By B. Koraz. Edgewood College.
The government’s sponsorship of a series of initiatives to promote the teaching of parenting skills—the SureStart programme buy prilosec 40 mg mastercard, the National Family and Parenting Institute and numerous subsidised voluntary organisations—has been criticised as an intrusion on parental autonomy (Fitzpatrick 1999) trusted prilosec 20mg. The notion that doctors should encourage order prilosec 40 mg visa, if not directly sponsor, such programmes is now widely accepted. Yet it marks a dramatic reversal of what was traditionally regarded as good medical practice. In an essay first published in 1950, the famous child psychotherapist Donald Winnicott insisted that ‘we must see that we never interfere with a home that is a going concern, not even for its own good’ (Winnicott 1965:132). He warned that ‘doctors are especially liable to get in the way between mothers and infants, or parents and children, always with the best intentions, for the prevention of disease and the promotion of health’. Winnicott, famed for his sensitivity to children’s mental states, was acutely aware that intruding between children and their parents, who are the most reliable guarantor of their interests, could have a destabilising effect. In a later essay, entitled ‘Advising Parents’, Winnicott amplified his views. He carefully distinguished the legitimate sphere of medical intervention—the treatment of disease—from giving ‘advice about life’, which was beyond their competence: Doctors and nurses [should] understand that they do not have to settle problems of living for their clients, men and women who are often more mature persons than the doctor or nurse who is advising. While offering information and support to parents, expert intervention diminishes the value of parents’ intimate experience of dealing with their own children. The intrusion of an external source of authority into the family undermines not only confidence but also accountability. Any third party intrusion between parents and children (Furedi 2000) is likely to weaken their own capacities to work through and resolve conflicts. Though motivated by a desire to provide help and support to families in need, parenting projects are likely to weaken parental authority still further. If GPs generally take on a wider role in family support and the promotion of parenting, they will be drawn into a more intrusive and authoritarian approach to their patients. The result will be damaging to doctor-patient relationships, and inevitably to professional status. The relatively high standing of general practice which makes it such an attractive base for New Labour’s moral engineering projects is a wasting asset, one likely to be expended very rapidly if GPs assume the shabby mantle of social work. It is rather ironic that, after seeking to take over the management of the social as well as the medical problems of the neighbourhood, many GPs complain of high levels of stress (not to mention a growing inclination among their patients to assault them). Following the scandal of the high death rates at the Bristol children’s heart surgery unit (culminating in disciplinary action against three doctors in June 1998), the Kent gynaecologist Rodney Ledward (struck off the medical register in October 1998 for gross negligence), and numerous less grievous cases of incompetence or corruption, the Shipman case provided further impetus to the drive to tighten administrative control over the medical profession (Abbasi 1999). In the closing months of 1999, a flurry of documents indicated the direction of measures for tougher action against rogue or ‘under-performing’ doctors and for closer regulation of the profession as a whole. The GMC published its long-awaited plans for the regular ‘revalidation’ of doctors based on an assessment of their fitness to practise (Buckley 1999). The RCGP and the General Practitioners Committee of the BMA jointly produced proposals on how revalidation could be implemented in general practice (RCGP October 1999, November 1999). Meanwhile the government’s chief medical officer, Liam Donaldson, issued a consultation paper on ‘preventing, recognising and dealing with poor performance’ among doctors, proposing ‘assessment and support centres’—immediately dubbed ‘boot camps’ or ‘sin bins’—for delinquent doctors (DoH November 1999).
However purchase 20mg prilosec mastercard, it may be several days before a CT scan will show cerebral infarction and the EEG may be affected by residual sedation effective prilosec 20mg. Biochemical markers such as neutron-specific enolase in blood and cerebrospinal fluid may offer supportive A prolonged period of cardiac arrest or a persistently low evidence of severe brain injury prilosec 20 mg on-line. It may be necessary to consider Metabolic problems haemofiltration for urgent correction of intractable acidosis, Meticulous control of pH and electrolyte balance is an essential fluid overload, or severe hyperkalaemia, and to manage part of post-arrest management. Bicarbonate, with its well- established renal failure in the medium term. In renal failure recognised complications (shift of the oxygen dissociation after cardiac arrest, remember to adjust the doses of curve to the left, sodium and osmolar load, paradoxical renally excreted drugs such as digoxin to avoid toxicity intracellular acidosis, and hypokalaemia), should be avoided if possible. If used, it should be carefully titrated in small doses, using repeated arterial sampling to monitor its effects. Hypokalaemia may have precipitated the original cardiac arrest, particularly in elderly patients taking digoxin and diuretics. Potassium may be administered by a central line in doses of up to 40mmol in an hour. As it has few side effects, magnesium can be safely administered to patients with frequent ectopics or atrial fibrillation without waiting for laboratory confirmation of hypomagnesaemia. Even when the level is normal, the administration of magnesium may suppress arrhythmias. A urinary catheter and graduated collection bottle are necessary to monitor urine output. An adequate cardiac output and blood pressure should produce 40-50ml of urine Further reading every hour. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. Mild hypothermia in neurological A commitment to treat cardiac arrest is a commitment to emergency: an update. The course of circulatory and cerebral generally be managed in an intensive care unit and is likely to recovery after circulatory arrest: influence of pre-arrest, arrest need at least a short period of mechanical ventilation. Early myoclonic status and conscious level does not return rapidly to normal, induced outcome after cardiorespiratory arrest. Predicting longer term neurological outcome in the ● Premachandran S, Redmond AD, Liddle R, Jones JM. Cardiopulmonary arrest in general wards: a retrospective study The initial clinical signs are not reliable indicators. The of referral patterns to an intensive care facility and their duration of the arrest and the duration and degree of influence on outcome.
Surveying the damage wrought on British agriculture—and the balance of trade—a week after his parliamentary statement on the supposed BSE-nvCJD link generic prilosec 10mg amex, health minister Stephen Dorrell declared in exasperation in a Radio Four interview that ‘it’s not the cows that are mad generic 40mg prilosec with visa, it’s the public’ (quoted in Lang 1998) 20mg prilosec sale. But the mad cow panic did not begin on the farms or in the butchers’ shops or supermarkets. It began among the scientists, spread to the politicians and was amplified in their interactions with the media, which transmitted it to the public. Nobody was better placed to dampen down the panic than Dorrell, yet his statement served only to exacerbate the anxieties that devastated farmers in Britain and beyond. The history of the major scares confirms that they did not originate in spontaneous outbreaks of public anxiety. They each started among doctors and scientists who themselves became alarmed, either at the emergence of a new disease (Aids, nvCJD), or the recognition of a new risk factor (front sleeping, MMR, the Pill). In the absence of any effective treatment for any of these conditions, doctors sought to raise public awareness of them, in the belief that this was the only means of prevention. The scares took off when doctors’ own anxieties led them to turn to their contacts with government and the media to generate wider publicity around the focus of their concerns. A number of factors have encouraged medical and scientific experts to project their anxieties into the public realm. One is the wider crisis of medical confidence in tackling the ‘modern epidemics’ of coronary heart disease and cancer, now that the threat of infectious diseases has receded. In the 1970s and 1980s, the recognition that effective treatments for these conditions remained elusive led to a swing towards health promotion in the cause of prevention, the subject of the next two chapters. The emergence of Aids, ironically an infectious disease, but one for which neither vaccine nor treatment appeared likely to emerge in the near future, struck terror into the hearts of doctors throughout the West. Their immediate response was to put their hopes in raising public awareness of the danger of epidemic transmission. In the case of Aids in Britain, given the low incidence of HIV infection in the late 1980s, the fact that it is a fragile virus that is fairly difficult to transmit, and given also that it remained virtually exclusive to clearly 29 HEALTH SCARES AND MORAL PANICS defined high-risk populations, the risks of a major epidemic were negligible. However, the medical establishment’s anxieties about Aids, transmitted to the government, contributed to an official campaign that grossly exaggerated public risks and thereby exacerbated popular anxieties. The unfolding mad cow panic revealed the increasing irrationality of expert advice to the government and its consequences. When in early 1996, after some years of dismissing suggestions of a link between BSE and CJD, the scientists first noticed a handful of cases that raised this as a real possibility, they were understandably rattled. But instead of calming them down and encouraging further research, ministers themselves panicked and made dramatic public statements which did nothing to reduce risk, but had the effect of inducing mass anxiety and causing the collapse of the beef trade. In December 1997, some twenty months after the initial panic, the government’s committee of scientific and medical experts discussed a preliminary report of research which suggested the remote possibility that BSE could be transmitted in dorsal root ganglia (tiny knots of nerve tissue close to the spinal cord) of cattle slaughtered for consumption as beef (Fitzpatrick February 1998) The report estimated that in 1997 some six infected animals might get through the system, and in 1998 possibly three (out of more than two million cattle slaughtered).