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There was an implicit judgment prescribes them makes her feel as though of incompetence to know what was best for her anything is possible generic zestril 10 mg blood pressure lowering herbs. Even after map and are floundering in the wasteland beyond recovery is achieved order zestril 2.5 mg with amex blood pressure medication natural, it is hard to see past the the restitution narrative safe 5 mg zestril heart attack anlam, remember that you have ‘truths’ written into the medical case notes generic 5 mg zestril overnight delivery blood pressure for dummies. You have an expert patient who will show you what she needs and how you can Misdiagnosed schizophrenic several years ago, this best support her. It is normal to be she has recovered her confidence and ability vulnerable, after all, and not the other way enough to think about re-entering the world of around. Listen to me as I tell you what’s identity back officially because of the label important for me to be able to re-engage with life. The Reassure me of your support whenever I need it, official attitude is that the notes must be right, whatever my decisions. Be honest with me about and her good performance now is just a temporary your distress and sense of helplessness, and let me thing, she will probably relapse. The default know you will continue to be available as a setting is suspicion, not affirmation and resource to me. I would group enjoyed active and contributing lives and say that I want one who is a close reader of gained a large part of their sense of self from their illness and a good critic of medicine’ (Broyard work, paid and unpaid. Themedicalgaze In this chapter we have tried to make visible and is focused on the body–mind and its ‘truths’. The medical system often lived illness and disability, particularly when fails people like me by constantly re-engaging with chronic. The oppressive forces that keep patients the stubborn face of my disease and failing to with chronic conditions firmly pinned in their engage with the lived body behind it. In your well- role as permanent passive patient stimulate resis- meaning campaign to re-seek success in terms of tance in patient groups like Phoenix Rising. That cure you shuffle me in and out of tests and resistance must be nurtured to flow out into all treatments, expect me to comply and reject me if I the spaces inhabited by patients and within don’t pursue the goals of the clinicians, even when which they struggle to find a new ‘normal’ for the probability of success is very low. References Atkinson P 1997 the clinical experience: the construction Beckett C, Wrighton E 2000 What matters to me is not what and reconstruction of clinical experience 2nd edn. In: Illich I, Zola I K, and Society 15(7):991–999 McKnight J et al (eds) Disabling professions. Marion Bogoch B 1994 Power, distance and solidarity-models of Boyars, London, p 11–40 professional–client interaction in an Israeli legal aid Kimmel M 2000 the gendered society. Discourse and Society 5(1):65–88 Press, New York Broomfield J 1997 Other ways of knowing: recharting our Porter R 1993 the body and the mind, the doctor and the future with ageless wisdom. Ballantine Books, California Press, Berkeley, p 92–225 New York Porter R 1999 the greatest benefit to mankind: a medical Butler J 1993 Bodies that matter: feminism and the history of humanity from antiquity to the present. Routledge, London Fontana Press, London Connell R W 2002 Gender: short introductions. Polity Press, Taylor S E, Brown J D 1988 Illusions and well-being: a social Cambridge psychological perspective on mental health. Fosket J 2000 Problematizing biomedicine: women’s Psychological Bulletin 103:193–210 constructions of breast cancer knowledge. In: Potts L K Taylor S E, Brown J D 1989 Maintaining positive illusions in (ed) Ideologies of breast cancer: feminist perspectives. Vintage Books, New Psychology 8(2):114–129 York Tollifson J 1997 Imperfection is a beautiful thing. Critical Inquiry (ed) Staring back: the disability experience from the 8:777–795 inside out. Fourth Estate, London Garland-Thomson R 1997 Extraordinary bodies: figuring Wiginton K L 1999 Illness representations: mapping the physical disability in American culture and literature. Such intercul- tural contexts are both more complex and more Clinical reasoning in the intercultural demanding than the familiar environments in context 358 which students in the health professions typically Illustrating clinical reasoning and decision find themselves. Clinical reasoning within such making in the intercultural context 359 complex practice settings presents significant chal- lenges for all healthcare practitioners, not only for the demands and tensions of intercultural students. Despite the challenges inherent in inter- practice and communication 360 cultural settings, there is a relative paucity of infor- Strategies used to facilitate the development mation on best practice in facilitation of clinical of clinical reasoning and decision making in reasoning and decision making in such contexts. Using extracts from A structured fieldwork programme 362 research interviews undertaken with students Interdisciplinary teamwork 362 about their learning experiences in Vietnam, the Supervision, teaching and support from chapter illuminates the demands and tensions fieldwork educators 362 experienced by students. It also outlines processes Critical incident interviews 363 and strategies employed by fieldwork educators to facilitate students’ clinical reasoning in intercul- Recommendations and conclusions 363 tural settings. We present recommendations for academics and fieldwork educators for facilitating the clinical reasoning of students in intercultural fieldwork placements, and conclude with reflec- tions on the future of intercultural fieldwork, clinical reasoning and research. As the programme is to educate and train Vietnamese a fieldwork site it is complex and demanding staff in the orphanage (Vietnamese-trained phy- because of the sociopolitical environment, the siotherapists, paediatricians, teachers and carers) attendant intercultural interactions, the interdisci- about optimizing feeding, communication, play, plinary nature of the placement and the complex mobility and other activities of daily living with needs of the children and staff of the orphanage. The aim is not to ‘treat’ or provide direct with large numbers of children and staff, respond- therapy to individual children, except when model- ing to different and at times competing requests for ling skills and supporting capacity development for help and advice. The second goal pertains to student described several approaches to conceptualizing learning issues. Because they are neither fluent intercultural competence and a range of other basic in the language (needed to elicit case histories) competencies including Vietnamese language skills nor able to perform detailed diagnostic assess- and knowledge of Vietnamese history and culture; ment, students appear not to use hypothetico- skills in training and working with interpreters; deductive and pattern recognition approaches to working with children with physical and intellec- reasoning, which are perhaps more appropriate tual impairments; training and educating others to the delivery of treatment in like cultures and (Vietnamese staff, other volunteers at the orphan- treatment within medical contexts. The term ‘intercul- approaches to clinical reasoning and appear to tural competence’ refers to cultural self-awareness, use interpretive approaches, particularly the inter- knowledge of ‘the other’, and skill in mediating active, narrative, collaborative and ethical/prag- communication (Sodowski et al 1994). We interviewed students the client-centred model of clinical reasoning in the country and/or upon return to Australia described by Higgs & Jones (2000) best describes about their experiences in Vietnam. The critical the approach to clinical reasoning sought in the incident approach, a specific narrative device Vietnam placements. The client-centred approach through which meaning is ascribed to a significant involves the application and integration of cog- event via guided reflection, was chosen because it nition (thinking about the clinical problem), provided a contextually sensitive means through professional knowledge, considerations of the which the students could make sense of both environment, clients’ input (in this case prefer- their clinical decision-making processes and their ences expressed by children and requests from Facilitating clinical decision making in students in intercultural fieldwork placements 359 staff), and metacognition (monitoring one’s think- the propensity for students to employ narra- ing and the interaction of all the factors men- tive reasoning processes naturalistically, in tioned earlier – especially important in the response to the specific demands of the setting, intercultural setting). In our case, the clinical reinforced the appropriateness of the adoption problem might be a child’s needs for mobilizing, of a critical incident approach to programme eval- play or self-care, carers’ needs for training, or uation. It allowed us to capture rich narratives determining how to enrich the children’s environ- and thick descriptions of intercultural interactions ment. Within the context of this client-centred and the nature and demands of clinical reasoning reasoning model, students have relied most sig- and decision making in situ. An excerpt from one nificantly upon processes of narrative reasoning such critical incident interview is presented here (Mattingly 1991) to articulate and refine their clin- as an exemplar of the experience of being in a ical decision making. Narrative reasoning often complex intercultural environment and doing entails practitioners creating or sharing stories continuous reasoning. Group reflection (dis- was conducted early in John’s placement in Viet- cussed later in the chapter) is therefore an impor- nam. I wanted to step in but I had to taking a lot of time because the child was feeding recognize my professional boundaries. That was the very slowly and then the carer came in and took sort of relationship that the child had with the carer over and said ‘let me show you how to do it’. She and that’s how he’s probably fed a lot of the time, then sort of grabbed the child’s head, pushed his so I had to step back and that was very difficult to head back, shoved the spoon straight down his do because I would usually jump in there before I’d mouth and continued shovelling in and this was think about it.
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This winding included within the cryostat with the main the magnetic resonance imaging system 579 Table 20 purchase zestril 2.5 mg with visa blood pressure medication yellow teeth. Gaps in this foil should gradient G is superimposed on the main field B0 so be carefully filled buy 5mg zestril fast delivery blood pressure medication new zealand. Only those protons in slice location z will ? Magnet strength is measured in tesla purchase 5 mg zestril amex pulse pressure low diastolic. Protons outside slice position z are unaffected and ? Superconducting magnet requires liquid helium will give no signal so specific regions can be spatially as a cryogen purchase zestril mastercard blood pressure medication list. This gradient field is very small, typically 5 mT to 580 Magnetic resonance imaging 15 mT over the main field of 1 T. Gradient coils serve the three axes making up field must be perfectly uniform otherwise the small the patient volume shown in Fig. Image data signals from these axes are produced by switching the gradient field strengths Null in a controlled sequence. They are not active all the time (unlike the y main magnetic field) but are switched on when x required for signal collection. The Z-axis slice to one side (left) the gradient linearly decreases in strength position is frequency encoded. These are: overcome magnet inhomogeneities; as the main magnet field strength increases so do the gradient ? the main electromagnet (resistive or supercon- field strengths. The gradient coils are very thick windings since they 20 must carry a current of up to 100 A. The receiver coils are placed near the anatomical region of interest in order to improve signal strength. The slope can be steeper since large These have been described in Chapter 2 as currents magnets ( 1T) can have gradient strengths approaching induced in a conductor by the varying magnetic field. There is always an electrical field associated with a Active shielding coil Main magnet coils Gradient coils x,y,z Figure 20. The precisely shaped sinc-pulse is circulate in the volume of adjacent conductive mate- amplified to give 90° or 180° power levels or interme- rial (patient tissue). These eddy currents interact diate levels when smaller ‘flip angles’ are being used. Eddy currents are (demodulated) to give low frequency signals before experienced in high-field superconducting magnets digitization; only frequency and phase differences are occurring in only a small way in smaller strength important and not the absolute frequency value. For ? G and G encode for frequency; G encodes for maximum efficiency Q they are tuned to resonate z x y phase. Their application significantly increases the image signal to noise ratio (courtesy of Siemens Medical Systems). Effective penetration Surface coils are small coils placed immediately adja- depth is roughly equal to the coil radius. Surface coils cent to the body region of interest (spine, neck, knee are used primarily as detectors, the pulse transmission etc. Most surface coils are used strictly as receivers with the standard body coil as the transmitter. Sur- By joining a pair of coils at 90° to one another and face coils do not surround the body but are placed driving them during the transmit cycle through a close to the organ of interest. They have a selectivity power divider and phase shifter a rotating field can 584 Magnetic resonance imaging is phase shifted by 90°. Signal reception is increased by proximity of the organ to (a) Surface coil the receiver antenna and noise and reflections are decreased because signals outside the region of inter- est are very weak. Reducing the field of view also improves resolution since there is smaller voxel vol- ume. Non-uniformity is caused by difference in signal strengths from organs near the coil to ones that are more distant. A typical design consists of six coils that can be combined to give surface or 3-D configurations. They cover a wider anatomical area reducing imaging time for larger fields of view. Surface coils are available that use a ‘ladder’ configuration where individual coils are switched through to a common receiver. In a similar fashion the same principle the three gradient fields Gz, Gx, and Gy are switched in gives a quadrature detector which is phase sensitive. The size of the image matrix has increased with improved accuracy of location from Box 20. The eventual image matrix can be interpolated to a larger size (10242) if necessary. A wide frequency range will excite regions out- strength and the bandwidth of the radio-frequency side the slice of interest causing cross-talk. The strength of the gradient must be large reason gaps between slices are maintained, usually enough to overcome slight inhomogeneities that are between 30 and 50% of the slice width. The Y-gradient (b) is switched during acquisition depending on matrix size (three steps for this simplified example). The fre- short time which causes another frequency change in quency changes necessary to separate each pixel are the proton signal (after Gz) depending on their posi- calculated in Box 20. When Gy is switched the main magnetic field is necessary to achieve good off the protons resume their original frequency but image definition in large matrix sizes. This is usually the pure the Y-axis since the momentary change in frequency signal for hydrogen protons at the main magnet field caused by Gy, caused them to be dephased. Step numbers are typically 128, 256 or Three gradients select z-axis (slice position) and x- and 512. Gradient fields can now be used in an alternative expression where impose a negative and positive field change with a the wave is travelling in direction x: middle null point where the overall magnetic field is y Acos( t kx) unaltered. The concept of rotational motion has been discussed in We define Chapter 2, Section 2. If P rotates about O with a uni- form speed then this describes simple harmonic oscil- 2p k lation. The k-space data y cos?v ?? ? ? ?? l ?? set is two-dimensional for a 2-D image containing 588 Magnetic resonance imaging full information on received signal frequency and signals undergo some form of truncation. These ? G identifies the slice position; the slice encode signals are composed of a series of sine waves, each z gradient. The wave ? G is now switched on for a short period, causing number domain or k-space describes a 2-D matrix of y the protons in the vertical axis to alter frequency positive and negative spatial frequency values, encoded momentarily according to their position along the as complex numbers (e. Euler’s formula protons resume their pre-Gy Larmor frequency enables the Fourier transform to be expressed in when Gy is switched off but retain a phase differ- complex form, extracting ‘real’ and ‘imaginary’ roots ence, depending on their position in the matrix (phase and amplitude) where columns. In magnetic resonance fore the frequency encode or readout gradient imaging the ‘real’ and ‘imaginary’ cosine and sine. Rather than recording and storing individual resonance frequencies, the time dependent radio-frequency bursts are stored which are related to the frequency domain data by an inverse Fourier transformation. Conceptually, k-space is infinite, but practically it is limited to the frequencies which have been used in the spatial encoding of the data. As the high frequency component of the Fourier transform is restricted the square wave becomes less square and the sharp edges become slopes. In practice therefore the there is a practical limit to the highest frequency that frequency is limited (truncation), consequently this can be measured (bandwidth of the electronics) so the degrades the square wave and gives it sloping sides.
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In diseases that are more widespread an entire lobe may be removed (lobectomy) buy zestril without prescription arteria gastroepiploica, or even an entire lung (pneumonectomy) 10mg zestril amex blood pressure medication kidney. They may be directly connected to the trachea buy zestril cheap blood pressure medication dehydration, or to the oesophagus order zestril 2.5 mg with amex blood pressure up heart rate down, or may have no connection. It is separated from the rest of the lung by a fold of pleura called the mesoazygos that contains the azygos vein at its lower end. The mezoazygos is seen as a thin line, at the lower end of which the azygos vein casts a circular shadow. Sequestration of lung tissue: An area of lung may not have any communication with the bronchial passages. Displaced bronchi may arise from the trachea above its bifurcation, or even from the oesophagus. They may replace a normal segmental bronchus, may supply an accessory lobe or may be blind. The right and left pleurae (singular = pleura) are thin serous membranes that are closely related to the corre- sponding lungs and to the corresponding half of the thoracic wall. The arrangement of the pleura is best understood by thinking of it as a closed sac that is invaginated (from the medial side) by the corresponding lung. Apart from lining the surfaces of the lung, the visceral pleura dips into the fssures of the lungs, and lines the contiguous sides of the lobes. The parietal and visceral layers of pleura are in contact with each other being separated only by a potential space which is called the pleural cavity. Under certain diseased conditions fuid or air may be present in the pleural cavity thus separating the parietal and visceral layers. The costovertebral pleura lines the inner aspect of the ribs and intercostal spaces, part of the inner surface of the sternum, and the sides of thoracic vertebrae (19. However, the pleura is not as extensive as the diaphragm so that some parts of the latter are not covered by pleura. The mediastinal pleura extends as a tube over the structures passing between the mediastinum and the lung (bronchus, pulmonary artery, pulmonary veins) and becomes continuous with the visceral pleura at the hilum of the lung. This pleura extends for some distance below the hilum forming a double layered fold which stretches from the mediastinum to the lung. The line along which bending occurs is called the line of costomediastinal reflection of the pleura. When traced backwards, the costovertebral pleura is refected from the sides of the vertebral bodies onto the mediastinum. The line along which this bending takes place is called the line of costodiaphragmatic reflection. It is of practical importance to know the relationship of the lines of pleural refection (described above) to the surface of the thorax. Above this level, it covers the apex of the lung (that lies in the root of the neck) and is called the cervical pleura (It is also called the dome of the pleura). The cervical pleura extends upwards up to the level of the neck of the frst rib (corresponding to the upper part of the frst thoracic vertebra). It is covered by a sheeth of fascia called the suprapleural membrane (which stretches from the transverse process of the seventh cervical vertebra to the inner border of the frst rib. Both on the right and left sides the cervical pleura is related, anteriorly, to the subclavian artery and to the scalenus anterior muscle (19. The costocervical trunk runs upward in front of the cervical pleura and then arches above it to reach its posterior aspect. The superior intercostal artery descends posterior to the cervical pleura to the brachiocephalic artery and the right brachiocephalic vein. The left cervical pleura is related anteromedially to the left subclavian and left common carotid arteries, and to the left brachiocephalic vein. From what has been said about the pleura and lungs it will be obvious that it is only the costal surface of the lung, and the costal pleura that come in contact with the external wall of the thorax. As seen from the front, the cervical pleura can be represented by a line that is convex upwards, and lies above the medial one-third of the clavicle. The medial end of the line lies behind the sternoclavicular joint and is continuous with the upper end of the line of costomediastinal refection. From here the line of costomediastinal runs downwards and medially to reach the midline at the level of the sternal angle, where it comes in contact with the corresponding line of the opposite side. On the right side the line runs downwards in the midline to reach the xiphisternal joint. On the left side the line runs downwards in the midline up to the level of the fourth costal cartilage (the right and left pleurae being in contact with each other from the level of the sternal angle up to this level). It then passes downwards and laterally to reach the lateral margin of the sternum and runs downwards a short distance lateral to this margin to reach the sixth costal cartilage about 3 cm from the midline. The lower ends of the lines of costomediastinal refection (described above) are continuous with the anterior ends of the lines of costodiaphragmatic refection which are as follows. It then winds round the anterior, lateral and posterior aspects of the thorax forming a curve convex downwards. In the midclavicular line, the line of refection is at the level of the eighth rib. At its posterior end the refection lies at the level of the spine of the twelfth thoracic vertebra about 2 cm from the midline (19. On the left side the line of costodiaphragmatic refection begins at the sternal end of the sixth costal cartilage (i. From the above it will be clear that, except near the sternum, the line of refection of the pleura is higher than the costal margin to which the diaphragm is attached. Between the lower limit of the pleura and the costal margin, the diaphragm is in direct contact with ribs and intercostal spaces. The line along which the posterior part of the costovertebral pleura gets refected onto the mediastinum can be represented by a vertical line about 2 cm from the middle line. It extends, above up to the level of the spine of the second thoracic vertebra; and below to the level of the spine of the twelfth thoracic vertebra. From a clinical point of view, it is important to know the relationship of the pleura to the surface of the body. The visceral pleura is supplied by autonomic nerves (that reach it through the lung). In contrast, the parietal pleura is supplied by cerebrospinal nerves (intercostal, phrenic) and is very sensitive to pain. We have seen that these nerves pass into the abdominal wall and supply skin and muscles there. Because of this fact pain arising from the lower part of the costal pleura (in pleurisy or pneumonia) can be referred to the front of the abdomen. Pleurisy may be dry or may be accompanied by effusion of fuid into the pleural cavity. During respiration the two layers of pleura rub against each other resulting in pain. The friction produces a sound (pleural rub) that can be heard through a stethoscope. We have seen that normally the pleural cavity is a potential space containing a thin flm of serous fuid that separates visceral and parietal pleura.
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