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By L. Fedor. Central Methodist College.

Key elements of preventive medicine and infection control include: • Clean drinking water – uncontaminated by sewage and waste water • Hand washing – soap production is a priority discount 60mg mestinon with mastercard. Incineration is probably the best option order mestinon 60mg, followed by deep burial – away from water sources. Adequate rubbish disposal and trapping are probably the best methods for rodent control. Depending on climate mosquitoes may be a problem; stagnant water and rotting soft wood are foci for the mosquito larvae. Although many illnesses are infectious before symptoms become apparent it is important that any person who becomes unwell, particularly with fever or diarrhoea, is isolated immediately in an attempt to minimise further infections. With diarrhoeal illness – simple hand washing is usually sufficient for the caregiver. With febrile illnesses or those with respiratory symptoms then barrier precautions should be used – gloves, gown, facemask (N95), and goggles should be used. If this level of protection is not possible then some form of face mask is needed when with the patient and hand-washing, changing clothes (hot wash), and showering before contact with the healthy. For strangers arriving particularly during a pandemic consider 10-14 days isolation, followed by clothes burning and a through wash with soap before entering the community. There are no current infectious diseases with longer incubation times than 10-14 days. Provided the newcomer is symptom free at the end of this period you should be safe. However, among the current potential pandemic causes there are not currently carrier states although this needs to be considered. The recent tsunami in southern Asia clearly demonstrates how quickly public health can break down. Despite widespread knowledge even in developing third world countries about the basic principles of public health and hygiene latrines have been dug next to water supplies, water wasn’t being boiled, and in some places no effort was made to burn or dispose of rubbish, and it was just allowed to accumulate. While you can argue that some of this was due to “shell shock” from the disaster itself it just goes to show how the fundamentals can go out the window in a stressful situation. At present there is a heavy reliance on investigations; in a long-term austere situation history and examination will come into their own again. History taking and Examination: With very limited access to investigations the importance of clinical examination will again take on enormous importance. While modern doctors are competent at physical examination there is heavy reliance on special tests, and many of the skills of accurate physical examination have faded. The basics are easily learned from any clinical skills textbook (We recommend Talley and O’Connor, Physical Examination) and with a little practice. It is almost certain that in long-term austere situations that physical examination will come into its own again. The history 95% of the time is all that is required to know exactly what is going on. The examination and investigations may be used to confirm your thoughts, but it’s the history that usually gives you the diagnosis. Investigations: Laboratory tests: Lab tests which are possible in an austere environment are discussed in the Laboratory chapter. These include basic urine analysis, blood typing, and cross matching, and simple cell counts. There are several low-tech ways that are reasonably accurate in diagnosing fractures. Fractures of the long bones (tibia, fibula, femur, humerus, clavicle, ribs, etc), can be diagnosed by either percussion, or a tuning fork, and a stethoscope. A bony prominence on one end of the bone in question is tapped, or the base of a vibrating tunning fork is placed against it, and the stethoscope is applied to the other end. If a fracture exists on one side and not the other the gap in the bone at the fracture site will result in less sound being transmitted so the sound will be somewhat muted on the side of the fracture. To diagnose a hip fracture the sound source is applied to the patella (knee cap) and the stethoscope applied over the pubic symphysis. The technique is less effective on the obese as fatty tissue will absorb sound waves. For long bones running near the surface of the body a fracture can be localized by drawing the tuning fork along the bone slowly (>30 sec, but <60 sec) until a very localized source of pain is identified (<3 cm). A cone formed from rolled paper can act as a substitute for a stethoscope but is less than ideal. Once again, the reality will be that the most useful method for diagnosing fractures will be clinical examination. This is also the case for the clinical chest examination in patients who would previously have had a chest x-ray. Treatment The trick to learn for patient care in a truly austere situation is to do what you can do extremely well.

Attending academic half-days on physician the development of active coping skills positively infuence self-care or workshops that offer active coping strategies the well-being of trainees on many levels (Shapiro et al 2000) 60 mg mestinon overnight delivery. However mestinon 60mg amex, these are frequently not aligned with, or reinforced Regular, informal, small-group discussions with his peers by, the informal and hidden curricula in which residents learn. Such reconnection will, in turn, foster of the faculty role models they work with every day, (e. Few medical schools a survey examining resident physician satisfaction both within have wellness programs to support their faculty, not only in and outside of residency training and mental health in Alberta. Sources of stress for residents and recom- temic aspect of the hidden curriculum, and this also infuences mendations for programs to assist them. The infuence of personal and environmental factors on professionalism in medical edu- Strategies to promote a healthy working and learning environ- cation. Some faculties of medicine have done just this by developing innovative, bottom-up, relational-centred care and teaching models that are transforming the environment in which all physicians and health care teams function. They emphasize mentorship, communication and compassion, and increased “face time” between residents and faculty in order to promote healthy role modelling and reduce trainee distress (Mareiniss 2005, and Cottingham et al 2008). In addition, postgraduate Case medical education offces have taken steps to develop health A third-year resident who provides on-call services at a and safety policies specifcally for their trainees, presumably to mid-sized community hospital is called to the emergency delineate appropriate local responses to identifed inadequacies room to consult on a patient. Environmental health risks include accidents confrmed the resident’s confdence in their expanding and exposures to hazardous agents such as chemicals and knowledge and skills. Occupational risks include exposures to blood and other bodily fuids and to respiratory pathogens. Personal safety The triage nurse directs the resident to the room where the risks include exposure to violence perpetrated by patients or patient is waiting and closes the door behind her. The resident To ensure the protection of their residents, postgraduate concludes that the environment is no longer safe and gets medical education offces are required to collect immunization up to leave the room, at which point the patient blocks the data on their trainees and to adhere to a communicable disease door, shoves the resident, and picks up the chair in front policy for residents who have or present a risk of transmissible of him with a motion to throw it directly at the resident. In addition, programs traditionally offer orientation in working safely with hazardous materials and in communicable Many minutes later, when the resident manages to calm disease precautions and protocols. Individual programs that the patient to the point where the resident can make a safe involve specifc and frequent environmental exposures (e. Although they discuss the appropriate man- training to minimize risks of special relevance to these residents. These include but are not limited to exposures A further challenge of preparing residents to protect their own to hazardous materials and communicable pathogens, aggres- safety is that some risks are not immediately apparent, or may sive and violent patients, and repetitive strain injuries. Many of same time, elements of postgraduate training put residents at these are related to the number of hours spent in the health care additional risk of which trainees and their programs or institu- setting, very often at the least secure times. On-call residents tions may not be suffciently aware and so may not adequately and their nursing colleagues are frequently in the position of address. This, combined with their relative inexperience in identifying when a situation is getting out of hand, can increase their risk of assault by a patient. Like many mid-level residents, this resident is trying to bal- ance the confdence gained from working more indepen- These incidents can be extremely stressful to residents, who dently with the limitations of their experience. Residents may feel inadequately trained to deal with them on their own may not consider that they will be placed in situations that and may be unfamiliar with reporting protocols. Accreditation could cause them harm, and therefore rely on hospital poli- visits routinely examine the physical layout where residents cies and procedures to ensure their safety needs are met. In train to ensure they are properly equipped, for example by this case, such procedures were fawed. The resident was means of alarms and proximity to support staff, to prevent focused on making a proper diagnosis and management violent assaults by patients. However, these assessments might plan, rather than on assessing the risk of the situation. The not examine other less controllable settings were residents resident began the patient encounter without considering see patients, such as community clinics and patients’ homes. Additionally, the resident may not have had the skills Where specifc education and training programs exist to and training to calm an increasingly agitated patient, and manage workplace violence, residents and students are more did not have a supervisor present to review the situation likely to report incidents and get the support they need. Intimidation and harassment by faculty, staff and colleagues can present safety risks that An additional risk for this resident was inherent in the residents are, generally speaking, reluctant to disclose. In addi- location of the call room in a portable building outside the tion, excessive fatigue from long work hours can affect judg- main hospital where the resident could have been isolated ment and reaction times, leading to increased risk of needle from any security back-up, and from which the resident stick injuries, adverse events, medical error and motor vehicle was required to travel in the dark to get to the work site. Protecting Residents are aware that certain risks are associated with the the safety of medical students and residents [editorial]. Trainee miss out on a great learning opportunity, or fear of repercus- safety in psychiatric units and facilities: The position of the sion if they appear too hesitant or dependant, residents may Canadian Psychiatric Association. A pilot survey that residents are trained in risk assessment and in policies and of patient-initiated assaults on medical students during clinical procedures to follow when breaches occur. In different parts of the world, including our own, health and Case education systems have struggled with the issue of resident One of the nurses has made a complaint about a senior work hours. In Canada, we have typically negotiated work resident’s level of irritability, and another is questioning hours on a provincial/territorial basis, in keeping with the whether the resident is practising safely: apparently, the fundamental structure of our health care system.

This glutamate cheap mestinon 60 mg line, after losing its amino group discount mestinon 60 mg overnight delivery, is then utilized in the synthesis of glucose in the kidney. The generation of ammonium ions from glutamine has a specific role in acid–base homeostasis, as ammonium ion excretion serves as the main vehicle for the excretion of excess hydrogen ions to prevent acidosis. Carbon Metabolism For most amino acids, removal of the amino nitrogen group generates their ketoacid analogues. Many of these are already in a form for entry into the pathways of oxidative metabolism (Figure 10-3). All the others have specific degradation systems that give rise to intermediates that can be metabolized in these oxidative pathways. This is particularly true in non-growing adults, who on average consume, and therefore oxidize, about 10 to 15 percent of their dietary energy as protein (Appendix Table E-17). The contribution of protein to energy needs may be significant during periods of energy restriction or following the utilization of the body’s limited endogenous carbohydrate stores. Protein oxidation also has been shown to rise considerably in highly traumatized or septic individuals, which results in large amounts of body protein loss; this loss can compro- mise recovery or even lead to death (see below) (Klein, 1990). It is much less in periods of chronic starvation because of various metabolic adaptations related to ketone utilization, or on protein-restricted diets. Whether glucose or fat is formed from the carbon skeleton of an amino acid depends on its point of entry into these two pathways. The carbon skeletons of other amino acids can, however, enter the pathways in such a way that their carbons can be used for gluco- neogenesis. This is the basis for the classical nutritional description of amino acids as either ketogenic or glucogenic (i. Some amino acids produce both products upon degradation and so are considered both ketogenic and glucogenic (Figure 10-3). It has been argued that the majority of hepatic amino acid catabolism is directed in an obligatory fashion to glucose synthesis (Jungas et al. This cycle also involves the peripheral synthesis of glutamine, an amino acid that is utilized in substantial quantities by the intestinal cells in which it is used for energy and for the synthesis of proline, citrulline, and nucleic acids. A significant proportion of the glucose synthesized in the liver is due to recapture and recycling via the liver of 3-carbon units in the form of lactate derived from anaerobic glucose breakdown in muscle (the Cori cycle). Hepatic gluconeogenesis also occurs via the glucose–alanine cycle (a direct parallel of the Cori cycle) and the glucose–glutamine cycle. Since the nitrogen donors may be either glucogenic or ketogenic amino acids, these cycles function as mechanisms for transporting nitrogen from the periphery to the liver as well as for glucose production. The cycle involving glutamine transport from the periphery to the gastrointestinal tract is also vital to the synthesis of arginine and proline and is critical to the preven- tion of the build up of excessive ammonia in the circulation. Nonprotein Pathways of Amino Acid Nitrogen Utilization Although in general the utilization of dietary amino acids is dominated by their incorporation into protein and their role in energy metabolism, amino acids are also involved in the synthesis of other nitrogenous com- pounds important to physiological viability as shown in Table 10-5. Some pathways have the potential for exerting a substantial impact on the utili- zation of certain amino acids, and may be of potential significance for the requirements for these amino acids. This is particularly true for glycine, which is a precursor for six nitrogenous compounds, as shown in Table 10-5. Its utilization in the synthesis of creatine (muscle function), heme (oxygen transport and oxidative phosphorylation), and glutathione (protective reactions which are limited by the amount of available cysteine) is not only of physiological importance, but can also involve substantial quantities of the amino acid. For example, in the absence of a dietary source of creatine, adults require at least 1. In premature infants, mainly fed human milk, there is evidence that the glycine supply may be a primary nutritional limitation to growth (Jackson, 1991). This so-called dispensable amino acid is then needed in the diet for optimum growth and may be termed “conditionally indispensable. These may be important nutritional con- siderations in individuals consuming marginal amounts of proteins of plant origin and undoubtedly have an impact on overall amino acid utilization when protein intake is very low. Clinical Effects of Inadequate Protein Intake As outlined above, protein is the fundamental component necessary for cellular and organ function. Not only must sufficient protein be pro- vided, but also sufficient nonprotein energy (i. Similarly, unless amino acids are present in the diet in the right balance (see later section, “Protein Quality”), protein utilization will be affected (Duffy et al. Hypoalbuminemic malnutrition has been described in hospitalized adults (Bistrian, 1990) and has also been called adult kwashiorkor (Hill, 1992). Clearly, protein deficiency has adverse effects on all organs (Corish and Kennedy, 2000). Furthermore, protein deficiency has been shown to have adverse effects on the immune system, resulting in a higher risk of infections (Bistrian, 1990). It also affects gut mucosal function and permeability, which, in turn, affects absorption and makes possible bacterial invasion from the gut, which can result in septicemia (Reynolds et al. Protein deficiency has also been shown to adversely affect kidney function, where it has adverse effects on both glomerular and tubular function (Benabe and Martinez-Moldonado, 1998). Total starvation will result in death in initially normal-weight adults in 60 to 70 days (Allison, 1992).

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