Mini Medical School 2014

Newcastle University annually host a lecture series for students who are looking to apply to medicine. The lecture series covered a range of topics over 6 weeks, from immunology to forensic pathology. It would take forever to write about all of the interesting things that I have learned, so instead I'm going to go over a few things I found particularly interesting.

How to fool the police with raspberry jam and a dog

A talk given by a forensic pathologist was definitely one of my favourites. He told us a story about a case he had been called to…

'So the police had attended a scene after a man was found collapsed and dead in a block of flats. They had found a suspicious red pool stain on the pavement in an alley about 300 meters from the house followed by a blood trail all of the way to the body…It seemed obvious to the police what had happened until the body was examined, when it became evident that there were no injuries and the man had actually died of a massive heart attack. So what was the cause of the pool and the drops of blood up to the body?! Well basically, what had happened was that the man had been shopping and bought some raspberry jam. When his chest began to hurt, he had dropped his shopping and the glass had smashed on the floor leaving a stain. Later a man had been walking his dog and the dog had stepped on the glass and cut its paw. The dog walker had then gone to find the source of the dropped shopping and had taken his dog up to the flat and found the man there. So the stain was in fact jam, and the drops were blood, but weren't human.'

I thought this was great and was the epiphany of the phrase 'things aren't always what they seem!'

X-linked carriers of chronic granulomatous disease

This is a sex linked genetic disorder which affects the phagocytes. They are able to detect and isolate irregularities in the body such as parasites, but are unable to inject the chemicals into them to kill them. The treatment for this disorder is prophylactic antibiotics to try to prevent illness from developing and becoming serious due to the defect in the immune system. Because the disorder is x-linked, women are not classed as sufferers but instead are classed as carriers. Until recently, carriers did not receive the same treatment as sufferers until Dr Alex Battersby conducted some research and discovered that often women suffer the same (if not worse) symptoms as men who are classed as sufferers. She explained that this is due to the fact that obviously women have two X chromosomes; one from their mother and one from their father and usually only one has the gene for CGD. Because in the cells of women only one X chromosome is activated, and because the process is random in each individual cell, carriers experience varying levels of symptoms. I wasn't aware that this was the case and found this particularly interesting. It's odd to think that despite the fact that two women have the same gene in the same frequency they could suffer different levels of symptoms. 

Medical physics and games consoles 

I must admit that I'm not a huge fan of physics, so I wasn't overly excited for this lecture but it ended up being one of my favourites. This was probably the most interactive lecture but the content was so interesting. They conducted a few experiments at the front of the lecture theatre. They started by showing us how you could display a ECG using two buckets of water and a wire connected to an amp.  So they grabbed one of their colleagues and hooked them up to the bucket and sure enough, the standard squiggly lines appeared on the screen. But then, the more interesting part was when they altered the frequency of the receiver to measure the electrical impulses in the muscles as opposed to in the heart. They had the man place his arm into the water and a few small lines came up onto the screen. They asked him to tense his arms and the lines on the screen became more frequent and had larger amplitudes. Another experiment they conducted involved an Xbox 1. This game console uses infrared to identify the shapes in front of the console so that gamers are able to use their bodies to control the game. The physicists used this to show us how these waves can display an image in 3D which could not usually been seen by the naked eye. They used a video camera to show the little white dots which covered the person standing in front of the camera in real time as they moved around. They used a programme to take a 'picture' using the infrared to create a 3D image of the man. This was pretty cool but I wasn't really sure how it could be used in medicine, until they started to talk about scoliosis. This is a condition which affects the curvature of the spine and used to require regular X-rays to monitor. With the knowledge that X-rays are dangerous to patients when they are overexposed to that kind of radiation, doctors were reluctant to continue to monitor the condition in this way and agreed that it was necessary to find an alternative. The medical physicists then came to the rescue when they realised that this technology could be used! I think it's crazy that this technology can be put to use in so many ways other than just for gaming. 

I would definitely recommend mini med school to anyone looking to study medicine in the North East or anyone who has an interest in the sciences. 

Can we eliminate genetic disease through better awareness?

This was the question posed at a heretics meet last week. The group consisted of scientists but also other academics, so it was interesting to hear the various arguments and points of view that were sparked by the idea. 

The speaker, a good friend of mine, had named his talk sterilization and stated that he believed that we could considerably reduce the risk of children in the next generation being born with genetic diseases by introducing some simple protocols in the UK. He suggested having the entire population (above the age of 13) screened for genetic diseases to make them aware of their genetic make up and to ensure they are fully conscious of any genes they may be carrying which could be passed on to their potential children. This was the basis of his argument. He went on to state that before people decide to have a baby, the parents could cross their genomes, in a similar way to the way that we do it in Punnet squares at GCSE, to check the likelihood of their child being a sufferer of a given disorder. With this awareness they could then decide whether they would still like to have the child or whether something like IVF, for example, would be a better route for them. He proposed that they should be given 2 chances to have children who were genetic disease free naturally, followed by a chance at subsidised IVF, before they would be told they should no longer reproduce. So sterilisation would only be used in cases where people tried to cheat the system and continued to reproduce despite the fact that the children were suffering from genetic diseases and realistically the use of this title was an attention seeking stunt and he himself admitted that.

Of course the heretics society got hung up on the fact that he had suggested preventing people from having children, which to them seemed unfair, and in fact probably is. However, the main focus of his argument was actually pretty strong. If we consider the cost of sequencing a genome compared with the cost of treating a patient with CF for a lifetime, for example, the healthcare system could definitely benefit from taking measures to reduce the instances of these genetic diseases. Given that it could be fairly simple to determine probabilities in terms of the offspring suffering from the genetic disease. I would like to think that if people were aware of these probabilities, parents would consider this as a factor in their decision to have children. This being taken into account, I think it is likely that we would see a decrease in the incidence of genetic disease in the next generation purely through raising awareness. Of course the process would be expensive to implicate at first but I would see it as being similar to a vaccination program, such as the flu jab, which is offered to those who need it every year. This would be the case with the screening in my opinion. Every child who had turned thirteen in the past year (after the first year, of course) would be screened.

Something to consider, however, would be genetic diseases such as Huntington’s, which would not affect the sufferer until much later in life, but are also known to have no treatment. Some people may opt not to be screened because they would rather not know, and we need to consider that this is their right. However, this would interfere with the whole system and could affect the population in that the disease may be passed on to the next generation in an instance where it may not have been if protocol had been followed. We must think about the balance between ensuring that everyone’s rights are fully taken into account and making sure that the process is effective and of course cost efficient.

But obviously it shouldn’t be all about money. (Even though a lot of the issues in the NHS nowadays are…) We must ask ourselves if we think it is acceptable that children still wake up with Tay Sachs disease when this could have been prevented by a simple screening program to give parents the awareness they need to make informed decisions. We should be conscious of the suffering that comes with most genetic diseases. I watched a documentary recently based in a hospital in Newcastle, which is very local to me, and it really touched me. It followed several children who were in hospital for various different reasons, but one particular boy’s story, who was a sufferer of CF, particularly struck me. This young boy was about 12 and wanted to go to a sleepover at a friends house for his friends birthday, but because of his disease, was unable to sleep without oxygen at home and his friend’s mum didn’t want the responsibility of regulating and monitoring his oxygen through the night. So during his stay in hospital, he worked extra hard and attended physio sessions in order to try to clear his lungs enough, and gain enough fitness to be able to go an entire night with no oxygen. I, personally, had never thought about not being able to sleep without a machine being attached to me, let alone the things that go with that, such as the fact that he couldn’t stay at friends’ houses. As a child who grew up healthy and was always able to do everything I wanted to in terms of physical and mental ability, I can’t imagine living life as a young boy the way he has to. But this is completely unnecessary! We could reduce the risks of people being affected by these issues fairly easily if we were to introduce a simple awareness program to the population.

Of course there are lots of flaws in this idea, as there are in all new concepts, but I really do feel this is something that we could consider, or at least offer to potential parents to reduce the suffering of their offspring.

Diagnosis and Budgeting

 I have attended several talks in the past few weeks on various topics but all of these seem to have had one thing in common; the fact that budgets and quotas play a huge part in the role of a doctor.

The first in this series of talks was a talk given to my school’s medical society by Dr Greg Rubin from Durham University about the early diagnosis of cancer, in particular the role of GPs in the process. He stated that a quarter of cases of cancer are diagnosed in A&E and also that in terms of survival rates after diagnosis, the UK looks pretty bad compared with other countries including Denmark, the USA and Australia. The UK currently has 28 cancer care networks but this doesn’t seem to be enough. We were able to ponder the importance of a multitude of factors influencing the chances of survival of a cancer patient but the winner was always going to be the time of diagnosis. So how can the NHS ensure that diagnosis takes place early enough?

A few factors were mentioned:

-The ability of patients to recall significant symptoms that are often unknown, such as a persistent cough. Failure to mention something that may seem trivial to a patient due to a lack of knowledge on the topic could mean a doctor misses a diagnosis, which could save a life. This highlights the importance of awareness of common symptoms of various cancers. It becomes slightly difficult, however, to fully educate the population when we consider that there is a fine line between education for the good of the population and education that could cause panic and be seen as scaremongering. For example, the last thing busy, overprescribed, understaffed hospitals need is Mrs Smith who has had a cough for two days and is convinced she has cancer walking into their emergency department demanding tests. We also need to think about the fact that education of an entire population is not going to be cheap and can the NHS afford all of the campaigns that would be necessary to publicise the unknown symptoms of less common cancers? Should cost come before the health and awareness of the population? Would it in fact save money to educate people and thus reduce the number of emergency cancer cases seen by catching it earlier?

-This brings us nicely to the second factor; the early diagnosis of cancer. Of course identifying cancer in patients early will increase their chances of survival. So what is involved in diagnosing cancer in a patient? I attended Mini Medical School at Newcastle University where the topic was ‘Diagnosis-art, science or hunch?’ and the diagnostic process was also touched upon in the lecture given by Dr Rubin. There are several steps to diagnosing a patient, most of which do not directly involve a doctor. Before the doctor even sees the patient, the patient has the appraisal phase, where they decide that they are ill and need treatment. This requires knowledge of what it means to be ill. Of course there is the medical model of illness, where one has a disease and is suffering from symptoms. Then there is the general state of health, both mental and physical whereby general wellbeing would be defined as healthy. So the patient decides that they are unhealthy but does not necessarily head straight to the GP but might first consult a friend, member of their family or self medicate, for example just take a paracetatmol. But this doesn’t work so they decide that they need to go to the doctor. They may not give the doctor all of the relevant information and are generally worried about the outcome of the appointment, so it's fair to say that the doctor has a difficult job ahead of them. Not only do they have the responsibility of this person's health being entrusted to them, they also have the healthcare systems rep to uphold, especially after incidents such as the MidStaffs enquiry. But added to all of that, they have budgets to stick to. Does this put them off taking potentially necessary tests? Would they take a test if they had unlimited money to do so? Would they refer more people to specialists if there wasn't a huge waiting list?

The main question we need to ask in these cases is is the quality of care restricted by a lack of resources? And the obvious answer is yes but more importantly, what can we do about it? 

Horrible Hormones

I thoroughly enjoyed a lecture given by a senior lecturer at Newcastle University about common endocrine disorders and their biochemical causes. Of course I was already aware of how important hormones are to the body, but the way in which one tiny change can affect the body is truly extraordinary. 

The centre of this talk was obviously the pituitary gland and the way tumours associated with it affect the body. I learned that the pituitary gland is made of two sections with separate functions; the anterior and the posterior. A hormone produced in the anterior called prolactin is associated with the production of milk in mammals and also 'switches off' the menstrual cycle during this process to prevent further reproduction. Without considering this factor, the West decided to send bottled milk to Africa for children to be fed with rather than breast milk from mothers, which meant they no longer required milk which halted prolactin production and restarted the menstrual cycle. This effectively reversed mother nature's contraception and caused a population surge. This is a good example of when meddling with nature can have unexpected consequences, something which should always be considered in medicine. The posterior of the pituitary gland is associated with the production of ADH and oxytocin, but the main disorders discussed related to the anterior. 

The presentation of pituitary tumours seemed to be fairly generic at first, but could be anything from excess/deficiency in hormones to apoplexy in acute cases. They can also cause bitemporal hemianopia; a change in the field of vision due to pressure on the optic nerve or chiasm. Depending on where the gland is altered, there are varying physical effects. 

One disorder is acromegaly, which is an excess of growth hormones, caused by hypopituitarism. An example used by the lecturer was a man called Gary Tiplady who was 7ft3! Because these tumours are so slow growing, the tumours are often not noticed for years, by which time the patient often has many other problems related to pituitary adenomas. This includes Cushing's diseases, caused by an excess in secretion of ACTH and production of steroids by the adrenals glands and can result in conditions such as diabetes, osteoporosis and obesity if not recognised and treated. Another condition could be Addison's (which JFK had) which is often known as tuberculosis of the adrenal glands and presents as increased pigmentation and often also vitiligo, which contrasts massively on the skin. People may have an Addisonian crisis if they have a lack of steroids which is why people who take steroid medication will carry a card around with them stating this. 

We also looked at the thyroid as an area where problems often arise, thinking about both hypothyroidism and thyrotoxicosis. Hypothyroidism is often caused by an iron deficiency, but this cause is uncommon in the UK due to a good supply of iron in the diet. Thyrotoxicosis, however, is the opposite and can result in conditions such as Grave's disease, which is sometimes known as thyroid eye disease due to an antibody causing inflammation of the eye, meaning the patient often sees double. Grave's disease can also cause atrial fibrillation due to the overactive thyroid and this was exhibited in George Bush senior, when he collapsed on a golf course while in office as president as a symptom of his condition. This can be treated with inhibition of hormone synthesis orally or in extreme case with thyroid surgery. Alternatively, and more commonly in more current medicine, it can be treated with radioiodine, which is taken by the patient and ablates the thyroid. The patient is then given hormone replacement therapy to maintain the correct hormone balance usually controlled by the thyroid. 

In the most extreme cases, hormone deficiency can cause pituitary apoplexy, which can present as a subarachnoid haemorrhage, with symptoms such as a severe headache and visual loss. It is vital in these cases that the hormones are replaced as quickly as possible otherwise it is potentially fatal. 

Overall, the talk outlined to me that there are so many things that can go wrong with hormones in the body and it is so important that doctors are able to spot these disorders and treat them effectively. I was fascinated by the variety of conditions and the biochemistry that causes them. I continue to be amazed by the complexity of the human body, where there are so many opportunities for things to go wrong, yet the majority of us are lucky enough to be unaffected by these conditions. It seems almost unfair that most of us go through our lives completely blissfully unaware that these conditions exist and it's purely down to our genes and luck that we are not directly affected by them. It is in these situations where the vigilance and care of doctors, nurses and other medical professionals really come into their own and are able to provide life changing care and treatment. 

Work Experience

Last week I spent  4 days in my local hospital following several very busy doctors around! I was able to spend time in various departments of the hospital.

Surgery

I watched several operations both laparoscopically and open, all of which were extremely interesting. I particularly enjoyed a mini stomach bypass on an obese man. I was amazed by the innovative equipment the surgeons had access to and was fascinated by the intricate manoeuvres they could perform. The bypass was performed in about an hour, with no complications. More than the actual procedures, however, I was watching the interactions between the doctors and scrub nurses. It was interesting to see the team of people working together on the one operation and it really confirmed to me that being a doctor is definitely a job for a team player. I took opportunities to ask the doctors about their lives and their training and one thing that stuck in my mind was when a surgeon told me that if I wanted to make money and be praised then I shouldn't be a doctor, but went on to say that if I wanted to make a difference to people and have good job satisfaction then I was making the right decision. I think I am. I asked him what the worst part about being a doctor was, and he told me it was most definitely the family life (or lack of, for that matter). This is something I'm sure I cannot fully understand, given that I am only 17, and have lived away from my family since I was 14 at boarding school. However, I know it is fully possible to have a family life in the medical profession, it just may not be completely conventional, but that being said, I don't think I would enjoy a conventional life. I think I will enjoy the challenge, being constantly stretched. I also attended a lunchtime meeting with the consultants where they discussed all of the new cancer patients they would be dealing with and the direction they thought their treatment should go in. One of the consultants told me that the reason for this meeting was to get as many opinions as possible and ensure the patient was receiving the best care possible, yet another example of doctors acting in a team.
A&E
I absolutely loved my morning in A&E again! I followed a lovely nurse, who showed me everything there was to see! There were some difficult cases and of course dealing with sudden loss is a major issue in A&E. Something that stood out hugely in A&E was the importance of good nurses and good bedside manner. A lot of the people who came in were distressed and their relatives and loved ones were upset and worried, requiring friendly faces and chatty nurses to take their minds off the hard time they were going through. I enjoyed talking to the patients and laughing with them as they had bloods taken and obs done because I felt as though I was helping them slightly. I was really stretched in A&E where the consultant asked me what I wanted to gain from my morning in her department and I told her I wanted to gain insight, experience and an idea of what it's like to be an A&E doctor, but also to be challenged. She rose to that straight away and handed me a case of a man who had been referred to A&E by MIU for them to then refer him to the specific department he needed. She asked me how efficient I thought this was and if I could think of a better pathway to go through. Well… It was 9am on a Tuesday morning and I had definitely been thrown in in the deep end but I loved it. I told her I thought it was very inefficient given that A&E had nothing to do with this particular patient until they were given his file by MIU, which seemed an unnecessary link if only
Cardiology
The cardiology department was probably my most challenging stint (stent ;) haha) in my work experience because it required a good level of understanding about all of the areas of the heart and the blood vessels around it. Luckily, this was my favourite chapter of the biology course, so I looked more into it! Thank goodness! I watched the procedure performed with catheters to investigate a stenosis in a lady's coronary artery and discussed with the doctor the procedure to insert a stent to widen the artery to prevent an MI. The doctor then took me to an audit meeting about a new blood thinning drug. He explained that this drug was better than Warfarin because with Warfarin, the blood needs to be tested regularly whereas with this drug, testing is much less frequent. This is positive because it means the drug has less of an impact on the patients life.
Interventional Radiology
Nowadays, surgery itself is much less invasive because of the fantastic advances in technology, and this includes certain operations which now don't even need to be operated on as such. They can be performed with ultrasound or X-Ray assistance. I watched a procedure where a lady had a gall stone stuck in her bile duct which was causing blockages and infection, but the woman was old and the risk of removing the gall stone, along with the stress it would cause her to have to undergo surgery, was deemed to not be worth it. So instead, the doctor used ultrasound to direct him to her liver, gave her a local anaesthetic, and used a needle to go through her liver to find the stone. He used dye which could be seen on a screen to be filling her bile duct, and the stone was so obvious. He then used the needle to guide a wire, over which he could pass a tube, to act as a bypass around the stone. This would prevent it from causing anymore blockages and less infections. The procedure took no more than 20 minutes! The personal side of this was more difficult than most of the others I watched, because the lady had dementia, and was very upset, asking why we had done that to her. She was crying and would beg me to let her go home and make her stop, reaching her hands out to me. I must admit, I wasn't overly sure how to approach this situation, given that I knew she couldn't go home just yet and was in no position to help her. I found it so hard to see her in pain the way she was, both emotional and physical. However, I was so touched by the way the other professionals in the room dealt with her and reassured her and calmed her down. They were so kind, patient and compassionate with her, which is exactly the type of doctor I hope to be one day.
Neurology
The final department I visited was a ward in neurology where I saw a lumbar puncture! I noticed on the ward how attentive the nurses were to the needs of the patients but also, how much administration the doctors had to! There was a lot of paper work and less patient contact that I expected. The doctors spent  quite a lot of time looking at scans and discussing treatment plans as opposed to seeing patients. I still enjoyed this though, because I was able to see lots of scans. 

Bad Science, Ben Goldacre

In my opinion, this book can be described as nothing other than brilliantly eye opening. Ben Goldacre discusses serious issues faced by the public, including medical professionals with a fantastic sense of humour and flair. I seriously enjoyed reading his book.
I enjoyed his chapter about Gillian McKeith, but that was mostly due to his whit as opposed to the science based knowledge he wrote about, which was definitely not lacking in other areas of the book. To start with, he debunked techniques that are widely used in schools, called 'brain gym', which I myself have been subjected to and wasn't overly enamoured by. These techniques include things such as creating 'brain buttons' which can be used to stimulate your carotid arteries from outside your ribcage by simply rubbing your chest. Obviously impossible. He then goes on to discuss the fact that the cosmetics industry are using long words which the general public are unlikely to understand in order to sell more products on the basis that if people do not understand the sciencey words they are likely to think that the product will be beneficial to their health. For example, the use of the names of specific compounds that are ingredients in the cream, when in fact, if you look closely enough at the packaging, or any of the advertising for the product, there are no claims that those specific chemicals will actually make you look better. As the author states, the claim is made for the cream on the whole, because as we are all aware, moisturising the skin will make it look nicer, but that could be done using a cheap cream as opposed to the expensive one with the magic, fancy chemical. This is an interesting point, which basically encompasses the message Ben Goldacre is trying to get across for the rest of the book, and that is the fact that we are too quick to believe the things we are told, particularly when it comes to scientific fact.
A fantastic example of this is the famous case with the MMR vaccines being linked to autism. The case which was eventually disproven, but only after thousands of children didn't receive the safe vaccination they needed to protect them from extremely dangerous diseases. This book addresses the idea that we are so easily misled in a clever and humorous way that keeps the reader engaged in even the most potentially tedious areas of deeply confusing statistical methods.
One thing I'm really glad I've been able to take from this book was knowledge of the Cochrane Collaboration, an organisation who carry out reviews of clinical trials and review them systematically, which has provided us with a database of information about how well the trials were conducted and the results found over a collection of trials as opposed to just one.
Overall, I loved reading Bad Science and feel that it educated me on the pharmaceutical industry as well as opening my eyes to some of the money making scams and how the media mislead us on scientific topics every day. I would definitely recommend it.

How much of our brain do we actually need?

I attended a gifted and talented conference a few months ago where we were told about a man who had walked into a hospital with enlarged ventricles meaning that his actual brain tissue was reduced massively. I was so fascinated by this because I could not get my head around the fact that the brain can be so significantly damaged and for someone to be able to function with almost no real problems. I read further into this and found that this man had an IQ of 75, which is of course below average but by no means unusual, and definitely does not indicate the level of damage to his brain tissue which was seen. To me this shows just how much our brains can adapt to certain circumstances. This is especially impressive considering that the man had suffered from hydrocephalus as a child, which can often kill. The man must have had immensely increased intracranial pressure which, in his severe case should have caused some sort of mental disability. 

Another interesting case of brain injury (that I read about in Impulse) was the case of Phineus Gage, who had a metal rod driven through his brain, but managed to survive reasonably unchanged, given the circumstances. This is due to the fact that the rod penetrated his left frontal lobe, the area of the brain associated with recognising consequences and knowing the difference between right and wrong (among other things of course), which would explain why Gage's injury only resulted in a change in his voluntary behaviour. This was, of course, famously recognised by his peers, and the reason he was fired from his job as a foreman. 

I find it incredibly interesting that the brain is such a complex and vital organ, but can take serious damage without fatal consequences. When even the smallest thing goes wrong, for example in 'silent strokes', it can have significant effects, such as the onset of vascular dementia, but others can have a huge steel rod pushed through and remain mentally competent. It is definitely fair to say that the human body is a well oiled machine and something I often wonder if I will ever truly get my head around.