East of England Intensive Care2013 Christmas Quiz

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Question 1. Proning is back in fashion for ARDS, but what was this device usedfor?

Answer 1. Eve Riley Resuscitation Table on which in 1930 anyone unconscious througheither drowning or suffocation was rocked back to life.

Question 2. In the season of good will and pandemics, what is this bug? Why is itso good at what it does?

Answer 2. The Ebola virus. Which causes severe viral haemorrhagic fever (VHF) outbreaksin humans and has a case fatality rate of up to 90%.The virus is transmitted to people from wild animals and spreads in the human populationthrough human-to-human transmission.There is no treatment or vaccine available for either people or animals.

Ebola produces a protien which interferes with the signaling of neutrophils and dendriticcells, which allows the virus to evade the immune system by inhibiting early steps ofneutrophil activation. The viral particle budding causes the release of inflammatorycytokines (TNF-α, IL-6, IL-8.). This results in a loss of vascular integrity and damage to theliver, which leads to coagulopathy.

Question 3. What is the eponymous name for Factor IX deficiency and who was itnamed after?

Answer 3. Christmas disease (Haemophilia Type B)Stephen Christmas – During a trip to London Stephen was admitted to hospital withbleeding. A sample of his blood was sent to the Oxford Haemophilia Centre in Oxford,where Rosemary Biggs and R.G. McFarlane discovered that he was not deficient in FactorVIII, which is normally decreased in classic haemophilia, but a different protein, whichreceived the name Christmas factor in his honour (and later Factor IX). Stephen wasdependent on blood and plasma transfusions, and was infected with HIV in the periodduring which blood was not routinely screened for this virus.

Question 4. In 1952 a use for medical students was finally found, but by whom,where and why?

Answer 4. Bjørn Aage Ibsen who founded the world's first intensive care unit inCopenhagen.

The patient's name was Vivi, and when Bjørn Ibsentreated her, she was 12 years old and dying of paralyticpoliomyelitis. “Everyone expected her to die”, but Ibsen,a freelance anaesthetist, thought he could save her. Heproposed a radical departure from the standardtreatment by suggesting that polio patients could betreated in the same way as he had been managingcurarised patients during surgery. “He said, in the OR weintubate and ventilate them and they do alright. Wecould do exactly the same with the polio patients”. Asurgeon did a tracheostomy on the girl, but when Ibsenbegan trying to ventilate her, he found he could not pushany air into her lungs. “At that moment, according to the

legend, all the other doctors left the room”. But Ibsen administered thiopentone, andfound he was then able to ventilate without difficulty using intermittent positive pressureventilation with a bag and Waters' to-and-fro system with carbon dioxide absorptionconnected to a cuffed tracheotomy tube. She regained consciousness, and hertemperature fell. This demonstration convinced the hospital that the new technique wasthe way forward, so he organised shifts of about 1500 volunteer medical students,nurses, and retired staff to do this ventilation on polio patients. Supervised byanaesthetists and dedicated nursing staff, the work of these volunteer teams usingIbsen's techniques slashed mortality rates from 87% to less than 15% among patientswith bulbar poliomyelitis. The hospital then arranged for the same methods to be appliedto other patients with respiratory failure, and concentrated them into three speciallydesignated wards.

Question 5.

Track 8. In which century and country was this device first described?

Answer 5. Track 8 on Radiohead’s seminal sophomore 1995 album is ‘My Iron Lung’.Negative pressure ventilation was first described in 1670 (C17) by Englishscientist John Mayow and a working model was built.

Question 6. Name these two plants and describe their common medicinal uses.

a) b)Answer 6. a) Digitalis Purpurea, containing digoxin (commonly used in rate controlof atrial fibrillation). b) Atropa Belladonna, containing the anticholinergic agent atropine(commonly used in the treatment of bradyarrhythmias).

Question 7.“A merry Christmas, uncle! God save you!" cried a cheerful voice. It was the voiceof Scrooge's nephew, who came upon him so quickly that this was the firstintimation he had of his approach.

"Bah!" said Scrooge, "Humbug!"

In 1844 who was called "Humbug, Humbug!" the insult ultimately ruining him andleading to his suicide three years later?

Answer 7. In 1844 the dentist Horace Wells demonstrated the first anaesthetic withnitrous oxide in Boston, Massachusetts. The gas was not delivered for long enough or aninsufficient dose was administered and the patient, undergoing a tooth extraction,shouted out in pain, Wells was booed out of the operating room with cries of: “Humbug,Humbug” . Wells was unfairly discredited by the medical establishment and neverrecovered from the humiliation. Wells gave up dentistry and became a travellingsalesman. He later committed suicide by slicing open his femoral artery whilst under theinfluence of chloroform.

However Horace Wells had almost certainly used nitrous oxide anaesthesia successfullybefore the failure in Boston and should be regarded as the founder of generalanaesthesia.

Question 8. What did Dr Bruno Lunenfeld and the nephew of Pope Pius XII find sostimulating about Italian convents?

Answer 8. They collected menopausal nuns urine for FSH

Lunenfeld was a medical student in the early 1960s. At the time, he recognized that duringmenopause women’s urine was likely to contain high levels of the hormones thatstimulate ovulation. Why? Because as the ovaries decline, the pituitary gland raises thesehormone levels in an intensifying attempt release the remaining eggs.

Of course, finding a regular source for of such urine presented a problem. At aconference in Italy, however, Lunenfeld met the nephew of Pope Pius. He had a greatsource: nuns. “Where better to get large amount of FSH than from women atmenopause? Convents were a perfect place.”

Question 9. We all know that Father Christmas lives at the North Pole but whichone: the geomagnetic, true, dip, orbital or map pole? Or is it the town of NorthPole in Alaska whose post office receives hundred of thousands of letters forSanta every year?

What happens to the North Pole around three times every million years?

Answer 9. It moves to the South Pole. Our planet's magnetic field periodically flips itsdirection, with the magnetic North and South Poles switching places. The geologicalevidence suggests the field flips about once every 400,000 years, and it's been about780,000 years since the last reversal. It is thought we may be entering a new reversal butit will take from 1,000 to 10,000 years to complete.

Question 10. Cardiothoracic surgeons are a highly cultured lot who like listeningto classical music while ferreting about in people’s chest, but what prestigiousprize did Uchiyama et al win with their research paper assessing the effect oflistening to La Traviata, on heart transplant patients who are mice?

J Cardiothorac Surg. 2012 Mar 23;7:26. Auditory stimulation of opera musicinduced prolongation of murine cardiac allograft survival and maintainedgeneration of regulatory CD4+CD25+ cells.

Answer 10. The Ig Nobel prize for medicine. The Ig Nobels are the antithesis of the nobelprize awards. Awarded for the ridiculous or bizarre in scientific research they are handedout to the winners each year by genuine Nobel laureates. The winner in 2006 also surelydeserved the award with this priceless research paper... "Termination of IntractableHiccups with Digital Rectal Massage," Francis M. Fesmire, Annals of Emergency Medicine,vol. 17, no. 8, August 1988 p. 872.

Question 11. Intravenous therapy has been controversial long before VISEP, SAFE,starches and scientific fraud. The invention of the first intravenous infusiondevice, made from a pig's bladder and a quill rather than PVC and Teflon, iscredited to Sir Christopher Wren who is also famous for his architecturalachievements.

Sir Christopher Wren

What was the first intravenous fluid infused by Sir Christopher in 1658? Crystalloid,colloid or something else?

A. The first experiment consisted of the instillation of a mixture of wine, ale, opium andliver of antimony into a dog. It is recorded that the dog tolerated this well...

Question 12. The picture below is of an early piece of medical equipment from the1930s called the "Hyman otor"

What would one do with a “Hyman otor” and how would one do it?

Answer 12. The Hyman otor is the first example of a defibrillation device. Introduced intothe stopped heart percutaneously. In a way, it was truly ground breaking in that it was, ina sense, also implantable. Disappointingly, it is unclear whether it actually worked,however.