Y. Mezir. University of Hawai`i, West O`ahu.

Sterilization Place the wrapped dressings and combos in a pan or cookie sheet and bake at 350° for 3 hours discount naproxen 250 mg on-line. When cooled discount 500 mg naproxen with mastercard, store in a plastic bag for protection, keeping sizes separate for convenience. After that the scissors will lose their edge and be impossible to sharpen, the needle holders will begin to let the needles twist, and the forceps ratchets keep slipping. If you are preparing for a long-term scenario then you need to invest in good quality equipment, otherwise, they won’t last the distance. The top quality equipment is designed to be reused in a hospital several thousand times and still work well – this is more often than you will use them in a hundred years! A good metal worker will be able to create instruments to a high standard but it very unlikely that they will ever match good quality pre-crash instruments. This also assumes that you will have access to a craftsman and a forge but it is potentially an option. Scalpel blades can be manufactured from thin pieces of steel – provided it they be sharpened to hold an edge. Many automotive tools are very similar to some medical instruments, and provided they are cleaned and sterilised may function well. Suture material and needles: Most suture (particularly the non-absorbable) material will keep for a very long time. As with instruments it is likely a competent metal worker will be able to produce a reasonable range of suture needles. It is not exactly gut, it is the muscular layer stripped from the wall of the small bowel of sheep’s intestines and preserved in alcohol. Cotton thread can be used both for skin suturing and internal sutures (even though it is not absorbable it can be left in place). Other equipment and supplies: The trick with improvising medical equipment is ingenuity. Many items of medical equipment have multiple uses some are a poor second choice to proper equipment, others do a first class job; the key is think broadly about possible uses. Below is a list of just a couple of ideas for improvised equipment but it’s just a starting point, there is vast potential: Splints – For a fracture to heal it needs to be immobile, and comfortable, and not cause pressure points. Plaster of Paris and fibreglass have been used for most long- term splinting for the last decades. Splints can be manufactured from just about anything that can immobilise a fracture site. Wood, plastic, strips of material, spun wool all in various combinations can be used to construct an adequate splint for a limb. One author has previously manufactured a perfectly workable traction splint for a broken femur from fencing wire, duck tape, and some insulation foam. Fly Trap – Flies are a major vector for disease transmission particularly of diarrhoeal disease. Simple flytraps can be made with plastic soda bottles (of which there will be thousands around for years to come, regardless of what disasters may befall us – given their slow decomposition). However, these traps can collect thousands of flies which decompose slowly so you need to consider how you will dispose of them. These are small plastic cylinders with a mouth piece which the patient breathes in and out through. The medicine is sprayed into the chamber of the cylinder and the patient breathes it in. The concept is that if medication is delivered into a confined space it doesn’t disperse so quickly so by having the patient breath in and out through the spacer more of the medicine is delivered to the lung. A perfectible useable Spacer can be made from a 2L plastic soft drink bottle; the patient breaths in and out through the mouth of the bottle, vent holes are cut in the base, and a hole for the inhaler to spray through on the side. Medications Modern medications: While these will eventually run out it is important to realise, as is discussed elsewhere, that the expiry dates on many medications have little relationship to how long they are safe and effective. The following information is for entertainment purposes only, and we do not recommend relying on this information except in a life- threatening emergency. Expiry dates simply reflect the longest period of time the drug companies are prepared to admit they have studied stability for. Several companies (probably most – but they don’t own up to having the data) have stability data extending 5 or 10 years beyond the expiry date on the packet. It has been cynically said that expiry dates are more about marketing, turnover, and profits than about patient safety. The requirements, aside from knowledge and time, are access to basic high school level laboratory equipment (there is also plenty of room to substitute things such as Pyrex kitchen bowls, measuring cups and kitchen scales), and some chemical reagents – which may need to be made themselves - the need to produce chemicals to produce other chemicals. It is likely that only a larger community could spare the resources to sustain a meaningful manufacturing system. We believe that community specialisation is likely to occur, and that medicine production (and medical supplies), and the provision of medical services may well be a desirable area of specialisation. The quality of the drugs produced will be significantly lower than current pharmaceutical standards; it becomes a risk/benefit situation in terms of using them. Like other areas of preparedness this requires advanced thought and preparation about what you consider you may wish to manufacture.

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Hyperthermia thermometers are thermometers that allow the reading of higher than normal temperatures to more accuracy than standard thermometers order 500mg naproxen with visa. Purchase recommendations: For each ten people have at least two standard thermometers buy 500 mg naproxen mastercard, one basal thermometer, and one hypothermia thermometer. Hyperthermia thermometers should be purchased at the rate of one to every twenty people if you expect to see heat injuries commonly, otherwise, a normal clinical thermometer will usually suffice. Rectal versus oral versus universal tips - get universal tips (midway between oral and rectal, and they can be used for either in a pinch) for the clinical and basal thermometers, rectal for the hypothermia and hyperthermia thermometers. Then there are the simple but easily overlooked tools that make ongoing care not only practical but less strenuous and safer for both patient and caregiver. Bandage Scissors: Designed to cut away bandages next to the body without poking holes in your patient. Permanent Marker: To write on dates or times on dressings to know when they were last changed if there is more than one caregiver. Also used to mark skin (it wears off with repeated washing and normal skin replacement). Transfer Belt: Known by various names such as walking belt, safety belt, gait belt, etc. The commercial version is a 3” wide sturdy fabric strap that is easily buckled around the patient so the caregiver can assist them with standing up, transferring, or walking. It can also be fashioned from a pair of sturdy pants suspenders or an ordinary (wide) clothing belt. It provides a handle for the caregiver to grab on to by placing it around the middle (lower stomach area) of the patient and holding onto the rear of the belt. It isn’t always practical to reach into your pocket for everything and setting tools, dressings, etc. Clothing Protectors: Another simple yet important item that can be fashioned readily from any soft or fluid resistant material. Intended to catch spills while eating/feeding and protect the patient while washing hair or performing treatments. They may tie behind the neck or have a wrap-around collar that fastens with Velcro. By protecting from spills they also save a lot of time by guarding against the necessity of clothing and bed linen changes. Flashlight: This serves a dual role as both as assessment tool for the eyes, ears, nose and mouth, and the means to check a patient at night without awakening them with overhead lighting. Gowns: Caring for people may routinely require exposing differing areas of their body for washing, administering medications, changing dressings and bandages or measuring vital signs. Having to undress a person each time is time-consuming and impractical as well as potentially painful. Modesty dictates that we be able to cover the patient when exposure is not otherwise needed. Open back gowns while the bane of hospitalized patients world-wide represent the most practical means of combining protection with accessibility when shirt and pant style clothing is not practical or possible, as when casts or external appliances interfere. Vanity issues aside it may be necessary to trim nails to address issues of hygiene (germs love to hide under nails) and prevent inadvertent self-injury by a patient who may flail about with pain or fever delirium. Having properly designed and sized clippers for the fingers and toes makes this task much easier for all concerned. Providing On-Going Care Having identified our goals we can move on the issue of how we are to address them. There are several areas that need to be addressed as part of the entire care “package” or plan. Databases: Vital Signs Having a database of vital signs is the key to recognizing abnormal vital signs later on. In an ideal situation you would have a record that details normal laying, sitting and standing blood pressures for your patient, as well as a resting pulse, and respirations, along with a temperature. Make sure to note whether the normal pulse is - 152 - Survival and Austere Medicine: An Introduction regular and strong in quality and rhythm, or irregular, weak, or bounding (very strong). Having a database of temperatures over time will allow you to gauge the effectiveness of antibiotics, for instance, or the onset of an infection. Similarly a person who is acutely dehydrated will see an increase in their temperature. Pulse Pulses may indicate a general state of health in the absence of illness or injury. A very rapid, thin pulse may indicate the presence of shock, whereas a slow pulse might signal that the patient is relaxed and relatively pain free.

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D - 16 - Gross Anatomy and Embryology Gross Anatomy Module (125 items) Systems Blood & Lymphoreticular System 1%–5% Nervous System & Special Senses 5%–10% Musculoskeletal System 10%–15% Cardiovascular System 20%–25% Respiratory System 10%–15% Gastrointestinal System 20%–25% Renal & Urinary System 1%–5% Female Reproductive System & Breast 5%–10% Male Reproductive System 1%–5% Endocrine System 1%–5% Embryology Module (20 items) Systems Blood & Lymphoreticular System 5%–10% Nervous System & Special Senses 5%–10% Musculoskeletal System 5%–10% Cardiovascular System 5%–10% Respiratory System 5%–10% Gastrointestinal System 10%–15% Renal & Urinary System 5%–10% Female Reproductive System & Breast 1%–5% Male Reproductive System 1%–5% Endocrine System 5%–10% - 17 - 1 cheap naproxen 250mg otc. A 45-year-old woman has a uterine leiomyoma that is 5 cm in diameter and is pressing on the urinary bladder buy 250mg naproxen with mastercard, causing urinary frequency. A 5-year-old girl is brought to the emergency department because of fever and severe abdominal pain. In the examination room, she keeps her right hip flexed and resists active extension of the hip. The inflamed structure associated with these symptoms is most likely in contact with which of the following structures? A 61-year-old man comes to the physician because of a 3-month history of episodes of headache, heart palpitations, and excessive sweating. A 6-year-old boy has a large intra-abdominal mass in the midline just above the symphysis pubis. During an operation, a cystic mass is found attached to the umbilicus and the apex of the bladder. A 55-year-old man who has alcoholic cirrhosis is brought to the emergency department because he has been vomiting blood for 2 hours. He has a 2-month history of abdominal distention, dilated veins over the anterior abdominal wall, and internal hemorrhoids. A 3-year-old girl with mild craniofacial dysmorphosis has profound hearing deficits. Further evaluation indicates profound sensory auditory deficits and vestibular problems. Altered development of which of the following is most likely to account for these observations? A 19-year-old woman comes to the physician because of a 5-day history of increasingly severe right lower abdominal pain and bloody vaginal discharge. Which of the following is the most likely location of this patient’s fertilized egg? A 22-year-old man is brought to the emergency department because of a suprahyoid stab wound that extends from one side of the neck to the other. His tongue deviates to the right when protruded; there is no loss of sensory modality on the tongue. Resection of the tumor is scheduled, and the physician also plans to obtain samples of the draining nodes. To find these nodes, a radiotracer is injected adjacent to the tumor and images are obtained. The first draining sentinel node in this patient is most likely found at which of the following locations? This patient most likely has an abnormality of which of the following fetal structures? A 70-year-old man has a 90% blockage at the origin of the inferior mesenteric artery. Which of the following arteries is the most likely additional source of blood to the descending colon? A 30-year-old man comes to the emergency department 1 hour after injuring his left knee in a volleyball game. He says he twisted his left leg when he fell to the floor after he and a teammate accidentally collided. When the patient sits on the edge of the examination table, the left knee can be displaced anteriorly at an abnormal degree. A 70-year-old man is brought to the emergency department because of a 1-week history of increasingly severe left-sided lower abdominal pain and passing gas in his urine. A 60-year-old man has tenderness in the region distally between the tendons of the extensor pollicis longus and extensor pollicis brevis (anatomical snuffbox) after falling on the palm of his right hand. A 20-year-old man is brought to the emergency department 1 hour after he was involved in a motorcycle collision. On auscultation, a harsh continuous murmur is heard at the left of the sternum between the first two ribs. Arterial blood oxygen content is slightly higher in the right hand than in the left hand. A 50-year-old woman is brought to the emergency department because of severe upper abdominal pain for 24 hours. Physical examination shows jaundice and tenderness of the right upper quadrant of the abdomen. Serum studies show a bilirubin concentration of 5 mg/dL, alkaline phosphatase activity of 450 U/L, and lipase activity of 400 U/L (N=14–280). A 6-year-old boy is brought to the physician by his parents for a follow-up examination because of a heart murmur that has been present since birth.

Conjugated linoleic acid supplementation in humans: Effects of body composition and energy expenditure naproxen 500 mg otc. Fish consumption and mortality from all causes cheap 250 mg naproxen with mastercard, ischemic heart disease, and stroke: An ecological study. Dose-response effects of dietary γ-linolenic acid- enriched oils on human polymorphonuclear-neutrophil biosynthesis of leukotriene B4. Hydrogenation alternatives: Effects of trans fatty acids and stearic acid versus linoleic acid on serum lipids and lipoproteins in humans. In addition to the activities identified with a sedentary lifestyle, an average of 60 minutes of daily moderate intensity physical activity (e. Because the Dietary Reference Intakes are provided for the general healthy population, recommended levels of physical activity for weight loss of obese individuals are not provided. For children, the physical activity recommendation is also an aver- age of 60 minutes of moderate intensity daily activity. Also regular physical activity may improve mood by reducing depression and anxiety, thereby enhanc- ing the quality of life. The beneficial outcomes of regular physical activity and exercise appear to pertain to persons of all ages, and both women and men of diverse ethnic groups. It seems reason- able to anticipate continuation of the current trend for reductions in occupational physical activity and other energy expending activities of daily life. Hence, to increase physical activity and to thereby facilitate weight control, recreational activities and physical training programs need to add, and not substitute for, other physical activ- ities of daily life. History of Physical Activity Recommendations United States In 1953, Kraus and Hirschland (1953) alerted health and fitness pro- fessionals, the general public, and President Dwight D. Kennedy, the council was renamed the President’s Council on Physical Fitness, and in 1965 it estab- lished five levels of physical fitness for adult men and women. Activities such as walking, jogging, and bicycling three times a week for 20 minutes were recommended. In addition, that report recommended combining sensible eating with regular physical activity and acknowledged that physical activity and nutrition work together for better health. An early initiative was the Toronto International Conference on Physical Activity and Cardiovascular Health in 1966. Toronto was also the site of the 1988 International Consensus Conference on Exercise, Fitness and Health. In 1992, coinciding with Canada’s 125th birthday, the Second International Conference on Physical Activity, Fitness, and Health was held. That meet- ing resulted in publication of the report, Physical Activity, Fitness, and Health (Bouchard et al. Most recently, in cooperation with Health Canada and the Canadian Society of Exercise Physiology, Canada’s Physical Activity Guide to Healthy Active Living has been published (Health Canada, 1998). For moderate and vigorous activities, the Canadian recom- mendations are for 4 or more days per week and also include participation in flexibility activities (4–7 days per week) and strength activities (4–7 days per week). Energy expenditure can rise many times over resting rates during exercise, and the effects of an exercise bout on energy expenditure persist for hours, if not a day or longer (Benedict and Cathcart, 1913; Van Zant, 1992). Further, exer- cise does not automatically increase appetite and energy intake in direct proportion to activity-related changes in energy expenditure (Blundell and King, 1998; Hubert et al. In humans and other mammals, energy intake is closely related to physical activity level when body mass is in the ideal range, but too little or too much exercise may disrupt hypothalamic and other mechanisms that regulate body mass (Mayer et al. However, as men- tioned in Chapter 5, the increase in daily energy expenditure is somewhat greater because exercise induces an additional small increase in expendi- ture for some time after the exertion itself has been completed. Because it is the most significant physical activity in the life of most individuals, walking/jogging is taken as the reference activity, and the impact of other activities can be considered in terms of exertions equiva- lent to walking/jogging, to the extent that these activities are weight bear- ing and hence involve costs proportional to body weight. The middle panel describes the energy expended in kcal/hour for walking or jogging at various speeds by individuals weighing 70 or 57 kg (the reference body weights for men and women, respectively from Table 1-1. The energy expended per mile walked or jogged is essentially constant at speeds ranging from 2 to 4 miles/hour (1 kcal/mile/kg for a man [70 kcal/mile/70 kg] to 1. The upper panel shows the rate of energy expenditure as a function of walking/ jogging speed. The middle panel shows the energy expended by a 70-kg man ( ) and by a 57-kg woman (▫) while walking/jogging 1 h at various speeds. The lower panel shows the increase in daily energy expenditure induced by walking/jogging 1 m at various speeds for a 70-kg man (●) and a 57-kg woman ( ). Energy expenditures while walking or running at speeds of 2, 3, 4, 5, or 8 mph are 2. Energy expenditures while walking or running at speeds of 2, 3, 4, 5, or 8 mph are 2. While this is true, because energy expenditure increases with increasing body weight, there is a greater total daily energy expenditure in obese subjects (Table 5-10 and 5-11). The second “active” column illustrates a mix of activities as reflected by the average time spent per day on various forms of activity and exercise. A somewhat simplified approach, instead of recording all activities, would be to evaluate whether the level of daily living activities is compara- ble to that depicted in Tables 12-2 and 12-3. The factorial approach summations of various estimates of activities and durations applied in Tables 12-2 and 12-3 to evaluate energy turnover is more convenient than previous procedures inasmuch as it is applicable without making reference to body weight, as required, though often ignored, in estimating increments in energy expenditure in terms of their cost in kcal.