By B. Barrack. Northwestern College, Iowa.

Several clinical studies have shown that the probability of successful defibrillation and subsequent survival to hospital discharge is inversely related to the time interval between the onset of VF and delivery of the first countershock cheap 100 mg aurogra with visa. The chance of success declines by about 7-10% for each minute delay in administering the shock generic aurogra 100 mg with amex. During VF the myocardial cells continue to contract rapidly and exhaust the limited oxygen and high energy phosphate stores contained in the cells, which are not replenished. Anaerobic metabolism results in intracellular acidosis as cellular homeostasis breaks down. In the absence of defibrillation, the Five minutes amplitude of the fibrillatory waveform decreases progressively as myocardial oxygen and energy reserves are exhausted and terminal asystole eventually supervenes. This process may be slowed by effective basic life support techniques that provide a limited supply of blood to the myocardium. Electrocardiographic appearances In VF the electrocardiograph shows a bizarre, irregular 10 minutes waveform that is apparently random in both frequency and amplitude. VF is sometimes classified as either coarse or fine, depending on the amplitude of the complexes. The treatment of each form is the same and the only practical implication of a distinction is to give some indication of the potential for successful defibrillation and to serve as a reminder that VF may be mistaken for asystole. Epidemiology VF is the commonest initial rhythm leading to cardiac arrest, Pulseless ventricular tachycardia is treated in the same way as VF particularly in patients with coronary heart disease. VF may be 5 ABC of Resuscitation preceded by ventricular tachycardia and is seen in up to 80-90% of those patients dying suddenly outside hospital in whom the cardiac rhythm can be monitored without delay. It is therefore important that those general practitioners and ambulance staff who are often the first to attend to such patients should carry defibrillators. Considerable effort is being devoted to training members of the public to carry out basic life support to extend the window of History of defibrillation opportunity for successful defibrillation. This has been effective Prevost and Batelli are usually credited with the discovery in in reducing the delay in defibrillation, and impressive rates of 1900 that VF could be reversed by defibrillation. Their work remained dormant for many years, probably because the importance of VF in humans was not recognised until the 1940s. Wiggers Electrical defibrillation repeated their work in the 1930s, which then prompted Claude Electrical defibrillation is the only reliable method of Beck, a surgeon in Cleveland, to attempt defibrillation in humans who developed VF while undergoing thoracotomy. Between 1937 and 1947 Beck made several unsuccessful Defibrillation aims to depolarise most of the myocardium attempts using a homemade AC defibrillator, developed by simultaneously, thereby allowing the natural pacemaker tissue Kouwenhoven, with electrodes placed directly on the heart. Depolarisation of a critical mass His first success came in 1947 when VF developed in a 14 year of myocardium is necessary and this depends on the old boy whose chest was being closed after surgery for funnel transmyocardial current flow (measured in Amperes) rather chest.

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Aspiring surgeons can hate being on a surgical firm (as I did as an undergraduate) and buy cheap aurogra 100 mg line, equally buy 100 mg aurogra overnight delivery, career physicians or general practitioners can love their theatre time. With a little knowledge regarding the staff and general running of theatres you will find your time much more enjoyable. The golden rule is if in doubt ask, but there are other secrets to being in theatre. Getting to Know the Staff The following people, who can seem unnerving at first, staff theatres. Any procedure done under local anaesthetic does not require an anaesthetist. All of these individuals are senior and have invariably worked together for many years so know each other well. As with any circle of friends,the newcomer finds it dif- ficult to break into the ring and should not be put off if the first few attempts fail. The first and most important thing to do when you walk into the operating theatre is to 67 68 What They Didn’t Teach You at Medical School introduce yourself to all present. Make sure that the nursing staff know your name and grade,particularly the scrub nurse. You will find that the scrub nurse can be your best ally during a difficult operation and the trust and friendship that develops between you will be invaluable when you are operating alone or when on-call. I have been saved on more than one occasion by the scrub nurse, who has told me which suture type my consultant prefers for wound closure. This has allowed my consultant to gain confidence in me and prevents embarrassing ticking off sessions on the post- operative ward round. When talking to your registrar or consultant in the first few weeks of your post, before you know them well, keep small talk to appropriate breaks in the surgeon’s concentration and the subject professional at first. Learning Anatomy Theatres are the place to improve your knowledge of anatomy, but not to ‘learn’ it. This may sound strange,but I guarantee that you will find it more productive to learn your anatomy at home before entering the operating theatre. When you are assisting you can then see the anatomy you have learnt come to life and appreciate it in three dimensions as well as see variations between individuals. All theatre operation lists must be submitted a day in advance (except emergency lists), so that it is always possible to find out which operations are to be performed the following day. Your seniors will always question you in theatre on your anatomy and it pays to read up the night before. Do this every time and not only will you impress your boss,but you will accel- erate your anatomical and surgical knowledge. If you feel the timing is not appropriate then wait until after the operation and then ask (I often do this – it shows maturity and an under- standing that the surgeon is concentrating). The Operating Theatre 69 Don’ts 1 Engage in conversation during emergencies. Your seniors are not out to get you and there will be a good reason that you may not understand.

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His director was having passed his final Fellowship he became a rather complicated and never came into general demonstrator of anatomy for a time and was then use buy generic aurogra 100mg line. He also designed quite a useful tilting table appointed clinical assistant to both the orthopedic for holding a patient during operation for con- and massage departments discount 100mg aurogra overnight delivery. These two appoint- genital dislocation of the hip, and he suggested ments initiated his ever-increasing interest in the use of copper strips to facilitate the removal orthopedic surgery, for he had the privilege of of a plaster-of-Paris splint. Elmslie, who was in charge of both cal papers, all the articles he wrote, probably not 205 Who’s Who in Orthopedics more than 20 in all, were devoted to orthopedic tional value in committee work: on more than subjects. He published a second paper in a French one occasion it was Eric who came to the rescue, journal, one dealing with the manipulation of and who, with a few wise words, coupled perhaps joints. He also contributed to the later editions of with a touch of his wit, was able to smooth out that well-known textbook on diseases of children, differences when discussion of a difficult problem which still bears the name of the original authors, was becoming somewhat heated. In the Second World began to work at the Children’s Hospital, a friend War he readily responded to an appeal for help at “Bart’s” persuaded him to go for a trip to South from an emergency hospital near St. Fortunately for him, a Miss Antoinette which was staffed by some of his friends of St. Marie Roux was traveling home to Pretoria in the Bartholomew’s Hospital and was being over- same ship—the lady who a few years later whelmed with casualties from Dunkirk. Later he became his devoted wife and eventually pre- became an official surgeon of the Emergency sented him with a son and a daughter. Of Eric Lloyd it can be said with truth “His As a Fellow of the Royal Society of Medicine, integrity stands without blemish. He was a Fellow of the British Orthopedic Associa- tion and a member of the Société Internationale de Chirurgie Orthopédique et de Traumatologie. Having been born a member of an old and dis- tinguished Quaker family, he always remained a keen and faithful Friend. At the beginning of the First World War, before he qualified, he served for a time in the Friends Ambulance Unit. When he went to live in that charming house he had in Hertfordshire, he became an active and valued member of the Friends of Harpenden. He was a member of the local golf club and became a vice president of the local horticultural society. It was his deep sincerity and integrity, coupled with cheerful friendliness, which made Eric Lloyd a real friend of all he met. The painstaking thoroughness with which he ap- proached every surgical problem never failed to impress his patients or their parents, while his Adolf LORENZ natural charm and kindliness soon won their hearts. They became convinced they were dealing 1854–1946 with a man they could trust to do the utmost that surgery made possible, and they knew he would Adolf Lorenz was a dominating figure in tell them the truth if complete cure was impossi- European orthopedics during the closing years of ble. The same happy relations existed with his the nineteenth century and by then he had stan- colleagues who, without exception, were his real dardized his manipulative technique for the friends. As a surgeon he earned their esteem bloodless reduction of congenital dislocation of and admiration for his skill, his sound judgment the hip. It was not until 1904 that he began to and his obvious integrity and loyalty.

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