My Elective Experience – Ms Laura Dugan

During the summer of 2016, Ms Laura Dugan undertook a clinical elective at the Vancouver General Hospital in British Columbia.  The four-week elective was possible through the Dr Nicholas and Mrs Maura Martin Scholarship.  Laura describes her experience below:

In June 2016, I was awarded the Dr Nicholas and Mrs Maura Martin Scholarship, a huge honour that allowed me to complete a four-week elective in cardiology in Vancouver General Hospital in British Columbia in Canada. The elective was completed under the supervision of cardiologist Dr Victor Huckell.

The experience was exceptional. In North America, students are given a higher level of individual responsibility than students tend to be given in Ireland. As a result, after two days of intense training, in how the outpatient clinic operated, I was seeing all of my patients entirely on my own.

Every morning before clinic began, we received one hour of teaching. This involved Dr Huckell choosing one aspect of cardiology and finding innovative ways to teach it to us. The morning sessions were always very interactive and questions and comments were actively encouraged. Every day we were assigned some reading material and we were expected to complete this assignment before the next session. Reading assignments usually included journal articles on the topic of the day’s discussion and/or articles that caught our attention, for either a good or a bad reason. The following morning, these topics were then discussed.

When the morning teaching session ended, clinic began and we would start seeing our patients. Before seeing a patient, I would first read their file and any previous letters from the clinic to their GP regarding their care. Then I would call the patient in and take their full history with a focus on their cardiovascular symptoms and needs. After this I would discuss any of their previous test results with them and then perform a complete examination of the cardiovascular system on each patient. Once this was concluded, I would then decide on their treatment plan including what tests I would propose, if any, what medication changes I would recommend and what lifestyle changes I would advise them to make.

Once this was completed, I would call Dr Huckell. Dr Hucknall would then briefly examine the patient and run through the full history and the proposed plan.  Dr Huckell would at that point comment on the plan and make any necessary changes as well as advising me on my history taking and delivery skills, and my exam findings –  he would always find a key learning point in each patient for me. After he left, I would go through the recommended treatment plan with the patient and make sure they were fully informed. I was also responsible for booking any tests that needed to be booked and dictating the appropriate letter to the patient’s GP.

Working like this gave me the opportunity to get some real experience about what it would be like to work as a doctor. It taught me not to look at a patient as a series of systems but to think of the patient as a whole and accordingly consider their holistic care.

The amount of practical experience I obtained during this elective was invaluable and will stand to me throughout my career. Furthermore, I gained some very useful practical cardiological skills such as evaluating murmurs, listening for added heart sounds and taking and evaluating ECGs.

Ms Laura Dugan at Vancouver

Laura Dugan [second from right] with colleagues from Vancouver General Hospital

Overall it was a wonderful personal and professional experience, none of which would have been possible without the Dr Nicholas and Mrs Maura Martin Scholarship. I wish to thank the donors so much for providing me with this opportunity – an experience I will always treasure.

Yours sincerely,

Laura Dugan

Medical Students Test their Clinical Skills at SimWars

The School of Medicine at University College Dublin hosted ‘SimWars’, a medical simulation competition for medical and nursing students in Ireland on 25th February.

The event was organised by members of the Emergency Medicine Student Society of Ireland EMSSI and saw students work in teams of five to manage a number of simulated medical emergency scenarios which included using medical mannequins, actors and digital technologies. Together these provided students with a realistic and immersive learning experience.

The event represented an opportunity for students to test not only their clinical skills, but also their ability to work as a team and perform under pressure. Expert emergency doctors and advanced paramedics from Loughlinstown Ambulance Station provided feedback on their collective and individual performances throughout the day, as well as delivering teaching sessions on topical issues within emergency medicine.

A judging panel of Professors and Doctors oversaw the capabilities and decisions of forty students who participated in the competition, representing the medical schools of University College Dublin, Trinity College Dublin, The Royal College of Surgeons, NUI Galway and University College Cork. Judges included Professor John Ryan, Dr. David Menzies, Dr. Alan Watts, Dr. Lisa Guthrie, Dr. David Monks and Dr. Eimhear Quinn.

After managing both a polytrauma and a peri-arrest simulation that morning, teams from Trinity College Dublin and NUI Galway were put forward as the highest performing teams to participate in the SimWars Grand Final, which took place that afternoon in the Garret Fitzgerald Debating Chamber in UCD. In front of a live audience, both teams performed a tight battle with NUI Galway coming out on top to scoop the SimWars Cup for its first year and taking the competition to the West for 2018.

Two final year medical students at UCD, Jamie Condren and Tiarnán Byrne both organised the event. Jamie stated

It is really encouraging to see healthcare students around the country training together alongside doctors and pre-hospital practitioners who have given up time to teach them in the evenings after classes and shifts are done. It’s clear that students recognise the real value of simulation training in terms of bridging the gap between theory and clinical practice.

Dr. David Menzies, a consultant in emergency medicine at St. Vincent’s University Hospital said

Imulation education plays a key role in the training of emergency physicians. The ‘SimWars’ competition represents a unique opportunity for students to consolidate important clinical and interpersonal skills using this immersive style of learning.

Congratulations to all who organised and attended this successful event!

UCD Medicine Alumnus Named IDSA President

Dr William G Powderly, former Dean of Medicine & Head, UCD School of Medicine, has been named as President of the Infectious Disease Society of America (ISDA), an organisation of physicians, scientists and other health care professionals dedicated to promoting health through excellence in infectious disease research, education, prevention and patient care.

In assuming the leadership role of this prestigious organisation with over 10,000 members across the United States of America, Dr Powderly pledge to continue the Infectious Diseases Society of America’s commitment to improving the health of all people, communities and society. Several new Board members were also announced bringing expertise in areas ranging from diagnostics and HIV to compensation, paediatrics and guidelines development.

“We are reaching out to the new presidential administration and Congress to help shape their understanding of critical health care challenges and opportunities, including efforts to improve patient safety, lead cutting-edge biomedical research, strengthen public health infrastructure, advocate for patients with HIV and other infectious diseases, and guide the development of critically needed new antibiotics and diagnostics,” said Dr Powderly.

“I look forward to working closely with my colleagues on the Board who embody strong representation from women and men whose experience and perspectives reflect the diversity of our field.”

Dr Powderly said he is energized to work with the Board to promote IDSA’s strategic priorities, which include:

  • Promoting the value of the infectious diseases (ID) physician
  • Attracting the best and brightest to the field of infectious diseases
  • Promoting leadership in antibiotic resistance and stewardship
  • Producing useful, timely and relevant guidelines
  • Promoting ID and HIV research and its clinical translation
  • Advocating for funding of prevention and public health programs in ID and HIV

About Dr William G Powderly, MD, FIDSA

A graduate of the UCD Medicine, Professor Powderly received his MB BCh BAO in 1979 and was awarded an MD degree by the University in 1987.  Bill undertook his basic medical and higher specialist training in Ireland and in the United States where he established himself as a distinguished academic clinician.  He was Professor of Medicine at Washington University School of Medicine in St. Louis and Chief of the Division of Infectious Diseases until July 2004 when he returned to Ireland.

Prof Powderly was appointed as a consultant in infectious disease medicine and the UCD Professor of Medicine & Therapeutics at the Mater Misericordiae University Hospital.  He was appointed Dean of Medicine and Head of School at the UCD School of Medicine in 2005 and was re-appointed to this role in 2010, serving a total of 8 years as Head of Ireland’s leading Medical School.  In 2008, he was appointed as the inaugural Chief Academic Officer at Dublin Academic Medical Centre, Ireland’s first academic-led health centre.

Prof Powderly returned to the United States of America in January 2013 following his appointment as the J. William Campbell Professor of Medicine and co-director of the Washington University School of Medicine’s Division of Infectious Diseases in St. Louis.  He was appointed as the Larry J. Shapiro Director of the Institute for Public Health at the Washington University in July 2013 and is an attending physician at Barnes-Jewish Hospital.

Prof Powderly has held leadership positions throughout his career in UCD and at Washington University.  He was a member of the Irish Medical Council from 2006 until 2012, chairing their Professional Development Committee and was a member of the US Adult AIDS Clinical Trials Group (including Vice-Chair of the Group and chair of its Scientific Steering Committee).  He has served on numerous advisory groups within the National Institutes of Health and Centers for Disease Control and Prevention in the USA.  Prof Powderly was the inaugural chair of the HIV Medicine Association (HIVMA) in the US and was a founding member of the St. Louis Infectious Diseases Society. He is a Fellow of the Infectious Diseases Society of America, of the Royal College of Physicians of Ireland, and of the American Association for the Advancement of Science.

Prof. Powderly is widely published in the areas of HIV and AIDS with over 300 original articles or book chapters.  Together with Prof. Jonathan Cohen, Dean of the School of Medicine at Brighton and Sussex in the UK, he has edited a major international textbook in Infectious Diseases.  His research interests include advancing care in HIV, focusing on long-term complications and antiretroviral therapy; fungal infections, especially cryptococcosis; and the translation of clinical advances to public health and public policy.  Professor Powderly has a special interest in HIV care and brings a global perspective to IDSA with more than 25 years of active engagement in research to improve treatments for patients with HIV.

Bill remains a strong supporter of Irish Medical Education and has established student elective exchanges between UCD and Washington University.  He and his wife Betsy are frequent visitors to Ireland and their daughter, Ailis is a second year UCD Graduate Entry Medicine student having graduated from UCD with a Bachelors of Business and Law degree in 2015.

About the Infectious Diseases Society of America

The Infectious Diseases Society of America (IDSA) is an organization of physicians, scientists, and other health care professionals dedicated to promoting health through excellence in infectious diseases research, education, prevention, and patient care. The Society, which has nearly 10,000 members, was founded in 1963 and is based in Arlington, VA. For more information see here.

New IDSA Board Members

Dr. Powderly is pleased to be working with those joining the IDSA Board, including:

  • Angela Caliendo, MD, PhD, FIDSA – Chair of the Microbiology Medical Devices Panel for the Food and Drug Administration (FDA), Dr. Caliendo is professor and executive vice chair of medicine and director of the Division of General Internal Medicine at Alpert Medical School of Brown University, Providence, R.I. She was the co-chair of the Clinical Laboratory & Standards Institute (CLSI) Subcommittee on Quantitative Molecular Diagnostics for Infectious Diseases, a member of the CLSI Subcommittee on Genotyping for Infectious Diseases and an advisor on the Subcommittee on Antiviral Susceptibility Testing. Dr. Caliendo is past president of both the Association of Molecular Pathology and Pan-American Society for Clinical Virology.
  • Joel Gallant, MD, MPH, FIDSA – A respected expert on HIV and AIDS, Dr. Gallant has published extensively on the topic, including authoring a book for consumers, “100 Questions and Answers About HIV and AIDS.” Currently he is medical director of specialty services at Southwest CARE Center in Santa Fe, N.M. and adjunct professor of medicine in the Division of Infectious Diseases at the Johns Hopkins University School of Medicine, Baltimore. Dr. Gallant also is professor of medicine at the University of New Mexico, Division of Infectious Diseases, Albuquerque.
  • Dan McQuillen, MD, FIDSA – Dr. McQuillen is passionate about documenting the value of infectious disease specialists at the national level. He is director of the Solid Organ Transplant Infectious Disease service and senior staff physician in the Department of Infectious Diseases at Lahey Hospital & Medical Center, Burlington, Mass. He is a former chair of IDSA’s Clinical Affairs Committee and current president of the Massachusetts Infectious Diseases Society. His interests include tick-associated infections, management of Clostridium difficile infection and HIV.
  • Larry Pickering, MD, FIDSA, FPIDS – Long dedicated to improving health in children including by promoting the benefits of vaccination, Dr. Pickering is adjunct professor of pediatrics at Emory University School of Medicine, Atlanta. He is the past senior advisor to the director of the National Immunization Program/National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention, Atlanta. Rejoining the IDSA Board after having previously served on it, Dr. Pickering also led or co-chaired panels that developed clinical practice guidelines for immunization programs and the management of infectious diarrhea. He is a past president of the Pediatric Infectious Diseases Society.
  • Cindy Sears, MD, FIDSA – Dr. Sears is rejoining the Board, having previously served as treasurer. Professor of medicine and molecular microbiology and immunology at the Johns Hopkins University School of Medicine and Bloomberg School of Public Health, Baltimore, Dr. Sears also is an attending physician at Johns Hopkins Hospital. She is dedicated to ensuring the publication of high-quality guidelines, and previously served as vice chair of the IDSA Education and Research Foundation. Dr. Sears is interested in research on the relationship of bacteria and the microbiome to colon cancer development.

They will join members continuing their service on the Board, including:

  • Paul Auwaerter, MD, MBA, FIDSA, president-elect, Johns Hopkins University School of Medicine, Baltimore
  • Johan Bakken MD, PhD, FIDSA, past president, St. Luke’s ID Associates, Duluth, Minn.
  • Helen Boucher, MD, FIDSA, treasurer, Tufts Medical Center, Boston
  • Henry “Chip” Chambers, MD, FIDSA, University of California, San Francisco
  • Janet Englund, MD, FIDSA, Seattle Children’s Hospital
  • Thomas Fekete, MD, FIDSA, Temple University Medical School, Philadelphia
  • Lawrence Martinelli, MD, FIDSA, Covenant Health, Lubbock, Texas
  • Thomas Moore, MD, FIDSA, IDC of Kansas, Wichita, Kan.
  • Trish Perl, MD, MSc, FIDSA, UT Southwestern Medical Center, Dallas
  • David Kimberlin, MD, FIDSA, University of Alabama at Birmingham
  • Keith Kaye, MD, MPH, FIDSA, University of Michigan Medical School, Ann Arbor, Mich.

Erythropoietin Not Quite a Boost for Patients with Traumatic Brain Injury

A double-blind randomised controlled trial reported in the Lancet has called into question the routine use of erythropoietin (EPO) treatment of patients with traumatic brain injury.  The international research study carried out in more than 600 patients across seven countries was led by Professor Alistair Nichol, UCD Professor of Critical Care Medicine at St Vincent’s University Hospital and Co-chair of the Study Management Committee based in Melbourne Australia.  The group has concluded that erythropoietin does not improve functional outcome at six months as would be shown by a reduction in the number of patients with an Extended Glasgow Outcome Scale (GOS-E) measure of 4 or lower.  While there are some indications that EPO treatment might reduce mortality in patients with traumatic brain injury, rigorous future investigations are required in this patient population before its routine use could be recommended.

Professor Nichol noted,

This study would appear to rule out calls for the routine use of EPO in patients with traumatic brain injury (TBI).  EPO gained notoriety as a performance-enhancing drug amongst distance runners and cyclists due to the way in increases the amount of oxygen that the blood can carry. However, EPO has many different affects in the body, such as encouraging new brain cell growth, which is independent of effects on blood. And early research results suggested that it might improve patient outcomes after trauma.  While our study, a double-blind, placebo-controlled clinical trial, found no improvement as measured by the amount of patients who could live independently after TBI, it did show a trend towards lower mortality with EPO.

As patients with traumatic brain injury have a high incidence of proximal deep venous thrombosis, careful clinical and diagnostic monitoring is necessary.  This latest study objectively described the incidence of proximal deep venous thrombosis in patients with moderate or severe traumatic brain injury.  The results of an adjusted 6-month mortality analysis suggest a potential reduction in mortality in patients with traumatic brain injury who receive erythropoietin treatment. However, further investigation is required to examine this clinical outcome before investigators could encourage routine use of erythropoietin in traumatically injured patients.

Evidence before this Study

At the time when the Eryrthropoietin in Traumatic Brain Injury (EPO-TBI) protocol was developed, two large randomised controlled trials studying the effect of erythropoietin in critically ill patients as a transfusion-sparing agent had reported significantly lower mortality with erythropoietin compared with placebo in subgroups of critically ill trauma patients.

Those findings had led to calls for the routine use of erythropoietin in trauma patients.  Preclinical data suggested that neurocytoprotective effects attributable to erythropoietin had the potential to ameliorate secondary brain injury. The EPO-TBI Investigators postulated that the recorded reduction in mortality could be attributable to these effects and therefore undertook a multicentre randomised controlled trial. Iinvestigators used a factorial study design to assess the effect of erythropoietin and transfusion thresholds on neurological recovery in patients with traumatic brain injury.  Their findings showed no improvement in neurological function of survivors at 6 months. Fewer deaths at 6 months were recorded in patients who received were recorded in patients who received erythropoietin. However, this difference was not statistically significant. The study enrolled 200 patients and was therefore probably underpowered to detect clinically important differences in patient-centred outcomes and did not actively screen for deep venous thrombosis.

Added Value of this Study

The study reported by Nichol et al provides high-level evidence that, after traumatic brain injury, erythropoietin does not improve functional outcome at 6 months as would be shown by a reduction in the number of patients with a GOS-E of 4 or lower. It also, for the first time, objectively describes the incidence of proximal deep venous thrombosis in patients with moderate or severe traumatic brain injury. The results of the adjusted 6-month mortality analysis suggest a potential reduction in mortality in patients with traumatic brain injury who receive erythropoietin treatment, especially when considered in conjunction with those of the other published randomised controlled trials in this patient group, but this effect remains uncertain. The findings also add to the body of evidence suggesting that erythropoietin might improve survival in patients with brain trauma.  Further investigation of EPO in this patient group is required.

Commenting on the study, Graham Love the Chief Executive of the Health Research Board said,

I would like to congratulate Professor Nichol and his team on their contribution to this significant finding and it’s publication in the Lancet. Sometimes ruling a treatment out, will make as big an impact on patient care and health service delivery, as confirming a new discovery.

In either case, what is crucial to the delivery of improved patient care is the capability to conduct clinical trials to the highest international standards.

Professor Nichol recently won a substantial award from the HRB to dramatically increase the capacity of the HRB Irish Critical-Care Clinical Trials Group. I would hope that this is just the start of a very long and very productive cycle of results that will constantly improve and enhance the delivery of quality care to patients in Ireland and internationally,

HRB Irish Critical Care Clinical Trials Group

The HRB Irish Critical-Care Clinical Trials Group (ICC-CTG) led by Professor Alistair Nichol, UCD Professor of Critical Care Medicine at St Vincent’s University Hospital.  Thousands of critically ill patients pass through Irish intensive care units (ICU) each year. Sadly the nature of their conditions can often result in death, or mean they survive with a long term disability. The HRB Irish Critical-Care Clinical Trials Group aims to bring together doctors, nurses and researchers to test new treatments that can improve outcomes for these patients.  Prof Nichol and his Colleagues in the Irish Critical Care Trials Group and Beaumont hospital (Dr Rory Dwyer, Dr James O’Rourke and Dr Criona Walsh) were able to enroll patients in Ireland into this study.  Furthermore, Prof Nichol’s collaborations with the Australian and New Zealand Intensive Care Research Centre in Melbourne has facilitated the conduct of these world-class international studies in Ireland.

Our network will offer ICU patients the highest quality care, give them access to the latest innovations in intensive care and ensure future patients benefit from the lessons learned in national and international research. The group includes the academic leadership in our specialty and encompasses more than 75% of all the ICU capacity in Ireland,

says Professor Alistair Nichol, Chair of the network who is UCD Professor of Critical Care Medicine at St Vincent’s University Hospital and Monash University Melbourne.

Initial work to be addressed by the ICC-CTG:

  • PHARLAP- will establish whether the way we ‘set’ the breathing machine helps reduce further lung damage in patients with a severe lung disease (Acute Respiratory Distress Syndrome or ‘ARDS’). A small research study by some of the group members showed that reducing the size of each breath in conjunction with an occasional sustained deep breath through the ventilator appeared to reduce further damage to the lungs. But the study size was too small to make definitive conclusions. So a larger study, which this HRB network now makes possible, will assess whether patients with ARDS are better off on this PHARLAP breathing strategy.
  • TRANSFUSE- Does giving ‘fresher’ blood versus ‘older blood’ in transfusions make a difference to patients who are admitted to ICU. This study will result in a worldwide practice change if it finds freshest available blood use is best for ICU patients, but if there is no difference this will provide great confidence to blood banks that current practice is optimal.
  • The network will also carry out test studies to determine which of the common treatments used to help reduce bleeding from the stomach when people are very unwell is best.
  • The network will also provide extra training for junior doctors and nurses in Ireland, so they can be future world leaders in research within the Irish health system.