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Later in the chapter we will address the issue of practical and laboratory based teaching order genuine ventolin on-line asthma management guidelines. While it is increasingly likely that your institution will provide some form of ‘teach the teachers’ course it is relatively unlikely that it will specifically address clinical teaching generic 100 mcg ventolin otc asthma symptoms in 9 month old. It is a fact that clinical teaching is the most neglected area of all teaching despite being the one where more deficiencies have been found than in any other order generic ventolin asthma definition 6th. The conclusion of one extensive study was that ‘many (clinical) teaching sessions, particularly ward rounds, were hap- hazard, mediocre and lacking in intellectual excitement’. In one study of medical schools in North America, it was stated that there were few students who could report having been monitored in the interview and physical examination of more than one or two patients and that a surprising number had been awarded their degree without ever having been properly supervised in the complete data-collecting process of even one patient! It is our experience, with notable exceptions, that a similar situation can be found in many medical schools in other parts of the world. THE ATTRIBUTES OF AN EFFECTIVE CLINICAL TEACHER These have been identified on the basis of the opinions of experts, the perceptions of students and from the observations of actual clinical teaching. Considering the limited nature of the research there is a remarkable consistency in the results. It might be helpful to start by checking yourself against these attributes. Do you encourage active participation by the students and avoid having them stand around in an observa- tional capacity? Do you focus on the integration of clinical medicine with the basic and clinical sciences or do you spend 72 most of the time on didactic teaching of factual material? Do you closely supervise the students as they inter- view and examine patients at the bedside and provide effective feedback on their performance or do you rely on their verbal case presentations in the teaching room? Do you provide adequate opportunities for your students to practice their skills? Do you provide a good role model, particularly in the area of interpersonal relationships with your patients? Is your teaching generally patient-orientated or does it tend to be disease-orientated? Should your honest answer to some of these questions be ‘no’ then you are probably a typical clinical teacher as many studies have shown that all of these characteristics are rarely present. Just becoming aware of such attributes should encourage you to be more critical of your approach. The remainder of this chapter will deal more specifically with the planning and the techniques which can be introduced to enhance the effectiveness of your clinical teaching. IMPROVING CLINICAL TEACHING If you are a clinical teacher with no responsibilities for the planning of the curriculum, there may be few educational initiatives open to you other than to improve your hospital- based or community-based teaching. What you should aim to do is to try and acquire as many as possible of the attributes described in the previous section. There are no hard and fast rules as to how you can achieve this aim but the following points may be helpful. Plan the teaching: it is possible that you will have received highly specific instructions from the medical school particularly if you are teaching in a structured programme (see later). If not, it is worthwhile contacting the department head or the course co-ordinator to see if there are defined objectives for the part of the curriculum in which your teaching is placed. In doing so you must taken into account your time, the duration of the students’ attachment, the number of students and the seniority of the students.

The Oakley chart 48 Resuscitation of infants and children Further reading ● APLS Working Group generic ventolin 100mcg without a prescription asthma heart rate. Guidelines 2000 for cardiopulmonary resuscitation and cardiovascular care—an international consensus on science ventolin 100mcg overnight delivery asthmatic bronchitis not getting better. Paediatric life support: an advisory statement by the Paediatric Life Support Working Group of the International Liaison Committee on Resuscitation generic ventolin 100mcg otc asthma symptoms on babies. Length based endotracheal tube and emergency equipment selection in paediatrics. Inaccuracy and delay in decision making in paediatric resuscitation and a proposed reference chart to reduce error. Intraosseous infusion needle placed in the upper tibia ● Oakley P, Phillips B, Molyneux E, Mackway-Jones K. Recommended guidelines for uniform reporting of circulatory access for infants and children. Resuscitation drugs, paediatric advanced life support: the paediatric utstein style. Complications are uncommon and usually result from prolonged use of the site or poor technique. Marrow aspirate can be drawn and used to estimate concentrations of haemoglobin, sodium, potassium, chloride, glucose, venous pH, and blood groups. If circulatory access proves impossible to achieve within two to three minutes, some drugs, including adrenaline The algorithms for paediatric basic life support and paediatric (epinephrine) and atropine, can be given down the tracheal advanced life support are adapted from Resuscitation Guidelines tube. Data from studies on animals and humans suggest that 2000, London: Resuscitation Council (UK), 2000. The diagrams the endotracheal dose of adrenaline (epinephrine) should be of Guedel oropharyngeal airways and Laerdal masks are adapted 10 times the standard dose, but doubts have been cast on the from Newborn Life Support Manual, London: Resuscitation Council reliability of this route and intravenous or intraosseous drug (UK). The diagram of and intraosseous infusion needle is courtesy administration is preferable. In England alone, more than 50 000 medically unattended deaths occur each year. The survival of countless patients with acute myocardial infarction, primary cardiac arrhythmia, trauma, or vascular catastrophe is threatened by the lack of immediate care outside hospital. The case for providing prompt and effective resuscitation at the scene of an emergency is overwhelming, but only comparatively recently has this subject begun to receive the attention it deserves. Development The origin of the modern ambulance can be traced to Baron von Larrey, a young French army surgeon who, in 1792, devised a light vehicle to take military surgeons and their equipment to the front battle lines of the Napoleonic wars. Larrey’s walking Seattle fire truck carts or horse-drawn ambulances volantes (“flying ambulances”) were the forerunners of the sophisticated mobile intensive care units of today. The delivery of emergency care to patients before admission to hospital started in Europe in the 1960s. Professor Frank Pantridge pioneered a mobile coronary care unit in Belfast in 1966, and he is generally credited with introducing the concept of “bringing hospital treatment to the community. The use of emergency vehicles carrying only paramedic staff, who were either in telephone contact with a hospital or acting entirely without supervision, was explored in the early 1970s, most extensively in the United States. The Medic 1 scheme started in Seattle in 1970 by Dr Leonard Cobb used the fire tenders of a highly coordinated fire service that could reach an emergency in any part of the city within four minutes.

In this technique purchase ventolin 100mcg online asthma yellow zone, the weakly intense ultrafast pulses are first stretched in time to between 100 and 1000 ps (a picosecond (ps) is 1000 fs) discount 100 mcg ventolin amex asthmatic bronchitis coughing up blood, then amplified by about a million times in one or more further Ti:sapphire laser crystals order ventolin once a day asthma treatment definition, and finally recompressed to femtosecond durations. A typical peak power achievable with an amplified Ti:sapphire laser today is a hundred billion watts for a laser beam area of one square centimetre (the highest is just over a thousand million billion watts per square centimetre), which contrasts with an incident power of about 0. For further details concerning the physics which underpins the operation of ultrafast lasers and their amplifi- cation, the interested reader is referred elsewhere for information (see Further reading). For studies in molecular physics, several characteristics of ultrafast laser pulses are of crucial importance. A fundamental consequence of the short duration of femtosecond laser pulses is that they are not truly mono- chromatic. This is usually considered one of the defining characteristics of laser radiation, but it is only true for laser radiation with pulse durations of a nanosecond (0. Because the duration of a femtosecond pulse is so precisely known, the time-energy uncertainty principle of quantum mechanics imposes an inherent imprecision in its frequency, or colour. Femtosecond pulses must also be coherent, that is the peaks of the waves at different frequencies must come into periodic alignment to construct the overall pulse shape and intensity. The result is that femtosecond laser pulses are built from a range of frequencies: the shorter the pulse, the greater the number of fre- quencies that it supports, and vice versa. The second requirement for investigations in ultrafast photophysics is one of wide wavelength coverage. The capacity for wavelength tuning is an essential ingredient in studies of molecular dynamics due to the different energy gaps that separate the quantum levels of molecules: vibrational res- onances are excited with infrared light for example, whilst electronic states that correspond to different arrangements of the molecular electrons are reached by light in the visible and ultraviolet spectrum. The high output power of chirped-pulse amplified femtosecond lasers renders them ideal for synchronous pumping of optical parametric devices, whereby photons of light at one frequency are converted through their self-interactions in non- centrosymmetric media into photons at different frequencies. Today, the Laser snapshots of molecular motions 7 application of such schemes offers continuous tunability from the near ultraviolet, through the visible, into the infrared regions of the spectrum. An important point is that these advances have been complemented by the concomitant development of innovative pulse-characterisation pro- cedures such that all the features of femtosecond optical pulses – their energy, shape, duration and phase – can be subject to quantitative in situ scrutiny during the course of experiments. Taken together, these resources enable femtosecond lasers to be applied to a whole range of ultrafast pro- cesses, from the various stages of plasma formation and nuclear fusion, through molecular fragmentation and collision processes to the crucial, individual events of photosynthesis. For isolated molecules in the gas phase, this approach was pioneered by the 1999 Nobel Laureate, A. The nature of what is involved is most readily appreciated through an application, illustrated here for the photo- fragmentation of iodine bromide (IBr). The forces between atoms in a molecule are most conveniently respre- sented by a surface of potential energy plotted as a function of the inter- atomic dimensions measured in ångströms (Å) (10Å are equivalent to a millionth of a millimetre). For the IBr molecule in the gas phase, the elec- tronic ground state in which the molecule resides at equilibrium is char- acterized by a bound potential energy curve, labelled V0 in Figure 1. The dissociative process is governed by two, interacting potential energy curves V1 and V1 for different excited states, which enable the molecule to break up along a coordinate leading to ground-state atoms (I Br) or along a higher energy route which leads to excited bromine (I Br*). The same figure illus- trates how femtosecond laser pulses configured in a pump-probe sequence can be applied to monitor the time-evolution of the photodissociation. Real-time femtosecond spectroscopy of molecules can be described in terms of optical transitions excited by ultrafast laser pulses between potential energy curves which indicate how different energy states of a molecule vary with interatomic distances. An initial pump laser excites a vertical transition from the potential curve of the lowest (ground) electronic state V0 to an excited state V1. The fragmentation of IBr to form I Br is described by quantum theory in terms of a wavepacket which either oscillates between the extremes of V1 or crosses over onto the steeply repulsive potential V1 leading to dissociation, as indicated by the two arrows.