By I. Jensgar. Ursinus College.
As with an oral examination for medical finals or the defense of a writ- ten thesis proven 3.03 mg drospirenone, listen carefully to the questions posed generic drospirenone 3.03mg. Think carefully about the reply before opening your mouth and allowing words to pour forth 3.03mg drospirenone fast delivery. Answer the question asked (not the one you would like it to have been) concisely and carefully order 3.03mg drospirenone with mastercard, and then wait for the next question. There is no need to fill all silences with words; the judge and others will be making notes, and it is wise to keep an eye on the judge’s pen and adjust the speed of your words accordingly. Pauses between questions allow the judge to finish writing or counsel to think up his or her next question. If anything you have said is unclear or more is wanted from you, be assured that you will be asked more questions. Be calm and patient, and never show a loss of temper or control regard- less of how provoking counsel may be. An angry or flustered witness is a gift to any competent and experienced counsel, as is a garrulous or evasive wit- ness. Stay well within your area of skill and expertise, and do not be slow to admit that you do not know the answer. Your frankness will be appreciated, whereas an attempt to bluff or obfuscate or overreach yourself will almost certainly be detrimental to your position. Doctors usually seek consensus and try to avoid confrontation (at least in a clinical setting). They should remember that lawyers thrive on the adversarial process and are out to win their case, not to engage on a search for truth. Thus, lawyers will wish to extract from witnesses answers that best sup- port the case of the party by whom they are retained. However, the medical witness is not in court to “take sides” but rather to assist the court, to the best of the expert witness’ ability, to do justice in the case. Therefore, the witness should adhere to his or her evidence where it is right to do so but must be prepared to be flexible and to make concessions if appropriate, for example, because further evidence has emerged since the original statement was pre- pared, making it appropriate to cede points. The doctor should also recall the terms of the oath or affirmation—to tell the truth, the whole truth, and nothing but the truth—and give evidence accordingly. The essential requirements for experts are as follows: • Expert evidence presented to the court should be seen as the independent product of the expert, uninfluenced regarding form or content by the exigencies of litiga- tion (30). If the expert cannot assert that the report contains the truth, the whole truth, and nothing but the truth, that qualification should be stated on the report (32). In England and Wales, new Civil Procedure Rules for all courts came into force on April 16, 1999 (34), and Part 35 establishes rules governing experts. The expert has an overriding duty to the court, overriding any obliga- tion to the person who calls or pays him or her. An expert report in a civil case must end with a statement that the expert understands and has complied with the expert’s duty to the court. The expert must answer questions of clarifica- tion at the request of the other party and now has a right to ask the court for Fundamental Principals 57 directions to assist him in conducting the function as an expert. The new rules make radical changes to the previous use of expert opinion in civil actions. Most pit- falls may be avoided by an understanding of the legal principles and forensic processes—a topic of postgraduate rather than undergraduate education now. The normal “doctor–patient” relationship does not apply; the forensic physi- cian–detained person relationship requires that the latter understands the role of the former and that the former takes time to explain it to the latter. Meticulous attention to detail and a careful documentation of facts are required at all times. You will never know when a major trial will turn on a small detail that you once recorded (or, regrettably, failed to record). Your work will have a real and immediate effect on the liberty of the individual and may be highly influential in assisting the prosecuting authorities to decide whether to charge the detained person with a criminal offense. You may be the only person who can retrieve a medical emergency in the cells—picking up a subdural hematoma, diabetic ketoacidosis, or coro- nary thrombosis that the detaining authority has misinterpreted as drunken- ness, indigestion, or simply “obstructive behavior. Get it wrong, and you may not only fail to prevent an avoidable death but also may lay yourself open to criminal, civil, and disciplinary proceedings. You clearly owe a duty of care to those who engage your services, for that is well-established law. The issue of whether a forensic physician owes a wider duty to the victims of alleged crime was decided in the English Court of Appeal during 1999 (35). On December 20, the judge accepted a defense submission of no case to answer and directed the jury to return a verdict of not guilty. She claimed to suffer persistent stress and other psychological sequelae from fail- ing to secure the conviction of her alleged assailant and knowing that he is still at large in the vicinity. The claimant did not contend that there was any general duty of care on the part of a witness actionable in damages at the suit of another witness who may suffer loss and damage through the failure of the first witness to attend and give evidence in accordance with his or her witness statement. When the case came before the Court of Appeal, Lord Justice Stuart- Smith stated that the attempt to formulate a duty of care as pleaded, “is wholly misconceived. If a duty of care exists at all, it is a duty to prevent the plaintiff from suffering injury, loss or damage of the type in question, in this case psychiatric injury. A failure to attend to give evidence could be a breach of such duty, but it is not the duty itself. It seems to me that she must have owed a duty of care to carry out any examination with reasonable care, and thus, for example, not to make matters worse by causing injury to the plaintiff. Revised interim guidelines on confidentiality for police surgeons in England, Wales and Northern Ireland. Association of Police Surgeons (now the Association of Forensic Physi- cians), East Kilbride. The Stationery Office, London, 1999; and on the Department of Constitutional Affairs (formerly Lord Chancellor’s Department). Sexual Assualt Examination 61 Chapter 3 Sexual Assault Examination Deborah Rogers and Mary Newton 1. All health professionals who have the potential to encounter victims of sexual assaults should have some understanding of the acute and chronic health problems that may ensue from an assault. However, the pri- mary clinical forensic assessment of complainants and suspects of sexual assault should only be conducted by doctors and nurses who have acquired specialist knowledge, skills, and attitudes during theoretical and practical training. There are many types of sexual assault, only some of which involve pen- etration of a body cavity. This chapter encourages the practitioner to under- take an evidence-based forensic medical examination and to consider the nature of the allegation, persistence data, and any available intelligence. The chapter commences by addressing the basic principles of the medical examination for both complainants and suspects of sexual assault. Although the first concern of the forensic practitioner is always the medical care of the patient, thereafter the retrieval and preservation of forensic evidence is para- mount because this material may be critical for the elimination of a suspect, identification of the assailant, and the prosecution of the case.
Weight loss Contrary to popular opinion discount drospirenone 3.03mg, there is no firm evidence that acupuncture is effective in promoting weight loss purchase drospirenone 3.03mg otc. The effects of pressing ear points at ear meridian points on obesity- related parameters including body weight 3.03 mg drospirenone fast delivery, body fat purchase drospirenone 3.03mg visa, body mass index and waist:hip circumference was studied in two groups of non-obese healthy and obese volunteers. Other conditions Conditions for which acupuncture has been used but for which there is no robust evidence include glaucoma120 and Bell’s palsy. Evidence for other applications is sparse and the Scottish verdict of ‘not proven’ would seem to be the most appropriate in these circumstances. The most popular therapy arranged for patients was acupuncture (47% of respondents). Pain relief and musculo- skeletal disorders were the most frequently cited conditions treated; other applications included smoking cessation, stress and morning sickness. Reasons for not offering acupuncture were lack of demand (63%), lack of knowledge of the services available (63%) and lack of guidelines on how to assess the competence of practitioners. In Australia the use of acupunc- ture by doctors has increased greatly since the 1984 introduction of a Medicare rebate for acupuncture. Cost-effectiveness studies of acupuncture Cost-effectiveness studies of acupuncture have been mainly restricted to the treatment of pain. This Traditional Chinese medicine | 149 result was robust to sensitivity analysis. The provision of the treatments represents an additional healthcare cost in four out of the five studies considered. The authors acknowledged that estimates of cost-effectiveness may be less favourable in situations for which the complementary treatment is offered routinely rather than in the novel situation of a clinical trial. Most states (27) allow herbal medicine within the scope of acupuncture practice; only a few states (10) require the super- vision of a physician for the almost 11 000 practising non-physician acupuncturists. The number of acupuncturists is rapidly growing and is projected to quadruple by 2015. Acupressure relieves muscular tension, facilitating blood flow and therefore distributing more nutrients and oxygen throughout the body, as well as removing waste prod- ucts. The technique involves repeatedly pressing the acupuncture points for 3–5 seconds and then releasing the pressure. It is believed that the prac- titioner’s qi helps to strengthen the weakened qi of the patient. Thus it is important that the practitioner maintains a healthy body so that his or her qi is stronger than that of the recipient. Acupressure has been used to relieve mental tension, for tired and strained eyes, headaches, menstrual cramps and arthritis, as well as to promote general healthcare. Areas of scar tissue, boils, blis- ters, rashes and varicose veins should also be avoided. Certain pressure points should be avoided during pregnancy and in patients with hyper- or hypotension. Shiatsu This is a deeply relaxing therapy originating in Japan that provides stimula- tion by using the fingers and palm of the hand to apply pressure and gentle stretches to the meridians. It consists of a whole body treatment, as it is believed that a disorder in one area can have effects elsewhere on the body. It is similar to both Traditional Chinese medicine | 151 acupuncture and acupressure in its effects but uses a glowing wick instead of needles or fingertips as the source of stimulation for the acupoints. Tradi- tionally moxa is the dried leaves of Artemisia vulgaris and Artemesia argyi and other species of mugwort, made into various forms including: • punk – loose moxa, rather like green cotton-wool • moxa rolls – similar to cigars in appearance • moxa cones. Another method is for a small moxa cone to be placed on the blunt end of an acupuncture needle while it is in place. It is lit at its apex and burnt down until the patient is able to feel the heat; it is then removed. Chinese herbal medicine In the west it is quite normal to equate the word ‘herbal’ with something that grows in the garden. Certainly most Chinese herbal remedies are made from plant material, but others are of mineral or animal origin, e. In China and other Asian countries the practice is still wide- spread, but it has been largely discontinued elsewhere after action by regula- tory authorities with enthusiasm that may occasionally be misplaced. The famous highly aromatic salve marketed around the world known as Tiger Balm was once the subject of a dawn raid of Chinese herbalists by police in Manchester. They thought that they had uncovered the illegal use of parts from a protected wild animal. There were a few red faces when it was realised that the title merely referred to the nickname of the brand owner! History China’s greatest materia medica (Pen Ts’ao) was published by Li Shizhen in 1578. Secret recipes (also known as ‘prepared medicines’) were the equivalent of modern patent medicines. By the time of the Ming dynasty (1368–1644) more than 60 000 formulae had been recorded in the 1406 book entitled Formulas of Universal Benefit (Pu Ji Fang). In recent years many of these formulae have passed into public usage, but there may be as many as 5000 licensed patent medicines still circulating in China. The most famous factory is at the Tong Ren Tang pharmacy in Beijing, which has been operated by the same family since the late seventeenth century. These are: • cooling • diaphoresis • elimination • emesis • mediation • purging • tonification • warming. Traditional Chinese medicine | 153 Categorisation of Chinese herbs Chinese herbs may be categorised according to: • the four natures • the five tastes • the meridians. The herbs are ascribed qualities ranging from cold (extreme yin), cool, neutral to warm and hot (extreme yang), and are often used in combination according to the deficiencies or excesses of these qualities in the patient. The five tastes The five tastes are: • Pungent: pungent herbs are often used to generate sweat and to direct and vitalise qi and the blood • Sweet: sweet-tasting herbs are often used to tonify or harmonise bodily systems • Sour: sour tasting herbs are most often used as astringents • Bitter: bitter tasting herbs are used to dispel heat and purge the bowels • Salty: salty tasting herbs are used to soften hard masses as well as purge and open the bowels. In other forms of herbal medicine, especially western herbal medicine, herbs are often delivered singly or combined into very small formulae of herbs with the same function. In contrast, Chinese herbalists rarely prescribe a single herb to treat a condition. Medicinal substances are combined to: • increase therapeutic effectiveness by synergy • reduce toxicity or adverse reactions • accommodate complex clinical situations • alter the actions of the substances. A typical Chinese herbal formula usually comprises the following components:154 • The main ingredient, which treats the main disease • The associate ingredient, which assists the main ingredient • The adjuvant, which acts as an enhancer of the main ingredient, and moderates or eliminates the toxicity of other ingredients; it may also have an opposite effect to the main ingredient to produce supplementary benefits • The guide ingredient (or envoy), which focuses the actions of the formula on certain meridians or areas of the body, or harmonises and integrates the actions of the other ingredients. Traditional Chinese medicine | 155 Presentation When herbs are prescribed for individual patients the practitioner weighs out a day’s dosage of each herb and combines them in a bag. The boiling process takes from 30 minutes to 60 minutes, and portions of the resulting decoction are consumed several times during the day. Another modern way of delivering herbs is through granulated herbs, which are highly concentrated powdered extracts. These powders are made by first preparing the herbs as a traditional decoction, after which the decoction is dehydrated to leave a powder residue. Practitioners can mix these powders together for each patient into a custom formula.
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