Cialis Professional

By R. Murak. Judson College, Elgin IL. 2019.

Being able to define the public health knowledge 40mg cialis professional, skills and attitudes they apply may assist physicians in improving the quality of their care and their contribution to the health patients and the community 40 mg cialis professional. Individual patient-physician encounter At the core of medicine is the encounter between physician and patient cialis professional 20mg. During these encounters cialis professional 40mg, the concept of the determinants of health and of the socio- ecological model of health provides an understanding of why the patient became ill and his chances of regaining health 20 mg cialis professional. The determinants of health may also determine the patient’s capacity to deal with disease and to follow the physician’s advice cialis professional 40 mg. Familiarity with models of health behaviours provides the physician with pointers on how to counsel on lifestyles and treatment 20mg cialis professional. Epidemiology and evidence-based medicine are essential to efficient investigation cialis professional 20 mg, accurate diagnosis , and effective decision-making with regard to the management and interpretation of new information generated by research . As results of general epidemiological enquiry often underlie health information on the frequency of disease in populations, being able to interpret this information allows physicians to prioritise differential diagnoses according to the lifestyles and the determinants of the health of their patients. Explaining the impact of avoidable risk factors, the meanings of test results and the risks and benefits of different ways of managing disease requires knowledge of a number of epidemiological concepts. Accurate diagnosis and management of environmental disease requires the physician to take an environmental history (11) and have knowledge of how to control environmental disease or knowledge of local public health services which may be required to solve the problem. Preventive intervention Preventive intervention is perhaps the most obvious way in which physicians put public health knowledge, skills and attitudes into practice. Physicians may intervene as part of a public health programme, for instance by participating in vaccination programmes, by setting up in-practice prevention programmes or by using opportunities for clinical prevention. To do so, physicians need to be up to date with public health programmes and clinical prevention guidelines. For areas where there are no national or regional evidence-based preventive care guidelines, there are a number of reliable sources that provide guidelines as well as discussions of the evidence and rationale for the guidelines. This gives physicians information on the risks and benefits of the interventions which they can discuss with their patients. The approach to disease management is not very different from the approach to prevention, both are based on assessment of the risks and benefits of interventions, which may include watchful waiting. As prevention differs from treatment in that it does not tackle an existing problem, differences in ethical values may come into play. Practice population To maintain the health of the people in their area, physicians assess the needs of their practice population and community, orient their practice to meet those needs and advocate for the health of the local community. Here again the physicians are using epidemiology and applying the principles of health promotion; community development and empowerment. Physicians also play a role in protecting populations from environmental and transmissible disease. As diagnosticians in direct contact with patients, they are in a unique position to identify and report unusual occurrences of disease. They are also well placed to assess possible disease sources and advise on how to reduce the spread of disease. In doing so, they are familiar with the basics of outbreak prevention and control as well as with local public health services. They borrow from management science to prioritise and implement change and to develop practice systems that improve the delivery of care. The Australian ‘Green book’ gives practical advice on how to improve delivery of preventive care, some of which can be adapted to improving patient management and follow-up (14). As part of the health system, physicians collaborate with other professionals to provide a comprehensive service. They know the resources in their area and they know how to advocate for their improvement. In so doing, they apply notions of health service organisation as well as leadership and communication skills. They also balance the needs of individuals against the needs of their practice population, employing concepts from health economics as well as applying the ethics of population medicine. Finally, physicians use the principles of infection control to prevent iatrogenic infections and cross infections between patients attending their practice. Issues specific to rural areas All these roles and responsibilities apply as much to general practice as to other branches of medicine - and as much to rural as to urban practice. However, the type, place and context of practice influence the depth of competence required in different aspects of public health. The physician in a rural general practice is likely to be one of the few health professionals in the area. In small regions, they may have privileged contact with influential people and organisations – and indeed, they may be seen as a resource for all types of health issues, including public health and community issues. This provides an excellent opportunity to advocate for health, practice health promotion and influence health protection practices and infrastructure. Changing hospital policy from the wards: An introduction to health policy education. Public health in the undergraduate medical curriculum – can we achieve integration? Public health education for medical students: Rising to the professional challenge. Towards unity for health: Challenges and opportunities for partnership in health development. Putting prevention into practice: Guidelines for the implementation of prevention in the general practice setting. Every effort has been made to ensure that the information in this chapter is accurate. This does not diminish the requirement to exercise clinical judgement, and neither the publisher nor the authors can accept any responsibility for its use in practice. Miller School of Medicine is part of the larger University of Miami Health System, which was founded in 1952 and is now home to the third-largest public hospital and third-largest teaching hospital in the United States. Serving more than one million patients every year, the hospital system extends its patient care and educational resources to South Florida, South America and the Caribbean. Big changes with small adjustments Israel Diaz, who has been with the University of Miami for over 16 years, manages the department of radiology, which consists of 50 radiologists at three hospitals. In 2012, the University of Miami transitioned its billing payment system and experienced unforeseen barriers. The radiology department endured constant backlog that, according to Diaz, “only got worse when a coder went on vacation or got sick. We had issues keeping up with the volume, so we started a small project with 3M CodeRyte CodeComplete to take care of a growing backlog of radiology notes. Miller School of Medicine But this was not Diaz’s frst experience with 3M Health Information Systems. Services provide a full-service, outsourced coding solution comprised And once they got going, Diaz says he saw immediate results. It relieved us from having to who perform medical and surgical hire and train coders. We received better coding, faster turnaround time and coding for technical, multi-specialty no hassles with stafng. With 3M CodeComplete, organizations When considering an outsourced coding solution, Diaz says that compliance can have, on average, a 48-hour was at the top of his “must-have” list. He also needed a service that had a turnaround time for processing their speedy turnaround rate. In addition to With the type of volume the department experiences, it couldn’t aford to put improved coder productivity, clients productivity at risk. Finally, compliance is the most important aspect of medical coding, and 3M is very good at compliance,” says Diaz. The results Call today By using 3M CodeComplete, Diaz says his radiology department sees remarkable For more information on how results for his team and organization. Their department has a very low denial rate 3M products and services can assist and are below their denial threshold. Once you have signed and submitted the form, your agreement with the University becomes legally binding. If the information is incorrect the University is entitled to reject your application, terminate your admission or cancel your registration immediately. Ashammakhi Summary tem cells have a capacity for self-renewal and capability of proliferation and differentiation to various cell lineages. The use of amniotic fluid derived cells, umbilical cord cells, fat and skin tissues and monocytes might be an adequate “ethically pure” alternative in future. Stem cells can improve healthcare by using and augmenting the body’s own regenerative potential. Hopefully, this will help to provide therapeutic treatment for conditions where current therapies are inadequate. Human body has an endogenous system of regeneration through stem cells, where stem cells are found almost in every type of tissue. Regenerative medicine comprises the use of tissue engineering and stem cell technology. This review is not meant to be exhaustive, but aims to highlight present and future applications of stem cells in this exciting new discipline. We will briefly discuss tissue engineering and stem cell technology including their different sources. He was unsuccessful but his experiments were among the first attempts at what we now describe as tissue engineering. He had positively concluded that with the advent of biomaterials science it would be possible to regenerate and produce new tissues by loading viable cells onto “smart” engineered scaffolds (1). These forums recommended that tissue engineering be designated as an emerging engineering technology. The new speciality was then famously described in an article by Langer and Vacanti in Science. They wrote (3): “Tissue engineering is an interdisciplinary field that applies the principles of engineering and the life sciences toward the development of biological substitutes that restore, maintain, or improve tissue function”. Since then the novel speciality has successfully expanded and excited scientists and clinicians alike. They injected bone marrow cells into irradiated mice, nodules developed in the spleens in proportion to the number of bone marrow cells injected. Later on, they obtained evidence that these cells were capable of infinite self-renewal, a central characteristic of stem cells (4). Thus, stem cells by definition have two defining properties the capacity of self-renewal giving rise to more stem cells and to differentiate into different lineages under appropriate conditions. Their potential to differentiate into different cell types seems to be more limited (5) (Table 1). The capability for potency and the relative ease to isolate and expand these cells are invaluable properties for regenerative medicine. Several ideas have been put forward to explain stem cell lineage and fate determination. This three-dimensional (3D) microenvironment is thought to control genes and properties that define “stemness”, i. Further studies on the niche might give us a better understanding on the control of stem cell differentiation. Stem cells might be appropriately differentiated cells with the potential to display diverse cell types depending on the host niche. Furthermore, stem cells implanted into a totally different niche can potentially differentiate into cell types of the new environment (7). For example, human neuronal stem cells produced muscle cells when they were implanted in skeletal muscle (8). Bone marrow cells differentiated into neuronal cells when they were transplanted into a neural environment (9,10). This can have clinical implications for example since both liver and pancreas develop from the same embryological line, specific growth factors and culture Topics in Tissue Engineering, Vol. Stem cells for regeneration techniques achieved the “transdifferentiation” of liver cells to islet cells (11). Stem cell Definitions Stem cell A cell with the ability for self-renewal and differentiation potential. Self-renewal Asymmetric cell division which leads to at least one daughter cell which is equal to the mother cell. Commitment Engaging in a defined pathway which leads to differentiation and inability for self- renewal. Progenitor cell A proliferative cell with the capacity to differentiate but with no self-renewal ability. Multipotency Ability to form multiple cell lineages which form an entire tissue, usually specific to one germ layer, e. Plasticity Controversial possibility for adult stem cells to show higher potency in response to different microenvironments. On 17 January 1912 in one of his experiments he placed part of chicken’s embryo heart in a fresh nutrient medium. Every January 17 , the doctors and nurses would celebrate with Carrel, singing “Happy Birthday” to the chicken tissue (12). Even though these cells were unlikely to be embryonic and possibly more related to cord-derived cells, this experiment showed the future potential of tissue culture. The hypoblast forms yolk sac, while the epiblast differentiates into three classical layers of the embryo; ectoderm, mesoderm and endoderm with potential of forming any tissue (Fig. Before their clinical use, ethical and scientific questions need to be resolved, e. In 1869, Paul Langerhans as a medical student observed for the first time beta islet cells as microscopic islands of a different structure in the pancreas (16). These complex mini-organs the pathological site of diabetes have always fascinated transplant and regenerative scientist not just for their complexity but also for their important clinical relevance.

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An 18-year-old man is brought to the emergency department 10 minutes after he sustained a stab wound to his chest 40 mg cialis professional. His pulse is 130/min 20 mg cialis professional, respirations are 8/min and shallow cialis professional 20mg, and palpable systolic blood pressure is 60 mm Hg 20mg cialis professional. Examination shows a 2-cm wound at the left sixth intercostal space at the midclavicular line cialis professional 40mg. A 27-year-old man is brought to the emergency department 20 minutes after his roommate found him unconscious on their bathroom floor cialis professional 20 mg. B - 136 - Internal Medicine Advanced Clinical Systems General Principles 5%–10% Immunologic Disorders 1%–5% Diseases of the Blood 5%–10% Mental Disorders 1%–5% Diseases of the Nervous System 5%–10% Cardiovascular Disorders 10%–15% Diseases of the Respiratory System 10%–15% Nutritional and Digestive Disorders 10%–15% Female Reproductive System 1%–5% Renal cialis professional 40 mg, Urinary 40mg cialis professional, Male Reproductive Systems 5%–10% Diseases of the Skin 1%–5% Musculoskeletal and Connective Tissue Disorders 1%–5% Endocrine and Metabolic Disorders 8%–12% Physician Task Promoting Health and Health Maintenance 5%–10% Understanding Mechanisms of Disease 5%–10% Establishing a Diagnosis 35%–45% Applying Principles of Management 40%–50% Site of Care Emergency Department 20%–30% Inpatient 70%–80% Patient Age 17 to 65 65%–75% 66 and older 25%–35% - 137 - 1 . A previously healthy 67-year-old man is admitted to the hospital because of lethargy , confusion, muscle cramps, and decreased appetite for 7 days. A 67-year-old woman is brought to the emergency department because of severe chest pain 4 hours after undergoing outpatient endoscopy and dilatation of an esophageal stricture caused by reflux. Rectal examination shows no masses; test of the stool for occult blood is positive. A 72-year-old woman is brought to the emergency department 1 hour after the sudden onset of right facial droop and weakness of the right arm and leg. One day after undergoing cholecystectomy, a 37-year-old man becomes increasingly tremulous and anxious. Administration of which of the following is the most appropriate next step in management? Fourteen hours after admission to the hospital for treatment of severe hypertension, a 32-year-old woman has stridor. Her pulse is 140/min, respirations are 32/min, and blood pressure is 140/85 mm Hg. E - 141 - Comprehensive Basic Science The Comprehensive Basic Science Examination is a general, integrated achievement test covering material typically learned during basic science education, with somewhat more emphasis on second-year courses in medical schools with traditional curricula. Systems General Principles of Foundational Science 15%–20% Biochemistry and molecular biology Biology of cells Human development and genetics Biology of tissue response to disease Pharmacodynamic and pharmacokinetic processes Microbial biology Normal age-related findings and care of the well patient Immune System 1%–5% Blood & Lymphoreticular System 5%–10% Behavioral Health 1%–5% Nervous System & Special Senses 5%–10% Skin & Subcutaneous Tissue 1%–5% Musculoskeletal System 5%–10% Cardiovascular System 5%–10% Respiratory System 5%–10% Gastrointestinal System 5%–10% Renal & Urinary System 5%–10% Pregnancy, Childbirth, & the Puerperium 1%–5% Female Reproductive System & Breast 1%–5% Male Reproductive System 1%–5% Endocrine System 5%–10% Multisystem Processes & Disorders 5%–10% Biostatistics, Epidemiology/Population Health, & Interpretation of the Medical Lit. A 16-month-old boy is brought to the physician by his mother for a well-child examination. His mother expresses concern that he did not walk until the age of 14 months, whereas his older sister walked at the age of 10 months. A 77-year-old woman is visited by the home care nurse who notes that the patient is more lethargic than usual. An increase in the serum concentration or activity of which of the following provides the strongest indication that the patient is dehydrated? A male newborn delivered at 26 weeks’ gestation develops respiratory distress immediately after a spontaneous vaginal delivery. The most likely cause of this patient’s breathing difficulties is insufficient production of which of the following substances? A 28-year-old woman, gravida 1, para 1, comes to the physician because of progressive fatigue since delivering a male newborn 6 months ago. Pregnancy was complicated during the third trimester by severe bleeding from placenta previa. She required multiple blood transfusions during the cesarean delivery, but she did well after the delivery. A 12-year-old African American boy is brought to the physician by his mother because of a swollen right earlobe for 3 weeks. The mother developed a thick rubbery scar on her abdomen after a cesarean delivery 12 years ago. Physical examination shows a nontender, flesh-colored swelling of the right earlobe. A 5-year-old boy is brought to the physician by his parents because of an 8-month history of difficulty walking. His parents say that he limps when he walks and has a waddling gait; he also has difficulty standing. When getting up from a sitting position, he uses his hands to walk up his thighs and push his body into a standing position. His mother is an only child, but she has an uncle who became bedridden as a child and died of respiratory arrest. This patient most likely has a mutation in the gene coding for which of the following proteins? A 27-year-old man comes to the physician because of pain with urination for 3 days. Physical examination shows no abnormalities except for a clear, watery urethral discharge. A 20-year-old college student develops fever, severe pharyngitis, hepatosplenomegaly, and lymphadenopathy. A 2-year-old boy with Down syndrome is brought to the physician by his mother for a follow-up examination. His blood pressure is increased in the upper extremities and decreased in the lower extremities. The parents are both Rh-positive, but IgG isohemagglutinins are found in the mother’s blood. Which of the following parental blood types is most likely to cause this condition? A previously healthy 42-year-old woman comes to the emergency department because of progressive shortness of breath and intermittent cough productive of blood-tinged sputum for 10 days. His mother informs the physician that the family members belong to a religious denomination that does not consume meat. Her son refuses to eat dark green vegetables or to take vitamin pills, stating that they make him feel nauseated. It is most appropriate for the physician to ask the mother which of the following questions next? A 64-year-old man comes to the physician because of a 3-day history of painful rash over his right flank. Physical examination shows clustered lesions in a band-like area over the right flank. An investigator has conducted an experiment to determine whether certain environmental exposure morbidity is eliminated if a person carries a specific allele of three different genes on three separate chromosomes. The frequencies of an individual having the allele for these respective genes are 0. The probability that a randomly selected individual will have all three alleles is closest to which of the following? A health inspector confiscates chickens smuggled into Taiwan from mainland China after she discovers them in the hold of a ship. Testing shows that, although the chickens appear healthy, they are infected with the H5N1 subtype of the influenza A virus. Which of the following is the primary concern for human health from these virus-infected chickens? A 42-year-old woman comes to the physician for a routine health maintenance examination. Fasting serum studies show: Glucose 105 mg/dL Cholesterol, total 210 mg/dL Triglycerides 185 mg/dL C-reactive protein 0. A - 149 - Comprehensive Clinical Science The Comprehensive Clinical Science Examination is a general, integrated achievement test covering material typically learned during core clinical clerkships. Systems General Principles, Including Normal Age-Related Findings and Care of the Well Patient 1%–5% Immune System 1%–5% Blood & Lymphoreticular System 1%–5% Behavioral Health 5%–10% Nervous System & Special Senses 5%–10% Skin & Subcutaneous Tissue 1%–5% Musculoskeletal System 5%–10% Cardiovascular System 5%–10% Respiratory System 10%–15% Gastrointestinal System 5%–10% Renal & Urinary System 5%–10% Pregnancy, Childbirth, & the Puerperium 5%–10% Female Reproductive System & Breast 5%–10% Male Reproductive System 1%–5% Endocrine System 5%–10% Multisystem Processes & Disorders 5%–10% Biostatistics, Epidemiology/Population Health, & Interpretation of the Medical Lit. It is unlikely that it will directly benefit the study subjects but very likely that it will benefit future patients. There is a risk for short-term minor gastric discomfort but essentially no risk for long-term adverse effects. The investigator concludes that disclosure of the risks may discourage participation in the trial. A 25-year-old man comes to the emergency department because of a 1-month history of fever, chills, nonproductive cough, and progressive shortness of breath; he now becomes short of breath after walking 20 feet. This patient is most likely to have which of the following immunologic abnormalities? A 27-year-old man is brought to the emergency department 20 minutes after his roommate found him unconscious on their bathroom floor. A 15-year-old boy has had pain in the knee since sustaining an injury in a high school football game 6 weeks ago. The high school trainer has been treating him with heat and ultrasound, without significant improvement. A 2-week-old boy is brought to the physician because of a 3-day history of persistent discharge from his eyes. Examination of the eyes shows tarsal inflammation and a thin mucopurulent discharge. Testing of scrapings from the tarsal conjunctivae is positive for Chlamydia trachomatis. Which of the following is the most likely mode of transmission of this patient’s infection? A 62-year-old man comes to the physician because of blood in his urine for 24 hours. Abstinence from which of the following is most likely to have prevented this condition? A 21-year-old nulligravid woman who is not using contraception has had irregular menstrual periods since menarche at age 13 years. On pelvic examination, there is copious cervical mucus and slightly enlarged irregular ovaries. A 50-year-old man has a 1-hour history of unremitting chest pressure and “gassiness. Physical examination shows no abnormalities except for a blood pressure of 140/80 mm Hg. A 32-year-old nulligravid woman comes to the physician because of a 20-minute episode of shortness of breath when she awoke this morning. Physical examination shows erythema, swelling, warmth, and tenderness behind the right knee; a cord-like mass can be palpated. A 4030-g (8-lb 14-oz) newborn has internal rotation of the left upper extremity at the shoulder, extension at the elbow, pronation of the forearm, and flexion of the fingers following a low forceps delivery. Passive range of motion of the left upper extremity is full; the newborn does not cry or grimace when the left arm, shoulder, or clavicle is palpated. He has a 5-year history of progressive difficulty falling asleep at night and waking up early in the morning. A 22-year-old woman comes to the physician because of a 1-year history of intermittent lower abdominal cramps associated with bloating and mild nausea. The cramps are occasionally associated with constipation and bowel movements relieve the pain. A 10-year retrospective study is conducted to determine factors that could predispose women to have children with complex congenital heart disease. A total of 1000 women were asked whether they had flu-like symptoms during their first trimester. The investigators found that women who had children with complex congenital heart disease were five times more likely than women with healthy newborns to report flu-like symptoms in their first trimester. Which of the following features of this study is most likely to affect the validity of this conclusion? An asymptomatic 32-year-old woman comes to the physician for a follow-up examination. She has a 10-month history of hypertension that has been difficult to control with medication. Current medications include metoprolol, lisinopril, hydrochlorothiazide, and nifedipine. Five days after falling and hitting her chest, a 55-year-old woman has acute midsternal chest pain that radiates to the back and is exacerbated by deep inspiration. Immediately following the accident, she had acute sternal pain that resolved in 1 day. A 19-year-old primigravid woman comes to the physician for her first prenatal visit. A 37-year-old woman comes to the emergency department 40 minutes after the onset of shortness of breath, dizziness, and an itchy rash. Two days after beginning primaquine for malaria prophylaxis, a 17-year-old African American boy is brought to the physician because of dark urine and yellowing of his eyes. A 17-year-old boy comes to the physician because he believes that his penis is too large. He has been uncomfortable with the size of his genitals since he underwent puberty 4 years ago. He is concerned that people will see the bulge of his genitals under his clothing. Although he has never had sexual intercourse, he is afraid that his size will make it difficult or painful for most women. He plays intramural basketball but no longer undresses in front of teammates or uses public showers. On mental status examination, he appears embarrassed, and he describes his mood as "okay. A - 157 - Introduction to Clinical Diagnosis Systems General Principles 15%−20% Human development and genetics Gender, ethnic, & behavioral considerations affecting disease treatment & prevention Progression through life cycle Psychologic and social factors influencing patient behavior Patient interviewing, consultation, and interactions with the family Medical ethics, jurisprudence, and professional behavior Nutrition Hematopoietic & Lymphoreticular System 1%−5% Central & Peripheral Nervous System 15%−20% Skin & Related Connective Tissue 1%−5% Musculoskeletal System 5%−10% Respiratory System 10%−15% Cardiovascular System 15%−20% Gastrointestinal System 10%−15% Renal/Urinary System 1%−5% Reproductive System 5%−10% Endocrine System 1%−5% - 158 - 1. A 6-month-old boy is brought to the physician because of left knee swelling for 24 hours. Three months ago, he had three large hematomas on his forehead that resolved without treatment.

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The physician’s job is to determine the patient’s fear 20 mg cialis professional, educate the patient about the nature of the illness cialis professional 20 mg, and help him or her make an informed decision 20mg cialis professional. Patient assessment of risk and level of risk taking Some patients will reject the physician’s interpretation of the nature of their com- plaint because of their own risk-taking behavior cialis professional 20mg. They may be more willing or less willing to take a risk than the physician thinks is reasonable 40 mg cialis professional. The physician’s job is to educate the patient about the nature of their illness and the level of risk they are assuming by their behavior 40mg cialis professional, and then help them make an informed decision cialis professional 40mg. In the end cialis professional 40 mg, if the patient decides to refuse the physician’s suggestions for evaluation and treat- ment after being fully informed of the risks and benefits , they have the capacity to refuse care and should be treated with therapies that they will accept . Ques- tions about alcohol or drug abuse, child abuse, and sexual activity are common areas where this occurs. The physician may detect inconsistencies in the history or pick up secondary clues that give an idea that this may be happening. The best way to handle this situation is to get corroborating evidence from the family, current and previous physicians, and medical records. The environment Disruptive environments for the examination Excess noise or interruptions, including background noise or children in the examination room, make it hard to be accurate in examination. This may be unavoidable in some circumstances like in the Emergency Department with its chaotic environment and constant noise from disruptive patients. If it is impos- sible to remove the noise, make sure it is compensated for in some other way. It may take longer to gather information in these circumstances, but the physician will be rewarded with increased accuracy. Disruptive interactions between the examiner and the examined Patients who are uncooperative, delirious, agitated, or in severe pain, as well as crying children are in this category. In this circumstance, the physician must sim- ply try his or her best to do a competent examination over the interruptions. Providing pain relief for patients with severe pain early in the encounter will usu- ally help to obtain a better history and more accurate examination. Occasionally in the Emergency Department, patients have to be sedated in order to examine them properly. Reluctant co-workers As a physician, nurses, residents, and other physicians may disagree with your evaluation. If you believe that your evaluation is correct and evidence-based, their opinions should not stand in the way. For instance, if a patient comes to the Emergency Department with the worst headache of their life, the correct medi- cal action is to rule out a subarachnoid hemorrhage. This Sources of error in the clinical encounter 241 is true even if the radiologist asks to wait until morning to do the procedure or if the nurses say that the spinal tap is unnecessary since it takes more nursing time. The physician must know when to stand his or her ground and stick up for the patient. Incomplete function or use of diagnostic tools Diagnostic instruments and tools should be functioning properly and the exam- iner should be an expert in their use. One should know how the stethoscope, blood pressure cuff, ophthalmoscope, otoscope, reflex hammer, and tuning fork are correctly used and check on them before use. This would also apply to more technological tools such as x-rays and other imaging devices, electrocardiograms, transcutaneous oxymetry measuring devices, just to name a few of the common diagnostic tools in com- mon usage. Strategies for preventing or minimizing error in the clinical examination The following suggestions will help to avoid making errors in the clinical exami- nation. In order to serve this purpose, the examination must be done in a meticulous and sys- tematic way. It is necessary to make sure the environment is user friendly to the physician and the patient. Physicians should review and summarize the history with patients to make sure the data are correct. Make sure the physical examination findings are accurate by repeating them and observing how they change with time and treatment. Physicians need to ensure that all the information is gathered personally, without relying on secondhand information. Overall, physicians should not make clinical decisions based on an incomplete history due to the inability to accurately understand the patient, or based on secondhand history that is not corroborated. The physician should determine which tests are most useful in order to refine the diagnosis. O b ject ive information gathered during the patient examination and from diagnostic tests. A Assessment of the patient’s problem including a differential diagnosis and the likelihood of each disease on the list, as well as other psycho-social problems that may affect the diagnostic process or therapeutic relationship. Make a determination of the nature of the patient’s problem and the interpretation of that problem, the diagnosis. Initially this will be a provisional diagnosis, differential diagnosis, or just a summary statement of the problem. This will occur more often during medical school and residency training, and may be difficult to do in private practice. However, even experienced physicians will occasionally ask colleagues to check part of their clinical examination when things don’t quite add up. Obtaining reasonable and timely consultation with a special- ist is another way of double checking examination findings. Physicians need to make sure that physical examination tools are working properly and that they know how to use them well. The physician should look at the results of diagnostic tests objectively, applying the principles of med- ical decision making contained in the next several chapters. The physician should not be overly optimistic or pessimistic about the value of a single lab test, and should apply rigorous methods of decision making in determining the meaning of the test results. The physi- cian should remember that the patient is functioning within a social con- text. Emotional, cultural, and spiritual components of health are important Sources of error in the clinical encounter 243 in getting an accurate picture of the patient. If this is a serious problem, individual physicians could consider dictating charts or using a computer for medical charting. George Bernard Shaw (1856–1950): The Doctor’s Dilemma, 1911 Learning objectives In this chapter you will learn: r the uses and abuses of diagnostic tests r the hierarchical format to determine the usefulness of a diagnostic test The Institute of Medicine has determined that error in medicine is due to overuse, underuse, and misuse of medical resources – resources such as diagnos- tic tests. In order to understand the best way to use diagnostic tests, it is helpful to have a hierarchical format within which to view them. The use of medical tests in making a diagnosis Before deciding on ordering a diagnostic test, physicians should have a good rea- son for doing the test. Examples of this are a throat culture in a patient with a sore throat to look for hemolytic group A streptococcus bacteria or a mammogram in a woman with a palpa- ble breast mass to look for a cancer. Examples of this are the phenylketonuria test in a healthy newborn to detect a rare genetic disorder, a mammogram in a woman without signs or symptoms of a breast mass, or the prostate specific antigen test in a healthy asymptomatic man to look for prostate cancer. Screening tests will not directly benefit the majority of peo- ple who get them, since they don’t have the disease, but the result can be 244 The use of diagnostic tests 245 reassuring if it is negative. In general there are five criteria that must be met for a successful screening test – burden of suffering, early detectability, test validity, acceptability, and improved outcome – and unless all these are met, the test should not be recommended. One example of this is monitoring the prothrombin time in patients on warfarin therapy. This checks the patient’s level of anticoagulation and prevents levels from being either too low, thus leading to new clotting, or too high, and leading to excess bleeding. Another example is therapeutic gen- tamycin level in patients on this antibiotic to reduce the likelihood of toxic levels causing renal failure. Important features to determine the usefulness of a diagnostic test There are several ways of looking at the usefulness of diagnostic tests. This hier- archical evaluation uses six possible endpoints to determine a test’s utility. The more criteria in the schema that are fulfilled, the more potentially useful the test will be. This is usually a function of the instrumentation or operator reliability of the test. While precision used to be assumed to be present for all diagnostic tests, many studies have demonstrated that with most non-automated tests, there is some degree of subjectivity in test inter- pretation. It is also present in tests commonly considered to be the “gold standard” such as the interpretation of tissue samples from autopsies, biopsies, or surgery. The determina- tion of accuracy depends upon the ability of the instrument’s result to be the same as the result determined using a standardized specimen and 1 W. A person with more experience, better train- ing, or more talent will get more precise and accurate results on many tests. If a test is very expensive and not covered by health insurance, the patient may not be able to pay for it, making it a useless test for them. The substances may also prevent the test from picking up true positives and thereby make them false negatives. An example of this if a person eats poppy- seed bagels, they will give a false positive urine test for opiates. Criterion-basedvalidity describes how well the measurement agrees with other approaches for measuring the same characteristic, and is a very important measurement in studies of diagnostic tests. The result of a gold-standard test defines the presence or absence of the dis- ease (i. There are very few true gold standards in medicine and some are better or scientifically more pure than others. These are traditionally consid- ered to be the ultimate gold standard, but their interpretations can vary with different pathologists. Theoretically, all bacteria that are present in the blood should grow on a suitable culture medium. Sometimes, for technical reasons, the culture does not grow bacteria even though they were present in the blood. This can occur because the technician doesn’t plate the culture properly, it is stored at an incorrect temperature, or there just happened to be no bacteria in the particular 10-cc vial of blood that was sampled. This is a set of fairly objective cri- teria for making a diagnosis of rheumatic fever. Factors that could decrease the accuracy of these criteria are that a component of the criteria, such as temperature, may be measured incorrectly in some patients, or another criterion like arthritis may be interpreted incor- rectly by the observer. These criteria are objective, yet depend on the clinician’s interpretation of the patient’s descrip- tion of their symptoms. As mentioned previously, x-rays are open to variation in the reading, even by experienced radiologists. If we are ultimately interested in finding out how well a test works to separate the diseased patients from the healthy patients, we can follow everyone who received the test for a specified period of time and see which outcomes they all have. This technique works as long as the time period is long enough to see all the possible dis- ease outcomes, yet short enough to study realistically. Does the result of the test cause a change in diagno- sis after testing is complete? If we are almost certain that a patient has a dis- ease based upon one test result or the history and physical exam, we don’t need a second test to confirm that result. Diagnostic thinking only considers how the test performs in making the diagnosis in a given clinical setting, and is therefore closely related to diagnostic accuracy. The setting within which this thinking operates is dependent on the prevalence of the disease in the patient population being tested. For example, the venogram is the gold-standard test in the diagnosis of deep venous thrombosis. It is an expensive and invasive test that can cause some side effects, although these side effects are rarely lethal. Part of the art of medicine is determining which patients with one negative ultrasound can safely wait for a confirmatory ultrasound 3 days later, and which patients 248 Essential Evidence-Based Medicine need to have an immediate venogram or initiation of anticoagulant medica- tion therapy. This considers biophysiological parameters, symptom severity, functional outcome, patient utility, expected values, morbidity avoided, mor- tality change, and cost-effectiveness of outcomes. We will discuss some of these issues in the chapter on decision trees and patient values (Chapter 31). Even a cheap test, if done excessively, may result in prohibitive costs to society. Out- comes include the additional cost of evaluation or treatment of patients with false positive test results and the psychosocial cost of these results on the patient and community. Other outcomes are the risk of missing the correct diagnosis in patients who are falsely negative and may suffer negative out- comes as a result of the diagnosis being missed. Again, physicians may need to also consider a cost analysis for evaluating the test. Interestingly, the per- spective of the analysis can be the patient, the payor, or society as a whole. Overall, patient or societal outcomes ultimately determine the usefulness of a test as a screening tool. Bertrand Russell (1872–1970): The Philosophy of Logical Atomism, 1924 Learning objectives In this chapter you will learn: r the characteristics and definitions of normal and abnormal diagnostic test results r how to define, calculate, and interpret likelihood ratios r the process by which diagnostic decisions are modified in medicine and the use of likelihood ratios to choose the most appropriate test for a given purpose r how to define, calculate, and use sensitivity and specificity r how sensitivity and specificity relate to positive and negative likelihood ratios r the process by which sensitivity and specificity can be used to make diag- nostic decisions in medicine and how to choose the most appropriate test for a given purpose In this chapter, we will be talking about the utility of a diagnostic test. This is a mathematical expression of the ability of a test to find persons with disease or exclude persons without disease. These are the likelihood ratios and the prevalence of disease in the target population. Additional test characteristics that will be introduced are the sensi- tivity and specificity. These factors will tell the user how useful the test will be in the clinical setting. Using a test without knowing these characteristics will result in problems that include missing correct diagnoses, over-ordering tests, increas- ing health-care costs, reducing trust in physicians, and increasing discomfort 249 250 Essential Evidence-Based Medicine and side effects for the patient.

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Experi- tion to strategies that aim to increase the overall level of mental studies show that reflective practice enhances diag- clinicians’ knowledge cialis professional 20mg, other educational approaches focus 161 nostic accuracy in complex situations 40mg cialis professional. However cialis professional 20 mg, even on increasing physicians’ self-awareness so that they can advocates of this approach recognize that it is an untested recognize when additional information is needed or the assumption in terms of whether lessons learned in educa- wrong diagnostic path is taken 20 mg cialis professional. Singh and colleagues advocate this strategy 40 mg cialis professional; their definition of types of situational awareness is similar to what One could argue that effectively incorporating the education 115 cialis professional 40mg,155 and training described above would require system-level others have called metacognitive skills 20mg cialis professional. For instance cialis professional 40 mg, at the level of healthcare systems , in Hall champion the idea that metacognitive training can reduce diagnostic errors , especially those involving subcon- addition to the development of required training and edu- scious processing. The logic behind this approach is appeal- cation, a concerted effort to increase the level of expertise of ing: Because much of intuitive medical decision making the individual would require changes in staffing policies and involves the use of cognitive dispositions to respond, the access to specialists. These would orient clinicians to the general allow the less expert clinician to function like a more expert concepts of metacognition (a universal forcing strategy), clinician. Computer- or web-based information sources also familiarize them with the various heuristics they use intu- may serve this function. These resources may not be very itively and their associated biases (generic forcing strate- different from traditional knowledge resources (e. Once the initial diagnosis is made, the clinician figuratively gazes into a These approaches focus on providing better and more ac- crystal ball to see the future, sees that the initial diagnosis is curate information to the clinician primarily to improve not correct, and is thus forced to consider what else it could calibration. A related technique, which is taught in every medical for reducing medical errors have formed the background of school, is to construct a comprehensive differential diagno- the patient safety movement, although they have not been 163 164 sis on each case before planning an appropriate workup. Nolan advo- Although students and residents excel at this exercise, they cates 3 main strategies based on a systems approach: pre- rarely use it outside the classroom or teaching rounds. As vention, making error visible, and mitigating the effects of we discussed earlier, with more experience, clinicians begin error. Most of the cognitive strategies described above fall to use a pattern-recognition approach rather than an exhaus- into the category of prevention. Other examples of cognitive The systems approaches described below fall chiefly into forcing strategies include advice to always “consider the the latter two of Nolan’s strategies. One approach is to opposite,” or ask “what diagnosis can I not afford to provide expert consultation to the physician. Usually a diagnostic decision-sup- only in artificial situations and many of them have been per- port system is used once the error is visible (e. The history of these systems is reflective of the overall Using the system may prevent an initial misdiagnosis and problem we have demonstrated in other domains: despite may also mitigate possible sequelae. A variety they do use them, many physicians are simply reluctant to of diagnostic decision-support systems were developed out 181 use decision-support tools in practice. Miller’s overall conclusions were that while data on how often they are used compared with how often the niche systems for well-defined specific areas were they could/should have been used. The title, “A Report Card on data into the programs, it is likely that their usage would be Computer-Assisted Diagnosis—The Grade Is C,” of Kas- even lower or that the data entry may be incomplete. In a subsequent study, Berner tering, because what is usually displayed is a (sometimes 167 and colleagues found that less experienced physicians lengthy) list of diagnostic considerations. Also, as Teich and colleagues noted with of the Iliad system in educational settings. More disturbing was potentially useful, but the limited interest in them has made that use of the system actually increased costs, perhaps by several commercial ventures unsustainable. Because such puzzles occur rarely, which was initially begun as a pediatric system and now is there is not enough use of the systems in real practice 174–178 also available for use in adults. A second general category of a 179 180 Miller and Berner have reviewed the challenges in systems approach is to design systems to provide feedback evaluating medical diagnostic programs. Overconfidence represents a mismatch be- ficult to determine the gold standard against which the systems tween perceived and actual performance. It is a state of should be evaluated, but both investigators advocate that the miscalibration that, according to existing paradigms of cog- criterion should be how well the clinician using the computer nitive psychology, should be correctable by providing feed- 179,180 compares with use of only his/her own cognition. In this program, radiologists keep back can improve the basis on which the clinicians are track of their agreement with any prior imaging studies they judging the frequency of events, which may improve re-review while they are evaluating a current study, and the calibration. In this framework, a possible approach to reducing diagnostic error, overconfidence, and Pathology. Experiments confirm that feedback can improve perfor- 184 This act mandated more rigorous quality measures in regard mance, especially if the feedback includes cognitive in- to cytopathology, including proficiency testing and manda- formation (for example, why a certain diagnosis is favored) 189 tory reviews of negative smears. Even with these mea- as opposed to simple feedback on whether the diagnosis was 185,186 sures in place, however, rescreening of randomly selected correct or not. A recent investigation by Sieck and 131 smears discloses a discordance rate in the range of 10% to Arkes, however, emphasizes that overconfidence is 30%, although only a fraction of these discordances have highly ingrained and often resistant to amelioration by sim- 190 major clinical impact. There are no comparable proficiency requirements for The timing of feedback is important. Immediate feed- 187 anatomic pathology, other than the voluntary “Q-Probes” back is effective, delayed feedback less so. Q-Probes are highly focused re- feedback often is not available at all, much less immediately views that examine individual aspects of diagnostic testing, or soon after the diagnosis is made. In fact, the gold stan- including preanalytical, analytical, and postanalytical er- dard for feedback regarding clinical judgment is the au- rors. Q-Tracks are monitors that “reach beyond the testing some cases adopted, as a method of improving performance phase to evaluate the processes both within and beyond the 191 and calibration. The accuracy of radiologic diagnosis is most isons with all other participating labs. Several monitors sharply focused in the area of mammography, where both evaluate the accuracy of diagnosis by clinical pathologists false-positive and false-negative reports have substantial and cytopathologists. In considering the reasons for this difference in performance, the authors point out that 85% of smears have been available commercially for a number of mammographers in the United Kingdom voluntarily partic- years. A recently completed randomized trial of 30 mammographers is 5,000 mammograms per year. Pap smear results showed a very slight advantage of the 194 As an initial step toward performance improvement by computer programs over unaided cytopathologists, but providing organized feedback, the American College of earlier reports of the trial before completion did not show Berner and Graber Overconfidence as a Cause of Diagnostic Error in Medicine S15 193 any differences. The authors suggest that it may take time Feedback in Other Field Settings (The Questec Experi- for optimal quality to be achieved with a new technique. A fascinating experiment is underway that could In the area of computer-assisted mammography inter- substantially clarify the power of feedback to improve cal- pretation, a randomized trial showed no difference in ibration and performance. This is the Questec experiment cancer detection but an increase in false-positives with sponsored by Major League Baseball to improve the con- the use of the software compared with unaided interpre- sistency of umpires in calling balls and strikes. Questec is a 195 company that installs cameras in selected stadiums that tation by radiologists. It is certainly possible that tech- nical improvements have made later systems better than track the ball path across home plate. At the end of the earlier ones, and, as suggested by Nieminen and col- game, the umpire is provided a recording that replays every 194 196 pitch, and gives him the opportunity to compare the called leagues about the Pap smear program, and Hall 201 about the mammography programs, it may take time, balls and strikes with the true ball path. Umpires have perhaps years, for the users to learn how to properly vigorously objected to this project, including a planned civil interpret and work with the software. The results from this study light that realizing the potential advantages of second have yet to be released, but they will certainly shed light on opinions (human or automated) may be a challenge. Sir William Osler championed the belief that med- icine should be learned from patients, at the bedside and in Follow-up. This approach was espoused by Richard delmeier and Gandhi et al is to promote the use of 31,75 Cabot and many others, a tradition that continues today in follow-up. If the follow-up were done soon enough, this autopsy rates was suspended a decade ago, at which point approach might also mitigate the potential harm of diagnos- the autopsy rate had already fallen to 7%. Most trainees in tic error, even without solving the problem of how to pre- medicine today will never see an autopsy. An innovative candidate is the “Morbidity and Mor- The strategies suggested above, even if they are successful tality (M & M) Rounds on the Web” program sponsored by in addressing the problem of overconfidence or miscalibra- the Agency for Healthcare Research and Quality tion, have limitations that must be acknowledged. These cases are attractive, capsulized gems that, like an autopsy, have the potential to educate clinicians regarding Tradeoffs in Time, Cost, and Accuracy medical error, including diagnostic error. The unknown As clinicians improve their diagnostic competency from factor regarding this endeavor is whether these lessons will beginning level skills to expert status, reliability and accu- provide the same impact as an autopsy, which teaches by the racy improve with decreased cost and effort. Local using the strategies discussed earlier to move nonexperts “morbidity and mortality” rounds have the same potential to into the realm of experts will involve some expense. In any alert providers to the possibility of error, and the impact of given case, we can improve diagnostic accuracy but with 199 these exercises increases if the patient sustains harm. A final option to provide feedback in the absence of a Several of the interventions entail direct costs. For in- formal autopsy involves detailed postmortem magnetic res- stance, expenditures may be in the form of payment for onance imaging scanning. This option obviates many of the consultation or purchasing diagnostic decision-support sys- traditional objections to an autopsy, and has the potential to tems. Even S16 The American Journal of Medicine, Vol 121 (5A), May 2008 strategies that do not have direct expenses may still be cascade effects, where one thing leads to another, all of 203 costly in terms of physician time. The risk of changing a “right” nition, and heuristic synthesis takes place essentially instan- diagnosis to a “wrong” one will necessarily increase as the taneously for the vast majority of medical problems. The number of options enlarges; research has found that this 99,168 process is effortless. Like Applying conscious review of subconscious processing physicians, most patients much prefer certainty over ambi- hopefully uncovers at least some of the hidden biases that guity. Patients want to believe that their healthcare provid- affect subconscious decisions. The hope is that these events ers know exactly what their disorder is, and what to do outnumber the new errors that may evolve as we second- about it. However, it is not clear that conscious involved and the probabilistic nature of medical decisions is articulation of the reasoning process is an accurate picture unlikely to be warmly received by patients unless they are of what really occurs in expert decision making. Although these arguments may not be 2 persuasive to the individual patient, it is clear that the time The Risk of Diagnostic Error May Actually Increase. Thus, The quality of automatic decision making may be degraded in deciding to use methods to increase reflection, decisions if subjected to conscious inspection. As pointed out in must be made as to: (1) whether the marginal improvements 127 Blink, we can all easily envision Marilyn Monroe, but in accuracy are worth the time and effort and, given the would be completely stymied in attempting to describe her extra time involved, (2) how to ensure that clinicians will well enough for a stranger to recognize her from a set of routinely make the effort. There is, in fact, evidence that complex decisions 204 are solved best without conscious attention. A comple- Unintended Consequences mentary observation is that the quality of conscious decision Innovations made in the name of improving safety some- making degrades as the number of options to be considered 205 times create new opportunities to fail, or have unintended increases. In this framework, we should carefully examine the possibility that Increased Reliance on Consultative Systems May Result some of the interventions being considered might actually in “Deskilling. Tsai and 207 Most of the education and feedback efforts, and even the colleagues found that residents reading electrocardio- consultation strategies, are aimed at increasing such reflec- grams improved their interpretations when the computer tion. Imagine a physician who has just interviewed and interpretation was correct, but were worse when it was 208 examined an elderly patient with crampy abdominal pain, incorrect. A study by Galletta and associates using the and who has concluded that the most likely explanation is spell-checker in a word-processing program found similar constipation. There is a risk that, as the automated programs get sidering this diagnosis before taking action? The extra time the reflective process A summary of the strategies, their assumptions, which takes not only affects the physician but may have an impact may not always be accurate, and the tradeoffs in implement- on the patient as well. Studies Mitigating Harm show that experts seem to know what to do in a given More research and evaluation of strategies that focus on situation and what they know works well most of the time. The re- What this means is that diagnoses are correct most of the search approach should include what Nolan has called time. As Gladwell discussed in an article in The New Yorker on homelessness, however, the solutions to address for addressing diagnostic errors have focused on preven- the “unusual” (or the “unhappy families” referenced in the tion; it is in the area of mitigation where the strategies are epigraph above) may be very different from those that work sorely lacking. So while we are not advo- cating complacency in the face of error, we are assuming Debiasing that some errors will escape our prevention. For these situ- Is instruction on cognitive error and cognitive forcing strat- ations, we must have contingency plans in place for reduc- egies effective at improving diagnosis? Does If we look at the aspects of overconfidence discussed in it transfer from the training to the practice setting? However, the latter two may How much feedback do physicians get and how much do be affected by addressing the former ones. What are the most correct or incorrect, arrogance and complacency would not effective ways to learn from the mistakes of others? Our review demonstrates that while all of the methods to Follow-up reduce diagnostic error can potentially reduce misdiagnosis, How can planned follow-up of patient outcomes be encour- none of the educational approaches are systematically used aged and what approaches can be used for rapid follow-up outside the initial educational setting and when automated to provide more timely feedback on diagnoses? Our review also shows that on some level, physi- Minimizing the Downside cians’ overconfidence in their own diagnoses and compla- Does conscious attention decrease the chances of diagnostic cency in the face of diagnostic error can account for the lack error or increase it? That is, given information and incentives to examine possibility that conscious attention to diagnosis may actu- and modify one’s initial diagnoses, physicians choose not to ally make things worse? We 5% in the perceptual specialties up to 15% in most other return to the problem that prompted this literature review, areas of medicine. In this review, we have examined the but with a more focused research agenda to address the possibility that overconfidence contributes to diagnostic er- areas listed below. Overconfidence Physicians Overestimate the Accuracy of Their Because most studies actually addressed overconfidence indirectly and usually in laboratory as opposed to real-life Diagnoses settings, we still do not know the prevalence of overconfi- Overconfidence exists and is probably a trait of human dence in practice, whether it is the same across specialties, nature—we all tend to overestimate our skills and abilities. Physicians’ overconfidence in their decision making may simply reflect this tendency. Physicians come to trust the fast and frugal decision strategies they typically use. These Preventability of Diagnostic Error strategies succeed so reliably that physicians can become One of the glaring issues that is unresolved in the research complacent; the failure rate is minimal and errors may not to date is the extent to which diagnostic errors are prevent- come to their attention for a variety of reasons. The answer to this question will influence error-reduc- acknowledge that diagnostic error exists, but seem to be- tion strategies. They Berner and Graber Overconfidence as a Cause of Diagnostic Error in Medicine S19 believe that they personally are unlikely to make a mistake.

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If the breath is not successful cialis professional 20 mg, move directly back to compressions and check the airway for an obstruction before attempting subsequent ventilations 20mg cialis professional. With mouth-to-mouth ventilations cialis professional 40 mg, the patient receives a concentration of oxygen at approximately 16 percent compared to the oxygen concentration of ambient air at approximately 20 percent cialis professional 20mg. If you are otherwise unable to make a complete seal over a patient’s mouth 40mg cialis professional, you may need to use mouth-to-nose ventilations: Ÿ With the head tilted back 40 mg cialis professional, close the mouth by pushing on the chin 20 mg cialis professional. This barrier can help to protect you from contact with a patient’s blood cialis professional 40mg, vomitus and saliva , and from breathing the air that the patient exhales . With your other hand (the hand closest to the patient’s chest), place your thumb along the base of the mask while placing your bent index finger under the patient’s chin, lifting the face into the mask. When using a pocket mask, make sure to use one that matches the size of the patient; for example, use an adult pocket mask for an adult patient, but an infant pocket mask for an infant. Also, ensure that you position and seal the mask properly before blowing into the mask. Also, pay close attention to any increasing difficulty when providing bag-valve-mask ventilation. This difficulty may indicate an increase in intrathoracic pressure, inadequate airway opening or other complications. One rescuer gives 1 ventilation every 6 to 8 seconds, which is about 8 to 10 ventilations per minute. At the same time, the second rescuer continues giving compressions at a rate of 100 to 120 compressions per minute. There is no pause between compressions or ventilations and rescuers do not use the 30 compressions to 2 ventilations ratio. This process is a continuous cycle of compressions and ventilations with no interruption. As in any resuscitation situation, it is essential not to hyperventilate the patient. That is because, during cardiac arrest, the body’s metabolic demand for oxygen is decreased. With each ventilation, intrathoracic pressure increases which causes a decrease in atrial/ ventricular filling and a reduction in coronary perfusion pressures. Hyperventilation further increases the intrathoracic pressure, which in turn further decreases atrial/ventricular filling and reduces coronary perfusion pressures. It is common during resuscitation to accidently hyperventilate a patient due to the emotional response of caring for a patient in cardiac arrest. You should be constantly aware of the ventilations being provided to the patient and supply any corrective feedback as needed. Recovery Positions While not generally used in a healthcare setting, it is important to understand how and when to use a recovery position, especially when you are alone with a patient. In most cases while you are with the patient, you would leave an unconscious patient who is breathing and has no head, neck or spinal injury in a supine (face-up) position and maintain the airway. If the patient is an infant, follow these steps: ŸŸ Carefully position the infant face-down along the forearm. The pads need to be adhered to the skin for the shock to be delivered to the heart. Rescuers may perform compressions from the time the shock advised prompt is noted through the time that the prompt to clear occurs, just prior to depressing the shock button. Be sure to follow the manufacturer’s recommendations and your local protocols and practices. However, take steps to make sure that the patient is as dry as possible, is sheltered from the rain, is not lying in a pool or puddle of water and his or her chest is completely dry before attaching the pads. If this is the case, act swiftly and remove the patch with a gloved hand and wipe away any of the remaining medication from the skin. Rescuers call for a position change by using an agreed-upon term at the end of the last compression cycle. The rescuer providing compressions should count out loud and raise the volume of his or her voice as he or she nears the end of each cycle (… 21 … 22 … 23 … 24 … 25 … 26 … 27 … 28 … 29 … 30). The rescuer at the chest will move to give ventilations while the rescuer at the head will move to the chest to provide compressions. Coordinated, efficient, effective teamwork is essential to minimize the time spent not in contact with the chest to improve patient outcomes. All of these activities could affect your ability to maintain contact with the patient’s chest. One important aspect is minimizing interruptions in chest compressions, which helps to maximize the blood flow generated by the compressions. This coordinated team approach also includes integrating and assimilating additional personnel, such as paramedics or a code team, who arrive on scene. They are supervised by a leader, who keeps the crew on task and gets the race car back on the track. The quality, efficiency and swiftness of the crew’s actions can ultimately affect the outcome of how the race car performs. How you function within a team setting, including how additional personnel assimilate into the team, may vary depending on your local protocols or practice. Integration of More Advanced Personnel During resuscitation, numerous people may be involved in providing care to the patient. Rescuers must work together as a team in a coordinated effort to achieve the best outcomes for the patient. Characteristics of effective teamwork include well-defined roles and responsibilities; clear, closed-loop communication; and respectful treatment of others. Coordination becomes even more important when more advanced personnel such as an advanced life support team or code team arrives on the scene. This coordination of all involved is necessary to: ŸŸ Ensure that all individuals involved work as a team to help promote the best outcome for the patient. Basic Life Support for Healthcare Providers Handbook 23 Ultimately, it is the team leader who is responsible for this coordination. When more advanced personnel arrive on scene, it is the team leader who communicates with advanced personnel, providing them with a report of the patient’s status and events. The team leader also sets clear expectations, prioritizes, directs, acts decisively, encourages team input and interaction and focuses on the big picture. Crew Resource Management During resuscitation, crew resource management helps to promote effective and efficient teamwork. Crew resource management is a communication process that centers around the team leader, who coordinates the actions and activities of team members so that the team functions effectively and efficiently. For example, when new individuals arrive on the scene or when team members switch roles during an emergency, it is the team leader who is responsible for coordinating these activities. Crew resource management also guides team members to directly and effectively communicate to a team leader about dangerous or time-critical decisions. It was developed as a result of several airline disasters as a way to prevent future incidents. Crew resource management has been shown to help avoid medical errors in healthcare. To effectively communicate via crew resource management, team members should get the attention of the team leader, and state their concern, the problem as they see it and a solution. Working together, the team should then be sure to obtain direction from the team leader. Basic Life Support for Healthcare Providers Handbook 25 Pediatric Considerations Children are not small adults. In most instances, determining whether to treat a child as a child or as an adult has been based on age. However, for the purposes of this course, a child is defined as the age of 1 to the onset of puberty as evidenced by breast development in girls and underarm hair development in boys. Consent Another factor to consider when caring for children and infants is consent. Legally, adults who are awake and alert can consent to treatment; if they are not alert, consent is implied. However, for most infants and children up to the age of 17 years, you must obtain consent from the child’s parent or legal guardian if they are present regardless of the child’s level of consciousness. To gain consent, state who you are, what you observe and what you plan to do when asking a parent or legal guardian permission to care for their child. If no parent or legal guardian is present, consent is implied in life-threatening situations. Always follow your local laws and regulations as they relate to the care of minors. Science Note Most child-related cardiac arrests occur as a result of a hypoxic event such as an exacerbation of asthma, an airway obstruction or a drowning. As such, ventilations and appropriate oxygenation are important for a successful resuscitation. In these situations, laryngeal spasm may occur, making passive ventilation during chest compressions minimal or nonexistent. Airway To open the airway of a child, you would use the same head-tilt/chin-lift technique as an adult. However, you would only tilt the head slightly past a neutral position, avoiding any hyperextension or flexion in the neck. Basic Life Support for Healthcare Providers Handbook 27 Table 1-2 Airway and Ventilation Differences: Adult and Child Child (Age 1 Through Adult Onset of Puberty) Airway Head-Tilt/Chin-Lift Past neutral position Slightly past neutral position Ventilations Respiratory Arrest 1 ventilation every 5 to 1 ventilation every 3 seconds 6 seconds 28 American Red Cross Compressions The positioning and manner of providing compressions to a child are also very similar to an adult. Place your hands in the center of the chest on the lower half of the sternum and compress at a rate between 100 to 120 per minute. Compressions-to-Ventilations Ratio When you are the only rescuer, the ratio of compressions to ventilations for a child is the same as for an adult, that is, 30 compressions to 2 ventilations (30:2). However, in two-rescuer situations, this ratio changes to 15 compressions to 2 ventilations (15:2). Apply one pad to the center of the child’s chest on the sternum and one pad to the child’s back between the scapulae. Be sure that the pads will not touch each other if considering a traditional pad placement on the anterior chest. Always follow local protocols, medical direction and the manufacturer’s instructions. Primary Assessment Variations: Infant When assessing the infant’s level of consciousness, you should tap the bottom of the foot rather than the shoulder and shout, “Are you okay? For an infant, check the brachial pulse with two fingers on the inside of the upper arm. The pediatric assessment triangle—Appearance, Effort of breathing and Circulation—can give you a more accurate depiction of an infant’s status. Regardless of what tool is used, the recognition of an unresponsive infant is the priority. Airway To open the airway of an infant, use the same head-tilt/chin-lift technique as you would for an adult or child. However, only tilt the head to a neutral position, taking care to avoid any hyperextension or flexion in the neck. Be careful not to place your fingers on the soft tissues under the chin or neck to open the airway. Table 1-4 illustrates airway and ventilation differences for an adult, child and infant. Basic Life Support for Healthcare Providers Handbook 31 Table 1-4 Airway and Ventilation Differences: Adult, Child and Infant Child (Age 1 Through Infant (Birth to Adult Onset of Puberty) Age 1) Airway Head-Tilt/ Chin-Lift Past neutral position Slightly past neutral Neutral position position Ventilations Respiratory Arrest 1 ventilation every 5 to 1 ventilation every 1 ventilation every 6 seconds 3 seconds 3 seconds Compressions Although the rate of compressions is the same for an infant as for an adult or child, the positioning and manner of providing compressions to an infant are different because of the infant’s smaller size. The firm, flat surface necessary for providing compressions is also appropriate for an infant. However, that surface can be above the ground, such as a stable table or countertop. Often it is easier for the rescuer to provide compressions from a standing position rather than kneeling at the patient’s side. The fingers should be oriented so that they are parallel, not perpendicular to the sternum. Rescuers may use either their index finger and middle finger or their middle finger and fourth finger to provide compressions. Fingers that are more similar in length tend to make the delivery of compressions easier. The ratio of compressions to ventilations is the same as for an adult or child, that is, 30 compressions to 2 ventilations (30:2). The rescuer performing chest compressions will be positioned at the infant’s feet while the rescuer providing ventilations will be at the infant’s head. To provide compressions using this technique: ŸŸ Place both thumbs on the center of the infant’s chest side-by-side about 1 finger-width below the nipple line. While positioned at the infant’s head, the rescuer providing ventilations will open the airway using 2 hands and seal the mask using the E-C technique. With two rescuers, the ratio of compressions to ventilations changes to that of a child, that is, 15 compressions to 2 ventilations (15:2). When applying the pads, place one pad in the center of the anterior chest and the second pad in the posterior position centered between the scapulae. You need to be able Ato recognize that a patient who cannot cough, speak, cry or breathe requires immediate care. A conscious person who is clutching the throat is showing what is commonly called the universal sign for choking. Other behaviors that might be seen include running about, flailing arms or trying to get another’s attention. Caring for an Adult and Child For an adult or child, if the patient can cough forcefully, encourage him or her to continue coughing until he or she is able to breathe normally.

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