Amputations During the Civil War

Amputations During the Civil War Amputations became widespread during the Civil War  and the removal of a limb was the most common surgical procedure in battlefield hospitals. Its often assumed that amputations were performed so often  because surgeons at the time were unskilled and simply resorted to procedures bordering on butchery. Yet most Civil War surgeons were fairly well-trained, and the medical books of the era detail precisely how amputations could be performed and when it was appropriate. So its not as if the surgeons were removing limbs out of ignorance. Surgeons had to resort to such a drastic measure because a new type of bullet came into widespread use in the war. In many cases, the only way to try to save a wounded soldiers life was to amputate a shattered limb. The poet Walt Whitman, who had been working as a journalist in New York City, traveled from his home in Brooklyn to the battlefront in Virginia in December 1862, following the Battle of Fredericksburg. He was shocked by a gruesome sight he recorded in his diary: â€Å"Spent a good part of the day in a large brick mansion on the banks of the Rappahannock, used as a hospital since the battle – seems to have received only the worst cases. Outdoors, at the foot of a tree, I notice a heap of amputated feet, legs, arms, hands, c., a full load for a one-horse cart.† What Whitman saw in Virginia was a common sight at Civil War hospitals. If a soldier had been struck in the arm or leg, the bullet tended to shatter the bone, creating horrendous wounds. The wounds were certain to become infected, and often the only way to save the patients life was to amputate the limb. Destructive New Technology: The Minià © Ball In the 1840s an officer in the French Army, Claude-Etienne Minià ©, invented a new bullet. It was different than the traditional round musket ball as it had a conical shape. Minià ©Ã¢â‚¬â„¢s new bullet had a hollow base at the bottom, which would be forced to expand by gases released by the igniting gunpowder when the rifle was fired. While expanding, the lead bullet fit snugly into the rifled grooves in the gun’s barrel, and would thus be much more accurate than earlier musket balls. The bullet would be rotating when it came from the barrel of the rifle, and the spinning action gave it increased accuracy. The new bullet, which was commonly called the Minià © ball by the time of the Civil War, was extremely destructive. The version which was commonly used throughout the Civil War was cast in lead and was .58 caliber, which was larger than most bullets used today. The Minià © Ball Was Feared When the Minià © ball struck a human body, it did enormous damage. Doctors treating wounded soldiers were often perplexed by the damage caused. A medical textbook published a decade after the Civil War, A System of Surgery by William Todd Helmuth, went into considerable detail describing the effects of Minià © balls: The effects are truly terrible; bones are ground almost to powder, muscles, ligaments, and tendons torn away, and the parts otherwise so mutilated, that loss of life, certainly of limb, is almost an inevitable consequence. None but those who have had occasion to witness the effects produced upon the body by these missiles, projected from the appropriate gun, can have any idea of the horrible laceration that ensues. The wound is often from four to eight times as large as the diameter of the base of the ball, and the laceration so terrible that mortification [gangrene] almost inevitably results. Civil War Surgery Was Performed Under Crude Conditions Civil War amputations were performed with medical knives and saws, on operating tables which were often simply wooden planks or doors which had been taken off their hinges. And while the operations may seem crude by today’s standards, the surgeons tended to follow accepted procedures spelled out in the medical textbooks of the day. Surgeons generally used anesthesia, which would be applied by holding a sponge soaked in chloroform over the patient’s face. Many soldiers who underwent amputations did eventually die due to infections. Doctors at the time had little understanding of bacteria and how it is transmitted. The same surgical tools might be used on many patients without being cleaned. And the improvised hospitals were commonly set up in barns or stables. There are numerous stories of wounded Civil War soldiers begging doctors not to amputate arms or legs. As doctors had a reputation for being quick to resort to amputation, soldiers often referred to the Army surgeons as butchers. In fairness to the doctors, when they were dealing with dozens or even hundreds of patients, and when faced with the gruesome damage of the Minià © ball, amputation often seemed like the only practical option.

The Great Kanto Earthquake in Japan, 1923

The Great Kanto Earthquake in Japan, 1923 The Great Kanto Earthquake, also sometimes called the Great Tokyo Earthquake, rocked Japan on September 1, 1923.  Actually, the city of Yokohama was hit even worse than Tokyo was, although both were devastated.  It was the deadliest earthquake in Japanese history. The quakes magnitude is estimated at 7.9 to 8.2 on the Richter scale, and its epicenter was in the shallow waters of Sagami Bay, about 25 miles south of Tokyo.  The offshore earthquake triggered a tsunami in the bay, which struck the island of O-shima at a height of 12 meters (39 feet), and hit the Izu and Boso Peninsulas with 6 meter (20 foot) waves.  Japans ancient capital at Kamakura, almost 40 miles from the epicenter, was inundated by a 6-meter wave that killed 300 people, and its 84-ton Great Buddha was shifted nearly a meter.  The north shore of Sagami Bay rose permanently by almost two meters (six feet), and parts of the Boso Peninsula moved laterally 4 1/2 meters or 15 feet. The Effects of the Earthquake The total death toll from the disaster is estimated at about 142,800.  The quake struck at 11:58 am, so many people were cooking lunch.  In the wood-built cities of Tokyo and Yokohama, upended cooking fires and broken gas mains set off firestorms that raced through homes and offices.  Fire and tremors together claimed 90 percent of the homes in Yokohama and left 60% of Tokyos people homeless.  The Taisho Emperor and Empress Teimei were on holiday in the mountains, and so escaped the disaster. Most horrifying of the immediate results was the fate of 38,000 to 44,000 working class Tokyo residents who fled to the open ground of the Rikugun Honjo Hifukusho, once called the Army Clothing Depot.  Flames surrounded them, and at about 4:00 in the afternoon, a fire tornado some 300 feet tall roared through the area.  Only 300 of the people gathered there survived. Henry W. Kinney, an editor for Trans-Pacific Magazine who worked out of Tokyo, was in Yokohama when the disaster struck.  He wrote, Yokohama, the city of almost half a million souls, had become a vast plain of fire, or red, devouring sheets of flame which played and flickered.  Here and there a remnant of a building, a few shattered walls, stood up like rocks above the expanse of flame, unrecognizable...  The city was gone. The Great Kanto Earthquake sparked another horrifying result, as well.  In the hours and days following, nationalist and racist rhetoric took hold across Japan.  Stunned survivors of the earthquake, tsunami, and firestorm looked for an explanation, looked for a scapegoat, and the target of their fury was the ethnic Koreans living in their midst.  As early as mid-afternoon on September 1, the day of the quake, reports, and rumors started that the Koreans had set the disastrous fires, that they were poisoning wells and looting ruined homes, and that they were planning to overthrow the government.  Approximately 6,000 unlucky Koreans, as well as more than 700 Chinese who were mistaken for Koreans, were hacked and beaten to death with swords and bamboo rods.  The police and military in many places stood by for three days, allowing vigilantes to carry out these murders, in what is now called the Korean Massacre. In the end, the earthquake and its aftereffects killed well over 100,000 people.  It also sparked both soul-searching and nationalism in Japan, just eight years before the nation took its first steps toward World War II, with the invasion and occupation of Manchuria. Sources: Denawa, Mai.  Behind the Accounts of the Great Kanto Earthquake of 1923, The Great Kanto Earthquake of 1923, Brown University Library Center for Digital Scholarship, accessed June 29, 2014. Hammer, Joshua.  The Great Japan Earthquake of 1923, Smithsonian Magazine, May 2011. Historic Earthquakes: Kanto (Kwanto), Japan, USGS Earthquake Hazards Program, accessed June 29, 2014.

Media Violence and Children Essay Example | Topics and Well Written Essays - 500 words

Media Violence and Children - Essay Example Its negative impact is beyond the scope of simple parenting skills. The situation requires vigilant engagement and extra effort on the part of parents so that this issue is effectively addressed. Parents must be involved in choosing the kind of media that their children are exposed to. Increased activism also becomes imperative. Parents should call for a mechanism of control and even some censorship, in addition to a standardized filtering system from policymakers. Media is an omnipresent factor in the lives of many people. It can be accessed easily by the public at any time and on their terms. The question becomes is society conscious of what is being delivered to them through these media sources. For example, individuals tend to turn on television for background noise during everyday chores. This is when adolescent may begin watching negative content unintentionally. Consequently, it is important to evaluate media content daily and discover if there is true value to what is seen or heard. Even cartoons, typically stereotyped as being innocent in nature, illustrate overly animated characters freely engaging in violence with no concern for consequences. In the classic cartoon, Tom and Jerry, the mouse plots various schemes of violence to stop a cat from catching him. Unrealistically and comically, this show encourages adolescents to devise vengeful tactics. Additionally, it portrays violence to be humorous and acceptable. If peer pressure were a factor in the lives of adolescents, they would be inclined to try a drug since in many movies and television shows drugs are practically advertised. In the show Weeds, the normalcy factor is not eliminated when the mother herself is a drug dealer who uses her children as a means of dispensary. There are many television shows that portray different scenarios, all in which we must caution ourselves in the sense that adolescents are immature. Sex and drugs are also prominent fixtures in violent media. In the

How i plan to study Essay Example | Topics and Well Written Essays - 500 words

How i plan to study - Essay Example [Author not known1, 2005].The first step of my study plan is to diligently attend all the lectures pertaining to my subject and try to seek clarification in case of any doubts regarding the topic discussed . The next step is to identify the important points . I will capture the main ideas in the form of notes. [Landsberger, 2005]. I will utilize mind-mapping technique because it is an effective tool of taking notes. It is a technique of taking notes through key words and images. This method helps in quick jotting down of relevant information and is an effective method to remember and review the contents of the lectures. In mind mapping technique, the sentences and paragraphs will be represented in the form of key words and images. Circle the most important word represented by symbol or phrase. Write the related topic outside the circle close to each other. Gradually, the map expands in the direction the topic navigates. This helps the topic in being more specific or detailed. [Landsberger, 2005] Thirdly, I will link and cross-reference key words and images utilized in the mind maps. [Author not known2, 2005]. This will help me to relate to the key notes, phrases, questions and images mentioned in the notes. Fourthly, I will memorize the contents learnt in the classroo

Search and Seizure 4th Ammendment Research Paper

Search and Seizure 4th Ammendment - Research Paper Example The officer must swear, under oath, by it. The amendment has been shaped by various cases along the way, examples being Mapp vs. Ohio in 1961, Katz vs. the United States in 1967, and United States vs. Jones in 2012. 1. Introduction Amendment IV of the bill of rights states, â€Å"The right of the people to be secure in their persons, homes, papers, and effects, against unreasonable searches and seizures, shall not be violated, and no warrants shall issue, but upon probable cause, supported by affirmation or oath, and particularly describing the place to be searched, and the things or persons being searched† (Asimow and Mader, 2004). Amendment IV has three sections; the first affords protection for the home, belongings, and the person of the individual. The second acts to prohibit seizures and searches, which are unreasonable, while the third insists based on a warrant, which means they must describe specifically what is to be seized, grounded by probability cause. The amendmen t is especially of importance given recent occurrences that have to do with invasion of the privacy of Arab Americans after 9/11. This paper will deal with the 4th amendment’s history, applicability, the rules for exclusion, exceptions made to the requirement of a warrant, and finally compile a number of important cases. 2. Adoption of Amendment IV Amendment IV, just like numerous other laws in the United States, has roots in the legal doctrine of England. Therefore, it is important to study its origin in both England and the United States. 2.1 History in the law of England In 1604, Sir Edward Coke ruled that everyone house was their fortress and castle, on top of being a defence against violence and injury, in the Semayne’s case. This case led to the acknowledgement that the monarchy did not possess unchallenged ability for the intrusion of its subject’s dwellings. The ruling, however, permitted agents of the government to carry out seizures and searches with l awful purpose, and possession of a warrant. Intensity of court cases against officers of the state had grown in bounds by 1760, especially since some of the officers still utilized general warrants (Taslitz, 2006). The case involving John Entick, into whose home Nathan Carrington, a messenger of the king, had entered forcibly in order to arrest his friends for the publishing of seditious papers. In the case, Charles Pratt ruled that the warrant was lacking in probable cause and that it did not specify which documents were to be seized (Taslitz, 2006). This case was a precedent in the limitation of the executive’s power to intrude on property deemed private. 2.2 History in America General Warrants and their use were barred via the enacting of legislation by the Massachusetts colony in 1756. This was brought about by complaints from the public over the 1754 Excise Act, which granted powers to the taxman that enabled the utilization of general warrants for the seizure of uncusto med and prohibited goods (Taslitz, 2006). James Otis, in a court petition, in 1761, denounced these policies, but the court ruled against him. After the election to the colonial legislature of Massachusetts, he pushed through legislation that demanded the granting of writs of assistance by judges, with the officer demanding them to be put under oath. However, the British governor overturned this. The Virginia declaration of rights, however, abolished general warrants

Reflective Summary On Prescribing Practice Learning Nursing Essay

Reflective Summary On Prescribing Practice Learning Nursing Essay The author, a nurse practitioner based in an Emergency Department (ED), from here on in will be referred to as the practitioner. The practitioner is currently employed in a development role with the view, following training, of becoming an acute care practitioner. This will entail working autonomously: taking accurate clinical histories, physical examination, gain differential and working diagnosis and organise a plan of care. This plan of care could well include a number of prescribed medications. Hence it is in the practitioners job description (as it is increasingly in many specialist/autonomous nursing roles) to become a Nurse Independent and Supplementary Prescriber (NISP). The Cumberlege Report (1986) suggested that nurses should be able to prescribe independently and highlighted that patient care could be improved and resources used more effectively by doing so. It identified that nurses were wasting their time requesting prescriptions from Doctors. Since the publication of this seminal piece of work, non-medical prescribing has been analysed, reflected upon, researched at great lengths and changes in practice made (DoH 1989, 1999, 2006 2008; Luker et al 1994; Latter et al 2011) and is still under constant review. The aim of this portfolio is to: Reflect on practice as a means of on-going personal and professional development. Demonstrate a capability of integrating learning into practice. Submit a range of material mapped against the module learning outcomes, NMC 2006 prescribing standards, domains of practice and core competencies. Establish an evidence-based approach to practice competence as a safe independent supplementary prescriber. This prescribing practice portfolio will be a reflective portfolio using Rolfe et al (2001) model of reflection to aid learning from experience and close the gap between theory and practice. This model has been chosen as it is something the practitioner is familiar with and has used before. The portfolio will conclude with a reflective summary on prescribing practice learning which will draw together the evidence used to support achievement of the competences identified. After discussing with colleagues who have already completed the NISP course, the practitioner is aware of the complex nature and volume of work that is required over the duration of it. There is a feeling of nervousness due to this but also a feeling excitement over what will be learnt. If successful the practitioner believes her practice will be enhanced significantly as she will have the ability to give patients seamless care. References Department of Health. (1986) Neighbourhood Nursing: A Focus for Care. (Cumberlege Report). London: HMSO Department of Health. (1989) Report of the Advisory Group on Nurse Prescribing. The Crown Report). London: HMSO Department of Health. (1999) Review Of Prescribing, Supply And Administration Of Medicines. (The Crown Report Two) London: HMSO. Department of Health. (2006) Medicines Matters. London: HMSO Department of Health. (2008) Making Connections: Using Healthcare Professionals to Deliver Organisational Improvements. London: HMSO Latter, S. Blenkinsopp, A. Smith, A. Chapman, S. Tinelli, M. Gerard, K. Little, P. Celino, N. Granby, T. Nicholls, P. Dorer, G. (2011) Evaluation of nurse and pharmacist independent prescribing. Faculty of Health Sciences, University of Southampton; School of Pharmacy, Keele University on behalf of Department of Health [Online] Available at http://eprints.soton.ac.uk/184777/ [Accessed 15th Sept 2012] Luker, K. Austin, L. Hogg, C. Ferguson, B. Smith, K. (1998) Nurse-Patient Relationships: The context of Nurse Prescribing. Journal of Advanced Nursing. (28) 2: 235-242 Rolfe, G. Freshwater, D. Jasper, M. (2001) Critical Reflection in Nursing and the Helping Professions: a Users Guide. Basingstoke: Palgrave Macmillan. Consultation Holistic Assessment Case Study In this case study the consultation, diagnosis, prescribing options and decisions of a 35 year old female seen in the ED will be discussed. This case study will aim to improve the practitioners knowledge of conducting a consultation and its relationship with making a diagnosis and treatment options. To maintain confidentiality, in line with the code of professional conduct, the patient will be referred to as Mrs A (Nursing and Midwifery Council (NMC), 2008). Consultation Examining the holistic needs of the patient is the first of seven principles of good prescribing (National Prescribing Centre (NPC), 1999) and must be undertaken before making a decision to prescribe (NMC Practice Standard 3, 2006). Holistic assessment takes into consideration the mind, body and spirit of the patient (Jarvis, 2008). Traditionally consultation and making a diagnosis has been completed by Doctors. However, nurse diagnosis would appear to have been formally acknowledged since The Crown Two Report (DoH, 1999) as part of the independent prescriber role. Horrocks et al, (2002), found greater patient satisfaction with nurse consultations than with GP consultations. Jennings et al, (2009) and Wilson Shifaza, (2008) also found this to be true of nurse practitioners working in emergency departments. Importantly, they also found no significant variation in other health outcomes. Most of these studies found that consultations with nurses were to some extent longer, they offered more advice on self-care and self-management and that nurses gave more information to patients. Although there are various consultation models that have been described (Byrne Long, 1976; Pendleton et al, 1984; Neighbour, 2005; Kurtz et al, 2003; Stott Davis, 1979), these are based upon observation of doctor, not nurse consultations. Nevertheless, the consultation models and skills described in the medical literature are relevant to all practitioners (Baird, 2004). Consultation models help the practitioner centre the consultation around successful information exchange and try to provide a theoretical structure. Consultation models can also be used to help make maximum use of the time available at each consultation (Simon, 2009). Traditionally the medical model is used to assess patients however; it does not take into account the social, psychological, and other external factors of the patient. The model also overlooks that the diagnosis (that will affect treatment of the patient) is a result of negotiation between doctor and patient (Frankel et al, 2003) In this case study, the practitioner has used Roger Neighbours model of consultation. This was found by the practitioner to be simple and easy to remember, whilst covering all areas needed to make an effective consultation and assessment. He describes a 5 stage model which he refers to as a journey with checkpoints along the way: Connecting establishing a relationship and rapport with the patient. Summarising taking a history from the patient including their ideas, expectations, concerns and summarising back to the patient to ensure there are no misunderstandings. Handing over negotiating between the practitioners and patients agenda and agreeing on a management plan. Safety netting the consideration of what if? and what the practitioner might do in each case. Housekeeping reflecting on the consultation. (Neighbour, 2005) Connecting Mrs A was called through to the Rapid Assessment and Treatment area in the ED. It was apparent from Mrs As facial expression and limp that walking caused her pain. Silverman Kinnersley, (2010) state that non-verbal communication is extremely important and can often provide clues to underlying concerns or emotions. The practitioner had never met the patient before so had no previous relationship with her but was aware that she may have pre-conceived ideas about the ED which may have caused her anxiety. The practitioner introduced herself to Mrs A, explained her job role, the process that was about to be undertook and consent obtained. During this time eye contact was maintained and the practitioner also asked Mrs A how she would like to be addressed. This was done to try and build up a rapport with Mrs A, to help her feel at ease and reassure her. Simon, (2009) and Moulton, (2007) agree and state that rapport is essential to effective communication and consultation. Mrs A was also of fered a trolley to sit on to make herself comfortable and the curtains pulled around for privacy and dignity. On reflection the practitioner was aware that the environment was a busy and noisy assessment area and this can have a negative impact on the consultation (Silverman et al, 2005). Identifying this with Mrs A and apologising may have re-assured her further and gained trust and respect. Summarising The practitioner began with an open ended question and did not interrupt the patients response. Neighbour, (2005) and Moulton, (2007) advise this to open the consultation. Gask Usherwood, (2002) found that if a practitioner interrupts, patients then rarely disclose new information, which could lead to not finding out the real reason for the consultation. Mrs A revealed that she received an insect bite to her right lower leg 5 days ago, since then the surrounding skin had become swollen, increasingly red, painful and hot to touch. She explained that the redness was spreading up her leg and the pain was getting worse. Mrs A explained that she was concerned that it was not going to get better and was very worried that it had got worse during the last 3 days. Upon questioning Mrs A also complained of malaise and that she had been feeling very hot and cold and at times. She had been managing to eat and drink as normal. Mrs A lived with her husband, was a non smoker and drank alcohol occasionally. She had no past medical history and took no prescribed or over the counter (otc) medications. It was also elicited that she was allergic to Penicillin which she had an anaphylaxis reaction to. Taking a medical, social, medication and allergy history is important as it can be relevant to the presenting complaint, makes sure key information has not been overlooked and is essential in preventing prescribing errors (Bickley, 2008; Young et al, 2009). The practitioner actively listened to what Mrs A was saying by maintaining eye contact, using open questions and by summarising the history back to clarify points and to make sure nothing was missed. On reflection the practitioner feels this also gave the opportunity for Mrs A to add any further information not disclosed so far. Closed questions were then used to gain specific information related to the initial information given, this is advised by Young et al, (2009) and Moulton, (2007). Effective communication is important as Epstein et al, (2008) explains that a precise history can supply at least 80% of the information necessary for a diagnosis. Upon examination there was obvious erythema. Light palpation revealed that the area was very warm and tender. Neurovascular assessment was performed and was unremarkable. Mrs As chest was clear, heart sounds normal and her abdomen was soft, non tender. Physical examination is important as it is used to detect physical signs that the patient may not be aware of and can be used to confirm or disprove a possible diagnosis. It also suggests to the patient that their illness is being taken seriously. (Bickley, 2008, Charlton, 2006). Observations were taken including blood pressure, heart rate, temperature, respiratory rate and oxygen saturations. All were within normal parameters except her temperature which was 38.2 degrees Celsius. Venous blood was taken to check haematological, biochemical and coagulation status. Mrs A white cell count (WCC) and C-reactive protein (CRP) levels were raised, all other blood results were normal. Handing Over Before making a final diagnosis, it is important that differential diagnoses are excluded (Nazarko, 2012). The practitioners differential diagnoses were deep vein thrombosis (DVT) or venous eczema. However, Mrs A had a straightforward history (insect bite) that together with her observations (raised temperature), examination findings (redness, heat, swelling and pain) and blood results (raised WCC and CRP) indicated an alternative diagnosis, so DVT and venous eczema were ruled out. The practitioners working diagnosis was cellulitis. This was discussed with Mrs A and she appeared reassured that a diagnosis had been made. The practitioner explained that she would like to discuss this with a senior Doctor to help decide on a treatment plan. The practitioner presented the patient to an ED Registrar who agreed with the diagnosis. Diagnosis, treatment and prescribing options were then discussed to aid the practitioners learning. Cellulitis is a bacterial infection of the skin and subcutaneous tissue which is potentially serious (Epstein et al, 2008). It is caused by one or more types of bacteria, most commonly streptococci and staphylococcus aureus (Nazarko, 2012). Cellulitis usually occurs on the lower legs, arms and face but can arise anywhere on the body (Bickley, 2008). Patients with cellulitis present with signs of inflammation, distinctively heat, redness, swelling and pain (Nazarko, 2012). Inflammation is localised initially but increases as the infection progresses. Patients can be systemically unwell (pyrexial, tachycardic, hypotensive) and white cell count and C-reactive protein levels will be markedly raised (Beldon, 2011, Wingfield, 2009, Nazarko, 2012). It appears there is a general lack of evidence based literature surrounding the treatment of patients with cellulitis. The practitioner could only find one national guideline on the management of cellulitis in adults, which was published in 2005 by the Clinical Resource Efficiency Support Team (CREST, 2005). However, to the practitioners knowledge, these have not been validated by a clinical study. Morris, (2008) found in his systematic review that antibiotics cure 50-100% of cases of cellulitis but did not find out which antibiotic regime was most successful. Kilburn et al, (2010) also could not find any definitive conclusions in their Cochrane review on the optimal antibiotics, duration or route of administration. Eron, (2000) devised a classification system for cellulitis and its treatment which CREST used in their guidelines. This system divides people with cellulitis into four classes and can serve as a useful guide to admission and treatment decisions. However Koerner Johnson, (2011) found in their retrospective study, comparing the treatment received with the CREST guidelines, that patients at the mildest end of the spectrum were over treated and at the more severe end undertreated. They also found a significant variation in antibiotic regimes prescribed for patients with cellulitis. Marwick et al, (2011) questioned whether classes I and II could actually be merged to improve treatment. The practitioners trust has antibiotic guidelines (updated yearly) which also include a classification system. This aids the prescriber in choosing the correct antibiotic, dose, route and duration for certain conditions, cellulitis being one of them. After discussion with the Registrar it was determined that Mrs A was in Class I or non-severe which meant she could be managed with oral antibiotics on an outpatient basis. The practitioners trust and CREST, (2005) guidelines advise first line treatment for non-severe or class I cellulitis as oral Flucloxacillin 500mg, three times a day. Flucloxacillin is a moderately narrow-spectrum antibiotic licensed for the treatment of cellulitis. However, Flucloxacillin was contra-indicated for Mrs A as she had a severe penicillin allergy (British National Formulary, (BNF) 2012). Clarithromycin is a macrolide which has an antibacterial spectrum that is similar but not identical to that of penicillin; they are thus an alternative in penicillin-allergic patients (BNF, 2012). Clarithromycin is licensed and recommended by CREST, (2005), and by the practitioners trust, as an alternative to Flucloxacillin in cellulitis for patients with a Penicillin allergy. It is indicated in the BNF, (2012) for the treatment of mild to moderate skin and soft-tissue infections. It demonstrates suitable pharmacokinetics, with good distribution into skin and soft tissues, and is effective against the large majority of staphylococcal and streptococcal bacteria that cause cellulitis (Accord Healthcare Limited, 2012), (See drug monologue page 21-28). There were no contraindications in prescribing Clarithromycin for Mrs A. The option of not having any medication was discussed with Mrs A however, she wanted treatment so the benefits and side effects of Clarithromycin was explained, and consent obtained from Mrs A to prescribe the antibiotics and to be discharged, (NMC Practice Standard 5, 2006). Dose and duration were then also clarified and the importance of taking the antibiotics as prescribed and to complete the full course. On reflection, by discussing and deciding on the best treatment together this would hopefully promote concordance. Negotiating with patients and agreeing on a management plan is very important aspect of reaching patient centred care (Neighbour, 2005). Using an FP10 Clarithromycin tablets 500mg twice a day was prescribed by the Registrar (as the practitioner was not a licensed prescriber, NMC Practice Standard 1, 2006), as per trust guidelines, for 7 days. Paracetamol tablets 1g four times a day was also prescribed for its analgesic and anti-pyretic properties (BNF, 2012). A stat dose of both were prescribed and the practitioner asked the nurse to administer the first dose (NMC Practice Standard 9 14, 2006), and was aware that by delegating this task the prescriber remained accountable. The FP10 was given to the patient to take to the pharmacy of her choice for them to dispense (NMC Practice Standard 10, 2006), (See mock prescription page 29). The practitioner did not initially contemplate cost effectiveness but on reflection it has been recognised that this needs to be taken into consideration when prescribing (NPC, 1999). Intravenous antibiotics may have been prescribed, which may have meant an admission into hospital or administration by nurses on an outpatient basis; thus would have increased the cost of treatment significantly. Admission to hospital can also be overwhelming and can put the patient at risk of hospital acquired infections and increased risk of antibiotic resistance (Wingfield, 2008). Safety Netting The erythematous border was marked, with the patients consent, with permanent pen to monitor for any improvement or additional spread of infection (CREST, 2005, Beldon, 2011). The practitioner advised Mrs A that she should return or see her GP if she had worsening symptoms or if by the completion of the course of antibiotics symptoms had failed to resolve. Mrs A was also advised that, if a similar incident occurred, she should seek medical assistance early so that treatment could begin as soon as possible to reduce the risk of severe and long-term complications. In addition it was recommended that she should drink plenty of fluids to prevent dehydration, elevate the leg for comfort and to help reduce the swelling (CREST, 2005, Beldon, 2011). Mrs A was warned that there could be an increase in erythema in the first 24-48 hours of treatment (CREST, 2005). This advice and information empowered Mrs A and made sure that her discharge was as safe as possible. The practitioner brought the consultation to a close by asking Mrs A if she had any questions or if there was anything else she would like to discuss. This gave Mrs A the opportunity of clarifying any information given by the practitioner and the opportunity to divulge any information or concerns not previously mentioned. This re-assured the practitioner that she had addressed her problem appropriately. Housekeeping The practitioner made sure there was clear concise documentation of the consultation and choice of prescription in Mrs A notes (NMC Practice Standard 7, 2006). A discharge letter was also produced to send to her GP NMC Practice Standard 6, 2006). Once the prescription was ready, Mrs A was discharged. This case study has shown the practitioner the importance of effective communication in consultation. By following Neighbours consultation checkpoints it gave structure to the consultation and will be used by the practitioner in future practice. It has also helped the practitioner to gain an understanding of different prescribing options and how to explore these further. For example, the practitioner did find when reading around the subject that there has been some research on the use of corticosteroids in cellulitis to increase resolution, however, to the practitioners knowledge, this is not currently advised in any guidelines and further research is needed. The practitioner would also like to be involved in the development of a cellulitis pathway at her place of work. This could include an algorithm to aid practitioners to differential diagnosis so patients can receive appropriate treatment and reduce the incorrect prescribing of antibiotics. As there are no National Institute for Health and Clinical Excellence (NICE) guidelines on the treatment and management of cellulitis, treatment of patients is not standardised and consequently quality of care could be affected. The optimal choice for antimicrobial therapy requires review and definitive study in clinical trials. References Accord Healthcare Limited (2012) Summary of Product Characteristics for Clarithromycin Capsules 500mg. [online]. Electronic Medicines Compendium. Datapharm Communications Ltd. Available from: http://www.medicines.org.uk/EMC/medicine/25914/SPC/Clarithromycin+500mg+Tablets/ [Accessed 21ST September 2012] Byrne, P. Long, B. (1976) Doctors Talking to Patients. London, HMSO. Baird, A. (2004) The Consultation. Nurse Prescriber. (1) 3: 1-4 British National Formulary: No. 64 (2012) London: BMJ Group and Pharmaceutical Press. Bickley, L. (2008) Bates Guide to Physical Examination and History Taking. 6th Ed. London: Lippincott, Williams and Wilkins. Beldon, P. (2011) The Assessment, Diagnosis and Treatment of Cellulitis. Wound Essentials. (6): 60-68. Clinical Research Efficiency Support Team (2005) Guidelines on the Management of Cellulitis in Adults. Belfast: Clinical Research Efficiency Support Team. Charlton, R. (2006) Learning to Consult. Abingdon: Radcliffe. Department of Health (1999) Review Of Prescribing, Supply And Administration Of Medicines. (The Crown Report) London: HMSO. Epstein, O. Perkin, G. Cookson, J. De Bono, D. (2008) Clinical Examination. 4th Ed. London: Mosby. Eron, L. (2000) Infections of Skin and Soft Tissues: Outcome of A Classification Scheme. Clinical Infectious Diseases. (31) 287 Frankel, R. Quill, T. McDaniel, S. (2003) The Biopsychosocial Approach: Past, Present, and Future. Rochester: University Of Rochester Press. Gask L, Usherwood, T. (2002) ABC of Psychological Medicine: The Consultation. British Medical Journal (324) 7353: 1567-1569. Horrocks, S. Anderson, E. Salisbury, C. (2002) Systematic Review of Whether Nurse Practitioners Working in Primary Care Can Provide Equivalent Care to Doctors. British Medical Journal. (324) 7341: 819-823. Jarvis, C. (2008) Physical Examination and Health Assessment. 5th Ed. Missouri: Saunders Elsevier. Jennings, N., Lee, G., Chao, K., Keating, S. (2009) A Survey of Patient Satisfaction in a Metropolitan Emergency Department: Comparing Nurse Practitioners to Emergency Physicians. International Journal of Nursing Practice (15) 213-218. Kilburn, S., Featherstone, P., Higgins, B., Brindle, R. Interventions for Cellulitis and Erysipelas. Cochrane Database Systematic Reviews. 2010 Issue 6, Art. No. CD004299. DOI:  10.1002/14651858. Koerner, R. Johnson, A. (2011) Changes in the classification and management of Skin and Soft Tissue Infections. Journal of Antimicrobial Chemotherapy. (66) 232-234. Kurtz S, Silverman J, Benson J, Draper J. (2003) Marrying Content and Process in Clinical Method Teaching; Enhancing the Calgary-Cambridge Guides. Academic Medicine (78) 8: 802-809. Marwick, C. Broomhall, J. McCoowan, C. Phillips, G. Gonzalez-McQuire, S. Akhras, K. Merchant, S. Nathwani. Davey, P. (2011) Severity Assessment of Skin and Soft Tissue Infections: Cohort Study of Management and Outcomes for Hospitalised patients. Journal of Antimicrobial Chemotherapy. (66): 387-397 Morris, A. (2008) Cellulitis and Erysipelas. Clinical Evidence. [online] BMJ Publishing Group Ltd. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907977/ [Accessed 10th September 2012] Moulton L. (2007) The Naked Consultation: A practical Guide to Primary Care Consultation skills. Abingdon: Radcliffe. National Prescribing Centre. (1999) Signposts for Prescribing Nurses General Principles of Good Prescribing. Prescribing Nurse Bulletin. (1): 1-4. Nazarko, L. (2012) An Evidence-Based Approach to Diagnosis and Management of Cellulitis. British Journal of Community Nursing. (17) 1: 6-12. Neighbour, R. (2005) The Inner Consultation. How to Develop an Effective and Intuitive Consulting Style. 2nd Ed. Oxford: Oxford-Radcliffe. Nursing and Midwifery Council (2006) Standards of Proficiency for Nurse and Midwife prescribers. London: Nursing and Midwifery Council. Nursing and Midwifery Council (2008) The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives. London: Nursing and Midwifery Council. Pendleton, D. Schofield, T. Tate, P. Havelock, P. (1984) The Consultation: An Approach to Learning and Teaching. Oxford: Oxford University Press. Silverman, J. Kurtz, S. Draper, J. (2005) Skills for Communicating with Patients. 2ND Ed. Oxford: Radcliffe. Silverman, J. Kinnersley, P. (2010) Doctors Non-Verbal Behaviour in Consultations: Look at the Patient Before You Look at The Computer. British Journal of General Practice. (60): 76-8. Simon, C. (2009) The Consultation. InnovAiT (2) 2: 113-121. [online] Available at http://rcgp-innovait.oxfordjournals.org/content/2/2/113.full. [Accessed 13th September 2012] Stott, N. Davis, R. (1979) The Exceptional Potential in Each Primary Care Consultation. Journal of the Royal College of General Practitioners. (29): 201-5. Wingfield, C. (2009) Lower Limb Cellulitis: A Dermatological Perspective. Wounds UK. (5) 2: 26-36. Wingfield, C. (2008) Cellulitis: Reduction of Associated Hospital Admissions. Dermatological Nurse 7(2): 44-50. Wilson, A. Shifaza, F. (2008) An Evaluation of the Effectiveness and Acceptability of Nurse Practitioners in an Adult Emergency Department. International Journal of Nursing Practice. (14): 149-156. Young, K. Duggan, L. Franklin, P. (2009) Effective Consulting and History-Taking Skills for Prescribing Practice. British Journal of Nursing. (18) 17: 1056-1061. Drug Monologue. Name of Drug Clarithromycin Drug Classification Macrolide Therapeutic Uses(s) Clarithromycin film-coated tablets are indicated in adults and adolescents 12 years and older for the treatment of the following bacterial infections, when caused by clarithromycin-susceptible bacteria. à ¢Ã¢â€š ¬Ã‚ ¢ Acute bacterial exacerbation of chronic bronchitis à ¢Ã¢â€š ¬Ã‚ ¢ Mild to moderate community acquired pneumonia. à ¢Ã¢â€š ¬Ã‚ ¢ Acute bacterial sinusitis à ¢Ã¢â€š ¬Ã‚ ¢ Bacterial pharyngitis. à ¢Ã¢â€š ¬Ã‚ ¢ Skin infections and soft tissue infections of mild to moderate severity, such as folliculitis, cellulitis and erysipelas Clarithromycin film-coated tablets can also be used in appropriate combination with antibacterial therapeutic regimens and an appropriate ulcer healing agent for the eradication of Helicobacter pylori in patients with Helicobacter pylori associated ulcers Dose range and route(s) of administration Adults and adolescents (12 years and older) à ¢Ã¢â€š ¬Ã‚ ¢ Standard dosage: The usual dose is 250 mg twice daily. à ¢Ã¢â€š ¬Ã‚ ¢ High dosage treatment (severe infections): The usual dose may be increased to 500 mg twice daily in severe infections. Children younger than 12 years: Use of Clarithromycin film-coated tablets is not recommended for children younger than 12 years. Use Clarithromycin paediatric suspensions. Clinical trials have been conducted using clarithromycin pediatric suspension in children 6 months to 12 years of age. Elderly: As for adults Dosage in renal functional impairment: The maximum recommended dosages should be reduced proportionately to renal impairment. In patients with renal impairment with creatinine clearance less than 30 mL/min, the dosage of clarithromycin should be reduced by one-half, i.e. 250 mg once daily, or 250 mg twice daily in more severe infections. Treatment should not be continued beyond 14 days in these patients. Patients with hepatic impairment: Caution should be exercised when administrating clarithromycin in patients with hepatic impairment Administered orally. Pharmacodynamics Mode of Action Clarithromycin is a semi-synthetic derivative of erythromycin A. It exerts its antibacterial action by binding to the 50s ribosomal sub-unit of susceptible bacteria and suppresses protein synthesis. It is highly potent against a wide variety of aerobic and anaerobic gram-positive and gram-negative organisms. The 14-hydroxy metabolite of clarithromycin also has antimicrobial activity. The MICs of this metabolite are equal or two-fold higher than the MICs of the parent compound, except for H. influenzae where the 14-hydroxy metabolite is two-fold more active than the parent compound. Side Effects Dyspepsia, tooth and tongue discoloration, smell and taste disturbances, stomatitis, glossitis, and headache; less commonly: arthralgia and myalgia; rarely: tinnitus; very rarely: dizziness, insomnia, nightmares, anxiety, confusion, psychosis, paraesthesia, convulsions, hypoglycemia, renal failure, interstitial nephritis, leucopenia, and thrombocytopenia Interactions Aprepitant Clarithromycin possibly increases plasma concentration of aprepitant Atazanavir Plasma concentration of both drugs increased when Clarithromycin given with atazanavir. Atorvastatin Clarithromycin increases plasma concentration of atorvastatin. Cabazitaxel Avoidance of clarithromycin advised by manufacturer of cabazitaxel. Calcium-channel Blockers Clarithromycin possibly inhibits metabolism of calcium-channel blockers (increased risk of side-effects). Carbamazepine Clarithromycin increases plasma concentration of carbamazepine. Ciclosporin Clarithromycin inhibits metabolism of ciclosporin (increased plasma concentration). Colchicine Clarithromycin possibly increases risk of colchicine toxicity-suspend or reduce dose of colchicine (avoid concomitant use in hepatic or renal impairment). Coumarins Clarithromycin enhances anticoagulant effect of coumarins. Disopyramide Clarithromycin possibly increases plasma concentration of disopyramide (increased risk of toxicity). Dronedarone Avoidance of clarithromycin advised by manufacturer of dronedarone (risk of ventricular arrhythmias). Efavirenz Increased risk

Ethnography - Inter-team Conflict with the Coach :: Ethnography

Ethnography - Inter-team Conflict with the Coach Recently, two strong sophomore players quit the varsity women’s water polo team. They said that they were no longer having fun, one saying that the time commitment â€Å"just was not worth it anymore,† while the other said that playing polo at Oxy was making her more and more unhappy.† Earlier in the season, one of the players who was named first team All American and MVP of the National Tournament, also almost quit the team for good. Again, her reasoning was that the game was not fun for her anymore. She also expressed that she felt unappreciated by the coach for her efforts at Nationals, as well as for her leadership on the team on a regular basis. These withdrawals reminded me of the last two years when I was on the team. I recall how often I would hear the other players express their discontent about being on the team. However, the problem did not lie in the team in itself, but rather in the coach and his ways. Interestingly, although I was a member of the team, I truly was not aware of the problem at hand. I, above and beyond, was a novice player and almost never received anything but positive encouragement from the coach. It is important to realize that I had never played, or even seen, the game of water polo before coming to Oxy, and therefore learned a lot by coming to practice and watching and learning from the reminders and criticism that the coach would give. Nevertheless, I did have a lot of experience swimming under various coaches—some of whom where the meanest of the mean. It is for this reason that I felt that the other players were often being overly sensitive to the criticisms (which I viewed more often than not as constructive) that the coach would give. Of course, there would betimes that I felt that he would pick on (or yell more at) certain players. But I believe that there are few coaches that specifically try to bring down moral and cause players to hate the game. Yet, despite the fact that the coach may not mean to bring down moral and cause players to hate the game, it seems he has done something to cause two, almost three, players that played in the National Championship tournament to quit the team.