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The use of models order kamagra 50mg mastercard erectile dysfunction medication natural, diagrams purchase 50mg kamagra free shipping erectile dysfunction treatment sydney, and photographs can help illustrate points clearly. The plaintiff attorney will try to chal- lenge your reputation and make you nervous. Jurors expect attorneys to be arrogant and aggressive, in part based on portrayals of attor- neys by the media. I have been involved in several cases in which the same attorney who grilled me on one case asked if he could hire me on a different case because I did such a good job under fire at a deposition. If you recog- nize that these attorneys are only doing what is expected of them, it may help in removing some of the emotion from the situation. Outside the courtroom, either before, during, or after breaks, always retain your professional demeanor. Jurors could see you and think that you are not taking the case seri- ously. Also, do not talk about the case until your lawyers says it is okay, because the other side can pick up remarks. ACKNOWLEDGMENT This is an excerpt from an article entitled “Pathologists and the Judi- cial Process: How to Avoid It” by Jonathan I. This por- tion of the article was selected because it explains so well the purpose of pretrial discovery and provides valuable insight into the conduct of a deposition. Discover strategies for avoiding legal pitfalls if you must ever give a deposition. Chapter 6 / Communication and Patient Safety 63 III THE CLINICAL FACE OF LITIGATION 64 Gorney Chapter 6 / Communication and Patient Safety 65 6 Communication and Patient Safety Mark Gorney, MD SUMMARY Faulty communication is among the most common underlying causes of medical error and frequently erodes the doctor–patient relationship. Communication should be understood in the broad- est sense, including nonverbal, oral, and written. This chapter reviews the most common mechanisms responsible for commu- nication failures and recommends specific routines to minimize or avoid them altogether. Key Words: Poor listening habits; nonverbal; speech tempo; body language; repetition. INTRODUCTION Patient anger underlies many malpractice claims and frequently results from ineffective communication. The breakdown is usually between doctor and patient but may also involve miscommunica- tion between physicians and nurses or between physicians and family members. Mastering the art of listening and increasing one’s awareness of both verbal and nonverbal expression are important aspects of contem- porary medical practice. Patients are increasingly assuming responsi- From: Medical Malpractice: A Physician’s Sourcebook Edited by: R. They often have sufficient knowledge about their condition to ask intelligent questions, which may make the physician defensive, evasive, or hos- tile. This may be perceived by the patient as arrogance, leading to feelings of frustration, disappointment, and anger. Listening is an active, cognitive process that involves interpreting what is heard and deciding on a response. Most of our waking day is spent in some form of communication, and much of that time is listening. In the office and at the bedside, the amount of time a physician spends listening is even greater. According to Edward Kelsay (1), of the four basic communication skills (listening, speaking, reading, and writing), listening is the least apt to be formally taught. Nichols of the University of Minnesota, a nationally recognized authority and researcher on the nuances of listening, believes that effective listening requires conscious effort (2). Busy physicians are at high risk of falling into poor listening behaviors. Nichols has iden- tified the following 10 bad habits in listening behaviors that can lead to serious doctor–patient misunderstandings. A subconscious resis- tance to listening may arise if we become bored while listening to complaints that we have heard many times before from many other patients.

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Matching abnormality of the brain that results in the work setting to the individual’s specif- seizures kamagra 100 mg mastercard erectile dysfunction ultrasound. Conditions Affecting the Brain 61 Classification of Seizures dergoes rapid 50 mg kamagra visa erectile dysfunction causes lower back pain, jerky movements. The teeth are clenched tightly together and Individuals with epilepsy can exhibit a control of the bladder or the bowel may be variety of seizures with varying symptoms, lost. The seizure generally lasts less than ranging from muscle spasms or confusion a few minutes. Seizures can sciousness is gradually regained, but indi- be mild or severe, can occur frequently or viduals may experience confusion, rarely, and can change their pattern of difficulty in speaking, and headache. Depending on the though postseizure symptoms usually dis- type, seizures usually last only seconds to appear within several hours, the fatigue minutes. Between seizures most individ- experienced may be overwhelming, often uals are able to function normally. Classification of seiz- Table 2–5 Common Types of Seizures ures is important so that appropriate man- Associated with Epilepsy agement and treatment can be determined. Seizures are classified as generalized, in which nerve cells discharge abnormally Generalized seizures throughout the brain, or partial, in which 1. Absence (petit mal) ited to one specific part of the brain (Browne & Holmes, 2001). Although there Partial seizures are many classifications of seizures relat- 1. Although a tonic-clonic seizure may be Generalized Tonic-Clonic Seizure frightening to those who witness it, indi- (Grand Mal) viduals experiencing the seizure are usu- ally in no imminent danger unless there An abnormal discharge of nerve cells are hard, sharp, or hot hazards within the throughout the brain results in a general- immediate environment. No attempt ized tonic-clonic seizure, sometimes called should be made to move individuals ex- a grand mal seizure. Some individuals ex- periencing a seizure except when neces- perience an aura (warning sign) immedi- sary to protect them from such hazards. They may To avoid injury, there should be no at- see a flash of light, have an unusual taste tempt to restrain individuals during a ton- in the mouth, or have other unusual ic-clonic seizure, to pry open clenched sensations. As the seizure develops, indi- teeth, or to place hard objects in the indi- viduals lose consciousness and fall down, vidual’s mouth. Individuals should be entering a tonic state in which there is gen- placed on their side during a seizure so eralized body rigidity. Muscles then enter that secretions can drain from the mouth a clonic state so that the whole body un- and do not compromise the airway. Jacksonian Like tonic-clonic seizures, absence seizures can remain limited to one part of seizures are classified as generalized, the body or can go on to develop into full- because nerve cells discharge throughout blown tonic-clonic seizures. Children most commonly ex- Other types of partial seizures may have perience this type of seizure. Complex-partial seizures are characterized by brief blank (psychomotor) seizures are characterized by spells or staring spells and a loss of aware- a loss of awareness of the surroundings. The seizure Individuals may pace, wander aimlessly, generally lasts for only seconds. The indi- make purposeless movements, and utter vidual does not fall, and there are usual- unintelligible sounds. The seizure can last ly no outward motor manifestations of up to 20 minutes, with mental confusion absence seizures, although abnormal lasting for a few minutes after the seizure blinking or slight twitching may occur is over. Because of the limited visi- toms of complex-partial seizures, often ble symptoms of the seizure, those around attributing the symptoms to alcohol, the individual may misinterpret absence drug abuse, or mental illness. When children experience frequent Status Epilepticus absence seizures, school performance may be disrupted. Because there may be no Status epilepticus is a term used to de- significant signs that are easily observed scribe seizures that are prolonged or that during the seizure, the seizure disorder come in rapid succession without full re- may not be diagnosed, and poor school covery of consciousness between seizures. Recognition of symptoms and life–threatening and consequently re- appropriate diagnosis are crucial to enable quires immediate medical attention and children to achieve maximum school treatment (Lowenstein & Alldredge, 1998). Absence seizures may disappear spontaneously with age, although some Diagnosis of Epilepsy individuals who have had absence seizures later go on to develop tonic-clonic seizures. Individuals who are having a seizure for the first time usually undergo medical Partial Seizures evaluation by a neurologist to determine whether the seizure is a symptom of an When nerve cells discharge in an isolat- acute medical or neurological illness that ed part of the brain, partial seizures occur. Exten- and symptoms are very localized, depend- sive physical examination and blood tests ing on the part of the brain affected. One are usually part of initial screening, as well type of focal seizure, a Jacksonian (simple- as a detailed history of the precipitating partial) seizure, begins with convulsive factors that appeared to trigger the seizure.

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If you regularly treat young people buy 50 mg kamagra fast delivery how does an erectile dysfunction pump work, you should familiarize yourself with the existing statutory provisions in your state and keep up to date order kamagra 50mg without a prescription erectile dysfunction quizlet. Religious and Other Obstacles Occasionally, you may be placed in the difficult position of being refused permission to treat or conduct diagnostic tests on the basis of a patient’s religious or other beliefs. Although grave consequences may ensue, there is little that you can do in most states beyond making an intense effort to convince the patient. In some states, court intervention Chapter 14 / Plastic and Reconstructive Surgery 185 may be obtained. Here too, knowing the law of the state in which you practice is advisable. If a patient is either a minor or incompetent (and the parent or guard- ian refuses treatment), and you know serious consequences will ensue if appropriate tests and/or treatment are not undertaken, then your legal and moral obligations change. You must then resort to a court order or another appropriate governmental process in an attempt to secure sur- rogate consent. The participation of personal or hospital legal counsel is advisable to ensure that the legal requirements applicable in your locale are met. However, you should inform the patient of the treatment’s risks and consequences and record such discussions. In general, it is important to discuss the following six elements of a valid informed consent with your patients and/or their families. The nature and purpose of the proposed treatment or procedure and its anticipated benefits. In situations where the nature of the tests or treatment is purely elective, as with cosmetic surgery, the disclosure of risks and conse- quences may need to be expanded. In addition, an expanded discussion should take place regarding the foreseeable risks, possible untoward consequences, or unpleasant side effects associated with the procedure. This expansion is particularly necessary if the procedure is new, experi- mental, especially hazardous, purely for cosmetic purposes, or capable of altering sexual capacity or fertility. Documentation Written verification of consent to diagnostic or therapeutic proce- dures is crucial. However, also remember that in an increasing number of circumstances, laws now require the completion of specifically designed consent forms. If your records disclose no discussion or consent, then the burden will be on you to demonstrate legally sufficient reasons for such absence. It is a test of your good judgment of what to say to your patient and of how to say it to obtain meaningful consent without frightening the patient. No permit or form will absolve you from responsibility if there is negligence, nor can a form guarantee that you will not be sued. A well-drafted informed consent document is proof that you tried to give the patient sufficient information on which to base an intelligent decision. Such a document, supported by a handwritten note and entered in the patient’s medical record, is often the key to a successful malprac- tice defense when the issue of consent to treatment arises. The Therapeutic Alliance Obtaining informed consent need not be an impersonal legal require- ment. When properly conducted, the process of obtaining informed consent can help establish a “therapeutic alliance” and launch or rein- force a positive doctor–patient relationship. If an unfavorable outcome occurs, that relationship can be crucial to maintaining patient trust. A common defense mechanism against uncertainty is for a patient to endow his or her doctor with omniscience in the science of medicine, an aura of omnipotence. By weighing how you say something as heavily as what you say, you can turn an anxiety-ridden ritual into an effective therapeutic alliance. Rather than shattering a patient’s inherent trust in you by presenting an insensitive approach, your dialogue should be sympa- thetic to the patient’s particular concerns or tensions and should project believable reactions to an anxious and difficult situation. Consider, for example, the different effects that the following two statements would have: 1.

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Especially purchase 100 mg kamagra fast delivery drugs for erectile dysfunction, Necrotizing fasciitis is a rare buy 100 mg kamagra overnight delivery erectile dysfunction drugs walgreens, rapidly progressive, and of- small sinus tracts can be detected with this technique. Early diagnosis is sue masses is color or power Doppler US [3, 4, 10, 12- mandatory because the disease may have a fatal course if 14]. An abscess shows absence of flow within its contents adequate therapy (extensive surgical debridement and an- and hyperemia in its direct surroundings. Causative organisms Doppler US helps to discriminate inflammatory and in- are S. Although necro- fectious fluid collections from non-inflammatory collec- tizing fasciitis in its early phase can mimic cellulitis, tions, but it is not possible to discriminate between in- imaging can be helpful in the diagnosis. Finally, US is extremely valuable in detecting (a) fascial thickening and accumulation of fluid, (b) fluid collections and abscesses around orthopedic hard- cloudy fluid or loculated abscess in the fascial plane, al- ware (Fig. The value of CT and MRI is limited by lowing US_guided diagnostic aspiration, (c) subcuta- the presence of artifacts, especially next to orthopedic de- neous soft-tissue swelling, and (d) eventually, gas in soft vices. CT demonstrates decreased attenuation of the superfi- CT demonstrates a focal fluid collection (HU>20) cial fascia compatible with necrosis and relative sparing whose density varies with the relative amounts of pro- of the muscular compartment. The central cavity seen dissecting along fascial planes and deeper fluid col- is surrounded by a thick irregular rim that enhances after lections appear. The MR image of necrotizing fasciitis resembles that of infectious cellulitis to a certain extent; however, there is also involvement of the deep fascia and intramuscular spaces. Abnormal gadolinium enhancement is caused by contrast extravasation from damaged capillaries in areas of necrosis. The depth of the soft-tissue involvement does not seem to be a reliable parameter to differentiate be- tween cellulitis and necrotizing fasciitis [6, 9]. Soft-Tissue Abscess An abscess is defined as a collection of necrotic tissue, neutrophils, inflammatory cells, and bacteria walled off a b by highly vascular connective tissue. Clinical inspection showed minor cellulitis but subsequently liquefy to form a localized pus swelling but normal aspect of the skin. Deep abscesses, such as subperiosteal ab- part of the orthopedic hardware and extreme varus deformity of femoral neck, suggesting loosening. These imaging findings can be better seen with MR; the low signal intensity of the fluid on T1 and its high signal intensity on T2 contrast nicely with the enhancing rim. The presence of an enhancing rim on post-gadolinium images has a high sensitivity and specificity for the diagnosis of soft-tissue abscess. Osteomyelitis a Osteomyelitis is defined as an infection of the bone mar- row. The incidence of Haemophilus influenzae osteomyelitis has decreased dramatically since the intro- duction of HIB vaccination. In infants, dia- physeal vessels penetrate the growth plate to reach the c epiphysis, facilitating epiphyseal and joint infections in this age group. In older children, the growth plate constitutes a barri- A 13-year-old girl presented er for the diaphyseal vessels. Vessels at the metaphysis with complaints of periods of terminate in slow-flow venous sinusoidal lakes, predis- low-grade fever and a progres- d posing the metaphysis as the starting point for acute sive swelling of the proximal hematogenous osteomyelitis. A metaphyseal defect is present, as shown with ultra- The increased pressure within the medullary cavity sonography (a) and radiography (b). Conventional radiography is usually the initial modality demonstrating deep soft-tissue swelling in early disease. Bone destruction and periosteal reaction become obvious only 7-10 days after the onset of disease. Nonetheless, con- ventional radiography is a screening method that may sug- gest the diagnosis, exclude other pathology, and can be correlated with other imaging findings. Recently, several reports have recommend the use of US for the early diagnosis of osteomyelitis, especially in Fig. A 9-year-old girl changes comprises deep edema, thickening of the perios- with a 7-month history of teum, intra-articular fluid collection, and subperiosteal ab- arthralgia presented with a 3- scess formation (elevation of the periosteum by more than week history of a swelling at the sternoclavicular joint on 2 mm). The de- Although the cortex (vertical tection of subperiosteal abscesses is especially important arrows) appears to be intact, there are echoes from the because in these patients ultrasonographically guided as- b medulla (curved arrows), piration or surgical drainage has to be considered, where- suggesting subtle permeative as patient with osteomyelitis without abscesses can be changes of the cortex facilitating the passage of sound waves into treated with antibiotics only.

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