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For his On his return home he engaged in a general sur- outstanding service to the army he received the gical practice buy discount levitra plus 400mg on line erectile dysfunction lubricant. As examples of his diverse ment of great interest in the ﬁeld of hand surgery purchase cheap levitra plus what do erectile dysfunction pills look like, interests and attainments he published on such particularly among the younger men in the topics as cleft-palate repair best order for levitra plus what std causes erectile dysfunction, arterial suture, a pos- service, and culminated in the organization of the itive pressure apparatus to be used during thora- American Society for Surgery of the Hand in cotomy, and a guide for the Smith–Petersen nail. Bunnell served as the Society’s ﬁrst His ﬁrst publication on the upper extremity president. Up to the time of his death, he con- came in 1918 and was entitled Repair of Tendons tinued as its guiding force and as a source of in the Fingers and Description of Two New inspiration to its members. Following this and at intervals instrumental in encouraging the formation of during his lifetime, he produced over 50 papers hand clubs or societies in Scandinavia, England, covering many aspects of reconstructive and South America, and Japan. These original contributions After the war, and with some misgivings, he encompassed such subjects as atraumatic tech- gave up his general surgical practice to devote his nique, physiological reconstruction of the thumb full time to reconstructive surgery. Bunnell appeared repair of extremity nerves and the facial nerve, quiet, almost retiring in nature. To his closer active splinting, intrinsic-muscle contracture of acquaintances, however, he was dynamic and the hand, tendon transfers for the upper extrem- untiring. He was blessed with great physical ity, plastic aspects of reconstruction, surgery of stamina, which served him well, both in his pro- the rheumatic hand, and many others. His modesty and lack of fear were mented the principles of reconstructive surgery among his dominant characteristics. He displayed that are applicable to all parts of the body, great warmth of personality and to his immediate although the main emphasis was directed toward contemporaries he was affectionately known as the upper extremity and hand. He was a Surgery of the Hand rapidly achieved world- master of comparative and human anatomy, sub- wide distribution and was translated for publica- jects that to him were of living and vital interest. He was book is and will continue to be a contribution never thwarted by an unexpected condition or never to be forgotten in the annals of medical event, and he strove untiringly for perfection in literature. His judgment was unerring and his deci- 48 Who’s Who in Orthopedics sions were promptly executed. Sterling Bunnell, world renowned surgeon, always along the lines of basic principles, the teacher, and author of Surgery of the Hand died at details to fall in line as a natural expression of his his home in San Francisco on August 20, 1957. He was never a defeatist; he was always death ended an active life of scientiﬁc inquiry and hopeful, no matter how serious or complicated the accomplishment. His searching mind and the ready applica- Elizabeth Bunnell, and a son, Sterling Bunnell, Jr. Bunnell stressed the same sound principles of surgery he practiced himself and was critical if his student failed to rise to this standard. As a result, he has left us not only the fruits of his labors in the way of scientiﬁc accomplishment, but also the in- spiration that he so dynamically displayed during his lifetime. Through his efforts, surgery of the hand has been nourished and developed to the state of worldwide recognition it enjoys today. The acceptance of his scientiﬁc and surgical accomplishments came early, both in the United States and abroad, as evidenced by society mem- berships and awards. He was a licentiate of the American Boards of General, Plastic, and Ortho- pedic Surgery. He was an honorary member of the American Orthopedic Association, the American Academy of Orthopedic Surgeons, the Western Orthopedic Association, the California Society of Plastic Surgeons, the Societal Latino-Americana Sir Stanford CADE de Ortopedia y Traumatologia, an honorary fellow of the British Orthopedic Association, 1895–1973 and a foreign corresponding member of the Societas Ortopedica Scandinavica. Petersburg, member of the American Surgical Association, received his early schooling in Antwerp, and American Association of Plastic Surgeons, entered the Medical School of the University of American Society of Plastic and Reconstructive Brussels in 1913. In 1914, he joined the Belgian Surgery, American Association for the Surgery of Army, and at the fall of Antwerp, he was evacu- Trauma, American Society for Surgery of the ated to England where he resumed his medical Hand, and an emeritus member of the Hand studies. He was a Fellow of the where he was appointed to the surgical staff in American Occupational Therapy Association 1924. He was a broadly experienced general surgeon, He was consultant to the Surgeon General of but developed a special and overriding interest the United States Army, to the United States in the treatment of malignant diseases not only Navy, and to the Alaska Department of Health. He by surgery but also by radiotherapy and, in due received the United States Medal for Merit, Ordre course, chemotherapy. He was, thanks to the National de la Legion d’Honneur, and Ordem encouragement of Ernest Rock Carling, one of the Nacional do Cruzeiro do Sul. His enormous experience in this ﬁeld is ternity and the Sigma Xi scientiﬁc society. In San encapsulated in his book Malignant Disease and Francisco, he was a staff member of the Stanford its Treatment by Radium, ﬁrst published in 1940 University Hospital, the St. Francis Memorial with a four-volume second edition in 1948, which Hospital, and Children’s Hospital. He also wrote extensively on 49 Who’s Who in Orthopedics breast cancer, melanoma, and tumors of the when he felt it a duty to set a good example to musculoskeletal system. The approach discussed in his 1955 paper on Bartholomew’s Hospital Medical School. Cade’s Surgeons in 1852 and appointed house surgeon hospital career was interrupted by the Second to St. In July 1854 he World War in which he served in the medical became registrar and demonstrator of morbid branch of the Royal Air Force, making signiﬁcant anatomy and thereafter never lost his interest in contributions to the safety of ﬁghter pilots and this subject. He retired from the active staff tled “The Formation and Growth of the Bones of of Westminster Hospital in 1960 and was subse- the Human Face. In the same year, on the resignation of Sir James Paget, he was elected Surgeon to St. Bartholomew’s Hos- pital and Examiner in Surgery to the University of Cambridge. He practiced in Queen Anne Street and held the appointments of Surgeon to the Charterhouse and Professor of Anatomy at the College of Surgeons. He claimed that septicemia was almost unknown in his wards and, though he did not refer to Lister’s theories of asepsis, the principle of his treatment was, in fact, a modiﬁed Listerism. His last publication, on “The Avoid- ance of Pain,” was delivered to the Section on Surgery at the Bath meeting of the British Medical Association. Having gained a prominent place in the esteem of his colleagues, and being recognized as one who represented the highest merits of British surgery, he died at the age of 49 years, and was buried at Kensal Green Cemetery on October 29, 1879. To Callender belongs the distinction of solving the problem of the fate of the premaxilla in man. George William CALLENDER Galen, Vesalius, Sylvius (Dubois), Colombus, 1830–1879 Falloppius, Riolan, Tyson, Nesbitt, Albinus, Daubenton, Vicq d’Azyr, Camper, Goethe, George William Callender was born at Clifton, Soemmering and other nineteenth-century Gloucestershire, on June 24, 1830. His father was anatomists had made contradictory contributions a member of an old Scottish family, though his to the literature. It was due to the careful investi- immediate ancestors had settled in Barbados. His gations of Callender that the truth of the devel- early education was gained at “The Bishop’s opment of the maxilla emerged. College,” Bristol, and if it had been left to his choice he would have joined the navy; but many members of the family had entered the medical profession and in due course he studied medicine with his uncle, Dr. At ﬁrst he disliked his occupation but he persevered, especially after the death of his mother in 1848, 50 Who’s Who in Orthopedics herself was an American lady and the daughter of a regular ofﬁcer in the United States Army.
Lesser responses include medial movement purchase levitra plus cheap online erectile dysfunction diabetes viagra, tensing order genuine levitra plus line impotence lotion, or corrugation of the pharyngeal wall purchase 400 mg levitra plus with visa impotence postage stamp test. In addition there may be head withdrawal, eye water- ing, coughing, and retching. Some studies claim the reflex is absent in many normal individuals, especially with increasing age, without evident functional impairment; whereas others find it in all healthy individuals, although variable stimulus intensity is required to elicit it. The afferent limb of the reflex arc is the glossopharyngeal (IX) nerve, the efferent limb in the glossopharyngeal and vagus (X) nerves. Hence individual or combined lesions of the glossopharyngeal and vagus nerves depress the gag reflex, as in neurogenic bulbar palsy. Dysphagia is common after a stroke, and the gag reflex is often performed to assess the integrity of swallowing. Some argue that absence of the reflex does not predict aspiration and is of little diagnos- tic value, since this may be a normal finding in elderly individuals, whereas pharyngeal sensation (feeling the stimulus at the back of the pharynx) is rarely absent in normals and is a better predictor of the absence of aspiration. Others find that even a brisk pharyngeal response in motor neurone disease may be associated with impaired swallowing. A video swallow may be a better technique to assess the integrity of swallowing. Journal of Neurology, Neurosurgery and Psychiatry 1996; 61: 96-98 Cross References Bulbar palsy; Dysphagia Gait Apraxia Gait apraxia is a name given to an inability to walk despite intact motor systems and sensorium. Patients with gait apraxia are often - 133 - G Ganglionopathy hesitant, seemingly unable to lift their feet from the floor (“magnetic gait”) or put one foot in front of the other. Arms may be held out at the sides to balance for fear of falling; fear may be so great that the patient sits in a chair gripping its sides. These phenomena may be observed with lesions of the frontal lobe and white matter connections, with or without basal ganglia involvement, for example in diffuse cere- brovascular disease and normal pressure hydrocephalus. A syndrome of isolated gait apraxia has been described with focal degeneration of the medial frontal lobes. In modern classifications of gait disorders, gait apraxia is subsumed into the categories of frontal gait disorder, frontal disequilibrium, and isolated gait ignition failure. Gait apraxia is an important diagnosis to establish since those afflicted generally respond poorly, if at all, to physiotherapy; moreover, because both patient and therapist often become frustrated because of lack of progress, this form of treatment is often best avoided. Human walking and higher- level gait disorders, particularly in the elderly. Neurology 1993; 43: 268-279 Rossor MN, Tyrrell PJ, Warrington EK, Thompson PD, Marsden CD, Lantos P. Progressive frontal gait disturbance with atypical Alzheimer’s disease and corticobasal degeneration. Journal of Neurology, Neurosurgery and Psychiatry 1999; 67: 345-352 Cross References Apraxia Ganglionopathy - see NEUROPATHY Ganser Phenomenon The Ganser phenomenon consists of giving approximate answers to questions which can at times verge on the absurd (Q: “How many legs does a cow have? This may occur in psychiatric disease, such as depression, schizophrenia, and malingering, and sometimes in neurological disease (head injury, epilepsy). A Ganser syndrome of hallucinations, conver- sion disorder, cognitive disorientation and approximate answers is also described but of uncertain nosology. London: Arnold, 2001: 74-94 Gaping Gaping, or involuntary opening of the mouth, may occur as a focal dystonia of the motor trigeminal nerve, also known as Brueghel syn- drome after that artist’s painting De Gaper (“Yawning man,” ca. Afflicted individuals may also - 134 - Gegenhalten G demonstrate paroxysmal hyperpnea and upbeating nystagmus, sug- gesting a brainstem (possibly pontine) localization of pathology. The condition should be distinguished from other cranial dystonias with blepharospasm (Meige syndrome). Neurology 1996; 46: 1767-1769 Cross References Blepharospasm; Dystonia; Nystagmus Gaze-Evoked Phenomena A variety of symptoms have been reported to be evoked, on occasion, by alteration of the direction of gaze: ● Amaurosis: lesion, usually intraorbital, compressing central retinal artery ● Laughter ● Nystagmus: usually indicative of cerebellar lesion; may occur as a side-effect of medications; also convergence-retraction nystagmus on upgaze in dorsal midbrain (Parinaud’s) syndrome ● Phosphenes: increased mechanosensitivity in demyelinated optic nerve ● Segmental constriction of the pupil (Czarnecki’s sign) following aberrant regeneration of the oculomotor (III) nerve to the iris sphincter ● Tinnitus: may develop after resection of cerebellopontine angle tumors, may be due to abnormal interaction between vestibular and cochlear nuclei ● Vertigo Cross References Leopold NA. Journal of Neurology, Neurosurgery and Psychiatry 1977; 40: 815-817 Gaze Palsy Gaze palsy is a general term for any impairment or limitation in conjugate (yoked) eye movements. Preservation of the vestibulo-ocular reflexes may help dif- ferentiate supranuclear gaze palsies from nuclear/ infranuclear causes. Cross References Locked-in syndrome; Supranuclear gaze palsy; Vestibulo-ocular reflexes Gegenhalten Gegenhalten, or paratonia, or paratonic rigidity, is a resistance to pas- sive movement of a limb when changing its posture or position, which is evident in both flexor and extensor muscles (as in rigidity, but not spasticity), which seems to increase further with attempts to get the patient to relax, such that there is a resistance to any applied movement - 135 - G Gerstmann Syndrome (German: to counter, stand ones ground). However, this is not a form of impaired muscle relaxation akin to myotonia and paramyotonia. For instance, when lifting the legs by placing the hands under the knees, the legs may be held extended at the knees despite encouragement on the part of the examiner for the patient to flex the knees. Gegenhalten is a sign of bilateral frontal lobe dysfunction, espe- cially mesial cortex and superior convexity (premotor cortex, area 6). It is not uncommon in elderly individuals with diffuse frontal lobe cerebrovascular disease. Cross References Frontal release signs; Myotonia; Paramyotonia; Rigidity; Spasticity Gerstmann Syndrome The Gerstmann syndrome, or angular gyrus syndrome, consists of acalculia, agraphia (of central type), finger agnosia, and right-left dis- orientation; there may in addition be alexia and difficulty spelling words but these are not necessary parts of the syndrome. Gerstmann syndrome occurs with lesions of the angular gyrus and supramarginal gyrus in the posterior parietotemporal region of the dominant (usually left) hemisphere, for example infarction in the territory of the middle cerebral artery. All the signs comprising Gerstmann syndrome do fractionate or dissociate, i. Nonetheless the Gerstmann syndrome remains useful for the purposes of clinical localization. Archives of Neurology 1992; 49: 445-447 Mayer E, Martory M-D, Pegna AJ et al. London: Imperial College Press, 2003: 92-94 Cross References Acalculia; Agraphia; Alexia; Finger agnosia; Right-left disorientation Geste Antagoniste Geste antagoniste is a sensory “trick” which alleviates, and is character- istic of, dystonia. Geste antagoniste consists of a tactile or propriocep- tive stimulus, which is learned by the patient, which reduces or eliminates the dystonic posture. For example, touching the chin, face or neck may overcome torticollis (cervical dystonia), and singing may inhibit blepharospasm. They are almost ubiquitous in sufferers of cervical dystonia and have remarkable efficacy. The mechanism is unknown: although afferent feedback from the periphery may be relevant, it is also possible that concurrent motor output to generate the trick movement may be the key element, in which case the term “sensory trick” is a misnomer. Journal of Neurology, Neurosurgery and Psychiatry 2002; 73: 215 (abstract 10) Cross References Dystonia; Torticollis Gibbus Angulation of the spine due to vertebral collapse may be due to osteo- porosis, metastatic disease, or spinal tuberculosis. Cross References Camptocormia; Myelopathy Girdle Sensation Compressive lower cervical or upper thoracic myelopathy may pro- duce spastic paraparesis with a false-localizing mid-thoracic sensory level or “girdle sensation” (cf. The pathophysiology is uncer- tain, but ischemia of the thoracic watershed zone of the anterior spinal artery from compression at the cervical level has been suggested. References Ochiai H, Yamakawa Y, Minato S, Nakahara K, Nakano S, Wakisaka S. Clinical features of the localized girdle sensation of mid-trunk (false localizing sign) appeared [sic] in cervical compressive myelopathy patients. Journal of Neurology 2002; 249: 549-553 Cross References “false-localizing signs”; Paraparesis; Suspended sensory loss “Give-Way” Weakness - see COLLAPSING WEAKNESS; FUNCTIONAL WEAKNESS AND SENSORY DISTURBANCE Glabellar Tap Reflex The glabellar tap reflex, also known as Myerson’s sign or the nasopalpebral reflex, is elicited by repeated gentle tapping with a finger on the forehead, preferably with irregular cadence and so that the patient cannot see the finger (to avoid blinking due to the threat or menace reflex), while observing the eyelids blink (i. Usually, reflexive blinking in response to tapping habituates quickly, but in extrapyramidal disorders it may not do so.
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His surgical skill was evident to equivalent of 2 years of college levitra plus 400mg fast delivery erectile dysfunction under 40, he entered Tufts the trained observer and was even more evident Medical School where he obtained his medical in the smooth convalescence of his patients and degree in 1905 generic levitra plus 400 mg visa erectile dysfunction at age 31. Following a year of rotating in the excellence of his operative results buy generic levitra plus 400 mg erectile dysfunction freedom book. But ated by a host of loyal and grateful patients and he needed larger ﬁelds for his talents and returned their families and by referring physicians, who to the Children’s Hospital in 1913 by Model-T recognized his sound common sense, his sure Ford, with very little money in his bank account quick grasp not only of the local problem but of and a devoted wife at his side to begin his chosen the patient’s hopes, fears, and needs. He First there was residency training for 2 years, never fussed over patients; his innate sympathy after which he became a junior member of the for his fellow man was masked by a gruff manner Children’s Hospital visiting staff. Then came of speech, which frightened the timid nurse or World War I, which had a decisive inﬂuence on resident but was easily penetrated. Before the United States declared acquaintance permitted one to recognize his war on Germany, he volunteered for duty with the warm underlying personality and his superior original Harvard group, which went overseas in intellect. Ober continued Lovett’s custom of going to he was in the company of such men as Walter New York and Philadelphia about once a month Cannon, Harvey Cushing, Elliot Cutler, and to see patients in consultation. For many years he Robert Osgood and served as head of the ortho- spent a fourth of his time away from his home pedic section of the hospital in France for almost base in these cities. During that time nearly 25,000 patients always spent in Northeast Harbor, Maine, where with war wounds were cared for in Base Hospi- he cared for summer residents and Down-East tal No. Lovett visited the a lunch eaten with dispatch, a friendly game of stricken areas in that state and laid plans for the cards was fun for himself and his companions. He convalescent care of the hundreds of children who was a witty and sage conversationalist, illustrat- were severely crippled by the disease. As there ing the point he wished to make by quoting in was not a single orthopedic surgeon in Vermont, dialect an apropos remark by some down-in- and state medicine was unknown anywhere in the Maine character of his acquaintance. United States and unthinkable in Vermont, ﬁnan- The ofﬁces and honors that came his way were cial support for the program of rehabilitation many. The total cost of the Medical Society and of the American Orthopedic rehabilitation program for poliomyelitis patients Association. He was chairman of the Advisory in Vermont hospital, professional, and home care, Committee of the National Foundation for Infan- was provided by the annual budget of about tile Paralysis and received honorary degrees from $30,000. From 1919 till his retirement Lovett Fund was used to support the early studies in 1946, Dr. Ober made an annual tour of the on rheumatoid arthritis, sponsored by Harvard poliomyelitis clinics in Vermont. He prescribed Medical School and carried out at the Massachu- the treatment to be carried out and selected setts General Hospital. With knowledge of rheumatoid arthritis and the large this wealth of clinical material he developed amount of productive research now going on in many surgical techniques of rehabilitation by this ﬁeld received its impetus in some part from muscle transposition and by joint stabilization. These included original muscle transplants to In addition to the Lovett Fund, he also raised improve function and to correct deformities in funds to support research at the children’s medical weak shoulders, elbows, hips, knees, and ankle. His interests were not conﬁned to polio- There is no better example of his unselﬁsh myelitis. He also devised an operation for soft- devotion to duty than his work at the New tissue release in severe club-foot deformity. Suitably modiﬁed, it is used today as a standard He was its surgeon-in-chief for 17 years, respon- procedure. Painful feet and lame backs were two sible for the professional care of its children, most clinical problems that challenged his resourceful of whom were suffering from skeletal tuberculo- mind and to which he brought new insight. Ober’s originality of concept and care in mornings, at the Home, members of the staff and execution of his newly devised surgical proce- many regular visitors were encouraged to discuss dures gained them early acceptance even by his freely the problems of each patient. All those professional rivals in a day when clinical rivalry attending rounds quickly developed an apprecia- was intense and sometimes bitter. Under his The residents and younger associates whom he conscientious supervision, the Peabody Home trained adopted and championed his techniques. For the last 14 years of his life he was a Although his clinical work was his vocation, member of the Peabody Home Board of Trustees. He enjoyed teaching His active private practice continued until his and was an effective teacher. It could be said of him that the reward for writing and was the man who made the second work well done was the ability to do more work. He was working on the third lished by his Yankee dislike of sham and by his edition at the time of his death. O’Connor organized and directed many teaching courses on the subject of arthroscopy, the attendance at which was always capacity. He found time to write several papers, a monograph, and two books on arthroscopy. He demonstrated unusual courage, particularly during the difﬁcult terminal period of his illness, and never gave up hope. O’Connor, a pioneer in the devel- opment of arthroscopic surgery, died on Novem- ber 29, 1980, in Bandon, Oregon, where he spent his last days, following a ﬁght against cancer of the lung. O’CONNOR 1933–1980 Born in Chicago, Illinois, and educated at De Pauw University, Indiana, and Northwestern Medical School, Illinois, Dr. O’Connor began his medical career as a general practitioner in Telluride, Colorado. Later, returning to Louisville, Kentucky, he completed his orthope- dic training in 1968 under the supervision of Pro- fessor James Harkess, and settled in West Covina, California. O’Connor traveled to Tokyo, Japan, where he studied the arthroscopic techniques of Dr. Masaki Watanabe, and returned to the United States with a Watanabe arthroscope. Perceiving quickly the great potential of this instrument, he became its prime advocate in southern California. Overcoming the natural Hiram Winnett ORR resistance to new techniques, he persisted in his attempts to teach other orthopedists its value as a 1877–1956 diagnostic tool as well as its potential for intra- articular surgery. In the process he helped to Hiram Winnett Orr (the Hiram was replaced by develop the ﬁrst operating arthroscope and the enigmatic initial H as soon as he learned to became the ﬁrst to employ the instrument in sign his name) was born in West Newton, PA, meniscal surgery. After graduating est in intra-articular photography, including from the local high school at the age of 15 years, movies, 35-millimeter slides, and videotapes. In Lincoln, 249 Who’s Who in Orthopedics he lived with his maternal uncle, Dr. It remains, however, a viable option Winnett, a busy general practitioner. He gave his collection of more than 2,600 general practitioner, and in 1904 went to Chicago items to the American College of Surgeons, and where he fell under the spell of Dr. John Ridlon, it is now on permanent loan to the University of the Professor of Orthopedic Surgery at North- Nebraska College of Medicine. After spending a summer in tion of books on Anne of Brittany and her era was Chicago working with Dr.
Trainers are Further reading recruited from the statutory ambulance service and the voluntary first aid and life saving societies; many schemes have ● Resuscitation Council (UK) cheap levitra plus 400mg online erectile dysfunction generics. Cardiopulmonary Resuscitation: Guidance for practice and training for hospitals generic 400mg levitra plus with mastercard erectile dysfunction treatment devices. Cardiopulmonary Resuscitation: enforces the theoretical instruction provided purchase levitra plus 400 mg erectile dysfunction treatment melbourne. The problem is to discover the best way to ensure that ● Martean TM, Wynne G, Kaye W, Evans TR Resuscitation: resuscitation skills are well taught, well learnt, and well Experience without feedback increases confidence but not skill. Much effort has been put into the development of ● Kaye W, Mancini ME, Rallis SF. Educational aspects: resuscitation training courses for lay people as well as healthcare training and evaluation. Theoretical skills can be learnt in the classroom, from written material or computer programmes. The acquisition of practical skills, however, requires the use of training manikins. It is impracticable as well as potentially dangerous to practise these procedures on human volunteers. Adult and paediatric manikins are available from several manufacturers worldwide; this chapter concentrates on those generally available in the United Kingdom. Manikin selection: general principles Training requirements The growing number of different manikins available today can make choosing which manikin to purchase a complex process. Manikins are vital for learning practical cardiopulmonary resuscitation skills The most important question to ask initially is: which skills need to be acquired? This will obviously depend on the class under instruction; the requirements of a lay class will be quite different from those of professional hospital staff learning advanced life support skills. For large classes it may be better to maximise the practical hands-on exposure by investing in several cheaper With all manikins, realistic appearance, manikins rather than rely on one or two expensive, more accurate anatomical landmarks, and an appropriate response to any attempted complex models. Models vary greatly in sophistication, but most provide some qualitative indication that technique is adequate, such as audible clicks when the depth of chest compression is correct. Some manikins incorporate sensors that recognise the correct hand position and the rescuer’s attempts at shaking, opening the airway, and Resuscitation skills that can be practised palpation of a pulse. The depths of ventilation and chest on manikins compression may also be recorded. An objective assessment of Basic life support performance may be communicated to the student or ● Manual airway control with or without instructor by means of flashing lights, meters, audible signals, simple airway adjuncts or graphical display on a screen. A permanent record may be ● Pulse detection obtained for subsequent study or certification. A score, indicating the number of correct ● Precordial thump manoeuvres, may form the basis of a test of competence. A minimum score of 70% correct ● Defibrillation and cardioversion ● Intravenous and intraosseous access cardiac compressions and ventilations may be taken to (with or withoutadministration of drugs) represent effective life support. This score on a Skillmeter Related skills Resusci Anne manikin is acceptable to the Royal College of ● Management of haemorrhage, fractures, etc. General Practitioners of the United Kingdom as part of the ● Treatment of pneumothorax MRCGP examination. Some care is required, however, and the “skin” should not be permanently marked by lipstick or pens or allowed to become stained with extensive use. Many currently available manikins have replacements available for those components subject to extensive wear and tear. This is particularly true for the face, which bears the brunt of damage and where discoloration or wear will make the manikin aesthetically unattractive. A carrying case (preferably rigid and fitted with castors for heavier manikins) is essential for safe storage and transport. Cross infection and safety To minimise the risk of infection occurring during the conduct of simulated mouth-to-mouth ventilation the numbers of Manikins can be students using each manikin should be kept low and careful used for a attention should be paid to hygiene. Students should be free of variety of communicable infection, particularly of the face, mouth, or training exercises respiratory tract. Faceshields or other barrier devices (see Chapter 18) should be used when appropriate. Manikins should be disinfected during and after each training session according to the manufacturer’s instructions. Preparations incorporating 70% alcohol and chlorhexidine are often used. Hypochlorite solutions containing 500ppm chlorine (prepared by adding 20ml of domestic bleach to 1l of water) are effective but unpleasant to use. They are best reserved for the thorough cleaning of manikins between classes. Moulded hair has now replaced stranded or artificial hair and is much easier to keep clean. Many modern manikins feature a disposable lower airway consisting of plastic lungs and connecting tubes. Expired air passes through a non-return valve in the side of the manikin during expiration. All disposable parts should be replaced in accordance with the manufacturer’s recommendations. Other manikins use a clean mouthpiece and disposable plastic bag insert for each student. Cost Some manikins Cost will depend on the skills to be practised and the number produce printed of manikins required for a class. Sophisticated skills, such as reports on performance monitoring, recording, and reporting facilities, increase cost further. Any budget should include an allowance for cleaning, provision of disposable items, and replacement parts. Another consideration is the ease with which the manikins can be updated when resuscitation guidelines and protocols change. Manikins for basic life support Airway The ability to open the airway by tilting the head or lifting the jaw, or both, is a feature of practically all manikins currently available. Modern manikins cannot be ventilated unless the appropriate steps to secure a patent airway have been taken. Regrettably, some manikins require excessive neck extension to secure airway patency; such action would be quite inappropriate in the presence of an unstable injury to the cervical spine. Back blows and abdominal thrusts used to treat the choking casualty can be practised convincingly only on a manikin made specifically for that purpose. Choking Charlie can be used for the simulation of the management of choking 98 Training manikins Breathing Most currently available manikins offer realistic simulation of chest wall compliance and resistance to expired air ventilation.