By S. Ningal. Northwest Missouri State University.

Why Leape chose to use the much lower figure of 4% injury for his analysis remains in question buy 10 mg lipitor with mastercard. Using instead the average of the rates found in the three studies he cites (36% discount lipitor 10 mg amex, 20% lipitor 5 mg amex, and 4%) would have produced a 20% medical error rate 10mg lipitor visa. The number of iatrogenic deaths using an average rate of injury and his 14% fatality rate would be 1 buy lipitor 20mg overnight delivery,189,576. Leape acknowledged that the literature on medical errors is sparse and represents only the tip of the iceberg, noting that when errors are specifically sought out, reported rates are “distressingly high. First, he found that each patient had an average of 178 “activities” (staff/procedure/medical interactions) a day, of which 1. This may not seem like much, but Leape cited industry standards showing that in aviation, a 0. In trying to determine why there are so many medical errors, Leape acknowledged the lack of reporting of medical errors. Medical errors occur in thousands of different locations and are perceived as isolated and unusual events. But the most important reason that the problem of medical errors is unrecognized and growing, according to Leape, is that doctors and nurses are unequipped to deal with human error because of the culture of medical training and practice. Medical mistakes are therefore viewed as a failure of character and any error equals negligence. Leape cites McIntyre and Popper, who said the “infallibility model” of medicine leads to intellectual dishonesty with a need to cover up mistakes rather than admit them. There are no Grand Rounds on medical errors, no sharing of failures among doctors, and no one to support them emotionally when their error harms a patient. Leape hoped his paper would encourage medical practitioners “to fundamentally change the way they think about errors and why they occur. Therefore, the iatrogenic death rate dwarfs the annual automobile accident mortality rate of 45,000 and accounts for more deaths than all other accidents combined. The survey found that more than 100 million Americans have been affected directly or indirectly by a medical mistake. Forty-two percent were affected directly and 84% personally knew of someone who had experienced a medical mistake. Leape used a 14% fatality rate to determine a medical error death rate of 180,000 in 1994. The authors learned that the American College of Surgeons estimates that surgical incident reports routinely capture only 5- 30% of adverse events. In one study, only 20% of surgical complications resulted in discussion at morbidity and mortality rounds. They also suggest that our statistics concerning mortality resulting from medical errors may be in fact be conservative figures. An article in Psychiatric Times (April 2000) outlines the stakes involved in reporting medical errors. General Accounting Office responsible for health financing and public health issues, testified before a House subcommittee hearing on medical errors that "the full magnitude of their threat to the American public is unknown” and "gathering valid and useful information about adverse events is extremely difficult. A survey of nurses found that they also fail to report medical mistakes for fear of retaliation. Pharmacology texts also will tell doctors how hard it is to separate drug side effects from disease symptoms. Treatment failure is most often attributed to the disease and not the drug or doctor. Doctors are warned, “Probably nowhere else in professional life are mistakes so easily hidden, even from ourselves. Jay Cohen, who has extensively researched adverse drug reactions, notes that because only 5% of adverse drug reactions are reported, there are in fact 5 million medication reactions each year. Dorothea Wild surveyed medical residents at a community hospital in Connecticut and found that only half were aware that the hospital had a medical error-reporting system, and that the vast majority did not use it at all. Wild adds that error reporting is the first step in locating the gaps in the medical system and fixing them. With the discovery of the “germ theory,” medical scientists convinced the public that infectious organisms were the cause of illness. Medication Errors A survey of a 1992 national pharmacy database found a total of 429,827 medication errors from 1,081 hospitals. The error rate intercepted by pharmacists in this study was 24%, making the potential minimum number of patients harmed by prescription drugs 417,908. A 2003 study followed 400 patients after discharge from a tertiary care hospital setting (requiring highly specialized skills, technology, or support services).

Therefore buy cheap lipitor 10mg on-line, for such individuals there must be a corre- sponding increase in carbohydrate derived directly from carbohydrate- containing foods order lipitor 5mg visa. Additional consumption of dietary protein may assist in meeting the need through gluconeogenesis lipitor 10mg lowest price, but it is unlikely to be con- sumed in amounts necessary to meet the individual’s need generic lipitor 20 mg. A requirement for such individuals cannot be determined since the requirement for carbohydrate will depend on the particular energy expenditure for some defined period of time (Brooks and Mercier buy lipitor 10 mg lowest price, 1994). They are composed of various proportions of glucose (dextrose), maltose, trisaccharides, and higher molecular-weight products including some starch itself. These syrups are also derived from cornstarch through the conversion of a portion of the glucose present in starch into fructose. Other sources of sugars include malt syrup, comprised largely of sucrose; honey, which resembles sucrose in its composition but is composed of individual glucose and fruc- tose molecules; and molasses, a by-product of table sugar production. With the introduction of high fructose corn sweeteners in 1967, the amount of “free” fructose in the diet of Americans has increased consider- ably (Hallfrisch, 1990). Department of Agriculture food consumption survey data, nondiet soft drinks were the leading source of added sugars in Americans’ diets, accounting for one-third of added sugars intake (Guthrie and Morton, 2000). This was followed by sugars and sweets (16 percent), sweetened grains (13 percent), fruit ades/drinks (10 percent), sweetened dairy (9 percent), and breakfast cereals and other grains (10 percent). Together, these foods and beverages accounted for 90 percent of Ameri- cans’ added sugars intake. Gibney and colleagues (1995) reported that dairy foods contributed 31 percent of the total sugar intakes in children, and fruits contributed 17 percent of the sugars for all ages. The majority of carbohydrate occurs as starch in corn, tapioca, flour, cereals, popcorn, pasta, rice, potatoes, and crackers. Between 10 and 25 percent of adults consumed less than 45 percent of energy from carbohydrate. Less than 5 percent of adults consumed more than 65 percent of energy from carbohydrate (Appendix Table E-3). Median carbohydrate intakes of Canadian men and women during 1990 to 1997 ranged from approximately 47 to 50 percent of energy intake (Appendix Table F-2). More than 25 percent of men consumed less than 45 percent of energy from carbohydrate, whereas between 10 and 25 per- cent of women consumed below this level. Less than 5 percent of Canadian men and women consumed more than 65 percent of energy from carbo- hydrate. Data from the Third National Health and Nutrition Examination Survey shows that the median intake of added sugars widely ranged from 10 to 30 tsp/d for adults, which is equivalent to 40 to 120 g/d of sugars (1 tsp = 4 g of sugar) (Appendix Table D-1). Potential adverse effects from consuming a high carbohydrate diet, including sugars and starches, are discussed in detail in Chapter 11. Behavior The concept that sugars might adversely affect behavior was first reported by Shannon (1922). The notion that intake of sugars is related to hyperactivity, especially in children, is based on two physiological theories: (1) an allergic reaction to refined sugars (Egger et al. A number of studies have been conducted to find a correlation between intake of sugars and adverse behavior; some have been reviewed by White and Wolraich (1995). Most of the intervention studies looked at the behavior effects of sugars within a few hours after ingestion, and therefore the long-term effects are unclear. A meta-analysis of 23 studies conducted over a 12-year period concluded that sugar intake does not affect either behavior or cognitive performance in children (Wolraich et al. Dental Caries Sugars play a significant role in the development of dental caries (Walker and Cleaton-Jones, 1992), but much less information is known about the role of starch in the development of dental caries (Lingstrom et al. Early childhood dental caries, also known as baby-bottle tooth decay or nursing caries, affects about 3 to 6 percent of children (Fitzsimons et al. This is associated with frequent, prolonged use of baby bottles containing fermentable sugars (e. Increased consumption of sugar-containing foods has been associated with a deterio- ration of dental health in 5-year-old children (Holbrook et al. Chil- dren 5 or 8 years of age who consumed sweet snacks between meals more than five times a day had significantly higher mean decayed and missing teeth and filled scores than children with a lower consumption (Kalsbeek and Verrips, 1994). Root caries in middle-aged and elderly adults was sig- nificantly associated with sucrose consumption (Papas et al. Hence, it is diffi- cult to rationalize the relationship of sugars and dental caries as simply “cause-and-effect” (Walker and Cleaton-Jones, 1992). Caries occurrence is influenced by frequency of meals and snacks, oral hygiene (tooth-brushing frequency), water fluoridation, fluoride supplementation, and fluoride toothpaste (Holbrook et al.

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Alex injected another couple of mls of heroin cheap lipitor 10 mg with amex; she was still worried about giving her too much and dropping her blood pressure to her boots 10mg lipitor with amex. She turned to her instruments - they were a real mix (like everything else) – she had one good set of quality suture instruments they had foraged early on – a needle holder effective 40 mg lipitor, two forceps buy lipitor 10mg fast delivery, a pair of clips and some scissors - and a average quality university science dissection kit buy 40 mg lipitor otc, the most handy item being a reusable scalpel - which she had just sharpened - before having boiled the whole lot for 20 mins. She had no gloves, but catching a viral infection from a patient was really the least of her problems anyway – what choice did she have. She checked her hands and fortunately had no open cuts or grazes – although again it mattered little – she had to do the surgery and while it was good she had no open wounds she would have continued anyway. Wet, lather, scrub, rinse, repeat – hands and forearms – she had always questioned the merits of scrubbing for 5 minutes when you were going to be wearing 2 layers of latex gloves, but now, under these circumstances she understood clearly the origin of these old surgical rituals – with no gloves and very limited antibiotics, she want to reduce as much as she could any bugs living on her hands. When she had finished washing her hands she had Kate pour alcohol over them, and she allowed it to evaporate off as see pondered what she was about to do – she pushed all of her thoughts of self doubt to the side and took a deep breath. She laid out all the instruments, syringes and sutures – almost looks like a proper operating theatre she thought to herself with a smile. She picked up a piece of clean, if not sterile, decades old gauze with some sterile salad tongs soaked it in the dish of homebrewed alcohol. She then started to clean – in an expanding circle, starting first where she was going to make the first cut and expanding out in wet overlapping circles. The she picked up the 20 ml syringe with the last of her 1% lignocaine and slowly infiltrated it into the area she intended to cut. Having infiltrated the local, she again asked Sue how she was feeling, this time the only response was an incoherent groan. She picked up the scalpel; she made a small 2-inch cut 1-inch above her pubic bone. She cut through the fat down onto the rectus sheath; she made a small cut in the sheath and poked a finger through. She asked Kate to give some more heroin and she injected some more local anaesthetic. After waiting another couple of minutes she stretched the rectus sheath and the muscles opening a small 1 1/2 in gap - through the transparent peritoneum beneath she could see the blue tinge that signified blood. This was the most stimulating part of the operation, and as expected Sue moaned and started to pull her legs up. Alex leaned on to her legs, pushing them down and spoke meaningless platitudes to her, despite the movement she was still pretty stoned on the heroin, and the local was helping a lot. Having sucked most of the blood out she fished around for a fallopian tube with her index finger - she pulled the left one up into the wound - that was the side the pain had started on, wasn’t it? There distending the end of the tube was the ectopic pregnancy purple and congested looking - oozing heavily. She picked up her gut ties, and looped first one and then another around the base of the ectopic and pulled them tight. The bleeding stopped and the ectopic and the tube end became pale, she picked up the small sharp scissors and cut along above both her ties. With the bleeding controlled she poked the fallopian tube back inside and reached for the now cooling pot of boiled water- she added a splash of povidine to it. Using the small sterile glass jug, she ladled the water into the wound, sloshing it around washing out blood clots and hopefully any bugs, which had found their way in. She suctioned the water out and began to close the rectus sheath with her last 2/0 nylon suture and finished the skin with some 3/0 - at least she had a couple more of those – fortunately she had a large supply of fishing nylon and some of that was pretty fine - that would do in a pinch - but she wasn’t quite resorting to that yet. She still had a small stash of several types of antibiotic tablets - but they were all more than 10 years old and god knew their potency. Again with some extra help they moved Sue over onto one of the beds in the small two-bed ward. She had thought before about manufacturing Ether but had shelved it in the too hard basket – she would have to think about it again. Worried that infection would set in, worried that everything was slowly running out and that even ingenuity and back yard chemistry can only go so far. Medical Equipment Suppliers These are companies that the authors have dealt with over time and have happy with the service they have provided. Things change, companies go bad, and we can offer no guarantee of how these companies are currently performing. We have no financial connection/interest with any of the following suppliers, except one author has an interest in Med-tech Tactical Tailor Military style medical bags www. Shipping tends to takes several days but they are good about confirming shipment and providing a tracking number. QuickClot, CinchTight straps, tactical laryngoscopes, airway roll-up kits, bags, wilderness medicine-oriented books and more.

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In general buy lipitor 10 mg low cost, the administration of an analgesic and a muscle relaxant are indicated 5mg lipitor free shipping. In the absence of other alternatives the following procedure may induce sufficient relaxation of the muscles to allow a successful reduction: ”A cigar is inserted into the rectum via the anus leaving at least a third of its length outside 5 mg lipitor overnight delivery. If a cigar is not available buy 10mg lipitor mastercard, the tobacco is removed from 5-10 cigarettes and placed into a cloth bag 5mg lipitor for sale, which is then inserted into the rectum so - 77 - Survival and Austere Medicine: An Introduction that an end which can be easily grasped remains outside. Sterile water is used as a lubricant, and, if a bag is used, the contents should also be thoroughly moistened prior to being inserted. After 5-15 minutes, the muscles should relax sufficiently to allow a successful reduction. At the first indication that the patient is experiencing any difficulty, the insert should be removed by gently pulling on the exposed portion. Safety in using this technique relies on the relatively slow rate of transfer of nicotine from the tobacco leaves to the patient coupled with the ability to immediately halt absorption by removing the insert. It is therefore strongly suggested that no attempt be made to use an infusion prepared by "dissolving out" nicotine from tobacco. Personal Communication Secondly it can be used to control some intestinal parasites and worms. For particularly severe infestations the dose may be repeated no sooner than 2 days after the original treatment provided a bowel movement has occurred in this period. Nicotine is toxic and some individuals are particularly susceptible to its effects; if the patient shows indications of susceptibility to nicotine poisoning, a second dose should not be administered. Its effectiveness in clearing parasites arises from the differences in sensitivity to nicotine between man and many common parasites. The primary problem with nicotine is the effect that produces the muscle relaxation also causes toxic effects, by activation of the nicotinic receptors in the nervous system. While the amount of nicotine in cigarettes and cigars is relatively constant there is large variation in concentration in both wild and cultivated tobacco. Like with Foxglove dosing is trial and error and using cultivated tobacco as a source of nicotine is potentially very risky and should avoided except in a major catastrophe. Nicotine is also an effective insecticide and can be used as a spray on vegetables to prevent insect infestations. Cannabis (Cannabis sativa) This plant is deserving of special mention due to its widespread availability and use. Small amounts taken infrequently produce relaxation, a degree of sedation, and appetite stimulation. Several studies have demonstrated that for patients with chronic pain, nausea from cancer treatment, or muscle spasm small amounts may improve daily functioning. However, larger amounts and chronic use do have significant medical consequences, and for patients with pre-existing mental illness regular use can - 78 - Survival and Austere Medicine: An Introduction worsen symptoms. Cannabis may be of value in the same way that any pharmacologically active substance can be, but this is not an endorsement of its recreational use. Honey While not technically a plant no discussion of botanical and herbal medicine would be complete without the mention of using honey as a healing agent. This is a common item in food storage programmes, but it needs to be in your medicinal storage preparations also. Change daily, cleansing the wound area with a strong solution of Echinacea root, repack with honey, then redress sterilely. A real strong solution of Echinacea will have a numbing effect which will make the wound cleansing less painful. A tablespoon eaten every 1-2 hours for a week or so should clear up an acute condition, then a tablespoon 3 x daily for a week or so should clear up the condition entirely. Other medicinal plants While there are many plants, which have medicinal, properties table 9. Other common medicines and there plant origins Plant Name Medication Clinical Uses Name Erthroxylum Coca Cocaine Local anaesthetic Atropa Belladonna Atropine Anti-Cholinergic – treats nerve (Deadly nightshade) agent exposure Mucuna Species L-Dopa Anti-Parkinson’s drug Ephedra sinica Ephedrine Sympathomimetic / Decongestant Pilocarpus jaborandi Pilocarpine Glaucoma therapy Cinchona ledeenana Quinine Anti-malarial Theobroma cacao Theophylline Asthma treatment Chondodendron Tubocurarine Muscle relaxant tomentosum Daphne genkina Yuanhuacine Induces abortion Figures 8. Poppy extracts provide the most practical option for managing severe pain in an austere situation. Beware: possession with the intention to use as a drug is illegal in many countries. For the majority there is very little evidence aside from anecdote to their efficacy. A common underlying principle of most alternative therapies is good nutrition and a healthy lifestyle – the value of this is clearly not in dispute.

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