trauma-iss20

magazine

T al he ls m tu ag de az nt in do e f ct or or s

Journal Review The latest medical updates

Mnemonics Help with taking a history

Flying doctors Good samaritan acts at 30,000ft

trauma traumaroom.com UK edition

Issue 20

Starting med school guide

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Imagine it all coming together.

Some of your favourite textbooks now available on STUDENT CONSULT include: Davidson’s Principles and Practice of Medicine, 20th Edition NEW EDITION Boon, Colledge, Walker and Hunter If you are a student with a deadline or ward round looming and need access to the most reliable information on clinical medicine, you can depend on Davidsons.

‘’If you buy one textbook of medicine it has to be this one’’ 5th Year Edinburgh Medical Student.

0443100578 • 9780443100574 • June 2006

Gray’s Anatomy for Students Drake, Vogl, Mitchell “Gray’s Anatomy for students...comes with colourful diagrams, and...readable text. The book is separated by region, and at the end of each chapter is surface anatomy and a few clinical cases. Scattered around the book are boxes entitled ‘In the Clinic’, which gives useful information like locating pulses... A good clinical focus.”

MAD magazine, the official journal of Barts and The London Students’Association 0443066124 • 970443066122 • October 2005

Great textbooks with a great advantage...

Wheater’s Functional Histology: A Text and Colour Atlas, 5th Edition Young, Lowe, Stevens, Heath

NEW EDITION

“A color atlas and text worth every penny because it will surely be referred to again and again.”

Life Science Book Review* review of last edition

STUDENT CONSULT titles are the core textbooks you need combined with the technology you expect. When you purchase a title with STUDENT CONSULT, a unique pincode unlocks online access with many valuable tools and bonus

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Immunology, 7th Edition Male, Brostoff, Roth, Roitt

NEW EDITION

“This book is in an easy to read format, colour diagrams

trauma

Time for the bandages to come off

Editor-in-Chief Ashley McKimm

Editorial Botox jabs, collagen implants and facelifts are all the rage these days so we thought we’d get some surgical enhancement ourselves over the summer. As you can see from our new design we’ve had a bit of a facelift but it doesn’t stop there ... we went for the full supermodel treatment this time!

Over the next few weeks we’ll be launching our upgraded website at www.traumaroom.com. It’s packed with new interactive features, revision resources and an archive of all our past articles - plus we’ve kept your existing favourites like free email too.

We’ll now also be updating our articles and medical school news every few days online so there’s more reasons to stop by between

Editorial Team Michelle Connolly GKT

Muhunthan Thillai Chelmsford

Richard Partridge Southampton

Gillian Fortworth Bristol

James Cohen London

Ashley McKimm trauma Editor-in-Chief

Newsdesk news@traumaroom.com Printing partners Witherbys, UK Advertising & Production Rob Peterson Tel - 020 7684 2343 ads@traumaroom.com

trauma Magazine PO Box 36434 London EC1M 6WA

Triage

Presenting History trauma is a free distribution magazine for the UK’s medical students.

You can find us in free in medical schools and campuses throughout England, Scotland, Wales and Northern Ireland, and online at traumaroom.com.

checking your Hotmail and buying the latest pathology book online.

And with the aid of chat rooms and discussion boards you’ll be able to interact with the site and other students. trauma is your community and we want you to be involved.

Whether you use the magazine to keep your hair dry on the sprint from lectures and the student union or simply as a beermat - we hope you enjoy it as much as we do producing it - though it’d be nice to hear that you read it occasionally ;) See you online at www.traumaroom.com!

Ashley McKimm trauma Editor-in-Chief

> What’s on the inside Is there a doctor on board?

Good samaritan acts at 30,000ft Page 8

Tel - 020 7684 2343 Fax - 087 0 130 6985 info@traumaroom.com

Latest News Page 4

Health warning trauma 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 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.

Get involved We’re always looking for keen medical students 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 traumaroom.com for more information and ways to get involved.

Medical Mnemonics Get help taking a history Page 14

> Reps Aberdeen Irene Wells Barts/London Mansum Ng Abi Norman Belfast Rosemary Reid Birmingham Ambereen Khan Brighton and Sussex Ameev Patel Bristol

Sheila Frisken GKT Shrabani Talukder Hull/York Fran Hazelton Mark Kavanagh Cambridge Imperial Kai Yuen Wong Hanieh Shirafkan Cardiff Leeds Fiona Kenny Nishant Pandey Derby Jonathan Lancashire Leicester Kirsty Lloyd Dundee Rosamund Simmons Liverpool Helen Richards Glasgow Manchester Alison Howarth Nasir Saeed Edinburgh

Secret Diary A cardiology SpR opens her heart Page 16

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Get Fresh!

Our freshers guide 2006 Page 10

Veer Vithalani Lesley McKee St Georges Laurine Hanna Warwick Stephanie Shayler Bil Salman UEA Michael Livingston

These are the fine people who help get this magazine to you through rain, storm and OSCE exams. We want to thank them for their help and would encourage you to get involved too. Check out our website for more information.

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trauma The Pulse

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

Medical Students

Almost half of US med students report harassment “Sure, we all feel harassed at some point but it's something we come to expect training as a doctor. I don't think it's any worse than in other professions.”

Will Haig University of Minnesota

NEW YORK Nearly half of US medical students report harassment during their training and four out of five feel belittled, according to a study published in this month’s BMJ. Students who reported harassment or belittlement were significantly more likely to be stressed, depressed or drink alcohol. They were also less likely to report positive ideas about becoming a doctor.

By their senior year a total of 42 per cent had felt harassed and 84 per cent belittled in the course of their training. 21 per cent of students described harassment from clinical professors and 25 per cent felt harassed by patients. Only 13 per cent however classified these results as severe.

“It’s a trend that has continued from medical training of decades ago,” says Will Haig, of University of Minnesota Medical School.

“Sure, we all feel harassed at some point but it’s something we come to expect training as a doctor. I don’t think it’s any worse than in other professions.”

The survey of over 2,300 medical students looked at whether they had felt harassed or bullied by doctors, patients or other students.

Information was collected anonymously and spanned 14 medical schools.

Katie Mellor, Leeds Experiences of belittlement and harassment and their correlates among medical students in the United States: longitudinal survey. Erica Frank, Jennifer S Carrera, Terry Stratton, Janet Bickel, and Lois Margaret Nora. BMJ 2006 333: 682

> Key facts > By their senior year a total of 42 per cent had felt harassed and 84 per cent belittled in the course of their training.

Junior Doctors

Shift rotas linked to increased risk of traffic accidents in junior docs 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 regis-

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trars 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 consecutive 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 per cent 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 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, BSMS

trauma Doctors have warned of the risk of using mobile phones outdoors during stormy weather in this month’s BMJ. It follows a 15 year old girl who was struck by lightning in a London park whilst using her mobile. When someone is struck by lightning the high resistance of human skin results in lightning being conducted over the skin without entering the body, explained the authors. Using a conductive material, such as a mobile phone, disrupts the flashover and results in internal injury with greater death rates. http://www.bmj.com/cgi/content/full/332/755 6/1513

More time for tea Adults in Japan who consumed higher amounts of green tea had a lower risk of death due to all causes including cardiovascular disease, according to a study in JAMA this month. But there was no link between green tea consumption and a reduced risk of death due to cancer. Those who consumed five or more cups a day had a risk of all-cause mortality that was 26 percent lower during the seven years of follow-up.

JAMA. 2006;296:1255-1265

New deposit account UK Biobank, a futuristic medical project aimed at improving the prevention, diagnosis and treatment of cancer, heart disease, diabetes and other serious conditions was launched this month.

The £61 million project will gather, store and protect a vast bank of medical data and material that researchers will study in decades to come. The aim is to understand how the complex interplay of genes, lifestyle and environment affect our risk of disease. It aims to eventually recruit half a million volunteers aged 40 to 69.

Sniffing out sepsis The University of Manchester has received £1m to develop a new device able to ‘sniff out’ harmful infections. The funding will be used to create a non-invasive wound monitor to treat patients with severe burns, skin ulcers or gaping wounds. When bacteria metabolises inside a wound, molecules of that bacteria are emitted into the air. Using state of the art sensors they hope to be able to detect and diagnose the presence of an infection almost instantaneously.

The NHS

Sports doc shortage for 2012 Olympics 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

The Pulse

Lightning Callers

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, Liverpool

Patient Care

Making medical errors causes burnout and depression CHICAGO Doctors who believe they have committed a major medical error in the last three months are more likely to report symptoms of burnout and depression, which may increase the risk of future errors.

The results of the study, published in the Journal of the American Medical Association (JAMA) showed that those who reported an error experienced substantially higher levels of burnout and were three times more likely to display the indicator signs for depression. The survey looked at doctors prospectively from qualification at quarterly intervals.

“In addition to the obvious negative effects of errors on patients, studies have shown that the physicians involved often experience shame, distress and depression,” says Dr Shanafelt the lead clinician in the study.

Almost 15 per cent of the 104 participants reported making an

error in the previous three months.

The connection between errors and the levels of distress also worked in reverse with those scoring high on burnout twice as likely to report an error in the next three months. They also found a trend towards increased future errors for physicians with symptoms of depression.

“Not only are physicians who perceive they have made errors more likely to experience burnout and symptoms of depression, but those who are distressed appear more likely to make an error in the next three months,” says Dr. Shanafelt “Much of the quality improvement movement has rightly focused on adjusting systems to prevent errors,” says Dr Colin West, one of the reports’ authors.

“It’s important to do whatever we can in the practice environment and care system to build in safeguards, but our study highlights the human dimension. If a

> Key facts > Those who reported an error were three times more likely to display the indicator signs for depression physician is experiencing personal distress, it makes a future error more likely. Making an error also has a strong effect on burnout, empathy and depression, and this forms a vicious cycle that can negatively impact patient care.”

Association of Perceived Medical Errors With Resident Distress and Empathy: A Prospective Longitudinal Study JAMA, September 6, 2006; 296: 1071 - 1078.

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trauma Patient Care

The Pulse

Sweet Dreams

Calls to kick rugby scrums into touch NOTTINGHAM Calls for contested scrums in rugby union to be banned have been made in the BMJ this month.

James Bourke, consultant surgeon and honorary medical officer to Nottingham Rugby Football Club, made the recommendations after experiencing six serious spinal cord injuries related to the contested scrum in his 30 years service.

In Australia no acute spinal cord injuries have occurred in rugby league since contested scrums stopped being allowed in 1996. “An incident involving two young players who are now wheelchair dependent occurred recently

in my experience in rugby union and have caused me to change my opinion on contested scrums,” says Bourke. “The consequences of injury are so great that the continuing risk of injury cannot be accepted.”

He believes rugby union should follow the example of rugby league in Australia and ban contested scrums. “Rugby union outlawed the ‘flying wedge’ and the ‘cavalry charge’ as they are potentially dangerous. It should now also outlaw the contested scrum,” he concludes.

6

Drinking is dangerous

Patient Care

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 per cent of the public stated that they trusted doctors, closely followed by teachers at 88 per cent.

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 having access to an increasing

Hum Psychopharmacol Clin Exp 2006; 21: 1-5

BMJ; 332: 1281;doi:10.1136/bmj.332.7552.1281

The NHS

> Key facts > 92 per cent of the public stated that they trusted doctors.

Journalists polled lowest at just 19 per cent. 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, KCL

Feeling sleepy? Don’t have a high sugar, low caffeine drink - it could make things worse, according to a study published in Human Psychopharmacology: Clinical and Experimental. The study of volunteers at Loughborough University found that an hour after consuming a high sugar, low caffeine drink they had slower reactions and experienced more lapses in concentration than if they had simply drunk a decaffeinated, nil carbohydrate drink.

Empowering patients LONDON Patients are to be given more power and say over how their local health services are organised and run, under new proposals launched by the Health Secretary Patricia Hewitt.

Under the plans Primary Care Trusts (PCTs) will for the first time be required to formally respond to public petitions if more than one per cent of the local community are unhappy with a particular health service. They also plan to put patients ‘at the heart of the decision making process’ when commissioning new services.

The changes will build upon the existing ‘patient forums’, of which there is currently one in each trust, by establishing new groups called ‘Local Involvement Networks’ (LINks). The DH hopes these will have more clout to influence services both in hospitals and the community.

PCTs will also be expected to publish a set of prospectuses that set out an assessment of the local needs and quality of current services, patient satisfaction levels and plans for future investment.

Drinkers are up to four times more likely than non-drinkers to be hurt from physical injuries such as a fall or punch, research from the University of Queensland shows.

The study published in the BMJ found that any alcohol consumption quadrupled the risk of injury for the first six hours and the risk remained at 2.5 times that of a nondrinker for the next 24 hours.

Quantity and specific drinks such as beer or spirits did not increase injury risk but mixing drinks increased injury five-fold. http://www.uq.edu.au

Better health step by step 100,000 pedometers costing £3 each are to be given to people who want to ‘get active and take the first step on a road to a fitter, healthier lifestyle’. The scheme is run jointly by the Department of Health and the Countryside Agency. “GPs and nurses will be trained to advise people on how to get the most out of their pedometer by setting goals on the road to becoming active,” said Caroline Flint, Public Health Minister. http://www.doh.gov.uk

Poor and accident prone Children from the poorest families in England and Wales face greater risks of dying from injury than children in all other social groups, according to a study published in the BMJ. The death rate for children belonging to the longterm unemployed was 13 times that for children of higher managerial and professional occupation parents. Inequalities were highest for pedestrian and household fire deaths. http://bmj.com/cgi/content/full/333/755 8/53

trauma

A tablet a day keeps the doctor away ALBERTA Patients who take their medicine regularly, even a placebo, have a lower risk of death than those with poor adherence, according to a study published in the BMJ this month.

The findings suggest that adherence to drug treatment may be a marker for overall healthy behaviour, with mortality being about half that for good adherers than those with poor compliance.

Researchers looked at 46,000 participants from 21 studies. “The observed association between good adherence to placebo and lower mortality also supports the existence of the healthy adherer effect, whereby adherence to drug therapy may be a surrogate marker for overall healthy behaviour,” suggested Betty Chewing, who conducted the research.

She points to research that the health improvement may not lie in the treatment but in patients’ emotional and cognitive processes of ‘feeling cared for’ and ‘caring for oneself’.

Smokers stay more sober BATH Nicotine may reduce blood alcohol concentration, according to findings from the National Institutes of Health.

The results published in ‘Alcoholism: Clinical & Experimental Research’ show that nicotine can reduce blood alcohol concentrations at dosage levels that could be achieved by human smokers. The effect may encourage more drinking to achieve a desired ‘high’, which can lead to greater levels of the toxic acetaldehyde in the body as well as chronic alcohol-related diseases.

“Since the desired effect of alcohol is significantly diminished by nicotine - particularly among heavy or binge drinkers such as college students - this may encourage drinkers to drink more to achieve the pleasurable or expected effect,” said Wei-Jung Chen, Associate Professor of Neuroscience and Experimental Therapeutics at the Texas A&M Health Science Centre College of Medicine. “In other words, ciga-

rette smoking appears to promote the consumption of alcohol.”

Researchers administered a range of individual nicotine doses along with an alcohol dose via intragastric tube with blood alcohol levels measured at various timepoints. They found that the interaction between alcohol and nicotine may be related to the nicotine dose.

“Nicotine appears to delay the emptying of the stomach contents, including alcohol, into the intestines, a major site for absorption,” says Chan. “A portion of the alcohol molecules are then subject to metabolism within the stomach, leaving less alcohol passing from the stomach to the intestinal tract for absorption, thus decreasing alcohol concentration measured downstream in the blood.”

“In summary the current findings should be a warning to the general public regarding the danger of abusing multiple drugs, since the pharmocokinetic interactions among these substances are often unpredictable and injurious.”

“Since the desired effect of alcohol is significantly diminished by nicotine particularly among heavy or binge drinkers such as college students - this may encourage drinkers to drink more to achieve the pleasurable or expected effect.”

Wei-Jung Chen Associate Professor of Neuroscience Texas College of Medicine

Singleton sickness

Slapping on sunscreen may cause skin damage

COPENHAGEN Living alone doubles your risk of serious heart disease, according to a Danish study of 138,000 adults published in the Journal of Epidemiology and Community Health. Age and living alone were the two strongest predictive factors for acute coronary syndrome.

The authors pointed out that lifestyle traits of those living by themselves, such as smoking, obesity, high cholesterol and less social support, may explain the difference.

CALIFORNIA Simply slapping on some sunscreen may cause more harm than good, according to a study due to be published in New Scientist later this month.

Research carried out at the University of California found that if people apply sunscreen less than once every two hours they might be better off not using any at all due to the effect of free radicals.

Kelly Hanson, a university chemist, along with her colleagues tested three UV filters commonly

http://bmj.com/cgi/content/full/333/755 7/15

The Pulse

Journal Review

found in sunscreens. After one hour they found that each compound had sunk into the skin meaning its protective effect was greatly reduced.

Worse, they found that the samples contained more reactive oxygen species than skin exposed to UV with no sunscreen on it.

Reactive Oxygen Species are free radicals that can damage skin cells and increase the risk of skin cancer.

Skin cancer charities already recommend that people go no

more than two hours without reapplying. Our findings tend to support that, says Hanson, and suggest that it may actually be necessary to reapply even more often.

The team also propose that antioxidants, such as vitamins C and E, could be added to sunscreens. “In previous work we’ve shown that antioxidants can help neutralise reactive oxygen species in the skin,” says Hanson.

Free Radical Biology and Medicine, DOI:10.1016/j.freeradbiomed.2006.06.011

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trauma Features

Is there a doctor on bo At thirty thousand feet above the earth there are no hospital facilities. With the nearest medical support four thousand miles away it's the last place that anyone would want to become ill. Over the loudspeakers a call goes out asking for a medical doctor on board. From that point onwards the care of one man with chest pain and the decision to divert four hundred passengers rested with junior doctor Krish Vedavanam.

It all started with a ham sandwich, Dr Vedavanam told trauma

“

It was November and I was flying from London to Toronto for the wedding of a close friend who had been on my GP training scheme.

With me were two other junior doctors - a paediatrician and a general physician. Arriving at Heathrow we found our Air Canada flight delayed by five hours.

After some time complimentary food arrived in the form of a ham or egg sandwich. Sitting opposite us in the terminal were a Muslim couple. I could tell as the woman was wearing a hijab.

I looked at her, then at the ham sandwich and said, “Are you sure you ought to be eating that?” She looked back blankly clearly not understanding. “Pork!” I said in a loud voice pointing at the sandwiches. Her husband responded and thanked me with some broken English.

I gave them my egg sandwich but not the cereal bar - it was full of sugar and I was sure they were both diabetic. They were really grateful for the sandwich. Later the man came up to me again and asked if he could phone his son in London from my mobile.

Finally at 9pm we boarded the plane. I was very tired and fell fast asleep just after take-off.

Is there a medical doctor on board?

Three quarters of the way into the journey, still in a daze, I heard

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the dreaded phrase over the loudspeaker - “If there are any medical doctors on board could they please make themselves known to the cabin crew”. My friend had already heard the message and had got up. I followed her.

Towards the back of the plane we found the man who I had given my egg sandwich too before the flight. He was complaining of central chest pain and looked generally unwell.

After my communication problems at Heathrow I was a little concerned about the ability to understand what was happening.

Luckily there happened to be an Urdu speaking stewardess onboard - the only one in Air Canada.

The gentleman told us that he was a cardiac patient and had chest pain at rest before starting his journey to Canada. Before stopping in London he had been in Saudi Arabia where he was given low molecular weight heparin and had been told to take another dose when he got off the flight - something we found rather surprising.

As he was already taking betablockers and GTN patches we tried another patch but there was no improvement. With difficulty we laid him down flat behind one of the bulkheads in the plane and gave him high-flow oxygen and treatment dose aspirin.

His wife was terrified by now.

She was scared he was going to die and, because of the language barrier, there was very little we personally could do to reassure her.

Although his observations were stable the pain was not improving.

It also emerged that they were

“ The airline medical kit, although containing items like morphine, didn't have a BM monitor. We had to put an announcement out for any passenger with a BM kit to come forward.

Luckily someone did.” both diabetic - just as we had suspected in the airport. The airline medical kit despite containing items like morphine, didn't have a BM monitor. We had to put an announcement out for any passenger with a BM kit to come forward.

Luckily someone did, but rather embarrassingly we had to call them back for a second time to explain how it worked.

As he was still in acute pain we decided to obtain IV access and gave him morphine.

Diverting the plane It was at that point we were asked to make the decision on whether to divert the plane.

Diverting a plane is a pretty big decision to make when you know it will affect the journies of 400 people on board.

We had a working diagnosis of acute coronary syndrome and decided that he needed medical treatment as soon as possible so informed the crew. The cabin crew, who had been great throughout the

Features

trauma

oard? flight, put together the procedure to reroute the plane.

The plane was diverted to Newfoundland, the most easterly point of Canada. It took a further 90 minutes to reach there. Luckily the gentleman was stable throughout the reminder of the journey.

Whilst other passengers and the cabin crew were strapped in on landing we weren't. As the plane came into land we were still with the gentleman trying to keep him comfortable - it was a strange experience.

On touching down in Newfoundland we were met by paramedics and they stretchered the gentleman off the plane. He remained stable and was quite comfortable at this point. His wife went with him.

After he had been ‘unloaded’ the pilot thanked us and the passengers applauded. It was a good feeling, not just the appreciation but also the relief of getting him to medical help. Although he had remained stable throughout we always had a fear in the back of our minds that he could deteriorate at any time - not something you want when the nearest hospital is three hours away and you have 400 people watching.

Back in the air Less than two hours later we were back in the air and continuing on our way to Toronto where we landed safely. Looking back the entire incident went smoothly. I do however understand how stressful it must be for doctors when someone takes more seriously ill - espe-

cially if they don’t have colleagues to help like we did.

After our experience I definitely feel all planes should carry a full doctors bag, as the onboard medical kit lacked some key items.

Although, I think most doctors wouldn’t hesitate to help in a similar situation, I feel it’s also really important to make sure you’ve got medical indemnity insurance for good samaritan acts.

As far as I am aware the gentleman recovered. We went onto our wedding, slightly late, but it was still an amazing day.

Fortunately our return flight to London was much less eventful and there were no further calls for doctors on board. This time I slept soundly.

Flight facts

”

> Medical emergencies are the most common reason for diverting an aircraft. > 75 per cent of medical emergencies among passengers take place whilst still on the ground. > 1 passenger per 39,600 need emergency medical assistance in-flight. > The most common problems are abdominal pain, chest pain, shortness of breath, syncope, and seizures. > Items falling from overhead lockers represent 6.3 per cent of incidents requiring treatment.

Wallace WA. Managing in flight emergencies.

BMJ 1995; 311: 1508 Cummings RO, Schubach JA. Frequency and types of medical emergencies among commercial air travelers. JAMA 1989;261:1295-9

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trauma Features

Get Fresh!

Medical school can be a scary place. There’s the dissection room, angry hospital consultants and the student union bar on a Wednesday night. But don’t go running for home just yet.

With the help of medical students who have been there and survived with most of their limbs intact, we’ll tell you how to survive in the land of colonoscopy clinics, cardiac vivas and neuro MCQs. So put on that white coat, swing that stethoscope round your neck and step out into the big bad world of becoming a doctor. We start with the essential induction to your new life.

Trust me I'm a doctor Ask most patients what a ‘medical student’ is and they'll screw up their eyes in confusion. Patients see you trailing around after the real doctors in your smart white coat and often view you in the same medically qualified club. As such you’ve unwittingly become a privileged member of society’s most trusted profession.

As a medical student you'll spend more time with patients than any other person in the team.

You’re in that middle-ground between being a member of the public and a medical professional.

Patients won’t find you quite as scary as a proper doctor and you'll be making an extra special effort to suck up in order to take their medical history.

Because of this they'll tell you things they've never told anyone and you'll witness grown men break down in tears behind that thin, flimsy cubicle curtain. It's all part of becoming a doctor – and a good one at that.

Just don't abuse it. Patients trust you with this information and you're legally bound to confidentiality. So no blabbing about it down the pub, it could be the

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patient's relatives at the next table.

Medical students have been kicked out of medical school on a number of occasions for abusing this – and they've no defence.

Make friends Whether you like it or not you’re going to be stuck with that big hairy guy who picks his nose for at least the next five years. There’s also a high probability that you’ll end up marrying one of those drunken idiots who vomited over you during freshers week.

You’ve got to remember that medicine is a team sport. Refuse to play ball with your colleagues and your performance and experience will suffer. Medical school isn't a competition, you either pass or fail – and the pass mark has already been set.

It’s better to drag your buddies with you when you pass the final exams rather than fall flat on your face when you attempt to go solo.

Work hard, play hard Unlike those other students studying embroidery or pole dancing, you’re going to have to do some hard studying during the course. You’ve made it to medical school which proves you’ve got a

few brain cells – but don’t let this go to that straight-'A' head of yours.

Medicine is one of those subjects which trumps the ‘A-levels are the hardest exams you’ll ever do’ line – in fact, it rips this theory to shreds, throws it on the ground and stomps all over it. Medicine is tough and there’s no escaping that.

But don’t get disheartened if you only scraped into medical school by the skin of your teeth and the number of zeros on daddy’s cheque to the alumni association, you don’t need to be a whizzkid to pick up a MBBS. A little common sense and good organisation is all you need. Medicine is a practical subject that requires lateral thinking and it’s the straight ‘A’ students who often struggle.

The easiest way to fail is to fall behind with the curriculum.

Remember that we’re learning about the human body – everything is linked. If you miss that lecture on the science behind gastric acid production the GORD workshop will leave you with a burning pain in your chest – and you won't understand why.

Keep on top of the work and you’ll be fine. This means occasionally being prepared to ditch drinking games at the union for a night with your head in the books.

Get involved You may not be keen on chasing after a ball on the rugby pitch, or testing your tactics in the chess team but that’s no excuse for not getting involved in uni activities.

It’s very unlikely that you won’t find at least one club or society that interests you, and in that rare case you can easily set up your own.

Joining a club isn’t just about improving your ball passing ability or checkmating skills, it’s all about making friends and being part of university life. With the team environment of medicine and being away from home you’ll need all the friends you can get.

Throughout your career you’ll realize that medicine is as much about who you know as what you know.

Freshers week is the time when you’ll meet more potential doctors than any other. Work the crowds and get involved. Remember that

students in the years above will be doctors soon. They’ll be able to bail you out of trouble, not just when you’re an incompetent student, but when you’re an incompetent doctor and they’re your boss. practice makes perfect

How to spot a

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Fresher

A little respect While other students will be playing with PCs we medical students get to play with people’s lives. Patients are often scared, in pain and may even be terminally ill. Put yourself in their position, treat them as you would want to be treated and you won't go wrong.

Watch out for the difference between consultants who treat patients like real people and those who think they’re just a piece of meat. Learn from it. By the time you finish medical school you should have a list of doctors who get the respect of both you and the patients, and a list of those who you wouldn’t want to treat a member of your own family.

When you reach consultant grade you want medical students to talk about you down the pub as a ‘great doctor’. That's when you'll know you've finally made it. You’ve got around twenty years to become this fantastic individual so start moulding yourself now.

Practice makes perfect Unlike A-levels your medical exams will test your practical skills and not just your academic knowledge. Sucking up pints down the union when you should be practicing sucking up blood may appear the better option at the time but could land you in trouble in a few years.

Sure, it’s difficult trying a new practical procedure, especially when it involves sticking sharp things into little old ladies but unless you force yourself to overcome this fear now you’ll struggle even more in the future – and noone wants to be a venflon virgin forever.

Watch someone experienced first and get them to talk you through the procedure. It doesn’t have to be the head of the anaesthetics department, one of your brave

A first year med student can be spotted more easily than a baby with chicken pox. Here’s what gives you away.

1 Can be spotted fighting over free tins of beans at freshers fairs.

2 Conversation over lunch includes topics other than resection of the small bowel.

3 Jump at the chance to sign-up for clinical trials to earn a fiver being injected with the Ebola virus.

4 They turn up to all lectures - even those that aren't compulsory.

5 Commonly throw up in the tube/taxi on the way back from the union.

6 Borrow every book on pathology from the library so no ‘proper’ medics can use them to revise for path exams.

7 Appear to drown when trying to do a ‘funnel’.

8 Clothes are badly stained with fat from the dissection lab.

9 End up on the floor after watching a surgeon make the first incision.

10 Still want to be a doctor because they ‘care deeply about mankind and want to repay their debt to society for their pitiful existence’

buddies is often a better bet as they can point out the areas where they struggled themselves.

Most medical schools and placement hospitals have a clinical skills centre where you can practice procedures. Dummies don’t care if it takes seventeen tries to get an arterial blood gas sample.

Ask at the centre for training workshops or times when you can practice by yourself.

Always remember that it’s not just getting the needle in the vein that’s important, there’s going to be a terrified little old lady attached to it. You’ll need to hold a conversation about her granddaughter’s new baby whilst

maneuvering that piece of metal in her arm.

Just like riding a bike, practical procedures become easier the more you do. You’ll soon be able to simultaneously extract blood and recall all eight grandkids in order without any trouble. enjoy it The last and most important point – enjoy it!! You’re one of only six thousand students each year accepted into medical school.

With electives, the best student events and an almost guaranteed job at the end, your life’s looking great already. Live it up!!

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trauma Features

Sucking up with style Soon you’ll be swinging your stethoscope round your neck and venturing into the big bad world of hospital life. Here’s how to look both cool and clever ...

Imagine this When your consultant can’t distinguish you from an RTA victim that’s been trailed through an articulated lorry sideways, there’s a problem. “Image is everything,” says Deborra Radcliffe, a professional image consultant. “Looking smart and dressing professionally can actually make you appear more intelligent than you actually are.”

Male magic “For men, wear a shirt and tie that complement each other with the same colour shades,” suggests Radcliffe. If you’ve less colour sense than a blind patient without a guide dog, high street chains

such as Next and Debenhams sell pre-packaged matching combinations. “Shirts with cufflinks will improve your ranking but only if you wear a jacket or white coat on top.” Pokemon ties are only acceptable if you’re doing paeds … or if your consultant has the mental age of a five-year-old.

Winning as a woman If you’re a woman, forget the skirt advises Radcliffe, “Women who power dress are taken more seriously.” For women who have a soft voice and mild manner, wear darker colours to appear more confident. “Students who ooze confidence should choose paler shades to help you take advantage of your womanly side—it will

make you appear more in touch with the patient’s perspective.”

Role play Making small talk with a patient about haemorrhoids can often put you in more pain than they are. The fear of talking to someone for the first time is all about being scared of the unexpected suggests Radcliffe. “Having a practised introduction when you meet a new patient can help you through this difficult period,” she advises. “The first 30 seconds of conversion is the most stressful and yet the most important for making a positive impression.”

Practise your speech and face expressions in front of a mirror, she suggests.

Escaping embarrassment Examining semi-naked patients can be an uncomfortable experience even for the most confident. You need to distance yourself from the reality of the situation suggests Radcliffe. “There’s nothing unnatural about nakedness— it’s just the human emotions we’ve attached to it,” she explains.

“Treating the consultation in a purely clinical way is one way to deal with this. Removing the concept of the ‘person’ from the ‘body’ often works.”

Living in halls You’ve just moved into the thirteenth floor of halls. Your room is the size of a matchbox. The person next door plays music so loud that cracks are forming in the wall and someone’s stealing your milk.

Don’t panic!! … here’s some advice. the kitchen and even the shower. So what, they might eat coco pops for breakfast but the fact that you eat ricicles isn’t exactly normal either!

Don’t hide in your room

Label your food If you have to share a kitchen then get your initials on your grub.

There’s nothing more irritating than finding someone has eaten your pack of choccy biccies by mistake.

Be open minded You’ll meet a greater diversity of people than ever before. You’ll have to share your living space,

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The hairy guy in room 13 may be frightening but staying in your room isn’t the answer.

Get out and meet people.

Your first year in halls is the easiest way to meet other medics. If you don’t push yourself to meet new people this term you’ll regret it later.

Sort out any problems If you’re slowly going deaf because of the loud music played by your neighbour confront him about it. Don’t shout, yell or throw your dissection scalpel at him.

Offer him a cup of coffee, explain calmly the problem and invite him

to hear how loud the music is himself.

Shower power If one of your floormates spends 45 minutes in the shower each morning shaving his/her legs then here’s a trick to get them out.

Most of the water outlets on each floor are connected so turn off and on the hot or cold taps in the sinks or showers. The water going from stifling hot to freezing cold should speed him up.

Don’t shop till you drop Save yourself the torture of dragging five tons of shopping back from the supermarket by getting it to come to you. Get together with the rest of the guys on your floor and order your beer and pizzas online. Enter you shopping list at Tesco.com or Sainburys.com and they’ll cope with all the trolley trauma. As long as you request it they’ll bring it right to your floor … so your don’t even have to change out of your pj’s!

The clean team Sort problems soon Share the laundry load. Team up with a mate and do a mass of laundry at one time. It’ll save you a fortune and you’ll have someone to hang out with while the machine goes round and round and round ... just keep your red boxer shorts out of her whites, ok? And, if you hang your CK pants up right away you might just escape the need to iron them.

If you do have any problems about living in halls get it sorted straight away. There’s no point letting things get you down. The staff in the student accommodation office have dealt with every conceivable problem so don’t feel embarrassed.

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Who’s who?

Medical Student Duration Role How to identify

5-6 years To be humiliated Can be spotted hiding behind curtains, tables and big textbooks to avoid being spotted.

ST1 Doctor Duration Role How to identify

1 year Secretary, telephone answering service and general slave.

Can be located by following the continuous bleeping sound emitted from a small box attached to their waist.

ST2 Doctor Duration Role How to identify

2-3 years They don’t even know. They’re trapped between knowing nothing and expected to know everything.

Look out for stressed, tired, angry people with stethoscopes.

Specialist Registrar Duration Role How to identify

5-6 years The last hope before having to call the consultant back from the golf course.

They look cool, calm and knowledgeable after the trauma of their SHO years ... but when the consultant asks a difficult question watch them fall apart!

Consultant Duration Role How to identify

Forever. They never die—they live on in the nightmares of med students and doctors.

The answer to all our prayers when things go wrong ... and the person who makes us feel wrong when we’re right.

Surrounded by a bright light and followed by a trail of angels who open doors for him.

The one everyone refers to as ‘God’ or ‘God, he's coming! Where are those results’.

Those big white things They’re called nurses.

Warning - Be nice to them!! If you think the wrath of a consultant is bad just wait to see what a staff nurse with a bedpan can do. As a medical student and junior doctor they can make your job ten times easier ... or damn near impossible!

There’s different varieties.

They start with student nurses (who you will feel sorry for ... their life is even worse than ours!) and then become staff nurses. This group have letters after their grade to explain how senior they are.

Finally charge nurses are the ones to be afraid of, they're the ones who get to boss everyone around.

Don’t mess with them!

There’s a new variety called Specialist nurses. They can do some of the tasks of doctors and are really useful if you need someone to show you how to suture or do some other procedure without having to ask your house officer or SHO. If you do ever manage to upset one of the nurses, even if it’s their fault, make sure you apologise.

Just trust me on this one! Offer to go make them a cup of coffee, or if the worst comes to the worst, a ‘thank you for all your help’ box of chocolates. You won’t regret it next time you need a favour.

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trauma Features

Mnemonics for taking a medical history If you find remembering those long medical lists more difficult than escaping early morning ward rounds, then here’s some helpful mnemonics courtesy of PasTest to make taking a medical history a little easier.

State the following before beginning any history: Introduction Permission How long it will take Confidential History followed by examination Name DoB Age Presenting complaint 'Can you tell me when you were last well and in your own words what has happened since then?'

(Do not interrupt the patient as they talk for at least 2-3 mins, provide appropriate non-verbal cues and show them that you are paying attention).

History of presenting complaint 'So you have told me about your illness; can I ask you if you think there was anything that might have TRIGGERED the onset of your illness?

And what has been the COURSE of your illness - has it got better over time, worse over time, has it stayed the same?

Have there been any periods where you have been completely free of the problem?

Over the course of 24 h when are you most bothered by your complaint?'

To recall this the mnemonic OPERATES may help: O Onset of complaint

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P Progress of complaint E Exacerbating factors R Relieving factors A Associated symptoms T Timing E Episodes of being symptom-free S Relevant Systemic and general inquiry can be added here Pain history A pain history can follow a similar format as shown below: LOTTRAADIO L Location O Onset - what were you doing when it started?

T Timing - how long did it last?

T Type (sharp/throbbing/gnawing?)

R Radiation A Associated symptoms (nausea/vomiting/sweating) A Aggravating factors D Decreasing factors I Intensity on a scale of 1-10 with 10 being the worst pain imaginable O Offset - what were you doing when it stopped?

Alternatively: SOCRATIC S Site O Onset - what were you doing when it started?

C Character (sharp/throbbing/gnawing?)

R Radiation A Associated symptoms (nausea/vomiting/sweating) T Timing - how long did it last?

I Improving/worsening factors C Count the pain on a scale of 110 with 10 being the most severe pain imaginable Past medical history In hospital before?

Illnesses? (see MCJ THHREADS) Operations?

Immunisation status?

Have you ever been abroad?

Risk factors Most apt for atheromatous disease (mnemonic - SHAHED) S Smoking H Hypertension A Alcohol H Hyperlipidaemia E Exercise and healthy Eating D DM MCJ THHREADS M MI C Cancer J Jaundice T TB H Hypertension H Hypercholesterolaemia R Rheumatic fever as a child E Epilepsy A Asthma D DM S Stroke Medications/allergies PILLS P Pills, patient taking any?

I Injections, eg Insulin/Inhalers

(as some patients forget to mention when asked about their medications) LL ILLicit drug use S Sensitivities to anything, ie allergies Family history Are your parents still with us?

If not what did they pass away with?

Do you have any siblings with the same illness?

Have any of your siblings passed away?

Do you have children, do they have anything similar?

Social history SAADLES S Smoking - pack years? 20/day for 1 year = 1 pack year A Alcohol within units? 1 unit = 1/2 pint beer/1 glass wine/1 measure spirit (female 14 units/week = 7 pints lager/male 21 units/week = 10 1/2 pints lager) ADL Activities of Daily Living how do you manage with bathing, cooking, cleaning, shopping? This section should also incorporate what job the person does and

whether their illness could be related to this E Enjoyment activities, ie recreational activities/hobbies S Social support, ie family, neighbours, carers, GP home visits, district nurses, home help, meals on wheels and financial problems In a respiratory history, it is important to include the following points: SOD PETe (no offence meant to anyone called Peter!)

S Smoking O Occupational exposure to various metals, allergens, etc.

D Drugs being used, ie medications such as amiodarone cause pulmonary fibrosis PET Pet exposure, eg cats, pigeons, etc General enquiries In every history don't forget to ask about the 4 (FAWR) non-specific symptoms the patient may exhibit: F Fever A Appetite W Weight loss (unintentional) R Reduced energy, ie fatigue/lethargy Functional enquiry Neurology HEADS FAINTS H Headaches?

E Epilepsy inquiry?

A Auditory problems?

D Double vision/Dizziness or problems with balance/co-ordination?

S Syncope?

F Faints/muscles Feel weak?

A HAllucinations?

I Intention/resting tremor?

N Numbness?

T Tingling sensation - pins and needles?

S Speech problems/Sphincter disturbance; urinary/bowel?

Cardiology HEARTS H Heart beat awareness, ie palpitations?

E OEdema - ankle swelling?

A Angina pain, ie chest pain?

R Rheumatic fever as a child?

T Tiredness?

S Shortness of breath/Syncope?

Respiratory COSFFS (coughs!)

C Cough/Chest pain?

O Sputum coughed Out, - colour? quantity? haemoptysis?

S Shortness of breath?

F Funny noises on breathing, ie wheeze and stridor?

F Feeling weak, ie lethargy/Fever?

S Speech impaired, ie hoarseness?

Gastroenterology Work anatomically from entry to exit Mouth Do you have trouble with your teeth?

Do you have any difficulty chewing your food?

Do you have difficulty swallowing your food?

Pharynx and oesophagus Difficulty in swallowing? (dysphagia) Pain on swallowing? (odynophagia) Do you have heartburn?

Stomach Any nausea or vomiting?

Is there anything unusual in the vomitus such as bile, blood (haematemesis)?

Do you have ulcers, relieved or exacerbated by food?

Liver, biliary tract and pancreas HEPATIC H Hepatitis inquiry, ie been abroad recently, in contact with anyone suffering from this, IV drug use, unprotected sex/anal sex?

E Enlarged breasts in males, ie gynaecomastia?

P Petechiae, ie easy bruising and bleeding?

A Abdominal swelling - Ascites?

T Too much alcohol consumption?

I Impaired glucose tolerance due to decreased pancreatic function hence polyuria, polydipsia and weight loss; DM? C Confusion and drowsiness; hepatic encephalopathy/Colour change, ie jaundice/Colic, ie right upper quadrant/Chills, ie fever and rigors?

Small and large bowels IF A BIT DAMP I Increased or decreased frequency of passing motions? (constipated?)

F Fluid stools? (diarrhoea) A Anal protrusions, piles or prolapse?

B Fresh Blood on toilet paper?

I Feeling of Incomplete emptying? (tenesmus) T Tarry foul-smelling stools? (melena) D Difficulty passing stools?

A Is the Appearance of the stools different? (Pale or discoloured stool) M Mucus or slime in stools?

P Pain on passing stools?

Renal system FUN PHISS F Increased Frequency of urination U Urgency N Nocturia P Polyuria H Hesitancy I Incontinence, urinary/Incomplete emptying of bladder S Stinging on urination?

S Something unusual in the urine, Blood? Discoloration? 'Frothy'?

Musculoskeletal STABS S Stiffness: morning or evening?

T Tenderness or pain in muscles or joints?

A Affected joints distribution, ie symmetrical, axial or peripheral?

B Bruising or bleeding into joint?

S Swellings around joint?

Psychological state SAD CASE S Suicidal ideations A Anxiety D Decreased mood/Delusions/Disordered thought C Difficulty Concentrating A Auditory or other hallucinations?

S Difficulties Sleeping E Eating normally?

Physical examination This must always begin by forming a general impression of the patient and assessing whether any of the following features are evident: JACCOLT J Jaundice A Anaemia C Cyanosis - peripheral and central C Clubbing O Oedema L Lymphadenopathy T Thyroid problem, ie goitre?

For a specific systems examination, the clinical method of choice that is widely adopted may be recalled by the following statement: I Prescribe Plenty Analgesics I Inspection P Palpation P Percussion A Auscultation

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Extract from Mnemonics for Undergraduates Dr Mubeen Chaudhry and Mr Shahed Yousaf ISBN 1904627889 Price ÂŁ10.50

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Features

The Secret Diary of a Cardiology SpR

trauma Monday I work for five men. One of them, Douglas, is a gentleman.

Three of them are reasonably selfcentred but bearable. John is a complete bastard. Not the kind of boss who is just looking out for himself and obsessed with private practice but somebody who is truly evil. I'm sure his own mother would agree with that.

Mondays are usually quiet. I have clinic in the morning with mainly post infarct patients. It's their six week check up. Are they on a healthy diet? Are they exercising slowly? A middle-aged Asian gentleman is still worried about having sex. I try to explain that at six weeks if he can climb a flight of stairs he should be able to start with non-penetrative sex. His English is very limited and I take to drawing him a diagram. He looks at it for a while and then tells me he has diabetes so can't do that.

Tuesday We're on take for general medicine today so I take the bleep at eight. There are several patients to be seen and my morning is spent sorting out the standard chest pains, pneumonias and headaches.

The hospital has initiated a manager to take all GP referrals which gets rid of a lot of the hassle.

We have a reasonably sick chap in the afternoon. He’s in septic shock after an ERCP. I spend an hour putting in lines and getting his pressures up. On answering the bleep the intensive care registrar tells me that he's busy so I start our man on noradrenaline which is against ward policy. The sister in charge tries to stop me but I tell her that we either start the norad or I give her the crash bleep and let her come running when he arrests.

She backs down.

We do the rounds with Dr Edwards, a young and nervous respiratory physician who insists on examining everyone again. I wonder if I’ll be like that when I grow up? I grab an Indian takeaway on my home. I eat out of the boxes and when finished pile them up on top of last weeks’ ones.

Wednesday * 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!

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The morning is spent in the cath lab with Douglas. He’s a fantastic teacher with a lot of patience

which is great for me. We stent a few patients. One of them is a bit tricky and Douglas watches over my shoulder but refuses to step in.

He gives me a smile and steps back. I get it after a few goes.

After lunch I catch up with our house officer (I refuse to call him an FY1). He’s a little cocky, especially for someone so soon out of medical school. He hasn’t sorted out the referrals I asked him about this morning so I try and be firm but I’m not very good on discipline. I agree to do a couple and we part on mutual terms.

“I spend most of the night chatting to fellow cardiologists but as the evening wears on things get silly. I end up on the dance floor with my house officer and somehow I end up nearly pulling him.”

I spend the rest of the day taking ward referrals. Most of them are decent but I have a run in with the gastro reg who insists on getting an emergency cath for a ward patient. I tell him that it isn’t indicated in this case but he insists on going to the consultant on call. I tell him to go ahead and we stare at each other for a few seconds like a playground game of chicken. He walks away but I don’t hear from him again so I guess he was the chicken.

My ex calls me as I’m walking in through the front door. The conversation is short and less than pleasant. He’s free tonight and wants to know if we want to meet up. I toss the mobile away and open a bottle of merlot.

Thursday I spend most of the day planning my research grants. I’m applying for funding to the MRC and the application process is harder than getting into medical school.

My research is due to start in the summer and I get to spend one morning a week sorting it out. I think the three years out of clinical medicine will

be a welcome break.

The afternoon is spent in the echo labs. The clinic is long and I keep getting interrupted by my house officer with problems that he should have sorted this morning. I refer him to the med reg on call.

The mess is having a night out and I arrive suitably late.

Spending time with colleagues out of work is one of the joys of medicine. People are so different outside the building. And the alcohol helps.

I spend most of the night chatting to fellow cardiologists but as the evening wears on things get silly. I end up on the dance floor with my house officer and somehow I end up nearly pulling him.

Friday John is doing his weekly ward round so I go in early to make sure the patients are sorted out. I have a reasonably bad headache. My house officer turns up soon after and we decide to ignore last night.

The round gets off to a good start but soon John is in his usual mood. He starts raving about minute details and most of his unjustified words are directed at our houseman. I step in every now and then to defend him. After a while John directs his anger at me and I take most of it.

Then I call him a wanker and storm off the ward. Actually I don’t. I calmly rebuke his antics with polite answers until he gets fed up and goes to see his private patients.

I have clinic in the afternoon and stay late to finish some letters.

On the way home I get a call from my ex. He’s around this weekend and asks if I'm free. I pause outside the tube station. I need a few seconds to think this one over.

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Weekend ward escape to

Brussels People don’t get excited about Brussels. It lacks the elegance of Paris, the nightlife of Amsterdam and is even overshadowed by the romance of it’s own northern sister Bruges. But that’s exactly why Brussels has it’s charm. No-one expects to like it, in fact many visit already certain they’ll be disappointed, but most leave confounded. If you don’t expect to fall in love with the city at the heart of Europe you might just do so.

Where to stay?

Hotels in Brussels are nothing to shout about. There’s the scores of sterile, functional chains catering for the constant trips of politicians to this EU hub. Amigo is the one exceptional hotel in the city and is priced exceptionally to boot so it tends to be the haunt of top politicians and celebrities. If you’ve still to make your millions try the centrally located and practical George V (Rue ‘t Kint) or NH Grand Place (Rue D’Assaut) instead. Visitors who are more frugal with their budget should try Bruegel (Rue Du St-Esprit) - a newly refurbished youth hostel situated a few minutes from the main square. You can stay in a double room for just 20 euro a night.

There’s a 1am curfew - but it has it’s own bar which stays open until the last man is standing.

Eating Belga Queen - (Rue du Fosse aux Loups) A stylish (and moderately expensive) restaurant set in a giant converted bank where you can dine with the Brussels elite. The food is typically Belgian and served by waiters dressed conspicuously like monks. Watch out for the transparent toilet doors that confuse many a tourist.

Chez Leon - (Rue des Bouchers) Gracing the backstreets of Brussels for over a century Chez Leon is a cheap and cheerful place to sample great ‘moules and frites’ for under 15 Euros a time.

Key attractions Manneken-Pis - This takes the piss! Belgium’s most popular tourist attraction is a tiny bronze statue of a boy peeing. Nobody really knows what he symbolises or why he’s there. More interest-

ing is why the scores of tourists crowded around stare for so long.

Grand Place - This is the tourist centre and is enclosed in magnificent Baroque buildings. Worth a few hours sipping a hot chocolate while watching the weird antics of your fellow travellers.

Nightlife Le Bier Circus (Rue de l’Enseignement) - 200 beers which means there’s just enough time to try them all and turn up sober for the Monday ward round. Intimate and with knowledgeable staff it’s the ideal place to savour the flavour of Belgian beer and get esquisitely drunk.

Day Trips Bruges, which egotistically has dubbed itself the ‘Venice of Northern Europe’ is only an hour by train. 3 million people mob this tiny town of 100,000 every year scoffing the ‘moules et frites’ and sipping on Belgian beers. Nice place for some food, some walking but boring after dark.

If you’re looking for some proper nightlife Antwerp is the place where you’ll find the locals.

90 minutes away it’s also a good spot for some hardcore shopping away from the tourist traps of Brussels and Bruges.

Key facts > Population - 2,090,000 > Language - French (85%) and Flemish > Currency - Euro > Belgium produces 172,000 tons of chocolate a year. > World defining inventions from Belgium include the Smurfs, waffles and french fries.

The pics Clockwise from top left Mannekin-Pis; Moules et frites; Atomium; Belgian chocolates; European Parliament; Bruges; Beer.

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trauma The Mess

Dr who?

Ethical advisor What’s the deal with DNR? I'm an SHO. Recently, an elderly cancer patient relapsed following chemo. Although the patient and his relatives are still hopeful, the consultant thinks he's only got a few weeks to live. As the situation is medically futile (he has secondaries in several places, including his ribs) we're thinking of making him a ‘DNR’ case. Would that be ethically right if the patient and his relatives still believe he can “pull through”?

There is much confusion in the medical profession regarding DNR decisions. A DNR order is simply an advance decision that CPR will not be attempted. To refresh your memories, you should consider a DNR (or DNAR) order when: 1.

The resuscitation is likely to be futile (more on this later).

2.

A competent patient has validly refused resuscitation (including through the use of an advance directive which, remember, is legally binding in England and Wales).

3.

The resuscitation will probably lead to a quality of life so low that it would not be in the patient’s best interests.

Your consultant is invoking (1) to justify his decision. There is much debate, however, over the meaning of ‘futile’. In some cases, what constitutes futile treatment is obvious. Giving antibiotics to a dead patient is obviously futile (and unethical since it’s a waste of limited resources!). But is a treatment or procedure with a one per cent chance of success ‘futile’? This will depend on how the individual balances the burdens and benefits of the treatment or procedure. In short, there is an evaluative component in establishing futility. This value judgement points to the importance of discussing the issue with the patient.

The patient may have good reasons to persevere despite the odds.

He may wish to attend a grandchild’s upcoming wedding or to finish writing a novel.

Ultimate responsibility for the DNR decision rests not with the patient, but with the most senior

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doctor in charge of the patient and he or she should document the decision and its supporting reasons on the medical records.

When arriving at a decision, the senior doctor should, whenever possible, discuss the issue with the patient and relatives (competence and confidentiality permitting) and the rest of the medical and nursing team (including the patient’s GP). Most of the time, there will be no conflict between the wishes of the patient and those of the medical team. In a few cases, there will be disagreement.

A joint statement from the BMA, the Resuscitation Council and the RCN illuminates the issue: Doctors cannot be required to give treatment contrary to their clinical judgement, but should, whenever possible, respect patients’ wishes to receive treatment which carries only a very small chance of success or benefit.

The statement is open to interpretation, but the ‘safe’ option is to adhere to the patient’s wishes regarding resuscitation. As usual, when in doubt, consult trusted colleagues, your defence organisation or the BMA Ethics Department.

Your hospital should have a written policy regarding resuscitation attempts. It may be wise to track it down.

Daniel K. Sokol, Imperial College Medical Ethics Unit, London. www.medicalethicist.net Medical Ethics and Law - Surviving on the Wards and Passing Exams Sokol and Bergson £14.95 ISBN 0954765710

You’ve probably realised by now that doctors can have weirdest names.

Here’s the world’s most appropriate (and inappropriate!). They’re all real, you can check them for yourself on Medline Cardiology Dr Trulove, Dr Love, Dr Hart, Dr Valentine, Dr Everhart Dentistry Dr Pullman, Dr Chu, Dr Cheek, Dermatology Dr Spot; Dr Rash, Dr Frye (burn specialist), Dr Tanner, Dr Skinner, Dr Whitehead ENT Dr Klotz (Clots); Dr Wax General Practice Dr Kwak; Dr Killer, Dr Yau (“yeow”); Dr Blood, Dr Coffin, Dr Patient, Dr Payne, Dr Slaughter, Dr B. Sick, Dr Stasick (pronounced stay sick); Dr A. Sickman, Dr Deadman, Dr Pulse; Dr.Ill, Dr Uhren, Dr Doctor, Dr Howard Hertz (pronounced HOW-it HERtZ) Gastroenterologists Dr Grunt, Dr Puppala (pronounced Poop-a-la), Dr Butt Hand Surgeons Dr Hand; Dr Palmer, Dr Nalebuff, Dr Watchmaker Neurology Dr Johnathan Treat Paine; Dr Megahead; Dr Brain, Dr Head Obstetrics and Gynaecology Dr Wiwi, Dr Ono, Dr Risk, Dr Fear, Dr Yell, Dr Dibble, Dr Fillerup, Dr Hyman, Dr Love, Dr B. Savage, Dr Pillow, Dr Storck, Dr Semen, Dr Hatch, Dr Born, Dr Hatcher, Opthalmology Dr Peek; Dr Glass, Dr See, Dr Seymour Landa Pain Management Dr Neupane, Dr Pain, Dr Ow Paediatrics Dr Donald Duckles, Dr B. Softness; Dr Childs, Dr Jelley; Dr Bunny, Dr Tickles, Dr Elfman, Dr Toy, Dr Kidd (4 so far) Psychiatry Dr Alter, Dr Reckless, Dr Brain, Dr Strange, Dr Wisdom; Dr Dippy, Dr Moodie, Dr Nutter, Dr Nutt; Dr Bummer, Dr Looney, Dr Dement, Dr Weiner Surgery Mr Butcher, Dr Deadman, Mr Yellin

trauma

While we medical students are puzzling over squiggles on ECG traces and marching around on never-ending ward rounds 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.

‘JOHN’ HOSPITAL PORTER (LONDON) I’ve been a porter in a busy London hospital for seventeen years. I’ve seen a lot of doctors in a lot of situations. I’ve seen consultants make their juniors cry and I've seen a surgical houseman floor his consultant with a right hook.

One night, when I first started out in this job, I had to rush some blood from the labs up to the fifth floor. I delivered the blood and was on my way back to control when I noticed a young doctor standing out on a balcony.

Normally I wouldn’t take any notice but this young man seemed a little too close to the edge of the balcony - it had a low metal rail that came up to your knees and the road was a long way down. It was pretty cold out there but I walked out of the ward and onto the balcony beside him.

He was staring out over the rooftops of central London and his eyes were glazed over. I stood for a while, not saying anything and then I offered him a cigarette. He looked at me and then took one.

We both lit up, not sure of what to say.

After a while I thought that I was probably mistaken and that he was probably out there getting some fresh air. I was about to go back in when he asked me why I had come out. I laughed nervously and said that I thought he was going to jump. He looked at me for a while and said that yes, he had

been thinking about it.

I remember exactly the way his shirt was smartly starched and his blue tie which was unbuttoned at the top. He wore a white coat which was usual back then. I didn't know what to say so I just stood there for a while.

He started to talk. He was having problems at work. His girlfriend was on the verge of breaking up with him. He had exams looming. I didn’t know what to say. I mean, he got paid a lot of money, probably had a flashy car and gained respect from a lot of people but deep down he was just a scared kid with a lot of pressures building up.

We talked for a while and then both walked back in. We had another cigarette and then we parted. He promised to talk to someone. I bumped into him a few times after that but then a month later he moved on to another hospital and I never saw him again.

Anyway, my advice to docs would be that as bad as it is, it can get worse. The thing that most junior doctors don’t realise is that whatever they’re going through the chances are their predecessors have been there before.

If you’re having problems at work or in your personal life than for God's sake talk to someone about them. Take some time out and you’ll often realise that things are never quite as bad as they seem.

When hospital food tastes like the leftovers from 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 -

Regular Coca-Cola Bottled 500ml It’s enough to make your top pop at ...

Greenfields Canteen Chase Farm Hospital

WOW!

95p

You lucky people it’s lower Norman’s Canteen University College Hospital

65p

LOW!

Ham sandwich on white bread (no salad) Suprise, suprise again it’s ...

Greenfields Canteen Chase Farm Hospital

WOW!

£2.59

Surely pigs are worth more ...

St. Bartholomew’s Canteen London

£1.10

LOW!

8 hours parking (for patients) Arrange a loan before you attend outpatients at ...

Great Western Hospital Swindon

WOW!

£35

Cheaper than the bus ...

Foresterhill Hospital Aberdeen

£5

LOW!

Next issue we’re looking for the lowest /highest price of a Snickers bar, a 450g box of Celebrations chocolates and a 330ml bottle of Evian.

Gavin Topham

Walking the corridors

The Mess

Hospital

19

Take Note Avoiding medicolegal problems with patient information

by Annmarie McTigue, Writer – MPS

Records management: NHS Code of Practice

Patient records and what to include in a patient’s notes can be a medicolegal minefield. Problems with records often arise in the clinical negligence claims and complaints that MPS sees. Doctors who fail to make adequate notes about their consultation with a patient or who change a record at a later date may find themselves in trouble if a claim results.

The important statutory requirement for compliance with records management principles is the Data Protection Act 1998. The two areas to consider while you are a student are:

Making notes

Getting into good habits

During your first clinical placements as a medical student, you probably won’t make notes in patient records. You may, however, make your own notes for discussion in tutorials. However, this raises some tricky issues. It breaks the principles of the Data Protection Act if you keep patient identifiable information unless you are authorised to do so. Moreover, it’s possible that you could lose your notebook, which may contain several different patients’ details. This could cause a serious breach in confidentiality.

Medical notes should allow another medical professional to reconstruct your consultations with the patient and so promote continuity of care. In addition, the Data Protection Act 1998 requires you to give an explanation of any information that “is not intelligible without explanation”.

Tip: Do not write down any patient identifiable information in

Previous medical history Referral details Arrangements for follow-up tests, further investigations and future appointments Consent – details of any consent given and discussion to reach that consent Treatment – the type and dosage of drugs or other treatment organised Information – what you have told the patient, including risks and benefits of any treatment Subsequent progress – how the patient responds to treatment, positive or negative Examination of the patient – important findings, both positive and negative, and details of objective measurements, eg blood pressure Diagnosis – in clear terms, how you came to this conclusion, possibilities ruled out, etc.

your own notes. This includes name, address, date of birth and hospital reference number.

Keeping medical records As you progress through your degree course, you will be writing in the patient notes, at first with supervision, then with more autonomy. This does, however, depend on your medical school and its curriculum.

A final year student at Nottingham Medical School, said: “In the first and second years, we never wrote anything in the notes. In the third year, you start to make notes, and this becomes the norm in the fourth and fifth years; you have to initial what you have entered and write ‘medical student’.”

Meanwhile, a fourth year at Hull York Medical School, told me: “Initially, we make notes for our own learning objectives. We don’t make any notes or additions in the patient’s records as a rule. This changed in the third year when I did a placement in the emergency department. I would be the first person to see patients, so would write a history in their notes before they saw a junior doctor.”

Medical records: regulations and government guidance General Medical Council In Good Medical Practice (2001), the GMC specifies that you should “keep clear, accurate, legible and contemporaneous patient records which report the relevant clinical findings, the decisions made, the information given to patients and any drugs or other treatment prescribed”.

It adds that you should “keep colleagues well informed when sharing the care of patients”.

to hold no more information about patients than you need for their medical care and use it only for that purpose, to store records securely and confine access to authorised personnel.

Tip: The mnemonic – PRACTISED – can help you to remember what to include when completing a patient’s notes:

Presentation pays off Content is important, but so is the way that notes are presented.

MPS recommends that notes are clear, objective and written up as soon as possible after the event. If information has been given to you by anyone but the patient (eg ambulance staff) record that person’s name and position.

Tip1: Tamper-proof – always write notes in pen so any attempt to amend records will be immediately apparent.

Tip2: Original – Medical records should not be altered or amended. If you discover a mistake, insert an additional note as a correction. Make it clear that this is a new note, not an attempt to tamper with the original record.

Supporting your education, protecting your future Student membership is FREE call 0845 900 0022 or visit www.mps.org.uk/student 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.