Monday, 9 April 2012

Royal Hospital of Bournemouth & Christchurch Stroke Unit

After getting in touch with Dr Damian Jenkinson, he agreed to let me observe an outpatients clinic he was doing last week. The clinic was following up a number of variety different ambulant patients who had seen Damien recently. It was the first time I’d been allowed to observe real consultations with patients so I was excited about seeing what life is like behind the doctor’s chair from patient to patient. We began by re-examining the patient history together going through the history of the differential diagnosis, diagnosis and treatment as well as letters sent between doctors for the patient, and discussed what had been going on. The problems varied from a suspected TGA – an electrical storm in the limbic system of the brain, to continuous treatment of a patient with atrial fibrillation who was taking a new anti-coagulant drug called ‘dabigatron’ which is beginning to rival the renowned ‘wharfarin’; despite being significantly more expensive it offered a much higher prevention of clotting cascades to the brain, the cause of ischemic stroke. We discussed the pros and cons of the use of the new drug, and Damian explained how new drugs were pioneered and approved by NICE, who weigh up the cost of the drug against the savings made to care services as well as years added to quality of life. Another patient had been diagnosed with prodrome migraines (without the classic migraine ‘headache’). Prodrome symptoms include a tingling feeling and flashing lights in the visual field. Beta blockers can be used to treat migraines (they work by blocking the transmission of certain nerve impulses). Next Damian explained the basic anatomy of the blood supply to the brain through the ‘circle of Willis’ consisting of carotid arteries vertebral arteries and basilar arteries. The next patient had suspected episodes of atrial fibrillation but also had a platelet dysfunction thus making it difficult to prescribe anticoagulants. Hence the patient was referred for a tape, which records heart activity for a certain period of time which can then be analysed by doctors on a computer. I was then allowed to witness an ECG scan of the patient and Damian explained how the ECG scan was first devised by Eindleven who placed cattle’s legs into four troughs and recorded microscopic electrical changes between the four legs and measuring heart activity from this!

After this I was asked if I would like to go and visit the stroke unit at Bournemouth Hospital! I leapt at the opportunity and so found myself at the hospital getting some ward experience! During the afternoon I observed the writing of a death certificate, ward rounds with patients, diagnosis of a new stroke patient, and minor stroke patient and also intensive care. The doctors on the unit were really enthusiastic about imparting their knowledge about stroke care to me and as a result I learnt absolutely loads! There are two types of stroke: ischemic and haemorrhage. Ischemic strokes account for 90% of strokes and are caused by a blood clot in the brain, which results in a lack of oxygen in a particular area of the brain (they also cause Transient Ischemic Strokes – mini strokes in which the brain is only without oxygen for a few minutes before the clot is broken up). This causes dysphasia and lack of muscle control across one side of the body. This is often caused by atrial fibrillation because it can result in large amount of blood moving up into the brain at once, and is more likely to clot. Patients who have atrial fibrillation are usually prescribed with Wharfarin, to prevent the possibility of a stroke, a drug which thins the blood and so reduces the likelihood of clotting. High cholesterol can also contribute towards strokes – as plaque builds up in the carotid artery, clots begin to form around it which can lodge in the brain causing the stroke. After a stroke thrombolytic drugs known as ‘clot busters’ can be used if deemed necessary to break up the clot and allow oxygen to return to the particular area of the brain (as examined in the ‘Telemedicine’ post). Wharfarin is not given to the patient after the stroke until two weeks have passed to quell the possibility of causing a haemorrhage stroke, although sometimes patients can refuse Wharfarin because of the constant blood checks that have to be made, and so can put themselves at risk of having another, potentially more serious stroke. Haemorrhage strokes are less common – these are caused by a bleed in the brain and tend to be more serious to repress. They are often caused by aneurisms, where arteries expand due to lack of support and can ultimately break. These can be stopped by inserting a coil around the blood vessel to prevent expansion – like the opposite of a stent. In some cases of haemorrhage strokes can cause the brain to expand (much like another area of the body may swell as a result of a trauma to the area) to a level where a part of the skull has to be removed. The part of the skull can either be replaced by a metal plate, or stored in the abdomen where the surrounding tissue will keep it alive until the brain has shrunk enough for the skull to be reconstructed.
On the ward, I was shown a number of different issues which face patients as they begin their regeneration after a stroke. Deep vein thrombosis is possible for patients who do not move around enough, as clots can form inside veins in the body, which can cause further complications to the regeneration process. Pulmonary embolism, where a blood vessel supplying blood to the lung is clogged by a clot, is extremely serious and can result in death; hence drugs to prevent this are regularly administered. After a stroke swallowing can be extremely difficult for patients (dysphagia) who are then vulnerable to dehydration and under nutrition. There is also a risk that food and fluid may go down the wrong way, getting into the windpipe (trachea) and so into the lungs. This is called silent aspiration. This can cause infection and, in serious cases, can lead to a chest infection or to pneumonia. Patients are often fed through a drip in the nose (sometimes more stubborn patients can remove these so occasionally mittens are administered to prevent this). Sometimes, patients are fed through a ‘peg’ which feeds food directly into the stomach. Other issues such as constipation can cause problems for doctors trying to treat their patients and sometimes canellas are inserted if the patient is constipated to the point where they cannot urinate. Occasionally patients come in who had actually not had a stroke, but have imagined it or made it up. These patients are sometimes referred to psychiatric help if needs be, and feigning a stroke can sometimes be a cry for help from a patient. The doctors showed me their forming drugs forms for patients and analysing test results for different levels of chemicals and minerals in the body. Finally, during the day, Dr Jenkinson compiled the structure for the cardiovascular health reform announced by Andrew Lansley last year!

The day gave me such a brilliant insight into life as a doctor, not only in terms of diagnosing patients, but also the jobs and issues facing doctors during a normal day. It also tapped into my increasing interest in neurology and neuroscience. I recently watched a programme called ‘Phantoms in the Mind’ after hearing about the studies of Dr Ramachandran, which I will be writing about soon! 

Tuesday, 20 March 2012

Telemedicine in Stroke Care and the Importance of Clot Busting Drugs

I went to a medical lecture last week where I met Dr. Jenkinson, a leading consultant in the NHS Stroke Improvement programme. He was responsible for the opening of the new stroke clinic in Christchurch where I live, and I attended the meeting for the public to explain the implications of the new service. The pioneering new clinic has introduced the usage of videoconferencing to examine patients and view brain scans to increase the use of clot busting drugs.
Clot busting drugs, also known as thrombolytics, dissolve blood clots in the body. After a stroke clot busters can be used to dissolve the thrombosis in the brain which is causing the ischemia. The rapid use of clot busters after a stroke can be vital in arresting the rapid death of brain cells caused by the condition, thus the introduction of what is being coined as ‘telemedicine’ – doctors on call over the internet! Dr Jenkinson suggested at Mobile and Wireless healthcare conference in Birmingham last year that’ telehealth technologies could provide strong benefit in treating other serious conditions. []
I’ve emailed Dr Jenkinson about potentially going to look around the stroke unit in Christchurch in the coming months so I will report back once I have visited!

Friday, 16 March 2012

Medical Research vs. Animal Rights: The Debate

Biomedical research relies heavily on the use of animals to test new drugs and medical procedures (such as transplantation) and to research biological ideas, such as genetics and behaviour.  The majority of medical achievements in the 20th century relied on the use of animals in some way. Yet the debate remains whether or not it is ethical to use involuntary subjects for testing. Animal rights campaigners maintain the view that testing on animals is not only totally unethical, but also unreliable and outdated. []
This post spawns from the recent news that animal rights activists are now targeting trade routes into the UK. Lord Draysdon commented (the Independent reported []) that as a result of this new movement against animal testing, ‘Medical research will wither in our universities, and as a result, people will suffer and die.’ A notable list of companies have allied with the activists such as The Channel Tunnel, P&O Ferries, British Airways and recently Air France as reported by PETA. The question arising now is if medical research on animals will still be viable let alone ethical! It is undeniable that if animal testing was halted there would be an immediate resultant reduction in biomedical progress. Perhaps animal rights activists should be reminded that until another viable method of testing is implicated, research into debilitating diseases such as cancer, Alzheimer’s and heart disease could be halted also. Yet their actions still convey a strong message to the public, and by attracting the public eye they increase awareness for their cause, putting pressure on research groups into finding new ways of researching.
Personally I am torn, my love of biology and nature is faced against my fervour for medical progress in treating the most debilitating diseases. I agree that it is unethical to test on animals, but what choice do we have? Even advanced computer models are not sophisticated enough to accurately predict real life experimentation, and certainly not as reliable as seeing the results ‘in the flesh’. How far should we allow ourselves to take the degradation of an animal’s life for a human’s? Until we can answer these questions, the nature of medical research could become under threat from persistent disruption from savvier animal rights activists. 

Wednesday, 7 March 2012

Quick Update!

 Been in and out of the nursing home over the past few weeks, trying to take in as much as possible! Over half term I had a little more time on my hands to pick up my student BMJ and have a good read of it. I’m finding it really good at giving a good overview of medical issues, without all the medical jargon which is beyond my knowledge! The student BMA hand out was really good too, and has provided me some more evidence for my EPQ project about the effects of social and economic backgrounds on medical practice in India. Finally, I discovered the Radio 4 programme ‘Inside Health’ yesterday afternoon after school, will be writing about some of the issues raised on the programme shortly...

Tuesday, 14 February 2012

Junior Doctors / Gap year plans!

Been watching the Junior Doctors programme on TV at the moment, it’s been really interesting for getting inside the life of an F1 or F2. It’s quite heartening to see them not always getting it right, it helps me to imagine how I might cope if I was a Junior Doctor, and how to learn from mistakes! One thing that’s really become apparent after watching this series and the last is that the age of the doctor really makes a difference to his or her level of care. Of course, competence comes from experience, so F2s are more confident than the F1s but those who are older tend to have a much greater depth of maturity and this helps their care. There was a student on the last series who was 29 by the time he was an F2 and he was by far the best of all of the doctors! For me, it’s really reinforcing the idea of going on a gap year before I start medical school. I feel like it’s really important to have real life experience and be worldly before one becomes a doctor, and the programme has backed up that idea. It would give me the opportunity to visit different parts of the world, and begin to live more like an adult. I would really like to visit Asia again after visiting India, and my cousin has made me aware of a contact she made in Sri Lanka who offers places in his hotel for volunteers at a really low cost! It works out relatively cheap per week in comparison with other more expensive schemes and I would really love to take the opportunity to go and see more of the world before I become highly invested in medical school. I would also love to see more of Europe, especially Eastern Europe, and also take the opportunity to get some real work experience in a hospital or do some really worthwhile voluntary work in local hospitals, seeing as places are limited below the age of 18.

Monday, 13 February 2012

In the news today: Organ Donation - the debate...

On the news today, new discussions have been surfacing on organ donation and how to bridge the large void in lack of organ donors to meet demand. There is the withstanding debate as to whether organ donation should become opt-out or remain opt-in – becoming opt out would mean that more people would become organ donors if they had no particular desire for their cadaver to remain intact, instead of the current system, which requires donors to have a particular desire for their organs to be used. According to the BBC with welsh government are planning to introduce an opt out scheme commencing by the summer of 2012 []

Awareness is increasing however; the previous three years have seen an increase of 25% in organ donors. The figures still full short of the 50% target set by the BMA for 2013. Suggested ideas to increase donation include allowing higher risk donors to donate, reducing the refusal rate with encouragement and to ventilate patients to no advantage to their health, but to increase their chances of successful donation. Obviously a system such as the latter would be seriously controversial and if there were complications in the process causing the patients health to be, it could give rise to mass rejection of organ donation by other patients too. Another option to be considered is of a ‘softer’ opt out, which allows families to say no to donation on behalf of their deceased relative. Another possible approach is reciprocity – those who are donors will have a higher priority for organ donation over those who do not. To begin to prioritise health care like this would, too, be controversial – instead of judging a patient on their state of health and fitness, patients could be judged on their social decisions, and although arguably fair, would no doubt give rise to further controversy.

When compared to Spain, the UK has a much lower donation rate – they operate on an opt out system, although they do ask the permission of the relative before any action is undertaken. They also incorporate the use of higher risk patients and have more intensive care beds, which means that more organs are readily available for donation.

Overall, I believe the best practice to be awareness. The population should adopt a psyche where one is clear that they are for or against donation of their organs to avoid discrepancy; currently 43% of families reject donation of their relative’s organs, purely because they did not know their wishes. Awareness would decrease the requirement of an opt out system, because people will become increasingly more conscious of the problem and take steps to sign up for the service to help. 
Went to a careers conference yesterday to hear lectures from doctors, careers advisers and current medical students talk about their experiences! Was really interesting to chat to the medical students about medical school and what it’s all really about... they chatted about their interviews and how they coped with the pressure of getting good grades and staying well rounded. They also gave me an insight into what being a med student is really like. I found out about optional modules which are available to medical students to make them more ‘well rounded’, such as languages and sciences such as anthropology. This made me feel more comfortable about the idea of medical school and has made me really excited about the prospect of going! It seems to be so diverse and wrought with opportunity to study what you are really interested in.