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.
