In March 2016 Dr Heidi Doughty was awarded the MWF Dorothy Ward International Travel Fund. Based in Birmingham, Heidi works as a part time Consultant in Transfusion Medicine and describes her professional passion as ‘Good Blood in Bad places’. She travelled to Bergen, Norway in August 2016 to research the use of whole blood in massive haemorrhage.
I chose to visit Bergen because the hospital based blood service there had recently introduced the provision of whole blood for the local Air Ambulance. The project is part of a larger programme of transfusion innovation due to the collaboration between Haukeland University Hospital, the pre-hospital community including the military, and the University. The visit gave me an opportunity to build on my own work as well as visit a transfusion system that is very different from the UK. I wanted to look at their transfusion support for haemorrhage and consider the implications of re-offering whole blood alongside component therapy in the UK.
I was extremely fortunate to secure professional leave from NHS Blood and Transplant. However, Norway is relatively expensive. Two cups of coffee and a cookie in a café may cost over £20. So, I needed to carefully consider the living costs. I used a combination of special offers for the flight and my sponsor, Prof Tor Hervig, had secured well-priced student hostel accommodation near the hospital. It was to be a 10 m² room with: duvet but no bedding; wash basin but shared bathroom; and internet but no Wi-Fi. I needed to rethink my packing list. So I took essential eating utensils, Ethernet cable and radio. However, I confess that I arranged to borrow local hospital bedding. The room may have been small but the hostel gave me a room with a wonderful view and an introduction to the most hilarious group of international students.
Bergen fish market
Getting down to work
I recommend arriving before a weekend to orientate. I had been met at the airport by one of the female consultants, Torunn. Her kindness and support really made the difference. We spent the Friday on formalities, Saturday – baking at her home and on Monday I was ‘good to go’. The most important time in any new project is the first face to face meeting with the ‘boss’. It provides the reality check. Tor had been injured. Many staff were away for their summer holidays or getting ready for conferences. I have MS and although well at the moment, I get tired. However, we had Tor’s small research team including the computer genius, Joar, who immediately secured Wi-Fi connectivity for both my laptop and Smart Phone. This meant I could remotely access my work emails and documents. The Bergen team asked me to review the impact of their Acute Transfusion Package introduced in 2007. They had extracted 13 years of data but offered it to me for analysis to provide a new perspective and lead on publication.
I reviewed the data in the context of the international literature. This was really interesting as I was not familiar with the early Nordic papers and guidelines. They were really early adopters of the new paradigm of massive haemorrhage management. In the blood bank, I followed the journey of the ‘whole blood’ from the donor, through platelet sparing white cell filtration to quality control. Most of the procedures were written in Norwegian so I learnt to use Translation software. I was also introduced to their new Multiplate Analyser ® designed to analyse platelet function. During the second week I visited some of the areas dealing with massive haemorrhage including Emergency department, ITU and the Air Ambulance. The most novel activity for me was writing a travel blog for MWF. It was a really interesting combination of reflective note writing and capturing the moment.
Looking across the waterfront to the historic Bryggen area
Capture the moment
One of the things that have learned during my travels is to ‘capture the moment’. This includes collecting and dating evidence such as policy documents, procedures, your own notes and photographs. In addition, back-up all electronic records. I found it useful to summarise my initial thought and findings in a PowerPoint presentation for the project team. I also integrated some of the findings into my presentation on UK practice given to the whole Department. This generated a more dynamic exchange and ideas. An unexpected area of interest was my experience of transfusion support for the Olympics because they were preparing for a 2017 sporting events.
Travel not only broadens the mind, it enlarges your professional and personal networks. The travel fellowship has built upon my past knowledge and should inform future developments. It was only 2 and half weeks and I wish it had been longer. However, I am confident that I will continue to work with the Bergen team and revisit. This visit was designed for my benefit but I hope I added value for them as a mature practitioner from the UK. Such travel fellowships continue the strong tradition in Medicine of taking a European and global outlook. All of us, but especially our patients, benefit. I strongly recommend my colleagues to apply because to quote “You will travel to learn and return to inspire”.
Air ambulance coming into land
Dr Karishma Shah
Academic Foundation Doctor in Orthopaedics
Oxford University Clinical Academic Graduate School
Oxford University Hospital
The Weekend Before:
The weekend before starting as an FY1 is always a flurry of emotions…
Daunting, exciting, anxiety-provoking.
It is the 'someday' you were always thinking of, and then suddenly that 'someday' is today. Your parents are probably still bubbling from the excitement of your graduation the weekend before, but you, you are just realising that gone with that ceremony is the sheepish comfort of saying “I’m just the Medical Student”, “I’ll ask the doctor”, “I think I’ll take this day off for study”!
And then, in the blink of an eye, you’re moving house and unpacking suitcases. And you’re trying to find that pretty dress to attend the Doctors’ Mess Ball- with people you've never met before. It feels like Freshers’ again!
As you begin the Shadowing Period:
This is the time the paperwork gets laid on really thick. You need to constantly check your emails because, ready or not (!), there's a landslide of emails coming your way!
Emails on contracts, on working time directives, on parking permits, on salary forms, on how to get IDs and how to use the IT systems…
And a little email on the all-important Statutory & Mandatory training.
At this point, the days have turned into nights and the nights into days and they have all amalgamated into a blur.
But, over a coffee & catch up with your dear friends from medical school, you can regain some perspective. Remember to appreciate just how fortunate you are to be able to work for the NHS- It is one of the greatest institutions in the world, and this must be a tried and tested protocol after-all.
The Shadowing Period:
Recently, the NHS has required all foundation schools to provide a shadowing period for FY1s.
This is the jump-start to your first rotation that you will always be thankful for.
Some foundation schools use time for team-building outdoor activities and others use it to simulate on-calls. But for most, this is a time to be on the wards and gain hands-on experience from the current FY1.
Medical school may have equipped you with the knowledge and techniques, but this is about getting your hands deep and dirty- learning how to answer bleeps, how to request bloods and whether to use a paper or electronic system to prescribe drugs.
The build-up has come and gone and Day 1 is here. 'Black Wednesday' they call it.
But, especially at a time like this, is your first day working for the NHS going to be dark and bleak?
Are the stormy clouds of political unrest surrounding the NHS going to follow you for every moment?
Not a chance!
Is that whisper tempting you to become a Management Consultant going to consume you?
No, it will just fade into oblivion.
This is the day you begin taking care of your own patients. You will have to listen to their personal stories, suture their wounded skin, empathise with their most intimate fears. And you will do this as though it were second nature- and that is why you are the people this great NHS is built on the shoulders of. You will become part of a team with the most intelligent, compassionate, dedicated and resilient people.
And as the days and weeks go on you will see that now is the time to write your own journey and all-in-all it will be more than you ever wished 'someday' will be.
So, make sure you get lots of rest and get ready for the ride!
MWF is currently offering junior doctors the chance to win £200 with our Junior Doctor Creative Prize! Submit your entry on the theme of 'The face of a doctor today' and you could be in with a chance of winning the cash prize along with the opportunity to present your entry at our conference in November.
The competition is open to all and you don't have to be a member to enter!
As students, when we decide to apply to Medical School we have to make an important decision with lasting consequences. It is a long but rewarding course and with it comes the opportunity to make even more career-influencing and life-altering choices. During my time at Medical School myself, and many of my colleagues, often found it challenging to know how to make the best decisions and how to choose between many good options. When all of the options could be successful but each is unique in what it offers, how does one make the right choice for themselves?
Whether it was which BSc degree to complete, which deaneries to rank highest for Foundation jobs, or indeed which type of Foundation job to apply for, it seemed as though we were always on the footstep of another important choice. I think the nature of most medical students is to research different options, maybe come up with an analytical system to rank choices, and to pre-empt the consequences of each route. I would like to share some of the principles I have learnt to help decision making become easier.
One of the most influential people for a student making an important decision is a mentor. A mentor acts as a sounding board, a person whom has the interest of their student at heart but also the technical knowledge and hands-on experience afforded by their working years. Most Medical Schools assign students well-established Consultants, and I have also found mentors in people I have met through my time at hospitals and the Medical School. Perhaps it is in the specific environments which we are drawn to that that we find the most influential people for us. For instance, I found a mentor in another medical student whom had a doctorate when I became interested in academic work; a foundation doctor on the ward whom was a national of the same foreign country as I; a female surgeon negotiating the stereotypes of a largely male speciality.
The old saying goes “Life is a journey, not a destination”. I did not fully understand what this meant until my final few years at Medical School when I worked alongside the university’s Head of Undergraduate Surgery, an Orthopaedic Surgeon. It happens all too often one can conjure an image of who they want to become, what they want to attain or where they want to be in the future. This method of thinking has doubtless been successful, but it risks turning every decision from a molehill into a mountain and putting one under the false pretence that there is only one road to success. Instead, this Surgeon often suggested that each option should be weighed-up against the other available options and the best route taken. When the next decision comes along, again it too should be weighed-up against the alternatives and the best chosen. By doing this, one finds themselves in the most conducive environment for their needs at that time, that the people they meet are those most likely to become stead-fast colleagues and life-time friends, and that the destination will be most suited for their specific interests.
I think one of the most common fears is the fear of making the “wrong choice”; of not choosing the “best” option. I want to suggest that there is no “perfect” option. Every choice is unique and offers different opportunities. Through taking a step back one can objectively evaluate their experiences and will realise that no choice is fully binding and decisions can be some-what undone, particularly for students and younger trainees. Instead, if each experience is taken as a learning opportunity, the soft skills developed can be invaluable when transferred to a different environment.
As people working in the medical profession we are constantly surrounded by choices. Choices which have a short-term impact, and those with longer-term consequences; decisions which will affect patients and their families, and those which will be more personal to us and our lives. However, through a strong support network, focusing on the options at hand and remembering that not many things are fully binding, we can be more confident in making these decisions. Choosing to go to Medical School might only be the beginning, but it is the beginning of having the privilege of endless opportunities- maybe too many opportunities!
Karishma Shah, UCL Graduate 2016
In March 2016 Dr Heidi Doughty was awarded the MWF Dorothy Ward International Travel Fund. Based in Birmingham, Heidi works as a Consultant in Transfusion Medicine and is travelling to Bergen, Norway to research the use of whole blood in massive haemorrhage. As she embarks on her trip, we follow her travel journal.
26th July 2016 - Taking Transfusion Forward
On Friday 29th July, I leave Heathrow early in the morning to fly to Bergen on the Western Coast of Norway. Today though – I'm trying to do my packing supervised by my kitten Sophie and I'm really excited.
I'm traveling to Bergen to investigate the role of whole blood in massive haemorrhage. Massive haemorrhage or bleeding is a medical emergency and an immediate threat to life. Common causes of bleeding include childbirth, major surgery and gastrointestinal bleeding. My particular interest is the use of blood in trauma. During the last decade the management of massive bleeding has radically changed. The emphasis is to stop the bleeding as soon as possible and to resuscitate using blood instead of saline.
Military and civilian clinical guidelines now recommend the use plasma and platelets as well as red cells, to help the patient’s blood to clot better. An alternative way of doing this would be to give whole blood however, this is rarely offered by modern blood services. They take a pint of whole blood and then divide it up into the separate elements. This approach means more patients can be treated and it is much better for most patients. So it will really take a big change to reintroduce the use of whole blood.
Bergen is one of the few centres in Europe working on the modern evaluation of the use of whole blood. There is a unique partnership between the military, civilian and academic communities working on both the clinical and the laboratory aspects of whole blood collection, storage and use. The aim of my visit is to review the recent clinical and laboratory work with a view to informing a program for the UK.
So what to pack? I am only going for 18 days but Bergen is meant to be the wettest place in Norway…
30th July 2016 - A Good Night's Sleep
A good night's sleep makes an enormous difference now that I'm pretty well settled into my room. I’m staying in a student hostel near the Haukeland Hospital sitting on a hill above Bergen. It's very international with students and staff from all over the world and I have a small room with shared facilities. It is basic but I am really lucky that I have a fantastic view that looks out over the city.
Bergen was founded by King Olav Kyrre in 1070 AD, and became Norway’s first capital in the 13th century. Until the 1830s Bergen was the biggest town in Norway and was for a while in the Middle Ages, the largest town in Scandinavia.
I didn’t know much about the Hanseatic League until I briefly visited Bergen last year, but I was reminded again when I visited Kings Lynn last month. Kings Lynn is also a Hansa port and shows how our international links have been so important to the UK. The links are not just limited to commercial trade but also the exchange of culture and knowledge.
I visited Kings Lynn to exchange some of the current thoughts around the management of massive haemorrhage and it was really interesting not just to meet the clinical teams, but to seee how the laboratory services are underpinning the developments. I will be doing something quite similar here in Norway.
The plan today is confirm the walking route to the hospital and meet up with friends.
Saturday 30 July: Coffee and Cakes
Travel is a wonderful thing and you can meet incredible people. Many have fascinating stories to tell and I think the best way to hear these stories is over coffee and cakes.
Today I met Danny in the hostel. He arrived from Spain 3 weeks ago and is working on fatty acids. We worked together in the kitchen making breakfast and chatted about working as doctors and researchers. We may complain about the NHS, but you should hear some of the international stories!
A South African friend is working in Bergen for a short period of time and both of us are interested in training colleagues to collect whole blood. It is the sort of thing you may have to do if you're working in places without lab support. He showed me his new favourite coffee shop, BKB in Thormøhlens Gate. It is a small place, slightly hidden away and has a really good feel. Most things in Norway are expensive by international standards so it is important to take advantage of the refill system for coffee! Although one refill is usually enough because Norwegian coffee is turbo charged! Don’t forget to enjoy your coffee with a bun too, the baking tradition is great in Bergen.
Funnily enough, I spent the evening baking homemade pizzas and Norwegian specialities, Skillingsboller (penny buns) and Kanelknuter (cinnamon knots). What a great end to the day.
1st August - Networking
Today was my first day in the office, Or to be technically correct, my first day in the ‘Avdeling ved immunologi og transfusjonmedisin’ (Bergen Blood Bank or BBB for short).
I said ‘Hei!’ to all and then settled down in Tor’s office to look at the various projects they are working on. Tor is my sponsor here and sadly injured himself shortly before I arrived but he bravely made his way on crutches into the hospital to see me - what an incredible personal commitment!
One of the first things I did was ask to test the ‘network’. It helps to have a young person (Joar) to do this. My first question; could I connect my work laptop from Birmingham to the Bergen WiFi? Secondly, could I then remotely dial-up and access my accounts in the UK? And the answer was yes to both! (Not only that, but I could was able to connect my smart phone to the WiFi which gave me access to my beloved digital radio).
I am just astonished at such things (this probably reflects my age). The digital era has revolutionised the way we can do business. Professionally, it allows us to collaborate in ways we could not have imagined. Last year I was using Dropbox with colleagues in Sierra Leone. I use broadband telephones not only talk face to face with colleagues, but also to contact my family and friends.
It reminds me of how much we value being connected. However, I believe that in the digital age that the best form of networking should be about real human connections. (like being a blood donor). I really value my networks but exchanging emails is not the same as sharing bread in the hospital canteen.
3rd August - A sense of perspective
I got up at 6am this morning. It was already bright in the sky but the street lights were still on in Bergen. I started to work and think about the discussions from the last two days. The local team have invited me to review their data for massive transfusion for the last 13 years. They are keen to have an international perspective on the impact of introducing an Acute Transfusion Pack. It is quite a privilege.
Massive haemorrhage is a medical emergency and it affects many clinical specialities. The management includes haemorrhage control and resuscitation, often with blood if available. Since 2006 there has been a paradigm shift in transfusion support with the introduction of Transfusion Packs containing a balance of blood components. The aim is to try and provide the equivalent of whole blood. Bergen introduced their pack in 2007.
One of my problems is how best to sort the data to tell their story. I needed perspective and time to think. So at 10.30, as the sun was shining, I decided to go up Mount Ulriken. Ulriken is the largest of the mountains around Bergen and the cable car station is close to the hospital. I always believe you should grab opportunities when you can. From the top you can see Bergen and the surrounding area. In short you get a different perspective.
I went for a walk on the top of the mountain. The Norwegian definition of an ‘easy round route’ needs to be considered with care. The route was tough and perhaps a little ambitious as my balance is not too good these days. There was a risk of getting fixed on the details of the path as it was very uneven and still slippery from the recent rain. However, I took my time. Looking up and around me I could begin to see the bigger picture.
It was fantastic.
Tuesday 9th August - Time for a change
I am now in my second week and need to pull together everything I've learnt in Norway. We are still crunching data, but I think we now have a story to tell about their change in transfusion support for massive bleeding. As part of my review, I have started read more of the Scandinavian literature including the multi-disciplinary Nordic guidelines. It is fascinating to see how teams in different countries have addressed the same problem during the last 10 – 15 years.
Today was my turn to present to the Bergen department as part of their professional development program. I chose ‘Transfusion support for Massive Haemorrhage: a UK perspective’. I started with the lessons learnt from both civilian and military experience and focussed on some of the practical and organisational issues. I related it to what I have read recently and the implications for their local emergency planning.
One of my favourite Scandinavian titles is ‘Time for a Change’. Change in this area is happening in the UK and elsewhere, but it has taken a decade. Recently, there have been a number of revised guidelines which cover the management of haemorrhage. However, we now need to translate these into effective patient care in a timely manner using resources wisely. It will take locally sensitive organisation, teamwork and clinical leadership.
The Medical Women’s Federation Spring Conference, 'Medicine at the Margins: Creative Solutions to Healthcare Challenges', took place on Friday 13th May 2016 at the John McIntyre Conference Centre Edinburgh. This is situated within the Pollock Halls of Residence and has a very scenic backdrop with Arthur’s seat very close by.
Our first speaker was Dr Christine Goodall OBE, a senior lecturer and honorary consultant oral surgeon at Glasgow University who founded the charity Medics against Violence (MAV) in 2008. Due to their educational programmes reaching those in primary and secondary schools, youth clubs and prisons, there has been a reduction in homicide and serious assault in Scotland. Behaviours which can lead to what she termed ‘recreational violence’, such as excessive drinking and knife carrying, have also reduced in the younger age group, who have participated in the programme whilst at school. She described other ‘teachable moments’ as being parenting, when assaulted, when arrested and when convicted. MAV also runs the Navigator programme at Glasgow Royal Infirmary which follows up A&E attenders who have presented due to violence, drugs, alcohol, homelessness and domestic or sexual violence. Another programme started in 2010 is Ask, Support, Care (ASC) and trains all health professionals including dentists, vets, fire officers and hairdressers to recognise and respond to signs of domestic abuse. (Non accidental injury to a victim’s pet can be a feature of domestic violence.) Domestic abuse is estimated to affect 1 in 4 women in Scotland and has significant health and social consequences.
Next, Dr Rosie Hague described her career which led to her becoming the first consultant in paediatric infectious diseases and immunology in Scotland and thus responsible for setting up the service. This began with an elective in Nepal and going in to Paediatrics when she failed to get the Obstetrics job she wanted. The AIDs epidemic in the 1980s sparked her interest in the transmission of the disease from mother to child and her research led her to posts in Newcastle and Denver Colorado before returning to a consultant post in Edinburgh. She told us about the discovery of the methods which have reduced HIV transmission from mother to child from 25% to 1-2% and the testing regime for the baby to reach a diagnosis as early as possible. For those children who are found to be HIV positive, appropriate treatment regimes were devised. There is still stigma around HIV, particularly amongst African women and because breast feeding is almost universal in this group, she feels that many of them continue to breast feed against advice because not to do so leads to an assumption that the mother is HIV positive. As HIV is now a chronic disease the timing of disclosure to the child about their condition is important and as they become teenagers they need counselling about their sexuality. Besides infectious diseases Dr Hague has an interest in primary immune deficiencies and concluded her talk with hope for the future.
The first abstract was presented by Dr Yesim Karapinar who, having spent precious time trying to locate the equipment she needed to cannulate a patient on a strange ward, came up with the idea of procedure specific trays in treatment rooms. The second abstract from Dr Jacqueline Andrews told us about the Leeds Female Leaders Network set up for women to inspire each other whilst working towards gender equality in the workplace and leadership positions.
Alison Cameron, Leadership Associate at the Kings Fund gave a very personal account of her descent in to loss of career, alcohol abuse and homelessness after a diagnosis of PTSD which followed the deaths of 2 of her colleagues whilst they were working on a project in Russia connected with the Chernobyl disaster. She asked us to think about how we describe ourselves. Is it by the title of our job? What then happens if this is taken away as happened to her? She is a believer in shared decision making in medicine because this empowers the patient not only to make decisions about their own care but to have a wider role in the development of health care policies. Self management was her own starting point to recovery and she now advises health and social care organisations including NHS England on how to work in partnership with those who use the service.
Miss Elaine Griffiths, Chair of the Medical Royal Colleges Flexible Training Committee presented the results of the recent Parental Leave Survey. The responses highlighted that most trainees were straight back in after returning from a period of parental leave with no shadowing and that departmental changes are not being communicated to those on leave which can lead to difficulties on their return. Facilities for breast feeding mothers were found to be lacking. Many commented that they were not allowed to use the rooms allocated for the use of patients but were expected to express breast milk with little privacy or in the toilet. The survey also highlighted that very few male trainees have taken parental leave.
After lunch we had a choice of three workshops to encourage active participation and discussion. These were
- ‘The Show must go on – Health and the Performing Artists’
- ‘It’s a family disease – living with alcoholism’
- ‘Old Docs, New Tricks? Working Longer’
Another inspirational talk followed, from Ann Maxwell OBE, Co-founder of the Muir Maxwell Trust which has raised £9m since 2003 to both raise awareness of complex childhood epilepsies, and to give practical support to children and families struggling to cope with epilepsy (such as the provision of night time alarms to detect seizures). She described it as ‘a field that chose me’ as her youngest child Muir has severe epilepsy. She has continued to work towards her goal of seeing better outcomes for the children coming behind her son despite being diagnosed herself with a craniochondrosarcoma in 2006.
Our next speaker was Philippa Whitford, a consultant breast surgeon and since 2014 MP for Central Ayrshire sitting on the Parliamentary Health Select Committee. As well as talking about her experiences as an MP and the usefulness of her mobile phone as a tracking device for her husband to time meals when she is working from home, and FaceTime calls when she is in London, she told us about her 2 trips to Gaza. The blockade has had considerable impact on the treatment and survival of women with breast cancer. Continuous supplies of drugs including chemotherapy are unreliable and at 40% the survival rate is half what it is here. Over treatment with surgery due to poor access to diagnostic services and radiotherapy means many women are left with disabling lymphoedema.
Prizes were awarded for the abstracts to both presenters. The poster prize was won by Dr Alice Howe, FY1 North Devon District Hospital for ‘Together we can end female genital mutilation; our new statutory obligations under the amended female genital mutilation act 2003 (sections 70-75 of the serious crime act 2015) explained’. The Katherine Branson Essay Prize winners were Helena Fawdry, 3rd year student at Liverpool university, and Karthika Velusamy, 4th year student at Leeds.
We ended the day with the Dame Hilda Rose Memorial Lecture ‘The Importance of Women’ given by Dr Catherine Calderwood, the Chief Medical Officer of Scotland. She reminded us that Dame Hilda Rose remains the only woman to have been President of the Royal College of Obstetrics and Gynaecology. She began by talking about some pioneering women in medicine beginning with Dr James Barrie who graduated from Edinburgh University in 1812 and was an outstanding Army Surgeon. Only on his death from dysentery in 1865 was he found to be a woman, a fact not made public for 100 years. She moved on to talk about women as patients today, their physiological differences from men, unique diseases and the importance of the health of women to that of the next generation. Clinical trials of drugs often exclude women yet the results are extrapolated and fail to account for the gender differences in pathophysiology. This may contribute to poorer outcomes in women. Diseases which only affect women such as endometriosis do not attract the same resources and research as those that affect both sexes but can have a significant effect on families and working days lost. Many adult diseases have their developmental origins in the womb for example cardiovascular disease in the offspring of obese mothers, thus the future health of the whole nation becomes dependent on the health of women of chid bearing age. Perinatal depression, the commonest complication of pregnancy has also been shown to influence the mental health of the child in later life. She concluded by reminding us that maternity leave was not introduced until 1971. In a profession now dominated by women she considered the barriers to positions of leadership and encouraged us to take as example the V formation of flying geese. Different specialties inevitably demand different attributes and some will remain more suited to men, however the opportunities should be equal.
The meeting was followed by the AGM and then our new President Dr Parveen Kumar gave her Presidential address. Whilst considering the future challenges of the MWF going forward her quote ‘If you educate a man you educate a person, if you educate a woman you educate a whole family’ seemed to reflect on the themes of the day.
On the Thursday evening prior to the conference several members met at ‘Spoon’ for an informal supper. The conference dinner was held at the John McIntyre conference centre and was followed by a ceilidh band which got some of us up and dancing!