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5. Initiate IV access with a saline lock or 0.9 % normal saline KVO. A. The left arm is the site of choice to facilitate Cardiac Cath Lab procedures and two IV lines are preferred. Administer aspirin ASA ; 324 mg PO chewed ; . A. Withhold aspirin for any of the following: ii. Allergy to ASA or NSAIDS. iii. Recent GI bleeding. iv. Acute hemorrhagic stroke. Administer nitroglycerin nitrolingual ; 0.4 mg SL every 3-5 minutes for a total of 3 doses. A. Withhold or discontinue all nitrates for any of the following: ii. Systolic blood pressure 100 mmHg. iii. Recent erectile dysfunction drug use: 1. Viagra 24hrs. 2. Cialis, levitra 48 hrs. B. Use nitrates with caution in patients with right ventricular infarction RVI ; . Patients who have no relief of pain after three doses of nitroglycerin nitrolingual ; SL and NO obvious acute ECG changes do not require administration of additional nitroglycerin. Administer nitroglycerin paste nitro-bid ; TD 1 inch to the left chest if: A. ST elevation consistent with an acute injury pattern is present on 12 Lead ECG. This can be administered with the first SL dose. OR B. Patients have partial or complete relief of pain after three doses of nitroglycerin SL and if blood pressure remains 100 mmHg systolic. If the patient experiences any change in level of consciousness remove the nitroglycerin paste nitro-bid ; . If systolic blood pressure drops below 100 mmHg and lung sounds are clear administer a 500 cc normal saline bolus and reevaluate. Discontinue the use of nitrates at this point and manage hypotension per the cardiogenic shock protocol.
The materials should be based on the research question. For example, in the Yemen study the operational research question was: "Will problem-based pharmacotherapy teaching improve the competence in prescribing drugs according to the six-step WHO method". Both for the tests and for the teaching programme patient cases were developed for the two clinical subjects asthma and diarrhoea ; and at four different levels of complexity uncomplicated case, case with contraindication to the first-line drug, serious case, and a case with side-effects to the first-line drug ; . All patient cases had the same format and contained relevant information about the patient, e.g. history, examination, results, diagnosis. Some examples are given in Annex 3. A treatment plan form should be developed for the teaching programme. The same form can serve as a scoring form during the test Annex 4 ; . This form contains the six WHO steps variables ; and, on the right hand side, a coding system for each step. In the Yemen study students were trained to use these forms when solving a patient problem, and were also tested with the same forms and sonata.
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Rabies This vaccine should be encouraged for long stay travellers especially children and those in remote areas. It should be considered for those on even brief trips if their activities are likely to bring them in to contact with animals. For a list of countries free of rabies see : cdc.gov travel , go to Yellow Book 2005-2006, go to Table of Contents: Condensed Format, Chapter 4 "Prevention of Specific Infectious Diseases" and choose Rabies. Scroll down to Table 4-14, "Countries and political units reporting no cases of rabies during 2003". The risk of acquiring rabies is particularly high in Asia where 90% of all human rabies deaths are reported. Pre-travel vaccination under Section 29 ; is 3 doses given on days 0, 7 and 28. Post-exposure after a bite ; care is much easier if the traveller has had a pre-travel rabies series. All that is required is two booster doses of vaccine three days apart. If no pre-travel series has been given five doses of vaccine are required.
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Discussion The PTSD Life-Chart Method PTSD-LCM ; provided a comprehensive picture of the longitudinal progression and resolution of PTSD symptoms and comorbidities in relationship to life experiences and responses to treatment. Because of its systematic, longitudinal approach, retrospective life-charting facilitated a detailed portrait of patients' histories and, in one instance, revealed a prior traumatic event and a period of amnesia not initially evident or reported. The life charts illustrated diverse presentations of the illness architecture such as PTSD after discrete traumatic events, delayed onset following war trauma, and chronic PTSD from repeated early traumatic experiences. The continuity of retrospective and prospective life-charts enabled the clinician or researcher to place the entire evolving course of illness and response to treatment into lifelong context. The prospective life-chart was particularly helpful for tracking symptom response to therapeutic interventions. It revealed both gradual as well as rapid and dramatic changes over the course of months Fig. 4 ; . This type of longitudinal evaluation has value as a research method and as a clinical tool for illustrating an individual's symptoms and responses to treatment, as well as providing a concise, transferable medical record. Such a vehicle will facilitate transitions of care across different programs, care providers, and consultants, thereby potentially saving the time spent on its initial completion. It may also form a longitudinal template for considering stages of illness progression and the therapeutic interventions specific to each stage. Retrospective life-charting has the liabilities of depending on patients' recall as supplemented by other input ; and being time consuming. Nevertheless, we suggest the utility of such a detailed approach as part of the initial phases of intake and therapy. Once completed, a life chart provides a concise longitudinal condensation from which to consider psychotherapeutic and pharmacotherapeutic options. Prospective life-charting is a structured, daily, self-report instrument and depends on the patient's ability to assess a variety of symptom severities that do not have precisely delineated cutoffs, and to report them accurately. It is our experience that instruction from a mental health provider and a minimum of practice results in a rapidly completed, user-friendly tool. Pilot experience with this instrument suggests its applicability and utility. Formal reliability and validity studies of both PTSD life-chart assessments appear indicated. References!
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