bluuebunny/crossref_metadata_2025 huggingface dataset:
History taking
Authors: Thomas Robert H. , Bessant Rupa
Published: November 2020

Welcome to station 2, history taking. We would like to start by saying that having worked very hard to pass the written papers you deserve to be sitting this prestigious exam and PACES is an opportunity to perform as a clinician and formally demonstrate your unique clinical skills that make you an excellent physician. History taking is traditionally an area of the PACES exam that candidates find very difficult. Taking a good history from a patient is the most fundamental skill of a training physician and PACES candidates often feel that their general daily work practice is adequate preparation for this station. This is not the case, despite most candidates being well skilled in clerking a patient from A&E or clinic where few limitations apply. Unfortunately, faced with strict time constraints, exam anxiety and often deliberately unusual scenarios, poorly prepared PACES candidates may demonstrate a fundamental weakness in what should be a basic part of physician training. Do not devalue your chance of success in the PACES examination by poor preparation or anxiety. The practice needed in order to succeed in the history taking station should not be underestimated. As well as running out of time, a candidate’s main concern is the broad range of scenarios that can be chosen as an examination topic and this can easily unsettle and panic even the best prepared. This chapter offers a structured approach that will help to alleviate this fear. The stopwatch begins once a candidate has been handed the scenario (usually in the form of a letter addressed to the candidate from another healthcare practitioner). • 5 minutes private preparation – candidate then called into the exam room. • 14 minutes with the patient being observed by examiners. • 1 minute of personal reflection time. • 5 minutes for questions from the examiners. The initial preparation period is of huge importance and when sitting PACES, we would suggest using the structured template in Fig. 4.1 which can be adapted to any scenario given to a PACES candidate in the exam. We would encourage you to memorize this template for reproducibility during this preparation time.
Anomalous scattering and absolute configuration
Authors: Glusker Jenny Pickworth , Trueblood Kenneth N.
Published: November 2020

The concept of the carbon atom with four bonds extending in a tetrahedral fashion was put forward by van’t Hoff and Le Bel in 1874. It coincided with the realization that such an arrangement could be asymmetric if the four substituents were different, as shown in Figure 10.1a (van’t Hoff, 1874; Le Bel, 1874). Thus, for any compound containing one such asymmetric carbon atom, there are two isomers of opposite chirality (individually called enantiomers), for which threedimensional representations of their structural formulas are related by a mirror plane. Aqueous solutions of these enantiomers rotate the plane of polarized light in opposite directions. As discussed in Chapter 7, Pasteur showed that crystals of sodium ammonium tartrate had small asymmetrically located faces and that crystals with these so-called “hemihedral faces” rotated the plane of polarization of light clockwise, while crystals with similar faces in mirror-image positions rotated this plane of polarization counterclockwise. Thus the external form (that is, the morphology) of the crystals illustrated in Figure 10.1b was used to separate enantiomers (see Patterson and Buchanan, 1945). Pure enantiomers can only crystallize in noncentrosymmetric space groups unless both isomers are present. But even if the chemical formula and the three-dimensional structure of a molecule such as tartaric acid have been determined by standard X-ray diffraction methods, there is an ambiguity about the absolute configuration. Information about the absolute configuration is not contained in the diffraction pattern of the crystal as it is normally measured. Thus, although the substituents on the asymmetric carbon atoms have been identified, and even the detailed three-dimensional geometry of the molecule has been determined, it is not known which of the two enantiomers (mirror-image forms, analogous to those shown in Figure 10.1a) represents the three-dimensional structure of a particular individual molecule that has some distinguishing chiral property, such as the ability to rotate the plane of polarized light to the right. In other words, what is the absolute structure of the dextrorotatory form of the compound under study? A means of determining the absolute configurations of molecules was, however, provided by X-ray crystallographic studies.
Micro- and noncrystalline materials
Authors: Glusker Jenny Pickworth , Trueblood Kenneth N.
Published: November 2020

The crystalline state is characterized by a high degree of internal order. There are two types of order that we will discuss here. One is chemical order, which consists of the connectivity (bond lengths and bond angles) and stoichiometry in organic and many inorganic molecules, or just stoichiometry in minerals, metals, and other such materials. Some degree of chemical ordering exists for any molecule consisting of more than one atom, and the molecular structure of chemically simple gas molecules can be determined by gaseous electron diffraction or by high-resolution infrared spectroscopy. The second type of order to be discussed is geometrical order, which is the regular arrangement of entities in space such as in cubes, cylinders, coiled coils, and many other arrangements. For a compound to be crystalline it is necessary for the geometrical order of the individual entities (which must each have the same overall conformation) to extend indefinitely (that is, apparently infinitely) in three dimensions such that a three-dimensional repeat unit can be defined from diffraction data. Single crystals of quartz, diamond, silicon, or potassium dihydrogen phosphate can be grown to be as large as six or more inches across. Imagine how many atoms or ions must be identically arranged to create such macroscopic perfection! Sometimes, however, this geometrical order does not extend very far, and microarrays of molecules or ions, while themselves ordered, are disordered with respect to each other on a macroscopic scale. In such a case the three-dimensional order does not extend far enough to give a sharp diffraction pattern. The crystal quality is then described as “poor” or the crystal is considered to be microcrystalline, as in the naturally occurring clay minerals. On the other hand, in certain solid materials the spatial extent of geometrical order may be less than three-dimensional, and this reduced order gives rise to interesting properties. For example, the geometrical order may exist only in two dimensions; this is the case for mica and graphite, which consist of planar structures with much weaker forces between the layers so that cleavage and slippage are readily observed.
The obstetric patient
Authors: Andrew Marion I , Cyna Allan M
Published: November 2020

The obstetric anaesthetist’s clinical practice is concerned with the safety of not one, but two intricately interwoven individuals, and much of this takes place in the presence of a third party—partner, friend or relative. Pregnancy and birth are natural and normal processes in the lives of most people. In this context, communication might be expected to be a matter of common sense and somewhat intuitive. How we communicate with women is a pivotal factor in determining their experience and, although recognized as such by many within the midwifery community , this is perhaps less so by doctors. Advances in medicine and changes in society over the last 100 years have resulted in a safer but, socially and technologically, a more complex experience for both women and their babies. Communication in childbirth originally occurred between women caring for each other, but this subsequently became dominated by an authoritarian medical machine, which has left some women feeling vulnerable and ‘processed’. Recognition of the importance and value of patient rights and satisfaction has been responsible for a cultural shift in many maternity units. However, the medicalization of childbirth continues to take over even when labour is proceeding normally. Anaesthetists are perfectly positioned as providers of analgesia and anaesthesia, within a multidisciplinary team, to communicate with women in a way that empowers them and supports their autonomy. Women become highly focused on the pregnancy and labour as the evidence looms ever larger in front of them. Pregnancy and childbirth usually represent a challenging psychological and physiological experience. This focus of attention on the pregnancy makes women highly suggestible to subconscious communications. For this reason, messages received can function as powerful determinants of how women perceive their pregnancy, and respond during childbirth. Central nervous system (CNS) changes occur that reduce anaesthesia requirements during pregnancy and increase hypnotizability, dissociation, daydreaming and an ability to use imagery to experience labour in a fulfilling way. There is a range of emotional responses to pregnancy. For some, there is joy and excitement, while for others there is no excitement—just fear and anxiety. Overlaying this, there may be pre-existing generalized anxiety, social concerns, obstetric problems and other complications.
Intraoperative awareness
Authors: Bejenke Christel J
Published: November 2020

Intraoperative awareness (IOA) represents a range of heterogeneous experiences and is a topic of considerable relevance, not only to anaesthetists, but to all theatre staff. This chapter focuses on communications that the anaesthetist may find helpful in ameliorating or preventing adverse sequelae associated with IOA. This is a well-described, infrequent complication of general anaesthesia which can have serious long-term psychological consequences. First recognized as a medical complication in 1846, there have been numerous reports since the 1950s. Considerable research has been devoted to its understanding and prevention over the past two decades. IOA has increasingly come to the attention of clinicians, patients and the media. It is also a medico-legal issue and high compensation awards have been made. The ASA practice advisory for anaesthesiologists states that, ‘Intraoperative awareness occurs when a patient becomes conscious during a procedure performed under general anaesthesia and subsequently has recall of these events.’ This may include: sensations of weakness; inability to communicate, move or scream; auditory and tactile perceptions; feelings of helplessness; acute fear, panic and pain; believing to have been abandoned and betrayed; and being dead, or about to die. Explicit awareness (declarative memory) permits conscious recall of intraoperative events such as auditory, visual and tactile experiences, paralysis and pain. There is a striking similarity of experiences among patients, but only a minority (35 % ) may inform their anaesthetists. Explicit awareness has been the subject of the majority of investigations related to IOA and is the main topic of this chapter. Implicit awareness (non-declarative memory): information can be recollected but cannot be recalled or consciously retrieved. There is strong evidence for auditory information-processing of material relevant to the patient’s well-being, whether beneficial or threatening. The overall incidence of IOA varies, but has been reported to be between 0.1 and 0.9 % with 30 000–40 000 cases annually in the USA. However, the true incidence of recall is probably underestimated. According to a 2010 report by the ASA closed claims project, IOA occurs in less than 1 in 700 cases. Causes were largely attributed to light anaesthesia and anaesthetic delivery problems.
Administrators
Authors: Simmons Scott W
Published: November 2020

In our modern healthcare systems, clinicians find themselves dealing face-to-face with administrators at many different levels. Unfortunately, there often appears to be a major disconnect between the two parties, and priorities may appear to be vastly different. For the busy clinical anaesthetist who encounters this in passing, there may be transient frustration and confusion before simply getting on with the job. For the anaesthetist with a designated management role, the problem doesn’t go away that easily. Both, however, will benefit from some deeper insight into the nature of these interactions to help everyone to better achieve their goals. The ‘LAURS’ concept as presented in Chapter 2 emphasizes the generic attributes of the approach to a meaningful interaction. Of particular interest in attempting to apply this framework to our dealings with administrators is the recognition that the management ‘world’ is exactly that — a seemingly different place that abounds with its own distinctive language, practical tools, and approaches to problem solving with which most clinicians have little familiarity. There may indeed be a sense of entering a different domain, much like the person entering the healthcare system as a patient. Hence in this chapter there is a deliberate intent to present some of these practical tools and perspectives to help better understand this other world and the people who abide there and relate it to these general principles. The results may be surprising. Dr Celia Roberts has recently been appointed Director of the Anaesthesia Service of a large public teaching hospital. Being an expert in her field she had conducted research, written several papers and been responsible for the teaching of specialist trainees. There is little in her chosen area of expertise that she doesn’t know how to deal with. In her day-to-day work she needs to think on her feet, work independently and be accountable for her individual actions. Where appropriate, she assumes a leadership role, giving clear and concise instructions to the team around her. Celia approaches her work with a high commitment to one-to-one interaction between herself as a skilled exponent of a specialised craft—clinical anaesthesia—and the patients who are seeking her help.
Examination of the cerebellar system
Authors: Zengeya Stanley Tamuka , Serane Tiroumourougane V
Published: November 2020

Although many books include cerebellar examination as part of the motor examination, it is discussed separately here in view of its importance. As children with cerebellar diseases are not often seen in routine clinical practice, candidates tend to neglect this system in their preparation and so find it difficult in the exam. Assessment involves examination of the gait and coordination, which tests both cerebellar midline and hemispheric function (tables 10.1 and 10.2). In the exam, you may pass through a station asking you to examine either the cerebellar system or the gait alone. If such an instruction is given, be clear what you need to focus on. Key competence skills required in the cerebellar examination are given in table 10.3. These steps are repeated for every system to reiterate their importance and to help you recollect the initial approach of any clinical examination. Also refer to chapter 4. • On entering the examination room, adhere to infection control measures by washing your hands or decontaminating with alcohol rub. • Introduce yourself both to the parents and the child. • Ask the name and age of the child, if not already told by the examiner. • Speak slowly and clearly with a smile on your face. • Explain what the examination involves and obtain consent. • Establish rapport with the child and parents. • Expose adequately while ensuring their privacy. • Positioning: to examine the older child, they may sit on the edge of the bed or on a chair when they are not acutely ill. It is preferable to examine the younger child on their parent’s lap rather than on a couch, which can cause much apprehension. The aim of the visual survey is to capture every available clue, which should help you to arrive at the correct diagnosis. • Look at the child and try to estimate the approximate age. • Always consider whether the findings combine to form a recognizable clinical syndrome. Common syndromes with cerebellar involvement include ataxia telangiectasia, Dandy–Walker cyst, Chiari malformation, and Friedreich’s ataxia.
Is the ‘Environment’ Good to Eat or Good to Paint? Faunal Consumption and Avoidance among Hunter-Gatherer-Fishers in the Beagle Channel Region (Tierra del Fuego, South America)
Authors: Fiore Dánae , Tivoli Angélica
Published: November 2020

This chapter discusses some aspects of the multi-dimensional nature of human–environment relationships. It focuses on the interaction established between people and animals in the Beagle Channel region (Tierra del Fuego, South America; Figure 5.1) through an analysis of taxon selection or avoidance in two inter-related spheres: subsistence and ceremonial art. The selection or avoidance of a particular species can be related to environmental, economic, political, and ideological factors, and our aim is to point out which of these factors influenced the high exploitation of certain taxa and the low representation of others. We achieve this by comparing archaeological data with spatially and temporally contemporaneous ethnographic information about the representation of animal species in ceremonial body paintings. Thus, we seek to explain whether the selection of some species and the avoidance of others in the subsistence sphere was being reinforced by or forbidden according to symbolic values that stemmed from the ceremonial sphere. Such questions derive from a theoretical premise that dismisses the notion of absolute optimality in human practices. It proposes instead that people’s actions and decisions are not guided only by rational principles and cost-minimizing aims: they can also be non-rational and non-optimal, and yet can make a socio-economic system function and reproduce efficiently through time and space without collapse. We argue that archaeological techniques and data have much to contribute to an understanding of the complexity of human–environment relations—particularly the ability to critique the overly simplistic economic models that often feed into popular and bureaucratic approaches to human environments. During the last fifteen years, one of the most popular approaches to subsistence in prehistoric and non-industrial societies has been the application of optimality models (e.g. Broughton 1994; Grayson and Delpech 1998; Nagaoka 2002, among others). In principle, these models were conceived as methodological tools through which the researcher lays out a hypothetical scenario of how resources should be consumed if people were trying to minimize costs and maximize benefits towards reaching an optimal result.
An Inheritance of Loss: Archaeology’s Imagination of Disaster
Authors: Holmberg Karen
Published: November 2020

Disasters often de-scribe (Blanchot 1995: 7); they evade written description or complete encapsulation in the narratives we try to create about them. In this chapter, I explore the inveterate metaphor that Pompeii and the AD 79 eruption of Vesuvius have provided in both archaeological literature and larger Western culture. I suggest that this metaphor is not only incomplete, which per Blanchot’s admonition is inherent to accounts of disaster, but is also erroneous and needs to be significantly revised in terms of how it frames environmental perceptions of the past and present and the temporality of the archaeological record. While much of the entrenched allegorical role of Pompeii should be jettisoned, the metonymy of the site remains exceptionally important in that it reveals how integral archaeological fieldwork can be in larger societal conceptions of how humans and their environment intersect in the promiscuous nature and culture of disaster. Kiran Desai’s Man Booker Prize winning work, The Inheritance of Loss (2006: 305), includes a passage that describes a 1980s riot scene in north-east India at the foot of the Himalayas: . . . The cook could see the fires burning below him and the men scattering. As they crossed the heat vapours of the flames, they seemed to ripple and blow like mirages. Above was Kanchenjunga, solid, extraordinary, a sight that for centuries had delivered men their freedom and thinned clogged human hearts to joy. But of course the cook couldn’t feel this now and he didn’t know if the sight of the mountain could ever be the same to him. . . . How could anything be the same? The red of blood lay over the market in slick pools mingled with a yellow spread of dal someone must have brought in anticipation of a picnic after the parade, and there were flies on it, left behind old slippers, a sad pair of broken spectacles, even a tooth. . . . This literary example of a disaster scene collocates some key archaeological research topics: landscape, memory, monumentality, material culture, the interface of nature and culture, and the passage of time.
Effects of Ocean Acidification on Marine Biodiversity and Ecosystem Function
Authors: Barry James P. , Widdicombe Stephen
Published: November 2020

The biodiversity of the oceans, including the striking variation in life forms from microbes to whales and ranging from surface waters to hadal trenches, forms a dynamic biological framework enabling the flow of energy that shapes and sustains marine ecosystems. Society relies upon the biodiversity and function of marine systems for a wide range of services as basic as producing the seafood we consume or as essential as generating much of the oxygen we breathe. Perhaps most obvious is the global seafood harvest totalling over 100 Mt yr–1 (82 and 20 Mt in 2008 for capture and aquaculture, respectively; FAO 2009) from fishing effort that expands more broadly and deeper each year as fishery stocks are depleted (Pauly et al. 2003). Less apparent ecosystem services linked closely to biodiversity and ecosystem function are waste processing and improved water quality, elemental cycling, shoreline protection, recreational opportunities, and aesthetic or educational experiences (Cooley et al. 2009). There is growing concern that ocean acidification caused by fossil fuel emissions, in concert with the effects of other human activities, will cause significant changes in the biodiversity and function of marine ecosystems, with important consequences for resources and services that are important to society. Will the effects of ocean acidification on ecosystems be similar to those arising from other environmental perturbations observed during human or earth history? Although changes in biodiversity and ecosystem function due to ocean acidification have not yet been widely observed, their onset may be difficult to detect amidst the variability associated with other human and non-human factors, and the greatest impacts are expected to occur as acidification intensifies through this century. In theory, large and rapid environmental changes are expected to decrease the stability and productivity of ecosystems due to a reduction in biodiversity caused by the loss of sensitive species that play important roles in energy flow (i.e. food web function) or other processes (e.g. ecosystem engineers; Cardinale et al. 2006). In practice, however, most research concerning the biological effects of ocean acidification has focused on aspects of the performance and survival of individual species during short-term studies, assuming that a change in individual performance will influence ecosystem function.
Earth as a Snowball
Authors: Zalasiewicz Jan , Williams Mark
Published: November 2020

Our attempts to reconstruct the climate of the distant Archaean in Chapter 1 might seem a little like reading a volume of Tolstoy’s War and Peace recovered from a burnt-out house. Most of the pages have turned to ash, and only some scattered sentences remain on a few charred pages. The Proterozoic Eon that followed began 2.5 billion years ago, thus is not quite so distant from us in time. We know it a little better than the Archaean—at least a handful of pages from its own book have survived. And this book is long—the Proterozoic lasted nearly two billion years. This is as long as the Hadean and Archaean together, and not far short of half of Earth’s history. Like many a soldier’s account of war, it combined long periods of boredom and brief intervals of terror—or their climatic equivalents, at least. The latter included the most intense glaciations that ever spread across the Earth. Some of these may have converted the planet into one giant snowball. The earliest traces of glaciation on Earth are seen even before the Proterozoic, in rock strata of Archaean age, 2.9 billion years old, near the small South African town of Pongola. These rocks include sedimentary deposits called tillites, which are essentially a jumble of rock fragments embedded in finer sediment. The vivid, old-fashioned term for such deposits is ‘boulder clays’, while the newer and more formal name is ‘till’ for a recent deposit and ‘tillite’ for the hardened, ancient version. Many of the ancient blocks and boulders in the tillites of Pongola are grooved and scratched—a tell-tale sign that they have been dragged along the ground by debris-rich ice. This kind of evidence is among the first ever employed by scientists of the mid-nineteenth century, such as Louis Agassiz and William Buckland, to tell apart ice-transported sediments from superficially similar ones that had formed as boulder-rich slurries when rivers flooded or volcanoes erupted. Ice, then, appeared on Earth in Archaean times.
Birth and Death of the Holocene
Authors: Zalasiewicz Jan , Williams Mark
Published: November 2020

It is just the latest of many climate phases of the Quaternary Period. The 103rd major shift in climate-driven global oxygen isotope values, to be precise, since the official-designated beginning of the Quaternary Period, 2.58 million years ago. And, many of those major phases, as we have seen, include dozens of climate oscillations far greater in scale than humans have witnessed since written records began. Nevertheless, it is our warm phase, that within which our civilization has grown, and hence it has been separated as a distinct epoch, the Holocene, a little over 0.01 of a million years long. Its counterpart is the Pleistocene Epoch, in which reside those other 2.57 million years of Quaternary time, and those other 102 major climate oscillations. Thus, we live—at least as far as formal geological nomenclature goes—in a privileged time. When this epoch began, Homo sapiens had already existed for some 150,000 years. As a species its prospects might not have seemed bright: this creature lacked anything terribly impressive in the way of claws or teeth or thick fur or armour. But by being ingenious at developing what one might describe as artificial claws and teeth—axes and spears and arrows—it could kill and eat mammals considerably larger than itself. In those early days, it might not have prospered, exactly, but it clung to existence, seemingly weathering at least one very bad patch, several tens of thousands of years ago, when its numbers dropped almost to extinction levels. It survived the climate oscillations of the late Pleistocene—the droughts and floods and episodes of bitter cold and killing heat—by adapting its behaviour or migrating as best it could. Its migrations from its place of origin, Africa, were on an epic scale. The many thousands of individual and collective stories of hope, fear, endurance, courage, tragedy, and (less commonly) triumph are all lost. What remains is the evidence that humans, by the beginning of the Holocene, had spread widely over Europe and Asia, ousting (it seems) their kindred hominin species, Homo neanderthalensis and Homo erectus.
The Strategic Approach to Getting the Right Job
Authors: Watkin Sara , Vincent Andrew
Published: November 2020

The majority of doctors will remain a consultant in the same post for 25–30 years. Despite this, many juniors wait until 3 months before their Certificate of Completed Training (CCT) date, and then apply for the first few jobs that come along, simply hoping for the best that they will get a job where they will fit in and be happy. In this chapter we consider simple strategies that will help you get the right job for you, rather than just any job. In an ideal world this preparation should have started 2 years ago. However, if you are just picking this book up for the first time, having already started applying for jobs, even at this stage there is still lots of advice that can reduce the chances of you making a wrong decision that might affect you and your family for many years. A consultant job marks the accumulation of many years of hard work. It also defines our life both in and outside work for the next 30 years. Consequently, it is important to get the right one. Preparation for getting this post ideally needs to occur at least 2 years before the first interview by careful review of your CV with the help of your educational supervisor, focusing on clinical and non-clinical experience, audit, research, teaching and training, involvement in leadership and management to ensure that you will have the correct skills and attributes at the right time. Looking at specific or example job descriptions, and particularly the essential and desirable short-listing criteria, by going to the National Health Service (NHS) Jobs website (www.jobs.nhs. uk) (Box 1.1 ) will provide clearer guidance on what will be needed both within your speciality and within the type of institution you would like to work. Box 1.2 asks a series of questions which you might want to consider when reviewing your progress towards developing the right experience to get the type of consultant job you would really like. Not all questions will be relevant to everyone.
Understanding You and Your Interviewers
Authors: Watkin Sara , Vincent Andrew
Published: November 2020

This chapter seeks to demystify the complex area of human behaviour and motivation in a manner that makes it not only accessible but also useful to someone facing an interview situation. Far from being filled with complex, interrelated behavioural constructs, we have simplified a genuinely complex area sufficiently to allow practical application in the form of conscious competence. A thorough understanding of what makes people tick is a significant competitive advantage in an interview. This section is in sufficient depth to give you the edge, but if you would like to understand more about behaviour, difference and influencing, then we’d strongly recommend attending a good course on the subject. It will benefit your interview and indeed the rest of your working life. . . . Can and should we consider ‘classifying’ individuals? . . . Some might consider that delving into human psychology in interviews represents a risky departure from the factual and predictable into a less ‘tangible’ field. We see it differently. An otherwise good candidate who ignores interpersonal difference at interview runs the risk of being inadvertently declined, not because he/she is not worthy of appointment but because he/she is simply a poor behavioural match to the decision makers. It is vital that we appreciate the decision to appoint is as much an emotional one as a logical one, however much we would like to kid ourselves otherwise. Interviewers hold a mandate to assess candidates for ‘fit’ to the department they will join. After all, you may well work with your new colleagues for many years and those years could seem long for everyone if the fit is not good. Fit is very much an emotional judgement, rather than an objectively detached one. Whereas many inputs will form the ultimate decision to appoint or not, likely fit with fellow department members will be an important consideration, with roots firmly in ‘gut feeling’ rather than rational assessment. What is important is that you adopt a simple and easily manageable framework for behaviour that allows you to adequately and smoothly adapt your approach with confidence.
Getting the Job—What Next?
Authors: Watkin Sara , Vincent Andrew
Published: November 2020

Congratulations. You were successful at your consultant interview and you are now looking forward to the next phase of your career. So what happens next? It’s easy to think of the journey as being essentially complete at this point, but we strongly advocate using this period—between acceptance and starting—productively to ensure that your interview success turns into a fulfilling consultant career. This chapter outlines some of the key things to consider during the period leading up to starting as a consultant and in those very first few days and weeks in your new post. The chapter starts by looking at some of the immediate considerations: • When should you resign? • When should you start? • Should you take a break? It then moves on to think about how you start to establish yourself in the first 90 days as a new consultant—probably the most important period you have to face yet! It is very tempting, having been offered a consultant post, to immediately resign your StR or SAS post—don’t! Your offer of a post no doubt came with some conditions. These might include: • Subject to references • Subject to a satisfactory health check • Subject to confirmation of your qualifications Until you have confirmation that all of the conditions have been satisfied, hold back from handing in your notice. We’re not being pessimistic and you are probably reasonably certain that everything will be fine, but until you actually hand in notice, you have full employment rights with your present employer, even if they know that you intend to leave. Until you have the security of employment confirmation without conditions, it is just safer to be cautious. Depending on factors such as the remaining length of your post, etc., it is usual to have to give 3 months’ notice if you are resigning from an StR or SAS post. If you are in a locum consultant position, check your contract and if necessary seek advice from Medical Staffing. Before deciding on your resignation date consider what this might mean for your starting date.
Background Physics
Authors: Magee Patrick , Tooley Mark
Published: November 2020

This chapter covers the background physics that is not otherwise covered in the relevant chapters associated with the equipment discussed. It is a useful introduction to some loosely related, but widely applicable concepts. Any measurement made by the anaesthetist can be simplified and made easier to understand if it is represented by its basic dimensions. Dimensions are the basic components of equations and are independent of the units used. For example a common term in physics and medicine is velocity, which has the dimensions of length per unit time, written dimensionally as [L][T]−1. This means that, independent of the measurement system used, the measurement of velocity requires that the numerical value of a length be divided by the numerical value of a time. Equations or graphical axes can be predicted and their validity can be checked by dimensional analysis. Each side of an equation can be represented in basic dimensions and both sides should balance. The dimensions needed to describe most events are mass [M], length [L], time [T], and temperature [θ]. An example of dimensional analysis is described later in this chapter but first units must be discussed. All measurements need to have their correct unit and symbol attached to them. Equations have a unique language and the syntax must be correct for communication within the international community. In the past many different systems of units were used; one was Imperial, another c.g.s. The Systéme International (SI) of units was established in 1960 and is now the recognised system of measurement communication. For completeness the base quantities are shown and some useful derived physical quantities are shown in Table 3.1 In the SI system the combination of basic units involves multiplication and division but multiplication is shown as a space and division is shown as a negative superscript. For example, velocity, in metres per second, is m s−1. Prefixes to the name of each unit are usually in multiples of 103 and 10−3. There are a few non-SI units that are still used in medicine, (not just anaesthesia) and these seem resilient to change. One is the millimetre of mercury (mmHg) for intravascular pressures (100 mmHg = 13.3 kPa), and total and partial gas pressures.
Aids to Intubation
Authors: Magee Patrick , Tooley Mark
Published: November 2020

This device was invented by Sir Ivan Magill and Sir Robert Macintosh to visualise the vocal cords to aid intubation. The curved blade of the Macintosh laryngoscope is still popular as the standard and its design has been reshaped in recent years to reduce the biomechanical forces on the teeth [Bucx et al. 1997, Bucx et al. 1994]. The straight blade of the Magill laryngoscope can make the view easier under some circumstances, as do modern variants [Henderson 1997]. The handle has a battery and a light source in it, and the light is transmitted by a fibre optic cable to the tip of the blade, which is usually at right angles to the handle. There are many different shaped blades to suit different circumstances, particularly to visualise the anatomically different airway of the neonate. Other variants to aid difficult intubations include the Polio laryngoscope, in which the angle between the handle and the blade is an obtuse one and the McCoy laryngoscope, which has a lever to manipulate the tip of the laryngoscope blade to improve the view of the vocal cords [McCoy et al. 1993]; some of these devices are shown in Figure 24.1. In recent years a new range of laryngoscopes has been introduced with fibre optic systems that allow indirect visualisation of the vocal cords via an eyepiece or a small video screen. These devices clearly improve access to the airway where there would otherwise be a laryngoscopic view with a high Cormack-Lehane score. They currently include the McGrath [Ray et al. 2009], the Glidescope, the Airtraq [Lange et al. 2009] (shown in Figures 24.2(a) and (b)), the C-MAC [McElwain et al. 2010 and others] and testing to date has been on manikins. As with all new devices, their efficacy depends on the skill of the user; one study has demonstrated greater skill with the familiar Macintosh laryngoscope than with the newer ones [Powell et al. 2009]. With the emergence of Jakob–Creutzfeldt disease and the recognition of the infectious risk of prions from tonsillar tissue on laryngoscope blades, a range of disposable paediatric blades has been produced, with variable quality of mechanical flexibility and light quality [Goodwin et al. 2006].
Artificial Ventilators
Authors: Magee Patrick , Tooley Mark
Published: November 2020

When pressure is applied by the ventilator to drive gas into the lungs, energy is expended to overcome airway resistance R to gas flow in the airways, in order to store gas in the alveoli, whose readiness to having their volume increased is represented by the concept of compliance, C. The storage of gas within individual compliances represents potential energy storage. The acceleration of gas and anatomical components within the system represent kinetic energy change, resisted by the inertance, I, of the system. At conventional ventilation frequencies, these kinetic energy changes are negligible compared with the other energy changes taking place. Inertance can be ignored and the system behaves like a flow resistor in series with a compliance. These variables determine the pressure and volume changes that take place within the lung. As ventilation frequency increases into the high range, inertance becomes significant and the frequency response of anatomical structures becomes important, with phase differences between pressure and volume signals occurring [Lin et al. 1989]. Mechanical resistance, R, in the system is largely due to resistance to gas flow down airways and is defined as pressure change per unit flow ΔP/Q, typically 4 cm H2O l−1 s. at 0.5 l s−1. However there is a contribution from viscous resistive forces in the lung and chest wall tissues. High resistance may require long inspiratory times, while expiratory times that are too short may lead to gas trapping in alveoli. Excessive resistance may mean that the power required to ventilate the patient may exceed that available to the ventilator. Compliance, C, is a measure of the capacitative properties of the alveoli and is defined as volume change per unit pressure change ΔV/ΔP. It is not uniform throughout the respiratory cycle and has values in the range 0.05–0.10 L (cmH2O)−1. Dynamic compliance is the value given to this variable throughout the inspiratory period to the end of inspiration, when airway pressure is highest. During the inspiratory pause, airway pressure falls to a plateau during which the static compliance can be measured, which is greater than the dynamic compliance.
Ophthalmology
Authors: Gupta Pawan
Published: November 2020

Approximately 2% of ED attendances comprise patients with eye complaints. Most of the time this group of patients is seen by a junior doctor with very little training in thorough and relevant history taking and examination. The majority of such eye problems can be treated in the ED without requiring any intervention from an ophthalmologist. But a few may require immediate action and subsequent referral to the on-call ophthalmologist. Most of the emergencies require a standard approach to history taking followed by an examination, although some (acid or alkali burns) may need immediate treatment, which is given while the assessment is being done. In ophthalmology, the history will help indicate the part of the eyes to focus on during the physical examination. The following points should be covered in the history: • Associated trauma • Pain versus irritation • Photophobia • Discharge—colour, quantity and consistency • Loss of vision • Pattern and speed of onset of symptoms • Any past eye problems in the same or the other eye. During the physical examination always measure VA separately for each eye by using Snellen’s chart and document your findings. If the patient wears glasses, these should be kept on during the test. The examination should also include a good look at the eyelids (both from outside and inside), conjunctivae, cornea, pupils and their size and reaction, visual fields, eye movements, and ophthalmoscopy. Do not forget to evert the upper eyelid with the help of a cotton bud as tiny foreign bodies often hide underneath it and their removal will immediate relieve the symptoms—the patient will be very grateful! Patients with potentially serious pathology requiring immediate ophthalmology referral include those with: • Sudden loss of vision • New reduction in VA • Acute red and painful eye (suspect acute glaucoma) • Penetrating eye injuries • Chemical burns to the eye • Suspected iritis, herpes zoster infection, and orbital cellulitis (referral on the same day). The questions in this chapter cover the common eye emergencies and a few uncommon but serious pathologies.
Use of contrast in ultrasound
Authors: Jansson Tomas , Nilsson Anders
Published: November 2020

In 1968, Drs Pravin M. Shah and Raymond Gramiak at the University of Rochester, New York, were conducting a study with the ultimate goal to investigate whether heart stroke volume could be estimated from the extent and duration of cusp separation of the aortic valve, as measured with M-mode ultrasound. Simultaneously, as the reference, they also measured cardiac output with the indicator dilution technique. Here, a bolus of a dye (indocyanine green) is injected and blood is sampled downstream to determine the rate at which the indicator has been transported from the injection site. In Dr Shah’s own account of the experiments, he explains that the routine at his university then was to place a catheter in the left atrium with the trans-septal technique, i.e. inserting the catheter in a vein and penetrating into the left atrium via the right atrium. During the injections of the dye, somewhat to their surprise, they observed a striking echo enhancement across the aorta. The enhancement also appeared when saline and dextrose in water was flushed through the catheter. Dr Gramiak reminded himself of a comment from Dr Claude Joyner, that a temporary echo-enhancement could be observed during saline injections, and they speculated that miniature bubbles produced by gaseous cavitation upon rapid injection of the fluid gave rise to the enhancement, and raised the idea that this could be used as a contrast agent. An in vitro study by Frederick Kremkau provided strong evidence that gas bubbles were actually responsible for the echo enhancement. It is interesting to note how discoveries are made independently around the world, when the time is ripe. At the same time in Lund, Drs Inge Edler and Kjell Lindström performed studies to measure blood flow in the heart. At this point no ultrasound Doppler signals had been recorded from the inside of the heart, and they used a calf heart in an in vitro model to verify that signals could be obtained when water and blood was led through the model.
SBAs for the Final FRCR 2A
Authors: Lindsay Richard , Gillespie Scott , Kelly Rory , Sathyanarayana Raghuram , Burns Paul
Published: November 2020

Providing everything you need to pass the FRCR Part 2A, this book provides a thorough assessment of a candidate's radiological knowledge. The book is divided into six chapters, with 75 questions in each chapter, mirroring the modules and exam papers laid out by the Royal College of Radiologists. This makes you as familiar as possible with its style, content and structure and facilitates directed learning. All questions have been formulated to reflect the current best practice and evidenced-base, ensuring candidates' knowledge of their field is up-to-date. A detailed explanation is provided for each question, including references to review publications or widely-used textbooks, which allow detailed follow-up on the issues discussed.
The Circular Ruins
Authors: Bradley Richard
Published: November 2020

This is not a book about a period or a place; it is about an idea. Why did so many people in prehistoric Europe build circular monuments? Why did they choose to live in circular houses, when other communities rejected them? Why was it that those who preferred to inhabit a world of rectangular dwellings so often buried their dead in round mounds and worshipped their gods in circular temples? The best way of introducing such questions is through a specific example. Certain monuments exert a special fascination. Beside the road at Uisneach in the Irish Republic is a signboard which makes some remarkable claims. This was the ‘site of the Celtic festival of Beltane’ and ‘an ancient place of assembly’. It was associated with ‘the Druidic fire cult’ and the ‘seat of Irish kings’. The notice makes a still more intriguing assertion, for the Hill of Uisneach was also the ‘sacred centre of Ireland in pagan times’. The archaeology of the hill is hardly less remarkable, and it is easy to see how it has suggested such ideas. Some interpretations of the site are based on its distinctive topography, and others on literary evidence (Schot 2006, 2011). The hill is an irregular plateau which rises out of an extensive plain. It is also at the junction of two different landscapes. To the east, there have been many discoveries dating from the prehistoric and early medieval periods. To the west, where the soil is less fertile, they are comparatively rare. Uisneach dominates the view from all directions. It also commands an extensive vista on every side. Indeed, Macalister and Praeger (1928) who studied its archaeology over eighty years ago published a map showing the land that can be seen from the hilltop. Although it is claimed that twenty Irish counties are represented, the area does not extend as far as the coast (Figure 1). Not all those regions can be observed from a single point. In order to appreciate the full extent of the view, it is necessary to move between a series of ancient monuments.