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By N. Hanson. Pomona College. 2018.

Evidence ● Consider plasma expanders and prophylactic antibiotics suggests that aspirated fresh water is more likely than seawater to produce pulmonary oedema buy 100 mg viagra professional reflexology erectile dysfunction treatment. Rewarming Extracorporeal membrane oxygenation with extracorporeal warming is the gold standard treatment for patients with profound hypothermia buy viagra professional 100mg on-line reflexology erectile dysfunction treatment. The Swiss Mountain Rescue Service has recovered the bodies of 46 individuals over the years, all with deep hypothermia from burial in snow. Conscious patients can be placed in a bath maintained at a temperature of 42 C. Shadowing in the left Fluid and electrolyte balance lower zone Plasma electrolyte differences between patients who aspire and right mid-zone fresh water and seawater are seldom clinically important. In represents either situation, the patient is often hypovolaemic and in need aspirated of intravenous fluid replacement, preferably using a crystalloid. The Metabolic acidosis should be corrected by adequate patient is at the risk of oxygenation and plasma expansion; administration of sodium developing bicarbonate should be unnecessary. Water intoxication adult resulting in fits has been reported in infants after near respiratory distress drowning in backyard pools. Embolism of infected ● Chest compression alone for circulatory arrest ● No re-warming for deep hypothermia material from the lungs to the arterial tree may result in brain ● Intubate unconscious patients abscesses or death from systemic aspergillosis. A blood culture ● Defibrillation is unlikely to succeed should be undertaken in all instances in which aspiration has ● Associated trauma may include fracture of the cervical spine occurred. Leptospirosis has been reported after immersion in lakes or reservoirs, possibly due to ingestion of water contaminated with rats’ urine. Outpatient follow-up with a chest x ray taken two weeks later is advisable for all patients who have been immersed in water, irrespective of their clinical state on admission. Prognostic signs Resuscitation in hospital A pH of 7 or less indicates severe acidosis and is a poor ● Aspiration is an indication for admission prognostic sign. A low PaO2 provides an early indication that ● Facilities for extracorporeal blood re-warming should be water has been inhaled with the attendant risk of pulmonary available oedema. The presence of ventricular fibrillation is an adverse ● Correct arterial blood gas measurements for low core sign and responds poorly to defibrillation when the core temperature ● Pulmonary oedema seldom develops later than four hours temperature is below 28 C. The circulation must be supported after immersion by chest compression until further attempts can be made when ● Blood-born sepsis is a late complication the core temperature has been raised above this level. Effects of tonicities of Resuscitation from accidental hypothermia of 13. Circum-rescue collapse, ● Walpoth BH, Walpoth-Aslan BN, Mattle HP, Radanov BP, Schroth sometimes fatal, associated with rescue of immersion victims. Much of the experimental evidence on the role of route, but the intraosseous route is used drugs has been derived from animal work, but the results have occasionally, particularly in children. They include: Current resuscitation guidelines recommend that drugs ● Haemorrhage should be used when scientific evidence shows that drugs are of ● Arterial puncture value, rather than for historical or theoretical reasons, or on ● Extravascular drug administration regardless of the vein used the basis of anecdotal evidence alone. In many cases the ● Pneumothorax if cannulation of the subclavian vein is attempted strength of the evidence of benefit is inadequate to make a Central venous cannulation may be hazardous after the definite recommendation. In most cases, guidance represents administration of thrombolytic drugs, and, if required, in this a compromise between the available scientific evidence and a circumstance the femoral approach is recommended. The routes by which drugs may be administered in these circumstances are also described. Routes of Drug administration Intravenous routes Peripheral venous cannulation is safe, easily learned, and does not require interruption of CPR. A large vein, usually in the antecubital fossa, is the site of choice, and drugs injected here during CPR reach peak concentration in the major systemic arteries 1. This circulation time is reduced if the bolus of drug is followed by a normal saline flush, so once a cannula is in place it should be connected to an intravenous infusion that can be run in rapidly to aid drug administration. Raising the limb and massaging the veins will also speed delivery to the central circulation. Central venous cannulation allows drugs to reach their site of action more rapidly and in a higher concentration, but the technique requires greater skill. It is particularly useful when cannulation of peripheral veins is technically difficult.

Getting your bearings It is important to find out as much as possible about the context A lecturer holds forth cheap 50mg viagra professional mastercard erectile dysfunction middle age. An understanding of the context will allow you to prepare a What you need to know before planning a lecture lecture that is both appropriate and designed to move students on from where they are buy viagra professional 50 mg with amex erectile dysfunction doctors in memphis tn. The successful teacher is no longer on a height, pumping knowledge at high pressure into passive receptacles. These will help to define Optional student activity designed to the teaching methods and the structure. If, for example, the reinforce learning second key point • Summarise purpose of the lecture is to introduce new knowledge and • Repeat main themes and conclude concepts, then a classic lecture structure might be most appropriate. On the other hand, if the purpose is to make the students Example of a lecture plan with a classic structure aware of different approaches to a particular clinical problem, a problem oriented design in which alternative approaches are presented and discussed might be a more appropriate format. Which teaching media should be used (for example, slides, overheads, handouts, quizzes)? The most Discuss strengths and weaknesses appropriate media will differ depending on the venue, class size, of solution 1 and topic. Optional student activity based on solution 1 Offer solution 2 Choosing the medium for delivering the lecture Discuss strengths and weaknesses of solution 2 x Which teaching media are available at the teaching venue? Optional student activity based on x Which teaching media are you familiar with? Example of a lecture plan with a problem oriented structure x Which medium would encourage students to learn through interaction during your lecture? Getting started In the first moments of a lecture it is important that the students are given some sense of place and direction. Thus a brief summary of the previous lecture and an indication of the Handouts major themes and learning objectives for the current session x Handouts can encourage better learning if they allow students provide both you and the students with a relatively easy start. If more time to listen and think you are working with a new group it may be useful to indicate x Handouts should provide a scaffold on which students can build the ground rules for the session—for example, “switch off their understanding of a topic x Handouts should provide a summary of the major themes while mobile phones,” or “ask questions at any time. However, you can use various methods to encourage students to take a more active part in the learning process. Students’ attention (and recall) is best at the beginning and Better Lecture without student activity end of a lecture. Recall can be improved by changing the format of your lecture part way through. It is also important Lecture with student activity when planning a lecture to think about activities and exercises that will break up the presentation. Ask questions It is useful to ask questions of the group at various stages in the lecture, to check comprehension and promote discussion. Many lecturers are intimidated by the silence following a question and fall into the trap of answering it themselves. It takes time for students to move from Start of lecture End of lecture listening to thinking mode. A simple tip is to count slowly to 10 Student activity Time in your head—a question is almost certain to arrive. Graph showing effect of students’ interaction on their ability to recall what Get students to ask you questions they have heard in a lecture. Adapted from Bligh, 2000 (see “Recommended An alternative to getting students to answer questions is to ask reading” box) them to direct questions at you. A good way of overcoming students’ normal fear of embarrassment is to ask them to prepare questions in groups of two or three. When asked a question, you Involve me, and I understand” should repeat it out loud to ensure that the whole group is Chinese proverb aware of what was asked. Seeking answers to the question from other students, before adding your own views, can increase the level of interaction further. The lecturer invites answers to a question or problem from the audience and writes them, without comment, on a board or overhead. After a short period, usually about two or three minutes, the lecturer reviews the list of “answers” with the class. The answers can be used to provide material for the next part of the lecture or to give students an idea of where they are before they move on.

Furthermore he noted that ‘the list of daily activities to which health can be related is ever growing and with the current operating perspective of medicine it seems infinitely expandable’ viagra professional 50 mg visa erectile dysfunction fertility treatment. In the late 1970s viagra professional 100 mg with amex impotence erecaid system esteem battery operated vacuum impotence device, another American sociologist, Robert Crawford, characterised health promotion as ‘victim-blaming’, an ‘ideology which blames the individual for her or his illness and proposes that, instead of relying on costly and inefficient medical services, the individual should take more responsibility for her or his health. At- risk behaviour is seen as the problem and changing life-style, through education and/or economic sanctions, as the solution’ (Crawford 1977). On the one hand, they served to ‘reorder expectations and to justify the retrenchment from rights and entitlements for access to medical services’. On the other, they attempted ‘to divert attention from the social causation of disease in the commercial and industrial sectors’. The Health of the Nation It was not until after her third general election victory in 1987 that Margaret Thatcher seriously set about reforming the health service. The 1989 White Paper Working for Patients heralded the introduction of the internal market into the NHS, with hospital trusts and GP fundholding. Yet, by the time these measures became operational in 1991, Mrs Thatcher had been replaced by John Major, and it was under his leadership that the Health of the Nation policy was introduced, with a Green Paper in June 1991 and a White Paper in July 1992 (DoH 1991, DoH 1992). This comprehensive health promotion programme was ideally suited to Major’s attempt to 75 THE POLITICS OF HEALTH PROMOTION project a more conciliatory ‘one nation’ Toryism in contrast to his predecessor’s combative and divisive style. It also provided the perfect complement to the internal market reforms, appearing to soften their competitive edge while being quite consistent with their individualistic ethos. A cursory inspection of the Health of the Nation package reveals that many lessons had been learned from Owen’s ill-fated venture into health promotion in the 1970s. In his foreword to the Green Paper, health minister William Waldegrave indicated his concern to avoid criticism on the grounds of ‘victim-blaming’: ‘for too long… the health debate has been bedevilled by the two extreme claims of, on the one hand, “It’s all up to individuals”, and on the other, “It’s all up to Government”’ (DoH 1991:v). In what might be regarded as an early formulation of ‘the third way’, he insisted that ‘we need a proper balance between individual responsibility and Government action’. The subsequent White Paper, presented by Waldegrave’s successor Virginia Bottomley, continued this theme, emphasising that We must get the balance right between what the Government, and Government alone can do, what other organisations and agencies need to do and, finally, what individuals and families must contribute if the strategy is to succeed. The White Paper proposed a Cabinet-level coordinating committee and outlined specific roles for local authorities, the media, the Health Education Authority, and for employers and health professionals. It announced arrangements for providing funds for voluntary organisations, recognising that they could play a significant part through ‘self- help’, ‘bringing people together to share common problems’; through ‘direct service provision’, offering a ‘wide variety of services’; ‘community health’; ‘health education and promotion, education for health professionals, fund raising and support for research’ (DoH 1992:24–5). Though there were many differences between the circumstances in which the first two government initiatives in health promotion took place, one constant feature was the poor relations prevailing between the medical profession and the government. The internal market reforms presented in the 1989 White Paper were drafted without any consultation with doctors’ leaders and in 1990 a new contract was imposed on GPs after it had been overwhelmingly rejected by GP representatives (Timmins 1995:467). However, it rapidly emerged that, whatever the positions of their leaders, many doctors could see benefits in both hospital trusts and fundholding, and many GPs were keen to take advantage of the incentives offered by the new contract. Furthermore, some GPs who remained hostile to fundholding were keen on the preventive strategy advanced in the Health of the Nation documents and encouraged by the new contract. The endorsement by the BMA and the RCGP of a lavish Health of the Nation information pack, produced by the government and distributed free of charge to every GP, indicated the profession’s general approval for the policy, whatever its past conflicts with the government. Perhaps the most distinctive feature of the Health of the Nation policy was its identification of ‘key areas for action’ and its setting of precise targets in each of these areas. The five key areas were CHD and stroke, cancers, mental illness, HIV/Aids and sexual health, and accidents; the White Paper set fifteen targets in these areas and an additional ten ‘risk factor’ targets in matters such as smoking, diet and blood pressure. Though some of the targets— such as the aim to reduce the suicide rate by 15 per cent and the teenage pregnancy rate by 50 per cent by the year 2000—provoked mockery, the very precision of the figures conveyed the seriousness of the government’s commitment to its health promotion policy. Though this approach to defining objectives was widely criticised as a style of socialist planning, its inspiration came from the US health promotion policy introduced in the early 1980s, which had set 126 ‘achievable’ objectives in reducing the burden of ill-health (US Department of Health, Education and Welfare 1980). It is possible to evaluate the policy by placing a tick or a cross against each of its targets: thus death rates from CHD and stroke, and from breast cancer in women and lung cancer in men, fell to meet the targets (though cynics observed that they had been declining at this rate for some years), but rates of obesity and inactivity, teenage smoking, drinking among women and suicide among men, continued to rise (Calman 1998:51). However, to judge the policy merely according to its own targets would be to underestimate its influence (Nuffield Institute for Health et al. Whether or not individual behaviour changed, the fact that, for example, in the course of the 1990s the smoker came to be regarded as a pariah, rather than as a person of coolness and sophistication, reflects the wider impact of the climate of opinion around issues of health that this policy did much to encourage. When a young woman said to me in the surgery ‘I don’t lead a bad life—I don’t smoke, or drink much and I eat sensibly—so why do I feel ill all the time? The greater impact of official health promotion propaganda in the 1990s compared with a decade earlier also revealed the enhanced sense of individual isolation that resulted from the Thatcher years. This was the result of a number of factors, including the persistence of mass unemployment and the resulting job insecurity and the increasing instability of family relationships. The breakdown of institutions and traditions of collectivity during the 1980s, best exemplified by the defeat and demoralisation of the trade unions, exacerbated the fragmentation of communities as well as labour movement organisations.

Medicine” by the American Orthopedic Society He did postgraduate work in orthopedic surgery for Sports Medicine viagra professional 50 mg fast delivery erectile dysfunction caused by hydrocodone. Slocum discount 100 mg viagra professional overnight delivery impotence in young males, that he approached “the whole business of the knee and its intricacies with a healthy measure of scholarly curiosity, a bit of respect for the Original Designer, and enough self-effacing wit to keep his considerable technical accomplishments in perspective. He was well aware of social problems, and was always looking for ways to improve the human condition. In 1947, he was instrumental in establishing the Easter Seal School and Treatment Center in Eugene. For years he sponsored scholarships for students in sports at the University of Oregon and served on the Board of the University of Oregon Develop- ment Fund. An avid historian, he lectured on sub- jects relating to the pioneers, the growth of the colonies, and the courage of our forebears. Even on his death bed, ill with leukemia, he 1907–1992 read computer books and magazines, trying to comprehend another world. Stan James Ian Smillie’s career was guided by the pursuit of described the essence of Donald Slocum’s thirst excellence and a single-minded intent to establish for knowledge: “If Don was set down in the orthopedic surgery as a specialty in its own right. After 3 years as a clinical assistant to Sir Walter Recognized by orthopedists and sports-medicine Mercer, he was placed in charge of the war-time specialists as a giant in his field, Dr. Slocum made Emergency Medical Service Orthopedic Hospital innumerable contributions to his associates, as at Larbert in 1939. There he developed a team of well as to the multitude of patients under his sur- expert surgeons, nurses and therapists and an gical care. Guided by a strong desire to learn and orthopedic workshop, which eventually spawned contribute, Dr. Slocum changed the direction of virtually all the senior orthotists in Scotland. In 1948 he became surgeon-in-charge of the orthopedic service of the Eastern Region of Scot- land and also gained the Gold Medal at the ChM examination of the University of Edinburgh. He was a Nuffield Traveling Fellow to the United States of America and Canada in the same year. At the Bridge of Earn Hospital, he further devel- oped his team concept and his ideas on the con- tinuum of rehabilitation—each trainee spent one element of his rotation in the hospital’s rehabili- tation unit. He also established orthopedic clinics in Dundee, not with the entire approval of some of the general surgeons. In 1967, he was appointed professor of ortho- pedics in a newly established chair of the Uni- 308 Who’s Who in Orthopedics versity of St. When the advanced he gave them, but also for his style, and a certain medical school was transferred to Dundee, he flamboyance. I remember my first sight of him became professor of orthopedics of that univer- in hospital whites, smoking a Burma cheroot; a sity. By this time he had established himself as more persistent image through the ensuing years one of the few world authorities on the knee, was of the “wee man’ dressed in an elegantly while continuing to be a brilliant and inventive tailored dark coat and a wide-brimmed, black surgeon, as well as an unusually charismatic and fedora. This was recognized by invita- Sadly, his final years were marred by severe tions to teach in many parts of the world, includ- physical disability, although his mind remained as ing North, Central and South America, Europe, alert as ever. Throughout this time he was cared the Mediterranean, and the Near and Far East. He all these places his monographs on Injuries of the died at his home near Blairgowrie in his 84th year. Knee Joint and Diseases of the Knee Joint had He was survived by Jenny, two daughters from his preceded him. The first went into five editions and first marriage and Jenny’s three children. These pub- lications were the result of personal observation, data collection, careful pathological analysis and considered judgment. The operations that he described were effective and saved many knees from considerable malfunction. Although some of these procedures have been superseded by new technology, the basic principles of comprehensive assessment, accurate diagnosis, and progressive rehabilitation still hold. Smillie’s academic and professional career was finally capped by his presidency of the International Society of the Knee from 1981 to 1983.