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Liv 52

By N. Garik. University of Richmond.

However purchase 60 ml liv 52 with mastercard, if you need to request an unusual or urgent investigation then telephoning the department is not only courteous order 60 ml liv 52 mastercard, but it will ensure that the test is actually performed generic 120 ml liv 52 with mastercard. This is particularly important outside normal working hours when samples are often only picked up from the drop box (where the porters or vac- uum chutes leave them) if the technician is telephoned in advance liv 52 200 ml amex. When speaking to departments always ensure that you are talking to the relevant person at the start of the conversation and then explain your request. There is rarely any problem with requests being accepted unless it is the middle of the night where you will be asked 71 72 What They Didn’t Teach You at Medical School for clinical justification. This is rarely a taxing matter however, and a simple reply usually suffices. One small note that will win you favour is to inform the on-call technician in advance if you know that you will be taking a sample in the middle of the night. This information is invaluable as they will keep the machines running and stick around in the hospital until the sample arrives. In small hospitals the technicians often go home, as there is little work at night and only return to the hospital if bleeped by you. Saving them a journey home and back again will make their life easier and also means that you will get your result faster. Usually you will be waiting up to get the result, so you can see how a one-minute telephone call at 9 p. You will be introduced to them in the first week of your post (supposedly), but quite often the time you start a job is when they are away on holiday. During your‘interview’, which is more like an informal chat, you will be asked what your expectations of the post are and what your career plans are (if you have any). If you have any professional or personal problems that may interfere or are interfering with your job you should discuss them with your tutor. Your tutor will be surprisingly understanding and is there to help you rather than to intimidate or hinder you. The purpose of this meeting is not only for you to find out what is expected of you, but also for the department to find out what you expect of them. It may sound unusual that you can have expectations, but if you are in a training post then the trust and department has an obligation to provide ward- and lecture- based‘bleep-free’teaching,as well as practical on-the-job training. Often departments and trusts do not provide the required teaching and it is not unreasonable to make a complaint about this early on in your post to your clinical tutor. With decreasing hours on the job it is important to get the most out of your training. General Medical Council Registration It is surprisingly easy to get full registration and here is why: the government has spent in excess of £150000 to train you over a period of five to six years depending on your 73 74 What They Didn’t Teach You at Medical School course. They want to register you because they need a return on their investment. In fact your salary as a pre-registration house officer (PRHO) is paid not by your hospital, but by your medical school and the hospital is paid to take you on. What this means is that, as a PRHO, you are there to learn and not just provide a service for the hospital. On the contrary, most consultants will pick up on who is a good or bad PRHO very quickly and make a note of things for your refer- ence. The efforts you put in as a PRHO will ultimately get you a good reference and provide you with the knowledge that will get you into a good senior house officer (SHO) post. Once you are into your second house job you will need to start thinking about which SHO/F2 posts to apply for. At this stage,once you have decided on a basic career path (that is medicine, surgery, general practice, obstetrics and gynaecology, etc. Rotations These are a series of six-month posts linked to one hospital, but usually based at several hospitals within close proximity.

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Debate still continues as to the optimal fluid for resuscitation in acute hypovolaemia generic liv 52 200 ml amex. It is the volume of fluid that is probably the most important factor in initial resuscitation generic liv 52 120 ml free shipping. Once reasons: 30-40% blood volume has been replaced buy liv 52 100 ml without prescription, it is necessary to consider the additional use of blood purchase 200 ml liv 52 free shipping. Intravenous fluid ● Increased blood pressure dislodges blood clots resuscitation in children should begin with boluses of 20ml/kg, ● Increased blood pressure accelerates titrated according to effect. As hypothermia ● Hypothermia may result in arrhythmias a result, intravascular retention of crystalloids is poor 68 Resuscitation of the patient with major trauma (about 20%) and at least three times the actual intravascular Crystalloids volume deficit must be infused to achieve normovolaemia. Advantages Colloids ● Balanced electrolyte composition ● Buffering capacity (lactate) Colloids are large molecules that remain in the intravascular ● No risk of anaphylaxis compartment until they are metabolised. Therefore, they ● Little disturbance to haemostasis provide more efficient volume restoration than crystalloids. The main colloids Disadvantages available are derived from gelatins: ● Poor plasma volume expansion ● Large quantities needed ● Gelofusine ● Risk of hypothermia ● Haemaccel (unsuitable for transfusion with whole blood ● Reduced plasma colloid osmotic pressure because of its high calcium content). In an adult, about 250ml (4ml/kg) hypertonic saline dextran (HSD) provides a similar haemodynamic response to that seen with 3000ml of 0. Hypertonic saline acts through several Colloids pathways to improve hypovolaemic shock: Advantages ● Effective intravascular volume expansion and improved ● Effective plasma volume expansion organ blood flow ● Moderately prolonged increase in plasma volume ● Reduced endothelial swelling, improving microcirculatory ● Moderate volumes required blood flow ● Maintain plasma colloid osmotic pressure ● Lowering of intracranial pressure through an osmotic effect. Appropriately cross-matched blood is ideal, but the urgency of the situation may only allow time to complete a type-specific cross-match or necessitate the immediate use of “O” rhesus negative blood. Deranged coagulation may be a significant problem with massive transfusion, requiring administration of clotting products and platelets. Intravenous fluids should ideally be warmed before administration to minimise hypothermia; 500ml blood at 4 C will reduce core temperature by about 0. Large volumes of cold fluids can, therefore, cause significant hypothermia, which is itself associated with significant morbidity and mortality. If the patient is pregnant the gravid uterus should be displaced laterally to avoid hypotension associated with aortocaval compression; blankets under the right hip will suffice if a wedge is not available. If the patient requires immobilisation on a spinal board, place the wedge underneath the board. Disability (neurological) A rapid assessment of neurological status is performed as part of the primary survey. Although an altered level of consciousness may be caused by head injury, hypoxia and hypotension are also common causes of central nervous system depression. Be careful not to attribute a depressed level of consciousness to alcohol in a patient who has been drinking. A more detailed assessment using the Glasgow Coma Score can be performed with the primary or secondary survey. Blood—one unit of packed cells will raise the haemoglobin by about 1g/l 69 ABC of Resuscitation It is important to document pupillary size and reaction to Neurological status can be light. If spinal injury is suspected, cord function (gross motor assessed using the simple and sensory evaluation of each limb) should be documented AVPU mnemonic: early, preferably before endotracheal intubation. High-dose corticosteroids have been shown to reduce the degree of ● Alert neurological deficit if given within the first 24 hours after ● Responds to voice ● Responds to pain injury. Methylprednisolone is generally recommended, as early ● Unconscious as possible: 30mg/kg intravenously over 15 minutes followed by an infusion of 5. Glasgow Coma Scale Eye opening Verbal response Motor response Spontaneously 4 Orientated 5 Obeys commands 6 To speech 3 Confused 4 Localises to pain 5 To pain 2 Inappropriate words 3 Flexion (withdrawal) 4 Never 1 Incomprehensible 2 Flexion (decerebrate) 3 sounds Silent 1 Extension 2 No response 1 Exposure Remove any remaining clothing to allow a complete examination; log roll the patient to examine the back. Hypothermia should be actively prevented by maintaining a warm environment, keeping the patient covered when possible, A comatose patient (GCS 8) will require endotracheal intubation. Secondary brain injury is minimised by ensuring warming intravenous fluids, and using forced air warming adequate oxygenation (patent airway), adequate ventilation devices.

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Prolonged seem to be tolerant of hypoxia and resuscitation should be attempts in such patients are rarely successful and are continued for longer than in adults associated with a high incidence of cerebral damage purchase 120 ml liv 52 amex. Drug intake before cardiac arrest Sedative purchase 100 ml liv 52, hypnotic discount 200 ml liv 52, or narcotic drugs taken before cardiac arrest also provide a degree of cerebral protection against the effects of hypoxia and resuscitative efforts should be prolonged accordingly discount 60 ml liv 52 mastercard. Remediable precipitating factors Resuscitation should continue while the potentially remediable conditions giving rise to the arrest are treated. Such conditions Temperature include tension pneumothorax and cardiac tamponade. The outcome after cardiac arrest due to haemorrhagic Resuscitation efforts should be continued for much longer in hypovolaemia is notoriously poor. Factors to be taken into hypothermic than in normothermic patients; situations have been reported of survival with good neurological function after account include the immediate availability of very skilled more than 45 minutes submersion in water. Even under should be continued in hypothermic patients during active optimal conditions survival rates are poor and early rewarming using cardiopulmonary bypass if available and termination of resuscitation is generally indicated if bleeding appropriate (see Chapter 15) cannot be immediately controlled. Pacing should be reserved for relation to resuscitation, which need to be addressed. However, the question arises as to the Such intervention should be reserved for patients with a wisdom and practicality of death being determined in some potentially good prognosis—for example cases of hypothermia, drug overdose, and those with conditions cases by non-medical healthcare professionals, such as nurses amenable to immediate cardiac, thoracic, or abdominal and ambulance personnel. Formal certification must, by law, be undertaken by a registered medical practitioner, and this requirement will not change. Extract of Joint Royal Colleges Ambulance Liaison Nevertheless, it is possible to identify patients in whom survival Committee Guidelines is very unlikely and when resuscitation would be both futile and Group A—Conditions unequivocally associated with death distressing for relatives, friends, and healthcare personnel, and ● Decapitation situations in which time and resources would be wasted in ● Massive cranial and cerebral destruction undertaking such measures. In such cases it has been proposed ● Hemicorporectomy (or similar massive injury) ● Decomposition that the recognition of death may be undertaken by someone ● Incineration other than a registered medical practitioner, such as a trained ● Rigor mortis ambulance paramedic or technician. In introducing such a ● Fetal maceration proposal, it is essential to ensure that death is not erroneously In these groups, death can be recognised by the clinical diagnosed and a potential survivor is denied resuscitation. In addition, (CPR), for more than 20 minutes in a normothermic patient a further group of patients with terminal illness should not be ● Patients who have received no resuscitation for at least 15 resuscitated when the wishes of the patient and doctor have minutes after collapse and who have no pulse or respiratory effort on arrival of the ambulance personnel been made clear. Timings must be accurate No instances have been recorded of patients surviving with In all these cases, the ECG record must be free from artefact the conditions listed in group A, nor of adults who have been and show asystole. There must be no positive history of sedative, submersed for over three hours. Authorities are agreed that it is hypnotic, anxiolytic, opiate, or anaesthetic drugs in the totally inappropriate to commence resuscitation in these preceding 24 hours circumstances. The futility of CPR in patients with mortal Group C—Terminal illness trauma has been highlighted in several publications. Cases of terminal illness when the doctor has given clear The concept of a “Do Not Resuscitate” policy has received instructions that the patient is not for resuscitation international support for patients with terminal illness whose condition has been recently reviewed by the family doctor, in consultation with the relatives and patient where appropriate. Issues in training A study of 1461 patients found that when persistent ventricular fibrillation was excluded, all survivors had a return of Use of the recently dead for practical skills training spontaneous circulation within 20 minutes. No patient survived Opportunities for hands-on training in the practical skills required for resuscitation are limited. In another group of intubation cannot be taught to everyone attending a cardiac 1068 patients who experienced out-of-hospital cardiac arrest, arrest. Although the laryngeal mask may offer an alternative only three survived among those who were transported to option for airway management in the short term, the hospital with ongoing CPR. Those three survivors were introduction of that device on a widespread scale into discharged from hospital with moderate to severe cerebral anaesthetic practice has, in itself, reduced the opportunities for disability. These findings support the proposal that death may training in the anaesthetic room. Manikin training offers an alternative, but most would agree that training on patients is be recognised in normothermic patients who have had a period required to amplify manikin experience. Informed collapse to the arrival of ambulance personnel exceeds consent is difficult to obtain at the sensitive and emotional time 15 minutes, provided that no attempt at CPR has been made in of bereavement, and approaches to relatives may be construed as coercion. Proceeding without consent may be considered as that time interval and the ECG has shown an unshockable assault. This recommendation is supported by a review of 414 The dilemma does not stop with tracheal intubation, and other patients who had not received any CPR in the 15 or more techniques, such as fibre optic intubation, central venous access, minutes to ambulance arrival. No patient survived who had a surgical cut-down venous access, chest drain insertion, and non-shockable rhythm when the first ECG was recorded. This resulted in an algorithm for ambulance personnel 105 ABC of Resuscitation encountering death in these conditions, which has been The involvement of relatives and close friends accepted by the Professional Advisory Group of the Scottish Ambulance Service and the Central Legal Office to the Bystanders should be encouraged to undertake immediate basic life support in the event of cardiorespiratory arrest.

Institutions are thus required to gather data about learning and teaching and present it as evidence for their claims of effectiveness and quality buy 120 ml liv 52 free shipping. Institutions generic 120 ml liv 52 free shipping, in turn buy liv 52 200 ml on-line, have exerted accountability demands onto faculties liv 52 100 ml free shipping, teaching departments and individuals. They commonly require that courses be evaluated on a regular basis and that teachers evaluate their teaching and use the information obtained for both the improvement of teaching and of courses. Evaluation: some definitions and principles Evaluation is a process of obtaining information for judgement and decision making about programmes, courses and teachers. Assessment, a term which is sometimes used interchangeably with evaluation, is about obtaining information for judgement and decision making 189 about students and their learning. However, the results of an assessment of student learning is a very important part of evaluation. We are sure you will be familiar with some of the ways commonly used to gather information – questionnaires and interviews for teaching evaluations, and assignments and examinations to assess student learning. Strategies for judgement and decision-making are less well-developed, however, and we will look at these later in the chapter. This is intended to assist in change, development and improve- ment of teaching. This is used to make decisions such as whether to promote or re-appoint a teacher. Whatever the intentions of an evaluation, you will find it useful to keep in mind that there are several sources of evaluative information and methods you can use to get this information. For example, if you are particularly interested in the students’ experience, you may decide to use several different methods including diaries, ques- tionnaires and focus groups. Space does not allow us to explore all of these sources and methods, which of course can be used in a wide range of combinations. For more help, we recommend you consult someone in your institution’s teaching unit or review the references provided at the end of the chapter. However, in deciding among the options in the table, you need to be aware that two fundamental characteristics of evaluation are validity and reliability. Other important characteristics are the practicality of an evaluation and, of course, its acceptability to all those involved. Validity refers to the truthfulness and appropriateness of information provided as evidence of learning and teaching. For example, high levels of student achievement may not be a valid indicator of teaching competence because of the problem of identifying the relative contribution of teacher, student effort, library resources, students’ peers, and so on. Students can provide valid feedback on the availability of resources and teacher behavior, for example, because they observe and experience these things as part of their course. For example, information about a teacher based on the results of just one student survey will not be as reliable as information derived from several surveys conducted over several years and from a representative range of classes taught. The reliability of an evaluation may also be enhanced if different, but valid methods, are used in combination. Now, armed with this background knowledge, how might you go about evaluating your teaching? Planning evaluation as part of your teaching Among the things you need to think about are the following: Determine what are your institution’s formal require- ments for evaluation. For example, is there a requirement that you should gather student feedback on a regular basis for curriculum development or for promotion or tenure? Make contact with the staff of your teaching unit who will at least be able to advise you if not provide direct evaluation services to you. As we have already suggested, evaluation is an important element of good teaching and so it is something you should be doing all the time. Matters you will need to consider in your plan are how and when you will evaluate your teaching, how you will evaluate student learning and what you will do with the information you gather. You must have some plan to use the information in ways to improve or develop learning and your teaching otherwise there is little point in doing it at all. One way of using information will be to incorporate it into an on-going record of your work known as a Teaching Portfolio.

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Liv 52
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