Lynne M. Yancey, MD, FACEP

• Assistant Professor
• Division of Emergency Medicine
• University of Colorado Denver School of Medicine
• Aurora, Colorado

Many of these are associated with long-term disability medicine chest order genuine compazine on-line, making early detection and identification vital symptoms 0f low sodium order compazine 5 mg on line. Although early involvement of genetic specialists in the care of such children is prudent symptoms 2 order compazine toronto, primary care physicians are at times required to contribute immediate care symptoms 5 weeks 3 days discount compazine 5mg amex, and subsequently assist with long term management of suctients medicines 604 billion memory miracle order 5mg compazine with visa. Teratogenic disorders (fetal alcohol syndrome medications prolonged qt generic 5mg compazine fast delivery, coumarin, Accutane, anticonvulsants) 2. Objectives 2 Through efficient, focused, data gathering: ­ Formulate a phenotype from relevant family history. Unless genetic screening is supported financially, it may become limited to the affluent. This situation creates a risk that genetic disability will become a marker of social class. The morbidity and mortality associated with diabetic complications may be reduced by preventive measures. Intensive glycemic control will reduce neonatal complications and reduce congenital malformations in pregnancy diabetes. Gestational diabetes mellitus Key Objectives 2 Diagnose diabetes mellitus and diabetic ketoacidosis according to established criteria for children and adults. Objectives 2 Through efficient, focused, data gathering: ­ Diagnose diabetes mellitus and associated complications. Patients with long-standing diabetes may develop diabetic retinopathy that is sufficiently severe to render them potentially dangerous to others when driving a car. If the patient does not heed the advice against driving, the physician needs to decide whether the harm from disclosure balances the harm of maintaining confidentiality and act according to that decision. If the patient is not fit to drive a vehicle on public highways, the physician is required to report this fact. The team of professionals that need to be involved includes family physicians, dieticians, nurses, social workers, pharmacists, podiatrists, ophthalmologists, endocrinologists, cardiologists, nephrologists, etc. It is essential that the inter-professional relationship be based on respect and clear communication. Certain tasks need to be delegated between physicians and other health care workers. All involved must work in a collegial way within the care team structure and maintain respect for the role of the other health professions at all times. Compare the mechanism of action of insulin to that of various classes of oral hypoglycemic agents. Fortunately, it is an uncommon clinical problem outside of therapy for diabetes mellitus. Associated with normal insulin levels (large extrapancreatic mesenchymal tumors) b. Objectives 2 Through efficient, focused, data gathering: ­ Identify those patients with true hypoglycemia as opposed to pseudohypoglycemia. Outline the normal homeostatic response to fasting that prevents blood glucose concentrations from falling. Outline the roles of epinephrine, glucagon, growth hormone, and cortisol in the fasting state. Objectives 2 Through efficient, focused, data gathering: ­ Differentiate between various causes by seeking corroborative evidence. Although in themselves nail changes may be innocuous, they frequently provide significant diagnostic hints of underlying disease. Hour-glass nail/Finger clubbing (lung disease, cyanotic heart disease, colitis, etc. Onycholysis separation of nail plate from nail bed (impaired viability of nail bed/impaired circulation thyroid disease, trauma, fungal). Onychogryphosis thickening of nail plate (chronic inflammation, tinea, psoriasis) f. Blue-green (pseudomonal nail infection) Key Objectives 2 In patients with nail changes differentiate between changes in shape, surface, and color. Objectives 2 Through efficient, focused, data gathering: ­ Differentiate local from systemic problems. Medication use (nitroglycerin) or medication withdrawal (analgesic) Key Objectives 2 Differentiate benign headaches from those caused by potentially serious causes. Objectives 2 Through efficient, focused, data gathering: ­ Differentiate between the various causes of headache. In a patient with headache, the primary care physician may miss a serious headache, such as subarachnoid hemorrhage. Although serious causes for headache are not frequent, failure to diagnose has potentially disastrous consequences. Adults/older children have otitis less commonly, but may be affected by sequelae of otitis. Outline the transformation of sound waves from the time they are "caught" by the auricle to the fluid waves within the cochlea, the motion of the organ of Corti, depolarization of the auditory nerve, and organization by the brain into complex sounds. The concomitant finding of aphasia is diagnostic of a dominant cerebral hemisphere lesion. Acute hemiplegia generally heralds the onset of serious medical conditions, usually of vascular origin, that at times are effectively treated by advanced medical and surgical techniques. If the sudden onset of focal neurologic symptoms and/or signs lasts<24 hours, presumably it was caused by a transient decrease in blood supply rendering the brain ischemic but with blood flow restoration timely enough to avoid infarction. Transient brain ischemia (<24 hours 50% acute infarct) thrombosis or embolism as below 2. Thrombosis (atherosclerosis, dissection, fibromuscular dysplasia, vasoconstriction) i. Objectives 2 Through efficient, focused, data gathering: ­ Differentiate between causes of hemiplegia based on time course (gradual progression during minutes or hours, or stuttering progression over hours or days with periods of improvement, or sudden onset with maximal deficit at onset, or abrupt severe headache) and the presence of risk factors for each of the causes listed above. Physicians have recognized the right of the patient to participate in medical decision making for the last 25 years. Unfortunately, close to 50 percent of individuals over age 85 have dementia, which usually precludes their understanding of many of the issues involved in choosing among treatment alternatives. In these situations, a surrogate must be identified to speak on behalf of the older patient. The commonest causes of neurological death are traumatic brain injury, cerebro-vascular accidents, and hypoxic-ischemic injury after cardiac arrest. Mildly demented patients, for example, may understand the issues involved in a simple surgical procedure well enough to allow them to choose or decline surgery, even if they no longer have the ability to balance their chequebook or live independently. Conversely, superficially intact patients may be unable to understand the pros and cons of a proposed intervention. An assessment of decision-making capacity can and should be performed by the primary physician; determining decision capacity for a specific medical intervention requires neither legal intervention nor psychiatric expertise. Nevertheless, the clinician can be satisfied that a patient is capable of making decisions if he or she has the following abilities, which can be determined at the bedside: 1. The ability to communicate (a translator, a communications board for aphasic patients, writing out questions with a deaf patient, etc. Often this assessment can be accomplished simply by asking the patient to repeat in his or her own words what the physician has explained. The ability to grasp the consequences of accepting and of declining the suggested treatment. Medical problems can sometimes be anticipated and a decision made in advance about what approach to use when they develop. As an example, individuals who have had a stroke which impairs swallowing can be expected to develop problems with aspiration; the issue of gastrostomy tube feeding is appropriate to raise in these cases, even before any complications have actually developed. An unfocused or unstructured investigation of anemia can be costly and inefficient. Red blood cell loss Obvious (trauma, metro/menorrhagia) or Occult (polyp, cancer) b. Macrocytic (B12folate deficiency) Key Objectives 2 In iron deficiency anemia exclude the possibility of serious gastrointestinal disease. In a patient who is bleeding but refuses a blood transfusion, determine whether the decision can be justified within the context of a relatively stable set of values. However, if the patient refuses because of a lifelong widely shared religious belief that prohibits blood transfusions, the capacity to give consent is probably present, and the decision should be respected. A very small proportion of the renal failure patient population receiving erythropoetin for treatment of anemia has developed pure red cell aplasia. Although studies have not identified the cause with certainty, the method of manufacture of the hormone, storage or method of administration, together or singly have been considered a possible cause. Patients receiving this drug need to know about the small risk involved and as a consequence have a choice in changing the type of medication or route/manner of administration pending identification of the cause. Prenatal diagnosis of sickle cell disease and thalassemia has been feasible for over 15 years and raises difficult ethical issues for parents and physicians. The decision to receive prenatal diagnosis is influenced by culture, religion, educational level, and the number of children in the family. Access to prenatal genetics services for the general population is important lest genetic screening become limited to the affluent. This has the potential of creating a situation wherein genetic disability becomes an indication of social class. Since the only pragmatic options for mothers are abortion or no children, it is vital that women not be pressured into prenatal diagnosis. Discuss erythropoesis within the bone marrow under the influence of the stromal framework, cytokines, and erythropoetin, a hormone produced in the kidney by cells that sense the adequacy of tissue oxygenation relative to need. Discuss the regulation of iron balance, availability of cobalamin and folic acid, and their absorption and anatomical site of absorption. Erythropoetin secreting tumor (hepato-cellular, renal cell, ovarian, uterine, hemangioblastoma) B. Relative polycythemia (decreased plasma volume: burns, diarrhea) Key Objectives 2 Since the most common cause of polycythemia is hypoxia secondary to pulmonary disease, elicit symptoms pertaining to altered lung function. Objectives 2 Through efficient, focused, data gathering: ­ Differentiate between causes of secondary erythrocytosis in patients without polycythemia related features. Ask about dyspnea, cough, cyanosis, hypersomnolence, long periods at high altitude, home oxygen therapy, history of heart or lung disease, family history, smoking history, exposure to carbon monoxide, or renal transplantation. Discuss whether the determination of red cell mass and plasma volume is necessary for the diagnosis of polycythemia or do measurements of hemoglobin levels to convey similar information. However, if accompanied by virilization, then a full diagnostic evaluation is essential because it is androgen-dependent. Hypertrichosis on the other hand is a rare condition usually caused by drugs or systemic illness. Objectives 2 Through efficient, focused, data gathering: ­ Determine which patients with recent onset of hirsutism require investigation. Identify the ovaries or adrenal as the site of increased androgen production in patients with hirsutism. Those who have correct word choice and syntax but have speech disorders may have an articulation disorder. However, if it lasts more than 2 weeks, especially in patients who use alcohol or tobacco, it needs to be evaluated. Tongue paralysis/Macroglossia (cranial polyradiculitis, allergic edema, stroke) ii. Silent/Non-speaking (catatonia/autism, depression, brainstem encephalitis) Key Objectives 2 Determine whether the speech apparatus is intact and the speech disorder is central. Objectives 2 Through efficient, focused, data gathering: ­ Elicit information indicative of inflammation/infection, voice abuse or misuse, smoking or alcohol. Identify the three main functions of the larynx as voice generation, airway protection from ingested material during swallowing, and cough production. Outline the anatomy of the hypopharynx, which extends from the base of the tongue to the upper cervical trachea and includes the larynx. It is crucial to distinguish acidemia due to metabolic causes from that due to respiratory causes; especially important is detecting the presence of both. Management of the underlying causes and not simply of the change in [H+] is essential. Outline how pulmonary and renal excretion of carbon dioxide and non-volatile acid respectively maintain body acid base balance. Outline the 3 different ways available to buffer secreted [H+] in the renal tubule. Contrast the value of urinary sodium concentration to that of chloride as a surrogate for volume status. Both partners must be investigated; male-associated factors account for approximately half of infertility problems. Although current emphasis is on treatment technologies, it is important to consider first the cause of the infertility and tailor the treatment accordingly. Infertility (inability to conceive after 1 year of intercourse, no contraception) a. Testicular (viral orchitis, varicocele, radiation, drugs, liver/renal failure) iii. Post-testicular abnormal sperm transport (obstruction of epididymis, ejaculatory duct, vas deferens, failure/retrograde ejaculation, stricture, vasectomy, sperm motility) c. Unexplained infertility Key Objectives 2 Outline the investigation for a couple with infertility. The ethical issues surrounding therapeutic donor insemination in same sex couples, surrogacy, donor egg, and other advanced reproductive technologies are still evolving and remain controversial. Outline the phases of the menstrual cycle from follicular phase, to luteal phase and ovulation. Outline spermatogenesis and its regulation including hormonal control and intratesticular paracrine factors.

Doctor Lyle made sure each hospital contract had a separate corporation with a different name medicine xyzal order genuine compazine on line. So some days we were Emer gency Medical Group medicine 801 purchase compazine 5mg line, Incorporated medications 4 less purchase generic compazine, and other days we’d be Emer gency Surgical Group symptoms tonsillitis order compazine 5 mg amex, Incorporated medicine effects purchase compazine 5 mg overnight delivery, and the whole thing got pretty creative treatment example discount 5 mg compazine free shipping. If there was a large percentage of trauma patients, we’d go in as Trauma Specialists, Incorporated. It employed those two All-American toxicologists, traumatologists, medical, surgical, pediatric, and acute-care specialists. Yes, both Doctors Monk and Walsh, and they’ve both worked for every one of our fine cor, cor, corpoooooraaations,” O’Fallen laughing so hard he couldn’t continue. One summer I went wildcattin’ with Alex, even though he was workin’ for Goldman, and when we were drivin’ by a maximum security prison, Alex said, ‘Hey, look at that, would you? It was simple cold call, but within a month he got the contract for Doctor Goldman to staff the prison health clinic. Alex continued with, ‘Our group deals primarily with the medi cal and psychological problems of prisoners, and we give our doctors intensive training in security and other unique aspects of prison medical care. I went on this big, long fabrication about our company and its interest in pro viding the best possible student health care doctors known to the medical world and, pretty soon, Doctor Lyle sent Doctor Bing in as our student health specialist. Then about a month later, we swit charooed Doctor Bing for Doctor Walsh, who was now also a spe the Rape of Emergency Medicine Page 180 cialist in correctional medicine and student health. Steinerman and Mahoney looked as wide-eyed and blank as Monk on the Death and Doughnut stool. Don’t get me wrong, though, we were successful beyond be lief, Alex and me, real rainmakers for organized emergency medicine. In fact, Doctor Lyle used to send my wife and me to his condo in the Bahamas every year for bein’ the top mosquito in the pyramid. Since I got the rheumatic heart, most insurance companies said I had a preexisting condition, and wouldn’t give me a medical policy. Alex and I had an expense account, but we used to stay at Steve Waterbury’s house. Steve Waterbury got thrown out of Good Sam in Cincinnati, which is where he went after Doctor Adkins got him thrown out of Dupage. You guys know that most staff doctors are too damn busy to give a shit who’s in the emergency room, even if it’s Monk screwin’ up. He’s a real pig, so we have to take him out to the best eatin’ spots in town for a couple of weeks. Then old fatso the Rape of Emergency Medicine Page 181 starts diddlin’ to undermine the contract of the docs runnin’ the emergency room. Usually he can get ‘em booted so he can give the ‘management’ contract to Pyramid, and stay on our Super Bowl guest list. Mahoney and Steinerman’s eyes were ready to pop out, listening to the excesses of the wrongdoers with their facile rhetoric. They were agog as Steinerman said, “Emergency medicine ‘man agement,’ the greatest hoax ever perpetrated on another group of physicians, let alone the American Public. Steinerman replied, “Only in emergency medicine, a specialty that’s getting worthy of a “Ripley’s Believe It or Not’ entry. Doctor Lyle made us scratch their names off of the mailin’ lists of the glossies he sent around the country advertisin’ Pyramid’s and Pinnacle’s ‘ser vices. Of course, Lyle doesn’t want to offend any of the major players in the Academy’s inbred crowd. It’s strictly the Delorenzos of the world he targets, insurgent groups of highly trained physicians with democratic scheduling, profit sharing, and distribution of duties, but without the resources to defend them selves against the Oscar-winning marketing performances of the crips and the bloods. The Academy’s got its own nonproliferation treaty, sweetheart-dealing amongst themselves while the protection ist leadership sells out the general membership. At first, a group of bloods had approached Lyle, urging him to join with them to endow a series of one-year fellowships, teaching emer gency medicine residents literacy skills in “management. When Lyle pondered the joint fellowship, he just didn’t like the concept of “fellows” studying the Sphinx of “management” for a postgraduate year. Deep down he was also afraid other physicians in other specialties would laugh at him. The Rape of Emergency Medicine Page 183 Lyle was sick of being on the perimeter of real medicine, and didn’t want to share his name with Goldman and the other crips on this new Rosetta stone they’d concocted. So he went ahead with his original plan to provide the sole endowment to a professional chair in emergency medicine at a university medical school that, ironi cally, didn’t even have a separate department of emergency medi cine. If the Pyramidology fellowships went well, he would just endow them with his own and Carolyn’s names. But now the time of recognition had finally come as Lyle walked through the college commons. Kensington, the large-headed presi dent of the American Academy of Emergency Physicians, and many other high-ranking pretenders to the throne were there to share in Lyle’s big day. Crip and blood luminaries came from all over the country, but many local emergency medicine specialists and profes sors were notably absent. The former-divinity-student’s benediction was, as usual, magnificent, and is old rectors at Trinity Church would have been proud of him, watching the prelate Lyle read his epistle like Saint Paul to the Corinthians. Lyle had learned a great deal from Valerie, and worked hard on his likability quotient, trying to catch up with Goldman’s popularity. Any (insured) patient who arrived at the steps of an emergency facility was considered a true emergency, no matter how trivial their the Rape of Emergency Medicine Page 184 complaint was. There they were, the kitchen schedulers, a group of inveterate sec ond raters with a colossal frat-house prank run wild, a junior-year abroad run amok, but embraced by the unknowing, and proclaimed as leadership by the self-anointed clerisy of emergency medicine. As Mark Twain said, “prosperity is the protector of principle,” and these very prosperous men were now men of principle. The “suits” loved the idea that “scrubs” saw patients while they made money, made money and lots of it, made money while they went to ceremonies honoring themselves, the American dream com ing true for the ebullient “suits. Instead of Lee Harvey Oswalds of the new specialty, they were the bold, innovative Lee Iacoccas, and instead of the real murderers of Jenny and Mary G. Lyle could see the recognition of the bluest of the old bloods, with the Rape of Emergency Medicine Page 185 their admiration for this combination physician, entrepreneur, and philanthropist. The ill-fitting Lyle had moved a few blocks east on Beacon Hill, and knew he’d be invited back for other ceremonies, pictures, and the respect his clever prosperity had bought. He real ized Oscar Wilde was wrong when he said, “No man is rich enough to buy back his past,” and even the “scrubs” working in the pit would curtsy to him now. Although they were members of the Academy and had free tickets to the gala, Mahoney and Steinerman abstained. After dinner, they decided to call Cecil Grimes, a black from the Latin and Harvard Med, now an internal medicine resident at the General. Ironically, Grimes had taken elec tives in the dead languages of both Latin and ancient Greek for four years, mentored by the few remaining dons unaxed by the Boston budget. The medical students and residents had already created a contest to determine the “nickname” of the new chair of emergency medicine. Grimes explained the ground rules of the new contest: the new title had to have at least three words beginning with the letter P – an other triple P for medicine. Only a person with a tongue for Latin isms could have created these guidelines, and Cecil said appellations poured in all day from as far south as Jacksonville and as far west as Honolulu. Bierman calculated Pyramid’s “generics” placed in the killing fields of the nation’s emergency rooms would catch up with Uncle Pol by the Rape of Emergency Medicine Page 186 the year two thousand and thirty. Tahoe and Eileen were on the floor with laughter as Grimes spoke over the speaker phone. The Duke University’s emergency medicine residency program had a virtual tie with Randy Peterson’s Pyramid’s Pontius Pilate Profes sorship, and the University of Chicago’s Brian Accola’s entry, the Emergency Medicine Chair of Piss Poor Physicians. The Rape of Emergency Medicine Page 187 Chapter Fourteen: the Missing Chapter the Rape of Emergency Medicine Page 188 Chapter Fifteen: Chart Wars “A well-known, unshaven, unkempt, foul-smelling, slightly-cyanotic, sixty-two-year-old alcoholic gentleman was carried into our emergency room by three million lice, all scream ing, ‘Please save our host. The Connie Thompsons of the world changed all that, making medical charts into legal briefs. The medical chart for a one-centimeter, superficial laceration on the outside aspect of the small finger used to look something like this: Lac 1 cm. Now it was, the better and more the Rape of Emergency Medicine Page 189 detailed it was documented, the better and more detailed it was done. The “suits” gave themselves extra Krugerrands because they entered the new business of “quality assurance” and “risk manage ment,” seeing even fewer patients themselves because they had to spend more time telling the “scrubs” to write more on their charts. The “suits” also noted that with the use of dictating machines, the “scrubs” would say twenty-five percent more than if they had to handwrite it all. Sometimes the “scrubs” even grunted into seventy five-thousand-dollar, computer-assisted, voice recognition machines, cranking out even more verbiage, and generating laser-printed charts reading like textbooks. The kitchen schedulers congratulated them selves on this finding, giving themselves yet another raise. Since they had to skim more money off of the fees of the "scrubs" to give themselves more money to work on “quality assurance,” they had to hire less-qualified, lower-paid “scrubs” to see the patients in emergency rooms. So the more time and money the “suits” spent on “quality assurance,” the lower the quality they assured. They also had to attend more meetings on “risk management,” and the more money they spent on "risk management," the more the increased the actual risk to the sick and injured patients. It also turned out, the more health fairs and other nutty “products” and “services” they merchandised to the O-J-T-ers, the less care they delivered to the “consumers of the health care dollar. The same superficial laceration on the lateral aspect of the small finger required paragraph after paragraph of detailed medical histories, physical exams, descrip tions of the suturing (some of the moonlighting residents also or dered x-rays of the finger and a blood test to determine if there was the Rape of Emergency Medicine Page 190 extensive blood loss), and the pain medications given. The com puters also generated pages and pages of discharge instructions cov ering everything from persistent pain to the possibility of gas gan grene. Eventually the superficial lacerations to the small fingers, which were successfully treated for generations with Band-Aids, were universally sutured, the cuts generating charts whose dictation took far longer than the suturing itself. Since no one could scribble all this and function in a busy emer gency room, physicians usually stayed an extra hour or two after their shifts ended to perform the acts of composition. If attorneys saw a detailed, neatly-typed medical chart with no boxes left unfilled, they were much less likely to file a nuisance lawsuit. If a lawsuit was not filed because of an extensive chart, it became known in medical-legal circles as a “chart win. Monk had seen, misevaluated, and checked out many “talk and die” patients, discharging them to a premature Kingdom Come. Monk, the emergency medicine variant of the Bos ton Strangler, had also sent several children off to “go home and die” preventable deaths with his thumbprints on their neck, but it did not go unnoticed that General George Patton Monk never lost a chart war. One evening, Steinerman relieved the well-documented Monk, and, as usual, the Generalissimo had a logjam of patients in the waiting room. When Steinerman entered the hospital, he was taken aback by the sight of one of those soda machines, a huge, neon Pepsi machine shaped like a big fat can of Pepsi with its convex belly sticking out into the waiting room. Suddenly he jumped when the whole machine shaped like a big can started blinking on and off. Steinerman ordered a blood test and urinalysis, gave the boy some intravenous fluids, and called the surgeon who wanted to know the results of the blood test before driving in on a Sunday afternoon, but Steinerman insisted Fay clearly had a surgical abdomen. The grum bling surgeon drove in thinking all the while of how he was going to skin this insistent messenger if he was wrong, but the surgeon did know Steinerman was usually right, so he had asked what the surgi cal nursing crew and the anesthesiologist, Doctor Larry Capaci, be called in for emergency surgery. When Ca paci went to put the breathing tube into his trachea, the sphincter at the lower end of the esophagus – a circular muscle acting like a valve holding the stomach contents in place – suddenly relaxed. A Yellow stone Geyser of Pepsi Cola suddenly gushed up his esophagus under carbonated force, flooding his airway. Capaci scrambled to find the trachaea trying to place the breathing tube to secure the airway, but there was too much foam, and the suction machine gave out, as it always does in emergencies. Resistant organisms emerged, the bacteria proliferated exuber the Rape of Emergency Medicine Page 193 antly, and within a week the Fay boy succumbed. Weasel was a natural outgrowth of the frenetic growth of emergency medicine contract development. Weasel was of that species known as the “weasels,” a species of the genus “suits,” a virulent subspecies, far from endangered, and a rapidly-proliferating form of miscreants in the world of emergency medical care. First of all, he referred patients to daytime col leagues bypassing the on-call list. Weasel carefully worded the chart (“ and the patient specifically requests by name, Doctor [Cro] “) so that he could use chart wars in defense of Cro in case the other gastroenterologists started a shit war with Cro. The same went for the selected urologist from the correct synagogue receiving obstructed bladders in some very desper ate, fidgety men (piss wars), and the orthopedist, quite grateful to win a daytime broken-hip (war) in an osteoporotic Medicare gal. Spit wars were uncommon, simply a peacock show of feathers, since most of the pulmonologists were too overburdened to be bothered. The phenomenal financial success of the careerist “managers” went the Rape of Emergency Medicine Page 195 unchallenged, in part, because of the kitchen scheduling fee of the relaxed "suits" was kept top secret, especially from the primary care doctors. Weasel ensconced himself by forming a daytime misalliance with the heavy-hitting players performing pricey, big-ticket procedures – the cardiologist, gastroenterologist, orthopedic surgeon, and urologist from the correct temple – and was able to achieve the status of the referring general practitioner. Weasel skimmed a cool, seventeen thousand dollars a month after expenses for kitchen scheduling one emergency room along with the false pretense of “quality assuring” and “risk managing” the single emergency room – not seventeen hundred, but seventeen thousand dollars a month after expenses for “managing” one hospital – and Weasel received cases of wine and scotch over the holidays to boot. The night-time shifts were covered by the other two “future part ners,” local moonlighting residents, and a few of the young, recently graduated, residency-trained, emergency physicians. These grabby non-nocturnal weasels also saw the value of an institu tion like the American Academy, many of them were quite active in it. It was no secret there were many weasels sucking in seventeen grand a month for kitchen scheduling one emergency room. They made it known they would drop out of the Academy, refusing to pay the dues money of the residents who worked for them if the Acad emy ever questioned their modus operandi. Steinerman was unaware when he got that first call from Weasel that the Rape of Emergency Medicine Page 196 Weasel was desperate to fill in the blanks because he was getting rid of the two “partners. Weasel asked Steinerman to work many daytime shifts because Weasel realized, like so many of his ilk, that he lost money every day he was in the emergency room actually seeing and treating patients. Patient care had to be turned into a sideline while he was out and wheeler dealering, particularly finding appropriate “scrubs” to see the pa tients, and then shortchanging them by taking his handsome cut out of their fees. When Weasel became more active in his extracurricular activities, he gave Steinerman his day shifts more often. He rapidly became com pletely uninterested in seeing patients at all, something quite com mon with the “suits.

This is a grave condition and results from infection which has taken place during labor or afterward symptoms knee sprain purchase 5mg compazine visa. The septic matter may be carried in on the fingers or instruments by the physician or attendants medications without a script compazine 5 mg low price, etc medicine allergies proven 5mg compazine. The attack is usually ushered in during the second to the fourth day by a chill medicinenetcom best order compazine, or chilly sensations treatment 7 cheap compazine online visa, etc medicine 029 order compazine with amex. The discharge may be increased at first, but later diminished and may cease; or it may be abundant, frothy and of a very fetid odor. Secretion of milk may fail, the bowels are usually constipated, pain in the abdomen develops. Hot and cold sponging may be given to reduce the temperature, a little alcohol can be added to the water or the cold or hot pack may be used. From one to two ounces of whisky may be given every three to four hours in the form of milk punch and, if possible, as much red or port wine also. Place the patient in a hot water or vapor bath, or wrap blankets wrung out of hot water around her, and pile the bedding on until a profuse sweat is started. Chloral hydrate in thirty to sixty grain doses in three ounces of water may be injected into the rectum if the other remedies fail. It usually arises from an extension of a blood clot (thrombosis) of the womb or pelvic veins, to the thigh (femoral) vein, resulting in a partial or complete obstruction of the vein. These are general feelings of weariness, stiffness and soreness of the leg, especially when it is moved. There may first be pain in the region of the groin; or pain from the ankle to the groin and followed by swelling. Later there is pitting on pressure, but not at first, because the skin is extremely stretched. Fever may accompany the attack, but it will subside long before the swelling of the leg has disappeared. The vein may be felt as a hard lash-like cord, a red line of inflammation marking its course along the inner and under side of the thigh. Absorption of the clot takes place, or the vessel remains closed, and another (compensatory) circulation is established. The following is a good lotion:- Compound Soap Liniment 6 ounces Laudanum 1-1/2 ounces Tincture Aconite Root 1/2 ounce Tincture Belladonna 1/2 ounce Wet the flannel or cotton with this. After the acute symptoms have passed the following ointment may be put on the leg:- Ichthyol 45 grains Iodide of Lead 45 grains Chloride of Ammonium 10 grains Alboline 1 ounce the parts should not be rubbed lest a clot be loosened and travel in the general circulation and thus endanger life. Count back three months from the first day of the last menstruation and add seven days to the date thus obtained. To be more accurate, you should add only six days in the months of April and September, five days in December and January, and in February four days. It is a motion, of the foetus (child) in the womb, imparted to the abdominal walls, and is felt from the sixteenth to the twentieth week. So that the woman will know how to live properly, and also that he will be given the urine twice each month to examine. This is for her protection and is necessary, because anything that may be wrong with the kidneys can be corrected much easier, and diet, etc. Constipation is frequently present and the diet must be chosen with reference to that also. The pores of the skin should be kept open so that the kidneys will have less work to do. This promotes the proper circulation of the blood, favors rest and sleep, relieves the "blues," tones the whole system, gives her good wholesome air and makes everything look better. She should not ride a horse, run, jump, dance, or do any jerky or violent exercise; no heavy lifting or reaching up. Garters and corsets are injurious, especially when the pregnancy has reached four or five months. The Roman women were accustomed to wear a tight girdle about their waists which was called a cincture. The term enciente is derived from this, and is frequently used to indicate pregnancy. There are premonitory symptoms such as bearing down feeling in the pelvis, backache, frequent desire to pass water, a discharge from the vagina, and sometimes a little bloody flow. Diseases of the womb, disease in the father, constipation, falls, over-exertion, violent emotions, such as shock, fright, anger, blows on the abdomen, over-lifting, reaching up, sewing on machine. The nipple, if much drawn in and small, should be "pulled out" once or twice daily. It will do to rub sweet oil on the breasts every evening in order to relieve the tightness and discomfort, especially after the pregnancy has advanced some months. Not if it makes her very nervous; but toothache can cause more harm from a diseased tooth than if it were treated carefully. The enlarged womb presses upon the veins and thus obstructs the return flow of the blood. The woman should lie down a good part of the time if possible, and also wear a perfectly fitting elastic stocking. Some women claim it does; it certainly puts the muscles in better condition and strengthens the muscles of the abdomen which have so much part in the labor. No, but the food should be as concentrated as possible; egg-nog, ice cream, a bit of rare steak, etc. It is caused by the womb sinking down lower in the pelvis the last month, and this lightens the pressure upon the diaphragm and lungs. They occur during the last few weeks of pregnancy at irregular intervals and are usually in the abdomen. The "show" pains begin generally in the back and are quite regular, one every twenty minutes or half hour. Yes, generally a few ounces, then it begins to gain at the rate of four to six ounces each week. The first day the baby is deaf, but his hearing develops and becomes very acute so that he is very much disturbed by sudden, sharp noises. At six months of age the fontanelle is somewhat larger than it was at birth because the brain expands faster than the boney matter deposited around the edges in the skull bones. After this another deposit of bone goes on more rapidly than the growth of the brain substance, and by sixteen or eighteen months the opening should be entirely closed. The head and face should be washed first and dried; then the body soaped and the infant placed in the tub with its head and body well supported by the hands. The bath should be given quickly with no special rubbing, drying with a soft towel. In the case of infants who are delicate and feeble, when the bath seems to harm them; in all forms of acute sickness, unless the bath is directed. In eczema and many other forms of skin diseases a great deal of harm is often done by soap and water or water baths. If possible the bath should be given in front of an open fire, in a room where the temperature is from seventy to seventy-two F. A folding rubber bath-tub is the best, next a papier-mache one; or if tin must be used, put a piece of flannel in the tub to protect the baby from the tin. Use for a dusting powder one part of salicylic acid and nineteen parts of starch on it. Usually when the foreskin is very long and very tight, so that one must use force to push it back, and always if it produces local irritation. Use good absorbent cotton and warm water, with a solution of boric acid if necessary, about two teaspoonfuls to a pint of warm water. Yes, and it needs to be loosened and kept so, or it will produce irritation and sometimes convulsions. The foreskin should be pushed back and the parts washed with absorbent cotton and water. Should redness and pus appear in the eye or eyes a few days after birth, what should be done? If the sore eyes are severe send for a physician as it may be the beginning of ophthalmia neonatorum. The folds between the gums and lips and cheeks may be gently and carefully cleaned twice a day unless the mouth is sore. Babies who suck a "pacifier" or a rag with sugar in it are very apt to have the disease. Yes, but the mother should thoroughly cleanse her nipple with a solution of boric acid after each nursing. It should be washed before and after every feeding with a solution of baking soda or boric acid of the strength of one even teaspoonful to twenty-four teaspoonfuls of water, or listerine, one teaspoonful to twenty-four teaspoonfuls of warm water, can be used. The hair should always be dried carefully; brush first with a soft towel and then with a fine, smooth hair-brush. No, for if the hair is washed and brushed, the oil from the scalp will keep it soft, glossy and healthful. It is an inflammation of the mouth where small particles looking like milk curds appear on the tongue, gums and cheek. Uncleanness, failing to keep the mouth-especially of bottle fed infants-and the nipples and bottles, clean. Thrush is parasitic in origin and is always due to uncleanness in bottles, nipples and the mouth, and is commonly associated with the stomach trouble. Boric acid in a saturated solution (five teaspoonfuls to a pint of distilled water) is a specific for it. Use a piece of absorbent cotton or soft linen on your little finger or small round piece of wood and dip in solution and apply. One teaspoonful of boric acid or baking soda to a pint of boiled water is usually sufficient; wash after each nursing or four or five times a day. Powdered Borax 1 teaspoonful Powdered Sugar 4 teaspoonfuls Put a pinch on the tongue every two or three hours. Apply gently to the inside of the mouth several times a day in thrush or any form of sore mouth or gums. It should be removed as soon as it is wet and placed in a covered pail in the bathroom, etc. Pure white soap only should be used, and the diapers should be thoroughly rinsed and boiled. No; it may be too acid, alkaline, too little of it or too concentrated, or have sand in it. The snug bands, flannel or knitted should be worn, not tight, three months; then if one is worn it should be loose. No, because they confine the dampness cause more sweating of the parts and may thus cause chafing, etc. They may be different sizes, eighteen by thirty-six inches, twenty-two by forty-four, or twenty-seven by fifty-four. A wet diaper left on too long; not drying the folds of the flesh properly; too much and too strong soap in the bath, or in the diapers when they are washed, or failure to wash the child clean. Use very little soap; no strong soap; rinse the body carefully; dry thoroughly after rinsing; use clean diapers; use dusting powder in the folds of the flesh, especially in fat babies. Place one pint of wheat bran in coarse muslin or cheese-cloth bag and put this in the bath water. Do not use any soap, and give only bran or salt baths or use pure olive oil and no water at all on the chafed parts. Keep a little piece of soft linen between the folds of the flesh, so they will not be irritated by rubbing together. This is the most common place for chafing, as it is so frequently wet and soiled; hence all napkins should be renewed as soon as wet and soiled and the parts always kept perfectly clean. Fine, red pimples appear, caused by excessive sweating and from irritation of flannel underwear. The entire body sponged frequently with vinegar and water (equal parts) and plenty of starch and boric acid powder used; starch, two parts; boric acid (one part) should be put on. The chest should be well covered with soft flannel, the limbs protected, but not cramped, the abdomen supported by a band, not too tight. It protects the abdomen, but its main use is to support the abdominal walls in very young infants and thus prevents rupture. Then in healthy infants a knitted band may be used and worn up to eighteen months. If the baby is thin and the abdominal organs are not protected by fat, they may be troubled with diarrhea and need protection. Of course this can be less or more elaborate, according to the conditions and circumstances of the parents, etc. The thinnest gauze flannel undershirts should be worn, the outside garments to be changed for the changing weather. They should not be kept too hot in the middle of the day, while in the morning and evening extra wraps should be used. There is no objection, if they are strong and well, to doing this in warm weather. Not as a rule, as they usually live in the nursery and they sweat readily while playing. In the winter he should sleep in a flannel nightdress and this can be made with a drawing string or button on the bottom so that he cannot expose his feet. In the summer he can wear a cotton night-dress and after the third month the skirt may be left off in very warm weather. By the time baby has entered his second month he may wear simple little "Bishop" dresses instead of his plain slips. At the end of the third month, the flannel band may be discarded, usually, and a ribbed knitted one used.

Statement from the Clinical Effectiveness Unit: Combined Hormonal Contraception and Venous Thromboembolism treatment plant order compazine mastercard. Low dose oestrogen combined oral contraception and risk of pulmonary embolism medicine expiration dates 5mg compazine amex, stroke medications used for adhd purchase compazine 5 mg online, and myocardial infarction in five million French women: cohort study treatment zone lasik discount compazine 5 mg. Trends in the incidence of venous thromboembolism during pregnancy or postpartum: a 30-year population-based study medications during childbirth order genuine compazine on-line. Combined Hormonal Contraceptives and Venous Thromboembolism: Review Confirms Risk is Small medicine etodolac purchase compazine 5 mg overnight delivery. Physical activity and changes in weight and waist circumference in midlife women: findings from the Study of Women’s Health Across the Nation. Increased visceral fat and decreased energy expenditure during the menopausal transition. Combined oral contraceptives: the risk of myocardial infarction and ischemic stroke. Risk of acute thromboembolic events with oral contraceptive use: a systematic review and meta-analysis. Haemorrhagic stroke, overall stroke risk, and combined oral contraceptives: results of an international, multicentre, case-control study. Reproductive history, oral contraceptive use, and the risk of ischemic and hemorrhagic stroke in a cohort study of middle-aged Swedish women. Cardiovascular risks associated with the use of drospirenone containing combined oral contraceptives. Association between the current use of low-dose oral contraceptives and cardiovascular arterial disease: a meta-analysis. Breast cancer and hormonal contraceptives: collaborative reanalysis of individual data on 53 297 women with breast cancer and 100 239 women without breast cancer from 54 epidemiological studies. Oral contraceptive use and risk of breast cancer: a meta-analysis of prospective cohort studies. Familial breast cancer: collaborative reanalysis of individual data from 52 epidemiological studies including 58,209 women with breast cancer and 101,986 women without the disease. Risk of breast cancer with oral contraceptive use in women with a family history of breast cancer. Oral contraceptive use and risk of breast cancer among women with a family history of breast cancer: a prospective cohort study. Cervical cancer and hormonal contraceptives: collaborative reanalysis of individual data for 16,573 women with cervical cancer and 35,509 women without cervical cancer from 24 epidemiological studies. Contraceptive failure in the United States: estimates from the 2006–2010 National Survey of Family Growth. Pregnancy after fifty: profile and pregnancy outcome in a series of elderly multigravidae. Spontaneous perforation of a pyometra in a postmenopausal woman with untreated cervical cancer and “forgotten” intrauterine device. Hip prosthesis infection related to an unchecked intrauterine contraceptive device: a case report. Ureteral obstruction associated with pelvic inflammatory disease in a long-term intrauterine contraceptive device user. Actinomycosis in a 70 year old woman with a forgotten intrauterine contraceptive device [Article in Icelandic]. Incidence of ovulation in perimenopausal women before and during hormone replacement therapy. Intrauterine 10mg and 20mg levonorgestrel systems in postmenopausal women receiving oral oestrogen replacement therapy: clinical, endometrial and metabolic response. Intrauterine release of levonorgestrel – a new way of adding progestogen in hormone replacement therapy. Intrauterine administration of levonorgestrel 5 and 10 mg/24 hours in perimenopausal hormone replacement therapy. Transdermal estrogen with a levonorgestrel releasing intrauterine device for climacteric complaints: clinical and endometrial responses. A 5-year follow-up study on the use of a levonorgestrel intrauterine system in women receiving hormone replacement therapy. Percutaneous estradiol gel with an intrauterine levonorgestrel releasing device or natural progesterone in hormone replacement therapy. Below is the list of contributors involved in the development of this clinical guideline. Dr Nelson declares the following interests: Grants/Research: Agile, ContraMed, Bayer, Merck; Honoraria/Speakers Bureau: Allergan, Aspen Pharma, Bayer, Merck; Consultant/Advisory Board: Allergan, Agile, Bayer, ContraMed, Intrarosa, Merck. The evidence identified up to this point was used to develop the first draft of the guideline. Search strategy: the literature search was performed separately for the different sub-categories covered in this clinical guideline. Articles identified from the search were screened by title and abstract and full-text copies were obtained if the articles addressed the clinical questions relevant to the guideline. Studies that did not report relevant outcomes or were not relevant to the clinical questions were excluded. The highest level of evidence that may be available depends on the type of clinical question asked. A body of evidence including studies 2++ High-quality systematic reviews of B rated as 2++ directly applicable to the case-control or cohort studies or target population and demonstrating high-quality case-control or cohort overall consistency of results; or studies with a very low risk of Extrapolated evidence from studies confounding, bias or chance and a rated as 1++ or 1+. Well-conducted case-control or A body of evidence including studies 2+ C rated as 2+ directly applicable to the cohort studies with a low risk of confounding, bias or chance and a target population and demonstrating moderate probability that the overall consistency of results; or relationship is causal. This will typically be where some aspect of treatment is regarded as such sound clinical practice that nobody is likely to question it. Recommendations where consensus is not reached will be redrafted in light of any feedback. If consensus is not reached on certain recommendations, these will be redrafted once more. Any group member who is not content with the decision can choose to have their disagreement noted within the guideline. Updating this guideline Clinical guidelines are routinely due for update 5 years after publication. The decision as to whether update of a guideline is required will be based on the availability of new evidence published since its publication. Updates may also be triggered by the emergence of evidence expected to have an important impact on the recommendations. She states that her periods have become more irregular and heavier over the past year. The progestogen-only implant should be stopped at age 50 as the risk of pregnancy is extremely low. Women over 40 using the progestogen-only injection should be counselled regarding use of alternative methods of contraception as there are safer methods that are equally effective. Auditable outcome Target the proportion of women over 40 who have a sexual history/sexually transmitted 97% infection risk assessment prior to intrauterine contraception provision. The proportion of women over 45 attending to discuss contraception who are 97% provided with information on the symptoms and treatment of common sexual issues associated with perimenopause and menopause. The proportion of women using hormonal contraception over 50 who have 97% received advice on when to stop their contraceptive method. The proportion of women over 49 using combined hormonal contraception who 100% have discussed a switch to an alternative, safer method. Robinson Kurpius2 Abstract: this study investigated the relationship of two contextual variables (the marital relationship and stress) with the experience of menopause for 224 married midlife women. These women completed the Dyadic Adjustment Scale, the Quality of Relationship Inventory, the Women’s Health Questionnaire, the Index of Sexual Satisfaction, and the Life Events Questionnaire for Middle-Aged Women. Marital quality, marital satisfaction, and stress predicted menopausal symptomatology. Women in dissatisfying marriages, characterized by less social support, less depth, and higher conflict, reported increased stress and more meno pausal symptomatology than did women in satisfying marriages. These findings suggest that relationship variables may override menopausal status in importance as midlife women move through the menopausal transition. Casamento, stress e menopausa: Desafios e prazeres da meia-idade (resumo): Este estudo investigou a relação de duas variáveis contextuais (a relação conjugal e o stress) com a experiência de menopausa em 224 mulheres de meia-idade, casadas. As mulheres responderam à Dyadic Adjustment Scale, Quality of Relationship Inventory, Women’s Health Questionnaire, Index of Sexual Satisfaction e Life Events Questionnaire for Middle-Aged Women. A qualidade conjugal, a satisfa ção conjugal e o stress permitiram prever a sintomatologia menopáusica. As mu lheres com casamentos insatisfatórios, caracterizados por menos suporte social, menor profundidade e maior conflito, referiram um aumento de stress e mais sintomatologia menopáusica do que as mulheres com casamentos satisfatórios. From a biomedical perspective, the menopausal process is depicted as the deterioration of women’s ability to reproduce. Other factors, however, are integral to the menopausal transition, and more than just biological chan ges need to be considered when trying to understand how women experience menopause. This study examined how contextual variables in a woman’s life are related to her experience of menopause. Although several contextual factors can affect adjustment to menopause, of interest in the current study were the marital relationship and stress. Increasingly, researchers have demonstrated that it is not just being married but the quality and interactions within the marriage that positively or negatively influence the physical and mental health of spouses. In a survey of 1004 couples, Schmoldt, Pope, and Hibbard (1989) reported a positive relationship between cohesive, cooperative, and companionable marriages and the general health and well-being of marital partners. Similarly, Levenson, Carstensen, and Gottman (1993) found that couples in satisfying marriages had better physical and psychological health than those in dissatisfying marriages. For couples who reported being dissatis fied, the wives had significantly lower levels of both physical and psycho logical health than their husbands. Even in earlier research (Gove, Hughes, & Briggs-Style, 1983), being unhappy in one’s marriage was found to be more detrimental to one’s psychological well-being than being single, divorced, or widowed. Marital relationship quality has emerged as an important contextual variable needing to be considered when studying women’s lives. In studies of women with breast cancer, the buffering effects of a supportive marital relationship in the adjustment processes have been demonstrated (Gove, Briggs-Style & Hughes, 1990; Hibbard & Pope, 1993; Hoskins et al. Even more significant is the research reporting the negative impact of unhappy marriages on women’s health (Fielder, 1998; Manne & Zautra, 1989; Roth-Roemer & Robinson Kurpius, 1996; Spiegel, Bloom, & Gottheil, 1983). Although menopause is a life transition and not a disease, it has strong health-related components. For example, research has shown that women in unhappy marriages experience more menopausal symptomatology such as sleep disturbance and vasomotor problems (Robinson Kurpius et al. Research by Kiecolt-Glaser and colleagues (1993) sheds light on the biological effects of being in a conflictual relationship. They found T-cell suppression and impairment of immune system functioning during negative and hostile marital interactions. It is evident from their findings that relationships wrought with tension and conflict may have a particularly negative impact on women’s health and well-being. Another aspect of a marital relationship related to women’s expe riences of menopause is sexual satisfaction. It is widely assumed that bio logical components, especially the naturally occurring depletion of hormo nes that signify the onset and course of menopause, are largely responsible for changes in midlife women’s sexual behavior and satisfaction (Abernethy, 1997). There is, however, evidence that midlife women’s sexual functioning and satisfaction are influenced by psychosocial considerations as well (Channon & Ballinger, 1986). Mansfield, Koch, and Voda (1998) found that sexual difficulties during peri-menopause may stem more from dissatisfying marital relationships than from the physical symptoms concomitant with menopause. While 60% of their women did not report changes in their sexual responsiveness due to menopause, they did identify qualities of their relationships that they would like to change, including improved passion, more romance and affection, and better com munication. Midlife women’s sexual satisfaction may also be related to their menopausal status. Studying menopausal status, menopausal symptoma tology, and various aspects of sexual functioning in midlife women, Cawood and Bancroft (1996) reported that hot flashes, night sweats, vagi nal dryness, and reduced interest in sex were each significantly correlated with menopausal stage, with post-menopausal women reporting the worst symptomatology. No relationship, however, was established between menopausal status and frequency of sexual intercourse, pain during inter course, and frequency of sexual thoughts. Interestingly, the women who identified themselves as being satisfied with their marriages reported fewer menopausal symptoms related to sexual functioning than did those who were less satisfied. In addition to studying the interaction of marital quality with the experience of menopause, it is also important to take into consideration the sexual component of the marital relationship. A second contextual variable that may be related to the experience of menopause is stress. Stress is often credited with causing hot flashes, a commonly reported and often distressing menopausal symptoms (Vliet, 1995). Swartzmann, Edelberg, and Kemmann (1990) challenged this causal assumption when they found that women were not more likely to report hot flashes following several stressors than they were at the beginning of a session designed to elicit a stress response. They found that post -menopausal women, as compared to pre-menopausal women, exhibited increased cardiovascular responses to behavioral stressors and that meno pausal status interacted with the nature of stressors to moderate the stress response. It is, therefore, important to consider the nature of the stressors when studying stress and menopausal symptomatology. Stressors, particularly those heightened by relationship variables, may play an important role in midlife women’s lives. In the early 1980s, Greene and Cook conducted two studies examining stress and menopausal symptomatology. In the first study, Greene and Cooke (1980) found that while women may experience increased menopausal symptomatology across the climacterium, the severity of symptoms was directly related to life stressors, not to menopausal status.

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