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Secret Diary v o u c h e r s e e p 2 F r e e £ 1 0 The trade in human tissues Big screen therapy Of a cardiology SpR s t u d y Free for Junior Doctors JuniorDr.com Issue 4TRANSCRIPT
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are expected
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which MMC has been steamrolled
has sent many junior doctors into a
ill-informed panic. Fearful of
unemployment and being forced to
move away from family and
friends it’s an unacceptable way to
treat ‘partners in healthcare’
Morale is rock bottom among
junior doctors - not just about our
jobs but about the future of the
NHS. We continue to agree that
changes need to be made but it is
essential to balance that with tak-
ing care of the workforce.
Failure of MMC will produce
thousands of disillusioned doctors.
Many are already planning to quit
if they get posted to far-flung parts
of the country. Instead our doctors
will work in the city travel to
Australia. Can we really afford to
lose them?
Before the national provision
of health in the UK does finally
collapse maybe it’s time to take
heed from Bevan ... doctors can
continue to treat people without
the NHS, but the NHS cannot treat
the people without it’s doctors.
JuniorDr
3
Tri
ag
e
Presenting History
JuniorDr is a free distribution mag-
azine produced quarterly for the
UK’s junior doctors. You can find
us in hospitals throughout
England, Scotland, Wales and
Northern Ireland, and online at
JuniorDr.com.
EditorAshley McKimmSHO Addiction Psychiatry
Editorial TeamMareeni RaymondLondon
Michelle ConnollyLondon
Hi Wu-LingNottingham
Muhunthan ThillaiChelmsford
Thanks toAndro Monzon, Rhys Ball, Rhona
Atkin, Mun Hong Cheang
Newsdesk
Printing partners
Witherbys, UK
Advertising & Production
Rob Peterson
JuniorDr
PO Box 36434
London
EC1M 6WA
Tel - 020 7684 2343
Fax - 0870 130 6985
Health warningJuniorDr is not a publication of the NHS,
Tony Blair, his wife, the medical unions or
any other official (or unofficial) body. The
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bring you out in a rash. All rights reserved.
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“The Government has tried
everything to solve the problem
of the coal industry - semi-star-
vation, imprisonment, extortion,
threats, the supplication of the
miner's leaders, and what is the
almost omnipotence of
Churchill’s oratory. All have
failed. The one truth the
Government has not yet learned
is ... you can get coal without the
coal owners, but you can’t get
coal without miners.”
Aneurin Bevan, Health
Minister (1945), widely credited
with the formation of the NHS.
Listen up Professors Crockard
and Heard who head the MMC -
Bevan, the hero of the NHS,
offered some advice during the
failure of the other great British
powerhouse - pay attention to the
workers.
Just like the miners, banding
changes have starved us with pay-
cuts, we’ve been forced to adopt
inflexible nightshift patterns and
the intensity of work has worsened
along with morale.
MMC is widely regarded as
sensible and essential by junior
doctors. We’re not disputing the
need for change. We are however
vehmently opposed to how it has-
being implemented.
The lack of consultation, spar-
sity of information and the speed at
The NHS cannot treat
people without doctorsEditorial
“Doctors can contin-
ue to treat people
without the NHS, but
the NHS can’t treat
the people without
it’s doctors.”
> What’s on the insideWhen doctors are expected to killThe role of doctors in administering
lethal injections on death row.
Page 10
The Secret Diary of a
Cardiology SpR
Page 19
MedicinemaThe new ‘blockbuster’
prescription
Page 14
Collagen corpses
The trade in
human tissues.
Page 17
Latest News
Page 4
Ashley McKimm
Editor
SHO Addiction Psychiatry, London
Th
e P
uls
e
JuniorDr
News PulseTell us your news. Email the team at [email protected]
or call us on 020 7684 2343.
Working Conditions
9am on Monday 22nd starts
the formal application process
for Modernising Medical
Careers - the UK’s largest ever
junior doctor recruitment and
training restructuring program.
Over two weeks junior doctors
are expected to compete for around
20,000 specialist training posts
nationally with applications
accepted solely online. A rapid
interview process for each special-
ity over a few days then follows
during two rounds of elimination.
Widespread disruption
On average three candidates
are expected to be interviewed for
every two posts. The absence of
both interviewees and senior inter-
viewers from clinical duties have
drawn fears of how hospitals will
cope.
“The number of consultants
involved in the process will be
considerable,” said David Pring,
York consultant in obstetrics and
gynaecology. “At the same time,
juniors will be trotting around the
country being interviewed. The
service impact will be huge.”
Clinical disruption feared as
MMC recruitment nears
LONDON
“It takes away peo-
ple’s flexibility in job
hunting but does
make the whole
process more effi-
cient.”
Kent Yip
SHO Medicine
Addenbrooke's Hospital, Cambridge
“SHO training needed
input - although MMC
had promise in con-
cept, it was appalling
in execution.”Nathan Borgeaud
SHO Anaesthetics
Homerton Hospital, London
22 January 2007
Round 1: Opening date for
applications
4 February 2007
Round 1: Closing date for appli-
cations
5 - 23 February 2007
Applicants (except GPs) offered
interviews if they have been
short-listed
24 February 2007
GP stage one selection day
Early March 2007
GP candidates notified of the
outcome of stage one selection
28 February - 13 April 2007
Interviews take place
19 April 2007
Programme offers made to suc-
cessful applicants
27 April 2007
FTSTAs offered to successful
applicants
28 April 2007Unfilled programme vacancies
re-advertised
28 April 2007
Round 2: Opening date for
applications
2 May 2007
Unfilled FTSTAs re-advertised
11 May 2007
Round 2: Closing date for appli-
cations
14 May - 27 May 2007
Local panels short-list applica-
tions
29 May 2007
Applicants offered interviews if
they have been short-listed
4 June - 22 June 2007
Interviews take place
23 June 2007
Offers made to successful appli-
cants
23-26 June 2007
Applicants accept/reject offers
Reproduced courtesy MMC
>MMC Timetable
> Your viewpoints
'Far from Perfect'
Modernising Medical Careers
has been greeted with widespread
panic by junior doctors many of
whom feel alienated from the sys-
tem and fearful of unemployment.
The BMA, who campaigned for
the process to be delayed by a year,
believes the process is ‘far from
perfect’ but admits some progress
has been made since its concep-
tion.
“Pressure from the BMA has
resulted in vital improvements. For
example, knowledge tests - which
would have had no basis in evi-
dence - have been dropped from
the process,” says Dr Jo Hilborne,
chairman of the BMA Junior
Doctors’ Committee.
“The number of posts doctors
can apply for has increased from
two to four and the number of
overall posts available has been
hugely expanded. Doctors will
now be asked to rank their four
choices in order of preference,
which will improve their chance of
getting the post they want, and
they will be able to submit ‘linked’
applications for posts with part-
ners.”
Th
e P
uls
e
5
JuniorDr
A&E departments struggle
to cope with pressuresA&E Departments are strug-
gling to sustain the four-hour
access target because of a short-
age of beds, according to a sur-
vey by the BMA and British
Association for Emergency
Medicine.
Just over half (54 percent) of
respondents believe the four-hour
target is met by their hospital
despite official figures setting a 98
per cent target. A third claimed
data manipulation was used in
order to meet these access targets.
Over 500 medical staff of all
grades were surveyed. Almost nine
out of ten (87 percent) of respon-
dents reported a shortage of avail-
able beds as the main reason for
not meeting the target.
“The report finds that doctors
and other staff are working excep-
tionally hard and putting in extra
hours to meet access targets.
Working towards the four-hour tar-
get on A&E waiting times has been
a fantastic achievement, it has
proved good news for patients and
the extremely long waits seen in
the last decade are now very rare,”
said Mr Don MacKechnie,
Chairman of the BMA’s
Emergency Medicine Committee .
“However respondents tell us
that despite this success, the level
of performance in many depart-
ments is proving unsustainable
and these departments are finding
it difficult to cope on a daily
basis.”
Respondents were also asked
if there were any clinical concerns
arising from efforts to meet the
access target. Two-thirds (66 per-
cent) of respondents said that
some patients may be moved to
inappropriate areas or wards and
over half (58 percent) reported
that patients may be discharged
from A&E before they had been
adequately assessed or stabilised.Mun Hong Cheang
LONDON
Patient Care
Brainy broccoliIntelligent children may be
more likely to be vegetarian as
adults, a study published in the
BMJ suggests. Raised IQ was
found to be statistically significant
after adjusting for better education
and higher occupational social
class. It may also help to explain
why children who score higher on
intelligence tests tend to have a
lower risk of coronary heart dis-
ease in later life.http://bmj.bmjjournals.com/cgi/rapidpdf/bmj.
39030.675069.55
Alternative prescriptionsSixty percent of doctors’ sur-
geries in Scotland prescribe home-
opathic or herbal remedies,
according to a study of nearly two
million patients published in the
British Journal of Clinical
Pharmacology. The findings have
led to a call for a critical review of
prescribing in the NHS and to the
high levels given to babies and
children.http://www.blackwellpublishing.com/bjcp
Heart of hearingA new stethoscope that
enables doctors to hear heart
sounds in extremely loud situa-
tions, such as transporting soldiers
in helicopters, has been unveiled
in Alabama, USA. The device
which uses ultrasound technology
enables accurate readings at noise
levels up to 120 decibels - similar
to that experienced at the front
row of a rock concert. It is expect-
ed to cost up to £400 when
released.
Don’t to bed aloneGoing to bed lonely can trig-
ger elevated early morning corti-
sol levels, according to a study by
Northwestern University. The hor-
mone, which is linked to depres-
sion and obesity when chronically
raised, was studied in 156 adults
who recorded their ‘loneliness’
feelings the previous evening in
diaries.http://www.northwestern.edu
Stay sleepy and safeFeeling tired? Contrary to
popular belief you may be less
likely to get hurt according to a
study published in the Journal of
the American Board of Family
Medicine. In the study of 2,500
patients those who had slept less
than normal in the last 24 hours
were found to be at higher risk of
injury. The authors suggest that it
may be that people change their
behaviour when sleepy.http://www.jabfm.org
Sixteen percent of specialist
medical registrars have been
involved in a road traffic acci-
dent while commuting to or from
work according to a recent sur-
vey by the Royal College of
Physicians.
The study of over 1,600 spe-
cialist 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 signifi-
cantly more risky.
Nearly half of specialists regis-
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 med-
ical care are working seven con-
Shift rotas linked to
risk of traffic accidentsLONDON
Working Conditions
secutive nights, the majority with
13-hour shifts, resulting in a 91-
hour 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 percent 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 recommend-
ed 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
Sports doc shortage for
2012 Olympics
The NHS
Th
e P
uls
e
JuniorDr
Parents get peckishAdults living with children eat
more saturated fat - the equivalent
of nearly an entire small pepperoni
pizza each week - than adults who
do not live with children, accord-
ing to research published in the
Journal of the American Board of
Family Medicine. Compared to
adults living without children,
adults living with children ate an
additional 4.9 grams of fat daily,
including 1.7 grams of saturated
fat.http://www.jabfm.org
Bleak futureLatest calculations by the
WHO and Harvard University sug-
gest that overall life expectancy by
2030 will have increased. Deaths
from heart disease and cancer will
increase as will HIV/AIDS deaths,
however those dying from infec-
tious diseases will decrease. 50 per
cent more people are also predict-
ed to die of tobacco-related disease
than of HIV/AIDS in 2015. By
2030, the three leading causes of
illness are predicted to be
HIV/AIDS, depression and
ischaemic heart disease.http://dx.doi.org/10.1371/journal.pmed.0030512
Up in smokeThe government is to raise the
legal minimum age to purchase
tobacco from 16 to 18 years from
1st October 2007. It will come
soon after the introduction of
smoke free public places and
workplaces on 1 July. The move
will bring England and Wales into
line with laws in Canada,
Australia, New Zealand and the
US.
http://www.dh.gov.uk
Poor and accident proneLansoprazole, the compound
found in common antacids, could
also be used to fight oral bacteria
linked with gum disease,
researchers at the University of
Rochester Medical Center and
Goteborg University in Sweden
have found. When the mouth
becomes acidic - a sign of bacteria
at work - lansoprazole kicks in dis-
abling the bacteria F. nucleatum
which produces a toxin allowing
other bacteria to attach to the tooth
surface and cause decay. If further
trials are successful they hope to
incorporate similar compounds
into toothpastes and mouthwashes
http://www.rochester.emu
6
Professor Ian Gilmore
President
Royal College of Physicians
“This fits with thework that we havebeen doing on medical professionalism.”
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
LONDONThere are insufficient num-
bers 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 NHS
Docs still the most trustedprofession
Doctors continue to top the
poll of professionals that the
public trust the most, according
to the latest annual survey com-
missioned 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 percent of the public stat-
ed that they trusted doctors, close-
ly followed by teachers at 88 per-
cent.
Only one in five trusted politi-
cians 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 doc-
tors 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
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 pro-
fessions in virtually every year
since 1983 when the poll began.Hayley McKenzie
LONDON
JournalReview T
he
Pu
lse
JuniorDr
Ecstasy can harm brainsof first-time users
Even a small amount of
MDMA, the psychoactive com-
pound in ecstasy, can be harmful
to the brain according to find-
ings presented at the annual
meeting of the Radiological
Society of North America.
The researchers examined 188
volunteers with no history of ecsta-
sy use but at high-risk for first-
time ecstasy use in the near future.
After 18 months the volunteers
were re-assessed and 59 had been
found to have taken on average 6
tablets.
They found that low doses of
ecstasy did not severely damage
the serotonergic neurons or affect
More than 500 sudden unex-
plained deaths occur each year
in England - around eight times
more than previously thought -
according to the study published
in the journal Heart.
Cases from 117 coroners
across England between 1997 and
1999 were assessed by an expert to
eliminate other identifiable causes
of death. The results show that
only around a third of cases of
SADS (sudden adult death syn-
drome) were correctly identified.
SADS cases tended to be
young with an average age of 32.
Almost two-thirds (63 percent)
were male. Furthermore, almost
one in five (18 percent) had a fam-
ily history of sudden unexplained
deaths before the age of 45.
They noted that although only
a small number had reported car-
diac symptoms in the previous 48
hours, nearly two-thirds had expe-
rienced cardiac symptoms at some
point in the past.
The authors conclude that
SADS should be a certifiable cause
of death, which should prompt
automatic screening of other fami-
ly members.Sudden adult death syndrome and other
non-ischaemic causes of sudden cardiac
death. Heart 2006 92: 316-320
CHICAGO
LONDON
Circumcision reduces HIVrisk, study stopped early
men,” said Robert Bailey, profes-
sor of epidemiology in the UIC
School of Public Health.
The clinical trial enrolled
2,784 HIV negative, uncircum-
cised men between 18 and 24 years
old in Kisumu, Kenya.
Until now public health organ-
isations have not supported cir-
cumcision as a method of HIV pre-
vention due to a lack of ran-
domised controlled trials.
Opponents of circumcision
had speculated that circumcised
men may feel they are not at risk of
contracting HIV and may be more
likely to engage in risky behaviour,
something which the Kenya study
disproves says Bailey.www.uic.emu
Shock number
of sudden
unexplained
cardiac deaths
mood. However, there were indi-
cations of subtle changes in cell
architecture and decreased blood
flow in some brain regions, sug-
gesting prolonged effects from the
drug, including some cell damage.
In addition, the results showed a
decrease in verbal memory per-
formance among low-dose ecstasy
users compared to non-users.
“We do not know if these
effects are transient or permanent,”
said Dr. de Win, radiological resi-
dent. “Therefore we cannot con-
clude that ecstasy, even in small
doses, is safe for the brain, and
people should be informed of this
risk”www.RSNA.org/press06
A study by the University of
Illinois has been stopped early
due to preliminary results indi-
cating that medical circumcision
of men reduces their risk of
acquiring HIV during heterosex-
ual intercourse by 53 percent.
The study’s independent Data
Safety and Monitoring Board met
on December 12 and halted the
trial recommending that all men
enrolled in the study be offered cir-
cumcision.
Study results show that 22 of
the 1,393 circumcised men in the
study contracted HIV compared to
47 of the 1,391 uncircumcised men
- 53 percent fewer infections.
“Circumcision is now a
proven, effective prevention strate-
gy to reduce HIV infection in
CHICAGO
7
Robert Bailey
Professor of Epidemiology
UIC School of Public Health
“Circumcision is nowa proven, effectiveprevention strategyto reduce HIV infec-tion in men.”
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99
Medical conditions from the
journals you just won’t believe!
Alopecia Walkmania
Loss of hair from prolonged use of personal
stereo headphones. (Journal of the American
Medical Association, 1984)
Toilet seat folliculitis
Skin irritation from spending too much time
on the toilet. (Archive of Dermatology, 1933)
Credit carditis
Pain over the rear and down the thigh due to
pressure on nerve from a wallet stuffed with
credit cards. (New England Journal of
Medicine, 1966)
Flip flop dermatitis
Skin disease on the feet from wearing flip-
flops. (BMA Journal, 1965)
Hookers Elbow
Painful shoulder swelling suffered by fisher-
man repeatedly jerking upwards on a fishing
line. (New England Journal of Medicine,
1981)
Beer drinkers finger
Swelling, bluish discolouration and wasting
of the finger caused by placing pop-top beer
can rings on the finger. (Journal of the
American Medical Association, 1968)
Jean folliculitis
Irritation of the hair follicles from the waist
down to the knees caused by ultra-tight jeans.
(New England Medical Journal, 1981)
Label lickers tongue
Ulcers in the mouth from sensitivity to lick-
ing sticky labels. (Journal of Dangerous
Trades, 1902)
Dog walkers elbowPain caused by constant tension and tugs
from a dog leash. (New England Journal of
Medicine, 1979)
Ice-cream frostbite
Frostbite on the lips from prolonged contact
with ice-cream. (New England Medical
Journal, 1982)
Nuns knee
Swelling of the kneecap from repeated
kneeling in prayer. (Diseases of occupations,
1975)
Chicken neck wringers finger
Partial dislocation and arthritis of the middle
finger joint from continued use of this finger
to dislocate chickens necks for slaughtering.
(BMJ, 1955)
Fea
ture
s
JuniorDr
JuniorDr
September marked a turning
point in the debate when the exe-
cution of a Californian inmate was
postponed indefinitely after the
doctors refused to participate.
They became opposed after a
judge’s ruling stated that doctors
would have to physically intervene
if the condemned person appeared
to be in pain.
Doctors would therefore have
been expected to tell prison offi-
cials whether the prisoner needed
more sedation, or possibly even to
administer more drugs. “Any such
intervention would be medically
unethical,” the anaesthetists
replied in a statement. “As a result,
we have withdrawn from partici-
pation.”
Lethal injections were sus-
pended as a result. Michelle
Connolly looks at the role of for
JuniorDr.
What’s legal?
Lethal injection under United
States federal law states that ‘the
punishment of death must be
inflicted by continuous, intra-
venous administration of a lethal
quantity of an ultrashort-acting
barbiturate in combination with a
chemical paralytic agent until
death is pronounced by a licensed
physician according to accepted
standards of medical practice.’ In
it’s simplicity lethal injection sim-
ulates a medical procedure - the
intravenous induction of general
anaesthesia.
The procedure
Once the prisoner has been
strapped to the table the arm is
swabbed with alcohol. Two 14-
gauge catheters, the largest com-
mercially available, are inserted,
one in each arm. The second is a
backup, in case the primary IV.
fails. Both catheters are flushed
with heparin to prevent clots form-
ing inside.
All condemned prisoners are
given the opportunity to make any
final statement they wish, and
then, on the warden’s signal the
drugs are administered.
Sodium thiopental (at 14 times
the normal dose) is used to induce
anaesthesia, pancuronium bromide
is the substance used to paralyse
the respiratory muscles and potas-
sium chloride is administered to
induce ventricular fibrillation.
Even without inducing VF
death would still follow by
When doctorsare expected to
At exactly 11pm on the 21st September 2006 forty-eight year old
Clarence Hill was strapped to the table at Starke Prison, Florida. The
warden gave the signal and a cocktail of lethal drugs was pumped into
his veins. At 11.12pm the ECG flatlined and Hill was pronounced dead.
Hill’s execution went ahead despite his lawyers arguing that the
lethal injection is inhumane. Many doctors in California agree and
believe the method of lethal injection, supposedly painfree, does cause
the condemned pain and should be banned.
“Even more sur-
prising was that in 43
percent of cases in
those four states lev-
els were consistent
with consciousness.”
Fea
ture
s
10
JuniorDr
asphyxiation. Death typically takes
8-10 minutes and is pronounced on
asystole. A coroner then signs the
death certificate and the procedure
is complete.
With the IV lines, a cardiac
monitor and a medical doctor on
standby the execution room is not
When doctorsare expected to kill
dissimilar from an acute medical
ward. The direct telephone line to
the Department of Justice in
Washington is perhaps the only
giveaway - the President is the
sole authority able to grant last-
minute clemency.
‘Inhumane execution’
The claim of the lethal injec-
tion being the most humane form
of capital punishment, is disputed
by many.
Leonidas Koniaris, professor
of surgical oncology at the
University of Miami, Florida, writ-
ing in The Lancet, suggests evi-
dence that judicial execution by
these means is not as humane as
death penalty proponents have
claimed.
Researchers obtained post-
mortem toxicology reports from
four of the 36 states killing prison-
ers via lethal injection. The results
indicated that levels of sodium
thiopental were lower than those
required for surgical anaesthesia.
Even more surprising was that in
43 percent of cases levels were
consistent with consciousness.
Determining consciousness
levels in prisoners who are paral-
ysed and who will not be resusci-
tated is both difficult and debat-
able. This lack of certainty has
however prompted the American
Veterinary Medical Association to
ban the use of neuromuscular
blocking agents, such as pancuro-
nium bromide, when putting ani-
mals to sleep.
The involvement of doctors
The involvement of doctors
varies considerably with 35 of the
38 death penalty states that rely on
lethal injection allowing doctors to
participate, and 17 states requiring
it. Participating doctors are
required to ensure that the Eighth
Amendment of the US
Death Row Cells
A Death Row cell is 6x9x9.5
feet high. Florida State Prison
also has Death Watch cells to
incarcerate inmates awaiting
execution after the Governor
signs a death warrant for them. A
Death Watch cell is 12x7x8.5
feet high.
Last Meal
Prior to execution, an inmate
may request a last meal. To
avoid extravagance, the food to
prepare the last meal must cost
no more than $40 and must be
purchased locally.
Contact
When a death warrant is
signed the inmate is put under
Death Watch status and is
allowed a legal and social phone
call. While on Death Watch,
inmates may have radios and tel-
evisions positioned outside their
cell bars.
Florida Department of Corrections
> Starke Prison, Florida
Fea
ture
s
11
- administering a lethal injection
> Starke Prison, Florida Execution Room
Picture: Florida Department of Corrections
One anae
One paediatrician
One radiologi
One oncologist
One clinician
One surgeonOne doctor
One doctor
One anaesthetist
One surgeon
On
Constitution, which prohibits
‘cruel and unusual punishment’ is
upheld.
It was a doctor who pushed the
syringe in Illinois's first lethal
injection execution and in Nevada,
doctors are required to examine
the condemned for good venous
access and to prescribe the fatal
drugs.
Some states, such as Illinois
and South Dakota, have attempted
to de-medicalise the death penalty
with laws decreeing that the assis-
tance of death does not constitute
medical practice. South Dakota’s
death penalty statute states that
“any infliction of the penalty of
death … may not be construed to
be the practice of medicine.”
The argument for medical
involvement
Despite the reluctance of med-
ical professionals to involve them-
selves many feel their presence is
essential for the welfare of the
prisoner. Each step of the execu-
tion procedure from the dosing of
fatal drugs to the pronouncement
of death ideally requires a medical
practitioner.
Where doctors are unavailable
these tasks are performed by
trained ‘technicians’ but as
Koniaris and his team point out the
worst toxicology reports were
obtained from states that
employed teams qualified only at
technician level.
Death row inmates often have
poor vascular access as a result of
intravenous drug use or obesity
and it is here that the skills of doc-
tors are particularly useful. In
Georgia one of the three doctors
present in the execution chamber
during procedures is an expert in
vascular access.
Many also use the argument
view that healthcare personnel
transform the executions from a
terrifying to peaceful environment
alleviating pain or giving the illu-
sion that pain is being alleviated.
The argument against
Firstly doctors argue that they
were not asked whether they
agreed with the medicalisation of
the death penalty prior to its re-
introduction in 1976.
Many doctors oppose the exe-
cution process on ethical grounds.
The president of Georgia’s medical
school, in a letter to the prison war-
den, condemned the involvement
of doctors saying their presence in
the chamber ‘compromised their
relationship with the inmate popu-
lation.’
More significantly in June
2006, the American Society of
Anaesthesiologists sent letters to
its 40,000 members urging them to
‘steer clear of any participation in
execution.’
“The worst toxicol-
ogy reports were
obtained from states
that employed teams
qualified only at tech-
nician level.”
The American Medical
Association (AMA) specifically
condemns the involvement of
doctors in state-sanctioned exe-
cutions. It cites eight acts con-
stituting direct involvement:
1. Administering lethal drugs
2. Maintaining injection
devices
3. Supervising technicians
4. Prescribing lethal drugs
5. Selecting intravenous access
sites
6. Inserting IV lines
7. Monitoring vitals
8. Pronouncing the prisoner
dead
Fea
ture
s
JuniorDr
Lethal injection was first considered in 1888 by a New York
doctor writing in the journal Medico-Legal. Initially this was not for
humane reasons but to rob the prisoner of the hero status which was
attached to hanging. He suggested the injection of 6g of morphine.
The idea didn’t catch on and New York state introduced the electric
chair instead.
In the UK the British Royal Commission on Capital
Punishment looked into lethal injection back in the 1950s
but following pressure from the BMA decided against it.
Lethal injection in its modern form was the brain-
child of Stanley Deutsch, an anaesthesiologist at the
University of Oklahoma. In response to the state
senator’s 1977 request for a cheaper alternative
to repairing the dilapidated oak electric chair,
Dr Deutsch recommended barbiturate as a
‘rapid, pleasant way to bring about uncon-
sciousness’ followed by a muscle relaxant
to bring about an ‘extremely humane’
death. Texas became the pioneer-
ing state for lethal injection as a
form of capital punishment. It was
doctors who watched as the drugs
were pumped into the veins of a
40 year old African-American. He
was dead within minutes and the
procedure was deemed a success.
Since then over over 700 men and
women have been executed by
lethal injection in the USA alone.
JuniorDr
Fea
ture
s
aesthetist
ian
ogist
One clinician
One doctor
One oncologist
One surgeon
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Missouri officials then sent
nearly 300 letters to anaesthetists in
the state and in Illinois to ascertain
their ‘willingness to participate in
execution’. To date not a single
recipient has said they would so it
seems the Society’s call is being
heard.
In a further development the
following month North Carolina’s
state medical board banned doctors
from participating in state execu-
tions.
Choosing to participate
Despite what appears as wide-
spread reluctance by the medical
profession to participate in lethal
injections many doctors are still
willing to assist in state execution.
An American Medical
Association survey found that 19
percent would inject lethal drugs
and 41 percent said they would per-
form at least one of the eight acts
(see table)2. Many individuals bal-
ance their clinical responsibility
against their duties to society and
agreed to their involvement. Many
also wanted to provide a ‘painless’'
death and were concerned with the
expertise of the technician-level
staff.
In a case that caused particular
furore among the medical profes-
sion, the governor of Kentucky,
who is a doctor, signed the death
warrant of a prisoner with an IQ of
74. Executive counsel John Roach
said Dr Fletcher did not violate the
American Medical Association
guidelines and that in signing a
death warrant, he is in ‘no way par-
ticipating in the conduct of an exe-
cution’.
Doctors still refuse to be pres-
ent in the execution room in
California. Their role in adminis-
tering lethal injections across the
United States is still uncertain - but
executions continue in the other
states.
History of the lethal injection
Koniaris LG, Zimmers TA, Lubarsky
DA and Sheldon JP (2005). Inadequate
anaesthesia in lethal injection for execu-
tion. The Lancet. 365: 1412-1414.
Groner JI (2002). Lethal injection: a
stain on the face of medicine. BMJ 325:
1026-1028.
Farber NJ, Aboff BM, Weiner J,
Davis EB, Boyer EG, Ubel PA (2001).
Physicians' willingness to participate in
the process of lethal injection for capital
punishment. Ann Intern Med. 135: 884-
888.
> References
Fea
ture
s
JuniorDr
The idea behind MediCinema
is extremely simple - install cine-
mas in hospitals for the sole pur-
pose and enjoyment of the
patients.
It offers everyone from chil-
dren visiting ill parents to elderly
patients recovering from hip
replacements the opportunity for a
‘night out’ at the movies where
they are able to watch the latest
blockbusters. Each Medicinema
shows a wide variety of film gen-
res from big action flicks to come-
dy - perfect for those who believe
laughter is truly the best medicine.
The team behind MediCinema
recognise the escapist qualities of
films and catching a movie in each
state of the art cinema can offer
patients a welcome relief from
what can often be a tedious time in
hospital.
Medicinema also allows fami-
lies of the patients to visit the cin-
ema which can give family and
friends something to really look
forward to.
The idea
The idea for Medicinema was
first devised by Christine Hill
MBE at St. Thomas’ Hospital, in
London - an idea which came to
her while watching patients on a
welcome break from the wards.
“One hot day I was watching
patients being wheeled to the river
to watch the boats on the Thames
when I noticed how like a cinema
screen it was. I thought this was
great when it was hot but when it
rained there was nothing for the
patients to do,” she explained.
“I thought of an on-site cine-
ma but with the idea of not having
the screen in the wards but away
from the medical environment
with nurses instead of ushers so
that the patients would feel secure
in the knowledge that they would
still have medical help on hand.”
Supporters
As you might expect each
Medicinema isn’t funded by the
NHS. MediCinema gets invalu-
able support from all the film dis-
tributors and The Walt Disney
Company as well as being the
nominated charity of the cinema
chain Vue.
MediCinema has also been
named as the film industry’s char-
ity by BAFTA. Numerous patrons
such as Dame Helen Mirren, Ewan
McGregor and Kate Winslet also
add the glamour of the silver
screen.
Charity Support Officer for
Medicinema at St. Thomas’s Lisa
Molson is excited about the future:
“We have just finished build-
ing a Medicinema at The Royal
Hospital for Sick Children
Yorkhill, Glasgow and are also
fundraising for a MediCinema at
the new Children's Centre in
Newport South Wales. We have
successfully completed a feasibili-
ty study for Stoke Mandeville
Hospital for Spinal Injuries and
are now commissioning one for
the Royal Victoria Infirmary in
Newcastle as well as being in dis-
cussion with several other hospi-
tals in the UK.”
It looks likely that
Medicinema will become a block-
buster itself.
MedicinemaBig screen therapyFor many patients staying in hospital can be a traumatic experience -
for a few it’s not far off a personal horror movie. Medicinema is a chari-
ty that aims to change that bringing therapy via the big screen and
changing that horror movie hospital experience into a comedy,
romance or in fact any genre of the patients choosing. Shrabani
Talukder tells us more.
14
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points transferred onto index cards
- the resulting points serve as jogs
to the memory.
The significance of active
recall
The third point to bear in mind
when approaching an important
set of examinations, is that active
recall is far more efficient than
passive review (i.e. reading) of
information. When memory is
actively stimulated in the learning
process, long term memory is con-
solidated. Therefore, by sitting
mock exams or engaging in ques-
tion and answer sessions, memory
is actively strengthened. If repeat-
ed often to start with, as long term
memory sets in, the length of time
between repetitions may be
reduced.
It is a formidable task facing
the student of medicine. To seek
assistance from experts is a sensi-
ble approach, and available from
revision specialists PasTest.
PasTest have previously offered
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ates but, from 2007, will run
Finals Revision Courses for
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Learning for
finalsFi
na
nc
e
JuniorDrMembers of few professions endure such an endless process of examination as do students and practitioners of medicine. Medical finals require
assimilation of large tracts of information, combined with the ability to identify from photographic evidence, face oral questioning and patient-cen-
tred testing. Literature on the mechanisms of memory tells us that there are no short cuts to the acquisition in memory of this volume of spe-
cialised, factual material. To flatten the graph of the 'forgetting curve' however, it seems that there are a few obvious learning techniques to apply.
15
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Understanding is the key to
remembering
Firstly, and unavoidably it
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by the level of meaning contained
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the more meaningful the informa-
tion is to you as a medical student,
the easier it will be to remember
the details.
Mnemonics and the
representation of memory
Also of significance is how
successfully you represent infor-
mation for yourself, a skill that
people possess in varying degrees
but which can be developed.
Mnemonics are verbal aids to
memory, whimsical lists, poems or
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nique is well developed in medi-
cine and there are websites devot-
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this is the form of revision where
the student takes notes from revi-
sion material a minimum of 3
times, resulting in a checklist of
In the first few days following a major traumatic
injury or surgical operation -
A. There is increased glucose formation from non-
carbohydrate sources
B. The patient is in nitrogen balance
C. Potassium balance tends to be negative because of
diminished potassium in the diet
D. Platelet aggregation increases
E. Third space fluid losses depend on the surgical pro-
cedure
Test yourselfThink you know the complications of splenic artery thrombosis? Or how to make the diagnosis of
Kawasaki’s Disease? This issue, in association with 123Doc, we bring you a selection of self-test
questions to check your medical knowledge.
Presented is a 73-year-old-male presented with a
lesion on his nose. It had progressed over the last 8
months.
The diagnosis is -
A. Squamous cell carcinoma
B. Basal cell carcinoma
C. Keratoacanthoma
D. Sebaceous hyperplasia
E. Malignant melanoma
Q1
In duodenal ulcer -
A. H.Pylori infection is associated in 80% of patients
B. Serum gastrin levels fall
C. Iron deficiency anaemia may be present
D. Misoprotosol neutralises gastric acid
E. Laparoscopic HSV may be necessary
Q5
Q2
The following may be useful in making a diagnosis
of Kawasaki's Disease -
A. Conjuctivitis
B. Rash in groin
C. Petechiae
D. Coronary artery aneurysm
E. Prolonged fever
Q3
Q4
Answers and Teaching Notes
1. B
The lesions of basal cell carcinoma typically
have a rolled, pearly edge with a central keratin
crater. The lesions are slow growing and tend to
be more common in older people. They also
tend not to metastasise; the spread is by local
invasion and along tissue planes. Treat: Rx
excision/radiotherapy.
2. CDE
More than 90% of duodenal ulcers are due to
H.Pylori. Serum gastrin levels are high in duo-
denal ulcer. They are extremely high in
Zollinger Ellison syndrome.
3. ABDE
Kawasaki disease presents clinically with pro-
longed fever, cervical lymphadenopathy, rash,
epidermal peeling on the hands and feet, espe-
cially around the fingertips, ocular conjunctivi-
tis, lymphadenopathy, fissured lips, oropharyn-
geal mucosal erythema, and arthralgia or arthri-
tis. Coronary artery aneurysms result from an
acute perivasculitis. Non-cardiovascular com-
plications include CSF pleocytosis, pulmonary
infiltrates and hydrops of the gallbladder. There
is also a neutrophil leukocytosis, thrombocyto-
sis, sterile pyuria and proteinuria, elevated
LFTs, raised ESR, and CRP. The aetiology is
unknown.
4. ADE
Following major trauma or surgery, increased
circulating cortisol produces an increase in glu-
coneogenesis from non-carbohydrate sources.
The breakdown of protein for gluconeogenesis
causes a negative balance. Negative potassium
balance is caused by cortisol-induced secretion
of potassium by the renal tubules and the
release of potassium from autolysed cells.
Platelet aggregation is enhanced and the ten-
dency for blood clot formation is increased.
Third space fluid loss depends on the size of the
surgery and may vary from 1-3ml/kg/H for
minor surgery to 15/kh/H with major surgery.
5. D
The splenic artery gives off branches like short
gastrics to supply:
- The fundus of the stomach
- Part of greater curvature, body and tail of pan-
creas
- The spleen
The lesser curvature of stomach and pyloric
antrum is supplied by the left gastric-br. coeliac
and by right gastric-br. of Hepatic. The superi-
or mesenteric is the artery of the midgut which
distributes to an area from D2-beyond the
ampulla of vater up to the left half of transverse
colon.
6. D
Squamous Cell Carcinoma is a malignant
tumour of keratinocytes. It usually arises in sun
damaged skin, scar tissue. It is more common in
transplant recipients, and this is thought to be
due to the immunosuppression these patients
receive. The lesions are typically hyperkeratot-
ic, ulcerated, expanding nodules; invasion of
the dermis allows metastases to local lymph
nodes. Treat: excision / radiotherapy.
7. A
Pancytopenia may be due to bone marrow fail-
ure (aplastic anaemia) or to bone marrow infil-
tration (leukaemia, lymphoma or non-
haemopoietic malignancy). Aplastic anaemia
may be idiopathic or secondary to drugs, parox-
ysmal nocturnal haemoglobinuria or Fanconi's
anaemia. In a child of this age, ALL, AMLor
aplastic anaemia would be the most likely caus-
es of pancytopenia. B12 deficiency could cause
pancytopenia, but would be unlikely in a child
of this age. Ablood film would help to distin-
guish between aplastic anaemia and leukaemia
as the latter condition may have circulating
blasts.
JuniorDr
Wo
rks
ho
p
16
Following a thrombotic obstruction at the ori-
gin of the splenic artery, which of the follow-
ing structures will be at risk of ischaemia?
A. Lesser curvature stomach
B. Head of pancreas
C. Jejunum
D. Fundus of stomach
E. Duodenum that is derived from midgut
Q7 A 5 year-old boy is presented to his GP with
lethargy and tiredness.
Hb 5.8 g/dl
WBC 2.8 x 109/l
Plts 35 x 109/l
Neutrophils 0.8 x 109/l
What would be the most helpful investigation?
A. Bone marrow aspirate and trephine
B. Peripheral blood immunophenotyping
C. Bone marrow cytogenetics
D. ANA and rheumatoid factor
E. Serum ferritin
Get Your £10 Study GrantTo activate, please go to www.123doc.com
and enter this code: JRDOC20
Q6A 60-year-old male complains of these lesions
developing over the last 8 months. The most
likely diagnosis is -
A. Behcet’s disease
B. Stevens-Johnson syndrome
C. Herpes simplex
D. Squamous cell carcinoma
E. Pemphigus vulgaris
In the constant pursuit of
‘forever youth’ collagen injec-
tions have become the UK's
treatment of choice, second only
to botox.
Collagen itself is a compound
found in abundance in skin, bone
and muscles and serves as scaf-
folding to strengthen and sup-
port these organs. In the beau-
ty industry it is used to
smooth out wrinkles and bol-
ster lips but unfortunately
treatments have to be repeated
as the effects are not perma-
nent.
The collagen used in the UK
is originally sourced from cows,
pig and human skin and these sam-
ples are grown for up to ten years
in laboratory conditions. In all
cases the collagen is highly puri-
fied and sterilised before
being converted into an
injectable form ready
for use in humans.
Collagen crime
Last year
however, The
Guardian newspa-
per disclosed that
collagen in UK
clinics was being
sourced from a
Chinese firm which
has been extracting
collagen direct from the
skin of executed Chinese
prisoners. Shockingly, according
to reports from agents at the com-
pany this practice is quite ‘nor-
mal’.
Bar the ethical concerns of this
collagen, there are also major
health risks to consider.
Transmission of disease especially
blood-borne viruses, such as hepa-
titis and vCJD, are possible -
although there are no records of
this happening. An inquiry by the
Department of Health has howev-
er reported cases of acute allergic
reactions to contaminated collagen
injections causing scarring and
disfigurement.
Regulation
As collagen products are not
strictly classed as either medicines
or cosmetics they bypass any cur-
rent regulations. This anomaly is
being reviewed at present by the
European Commission but any
legislation is several years away.
Mr Douglas McGeorge, presi-
dent of the British Association of
Aesthetic Plastic Surgeons
(BAAPS) emphasised the impor-
tance of consumer awareness:
“Stories like these only rein-
force the advice given by BAAPS
that patients should always see
reputable surgeons who have a
proper training in aesthetic proce-
dures and who are properly quali-
fied to give good and appropriate
advice,” he said.
“The hope is that the forth-
coming changes in the regulations
will eliminate the fringe clinics
offering poor advice and question-
able treatments with inferior prod-
ucts.”
They also hope that patients
will be more proactive in question-
ing where and how the con-
stituents used in their procedures
have been obtained.
Collagen corpsesIn today's celebrity culture, where looks are becoming more and more
central to a person’s confidence, the desire to fit into a set mould is
ever increasing.
But how far will the beauty and medical industries go to fulfil the
demands of such an image conscious public? Sinem Ayman high-
lights how fears have been raised about the origins of collagen for
implants.
“Hopefully the forthcom-
ing changes in the regu-
lations will eliminate the
fringe clinics offering
poor advice and
questionable treatments
with inferior products.”
Collagen has been widely used in cosmetic surgery and certain skin
substitutes for burns patients for the past 25 years. It’s use, particu-
larly for cosmetic implants, however is declining for a number of
reasons -
> There is a high rate of allergic reactions causing prolonged redness
and requiring inconspicuous patch testing prior to cosmetic use.
> Most medical collagen is currently derived from cows which intro-
duces the risk of transmitting prion diseases like variant CJD.
> New alternatives which use the patient’s own body fat or
hyaluronic acid are becoming readily available.
>Collagen Facts
JuniorDr
17
JuniorDr
Fea
ture
s
18
Monday
First things first. That incident
(if you’ve been following this col-
umn) with the aortic balloon pump
blew over. I was vindicated by an
internal hospital inquiry and
things were left at that. Of course
my boss was also vindicated
which can’t have been right as I
went against his orders to save
someone’s life - so we can’t both
have been right. But that’s how
these things work in the wonderful
system that is our NHS.
I’m now in (almost) full time
research at a nearby hospital.
Monday mornings are spent with
my supervisor. He’s a bright indi-
vidual but can be very demanding.
He often emails me late at night
usually asking me to present
something to him. This happened
yesterday so I’ve been up most of
the night trying to sort things out.
This morning he seems to
have forgotten about it. When I
ask him if he’d like to go over
things he tells me that he has
changed his mind and wants me to
look into another aspect of the
work. It would have been nice if
he’d told me this six hours ago.
The rest of the day is spent in
meetings looking over our work
and trying to figure things out. I
get home early and go out with
friends for dinner. We stay out too
late and I have too much
Californian Merlot to drink.
Tuesday
I’ve drunk a litre of mango
and blueberry smoothie as a pro-
phylaxis against my hangover and
it seems to have worked. Except I
keep needing to empty my blad-
der. I spend the entire day in the
lab. My current project is looking
into cardiac muscle cells and how
they respond to a host of different
chemical stimuli. It sounds pretty
boring and to be honest it mainly
is. There’s a billion dollar drug at
the end of it but my time here will
be up before we get anywhere near
that.
After lunch I have a meeting
with Jackson. He’s a senior
researcher here and spends most
of his time speaking to the drug
companies. He's thirty-five,
recently divorced, tall and thin
with a few streaks of silver in his
hair and a wickedly infectious
laugh - plus he actually looks good
in a lab coat.
He asked me out for a drink a
few weeks ago and when I said no
I think I seriously dented his con-
fidence. He’s been avoiding direct
eye contact since then - which is
kind of hard when we meet a cou-
ple of times a week. I can’t
remember my excuse but it was
something about needing time out
after my last disastrous relation-
ship.
I spend the rest of the day in
the lab. There is a problem with
one of my cell suspensions and by
the time I've sorted it out it's
almost ten at night. I get a cab
home and collapse in bed. I’ve got
real work tomorrow.
Wednesday
I spend the morning in the cath
lab back at my old hospital. I run
into a few consultants but not my
arch nemeses (the one who tried to
get me fired). We have four cases
and the last one, a fifty-seven year
old man, gets a little complicated.
Before I know it I have a problem
on my hands. We have a cardiotho-
racic team on site and I bleep the
on call consultant to bail me out.
He’s a friendly and straight talking
surgeon in the twilight of his
career. He takes the man straight to
theatre for an emergency CABG.
I spend the afternoon in clinic
but my mind keeps wandering to
my angio. I did nothing wrong and
having to proceed to an operation
is a known complication and
something you consent patients
for. But it’s the first time that it has
happened to me.
As soon as I’m done I go
straight to CITU. The patient is
awake and talking. I find the sur-
geon and thank him profusely. He
smiles and tells me that it’s the
most fun he’s had in weeks and
that if not for people like me he’d
be out of a job. I go home call my
parents for the first time in a long
while. They’re in a chatty mood so
we talk for a long time before I fall
asleep in front of the TV.
Thursday
Back in the lab today. More of
the usual but then my supervisor
calls me into his office before
lunch. He has an extra ticket to a
conference in Milan at the week-
end and wonders if I’d like to go.
The opportunity is immense but I
hesitate before answering. There
are five other people in my lab
and I’m the only medic.
It was hard at first as I tried
to grapple with basic scientific
techniques. On top of that I got
paid a lot more than them as my
salary came from outside the uni-
versity. This was reason enough
for resentment but I put a good few
months into building our relation-
ships. We’ve even been out for
drinks a few times.
I tried explaining all of this to
him but he just smiled. In research,
he explained, you had to take
whatever opportunities that came
your way. It wasn’t about pushing
other people down, it was simply
about making the most of what
was passed in front of you. I told
him I’d let him know by tomorrow.
I spent the afternoon feeling
guilty but by the end of the day
word had got round and I received
a multitude of snide comments. I
tried to brush them off with jokes
about shopping for shoes in Italy
but this made things worse. I don’t
think they realised how hurt I was.
Friday
The morning was spent in a
teleconference with a materials
supplier from Texas which sounds
a lot more exciting than it was.
Friday afternoons are free so I
popped back across London to see
how my CABG patient was doing.
His bed was empty which is usual-
ly a bad sign. The SHO on call told
me that he had arrested last night
and died. He’d been in asystole
throughout without a hope of com-
ing back.
I left and spent the rest of the
day in Starbucks with a novel and
a Mocha Latte with cream and
caramel sauce (more calories than
a double bacon cheeseburger). I
don’t normally get upset about
deaths, even if I’ve been somehow
involved but this had really gotten
to me. Perhaps I was better off in
research where the worst that
could go wrong was a cell line
dying.
But then that’s not why I went
to medical school in the first place.
I went to treat people not test
tubes. My lab colleagues were
right. I was different from them. I
called up my supervisor and told
him that I’d meet him at the airport
tomorrow morning.
I finished my coffee and then
called James to see if he was free
for dinner tonight. He
was.
Th
e S
ec
ret
Dia
ry o
f a
Ca
rdio
log
y S
pR
* 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!
MadridWeekend ward escape to
Where to stay?
Like any capital city staying in
Madrid is expensive. Visiting at
the weekend does let you take
advance of reduced rates when all
the business travellers have left.
Try the centrally located Petit
Palace Arenal (Calle Arenal)
approx £60 a room. If you’re still
waiting for your paycheck you
could try the Barbieri Internation
Hostel (Calle Barbieri), just a
short walk from the centre, which
offers double rooms from under
£30. Or if you’re planning a really
special weekend away you could
splash out on Hotel Santo Mauro
(Calle Zurbano) - the choice of res-
idence for the Beckhams at £250
per night.
Eating
Tapas will become addictive
whilst in Madrid. Pop into a bar,
order a drink and nibble the night
away with the locals - it’s how they
can stomach drinking until the
early hours of the morning.
The top tapas treats can be
found at Juana la Loca (Plaza
Puerta de Moros) or Alhambra
(Calle Victoria) which offers a
more lively experience with heavy
music and a younger crowd.
For a more sedate sit-down
meal consider La Viuda Blanca
(Calle Campomanes) which offers
a modern take on Spanish cuisine.
Key attractions
Palacio Real - Arguably the most
impressive building in Madrid
with fantastic gardens which are
perfect for a spot of lunch. There’s
3,000 rooms to the Royal Palace,
many of which you can wander
through.
El Teleférico de Madrid - This is
a 10 minute cable car ride that
departs from the park behind the
Royal Palace. It’s a great way to
see the city from afar and also ends
at a welcome restaurant.
Prado Museum - This is Madrid’s
most popular tourist attraction and
claims to have a higher concentra-
tion of masterpieces than any-
where else in the world. At any
time there’s 1,500 works of art on
display out of an impressive col-
lection of 9,000.
Parque del Retiro - Retiro means
retreat and is the most popular
park in Madrid. With a large lake,
monuments and shaded areas it’s
the perfect place to relax after
stomping around the Prado - which
is conveniently situated close to
the main entrance.
Nightlife
Plaza de Toros de Las Ventas -
Whether you amazed or are
appaled by bullfighting it’s cer-
tainly a big part of Madrino culture
and increasingly popular. Tickets
can cost from a few quid to over
fifty depending on where you sit in
this massive 25,000 seater stadium
with the action kicking off from
7pm.
Casa Patas (Casa Canizares) -
Flamenco is the other great
Madrino passion and certainly
worth an evening’s viewing. Casa
Patas offers one of the more
authentic experiences. Entrance is
approximately £25 and includes a
complementary drink.
Find the full Madrid guide at
JuniorDr.com
With bullfighters, women who dance clapping metal cymbals and huge
30 inch plates of paella there’s no doubt Madrid sees itself as a macho
city. Hardly a place for a relaxing weekend away you may think. Wrong.
Madrinos also have a strong reputation for enjoying themselves ... you
just have to let them take the lead.
JuniorDr
Fea
ture
s
19
Key facts
> Population - 2,905,100
> Language - Spanish
> Currency - Euro
> Madrid is Europe's highest
city (2,100 feet)
The pics
Clockwise from top left -
Tapas; Bullfighting at Plaza de
Toros de Las Ventas; Palacio
Real; Madrid city centre
Fea
ture
s
20
Medical Report - Mr S. Claus
Obesity
Santa isn’t just big-boned. He isn’t ‘jolly’. He is obese, with a BMI of well over 35. Obesity,
especially central or waist-predominant obesity, is an important risk factor for ‘Syndrome X’
- the clustering of a number of diseases and risk factors that heavily predispose for cardio-
vascular disease. These include diabetes mellitus, high blood pressure, high blood cholesterol
and combined hyperlipidemia. Apart from the metabolic syndrome, obesity is correlated with
a variety of other complications (all with TLAs), ranging from cardiovascular (CHF) to gas-
trointestinal (GoRD) and psychological (BDD). The answer is clear: Diet or Die Santa.
Cyclothymia
Santa locks himself away from the world for the majority of the year, not speaking to anyone
(except for his ‘elves’) and then appears incredibly happy, overjoyed with everything and
unable to stop himself laughing. He doesn’t sleep, excessively spends his money buying
presents for all and then get in his vehicle and speeds off - all the while dressed in bright
colours. A word of warning, high mood is often this is followed by irritation, recklessness
and sexual disinhibition - watch out Rudolf.
Albinism
His head, beard and eyebrows are white as snow. The most likely diagnosis would be
Albinism, a genetic abnormality where no pigment is found in human hair, eyes or skin,
making the eyes blue, the hair white, and the skin pale. It would also explain why he is only
seen at night - he lacks melanin, a protective pigment in his skin, burning easily from expo-
sure to the sun and suffering from photosensitivity.
Red Face
All those years of children leaving out ‘a little glass of whiskey to keep Santa warm’ may
have left him with a problem. Long-term alcohol use causes cirrhosis of the liver. As this
stops working and begins to shut down and the results are multi-systemic signs. The tiny
blood vessels in his face burst leaving a permanent red face, nose and cheeks. This would go
well with his jaundice, clubbing and gynaecomastia. It would also explain why he always
wears gloves and baggy clothes - and why the glass you left was always empty in the morn-
ing.
Haemorrhoids
Santa’s sleigh doesn’t look very warm and cosy. Assuming he starts off from snow-covered
Lapland and travels all across the world he must spend an awful lot of time sitting on a cold,
hard seat. He doesn’t appear to have much time for toilet breaks either. Too much pressure
on the rectal veins due to poor muscle tone or poor posture, coupled with obesity, sedentary
lifestyle and postponing bowel movements (or constipation) has been proven to cause haem-
orrhoids. It must also be very difficult for Santa to get help - he can’t exactly pop down to
his local chemist for a tube of Anusol.
Sexual Fetishes
He is a grown man who is always seen in the company of elves, children or a red-nosed rein-
deer. But just in case he happens to be reading this I’m not saying anything else. I wouldn't
want to go on his naughty list ...
Dr Fairytale
General Practitioner to the Stars
(B.H.S, M.&.S, R.S.V.P.)
Ass
esse
d b
y G
il M
yer
s
JuniorDr
Ask the
public
Describe the symptoms?
“Terrible pain. It’s better to sit
down. Massages help and I think
aspirin is good. You shouldn’t fly
either as this condition can get
worse and can be deadly.”
Paul, Transport Engineer
Who gets it?
“You get it when you’re old. It
only affects women but I don’t
know why.”
John, IT
Can it be fatal?
“Hmm. I don’t know anyone
who’s died from it. I’m sure you
can lose a leg though.”
June, Shop assistant
Is it contagious?
“Yes. I’ve got it. I got it from my
mother. I think all our family
have it. I’ve had an operation on
two of mine last year and they’re
much better.”
Patricia, Shop assistant
Is it preventable?
“Walking is good and don’t have
a desk job. Wearing stockings
helps too. You shouldn’t fly either
as it also causes them.”
June, Shop assistant
How can it be treated?
“You can get it cut out which I
guess is permanent. A lot of peo-
ple just cover them up with
make-up or clothing and deal
with the pain.”
Xantham, Driver
Hmm ... sounds like a DVTdoesn’t it? Not
quite. We asked them about varicose veins
which two people think is caused by flying.
See, we’re still needed after all.
We offered all our interviewees a factsheet
about varicose veins and advised John that
he could get them too - he wasn’t happy.
It’s tough being a doctor these
days. Patients turn-up having
researched their ailments on
Google. Sometimes a little reas-
surance that they don’t know
everything makes us feel better.
We did some spot check-ups out-
side a London hospital asking
the public to tell us about a com-
mon condition. Now, just what
was it?
JuniorDr
The UK's first part-time course in applied clinical ethics, designed specifically
for practising clinicians. Taught by leading authorities in the field, including
Prof. Raanan Gillon, and experts in medical law and conflict resolution. Covers
key issues in clinical ethics and methods of case analysis.
The course is intended for hospital doctors, surgeons, general practitioners,
nurses, managers and members of clinical ethics committees. No experience
of academic medical ethics necessary. Limited places available.
Directed by Dr. Daniel Sokol, Lecturer in Ethics, Keele University, and
Honorary Research Associate, Imperial College London.
� 24 Feb 2007 � 21 April 2007 � 9 June 2007
� 24 March 2007 � 19 May 2007 � 30 June 2007
6 x 1-Day Professional Training on Saturdays at Imperial College London
CME/CPD approval sought
Details: Ulrika Wernmark +44(0)20 7594 6886; [email protected]
Applied Clinical Ethics (ACE)
www.imperial.ac.uk/cpd/ace
Courses
Locums
Journalism
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The ‘must-attend’ event for
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For more information and to register visit -
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> Neurology
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Wouldn’t it be great if you could attend a
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A one-day event where top clinicians
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advances in each speciality over the last
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Now you can. Book online now for the
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MedicalUpdates
The Medical Journalists’ Association brings together medical writers,
the media, health professionals, and health charity workers.
> Meetings on major health and medical topics of the day
> A forum to meet colleagues
> Recognition and cash awards for distinguished work
> A website with your own address - visit www.mja-uk.org
> Professional advice when you need it
Wish to join? For more information visit www.mja-uk.org
Next Event - ‘Talking Sex’ on 15 March with presentations by fpa, Relate, the Brook, Sexual Dysfunction
Association, and Association of Sexual and Relationship Therapists.
Discussion. Buffet supper. Starts: 6.00pm for 6.30pm at Browns Courtrooms, 82-84 St Martins Lane, Covent
Garden, WC2. Tickets free. Apply via Rachel Vrettos: [email protected]
cannot make decisions about their
care. Capacity is not an all-or-
nothing affair, but can be present
in degrees and may fluctuate
depending on the patient’s mental
or physical state. Judging whether
someone has enough capacity to
make a decision will be based in
part on the decision to be made.
Generally speaking, the more seri-
ous the consequences of the deci-
sion, the more stringent the crite-
ria for capacity.
A patient may have enough
capacity to choose which arm will
receive an injection but not to
decide whether to have a life-sav-
ing operation. To assess capacity,
a doctor should also determine
whether the patient can under-
stand key aspects of the decision
(e.g. the purpose of the treatment,
its risks and benefits, etc.),
whether the patient has the cogni-
tive ability to believe and assess
the information, and whether men-
tal illness (e.g. depression) is not
affecting cognitive processes to
such an extent that capacity is
undermined.
Hope that helps!
Daniel K. Sokol, Lecturer in
Ethics, University of Keele, and
Honorary Research Fellow,
Imperial College, London.
www.medicalethicist.net
Any comments, questions or
cases? Contact
JuniorDr
EthicaladvisorI'm a house officer in London. As part of the FY1 Foundation Learning
Portfolio, we need to know the difference between consent, assent, and
capacity. Can you clarify? Dr Roland Hettige, St Mary's Hospital, London.
Consent
Consent is the patient’s volun-
tary agreement to an examination,
treatment or procedure. It can be
obtained orally, in writing, or by
co-operating (ie. ‘implied’ con-
sent, such as opening your mouth
for a tongue inspection).
Obtaining consent is typically a
process which requires the doctor
to establish whether the patient a)
is sufficiently informed b) is com-
petent enough to make the deci-
sion and c) is acting voluntarily.
At the risk of teaching the prover-
bial grandmother to suck eggs, a
signature on a consent form is not
sufficient to constitute valid con-
sent if you haven’t properly gone
through the a) to c) process.
Assent
Assent is also a patient’s
agreement to treatment, but the
patient lacks sufficient capacity to
give valid consent. Hence assent is
usually applied to situations
involving young children. So,
whereas a competent patient’s
consent can be translated as ‘yeap,
thanks for asking doc, go ahead; I
understand what this is about, I’ve
got enough marbles to appreciate
the situation, and no one’s forcing
me to have this’, assent is more
straightforward: ‘yeap, thanks for
asking, go ahead doc’. Assent, in
brief, is an agreement to partici-
pate which differs from consent in
that competence and voluntariness
are not required to the same
degree.
Capacity
Capacity is the legal term for
‘competence’. Without it, patients
Help with the portfolio: consent, assent, and capacity
Th
e M
es
s
22
Medical Ethics and
Law - Surviving on
the Wards and
Passing Exams
Sokol and Bergson
£14.95
ISBN 0954765710
Top
5medicalmovies
Flatliners (1990)
Kiefer Sutherland, Julia Roberts, Kevin Bacon
Five medical students get a little overexcited whilst
exploring the mysterious world between life and
death. By stopping the heart of one of the group they
stimulate a near-death experience and then just pray
they’ve been paying enough attention in lectures to
resuscitate them again.
Lorenzo’s Oil (1992)
Nick Nolte, Susan Sarandon
When their 5-year old son develops a nasty form
of adrenoleukodystrophy his parents don’t
believe their doctors when told it’s terminal.
Instead they set out to study the disease, take on
the pharmaceutical establishment and the medical
profession. As you can imagine for a Hollywood
blockbuster they come out on top.
Patch Adams (1998)
Robin Williams
Based on a true-story Robin William gets to clown
around as a medical student who attempts to ‘treat
the patient, not the disease’ by making them laugh.
Often cringe-worthy, occasionally inspiring, it may
just make you want to wear a red-nose to ward
rounds.
Outbreak (1995)
Dustin Hoffman, Rene Russo
Tense, edge-of-seat thriller as Mr Hoffman and
colleagues try to contain a virus that has hitched
it’s way into the US on a little monkey. Luckily
our heroes manage to avert total annihilation of
mankind single-handily - though they can’t save
the little monkey who dies in one of the more tear-
jerking scenes.
AwakeningsRobert de Niro, Robin Williams
Mr Williams graduates to doctor in this impressive
flick during which he treats comatosed catatonic
patients by administering L-dopa for the first time.
The spectacular results of the drug mirror real-life
events in New York during the 1960s and are pret-
ty awe-inspiring even with Williams in the lead.
JuniorDr
Hospital
When your hospital food tastes like the remnants of a liposuction pro-
cedure 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 -
Wh
ich
me
ss
is t
he
be
st?
What it’s got -Permanently in a messy state. No food in the fridge. Out of date
microwave meals in the freezer. Toilet blocked more often than
not. Two computers with internet that are usually off-line.
Stained couch after many nights being slept on by the surgical
team. Old television but at least it has Sky TV. In a nutshell, dis-
appointing for a tenner a month.
JuniorDr Score - 1/5
> Broomfield Hospital, Chelmsford
Sachet of tomato ketchup
Bet it goes all over your shirt too -
15pWOW!
Walking thecorridorsWhile we doctors are puzzling over squiggles on ECG traces, prescrib-
ing IV nystatin and ordering MR scans for patients with metal implants
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.
JANE
RADIOGRAPHER (SOUTHAMPTON)
You may not realise this but
there is currently a national short-
age of radiographers. This means
that as much as doctors complain
about working hours we get it
much worse. My day usually starts
at 8am. I arrive before most of the
consultants. If I’m working in MRI
or CT then I fire up the scanners
and send a test scan. Our equip-
ment is state of the art so it’s very
different from when I trained.
These days you have to be more
like a software engineer than an x-
ray technician.
I have a coffee at my desk and
then spend the morning in the
scanner. Most of it is standard stuff
but you do get the occasional
emergency. Most of my entertain-
ment comes from junior doctors
getting slapped around by our con-
sultants. There’s such a difference
in how they ask for scans.
I’ve realised that it is all about
confidence. I can usually tell when
a radiologist is going to accept a
scan. It’s because the young doctor
walks in with a respectful yet con-
fident air. They already know that
they’re going to get the scan before
they’ve started presenting the case.
By lunch things have started to
quieten down. There is always
some paperwork and another cof-
fee to drink. We also try and teach
the juniors a little each day. The
afternoon can get busy, depending
on where you work. For example,
there is always a request for an
MRI spine to rule out cord com-
pression at four-thirty on a Friday
afternoon - usually on a patient
they’ve been sitting on all week.
On call can vary from place to
place. As I work in quite a big hos-
pital my on calls are unfortunately
on site and they can be very busy.
You can get into arguments with
consultants as well - usually over
night scans.
We had one radiologist who
hadn’t paid for a link to his house
(despite all the money he was get-
ting from private scans). This
meant that he had to come in to
report scans. He would often ask
radiographers to look at CT brains
when on call.
Sure, after twenty years I can
tell if there’s a bleed but that’s
what they pay him to do. The first
time he asked me to do it I said I
would but then asked for his GMC
number so that next to my report I
could write a little paragraph about
him asking me to do it. He came in
pretty quickly and hasn’t bothered
me since.
On a normal day I’m supposed
to finish by five but I never leave
before six, often later. After the
consultants go home and the junior
doctors finish their shifts we’re
still there. I make sure that the
paperwork is all filled in and that
any urgent scans have been report-
ed. I have my fifth cup of coffee
and it’s usually me who turns the
lights off on the way out.
Belfast City Hospital
Belfast
Squeezelicious -
9pLOW!Royal Brompton Hospital
London
Ready salted crisps
Enough to make you choke -
57pWOW!Royal London Hospital
London
Just watch your arteries at this price -
35pLOW!Belfast City Hospital
Belfast
330ml can of Coke/Pepsi
Tell them to can it at -
70pWOW!North Middlesex Hospital
London
Fizztastic prices at -
40pLOW!Chase Farm Hospital
London
Next issue we’re looking for the lowest/highest price of a toothbrush, a
chocolate chip muffin and a portion of chips. Email [email protected].
Th
e M
es
s
23
Professional support and expert advice
Membership Helpline 0845 718 7187 or visit www.mps.org.uk
The Informal Consultation
by Annmarie McTigue, Writer, MPS
After all the years of hard work, you are now a qualified
doctor. . . and the hard work seems to get harder.
Revision, supervised procedures and exams have been
replaced by learning on the job and from experience. And
you’re working in the most trusted profession, a status
that brings its own challenges. You have probably won
new respect in the eyes of friends and family, who may
come to you for advice on aches and pains.
Although you are qualified, you are very much still learning, so your
newfound ‘doctor’ status may lead you to a medicolegal minefield –
the informal consultation.
Scenarios
1. You go to your parents’ house for a family lunch. Following a
general conversation with your sister-in-law, she says: “I’m so glad
you’ve made it today. I was going to book to see my GP, but you
can probably help.” She goes on to describe the symptoms of a
recurring ailment. What do you do?
2. You bump into a friend of a friend while training at the gym. The
last time you saw him he was “as high as a kite” on a night out. You
once treated him in A&E after an accident and he confided he was
on anti-depressants. He asks if you could write him a character
reference for a new job. As an acquaintance you would have qualms
about his social drug-taking, but as a doctor, you are also aware of
his previous history of depression. What do you do?
You may not see a problem with giving somebody some general
advice about an illness or writing that reference, and may be happy
to do it. Both these scenarios, however, could lead to a complaint or
claim if something went wrong.
Getting out of a tricky situation
So what would you do in the above scenarios?
In the first case, you are dealing with a family member and would
naturally wish to help. MPS would advise adopting an empathetic
approach to your sister-in-law, but explaining that it would be
better for her to see her usual GP. Explain that you would not be
able to properly diagnose any condition without being able to
review her medical history/notes or conduct the necessary
examination or tests. Add that it if you were to offer a diagnosis or
advice now on the basis of incomplete information, problems could
arise for both of you if a different, and possibly serious, condition
came to light in the future.
This second case puts you in an awkward position. It would be best
to explain that as you once treated him and also know him from
nights out, you would not be the best person to provide a reference
of the type he is requesting. If he persisted in his request, explain
that you would be able to write something in the form of a medical
report, which would need to include reference to any relevant past
medical history, adding that he would need to see and consent to it
being sent.
Better to be safe than sorry
If you find yourself in a grey area between professionalism and
your social or personal life, contact your protection organisation
for advice.
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.
1. GMC recommendations
The GMC’s Good Medical Practice does not offer specific
advice on dealing with informal consultations. However, there
are some general points to follow that should help you make a
judgment call.
Providing good clinical care
Good clinical care must include:
adequately assessing the patient’s conditions, taking
account of the history (including the symptoms, and
psychological and social factors), the patient’s views, and
where necessary examining the patient
providing or arranging advice, investigations or
treatment where necessary
referring a patient to another practitioner, when this is in
the patient’s best interests.
Avoid treating those close to you
Wherever possible, you should avoid providing medical care to
anyone with whom you have a close personal relationship. (the
GMC does not specify what constitutes a close relationship.)
Doctor–patient relationship
In most successful doctor–patient relationships a professional
boundary exists between doctor and patient. If this boundary
is breached, this can undermine the patient’s trust in their
doctor, as well as the public’s trust in the medical profession.
2. BMA guidance on treating family or friends
The BMA advises that treating family and friends should
generally be avoided, except in emergencies. It states that in
such cases a GP may fail to notice symtoms that a
dispassionate observer would note and if seeing somebody
outside the surgery, they may not be able to carry out all the
tests that would be done in a formal consultation.