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As you go on to read this book you will become more familiar with the different methods and should be able to find something in which 1 2 / PRACTICAL RESEARCH METHODS you are interested cheap 300 mg zyloprim overnight delivery treatment 1st degree burn. If so zyloprim 100mg sale treatment 2nd 3rd degree burns, you may find it interesting to delve deeper into statistical software. Or you might have been invited to take part in a focus group for a mar- ket research company and found it an interesting experi- ence. Perhaps now you would find it enjoyable to try running your own focus group? Or maybe you have been fascinated by a particular group of people and you would like to immerse yourself within that group, taking part in their activities whilst studying their behaviour? What personal characteristics do I have which might help me to complete my research? Think about your personal characteristics, likes and dis- likes, strengths and weaknesses when you’re planning your research. If you’re very good with people you might like to think about a project which would involve you con- ducting in-depth interviews with people who you find fas- cinating. If you absolutely hate mathematics and statistics, steer clear of large survey research. Or do you prefer to hide yourself away and number crunch, or spend hours on the internet? All of these personal characteristics suggest a leaning towards certain types of research. As you read this book you will find ideas forming – jot these down so that you can refer to them later when you come to plan your research. If your research is to be employment based, the chances are you will have work experience which you’ll find useful HOW TO DEFINE YOUR PROJECT / 3 when conducting your research project. This is valid ex- perience and you should make the most of it when plan- ning your research. Even if your project is not employment based, all of you will have other skills and experience which will help. For example, if you have been a student for three years, you will have developed good literature search skills which will be very useful in the re- search process. Some of you may have developed commit- tee skills, organisation skills and time management expertise. Think about your existing skills in relation to your proposed project as it will help you to think about whether your knowledge, experience and skills will help you to address the problem you have identified. Many research projects fail because people don’t take en- ough time to think about the issues involved before rush- ing to start the work. It is extremely important to spend time thinking about your project before you move on to the planning stage. Through careful thought you should stop yourself wasting time and energy on inappropriate methods as your research progresses. Consider the follow- ing example: EXAMPLE 1: JAMES James wanted to find out about students’ experiences of housing in his university town. When the replies started to come in, he realised that the questionnaires weren’t generating the type of information in which he was interested. When he talked through his concerns 4 / PRACTICAL RESEARCH METHODS with his tutor, it emerged that James was really inter- ested in attitudes towards, and experiences of, rented accommodation. His questionnaire had been poorly de- signed and was not generating this type of information. He had to scrap the questionnaire and construct an- other which he combined with a number of one-to- one interviews to get more in-depth information. He had spent three months designing and administering a questionnaire which had not produced the type of infor- mation he required. If he had spent more time thinking about the research, especially coming to terms with the difference between qualitative and quantitative research, he would have saved himself a lot of time and energy (see Chapter 2). THE FIVE ‘WS’ When you start to think about your research project, a useful way of remembering the important questions to ask is to think of the five ‘Ws’: X What?

The Eight Steps to Self-Diagnosis 55 are those who believe stress should be relieved but do it in ways that could cause a malady generic zyloprim 300mg with visa medications similar to lyrica, such as drinking discount zyloprim 300 mg without a prescription treatment integrity, drugging, or eating too much or too lit- tle. These activities (themselves an underlying disease) are often overlooked as a potential cause of a secondary mystery malady. This is because one of the symptoms of the underlying primary illness is denial. In the privacy of your own room, without the need to disclose the information to anyone yet, allow yourself to consider the possibility that your particular beliefs and lifestyle might be a contributing cause or perhaps even the main cause of your mystery malady. Step Eight: Take Your Notebook to Your Physician and Get a Complete Physical Exam The notebook you began in Step One probably has many pages by now. If you have not done so already, now is the time to take the results of all your good detective work and consult the “experts. In the next chapter, we will discuss how to create a proactive partner- ship with your physicians so you can more effectively enlist their help in your search for the correct diagnosis. And in Chapter 5, we’ll show you how to continue your medical detective work on the Internet. The last of the steps is to take your notebook full of clues to your physician and get a complete physical examination. Even if your doctor hasn’t been able to solve your mystery malady up to this point, a good relationship with the right practitioner can be one of your greatest resources in your quest for the correct diagnosis. In this chapter, we will explore the special needs of the mystery mal- ady patient and describe the traits you need to look for when selecting a physician. This chapter will also identify ways to create a lasting, creative, and productive partnership with that physician. Your role in creating such a therapeutic partnership will be emphasized and discussed in depth. With a willingness and commitment of both parties to make this vital collabora- tion work, the chances of reaching a diagnosis—and ultimately a cure— increase dramatically. Even if it takes some time, you’ll find that choosing the right doctor and creating a therapeutic partnership can have a dramatic impact on your overall healing. Feeling a sense of support from, confidence in, and comfort 57 Copyright © 2005 by Lynn Dannheisser and Jerry Rosenbaum. Most educated consumers of medical care are generally familiar with the things to look for in selecting the right physician: • Medical competence, including level of training, licensing, board cer- tification, and experience in the diagnosis and treatment of the med- ical area related to your concern • Good references, hospital privileges, and the respect of peers • Ease in obtaining appointments, diagnostic testing, and prescriptions for medications • Good listening skills • Ability to give clear explanations • Respect for patients (including not having patients wait more than twenty minutes without an explanation for the delay) • Reasonable fees and/or acceptance of your insurance • Belief in and practice of preventive medicine Unique Needs of the Mystery Malady Patient The qualities already listed are imperatives in any doctor-patient relation- ship. However, mystery malady patients have special needs and require some unique additional qualities in their physician. Understanding and Extra Support First and probably foremost, mystery malady patients become just that because no doctor has successfully diagnosed them. It is understandable, therefore, that you approach the task of finding the right physician already feeling disappointed and frustrated by the medical community. After all, you have been traveling from one specialist to another only to receive no diagnosis, misdiagnoses, or contradictory diagnoses. Unless physicians have experienced a mystery malady firsthand or through a family member, few of them can even begin to know the often unspoken emotional burden of having an undiagnosed disease—the lack of Creating a Proactive Partnership with Your Physician 59 control, the anxiety of not knowing if you will ever get well, the adverse impact on your relationships, the sense of isolation, and the abandonment and hopelessness you may feel. Nor do physicians necessarily appreciate the inordinate amount of patience, persistence, and inner strength required to deal with the chronicity of your symptoms, the decrease in your overall qual- ity of life that comes with the uncertainty, and the physical as well as emo- tional impairment of function resulting from your mystery malady. Yet it is not a psychiatrist you need; it is a medical doctor who is sen- sitive to the effects of living with an unidentified illness. To most physicians, illness is a disease process that can be measured and understood through testing and clinical observation. You need a doctor who understands this and can give you the compassion as well as the support you need during the time it takes to pursue answers. You need to feel you’re not being judged about your fears and anxieties. You need someone who is willing to give you extra time, extra patience, and extra effort as you seek symptom relief and explore alternatives while searching for a diagnosis. This is no small request in an era in which most doctors have doubled their patient loads in an effort to survive financially in a managed-care environment, despite their desire to give high-quality medical care. Assurance of Continuity of Care Many—if not most—mystery malady patients have a pressing, practical problem: these days, physicians live in a world of medical specialization where very few are willing to move beyond their niche. You, on the other hand, live in a world where your mystery malady may cross over several areas of specialization.

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Self-adhesive monitor or defibrillator electrodes do not require additional pressure discount 100mg zyloprim symptoms of flu. In patients with considerable chest hair cheap 300 mg zyloprim otc symptoms ulcer, poor Determinants of transthoracic electrode contact and air trapping will increase the impedance. Transthoracic impedance is ● Electrode size about 9% lower when the lungs are empty, so defibrillation is ● Electrical contact ● Number of and time since previous shocks best carried out during the expiratory phase of ventilation. It is ● Phase of ventilation also important to avoid positioning the electrodes over the ● Distance between electrodes breast tissue of female patients because this causes high ● Paddle or electrode pressure impedance to current flow. Defibrillator shock waveform The effectiveness of a shock in terminating VF depends on the type of shock waveform discharged by the defibrillator. Traditionally, defibrillators delivered a monophasic sinusoidal or damped sinusoidal waveform. Recently it has been shown that biphasic waveforms (in which the polarity of the shock changes) are more effective than monophasic shocks of equivalent energy. Defibrillators that deliver biphasic shocks are now in clinical use, and considerable savings in size and weight 50 Edmark result from the reduced energy levels needed. Biphasic shocks 2000 40 have been widely employed in implantable cardioverter Gurvich defibrillators (ICDs) because their increased effectiveness 30 allows more shocks to be given for any particular battery size. Defibrillators that use biphasic waveforms offer the 1000 20 potential of both greater efficiency and less myocardial damage 10 than conventional monophasic defibrillators. Much of this evidence has been gained from studies conducted during the 0 0 implantation of cardioverter defibrillators but some evidence shows that the increased efficiency of biphasic waveforms leads –10 to higher survival rates during resuscitation attempts. For example, a success rate of 70% means Edmark monophasic and Gurvich biphasic defibrillator waveforms failure in 30 out of 100 patients. If a further shock, with the same 70% chance of success, is given to those 30 patients an additional 21 successes will be achieved (70% of 30). When using a defibrillator with a monomorphic waveform it is recommended that the first shock should be at an energy 7 ABC of Resuscitation level of 200 J. Should this be unsuccessful, a second shock at the same energy level may prove effective because the Electrode position transthoracic impedance is reduced by repeated shocks. If two ● The ideal electrode position allows maximum current to flow shocks at 200 J are unsuccessful, the energy setting should be through the myocardium. This will occur when the heart lies in the direct path of the current increased to 360 J for the third and subsequent attempts. Although this equivalence is not left intercostal space clearly defined, and may vary between different types of ● An alternative is to place one electrode to the left of the biphasic waveform, a biphasic shock of 150 J is commonly lower sternal border and the other on the posterior chest wall below the angle of the left scapula considered to be at least as effective as a 200 J monophasic ● Avoid placing electrodes directly over breast tissue in women shock. Many automated biphasic defibrillators do not employ escalating shock energies and have produced similar clinical outcomes to the use of conventional monophasic defibrillators Electrode size or surface area in which the third and subsequent shocks are delivered at 360 J. Another technique to increase efficiency is the use of sequentially overlapping shocks that produce a shifting electrical vector during a multiple pulse Body size shock. This technique may also reduce the energy ● Infants and children require shocks of lower energy than requirements for successful defibrillation. The optimal current for terminating VF lies between 30 and 40 Amperes with a monophasic damped sinusoidal waveform. Studies are in progress to determine the equivalent current dosages for biphasic shocks. Manual defibrillation Manual defibrillators use electrical energy from batteries or from the mains to charge a capacitor, and the energy stored is then subsequently discharged through electrodes placed on the casualty’s chest. These may either be handheld paddles or electrodes similar to the adhesive electrodes used with automated defibrillators. The energy stored in the capacitor may be varied by a manual control on which the calibration points indicate the energy in Joules delivered by the machine. Modern defibrillators allow monitoring of the electrocardiogram (ECG) through the defibrillator electrodes and display the rhythm on a screen. With a manual defibrillator, the operator interprets the rhythm and decides if a shock is required. The strength of the shock, the charging of the capacitor, and the delivery of the shock are all under the control of the operator. Most modern machines allow these procedures to be performed through controls contained in the handles of the paddles so that the procedure may be accomplished without removing the electrodes from the chest wall. Considerable skill and training are required, mainly because of the need to interpret the ECG.

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The distension of the bladder results in reflex • Pounding headache sympathetic overactivity below the level of the spinal cord • Profuse sweating lesion discount zyloprim 100 mg with visa medicine to induce labor, causing vasoconstriction and severe systemic • Flushing or blotchiness above level of lesion hypertension buy cheap zyloprim 300mg online medications used to treat ptsd. The carotid and aortic baroreceptors are • Danger of intracranial haemorrhage stimulated and respond via the vasomotor centre with increased vagal tone and resulting bradycardia, but the peripheral vasodilatation that would normally have relieved the hypertension does not occur because stimuli cannot pass distally through the injured cord. Characteristically the patient suffers a pounding headache, profuse sweating, and flushing or blotchiness of the skin above the level of the spinal cord lesion. Other conditions in which visceral stimulation can result in autonomic dysreflexia include urinary tract infection, bladder Box 6. If • Sit patient up this lies in the urinary tract catheterisation is often necessary. If • Treat with: hypertension persists nifedipine 5–10mg sublingually, glyceryl Nifedipine 5–10mg capsule—bite and swallow or trinitrate 300micrograms sublingually, or phentolamine Glyceryl trinitrate 300 g sublingually 5–10mg intravenously is given. If inadequately treated the If blood pressure continues to rise despite intervention, treat with patient can become sensitised and develop repeated attacks antihypertensive drug e. Later management may include removal of bladder calculi or sphincterotomy if detrusor-sphincter dyssynergia is causing the symptoms; performed under spinal anaesthesia, the risk of autonomic dysreflexia is lessened. Biochemical disturbances Hyponatraemia The aetiology of hyponatraemia is multifactorial, involving fluid overload, diuretic usage, the sodium depleting effects of drugs such as carbamazepine, and inappropriate antidiuretic Box 6. Hyponatraemia It may occur (1) during the acute stage of spinal cord Acute —due to excessive intravenous fluids injury, when the patient is on intravenous fluids, or (2) in the Chronic —systemic sepsis chronic phase, often in association with systemic sepsis —excessive oral fluid intake frequently of chest or urinary tract origin, and often —drug induced e. Sepsis —review drugs should be controlled, fluids restricted, and medication —furosemide, potassium supplements reviewed. Hypertonic saline (2N) should be avoided because of —demeclocycline (occasionally) Hypercalcaemia the risk of central pontine myelinolysis. Furosemide Symptoms—constipation (frusemide) and potassium supplements are useful, but the rate Treatment—hydration of correction of the serum sodium must be managed carefully. The diagnosis is often difficult, and symptoms can include constipation, abdominal pain, and headaches. The problem is uncommon and diagnosis may be delayed, if the serum calcium is not measured. Para-articular heterotopic ossification After injury to the spinal cord new bone is often laid down in the soft tissues around paralysed joints, particularly the hip and knee. It usually presents with erythema, induration, or swelling near a joint. There is pronounced osteoblastic activity, but the new bone formed does not mature for at least 18 months. This has an important bearing on treatment in that if excision of heterotopic bone is required because of gross restriction of movement or bony ankylosis of a joint, surgery is best delayed for at least 18 months—until the new bone is Figure 6. Earlier surgical intervention may provoke further new bone formation, thus compounding the original condition. Treatment with disodium etidronate suppresses the mineralisation of osteoid tissue and may reverse up to half of early lesions when used for 3–6 months, and non-steroidal anti-inflammatory drugs are also used to prevent the progression of this complication. Postoperative radiotherapy may halt the recurrence of the problem if early surgical Box 6. It usually increases in severity during the first few weeks after injury, after the period of spinal shock. In incomplete lesions it is often more pronounced and can be severe enough to prevent patients with good power in the legs from walking. Patients with severe spasticity and imbalance of opposing muscle groups have a tendency to develop contractures. It is important to realise that once a contracture occurs spasticity is increased and a vicious circle is established with further deformity resulting. It maintains muscle • Improve comfort/posture bulk and possibly bone density, and improves venous return. An irritative lesion in —tizanidine the paralysed part, such as a pressure sore, urinary tract —dantrolene infection or calculus, anal fissure, infected ingrowing toenail, or —diazepam fracture, tends to increase spasticity. With these drugs, • intrathecal block (rarely used)—6% aqueous phenol the liver function tests need to be closely monitored.

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