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By N. Bengerd. California State University, Northridge. 2018.

Others consider it necessary to wait The potential benefits of vasodilator drugs that reduce for a week before SSEPs can predict poor outcome with cardiac afterload must be balanced against their potential certainty discount aspirin 100pills online. In the absence of other reasons to institute palliative care discount 100 pills aspirin with visa, full care should be continued for up to a week Judging the prognosis in patients who remain comatose before making a final evaluation buy aspirin 100pills cheap, especially in otherwise fit after cardiac arrest is fraught with problems buy aspirin 100pills visa. Although fixed patients whose cardiac arrest had been caused by hypoxia rather dilated pupils are worrying discount 100 pills aspirin overnight delivery, they are not reliable as an indicator than by a primary cardiac arrhythmia of outcome aspirin 100 pills low price. Hypercarbia, atropine, and adrenaline 34 Post-resuscitation care (epinephrine) may all cause this sign in the immediate Blood glucose may rise as a stress response, particularly if there post-arrest phase. The absence of motor glucose levels should be kept within the normal range to avoid function at 72 hours has been used as a predictor, but may be the harmful effects of both hyperglycaemia (increase in cerebral affected by residual sedative drugs in the circulation. Adjunct metabolism) and hypoglycaemia (loss of the brain’s major investigations, such as computerised tomography scan, energy source) magnetic resonance imaging, and EEG, may be helpful. However, it may be several days before a CT scan will show cerebral infarction and the EEG may be affected by residual sedation. Biochemical markers such as neutron-specific enolase in blood and cerebrospinal fluid may offer supportive A prolonged period of cardiac arrest or a persistently low evidence of severe brain injury. It may be necessary to consider Metabolic problems haemofiltration for urgent correction of intractable acidosis, Meticulous control of pH and electrolyte balance is an essential fluid overload, or severe hyperkalaemia, and to manage part of post-arrest management. Bicarbonate, with its well- established renal failure in the medium term. In renal failure recognised complications (shift of the oxygen dissociation after cardiac arrest, remember to adjust the doses of curve to the left, sodium and osmolar load, paradoxical renally excreted drugs such as digoxin to avoid toxicity intracellular acidosis, and hypokalaemia), should be avoided if possible. If used, it should be carefully titrated in small doses, using repeated arterial sampling to monitor its effects. Hypokalaemia may have precipitated the original cardiac arrest, particularly in elderly patients taking digoxin and diuretics. Potassium may be administered by a central line in doses of up to 40mmol in an hour. As it has few side effects, magnesium can be safely administered to patients with frequent ectopics or atrial fibrillation without waiting for laboratory confirmation of hypomagnesaemia. Even when the level is normal, the administration of magnesium may suppress arrhythmias. A urinary catheter and graduated collection bottle are necessary to monitor urine output. An adequate cardiac output and blood pressure should produce 40-50ml of urine Further reading every hour. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. Mild hypothermia in neurological A commitment to treat cardiac arrest is a commitment to emergency: an update. The course of circulatory and cerebral generally be managed in an intensive care unit and is likely to recovery after circulatory arrest: influence of pre-arrest, arrest need at least a short period of mechanical ventilation. Early myoclonic status and conscious level does not return rapidly to normal, induced outcome after cardiorespiratory arrest. Predicting longer term neurological outcome in the ● Premachandran S, Redmond AD, Liddle R, Jones JM. Cardiopulmonary arrest in general wards: a retrospective study The initial clinical signs are not reliable indicators. The of referral patterns to an intensive care facility and their duration of the arrest and the duration and degree of influence on outcome. Cardiac arrest and cardiopulmonary resuscitation in post-arrest coma have some predictive value but can be adults. Although not valid immediately after the arrest, Cambridge: Cambridge University Press, 1997, pp. Mild adjuncts to support a clinical judgement of very poor therapeutic hypothermia to improve the neurologic outcome neurological recovery. Unless an informed, senior opinion has been sought, ● Zandbergen EGJ, de Haan RJ, Stoutenbeek CP, Koelman JHTM, received, and agreed, the decision to resuscitate must always be Hijdra A.

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ALTERNATIVE SMALL GROUP DISCUSSION TECHNIQUES As with any other aspect of teaching it is helpful to understand several techniques in order to introduce variety or to suit a particular situation buy cheap aspirin 100 pills on line. Such techniques include: One-to-one discussion Buzz groups Brainstorming Role playing Evaluation discussion 46 1 cheap aspirin 100 pills amex. One-to one discussion This is a very effective technique which can be used with a group of almost any size best 100 pills aspirin. It is particularly useful as an ‘ice- breaker’ when the group first meets discount 100pills aspirin amex, and is valuable for enhancing listening skills aspirin 100pills on-line. It can also be used to discuss controversial or ethical issues when forceful individuals with strong opinions need to be prevented from dominat- ing the discussion (Figure 3 generic aspirin 100 pills on-line. Buzz groups These are particularly helpful to encourage maximum participation at one time. It is therefore especially useful when groups are large, if too many people are trying to contribute at once or, alternatively, if shyness is inhibiting several students (Figure 3. Brainstorming This is a technique that you should consider when you wish to encourage broad and creative thinking about a problem. It is also valuable when highly critical group members (including perhaps yourself? If used frequently, it trains students to think up ideas before they are dismissed or criticised. The key to successful brainstorming is to separate the generation of ideas, or possible solutions to a problem, from the evaluation of these ideas or solutions (Figure 3. It is valuable in teaching interpersonal and communication skills, particularly in areas with a high emotional content. It has been found to be helpful in changing perceptions and in developing empathy. It is not a technique to use without 48 some experience so you should arrange to sit in on a role play session before using it in your own course. In this regard, your colleagues teaching psychiatry or counsel- ling should be able to help as will the Green Guide by Ernington (Figure 3. Plenary sessions In many group teaching situations, and sometimes conferences, subgroups must report back to the larger group. This reporting back can be tedious and often involves only the subgroup leaders who may present a very distorted view of what happened. By using these technologies, the distinctions between large and small group teaching tend to break down. However, some examples of the ways in which technology can be used specifically to support small group teaching are: By using electronic mail (e-mail) to communicate with one or more students Through electronic discussion groups By conferencing techniques using computer, sound and video. Implementing electronic teaching is different to other approaches in many ways. For instance, uninitiated colleagues will be totally uncomprehending if you object to being interrupted when you are working at your computer by saying you are ‘teaching’! One fundamental difference between face-to-face teaching and being ‘on-line’ is that you will be interacting with what is known as a ‘virtual’ group. This means that the group does not exist as an entity at any one time or place, but that it is dispersed both in time (within limits) and place and that the group interacts ‘asynchronously’ at different times. Furthermore, there are different rules of behaviour for electronic communication known colloquially as ‘neti- quette’ and which both you and your students should observe. To learn more about this topic you can search for it on the World Wide Web. EVALUATING SMALL GROUP TEACHING Evaluation implies collecting information about your teaching and then making judgements based on that information.

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You should inform the students about the plan when they start and listen to any comments they may make which might reasonably give you cause to modify the plan generic aspirin 100pills free shipping. Though clinical teaching is essentially opportunistic cheap aspirin 100 pills on-line, being dependent on the availability of patients discount aspirin 100pills free shipping, it is wise to keep a record of the conditions seen during your teaching so that by the end of the course you have covered a wide enough range of illustrative cases buy 100 pills aspirin with amex. You should buy discount aspirin 100 pills on-line, of course purchase aspirin 100 pills with visa, co- ordinate your teaching with other tutors who are involved with your group of students. Set a good example: it is surprising how infrequently students get the chance to watch an experienced clinician take a history, perform an examination and subsequently discuss the outcome and plans with the patient. It is normally impossible to do this on a working hospital ward round because pressure of time means that decision- making is given priority. However, the outpatient depart- ment or a community practice setting often provide better opportunities. One of the difficulties students might have under such circumstances is the contrast between what you do in practice and what you expect of the students. The important thing is for the students to see you in action, particularly in regard to the way you relate to the patients while at the same time achieve the medical aims of the encounter. Even in busy clinical situations it is important to demonstrate a concern for the patient’s feelings. Involve the student: the need for active participation is the recurrent theme throughout this book and nowhere is it more important than in the clinical teaching situation. This may range from talking to a patient, checking physical signs, presenting the case history, answering questions and looking up clinical information for presentation at the 74 next teaching session. In general try and make sure all the tasks are directly related to the patients the student has seen. Observe the student: as mentioned earlier, a consistent finding in studies of clinical teaching has been a lack of direct observation of student interactions with patients. All too often the clinical teacher starts with the case presentation and many never check to see whether the features described are actually present or were elicited personally by the student. Serious deficiencies in clinical skills are consistently found in interns and residents which must be an indictment of the undergraduate clinical teaching. Only a commitment to the somewhat boring task of observing the student take the history, perform the physical examination and explain things to the patient will allow you to identify and correct any deficiencies. This type of activity is particularly essential with junior students and must be conducted in a sympathetic and supportive way. Provide a good teaching environment: the more senior and prestigious you are, the more intimidating you are likely to appear to the students. It is vital that you adopt a friendly and helpful manner and reduce the natural and inevitable apprehension felt by your students. Not only may they be apprehensive about you, but they will also be apprehen- sive about their impending contact with patients. You can assist this by preparing the patients and by showing to the students you understand their fears. IMPROVING THE CLINICAL TUTORIAL Clinical tutorials are all too oftendidactic with the emphasis being on a disease rather than on the solving of patient problems. We firmly believe the clinical teacher should concentrate on the latter. The students will inevitably have many other opportunities to acquire factual information but relatively little time to grapple with the more difficulttask of learning to apply their knowledge to patient problems. It is sad, but true, that in traditional medical schools the students are often as much to blame as their teachers by encouraging didactic presentations, particularly when examinations are imminent. Surprisingly, clinical teaching 75 in problem-based schools often exhibits the same char- acteristics. Plan the teaching: once again it is important to establish the aims of the sessions you have been allocated. In either case you must be sure in your own mind what you intend to achieve in each session.

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