Humor and madness Essay Example | Topics and Well Written Essays - 500 words

Humor and madness - Essay Example Seriously, what are the odds of someone who faked insanity to escape his punishment suddenly taking on messianic attributes en route to â€Å"liberating† a group of mentally ill patients? In a fictional setting of course its viable. This happenstance borders on the fantastic, and it is highly remote that people could just walk into asylums on the pretext of chicanery and â€Å"heal† the insane with the power of laughter. The novel shows us the great divide between humor and madness as a form of symbolism in connoting sanity vis-à  -vis insanity. In the dour, oppressive wards of the asylum people are so rooted in madness that they have completely forgotten how it is to legitimately feel happiness and appreciate humor. And then comes McMurphy, whose witty, cheery approach enlivens up a ward which hadn’t heard true laughter in years. The novel highlights the fact that those embroiled in madness no longer have the capability to experience real joy. Thus, humor serves as a virtual shield for the protagonist, lest he fall into the same trap that the patients have found themselves in. He utilizes humor so that it would serve as insulation from the madness around him, but in the process he inspires the rest of the occupants of the ward. The relationship between humor and madness go hand in hand as the story unfolds, with humor standing as a unique symbol for free-thinking, fully functional human bei ngs and the absence thereof showing a descent into the recesses of madness. Once Mcmurphy has gradually empowered the patients with his own brand of rebellious humor, the reader would get a distinct notion that the patients had actually improved and that they were slowly entering the realm of reason again. This was clearly manifested in the scene where Harding, Scanlon, Sefelt and Doctor Spivey all could truly laugh at the end of their bending-the-rules fishing expedition. It is quite obvious that a reasonable understanding of the

Breyer Meat Packing Case Study Essay Example | Topics and Well Written Essays - 500 words

Breyer Meat Packing Case Study - Essay Example 14). Awareness of the details surrounding the cumulative trauma disorder would assist in informing the employees and the employer that â€Å"carpal tunnel syndrome is the disorder most commonly reported for this industry and is caused by repeated bending of the wrist combined with gripping, squeezing, and twisting motions. A swelling in the wrist joint causes pressure on a nerve in the wrist. Early symptoms of the disease are tingling sensations in the thumbs and in the index and middle fingers. Experience has shown that if workers ignore these symptoms, sometimes misdiagnosed as arthritis, they could experience permanent weakness and numbness in the hand coupled with severe pain in the hands, elbows, and shoulders† (Occupational Safety and Health Administration, N.D., par. 15). Question #2:  Ã‚  Assume  OSHA is  applicable.   Provide two (2) specific  recommendations to address the issue.

Ethics of Native American Mascots Essay Example for Free

Ethics of Native American Mascots Essay Ethics of Native American mascots is a controversial topic and should not be argued against because they are used ethically, complementary, and respectfully. The Native American Mascot controversy is a topic that has presented itself in recent years all across the country. Though there have been some issues, complaints, and moral questions brought up about the Native American mascot dilemma by a minority group of people, there is no legitimate argument to why these mascots should be banned. Ethically, there is nothing wrong with using Native American symbols as mascots. Native American mascots are ethical. Ethics is defined as â€Å"a system of moral principles and rules, the rules of conduct recognized in respect to a particular class of human actions or a particular group or culture, and also a branch of philosophy dealing with values relating to human conduct, with respect to the rightness and wrongness of certain actions and to the goodness and badness of the motives and ends of such actions† (dictionary. com). Native American mascots and logos for sports leagues has been a debate dating back as far as the late 1960s (Oguntoyinbo 2011). When talking about the ethics side of the argument, calling the images and logos unethical toward Native Americans is wrong because ethics, like the definition says, portrays to respect and class toward a group or culture. The purpose of mascots is to believe in something, to have a logo that brings teams and communities together for battle in sports, and to perform well and do your best so you stand tall and proud to be a part of your team and mascot. To be a warrior on a football field and literally have the warrior symbol, to be a brave, or the chiefs and represent honor, courage, and bravery would be astonishing. Native American mascots are complementary. The use of logos as mascots is to honor Native Americans, they are not used to offend, and they are not misguiding (King 2002). Though there are two sides to every argument, when a mascot is called degrading or any negative term other than complementary, it must have something border line if not over the top offensive on it. There is no legitimate argument for why an arrowhead on the side of a football helmet, a logo of a Native American chief’s head on the side of a school or even a tomahawk on a basketball jersey is being reverted to as degrading, but the controversy still continues. Some names can be offensive such as Redmen, Savages, etc. But if it is the name itself that offends, it needs to be argued that way and not toward the Native American mascot as a symbol. Arguing a mascot as degrading when really it is meant the name is disrespectful in itself because a mascot is a symbol of a team, not the name; it is also the strength and core of a team. Mascots are purposely portrayed as being ethical, complementary, and respectful, in fact â€Å"tribal names find their way onto all kinds of consumer products, such as the Jeep Cherokee and the Dodge Dakota. For the same reason, Indian images appear on U. S. currency, such as the old Indian-head nickel and the new Sacajawea dollar. The Army even names its helicopters after tribes: the Apache Longbow, the Kiowa Warrior, the Comanche, and the Blackhawk. If we were† to let the minority side of this argument change Native American mascots, then â€Å"a number of cities (e. g. , Chicago, Miami, and Milwaukee), plus about half the states, would have to be renamed (Miller 2001). Mascots are symbols, symbols of spirit, and symbols of strength. Native American mascots are respectful. The minority of people who argue this issue want these mascots to change because they believe that Native American mascots are disrespectful to Native Americans, they are portrayed disrespectfully, and everything about the mascot is portrayed disrespectful. Some even say that teams with Native American mascots do what’s called a tomahawk chop that supposedly represent Indian culture and meant for honoring them but that’s not true (Pewewardy 2000). Doing a tomahawk chop is in no way disrespectful, in fact, a tomahawk chop is used to pump up the crowd, it’s used to respect the heritage of the Native American, and it’s used to continue tradition. Being a part of a Native American mascot team, chances are the intent is to want to represent that logo and be the upmost respectful possible toward the heritage that the symbol represents. It is amazing how some can say that Native American mascots are disrespectful. A huge reason that Florida State University got to keep their symbol and logo the Seminoles is because the chief of the Seminole tribe in Florida strongly supports what Florida State does with the symbol and how it is respected. Disrespect is when a team of any name burns a mascot logo before a game, disrespect is when a sports game is not played by the rules, disrespect is when refusal to shake and opponents hand after a lost battle, not a logo that represents pride and respect for a team, school, and community. Ethics of Native American mascots is a controversial topic and should not be argued against because again they are not being used unethically, they are not degrading, and they are not being used disrespectfully. Schools shouldn’t have to change their mascot because a few minority people give speeches, write letters to the NCAA, or even protest about it. It should come down to what the tribes themselves want; they are the ones with their image portrayed out there as mascots. That would be the ethical and right way to go about this controversy. Ethics can play a big role when it comes to the Native American mascot issue. No matter which side is chosen to debate, ethics should always be considered one of, if not, the top motivation. Works Cited â€Å"Definition of ethics. † Ethics definition. Dictionary. com. Web. 15 November 2011 King, Richard. â€Å"Defensive dialogues: Native American mascots, anit-Indianism, and educationalinstitutions. † Academic Search Premier. Simile, February 2002. Web. 27 November 2011. Miller, John. â€Å"What’s in a (Team) Name? † Academic Search Premier. National Review, 16 April 2001. Web. 15 November 2011. Oguntoyinbo, Lekan. â€Å"The Name Game. † Academic Search Premier. Diverse: Issues in Higher Education, 28 April 2011. Web. 15 November 2011.. Pewewardy, Cornel. â€Å"Why Educators Should Not Ignore Indian Mascots. † Academic Search Premier. Multicultural Perspectives, 2000. Web. 27 November 2011.

Long Bone Fractures in Children: IN Fentanyl Treatment

Long Bone Fractures in Children: IN Fentanyl Treatment Introduction The clichà © that states children are just small adults is certainly not true in the case of long bone fractures. A childs experience of long bone fractures is dramatically different from that of an adult on account of their rapidly developing physiology (Wood et al 2003). This rapid development results in biochemical and physiological differences between a childs and an adults skeleton, the mechanisms of fracture and healing, are an important component of their treatment needs and consequently crucial part of emergency care management (Bonadio et al 2001). In addition, children, from infancy through to adolescence, have common fracture patterns related to their stage of development. The structural differences between the bones of a child and an adult enable childrens bones to endure greater forces and to heal quicker a childs remodeling potential supports full recovery with limited or no long term side effects from long bone fractures (Lane et al 1998). Injuries of all types are the second leading cause of hospitalization among children younger than 15 years (Landin 1997). Musculoskeletal trauma, although rarely fatal, accounts for 10% to 25% of all childhood injuries (McDonnell 1997, Landin 1997, Lane et al 1998). Boys have a 40% risk and girls a 25% risk of incurring a fracture before the age of 16 years (Landin 1997, Ritsema et al 2007). The most common site of fracture is the distal forearm which accounts for 50% of paediatric fractures. The rates of fracture increases with age as children grow; peaking in early adolescence. Fortunately, most fractures in children are minor greenstick and torus fractures constitute approximately 50% of all fractures in children (Landin 1997, Lane et al 1998, Gasc Depalokos1999, Richards et al 2006) and only 20% require reduction. Thus, the management of paediatric fractures is often straightforward. Without exception children will experience pain at the time of injury, attending the accident and emergency department and during recovery. The most common pain management strategies involve a multi-modal approach that includes both pharmacological and non-pharmacological components delivered via the least invasive technique (Worlock et al 2000). In practice this includes oral medication, such as oramorph, paracetamol, and NSAIDs, inhaled entonox, intranasal diamorphine (IND) or intravenous opioid where necessary and distraction with age appropriate devices, such as interactive books, bubbles, music and computer games in older children. Notably, IND is currently embraced as the key route of opioid delivery for children attending AED with fracture pain in the UK British Association for Accident and Emergency Medicine (BAAM E 2002). Parents and guardians of children frequently seek care in AED for the relief of pain from traumatic injuries and as a result the field of emergency medicine has assumed a leadership role in paediatric pain management. However, despite this the literature suggests the provision of pain relief for children attending AED remains suboptimal when compared to adults with the same injuries. Further discrepancies are reported between paediatric accident and emergency departments (PAED) and district general accident and emergency departments (DGAED) (Emergency Triage 2004). One reason suggested for these differences is the geographic distribution of specialised services, which are predominantly located in large cities where they are affiliated with universities. However, a recent audit by the British Association for Emergency Medicine (BAAEM 2005) of their guideline for the management of pain in children shows inconsistencies in provision of analgesia particularly for fracture pain throughout the country with no measurable difference between PAED and DGAED. A key feature of this guideline is the algorithm which advocates the use of IN diamorphine for acute moderate to severe pain in children over the age of one year (see appendix 1). The whole topic of analgesia in the paediatric population is complex and still imperfect especially in acute moderate to severe pain requiring urgent treatment in the emergency department (Schechter et al 2002). The road to pain free suffering is still paved with impediments such as failure of pain recognition and methods of delivery of analgesia (Murat et al 2003). Oral administration can be inadequate in an emergency situation with particular limitations in potential choice of drug and delay in gastric absorption and gastric emptying. Intramuscular (IM) and intravenous (IV) administration can be distressing to children and have been shown to influence future response to painful procedures (Gidron et al 1995, McGrath et al 2000, Fitzgerald et al 2005, Walker et al 2007). Rectal administration has limited acceptability given unpredictability of onset together with occasional problems of consent (Mitchell et al. 1995). By contrast, the efficacy and safety of the IN route has been well documented for desmopression acetate (DDAVP), insulin, antihistamines, midazolam and calcitonin (Jewkes et al 2004, Loryman et al 2006). In contrast, intranasal administration has a number of advantages. It is technically straightforward, socially acceptable and demonstrably effective. The nasal mucosa is richly vascular and administration by this route avoids the first-pass metabolism phenomenon Summary Studies in the 1990s such as Yearly Ellis (1992) have also demonstrated the efficacy of administration of intranasal medication via a nasal spray rather than drops in adults, although the efficacy of this application in the paediatric population remains to be proven. Intranasal administration is possibly the ideal route of analgesic administration in children. Currently, within the accident and emergency department (AED) of Bristol Royal Hospital for Children (BRHC) intranasal diamorphine is used as the first rescue analgesia in the paediatric population presenting with acute moderate to severe pain, most frequently in patients with long bone fractures who do not require intravenous access for resuscitation. Diamorphine is a semi synthetic derivative of morphine with a number of properties that render it a desirable analgesic agent for administration via the nasal route. It is a weak base with a pKa of 7.83 and is water soluble allowing high concentration to be administered in small volume (Rook et al 2006). Unfortunately the legal use of diamorphine is limited to two European countries i.e. United Kingdom (UK) and Sweden. Furthermore periodic problems with its availability during the past few years (with further shortfalls in availability predicted by the NHS purchasing and supply agency) have resulted in an alternative efficacious analgesia being sought for this population. Fentanyl, however, is a short rapidly acting opiate has several qualities that render it useful as an IN analgesia and a potential candidate to replace IN diamorphine in the AED for acute facture pain management in children. It has a very high lipid solubility, potency and diffusion fraction, and unlike diamorphine it is not a prodrug and does not cause histamine release (Reynolds et al 1999). Assessment of a patients pain experience is not directly accessible to others, collecting and analyzing information about the processes of pain relief and pain prevention is not straightforward and presents significant challenges to health care professionals. In children, this task is further complicated by their varied stages of physical and cognitive development. Recent research by Bruce Frank (2004) however, has shown that the ability to measure pain in the paediatric population has improved dramatically and that today there now exists a plethora of age appropriate pain assessment tools for acute pain in children ranging from pre-term infants to adolescents, the majority claiming validity (strength and robustness) and reliability (consistency). However, most clinical research into pain management strategies continue to rely on the gold standard self report and visual analogy score tools (mostly 0-10) (Chalkiadis 2001, Walker et al 2007). Although these tools are reliable they are not always adapted appropriately for a childs stage of development. Childrens understanding of pain and their ability to describe pain change with increasing age in a developmental pattern consistent with the characteristics of Piagets preoperational, concrete operational and formal operational stages in cognitive development (Smith et al 2003). The quality or int ensity of the pain can be difficult to determine in children, as most tools rely upon a patients relative judgment between the intensity of present pain versus a patients worst pain experience (Murray et al 1996). These tools can therefore be unreliable where a childs age of development means they have limited or no memory of pain experience. Stevens et al (2002) recently described a conflict of understanding that resulted in a study bias and an insignificant reported power of (p=0.6). In the study an 8 year old boy had chosen the VAS (0-10) but frequently reported his score as 10, although he understood the increasing value of the scoring system further questioning identified he perceived 10 of 10 to be a good score and 0 of 10 to be poor. The boy was at a stage of development that limited his understanding of less is more. This case highlights the importance of utilizing a pain assessment technique that reliably accounts for a childs age of development. A preliminary search of literature suggests there is currently exists limited research to support for the use of intranasal diamorphine or intranasal fentanyl for the management of acute pain in long bone fracture in children as evidenced based medicine. Despite this lack of evidence it remains a key strategy within paediatric AED for the pain management of long bone fractures and is anecdotally reported as a gold standard for paediatric pain management. Therefore; its lack of availability could profoundly compromise pain management for this population. Thus, this extended literature review will examine the efficacy of intranasal fentanyl as an alternative to intranasal diamorphine for traumatic fracture pain in children attending accident and emergency departments. However, in these days of evidence based medicine, it clearly needs to be established beyond all reasonable doubt. In view of that only research into paediatrics will be included increasing the credibility of its applicat ion to practice. SEARCH STRATEGY A range of complimentary search techniques were used to capture key research including a systematic electronic literature search of the Cochrane library, Embase, CINAHL, Proquest, Medline, PubMed since 1990 up to 2009 (this has to be to year of submission). The scope of the search was extended beyond the recognised five years of current research so as to include the empirical work into the development of IN analgesia in children. Key words used included the following: pain, acute pain management, intranasal diamorphine, intranasal fentanyl, procedural, accident and emergency, emergency department, child, pediatric, paediatric, child and fracture pain, as well as various combinations. In addition, in order to ensure the completeness of the search, an internet search was completed using the Google search engine, IASP, Pain Journal, Paediatric Nursing, BAAEM, NICE, Medline, EBM; the RCN was also utilised. Backward chaining of references found was also performed to ensure all relevant papers were identified. Although this review identified twenty seven citations it should be noted that historically there are fewer Randomised Controlled Trials (RCT) in children compared to adults possibly due to problems gaining ethical approval and consent. Additionally even experienced researchers will be unable to find all relevant papers and much research is not submitted for publication. The studies identified were divided into the three modalities of IN route, IN diamorphine and IN fentanyl with the majority presenting evidence for the IN route. All papers were critiqued using a tool published by the Learning and Development Department within the Public Health Resource Unit of the NHS (www.phru.nhs.uk/casp). The tool facilitated critiquing different forms of quantitative research and is based on work by Sackett (1986), Sackett et al (1996) and Phillips et al (2008) (see appendix 2). The results of the critique process for each paper and level of evidence applied in line with the modalities they address informed understanding of current practice and development of a research proposal. STRUCTURE OF THE LITERATURE REVIEW This literature review will focus on determining whether IN fentanyl is an effective alternative to IN diamorphine for the management of long bone fracture pain in children attending an AED. The scope of the literature review considers literature from 1990 onwards although occasionally earlier research has been referenced. Given the limited available evidence on the topic the following review structure has been selected. Chapters 1, 2 3 will present the evidence sourced on each theme intranasal route, intranasal diamorphine and intranasal fentanyl with a short summary to conclude each chapter. Chapter 4 will present an in-depth discussion and conclusion on the utility of the evidence, its application to practice and the requirement for a multi-centred comparative randomised control trial to improve the credibility of the evidence base for this field of treatment. Finally chapter 5 will present a research proposal for a comparative study of these modalities. Intranasal (IN) route of medication delivery in children. Nasal administration of drugs has been reported as having several significant advantages over current practice which are predominately oral, IM, IV and rectal (Williams Rowbotham 1998). It is emerging as a low-tech, inexpensive and non-invasive first line method for managing either pain or other medical problems (Wolf et al 2006). Nasal medication delivery takes a middle path between slow onset oral medications and invasive, highly skilled delivery of intravenous medications. The nose has a very rich vascular supply, IN facilitates direct absorption to the systemic blood supply due to increased bio-availability of the drug by missing first pass metabolism, It avoids the potentially technically difficult of sterile intravenous access, is essentially painless and is considered acceptable to children when compared to other routes of administration (Shelly Paech 2006) (see table 1). a theory which will be considered when reviewing the studies within this chapter Therefore suggesting th e IN route will result in therapeutic drug levels, effective treatment of seizures and pain without the need to give an injection or a pill, furthermore; it is quite inexpensive, an advantage in this era of increasingly expensive medical technology (Shelly Paech 2006). Additionally given the complexity of the developing child and the known consequence of poorly managed pain on the future responses to pain the IN route does, if it is as efficacious and as safe as suggested offer one of the most acceptable, definitive forms of analgesia delivery in children. The degree of accuracy of the previous statements will be established within this chapter by critically reviewing the 16 studies identified on IN medications other than intranasal diamorphine or intranasal fentanyl in the paediatric population (see table 2) as these agents are considered individually in later chapters. The rigour of the studies will be addressed within this chapter and reflect the level of evidence applied according to Sackett (1986) criteria (see appendix 3). Most studies reviewed were randomised clinical trials and in some cases compared against a placebo Conversely, this does not concur with the trials discussed earlier (Lahat et al 1998, Al-rakaf et al 2001, Fisgin et al 2002, Mahmoudian and Zadeh 2004 and Holsti et al 2007) where significant dosing was applied or in Wilson et al (2004) who retrospectively studied 30 children age 2-16 years receiving 0.3mg/kg at 5mg/1ml INM and 13 patients receiving rectal 0.2mg/kg diazepam for seizures. The authors report equal efficacy for both routes. Success of these agents was considered on cessation of seizures, no reported complication and not needing to attend A+E. A total of 27/30 families who had used INM found it effective and easy to use. Although 20/24 (83%) who had previously used rectal diazepam still preferred it mostly due to the coughing and the volume of liquid administered via the IN route. Given it is generally considered that the optimum IN dose as stated above is 0.1- 0.2 ml per nostril, all but the studies discussed so far were using drug concentration and dosing regimes whic h resulted in large volumes of liquid being dripped in to the nasal cavity. This is particularly poignant in Wilson et al (2003) who compared buccal to IN midazolam in 53 children aged 3-12 years experiencing seizures lasting > 5 minutes attending AED. A key feature of this study is the mean age of the children (age 9 years), mean weight (24kg) the study drug concentration as with previous studies was of 5mg /ml. IN dosing was at a dose of 0.3mg/kg. Given these figure the average dose would have been 7.2mg = a volume of 1.4ml being administered. Since the comparative route of administration for this study was buccal there is a possibility that part of the IN dose was buccally absorbed therefore creating a flaw in this study methodology, raising questions over why this comparative route was chosen and suggesting the only real conclusion to be taken from this particular study is buccal midazolam is effective and safe in children. Furthermore although this is described as a blind RCT and the authors claim the time to cessation of seizure was quicker for the INM group 2.43 (SD 1.67) to 3.52 (SD 2.14) for buccal route there is little detail on the blinding process or data collection procedure suggesting the rigour of the study maybe flawed therefore the efficacy and safety claimed for the IN route should not be embraced without further study. On the other hand Fisgin et al (2002) and Hardord et al (2004) compared the INM with rectal diazepam. In Fisgin et al (2002) in an unblinded RCT equivalence study the authors compared INM with rectal Diazepam to ascertain the safety and efficacy of INM for the development of a clinical protocol in the management of prolonged seizure in children attending the AED. Forty five infants and children age 1 month -13years experiencing prolonged seizures > 10 minutes were either given INM 0.2mg/kg or rectal diazepam 0.3mg/kg. The authors report proven efficacy (p Intranasal Diamorphine (IND) The delivery of opioids via the IN route is perhaps one of the most valuable indications for IN medication delivery. Acute pain is a frequent experience for children whether attending an AED, hospital and hospice setting (Hamer et al 1997). Furthermore it is not unusual for them to experience frequent episodes of breakthrough pain which requires additional support from fast acting analgesic agents. Owing to the developmental and physiological difference in the paediatric population there is a need for a variety of effective treatment option from which to select and individualise the patients therapy to meet their needs. IN opioid is simply one such option available which may be useful in children. It has been suggested that the delivery of medications via the IN route results in rapid absorption with medication levels within the cerebral spinal fluid (CSF) being comparable with (IV) administration (Chien and Chang 1997). Diamorphine hydrochloride is a semi-synthetic derivative of morphine. It is extremely hydrophilic, which makes it ideal to use when preparing in high concentrations in solution, thus allowing high doses to be administered in smaller volumes via the intranasal route (Kendall Latter 2003). However, this route of administration can be a painful process as reported by adults (Henry et al 1998). Despite this the intranasal route is considered more acceptable to children and their parents and is thought to lessen the opioid side effect profile seen in IV administration (Stoker et al 2008). This concept has been well recognised throughout the UK and many centres already use intranasal diamorphine for acute pain in children, following the guidelines by the British Association for Accident and Emergency Medicine Clinical Effectiveness Committee (2002) (BAAEM). Although the administration of intranasal diamorphine is now a first line choice for moderate to severe acute pain for children atten ding AED, as is the case within our institution, there is very limited research to substantiate this practice although as noted above it has been readily accepted by the BAAEM for acute pain management in children and very successfully used within our institution A recent shortage of diamorphine evoked the search for an equally effective and acceptable alternative. Early research in animals and adults reported pharmacokinetics of nebulised inhalation and intranasal administration of diamorphine as detected morphine in plasma at six minutes (Masters et al 1988, Kendall 2001). Despite the age of this research and the fact that the later study was in adults, it is still quoted as creditable evidence to support this practice in paediatrics. However the legitimacy of this should be questioned, due to children not being just small adults but have physiological differences intrinsic to their age and stage of development which may affect the bodys absorption and level of toxicity in different ways to adults. The extensive literature search highlighted four randomized controlled trials (RCT) that demonstrate IND to be clinically superior to intramuscular morphine and inferior to IV morphine particularly in the management of acute pain in children, a case study of an 8 year old boy and clinical audit of IND for pain relief in children attending AED (see table 3). The key methodology in the RCTs by Wilson et al (1997), Kendall et al (2001), Brennan et al (2004) and Brennan et al (2005) suggest these are superiority studies where the authors hypothesised improved pain management with the IND when compared to a variety of routes. The rigour of the studies will be discussed later in the chapter. Although while the critiquing process takes place it is fundamentally accepted that RCT are considered level 1 or 2 evidence as opposed to case study or audits at Level 3b and therefore generally sourced to Latest published clinical evidence to support the use IND in the paediatric population is presented in an audit by Gahir Ranson (2006) of 54 children whose care was managed by the use of an integrated care pathway for acute pain management while attending the local AED. This integrated care pathway focused strongly on the use of IND. Data collection was on a one page performa and included consent, date, patient demographic, pain score and side effect profile. Data collection was retrospective and data analysis illustrated limited recording of side effect profile but improved pain scores. However only 60% of patients have this information documented so data collection was difficult. Despite this lack of hard evidence no clinical incident, including the side effect profiles, were reported. Thus suggesting the practice of IND for acute fracture pain management in children could be safe, effective and more acceptable to children than the more painful alternative of IM or IV administration. However there is limited strength in an audit, other than a review of practice (Bowling Ebrahim 2005) and in this case a key feature for review should be the documentation process in the department as there were facets in the care pathway administration documentation missing. Therefore this audit suggests that IND is safe and effective pain management for children, but this conclusion can not be categorically drawn from the limited data available. The potential outcome of this audit could be education on documentation, to do a more rigours prospective audit of practice. Unfortunately at this point it only offers an insight to their clinical practice which is favourable for this agent and route. Albeit as noted before IND has improved childrens pain management and over all experience of acute care in our PAED additionally as with the results of the audit we have experienced no side effects or complications, further highlighting the importance of seeking an alternative to IND which offers equally efficacy. Intranasal Fentanyl (INF) Monitoring of the usual observations and pain scoring in the child was recorded prior to the administration of fentanyl (20 micrograms for 3-7 year olds and 40 micrograms for 8-16 yrs) and continued at 5 minute intervals for the 30 minute period. Additional doses of fentanyl (20  µg) were available if required at 5 minute intervals. Pain assessment was achieved with two validated pain assessment tools, the visual analogue scale (VAS) in older children and the Wong-Baker Faces (WBF) for younger children. Both are reliable and known to support consistency in pain assessment. Though there was no mention of training for those assessing this primary end point using these tools in the paper therefore this should be considered in the overview of the standard of evidence produced by this study. Additionally although forty five patients were randomized following consent unfortunately no details on the randomization process was disclosed in the paper either. This may not be significant, but when reviewing the credibility of the authors claims these obvious omissions could be responsible for a flaw in this study and remains to be established. On the other hand, the methodology that has been disclosed in the paper appears sound as it addresses key areas of sample calculation (power of the study) as a superiority study with the sub groups size adequate to detect a significant difference (Greenhalgh 2004); demographics, blinding of the drugs, assessors and appropriate statistical analysis of the data therefore supporting the validity of the results claimed and the application of the results to the age of patient targeted that this literature review is aiming to find an analgesic alternative to IND for. The results concluded by Borland et al (2002), are a reduction in pain score at 10 minutes to 44.6 mm (95% confidence interval) 36.2-53.1 mm from 62.3 mm 53.2-69.4 mm (95% confidence interval) at assessment using the VAS and 2.2 (95% confidence interval 1.3-3.1) at 10 minutes from 4.0 (95% confidence interval 3.3-4.7) at assessment in 16 children using WBS. Visual analogue pain scores demonstrated clinically significant reductions in pain scores by 5 minutes that persisted throughout the entire study (up to 30 minutes) for both INF and IV morphine. The second primary end point of this study (side effect profile) showed no significant change in physiological parameter of the childrens pulse or respiratory rate, blood pressure or oxygen saturations, interestingly the side affect profile chosen for monitoring such as pulse and blood pressure are not considered to be one of the primary side affects of morphine, however nausea and vomiting which are was not assessed. Ultimately, there wer e no negative side-effects and the sizeable reduction in pain scores (compared to baseline assessments) was accomplished in children using INF by 10 minutes and maintained throughout the 30 minute period with the mean INF dose at 1.5 µg/kg and ranging from 0.5-3.4  µg/kg. Interestingly 35.5% of children in the INF group only required one dose. Given the clinical equivalency of these two agents and routes the authors conclusion that INF offers the benefits of a simple painless technique for treating acute pain is substantiated. These benefits suggest that the IN route could be a valuable technique not only in an AED but also for breakthrough pain by offering a fast onset of pain control in moderate to severe painful conditions. It could also provide pain relief and allow topical anaesthetics to take effect on the skin prior to IV establishment. Therefore this may be a suitable alternative to IND. A similar and more recent double blinded RCT trial by Saunders et al (2007) claimed efficacy of a larger dosing regimen with a mean dose of 2 µg/kg INF (50 µg/ml) for pain reductions in paediatric orthopaedic trauma compared with IVM at 0.1mg/kg in 60 3-12 year old children. This study reports positive outcome for INF following both patients and carers reporting very effective pain management and satisfaction using this treatment method. However there is little information in the paper of methodology and results are given in percentages rather than a P value or NTT which should be expected in a rigorous creditable RCT of two agents (Bowling Ebrahim 2005) reducing the level of evidence applied to the paper to L3. Even supposing the results are an accurate reflection of the efficacy and safety of INF, particularly the fact that no significant difference in pain score or side effect profile and INF is a way forward, the lack of detail the randomisation process and analysis of data in the study methodology merely implies that these results maybe flawed. Interestingly given the concentration of fentanyl 50 µg/ ml a dosing volume for a 25kg child would have required one ml = 0.5ml per-nostril therefore suggesting some of the administration may have been oral rather than IN and present the issues of bad taste which is put forward as a possible study limitation by the authors. Then again there are no complications or reports on taste presented in the results and the authors conclusion on the efficacy of INF for acute pain management in children may be founded. However, without sourcing more details from the authors it cannot be considered evidence to inform this dissertations aims but merely an ex ample of poor research or appropriate omission by publishers. Further suggesting there remains a requirement for more research on the topic within double blind, equivalence, RCT focused on INF efficacy and dosing with sound methodology that is transparent in publication to answer the dissertation question. Conversely an older and more rigorous study which also looked at dose related analgesic effect between routes of administration is by Manjushree et al (2002). The authors demonstrated the clinical efficacy of INF in a cohort of 32 children (aged 4-8 yrs) in a postoperative situation and with a double blind level 1 RCT. The study design gives the impression of sound methodology as blinding, assessment and analysis of data was appropriate and available for scrutiny in the paper, particularly the analysis of both nonparametric and nominal data. The only weakness is possibly the sample size of 32 patients. Although the authors performed a power calculation which identified 40 patients to show a significant affect, they only recruited 32 patients, furthermore, this appears to be an equivalency study where the authors hypothesised INF would be equal to and not inferior to IVF therefore would have needed a larger sample to de

Dale Earnhardt and Stock Car Racing Essay -- Stock Car Racing Dale Ear

Dale Earnhardt and Stock Car Racing Over 50 years ago a new sport was introduced. This sport was stock car racing. The organization that sponsors stock car racing is known as National Association of Stock Car Racing, NASCAR. The driver that is identifiable with NASCAR is definitely Dale Earnhardt. Over the years there have been many great stock car racers from Cale Yarborough to Richard Petty and Davy Allison, but no other name was better known than Dale Earnhardt. Whether on the track or in the crowds, there is no possible way a person can look without seeing a black number three or some other Earnhardt insignia. In first or last place, victory circle or behind the wall, the black GM Goodwrench Chevrolet could not be deprived of its respect. Who would have ever guessed that the legendary Dale Earnhardt’s life would be taken from him on the last lap of the biggest race of 2001? Dale Earnhardt was born on April 29, 1952. He was raised in Kannapolis North Carolina. Dale started racing at age twelve and won his first race at age fifteen. After winning his first race Dale decided that this was what he wanted to do as a career. Dale dropped out of high school in the ninth grade. Dale’s parents did everything they could to try to keep him in school but they were unable to. Earnhardt would soon find out just how hard it would be on him and his future career though. Dale Earnhardt came from a family of stock car racers. Dale’s father being a racer himself knew how hard it was to start racing. That is the main reason he tried to keep Dale from dropping out of high school to race. â€Å" They even offered Dale a new car to keep him in high school.† (1:72) Dale Earnhardt’s grandfather was also a racer. Dale was not very close to him though. â€Å"In an interview Earnhardt said that he regretted not knowing his grandfather very well. Earnhardt also mentioned the fact that his actions as a kid were embarrassing to him now.†(1:73) Being one of the most dominant drivers on the track, Dale quickly earned the nickname the Intimidator. Dale won his first Winston Cup championship in 1980. After his first Winston Cup championship Dale went on to earn 6 more championships to tie Richard Petty with 7 victories. The nickname Intimidator fit Dale very well. â€Å"He was known for causing wrecks to move himself up in the race.† (1:73) After several complaints from other drivers... ....†(6:1). Nobody can truly say what exactly happened that day and who knows if NASCAR will tell the truth in August but at least we will be closer to an answer than we are now. Earnhardt is the driver, the reason, and the person that made NASCAR is what it is today. Darrel Waltrip said it best when he said, â€Å"We have lost the best thing that ever happened to NASCAR†(6:1). As a renegade teenager or even a little fearsome racer, Earnhardt was the man who always came through. The legacy will be passed on through Dale Jr. and the Earnhardt name will be respected for the years to come. Sure NASCAR will get over this tragedy in time, but there will always be some trace of Intimidator, Dale Earnhardt. Works Cited 1. Pare, Michael A. Sports Stars, Detroit/ Michigan: U-X-O Publishing Co. 1998. 2. Bondi, Victor. American Decades 1980-1989, Detroit/Michigan: Gale Research Inc. 1996 3. Dodge, Herb. â€Å" We’ve Lost Dale Earnhardt,† Speedway Illustrated, (April 21, 2001) pgs. 72-85. 4. Bartlett, Jeff. â€Å"Circuit Breaker,† The End of an Era, (April 16, 2001) pgs. 2-5. 5. â€Å"Dale Earnhardt† www.daleearnhardt.com, online February 21, 2001. 6. â€Å"Dale† www.NASCAR.com, online February 21, 2001.

PFC Robert C. Burke-USMC :: essays research papers

  Ã‚  Ã‚  Ã‚  Ã‚  PFC Robert Charles Burke on 7 November 1949 in Monticello, Illinois and enlisted in the Marine Corps from Chicago, Illinois. The Marine died on 17 May 1968 in the Southern Quang Nam Province, Republic of Vietnam (South). He received the Congressional Medal of Honor posthumously for conspicuous gallantry and intrepidity at the risk of his life above and beyond the call of duty. PFC Burke was serving as a machine gunner with Company I, 3d Battalion, 27th Marines (3/27), 1st Marine Division (REIN), FMF.   Ã‚  Ã‚  Ã‚  Ã‚  The citation, which was signed by then President Richard M. Nixon, reads as follows:   Ã‚  Ã‚  Ã‚  Ã‚  Ã¢â‚¬Å"For conspicuous gallantry and intrepidity at the risk of his life above and beyond the call of duty for service as a machine gunner with Company I on Operation ALLEN BROOK. Company I was approaching a dry river bed with a heavily wooded tree line that borders the hamlet of Lee Nam, when they suddenly came under intense mortar, rocket propelled grenades, automatic weapon and small arms fire from a large, well concealed enemy force which halted the company’s advance and wounded several marines. Realizing that key points of resistance had to be eliminated to allow the units to advance and casualties to be evacuated. Pfc. Burke, without hesitation, seized his machine gun and launched a series of 1-man assaults against the fortified emplacements. As he aggressively maneuvered to the edge of the steep river bank, he delivered accurate suppressive fire upon several enemy bunkers, which enabled his comrades to advance and move the wounded marines to position s of relative safety. As he continued his combative actions, he located an opposing automatic weapons emplacement and poured intense fire into the position, killing 3 North Vietnamese soldiers as they attempted to flee. Pfc. Burke then fearlessly moved from one position to another, quelling the hostile fire until his weapon malfunctioned. Obtaining a casualty’s rifle and hand grenades, he advanced further into the midst of the enemy fire in an assault against another pocket of resistance killing 2 more of the enemy. Observing that a fellow marine had cleared his malfunctioning machine gun he grasped his weapon and moved into a dangerously exposed area and saturated the hostile tree line until he fell mortally wounded.

The Presidio San Elizario

The Presidio of San Elizario In 1598, the Spanish nobleman, Don Juan De Onate from Zacatecas, Mexico was leading a group of Spanish colonists from Mexico to settle the newly discovered province of New Mexico. The group traveled for weeks across the desert until it reached the banks of the Rio Grande River near the San Elizario area. Soon afterward, Onate proclaimed possession of this area in the name of his King, Phillip II. The small town of San Elizario is named after the French Saint Elcear, the French patron saint of the military.It is one of the oldest communities in the El Paso Area. The community was established during the late 1700’s. A presidio was built in the area in order to protect the Spanish settlers from the attacking Apache and Comanche Indian raiders. The exact date of when the presidio of San Elizario was first built remains a debate between many local historians. One well known area historian, Metz, writes, â€Å"The original presidio was built around 1773 and that the original chapel was built of mostly adobe and some wood, and took approximately 40 years to construct. Most of the work was done by prisoners, some of them Indian, mostly Apache. (254). As noted by an online source, the presidio itself was surrounded by a double wall of adobe measuring 13 feet tall by seven feet wide. Inside were barracks for soldiers and special officer quarters. Also within the fort were family residences, corrals, store rooms, and a small chapel. This small chapel was built in a box pattern reflecting the early â€Å"European colonialism. † (San Elizario). The chapel has gone through major changes throughout its history, yet still remains close to its original location to this day.As historian John O. West notes, the San Elizario Presidio is often mistaken as a mission. However, the presidio of San Elizario was not created to convert the local natives to Christianity, but in fact was created as a fort or presidio to protect the Camino Real an d other area settlements from Apache and Comanche Indian raiders. (19). An online source also notes that the presidio was involved in numerous military engagements and natural disasters which forced its movement many times throughout it’s early history. (Reyes).According to another historian, Douglas Kent Hall, â€Å"The presidio was moved 37 miles up the Rio Grande in 1780 to its current site. † (131). According to another internet source, â€Å"During the early 1830’s the unpredictable Rio Grande River changed course, virtually isolating San Elizario and its surrounding communities as an island in the middle of the Rio Grande. † (San Elizario). After the US-Mexico War of 1846-1848, the Treaty of Guadalupe Hidalgo was signed, establishing the Rio Grande River as the boundary between Texas and Mexico.This left San Elizario to become part of what is now the state of Texas. San Elizario is steeped in both Texas, and Hispanic history. Still remaining today, the San Elizario presidio and chapel has moved many times and gone through many changes since its original construction. One online source notes, in 1829, the Rio Grande flooded completely destroying the â€Å"Chapel at San Elizario. † (San Elizario). A different Website points out that the chapel that stands in the same location today was rebuilt in 1882. (Kohut). Another online source notes, the exterior has changed little from its original construction.The main difference was in the change of the front â€Å"facade,† as this added to the, â€Å"early European colonial,† influence on the contemporary construction of the time. A fire destroyed much of the interior of the chapel in 1935. The inside has undergone dramatic changes since then, again reflecting the influence of â€Å"European architectural style. † With â€Å"pressed-tin† covering the original ceiling covers and beams. Several additions have also been made to the exterior of the chapel . For instance, an orchard has been added to the east side of the chapel and the surrounding plaza.More adobe structures have also been added to the surrounding area in order to add to the formality of the area. The formal rectangular patterned streets and building orientation â€Å"reflects the elements of early Spanish colonialism. † In 1944 the chapel was repainted in order to honor the local soldiers who fought overseas in World War II. (San Elizario). A local college student writes in the Borderlands Website that a â€Å"major restoration of the chapel† began in 1993, however much work still needs to be done to the exterior walls of the structure.The Mission Trail Association, which was formed in 1986, has done much work to uphold the heritage of the chapel at San Elizario and other local Missions. Through their hard work, the Socorro and Ysleta missions, along with the San Elizario chapel have retained their beauty and strength through hundreds of years of faith and devotion. (Reyes). With the help of the Mission Trail Association and donations from tourists and local interest in its preservation, the San Elizario chapel can be a monument for many more generations to enjoy. Works Cited Hall, Douglas Kent.Frontier Spirit: Early Churches of the Southwest. New York: Abbeville Press, 1990. Print. Metz, Leon C. El Paso: Guided Through Time. El Paso, Texas: Mangan Books, 1999. Print. West, John O. â€Å"Presidio Chapel San Elceario: San Elizario, Texas, USA. † The Mission Trail: El Paso/Juarez. Ed. Laura Jusso. El Paso, Texas: Sundance Press, 1996. Print. Reyes, Blanca et al. â€Å"Area Missions are Part of Living History. † Borderlands. Web. 22 Jan 2009. â€Å"San Elizario Walking Tour. † El Paso County History. Web. 18 Dec 2009. Kohout, Martin D. â€Å"San Elizario Presidio. † Handbook of Texas Online. Web. 23 Apr 2009.