By G. Boss. Southern New Hampshire University.

OPERATING ROOM FIRES Historically discount buspirone 5mg fast delivery, operating room fires were associated with flammable anesthetics and static electricity buy buspirone 5 mg fast delivery. Although flammable agents have largely disappeared from modern operating rooms buy 5mg buspirone free shipping, fires and the mal- practice cases that can result from them unfortunately still remain cheap 5mg buspirone free shipping. Modern developments such as electrical cautery buspirone 5 mg low cost, lasers, and paper and plastic disposables have enhanced the surgical environment while add- ing new risks of fire. Three conditions must be present for a fire to occur in the operating room. These include drapes, dressings, gauze, surgical gowns, syringes, hair, gastrointestinal gases, petroleum-based ointments, and most plastics. Any concentration of oxy- gen in excess of 21% should be considered enriched. These gases can accumulate around the operative site as well as under drapes and in body cavities, such as the oropharynx. Ignition Source Heat sources typically include electrosurgical cautery, fiberoptic light sources, and lasers. Any combination of an oxygen-enriched environment, a flammable material, and a heat source in the same place at the same time is an accident waiting to happen. It is not uncommon to find patients receiv- ing oxygen-enhanced breathing mixtures while paper drapes, plastic endotracheal tubes, and electrical cautery are in use. Recently reviewed anesthetic and surgical malpractice cases have involved airway fires, combustion of surgical drapes, and facial fires from ignition near an oxygen mask or nasal cannula. From an anesthesiology standpoint, the most controllable variable is always the oxygen mixture delivered. Anesthesiologists named in claims involving fires may be called on to justify the indi- cations for the use of oxygen at the time of the fire as well as their decisions regarding the flow of oxygen used. Problems have arisen defending claims in which an anesthesiolo- gist was using oxygen prophylactically on a sedation case while the patient’s oxygen saturation was already high. An awareness of the risk of fire and communication between the surgeon and the anesthe- siologist can ensure that oxygen is turned off when an ignition source is in use or that oxygen is switched to air to prevent stuffiness under the surgical drapes. Oxygen tends to pool under the drapes and may require time to disperse even when switched off. When airway fires occur within the oropharynx, attention often focuses on whether an appropriate reinforced or laser endotracheal tube was used and whether there might have been an unnecessary oxygen leak. Reviewers of cases involving pediatric airway fires sometimes find that the oxygen delivered was actually in the adult range, many liters above the maximum minute ventilation of the child—possibly contributing to a large pooled oxygen leak. There will also likely be a determination of whether the endotracheal tube size was appropriate for the age of the child and whether the pressure at which the cuff leaked was quantified and documented by the anesthesiologist. If a fire develops in the operating room, a quick response can help limit the injury to the patient. Oxygen should be immediately eliminated until the fire has been extinguished. Drapes and other flammables should be removed from the vicinity of the fire immediately. Airway fires will likely require the removal and replacement of the endotracheal tubes. Patients who have sustained airway fires should be carefully moni- tored postoperatively for respiratory difficulties (5). Newly Identified Risks Although most of the risks of anesthesia have been known for decades, changes in perioperative techniques have added new risks, many of which have become apparent through the review of medical malpractice claims. Two of these risks, identified largely through reviews of adverse outcomes, are ischemic optic neuropathy in spine Chapter 10 / Anesthesiology 133 cases and respiratory arrests in sleep apnea patients after postopera- tive narcotics. ISCHEMIC OPTIC NEUROPATHY Ischemic optic neuropathy (ION) is the leading cause of blindness following general anesthesia. Depending on the surgical population, the incidence of ION has been estimated at between 0. TDC has noted an increased incidence of claims involving postopera- tive blindness or severe visual impairment following spine surgeries in which controlled hypotension was utilized. ION is a visual impairment that results from inadequate oxygen delivery by the vessels supplying the optic nerve.

In the red blood cell membrane discount buspirone 10mg on-line, for sium to leave the cell and sodium to enter the cell cheap 10mg buspirone overnight delivery. If example 5 mg buspirone with mastercard, most of the phosphatidylcholine is in the the permeability to K increases generic 5 mg buspirone, more potassium outer half order buspirone 10mg mastercard. Both ion channels and symporters are mem- would leave the cell, and the cell would become more brane proteins, not phospholipids. Membrane-spanning segments of in- decreases, less sodium would enter the cell, and the cell tegral proteins frequently adopt an -helical confor- would become less positive (hyperpolarize). Voltage-gated potassium channels nities for the polar peptide bonds to form hydrogen open with a delay relative to voltage-gated sodium bonds with one another in the hydrophobic interior of channels in response to depolarization. These segments are composed largely tantly, there is a delay in their closing relative to the of amino acids with nonpolar hydrophobic side chains sodium channels. During the afterhyperpolarization that interact with the surrounding lipids. There are no phase of the action potential, the sodium channels are covalent bonds with cholesterol or phospholipids, and closed, but the potassium channels remain open. An outward calcium cur- membrane potential that develops when a single ion is rent, an outward sodium current, or an inward chloride distributed at equilibrium across a membrane. The current could conceivably hyperpolarize the cell, but Goldman equation gives the value of the membrane these currents are not the basis for this phase of the ac- potential when all permeable ions are accounted for. A specialization occurs in myelinated sure of a solution, and Fick’s law refers to the diffu- axons in which the voltage-gated sodium channels are sional movement of solute. The permeability coeffi- preferentially distributed to the axonal membrane be- cient accounts for several factors that determine the neath the nodes of Ranvier. Intracellular K is high compared action potential jumps from node to node. Active transport always moves solute ance and a decreased capacitance associated with the against its electrochemical gradient. All the other op- myelinated regions of the axon, both of which pro- tions are shared by both active transport and equili- mote the electrotonic spread of the positive charge brating carrier-mediated transport systems. Nongated ion channels available at the terminals, using enzymes that reside in are not involved in the generation of action potential. Myelin contributes substantially to by ribosomes, which are not found in axons or termi- the effective membrane resistance, Rm. The supply of peptide transmitters in the axon stant increases as Rm increases because it is more diffi- terminal must be continuously replenished via axoplas- cult for ions to flow across the membrane relative to mic transport from the cell body. When essential component of axoplasmic transport; disrupt- an axon demyelinates, its space constant decreases and ing their integrity would diminish axonal transport and conduction velocity is slowed. GABA is the major inhibitory trans- deficits associated with multiple sclerosis. Activity of the GABA system sponsible for docking and binding synaptic vesicles to is widespread in the brain, and a disruption of GABA the presynaptic membrane to prepare them for release. The acute onset of symptoms in both tion of SNARES has no direct effect on other compo- people suggests food poisoning and not a chronic dis- nents of neurochemical transmission, including action order or a stroke. A toxin that blocked nerve-muscle potential propagation, transmitter-receptor interac- transmission would produce muscle paralysis or weak- tion, or uptake mechanisms. Spatial summation of synaptic poten- suggests abnormally high excitability and firing of sen- tials can occur if they are close enough that the space sory nerves. Ciguatera toxin, the product of a dinofla- constant spans the two synapses; therefore, properties gellate that sometimes contaminates red snapper and of the cell that increase the space constant would opti- other reef fishes, is probably the cause of the sensory mize the effectiveness of the two synapses. Ciguatera constant increases with increasing membrane resist- toxin binds to voltage-gated sodium channels and re- ance or decreasing cytoplasmic resistance. Temporal summation could also increase the conduction velocity because the action potential will effectiveness of the two synapses; this would be facili- no longer “jump” from node to node. Acetylcholinesterase is the enzyme tentials) will be more spread out and will have a slower that breaks acetylcholine down into acetate and rate of rise than normal. Blocking the function of opening of voltage-gated calcium channels and entry acetylcholinesterase would prevent the breakdown of of extracellular calcium into the nerve terminals. Defi- ACh, which would accumulate in the cleft because cient acetylcholine release by motor nerve terminals there is no uptake mechanism for ACh and it diffuses could explain muscle weakness. Catecholaminergic transmission is ef- polarization phase of the nerve action potential de- ficient, in part, because there is a significant reuptake pends on voltage-gated potassium channels. The of the catecholamines for repackaging into synaptic upstroke of the nerve action potential depends on volt- vesicles to use again.

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An inflammatory process up-regulates adhesion molecules on endothelial cells 35 generic buspirone 5 mg with mastercard. Analysis of cerebrospinal fluid is helpful when the results of other tests are inconclusive b order buspirone 5mg mastercard. If your cerebrospinal fluid is negative cheap buspirone 10 mg without a prescription, it will confirm that you do not have MS c buspirone 10mg cheap. Examining your cerebrospinal fluid will help us predict the course of your disease d buy cheap buspirone 5 mg on-line. A positive result from the cerebrospinal fluid is a definitive test for MS 36. Presence of Lhermitte’s sign 120 NURSING PRACTICE IN MULTIPLE SCLEROSIS: A CORE CURRICULUM 38. In patients who are being treated with steroids, side effects to report include: a. When assessing a patient who complains of cognitive difficul- ties, which of the following would you expect to see? In a woman age 32 who has had MS for 3 years, the risks of pregnancy can be explained as follows: a. Pregnancy has no long-term effect on your disease course but you may have an exacerbation in the postpartum months d. Signs of depression can indicate an acceleration of the disease process c. Depression is an unusual and serious sign in MS CHAPTER 22: CERTIFICATION STUDY QUESTIONS 121 44. When assessing a patient with MS, which of the following is a primary symptom: a. Which intervention would be most effective to decrease the intensity of MS symptoms? Which of the following would indicate that the patient has bladder dysfunction? Which of these instructions would you give to a patient who is experiencing bowel dysfunction? The anticholinergic medication that you are taking will decrease constipation b. When teaching a patient who has cognitive impairment due to MS, all of the following are appropriate except: a. Teaching in a familiar setting 122 NURSING PRACTICE IN MULTIPLE SCLEROSIS: A CORE CURRICULUM Answers to Certification Questions 1.

They are derived from particular factual disputes and proven 5mg buspirone, after articulation of them by the court as a guiding principle for future cases generic buspirone 10mg on line, have the force of stare decisis or precedent buy buspirone 5 mg fast delivery. Precedent is to be followed by future courts unless it is has outlived its usefulness or no longer makes sense 10 mg buspirone free shipping. That decision is made by an intermediate appellate court or the highest court in that state or by the legislature order buspirone 10 mg otc. When the defendant in a profes- sional liability case is the federal government or its employees, or arises under particularly defined circumstances that implicate federal law, 20American Bank & Trust Co. Chapter 2 / Litigation 23 then federal courts decide the dispute according to federal statutes and federal common law. All statutes—federal and state—must be interpreted or applied by courts to particular facts. This naturally gives courts some leeway to clarify the application of the statute and, by so doing, put an additional gloss on its plain language. If a statute is itself a statement of the common law, there is authority that a court can just amend it by inter- preting it in light of changing circumstances and conditions. When statues are amended in ways a legislature does not like, it can “correct” the court’s interpretation by restating or further amending the statute. In interpreting statutes courts must look to pertinent constitutional provisions, the purpose of the statute, how it relates to other statutes that also apply to the dispute, and to canons of statutory interpretation or aids in reading the text and ascertaining whether the enacting body “said what it meant, and meant what it said. A federal statute cannot be invalidated on constitutional grounds except by reference to the US Constitution. A state statute, however, must comply with both the federal and state constitutions as well as with federal statutory law that preempts the field. Although generally a stat- ute found in compliance with the US Constitution also satisfies its cor- responding state constitutional cognate, this is not always so. State constitutions sometimes provide greater protection to their citizens than analogous provisions of the federal constitution. The interplay between the hierarchy of courts and related statutes and constitutional provisions is an important dynamic to keep in mind when playing the litigation game. For example, from 1872 to 1975, California personal injury cases were governed by the rule of con- tributory negligence, a rule that by popular consensus was embodied in a statute unchanged in wording from when originally enacted. Another illustration of how the dynamic interplay between the rules of procedure, evidence and substantive liability can dispose of a mal- practice case short of trial is Martinez v. The plaintiff sued claiming that the doctor had not washed his hands and caused the infection. The doctor moved to summarily dispose of the case, presenting expert written testimony that there was no evi- dence he had caused the infection in plaintiff’s knee. Plaintiff opposed the motion, but did not submit any expert testimony contradicting the doctor; so the court ruled for the doctor. On appeal judgment was affirmed, the appellate court stating that the lower “court was presented with uncontroverted evidence that [plaintiff] could not prove at least one element [i. The Importance of the Players in the Litigation Game and of Storytelling The players include the parties, their attorneys, witnesses, and the court and jury (or in some cases, arbitrators). Chapter 2 / Litigation 25 of continuing it are likely riskier in terms of their self-interest than capping it. That assessment is an ongoing one based on the progress of the game and how application of the rules and the moves by the players stack up at any given time. Indeed, they are so essential that a popular saw holds that “any town that won’t support one lawyer, will always support two. If the lawyer makes a bad impression on others in that universe it hurts the client. It is largely through lawyers that the court and jury will assess you and your adversary, and determine who to favor in various decisions. Lawyers are, in essence, the main strate- gists and tellers of their clients’ stories. Your lawyer is also your guide through the legal labyrinth you must traverse; it is by and through your lawyer that, if you ask the right questions, you will learn the options available to win your case. Defendants in medical malpractice cases typically turn to their liabil- ity insurance company for a lawyer. Usually the carriers can be counted on to provide those they insure with well-qualified attorneys because they share with them the objective of winning. When the carrier informs you about the lawyer or law firm they have in mind to defend you, ask for a resume of the lawyer. Pick up the telephone if the lawyer has not contacted you first, and have a frank discussion about the attorney’s qualifications and experience.

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