By J. Knut. Clinch Valley College.

PRESSING ETHICAL ISSUES OF CONCERN TO PAIN CLINICIANS A recent survey of the membership of the American Pain Society and the American Academy of Pain Medicine was conducted to determine beliefs about ethical dilemmas in pain management practice (Ferrell et al discount zestoretic 17.5mg on line. The five issues that were found to raise the most frequent ethical concerns in the to- tal sample (N = 1 generic zestoretic 17.5mg free shipping,105) were (in rank order): (a) management of pain at the end of life; (b) general undertreatment of pain; (c) undertreatment of pain in the elderly; (d) impact of managed care on pain treatment; and (e) under- treatment of pain in children purchase zestoretic 17.5mg without a prescription. Among psychologists (N = 166) cheap 17.5mg zestoretic otc, the top five is- sues of ethical concern were ranked as follows: (a) general undertreatment of pain; (b) management of pain at the end of life; (c) undertreatment of pain in the elderly; (d) undertreatment of pain in children; and (e) accept- ing patients’ self-report of pain safe 17.5mg zestoretic. Scientific evidence shows that concerns about undertreatment of pain among specific populations have a factual basis. For example, Bauchner 338 HADJISTAVROPOULOS (1991) conducted a study at a U. Evidence for inadequate analgesia in children during and after surgery has also been obtained by other researchers (e. Similarly, seniors with dementia also tend to be undertreated for pain problems. Despite the lack of evidence that dementia reduces pain-related suffering (e. Marzinski (1991) found that although 26 of 60 inpatients with Alzheimer’s disease had painful conditions, only three patients had orders for routinely scheduled analgesics. Although psychosocial treat- ments for pain are available in many communities (e. Consequently, seniors are less likely to benefit from and participate in such treatment programs. In North Carolina, for example, a health professional was found liable for failing to treat pain adequately (Estate of Henry James v. Specifically, the jury deemed that Henry James’ dying days were made intolerable by the decision of a nurse and her employer (a nursing home) to reduce or withhold medication ordered by the patient’s physician. Cassidy and Walco (1996) examined whether the undertreatment of pain can be construed as ethically justifiable from any one of three philosophical perspectives. The possible justifications were: (a) the revisionist justifica- tion (i. Cassidy and Walco concluded that, given the lack of evidence for clinically significant reductions in pain sensi- tivity in undertreated populations and that the internal state of pain is not directly observable, the revisionist perspective is not tenable. The compar- ative justification is based on the view that the means of alleviating pain are sometimes more harmful than the pain itself. Although this can be true in rare instances, it would almost never apply to competently designed psy- chosocial interventions which are the focus of this volume. In terms of the pragmatic justification, pain can sometimes produce a positive outcome as it warns about injury or disease and alerts for the need for treatment. It can, therefore, be concluded that none of these justifications are typically applicable to populations that are neglected and undertreated and/or for whom effective psychosocial treatments can be de- veloped or are available. Hicks (2000) suggested that ethically sound pain management depends on professionals’ understanding of themselves. That is, clinicians need to analyze and assess their own beliefs about what constitutes quality of life when it comes to specific patient groups (including patients with cogni- tive impairments). They also need to ask themselves how much they value quality of life for the patient. Second, clinicians should analyze their views and feelings about specific patient populations (e. Do they sometimes see nursing home residents not as persons, but as a commodity that is cared for in exchange for money? Finally, Hicks (2000) suggested that clinicians should understand their views about clinical care and pain management. Clinicians who believe primarily that their role is to do no harm may provide care that is quite different from those who believe that their primary role is to do good. According to Hicks, patient-focused care is most attainable when the clinician carefully analyzes his or her own views and beliefs about clinical management. The area of pain assessment also raises a variety of concerns for clini- cians (i. After reviewing histopatho- logical findings, Giles and Crawford (1997) showed that physical evidence of many legitimate soft-tissue injuries cannot be detected by conventional medical imaging procedures because of device limitations. The lack of such objective evidence has resulted in many conflicts and disagreements, espe- cially in cases where pain patients make compensation and insurance dis- ability claims.

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New tech- niques for care and preventive measures for colon and rectal can- cer are constantly being sought buy zestoretic 17.5mg free shipping. Although their area of expertise is narrowly focused order 17.5mg zestoretic with mastercard, the prerequisite training in general surgery gives these specialists a good working knowledge of internal medicine purchase zestoretic 17.5mg with amex. This is important because many conditions that colon and rectal specialists treat originate elsewhere in the body zestoretic 17.5mg mastercard. Average salaries range from $158 order zestoretic 17.5 mg without a prescription,000 to $318,000 a year for practitioners. Colon and rectal surgeons have one of the longest training pro- grams in medicine. Completion of a five-year program in general surgery is a prerequisite to a one- or two-year residency in colon and rectal surgery. There were only 60 residents active at 37 accred- ited training programs in 2002; 14 percent were women. Neurological Surgery Neurological surgery, better known as neurosurgery, is the diagno- sis, evaluation, and treatment of disorders of the central, periph- eral, and autonomic nervous systems. Practitioners use high-tech equipment such as magnetic resonance imaging (MRI) to diagnose problems. They also meet with patients for regular physical exam- ination in the office. This can be a highly stressful and demanding specialty because it deals with the brain. The variation in outcomes is great; there are remarkable interventions and profound disappointments, as when a patient dies despite heroic intervention. The brain is a fascinating organ, and we are just beginning to understand its mysteries. Surgery and Surgical Specialties 57 The threat of malpractice is greater in neurosurgery than in some other specialties; as a result, insurance premiums are extremely high, as much as $300,000 a year in some states. The hours are long, and because neurosurgeons treat accidents and brain disorders that erupt suddenly, they may be called at any hour of the day. Because of the serious nature of the problems neurosurgeons deal with, prac- titioners get to know their patients well. Neurosurgeons treat brain and spinal cord cancers, hydrocephalus, lumbar and cervical disc disease, aneurysms, and head and spinal cord trauma. Neurosurgeons must be excellent problem solvers, and they must also understand the logic of anatomy, physiology, and integration of the nervous system. Neurosurgeons see a wide variety of conditions and serve a range of ages. They move between hospital visits, the operating room, and office settings. Neurosurgeons rank among the highest paid specialists, often earning more than $400,000 a year. In 2002 there were 778 residents at 94 accredited training pro- grams in neurosurgery. A year of a general surgery residency is required as well as a five- year residency in neurosurgery. Ophthalmology Ophthalmology is one of several surgical specialties without the word surgery in its title. Ophthalmology brings surgical, medical, and diagnostic prowess to the diseases and abnormalities of the eye. Because they work on such a small and delicate part of the body—the eye—ophthalmologists must possess excellent eye-hand coordination and technical skill. Ophthalmologists must be knowledgeable about optics, refraction, and visual physiology. While some of their patients are seen for only one procedure, ophthalmologists often have long-term relationships with patients who have vision problems. Because they face few life-and-death sit- uations, ophthalmologists deal very little with ethical issues like the right to die. Ophthalmologists spend time in office treatment as well as in the operating room. Ophthalmologists’ hours are much more controlled than are those in many other specialties. Annual average gross income ranges from $129,000 to $287,000, and liability insurance premiums are about average. There were 1,290 residents in 121 accredited training programs in ophthalmology in 2002.

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In older children (2–5 years) systemic con- ditions such as sickle cell anaemia or chest pathology (e cheap zestoretic 17.5mg with mastercard. Imaging in cases of acute abdominal pain is dependent upon the clinical symp- toms purchase zestoretic 17.5 mg online, suspected clinical diagnosis and the age of the child zestoretic 17.5mg free shipping. Plain film radiogra- phy of the chest and abdomen or abdominal and pelvic ultrasound may both be 10 considered as first-line imaging investigations and the imaging protocols are likely and to be dependent upon modality availability and local expertise buy cheap zestoretic 17.5 mg line. Vomiting Vomiting is an extremely common non-specific sign of abdominal pathology order zestoretic 17.5mg without prescription. However, the character of the vomitus and the age of the child can assist in the provision of a differential diagnosis (Table 5. Imaging is not routinely indicated in cases of isolated childhood vomiting, but where the vomiting is projectile and sustained, hypertrophic pyloric stenosis should be suspected and ultrasound performed9. Age Non-bilious vomit Bilious vomit Birth–2 months Gastroesophageal reflux Midgut volvulus Pyloric stenosis Small bowel obstruction Bowel atresia Hirschprung’s disease 2 months–2 years Rarely an organic cause Small bowel obstruction Intussusception Midgut volvulus Over 2 years Most causes not related to gastrointestinal tract abnormality The abdomen 77 Table 5. Age Cause of bleeding Neonate Necrotising enterocolitis Infectious colitis Infant Stress ulcer Meckel’s diverticulum Intussusception Child Polyp Inflammatory bowel disease Gastrointestinal bleeding Causes of intestinal bleeding are listed in Table 5. Scintigraphy is the imaging modality of choice to locate the source of an intestinal bleed. However endoscopy, in preference to barium studies, and ultrasound may demonstrate changes associated with inflammatory bowel disease or intussusception9. Constipation Abdominal radiography will show extensive faecal material as a normal feature in many children and therefore imaging is not helpful in the diagnosis or man- agement of constipation and should not be performed routinely9. Chronic diarrhoea Chronic diarrhoea is a non-specific sign of abdominal pathology. Clinical diag- nosis relies heavily on patient medical history and the pathological assessment of stool specimens. Barium examinations, if undertaken, may show signs of inflammatory bowel disease. However, for many patients presenting with diar- rhoea as a result of a small bowel mucosal disorder, only a non-specific malab- sorption pattern (thickened mucosal folds, bowel wall oedema, barium 6 flocculation) will be seen and, in these cases, more invasive diagnostic investi- gations (e. Gastric dilatation An over-distended gas-filled stomach can result from air swallowing during crying and is therefore a common finding on plain film radiographs of young infants and children. Only when little or no air is seen in the bowel distal to a distended stomach should concerns be raised and gastric outlet obstruction 4 considered. However, general preparation such as providing a procedural explanation will be necessary in order to gain the child’s confidence and co-operation, and such an explanation should be modified to accommodate the child’s level of under- standing. It is not always necessary to undress a child fully for plain film radi- ography of the abdomen but, when required, an appropriately sized examination gown should be provided. It is often possible to move clothes away from the area of interest without removing them entirely and this helps to maintain the dignity of the child. It should be remembered that even relatively young chil- dren are aware of their own sexuality and will feel uncomfortable with their clothes removed in the presence of strangers. In male children, underpants can be left on and lowered to the level of the symphysis pubis while still covering the genitalia. Lowering the underpants in this way also ensures that the testicles are displaced from the region of interest and are not within the primary beam (Fig. The antero-posterior projection of the abdomen, with the patient in the supine position, is the initial projection of choice for paediatric abdominal referrals. Additional antero-posterior projections with the patient erect or lying in the lateral decubitus position are occasionally necessary, but these projections should not be performed routinely. If a decubitus projection is required to demonstrate ‘free air’ within the abdomen then the left lateral decubitus is preferable to the Fig. In addi- tion, if perforation is suspected then an erect chest projection should also be undertaken as small amounts of free air under the diaphragm are easier to iden- tify on images produced using typical chest exposure factors. Supine abdomen Radiographic positioning for paediatric abdominal radiography is not signifi- cantly different to adult radiography of the abdomen although maintaining the correct position often requires the creative use of distraction and immobilisation techniques (Fig. To avoid rota- tion and movement prior to, or during, exposure the child’s hands are positioned near to their shoulders and held by the accompanying adult. A Bucky binder or sand bags may be applied over the child’s legs to aid immobilisation.

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