Tuesday, 4 March 2014

Karnevalzeit - Time for Carneval!

Finally getting round to a new post! It's been a busy few months. From November to February I have been working on 'die Notaufnahme', the emergency department for internal medicine - a busy, challenging and learning-rich experience. My last shift was particularly memorable, with the first festivities of Karneval beginning that day. Imagine a drunken warzone with clowns. Shortly after being greeted by a nurse in an orange wig, I began to take a history from a Sumo wrestler. A further 15 minutes was then spent trying to persuade an argumentative Cowboy to give a urine sample for toxicological screening. Highlight of the shift however was when a patient asked me to pray with her. She'd overheard me talking the night before to another patient that I knew from my church. She said that she also trusted in Jesus but was scared about what lay ahead. It was an immensely moving experience and dare I say it provided more peace and reassurance to the patient that the senior ward round that morning.

I'm now preparing to head back to the UK. From April I will be working in internal medicine again in lovely Preston. However, before I head back to the UK, there's just about time for a trip with my friend Dilu to Mainz for Karneval (see photos). 40 days to Easter!

Sunday, 6 October 2013

Erntedankfest - Harvest festival

So, autumn is well and truly here. The leaves are falling, the weather is cool and the sun is rising later than my alarm clock.  This Sunday is 'Erntedankfest' (harvest festival) here in Germany.  Today in church we thought about the many thinks that God gives to us (food, materials, abilities, chances to serve) and thanked him for these!  As part of this many people brought things grown in their gardens to share with each other in the church.  A couple at my homegroup brought me a 5L box of freshly pressed apple juice pressed by their family here in the Saarland - it tastes really good!  After hte service cake was also bountiful in it's abundance (gotta love the Omas).  For lunch I cooked Spätlzle (a German noodle dish) for the first time - my Chinese friend Dilu said it was 'lecker', so I guess it worked out!  My flatmate's chilli plants are also now ripening, however after my last tongue searing taste I've decided to go for milder spices!  I also found out today that we have grapes growing in our garden.  The landlord knocked on our door saying we're welcome help ourselves.  Photos of all these things are included beneath.

I'm feeling a little more at home with the day to functioning of the hospital now, however realise there is still a lot for me to learn.  I also need to improve my written German to get my patient discharge letters up to scratch.  From the 1st November I'll be working on the 'Notaufnahme' (Accident and Emergency), so the learning process will continue!  

Over the past week I've been reading the letter to the Ephesians from the Bible.  Whilst there are many material things we can be thankful for, our real thanks to God should be for his rescue plan for the world.  Through Jesus we can be made right with God and brought into a fantastic relationship with him. Fantastic news!  Beneath are two parts of particular encouragement read this week:

Ephesians 1:3-6
Blessed be the God and Father of our Lord Jesus Christ, who has blessed us in Christ with every spiritual blessing in the heavenly places, even as he chose us in him before the foundation of the world, that we should be holy and blameless before him. In love he predestined us for adoption as sons through Jesus Christ, according to the purpose of his will, to the praise of his glorious grace, with which he has blessed us in the Beloved.

Ephesians 3:14-19
For this reason I bow my knees before the Father, from whom every family in heaven and on earth is named, that according to the riches of his glory he may grant you to be strengthened with power through his Spirit in your inner being, so that Christ may dwell in your hearts through faith—that you, being rooted and grounded in love, may have strength to comprehend with all the saints what is the breadth and length and height and depth, and to know the love of Christ that surpasses knowledge, that you may be filled with all the fullness of God.

As usual, all comments, thoughts and questions are welcome!

Thursday, 3 October 2013

Sverige - Sweden!

Last weekend I had the great pleasure of teaching and preaching at the Swedish Christian Medical Student conference.  I was made to feel really welcome and greatly encouraged by my time with the students and doctors there.  Together we looked at the Bible verses Matthew 6:31-33 and Colossians 2:6-7, considering the treasure found in knowing, trusting and growing in Jesus.  We thought about what it means to 'walk in Christ' as a medical student and as a doctor, as well as what this might look like when working abroad.  There was also time for food, walks, (extreme)games, relaxing and praising God.  The concept of 'Fika' (swedish cake, coffee and conversation) was also introduced to me. Liz was also able to come with me, another blessing :-) Sweden is a really great place!

Matthew 6:31-33
Therefore do not be anxious, saying, ‘What shall we eat?’ or ‘What shall we drink?’ or ‘What shall we wear?’ For the Gentiles seek after all these things, and your heavenly Father knows that you need them all. But seek first the kingdom of God and his righteousness, and all these things will be added to you.

Colossians 2:6-7
Therefore, as you received Christ Jesus the Lord, so walk in him, rooted and built up in him and established in the faith, just as you were taught, abounding in thanksgiving.

In other news, I finally managed to enable comments on my blog without needing to register with Blogger.  Hence, your thoughts are greatly welcome!


Monday, 23 September 2013

Three weeks into German life!

Three weeks into German life!

Time is a bit short this week.  So, I've put together a brief photo selection from the last few weeks.  Your thoughts and comments very much welcome!

1. The journey here - on an A380!

2. Starting work; the walk to work, the nephrology department, my new uniform and the view from the ward!

3. Settling in at home: the gnome garden, Ikea furniture, my flatmates, a welcome gift from England and a reminder that God is a covenant keeper


4. Going shopping: The state 'car boot sale' with Dilu, getting ready for Oktoberfest, the British section at the supermarket, Tyrrell's crisps(!) and gummi bear beer!


5. The election campaign.

And of course the Queen of Germany is set to rule for at least another four years.


Tuesday, 10 September 2013

Two weeks in...

So here we are two weeks in.  It's been a somewhat intense german roller coaster ride with a mixture of challenges, blessings and encouragements.  I'm feeling a little more settled now and have been made to feel very welcome.  My flatmates have helped me with many questions and are correcting my German.  They've also been a huge support in sorting out administrative aspects of living and working here, as well as proving a relaxed social atmosphere within the apartment - perfect at the end of a busy workday!  I feel I'm now getting to grips with the 'hospital system' meaning work is becoming more manageable.  My colleagues on the ward have been very patient and supportive.  The work is very interesting and I'm learning huge amounts.  I feel exhausted by the end of most days however!  To make up for this there is a fantastic view of the town from our doctor's office on the 11th floor.  Each evening I return home with a list of things to read up on - results are somewhat limited by energy levels....  Best moments have been chatting with the patients and my colleagues. Scariest moments so far have been presenting patients at the lunchtime department meeting and giving the telephone handover of all the patients in the evening to the on-call team.  This may be superseded by being presented at the medical directorate meeting tomorrow morning...

Church here has been welcoming.  It's great to see a mixture of familiar and new faces.  I do still miss my Preston church family at All Saints however.  The preaching is also thematic rather than passage based, another thing I miss.  Still, I am very grateful for their support and weekly encouragements.  I'm trying hard to encourage all I see there in Christ.  To this end, I've been the last to leave each week!  From next Sunday I'm part of the translation team and so will be proving simultaneous translation of the service and preaching into English via headsets.  I should also be joining a homegroup for Bible study and mid-week fellowship in the near future. Excitingly a friend of mine here has put his trust in Jesus and was recently baptised.  We met up over the weekend and have now started to read the Bible together. The plan is to start with a mixture of Mark's gospel and the Psalms.  This is very encouraging indeed!  I also now have a bike, making getting around and such activities a lot easier.

So, what do the next few weeks hold?  At the end of the month I'm heading to the Swedish student Christian medical fellowship retreat.  Here I'll be giving two talks on being a Christian at medical school and then preach from Colossians chapter 2 on the Sunday morning.  I booked my flights last night and have managed to book the Friday and Monday off work.  Liz, my girlfriend, is also able to come.  Needless to say I'm looking forward to this weekend quite a bit!  The other big event is that of medical research. The university hospital here is heavily involved in research and the vast majority of students and doctors take part in this.  I've been an informal member of my Oberarzt's (registrar/consultant) research team for a few months now.  We've chatted briefly about me completing a research MD as part of the nephrology team.  Plan is to discuss the practicalities further after my first month's work. 

Today was capped with a rainbow at the end of work - a reminder of God's promises and his provision.  Regardless of yesterday, today or tomorrow's worries, he is the same and his plan for the world does not change!

Monday, 12 August 2013

Arriving in Germany

 Contemplating East --> Moving East...

Perhaps fittingly, my 26th Birthday has been first day living in Germany.  I've now been granted my license to practice medicine here and am underway with the remaining paperwork formalities.  Work will start on the 2nd September (God willing)!  More updates to come soon.  In the meanwhile, I thought I'd share a view of the market square here in Homburg-Saar with you.

(apparently today was the first rain for two months - made me feel at home!)

Saturday, 4 May 2013

COPD in Russia / ХОБЛ в России

“The draconian nature of Russian law is softened by the non-obligatory nature of its implementation”
An anonymous Russian saying

This week my blog post will consider the impact of chronic lung disease within Russia, focussing in on the role of smoking related disease, which amongst us medics is called COPD (chronic onstructive pulmonary disease).  Please see the previous post if you would like an introduction to COPD.

As is often the case, Russia has a unique situation, with its history, demographics and healthcare system all playing their part.  Intriguingly the situation of COPD in Russia has been a difficult topic to research.  Few studies seem to have been completed to define its incidence or prevalence.  With around 44 million smokers and rising, Russia has the highest smoking total and proportional prevalence in Europe.  Around 400,000 Russians are thought to die from smoking related diseases each year.    There are also significant barriers to primary care access and very limited screening.  Together this suggests significant under-diagnosis of COPD.

A primary health study conducted by Chuchalin et al within the Ryazan region of Russia (Рязань; population 1,306,600), ran from October 2004 to March 2005 (1).  Two districts were chosen, within which 16 primary health centres were chosen at random for recruitment.   Subjects received lung function tests and assessment for risk factors of chronic respiratory disease in the form of a household survey.  Results showed that whilst men are at greater risk: 60% of men smoke; 40% of men have occupational ‘dust’ exposure; prevalence of breathlessness, cardiovascular disease and chronic respiratory disease is two times higher in women than men.  Despite this 14% of men reported regular sputum production (4% women), suggesting some form of respiratory disease.  Low lung function was noted in 14% of the sample.  Overall COPD prevalence was said to be 1.6%, comparable with Russia as a whole.  It was noted that asthma treatment was also significantly underused, complicating the picture somewhat (the main drug of choice is theophylline – easily becomes toxic, many side effects, variable compliance).

What sense be made of this picture?  An extremely high level of smoking and occupational chemical exposures (especially amongst men), yet low rates of COPD.  I feel this study highlights some interesting and pertinent points within the peculiar ‘Russian paradox’

A society in smoking transition
Russia has been a society in transition.  As the soviet-era drew to a close, supplies of many goods became scarce.  Cigarettes were no exception.  This led to tobacco rationing, triggering the so called ‘tobacco riots’ where angry smokers caused chaos on the streets of Moscow and St Petersburg (2).  The Russian government responded by relaxing import laws, allowing multinational tobacco corporations to enter the Russian market.  With a population of 143 million citizens, few sales controls, low product taxation, a country previously naïve to marketing and eagerly desiring the western lifestyle, Russia was greatly attractive (3).   Today a pack of filtered cigarettes can cost less than $1 (£0.65).  As a result of the above Russia has become the third largest market for tobacco in the world.  All four major global tobacco firms now have high stakes in the Russian market, competing hard against one another in their sales drives.  The tobacco lobby is a formidable force affecting politics.  With the health impacts of smoking typically occurring in mid to late life, the long-term impacts of the smoking boom are only now being fully realised.  With smoking prevalence so high, COPD is an ever increasing burden.  Until recently little public awareness of the connection between smoking and chronic lung disease existed.  Hence smoking prevention is a relatively new concept! 

Sociodemographic changes
Russia is said to be experiencing a demographic crisis.  Deaths significantly outnumber births, meaning a comparatively higher number of the elderly.  Besides sub-Saharan Africa, the nations of the former Soviet Union (FSU) are the only world region to be experiencing a decline in life-expectancy.  Key to this is a huge gender disparity.  Men die increasingly young.  As COPD likelihood and severity increase with number of years smoked, many may never reach the point of significant impairment.  Men are also less likely to attend healthcare facilities (some truths are international!), and as such as less likely to receive a formal diagnosis for their breathing problems.

Healthcare provision
A multinational survey from the international COPD coalition noted several shortcomings in Russian COPD awareness and care provision (4).  It was found that patients viewed their symptoms as age/smoking related, rather than due to an underlying lung condition.  As a result, patients generally presented at advanced disease stages and chose to attend their GP rather than a respiratory physician.  Questions have also been raised regarding limited and outdated education of COPD treatment amongst primary care physicians.  Of those patients diagnosed with COPD, further barriers to effective care exist.  Whilst oxygen, inhalers and antibiotic therapy are available within Russia, provision varies depending on states and distance from large treatment centres.  Furthermore, treatment costs are not fully covered by the government or private insurance schemes.  As COPD is inversely associated with socio-economic status, many people simply cannot afford regular or optimal treatment.  Around 90% of formally diagnosed COPD patients within Russia are not receiving treatment recommended by national or international guidelines (5).

However it’s not all doom and gloom - changes are happening…

Smoking cessation
In 2008 Russia ratified the WHO Framework Convention on Tobacco Control, which called for a 10-15% decrease in smoking by 2015.  In summer 2010 the Russian Ministry of Health and Social development introduced warning labels on cigarette packaging for the first time.  Shortly after, President Vladimir Putin signed the national tobacco control concept paper.  Laws on public health relating to tobacco consumption began to be debated and rewritten, including discussions on smoking bans in public places, banning small tobacco retailers/kiosks, and limiting tobacco advertising including banning display case advertising in larger stores.  From June 2013 smoking will be banned in offices, school premises and around stations.  From 2014 this will extent to all public areas, including cafes, restaurants and long-distance trains.  Significant fines for breaking the rules are to be introduced (6).

Improved data collection, training and health services
Following on from the Ryazan study, COPD has now been mapped within a further 10 regions.  Over the past 3 years 35,000 primary care physicians have attended seminars on COPD, asthma, and smoking prevention.  The ‘Pulmobil’, a mobile COPD diagnosis and management centre was also unveiled in summer 2012, with the intention of enhancing service provision and coverage.  Studies are now on-going to assess the impact of these measures, including health centre utilisation by COPD patients.

Public awareness and attitudes
Media campaigns highlighting the health impact of smoking are increasingly common in newspapers, magazines and on television.  President Vladimir Putin has also publicly stated his desire for greater smoking cessation.  Surveys have shown mixed public opinion on the proposed changes; greater smoking controls for indoor public places such as offices and schools have generally been accepted; resistance has however been felt towards smoking bans covering shared stairwells, beaches and parks.  Increasing tobacco taxation also remains a politically sensitive topic, in particular amongst the industrial class, a loyal electoral base for President Vladimir Putin.  Critics of the proposed laws cite some impracticalities in the authoritarian nature of the rules and also question a lack of support for those wanting to quit smoking (7).  As is a common issue within Russia, it remains to be seen how rigidly the new rules are enforced.

Concluding remarks
COPD has long been underdiagnosed and undertreated in Russia.  Demographic changes are likely to exacerbate this situation in years to come.  The past five years have seen major changes in Russia, with increased public awareness, smoking controls and medical provision.  Whilst greater access to diagnostic facilities and provision of treatment is required, further barriers to COPD recognition can be overcome.

Thank you for reading this far - as usual, any comments greatly appreciated!

1) World Health Organisation (2006) Global Alliance Against Chronic Respiratory Diseases, Report of General Meeting 2005, Geneva. [online] Available at: http://www.who.int/respiratory/publications/WHO_NMH_CHP_CPM_05.4_eng.pdf [Accessed: 4 May 2013]

2) Greenstone.org (1997) Untitled. [online] Available at: http://www.greenstone.org/greenstone3/nzdl;jsessionid=E020827CE566B08981881AF4BB7ED8FE?a=d&d=HASH2255c5db003ea388a30032&c=cdl&sib=&ed=1&p.s=ClassifierBrowse&p.sa=&p.a=b&p.c=cdl [Accessed: 30 Apr 2013]

3) Holmes D. Smoking in Russia: will old habits die hard? Lancet. 2011 Sep 10;378(9795):973-4.

4) Scheld, J. (2007) ICC Country Report "Faces of COPD". The International COPD Coalition

5) World Health Organisation (2013) Global Alliance Against Chronic Respiratory Diseases, 7th General Meeting Report (2012), St Petersburg. [online] Available at: http://www.who.int/gard/publications/GARDGMReportStPetersburg2012.pdf [Accessed: 4 May 2013]

6) Rt.com (2013) Crackdown on smoking: Putin signs radical anti-tobacco bill into law — RT Russian politics. [online] Available at: http://rt.com/politics/putin-signs-radical-anti-smoking-bill-into-law-389/ [Accessed: 4 May 2013]

7) Harding, L. (2013) How will Russians cope with the smoking ban?. [online] Available at: http://www.guardian.co.uk/world/shortcuts/2013/feb/25/will-russians-cope-smoking-ban [Accessed: 1 May 2013]

Image 1 – http://gdb.voanews.com/44A8821F-E0E1-4B9B-A29A-71D9255FA12C_mw1024_n_s.jpg
Image 2 – http://stoletnik.ru/articles/novosti/2013/03/01/v-rossii-zapretili-kurit-v-liftax-i-pod-ezdax/