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T he purpose of this illustration generic cialis professional 20 mg free shipping, then order 40 mg cialis professional with visa, and o f the other illustrations in this section order cialis professional without a prescription, is not to dem onstrate that al­ lopathic medicine is wrong purchase cialis professional 40mg on line, but rather that it is fallible. T he work o f Johnson and Moss with radiation photography sug­ gests that there is a “life” or “energy field” surrounding the hum an body. This fact alone, if convincingly established, will not repudiate allopathic theory. But it will be evidence that there is a newly discovered phenom enon—the energy field—which m ight serve as an indicator for use in diagnosis and healing. T here no longer is m uch doubt that it works —doubts are only expressed about how it works. This is ironic, since there is no generally accepted theory of anes­ thesia in allopathic practice. Andrew Weil, a physician and drug researcher, describes the anomaly: alth o u g h anesthesia has been a ro u n d fo r over a h u n d re d years a n d alth o u g h m illions o f persons have been p u t into th e state u n d e r close observation, no satisfactory theory o f g en eral anes­ thesia exists; doctors have no idea w hat these d ru g s do to th e brain that accounts for th e state. In part, it is attributable to the inflexibility of allopathic prac­ The Varieties of Medicine 65 tice, its intolerance of inconsistencies. This is not surprising since all paradigm s—and allopathy is a rigid paradigm —elicit extraordinary loyalty. In tests perform ed at the M enninger Clinic in Kansas, Chief Rolling T hunder, a Shoshone medicine man, was asked to “cure” a contusion on a subject’s leg. He placed his m outh over and around the bruise, sucked vigorously, then dashed to the opposite side of the room and vomited. T he bruise disappeared at roughly the same time that the scientists in the room rushed to retrieve the vomitus. T o the scientists, the “cure” could only have been effected if the dam aged tissue in the bruised leg had somehow been physically extracted. O f course, it was not removed in the sense in which the scientists could have understood it. To the subject and the Chief, the sucking and the vomiting were elements of dram a underpinning a belief system—a belief that a cure could be achieved. T he two groups perceived the episode differently, and the explanation for the cure may lie in this perceptual difference. A cupuncture practice is inconsistent with W estern medical theory in several ways. T o begin with, for an operation to be perform ed on any part of the anatomy, acupuncture needles may be placed in different parts o f the body for different patients. In one hospital the needles might be inserted into the forearm s, while in a second, the placement points might be the neck and the ankles. Accord­ ing to the allopathic theory of pain—the specificity theory —this makes no sense. U nder allopathic theory, specific points in the body receive and transm it signals to the brain. T he theory dictates that the person will experience pain precisely at the point o f the stimulus. The manipulation of acupuncture needles is designed to restore harm ony to the body. In both 1971 and 1972, the American Academy of Parapsychology and Medicine sponsored interdisciplinary symposiums respec­ tively entitled “The Varieties of Healing Experiences: Exploring Psychic Phenom ena and Healing,”52 and “T he Dimensions of Healing: A Symposium. Two of the m ore fascinating, but problematic, reports feature Arigo, a natural healer from Brazil, who is now dead; and bodily control m anifested by the Swami Rama, an Indian yogi who dem onstrated his yogic training program under carefully controlled laboratory conditions at the M enninger Founda­ tion clinics. Arigo, an uneducated natural healer, saw thousands of patients in the course of his work. His diagnostic skills were carefully m easured against diagnosis rendered for the same patients by allopathic physicians, and com pared well with them. Arigo generated his diagnosis without the use of sophisti­ cated technology, largely on the basis of visual scans of a patient. A lthough he utilized some m odern techniques such as drugs, and occasionally perform ed surgery, his repertoire also included surgical repair without the use of any equipm ent. U nder similarly controlled conditions, the Swami also dem onstrated his ability to stop his heart from beating. After he was “wired” for the dem onstration and told to proceed, the electrocardiograph records re­ flected an increase in heart rate from 70 beats per m inute to about 300 per minute. T he experim enters had expected the heart rate to stop altogether and thus thought that the ex­ perim ent had been a failure. A fter a final examination of the records, the investigators concluded that the Swami had stopped his heart for at least 17 seconds. The growing literature on biofeedback contains unmistakable implications for self-care. A lthough we have achieved an e x trao rd in ary am o u n t o f sophistication in d ru g an d surgical th erap y in w estern m edicine, this developm ent has been a bit unbalanced. W e have alm ost forgotten th at it is possible for th e “patien ts” themselves to learn directly to low er th eir blood p res­ sure, to slow o r speed th eir heart, to relax at will. Stoyva and Budzynski have been investigating the use o f biofeedback to “decondition” or “desensitize. If an individual can be trained to exercise control over some bodily functions, self- healing and self-restoration are possible. The evidence assembled thus far suggests that everyone can “learn” to exercise some degree of control. T he psychic surgeon appears to perform surgery without instrum ents and can, in certain instances, penetrate the body wall with his hands. T he film I have seen, to be com­ prehended, requires a m ajor widening of perceptual gates. T here are explanations o f the practice based on theories relating to the “astral” or “spirit” body. These are ill-defined concepts, but they are in the same family o f concepts as the “energy” field or “field of m ind” theories. I return to this subject later, to discuss how the efficacy of the surgery, if there is any, is related to the patient’s and the healer’s belief in its efficacy. Jerom e Frank in Persuasion and Healing,60 a thought­ ful and provocative examination of the arts of healing, in­ cludes many illustrations. Frank also devotes attention to the healing power of shamans, particu­ larly in the American Indian tradition. A dherents o f yoga and m editation have also advanced The Varieties of Medicine 69 argum ents for the use of these practices in healing. Studies examining the physiological impact o f Hatha yoga reveal that yoga practitioners experience weight loss; significantly improve their respiratory functions, principally through lowered rates of respiration; increase their vital capacity and breath-holding ability; and develop resistance to physical stress. Carl Simonton has made efficacious use o f meditative techniques in the treatm ent o f cancer pa­ tients. Simonton first teaches his patients how to meditate and then instructs them about their disease process and the means by which the body’s natural immunities resist the cancer. He then asks them to m editate on the disease process and the “attack” on the disease by the im m une system. It sounds simplistic and perhaps it is, but according to Simonton, for those patients who use meditation the prognosis is roughly twice as favora­ ble as it is for another patient population matched for de­ mographics, severity of disease, and attitude. Prior to the nineteenth century, a traditional system of medicine was exclusively practiced in China. In the nineteenth century, W estern medicine was introduced to China by missionary doctors who founded both medical schools and hospitals on the W estern medical 70 Medicine: a. Over ensuing decades the two systems of medicine com peted for the loyalty of both the governm ent and pa­ tients. Today, both systems o f medicine practice side by side—it is called “walking on two legs” by the Chinese. The W estern model is superior in surgical technique, in achieve­ m ent o f hygienic conditions, and in the treatm ent of infec­ tious diseases that respond to antibiotics. Chinese practice is m ore efficacious in the treatm ent o f diseases that are chronic, degenerative, and psychosomatic; precisely those diseases that are the least affected by medical practice in this country. T he most reflective healers, whether physicians, natural healers, or chiropractors, acknowledge this.

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The consistent assessment of capacity in this regard and efforts to facilitate a patient’s decision is fundamental to protect their autonomy and best interests discount cialis professional uk. A Guide To Professional Conduct and Ethics for Registered Medical Practitioners buy discount cialis professional 20 mg on line, 7th Edition cheap 20 mg cialis professional with visa. The fact that over 13% of total Irish psychiatric admissions are aged 65 years and over speaks to the need to further develop old age psychiatry services order cialis professional 40mg visa. Administrative numbers expand with increasing bureaucratisation of health services. Other factors promoting discharge included state payments for the unemployed, public housing, and the development of primary care. It also influenced number of involuntary admissions, with an upward trend despite less available beds. We must achieve a selfless balance to avoid returning to the equivalent of the Victorian buildings that were built when labour and life were relatively cheap. However, an institutional basis form negative symptoms (clinical poverty syndrome) is questioned by findings that such symptoms persist for at least nine years after post- discharge. Tooth and Brooke (1961) predicted that of all the longstay patients in 1954 none would remain by 1970. They also said that all the needs of the mentally ill (except the mentally retarded) could be provided for with a bed ratio of 180/100,000 population. Private registered homes, wherein the mentally ill discharged from hospital may be placed, were likened to the original private madhouses. Planning for the Future planning norms (Trant Report) Sector size: 25-30,000 Day care places: 0. Hickey ea (2003) recommendations 66 day care places per 35,000 of the population, 11 being day hospital places and 55 being day centre places There is great variation in the provision of both day hospital and day centre places across Ireland, some areas providing services way below the optimum. Hostels for the homeless may become repositories for unmedicated actively psychotic patients. Penrose’s Law (after Lionel Penrose who discussed this phenomenon in 1939) = as number of psychiatric inpatients fall, number of prisoners rises. The move from asylum care has expanded the range of social ills viewed as being ‘psychiatric’. Within two years the population of mental hospital began to fall after rising steadily in most industrial countries for 150 years. The English hospitalisation rate in 1986 was 128/100,000 and the number of beds was reckoned to be dropping by about 4,000 per annum in early 1993. Comparative number of psychiatric beds per 1,000 population (Walsh & Daly, 2004) 1961 2001 Republic of Ireland 7. High rates were also associated with old age, single male and unskilled worker status. One-quarter of alcohol- and the same fraction of substance-dependence admissions were for less than 7 days, whereas as the same fraction of depressives were in hospital for 1-3 months. There was a large disparity in rates of bed/100,000 in 2001 between different health board areas (range 271. For the first time, 2003 saw admissions to general hospital psychiatric units (44%) surpass those to psychiatric hospitals (38%). Britain, especially its cities, has had to deal with culturally diverse groups presenting with psychiatric difficulties for much longer. Among the reasons cited for such high bed occupancy rates (125% in 1997) in London are concentrations of ethnic minorities with a high incidence of psychosis, unemployment, social isolation and deprivation, and homelessness. There is a great need to develop readily accessible interpretation services (incl. The Inspector of Mental Health services emphasised that psychiatric units in general hospitals had still not replaced some large psychiatric hospitals in 2008. Recommendations for such a move date at least to the Commission of Enquiry on Mental Illness in 1966 but the idea is much older having been broached by Conolly Norman (1853-1908) of the Richmond Asylum in Dublin in 1904. Longer stays in private facilities but more readmissions in health board hospitals and general hospital psychiatric units (72%) than in private units (59%). Schizophrenia admissions = 9%, 20% and 23% to private, general hospital, health board respectively. The number of approved posts at senior/specialist registrar level on 1/2/2002 = total 30 (general adult, 14; child/adolescence, 7; old age, 4; intellectual disability, 2; and 1 each for substance misuse, forensic, & rehabilitation). Consultant/population ratio varied from 1/9808 in East Coast Area Health Board (this includes St John of God private sector) to 1/18154 in North-Eastern Health Board. There were 10 permanent part-time consultants and 60 approved non-permanent consultants. Comhairle na nOspideal (2004a): 5 additional consultant posts were approved in 2003. Consultant/population ratio varied from 1/10,360 in Northern Area Health Board to 1/18136 in Southern Health Board. There were 14 permanent part-time consultants and 53 approved non-permanent consultants. The percentage net increases per specialty during 1993-2003 were emergency medicine 292, pathology 81, radiology 72, general medicine 70, paediatrics 68, psychiatry 47, surgery 35, and obstetrics/gynaecology 20; the average increase was 56%. Comhairle na nOspideal (2004b): The recommended number of posts were: general adult 1/25,000; special interest [s. Irish College of Psychiatrists (2005) Funding on mental health services accounted for just 6. Medical Council (2007) 3241 All admissions rate = 701/100,000 aged 16 years or over; first admission rate = 195. Half, 32%, and 19% of all admissions were to general hospital psychiatric units, psychiatric hospitals (incl. Admissions M = F, but rate of all admission higher for F and rate of first admission higher for M. Cause of all and first admissions by diagnostic group as %: depressive (28, 31), schizophrenia (19, 12), and alcoholism (13, 14). Involuntary admissions = 11% of all and 10% of first admissions; only 2% of all private admissions were involuntary. Services should be close to people in need, 3248 and must recognise the needs of special groups, e. A multidisciplinary team approach is employed, although considerable gaps remain in filling posts. There is a tension between sectorisation and the need for individual practitioners to gain expertise in defined areas of general adult psychiatry, i. Society requires education about mental health, mental illness, prevention, and services. Too often all that is offered is a ‘psychosis only’ service because of lack of resources and trained personnel in adequate numbers. It is a truism that, despite a widening demand for different services, that even the richest countries are unable to provide for all requests for assistance. A 2002 Irish survey (O’Keane ea, 2004) found that psychiatric clinical resources were not concentrated where they were needed most; rather they were best developed in the wealthiest areas. Services should ideally be subject to self-audit, research, modification when required, etc. A day centre might provide social activities, company, a cooked meal, possibly a bath and chiropody, but none of the remedial services found in the day hospital. A day hospital is a building to which patients may come, or be brought, in the morning, where they may spend several hours in therapeutic activity and whence they return subsequently on the same day to their own home or to a hostel. In practice, day hospitals rarely perform as an alternative to acute services, and are more likely to provide rehabilitation for patients discharged from hospital or care and treatment for 3246 For comparison, from specialist register: anaesthesia, 320; clinical genetics, 2; geriatric medicine, 53; neurology, 28; neuropathology, 3; neurosurgery, 16; paediatrics, 182; plastic surgeons, 37; rehabilitation medicine, 9. Longstay beds in Irish psychiatric hospitals fell from 11,355 in 1984 to 5,368 in January 1994. Longstay patient accumulation in general hospital psychiatric units became a major problem from the early 1990s with calls for ‘hospital hostels’ to be built for decanting purposes. It has become routine practice now to telephone around asking for the loan of an acute bed. Suffice it to say here that, despite the common belief that tolerance comes with age, it is more often older people who show less tolerance for the mentally ill. Proper information exchange between service providers is important in ensuring care both during and after admission. The care/treatment plan should include a risk assessment and a preliminary discharge plan that includes obstacles to discharge, such as homelessness. Admission consent forms conform with good administrative practice but do not obviate the requirement of consent for specific interventions.

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Severe sepsis & septic shock 72 Handbook of Critical Care Medicine An inoconstrictor has positive inotropic effects on the heart discount 40 mg cialis professional with mastercard, and causes peripheral vasoconstriction cialis professional 20mg otc. An inodilator has positive inotropic effects on the heart buy cialis professional now, and causes peripheral vasodilatation cialis professional 20mg with mastercard. Hence, in septic shock which is vasodilatory shock with generally intact cardiac function, noradrenaline or dopamine should be the drugs of first choice. Noradrenaline is more effective, and is more effective in maintaining renal perfusion, than dopamine, and so is the preferred drug. If the patient has suspected or proven cardiac dysfunction, dobutamine should be added. If there is no response to dobutamine and noradrenaline, consider using adrenaline. Vasopressin is used in patients with refractory septic shock, and is useful as a noradrenaline sparing agent. However, it causes severe peripheral vasospasm and can result in peripheral gangrene. It was earlier believed that dopamine in low doses selectively improves renal blood flow. While this effect is seen in healthy volunteers, there is no evidence that this benefit exists in patients with septic shock. However, clinicians often vouch that dopamine seemed to improve renal perfusion – this is simply because dopamine increases the blood pressure and hence improves renal blood flow. Severe sepsis & septic shock 73 Handbook of Critical Care Medicine There is no logic in using multiple inotropes of similar effect, since in the doses that are used, the adrenergic receptors are usually saturated anyway. For example it does not make sense to combine dopamine and noradrenaline, since noradrenaline is more effective and has the same effect as dopamine. An arterial line must be inserted to monitor the blood pressure whenever possible. Doses must be given in either micrograms per kilogram body weight per minute or micrograms per minute. Note that there is no defined maximum dose, and the maximum dose of any inotrope is that dose beyond which further increasing the dose either does not help to improve the blood pressure, or beyond which side effects manifest. Clinicians sometimes use suboptimal doses, and care should be taken to ensure that adequate doses are given. Drug Dose Dopamine 0-20 micrograms/kg/min Dobutamine 0-20 micrograms/kg/min Adrenaline 0-2 micrograms/kg/min Noradrenaline 0-2 micrograms/kg/min Vasopressin 0-0. Corticosteroids If shock persists despite adequate fluid replacement and inoconstrictors, there may be a place for replacement doses of corticosteroids. Corticosteroids in large doses have immunosuppressant effects, and in the past it was thought that this effect might help modulate the effects of sepsis. However, clinical trials showed that large doses of steroids were of no benefit, and may in fact increase the risk of infections. It was postulated that certain patients with septic shock may have relative adrenal insufficiency, and this was the cause for the lack of effect of adrenergic agents in these patients. Subsequent trials showed that replacement doses of corticosteroids improve haemodynamics and improve survival. The recommended dose of hydrocortisone is 200mg per 24 hours, given either as a continuous infusion or in 4 divided doses. Antibiotic therapy Broad spectrum intravenous antibiotics should be commenced as soon as possible after obtaining two or more blood cultures and other cultures as necessary. Antibiotic therapy should be re-assessed every few days and modifications made based on clinical response, suspected sites of infection, regional antibiotic sensitivity patterns, and results of cultures. Intravenous insulin is preferred, aimed at maintaining the blood glucose below 150mg/dL. Once the patient is stable and taking orally, the infusion could be switched over to subcutaneous insulin given three times daily. There is some evidence that insulin may exert anti-inflammatory effects, and hence, be beneficial in sepsis. Renal replacement therapy Renal replacement therapy is necessary in patients with acute renal failure; this is discussed further in the section on acute renal failure. Either intermittent haemodialysis or continuous renal replacement therapy could be used, and are equivalent in benefit. The choice of dialysis modality is determined by the haemodynamics of the patient; haemodynamically unstable patients cannot tolerate intermittent haemodialysis, and continuous veno-venous haemofiltration is the preferred modality. Bicarbonate administration There is no place for administration of bicarbonate to counteract acidosis or to improve cardiac function in patients with a pH over 7. Possible benefit maybe seen if the pH is lower, however, there is no consensus on this. Intermittent boluses are preferred to continuous infusions, and daily interruption of sedation enables early weaning. Activated protein C Human recombinant activated protein C has been shown in a large multicentre trial to improve survival in patients with severe sepsis and a high risk of death. Severe sepsis & septic shock 76 Handbook of Critical Care Medicine Bleeding is the most important side effect. Correction of haemoglobin and blood product administration Blood transfusion is not recommended unless the haemoglobin drops to 7g/dL. A haemoglobin of over 10g/dL is required only in patients with ischaemic heart disease. Platelet transfusion is 3 required only if the platelet count drops below 5000/mm in the absence of 3 bleeding, and below 30000/mm with active bleeding. Stress ulcer prophylaxis Stress ulcer prophylaxis should generally be given; proton pump inhibitors are more effective than H2 receptor blockers. The above therapies are based on clinical evidence, and contribute to better outcome. Recommendations are based on the Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock 2008. Consideration for limitation of support In spite of the best of care, severe sepsis and septic shock has a high mortality. The patient becomes progressively worse, and generally resistant hypotension develops as a terminal event. Severe sepsis & septic shock 77 Handbook of Critical Care Medicine It is important to discuss severity of illness and possible adverse outcome with the patient’s family, and make sure that expectations are realistic. If recovery seems unlikely, decisions of limitation or withdrawal of support should be considered. Since severe sepsis can suddenly affect previously well patients, this is all the more difficult. Severe sepsis & septic shock 78 Handbook of Critical Care Medicine Evaluating respiratory disease & airway management This section discusses the structure of the respiratory system and how to evaluate respiratory disease, and also deals with how to manage the airway. The respiratory system is divided into two parts – the upper and lower respiratory tract. The respiratory centres are stimulated by hypoxia, hypercapnoea, acidosis, and through various receptors within the lungs. The history, examination and investigations help to identify the abnormality in the respiratory system, diagnose its cause, and fine tune management appropriate to the patient. History Ask for a history of previous lung disease: x Asthma: duration, severity, compliance with medications, severity of exacerbations, previous intubation. Calculate the number of pack years (1 pack or 20 cigarettes for 1 year = one pack year). Has the patient Evaluating respiratory disease 79 Handbook of Critical Care Medicine stopped smoking now? Endocrine diseases: Cushing’s disease results in impaired immunity and increased risk of lung infections. Drug induced lung diseases: x Beta blockers: obstructive airways disease x Methotrexate, amiodarone: lung fibrosis x Corticosteroids and other immunosuppressive agents: increased risk of lung infections Cardiac diseases: valvular and congenital heart disease resulting in cor- pulmonale Previous lung surgery: patients maybe left with reduced lung reserve. Family history: Cystic fibrosis, alpha-1 antitrypsin deficiency, Kartegener’s syndrome, primary pulmonary hypertension Evaluating respiratory disease 80 Handbook of Critical Care Medicine Symptoms and signs Cough: the commonest respiratory symptom. Dry cough is seen in lung fibrosis, certain types of bronchiectasis, and pleurisy. Productive cough with purulent sputum is seen in bacterial infections of the lung. Cough can also be present in upper respiratory infections, such as laryngitis, pharyngitis, tonsillitis, sinusitis with post nasal drip. Sputum: most bacterial infections of the lung cause sputum production, which can be very variable depending on the type and severity of infection.