Y. Dudley. Southampton College.

Evidence from children and even infants is equally strong purchase nexium 20mg fast delivery, with approximately 60% seizure freedom with surgery buy nexium 40mg low price. Parents must be willing to accept the potential for motor buy nexium 20 mg lowest price, language buy nexium 40 mg with amex, cognitive, or visual def- icits as well as possible mortality. In order to proceed with surgery, we seek a ‘‘con- vergence of evidence. If not, bilateral subdural electrodes may need to be placed on the surface of the brain for better localization of the region or laterality of epileptogenicity. Once the area is identified, baseline neuropsychologic testing and occasionally a Wada procedure to lateralize memory and language will be performed. Subdural grid electrodes placed over the region of interest are often required for a 1-week monitoring period before resection to delineate both epileptogenic and functional cortex. The smallest resection possible is always strived for, but in cases of intract- able unihemispheric epilepsy (e. If the child is not a candidate for surgery, or the family and child do not wish to take the risk of loss of function, alternatives to further medication trials do exist and can be very beneficial. Whereas some would argue that these alternatives should be tried earlier than traditionally considered because of their relatively low side effect profile, they typically remain treatments of last resort. The ketogenic diet has been available as a dietary option since the 1920s, but starvation as a treatment for Intractable Epilepsy 109 epilepsy was even described in the Bible. This high-fat, adequate-protein, low- carbohydrate therapy requires careful calorie and fluid management. The entire family must be invested in the process and we require the family to take classes in its management. Traditionally, children are admitted for a 48-hr fast, followed by gradual introduction of the ketogenic diet as an eggnog preparation. Even children with intractable epilepsy may show significant seizure reduction. In a large retrospec- tive study at our institution, we found greater than 50% seizure reduction in 50% of patients and greater than 90% in 27%. Well-established side effects include constipation, slowed weight gain and growth, hyperlipidemia (reversible), and kidney stones (6%). A current trial of the Atkins diet, a therapy with less protein and calorie restriction that also induces ketosis, is underway as well. Vagus nerve stimulation has emerged over the past decade as another tool for intractable epilepsy. This therapy has been approved by the FDA since 1997, but is not officially approved for use in children under age 12. More than 25,000 patients have been implanted and more than 7000 of these patients were under age 18 at sur- gery. Standard stimulation settings of 30 sec on and 5 min off are initially programmed, but can be adjusted as needed. The vagus nerve stimulator is theorized to stimulate the nucleus solitarius and locus ceruleus, but its effects on the brain and EEG patterns are less clear. Efficacy is typically a 25–40% seizure reduction, similar to most new anticonvulsants. However, side effects are few and limited generally to voice change and hoarseness. In addition, a small magnet that causes an immediate stimulation to occur can be used to try and abort seizures, allowing the child and family a unique form of acute therapy. Reports of behavioral improvement have also been described in the recent literature. Corpus callosotomy can also be performed for intractable nonfocal epilepsy, commonly atonic seizures. Callosotomies have been used since 1940 and are either partial (anterior two-thirds) or complete in two stages. This therapy specifically ben- efits atonic seizures, but is more palliative than curative according to reports, with an approximate 8% seizure-free rate described. In catastrophic cases where a child is in persistent status epilepticus, the use of intravenous solumedrol or immunoglobulin has been described as a potential immunomodulating therapy.

Once you have passed Member of the Royal College of Surgeons parts 1 & 2 (the multiple choice questions) then you will be allowed to operate more freely than before and surgeons will be more willing to teach you generic nexium 20mg with visa. The underlying reason for this has yet to be explained but presumably stems from the initiation into the ‘surgeon’s club’ once you have your first Royal College qualification! Writing Police Statements Police statements can be exciting at first order nexium 40 mg mastercard, but soon become tiresome when you are handed cases by the basket purchase 20mg nexium free shipping. Anyone who has worked in the A&E department will tell you the same story buy nexium 40mg. However, although sometimes a chore, these statements often Getting on in Your Senior House Officer Post 79 form the backbone of legal cases and should be written in the most professional and organised manner possible. On the whole,most barristers do not twist medical state- ments or squeeze medical professionals into corners in court, but it only takes one carelessly written statement or a single wrong fact to put you into a corner, which is unpleasant (to say the least). Speaking from experience,having written a statement in the middle of a quiet night shift in the A&E department and sent it off, all seemed well. That was until I was summoned to court and realised that I had not written my statement in exactly the same format that I remembered because I had forgotten to keep a photocopy of it. The following is the accepted standard format for writing a statement for a casu- alty officer (A&E department SHO). Ward-based reports include the same informa- tion in a slightly different fashion and you should ask your seniors for advice. You should not use any abbreviations in a statement however well recognised they are. As an SHO you will be called as an actual witness not an expert witness and, therefore, in your statement you should give fact only and not opinion (see the section on going to court). Opinions lead to errors and the reputation of you and your department can be damaged. Format for Writing Police Statements (from the Accident and Emergency Department) I, (name), have the following qualifications: (include your degree(s) and post- graduate examinations if any). On (date) at (time) I was on duty as a (grade and speciality) in the (department) of (hospital with address). At (time) I saw (name of patient) who was brought into the department by (mode of transport, for example ambulance or wheelchair), having allegedly been assaulted/involved in a road traffic accident/attempted suicide, etc. The attending paramedic/police officer stated … Give the details given to you by the paramedics/police or any eye witnesses on the scene about the pre-hospital events which you know to be true. Particular details on the mechanism of any injury may be appropriate (for example damage to vehicles), but do not speculate. The patient told me … Give details of the history the patient gave you, writ- ing the patients own words in inverted commas if possible. My immediate or life-saving treatment was … (for example oxygen, intra- venous cannula and fluids). I requested the following investigations (list the investigations requested) and they showed (their results). Further treatment was necessary (for example mobilisation and stabilisation of a fracture, chest drain, etc. This was administered by … 80 What They Didn’t Teach You at Medical School The patient was discharged/referred to (give the speciality) at (time). Note: surprisingly often the police do not take detailed statements from admitting teams, so it is worth adding a note of the outcome of the patient. For example,at (time) Doctor X,the orthopaedic senior house officer saw Mr Smith. He was seen by the orthopaedic specialist registrar at (time) and transferred to the operating theatre for surgical fixation of (injury). In these final details it may be necessary to be vague if you are unsure of the admission details.

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This is because until very recently most chiro- practors in Canada held dual classifications as naturopaths (Clarke 1996) cheap nexium 40 mg. CHRISTIAN SCIENCE MEDICINE Christian Science Medicine is a spiritual healing system that rejects allopathic medicine order 20 mg nexium mastercard. According to Mary Baker Eddy (1934:109–123) discount nexium 40mg with amex, founder of the Christian Science religion: “The term Christian Science nexium 40 mg mastercard... Only through prayer and divine intervention can they be corrected, returning the person to health. And there was always testimony of healing and how you saw it interact in your life. You sort of shared in conducting that experience and where you found quotes within the bible... I heard stories of people getting over cancer, people who were born blind see- ing without glasses. CREATIVE VISUALIZATION Creative visualization was popularized by Shakti Gawain in the late 1970s. As a therapeutic medium, healing is accomplished by using the power of the mind to effect the elimination of illness or disease. For example, to cure oneself of cancer using this approach, one concretely imagines the destruction of the tumour or cancerous cells “regularly until it becomes Appendix: The Therapies | 131 reality,” endowing the visualization with positive energy throughout the process of healing (Alternative health dictionary 2003). CRYSTAL HEALING Crystal healing is based on the notion that certain stones can be used as conduits for healing energy. One of the participants in this research, Jane, offered to give me a crystal healing session. She asked me to sit down and hold my feet up slightly while she held two crystals at the soles of my feet. She told me that the crystals were creating a circuit of positive energy that would course through my body. Positive energy would enter my body through my right foot, travel up and around my body, and push negative energy out through the bottom of my left foot. She also diagnosed as she treated, telling me I had had an injury to my shoulder some years ago. At the end of the session she pronounced me “pretty okay” (field notes). EAR CANDLING Purported to have its “origin in ancient Egyptian, Chinese, and North American Indian cultures,” ear candling is one of a number of ways to remove toxins from the body (Natural Health Centre 1997). Specifically, it is a method of removing wax and other debris from the ear canal. This therapy is meant to improve hearing, vision, taste, smell, balance, and/or treat ear infections, sinus problems, dizziness, itching, and headaches (Bauer 1997). Having had periodic problems with pain in my ears, I was curious to experiment with ear candling. A hollow candle, wider at one end than the other, is made by wrap- ping cotton tape around a narrow cylinder, such as a pencil, which is then dipped in bee’s wax (field notes). The narrower end of the candle is placed in the client’s ear and “the opposite end of the candle is lit... In Marie’s words: People with ear problems, they’ve gone through procedures of having their ears syringed and it’s rather uncomfortable. Ear candling is much 132 | Using Alternative Therapies: A Qualitative Analysis gentler. A very old ancient way of cleaning the debris out of the ear and I usually do it twice, a week apart. During the treatment I lay on my side while the candle was placed in my ear and lit. As the candle burned down I heard a rushing sound that wasn’t unpleasant.

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After cardiac arrest buy nexium 20 mg cheap, non-pregnant adults suffer irreversible brain damage from anoxia within three to four minutes buy 20mg nexium, but pregnant women become hypoxic more quickly generic 40mg nexium with mastercard. Although evidence shows that the fetus can tolerate prolonged periods of The timing of caesarean section and the hypoxia buy 40mg nexium free shipping, the outlook for the neonate is optimised by immediate speed with which surgical delivery is caesarean section. Most of the operating theatre, or accident and emergency department, and children and mothers who survive basic and advanced life support are not successful within emergency caesarean deliveries are five minutes, the uterus should be emptied by surgical delivered within five minutes of maternal intervention. Given the time taken to prepare theatre packs, cardiac arrest this procedure is probably best carried out with just a scalpel. Time will pass very quickly in such a high-pressure situation, and it is advisable to practise this scenario, particularly in the accident and emergency department. Cardiopulmonary resuscitation must be continued throughout the operation and afterwards because this improves the prognosis for mother and child. After successful delivery both mother and infant should be transferred to their appropriate intensive care units Further reading as soon as clinical conditions permit. Report on Confidential enquiry into successful resuscitation in late pregnancy is that all midwifery, maternal deaths in the United Kingdom 1997–1999. London: nursing, and medical staff concerned with obstetric care should HMSO, 2001. Part 8: Advanced challenges in Retention of cardiopulmonary resuscitation skills is poor, resuscitation. Regular short periods of practice relieve aortocaval compression in resuscitation during late on a manikin are therefore essential. Members of the public and the ambulance service should ● Page-Rodriguez A, Gonzalez-Sanchez JA. Perimortem cesarean be aware of the additional problems associated with section of twin pregnancy: case report and review of the resuscitation in late pregnancy. Postmortem and perimortem cesarean is of particular importance as paramedics are likely to be the section: what are the indications? Sadly, some babies have irreversible brain damage Delivery by the time of delivery, but it is unacceptable that any damage ● Fetal distress ● Reduced fetal movement should occur after delivery due to inadequate equipment or ● Abnormal presentation insufficiently trained staff. For this reason, there should always ● Prolapsed cord be at least two healthcare professionals at all deliveries—one ● Antepartum haemorrhage who is primarily responsible for the care of the mother, and the ● Meconium staining of liquor other, who must be trained in basic neonatal resuscitation, to ● High forceps look after the baby. Whenever possible, there ● Severe pregnancy-induced hypertension ● Heavy sedation should also be a trained assistant who can provide additional help ● Drug addiction if necessary. Babies at increased risk make up about a quarter of ● Diabetes mellitus all deliveries and about two thirds of those requiring resuscitation; ● Chronic illness the remaining one third are babies born after a normal Fetal uneventful labour who have no apparent risk factors. Staff on ● Multiple pregnancy labour wards must, therefore, always be prepared to provide ● Pre-term ( 34/52) adequate resuscitation until further help can be obtained. It can be wall mounted or kept on a trolley, provided that one is available for each delivery area. It is essential that there should be an overhead heater with an output of 300-500 Watts mounted about 1m above the platform. This must have a manual control because servo systems are slow to set up and likely to malfunction when the baby’s skin is wet. These heaters are essential, as even in environments of 20-24 C the core temperature of an asphyxiated wet baby can drop by 5 C in as many minutes. Resuscitation equipment Facilities must be available for facemask and tracheal ● Padded shelf or resuscitation trolley tube resuscitation. The use of oxygen versus air during ● Overhead light resuscitation at birth is controversial because high ● Oxygen and air supply ● Clock concentrations of oxygen may be toxic in some circumstances. As the latest relief valve generation of resuscitation systems have air and oxygen mixing ● Facemask facilities it will usually be possible to reduce the inspired ● Oropharyngeal airways 00, 0 oxygen fraction to a lower level once the initial phase of ● Resuscitation system (facemask, T-piece, resuscitation is over. Additional equipment needed includes an bag and mask) ● Suction catheters (sized 5, 8, 10 gauge) overhead light, a clock with a second hand, suction equipment, ● Mechanical and/or manual suction with stethoscope, an electrocardiogram (ECG) monitor, and an double trap oxygen saturation monitor. But this is almost ● Intraosseous needle always unnecessary unless the amniotic fluid is stained with ● ECG and transcutaneous oxygen saturation monitor meconium or blood. Aggressive pharyngeal suction can delay ● Note: capnometers are a strongly the onset of spontaneous respiration for a considerable time. Most babies will start breathing during this period as the median time until the onset of spontaneous respiration is only 10 seconds. If necessary, the baby can be encouraged to breathe by skin stimulation—for example, flicking the baby’s feet; those not responding must be transferred immediately to the resuscitation area.

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