It might have been in an educational magazine hiv infection causes statistics minipress 2mg generic, in which a non-disabled "facilitator" will regale in words and text the latest prototype "image-workshop hiv infection after 1 year buy discount minipress 2mg online," using disabled people as guinea pigs while developing their "educational" ideas hiv infection and aids an overview generic 1mg minipress visa. Passive and still and "done to hiv infection rates berlin purchase minipress 1mg on-line," the images bear a bizarre resemblance to colonial pictures where "the blacks" stand frozen and curious hiv infection rates by age buy 1 mg minipress amex, while "whitey" lounges confident and sure antiviral group minipress 2.5mg low price. Whitey knows the purpose of this image, the black people appear not to (or at least, perhaps as employees, have no right to record visual dissent). The "positive" side of their ultra-minority inclusion, then, is that disabled people are there to demonstrate the successes of their administrators. But although the absence is near absolute, the non-representation of disabled people is not quite total. Taking the structured absence as given, I wanted to discover the terms on which disabled people were admitted into photographic representation. As Mary Daly once wrote of feminism, the job entails being a full-time, low-paid researcher of your own destiny. Disabled people are represented but almost exclusively as symbols of "otherness" placed within equations which have no engagement to them and which take their non-integration as a natural by-product of their impairment. The Family of Man; Another Way of Telling; diane arbus; Figments from the Real World. There were obviously lateral associations but only one, diane arbus, I knew to include images of disabled people. In the research for this book, I had begun to uncover sometimes hidden, sometimes open, but always continuous constructions of disabled people as outsiders admitted into culture as symbols of fear or pity. This was particularly true in literature3 but I wanted to see if it held 367 368 David Hevey true in photography, so I picked the books at random. They may have been connected in styles or schools but, as far as I knew, had no connection whatsoever on disability representation. Only Arbus was infamous for having centred disabled people in her work but I felt an uneasy faith that all of them would "use" disabled people somewhere. It showed the great "positive image" of an unproblematised and noble world-a world from which pain was banished. Where there are images of "working folk," their muscles and their sweat appear to be a part of the great spiritual order of things. Where there are images of black people, the images show poverty; some show harmony, but all are visually poetic. However, throughout the catalogue of the show, which contained 503 images show from 68 countries by 273 male and female photographers, there is only one photograph of someone identifiably disabled. Put together ten years after the Second World War, the Family of Man was about "positively" forgetting the past and all its misery. Although this publication and exhibition heralded a brave new world of postwar hope and harmony, on reading it it becomes clear that the inclusion of disabled people-even disabled people tidied up like black people and working people-was not a part of the postwar visual nirvana. The one image of a disabled person appears on the penultimate page of the 192-page publication. It is mixed in among six other images on that page and is part of the final section of the book, which covers children. In the final section, after five pages of innocent joy, you encounter on the sixth page three that remind you it is not like that always. At the top of these three is a disabled boy who appears to be a below-the-knee amputee. His body tilts to our right as he approaches the ball, while his crutch tilts to our left, to form a shape like an open and upright compass. The ball is situated in the triangle which his left leg and his right-side crutch make on the sand. The triangle shape is completed by a shadow which the boy casts from his right leg to the crutch (and beyond). The disabled boy is a reminder that all is not necessarily well in the world but he is doing his best to sort it out. Because he is "positively" adjusting to his loss, the image is allowed into the exhibition and the catalogue. In the Family of Man, disabled people were almost entirely absented because harmony was seen to rest in the full operation of an idealised working body. The exhibition and catalogue did not admit disabled people (bar one) because it did not see a position for disabled people within the new model army of postwar production or consumption. Photographically speaking, the decline of this high ground of postwar hope in the "one world, one voice, one leader" humanity was heralded (in historical photographic terms) by an equally influential but far more subversive exhibition, again at the Museum of Modern Art, New York, which was held in 1967. This exhibition was called New Documents and brought into a wide public consciousness reportage portraiture showing the human race as an alienated species bewildered by its existence. New Documents featured the work of Gary Winogrand, Lee Friedlander and Diane Arbus. The importance of these three photographers (and others like Robert Frank) is that their work heralded the breakdown the Enfreakment of Photography 369 of the universal humanism of the Family of Man into a more fragmented, psychic or surrealistic realism. The appalling reverse of the coin is that they anchored the new forms of a fragmented universe (to a greater or lesser extent) in new, even more oppressive images of disabled people. What is particularly crucial in terms of the representation of disabled people in this photojournalism is a clear (yet still uncritical) emergence of the portrayal of disabled people as the symbol of this new (dis)order. Whereas the tucked-away disabled person in the Family of Man had been a hidden blemish on the body of humanity, in a world of the Cold War, the Cuban Missile Crisis and Vietnam, disabled people were represented as the inconcealable birthmark of fear and chaos. The monograph that I had pulled from the shelf is from her posthumous retrospective, held at the Museum of Modern Art, New York, in 1972 and entitled diane arbus. She was born into an arriviste family of immigrants, whose money was made in the fur trade. She became a photographer through her husband, Allan Arbus, and worked with him in fashion photography. She moved away from that (and him) into work which still dealt with the body and its surrounding hyperbole but from a very different angle. It was on her own and in her own work that she became known, unwittingly according to her, as "the photographer of freaks. The monograph contains 81 black-and-white images, of which eleven are of disabled people. The first is demonstrated in two portraits of "dwarfs"; the second with the portrait of the "Jewish giant"; and the third with the imagery shot just before her death, that of the "retardees" (her term for people with Down Syndrome). Moreover, the "factual" recording of disabled people as freaks is accepted totally without question by major critics like Sontag, who says, "Her work shows people who are pathetic, pitiable, as well as repulsive, but it does not arouse any compassionate feelings. Once again, the entire discourse has absented the voice of those at its center-disabled people. Although she was profoundly misguided (as I demonstrate further on), there can be no doubt that her work paradoxically had the effect of problematising, or opening up, the issue of the representation of disabled people. Her critics and defenders have built a wall around her work (and any discussion of disability in her work) by "naturalising" the content. In this, the images of disabled people have been lumped into one label, that of "freaks. The process of analysis is not to rehabilitate her or her work but to break it down once and for all. She was a part of the "snapshot aesthetic" which grew up beyond the New Documents exhibition and exhibitors. This form attempted to overturn the sophisticated and high-technique processes of the Hollywood fantasy portrait, as well as rejecting the beautiful toning of much of the Family of Man. However, more than any of her peers, she took this aesthetic nearer to its roots in the family 370 David Hevey photograph or album (indeed she intended to shoot a project entitled Family Album). In terms of disability, however, Arbus read the bodily impairment of her disabled subject as a sign of disorder, even chaos; that is, as a physical manifestation of her chaos, her horror. Despite her relationships with disabled people (often lasting a decade or more) she viewed these not as social and equal relationships but as encounters with souls from an underworld. There was nothing new in this pattern of "reading" the visual site of a disabled person away from a personal value into a symbolic value which then seals the representational fate of the disabled person. There is no question of Arbus using her subjects "positively"-it is clear that she always intended them and their relationships to themselves and others to symbolise something other than themselves. She saw herself and her "freaks" as fellow travellers into a living oblivion, a social death. There is a perverse sense in which she was right-disabled people are expected to inhabit a living death-but the crucial thing is that she considered her projection to be more important than their reality. She "normalised" subjects like Morales, the Mexican Dwarf,9 or the Russian Midget Friends10 by specifically placing them in that great site of bourgeois culture and consumption, the home. The "shock" for the hundreds of thousands of nondisabled viewers was that these portraits revealed a hinter-land existing in spite of the segregationist non-disabled world view. She saw in the bourgeois promise to the immigrant family, her own family, a Faustian contract. Her Mephistopheles, her threat to the bourgeois privilege, was to move a non-disabled fear that dare not speak its name into the family snap. In a sense, this first period of her work (a period not of time but of understanding) is her least oppressive and in some ways complete. Far from making apologies for their presence, they are distinctly proud, they are committed to their identity. Although the disabled people portrayed existed within subcultures (such as the circus), they were clearly not segregated and it is this which shocked the public who flocked to her posthumous retrospective at the Museum of Modern Art in 1972. It is the conscious dialogue between Arbus and the subjects which "horrified" and yet fascinated people more used to compassionate victim images of disabled people obligingly subhuman and obligingly institutionalized as "tragic but brave. He wears a trilby at a rakish angle and his elbow leans casually on to the sideboard, resting just in front of a bottle of liquor. It is not clear quite what went on between Arbus and Morales (though Arbus had previously "spent the night" with another disabled subject, Moondance, as part of his agreement to be photographed) but the eroticism of the image cannot be denied. Not only is the so-called "dwarf " distinctly unfreaky in his three-quarters nakedness, he is positively virile! While the attire is crisp and clear, the flesh of the subject has been "zombified. Arbus had attempted to trace the psychic disorder of consumer society back to a primal state of terror within everyday life. That she believed disabled people to be the visual witness of this primal state is clear. That is, she accepted at the level of "common sense" the non-integration of disabled people. The disabled subjects themselves, at least in this early "freak" work, are treated reverentially. The "horror" of the process for non- the Enfreakment of Photography 371 disabled society is in her placing a disabled normality within a non-disabled normality. It was a spectacle, not a political dialectic (the disability paradox) that Arbus wanted to ensnare. For this she accepted, indeed depended, on the given segregation of disabled people as "common sense. This is illustrated in the monograph by the image entitled A Jewish Giant at Home with his Parents in the Bronx, N. Again, we see a cosy family setting of a front room with two comfy chairs and a sofa, two elderly and self-respecting pensioners, a lamp by the drawn curtains, a reproduction classic painting in a tasteful frame, and a giant. This image of A Jewish Giant with its glaring flash-lit room, its portrayal of "the beast" from the womb of the mother, shows less harmony, even a deliberate asymmetry from that of her "dwarf " images. In A Jewish Giant she had created an image which took her beyond the reverence in both form and content of her "dwarf " images. Unlike them, Eddie the Jewish "giant" directs his attention away from the presence of the camera, his only acknowledgement that an image is being made is by being on his feet like his parents. The flash has cast black halos round the bodies of the subjects and they begin to resemble a Weegee as a found specimen of urban horror. The image of the "giant" as he crouches towards his more formal parents is that of a father over two children. The classic family portrait of parents and child is completely reversed by her use of their size relationship. The body language of the "Jewish giant" is more "out of control" (that is, it diverges more from non-disabled body language signs) than that of the "dwarf. The alchemy, confrontation and visual disorder of the image bring Arbus closer to avenging the control and repression in her own family. During the ten years of their knowing each other, Eddie Carmel told Arbus about his ambitions, about his job selling insurance, about his acting hopes (and his despair at only being offered "monster" roles), and so on. Indeed, she appears to have disbelieved him, preferring her own projection of a metaphysical decline. His real tragedy is that he trusted Arbus, and she abused that trust outside of their relationship in an area within her total control, that is, photography. The visual dialogue within the image between herself and the subject in the "dwarf " works, although decreasing in the imagery of Eddie the "giant," was still prevalent and was important precisely because it created a snapshot family album currency within the imagery. Were the subject to disengage, to reject the apparent co-conspiracy (in reality a coercion) or contract between themselves and Arbus, the images would move from the genre of family album currency and understanding of millions, to a reportage subgenre position of one specialist photographer. The enfreakment in her disability images was internalised by the non-disabled viewers because the disabled subjects, while chosen for their apparent difference, manifested body language and identity traits recognisable to everyone. Arbus was concerned to show the dichotomy, even the pain, between how people projected themselves and how she thought they "really" were. The projection of this "imagined self " by the subject was through the direct gaze to camera (and therefore direct gaze to viewer). The image of A Jewish 372 David Hevey Giant, to Arbus, suggested a higher level of fear and chaos than the "dwarf " work. This higher level of discrepancy between order (the setting is still the family at home) and chaos (Eddie outgrowing that which contained him), than that manifested in the "dwarf " work, is also highlighted by the fact that, although the "giant" is on his feet posing with his parents, his dialogue is as much between him and his parents as between him and Arbus/the viewer. Arbus was reported to have told a journalist at the New Yorker of her excitement over this image, the first one that had worked for her in the ten years of photographing Eddie.
These dental practices have reported less anxiety hiv infection rates in south africa minipress 2 mg amex, less trauma hiv infection images discount minipress 1 mg fast delivery, reduced extractions due to caries stage 1 hiv infection timeline order 2 mg minipress overnight delivery, and an increase in happy young patients attending for dental care hiv infection via eye minipress 1 mg with visa. The treatment dovetails into the preventative approach to disease management anti viral cleanse generic 2mg minipress mastercard, and there are important considerations for the development of a Preventative Management System to record data hiv infection rate in rwanda purchase minipress 2.5 mg free shipping, and to develop a personalised treatment plan based on sound prophylaxis and preventive research and protocols. This preventative approach integrated with ozone treatment has an exciting potential. The resulting, tooth loss can diminish function and contribute to loss of self-esteem in elderly populations. This leads to more complex restorative challenges for dentists since the restoration of root caries poses a number of problems. Visibility and isolation from oral fluids (saliva, gingival secretion or haemorrhage) are particular problems, whilst the maintenance of pulpal integrity through the use of biologically acceptable dressings to the pulp-dentine reduces the depth of lesions but do not provide the aesthetic, physical and mechanical qualities required for a restoration. Whilst all these materials have their merits, they also have limitations in the restoration of carious lesions in conservative dentistry. The clinical success of amalgam is well established when compared to other dental materials for the treatment of root caries. However, amalgam cannot be used in areas where aesthetics are of prime importance (Seichter, 1987). Resin-based composites are now being used as either amalgam substitutes or amalgam alternatives. It should be noted that composites have no caries-preventive effects, and postoperative sensitivity, discolouration and recurrent caries are often observed in root caries restored with composite (Seichter, 1987). Incorporation of fluoride into composite resin materials also failed to show any beneficial effect in reducing demineralisation of root carious lesions when compared to glass ionomer cements (Dijkman et al, 1994; Takahashi et al, 1993; Torii et al, 2001; Vermeersch et al, 2001). Indeed, secondary caries has been reported as being the most common reason for replacement of Class V amalgam, composite or glass ionomer restorations (Qvist et al, 1990). Placement of a restoration may result in the tooth being subjected to a repeat restoration cycle where the restoration may ultimately fail, to be replaced by progressively larger restorations (Elderton, 1996). However, the issue of marginal adaptation has still been an ongoing technical problem. It should also be noted that arrested lesions remained unchanged during several years of observation (Lynch, 1996). The possibility of preventing and controlling root caries for all populations worldwide is a strong incentive. However, compared to enamel caries, there has been relatively limited research available into pharmaceutical management of root caries, and many of these studies have also been carried out in vitro. Ozone has strong oxidisation power and has been used as deodorisation, decolourisation and oxidisation. The mechanism of microbial inactivation by ozone is thought to occur by general inactivation of the whole cell in micro-organisms. The use of ozone in medicine Ozone has been used in several medical applications (Papas et al, 1987; Belianin and Shemelev, 1994; Shiratori et al, 1993; Paulesu et al, 1991; Bocci, 1994; Riva Sanseverino, 1995; Cooke et al, 1997; Цzmen et al, 1993; Romero Valdes et al, 1993; Rodriqueuz et al, 1997; Dolphin and Walker, 1979; Gloor and Lip- phardt, 1976). Many studies have investigated the use of this therapy in the treatment of ocular diseases as optic neuropathies, glaucoma, central retinal vein obstructions and degenerative retinal diseases. This oxidant reacts with many blood components such as lipo-proteins, plasma proteins, lymphocytes, monocytes, granulocytes, platelets and erythrocytes. Since the oxidising effect of ozone is almost linearly related to its concentration in the blood, above a certain threshold it becomes very cytotoxic and produces haemolysis. The half-life of ozone is short and this oxidant rapidly converts into oxygen via endothermic reaction. Among ozone biological effects (Belianin and Shemelev, 1994; Bocci, 1997 and 1999; Viebahn, 1999), the improvement of oxygen metabolism, increasing cell energy, the immunomodulator property and the enhancement of the antioxidant defence system are some of the beneficial effects of ozone in medical use. The use of ozone therapy on age-related degenerative retinal maculopathy demonstrated a decrease in lipid peroxidation but an increase in superoxide dismutase and an enzyme scavenger of anion superoxide. In this respect, ozone was capable to minimise the damage produced by lipid peroxidation by increasing antioxidant defence system (Barber et al, ґ 1999; Leon et al, 1998; Paralta et al, 1999; Bocci, 1996a and 1996b; Riva Sanseverino et al, 1990). In addition, ozonised blood was shown to have a protective effect on ischaemia-reperfusion injury in different organs such as liver, kidney and brain. These authors also stated that lactate production was inhibited and survival time was significantly increased. Patients were treated with ozone by rectal administration (dose10 mg) for 15 sessions. In their study, groups pretreated with ozone and antibiotics in combination showed a significant increase of survival of rats in comparison with the groups treated only with antibiotics. Ozone pretreatment in combination to antibiotics was capable of reducing the mortality. The microorganisms have developed resistance to antibiotics, so that in the pharmaceutical field new germicidal products such as cephalosporine and quinolones are being continuously developed. Ozone applied prophylactically was able to increase or support the antibiotics action. In this respect, medical treatment with ozone appears to be safe, therapeutically beneficial, and cost-effective. Ozonised sunflower oil ґ (Oleozon) has shown antimicrobial effects against virus, ґ bacteria and fungi (Sechi et al, 2001). Oleozon is a substance produced by the reaction of ozone with unsaturated fatty acids present in sunflower oil, this reaction occurs almost exclusively with carbon-carbon double bonds and produces several compounds such as hydrogen peroxide (Sechi et al, 2001). The use of ozone in dentistry the preventive and therapeutic effects of ozone in medicine have been well established (Baysan et al, 1999). Unfortunately, there are very few studies on the use of ozone for dental purposes. The numbers of micro-organisms that have been found in water samples collected from dental units may exceed current limits for water quality and are perceived as a potential health risk to patients and dental personnel (Barbeau et al, 1996; Williams et al, 1993). Fortunately, ozone has successfully been employed for the treatment of dental unit water lines since 1990s. The microbial effect of ozone on dental treatment units lasted longer when compared to the conventional methods such as hydrogen peroxide/sliver ion solutions in vivo and in vitro (Putnins et al, 2001; Lee et al, 2001; Filippi et al, 1991; Filippi, 1995 and 1997). Filippi, 1997 tested the effect of ozone on Pseudomonas aeruginosa, a potentially pathogenic micro-organisms, which is frequently found in dental treatment units. After ozone treatment (10 mg ozone/ml water), there were no micro-organisms detected in water. Subsequently, ozonated water was considered to be an alternative to a sterile isotonic solution for oral rinse during dental surgery, or following tooth extraction processes. Filippi, 1998 investigated that ozonised water applied on a daily basis can accelerate the healing rate in oral mucosa. Between the second and 7th postoperative day, there were no further effects observed related to ozone. However, the author stated that the effect observed in the first 48 hours, modified the final wound closure thereby under the influence of ozone, more wounds were closed after seven days and cell proliferation commenced earlier. These authors stated that the use of ozone is completely safe as ozone dissipates very quickly in water. However, medically relevant properties of ozonated water in oral surgery still remain to be proved. Antimicrobial Effects of Ozone on Caries H 201 A denture cleaner using ozone bubbles (Ozone concentration approximately 10 ppm) was considered as clinically appropriate in view of its strong disinfecting and deodorising power, and high biological safety (Filippi, 1999). The effectiveness of this cleaner against Candida albicans was investigated and levels of this microbe were found to decrease to about 1/10 of their initial value after 30 min. The researchers reported that ozone treatment caused a slight change in the Au-Cu-Ag-Pd alloy in terms of reflectance. However, the changes were significantly less than those caused by acid-electrolyzed water and one of the commercial denture cleaners. However, there has been no study concerning the clinical evaluation of ozone on its therapeutic benefits that it may offer for the management of root caries. The authors believe that the use of ozone in dentistry is conservative and harmless. This proposed ozone delivery system has been investigated in in vitro and in vivo studies. Recent clinical studies, which were also conducted by Baysan and Lynch have demonstrated the effect of ozone on the microbial flora and clinical severity of primary root caries by the ozone delivery system (Suzuki et al, 1999). In addition, these authors investigated the safety and efficacy of the use of ozone for the management of root caries in a longitudinal study. The vacuum pump pulls air at 615 cc/min through the generator to supply ozone to the lesion and purges the system of ozone after ozone treatment. The tightly fitting cup seals the selected area on the tooth to prevent escape of ozone. The system then draws a liquid reductant through the sealing cup to further neutralise residual ozone. The reductant mainly contained deionized water, sodium benzoate, methylparaben, sodium fluoride, xylitol and citric acid. Plaque was removed using a hand-held standard fine nylon fibre sterile toothbrush with water as a lubricant within 15 min of extraction. Each tooth was dried using dry sterile cotton wool rolls and a dental three-in-one air syringe. Following sampling, a reductant from the ozone delivery system was only applied to the samples for a period of 10 s in the control group. The excavator blade was used to traverse the lesion in line with the long axis of the tooth across the maximum gingival/occlusal dimension. Subsequently, ozone was delivered into the cup closely adapted to each remaining lesion for a period of either 10 or 20 s at room temperature (23 жC). Each sample was immediately put into a sterile vial and weighed using a Sartorius micro-balance. Instantly, these were In vitro study 1 In this study, a novel ozone delivery system (HealOzone, CurOzone U. The number of each colony type was counted and the number of colony forming units (cfus) was then calculated. In vitro study 2 this study assessed the efficacy of ozone (from the delivery system described above) on S. Preparation of saliva-coated glass beads 5 ml of unstimulated human saliva from one donor was collected into a sterile container for each experiment; 1 ml volumes of saliva were clarified by centrifugation for 2 min. The salivary supernatants were pipetted into a sterile universal bottle and filtered using 0. Test procedure 40 sterile saliva-coated glass beads were randomly divided into two groups (test and control) for S. Each glass bead was put into a sterile bijou bottle with 3 ml of Todd-Hewitt broth for control and test groups and agitated for 2 s. Immediately thereafter, ozone was applied for 10 s to each glass bead in the test groups for either S. Subsequently, these glass beads (control and test groups) were placed in 3 ml of Todd-Hewitt broth with six more sterile glass beads and vortexed for 30 s. Statistical analyses Microbiological counts from the test and control groups of each study were transformed as log10 (cfus1) prior to statistical analyses in order to normalise their distributions and ensure variance homogeneity. Statistical analyses of the data were conducted using paired Student t-tests to determine the significance of differences observed between the test and control groups (the threshold of significance was 0. Colony forming units for each sample were then analysed by their weights for both time periods. There was a significant difference in log10 (cfu1) per mg between the time periods (p 0. Discussion It was demonstrated that exposure of carious dentine to ozone produced by a novel ozone-generating device for periods of either 10 or 20 s substantially reduced the levels of total micro-organisms, to 1% of the control values. Presumably, ozone dissipates quickly in water and kills micro-organisms via a mechanism involving the rupture of their membranes in the lesions. It was demonstrated that exposure of carious dentine to ozone produced by a novel ozone-generating device for periods of either 10 or 20 s substantially reduced the levels of total microorganisms, to 1% of the control values. Saliva-coated glass beads were used to demonstrate the efficacy of ozone was tested specifically on S. Results in test groups obtained from saliva-coated glass beads showed a greater reduction compared with the carious dentine samples following ozone application. Bocci et al (1993) suggested that treating human blood with low ozone concentrations for the management of vascular disorders, chronic viral and autoimmune diseases can actually activate cells of the immune system and this treatment regime would be beneficial. However, it should be noted that ozone concentrations and time of exposure should be considered (Baysan, 2002). In principle, the potential toxicity of ozone should not prevent its use as a therapeutic agent (Hermґ andez et al, 1995). Furthermore, Bocci(1991) reported that human blood treated with the correct dose of ozone can minimise the formation of free radicals and convert oxidants to less toxic species. Mixed into pyrogen free water, the half-life of ozone is nine to ten hours (at pH 7 and 20 жC); and at 0 жC, this value is doubled. Therefore, ozonated water was employed as a mouthrinse during dental surgery, or following tooth extraction procedure (Filippi, 1999). Ozone application for a period of 10 s was also capable of reducing the numbers of S. Prevention of renal injury after induction of ozone tolerance in rats submitted to warm ischemia. Anti-microbial effects of a novel ozone generating device on micro-organisms associated with primary root carious lesions in vitro. Effect of ozone on the microbial flora and clinical severity of primary root caries. Reversal of primary root caries using dentifrices containing 5,000 and 1,100 ppm fluoride. The use of an ozonised sorbent in treating patients with progressive pulmonary tubercu- 16. Secondary caries in dentine around composites: a wavelength-independent microradiographical study. Ozone in the room air when using water ozonating equipment in the dental treatment area.
For a century hiv infection rate saskatchewan buy minipress 1 mg without prescription, optometrists had been the go-to representatives for refractive eye care antiviral kleenex proven 2.5bottles minipress, which antiviral side effects purchase minipress 2.5mg, until that point hiv infection cycle diagram purchase 2.5 mg minipress with mastercard, meant the dispensing of glasses and contact lenses hiv infection clinical stages order minipress 2 mg on-line. Boosters talked breathlessly about how this could eliminate the need for corrective lenses forever hiv transmission statistics uk discount minipress 2.5bottles on-line. From the start, questions abounded on what this new subfield of eye care meant for optometrists and their patients. To make matters worse, another problem had arisen at much the same time: the field of ophthalmology was undergoing increasing specialization, which placed further pressure on its members to enter this new area of eye care. The discipline of laser surgery seemed like the perfect place for industrious ophthalmologists to move into, especially given the growing patient interest. Some stayed out of the game entirely: in an October 1995 survey of 500 Review of Optometry subscribers, 62% reported no affiliation with a laser center and no plans to join one. Other optometrists tried to get in on the action (not to mention protecting their patients) by taking the role as patient educators and advocates. But then in early 2000s, the dot-com bubble popped, and the volume of procedures dipped for a few years. In 2004, the number of laser refractive surgeries nearly recovered to that high water mark of the year 2000, but never surpassed it. The economy took a nosedive and laser refractive surgery-typically an elective procedure-followed the plunge. The numbers bottomed out in 2011-2012 at about 600,000 procedures a year, less than half than that of its high point. More sophisticated screening technologies will continue to improve the ability of optometrists to screen refractive surgery patients and educate them about procedure eligibility. It better integrated them into the fabric of the health care system and broke down barriers with ophthalmology. Although this study quantified the extent of the problems, the results were not exactly unexpected. But recently, a new development has emerged in the care of refractive surgery patients. Surgical alterations to the eye began to be seriously considered in this year when Lendeer Jans Lans, an ophthalmology teacher in Holland, published theoretical work on the potential for cutting the cornea to correct astigmatism. Two years later, Lans incorporated electrocauterization to heat the corneal stroma in an attempt to alter its shape. Comparison of performances of femtosecond laser and microkeratome for thin-flap laser in-situ keratomileusis. His influence cuts across generations, with both his contemporaries and younger optometrists expressing admiration and respect for him as a doctor, an educator and a person. Louis, began practicing optometry in 1950 and still sees patients three mornings a week, giving him an astounding and likely record-breaking 66 years in clinical practice. He wanted his boys to go to college, so he made sure my brother Eddie and I had that chance. Basic training mainly consisted of walking like crazy, building your endurance up. But the interesting part about that was that, after you finished training, a new unit would be created-we were just building up our military at that time. This new organization started and it was called the 93rd Medical Gas Treatment Battalion. We were in a portable hospital unit, treating poison gas by washing it off soldiers who had been exposed. We would take care of a whole division of infantry, which is 16,000 to 17,000 men, so we had to travel fast. Later in the war, I was promoted from private first class to staff sergeant and reassigned to England. The Battle of Britain was already over by then, but there were still no lights allowed in case of attack. Not quite a year later, while I was stationed in Southampton, I went for a walk one morning and I heard this incredible roar in the air. Southampton is just across the English Channel from France and those were our planes going in for the attack. At the have made the strides it did time, medical school was s eight years, dentistry was s without the G. I enrolled in what was then called Northern Illinois College of Optometry, in Chicago. My mother was going to an ophthalmologist gram that really did so much for our country. So I offered to do all his refractions for him, and he could do the What was optometry like when you entered practice? A huge number of optometrists had descended how I got interested in pathology, because I saw it all on every state, because the schools were putting out so the time. It added so many talented people to our ranks at Yes, I would be at the ophthalmology office in the just the right time for what the profession was taking mornings and in the afternoons I was building my own on then. But I have to say, optometry was boring at pathology and such-really started with our generathat time. Boy, I never said with optical devices in some way, but they still assoso many Hail Marys in my life as when they stuck that ciated us with jewelry stores. Then in 1961, a young ophthalmologist in town was looking to get in touch with an optometrist. He asked four different optical stores who they recommended, and they all said me. His dad had started the ophthalmology center at Washington University, and I became their contact lens guy. So, you got interested in contact lenses because they could help post-cataract aphakic patients? What would you do if a patient came in with a problem that was more medical, like an infection or a foreign body? They gave me their consent to use an anesthetic if I wanted, to tide the patient over until I got them to the ophthalmologist. He was an optometrist, a teacher, er, "We only had about 30 people at a PhD and a researcher. He made optometry y a real profession and got us more respectabillthe first Heart of America meeting, ity than anyone. He would invite me to talk at What do you think of the current make-up of optomhis OptiFair meetings and he literally made my career etry, with medical topics so much a part of it? He would list the speakers in the ads for My generation really distinguished itself by taking the meeting and that got our names out there. You can be very friendly and close to your tact lens education, so I talked with them about an idea patients without being too personal. T hough Review of Optometry has been the longest-running publication in the field of optometry, this achievement would not have been possible without the continued efforts of our authors-thought leaders who have remained at the forefront of the topics we have covered over many decades. To celebrate them, we asked several for their impressions of articles they authored in a previous era of optometric care to see what they think today of their early work in the field. Even now, there are still a few older patients who remember receiving their rigid contact tact m lenses and are still happy with them to this day. Viewing fluorescein patterns and lens movement were an essential part of the fitting procedure. For the most part, it was necessary for practices to have on-site lens modification equipment where contact lenses could be modified according to patient symptoms and needs. The addition of edge treatments or peripheral curve modifications could make the difference between success and failure in lens adaptation. Most contact lens manufacturers were initially small mom-and-pop operations that were eventually absorbed into larger organizations. A second important factor was a motivated patient, one who would stick with the optometrist until they were happy or until all other options were exhausted. We determined the necessary spherical power, center and edge thickness, base curvature diameter and peripheral curves. The cosmetically unacceptable scleral lens was left in the dust in the forties and fifties; by 1960, the "invisible" corneal contact lens was king. Concerning the tear issue, the challenge first and foremost was the patient achieving lid adaptation to the lens. Frequently noted problems were onset of profuse tearing until the l lens settled and then having to live with foreign l body sensation until the lid and cornea were b desensitized. In fact, with a quality lab and proper edge modifications, a remarkable number of patients did quite well. That meant proper movement of the contact lens to allow tears to circulate freely without slippage, which required modifications of diameter and peripheral curves until the patient goal was met. Patients had to receive strict instructions regarding cleaning and avoidance of eye make-up and face creams during lens wear. However, the need for the cornea to receive enough oxygen is a story for another time. But a motivated 1960 contact lens patient would fight against the optometrist for even mentioning discontinuation of that magic piece of plastic that was custom-designed for them. The present-day patient would simply agree with the practitioner and look for an alternate contact lens modality or consider refractive surgery. The materials for it came from my clinical experiences in the Veterans Health Administration hospital system early in my career. I had just graduated from optometry school, where, like many other optometrists of the time, I was trained principally in vision correction measures, including management of low vision, aniseikonia and other visual anomalies. For the most part, optometrists then could be described as general all-purpose practitioners, though some more well-known individuals engaged in contact lens specialty practices. Furthermore, optometric curricula in the 1970s was only beginning to include biomedical education as a standard, with a specific focus on biochemistry, human anatomy and physiology, physical diagnosis, systemic and ocular pharmacology and microbiology. When this article was apublished, residency education in the mid-1970s was one of the most notable he movements occurring in the profession. This optional advanced clinical training le has largely been responsible for the recent generation of numerous "subspecialty" clinicians who have expertise in treating ocular disease, pediatric optometry, binocular vision, low vision and specialty contact lenses. Overall, the restructuring of the optometric educational curriculum to include biomedical courses as well as the more traditional vision science education along with extensive externship experiences, the inclusion of optometric services in Medicare and many other third-party insurance provider programs, the advent of residency education and access to the Veterans Health Administration system have transformed optometry into a robust primary eye care profession. While challenges continue to exist, these changes over the last several decades have made it so that patients of all ages now receive highly competent and compassionate care from their optometrist. There is a better understanding of risk factors associated with the disease, which allows for the calculation of the probability of developing glaucoma over a five-year period. The most obvious impact regarding the diagnosis of glaucoma during this time involves technology. New instrumentation allows us to detect change and monitor over time for both structural and functional damage caused by glaucoma. For example, technology like automated perimetry, confocal laser scanning ophthalmoscopy, pachymetry, more sophisticated tonometry and ocular coherence tomography devices now assist practitioners in refining their diagnosis and treatment efforts. Couple this with normative databases and sophisticated algorithms to interpret the data, and we can not only detect the initial damage from glaucoma, but also determine whether clinically significant progression of this damage is occurring. I am sure that new technologies and a better understanding of this disease will continue to advance the care we provide to glaucoma patients. The first was how long we have both been educators and authors; the second was how much of what we said in this article 33 years ago has changed, while simultaneously still staying part of the scope of the standard of care. Additionally, genetic testing enables us to provide information to patients regarding their risk for progression based on genetic factors, presence of a history of smoking and body mass index values. Binocular indirect ophthalmoscopy was typically performed back then to look for elevation, presence of fluid and other macular abnormalities, and is still done today. Additionally, fundus photography was also performed using a 50-degree fundus camera-still done today-and patients were typically referred to a retinal specialist for fluorescein angiography, which is also still done today. Earlier detection and treatment can help save vision and prevent irreversible damage. Fundus autofluorescence is also in use to detect changes that are not evident even with color photography or ophthalmoscopy. These technologies will likely play an important role as drugs that slow or even prevent the progression of dry, atrophic changes continue to arrive on the market. Though a chronic and essentially lifelong injection regimen is still currently required to control the condition, the future holds promise for better injection schedules as even newer agents become available. In the 1970s and early 1980s, manual s Goldmann kinetic perimetry was e, the standard. It took a lot of time, experience and active involvement nt from the operator and created angst in many patients as well. The early Omni comanagement center directors all paid their dues by doing many 5 isopter Goldmann fields! The 1985 article covers several topics, including supra-threshold screening perimetry in comparison with threshold tests. If you are testing for retinitis pigmentosa, headaches or a hemianopic defect from a stroke, there is nothing better and faster than a suprathreshold screening field such as an 81 or 120 full field. However, most offices are in "threshold mode" and order a 24- or 30-degree threshold field for everyone and everything-not always necessary, for sure. The article also mentions that it typically took 12 to 18 minutes per eye to perform 30-degree testing-something which newer technology and ongoing research has altered to 24-degree testing performed in just a matter of minutes. It was also interesting to read the transcript of that session in which both hydrogel extended wear and the newer modality of gas permeable extended wear was discussed. Thirty years ago, traditional orthokeratology was unpredictable and not highly effective: it took the development of high Dk polymers, reverse curve technology and corneal topography to make it i the highly successful mainstream option that we enjoy today. Much of the discussion during that e forum revolved around concerns of complications fo from hydrogel extended wear and patient noncomfr pliance.
Besides hiv infection rate dc cheap 2mg minipress mastercard, inadequate and unstable funding has also reduced the capacity to effectively deliver services of the nature that are valued by people uganda's soaring hiv infection rate linked to infidelity buy minipress 2mg mastercard. On the other hand markets do respond to individual demands and in a multiplayer environment competitive pressures do force a certain level of efficiencies and innovation antiviral gel for chickenpox buy minipress 2.5 mg on line. But then markets function on certain assumptions such as perfect information latent hiv infection symptoms generic minipress 2.5mg on-line, free entry and exit hiv infection rates japan buy minipress 1 mg, a fair distribution of income with all having an ability to pay etc hiv infection world map order minipress 2 mg without a prescription. The health sector are characterized by a wide range of market failures - high element of risk and uncertainty; moral hazard, adverse selection, externalities, asymmetrical distribution of information making the sovereignty of the consumer notional; several barriers to entry such as licensing and prices etc. It is for these reasons that even in market economies government intervention has been found to be unavoidable. In the absence of such intervention not being effective, households spend substantial amounts on health care, paying whatever is demanded as individuals do not bring with them market power. The health markets in India are competitive and in the unregulated, fee for service payment system, providers are able to maximize profits by increasing volume, use of high cost technology and intensive resource use, increasing the overall cost of care, necessitating designing of alternative systems of financing health care that would have incentives to contain cost. For the reasons stated above, the Commission recommends that India consider alternative financing systems that will encourage more accountability, sustainability, better efficiency and reduced cost. Four models that merit serious consideration are: (i) community-based health insurance; (ii) capitation; (iii) vouchers; and (iv) social health insurance. Once this is put in place, the law banning practice by untrained and non-authorized persons should and can be enforced. They have been found to be particularly effective, in Indonesia and Latin Amercian countries, in buying specific services that have cost-effective solutions. For example, in the case of deliveries and cataract, conditions that are specific, not an emergency and also verifiable, Village Health Committees / local bodies / Self Help Groups etc. For the success of this system of financing, which has the potential of being misused at the distribution level, effective monitoring will need to be ensured and the accredited provider institutions contracted to supply the services at pre negotiated rates. In other words, the provider cannot be permitted to take any additional money from the patients. Such a system of payment can be extended to other specific conditions/diseases as more experience is gained and provider responses and other system issues studied. The implication of this on the one hand is that the provider bears the entire risk and therefore has no incentive to over treat or overmedicate anyone. On the other hand, it implies that people will be willing to enrol with the provider only if they perceive to be getting good treatment. Such a procedure has the potential of being effective in not only making the provider institution more accountable to the patients but also for measuring patient satisfaction. This should be an essential pre-requisite in the designing of health care systems for, in India, the problem is not excessive consumption of health services but an accumulated deficit that needs to be addressed. Further, the design features will also require delegating authority and providing managerial and financial autonomy. The capitation system has the advantage of capping expenditure and shifting responsibility to the provider/facility. In other words, if additional funds are required the hospital management committees / local bodies / hospital authorities will need to mobilize the resources. Savings, if any, can be utilized for improving the facility or for other health-related activities. However, as a model, the capitation system requires high quality and rigorous monitoring. Since this is a new form of financing and the public health administrative system does not have the requisite capacity to regulate, enforce and monitor contracts, the Commission recommends that in a few districts this model be pilot tested adopting different phases as depicted in. Insurance at one level promotes equity as it empowers an individual in need of health care to access a comparable quality of care irrespective of economic status. At another level, insurance also functions on the principle of cross-subsidization where the rich, healthy and the young subsidize the sick, old and the poor. Therefore, for assuring equitable access to secondary care and reducing the financial burden on households, social health insurance is recommended as a way forward. Social insurance implies insuring persons against a definite risk and has a broader social objective than self-interest. Even if insurance is made mandatory, private insurance is not considered a reliable vehicle as it is known to discard all high risks. Will require a catalyst with a large risk pool for Social Health Insurance/ cross-subsidizing the poor as private insurance will cover only the top creamy layer of 10%. Mandatory insurance is the only way of obtaining the desired size of the risk pool required for keeping premiums low and making them affordable for the poor who are the main target group. For the rest, at the district level, risk pools could be constituted around professional or occupational groups like Self Help or Micro-Credit Groups, weavers, fishermen, farmers, and agricultural labourers and other informal groups not covered under any cooperative network constituted into societies, federations or cooperatives and given management control. In Kozhikode (Kerala) it is observed that almost 90% of the population is covered under some form of network or the other. Such groups can then be provided credit to pay the premium and the amount recovered in monthly instalments. Hospitals with 500 beds or more can be permitted to organize themselves into Health Maintenance Organization which may require a minimum threshold of 100,000 members for its viability. Making all pay and share the costs enables people to realize the value of health and take responsibility to stay healthy (proper diet, no consumption of liquor or tobacco, etc. For ensuring that both the rich and the poor are part of the risk pool, the Government may extend a maximum subsidy of 30% (equally shared by the Centre and State) wher- ever the enrolment is 70% of the resident population in a Gram Panchayat notified area, or the risk pool exceeds 15,000. This is on par with what those purchasing private insurance get by way of income tax exemptions. Providing a subsidy on this condition will enable incentives and building community solidarity. To keep administrative costs low, not exceeding 10%, the district administration should utilize its official machinery and local bodies for propagating the scheme and collecting premiums regularly. This in itself would be a subsidy of about 20% to the insured in terms of lowered premiums. Developing health insurance markets for secondary care At present, health insurance is a very small and insignificant part of health financing with a total premium collection estimated at Rs 1,100 crore, though growing at 22% per year. Private insurance is concentrated in about 8 cities and 90% of the market share is with the public sector insurance companies. The attempt to use this mechanism to protect the poor from income shocks under the Universal Health Insurance Scheme failed due to two factors: one, the risk pool being confined to below poverty line families already high risk and therefore a losing proposition; and two, not having any institutional mech- Table 3. In addition, if the Government were to extend one-third premium subsidy for all the poor, it would add another Rs 9000 crore. Such a move will have five advantages: (i) the administrative expenditures will come down further; (ii) optimize utilization of facilities; (iii) pro- vide access to urban slum populations and other poor to medical facilities without the Government having to invest additional resources for establishing primary health facilities and health posts in urban areas; (iv) facilitate establishment of the largest re-insurance programme in the country; and (v) later also facilitate a mechanism for equalizing risk - as a concept this implies that all insurance companies pay a part of their premium to this Corporation which in turn reimburses them in proportion to the level of risk. This is the one antidote for health insurance companies not to cherry pick and not resort to excluding high risks under one stratagem or another. But for this Corporation to be successful, the culture of management will have to be modernized and professionalized. Second, with consolidation on the demand side, the comprehensive package can be integrated and enforced in hospitals. In the absence of such a consolidation of the market on the demand side, and given the inelasticities of the secondary and tertiary care markets, providers are able to pick and choose what they want to provide and at the rates they wish to charge - an environment where the government and insurance companies are getting short changed. Third, it will also facilitate shifting the current emphasis of insurance schemes on hospitalization and surgery, ignoring primary care interventions. Finally, in the absence of such a framework, merely exhorting the private sector to implement the core package will not yield the desired results and nor will commercial insurance companies find it viable to cover the poor, sick and elderly. In such a scenario, private insurance companies tend to enhance their stock value by cream skimming, leaving all the high risks to public systems to bear. Undertake disease classification, development and analysis of datasets, mechanisms for controlling market failures like moral hazard and induced demand, and enable risk assessment for arriving at a fair premium, etc. This will need to be expanded to develop systems for quick redressal of grievances against insurance companies or provider hospitals. We have already lost enough time with ad hoc responses to the crisis that is building up in the health sector. A systematic approach needs to be adopted based on an exhaustive debate on the merits and demerits of the various options available aimed to provide risk protection to the poor based on carefully thought-out designs and to be implemented over a period of 10-15 years. Ensuring chlorination of and monitoring fluoride content in drinking water resources. Preventing water accumulation in open places and ensuring that families keep overhead tanks covered. Substantial investments have to be made to strengthen, upgrade and expand the public health infrastructure to enable them to conform with norms and standards. Besides, till social health insurance does not get rooted, the only option available for insuring the poor against risk and impoverishment is by providing good quality care in the public hospitals. Such investments would be reflective of a pro-poor policy framework as data shows that of the poor who availed of health services, two thirds utilized the public hospitals. Secondly, the existing system has, in several parts of the country, collapsed for reasons other than under-funding. Lack of accountability, rampant indiscipline, corruption and weak governance and poor management characterize the functioning of the public health infrastructure in the country, more noticeably at the primary level. This needs correction, but such correction will be possible only by incentivizing the system and the active participation of civil society. Thirdly, the government needs to accept its responsibility to provide basic primary health care to its citizens. To do so within the framework of the guiding principles and to assure that the system is accountable, the involvement of the community and locally elected bodies would be critical. But such involvement does require to be preceded by intensive training and raising of awareness on the various issues pertaining to health as was done in Kerala. To carry out these functions, training and funds should be made available by the Government for bridging deficits, if any, and be authorized to raise local taxes. Undertake Promotive activities to ensure 100 % access to safe water; toilets; and schooling of all children 2. Promote implementation of social legislation against dowry, early marriage and girl infanticide and violence against women. Provide assistance to the Gram Panchayat in carrying out all the mandatory duties listed. Assist in training the community drug depot and providing easy access to medicine & conducting the clinics. It is therefore essential that this intervention be designed keeping in view the historical experience and view it more as a part of the demand side strengthening than an input from the supply side. Since the conditions of work are extremely unsatisfactory, making the subcentres virtually non- functional, investment for building this infrastructure has to be given priority. This would ensure that subcentres are constructed as per need, at locations convenient to them and owned by them. The construction of such units will generate rural employment and unleash awareness about health. Such construction should be taken up even in areas where there is a subcentre building but is either in an unusable condition or unsuitable location. On the other hand, several subcentres have unviable and unmanageable jurisdictions. There is a need to increase the number of subcentres based on a need-based survey to be measured both in terms of population (caseload) and distance (such as not being more than half an hour away). Such skills should be hired on per case / per day basis for running weekly clinics, school clinics every quarter, assisting in specific services required by the community, etc. This would help strengthen the focus on the intersectoral coordination of health and its determinants. Such information dissemination will be the most powerful tool for making people aware of their health status and for assessing the corrective action that needs to be taken, among which social groups and for what. Just one such administrative action will improve efficiency, increase savings and much enable greater cohesiveness in administration and supervision. The market at this level is highly competitive with a well-entrenched private sector filling the void that an underfunded public sector has created. However, since these markets are also inelastic, people still seek treatment even at the cost of impoverishing themselves. Therefore, till a social security system is in place, it is imperative that public facilities be upgraded and provided adequate budgets to create the necessary posts, upgrade equipment, expand the facilities and beds strength to cater to the increased demand for such service. These charges should be the basis for service provisioning in the public or private sector and must be mandated by law. Reducing the disease burden Nutritional security is a fundamental determinant of health and therefore an important prerequisite for the effective containment of disease. Research done elsewhere show a causal connection between low birth weight and higher probability of acquiring diabetes or hypertension and obesity at later ages. Considering that it is predominantly the poor who have low birth weight babies, increased incidence of diseases that are expensive to treat among this segment of the population has serious financial implications, both for the poor households as well as public finances that are spent on subsidizing the care of the poor. Therefore, beside the moral imperatives of addressing such "hidden hunger", the utilitarian argument of cost effectiveness of policy intervention would also support strong public action on taking concerted action to reduce the unacceptably high levels of malnutrition in India and improve overall population health. Besides, as the Government gradually shifts towards being a purchaser of care, there will be need for institutional capacity with professionalized skills to attend to the complex tasks of negotiating, contracting and monitoring. If these districts are focused upon single-mindedly and monitored closely there could be substantial benefits in terms of improved health and reduced disease burden in the country as a whole. Since persistence of disease and the high risk in these districts is largely on account of poor programme implementation, intervention by the Central Government in the form of extra budgetary support for appointing full-time front line public health functionaries and closely monitoring them could be very useful. Accordingly, it is recommended that for these districts, Central assistance may consist of a comprehensive package of recurring and non-recurring components, including recurring expenditures for critical posts for ensuring that the program targets are achieved within the time lines laid down. Given the exorbitant rates of advertisements on commercial channels and small budgets, the frequency and spread of information are low. Likewise, advertising non-health products without providing full information, and use of images and data that could cause confusion need to be regulated.
Even with a complete airway obstruction hiv infection rates ukraine order minipress 1 mg with mastercard, positivepressure ventilation is often successful antiviral quiz effective minipress 2.5mg. It is bacterial antiviral uk order minipress 2 mg with amex, with fever hiv infection rates by county discount minipress 2.5 mg overnight delivery, rapid onset hiv infection rates msm minipress 1mg with mastercard, possible stridor antiviral drug cures hiv purchase minipress 2.5mg visa, patient wants to sit up to keep airway open, and drooling is common. Tracheitis presents in a similar manner to epiglottitis and the patient will also appear very sick. Wheezing in the breathing patient with respiratory distress indicates lower airway disease, which may come from a variety of causes. Use Albuterol (Proventil) and Ipratropium (Atrovent) for the known asthmatic in severe respiratory distress. Stridor, gagging or choking in the breathing patient with respiratory distress may indicate upper airway obstruction. Tape only 3 sides down so that excess intrathoracic pressure can escape, preventing a tension pneumothorax. It may help respirations to place patient on the injured side, allowing unaffected lung to expand easier. If it is very large, cutting may be possible, with care taken to not move it while making the cut. Use the intercostal space between the 2nd and 3rd ribs on the midclavicular line, going in on the top side of the 3rd rib. Cardiac arrest in children is primarily due to lack of an adequate airway, resulting in hypoxia. If the patient converts to another rhythm or has a return of circulation, refer to the appropriate protocol and treat accordingly. When assessing for a pulse, palpate the brachial or femoral arteries for infants and the carotid or femoral artery for children. Toxic ingestion / exposure Refer to pediatric reference material when unsure about patient weight, age and / or drug dosage. The minimum dose of Atropine that should be administered to a pediatric patient is 0. Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic intervention. If you are unable to get the monitor to select a low enough joule setting, contact Online Medical Control. In order to be successful in pediatric arrests, a cause must be identified and corrected. If the patient converts to another rhythm, follow the appropriate protocol and treat accordingly. If the patient converts back to ventricular fibrillation or pulseless ventricular tachycardia, defibrillate at the previously used setting. Defibrillation is the definitive therapy for ventricular fibrillation and pulseless ventricular tachycardia. Naloxone (Narcan) administration may cause the patient to go into acute opiate withdrawal, which includes vomiting, agitation, and / or combative behavior. Naloxone (Narcan) may wear off in as little as 20 minutes causing the patient to become more sedate and possibly hypo ventilate. Treat patients early, no need to wait for patient to begin vomiting to administer Ondansetron (Zofran). Patients receiving medications such as narcotic analgesics may require concurrent administration of Ondansetron (Zofran) to reduce nausea associated with such medications. It can occur when insulin levels become inadequate to meet the metabolic demands of the body for a prolonged amount of time (onset can be within 12 24 hours). Without enough insulin the blood glucose increases, and cellular glucose depletes. Hypoglycemia: · Always suspect Hypoglycemia in patients with an altered mental status. Predisposed by use of: tricyclic antidepressants, phenothiazines, anticholinergic medications, and alcohol. Heat Cramps consists of benign muscle cramping secondary to dehydration and is not associated with an elevated temperature. Vital signs usually consist of tachycardia, hypotension, and an elevated temperature. Heat Stroke consists of dehydration, tachycardia, hypotension, temperature > 104° F (40° C), and altered mental status. Patients at risk for heat emergencies include neonates, infants, geriatric patients, and patients with mental illness. Heat stroke occurs when the cooling mechanism of the body (sweating) ceases due to temperature overload and / or electrolyte imbalances. With temperature less than 88° F (31° C) ventricular fibrillation is common cause of death. If the temperature is unable to be measured, treat the patient based on the suspected temperature. All hypothermic patients should have resuscitation performed until care is transferred, or if there are other signs of obvious death (putrification, traumatic injury unsustainable to life). If V fib is not present, then all treatment and transport decisions should be tempered by the fact that V fib can be caused by rough handling, noxious stimuli or even minor mechanical disturbances, this means that respiratory support with 100% oxygen should be done gently, including intubation, avoiding hyperventilation. Do not attempt to rewarm deep frostbite unless there is an extreme delay in transport, and there is a no risk that the affected body part will be refrozen. Grand mal seizures (generalized) are associated with loss of consciousness, incontinence, and tongue trauma. Jacksonian seizures are seizures, which start as a focal seizure and become generalized. Cardiac To use this scale, your doctor should explain that each face shows how a person in pain is feeling. Rating the intensity of sensation is one way of helping your doctor determine treatment. Pain severity (010) is a vital sign to be recorded pre and post medication delivery and at disposition. Contraindications to morphine use include hypotension, head injury, and respiratory distress. All patients should have drug allergies documented prior to administering pain medications. All patients who receive pain medications must be observed 15 minutes for drug reaction. Tricyclic: 4 major areas of toxicity: seizures, dysrhythmias, hypotension, decreased mental status or coma; rapid progression from alert mental status to death. If it can be done safely, take whatever container the substance came from to the hospital along with readily obtainable samples of medication unless this results in an unreasonable delay of transport. Naloxone (Narcan) may wear off in as little as 20 minutes causing the patient to become more sedate and possibly hypoventilate. Once the patient is determined to be an actual or potential major trauma / multiple system patient, personnel on scene and / or medical control must quickly determine the appropriate course of action including: 1. The onscene time for major trauma patients should not exceed 10 minutes without a documented, acceptable reason for the delay. It is the responsibility of the responding jurisdiction to notify their appropriate coordinating hospital as soon as possible, giving a brief description of the incident and the estimated number of victims. The transportation officer should maintain a constant contact with the coordinating hospital until the scene has been cleared of salvageable victims. A Pediatric Trauma Victim is a person < 16 years of age exhibiting one or more of the following physiologic or anatomic conditions Physiologic conditions · Glasgow Coma Scale < 13; · Loss of consciousness > 5 minutes; · Deterioration in level of consciousness at the scene or during transport; · Failure to localize to pain; · Evidence of poor perfusion, or evidence of respiratory distress or failure. If transport to a Pediatric Trauma center will add greater than 15 minutes, transport to the nearest trauma center. Pedestrian/Bicyclist thrown, run over or with significant (> 20 mph) impact Motorcycle crash > 20 mph Other motorized equipment crashes where the patient has the potential of significant injury Signs of/suspicion of abuse Step 4Assess special patient or system considerations of trauma patients Anticoagulant and bleeding disorders on prescription blood thinners Significant burns (+/ trauma mechanism) or inhalation injury, chemical injury electrical injury or frostbite triage to burn center. Blunt injuries are harder to detect and diagnose, and have a death rate twice that of penetrating wounds. Burn patients are prone to hypothermia Never apply ice or cool burns that involve >10% body surface area. Patient should be transported by personnel not involved in decontamination process. Determine severity (see chart), contact Medical Control and transport accordingly. Determine severity of burn, contact Online Medical Control and transport accordingly. Patients with unstable airway or who are rapidly deteriorating should be transported to the closest appropriate facility. Tension pneumothorax Medical the second six injuries may be subtler and not easily found in the field: 7. Pulmonary contusion · · · A sucking chest wound is when the thorax is open to the outside. The occlusive dressing may be anything such as petroleum gauze, plastic, or a defibrillator pad. A flail chest is when there are extensive rib fractures present, causing a loose segment of the chest wall resulting in paradoxical and ineffective air movement. Decompress between the 2nd and 3rd ribs, midclavicular placing the catheter over the 3rd rib. All victims should be transported for evaluation due to potential for worsening over the next several hours. Allow appropriately trained and certified rescuers to remove victims from areas of danger. With pressure injuries (decompression / barotrauma), consider transport for availability of a hyperbaric chamber. All hypothermic / drowning patients should have resuscitation performed until care is transferred, or if there are other signs of obvious death (putrification, traumatic injury unsustainable to life). Hip dislocations and knee and elbow fracture / dislocations have a high incidence of vascular compromise. The most important item to monitor and document is a change in the level of consciousness. A physician should evaluate any prolonged confusion or mental status abnormality, which does not return to normal within 15 minutes or any documented loss of consciousness. Begin irrigating immediately, because irreversible damage can occur in a few minutes. Anatomic conditions · Penetrating trauma to the head, neck, or torso; · Significant, penetrating trauma to extremities proximal to the knee or elbow with evidence of neurovascular compromise; · Injuries to the head, neck, or torso where the following physical findings are present; · Visible crush injury; · Abdominal tenderness, distention, or seatbelt sign; Pelvic fracture; Flail chest; · Injuries to the extremities where the following physical findings are present: Amputations proximal to the wrist or ankle; Visible crush injury: Fractures of two or more proximal long bones; Evidence of neurovascular compromise. In prolonged extrications or serious trauma consider air transportation for transport times and the ability to give blood. Major trauma patients are to be transported to the closest pediatric trauma center. If unable to access patient airway and ventilate, then transport to the closest facility for airway stabilization. The onscene time for major trauma patients should not exceed 10 minutes without documented, acceptable reason for the delay. With the exception of airway management, traumatic cardiac arrests are "load and go" situations. Resuscitation should not be attempted in cardiac arrest patients with spinal transection, decapitation, or total body burns, nor in patients with obvious, severe blunt trauma that are without vital signs, pupillary response, or an organized or shockable cardiac rhythm at the scene. Patients in cardiac arrest with deep penetrating cranial injuries and patients with penetrating cranial or truncal wounds associated with asystole and a transport time of more than 15 minutes to a definitive care facility are unlikely to benefit from resuscitative efforts. Breech Delivery: · Footling breech, which is one or both feet delivered first · Frank breech, which is the buttocks first presentation When the feet or buttocks first become visible, there is normally time to transport patient to nearest facility. At this point, the two fingers should be placed between the chin and the vaginal canal and then advanced past the mouth and nose. Shoulder Dystocia: · Following delivery of the head the shoulder(s) become "stuck" behind the symphisis pubis or sacrum of the mother. Ectopic Pregnancy · the patient may have missed a menstrual period or had a positive pregnancy test. Pelvic Inflammatory Disease · Be tactful when questioning the patient to prevent embarrassment. After delivery, massaging the uterus (lower abdomen) will promote uterine contraction and help to control postpartum bleeding. If delivery becomes imminent while enroute, stop the squad and prepare for delivery. Effective ventilation can be determined by; Chest rise, Bilateral breath sounds, and Increasing heart rate. Each individual Medical Director reserves the right to choose not to supply or use medication included in the protocol at his / her discretion. The Medical Director also reserves the right to decide which (or all) agent to supply if multiple medications are listed for an application. Although, where available, this document lists available alternate medications, the alternate medications are not necessarily intended to be carried routinely. These agents are intended to be added to the drug box in the event of a shortage of the primary listed agent. It is the individual Medical Directors and the individual agencies responsibility to communicate shortages and substitutions with the staff. It is the individual providers responsibility to review the protocols and dosing for substituted medications. Therapeutic action Beneficial action expected from a desired concentration of a medication 7.
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References
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