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Minutes of  Plymouth Medical Society Meeting:
Friday 14th October 2016
Dr John Challenor
It’s Never Too Late
Anecdotes and aphorisms


We were delighted to be entertained by John Challenor in his President’s introduction to the Plymouth Medical Society for this year.  He introduced the programme with an overview of the talks, and thanked Dr Andrew Marshall and other members of the Society for the help and support that he had in planning the talks.
John went on to describe the stages of his career in medicine.  He grew up in Derbyshire, and initially was not on a scientific path, choosing a university course in the humanities, and starting his working life in manufacturing.  At the age of 28, he decided that he would like to enter medical school, and investigated getting into Manchester Medical School as a mature student.  This involved recruiting the support of Mrs Ketley, in the admissions office, which involved the strategic use of gifts of chocolate in various forms, as a way of gaining access to the Admissions Tutor, Dr Beswick.  John remains grateful to this day to Ting To, a concert pianist who was also on a career path change to medicine, but To had decided to remain in London, thus creating a vacancy in Manchester, which was offered to John if he could accept with 2 weeks notice, which he did.
John first came to Plymouth to do his elective period with Dr Michael Grayson, during which time he wrote a dissertation on inflammatory bowel disorder.  He qualified from Manchester in July 1978, and remembers the long hours of his first medical jobs.  He recalled the advice to consider not acting when this might harm the patient:  ‘Don’t just do something, stand there!’  He described how he had taken a telephone referral of a patient, and had concluded that he would be seeing his first patient with tetanus, who turned out to have mumps.  The advice from the duty consultant was ‘When you hear hoof beats, think horses, not zebras’.  
John met George Davidson in the midst of a caesarean section, and he was detailed to look after his daughter, Rachel, who was coming to Plymouth for her first medical job.  This had the happy outcome that they subsequently married, and have 2 children.  
John initially chose a career in General Practice, and joined a rural practice close to Plymouth.  He embarked on a barn conversion, which was to be the definitive family home. During this period in his working life, John developed his interest in Occupational Medicine, for which he relinquished his partnership in General Practice.  The last 9 years of his career was given to working in Occupational Medicine for the Devon and Cornwall Constabulary.  This he describes as challenging work, and many doing this kind of work have been rewarded with referral to the GMC for the trouble!  
He then related his activities after his medical career.  He continues to sit on the Faculty of Occupational Medicine Ethics Committee.  He has hiked to Everest Base Camp with his daughter Zoe, and he has enjoyed cycling and hiking in various challenging destinations.  
The talk concluded with a demonstration of Tai Chi by John’s teacher, John Hamlett.  This proved an enjoyable and helpful activity for him for retaining flexibility and balance.  
The lecture concluded with the Maxim, from the world of flying, ‘Make slow adjustments and rely on the inherent stability of the aircraft.’
We are grateful for an entertaining introduction to John’s year as president.  
      



Minutes of  Plymouth Medical Society Meeting:
Friday 11th November 2016
Robin and Nikki Cordell
Armistice Day Lecture
The medical contribution to the campaign in Afghanistan and beyond

We were delighted to have such a fitting and well informed lecture on some of the aspects of delivering medical care in the heat of battle on the evening of November 11th.  Robin was able to illustrate aspects of caring for injured battlefield casualties, and the problems around rehabilitation.  Nikki spoke on aspects of the ethics of the situations presented by the conflicts.

Robin began by talking about Baron Larrey, who was Medical Officer to Napoleon Bonaparte, who developed the Ambulance Volante, and who established a firm principle that medical aid is given to friends and foe alike, and this principle lies behind the ethics of medical care in any conflict zone.  Another distinguished medical officer was Noel Godfrey Chavasse, who was awarded the Victoria Cross twice, and rescued men very close to no-man’s land.  On the second occasion in 1917 he died 2 days after being injured.  
Robin illustrated the care in the field by showing a video of a Chinook helicopter in 2007 evacuating a casualty onto the ER in a tent medical facility in Camp Bastion.  The tent was later replaced by a substantive building.  
Robin related how many lessons had been learnt in the major railway disaster in Germany, which were used to establish the Major Incident Medical Management principles.  Telemedicine was increasingly used during the conflict in Afghanistan, and crucial to all success was the importance of team working, and shared objectives of the team members.  In this respect, the culture at Camp Bastion was outstanding.  Excellence can only exist where there are effective teams, and this is an aspect of medical care within the NHS that currently receives little more than lip service.  

Nikki then spoke about the ethics of delivering care to people with a different heritage.  There are contributions which doctors working in this situation will be making to Governance, Reconstruction, and Development.   There are problems of ethical drift, and pressure to compromise on the fundamental rules.  Along with this, there are also conflicts between the military and the humanitarian goals.  These should be resolved using the Oslo guidelines (Humanity, Neutrality, Impartiality, and respect for the local Government).  There should be a respect for the local medical systems, as these will bear the responsibility for on going medical care.  In Iraq, the local medical services operate at a high level, but in Afghanistan, the local systems are highly degraded.  

The help given to local medical services consist of direct assistance, indirect assistance, and infrastructure support.  Sadly there may be unintended consequences, and local doctors often were targeted as a result of perceived collusion with an enemy.  This was a specific problem with the implementation of the campaign to eradicate Polio, and involvement of military personnel with this has caused issues with implementation.  
The quality of people is the key to delivery of good care, and central to an effective system on the recruitment and training of people with the right qualities.  

Dr Nikki Cordell is a member of the Faculty of Occupational Medicine, and has until been recently been President of the Occupational Medicine division of the Royal Society of Medicine.  She qualified from Glasgow in 1989 and joined the forces in 1995.  She developed a career in Occupational Medicine as well as serving in numerous theatres of military action.  

Dr Robin Cordell is also a member of the Faculty of Occupational Medicine, and a Fellow of the Royal College of Physicians.  He is immediate Past President of the Society of Occupational Medicine.  He qualified in 1983 from St Georges, and in 1992 joined the army.  He served in several locations around the world, and from 2008 to 2011 was the Allied Command Operations Medical Advisor in SHAPE, Belgium.  

We are grateful to our speakers for an interesting and informative lecture that gave a special insight into the delivery of good medical care under challenging conditions.  



      

Minutes of  Plymouth Medical Society Meeting:
November 25th
Murder Most Foul: Agatha Christie’s Poisons
Presented by Mrs Jan Sellick


We were treated to an excellent and entertaining talk on aspects of Agatha Christie’s life, particularly focussing on her interest in the poisons that were used in her plots.  The presentation was given by Mrs Jan Sellick, who studied Modern Languages at Swansea, and is the Chairman of the South Devon Fine Arts Society.  

 Agatha Christie died in 1976, and is the world’s most popular crime writer, having written 66 detective novels, and sold over 2 billion copies of her books.  In 1956 she was awarded the CBE, and in 1968 Dame Commander of the British Empire.  She was also an expert in Photography, Archaeology, Plants, and an accomplished pianist.  
She acquired extensive knowledge of poisons whilst working in the pharmacy at Torbay Hospital during WW1, and her knowledge of potential poisons was of great value to her in planning the fate of the victims in her detective stories.  Arsenic was of particular interest, and she was familiar with this in the form of Fowler’s solution.  Arsenic poisoning killed 8 out of 300 of Christie’s victims, whilst other poisons were ricin, strychnine, phosphorus, thallium, and curare.  

Agatha was born into a wealthy family in Torquay, and was only 11 when her father died at the age of 55.  She was driven partly by the need to earn money.  She married Archie in 1914, and divorced in 1926.  She went on to meet and marry Max in 1930.

She came up with Inspector Poirot on a Belgium refugee who she had seen during WW1, particularly noting his short stature and moustache.  She came up with Miss Marple in 1942, and had wanted to have Poirot killed off at that stage, but was persuaded otherwise.  

The volume and continuing popularity of her books is testament to the genre, and to her skill as a writer.  We have an insatiable appetite for the stimulation provided.  Her writing commands the attention of the reader from the top to the bottom of the page, and then for the next page.  The Mousetrap has now been running continuously on the London Stage for 63 years.  

We are indebted to Jan for a fascinating talk on one the remarkable local heroes.  The members proceeded to a most enjoyable meal, and we are glad to report that there were no fatalities!


 


      

Minutes of  Plymouth Medical Society Meeting:
Friday December 9th

Birmingham’s two: deadly sins?  Exploring the signs and symptoms in Breughel’s medical morality tale.  Dr Mike McKiernan.

Mike McKeirnan is an accredited specialist, and Fellow of the Faculty of Occupational Medicine.  In 2007 he took a course in art, for which he has always had an active interest, and delighted us for this meeting by sharing his thoughts on the painting by Pieter Bruegel the Younger, Two Peasants binding Faggots.  The painting is in the Barber Institute of Fine Arts, University of Birmingham.  



Mike discussed his interpretations of aspects of this painting, and how this might be related to contemporary knowledge of medicine and illness.  The figure in green is very thin compared to his partner.  The appearance of the 2 is suggestive of being surprised in an act of theft.  His head is bound, which suggests to our speaker that the head is bound, and this might be a statement that the peasant was suffering from syphilis, which was widespread at the time.  
The figure in the back ground cutting the wood from the tree has a similarity to a scorpion, which is Scorpio, sign of the Zodiac.  This significance of this is uncertain.  There was a major conjunction between Saturn and Jupiter under the sign of Scorpio in November 1484.  

Mike was able to show some portrayals of the Pox, Syphilis, in the art of the period.  

Bruegel made references to indulgences in his art, which were a major factor in moving Martin Luther to question the legitimacy of the Papal power

Mike summarised his talk on this painting in the following points.

It shows an amusing rustic scene.

A social commentary on the state of the poor and needy.

A historical record of a STD epidemic.

A tortuous take of religious and political intrigue, high finances and low morals.

A devotional image of a long suffering soul.

An excuse to air his views….
And an opportunity to visit Plymouth’s famous Medical Society.

Mike finished by stated that the views expressed were his own, and he is not able to give any expert evidence to support his suppositions.  This indeed made the talk all the more interesting, and we are very grateful to him for being our guest.


      

Notes on Plymouth Medical Society Meeting:
Friday January 6th 2017

Simon Riley:  Medicines – evolution over 4 decades.  
Musings of a hospital pharmacist



We were delighted to have Simon Riley talk about the changes that he had seen at the sharp end of his professional life over his career.  
The meeting began with the sad announcement by the President of the death of Dr Mark Churcher on Christmas day.  We will miss his enthusiastic support for the Plymouth Medical Society.

Dr Challenor reminded members about the Plymouth Medical Society, and encouraged members to explore this.

Simon graduated in 1976 from the London School of Pharmacy, and since then has worked at Guys, Georges, and Derriford Hospitals.  He has worked for the last 8 years in the independent sector.  He discussed the training, and described it as highly science based with little regard for the practical aspects of his craft.  His first picture was of ancient plant pharma, in the form of a cannabis leaf!  
Doctors have always relied heavily on the skills of the pharmacist, and in some cases taken this very much for granted for keeping their patient safe.  Over the years Simon noted that many of the pharmacies tended to be in basements, which have been dark and airless places.
When Simon began his work, the pharmacist would mix Heroin, and this has evolved through several stages.  Now the active component is available in multiple formulations, and opiate derivatives.
During his career, he has witnessed the development of TPN in the last 1980’s, and he was involved in the mixing of these at St Georges Hospital.  Now a wide array of such preparations comes complete from the manufacturers.  Cytotoxic treatments for malignant disease have developed from the pharmaceutical industry.  Methods of administration of many drugs have increased, and to illustrate this, he showed a picture of the number of devices used to administer treatments for asthma.  Drugs have come and gone.  Sometimes the wonder drug has been found to have serious side effects after release, the most notorious example of this being thalidomide.  Diclofenac is still widely used, but there are concerns about its use, and the effects that it is having on the wider ecosystems with particular reference to toxic effects on vultures.  
HIV and it’s treatment came in 1981 whilst Simon was working at St Georges Hospital in London, and he discussed the practice of parallel importing of medications used in treatments that resulted in significant savings on the medication expenditure.  This practice is no longer possible under current legislation.
Biological treatments are the new arrival, and these agents are extremely expensive.  The funding of modern medications is the challenge now facing the professions and politicians and it can be difficult to see how some of these tensions will be resolved.
We are most grateful to Simon for an entertaining and informative talk.



      

Notes on Plymouth Medical Society Meeting:
Friday February 10th 2017
Dr Raymond Sparrow
Synthetic Biology Meets Mechanical Engineering


We were very grateful to Dr Raymond Sparrow who was able to accept a late invitation to address the society on his research interest.  He gave a fascinating talk on the use of nano-technology in the application of knowledge to influence biological systems.  Raymond, who works at the Plymouth Marine Laboratory, and Plymouth University, kindly gave me a précis of his talk, which follows.

Over that past 15 years, research in biology, physics and engineering have created opportunities at the interface of these disciplines.  It has become evident that the principles of mechanical engineering can be applied to biology in the new field of “synthetic biology”.
Research in the area investigates how to build artificial, biological based machines using engineering principles and procedures.  This is by taking molecular and subcellular components and principles of naturally occurring biological systems, then characterizing and simplifying them.  These components can then be used to engineer what would essentially be artificial (synthetic) biological materials, devices, machines and systems.  Such development can be used for application in medicine, energy, the environment and industry.  There are two main areas of synthetic biology.  One is the ‘top down’ approach.  Here the cells genetic and protein synthesis systems are used – essentially a variation of genetic engineering.  The second is the ‘bottom up’ approach.  Here individual molecules or collections of molecules are used.  These components can be taken from different special and combined together to produce a new device or machine.

It is a considerable challenge to work at the molecular scale.  The technologies of nano-imaging and manipulation technologies of biological samples have progressed significantly and now can image, characterise and manipulate biological molecules from the macro down to the nano-scale.  Their behaviour can be predicted, quantified and used in ways not possible previously.  These advanced techniques have made synthetic biology possible.

Internationally, synthetic biology is still in its early stages of development.  The challenge is to integrate biological molecular components with each other and with non-biological components to yield new technologies.  The initial focus will be on bio-photonic bio-nanodevices and molecular bio-materials.  However considerable progress has been made in some areas – particularly in the more conventional ‘top down’ genetic engineering approach.  This has mainly been due to the fact that this approach arose from an already existing established research theme.  

We are most grateful to Raymond for helping with a gap in the programme, and for illuminating a growth area, and explaining the work with great clarity.  



      

Notes on Plymouth Medical Society Meeting:
Friday January 27th 2017
Dr Gerard Woodroof:  Sailing
To the South Pacific Islands

We were delighted to have Dr Gerard Woodroof speak to us about his experiences in the open ocean.   He was able to bring his talk forward by 2 weeks as the speaker for the evening had unforeseen family illness to contend with.  We are most grateful for his flexibility.  
Dr Woodroof had been in the Royal Navy for 20 years, which he described as being paid to go sailing.  He then became the first occupational physician to the staff at Derriford Hospital, from which he retired as an NHS post in 2011.  He has since then twice sailed the Atlantic Ocean, and has also sailed around the South Pacific Islands.  Gerard began sailing as a toddler, so was experienced in the art.
He participated in the ARC, Atlantic Rally for Cruisers in the Ocean going Yacht, Skyelark.  He described how the build of a yacht suitable for ocean going is of a higher specification than suitable for flotilla sailing in more sheltered waters.  The sailor needs to be prepared for the worst that can happen.  The yacht must have the power necessary for the anticipated conditions.  Radio communication is vital, and he described SSB, single side band radio, which can have a range of 2,000+ miles.  Satellite phones are also vital.  The crew on the voyage may be people who have previously worked together, or may be complete strangers to each other before the sailing adventure.  He discussed some of the emergencies that might present during a sailing trip:
Hole in the hull
Loss of sail
Damage to steering
Illnesses.
The equipment will include first aid materials, He discussed the survival crafts, which are available, and showed the type of life craft in which a sailing couple survived for 118 days.  Fresh fruit goes on board for scurvy prevention.  Sailors must drink at least 1L of water every day, and this needs to be carried.  Another essential item is adequate supplies of loo paper, which is one roll per person per day.  
Life at sea has its testing moments.  24 hours a day for 3 weeks at sea requires a discipline of mind, and for members of the crew to understand their duties above and below deck.  The below deck duties are mainly cooking and sleeping!  
On the ocean trips the crews were able to enjoy fishing, and he named Marlin, Tuna and Flying Fish as quarry, which contributed to the table.  We were shown some dramatic sunsets, but also some rather dramatic weather from winds and waves.  
On his Pacific trip he flew out to Tahiti, and he showed us various ports of call, including Pitcairn, made infamous by the Mutiny on the Bounty.  Tahiti was the home to Paul Gaugin.  This was illustrated by his painting by him of a Polynesian girl, and some explanations of local codes of sexual etiquette.   
Tahiti was the location of many nuclear tests in the 1960’s.  The culture is French, and the cost of living is high as all supplies need to be brought from France.  
Gerard concluded his talk by relating his experience of dealing with a sick crewmember.  The fellow sailor, aged 64, presented to him complaining of abdominal pain, and looking pale and ill.  He was in atrial fibrillation, and for reasons know only to him had decided to discontinue his medication prior to sailing.  Within a short period after discussing his symptoms he appeared to go into cardiac arrest, but all this happened in the dark within a confined space.  Attempts to save his life were in vain.  The news was passed to other crewmembers, but not before tea was safely in hand.  The crew then had to deal with the situation of a deceased member of the crew on board.  All the details had been logged, and Gerard requested permission for a burial at sea.  This was declined, and the yacht sailed for 4 days in tropical heat with the deceased in a body bag on the deck.  They were met by a police launch when they arrived at the port.  A post mortem examination established that he had died of a non-survivable cause, and there was no suspicion of foul play.  
The account of this event illustrates that events can happen quite outside the sailors’ control, and can pose a challenge to the most experienced sailors.  
We are grateful to Gerard for giving an interesting and entertaining talk.




      

Notes on Plymouth Medical Society Meeting:
Friday February 24th 2017
Mr Guy Dargert
The Snake in the Clinic.  Psychotherapy’s role in illness and healing

We were delighted to have as our speaker on this evening Mr Guy Dargert, who has worked for many years as a staff mediator within the NHS.  He is an accredited psychotherapist who has written extensively.  The work of psychotherapy is a set a techniques used to treat mental health and emotional problems and some psychiatric disorders, from a definition given by the NHS in 2008.  From the WHO in 1964, ‘health is a state of complete physical, mental, and social well being and not merely the absence of disease or infirmity’.
Guy spoke about the tradition of the healer dating back to Asklepios in ancient Greece.  He was a god who was the son of Apollo, and whose mother died at the time of his birth, and he was ‘cut out of the womb’.  Asklepios had 2 sons, Machaon and Podilarios, who were physicians in the Trojan wars.  Machaon dealt with physical injuries and disease, and his brother dealt with the sense of wellbeing, which addresses the unseen.  Psychotherapy addresses the unseen and matters of the mind.  
Asklepios is shown having a staff, which was characteristic of healers, who were itinerant in their work.  In this there are parallels with Jesus, and Guy showed pictures which demonstrated the similarities in the way both were depicted.  Asklepios also had a snake, known for its ability to coil up in the underworld.  This represents  inner wisdom.  Healing was thought to come from dark forces, and Hades complained to Zeus about Asklepios, and consequently struck him down.  He was then raised to the heavens.  
There are no accounts of any jealousy with Asklepios, as there was with Constantine, who had the great gods destroyed.  Asklepios had the forces of the underworld and plant medicine at his disposal.
There was a bad plague in Rome, and as a result of this the Emperor sent to Greece to summon healers.  The Romans bought a sacred snake to Rome, and Guy showed this in his presentation of the house of healing in Rome, built on Tiber Island and called the Asklepion.  The imagery of the snake was becoming central to the role of the healer.  
The early Christian Saint of healing was St Bartholomew and Guy was able to illustrate how the roles of the Christian Saint and Asklepios have similarities.  Was saw how the tradition of healings waters have a long history, and this was illustrated with a picture of a holy well in the middle of a field near Findon on the South Downs.  
Guy also discussed the role of theatre and drama in achieving catharsis, and making things whole again.  There is also a long history of treating psyche and soma as parts of the human condition that cannot be viewed in isolation.
We were delighted by this fascinating talk in which Guy observed that many doctors in practice were unaware of the history of the symbols that are so widely used in the medical profession in which reference to the staff and the snake are commonplace.  


      

Notes on Plymouth Medical Society Meeting:
Friday March24th 2017
Medical Work in the Amazon Basin and Sierra Leone
Dr Sarah Challenor and Dr Iain Gould


We were given an interesting and informative talk of the work abroad from Dr Sarah Challenor and Iain Gould on their visits to 2 contrasting parts of the world.  Dr Challenor talked about her work when she joined the Vine Trust, and worked as a volunteer in the Amazon Basin in Peru.  The Vine Trust was founded in 1985,  and its motto is ‘to connect people to change lives. ‘  The Vine Trust has projects in Peru and Tanzania.  The state medicine in Peru is only free to children up to the age of 18, so services are mostly unaffordable to most of the population.  
Sarah.  This creates a gap that NGO’s fill by providing care to the whole population.  Volunteers join the boats for 3 week tours of duty, which each have a staff of locals for permanent staff.  The volunteers from the UK were doctors, medical students, dentists and opticians.  
Typical workload consists of conditions seen frequently in the UK such as colds, asthma, chest infections, and for the context of Peru, iron deficiency anaemia and dehydration which are not often seen at home.  Parasite infestation was very common, and related to the lack of clean water for drinking.
Sarah gave two cases to illustrate the typical problems of working in a different environment to that within a modern NHS hospital, and disease prevalence.  The first example was a man of 56 with a six month history of PR bleeding, loose stool, tenesmus, weight loss and abdominal pain.  The main diagnosis in the UK to consider would be malignancy.  Within the local context the first suspect is parasite infestation, and he was given mebendazole with a plan to review on the next boat visit which would be 4-5 months time.  
The second example was a 48 year old woman, who was complaining of feeling lethargic, multiple episodes of syncope associated with chest pains and palpitions.  In the UK this would require extensive investigations that were not available in the Peru context.  The patient was diagnosed with iron defiency anaemia without any investigations, and treated with iron and multivitamins.  
The difference to working in the UK.  Working with whole families, working with interpreters, malnutrition, infectious disease, lack of resources, and all diagnoses based on history and examinations.  
There is a high incidence to infectious diseases, Insect borne, Malaria, Dengue, Yellow Fever, and Leishmaniasis.  Water born, Hepatitis A + E, Typhoid, E Coli, Amoebic dysentery, Giadiasis, worms, and Leptospirosis.  

Dr Iain Gould followed Sarah by talking about his experience of visiting Sierra Leone, working within a setting that was also lacking in anything but the most simple medical equipment and facilities.  

Iain had been in the US navy prior to starting medical studies at Peninsula Medical School.  He visited Masanga Hospital in Sierra Leone for his elective period.  He was inspired to make the visit to the country by Dr Austin Hunt.  Iain initially thought that he would like to make the journey by motorbike, but that plan needed to change when the group became 3 in size!  He travelled via Casablanca, Freetown airport, and 3 hour journey in taxi to the hospital.  On the first day, he observed a neonate being treated for convulsions.  He was able to see at first hand how the staff were able to cope with a dearth of required equipment.  Theft of vital medical equipment and supplies one of the complicating issues.

Masanga Hospital was set up in its present form in 2006 after the civil war.  The Hospital had been under rebel control, and had become a wreck.  In 2012 it had a proven track record in terms of numbers of patients seen and treated.  

The purpose of the visit was to educate the population in the wake of the Ebola epidemic, and to assist in giving reliable information.  He showed an educational video aimed to improving the understanding of the condition, and were able to take an AP for help with the programme.  

The programme takes people through the personal protection protocols in the eventuality of dealing with contact with an infected person or cadaver.  He showed a tribute to the local doctors who had lost their lives in the Ebola outbreak.  

He showed us some of the activities which could be enjoyed in the down time, including a swimming pool wild life park.  

We are grateful to Sarah and Iain for presenting an excellent talk on their time abroad.