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It is mandatory to take this course before entering your membership examination buy 100mg extra super levitra visa. 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 extra super levitra 100mg on line. 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 purchase 100mg extra super levitra, but soon become tiresome when you are handed cases by the basket. Anyone who has worked in the A&E department will tell you the same story. 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. It is acceptable to state that the patient was admitted under the care of the on-call team (stating speciality). At the end of your statement you should write‘End of statement’ and sign it.
No reaming of the cavity was performed because of the inherent fragility of the acetabular walls discount extra super levitra 100 mg with amex. A socket generic 100mg extra super levitra with amex, 37 to 42mm in outside diameter buy extra super levitra 100 mg overnight delivery, was cemented into the acetabular cavity. In 81 of the 118 procedures, a bone autograft obtained from the femoral head and neck was used to enlarge and reinforce the roof on the undeveloped original acetabulum. The femoral component was implanted at the level of the lesser trochanter except in 5 hips, in which it had to be placed below. In 19 of them, the osteotomy was performed to align an angulated femur that had been osteotomized previously, whereas in 2 hips the osteotomy was performed to shorten the femur. Although reduction was usually tight, muscle releases or tenotomies were not performed. Reduction was achieved by pressure directed inferiorly on the femoral neck, with the limb held in adduction, the hip ﬂexed slightly, and the knee ﬂexed at 90° to relax the sciatic nerve. Reattachment of the greater trochanter was carried out routinely using three or four wires. Postoperative treatment included anticoagulation therapy and systemic antibiotics. Passive motion exercises of the operated joint were undertaken immediately postoperatively. Clinical and radiologic evaluation was performed every year for the ﬁrst 5 postop- erative years and every 2–3 years thereafter. Hip functional results were rated accord- ing to the d’Aubigné grading system and the Harris hip score. The hip score was classiﬁed into six categories: excellent, 18 points; very good, 17 points; good, 16 points; fair, 15 points; poor, 14 points; and bad, ≤13 points. Radiologic analysis was performed on serial anteroposterior radiographs of the pelvis. On the pelvic side, the position of the socket relative to the horizontal and vertical teardrop lines according to De Lee and Charnley were noted. Linear wear was measured according to the technique described by Livermore et al. On the femoral side, parameters inves- tigated included the evolution of radiolucent lines in the seven zones of the femur and stem subsidence. A long-standing radiograph of the lower part of the body was performed 1 year postoperatively to assess the result of the THA pelvic tilt, leg lengthening, and residual length discrepancy. Finally, correction of the lordosis and lateral curvature of the spine were evaluated on anteroposterior and lateral radiographs of the lumbar spine. A survivorship analysis was performed to determine the overall success of the THA. Failure was deﬁned as an implant that had been revised or that was radiologically loosened at the time of follow-up. The survival curve was derived from the cumulative survival rate over time, as calculated from the actuarial life table. At the last follow-up evaluation, 41 patients (48 hips) had died and 7 patients (9 hips) were lost to follow-up. The follow-up of 48 patients ranged from 1 to 10 years for 14 and 10 to 27 years for the remaining 34. Forty patients (61 hips) were still alive with a mean follow-up of 22 years (range, 18–32 years). One intraoperative fracture of the femur was treated with cerclage wires and healed with no further complication. One peroneal nerve palsy recovered completely less than 1 week after the procedure. An open reduction had to be performed, and no further episode was observed. Heterotopic ossiﬁcations were observed in four hips and were classiﬁed according to Brooker et al. The two latter hips had to be revised to perform heterotopic bone removal. At the last follow-up examination, clinical results according to the d’Aubigné grading system were rated as excellent in 56 of the 118 hips (47. The mean Harris hip score improved from 32 preoperatively to 86 at the latest follow-up. Of the 118 hips, 10 had a persistent instability and a positive Trendelenburg sign.
Development The origin of the modern ambulance can be traced to Baron von Larrey discount extra super levitra 100mg fast delivery, a young French army surgeon who discount extra super levitra 100 mg with visa, in 1792 order extra super levitra 100mg on line, devised a light vehicle to take military surgeons and their equipment to the front battle lines of the Napoleonic wars. Larrey’s walking Seattle fire truck carts or horse-drawn ambulances volantes (“flying ambulances”) were the forerunners of the sophisticated mobile intensive care units of today. The delivery of emergency care to patients before admission to hospital started in Europe in the 1960s. Professor Frank Pantridge pioneered a mobile coronary care unit in Belfast in 1966, and he is generally credited with introducing the concept of “bringing hospital treatment to the community. The use of emergency vehicles carrying only paramedic staff, who were either in telephone contact with a hospital or acting entirely without supervision, was explored in the early 1970s, most extensively in the United States. The Medic 1 scheme started in Seattle in 1970 by Dr Leonard Cobb used the fire tenders of a highly coordinated fire service that could reach an emergency in any part of the city within four minutes. All firefighters were trained in basic life support and defibrillation and were supported by well-equipped Medic 1 Seattle ambulance ambulances crewed by paramedics with at least 12 months full-time training in emergency care. In the United Kingdom the development of civilian paramedic schemes was slow. The Brighton experiment in ambulance training began in 1971 and schemes in other centres followed independently over the next few years. It was only due to individual enthusiasm (by pioneers like Baskett, Chamberlain, and Ward) and private donations for equipment that any progress was made. A pilot course of extended training in ambulance was launched after the Miller Report (1966-1967) and recognition by the Department of Health of the value of pre-hospital care. Three years later, after industrial action by the ambulance service, the then Minister of Health, Kenneth Clarke, pronounced that paramedics with extended training should be included in every emergency ambulance call, and he made funding available to provide each front-line ambulance with a defibrillator. In Scotland an extensive fundraising campaign enabled advisory defibrillators to be placed in each of the 500 emergency vehicles by the middle of 1990 and a A helicopter is used to speed the response 50 Resuscitation in the ambulance service sophisticated programme (“Heartstart Scotland”) was initiated to review the outcome of every ambulance resuscitation attempt. Chain of survival The ambulance service is able to make useful contributions to each of the links in the chain of survival that is described in Chapter 1. Early awareness and early access The United Kingdom has had a dedicated emergency call number (999) to access the emergency services since 1937. In Europe, a standard emergency call number (112) is available and a number of countries, including the United Kingdom, respond to this as well as to their usual national emergency number. NHS Training Manual All ambulance services in the United Kingdom now employ a system of prioritised despatch, either Advanced Medical Priority Despatch or Criteria Based Despatch, in which the call-taker follows a rigorously applied algorithm to ensure that the urgency of the problem is identified according to defined criteria and that the appropriate level of response is assigned. Three categories of call are usually recognised: ● Category A—Life threatening (including cardiopulmonary arrest). The aim is to get to most of these calls within eight minutes ● Category B—Emergency but not immediately life threatening ● Category C—Non-urgent. An appropriate response is provided; in some cases the transfer of the call is transferred to other agencies, such as NHS Direct. L Having assigned a category to the call (often with the help of a computer algorithm), the call-taker will pass it to a dispatcher who, using appropriate technology such as automated vehicle location systems, will ask the nearest ambulance or most appropriate resource to respond. In the a case of cardiorespiratory arrest this may also include a a community first responder who can be rapidly mobilised with y an automated defibrillator. The ambulance control room staff will also provide Chain of survival emergency advice to the telephone caller, including instructions on how to perform cardiopulmonary resuscitation if appropriate. The speed of response is critical because survival after cardiorespiratory arrest falls exponentially with time. The Heartstart Scotland scheme has shown that those patients who develop ventricular fibrillation after the arrival of the ambulance crew have a greater than 50% chance of long-term survival. The ambulance controller should ensure that patients with suspected myocardial infarction are also attended promptly by their general practitioner. Such a “dual response” provides the patient with effective analgesia, electrocardiographic monitoring, defibrillation, and advanced life support as soon as possible. Early cardiopulmonary resuscitation The benefits of early cardiopulmonary resuscitation have been well established, with survival from all forms of cardiac arrest at least doubled when bystander cardiopulmonary resuscitation is undertaken. All emergency service staff should be trained in effective basic life support and their skills should be regularly refreshed and updated.
Involve the student: the need for active participation is the recurrent theme throughout this book and nowhere is it more important than in the clinical teaching situation buy extra super levitra 100 mg lowest price. This may range from talking to a patient buy discount extra super levitra 100mg online, checking physical signs buy 100mg extra super levitra fast delivery, presenting the case history, answering questions and looking up clinical information for presentation at the 74 next teaching session. In general try and make sure all the tasks are directly related to the patients the student has seen. Observe the student: as mentioned earlier, a consistent finding in studies of clinical teaching has been a lack of direct observation of student interactions with patients. All too often the clinical teacher starts with the case presentation and many never check to see whether the features described are actually present or were elicited personally by the student. Serious deficiencies in clinical skills are consistently found in interns and residents which must be an indictment of the undergraduate clinical teaching. Only a commitment to the somewhat boring task of observing the student take the history, perform the physical examination and explain things to the patient will allow you to identify and correct any deficiencies. This type of activity is particularly essential with junior students and must be conducted in a sympathetic and supportive way. Provide a good teaching environment: the more senior and prestigious you are, the more intimidating you are likely to appear to the students. It is vital that you adopt a friendly and helpful manner and reduce the natural and inevitable apprehension felt by your students. Not only may they be apprehensive about you, but they will also be apprehen- sive about their impending contact with patients. You can assist this by preparing the patients and by showing to the students you understand their fears. IMPROVING THE CLINICAL TUTORIAL Clinical tutorials are all too oftendidactic with the emphasis being on a disease rather than on the solving of patient problems. We firmly believe the clinical teacher should concentrate on the latter. The students will inevitably have many other opportunities to acquire factual information but relatively little time to grapple with the more difficulttask of learning to apply their knowledge to patient problems. It is sad, but true, that in traditional medical schools the students are often as much to blame as their teachers by encouraging didactic presentations, particularly when examinations are imminent. Surprisingly, clinical teaching 75 in problem-based schools often exhibits the same char- acteristics. Plan the teaching: once again it is important to establish the aims of the sessions you have been allocated. In either case you must be sure in your own mind what you intend to achieve in each session. Involve the student: make it clear from the beginning that you expect most of the talking to be done by the students and that all of them are to participate, not just the vocal minority. At the first session, explain what tasks you expect them to perform in preparation for each tutorial. You may, for example, expect them to prepare cases for discussion or to read up aspects of the literature on a particular subject. Provide a good teaching environment: the way in which you set up the session is vital for its success, particularly when you wish to encourage active participation. Your role as a facilitator, not the fount of all knowledge, must be emphasised and you must resist the temptation to intervene with extra information all the time. This is very hard to avoid but if it happens too frequently you will soon find all conversation is channelled in your direction and there will be no interaction between the students. As the clinical tutorial is another form of small group teaching you should read Chapter 4 for further advice. Concentrate on clinical problem solving: in the last thirty years there has been a substantial research effort into how doctors and students go about solving clinical problems. The findings have major implications for the clinical teacher, though as yet there is little evidence that this has been widely recognised. The traditional way of teaching students is to require them to take a full history, perform a comprehensive examination and only then come up with a differential diagnosis. The implication has been that clinical examination is a routine and sequential process with serious thinking about diagnosis and management being deferred until the student is away from the bedside. This is not the way doctors or students actually operate even though they may appear to do so on superficial observation.
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