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Many students, when asked by a teacher or professor to volunteer in front of the class, shy away, avoid eye contact, and try to seem as plain and unremarkable as possible. The same is true in dental school – unless it comes to laughing gas.
As a fourth year dental student, I’ve had times where I’ve tried to avoid professors’ questions about anatomical variants of nerves, or the correct way to drill a cavity, or what type of tooth infection has symptoms of hot and cold sensitivity. There are other times where you cannot escape having to volunteer. These include being the first “patient” to receive an injection from one of your classmate’s unsteady and tentative hands. Or having an impression taken with too much alginate so that all of your teeth (along with your uvula and tonsils) are poured up in a stone model.
But volunteering in the nitrous oxide lab … that’s a different story. The lab day is about putting ourselves in our patients’ shoes, to be able to empathize with them when they need to be sedated. For me, the nitrous oxide lab might have been the most enjoyable 5 minutes of my entire dental education.
In today’s dental practice, nitrous oxide is a readily available, well-researched, incredibly safe method of reducing patient anxiety with little to no undesired side effects. But this was not always the case.
The Oxford Textbook of Anaesthesia for Oral and Maxillofacial Surgery argues that “with increasingly refined diets [in the mid-nineteenth century] and the use of copious amounts of sugar, tooth decay, and so dentistry, were on the increase.” Prior to the modern day local anesthesia armamentarium, extractions and dental procedures were completed with no anesthesia. Patients self-medicated with alcohol or other drugs, but there was no predictable or controllable way to prevent patients from experiencing excruciating pain.
That is until Horace Wells, a dentist from Hartford, Connecticut started taking an interest in nitrous oxide as a method of numbing patients to pain.
Dr Horace Wells, by Laird W. Nevius. Public domain via Wikimedia Commons.
Wells became convinced of the analgesic properties of nitrous oxide on December 11, 1844 after observing a public display in Hartford of a man inhaling the gas and subsequently hitting his shin on a bench. After the gas wore off, the man miraculously felt no pain. With inspiration from this demonstration and a strong belief in the analgesic (and possibly the amnestic) qualities of nitrous oxide, on December 12, Wells proceeded to inhale a bag of the nitrous oxide and have his associate John Riggs extract one of his own teeth. It was risky—and a huge success. With this realization that dental work could be pain free, Wells proceeded to test his new anesthesia method on over a dozen patients in the following weeks. He was proud of his achievement, but he chose not to patent his method because he felt pain relief should be “as free as the air.”
This discovery brought Wells to the Ether Dome at the Massachusetts General Hospital in Boston. Before an audience of Harvard Medical School faculty and students, Wells convinced a volunteer from the audience to have their tooth extracted after inhaling nitrous oxide. Wells’ success came to an abrupt halt when this volunteer screamed out in pain during the extraction. Looking back on this event, it is very likely that the volunteer did not inhale enough of the gas to achieve the appropriate anesthetic effect. But the reason didn’t matter—Wells was horrified by his volunteer’s reaction, his own apparent failure, and was laughed out of the Ether Dome as a fraud.
The following year, William Morton successfully demonstrated the use of ether as an anesthetic for dental and medical surgery. He patented the discovery of ether as a dental anesthetic and sold the rights to it. To this day, most credit the success of dental anesthesia to Morton, not Wells.
After giving up dentistry, Horace Wells worked unsuccessfully as a salesman and traveled to Paris to see a presentation on updated anesthesia techniques. But his ego had been broken. After returning the U.S, he developed a dangerous addiction to chloroform (perhaps another risky experiment for patient sedation, gone awry) that left him mentally unstable. In 1848, he assaulted a streetwalker under the influence. He was sent to prison and in the end, took his own life.
This is the sad story of a man whose discovery revolutionized dentists’ ability to effectively care for patients while keeping them calm and out of pain. As a student at the University of Connecticut School of Dental Medicine, it is a point of pride knowing that Dr. Wells made this discovery just a few miles from where I have learned about the incredible effects of nitrous oxide. My education has taught me to use it effectively for patients who are nervous about a procedure and to improve the safety of care for patients with high blood pressure. This is a day we can remember a brave man who risked his own livelihood in the name of patient care.
Featured image credit: Laughing gas, by Rumford Davy. Public domain via Wikimedia Commons.
Ebola is a widely known, but poorly understood, virus. Even in West Africa, in the middle of the 2014 West African Ebola Epidemic, the vast majority of patients with a differential diagnosis of Ebola Virus Disease (EVD) will in fact be suffering with something else serious and potentially fatal. The possibility of EVD should not over-shadow other investigations and management.
Peter Piot’s team discovered Ebola in 1976 – he’s now the head of the London School of Tropical Medicine and was reassuringly quoted in 2014 as saying ‘I would sit next to an infected person on a train’. It is one of two Filoviruses (the other being Marburg) and according to the CDC, it has caused thirty-four outbreaks, twenty-four of which have been in Sub-Saharan Africa, with total fatalities numbering only in the thousands. Transmission relies on direct contact with bodily fluids containing the virus, either through broken-skin or through mucous membranes. Airborne, droplet- aerosol transmission does not seem to be a popular mechanism of spread, though it is possible that this does occur. Symptoms are visible as soon as people are contagious and Ebola Virus is not, therefore, what Piot termed the ‘right kind of virus’ to start an epidemic in a major western city. It is conceivable that an outbreak could occur, but it lends itself to active case finding, contact tracing, and containment far more easily than, for example, the flu-viruses.
Ebola Virus Particles: Colorized scanning electron micrograph of filamentous Ebola virus particles (green) attached to and budding from a chronically infected VERO E6 cell (blue) (25,000x magnification). Credit: NIAID. CC BY 2.0 via NIAID Flickr.
Its relative fame therefore, is probably related to three aspects of EVD: the extremely high (both untreated and treated) case fatality rates (as high as 90% in some outbreaks); the extremely rapid onset and dramatic nature of its symptoms (it is a hemorrhagic fever and death is usually preceded by haemorrhage and widespread organ necrosis); and finally the enigmatic nature of the outbreaks–the animal reservoir is not yet clarified (though fruit bats are currently the most likely candidate). This last aspect allows popular descriptions of the virus to describe it as lurking in the sinister darkness of the African jungle, waiting to emerge on an unsuspecting population.
If you work in the global north in a modern, well-equipped hospital, the management of a low-risk of an extremely dangerous event must be governed by national and international protocols rather than the arbitrary decisions of individual clinicians. Members of medical teams should ensure that these protocols are available, and followed – they govern isolation techniques, blood sample procurement and delivery, and contact tracing.
If you work in a region where Ebola epidemics are a possibility then you will be faced with a vast number of challenges to identify and manage these cases: poor data collection and management systems, weak public health infrastructure, limited availability of personal protective equipment and, perhaps most importantly, a population who are vulnerable because of (in many cases) limited education, weakened immunity and cultural practices that encourage transmission. In these contexts the epidemic potential of the virus is greatly magnified. The 2014 epidemic has demonstrated that the international community is quite content to allow widespread transmission across several countries until expatriates are affected. The overstretched expatriate and national staff of the responding agencies have two jobs – to manage as best they can with epidemic control and to advocate for, and demand the vast resources – human and financial – that are needed to control the spread of a disease that reflects poverty and lack of long term investment in regions of the world that are vulnerable to so many other threats to life and health.
Few fields develop as rapidly as medicine, with new breakthroughs in research, tools, and techniques happening everyday. This presents an interesting challenge for many medical publishers — trying to get the latest information to students, practitioners, and researchers as quickly and accurately as possible. So we are delighted to present a Q&A with Associate Editorial Director of Medicine Books, Craig Panner. Craig began his career at Oxford University Press eight years ago, and currently works across Oxford University Press’s medicine titles. In the interview below, Craig talks not only about his role, but also the medical publishing landscape in general, both past and future.
Could you tell us about your position as Associate Editorial Director?
My role is something of an interdepartmental liaison between the Medicine UK office and the psychology and social work group here at Oxford University Press. Collectively, we all work very closely together and when you have departments on both sides of the Atlantic, I think it is imperative to maintain and promote open lines of communication which is what I strive to do on a daily basis. Additionally, as Associate Editorial Director, I am also the commissioning editor for neurology and neuroscience, a role which I not only love, but I think helps keep me connected to, and informed about, what the other commissioning editors encounter on a daily basis.
In your experience, what are some of the challenges of transitioning medical books to an online environment?
Work in the computer lab by MCPearson. CC-BY-SA-3.0 via Wikimedia Commons.
I think one of the biggest challenges is that everyone has ideas of what they want, what functionality they expect, and how to be able to use that material. But like many things, we can’t please everyone so it becomes a matter of identifying the greatest common need and how to meet those requirements. Another large challenge is that the online environment is a constantly moving target, if you will: new functionalities are introduced, the “it” product is rolled out, and other similar bells and whistles are discovered and customers often want that too. But when we’re talking about a platform product like Oxford Medicine Online and the huge amount of data that is available, it’s often too difficult to demonstrate why instant changes can’t be incorporated.
What was the state of medical publishing when you began your career vs. how it is done now?
When I started in the publishing world (as a proofreader) back in 1992, everything was print. I remember when the company received its first apple computer: it was kept in an open office and you had to sign up to book time to use it. And, oddly, it was never in use: everyone was more comfortable using the mimeograph machine and the typewriters by their desk. But, in about the next five or six years, the online explosion happened and journals suddenly became available electronically, first via consortia only, then as individual subscriptions, and then individual articles.
Could you discuss Oxford’s relationship with the Mayo Clinic, and how it has grown or changed over the years?
Mayo Clinic is the largest integrated, not-for-profit group practice in the world, with nearly 4000 physicians and scientists at their three primary sites in Minnesota, Florida, and Arizona. And given that Oxford University Press is the largest and oldest university press in the world, it seemed like a natural fit for the two organizations to work together. For almost five years now, Mayo Clinic and Oxford University Press have continued to work together to create, prepare, and disseminate medical reference works that any practicing clinician, anywhere in the world, would find useful for their continued professional development. When we first began working together, the Mayo Clinic Scientific Press series of books was predominantly print. But with the launch of Oxford Medicine Online, and the subsequent development of the Oxford eLearning Platform, the Mayo titles now have the added functionality of utilizing the questions and answers that accompany many of the Mayo Clinic Board Review books for a truly interactive experience that more fully prepares doctors preparing to take their board exam, as well as doctors maintaining their certification, in a real time environment.
What are some of the greatest challenges of medical publishing?
Everyone is busy and everyone works more than a 40-hour week. Finding the time to develop and undertake, much less publish, a medical text is a real juggling act. Thankfully, with the history of Oxford University Press and the quality publications that we produce, we are a trusted publishing house where authors and editors can go with confidence. Another challenge in medical publishing is the time that it takes to produce a work. Not only does it take a fair amount of time to develop, to write or collate chapters, and to deliver the work, but in the old days, it would take a year to publish a book. Medical research and techniques move far more quickly than that time-frame would permit which is why the Medicine group now publishes works between 3.5 months to 5.5 months from receipt. All to better meet the needs of our readers.
Where do you think medical publishing is headed in the future?
I wish I knew! The electronic environment will obviously play a huge role for the rest of my career but given that it, literally, changes daily and the needs and expectations of our readers changes with it, it is impossible to guess where things are going. And that’s what makes publishing so much fun. I can say that I think that immediate access to point of care information, along with suggested secondary and tertiary information will become second nature. The online environment won’t do the thinking for the clinician, but it will certainly supplement their decision making and knowledge base far more completely than anything that we’ve had previously.
How has the process of actually doing medical research changed over the years? In other words, how are people accessing the content then vs. now?
Medical research has definitely changed over the years. When I first started out, clinicians and researchers had offices lined with books and journals, filing cabinets filled with journal reprints, and personal databases (for the electronically savvy) of key articles. Much of that is gone now and when you speak with a junior doc they will often say that everything they need is available to them electronically. Searching the web is obviously faster but the ability to utilize the web to link journals, books, databases, and the like has expanded the available knowledge base of today’s clinician, no matter where in the world they are located. And because of how we do research and how we follow up with patients, a doctor can now check up on, and advise upon, a patient from anywhere that they are traveling to. Geographic boundaries really no longer exist.
How have extra online features, like multimedia, changed the way medical research is done?
The various additional features that the online environment facilitates are amazingly useful in this busy world we live in. Not only do these extra features teach the reader on their own schedule, but these features can help facilitate the decision making process. If we are talking about videos that show two different, but somewhat similar, symptoms the multimedia material can help show, literally, how the two disorders are different. Likewise, being able to quickly reference additional material via a third party database–let’s say genotypes, for instance–you negate the need to stop what you’re doing, go to a book, a journal, or even the library but, instead, go directly to the source, find what you need, make the judgment and continue with your work. Medical research really is nothing like it was five years ago and will not be the same five years from now.
Craig Panner is the Associate Editorial Director of Medicine Books, and works in Oxford’s New York office.
Oxford Medicine Online is an interconnected collection of over 500 online medical resources which cover every stage in a medical career. Our aim is to ensure that the site delivers the highest quality Oxford content whilst meeting the requirements of the busy student, doctor, or health professional working in a digital world.
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With our announcement of Place of the Year 2012 and NASA’s announcement at the American Geophysical Union on December 3rd, and a week full of posts about Mars, what beter way to wrap things up than by pulling together information from across Oxford’s resources to provide some background on the Red Planet.
Of Gods and Men
While the planet been subject to study since humans first gazed into the sky (as one of the few planets visible to the naked eye), the English name for the planet comes from the Roman god of war, Mars. Latin marks many astronomical names, such as mare, which refers to the dark areas of the Moon or Mars. Sol (Latin for Sun) refers to a solar day on Mars (roughly 24 hours and 39 minutes). However, be careful not to mix up martialists, those born under its astrological influence, with martians, aliens from the planet. (Not that it always had that meaning.) Mars has two moons: Phobos and Deimos (those Latin names again!). The Romans, as usual, stole their planet-naming scheme from the Greeks. Ares, the Greek god of war, provides a pre-fix for a number of Mars-related words: areocentric, areˈographer, areo-graphic, are-ography, are’ology. It’s important to remember that these names reveal how people related, and continue to relate to the sky.
The Martian People
What has fueled our fascination with Mars all these years? Everyone from scientists to poets has kept it in our thoughts over the centuries.
Almost all ancient world cultures closely observed its pattern through the sky, although this was often a confluence of gods, astrology, and astronomy. Aristotle and Ptolemy were among the ancient theorists. The Renaissance saw new discoveries from Brahe, Kepler, and Cassini among others, made possible by the telescope and advanced mathematics, as we moved from a geocentric to a heliocentric view of the universe (although Mars’s eccentric orbit caused considerable annoyance).
In the 19th century, Giovanni Schiaparelli was the first to create a detailed map of Mars. Percival Lowell (1855-1916), who saw himself as a successor to Schiaparelli, searched for signs of intelligent life on Mars and made numerous invaluable observations, even if many of his speculations have now been dismissed. Moreover, his legacy, the Lowell Observatory, continues to watch the stars. Astronomer Richard Proctor (1837-88) researched the rotation period of Mars and rightly dismissed the canals as an optical effect.
Scientific breakthroughs naturally inspired artists throughout the ages. In the Renaissance, writers struggled to make sense of a new vision of the universe; in the 19th century, science fiction emerged and it has grown and adapted to every medium in the 20th. H.G. Wells (1866–1946) and Edgar Rice Burroughs (1875-1950) built on scientific discoveries with novels such as The War of the Worlds and The Princess of Mars. In 1938, Orson Welles’s (1915-1985) famous dramatization of The War of the Worlds led many Americans to believe that Martians had invaded New Jersey. The story was adapted to film in 1953 and again in 2005. One of the masterpieces of Soviet cinema, Aelita, is based on an Aleksey Tolstoy science fiction novel. In television, Mars has provided the backdrop or villians for numerous programs, such as the Ice Warriors, one of the great monsters of Doctor Who. UFOs still capture the imagination.
The planet has also provided ideas to musicians as diverse as Gustav Holst and David Bowie, and populated the night skies of artists. And we cannot forget those with the surname of Mars, most of all confectioners Frank C. Mars and Edward Forrest Mars (1904-1999). Mars, Inc. and the famous Mars Bar are often associated with the planet although the origin of their names is distinctly earthly.
A History of Martian Space Exploration
The National Aeronautics and Space Administration (NASA), Russian Federal Space Agency (ROSCOSMOS), and the European Space Agency (ESA) have all been involved in the exploration of Mars, from probes to rovers. In 1962 the Soviet space program began lanching Mars probes, the last of which was Mars 96 (in 1996). In 1975, NASA sent two Viking probes to Mars. In 1996, NASA begins a series of missions called Mars Surveyor and has sent numerous probes, rovers, and more to the Red Planet in the past 20 years, including the Mars Pathfinder (and the rover Sojourner), the Mars Odyssey, the Mars Global Surveyor, and two rovers, Spirit and Opportunity.
But space exploration is not without its setbacks. The Soviet Union failed in its Phobos missions in 1988, and NASA lost communication with the probe New Millennium Deep Space-2 in 1999. The European Space Agency’s Mars Express probe continues to provide valuable information although the Beagle 2 lander was lost.
There has been much speculation about the geography and geology of Mars, with new theories arising as our technology improves.
Mars is a terrestrial planet with numerous montes (mountain ranges), valles (valleys) , rima (long narrow furrows), and cave systems. Its most famous geographical features are the Olympus Mons (giant volcano) and Valles Marineris (system of canyons).
In the 19th and 20th centuries, people speculated about Martian canals, faint markings of the surface that once led people to believe the planet had flowing, liquid water. (The word canal actually comes from a mis-translation Giovanni Schiaparelli’s work; canali (Italian) actually means channels.) Wrinkle ridges further added to the mystery.
Without a thick atmosphere to burn up descending asteroids, Mars is pockmarked with impact craters. The Mars Curiosity Rover landed in the Gale Crater, just south of Mars’s equator. Previous rovers have attempted to measure Marsquakes, the Martian equivalent of earthquakes, as the Red Planet may have its own system of tectonic plates.
The Long Arm of Outer Space Law
In space, no one can hear you scream, but that doesn’t stop the lawsuit.
What would we call our red planet lawmen? Marshals of course — although martial and marshal aren’t actually related. And be sure to check back tomorrow to hear from our space lawyer!
Recommended resources from A Dictionary of Space Exploration
Oxford University Press’ annual Place of the Year, celebrating geographically interesting and inspiring places, coincides with its publication of Atlas of the World – the only atlas published annually — now in its 19th Edition. The Nineteenth Edition includes new census information, dozens of city maps, gorgeous satellite images of Earth, and a geographical glossary, once again offering exceptional value at a reasonable price. Read previous blog posts in our Place of the Year series.
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