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If the arrhythmia persists purchase pariet 20 mg otc, the machine will charge itself and indicate that a further shock is required cheap pariet 20mg with visa. Advantages of AEDs The simplicity of operation of the AED has greatly reduced training requirements and extended the range of people that Electrode position for are able to provide defibrillation buy pariet 20mg with visa. The advent of the AED has AED allowed defibrillation by all grades of ambulance staff (not just specially trained paramedics) and in the United Kingdom the goal of equipping every emergency ambulance with a defibrillator has been achieved. Many other categories of healthcare professionals are able to defibrillate using an AED, and in most acute hospital wards and many other departments defibrillation can be undertaken by the staff present (usually nurses), well before the arrival of the cardiac arrest team. It is almost impossible to deliver an inappropriate shock with an AED because the machine will only allow the operator to activate the appropriate control if an appropriate arrhythmia is detected. The operator, however, still has the responsibility for delivering the shock and for ensuring that everyone else is clear of the patient and safe before the charge is delivered. Public access defibrillation Conditions for defibrillation are often only optimal for as little as 90 seconds after the onset of defibrillation, and the need to reduce to a minimum the delay before delivery of a countershock has led to the development of novel ways of providing defibrillation. This is particularly so outside hospital where members of the public, rather than medical personnel, usually witness the event. The term “public access defibrillation” is used to describe the process by which Defibrillation by first aiders defibrillation is performed by lay people trained in the use of an AED. These individuals (who are often staff working at places where the public congregate) operate within a system that is under medical control, but respond independently, usually on their own initiative, when someone collapses. Early schemes to provide defibrillators in public places reported dramatic results. In the first year after their introduction at O’Hare airport, Chicago, several airline passengers who sustained a cardiac arrest were successfully resuscitated after defibrillation by staff at the airport. In Las Vegas, security staff at casinos have been trained to use AEDs with dramatic result; 56 out of 105 patients (53%) with VF survived to be discharged from hospital. The closed circuit TV surveillance in use at the casinos enabled rapid identification of potential patients, and 74% of those defibrillated within three minutes of collapsing survived. Other locations where trained lay people undertake defibrillation are in aircraft and ships when a conventional response from the emergency services is impossible. In one report the cabin crew of American Airlines successfully AED on a railway station 13 ABC of Resuscitation defibrillated all patients with VF, and 40% survived to leave hospital. In the United Kingdom the remoteness of rural communities often prevents the ambulance service from responding quickly enough to a cardiac arrest or to the early Assess victim according to basic life support guidelines stages of acute myocardial infarction. Increasingly, trained lay people (termed “first responders”) living locally and equipped Basic life support, if AED not immediately available with an AED are dispatched by ambulance control at the same time as the ambulance itself. They are able to reach the patient Switch defibrillator on and provide initial treatment, including defibrillation if Attach electrodes necessary, before the ambulance arrives. Other strategies used Follow spoken or visual directions to decrease response times include equipping the police and fire services with AEDs. Analyse The provision of AEDs in large shopping complexes, airports, railway stations, and leisure facilities was introduced as government policy in England in 1999 as the “Defibrillators Shock indicated No shock indicated in Public Places” initiative. The British Heart Foundation has supported the concept of public access defibrillation After every 3 shocks If no circulation enthusiastically and provided many defibrillators for use by CPR 1 minute CPR 1 minute trained lay responders working in organised schemes under the supervision of the ambulance service. As well as being used Algorithm for the use of AEDs to treat patients who have collapsed, it is equally valid to apply an AED as a precautionary measure in people thought to be at risk of cardiac arrest—for example, in patients with chest pain. If cardiac arrest should subsequently occur, the rhythm will be analysed at the earliest opportunity, enabling defibrillation with the minimum delay. Sequence of actions with an AED Once cardiac arrest has been confirmed it may be necessary for an assistant to perform basic life support while the Safety factors equipment is prepared and the adhesive electrodes are ● All removable metal objects, such as chains and medallions, attached to the patient’s chest. The area of contact may need should be removed from the shock pathway—that is, from the front of the chest. Body jewellery that cannot be removed will to be shaved if it is particularly hairy, and a small safety razor need to be left in place. Although this may cause some minor should be carried with the machine for this purpose.

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They observe cheap pariet 20 mg with mastercard, ask questions purchase pariet 20 mg line, and make a judgment based on the candidate’s performance with all the patients trusted pariet 20 mg. Similarly, a structured oral examination is still a face to face session with examiners, but guidelines for the topics to be covered are provided. Alternatively, a series of patient scenarios and agreed questions may be used so that the content and difficulty of the assessment is standardised across the trainees. An alternative way to assess skills is to observe candidates’ interaction with Each of these adaptations is aimed at improving reliability, but patients 34 Skill based assessment the most important improvement comes from greatly increasing the number of patient problems, which may well Factors leading to lower reliability cause an impractical increased testing time. The more x Administrative problems (such as disorganised staff or noisy rooms) reliable a test, the more likely it is that a similar result will be obtained if the test is readministered. Reliability is sensitive to the length of the test, the station or item discrimination, and the heterogeneity of the cohort of candidates. Standardised patients’ portrayals, patients’ behaviour, examiners’ behaviour, and administrative variables also affect reliability. Questions to ensure validity The validity of a test is a measure of the degree to which the test actually measures what it is supposed to measure. Validity is x Are the patient problems relevant and important to the curriculum? The most basic evidence of validity comes x Have content experts (generalists and specialists) reviewed the from documenting the links between the content of the stations? The validity of a standard depends on the judges’ qualifications and the Judges (n≥12) must first imagine the minimally competent or borderline trainee reasonableness of the procedure they use to set it. When pass-fail decisions are being made, a skill based assessment should be “criterion referenced” (that is, trainees should be For each item in each checklist, judges record what they believe assessed relative to performance standards rather than to each the chances are that their imaginary trainee will be successful other or to a reference group). Although the use of OSCEs for skill based assessment is increasingly widespread, modifying more For each item in each checklist, traditional formats may be appropriate when they are judges revise (or not) their initial predictions combined with other forms of assessment or are used to screen trainees. The success of any skill based assessment depends on finding a suitable balance between validity and reliability and Item score = average of revised judgements Station pass mark = average of the item scores between the ideal and the practical. OSCE pass mark = average of the station pass marks Further reading A modified Angoff procedure for an OSCE x Gorter S, Rethans JJ, Scherpbier A, van der Heijde D, Houben H, van der Linden S, et al. Developing case-specific checklists for standardized-patient-based assessments in internal medicine: a review of the literature. The second picture and the picture showing an oral examination are from OSCE checklists do not capture increasing levels of expertise. A comparison of standard-setting procedures for an OSCE in undergraduate medical education. Guidelines for estimating the real cost of an objective structured clinical examination. At the lowest level of the pyramid This article explains what is meant by work based assessment and presents a is knowledge (knows), followed by competence (knows how), classification scheme for current methods performance (shows how), and action (does). In this framework, Miller distinguished between “action” and the lower levels. Work based methods of assessment target this highest level of the pyramid and collect information about doctors’ performance in their normal Does practice. Other common methods of assessment, such as multiple choice questions, simulation tests, and objective Shows how structured clinical examinations (OSCEs) target the lower levels of the pyramid. Underlying this distinction is the sensible but Knows how still unproved assumption that assessments of actual practice are a much better reflection of routine performance than Knows assessments done under test conditions. Miller’s pyramid for assessing clinical competence Methods Although the focus of this article is on practising doctors, work based assessment methods apply to medical students and trainees as well. These methods can be classified in many ways, Methods of collecting data but this article classifies them in two dimensions. The first Clinical records dimension describes the basis for making judgments about the quality of performance. The second dimension is concerned Basis for judgment with how data are collected. Administrative data • Outcomes of care • Process of care Basis for judgment • Practice volume Diaries Outcomes In judgments about the outcomes of their patients, the quality Observation of a cardiologist, for example, might be judged by the mortality of his or her patients within 30 days of acute myocardial infarction.

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Research at the new unit is cen- studied and best understood organisms buy 20mg pariet fast delivery, and become one of the tered on Brenner’s previous work on C cheap pariet 20 mg free shipping. Brenner’s nematode was an ideal subject because it was transparent purchase 20 mg pariet with mastercard, allowing scientists to observe every cell in its See also Bacteriophage and bacteriophage typing; Genetic body, and had a life cycle of only three days. Brenner and his code; Genetic identification of microorganisms; Genetic map- assistants observed thousands of C. Brock was born in Cleveland, Ohio, and has lived For his groundbreaking research and publishing efforts, in the midwestern states of the United States all his life. Brock has received many scientific achievement and educa- Brock’s 1967 summary article in Science, entitled “Life at tion awards in the United States and worldwide. High Temperatures” generated a great deal of interest, and spawned the branch of microbiology concerned with bacteria See also Extremophiles; Tag enzyme that live in extreme environments. After graduating from high school in Chillicothe, Ohio, Brock enlisted in the Navy. As a veteran, he enrolled at Ohio BROTH • see GROWTH AND GROWTH MEDIA State University in 1946. After grad- BROWNIAN MOTION • see BACTERIAL MOVEMENT uation he joined the antibiotics research department at the Upjohn Company. His relative lack of microbiology training to that point necessitated that he learn on the job. This embrac- ing of new aspects of research continued throughout his BrucellosisBRUCELLOSIS microbiology career. Leaving Upjohn after five years, he Brucellosis is a disease caused by bacteria in the genus accepted a position at Western Reserve University (now Case Brucella. In 1960 he moved to Indiana University and sheep; humans can become infected indirectly through as an Assistant Professor of Bacteriology. He remained there contact with infected animals or by drinking Brucella-contam- until 1971. In the United States, most domestic animals are In 1963, Brock had the opportunity to pursue marine vaccinated against the bacteria, but brucellosis remains a risk microbiology research at the Friday Harbor Laboratories of the with imported animal products. Brucella are rod-shaped bacteria that lack a capsule His diagrams of the twisted configurations called “knots” around their cell membranes. Unlike most bacteria, Brucella formed by the growing organisms became a cover story in cause infection by actually entering host cells. This work also stimulated his interest in the microbial ecology of sulfur cross the host cell membrane, they are engulfed by host cell springs, which led him to conduct research at Yellowstone vacuoles called phagosomes. In In particular, Brock isolated and named the bacterium animals, brucellosis is a self-limiting disease, and usually no Thermus aquaticus. This microbe was the first so-called treatment is necessary for the resolution of the disease. Archaebacteria are now However, for a period of time from a few days to several known to be a very ancient form of life, and may even consti- weeks, infected animals may continue to excrete brucella into tute a separate kingdom of life. Under warm, moist conditions, the bac- aquaticus is thus, one of the fundamental milestones of micro- teria may survive for months in soil, milk, and even seawater. Because the bacteria are so hardy, humans may become Brock’s discovery has also had a significant impact in infected with Brucella by direct contact with the bacteria. The enzymes of the bacterium are Handling or cleaning up after infected animals may put a per- designed to work at high temperatures. Brucella are extremely effi- merase is the basis of the polymerase chain reaction that is cient in crossing the human skin barrier through cuts or breaks used to artificially amplify the amount of deoxyribonucleic in the skin.

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Environmental causes of disease are a new and expanding area of research cheap pariet 20 mg with mastercard. Until more evidence emerges generic 20mg pariet mastercard, we must be careful not to jump to con- clusions discount 20mg pariet overnight delivery. On the other hand, because the occurrences of chemical sensitiv- ities, degenerative brain diseases, and many autoimmune disorders are clearly on the rise (some statistics say conservative estimates are now up to 15 percent of the population), it is difficult to ignore environmental factors as causes to be investigated. When considering such factors in your own case, find out if anyone else in your area is having the same or other signif- icant symptoms. Endocrinology is the study and treatment of glands (for example, the thy- roid) and the hormones they produce. The endocrine system is often tested *Mysterious pain often stems from the overuse of soft tissue, muscle, tendons, bursa, and ligaments. This may be due to poor posture or other improper body movements, such as sit- ting at a computer all day or talking with the telephone cradled between your head and shoulder. In women, it can be caused by constantly carrying heavy purses over the shoulders, and in men, it can result from sitting on a wallet. Hormones communicate broadly with other organs through the nervous system, cytokines (proteins that regulate the immune system), and growth factors. Endocrine disorders often cause imbalances in metabolism and as such are among the most difficult to diagnose; the metabolic system as a whole is a finely integrated network of an infinite number of chemical reactions occurring in all body cells, coordinated by signal systems such as hormones and enzymes. Common endocrine disorders include diabetes and other pan- creatic disorders and pituitary, adrenal gland, and thyroid disorders. One metabolic condition in children that has only recently been identified was for many years believed to be the result of deliberate “bad” behavior and thus psychological in origin. Today we know that bedwetting is actually a metabolic disorder and can be treated successfully with a nose spray at bed- time that replaces the hormone necessary for regulating the reabsorption of water in the kidneys. Examples are fractures, sprains, dislocations, head trauma, eye injuries, and tooth loss. Case Studies: Kara and Don Kara suffered for years from vaginal discharge and dyspareunia (pain with sex). Her gynecologist was perplexed by the persistence of erosions (sores) on her cervix despite numerous attempts at therapy, including antibiotics, antifungals, cauteri- zation, and even partial excision (removal of the cervical wall). Only years later, after doing research on the Internet, did Kara realize that she had been inserting her diaphragm upside down, resulting in chronic irritation (trauma) of her cervix. Another case study is Don, who suffered from poor vision for a number of years. He was eventually diagnosed with keratoconus, an unusual cone formation of the cornea. By following the Eight Steps, he sharpened his powers of observation and discovered he was inflicting this condition on himself by consistently rubbing his eyes with a turning motion (trauma). The Eight Steps to Self-Diagnosis 51 Because the word trauma implies a stressful injury requiring emergency treatment, it is easy to ignore the possibility that more subtle problems can also have their origins in a traumatic injury. In the age of modern med- icine we have some wondrous treatments and cures, but they can sometimes inflict a heavy penalty. Some iatrogenic effects are unavoidable and consid- ered reasonable; they are known, expected, and endured because the bene- fits of the treatment outweigh the negative side effects. As medical mysteries abound and solutions become even harder to come by, and as drug companies market aggressively and governmental reg- ulations become more lax, growing numbers of doctors and their patients are experimenting with “off-label” medication use (prescribing medications for something other than their approved purposes). A recent study showed that more than 115 million such prescriptions were written in one year (2003) and thousands of patients have suffered serious, permanent, and mysterious iatrogenic consequences. Also, there are documented cases of mistakes by overworked nurses and physicians, foreign sales of unauthorized drugs, self-treatment by patients, and an increase in elective surgeries and treatments to consider.

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