Best Practice of Suturing Wounds Within Pre-Hospital Setting

Best Practice of Suturing Wounds Within Pre-Hospital Setting Title: Review of best practice of suturing wounds within the pre-hospital and emergency department setting. Essay Suturing as a treatment for cutaneous wounds has been known to mankind for millennia. The Indian Surgeon Susruta (AD c380-c450) described techniques for skin closure using flax, hemp, and hair. Jaws of the common black ant were also known to be used at about this time. Galen recommended silk and catgut in about 150 AD. A Roman, Avicenna, is credited with describing the first monofilament suture in the form of pig bristles for infected wounds. (Moy R L et al. 2002) Suture material may have evolved from the first recorded human hair and fibrous vegetable material to highly sophisticated sterile materials with integral needles, but the basic optimum technique of â€Å"closing dead space, supporting and strengthening wounds until healing increases their tensile strength, approximating skin edges for an aesthetically pleasing and functional result, and minimizing the risks of bleeding and infection.† are largely unchanged. (Scott M 1993) In consideration of this subject, this essay will consider suturing in the context of the suturing of wounds in an Accident and Emergency Dept. or the pre-hospital setting as opposed to other considerations of suturing that are possible. The different ways of suturing. There are a great many different ways to suture a wound. The method employed will depend on factors such as the site and nature of the wound as much as it depends upon the training and experience of the operator In the general context, wounds may be closed by either primary or secondary suturing. Primary suturing takes place shortly after the injury and requires minimal cleaning and preparation. Secondary closure takes place when a delay of more than 24 hrs has occurred and requires a surgical â€Å"freshening† of the wound to remove and infection and granulation tissue. The presence of reddening or oedema of the wound margins, discharge of pus, persistent fever, or systemic toxicity are indications that primary closure should not be attempted as any infection in the wound must be controlled before closure takes place. If the decision to suture is taken, this should ideally (with very few emergency exceptions) take place in controlled sterile surroundings with proper suturing equipment. In terms of different ways of suturing, one can note that the textbooks suggest many different varieties of mechanisms with varying degrees of sophistication for closing skin in different circumstances. In broad terms however, sutures can be interrupted (single) or continuous (running suture), transcutaneous or subcuticular. Associated Infection risks to suturing in the pre hospital setting and the emergency department There is a considerable literature relating to bite wounds and the rationale underpinning the decision whether or not to suture in the pre-hospital setting. The authoritative papers in this area have identified Staphylococcus, Streptococcus, Eikenella, Pasturella, Proteus, Klebsiella, Hemophilus, Enterobacter, Capnocytophaga carnivorous (DF-2) and Bacteroides species as being frequent contaminants of animal bite wounds and such wounds must receive careful antiseptic treatment prior to suturing. (Morgan M et al. 2007) One definitive study on the subject of whether prophylactic antibiotics are important over and above standard wound cleaning and debridement found that a greater number of patients developed wound infections if they did not receive prophylactic antibiotics with deeper wounds being more likely to develop infection than superficial ones.( Dire D J 2001). In broad terms, suturing must be carried out with rigorous aseptic technique. By definition, this refers to the absence of pathogenic organisms. It may well be that the wound to be treated is already infected by its nature (viz. an animal bite or a dirty wound) but the aseptic technique is central to ensuring that no further infection is introduced into the wound. The main principles of an aseptic technique include: Keeping the exposure of susceptible sites to a minimum Ensuring appropriate hand decontamination prior to the procedure Using gloves (sterile or non-sterile, depending on the nature of the susceptible site) Ensuring that all fluids and materials used are sterile Checking that all packs used are sterile and show no evidence of damage Ensuring that contaminated and non-sterile items are not placed in the sterile field Not reusing single-use items Reducing staff and/or bystander activity (wherever possible) in the immediate vicinity of the area in which the procedure is to be performed. (HCAI 2008) In any discussion of infection risks, one must not overlook the possibility of the reverse infection of healthcare professionals becoming infected by coming into contact with tissue fluids from the patient. Scrupulous attention to the Health Dept’s published guidance on protection against infection with blood-borne viruses for healthcare professionals in 1998 (UKHD 1998) should help to minimise the risk of blood-borne virus transmission to health care workers from patients. Suturing always carries the attendant risk of a needle prick injury even in the most experienced hands. An unexpected move from the patient, a sudden thread break of even inattention, can easily have major repercussions if it results in a stick wound to the operator. (Bosch X 2003) Pros and cons of suturing. The purpose of a suture is to hold the edges of a wound together in good stable apposition until the natural healing processes are sufficiently well established to make the support provided by the suture material unnecessary and redundant. There is a distinct difference however, between the results from good and bad suturing. For example, if sutures are made excessively tight, the tissue becomes ischaemic from the pressure. This encourages persistence of infection and tissue necrosis. Too many sutures will also make a wound ischaemic. Materials which are multifilament or braided can allow bacteria to enter the wound (by wick action) but can exclude phagocytes. It is therefore appropriate to draw distinctions between the results obtained from optimal suturing and poor suturing. Sutures are not the only mechanism available for achieving wound closure. Synthetic and natural tissue glues, surgical staples and flexible non-tensile tapes all have their place in maintaining wound edge apposition. Choice of technique is dependent on the anatomy of the area to be closed, whether it is going to be exposed to movement stresses, as well as the type and depth of the wound itself. Criteria for the choice of closure is a vast subject and beyond the scope of a modest essay, but decisions for optimum means of wound closure have great implications for successful healing and good aesthetic results. (Spotnitz W D et al. 1997) Training involved to enable medical staff to perform suturing. Training staff to suture requires a combination of a knowledge of the physiology of the healing processes, anatomy and clinical experience. There are a number of teaching aids commercially available for suture training. It is not simply a matter of learning how to suture, but the motor skills are also capable of considerable enhancement once the basic techniques are acquired. (Judkins T N et al. 2008) Suturing v non suturing of wounds. Are there benefits to these alternative methods? Suturing has been tried and tested with modern materials for many years. It does have the downside that, in inexperienced hands it can have sub-optimal effects with poor aesthetic and functional results, wound ischaemia if done too tightly and raises the possibility of pathogens entering the wound along the suture line. Alternative methods of skin closure have been developed over the last 40 years including various glues and sealants. The majority are fibrin / thrombin based. The current commercially available glues are bacteriologically and virally sterile (which contrasts to the biologically derived early varieties). Glues have the downside that they are not good in sites that are under considerable tensile stress. Full thickness wounds, particularly those that involve the deeper structures need deep sutures to minimise stresses in the skin. Glues are best for minor skin wounds. (Mintz P D et al. 2001) Adhesive strips are used for minor wounds and have the advantages that they have less of an inflammatory reaction than sutures, lower infection rates and no risk of abscess development at suture locations. They also have greater tensile strength when used late in the healing process and are cheap. Staples are used for wound closure primarily in surgical situations. They require considerable practice and expertise in use for optimal results. Some authorities advocate their use in the pre-hospital setting (particularly on the sports field) to minimise blood contamination and to allow suturing at a later stage. (Orchard J W 2004) Paramedics suturing skills within pre hospital setting. There are a number of studies which have been done which demonstrate that, within the hospital setting, to use paramedics for suturing duties can reduce the number of patients who are waiting to see a medical practitioner by up to 25%. This study also noted a patient satisfaction rate that was superior to having to wait to see a doctor or nurse. There was no difference in the morbidity rates after one month. Those who object in principle to this use of a paramedic on the grounds that it would require training beyond the expertise of the practitioner would find the argument hard to support when one considers that paramedics are currently trained in more sophisticated skills such as intubation, cardiac resuscitation and critical patient assessment. Hale presented a prospective double blind trial to determine if Paramedics could determine which wounds could be safely repaired in the pre-hospital situation and found a very high correlation (almost 100%) between emergency specialists and paramedics in the wounds that were excluded from pre- hospital repair. The paramedics tended to be slightly more cautions than the emergency specialists in identifying which wounds should be brought into the hospital setting. (Hale D et al. 2000) Different types of sutures and there pros and cons, number of days that sutures should be in situ for. Even a brief overview of available suture materials would extend to many pages. In general terms therefore one has to consider the two major categories of Absorbable and Non-absorbable suture material. In general terms, absorbable sutures are to be preferred unless there is a need to fixate an anatomical structure. These two categories can be further subdivided into the braided group (which have properties of tissue drag and a capillary filling effect but handle well) and the monofilament group which slide easily but can be more difficult to retain a knot. Of the absorbable varieties, the modern synthetic types undergo hydrolysis in the tissues, produce minimal tissue reaction and their degradation products are CO 2 and H2O. Examples are Polyglycolic acid, Polydioxanon and Polylactate Studies show that all three retain their tensile strength until clinical tissue healing is complete with Polyglycolic acid being 60% absorbed within 21 days and Polylactates being 75% absorbed in 14 days. (Hsiao W C et al. 2000) Non-absorbable suture materials include silk, linen and cotton with synthetic varieties including nylon and Dacron and wire. References Bosch X. Second case of doctor-to-patient HIV transmission. The Lancet Infectious Diseases 2003; 3: 261. Dire D J (2001) Cat bite wounds : risk factors for infection. Ann Emerg Med 2001 Sep; 20 (9) : 973 9. Hale D, Sipprell K (2000) Ability Of Paramedics to determine which wounds can be repaired in the field. Pre-Hospital Emergency Care. Volume 4, Number 3, July September 2000 , pp. 245 249 (5) HCAI and Cleanliness Division Ambulance staff . Reducing infection through effective practice in the pre-hospital environment. Dept. of Health Publication HMSO : London 18th June 2008 Hsiao W C, Young K C, Wang S T, Lin P W. (2000) Incisional hernia after laparotomy : randomised comparison between early-absorbable and late-absorbable suture materials. World J Surg 2000; 24 : 747 751. Judkins T N, Oleynikov D, Stergiou N. et al. (2008) Enhanced Robotic Surgical Training Using Augmented Visual Feedback. Surgical Innovation, Vol. 15, No. 1, 59 68 (2008) Mintz P D, Mayers L, Avery N, Flanagan H L, Burks S G, Spotnitz W D.(2001) Fibrin Sealant : Clinical Use and the Development of the University of Virginia Tissue Adhesive Center. Annals of Clinical Laboratory Science 31 : 108 118 (2001) Morgan M, Palmer J. (2007) Dog bites. BMJ. 2007 Feb 24; 334 (7590) : 413 7. Moy R L, Waldman B, Hein D W. (2002) A review of sutures and suturing techniques. J Dermatol Surg Oncol. Sep 2002; 18 (9) : 785 95 Orchard J W (2004) Video illustration of staple gun use to rapidly repair on-field head laceration. Br J Sports Med 2004; 38 : e 7 Scott M. (1993) 32,000 years of sutures. N Engl J Med. . May 1993; 20 ( 5) : 15 27. Spotnitz W D, Falstrom J K, Rodeheaver G T. (1997) The role of sutures and fibrin sealant in wound healing. Surg Clin North Am. Jun 1997; 77 (3) : 651 69. UKHD (1998) UK Health Departments. Guidance for clinical health care workers: protection against blood-borne viruses. London : Department of Health, 1998. ################################################################ 12.12.2008 Word count 2,259 PDG

Romanticism Paper

The art of romanticism evolved during sass's, The art focuses on different human emotions, natural environment, a person's experience, differences among people, traditional way of life and on the unique talent that every artist possess. The art of romanticism is present in literary works, poetry, performing arts, and music. During the period of romanticism, poetic creations were focused on nature's attractiveness and individual experiences in a locality. One illustration is the â€Å"Song of Myself†, a poem created by Walt Whitman.In this poem, he compared nature with errors like things and other beings. One of the lines Is crafted this way, â€Å"My tongue every atom of my blood, and form from this soil, this air. † What Whitman wrote was based on his own individual experience but it speaks about no particular person. This kind of art shows feelings not only through the written words but also through the imagination that the reader has at the time that one reads the po em. Paintings during the romanticism period show liberty in social and artistic laws.The capacity of colors and lines were maximized to give the painting creation a unique and emotional theme. One painting that portrays a true to life story is the â€Å"Execution of the Citizens of Madrid†, The portrait showed how Madrid forces opposed the army of Napoleon who were invading their country. Upon scrutinizing the portrait it is not difficult to pinpoint the details that the painter wants to emphasize. It is clear that a man wearing a white shirt was about to be killed.Dark red, orange, and black colors were also used to show the negative and heavy feelings that the Individuals felt during that period. Geometric figures were also utilized to enhance the image shown in the painting. Through color blending and figure organization, the romanticism painters were able to showcase emotions and events in their art creations. Dance movements during the romanticism period show emotions th rough the different coordination. Ballet is one of famous dance movement that was developed during that time.Two major persons behind the development of romanticism dance are Audiophile Gaudier and Carlo Blasts. Gaudier is both a poet and a critic. He once said that dance was a visual performance that depicts attractive creations through graceful movements. For him, dancing is an art like how painting and sculptures ere classified as art works. On the other hand, Carol's disposition on dancing is particular and procedural. For him, dancing is a combination of structure, position, and training. Ballet, for example has to have the starting point, the climax, and an ending.He is not giving his dancers the option to create their own set of movements but all of them have to adhere to what his rules are. His dancers would have to portray the emotions that Carlo wants them to portray. Gaudier is different. He wants his dancers to think outside the box to create a unique coordination. Gaudi er allows is dancers to freely express themselves though dance movements and for him, it is where art is. Both of them have their own point of view about how dancing should be called an art and their contributions in the field were considered significant.Symphonies, piano, and opera are few of the music that was developed during the romanticism period. Beethoven was one of the significant persons during romanticism period in the field of music. He was a classical composer and was well- rounded in creating a piece out of the different instrumental sounds. His pieces were loud and full of energy. A person listening to his creation would imagine watching a dramatic play or feeling uneasy for an intensified problem. An opera can both have a serene and piercing theme.This depends on the song and the instruments being used. Opera music is not a stand-alone art. It can be played during a ballet performance or during a stage play. Opera can enhance the emotional expressions that an act shou ld portray. To give a concrete example, imagine an act during a storm; the opera singer will sing a fast and loud song to add intensity to the act. If the act is at a lake with a swan, the opera singer will sing in a slow and calm tone to ad peacefulness to the scene. Playing piano can enhance the imagery of a particular scene.Even if it is played alone, the sound that a piano creates can stimulate emotions of the listeners. Indeed, the music during the romanticism era creates a variety of moods. To sum up, the period of romanticism focuses on expressions and moods. The art in the field of music, painting, poetry and dancing were greatly affected by the art evolution during this era. These effects can be seen from different works that were introduced during the period. Reference Spore, D. J. 0. Reality Through The Arts

Learning and Intelligence Essay

We all learn well in our own different ways, we cannot all learn the same way. For example, some of us are visual learners (pictures, videos, etc), and some of us are incapable of learning visually, we learn well orally (speaking out loud, listening to someone else speak out loud, etc). Some of us just read over notes and learn well that way. Myth 2: That intelligence is largely fixed at birth, and can be accurately determined by IQ or similar standardized tests. There is no limit to intelligence, we are able to learn much more, and we are skilled at much more than that of which can only be determined in an IQ/ any other standardized test. For example, an individual can be creative (art, poetry, story writing, inventions). Myth 3: That there is only one form of intelligence. We all are skilled at different things; we cannot all be skilled at exactly the same stuff in exactly the same way. For example, some of us are good at art and some aren’t, then some of us are good at writing, it doesn’t necessarily mean if u aren’t good at playing soccer, then you won’t be good at playing tennis. Myth 4: That all intelligence is inherited. There is no limit to intelligence, although your level of intelligence can be inherited but a great deal of your intelligence is developed through your environment, experience and culture. Both your inherited intelligence and personal development of intelligence work together and builds new sets of skills and abilities. Myth 5: That intelligence is the same as logical, analytical thinking. Intelligence takes 3 forms: Analytical, Creative and Practical, But only Analytical intelligence is measured in IQ/other standardized tests, therefore there is no measured level for creative ability, practical or commonsense ability, athletic ability, musical ability, etc. Myth 6: That everyone has the ability to succeed at anything. Different aptitudes help people excel in different ways, for different things. For example, a great manager may not necessarily be good at playing the piano. Myth 7: That school is the main or best place to learn. School is not necessarily the best place to learn, just because we spend most of our time there, listening to people feed us information, some of us learn better when we are in our own comfort zone by taking in information all on our own. For example, I learn best at home in my lounge, my friend learns best while relaxing in her garden. Myth 8: That â€Å"standards† are the real test of learning, and can easily be measured by standardized written tests. These tests only measure a part of the intelligence of an individual. These tests cannot measure other greater abilities, skills and talents of an individual. For example, for these tests, a student can easily memorize information, but how do we know if they can apply this information? (iii) Learners get despondent, lack of motivation, hampers self-esteem development, lead to behavioral problems. Learners should experience success, so the learner build on their strengths. Schools should rather: Focus on developing strengths, not on weaknesses. Not waste time trying to †put in what was left out†. Try to â€Å"draw out what was left in† Search for talent, but train to develop skills and abilities. (iv) 1. Eat a good breakfast every morning, preferably with plenty of fresh fruit. 2. Eat a good lunch. 3. Make fish, nuts and vegetable â€Å"fats† key parts of your diet. 4. Exercise regularly to oxygenate the blood. 5. Cleanse the toxins out of your body. Exercise ~ Phys. Ed: Encourage learners to take part in sport/drama. School tuck-shop ~ sell healthier foods. Awareness Campaign: Discussions, posters, check lunch box content. (v) Howard Gardner, David Perkins, and Robert Sternberg have all been quite successful in helping spread knowledge about the meaning of â€Å"intelligence† and applications of this knowledge to education. The study and measurement of intelligence has been an important research topic for nearly 100 years IQ is a complex concept, and researchers in this field argue with each other about the various theories that have been developed. There is no clear agreement as to what constitutes IQ or how to measure it. There is an extensive and continually growing collection of research papers on the topic. Howard Gardner (1983, 1993), Robert Sternberg (1988, 1997), and David Perkins (1995) have written widely sold books that summarize the literature and present their own specific points of view. The following definition is a composite from various authors. Intelligence is a combination of the ability to: 1. Learn. This includes all kinds of informal and formal learning via any combination of experience, education, and training. 2. Pose problems. This includes recognizing problem situations and transforming them into more clearly defined problems. 3. Solve problems. This includes solving problems, accomplishing tasks, fashioning products, and doing complex projects. (vi) Warm environment Interactive method Build thinking skills Plenty of activations Apply it in practice Review and celebrate Four criteria when determining the best learning â€Å"state† : Orchestrating the environment. Setting the right mood and getting students’ attention. Early activity is vital. Bring on the music (vii) How you perceive information most easily How you organize and process information What conditions are necessary to help you take in and store information How you retrieve information (viii) Likely traits: Negotiates well Relates well Able to read others’ intentions Enjoys being with people Has many friends Communicates well Enjoys group activities Likes to mediate disputes How to strengthen learning: Do learning activities cooperatively Take lots of breaks to socialize Use â€Å"pair and share† activities. Use relationships and communication skills Do â€Å"partner talks† on the phone Have parties and celebration of learning Make learning fun Integrate socialization into all curricular areas (ix) Students’ reading levels should be checked first. Students should be matched in pairs, with tutor only a slightly better reader. Books should be chosen for the right reading and interest levels. Tutors are trained with a simple checklist, which shows them how to use â€Å"pause, promt and praise† techniques. . BILBIOGRAPHY Dryden, G & Vos, J. (2005). The New Learning Revolution. UK: Network Edcuational Press Ltd.

Defining Rotation and Revolution in Astronomy