Paediatric A&E

A&E has always been an area of medicine I have wanted to look into purely because it always seems so exciting and diverse. One of the reasons I love the idea of becoming a doctor is that I know I will never be bored and A&E has always appealed to me because of the need for quick and efficient problem solving and the ability to work under pressure. Some people might view this as scary or unpleasant but I love situations like that. So, when I was offered some time with a consultant in paediatric A&E at my local hospital, I jumped at the opportunity. I arrived and was sent straight to the staff room area which was full of doctors at computers typing away, with a big TV screen on the wall with names and DOBs and injuries on. I was introduced to a few doctors and told to just shadow anyone I liked. Great.

As soon as someone picked up a card to leave the room, I jumped up too and followed. A finger injury on a young boy following an incident with a folding chair… Oh dear! It was definitely difficult seeing the child so upset but it was nice to watch the way the doctor interacted with both the child and the parent. Reassurance, support and professionalism with the parent, and care, patience and compassion with the young child. 

After seeing the patient, I followed the doc to go and fill out a multitude of online forms to allow the boy to be discharged. That area of medicine is something which is definitely not well known among wannabe doctors, but it didn't bother me too much. I saw it as a pleasant break from patient contact to consolidate the things I'd seen and reset myself to go back to see more patients. 

I saw lots of chest infections but one which stands out was a young boy who was covered in a rash. I went into this consultation with a medical student who was doing a placement and after taking the history and conducting the physical examination, she suspected scarlet fever, but was unsure, and so didn't mention anything to anyone before relaying her findings to the consultant. By doing so, she avoided panic and ensured that no unnecessary concern was caused. The consultant then went to do her own exam and ruled this possibility out and diagnosed a chest infection. However, the medical student was still applauded for her efforts, despite her initial diagnosis being incorrect, because she was able to seek help and reassurance. This highlighted another, less obvious quality of a good doctor, and that is being able to check your work and recognise areas of weakness, asking for help where necessary, especially when the welfare of others is in question. 

Because I quickly got on really well with the medical student, she taught me how to take patient histories and taught me a method she had recently learnt called BINDS used when taking the histories of young children. B stands for birth, as in was the birth normal? Natural or Csection? I- Immunisations, are they up to date? N- nutrition, are they eating normally, enough, still have an appetite, drinking enough, less/more than usual? D- development, are they developing the way you would expect, do they act in similar ways to other children their age? S- social background, who do they live with? Do they live with any pets? 

Overall, I loved A&E experience :) 

Genetic Modification

This topic seemed to be a recurring theme in this month's New Scientists, and it got my attention. My first main interest was in a study being conducted by Oxitec, who were using GM mosquitos to fight the spread of dengue fever. The mosquitos were modified to die before reaching adulthood. A group of male GM mosquitos would be released into an affected area and then mate with normal (infected) females. Their offspring would die being reaching adulthood and the spread of the disease would be cut. Primary test in the Jacobina region of Brazil show that the number of eggs fell by up to 92% but there was no fall in the incidence of dengue fever. This, however, could be due to an extremely small sample size. The article states that a full epidemiological study must be conducted before results can be seriously considered. This concept is really topical in the world of medicine, with diseases like malaria causing so many deaths every year. If this study proves successful, could we be looking at seriously fighting malaria?
The second incidence of modification was in worms. Scientists had conducted a study involving the neurons of nematodes. They started by using electrical synapses to bridge a gap junction involved in recognition of salt concentration. They did this by injecting DNA onto the gonads of Caenorhabditis elegans which codes for a protein involved in establishing extra neural connections. They used mouse genes to avoid interaction with other neurons and found that the response to salt in the next generation of worms was massively depleted. The second investigation they conducted was in the smell of these worms. They added electrical synapses to neurons previously connected by a chemical link. This retraced the signals and eliminated the worms ability to recognise smells. This circuit for smell in the worms is comparable to circuits for eyesight in other organisms, which poses questions as to how else this technique could be used. One suggestion from the article was that it could be used to treat stroke victims. They could be given a pill to reconnect the damaged areas of their brain by creating neural bypasses to avoid damaged areas. Another important idea raised was that, by editing synaptic pathways, one could genetically modify an organism to possess a specifically grown brain circuit with a certain skill set. This could include organisms such as worms able to protect crops by identifying dangerous bacteria, which is definitely appropriate given the food crisis we are heading into. However, this made me wonder whether the genetic modification of organisms is ethical. Admittedly, in nematodes, it is less of a concern, particularly given their small CNS, but in larger organisms, it raises an issue for me. If we are able to insert skills be rewiring a brain in a certain way, why do we need to learn? What need to we have for education? When we are simply able to have an operation to allow us to have a certain skill set, why would anyone want to spent 4 years and a crazy amount of money to train in that skill? When society is levelled out in this way, it reduces the need for skilled individuals. I think this is a dangerous concept.
And I believe lots of the rest of the population agree with me that GM can be a little scary, perhaps just for different reasons. Another article was discussing GM crops, and it was heavily focused on the public opinion of this idea, which is generally fairly negative. They seem to be concerned about the ideas of 'tomatoes with scorpion genes in them,' and this concern seems to make them reluctant to consider the less shaky, more high tech ways of modification. They also appear to be unaware of how regularly genes are naturally swapped between species in the wild. This got me thinking why people have this view. Is it the fault of the scientific community? Or is it simply that they haven't bothered to do enough research into it themselves to see that there are alternatives that don't involve putting a salmon genes into strawberries? Either way, the scientific community is forced to concern itself with this public opinion, and I can't decide if this is right. I'm not sure that it seems right that professionals are forced to halt all progressions in their research if someone unqualified doesn't really like it much, particularly if the research is looking into solving a world issue, such as the food crisis. Granted, if the public are unhappy about GM crops, the research may be slightly useless because they won't buy the product, but can this concept be transferred to other areas? For example, stem cell research. To be answered.

Work Experience

Having already done some work experience in France and finding out how exciting it can be, it's fair to say when I was able to organise some more in England with an NHS doctor I was absolutely chuffed. I'd really struggled to find any work experience in the NHS because of my seriously busy schedule, particularly around exam season, but I finally managed to organise some with a doctor, called Sam, who had a clinic for looked after children. I spent a day with her in her clinic and was able to watch the complex interactions in a highly sensitive situation. This was unlike any other exposure I had had to medicine before and I enjoyed discussing the way these situations were handled with Sam, including how she handled the emotionally challenging cases she saw daily. Something that I found particularly difficult was the often detached and impersonal way the fosterers could talk about the children they were caring for. I found it difficult to see carers discussing 'problems' they were having with the children they were looking after while they were in the room. Often the carer would talk about the child in a very negative way, despite the fact that they were present at the time. I brought this up with Sam after one particularly difficult consultation, telling her how I found it sad that the young boy had to sit and listen to the carer basically complain about him. She explained to me that often the view of an outsider on these types of situations can be that they are harsh and upsetting but that through training and exposure, she reassured me that these things become easier and that finding it difficult was simply a sign of remaining compassionate, as opposed to be unsuited to a medical career.
Another part of this experience I found interesting was discussing ADHD, as it is diagnosed more often in looked after children than average. I learnt that this is because looked after children are often victims of trauma, which can cause similar symptoms meaning that they are misdiagnosed as having ADHD, when in fact they are simply responding to their hyper vigilance, as opposed to hyperactivity. When I got home, I looked into this more, and found an article which described that children who experienced trauma, such as violence, are much more sensitive to subtle changes in tone of voice, facial expression or body language due to a fight or flight mentality they have been forced to adopt. This explains why often at school, they can seem easily distracted by irrelevant concepts, such as sounds around them or the behaviour of other children. This can cause concentration on normal subjects to be hugely difficult for the children, and can be easily misdiagnosed as ADHD. The article (http://healthyliving.msn.com/diseases/adhd/diagnosis-adhd—or-is-it-trauma-1?pageart=2) states that often the drugs prescribed for ADHD can act as a stimulant, which of course would make the symptoms worse. This, to me, highlights how important it is to ensure the correct diagnosis is made, especially given that fostering, adoption and placement are all considered to be potentially traumatising.
Sam also allowed me to attend a genetics lecture organised by the department. Despite struggling to keep up with some of the more complex ideas, (especially those involving lots of acronyms that I had never heard of!) one thing I took out of the talk was an interest in Huntington's disease. This was brought up because it causes an ethical difficulty when screening looked after children whose grandparents have showed symptoms. If the parents do not wished to be screened or would rather not know if they have the mutation related with HD, it becomes difficult to screen the children, because of course if they are positive, it's obvious that one of the parents is also positive (because it is autosomal dominant mutation and does not skip generations). This is a problem because if a grandparent has symptoms or has been confirmed as having HD, there is a chance the child will also have it, and one could argue that the child deserves the right to be screened, particularly in cases where the gene is suspected to be from the father. This is due to greater instability in the paternal genes than maternal genes, meaning the mutation could be greater and therefore could lead to early onset Huntington's.

Impulse by Dr David Lewis

I recently read Impulse and thoroughly enjoyed it. Upon primary examination, while trying to choose a book to hand in for my school’s speech day as a prize, I was interested by the concept of the book; looking at why we do things without knowing why we do them. At first, it seemed as though it was mostly based on general psychology and so I did not expect to read much hardcore medicine related science, but was still interested nevertheless. I was pleasantly surprised to find that in fact the book was heavily science based and had plenty for me to get my teeth stuck into!

I read it while away on a trekking and volunteering expedition in the Atlas mountains in Morocco with a group, and managed to get them all interested in certain aspects of the book, such as how the length of index finger in comparison to ring finger can be used to find a ratio which is then used to determine the likelihood of the individual partaking in risky behaviour.

Another aspect of the book that I found particularly interesting was the section that discussed how animals can use a subconscious sense of smell to avoid inbreeding within their species. This caused me to do some further reading and I found that this occurs largely in birds, such as penguins. This also helps them to find their mates after a long period of foraging, and allows them to find their habitats after days at sea. The same principle applies with mice. They use the their sense of smell to detect which other mice are closely related to them, due to the genes relating to smell being on the same part of the genome as the genes related to the way the immune system identifies its cells. This produces the concept that if you smell similar, you are likely to be closely related. An experiment was done claiming that mice avoid inbreeding in this way, where a mouse was placed into a cage with its brother. When forced and with no other option, the mice would breed. However, if another, non-related male was introduced, the female would mate with the other male over the brother. Interestingly, if the second male was introduced after the female had fallen pregnant, the female would abort her current pregnancy to mate with the new male; a good mechanism to avoid inbreeding. Dr David Lewis claimed that this concept could be transferred and was proven to be in use among humans, in that we subconsciously find people with similar smells to our own less attractive, which is nature’s of way of preventing incest, using MHC (major histocompatibility complex) genes.

The overall message of the book is that a lot of what we do, or at least think we do, consciously, is in fact down to our genes or factors that we cannot control. This introduces the idea that ‘free will in an illusion.’ This is a dangerous concept, as highlighted in the final chapter of the book, due to the fact that it removes all personal responsibility and makes punishment of criminals significantly more difficult, particularly if it were to be widely recognised that free will is in fact a grand illusion. We would no longer be able to send murderers or psychopaths to prison because they could quite easily blame their subconscious (system I) brain and claim they were not in control of themselves; a dangerous and scary concept in my opinion.

The life of a clinical researcher

This evening I attended a lecture given by Dr Desa Lilic at Newcastle University about her life in clinical research. The talk was organised by Newcastle AMS, and I was lucky enough to be able to go along and listen. (Perhaps partly due to the fact that somewhere along the line in the organisation my friends and I were mistaken for undergraduate students at Durham Medical School as opposed to just Durham School!) 
Dr Desa Lilic opened her lecture by telling us how provocative she intended to be and that her aim was to make us think about the role of a clinician, and she stayed true to her word. She told us that in fact clinicians are not scientists. A clinician does not acquire the knowledge, but instead simply applies it. This concept was new to me because of course I had always been under the impression that clinicians really were scientists, in their labs, with their crazy hair and white lab coats. Well, maybe not quite like that, but I definitely thought they fell into the category of 'scientists.' 
However, once I started to think about it, I remembered why I want to be a doctor and not a scientists. Scientists acquire the knowledge and make the ground breaking discoveries, whereas doctors and clinicians use this knowledge to solve the problems faced by real people, and this of course requires interaction and application. This is the thing about medicine which really excites me! 
Next, we asked ourselves why people carry out research. My initial reaction would be to move forward in a way of thinking. When I don't understand something, or would like to know more about something, the first thing I will do is look more into it. Dr Lilic said that she had asked her colleagues what they thought and they all gave various answers such as better understanding of a disease, to help patients etc. The one which struck me, however, was for rewards and recognition. It had never really crossed my mind that going into medicine could make someone famous, and of course that is never anyone's intention in becoming a medical professional. However, Dr Lilic proceeded to illustrate that doing clinical research for fame or fortune is not sensible at all, using examples such as Watson and Crick. Of course they were not the only people responsible for the discovery of the molecular structure of DNA, and at least two of the main contributors were completely ignored in the papers they published. Notably, they used the research of Rosalind Franklin, who died prematurely, (possibly as a result of her exposure to radiation in her research) without her consent and she therefore received virtually no recognition at all for her efforts and for providing crucial information, without which Watson and Crick would not have been able to make the discoveries they did. Another example she used was in the discovery of myelomas which are used to produce monoclonal antibodies by fusing with B cells to form hybridomas. The discovery of the crucial deficient myeloma cell should have been credited to Michael Potter, but instead was credited to Milstein and Kohler. This was due to the fact that Milstein and Kohler applied the knowledge acquired by Potter and put it into a translational format. 
This led me to wonder whether science was in fact led by the researchers or by the market. Can scientists carry out good research without it having to directly lead to a new drug for example? Can scientists receive funding for research which will not lead to a development where there is a gap in the market? No, I really don't think they can. It seems that science has become market led and that all research must be applicable, which I think is a great shame. Dr Lilic made the point that all knowledge is useful knowledge and I would agree with this statement because although the research may not be directly applicable, it may be extremely useful in the future. For example, when Potter made the first myeloma deficient cell, he did have the use for it straight away, but without that research, we might not have had monoclonal antibodies. This shows that not all research must be directly applicable to be useful in science. I would like to end with a quote Dr Lilic included in her powerpoint. 'We don't choose our passions, they choose us', so the research should be based on the scientists' interests and the passions of the researchers, not the market. 

Audioprosthology work experience

A few weeks ago I was lucky enough to be able to follow an audioprosthologist for a few hours and see what the job involved. I must admit that I wasn't really sure what to expect from the morning but was still looking forward to it. It was so good to be able to go and learn about a field that I didn't already know very much about. Again, it had to be in french but it didn't bother me too much because I was counting it as my revision for my french mock which was coming up!! 

When I arrived I was greeted by a lovely lady called Murial Renard, who was kind enough to show me around the clinic she works in. Her job involves fitting hearing aids to children and I was able to watch this happen several times. I have to say I hadn't really considered working with children before because it hadn't appealed to me but after today it is definitely something I would like to think about. It was really amazing to watch the look on the children's faces when they could hear again and it was equally as wonderful to see how happy the parents were to see a change in their children. I felt privileged to be able to watch something like this happening so I can only imagine how incredibly satisfying it must be to be able to cause this. Even though it isn't a field I had considered, I feel as though it really showed me how much satisfaction there is in being a medical professional of this kind. It was also clear to me that the qualities I saw in all of the doctors in surgery were quite easily transferable to this profession. A sense of humour, good people skills and patience were all very important in the consultations I saw. I can't wait to be able to put these qualities to use myself and start helping people. 

Could viruses act as a replacement for antibiotics?

In one of my biology lessons today my teacher was talking about a microbiology course he had been on where he had been looking at the growth of bacteria in different conditions. He told my class about an experiment the people on the course with him had conducted involving viruses which attack bacteria called bacteriophages. I was extremely interested in this because straight away it got me thinking about the uses it could have,including as an antibiotic. This is especially important due to the thousands of antibiotic resistant strains of bacteria emerging, making it more difficult to treat patients suffering from diseases such as MRSA. He showed us an agar plate with his bacteria colonies beginning to grow with a wall down the middle. On one side of the wall was just the bacteria (E.coli)and on the other was the bacteria mixed with the bacteriophage. This interested me so much that I decided to do a little bit of research into bacteriophages. 

I discovered that phages, in the environment in general, work by producing enzymes called lysins which destroy the bacteria and therefore release hundreds more of the phages which had been held by the bacteria into the rest of the colony to attack more bacteria cells. 

Bacteriophages can therefore be used as an alternative to antibiotics due to their ability to perform the exact same function; destroying bacteria. This development of bacteriophages into medication as a treatment for bacterial infection would result in huge developments in the medical world. I found some information about an experiment conducted by the laboratory of William Smith which investigated the use of phages of the treatment of E.coli in mice. They wrote a paper which stated that a single dose of a certain E.coli phage was able to greatly reduce the number of that strain of E.coli in the alimentary tract of animals with a diarrhoea causing strain. This resulted in less fluid loss meaning that all of the animals treated with the phage survived.