A picture of a man with a nose on his forehead caught my attention as I was scrolling down the BBC News website.

It turned out that surgeons in China had spent nine months growing a nose on the forehead of a man whose original nose was damaged beyond repair in a traffic accident.

The surgeons had expanded the skin on the man’s forehead and then placed under it a piece of cartilage taken from his ribs. The forehead was used as the skin there is similar to that of a nose, furthermore the nose can be moved keeping blood vessels in place. The surgery left is said to be the easiest part.

The concept of growing additional parts isn’t a new one.  The report goes on to mention the ear that was grown on the back of a mouse in University of Massachusetts Medical School (Vacanti Mouse). A wire framework of an ear was made and tissues taken from cows and sheep were grown around. The structure was then attached to the back of a mouse whose immune system had been suppressed.

I also learnt of the nose that was grown on the arm of a patient who had lost his to cancer by doctors from the University College London. A glass mould of the man’s nose was taken, bone marrow cells were extracted and place in the mould. This was then grown in the lab. The nose was then transplanted on the man’s arm so that it could develop blood vessels and nerves. After that it would be placed on his face. (Jan, 2013)

China however is increasingly becoming the place to watch for medical advancements, with the government has spending “trillions of pounds on innovation.”¹

1 http://www.bbc.co.uk/news/world-asia-china-24282498

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Medsim

What I learnt from the Medsim conference I attended at Nottingham University;

- I was told how fairy tales and mythical creatures often originate from fact; I found out about the medical afflictions behind the werewolf, zombie and vampires. 

- Triage is defined by the Oxford dictionary as ‘the assignment of degrees of urgency to wounds or illnesses to decide the order of treatment of a large number of patients or casualties’. I learnt that there are different management plans depending on whether those injured are at a hospital or elsewhere. A Mass Casualty Incident is declared when the number of victims or the severity of their injuries overwhelms the doctors responding to an emergency or additionally if there are insufficient medical resources.

        It was made known to me that if an unconscious person does not start to breathe after his or her airway is cleared the person is left, and the doctor moves on to the next person. I realised that although the action seemed harsh, it was logical; more lives could be saved in the time that it would take to attempt to resuscitate the one unconscious person. 

- Later as groups we were forced to practice our first aid skills and implement triage when we were immersed into various simulations of emergency situations. What I learnt here was that in pressured scenarios it’s very easy to work solo and not take the time to communicate with teammates. However it is important to voice your actions and let other people know what you’re doing or you might end up wasting precious time due to the repetition of the same procedures.

- Medsim also introduced me to the different types of roles available in a hospital setting.  For example we talked to a radiographer, the lady was responsible for working both diagnostic and therapeutic imaging devices. For example she was proficient in conducting X-rays, Computed Topography (CT) scans (which take cross-sectional pictures of the body), ultrasounds and Magnetic Resonance Imaging (MRI) scans (they show sections of the body that are of the same type of tissue) to name a few. Radiography is a separate undergraduate course; you need not have a medical degree for work in the field.

            The role of a pathologist was also discussed. A pathologist, unlike a radiographer, must graduate with a medical degree. They specialise in the diagnosis of conditions and the behaviour and development of diseases. Pathologists spend a lot of time in the labs analysing biopsies.

             Nurses have jobs in close to every healthcare setting imaginable. Nurses are most hired type of staff in the NHS. Both nurses and doctors are integral to providing comprehensive healthcare however their roles do differ. For example doctors are responsible for diagnosis, planning the treatment, prescribing medication, essentially for all the decision-making. The nurses on the other hand have to physically administer the treatment. As result a nurse has fewer patients than a doctor however he or she spends a lot of more time with them. A very important part of a nurse’s job is to comfort the patient. In one of my hospital placements, an elderly lady was having her abdominal drain removed and was very worried about it. In response, her nurse held her hand, smiled and was able to comfort her and in the process make the whole situation easier for the doctor and the patient.  

The Impact the Syrian War has had on Health

The UN estimate that since the fighting in Syria begun two and a half years ago 100,000 people have been killed by the fighting. Recently there have also been figures highlighting the number of people presumed to be killed by chemical weapons, but I haven’t yet come across statistics outlining the number of casualties taken by secondary effects of the war.

By secondary effects I mean the resultant food shortages, the lack of water reaching refugee camps and the spread of disease. Before the reading a article on the New Scientist’s website, I hadn’t considered how the crisis in Syria was affecting the spread of disease, I’ve now learnt that it isn’t just the displaced Syrians whose health is being compromised but also the populations of the neighbouring countries.

The war has disrupted local health services, giving way to a large outbreak of measles in Northern Syria, further hindering the measles eradication efforts in the region. Médecins sans Frontières was hard put to deliver vaccines to the remaining inhabitants. The children arriving in refugee camps are all receiving vaccines for polio and measles. 

These camps however are full to the breaking, unsurprisingly with a quarter of the Syrian population now displaced, 2 million Syrians now call these camps home. These cramped conditions have accelerated the spread of:

-       ‘lung and gut infections’

-       hepatitis (the inflammation of the liver, most types are caused by viruses, symptoms include dark-coloured urine and pale bowel movements, jaundice …)

-       tuberculosis (is caused by bacteria that primarily damage the lungs, the bacteria is spread by sneezing and coughing, common symptoms include a bad cough, coughing up blood/mucus, night sweats …)

-       leishmaniasis (a parasitic disease caused by the bite of infected sand flies, there are several variations of the disease, common forms include the cutaneous type that causes skin sores and the visceral type which affects the spleen, liver, and bone marrow)

Neighbouring Jordan has received a large proportion of the Syrian refugees; tuberculosis was close to eliminated from the country. Similarly Schistosomiasis had become rare in the regions surrounding Syria.

(An infection caused by exposure to water sources containing a Schistosoma parasite which grows into a worm that resides in different body parts depending on its species, it cans cause fever chills, diarrhoea and can affect urination.)

Furthermore there is worry that there will be more fatal MERS virus cases due to the weakened condition of the refugees.

(Middle East Respiratory Syndrome was first reported in 2012 in Saudi Arabia, not much is known about the virus, however it is known to be a coronavirus meaning they have distinct “crown- like spikes on their surface. Coronaviruses are common viruses that most people get some time in their life that cause mild to moderate upper-respiratory tract illnesses”¹)

Within Syria, farmers have stopped vaccinating their livestock, but have not stopped exporting them. As a result reports of rabies, bovine TB and other such diseases have already emerged from the produce recipients.

As seen as 8/09/13

http://www.cdc.gov/coronavirus/ http://www.cdc.gov/coronavirus/about/index.htm¹

http://www.nlm.nih.gov/medlineplus/tuberculosis.html

http://www.nlm.nih.gov/medlineplus/hepatitis.html

http://www.nlm.nih.gov/medlineplus/leishmaniasis.html

http://www.nlm.nih.gov/medlineplus/ency/article/001321.htm

http://www.newscientist.com/article/dn24157-threatwatch-syrian-refugee-flood-brings-many-dangers.html#.Uit3WmQpZqs, Syrian refugee flood brings many dangers, 05 September 2013, D.MacKenzie

Profitable Healing

According to NHS figures more than 4,400 lives can be saved each year if healthcare standards at hospitals were the same during nights and on weekends as during the working day. As a result the NHS is making “24/7 care” a priority.

In response to this Dr Mark Porter, leader of the British Medical Association (BMA), said

‘But the calls we sometimes hear for a Tesco NHS, full service, 24/7, are just ridiculous.’

Reasons given as to why the concept was labelled as ludicrous included the fact that the NHS simply couldn’t afford it. Unlike Tesco, by functioning ‘comprehensively’ 24/7, the NHS would not make any profit.

A survey carried out by the BMA showed that doctors stated ‘financial constraints’ as one of the main barriers they faced when trying to implement changes, alongside shortage of time and excess bureaucracy.

I went and discussed this idea of full-time care with my aunt who is a nurse, living in London. She told me that she supported the notion of 24/7 care and as healthcare professional she wanted nothing more than to provide the highest standard of care for her patients. I then asked her, as a mother of three young children, how if implemented, the new plan would upset her family and social life and whether the implications would cause others to oppose it. After all if the doctors and nurses were unhappy, their productivity levels would decrease which could have adverse implications on the health care.

She told me that “people are always willing to work” and at the end of the day it all came down to affordability.

- http://www.bbc.co.uk/news/health-23031333 as seen on 1/09/13, 'Tesco-style NHS plan 'ridiculous'", Nick Triggle

Thursday at UZ Leuven

Today started off without a kidney transplant, as yesterday organs were acquired from a donor (a young girl who had committed suicide). The family of donor had given consent for the girl to be taken off the ventilator that was giving her 'life' ( she was in a coma). I was told that the organs were taken five minutes after the machine was turned off.

During the operation, I had the privilege of standing by the head of the patient (the anaesthesiologists quarters), and was able to see a great deal. An interesting snippet of information was that the 'glue' they used in surgery was made from the clotting factors of cows. I also didn't realise that the pieces of material used in surgery (for absorbing fluids, or providing support) were actually also covered in clotting factors. The patients awakes after surgery, about three minutes after the anaesthesia machine is turned off and its gases removed.

Later I joined the Doctors on a tour of the ward which had held people that had recently undergone any form of abdominal transplant and no longer needed intensive care. Communication between the doctor and patient is two way. The patient gives the doctor a report of his/her day. The doctor has a few follow up questions. And then the doctor gives a report to the patient which I though was great. The reports includes a summary of the blood test results and what the numbers and trends signify. The patients are then informed about the next step of their treatment even if all thats on the cards is taking it easy or trying to sit up for a while. I though such feedback reassures the patients by making every step of the treatment crystal clear and eliminating any sense of doubt that can lead to fear or dismay. 

The doctors also gets report about the patient from the nurses on the ward. The nurses are, I feel, responsible for providing support and comfort to the patients on a more personal level and therefore play an essential role. The patients have more contact with nurses and the nurses know the patients better. They know their preferences and dislikes and are furthermore able to comfort say an elderly women, say during the removal of a drain by holding her hand. 

During the tour the ward I saw an patient whose poor kidneys meant that he needed to use an dialysis machine. On the inner surface of his elbow crease he had an protrusion. I learnt this was where the surgeons fused the artery and vein together, leading to the vein itself thickening like an artery. This was where patient was hooked to the dialysis machine, as if the the machine was continually hooked to a single vein the vein would become damaged. 

After some more desk+document work, we paid a visit to the intensive care unit. Here the patient to doctor ratio is much smaller. The patients get more focused attention. The ward office has monitors the show the vitals such as heart rate of all the occupants. All recent transplants recipients are taken here directly after operation. 

Wednesday at UZ Leuven

7:30 is the time the surgeon's co-assistant arrives at the hospital. I, luckily, was exempt from this reporting time, which would have required me to leave home at 5:00, I entered at 9:00 instead. Working hours are for healthcare staff are longer than those of most professions. Given, the work is varied and has a huge practical element, there is still the tedious yet necessary task of documenting consultations and inputting the data received from tests as I experienced. Today at lot of time was spent doing that. 

Upon talking to a medical student currently doing his placements I gathered that one of the perks of being a general practitioner is that your schedule is more stable and your work hours friendlier than those of hospital staff. On the down side, its pretty much a solitary job. I remember in the operating theatre, the surgeon found an abnormality in patients' liver. He was immediately able to send a sample of tissue to a pathologist for analysis as well as call a colleague for a second opinion.

I had another opportunity of visiting the laboratories and saw a cardiovascular experiment being carried out on a pig. I learnt that whenever blood samples were collected, the syringe was first rinsed with heparin which prevents the clotting of the blood and allows the easy analysis of the samples by the centrifuge. 

Tuesday at UZ Leuven

Tuesday morning, I'm taken by a surgery student to an experiment he set up for his Ph.d. He is investigating how the length of ischaemia damages the small intestine due to reperfusion and he is also looking for biomarkers to help devise a test. Leuven has great labs, with some truly remarkable names doing some incredible research. The lab we went to was for student use, it wasn't extensive as that would involve a lot of non-existent financial investment. 

The experiment was carried out on rats that were the same weight, sex and breed to keep the varying factors to a minimum. We discussed the ethics component of the practical. Firstly all involved had passed an ethics examination, where the correct handling of small animals was covered. Then an ethics committee reviews the plan of the practical, they approve the methods and the number of animals used. Then the rats were all tranquillised  put on anaesthesia. When they woke they were put on painkillers. At the end, they would be euthanised. 

Helping out with the study was a fourth year medical student. She informed me of the Belgian medical education system. Incidentally she was also on call to help out with a study that looked at the ways ischaemia affected the kidneys during a liver transplant. In order to do so she had to be present at all the liver transplants during the week. She told me how last week there was three consecutive transplants. Belgium is part of a 'eurodonor' programme.  Where several countries have a joint waiting list, at organs are flown into countries that need them most.After Spain, Belgium is the largest donor of organs. It has a policy of presumed donor unless stated otherwise, however the wishes of the family of the decease is always respected. Livers need to transplanted within 10 hours after removal (a heart keeps for 4 hours and kidneys 24). As a result liver transplants take place at all odd times. Laura's colleague on call, had to manage with a few hours of sleep that week, he was practically inhaling coffee. This however made reflect on the personal sacrifice surgeons make. They are called to the hospital at various times, the job takes a toll on family and social life. Furthermore they have to remain focused and on their feet for several hours (up to eight for a liver transplant.) At least he or she has a little troupe of people for company. 

The transplant I was lucky enough to watch involved a liver from Germany from an anonymous donor. The organ was duly checked for viruses such HIV and CMV (which is a herpes virus that can easily be fatal for people with suppressed immune systems such as organ recipients).

During the operation I witnessed, first hand, the close relationship between surgeon and nurse. I learnt that nurses could specialise in surgery. At the operation, there was one nurse responsible for setting out the multitudes of equipment (surprisingly only three instruments were actual cutting devices, (scalpels).) He was able to hand the surgeon his equipment without the surgeon having to verbally ask for it. There was another 'run-around' nurse who wasn't in sterile uniform, she was picked up the used pieces of cloth used by the surgeon and his two co-assistants, and hung them up. By doing so they could be counted and the doctors could be sure that no textile was left inside the patient.

The surgical procedure involved hooking the patient onto a bypass machine so that the blood from the bottom of the body could go back to the heart. This machine was operated by a specialist. Technology prevailed in the operating theatre. The anaesthesiologists (there was two assistants and a supervisor) set up an electrocardiogram (EKG), they were measuring blood pressure, central venus pressure, heart rate. An anecdote exposed further the integral part that technology plays in healthcare, the coagulator machine which is used to seal tissues and vessels to prevent excess blood loss, wasn't working properly and as a result the operation had to be held for 45 minutes. The performing surgeon certainly wasn't happy as you can imagine as most patients are in a critical condition when suffering from acute liver failure.  

When a patient I'd already so ill it becomes of the utmost importance that their condition doesn't worsen. I was amazed by the level scrutiny by which everything and everyone around were made to be as sterile as possible. The surgeon washed his hands thrice in a particular manner, he wasn't able to touch the lower half of his body, a nurse had to do up his coat and then he covered the section she had touched with a extra piece of material. I heard these precautions were especially needed due to the spread of Methicillin-resistant Staphylococcus aureus (MRSA) through Belgian hospitals. The bacteria can infect deep tissues in the body and in these cases can be fatal. As in the name, the strain of bacteria is resistance to antibiotics as result its spread is hard to control. So big is the problem that a Dutch lady being treated in Belgium wasn't able to continue treatment in her home county the Netherlands due to fear of the bacteria spreading.