Initial trials show a 90 per cent success rate.

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Training

DH: Hire 'homegrown' docs (not the best qualified) LONDON Overseas doctors will not be hired by the NHS, even if they are the most qualified, unless an EU doctor would not be able to do the job competently, following controversial new rules by the Department of Health.

From July 2006 any NHS trust wishing to employ a doctor from outside the EU will have to prove that a ‘home-grown’ doctor could not fill the post, ending the current permit free training arrangement for international doctors.

The move is expected to radically change the composition of doctors practising medicine in the UK. Over 6,500 overseas doctors passed the PLAB exams in 2005 allowing them to practise in Britain. Under the regulations very few would be eligible to take a post under the current high levels of competition.

Overseas doctors already find it difficult to obtain a post in the UK. According to the BMA more than one-third who sat the PLAB exams in 2003 remained unemployed six months later - a figure which is expected to have risen substantially over that last few years since the study.

The competition Dr Tom Dolphin, deputy chair-

“In future [graduates] who wish to work or train in the NHS will need a work permit. To obtain a work permit an employer must show that a genuine vacancy exists, which cannot be filled with a resident worker. ” Lord Warner Health Minister

man of the BMA’s Junior Doctors Committee, supported the proposals: “It is good news that the Government is at last acknowledging the enormous competition for jobs that junior doctors are facing.

The lack of a well thought through system of medical recruitment has hit overseas doctors the hardest.

Thousands have come to the UK in the belief that training jobs are easy to come by, only to find themselves unemployed, and in many cases living in poverty, or forced to return home,” he said.

“It is in their interests, as well as those of UK graduates, that NHS recruitment policies are based on the realities of the job market, and these changes offer the opportunity for a much better managed system.”

Misinformed doctors The Department of Health and GMC have been attacked over the failure to educate overseas graduates about the realities of finding a UK based job - especially considering that over £350,000 is raised annually from PLAB exams fees.

In 2002 Sir Magdi Yacoub fronted a campaign by the NHS to recruit doctors from overseas. The aim was to attract around 1,000 specialists. The promotion failed with fewer than one hundred being recruited but it did lead to a surge of inexperienced international graduates who had heard of the doctor shortage in the UK. This caused applications to the PLAB to surge by over 70 per cent between 2001 and 2002.

Lord Warner did state that the DH would continue to work with the GMC to recruit a small number of overseas specialists: “We recognise that international doctors have made a huge contribution to the NHS since it was founded in 1948 and there will still be opportunities for overseas staff to come to the UK. We will continue to need small numbers of specialist doctors, who can bring their skills and experience to the NHS.”

> Your viewpoints “They DH did not consult anyone involved such as the BMA, Royal Colleges or overseas doctors. Is it because they don't consider them as valuable members contributing to the NHS?” Sudheer Surapaneni Psychiatry SHO St Ann’s Hospital, London

“This is a sudden, reactive and ill-informed decision that will affect thousands of doctors' careers and lives. It could also seriously affect the quality of patient care.”

Rahul Dev Staff Grade Medical Emergency Ward

> Key facts > 117,000 doctors currently working in NHS (increase of 27,417 since 1997) > There has been a 56 per cent increase in first year medical school places since 1997 > 6,500 overseas doctors passed the PLAB exams in 2005

trauma NHS

Knot possible: ties get axed LONDON Doctors and medical students have been advised to stop wearing ties in hospitals as they have been shown to spread ‘super-bugs’ such as MRSA and Clostridium difficile.

The BMA described ties as ‘functionless clothing items’ that were ‘rarely cleaned’. White coats also came under the spotlight from authorities.

The open-neck look has become increasingly popular with politicians such as Tony Blair and David Cameron, but research shows that the general public is not ready for a more relaxed look amongst the medical profession.

A paper published in the American Journal of Medicine concluded that doctors wearing ‘professional dress may favourably influence trust and confidence-building in the medical encounter’ when compared to

... though preferably alive and full of new ideas!

We’re recruiting the new ‘trauma’ team for the next academic year and we’d like you to be part of it. We’re looking for Editor Team Leader News Editor Feature Editor Webmaster Designer Distribution & Publicity Manager Reps (from each medical school) more relaxed attire.

Several medical schools encourage tucking in ties preserving the patient-doctor relationship.

Email editor@traumaroom.com for an information pack.

Rehman et al, 2005

Medical School Life

Med students on par with docs for cardiac LONDON Cardiac examination skills do not appear to differ among third-year medical students and qualified doctors, but may decline after years in practice, according to a study in the Archives of Internal Medicine this month.

Average competency scores of third and fourth-year medical students were significantly higher than those of first and second-year medical students. However, there was no difference in average score between them and practicing junior doctors. Cardiology trainees performed significantly better than all other groups.

The study at Stanford University School of Medicine, California, used a 50-question, computer-based multimedia test to evaluate the cardiac examination

skills of 860 students and doctors.

Participants took the test at one of 16 sites in the United States and Venezuela between July 2000 and January 2004.

“Cardiac examination skills do not improve after [the third year of medical school] and may decline after years in practice, which has important implications for medical decision making, patient safety, cost-effective care and continuing medical education,” the authors concluded.

“Improvement in cardiac examination competency will require training in simultaneous audio and visual examination in faculty and trainees.”

Arch Intern Med. 2006; 166: 603-604 www.jamamedia.org

PAIN RELIEF FOUNDATION

UK MEDICAL STUDENT

ESSAY COMPETITION 2006 The winner will receive a prize of £750 For an essay on an aspect of chronic pain, of not more than 3000 words The winning entry must be presented at the Pain Relief Foundation in November 2006 Closing date for entries is strictly 31 July 2006 Entry form available from: Brenda Hall, Pain Relief Foundation, Clinical Sciences Centre, University Hospital Aintree, Liverpool L9 7AL, UK Tel. 0151 529 5822, email b.hall@painrelieffoundation.org.uk www.painrelieffoundation.org.uk Registered Charity No. 277732

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trauma

Are sex hiding

Following the press furore over the numbe Britain's schools, Sinem Ayman asks Tim L about the situation within the health servi Ministers have been slammed for their complacency following the exposure of scores of sex offenders within our schools. But what’s the situation within the NHS? Health Minister Lord Warner was unable to answer the number of people working with children in the NHS who currently have cautions or convictions for sexual offenses.

An urgent review into sex offenders working within the education system is underway, but the Department of Health has given no such assurance of similar action is within the NHS. The Sex Offender Register has been in existence since 1997 listing the names and whereabouts of some 12,000 convicted sex offenders. Following the murder of Sarah Payne The News of The World, in a bid to enforce a US style ‘Megan's Law’, promised to publish pictures of each of the offenders until they had been outed.

Police chiefs petitioned the newspaper to halt its campaign, saying the publicity would only drive the offenders underground, where they would re-offend. As a result it was ruled it was not in the public interest for the Register to be made public; access rights were only granted to the members of a limited number of professions doctors being one of them.

However, as was exposed in The News of the World some doctors are more involved in the register than others - they're on it.

Drugs for sex Doctors intent on committing sexually acts within the NHS often use their status to exploit vulnera-

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ble patients. So called ‘Drugs for sex’ is doing for the medical profession what ‘cash for questions’ did for politics as the following case example shows:

> Case Example Mrs C J, a patient under Dr Rai's care, was prescribed diazepam, dihydrocodeine and chlormethiazole. She was dependent upon these drugs.

On the first occasion, Dr Rai attempted to kiss his patient and told her that if she ‘promised to go further’ with him, he would ensure she had an ‘adequate supply of drugs’. Manipulating the situation further, he reminded Mrs C J he also had the power to take the drugs away.

Shortly after this initial consultation, Mrs C J approached the doctor again for medication, on which Rai informed her he would not prescribe the drugs ‘unless she went further’ with him. Rai then ordered Mrs C J to perform oral sex on him.

(Extract condensed from GMC Tribunal)

The NHS is only beaten by the Peoples’Army of China in the title of the world’s largest employer.

Among this workforce of some 1.3 million there are known and unknown sex offenders. It’s something we have little information about and an area where it’s crucial to know more, feels Tim Loughton MP, Shadow Children’s Minister.

“We have asked the Secretary of State for Health, Patricia Hewitt, whether she is carrying out an investigation to determine

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x offenders in the NHS?

er of undisclosed sex offenders working in Loughton MP, Shadow Childrens' Minister ice and should patients be concerned. the number of sex offenders still employed within the health service but we've had no response that any such review is going on.”

Criminal records checks When we applied to medical school, and for doctors taking posts within an NHS hospital, criminal records checks are carried out to avoid the risk to patients. It seems, however, that many sex offenders are obtaining jobs despite these procedures.

“The Government stipulates that anyone coming into contact with children will have a CRB check, which we wholly support but the problem is that it’s uncertain with whom the responsibility of running the checks lies,” says Loughton.

With NHS cutbacks and overstretched medical personnel departments many doctors simply start posts without formal checks being carried out and simply get lost in the system. For locum doctors who work in hospitals but are employed through an agency the question of who is responsible for the CRB checks becomes even more complicated.

Keeping track of offenders There are numerous lists containing the names of people who pose a threat of which the largest is the Sex Offender Register listing some 29,000 names. There is also the Protection of Children Act Register which is supposed to cover the NHS, and the now infamous List 99 which names offenders caught working in schools.

Many however feel the numbers

just don’t add up.

“There’s an awful lot of people being missed,” feels Loughton. One concern is why the Protection of Children Act, which covers the NHS, isn’t as comprehensive as the Sex Offender Register.

> Role of

GMC

If a doctor has been found unfit to practice, the GMC, which licenses doctors to practise medicine in the UK has a number of options at its disposal.

It can: > Erase the doctor from the medical register. > Suspend the doctor’s registration for up to 12 months. > Place conditions upon the doctor's registration for a maximum of three years. > Record a public admonishment (reprimand) but take no action against the doctor's registration.

“All the headlines have concentrated on dodgy teachers, so schools have tended to be a more high profile area but that doesn't mean the problem does not apply to the NHS.” Loughton suggests a central list to which everyone can check against NHS staff. He feels the NHS is so fragmented with many services being contracted out that it adds to the confusion over whose job it is to run the vital CRB checks.

“PCTs, mental health and social care trusts are utilising more and more private contractors to provide their services, that’s why it’s absolutely imperative to

EXPOSED have one central list to which employers can refer to.”

No quick fix Despite pressure from the media and health minister it’s not a situation that Loughton sees a rapid solution too: “The Government can put into effect all sorts of protocols relatively quickly but in order for a proper vetting system to work, we need a system like that which is what envisaged under the Bichard Inquiry [set up after the Soham murders] recommendations,” he states.

“The Government has already started working on this but merely setting it up has already cost £54 million and it has been pushed back and back. We are many years away from a computer system where institutions can share information. The key thing is we need combined intelligence between the different authorities, not only between schools and education authorities but between hospitals, and social services and trusts as well.”

“Sex offenders are good at getting around the door so you have got to be one step ahead by maximising communication between groups. You’ll never get a full resolution because people who are hardened sex offenders are pretty clever at getting around the law and so some will not be caught.

Putting together a central list will hopefully allow us to catch a lot more, but the most important part of this is to give some assurance to

the public that when their child goes to see a health professional that they are seeing a health professional in safety,” says Loughton.

“Sex offenders are good at getting around the door so you have got to be one step ahead by maximising communication between groups. ” TIm Loughton MP Shadow Childrens’ Minister

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trauma Patients with a BMI over 30 are being refused joint surgery by a Sussex Primary Care Trust. It follows new NICE guidelines stating that patients’ lifestyles can be taken into account in determining if a treatment would be ‘clinically and cost effective’.

Is it ethical? Does it go against what we stand for as doctors? Michelle Connolly and Nicole Chiang asked those involved for their arguments.

Should obese people be banned from hip and knee replacement surgery?

Haslam - It is perfectly acceptable to 'ban' patients from any procedure if the risks outweigh the benefits. It's not a 'ban', rather a clinical decision not to operate. Hips and knees are no different; there is additional operative, anaesthetic and post-op risk in obese people.

Furthermore, the prosthesis is only under guarantee up to a certain weight and will not have as great a life-expectancy in an obese, compared to a lean, person.

What must be remembered, however, is that the decision to operate should always be clinical rather than financial, which is not the case in Suffolk.

Summers - We were shocked and thought it deeply unfair. Obesity can have a genetic grounding that is out of one's control. The decision to ban people from having operations should not relate to finance. Obese people pay taxes to fund the NHS just as the non-obese do and therefore everyone is entitled to the same treatment.

Keeble - It depends on what you mean by fair, and fair to whom. It could be argued that it is unfair on obese patients to say that they have to get their weight down before surgery, as this may delay

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surgery, but one could also argue that it is fair to them as it will hopefully reduce complications and increase the chance of success.

One could also argue that it is fairer to the wider community and the taxpayer to expect f r o m people a responsibility to society to increase their chance of the operation being a success.

Is it justifiable to impose such a ban on the grounds of cutting costs?

No. Only on clinical grounds. If the operation is not carried out on a fit person but on somebody with a BMI of 32, the hip will not improve on its own, it will deteriorate further. The patient is less and less likely to lose weight, due to increasing immobility, so the end result is the ‘hip from Hell’, which is more costly and complex to manage, when it inevitably is done by someone, somewhere, years down the line.

If an obese person is denied the operation on

Can pa be too fix financial grounds, will they get some of their tax refunded? Probably not!

Summers - If the Trust is

making the decision based solely on financial reasons then one must ask if their finances are organised properly? The governance of hospitals should be closely scrutinised and more care taken over the funds each trust receives from the Government.

Haslam -

In a BBC News Online article “Obesity patients were denied operations” you were quoted, Dr Keeble, as saying: "We cannot pretend that this work wasn't stimulated by pressing financial problems.” Would you like to elaborate?

Keeble - The health service in East Suffolk has substantial debts, projected at over £40m this time last year, so consultants and GPs decided we could not leave this problem to managers to sort out. We developed a clinical strategy to get the system back in to financial balance. Part of the strategy was to look at developing clinical thresholds for some surgical procedures. Our initial list contained 10 procedures but the press focused on hip and knee

replacement.

Under the East Suffolk rules, hip and knee replacement surgery will only be offered to obese people if their pain and disability is 'sufficiently significant to interfere with daily life and/or ability to sleep'.

Do you agree with the ruling?

Haslam That's OK, as it is a clinical definition, and is open to broad interpretation.

What worries you if such a ban is to be implemented in East Suffolk?

Haslam - It may spread geographically, and to other disease areas. Hip replacement is not a luxury, but an essential operation, what next? CABG banned in those with a BMI of 30+?

If you were to set the rule, on what basis will you entitle someone to hip and knee surgery?

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atients o fat to x?

Haslam - Purely and simply on clinical risk/benefit on an individual patient basis.

Dr David Haslam Chairman National Obesity Forum

Michael Summers Chairman The Patients’ Association

Dr Brian Keeble Director of Public Health Ipswich Primary Care Trust

“It may spread g e o g r a p h i c a l l y, and to other disease areas. Hip replacement is not a luxury, but an essential operation, so what next?

CABG banned in BMI 30+?�

Summers - I have some sympathy with this argument. It's unfair on the patient if they are to undergo an operation that has little chance of success. However, obesity is a disease and people with it should not be ostracised. Each case has to be looked at on its individual merits.

Dr David Haslam Chairman National Obesity Forum

Should obese people be forced to lose weight before undergoing surgery?

Summers - Yes, but only on

clinical grounds. There is also the moral argument that some people are large because they want to be like that, so making them lose weight could be seen as an infringement on their privacy.

What are the implications of this ban on patients, the NHS and doctors?

What do you say to the argument there's no point in letting obese people have replacement hips, as they'll only break under the weight?

Keeble - The implications for patients in the short term are delayed operations. In the longer term, we hope now that people in the area and their doctors are aware of these criteria, they may make more of an effort to get their weight down when they start to get symptoms. This will be good for

their general health and may even mean that they can avoid what is still a major operation.

approach sells papers, that the opportunity for such a mature debate never really materialised.

Should other PCTs adopt a similar approach?

Keeble - I have had several communications from PCTs across the country looking for more details on what we have done. By going public on this we helped to create the possibility for a mature debate to take place both about the responsibilities that people have for their own health and about what the NHS should and should not be funding. Unfortunately the media is so keen to sensationalise and criticise, presumably because they have worked out that this

11

trauma

Walking on all The family that walks on all fours was hailed as a scientific landmark and a point of contention for scientists all over the world. Discovered last summer in the south of Turkey, the three sisters and two brothers who walk and run on their feet and wrists were thought to be unique, the only human quadrupeds alive today.

However, since then others have been identified from Brazil to India - a discovery that has further intensified the scientific interest and controversy.

The Turkish siblings originally identified were heralded as evidence of an evolutionary link between our ape-like ancestors and the upright human beings we are today. However, scientific opinion remains divided over just what exactly is responsible for this four-limbed locomotion. trauma’s Fiona Kenny spoke to two leading researchers, Nicholas Humphrey, who believes the fourlimbed locomotion has a multifactorial grounding and Stefan Mundlos, whose team has recently published evidence of the genetic defect responsible for the family’s

12

unusual gait.

The original Turkish family Aged between 18 and 34, two of the daughters and one son have only ever walked on all fours. But the other two siblings are able to walk short distances upright, and all five are able to stand upright with their hands and knees flexed, albeit only for a short time.

The family is highly adept at walking on all fours and is able to move swiftly and easily up and down rough terrain. The calluses

on the palms of their hands are evidence to the length of time the family has used this locomotion, also known as a ‘bear crawl’.

Evolutionary psychologist Nicholas Humphrey, from the London School of Economics, spent time with the family at their home. The mother told him, “Everyone in our family did the bear crawl.”

Researchers have discovered that the parents, who are closely related and have 19 children in total, have handed down a unique genetic combination to the children. MRI scans show all five sib-

lings suffer from a rare form of cerebellar ataxia, largely due to hypoplasia. As the cerebellum controls balance, ataxics are unsteady and uncoordinated.

However, according to Professor Humphrey, “This condition cannot provide a sufficient explanation for the quadrupedality … there is a recent report of a young man with a congenital agenesis of the cerebellum that nevertheless learned to walk and ride a bicycle.”

Professor Humphrey believes the four-limbed locomotion to be the product of ‘extraordinary

trauma tinuing to walk some of the time.

Genetics and evolution

events involving a mutant gene and local cultural influences’.

And, without blaming the parents, he believes even the lack of parental influence to push the children to progress to walking was a significant factor. “They were accepting of the condition. The father thought his crippled children were a gift form Allah to test his love and devotion and his ability to look after disabled people.”

Seen in the BBC documentary ‘The family that walks on all fours’, a local physiotherapist was sent in to help the family walk upright. In the space of just a few hours the transformation was astonishing. Professor Humphrey said, “Their whole expectations had changed, they suddenly thought, we can do it after all.”

Reports from the local health service in Turkey have said even today several of the children, including the young man, are con-

The quadrupedal gait is not uncommon in children during the transition from crawling to walking but what is of significant note in this family is that they place all their weight on their wrists, splaying their fingers upwards thereby protecting them from damage.

Unlike our closest ancestors, chimpanzees and gorillas, this wrist walking allows the siblings to preserve the dexterity of the fingers so that the girls in the family are able to do fine needlework and crochet.

Some scientists believe the genetic mutation has caused the family to revert to some form of ‘backward evolution’ and this significant difference in gait illustrates the process of evolutional intelligence. Finger dexterity allowed hominids to use and manipulate tools, taking them that one step further towards modern day humanity.

But while Professor Humphrey does not believe the family are ‘literal throwbacks of evolution’ he said, “They could eliminate something about our past history. We have discovered a model for how our ancestors might have walked, one which anthropologists have not previously thought about.”

Stefan Mundlos, leader of the genetics team at the Max Planck Institute in Berlin also disagrees with such an idea, “Evolution does not go backwards. There is only one way into the future. However, mutations may result in the inactivation of a gene product that is necessary for certain steps in evolution and that thus may be able to destroy this evolutionary process.

This is called an atavism.”

Professor Mundlos’ team is conducting genetic analysis on the family’s DNA. He told trauma, “We have identified a locus on chromosome 17p which is highly likely to contain the gene for QL (quadrupedal locomotion) syndrome.” Using mutation analysis to identify this gene, Mundlos believes the gene will be “likely to encode a protein that is essential for brain development, in particular of the cerebellum.”

Both Humphrey and Mundlos acknowledge that the evolution of bipedality would have involved many genes and fine complex alterations, and agree that mutation in one gene cannot throw someone back into an earlier evo-

MRI scans illustrating cerebellar hypoplasia (arrows A & B), fourth ventricle enlargement (arrow C) and hypoplasia of the corpus callosum (B). lutionary stage. Professor Mundlos believes this single gene predisposes the family to a specific form of cerebellar damage which renders the siblings quadrupedal. But Professor Humphrey believes it to be more complex than a single mutant gene and that the involvement of “extraordinary cultural circumstances” is just as significant.

New cases Since ‘The family that walks on all fours’ was broadcast, Professor Humphrey has received numerous reports of other cases of quadrupedalism, contemporary and ancient.

He said, “We've seen photographs; all are hand walkers and look very similar, all with some form of cerebellar damage.” The genetic testing is currently being done on the Brazil group and Professor Humphrey said, “There are 30 or 40 genes already known which damage the cerebellum and my guess is that almost any of them might in this Turkish family produce the same outcome.”

He continued, “If it turns out that any or even all of the other families have the same gene which Professor Mundlos has located on chromosome 17p, it will suggest that there is a gene which specifically predisposes this family to be quadrupeds. It will be remarkable and I will eat my hat!”

“Evolution does not go backwards.

There is only one way into the future. However, mutations may result in the inactivation of a gene product that is necessary for certain steps in evolution and that thus may be able to destroy this evolutionary process.”

Stefan Mundlos Max Planck Institute, Berlin

The scientific world has now only to await the outcome.

Fiona Kenny

> References Professor Mundlos’ team’s work is published in the Journal of Medical Genetics: Turkmen et al (2006) Cerebellar hypoplasia and quadrupedal locomotion in humans as a recessive trait mapping to chromosome 17p. J. Med. Genet. 43: 461-464.

Professor Nicholas Humphrey London School of Economics Images kindly reproduced with permission.

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trauma

Karol Sikora On cancer, private medical schools and Snoopy mugs

Professor Karol Sikora was one of the first doctors to contradict general medical opinion and advocate alternative therapy in cancer treatment. He is regarded as one of the world's leading minds on cancer care and Britain's most outspoken and controversial doctor, he was also not quite what trauma's Natasha Murray was expecting when they met.

“I have no hobbies whatsoever but I do like trains! I was Father Christmas on the ‘Santa Special’ train and my daughters were my little helpers!”

Sikora is a fresh-looking, slight and particularly dressed man uncontaminated by the lethargy, which by his own admission, has infiltrated other senior medics of his generation. Far from the nerdy train-spotter his Press comments might suggest he appears animated and sincere and obviously loves his job: “I am happiest when I am working,” he smiles, sipping from a child-sized ‘Snoopy’ mug, “My wife understands that.”

His CV is a multitude of accolades with distinctions such as chief of the World Health Organisation Cancer Programme, professor of cancer medicine at Imperial College and senior advisor to several major pharmaceutical companies. Sikora’s work has

“Medical school selection has become so ‘socially engineered’ and political. I think the medical profession has lost the ‘nice bit’ of medicine, I think we need to try and retain a bit more of the ‘Dr Finlay’ approach.”

14

been fundamental to recent advances in cancer research and he has written several books on modern patient care.

The son of a Polish army captain and a Scottish schoolteacher, as a child Sikora launched homemade rockets from his backyard.

The premature death of his father just after hearing his young son had won a place at Cambridge meant a scholarly student life: “I lived at home with my mother and commuted in, so I wasn’t involved in the ‘drinking in the school bar’ kind of thing.”

The loss of his father to lung cancer, aged just 56, also had a massive effect on his career: “I realised I wanted to do something that involved a serious illness, and had a scientific base that was likely to change over my lifetime: both those things are true about cancer. Unfortunately, the speed of change in cancer and the clinical benefits has not been as fast as one would have predicted 30 years ago.”

Private Medical School Dean Ever controversial, Sikora has recently made the papers as he embarks on new crusade to, as he puts it, ‘dramatically diversify medical school entry’ as Dean of Britain’s first private medical school. Even with the recent opening of three new government funded medical schools it is something that Sikora feels passionately about: “Medical school selection has

become so ‘socially engineered’ and political. I think the medical profession has lost the ‘nice bit’ of medicine, I think we need to try and retain a bit more of the ‘Dr Finlay’ approach.”

Selection is limited to graduate applicants only and will occur over a gruelling two days. “We want students who are determined, motivated and capable. Our typical student would be in their twenties or earlier thirties who has had a bit of life and business experience,” Sikora explains. “We are just as willing to take a student with a degree in Anglo-Saxon history as one who has studied pharmacology, as long as we are convinced of their passion for medicine, and their intellectual capability.”

The Royal College of Physicians recently published a report suggesting that medical schools should move away from using top grades in science ‘A’ levels as the primary selection criteria, recommendations which are reflected in Sikora’s method. “A good doctor needs the ability to listen to his patient, and to understand what the patient is worried about. Medicine is more often not a technical exercise, and is about allowing the patient to express their worries and leave the room feeling satisfied … in the allotted time of course. Often these skills are innate and cannot be taught.”

A geek with the human touch Professor Sikora is a living, breathing oxymoron - a man with a

“We are just as willing to take a student with a degree in AngloSaxon history as one who has studied pharmacology, as long as we are convinced of their passion for medicine, and their intellectual capability.”

PhD in molecular biology whose work into gene therapy will revolutionise oncology, but says that doctors must rely less on technology. He is a man who, as a student canvassed for Harold Wilson, yet about to open a medical school charging an estimated £10,000 a year in fees, way out of financial reach of most applicants. He talks about training business-savvy students who will understand what makes the NHS tick, but is concerned that future medics will become merely technicians herded by financial managers. He is an avid train-spotter, but one with social skills. Yet despite his contradictions, Sikora does practice what he preaches. I leave after my allotted hour feeling satisfied and pleased that I had met a rare anomaly, a science geek with the human touch.

trauma Most people, with the exception of fishermen and extreme animal lovers, will be disgusted by the thought of maggots crawling onto their skin. You can instantaneously conjure up an image of a rotting body plagued with flesh-sucking creepy crawlies. In fact, myiasis is the very term given to the ‘infestation of live humans and animals with dipterous larvae which feed on the host’s dead or living tissue, liquid body substances or ingested food’. But as Amilia Youkhana explains, despite its ickiness, maggot debridement therapy (MDT) could be a significant part of the management of chronic inflammatory processes such as wounds, ulcers, burns and even necrotic tumours.

Chronic wounds and skin ulcers have always been difficult to treat. One important example is that of diabetic foot ulcers that frequently result in amputation.

Numerous observations of soldiers at war in past centuries have shown that wounds accidentally infested with maggots not only healed quicker but also appeared to protect the host from acquiring septicaemia. Since the late eighteenth century, studies of controlled, sterile management of infected wounds, abscesses and osteomyelitis with MDT had been successful and popular until the introduction of antibiotics and aseptic techniques in 1940’s, where it was used only as a last resort. Interest in the little creatures has grown recently because of the emergence of antibiotic resistant microorganisms - MDT can reduce the risk of acquiring an MRSA-related illness.

Certain species of larvae, particularly the green bottle blowfly (lucilla sericata), feed on necrotic tissue only and don’t invade internal organs or break away from each other. They provide a useful method of removing necrotic tissue that would normally impede new tissue formation. They also release exudates containing certain proteolytic enzymes and chemicals such as allantoin, ammonia

and calcium carbonate that act as antimicrobial agents and possibly as growth factors to encourage wound healing. Some believe that the physical effects of the crawling maggots and sucking of debris and bacteria also assist in these processes.

It is recommended that

“The latest technological instrument in the surgeon’s tray can be bought from your local angling shop.” between five and ten maggots are used per centimetre squared of wound and up to 1000 maggots can be introduced into the wound at any one time. They are kept in place via hydrocolloid dressings (double layered and designed to allow oxygen in and exudates and debris out) and are usually left for three days. A number of applications may be needed depending on severity of the wound and the amount of necrotic tissue removal desired. MDT is mostly used on chronic, external, non life-threatening wounds, where other interventions have failed, and has even been successfully used for necrotising fasciitis and other situations where surgery would have been risky.

Candidates should be chosen with care. Those with a purulent, sloughy, skin lesion that is resistant or not completely responsive to treatment will benefit from MDT. It can be used alone (important when costs need to be kept minimal) or supplementary to medical or surgical treatment. Although studies are difficult to accurately evaluate and compare, it has been observed that in 80-95 per cent of cases most or all debridement is removed via MDT. There is substantial evidence to advocate the use of larval therapy in chronic leg/pressure/venous stasis ulcers, diabetic foot wounds, traumatic and post-surgical wounds and even burns or necrotic tumours. MDT is simple, cost-efficient, effective and rapid, without any known side effects aside from itching/tickling sensations felt by some patients. It is becoming more and more popular in hospitals across the globe, and as our knowledge increases, will probably open the doorway to more unconventional forms of medical treatment.

(1) "Myiasis: The Rise and Fall of Maggot Therapy", D. Morgan, Journal of Tissue Viability , 1995, 43-51, 5(2)

Pros • Simple and fast.

• Cost-effective, especially in third world countries.

• Decreases chronic wound healing time and efficiency • Eliminates odour of necrotic tissue.

• Reduces morbidity and mortality by preventing infection of the wound.

• An alternative to medical/surgical methods that have failed or are unsuitable for the patient.

• No side effects reported apart from slight physical discomfort.

Cons • Disgust/revulsion/other psychological distress.

• Pain/tickling/itchiness.

• Fear of maggots escaping/ burrowing into skin/maturing into flies (in fact, this is not true as mature larvae need to leave the wound to turn into pupae and then adult flies).

• Potential allergic risk (although none has been reported thus far).

• Require an experienced clinician to select and sterilise the right species of maggots.

Maggots - Taking the bite out of wounds 15

trauma

1 A FRIEND IN YOUR POCKET FOR EVERY SITUATION

Find out about many more Oxford Handbooks at:

www.oup.com/uk/medicine/handbooks

When scientis get bor

trauma

sts red

Sitting in a lab all day can be a pretty dull job. If you’re one of the world's smartest brains that idle time can be a dangerous thing. You begin to start thinking about those things that the rest of us never worry about, like the pressures produced when penguins poo, or the forces required to drag sheep over different surfaces.

Luckily, there are awards to be won for all that weird thinking. Michelle Connolly gives us the lowdown on the recent Ig Nobel Awards visit to Britain.

If you want to read about weird and wacky research then the Annals of Improbable Research is the place to start. The journal’s popularity is soaring as more of the world’s most respected scientists vie to fill its pages. It’s not just the accolade of having your paper on the homosexual habits of necrophilic ducks published - the best research is recognised at the annual Ig Nobel Awards too.

Held at Harvard University the awards ceremony isn't your average ‘A’ list champagnequaffing, canapé-gobbling affair either. A succinct “welcome, welcome” suffices for an introduction speech and an eight-year-old ‘Miss Sweetie Poo’ keeps proceedings moving at a rapid pace by greeting any acceptance speeches deemed to be too long with shouts of “I’m bored, I’m bored!”.

Both the magazine and the awards are the brainchild of Marc Abrahams, a Harvard math graduate who, in 1991, decided achievements ‘that cannot or should not be reproduced’ must be acknowledged. Abrahams brought the Ig Nobels on tour to the UK in March and trauma caught up with him after the London show to find out more.

> Previous Winner The 1993 prize for literature was awarded to the 973 coauthors of a brief research paper in the New England Journal of Medicine. There were 100 times as many authors as pages.

As Abrahams acknowledges there’s often a little confusion between the Ig Nobels and a real Stockholm approved Nobel Prize.

He is certain the Swedish capital would see the funny side, even when it comes to using the word ‘Nobel’. “We tried to be careful that no-one would ever confuse it, but this is a world full of confused people so I’m sure some people still don’t get it.”

“By merely existing, the Igs make the Nobels shine all the more brightly, and real Nobel laureates have even been involved.”

> ‘Homosexual Necrophilia in the Mallard Duck’ Kees Moeliker, Rotterdam’s Natuurmuseum Actual Nobel Prize winners often present the handcrafted Ig Nobels to the plucky winners.

The awards, now in their 15th year, weren’t too difficult to start either. “It was surprisingly easy,” says Abrahams.

“MIT [Massachusetts Institute of Technology] gave us a beautiful place to hold the ceremony. We announced the Ig Nobels would be held one Thursday in October and that tickets would be free; all 350 were snapped up instantly.

Word got about and some quite eminent scientists came forward to hand out the prizes at the ceremony, wearing the strangest hats.”

> Previous Winner Medical students on having bought second-hand textbooks might find Silvers & Kreiner's paper on “The Effects of Inappropriate Pre-existing Highlighting on Reading Comprehension” applicable.

With such bizarre and farfetched research it’s often surprising how scientists obtain funding for their projects. Much of the research is done out of the scientists’ own pockets when they really do get bored of pipetting, says Abrahams, but “a surprising number of projects are indeed funded by industry”. A paper on ‘The effect of Star Wars on locust brain activity’ was actually funded by Volvo, and a paper on the flatulence of herrings was funded by the Navy, who in fact requested the research.

Surprisingly it’s not the Americans that dominate the Ig Nobel laureates. “Actually, the largest number are from the United Kingdom,” states

Abrahams - a fact that has annoyed some big cheeses in the British scientific world. Former chief scientific advisor to the Government, Robert May, even wrote to Abrahams demanding he stop awarding British scientists Ig Nobels, even if they wanted to receive them. “Perhaps he was just having a bad day,” quipped Abrahams.

After fifteen years of awards Abrahams has seen many examples of bizarre science. A study published in The Lancet, entitled ‘A man who pricked his finger and smelt putrid for five years’ was a strong contender for his favourite but that goes to a paper about ducks.

A Dutch museum curator was the proud recipient of the 2003 biology prize for his paper on ‘Homosexual Necrophilia in the Mallard Duck’. Kees Moeliker witnessed the death of a male mallard after it crashed into the window of Rotterdam’s Natuurmuseum. A second male duck, thought by Mr Moeliker to have pursued the deceased duck, mated with it for 75 minutes, constituting the first observation of homosexual necrophilia in the male duck.

For more examples of weird and wacky science, go to www.improbable.com

Marc Abrahams Ig Nobels Founder

17

trauma Humour

Humour

The new NHS Patients’ Behaviour Charter 1. Try to suffer from the disease for which you are being treated.

Remember that your doctor has a professional reputation to uphold.

Things you don’t want to hear during surgery “Stop! Come back with that! Bad Dog!” “Wait a minute, if this is his spleen, then what’s that?”

“Better save that. We’ll need it for the autopsy.”

“Everybody stand back! I lost my contact lens!”

“FIRE! FIRE! Everyone get out!”

“Damn! Page 47 of the manual is missing!”

“I hate it when they’re missing stuff in here.”

2. Do not expect your doctor to share your discomfort.

Involvement with the patient’s suffering might cause him to lose valuable scientific objectivity.

3. Be cheerful at all times. Your doctor leads a busy and trying life and requires all the gentleness and reassurance he can get.

4. Never die while in your doctor’s presence or under his direct care. This will only cause him needless inconvenience and embarrassment.

5. Never reveal any shortcomings that have come to light in the course of treatment by your doctor. The patient-doctor relationship is a privileged one and you have a sacred duty to protect him from exposure.

6. Never ask your doctor to explain what he is doing or why he is doing it. It is presumptuous to assume that such profound matters could be explained in terms that you would understand.

> Caught on camera

“Ya know, there’s big money in kidneys ... and this guy’s got two of ‘em.”

“Could you stop that thing from beating; it’s throwing my concentration off.”

“What’s this doing here?”

“Sterile, shcmedle. The floor’s clean, right?”

“Don’t worry. I think it is sharp enough..”

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HANDY CASH £2.75 is the net worth of a human’s most valuable body part - their skin. The average person has 14 to 19 square foot of skin, enough at today’s commercial cowhide rates to put almost 3 quid in your pocket - but only if it’s cut and dried first!

Gavin Topham

“Hand me that ... uh ... that uh.... thingie.”

trauma Review

Trauma Top Center: Under the Knife

non-medical medical books

5

Want to be a surgeon but don't want to get your hands dirty? Then Trauma Centre : Under the Knife may be what you've been waiting for. This animeinspired story-cum-puzzle surgical game makes use of the Nintendo DS's touch screen - you get hands-on surgical experience without ever having to struggle with your theatre gown.

As a knowledgeable medical student you'll notice straight away it doesn't score high on the realism stakes - the first operation is on the upper right brachium and uses a special green antibiotic gel which automatically heals small wounds. Despite this, it’s a whole lot of fun as you become more proficient in the art of ‘digital touch-screen surgery’.

You are Dr Derek Stiles, a relatively inexperienced surgical trainee, with a rather insouciant attitude. Then, your carefree approach almost costs one of your patients his life and you question whether you’re fit to be a surgeon after all.

Suddenly an emergency patient comes in and there’s only one doctor available you. With your exceptionally rare ‘Healing Touch’ power you manage to save the day.

The game follows a story format and as you progress and develop the character and his expertise. You’ll come across such problems as GUILT viruses (Gangliated Utrophin Immuno Latency Toxin) and medical terrorism. The story is told on the top screen and you complete all your operations on the touch-screen. You have up to 10 instruments to play with, including the stand a r d > A surgeon’s view sutures, a scalpel and forceps, and the slightly more bizarre such as a magnifying glass, vitals serum and massage glove.

Generally the operations are straightforward but sometimes they can become a little difficult to complete in the 5-minute time limit.

Nonetheless, this game is original and entertaining enough to keep you persevering and coming back for more - if you finish the story you can always redo previous operations in the challenge mode to see if you realGood fun! Another life saved ly are the eminent surgeon you claim without even washing my to be. hands! Attractive and obedient nurses come as a bit of a Summary: Fun and original, surprise. but sometimes way too hard.

Mr Anderson, Consultant Colorectal Surgeon, Arrowe Park Hospital, Merseyside

The House of God Samuel Shem (Black Swan) £7.99 Despite being nearly thirty years old this is the original pain, suffering and soul-destroying “life as a first year doctor” book. Hilarious, yet gut-wrenching at points it’s easy for any doctor to relate too. Although American and a touch over-dramatic at times it’s up there with the ‘Cheese & Onion’ for essential books that will shape your career.

Complications: A Surgeon’s Notes on an Imperfect Science Atul Gawande (Profile Books) £8.99 A beautifully written book that celebrates doctors for being humans too - and not always making people well. Atul Gawande was a surgical doctor in Boston and later went on to write for the New Yorker. He describes intimately his feelings as a surgeon and some insights into his fears facing surgery in the future.

Cynical Acumen: The Anarchic Guide to Clinical Medicine John Larkin (Radcliffe) £19.95 Described by the author as “The Hitchhiker’s Guide to Medicine” it deals with the more ‘practical’ aspects of being a doctor. Relating diverse aspects like cooking and religion to passing the MRCP it’s uniquely funny and surprisingly educational.

Bedside Stories: Confessions of Junior Doctor Michael Foxton (Guardian Books) £7.99

a

A compilation of Foxton’s columns in the Guardian over the course of two years. A bit of a rant at the failings of the NHS and the expectations of being a doctor but pretty hilarious at the same time.

Emergency!: True Stories from the Nation’s ER Mark Brown (Saint Martin’s Press) $7.99 Shocking, hilarious and explicit. Mark Brown collected the most tragic, inspiring and downright bizarre stories from ER physicians across the US. This is a compilation of over a hundred of the best. Laugh out loud funny and tear-jerkingly inspiring.

Talha Patel

19

Keeping out of trouble on the wards

by Annmarie McTigue – Writer, MPS

Whether you’re starting your first or final year of medical school, the chances are you’ll have some contact with patients. Some students begin working with patients from virtually the start of their courses, while for others it may be as late as their fourth year. At MPS, our medical school representatives and medico-legal advisers answer queries from students who are nervous about how to handle tricky situations involving patients.

Here’s a quick guide to keeping out of trouble on the wards.

Be prepared The general consensus is that you’ll get plenty of support from your school – so take advantage of it. Read your guidebook for advice on what to wear, how to approach and communicate with doctors, nurses and other hospital employees, and how to examine and take histories from patients.

Make the meetings Make sure you go to any introductory lectures and inductions; these meetings will probably address many of your concerns, but also offer an opportunity to ask any other questions and find out who you should contact if you experience a problem.

Take notes Keep a notebook to hand – there’ll be a lot to take in and remember.

Ask for help Speak to your supervisor or ward-based teacher if you have any concerns or are unsure about any task assigned to you.

Intimate examinations and chaperones Most patients feel embarrassed or unsettled by the lack of dignity an intimate examination involves, and they might not understand why it’s necessary to examine a particular part of their body when their symptoms are in a different area. Someone feeling vulnerable can easily misinterpret another’s actions as threatening or intrusive, so try your best to put them at ease. By explaining the reasons for examining that part of their body, warning of any discomfort or sensations they might feel, and giving them a chance to ask questions, you can avoid any potential misunderstandings that could lead to a complaint.

It is unlikely that you would be asked to do an intimate examination on your own, but if you find yourself in this position you must offer to find a chaperone and ensure the patient understands fully what you are proposing to do and why. For advice on why and when to use chaperones, see Casebook, May 2004, pages 13-14 at www.mps.org.uk.

Confidentiality You have a duty to ensure that information about a patient’s health and their healthcare is only available to those involved in their care.

Do not leave medical records/notes lying around.

Do not be indiscreet with patient details on ward rounds or on breaks.

Consent Consent is not an isolated event or a form; it is a process to be gone through with a patient. It involves explaining clearly and honestly what will happen and all the uncertainties, then ensuring that the patient understands and has the time to ask questions. If you have no knowledge of a procedure and are not capable of undertaking it, then you should not obtain consent from a patient for that procedure.

Your NHS trust will have a consent policy and you will be shown how to take consent properly.

See the MPS factsheet Consent – an Essential Guide for Students (www.mps.org.uk/essentials or e-mail student@mps.org.uk)

Tips from current medical students ‘Be confident, speak clearly and smile; a smile goes a long way to making patients feel more relaxed, especially when faced with a ‘hot off the press’ med student.’

‘Introduce yourself as a medical student and if they ask you difficult questions repeat this, reassuring the patient that their doctor should be able to answer any questions they may have.’

‘Get down to the patient’s level; it’s not pleasant when someone towers over you, especially if you’re worried about your health. Ask them if you can sit on the side of the bed or pull up a chair – this is often a useful ice-breaker.’

‘If you encounter a question or situation that you cannot deal with, don’t try and blag it – stress that you are a student and don’t be shy to ask for help.’

To join MPS FREE today

CALL 0845 900 0022 and get your FREE Student Membership pack