Connor Baltz is interested in baseball and becoming a doctor. He enjoys playing baseball and wants to pursue a career in medicine to help others as a physician.
Benny is a 54-year-old man whose lifestyle puts him at high risk for cardiovascular disease. He has a sedentary job and lifestyle aside from walking his dog once a day. His diet is unhealthy and high in cholesterol. He smokes 40 cigarettes per day. His father died of a heart attack in his late 40s, indicating a genetic risk factor.
A discussion of Paediatric Surgical problems in General (Family) Practice. A gentle run through of common problems and what to do about them.
A document explaining some of this in a little more detail can be found here"
https://docs.google.com/document/d/111L_iPRi28D_atB41eoq_lh1H-rMWXI1uuapt_jyT5c/edit
This 3 sentence document discusses the work of Sir Isaac Newton and how he built upon the work and discoveries of those who came before him. Newton acknowledged that he was able to make his scientific discoveries and see further than others because he stood on the shoulders of the scientific giants who laid the foundation and made discoveries before him. Their prior work allowed Newton to take the next steps in scientific progress and discovery.
Paediatric Pain and Sedation from #EuSEM15nataliemmay
Slides from my talk at #EuSEM15 on the management of paediatric pain and sedation for procedures in the Emergency Department with tips to change your practice.
Este documento presenta los resultados de un estudio realizado para evaluar alternativas para reducir el caudal en el Canal del Dique mediante el angostamiento de la sección por sectores y la construcción de la esclusa de Paricuica. El estudio incluyó análisis hidrológicos y de modelación hidráulica y numérica de la zona costera para cuantificar los efectos físicos y ecológicos de las alternativas. La mejor alternativa seleccionada consiste en la construcción de diques y rellenos que permitan reducir el caudal
Connor Baltz is interested in baseball and becoming a doctor. He enjoys playing baseball and wants to pursue a career in medicine to help others as a physician.
Benny is a 54-year-old man whose lifestyle puts him at high risk for cardiovascular disease. He has a sedentary job and lifestyle aside from walking his dog once a day. His diet is unhealthy and high in cholesterol. He smokes 40 cigarettes per day. His father died of a heart attack in his late 40s, indicating a genetic risk factor.
A discussion of Paediatric Surgical problems in General (Family) Practice. A gentle run through of common problems and what to do about them.
A document explaining some of this in a little more detail can be found here"
https://docs.google.com/document/d/111L_iPRi28D_atB41eoq_lh1H-rMWXI1uuapt_jyT5c/edit
This 3 sentence document discusses the work of Sir Isaac Newton and how he built upon the work and discoveries of those who came before him. Newton acknowledged that he was able to make his scientific discoveries and see further than others because he stood on the shoulders of the scientific giants who laid the foundation and made discoveries before him. Their prior work allowed Newton to take the next steps in scientific progress and discovery.
Paediatric Pain and Sedation from #EuSEM15nataliemmay
Slides from my talk at #EuSEM15 on the management of paediatric pain and sedation for procedures in the Emergency Department with tips to change your practice.
Este documento presenta los resultados de un estudio realizado para evaluar alternativas para reducir el caudal en el Canal del Dique mediante el angostamiento de la sección por sectores y la construcción de la esclusa de Paricuica. El estudio incluyó análisis hidrológicos y de modelación hidráulica y numérica de la zona costera para cuantificar los efectos físicos y ecológicos de las alternativas. La mejor alternativa seleccionada consiste en la construcción de diques y rellenos que permitan reducir el caudal
Haiku Deck is a presentation platform that allows users to create Haiku-style slideshows. The document encourages the reader to get started creating their own Haiku Deck presentation on SlideShare by providing a link to do so. It aims to inspire the reader to try out Haiku Deck's unique presentation style.
Este documento presenta la Ley General de Educación de México. Establece que la educación es un derecho de todos los mexicanos y que el Estado es responsable de proveer educación pública y gratuita de calidad a nivel preescolar, primaria, secundaria y medio superior. También define los objetivos y principios de la educación mexicana, como fomentar el desarrollo integral de los estudiantes, la democracia, la identidad nacional, los derechos humanos y la cultura. Finalmente, describe la estructura del sistema educ
The document is a scanned receipt from a grocery store listing items purchased including milk, eggs, bread, and fruit. The total for the grocery purchase came to $23.45 after tax. The receipt provides a record of the date, time, payment method, and items in a standard grocery transaction.
Este documento resume la investigación sobre el "voto económico", es decir, cómo los factores económicos afectan el comportamiento electoral. Explica que las crisis económicas suelen conducir a un mayor descontento público y castigo de los partidos gobernantes, especialmente si se les atribuye responsabilidad por la situación. Analiza cómo varios países europeos castigaron a los partidos gobernantes en las elecciones posteriores a la crisis financiera de 2008, aunque con matices dependiendo de los contextos nacionales. Finalmente, plantea la preocupación
This document is a magazine issue that discusses various extreme restaurants around the world. It begins with an introduction that notes people's increasing desire for adventure and unique experiences. It then profiles several restaurants that push boundaries through physical challenges, unusual settings, or interactive experiences. These include restaurants located on dangerous mountain hikes in China, serving potentially lethal pufferfish in Japan, simulating earthquakes in Spain, and dining in complete darkness or suspended over cities. The article explores restaurants around the globe, from underwater dining in the Maldives to theme restaurants in the US and Asia. It concludes by noting there is a wide variety of extreme dining options to suit different tastes, budgets, and risk levels.
This document discusses how conflict can negatively impact property investment worldwide. It describes several direct effects of conflict, including rapid declines in population from casualties and mass migration, as well as damage to infrastructure like homes and businesses. The document also explains indirect effects, such as economic downturns that hurt real estate values and development. Overall, conflict creates uncertainty that deters property investors until stability returns.
Este documento lista varios elementos de Internet que pueden ser útiles para la educación, incluyendo videos educativos en Youtube; wikis para compartir información; sitios educativos como Educar.com; plataformas de cursos en línea; correo electrónico y mensajería para comunicación; buscadores para encontrar información; blogs; aulas virtuales; repositorios en línea como Google Drive; y foros de discusión.
The document discusses the analysis and design of a G+1 framed structure using STAAD Pro software. It involves generating the 3D model in STAAD Pro, applying loads such as dead load, live load, wind load and seismic loads, analyzing the structure, and designing the reinforced concrete beams and columns. Loads considered include self-weight, imposed loads, wind loads calculated according to IS codes, and seismic loads. Beams are designed for bending moment, shear and torsion according to IS 456 and IS 13920. Columns are designed for axial force and biaxial bending according to IS 456. The results of the STAAD analysis and design are presented.
[CXL Live 16] How To Present Your Testing Results to Get Results by Lea PicaCXL
Are your executives and clients falling asleep during your testing presentations? Chances are your slide design and data visualizations are obscuring your valuable insights. With her special blend of neuroscience-based visualization principles, practical hands-on design techniques, and entertaining “tough love”, Lea will equip you with a fresh new toolbox that will get you and your data presentations remembered and acted upon.
Este documento proporciona instrucciones para el uso seguro y apropiado de un conservador de vinos, incluyendo consejos de seguridad, especificaciones técnicas, instrucciones de instalación, funcionamiento y mantenimiento. Explica cómo conectar y usar el aparato, ajustar la temperatura, limpiarlo y almacenar las botellas de vino de manera apropiada. También proporciona información sobre el desecho del embalaje y el aparato una vez que deje de funcionar.
These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPsychoTech Services
A proprietary approach developed by bringing together the best of learning theories from Psychology, design principles from the world of visualization, and pedagogical methods from over a decade of training experience, that enables you to: Learn better, faster!
TEST BANK For Community and Public Health Nursing: Evidence for Practice, 3rd...Donc Test
TEST BANK For Community and Public Health Nursing: Evidence for Practice, 3rd Edition by DeMarco, Walsh, Verified Chapters 1 - 25, Complete Newest Version TEST BANK For Community and Public Health Nursing: Evidence for Practice, 3rd Edition by DeMarco, Walsh, Verified Chapters 1 - 25, Complete Newest Version TEST BANK For Community and Public Health Nursing: Evidence for Practice, 3rd Edition by DeMarco, Walsh, Verified Chapters 1 - 25, Complete Newest Version Test Bank For Community and Public Health Nursing: Evidence for Practice 3rd Edition Pdf Chapters Download Test Bank For Community and Public Health Nursing: Evidence for Practice 3rd Edition Pdf Download Stuvia Test Bank For Community and Public Health Nursing: Evidence for Practice 3rd Edition Study Guide Test Bank For Community and Public Health Nursing: Evidence for Practice 3rd Edition Ebook Download Stuvia Test Bank For Community and Public Health Nursing: Evidence for Practice 3rd Edition Questions and Answers Quizlet Test Bank For Community and Public Health Nursing: Evidence for Practice 3rd Edition Studocu Test Bank For Community and Public Health Nursing: Evidence for Practice 3rd Edition Quizlet Test Bank For Community and Public Health Nursing: Evidence for Practice 3rd Edition Stuvia Community and Public Health Nursing: Evidence for Practice 3rd Edition Pdf Chapters Download Community and Public Health Nursing: Evidence for Practice 3rd Edition Pdf Download Course Hero Community and Public Health Nursing: Evidence for Practice 3rd Edition Answers Quizlet Community and Public Health Nursing: Evidence for Practice 3rd Edition Ebook Download Course hero Community and Public Health Nursing: Evidence for Practice 3rd Edition Questions and Answers Community and Public Health Nursing: Evidence for Practice 3rd Edition Studocu Community and Public Health Nursing: Evidence for Practice 3rd Edition Quizlet Community and Public Health Nursing: Evidence for Practice 3rd Edition Stuvia Community and Public Health Nursing: Evidence for Practice 3rd Edition Test Bank Pdf Chapters Download Community and Public Health Nursing: Evidence for Practice 3rd Edition Test Bank Pdf Download Stuvia Community and Public Health Nursing: Evidence for Practice 3rd Edition Test Bank Study Guide Questions and Answers Community and Public Health Nursing: Evidence for Practice 3rd Edition Test Bank Ebook Download Stuvia Community and Public Health Nursing: Evidence for Practice 3rd Edition Test Bank Questions Quizlet Community and Public Health Nursing: Evidence for Practice 3rd Edition Test Bank Studocu Community and Public Health Nursing: Evidence for Practice 3rd Edition Test Bank Quizlet Community and Public Health Nursing: Evidence for Practice 3rd Edition Test Bank Stuvia
Does Over-Masturbation Contribute to Chronic Prostatitis.pptxwalterHu5
In some case, your chronic prostatitis may be related to over-masturbation. Generally, natural medicine Diuretic and Anti-inflammatory Pill can help mee get a cure.
One health condition that is becoming more common day by day is diabetes.
According to research conducted by the National Family Health Survey of India, diabetic cases show a projection which might increase to 10.4% by 2030.
Haiku Deck is a presentation platform that allows users to create Haiku-style slideshows. The document encourages the reader to get started creating their own Haiku Deck presentation on SlideShare by providing a link to do so. It aims to inspire the reader to try out Haiku Deck's unique presentation style.
Este documento presenta la Ley General de Educación de México. Establece que la educación es un derecho de todos los mexicanos y que el Estado es responsable de proveer educación pública y gratuita de calidad a nivel preescolar, primaria, secundaria y medio superior. También define los objetivos y principios de la educación mexicana, como fomentar el desarrollo integral de los estudiantes, la democracia, la identidad nacional, los derechos humanos y la cultura. Finalmente, describe la estructura del sistema educ
The document is a scanned receipt from a grocery store listing items purchased including milk, eggs, bread, and fruit. The total for the grocery purchase came to $23.45 after tax. The receipt provides a record of the date, time, payment method, and items in a standard grocery transaction.
Este documento resume la investigación sobre el "voto económico", es decir, cómo los factores económicos afectan el comportamiento electoral. Explica que las crisis económicas suelen conducir a un mayor descontento público y castigo de los partidos gobernantes, especialmente si se les atribuye responsabilidad por la situación. Analiza cómo varios países europeos castigaron a los partidos gobernantes en las elecciones posteriores a la crisis financiera de 2008, aunque con matices dependiendo de los contextos nacionales. Finalmente, plantea la preocupación
This document is a magazine issue that discusses various extreme restaurants around the world. It begins with an introduction that notes people's increasing desire for adventure and unique experiences. It then profiles several restaurants that push boundaries through physical challenges, unusual settings, or interactive experiences. These include restaurants located on dangerous mountain hikes in China, serving potentially lethal pufferfish in Japan, simulating earthquakes in Spain, and dining in complete darkness or suspended over cities. The article explores restaurants around the globe, from underwater dining in the Maldives to theme restaurants in the US and Asia. It concludes by noting there is a wide variety of extreme dining options to suit different tastes, budgets, and risk levels.
This document discusses how conflict can negatively impact property investment worldwide. It describes several direct effects of conflict, including rapid declines in population from casualties and mass migration, as well as damage to infrastructure like homes and businesses. The document also explains indirect effects, such as economic downturns that hurt real estate values and development. Overall, conflict creates uncertainty that deters property investors until stability returns.
Este documento lista varios elementos de Internet que pueden ser útiles para la educación, incluyendo videos educativos en Youtube; wikis para compartir información; sitios educativos como Educar.com; plataformas de cursos en línea; correo electrónico y mensajería para comunicación; buscadores para encontrar información; blogs; aulas virtuales; repositorios en línea como Google Drive; y foros de discusión.
The document discusses the analysis and design of a G+1 framed structure using STAAD Pro software. It involves generating the 3D model in STAAD Pro, applying loads such as dead load, live load, wind load and seismic loads, analyzing the structure, and designing the reinforced concrete beams and columns. Loads considered include self-weight, imposed loads, wind loads calculated according to IS codes, and seismic loads. Beams are designed for bending moment, shear and torsion according to IS 456 and IS 13920. Columns are designed for axial force and biaxial bending according to IS 456. The results of the STAAD analysis and design are presented.
[CXL Live 16] How To Present Your Testing Results to Get Results by Lea PicaCXL
Are your executives and clients falling asleep during your testing presentations? Chances are your slide design and data visualizations are obscuring your valuable insights. With her special blend of neuroscience-based visualization principles, practical hands-on design techniques, and entertaining “tough love”, Lea will equip you with a fresh new toolbox that will get you and your data presentations remembered and acted upon.
Este documento proporciona instrucciones para el uso seguro y apropiado de un conservador de vinos, incluyendo consejos de seguridad, especificaciones técnicas, instrucciones de instalación, funcionamiento y mantenimiento. Explica cómo conectar y usar el aparato, ajustar la temperatura, limpiarlo y almacenar las botellas de vino de manera apropiada. También proporciona información sobre el desecho del embalaje y el aparato una vez que deje de funcionar.
These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPsychoTech Services
A proprietary approach developed by bringing together the best of learning theories from Psychology, design principles from the world of visualization, and pedagogical methods from over a decade of training experience, that enables you to: Learn better, faster!
TEST BANK For Community and Public Health Nursing: Evidence for Practice, 3rd...Donc Test
TEST BANK For Community and Public Health Nursing: Evidence for Practice, 3rd Edition by DeMarco, Walsh, Verified Chapters 1 - 25, Complete Newest Version TEST BANK For Community and Public Health Nursing: Evidence for Practice, 3rd Edition by DeMarco, Walsh, Verified Chapters 1 - 25, Complete Newest Version TEST BANK For Community and Public Health Nursing: Evidence for Practice, 3rd Edition by DeMarco, Walsh, Verified Chapters 1 - 25, Complete Newest Version Test Bank For Community and Public Health Nursing: Evidence for Practice 3rd Edition Pdf Chapters Download Test Bank For Community and Public Health Nursing: Evidence for Practice 3rd Edition Pdf Download Stuvia Test Bank For Community and Public Health Nursing: Evidence for Practice 3rd Edition Study Guide Test Bank For Community and Public Health Nursing: Evidence for Practice 3rd Edition Ebook Download Stuvia Test Bank For Community and Public Health Nursing: Evidence for Practice 3rd Edition Questions and Answers Quizlet Test Bank For Community and Public Health Nursing: Evidence for Practice 3rd Edition Studocu Test Bank For Community and Public Health Nursing: Evidence for Practice 3rd Edition Quizlet Test Bank For Community and Public Health Nursing: Evidence for Practice 3rd Edition Stuvia Community and Public Health Nursing: Evidence for Practice 3rd Edition Pdf Chapters Download Community and Public Health Nursing: Evidence for Practice 3rd Edition Pdf Download Course Hero Community and Public Health Nursing: Evidence for Practice 3rd Edition Answers Quizlet Community and Public Health Nursing: Evidence for Practice 3rd Edition Ebook Download Course hero Community and Public Health Nursing: Evidence for Practice 3rd Edition Questions and Answers Community and Public Health Nursing: Evidence for Practice 3rd Edition Studocu Community and Public Health Nursing: Evidence for Practice 3rd Edition Quizlet Community and Public Health Nursing: Evidence for Practice 3rd Edition Stuvia Community and Public Health Nursing: Evidence for Practice 3rd Edition Test Bank Pdf Chapters Download Community and Public Health Nursing: Evidence for Practice 3rd Edition Test Bank Pdf Download Stuvia Community and Public Health Nursing: Evidence for Practice 3rd Edition Test Bank Study Guide Questions and Answers Community and Public Health Nursing: Evidence for Practice 3rd Edition Test Bank Ebook Download Stuvia Community and Public Health Nursing: Evidence for Practice 3rd Edition Test Bank Questions Quizlet Community and Public Health Nursing: Evidence for Practice 3rd Edition Test Bank Studocu Community and Public Health Nursing: Evidence for Practice 3rd Edition Test Bank Quizlet Community and Public Health Nursing: Evidence for Practice 3rd Edition Test Bank Stuvia
Does Over-Masturbation Contribute to Chronic Prostatitis.pptxwalterHu5
In some case, your chronic prostatitis may be related to over-masturbation. Generally, natural medicine Diuretic and Anti-inflammatory Pill can help mee get a cure.
One health condition that is becoming more common day by day is diabetes.
According to research conducted by the National Family Health Survey of India, diabetic cases show a projection which might increase to 10.4% by 2030.
Our backs are like superheroes, holding us up and helping us move around. But sometimes, even superheroes can get hurt. That’s where slip discs come in.
Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
Adhd Medication Shortage Uk - trinexpharmacy.comreignlana06
The UK is currently facing a Adhd Medication Shortage Uk, which has left many patients and their families grappling with uncertainty and frustration. ADHD, or Attention Deficit Hyperactivity Disorder, is a chronic condition that requires consistent medication to manage effectively. This shortage has highlighted the critical role these medications play in the daily lives of those affected by ADHD. Contact : +1 (747) 209 – 3649 E-mail : sales@trinexpharmacy.com
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
18. Some people believe football is
a matter of life and death. I am
very disappointed with that attitude.
I can assure you it is much,
much more important than that.
Bill Shankley
Editor's Notes
Ladies and Gentlemen, It my pleasure to speak to you today at this conference. I hope you will find what I have to say is of value and I welcome your feedback afterwards about both the content and the nature of the presentation. My name is Ross Fisher and I am the Lead Surgeon for Trauma at Sheffield Children's Hospital. Previously I worked at Leicester Royal and was directly involved in the Regional Trauma Re-Organisation. As part of the British Association of Paediatric Surgeons I was Chair of the Trauma Group from 2008-2011 and was part of the Clinical Advisory Group for the Nation Trauma Re-organisation project so I have a fair handle on the Trauma Re-organisation project. Additionally I am the Chairman of TARNlet, the Trauma Audit and Research Network which analyses data on trauma management across the country so I have a fair handle on some of the numbers involved. So when asked to speak on trauma from a surgeon's perspective I thought that rather than talk about the blood, gore and clever operations I have done I thought it might be helpful, in the context of your network meeting to explain, from THIS surgeon's perspective how Paediatric trauma management and re-organisation will affect us all.
Trauma is biggest cause of death in childhood 50% of deaths in 1-15 year olds are due to trauma of one type or another, prinicipally RTA. In 2011 there 184 trauma deaths 150 at the scene/before transfer 34 in hospital
500 major trauma admissions in the UK in 2011 431 children underwent surgery 265 admitted to ITU/HDU with a mean length of stay of 6.5 days
Overall survival of these 500 children suffering major trauma is 93% It is within this context that we operate.
What is clear is that to survive, this cyclist requires the rapid and co-ordinated delivery of the combined efforts of a large, multi-disciplinary team. Out of what often appears only semi-ordered chaos comes a successful outcome in over 93% of major paediatric trauma cases. It may not seem like that to the casual observer but it strikes me that trauma is a team sport.
The analogy of trauma as a team sport may initially be hard to grasp but I felt it might be interesting to discuss and highlight some of the changes in trauma management around this concept of a team sport, rugby. To some it is just grown men fighting, to other observers there lots of screaming and grunting associated with violence, injury and blood. In fact it might be a trauma room. Indulge me a little A rugby team is made up of 15 players, some huge, some surprisingly small, each with specific individual roles for which they have been selected and positioned. But within the team these roles are often swapped due to the flow of the game with the designated runner being required to tackle and the huge forward finding himself required to run and pass. The success of the team is balanced on the coordination of these individuals to keep the ball from the hands of the opposition and safely deliver it to the try line by any means possible. Let's look at some of the roles and recent changes to their play.
Anyone with even just a passing interest in rugby knows that the majority of work is done by the forwards and it strikes me this is easily represented by the Emergency Department. Unsung heroes, seldom identified as individuals, working more as teams who take the brunt of the assault from the enemy aiming to stifle their attack and deliver the ball for our team to prosper from. One of the more significant changes in trauma management that the re-organisation will bring around is that major trauma units will see an increased activity as smaller units are formally bypassed. What many previously saw as the hand to hand combat over receipt of major trauma patients is being revolutionised by the development of effective trauma teams to receive, resuscitate and investigate such patients as well as the dramatic increase in specialisation and expertise of staff within units. The continued development of team leadership skills, resuscitation skills as well as targeted investigative skills are essential to the progress of trauma management.
One constant at virtually every major trauma are the anaesthetists, essential in the onward investigation and movement of the patient. The tongue sticking out is constant too! The advances in understanding of trauma pathophysiology owe a sad debt to civillians and military personnel in Afghanistan and Iraq where so much has been learned at some cost in recent years. One of the most dramatic changes to the prespective on trauma has been a better understanding of damage control resuscitation. The movement away from colloid/crystalloid infusion to massive blood and blood production infusion, targeted management of acute traumatic coagulopathy, permissive hypotension and urgent damage control laparotomy has been clearly shown to improve survival in exsanguinating injuries. And it is these injuries which lead to the majority of deaths. Whilst many in rugby see the sniping annoying scrum half as simply obstructing play it is clear that they are the playmakers facilitating both resuscitation and investigation and the onward movement of the patient.
The general surgeons. We like to see ourselves as the ball carriers, the real play makers. We certainly look to our big brothers in adult surgery involved in large numbers of life or death surgeries and are in awe, or, more likely, fear. Children are less likely to stabbed or shot than adults but our young adults do like to play grown ups so that remains an issue. What kills most children is blunt abdominal trauma sustained usually as a result of road traffic accidents. The place for urgent splenectomies or hemi-hepatectomies in paediatric surgery is thankfully rare as there is clear evidence of the value in decreased morbidity, mortality and blood use overall in the non operative management of such injuries. The place to manage such injuries is of course the intensive care unit and here we require a close co-operation with our intensive care colleagues. So bear with us whilst we shy away from major laparotomies where we need to pack livers and perform heroics. We've got evidence to back our reluctance! Er conservative management... There does remain a very small subgroup of major trauma patients that will require urgent surgery. Bleeding is what kills salvageable patients. And uncontrollable haemorrhage is what scares us. I really don't “do” blood. I can go a whole operating list and truly spill less blood than the anaesthetists. So faced with uncontrolled haemorrhage I'm not happy. One of the reasons alluded to above is that we just don't see such in our training. So I went off and got myself a bit better trained by doing the Definitive Surgical Trauma Skills course where I learned an awful lot. The essential in uncontrolled bleeding is NOT replacing blood with clear fluid, NOT wondering which investigation to carry out and NOT standing around wondering whether to operate or not but to “Get in, quick, stop the bleeding and get out.” It ain't pretty and it certainly isn't minimally invasive but it is the only way to stop the problem. And here we will often “phone a friend” to come help. The essential of the damage control laparotomy is precisely that, not an opportunity to fix everything but merely to assess the damage, stop the bleeding and GET OUT to allow you guys to fight the trauma triad of hypovolaemia, hypothermia and hypocoagulopathy. Teamwork.
Neurosurgery. Head injuries occurred in 79% of major paediatric trauma victims, was the cause of death in over half of in-hospital fatalities but only 17% of trauma victims underwent neurosurgery. The aim of management of closed head injuries is to prevent secondary damage and requires ventilation to normocapnia and urgent correction of hypovolaemia and hypotension. In this can be seen conflict with the proposed permissive hypotension approach for exsanguination and here the multi-disciplinary “team” approach to multi-system disorders is essential understanding that permissive hypotension is not a treatment goal but a necessary evil to be overcome as soon as possible by a damage control laparotomy.
The orthopods, bless them. The constant butt of everyone's jokes but we couldn't do without them. Whilst we are happy to leave them to straighten out the fractures it is important to remember that exsanguinating haemorrhage from pelvic fractures are a potentially fatal injury. The development of easily applied pelvic binders has superseded the need for complex external fixators. Rather than dismiss the 'pods in acute trauma management it is useful to consider the fact that a team is made of members who whilst they have specific titles should be able to take on any of the roles required. Whilst Martin Castrogiovanni is clearly not built for lightening pace there are many who tremble at the sight of 120kg of man mountain in full flight with the ball under his arm. Increasingly in trauma care the boundaries between specialities are blurring as the Trauma Surgeon develops, a ultilitarian, defined in one field but with experience and expertise in many. In the future I hope the role of specialist trauma physician will emerge as some scary hybrid of all the previously mentioned specialities.
ITU. So that's you lot? What can I say? Delicate pretty boys who come in once all the hard graft is done and scoop the glory, avoiding the carnage whilst everyone stands and watches unable to do anything? Harsh. And unfair. I don't have to tell you guys how trauma management has moved forward, how there is an increased burden of increasingly sick patients. Maybe what I should tell you is actually how much we all value what we do. The scariest thing ever said to me, in a previous hospital, when I asked for help from ITU, was “no”. Long story, and I eventually got the help I needed. We recognise that enormity of what you have to cope with as the trauma triad takes a hold and no-one else, save the prayers of the righteous, can do anything. we recognise how you pull patients back from beyond the precipice and offer hope when we think all hope is lost. We recognise that often it is you who are the most supportive and realistic with the families and you who draw back the multiple teams to ensure that the holistic nature of patient care, not just liver haematoma or lung contusion is managed. Thank you, you're doing a great job. Let's continue to work together as a team on this shall we?
This is one of the “back rooms” at Murrayfield. I highlight this because it would be arrogant and naïve to believe that we have covered all the major players involved in the delivery of advanced trauma care. Some may not wear numbers on their back or even appear pitchside but are an essential part of the team striving for success. whether that be radiology, physiotherapy, theatre staff, dietetics, pharmacy, occupational therapy and rehab, speech and language or the ward auxilliary. there are untold numbers without whose essential and developing input we would fail. It is important that as we develop our trauma networks to quantify and include the input of the backroom staff.
It may look like we are back to the forwards again but in this slide I wanted to highlight the change in practice that the trauma re-organisation will bring about in terms of patient transfer. Previously non specialised crews were detailed to “scoop and run” from incidents but more and more, as alluded to by Chris will there be specialised teams made up of highly trained paramedics and medical staff attending the scenes of major trauma and beginning the delivery of care both at site and during the transfer. Thus the blurring of roles of ED staff and transfer staff. Additionally transfer of the major trauma patient is no longer to the nearest casualty dept but to the definitive care facility of a Major Trauma Unit. As such we can consider Embrace as part of our forwards group as the transfer itself will not simply be an ambulance ride but part of the definitive care strategy. The communication and co-ordination to achieve this is being developed whilst protocols are established. The outcomes for patients will be audited and developed as part of trauma networks.
Which brings us to the suits. Nothing in medicine happens without people in suits and increasingly the ONLY people wearing suits are managers. The rest of us are naked. From the elbow down. The role of managers and commissioners in trauma management is important yet they are powerless once the team cross the white line as poor Martin Johnson learnt to his cost. The effective provision of resources, the support of data collation and audit, the integration of care pathways often across previous geographic boundaries, the attention to funding following the patient, the support and development of education, ALL are roles that are essential as the trauma networks are established and developed. Clinicians sometimes believe it all starts and ends with them but without effective engagement with the suits, trauma care will never reach its fullest potential.
Lastly, there are the supporters. Any sportsman, Olympians most recently, will tell you of the amazing effects of a partisan crowd. In trauma management, as a sport analogy I think the supporters are analogous to the smaller hospitals within the network, those without major Trauma unit designation; the Trauma Units and Local Emergency Hospitals. Whilst the intention is that the major trauma cases will be routed to bypass these smaller units there are two issues that will still require some trauma care to be delivered in the periphery. The first is a concerning statistic from the TARNlet database that shows that TEN % of children with major trauma were delivered to ED not by ambulance but by “other means”. In other words parents and carers are performing the “scoop and run” rather than waiting for advance care to arrive. As such, at least in the short term such units will still be receiving major trauma. Secondly, there is provision built into the guidelines that, if during a transfer and bypass, it is perceived that advanced care such as intubation is required, an ambulance may stop at a TU or LEH. Where previously the casualty would have then been admitted and initial care commenced it is envisioned that this care would be provided at the front door and the journey continued immediately. As such it can be seen that whilst peripheral hospitals will continue to have a supportive and rehabilitation role they may occasionally be required to step up into a more delivery role in the management of stabilising and transferring patients.
Which brings us to this. The pinnacle of sporting achievement if you are English. I'm Scottish. But as analogies go, this moment with Jonny Wilkinson kicking a drop goal to win the 2003 Rugby World Cup sums up the analogy of trauma as a team sport. With seconds to go and the match even the forwards had lumbered up the pitch to get within drop kick range, they channelled the ball back to the scrum half Matt Dawson who supplied Wilkinson who scored the winning point. It wasn't pretty and it wasn't orthodox, but England won. And so it is with trauma management- the coming together of a multi-disciplinary team, each playing their part to achieve victory.
Here's a wise man speaking about his view of a team sport. I think the analogy continues to work. Some people believe trauma management is a matter of life and death. It is, but I'm very disappointed with that attitude. I can assure you it is much MUCH more important than that.
I like to think that this slide answers one of life's great questions, are there any others?