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The system of evacuation and treatment of the sick and wounded – the chain of casualty care – like any chain order macrobid 100mg without a prescription, is as strong as its weakest link purchase macrobid 100 mg visa. The setting up of such a system requires planning ahead of time: an assessment of the tactical circumstances must be made; an analysis of the physical limitations and human resources carried out; and the resulting plan implemented macrobid 100 mg with visa. Wounded patients are transferred along a chain of medical care quality 100 mg macrobid, beginning with simple “life and limb-saving” procedures and continuing to ever-greater levels 6 of sophistication. The principle of echelons of care in a military system has been described in Chapter 1. In civilian practice patients also tend to follow a chain of evacuation and treatment although, in many countries, this is not very efcient. The wounded and sick have the right to be cared for and to have access to appropriate medical care. The red cross, red crescent and red crystal emblems symbolize the legal protection aforded the casualty and the medical personnel, who have the right and the obligation to care for the wounded and sick. The protective quality of these emblems is a function of the training and degree of discipline of the combatant forces, and their adherence to internationally accepted norms of behaviour on the battlefeld: the Geneva Conventions and their Additional Protocols. This protection begins with the frst aider in the feld and continues through all the levels of treatment. Special measures must be taken to prevent further injury to any casualties and to protect them from the elements (see Chapter 7). Specialized centre: defnitive surgical treatment including reconstructive procedures; physiotherapy and rehabilitation, both physical and psychological. Treatment on the spot may be self or “buddy”-treatment, or practised by a military medic or frst aider. First aid starts at the point of wounding, but can be given anywhere and everywhere along the evacuation line to the place of defnitive treatment. The closer to the battlefeld, the more prominent will be the role of military medical services. In purely civilian rural settings, village health workers, nurses or medical assistants are often the only health professionals available. Collecting the wounded at one specifc location allows for the proper organization of feld triage and their efcient evacuation. Besides basic frst aid and trauma life support, resuscitative measures may be begun here. A health centre or rural hospital might represent the intermediate stage, where more sophisticated resuscitation and emergency surgery are available. Efcient evacuation of the wounded to defcient surgical facilities is not an efective chain of casualty care. Levels of hospital competency difer from country to country and between geographic regions. These hospitals are usually stafed by general practitioners or medical assistants with some surgical training and equipped with a minimum of proper surgical facilities. The military equivalent is usually a forward feld hospital specializing in damage control and resuscitative surgery. There are factors external to the hospital, involving an analysis of the national and provincial health systems, and internal factors: hospital infrastructure, administration and functional organization, departments, available resources, medical personnel (number and expertise), non-medical support services, fnances (see Annex 6. Assessment results of a typical hospital in a low-income country disorganized by war. The pie-charts above show the various factors that afect the functioning of a hospital dealing with the added burden of war-wounded patients compounded by the constraints of a weakened health system, and help identify dysfunctional areas. An additional factor is the emotionally stressful presence of casualties who are related to, or friends of, the medical staf. Transport of some sort provides the connection between the diferent echelons of the chain of casualty care. It uses up additional resources and involves security risks (“mortality of the ambulance ride”), and perhaps even exposure to military activity. These extra costs must be weighed up against the likely benefts of moving the wounded. In many contexts, the availability of transport for the sick and wounded is almost a “luxury”. Moving wounded people is difcult, always takes longer than expected, adds to the trauma, and is often dangerous. Circulation of information between the diferent levels is assured by some means of Figure 6. Mobile telephone systems have a tendency to stop functioning – carriage ambulance. The efciency of the command and communication systems depends on strict observance of established procedures. The availability of advanced procedures closer to the battlefeld has many advantages. It allows quicker access to “life and limb-saving” emergency measures, thus decreasing both mortality and morbidity. The projection of resources applies particularly to treatment at the intermediate stage, but can be applied to any echelon in the chain. Forward projection of resources allows quicker access to life and limb-saving measures. When a front-line hospital is coming under bombardment, putting both patients and 6 personnel at risk, there is little point in attempting more than frst aid if evacuation to another facility is possible. Only a minimum of equipment is necessary for well-trained medics to perform endotracheal intubation or place a chest tube, and then quickly evacuate the patient.

Tese two diets are ofen eas a comparison of the diet as treatment for difcult ier for older children and adults to buy macrobid 100 mg line manage and to-control epilepsy against multiple antiseizure are sometimes used as predicates to order macrobid 100 mg visa the classic medications proved that the diet was superior in ketogenic diet cheap 100 mg macrobid otc. Recently buy macrobid 100 mg with amex, another Class I study found For now, the classic ketogenic diet remains the similar results (Lambrechts et al. However, less strict versions may Neurology publications gave further credence to be more realistic for certain individuals, especially the diet, and in 2010 led to the requirement for older children and adults. Tese metabolic diet inclusion of ketogenic diet therapies in Level 3 treatments are referred to collectively as “ketogenic and 4 Epilepsy Centers in the United States. Yes Yes Yes Yes What is the ratio of fat to carbo 4:1, 3:1, 2:1, 1:1 Approximately 1:1 Approximately 1:1 Approximately 2:1 hydrate & protein. How much carbohydrate is 8gm carb on a 4:1 40-50gm 40-60gm 10gm adolescents or 15gm adults for allowed on a 1000 Calorie 16gm carb on a 3:1 1 month diet. Yes Yes Yes Yes What is the overall diference in this is an individualized and An individualized and this is individualized but this diet focuses on limiting the amount design of these diets. This meal and emphasizes com it is within limits and should be con in their entirety for best allows more carbohydrate plex carbohydrates. The ratio of this diet and protein than the clas balance of low glycemic are used as a guide. A 2008 carbohydrates in combi limited but too much is discouraged better seizure-control and study showed that both nation with fat result in also liberalized for better diets are equal in eliminat steady glucose levels. A source of not intended to promote considered a low glycemic essential fatty acids must be ketosis. This syndrome is currently has partnered with the Astro Brain Tumour Fund an epidemic in many areas of the world, includ to help adults and children with brain cancer. Additional applications of ketogenic diet ther Improvements in metabolic syndrome were signif apies for other conditions have grown exponen icantly better in a group that followed a modifed tially in recent years. Matthew’s Friends developed a support system to help families prior to and during the diet to enhance the likelihood of success. Adjusting the therapy during the course of treatment to optimize efectiveness is ofen neces sary. Discontinuing the diet is usually the goal in childhood epilepsy: two to three years is the typi cal course of treatment. However, in some cases of epilepsy and other neurological disorders it may be necessary to continue with a modifed version of the diet indefnitely. Tese discussions are fre quently addressed at the Charlie Foundation and have become the topics of collaborative journal articles and professional guidelines spearheaded by nutritionists. News of ketogenic diet therapies spreads quickly through social media and the popu lar press. Tousands of copies of the Charlie Foundation’s Parent’s Guide to the Ketogenic Diet have been distributed in English and Spanish. Cooking videos of the most popular keto recipes have been added to the charliefoundation. In addi animal models of disorders including autism, cer tion, an App is under development for the modi tain mitochondrial diseases, diabetes, migraine, fed ketogenic diet. Similarly, Matthew’s Friends is Prader-Willi syndrome, neurodegenerative dis dedicated to developing and publishing delicious eases including Alzheimer’s and Parkinson’s, trau keto friendly meals. New research may Both the Charlie Foundation and Matthew’s expand the mission of the Charlie Foundation Friends have been continuously supportive of and Matthew’s Friends—or may bring new part research and have partnered in funding global ners supporting metabolic therapies for diverse symposia on ketogenic diets. In response to the increasing demands for A recent study in the journalObesity (2015) showed adult resources, the Charlie Foundation pro dramatic improvements in the health of obese chil duced a guide in 2014 titled “Modifed Ketogenic dren in just 10 days afer eliminating sugar in their Terapy for Neurologic and Other Conditions. The metabolic impact of Intended for use under medical supervision, it a sugar-free diet is one element of ketogenic diets describes portion sizes for protein, fat, and car that can be undertaken by anyone without the bohydrate and advice for optimal nutrition. Eliminating sugar Charlie Foundation has shared resources with can be a difcult task for most people and requires oncology medical professionals and expanded its strong motivation. A 2007 study published in website information to include this new popula Neuroscience and Behavioral Reviews showed that tion of users. Eliminating refned (processed) foods is a second Medical supervision for ketogenic therapies step that can be taken to improve one’s diet. Parent’s Guide to the Ketogenic Diet For conditions that may beneft from keto Modifed Ketogenic Diet Terapy: 1:1 and genic therapies, the Foundation designed a Pre 2:1 Prescriptions ketogenic Diet. Similar to the classic ketogenic High Fat diet, it eliminates gluten and sugar; however, it is KetoDietCalculator Guide for the Nutritionist not intended to induce ketosis. Instead, it can be and the User described as a whole foods Mediterranean-style diet that prepares the user for the transition to Professional’s Guide to the Ketogenic Diet ketogenic therapy and also aids in determining Frequently Asked Questions about which diet in the spectrum is best suited for their Ketogenic Diets needs and preferences. In addition, healthcare Comparison of Ketogenic Diet Terapies professionals can use the Pre ketogenic Diet as a screening tool to identify which individuals are Ketogenic Diet Primer for Health Professionals able to adhere to the lifestyle changes required for ketogenic diets. As new clinical and scientifc research Charlie Foundation for Ketogenic Terapies to continues to emerge, the Foundation will respond better defne its mission for the future: advocacy, with further resources to promote safe and efec awareness, and education. An expansion of edu tive use of ketogenic therapies and make it less cation eforts includes adult-focused media and daunting for the user to manage. Development of new resources in both Matthew’s Friends grew rapidly from Emma’s English and Spanish remains a goal. The charity has continued to grow rapidly, and Troughout the 22 years of its existence, the recently expanded into New Zealand and Canada. Charlie Foundation has continued to receive daily In 2016 it embarked on a new program called e-mails and letters from families and health pro KetoCollege, to ofer training for teams around the fessionals requesting assistance. Jim Abrahams globe, adding to and complementing the eforts has responded to the majority of these requests, of the Charlie Foundation to train ketogenic diet triaging some of them to support staf.

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With regard to proven macrobid 100mg impaired and dis gured veterans buy macrobid 100mg low price, these virtues are courage order 100 mg macrobid with visa, fearlessness macrobid 100mg free shipping, perseverance, and the readiness to die 8 Cic. Baroin, “Integrite du corps, maladie, mutilation et exclusion chez les mag istrats et les senateurs romains,” in F. Walters, “Invading the Roman Body: Manliness and Impenetrability in Roman Thought,” in J. Scars on the back, no matter how in icted, always had a negative connotation; see Plu. Besides, as Baroin argues, scars on the back also had a strongly cultural and stigmatizing value, being associated with slaves who had been beaten by a rod. Vergil also writes: “Virtus (male bravery) is more pleasing when it appears in a handsome body” (Aen. Although the principles of physiognomy did not apply directly to dis gured and impaired veterans—for physiognomy only analyzed congenital externals—the appearance of these veterans still played an important role. Deep-rooted prejudices about congenital deformities played, wittingly or not, a role in the judgment of persons who were mutilated during their lifetime. Mathieu, “De Cesar a Suetone, en nir avec les corps dans les batailles : Romains, Gaulois, Germains et Bretons,” in L. Faure, “Parures, corps et identites militaires dans l’armee Romaine imperiale,” in L. De Franchis, “La representation des blesses dans la troisieme decade de Tite-Live,” in F. Kriegsversehrte Aristokraten zwischen Recht und Religion, Ausgrenzung und Integration,” in J. In this passage the intact beauty of young men is contrasted with the shame of their deformity upon their return to civil society. Case Studies: Advantages and Disadvantages of War Injuries One should always take the author’s intention into account when in terpreting stories of war-wounded soldiers. The simplistic scheme of honorable and dishonorable scars in relation to their position on the body is valid and useful in analyzing literary sources about bravery on the battle eld. Writers often listed soldiers’ merits and military honors (decora) together with the injuries, for they were equally val ued, leading soldiers to boast about both. Despite being portrayed as conspirators against Rome, they are praised as brave warriors because their bodies only showed scars on the front after they were killed in battle, which indicated that they had fought bravely, Sal. Van Lommel | Heroes and Outcasts 97 Now we will look at attitudes towards wounded soldiers after their retirement. We will show by means of several examples what bene ts and disadvantages someone could experience because of his war wounds and in what manner these veterans dealt with their deformity. As the following case studies will show, the literary topos of heroic injured sol diers re ects only partially the Roman attitudes in reality. Starting with the advantages, some politicians capitalized on their war years by wearing no tunic underneath their toga at the elections. In this way, a part of their chest was bared to reveal their scars of bravery (the evidence of their military service), by which they hoped to receive the people’s vote. According to generally accepted beliefs, Ro mans who distinguished themselves in the army were considered eligible political candidates. Some would show their war scars in court to increase their authority and to convince the jury of their virtue and dignity through their past service for the Republic. Highlighting the rhetorical climax by showing scars on one’s chest seems not to have been a unique event in a court of law. On the one hand, they strengthened their argument, and, on the other hand, they won over the sympathy and support of the peo ple (plebs). Some soldiers became aware of the possible advantages and the pres tige to be gained by their war injuries and exploited them. In Plautus’ comedy Curculio, a soldier named Curculio appears on stage with an eye patch. He tries to attract attention by claiming that he had fought bravely during the war, while he actually had been wounded in the eye in an ordinary ght in an inn. His story has, however, little persuasiveness because his antagonists question the correctness of his words and mock him. The personage of Curculio was probably based on (ex-)soldiers’ behavior that was considered stereotypical and that must have held some truth in order for the audience to appreciate the humor. The aristocracy, on the other hand, could appeal to their ances tors’ good name and reputation via the imagines maiorum, or family portraits. Only the aristocracy had the privilege of carrying these family portraits at funeral processions, at which their ancestors’ various bene factions were commemorated with speeches. Although Tacitus may have exaggerated the soldiers’ physical conditions and used it as a literary device, archaeological evidence con rms the devastating physical toll—already visible at age 24 to 28—soldiers paid; for references see Van Lommel (above, n. Antieke oorlogsinvaliden, schoonheidsidealen en history of disability in de Romeinse Oud heid,” Geschiedenis der Geneeskunde 15 (2011) 72–73. Marius was not an aristocrat, but he had managed to climb the social ladder and had joined the political elite as homo novus, a new man, and he stands for consul at the next elections. These are my portraits, these are my patent of nobility, not left to me by inheritance as theirs were, but won by my own innumerable efforts and perils. Thus, Sallust describes how Marius uses his mutilation as a weapon in the electoral battle, probably because his military actions were his only credentials, and at the same time Sallust criticizes certain members of the aristocracy who have personally accomplished nothing but rather live on the repu tation of their forefathers. His speech delivers a message critical of the social structure with a remarkable conclusion: war wounds and virtus are inseparable.

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In the early days of the development of employment injury protection buy cheap macrobid 100mg, attention was concentrated on accidents at work cheap macrobid 100mg mastercard. It was only later that protection was widened to discount macrobid 100mg amex include diseases contracted during work processes cheap 100 mg macrobid mastercard. It proved difficult to define the diseases which ought properly to be within the protection of the employment injury law, while excluding common conditions which are prevalent among the general population. In 1925 the International Labour Conference was able to agree on only three diseases which could be so prescribed lead poisoning, mercury poisoning and anthrax. But research establishes new criteria of proof, and the accelerating development of industrial chemistry and physics brings in its train new hazards. In Ethiopia there is no systematized recording and reporting on work related injuries organized the national level. If there is, then only few manufacturing industries provide some information to the Ministry of Labour and Social Affairs. Hence, the data gathered from these few industries are incomplete and neither represents all industries nor show the actual magnitude of work related injuries of the country. The few studies carried out by individuals in Textile industries in 1991, 1988, and in tobacco factories, revealed an accident rate of 200/1000 person/ year, and 183/1000/year respectively. In one year, a total of 13,796 accidents were 147 Occupational Health and Safety reported making an over all work related accident rate of 178/1000 person/ year with a range varying from 10-390/1000 person/year, depending on the nature of industries. The highest work related accident rate was detected to be among the sugar plantation workers, followed by workers in Beverage, Textile and metal work industries. Part of body affected, type, causes and day of the week of work related injuries • Among the parts of body affected Brazilian steel workers, the commonest were hands; arms and eye. Regarding the distribution of work-related injuries by the days of the week, most studies revealed: • the highest injury rates occurred on Monday’s and the lowest on Thursday’s and Friday’s. Factors related to work related injuries • Many authorities believe that work-related injuries result from a complex interplay of multiple risk factors. S and China revealed that men have the highest rates of work-related injuries than women. These studies emphasized that work-related injuries in young subjects were more common due to lack of experience, lack of job knowledge and know how than in other subjects. Furthermore, many workers begin working at an early age and often without safety training. Determinants of work-related injuries-A Conceptual Framework for study of Work-related injury prevalence. Occupational disorder by system Respiratory Disorders Work-related respiratory disease is frequently a contributory cause and commonly a primary cause-of pulmonary disability. The clinical evaluation of pulmonary disease includes a minimum of four elements: 1/a complete history including occupational and environmental exposures, a cigarette-smoking history, and a careful review of respiratory symptoms; 2/ a physical examination with special attention to breath sounds; 3/ a chest x-ray with appropriate attention to parenchymal and pleural opacities, and 4/ pulmonary function tests. Low back pain prevention in work settings is best accomplished by a combination of measures, such as: a/ Job design (ergonomics); b/ Job placement (selection); Training and education (training of workers, managers, labour union representatives and health care providers). Prevention and Control Job design (ergonomics) Mechanical aids optimum work level Good workplace layout Sit/stand workstations Appropriate packaging Job placement (selection) careful history Through physical examination No routine x-ray Strength testing Job-rating programs Training and education Training workers Biomechanics of body movement (safe lifting) Strength and fitness Back schools 155 Occupational Health and Safety Training managers Response to low back pain Early return to work Ergonomic principles of job design Training labour union representatives Early return to work Flexible work rules Reasonable referrals Training health care providers Appropriate medication Prudent use of x-rays Limited bed rest Early return to work (with restrictions, if necessary) Skin disorders Any cutaneous abnormalities or inflammation caused directly or indirectly by the work environment is an occupational skin disorder. Work-related cutaneous reaction and clinical syndromes are as varied as the environments in which people work. A basic understanding of occupational skin disorders is therefore essential for everyone involved in occupational health. Occupational skin diseases are often preventable by a combination of environmental, personal, and medical measures. Eye disorders Every working day, there are over 2,000 preventable job-related eye injuries to workers in the United States. Occupational vision 156 Occupational Health and Safety programs, including pre-placement examinations and requirements for appropriate eye protectors in certain occupations, can prevent many of these injuries. Symptoms and signs of serious eye injury Symptoms of serious eye injury indicating immediate referral are the following: 1. Double vision Signs of eye injury that require ophthalmologic evaluation are the following: 1. One eye with an abnormal pupil size, shape, or reaction to light, as compared to the other eye 7. Laceration or perforation of the eye 157 Occupational Health and Safety Disorders of the Nervous System the nervous system comprised of the brain, spinal cord, and peripheral nerves, is a complex system responsible for both voluntary and involuntary control of most body functions. These are accomplished through a process of receiving and interpreting stimuli as well as transmitting information to the effectors organs. The adverse impacts of stressors from the work environment (physical, chemical, and psychological) are experienced in a variety of ways. The strategy focuses mainly on reducing job stress and providing employee mental health services (see Annex 1). Efforts to prevent stress-related disorders focus on ameliorating major areas of job stress; providing job security and career opportunity, a supportive social environment, and meaningful, creative, rewarding work; and making every effort to ensure worker participation in decision making and control of the work environment. Reproductive disorders 158 Occupational Health and Safety the prevention of reproductive disorders is an important public health priority. These problems include abnormalities that affect the reproductive function of both men and women as well as a wide range of unwanted pregnancy outcomes. In the United States, approximately one in seven married couples is involuntarily infertile.