Category Archives: things which made me think

Grenfell

It has been a tragic couple of months for London, Manchester and Britain as a whole. The terror attacks and the fire in the Grenfell Tower block are deeply saddening, and have really emphasised my appreciation for and the importance of not only our emergency services, but also the accepting and tolerant communities we have established.

I’m sure many of you, if not most, have seen images of these attacks. For me, a particular twitter post brought down the earth the realities of being a member of the emergency services. The sacrifices which these people are willing to make to help others, and the bravery of each and every one of them. I never thought a name on the back of a helmet could signify so much, but I believe it is a reflection of how we can be so willing to help others, regardless of race, religion, age, sexuality, and any other factor.

 

Following the Grenfell Fire, I read a really interesting article entitled, ‘Ahmed Kazmi: A GP’s experience of the Grenfell Tower fire’. http://blogs.bmj.com/bmj/2017/06/16/ahmed-kazmi-a-gps-experiences-of-the-grenfell-tower-fire/

Yet again, this made me step back and think of what the role of a doctor really is. The article reinforced to me that as a doctor you are not always curing people, saving lives or treating illnesses, and often this is just a small part of the day. One of the most important aspects of being a doctor is undoubtedly, dealing with people and Ahmed Kazmi proves that, as by comforting and playing with children, he was still acting as a doctor. I can see how it could have been very easy for him to leave the centre, seeing they didn’t need his medical knowledge. However, this has emphasised to me that help comes in so many forms, treatment, operations, a shoulder to cry on, a helping hand.

This makes me think again of the BBC documentary ‘Hospital’ in which a young junior doctor sat with the wife of a patient, after telling her that his chances were slim. Despite her stressful and busy day, finding the time to help and care for each patient and their family is essential, and in that situation it seemed to make even the silence much more comfortable.

I just thought I’d write a short article as I believe that this is something every aspiring medic should understand and consider – help and care come in a number of ways, and it is incredibly important to give every patient the time and support they both need and deserve.

Aspirin and Cancer

When talking to a friend today, she mentioned her idea for an EPQ – investigating the link between aspirin and cancer. Aspirin is taken by many to reduce the risk of heart attack and stroke [1], although I had not heard of its link to cancer before. I thought this was a really interesting topic, and have heard many stories of doctors themselves taking aspirin daily to improve their health. Therefore I would like to share the research I have done into possible uses for aspirin.

In doing this, I found that the most potential has been found regarding colorectal cancer. A hereditary condition called Lynch increases the risk of the development of cancers such as bowel cancer, womb cancer and colorectal cancer [2]. As it causes no symptoms itself, many with the condition often do not know they have the faulty gene which causes it [2]. In a trial of those with Lynch syndrome, those given aspirin had a 63% less chance (relatively) of developing colorectal cancer, in comparison to those who didn’t take aspirin and merely had a placebo [1]. I’m sure you’ll agree this is a huge decrease, and could potentially save lives and money for the NHS. While the cost of prescribing a daily dose of aspirin for a vast amount of the population would be high, the true question is whether this outweighs the cost of treating patients with colorectal cancer. Most importantly however, doing this is likely to save lives and provide a much better quality of life (cancer free).

Although, aspirin has not only been found to affect those with increased risk of colorectal cancer. In a similar study published in 2016, the long term use of aspirin was investigated. After 6 years of taking aspirin, there was a reduction of 19% in the risk of colorectal cancer, and 15% reduction in the risk of nay type of gastrointestinal cancer [1]. Colorectal cancer however, is not the only cancer that aspirin can effect. A systematic review also found an 11% decrease in the risk of death from prostate cancer [3]. This shows taking one small tablet each day could have huge benefits on health, especially when coupled with the reduction of heart attacks and strokes.

Undoubtedly, aspirin in low doses benefits human health. However, before everyone starts popping aspirin pills, the long term effects of the drug need to be investigated and known, alongside costs being totalled up. Aspirin may have negative effects on other areas of the body yet the evidence for the apparent use of aspirin in preventing cancer, heart attacks and strokes is abundant.

[1] https://www.cancer.gov/about-cancer/causes-prevention/research/aspirin-cancer-risk

[2] http://www.macmillan.org.uk/information-and-support/diagnosing/causes-and-risk-factors/genetic-testing-and-counselling/lynch-syndrome.html

[3] http://www.nhs.uk/news/2016/04April/Pages/Daily-low-dose-aspirin-may-help-combat-cancer.aspx

Book Review: When Breath Becomes Air – Paul Kalanithi

This book is undeniably honest, highlighting the realities of being a doctor, a patient, and dying. I am not embarrassed to say that I ended this book in tears, not only is it impeccably written but one of the most unique and useful books I have ever read.

“As a resident, my highest ideal was not saving lives – everyone dies eventually – but guiding a patient or family to an understanding of death or illness.”
― Paul KalanithiWhen Breath Becomes Air

Becoming a doctor should not be viewed through rose tinted glasses, something I know I have previously written about (a phrase which has certainly stuck with me). The stresses, long hours and innumerable tasks which are encumbered within medicine are written about in ‘When Breath Becomes Air’, and most importantly the realisms of just wanting to get work done. Through reading this book, I learnt how easy it is to slip into monotony, to just ticking patients off a list, however, that is not what being a surgeon, let alone a doctor, is all about.

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This has helped me realise that every patient who walks into a hospital is different, and that as a doctor you frequently meet people at their most vulnerable, most scared or most weak. How you approach a situation or initiate a conversation can impact hugely on how someone remembers their hospital experience or views hospitals for the rest of their life, and what can easily become just another patient in your day is a huge moment in a persons life. The humanity of being a doctor is truly emphasised within ‘When Breath Becomes Air’, with the personal stresses, commitment needed and responsibility felt being accentuated.

“The physician’s duty is not to stave off death or return patients to their old lives, but to take into our arms a patient and family whose lives have disintegrated and work until they can stand back up and face, and make sense of, their own existence.” 
― Paul KalanithiWhen Breath Becomes Air

Besides this, the second chapter of the book is as close to an account of death as possible. Dr Paul Kalanithi himself realised how as a doctor you deal with patients every day, but rarely do you experience what it is like, or the close proximity of death. I have not dealt with many loses in my life, and I think reading this book I got as close as possible to experiencing just a tiny part of what dealing with cancer can be like.

For me, being a doctor is a commitment to putting your patients first, and I believe that in many cases this is about making them feel comfortable, aware of what is happening but also recognising when not to bombard a patient with information. ‘When Breath Becomes Air’ is both phenomenally written and a just balance between science, patient care and first hand experience. I would recommend it to anyone, as it is a huge insight into what life is like as a neurosurgeon, but also death and how hospitals can influence lives.

‘People often ask if it is a calling, and my answer is yes. You can’t see it as a job, because if it’s a job, its the worst one there is’
― Paul KalanithiWhen Breath Becomes Air

Here is the amazon link for ‘When Breath Becomes AIr’

https://www.amazon.co.uk/When-Breath-Becomes-Paul-Kalanithi/dp/1847923674

 

Nature’s Medicine Cabinet – from Root to Remedy lecture

At the Cambridge Medicine Masterclass earlier this month, I listened to a lecture led by Sonja Dunbar, and was truly intrigued. If I’m honest, it was the lecture I thought I would be least interested in, as I expected it to focus on herbal remedies and the likes, yet it was much more medicine focused.

66% of all drugs have their origins in nature, and infant 80% of people in underdeveloped countries rely on traditional remedies from plants. Thus, their used simply cannot be ignored. Yet, what was a really interesting proposition was why are so many compounds in plants beneficial to humans? It is absurd to think that plants exist for our benefit, there are abundant defences to stop us using them. Spikes, thorns, bristles and chemical poisons all with the intention of helping the plant live longer, and protect the plants form those who are likely to eat it. A key example of this is the classic stinging nettle. These contain histamine, responsible for the itching felt after a sting and acetylcholine, a neurotransmitter. These are contained in a trichome, a specialised ‘hair’ in plants which is very similar to a hollow needle. Alongside this, stinging nettles contain Leukotriene, which promotes information and causes blood plasma to leak out of the membrane and lysosomes to swell, and serotonin. All of these chemicals are pumped in you your body when you are stung by a nettle.

Holly

This leads us to the scarcity-accessibility hypothesis, where a plant in an environment where it is more likely to be eaten, for example when other plants are scarce is likely to have the most defences. Examples of such plants  are Holly and cacti, both of which have visible mechanical defences – holly with its spiked leaves, and cacti with their needle-

cacti-needles_3cc3cf1c0f513010like spikes.

An interesting example of a plant which attempts to deter you form eating it, is the chilli. Chill is detected by TRPVI, the same receptor as vanilla, and vanillin and capsaicin are in fact structurally very similar. However, vanillin cannot get through the cell membrane, yet capsaicin can, and therefore binds to the receptor and tigers the brain into thinking you’ve eaten something hot. For most humans, this would not be a pleasurable experience and would put you off eating a chilli again. However, it gets better. Chilli’s receive no benefit from being eaten by mammals, as we grind and crunch seeds up due to our molars. Their seeds are therefore broken apart and cannot germinate to produce more plants. Although, birds eat chilli’s and don’t seem to find them hot. Why? Because birds don’t crush or grind the seeds, simply pass them through their digestive system and disperse them. They can travel great distances in a short space of time meaning that very little competition between the plants remains, and so birds do not find chilli’s hot, as the plant benefits from being consumed.

So, what are some examples of plants used in medicine? Foxgloves, contain digitoxin which helps to controlyour heart rate. It is a cardiac glycoside which interferes with sodium-potassium pumps, calcium ions and polarisation. In a high dose, it causes irregular heart rates, yet in a low does, it is very useful. Thus, from digitoxdigoxinstructurein digoxin has been developed, with less side affects and thus less associated dangers than the ‘pure’ substance, but with a very similar chemical structure.

Similarly, Aloe Vera contains 98.5% water, mannose-6-phosphate sugars and a collagen triple helix. It can be used in the treatment of thermal and radiation burns. It has been known to reduce swelling, stimulate faster tissue synthesis and help keep the wound clean and hydrated due to the high water content. Thus, it is used in many suncreams, after suns and in a gel to help prevent wounds from infection.

The lecture also spoke about the 2015 Nobel Prize in physiology or medicine. In 2013 there were 198 million cases of malaria, and is a disease which can easily escape detection due to the life cycle of the parasite. Theparasite enters liver cells where it can replicate for 2 weeks without detection. Eventually, the liver cells rupture and release the parasite, which consequently goes on to infect red blood cells. Here, the parasite escapes detection by wrapping itself in the cell membranes of cells from the organism – which will not be recognised as something harmful by the immune system. Cinchona  is an example of an early malaria remedy, which was so heavily sought after the plant nearly went extinct. Artemisinin also treats the fever of malaria, and with cold extraction, reduces 100% of the parasite load in monkeys and mice – incredible. Consequently, the death toll form malaria in the past 15 years has declined by 50%, and it is great to see the Nobel Prize being awarded for a medicine being developed for disease in underdeveloped/developing countries. This is because it takes around 12 years and £1.2 billion to take a drug to market, not something which is affordable to such counties, but malaria is a disease which takes millions of lives, and so any advancements could save countless lives.

What I learnt from this lecture is that biodiversity mattersin the hunt for new drugs. There are still plants we don’t know exist, and plants we do know exist but don’t yet recognise their uses. In destroying the biodiversity of our world, for example by deforestation, we could potentially be destroying cures for diseases. The ecology of the world we life in is important to allow us to survive, and while plants don’t exist for out benefit, they are incredibly useful.

(Source: Sonja Dunbar, Nature’s Medicine Cabinet Lecture, Cambridge University)

Ethics – A man and Australia

On a Tuesday evening, 4-5 aspiring medics from my year meet to discuss medical issues, and what could help us achieve our goal of getting into medical school. Something my mum likes to refer to as ‘Doctor Club’. This week, it was ethics. A series of information on cards was given to us in stages, and we were to decide what action we would take if we were the patients doctor. It went a little like this:

  • The patient was a 65 year old male, who after recent tests you have discovered has cancer. It is untreatable and slow growing. He is also planning and excited about an upcoming trip to Australia.
  • You learn that he recently lost his wife after a long battle with cancer, and has a history of struggling with clinical depression. This is particularly apparent when he hears of serious health issues. He is still very excited about his trip.

We had to make numerous decisions with different amounts of information, and it was based on a real case. Ultimately, the final question was would you tell the patient he had cancer before his trip to Australia, or wait for him to return? What do you think?

For me, this was incredibly difficult but an incredible insight into the factors which doctors need to consider on a day to day basis. It all came down to patient care. Here, the most prominent issue is not the mans cancer, but the probability of a serious bout of depression. I believe that in not telling him before his trip, but similarly not lying to him, you would be providing better patient care than if you were to tell him beforehand. Here in the UK, he has access to support and family members to help him accept his diagnosis, but in Australia there would be very little capacity for this. Also, we were told he would experience no symptoms of his cancer, and it would have no impact on his quality of life.

I found this interesting, as without knowing the man had a history of depression I know my answer would have been completely different – complete honesty. This highlighted for me the importance of medical teams and hospitals working together to produce accurate and up to date patient notes, and collaborations between GP surgeries, hospitals and clinics for example. Interestingly, the answer that the 3 medics who attended on Tuesday came to the conclusion the same as that of the doctor who made the decision themselves. It was only the aspiring vet who thought they would tell the patient before his trip. While the doctor themselves was questioned about their decision, and the case was deemed exceptional, it shows how guidelines have to be interpreted differently for each patient, in order to provide the key patient care. Here, in withholding information for perhaps a couple of weeks longer, the patient was cared for more than if he was told straight away.