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Intravenous Therapy

Intravenous therapy

Intravenous therapy or IV therapy is the administration of liquid substances directly into a vein. It can be intermittent or continuous; continuous administration is called an intravenous drip. The word intravenous simply means "within a vein", but is most commonly used to refer to IV therapy. Compared with other routes of administration, the intravenous route is the fastest way to deliver fluids and medications throughout the body. Some medications, as well as blood transfusions, can only be given intravenously.

Intravenous access devices

Needle and syringe

The simplest form of intravenous access is a syringe with an attached hollow needle. The needle is inserted through the skin into a vein, and the contents of the syringe are injected through the needle into the bloodstream. This is most easily done with an arm vein, especially one of the metacarpal veins. Usually it is necessary to use a tourniquet first to make the vein bulge; once the needle is in place, it is common to draw back slightly on the syringe to see blood return, thus verifying that the needle is really in a vein; then the tourniquet is removed before injecting. This is the most common method of intravenous drug use for illegal substances such as heroin, or in any case where a person must self-administer intravenous medication at home. It is also a convenient way to deliver life-saving medications in an emergency. However, in a controlled health-care setting, direct injection is rarely used since it only allows delivery of a single dose of medication.

Peripheral IV lines

This is the most common intravenous access method in both hospitals and paramedic services. A peripheral IV line consists of a short catheter (a few centimeters long) inserted through the skin into a peripheral vein. A peripheral vein is any vein that is not in the chest or abdomen. Arm and hand veins are typically used although leg and foot veins are occasionally used. Pediatricians sometimes use the scalp veins of infants. Part of the catheter remains outside the skin, with a hub that can be connected to a syringe or an intravenous infusion line, or capped with a bung between treatments. The caliber of cannulas is commonly indicated in gauge, with 14 being a very large cannula (used in resuscitation settings) and 24-26 the smallest. Blood can be drawn from a peripheral IV if necessary, but only if it is in a relatively large vein and only if the IV is newly inserted. Originally, a peripheral IV was simply a needle that was taped in place and connected to tubing rather than to a syringe. Today, hospitals use a safer system in which the catheter is a flexible plastic tube that originally contains a needle to allow it to pierce the skin; the needle is then removed and discarded, while the soft catheter stays in the vein. A peripheral IV cannot be left in the vein indefinitely, because of the risk of insertion-site infection leading to cellulitis and bacteremia. Hospital policies usually dictate that every peripheral IV be replaced (at a different location) every three days to avoid this complication.

Central IV lines

Central IV lines flow through a catheter with its tip within a large vein, usually the superior vena cava or inferior vena cava, or within the right atrium of the heart. This has several advantages over a peripheral IV:
- It can deliver fluids and medications that would be overly irritating to peripheral veins because of their concentration or chemical composition. These include some chemotherapy drugs and total parenteral nutrition.
- Medications reach the heart immediately, and are quickly distributed to the rest of the body.
- There is room for multiple parallel compartments (lumens) within the catheter, so that multiple medications can be delivered at once even if they would not be chemically compatible within a single tube.
- Carers can measure central venous pressure and other physiological variables through the line. Central IV lines also carry higher risks of bleeding, bacteremia, and gas embolism (see Risks below). There are several types of central IVs, depending on the route that the catheter takes from the outside of the body to the vein.

Peripherally inserted central catheter (PICC)

A PICC line is inserted into a peripheral vein, usually in the arm, and then carefully advanced upward until the catheter is in the superior vena cava or the right atrium. This is usually done by feel and estimation; an X-ray then verifies that the tip is in the right place. A PICC may have two parallel compartments, each with its own external connector (double-lumen), or a single tube and connector (single-lumen). From the outside, a single-lumen PICC resembles a peripheral IV, except that the tubing is slightly wider. The insertion site must be covered by a larger sterile dressing than would be required for a peripheral IV, due to the higher risk of infection if bacteria travel up the catheter. However, a PICC poses less of a systemic infection risk than other central IVs, because bacteria would have to travel up the entire length of the narrow catheter before spreading through the bloodstream. The chief advantage of a PICC over other types of central lines is that it is easy to insert, poses a relatively low risk of bleeding, is externally unobtrusive, and can be left in place for months to years for patients who require extended treatment. The chief disadvantage is that it must travel through a relatively small peripheral vein and is therefore limited in diameter, and also somewhat vulnerable to occlusion or damage from movement or squeezing of the arm.

Central venous lines

There are several types of catheters that take a more direct route into central veins. These are collectively called central venous lines. In the simplest type of central venous access, a catheter is inserted into a subclavian, internal jugular, or (less commonly) a femoral vein and advanced toward the heart until it reaches the superior vena cava or right atrium. Because all of these veins are larger than peripheral veins, central lines can deliver a higher volume of fluid and can have multiple lumens. Another type of central line, called a Hickman line or Broviac catheter, is inserted into the target vein and then "tunneled" under the skin to emerge a short distance away. This reduces the risk of infection, since bacteria from the skin surface are not able to travel directly into the vein; these catheters are also made of materials that resist infection and clotting.

Implantable ports

A port (often referred to by brand names such as Port-a-Cath or MediPort) is a central venous line that does not have an external connector; instead, it has a small reservoir implanted under the skin. Medication is administered intermittently by placing a small needle through the skin into the reservoir. Ports cause less inconvenience and have a lower risk of infection than PICCs, and are therefore commonly used for patients on long-term intermittent treatment.

Forms of intravenous therapy

Intravenous drip

An intravenous drip is the continuous infusion of fluids, with or without medications, through an IV access device. This may be to correct dehydration or an electrolyte imbalance, to deliver medications, or for blood transfusion.

IV fluids

There are two types of fluids that are used for intravenous drips: crystalloids and colloids. Crystalloids are aqueous solutions of mineral salts or other water-soluble molecules. Colloids contain larger insoluble molecules, such as gelatin; blood itself is a colloid. The most commonly used crystalloid fluid is normal saline, a solution of sodium chloride at 0.9% concentration, which is close to the concentration in the blood (isotonic). Ringer's lactate or Ringer's solution is another isotonic solution often used for large-volume fluid replacement. A solution of 5% dextrose in water, sometimes called D5W, is often used instead if the patient is at risk for having low blood sugar or high sodium. The choice of fluids may also depend on the chemical properties of the medications being given. Intravenous fluids must always be sterile. Composition of Common Crystalloid Solutions Ringer's lactate also has 28 mmol/L lactate, 4 mmol/L K⁺ and 3 mmol/L Ca²⁺. Effect of Adding One Litre

Infusion equipment

A standard IV infusion set consists of a pre-filled, sterile container (glass bottle, plastic bottle or plastic bag) of fluids with an attached drip chamber which allows the fluid to flow one drop at a time, making it easy to see the flow rate (and also reducing air bubbles); a long sterile tube with a clamp to regulate or stop the flow; a connector to attach to the access device; and connectors to allow "piggybacking" of another infusion set onto the same line, e.g., adding a dose of antibiotics to a continuous fluid drip. An infusion pump allows precise control over the flow rate and total amount delivered, but in cases where a change in the flow rate would not have serious consequences, or if pumps are not available, the drip is often left to flow simply by placing the bag above the level of the patient and using the clamp to regulate the rate; this is a gravity drip. A rapid infuser can be used if the patient requires a high flow rate and the IV access device is of a large enough diameter to accommodate it. This is either an inflatable cuff placed around the fluid bag to force the fluid into the patient or a similar electrical device that may also heat the fluid being infused.

Intermittent infusion

Intermittent infusion is used when a patient requires medications only at certain times, and does not require additional fluid. It can use the same techniques as an intravenous drip (pump or gravity drip), but after the complete dose of medication has been given, the tubing is disconnected from the IV access device. Some medications are also given by IV push, meaning that a syringe is connected to the IV access device and the medication is injected directly (slowly, if it might irritate the vein or cause a too-rapid effect).

Risks of intravenous therapy

Intravenous therapy has many risks and should therefore only be performed by trained personnel under medical supervision, using proper equipment.

Infection

Any break in the skin carries a risk of infection. Although IV insertion is a sterile procedure, skin-dwelling organisms such as Staphylococcus aureus or Candida albicans may enter through the insertion site around the catheter, or bacteria may be accidentally introduced inside the catheter from contaminated equipment. Infection of IV sites is usually local, causing easily visible swelling, redness, and fever. If bacteria do not remain in one area but spread through the bloodstream, the infection is called septicemia and can be rapid and life-threatening. An infected central IV poses a higher risk of septicemia, as it can deliver bacteria directly into the central circulation.

Phlebitis

Phlebitis is irritation of a vein that is not caused by infection, but from the mere presence of a foreign body (the IV catheter) or the fluids or medication being given. Symptoms are swelling, pain, and redness around the vein. It does not necessarily mean the IV device must be removed; warmth, elevation of the affected limb, or a change in the rate of flow may resolve the symptoms. Due to frequent injections and recurring phlebitis, the peripheral veins of intravenous drug addicts, and of cancer patients undergoing chemotherapy, become hardened and difficult to access over time.

Infiltration

This occurs when the tip of the IV catheter withdraws from the vein or pokes through the vein into surrounding tissue, or when the vein's wall becomes permeable and leaks fluid. It occurs frequently with peripheral IVs, and requires replacement of the IV at a different location. The symptoms of pain and swelling are temporary and not dangerous, unless a highly irritating medication was being given.

Fluid overload

This occurs when fluids are given at a higher rate or in a larger volume than the system can absorb or excrete. Possible consequences include hypertension, heart failure, and pulmonary edema.

Electrolyte imbalance

Administering a too-dilute or too-concentrated solution can disrupt the patient's balance of sodium, potassium, and other electrolytes. Hospital patients usually receive blood tests to monitor these levels.

Embolism

A blood clot or other solid mass, or an air bubble, can be delivered into the circulation through an IV and end up blocking a vessel; this is called embolism. Peripheral IVs have a low risk of embolism, since large solid masses cannot travel through a narrow catheter, and it is nearly impossible to inject air through a peripheral IV at a dangerous rate. The risk is greater with a central IV. Air bubbles of less than 30 milliliters generally dissolve into the circulation harmlessly. A larger amount of air, if delivered all at once, can cause life-threatening damage to pulmonary circulation, or, if extremely large (3-8 milliliters per kilogram of body weight), can stop the heart. One reason veins are preferred for intravenous administration is because the flow will pass through the lungs before passing through the body. Air bubbles can leave the blood through the lungs. A patient with a heart defect causing a right-to-left shunt is vulnerable to embolism from smaller amounts of air. Fatality by air embolism is vanishingly rare, in part because it is also difficult to diagnose. The few cases that are known to have stopped the heart occurred not by clinical intravenous therapy, but by self-adminstration of vaginal powders using air-bulb insufflators, when the vagina had severe bleeding.

External links

- [http://www.nursewise.com/courses/iv_hour.htm Nursewise]
- [http://healthlinks.washington.edu/nutrition/section6.html UWash] Category:Medical treatments

Vein

:In geology, a vein is a regularly shaped and lengthy occurrence of an ore; a lode. In biology, a vein is a blood vessel which returns blood from the microvasculature to the heart. Veins form part of the circulatory system. The vessels carrying blood away from the heart are known as arteries.

Biological Vein

Veins have one-way valves to prevent backflow caused by gravity. arteries In systemic circulation de-oxygenated blood from the capillary blood vessels is taken by veins to the right part of the heart. Differently, in the pulmonary circulation oxygenated blood from the lungs is taken to the left part of the heart by pulmonary veins. Another special case is portal circulation where the portal vein transports blood rich in products of digestion from the intestines to the liver. Names of important veins:
- Pulmonary veins
- Portal vein
- Superior vena cava
- Inferior vena cava
- Femoral vein
- Great saphenous vein Veins are used medically as points of access to the blood stream, permitting the withdrawal of blood specimens (venipuncture) for testing purposes, and enabling the infusion of fluid, electrolytes, nutrition, and medications. The latter is called intravenous delivery. It can be done by an injection with a syringe, or by inserting a catheter (a flexible tube). If an intravenous catheter has to be inserted, for most purposes this is done into a peripheral vein (a vein near the surface of the skin in the hand or arm, or less desirably, the leg.) Some highly concentrated fluids or irritating medications must flow into the large central veins, which are sometimes used when peripheral access cannot be obtained. Catheters can be threaded into the superior vena cava for these uses: if long term use is thought to be needed, a more permanent access point can be inserted surgically. The precise location of veins is much more variable from person to person than that of arteries.

Route of administration

In pharmacology and toxicology, a route of administration is the path by which a drug, fluid, poison or other substance is brought into contact with the body ¹. Obviously, a substance must be transported from the site of entry to the part of the body where its action is desired to take place (unless this is on the body surface). However, using the body's transport mechanisms for this purpose can be far from trivial. The pharmacokinetic properties of a drug (that is, those related to processes of uptake, distribution, and elimination) are critically influenced by the route of administration.

Classification

Routes of administration can broadly be divided into:
- topical: local effect, substance is applied directly where its action is desired
- enteral: desired effect is systemic (non-local), substance is given via the digestive tract
- parenteral: desired effect is systemic, substance is given by other routes than the digestive tract The following is a list of some routes of administration.

Topical

- epicutaneous (application onto the skin), e.g. allergy testing, topical local anesthesia
- inhalational, e.g. asthma medications
- enema, e.g. contrast media for imaging of the bowel
- eye drops (onto the conjunctiva), e.g. antibiotics for conjuncitivitis
- ear drops - such as antibiotics and corticosteroids for otitis externa
- intranasal, e.g. decongestant nasal sprays
- sublingual: e.g. nitroglycerine: the medication is taken up directly by the tongue's vascular supply

Enteral

- by mouth (orally), many drugs as tablets, capsules, or drops
- by gastric feeding tube, duodenal feeding tube, or gastrostomy, many drugs and enteral nutrition
- rectally, various drugs in suppository or enema form

Parenteral by injection or infusion

- intravenous (into a vein), e.g. many drugs, total parenteral nutrition
- intraarterial (into an artery), e.g. vasodilator drugs in the treatment of vasospasm and thrombolytic drugs for treatment of embolism
- intramuscular (into a muscle), e.g. many vaccines, antibiotics, and long-term psychoactive agents.
- intracardiac
- subcutaneous (under the skin), e.g. insulin
- intraosseous infusion (into the bone marrow) is, in effect, an indirect intravenous access because the bone marrow drains directly into the venous system. This route is occasionally used for drugs and fluids in emergency medicine and pediatrics when intravenous access is difficult
- intradermal, (into the skin itself) is used for skin testing some allergens, and also for tattoos
- intraperitoneal, (into the peritoneum) is predominantly used in veterinary medicine and animal testing for the administration of systemic drugs and fluids due to the ease of administration compared with other parenteral methods.

Parenteral (other than injection or infusion)

- transdermal (diffusion through the intact skin), e.g. transdermal opioid patches in pain therapy
- transmucosal (diffusion through a mucous membrane), e.g. cocaine snorting, sublingual nitroglycerine
- inhalational, e.g. inhalational anesthetics

Other

- intraperitoneal (infusion or injection into the peritoneal cavity), e.g. peritoneal dialysis
- epidural (synonym: peridural) (injection or infusion into the epidural space), e.g. epidural anesthesia
- intrathecal (injection or infusion into the cerebrospinal fluid), e.g. antibiotics, spinal anesthesia

Uses

Some routes can be used for topical as well as systemic purposes, depending on the circumstances. For example, inhalation of asthma drugs is targeted at the airways (topical effect), whereas inhalation of volatile anesthetics is targeted at the brain (systemic effect). On the other hand, identical drugs can produce different results depending on the route of administration. For example, some drugs are not significantly absorbed into the bloodstream from the gastrointestinal tract and their action after enteral administration is therefore different from that after parenteral administration. This can be illustrated by the action of naloxone, an antagonist of opiates such as morphine. Naloxone counteracts opiate action in the central nervous system when given intravenously and is therefore used in the treatment of opiate overdose. The same drug, when swallowed, acts exclusively on the bowels; it is here used to treat constipation under opiate pain therapy and does not affect the pain-reducing effect of the opiate. Enteral routes are generally the most convenient for the patient, as no punctures or sterile procedures are necessary. Enteral medications are therefore often preferred in the treatment of chronic disease. However, some drugs can not be used enterally because their absorption in the digestive tract is low or unpredictable. Transdermal administration is a comfortable alternative; there are, however, only few drug preparations suitable for transdermal administration. In acute situations, in emergency medicine and intensive care medicine, drugs are most often given intravenously. This is the most reliable route, as in acutely ill patients the absorption of substances from the tissues and from the digestive tract can often be unpredictable due to altered blood flow or bowel motility.

Notes

Note 1: In toxicology, "exposition" may often be a more appropriate term, however "administration" can be used for deliberate substance use.

Blood transfusion

Blood transfusion is the taking of blood or blood-based products from one individual and inserting them into the circulatory system of another. It can be considered a form of organ transplant. Blood transfusions may treat medical conditions, such as massive blood loss due to trauma, surgery, shock and where the red cell producing mechanism (or some other normal and essential component) fails (see blood diseases).

History

Roman Catholic authors take pains to discredit the contemporary chronicler Stefano Infessura's story of Innocent VIII's deathbed. As the Pope sank into a coma, the harrowing story was told that, at the suggestion of a Jewish physician, the blood of three boys was infused into the dying pontiff's veins. They were ten years old, and had been promised a ducat each. All three died. Historians of medicine note this event as the first reported historical attempt at a blood transfusion. ducat With Harvey's discovery of the circulation of the blood, more sophisticated research into blood transfusion began in the 17th century, with successful experiments of transfusions between animals. However, successive attempts on humans continued to bring death. The first fully-documented human blood transfusion was administered by Dr. Jean-Baptiste Denys on June 15, 1667. He transfused the blood of a sheep to a 15-year old boy (the boy later died, and Denys was accused of murder). Only in the first decade of the 19th century was the reason for such death found in the existence of blood types, and the practice of mixing some blood from the donor and the receiver before the transfusion allowed a greater number of successes. In 1818 Dr.James Blundell, a British obstetrician, performed the first successful transfusion of human blood to a patient for the treatment of postpartum hemorrhage. He used the patient's husband as a donor, and extracted four ounces of blood from his arm to transfuse into his wife. During the years 1825 and 1830, he performed 10 transfusions, five of which were beneficial and published his results. He also invented many instruments for the transfusion of blood. He made a lot of money from this endeavour, in the neighbourhood of today's equivalent of $50,000,000. In 1840, at St. George's School in London, Samuel Armstrong Lane, aided by Dr. Blundell, performed the first successful whole blood transfusion to treat hemophilia. While the first transfusions had to be made directly from donor to receiver before coagulation, in the 1910s it was discovered that by adding anticoagulants and refrigerating the blood it was possible to store it for some days, thus opening the way for blood banks. The first non-direct transfusion was performed on March 27, 1914 by the Belgian doctor Albert Hustin, who used sodium citrate as an anticoagulant. The first blood transfusion using blood that had been stored and cooled was performed on January 1,1916. It was performed by the Royal Army Medical Corps (RAMC), and the procedure was very successful. The first blood transfusion institute was set up by Alexander Bogdanov (who would sacrifice his own life in one of the experiments) in Moscow in 1925. There is an urban legend concerning one of the pioneers of blood transfusion research, Dr. Charles Drew. Drew's research led to the discovery that blood could be separated into blood plasma and red blood cells, and that the components could be frozen separately. Blood stored in this way lasted longer and was less likely to become contaminated. His untimely death after an automobile accident is commonly believed to have resulted partly from delayed access to emergency blood transfusion treatment because of his race. The popular television series M
- A
- S
- H once aired an episode (see Season 2, Episode 9 - "Dear Dad ... Three") propagating this legend. Contemporary eye-witness accounts however, contradict that version.

Precautions

Great care is taken to ensure that the recipient's immune system will not attack the donor blood, and also to avoid transfusing white blood cells that could initiate an immune attack on the host (graft versus host disease). Nevertheless, blood transfusion does suppress the immune system, increasing the risk of complications after surgery. In addition to the familiar human blood type (A, B, AB and O) and Rhesus (positive or negative) classifications, other red cell antigens are known to determine compatibility, to one degree or other. These other type become increasingly important in people who receive many blood transfusions as their bodies develop increasing resistance to blood from other people. There is increased awareness that a number of diseases (such as AIDS, syphilis, hepatitis B and hepatitis C and others) can be passed from the donor to recipient. This has led to strict human blood transfusion standards in developed countries, such as HIV blood screening. Standards include screening for potential risk factors and health problems including determining donor hemoglobin level, and answering a set of standard oral and written questions, as well as testing donated units for these infections. The lack of such standards in places like rural China, where desperate villagers donated plasma for money and had others' red blood cells reinjected, has produced entire villages infected with AIDS.

Procedure

Blood can only be administered intravenously. It therefore requires the insertion of a cannula of suitable caliber. Before the blood is administered, the personal details of the patient are matched with the blood to be transfused, to minimize risk of transfusion reactions. A unit (up to 500 ml) of blood is typically administered over 4 hours. In patients at risk of congestive heart failure, many doctors administer furosemide to prevent fluid overload.

Contraindications

The contraindications to a blood donor include:
- previous malaria or hepatitis.
- history of drug abuse
- donors who have received human pituitary hormone.
- donors with high risk sexual behaviour
- donors who have previously been transfused (depending on geographic location) Sometimes only parts of the blood are taken as a donation. Blood is made up mostly of plasma, red blood cells, white blood cells and platelets. Plasma and platelets can be donated separately in a process called ~apherisis. Blood is usually separated into components after being donated to make the most use of it. Donation of whole blood is generally reserved for treating young children and remote areas where the hospital summons donors when it needs them. Resulting blood component products also include albumin protein used to treat burns, clotting factor concentrates used to treat hemophilia, cryoprecipitate, fibrinogen concentrate, and immunoglobulin antibodies for immunological disorders. Donation of whole blood eliminates transfusion-related risk of illness for the blood donor, aside from the minuscule chance of infection or perhaps of localized injury to the donor site. While there is a theoretical risk to the donor when they donate plasma and have red cells reinfused, this risk is eliminated by proper sterilization procedures. However, this caused public health disasters in China where this practice was often unregulated. Modern, well-run blood plasma collection centers are completely safe. In the United States and other developed countries, they are maintained by pharmaceutical companies, using paid donors up to twice weekly. Donations are usually anonymous to the recipient, but products in a blood bank are always individually traceable through the whole cycle of donation, testing, separation into components, storage, administration to the recipient. This enables management and investigation of any suspected transfusion related disease transmission.

Complications

Possible complications in the recipient include:
- Febrile reactions
- Haemolytic reactions
- Allergic reactions
- Infection
- Fluid overload
- Acute respiratory distress syndrome

Animal blood transfusion

Veterinarians also administer transfusions to animals. Various species require different levels of testing to ensure a compatible match. Cats have 3 blood types, cattle have 11, dogs have a dozen, pigs 16 and horses have 34. The rare and experimental practice of inter-species blood transfusions is a form of xenograft.

Blood transfusion substitutes

There are currently no clinically acceptable oxygen-carrying blood substitutes for humans, however, there are widely available non-blood volume expanders and other blood saving techniques. These are helping doctors and surgeons avoid the risks of disease transmission and immune suppression, address the chronic blood donor shortage and address the religious objections of Jehovah's Witnesses. A number of blood substitutes are currently in the clinical evaluation stage. Most attempts to find a suitable alternative to blood have so far concentrated on cell-free hemoglobin solutions. Blood substitutes could make transfusions more readily available in emergency medicine and in pre-hospital EMS care. If successful such a blood substitute could save many lives, particularly in traumas where massive blood loss results.

External Links

- [http://www.al-hikmah.org/blood-transfusion.asp Blood Transfusion]

References

Category:Transfusion medicine Category:Surgery Category:Hematology ja:輸血

Syringe

A syringe consists of a plunger fitted to a tube, called the barrel, which has a small opening on one end. Syringes are used to transfer small amounts of liquids or gasses to or from otherwise inaccesible areas. It operates on the principle of suction by filling the barrel with the subtance at the opening when the plunger is drawn out, and expelling the substance when the plunger is depressed. The process of administering a substance with a syringe and needle is called an injection. The word syringe comes from the Greek syrinx, which means "tube".

Needle syringes

Syringes are used in conjunction with hypodermic needles for injections of liquid or gasses into body tissues, or for their removal from the body. They may also be used for injections across the rubber septum of a medical device, container, or scientific apparatus such as in certain types of chromatography. The injection of air into a blood vessel is undesirable, as it may cause a gas embolism. Prevention of embolisms by removing air from the syringe is the source of the familiar image of holding a syringe upside down, tapping it, and expelling a small amount of liquid before an injection into the bloodstream. gas embolism The barrel of a syringe is made of either plastic or glass, and usually has graduated marks indicating the volume of fluid in the syringe. Glass syringes may be sterilized by the use of an autoclave, however, modern medical syringes are made from plastic because it is cost-effective to dispose of them, which further reduces the risk of spreading blood-borne diseases. The re-use of needles and syringes has been associated with the spread of diseases, especially HIV and Hepatitis among IV drug users. In applications where transfer of pathogens is not an issue and a very high degree of precision is important (i.e., quantitative chemical analysis), glass syringes are still used because their tolerance is lower and the plunger moves more smoothly. Syringes may also be used when cooking meat to enhance flavor and texture by injecting juices inside the meat, and in baking to inject filling inside a pastry. Syringes have also been used for refilling ink cartridges with ink.

Rectal and vaginal syringes

For the administration of enemas or douches, there exist bulb syringes where a bulb is fitted with a nozzle, liquid is pumped into it, the nozzle is inserted into the rectum or vagina and the bulb is pressed upon for injection. There also exist fountain syringes where the liquid is in a bag or can and goes to the nozzle via a pipe. In earlier times, clyster syringes were used for that purpose.

External links

- [http://inventors.about.com/library/inventors/blsyringe.htm Inventors of the syringe]
- [http://www.qiaoyun.net/medicalsupplies/syringe/index.htm Latest the States syringes patents information], [http://www.qiaoyun.net/medicalsupplies/syringe/syringe-1.htm 1], [http://www.qiaoyun.net/medicalsupplies/syringe/syringe-2.htm 2], [http://www.qiaoyun.net/medicalsupplies/syringe/syringe-3.htm 3], [http://www.qiaoyun.net/medicalsupplies/syringe/syringe-4.htm 4], [http://www.qiaoyun.net/medicalsupplies/syringe/syringe-5.htm 5], [http://www.qiaoyun.net/medicalsupplies/syringe/syringe-6.htm 6], [http://www.qiaoyun.net/medicalsupplies/syringe/syringe-7.htm 7] Category:Medical equipment ja:注射器

Hypodermic needle

A hypodermic needle is a hollow needle commonly used with a syringe to inject substances into the body. They may also be used to take liquid samples from the body, for example taking blood from a vein in venipuncture. A hypodermic needle is used when the substance would not be reliably absorbed by the digestive system, as is the case with insulin and many other drugs or if the substance needs to be instantly delivered into the body. The substance can be injected just under the skin (subcutaneous injection), into a muscle (intramuscular injection), or directly into the bloodstream (intravenous injection). Less commonly, hypodermic needles are used for injection into joints (intra-articular injection), cerebrospinal fluid (spinal injection) or into the skin itself (intradermal injection). Virtually all current hypodermic needles and their associated syringes are designed for single use because they are hard to decontaminate and require sharpening after repeat use. Re-using or sharing needles can transmit many blood-borne diseases including AIDS and hepatitis C. Needles are normally used only once and disposed of in a sharps container. Normally made of stainless steel, the end of the needle is bevelled to create a sharp pointed tip. This allows the needle to easily penetrate the skin. When a hypodermic needle is inserted, the bevel should be facing upwards. The diameter of the needle is indicated by the needle gauge. Various needle lengths are available for any given gauge. There are a number of systems for gauging needles, including the Stubs Needle Gauge, and the French Catheter Scale. Needles in common medical use range from 7 gauge (the largest) to 33 (the smallest) on the Stubs scale. Twenty-one gauge needles are most commonly used for drawing blood. Although reusable needles remain useful for some scientific applications, disposable needles are far more common in medicine. Disposable needles are embedded in a plastic or aluminum hub that attaches to the syringe barrel by means of a press-fit (Luer) or twist-on (Luer-lock) fitting. It is estimated that about 10% of the population may have a phobia of needles (mostly children).

References

- [http://www.straightdope.com/mailbag/msyringe.html How do they get the hole through a hypodermic needle?] at The Straight Dope.

External links

- [http://home.columbus.rr.com/klamb/pages/needlephobia.htm The Needle Phobia Information Site]
- [http://www.dentalfearcentral.com/needle_phobia.html Needle Phobia and Dental Injections]
- [http://www.needles.cn Drilled & Rolled End Surgical Suture Needles] Category:Medical equipment

Tourniquet

:For the Christian metal band Tourniquet, see Tourniquet (band). A tourniquet is a tightly tied band applied around a body part (an arm or a leg) in an attempt to stop severe traumatic bleeding. Severe bleeding means the loss of more than 1,000 ml (1 liter) of blood. This flow of blood can soak a paper or cloth hankerchief in a few seconds. In such a situation, the bleeding will cause the death of the casualty in seconds to minutes. Other methods that should be applied first and in conjunction, if possible, include:
- direct pressure
- elevation of the limb or wound above the heart
- the use of a pressure point to slow the artery above the injury
- blood-clotting agents or bandages Even in cases of amputation, most bleeding can be controlled through these alternative methods. The rare exception is when a limb is shattered by massive trauma or when a major blood vessel is torn along its length. Even in these cases, the use of a pressure point above the wound (i.e. proximal to the wound), or application by a doctor of an hemostat, to clamp the blood vessel above the tear is strongly preferred. The use of tourniquets is taught to emergency medical technicians including combat lifesavers, and as a part of military first aid in basic training. It is also part of the French basic first aid courses (for bystanders). A tourniquet is a last resort method of bleeding control. Tourniquets are also used during some orthopedic surgeries to allow the surgeon to work in a bloodless field. When used this way the duration of application and pressure of the tourniquet are carefully monitored. Under these well controlled conditions complications from the tourniquet are rare.

Risks of a tourniquet

As the tourniquet stops the perfusion of the limb, the resulting anoxia can cause the death of the limb, forcing the later surgical amputation of the limb just below the level the tourniquet is applied. This is likely to occur when the tourniquet stays in place several hours. In any event, once a tourniquet has been applied, advanced medical care from a doctor or hospital will be required to salvage the limb if not save the life of the patient. The status of the tourniquet varies widely according to the country. This situation can be illustrated by the opposite philosophies applied in the United States and in France. In any case, the first aider/rescue should act according to the local conditions (laws, rescue organisation and philosophy).

In the United States

The decision to employ a tourniquet should be made by a paramedic or preferably a doctor if at all possible. But when severe external bleeding cannot be controlled by other means, a tourniquet may be the only way for a first-aider to save the casualty. (A medical professional would use a hemostat or resort to field surgery.) The first aid instruction no longer teaches the use of the tourniquet for the following reasons:
- the effectiveness of direct pressure, elevation and pressure points (controlling severe bleeding in up to 90% of cases as estimated by US medical sources)
- the vastly increased difficulty of reattaching an amputated limb when a tourniquet has been applied to the victim
- unnecessary use by poorly trained bystanders
- the unavoidable risks to both limb and life even when properly employed
- the rare nature of injuries that require tourniquets, which typically occur in unusual settings such as working with agricultural or industrial machinery and the battlefield The use of a tourniquet by a layperson in countries where it is considered outside the scope of practice of first aid may result in civil lawsuits and/or criminal charges, especially if the application was later found to have been unnecessary.

In France

In France, the tourniquet is taught to the general public, in the first level of first aid course (Attestation de formation aux premiers secours, 10 hours without any prerequisite). The French emergency medical service (Samu) considers that the rhabdomyolysis (destruction of the muscle cells due to the anoxia) is not likely to endanger the limb before six hours, i.e. the casualty receives advanced medical cares by a physician (either a medical prehospital team or at the emergency room of a hospital) long before the risk occurs. The act is thus considered as proportional to the risk (death by blood loss), and the first aider/rescuer is not likely to be condemned in case the limb is lost (although the legal risk is not totally absent): this loss would be attributed to the wound and not to the saving act. Especially, the tourniquet is considered as an alternative to avoid infection by contact with the blood of the casualty when the first aider has no protecting device (e.g. plastic bag, piece of cloth etc.).

When to use a tourniquet

A tourniquet should be applied only when other methods were tried and failed to stop life-threatening bleeding. A tourniquet could be used if a single first-aider is holding a pressure point and is forced by exigent circumstances to abandon the casualty to save lives (for example, to call for help or perform triage). However, this practice is not sanctioned in some countries, including the United States. Tourniquets are not used to treat snakebite; a constrictive band intended to slow the spread of poison through the lymphatic system in a snakebite victim should be fairly loose compared to a tourniquet.

How to make a tourniquet

To properly apply a tourniquet, a strap, preferably a large and non-elastic strap such as a necktie, belt, sling or scarf, is tightened around the limb, between the wound and the heart. Rubber tubing is more difficult to tighten properly and generally should only be used by paramedics or medical teams. If a suitable strap is not available, any improvised material long enough can be used. This is particularly important in the case of a severed femoral artery. Life-saving tourniquets have been fashioned from fabric, duct tape, elastic, rope, string, twine, and even wire. The less suitable the material, the more likely that amputation will later result. If at all possible, apply the tourniquet as low as possible above the injury. If later amputation is required, the placement of the tourniquet will demarcate the line of amputation, which can unnecessarily cripple a person by depriving them of a joint (knee or elbow) which could have been otherwise saved. French sources recommend that a tourniquet be applied above the elbow for an arm wound and above the knee for a leg wound. This is said to be because the forearm and the calf have two bones; the artery can slide between these bones, and the tourniquet will be inefficient. The tourniquet is usually tied with a slipknot. You can also wrap the strap around the limb and tie tightly; a stick is wound underneath the tubing and twisted until the strap is tightened so that the bleeding is stopped, the stick is tied in its present position with additional tubing or bandages. The name "tourniquet" is derived from this stick, which means "turning stand" in French. A tourniquet must not be tightened more tightly than is required to stop the bleeding. This is to minimize the tissue damage inflicted by the tourniquet. If a tourniquet is used, immediately mark the letter "T" on the victim's forehead with a marker, pen, or dirt; if possible write the date and 24-hour time the tourniquet was applied (example: "8/7 2215"). When transferring the patient to another person's care, be certain that receiving medical personnel know that a tourniquet has been applied. This is imperative to identify the patient for priority medical care which may save limb or life.

Once a tourniquet is done

Never loosen a tourniquet in the field: while the tourniquet maintaints the blood in the rest of the body, the limb is poorly oxygenated (anoxia), so the muscles controlling the blood vessels are relaxed (vasodilatation). If the tourniquet is released, the blood will flow through these wide opened vessels; the blood pressure will drop, causing an hypovolemic shock, or worse making the cardiac pumping inefficient. Additionally, after several minutes, toxins will begin to build up in the dead tissue below the tourniquet (rhabdomyolysis). These toxins can swiftly kill if introduced into the body's bloodstream. Some sources have in the past recommended periodic loosening of a tourniquet (no less often than every eight to ten minutes) in the attempt to prevent this build-up. However, the risks of this procedure include reopening the life-threatening wound as well as accumulated toxins in the blood, and it is best left to battlefield medical providers and medical professionals. In wilderness first aid, it is imperative that any person with a tourniquet be evacuated to advanced medical care as soon as reasonably possible. Immediate MEDEVAC is indicated if the limb is to be salvaged. If the limb is lost, MEDEVAC is indicated if transport will be delayed more than twenty-four hours. In triage, a person with a tourniquet should be considered "I" for immediate in the START protocol and at least "Yellow" or higher in other protocols.

External links

- [http://www.isracast.com/tech_news/090805_tech.htm On the risks of Tourniquet and a new bandage that might soon replace it] - A web article category:first aid

Hospital

from 1682.]] A hospital today is an institution for professional health care provided in part by physicians and nurses.

Terminology

During the Middle Ages the hospital could serve other functions, such as almshouse for the poor, or hostel for pilgrims. The name comes from Latin hospes (host), which is also the root for the words hotel and hospitality. Some patients just come just for diagnosis and/or therapy and then leave (outpatients); while others are "admitted" and stay overnight or for several weeks or months (inpatients). Hospitals are usually distinguished from other types of medical facilities by their ability to admit and care for inpatients. Grammar of the word differs slightly, with American English preferring that someone is "in the hospital", while Commonwealth English (including some Canadian English) prefers that someone is "in hospital". Commonwealth English also maintains that "an hospital" is the correct usage in situations where the noun in question must be prefixed with an article, (though in practice, it would be highly unusual to hear any speaker of British English say "an hospital" rather than "a hospital"), while in American English, "a hospital" is preferred, as the actual pronunciation of the phrase is easier due to the aspirated 'h' with which the word starts.

Types

The best-known type of hospital is the general hospital, which is set up to deal with many kinds of disease and injury, and typically has an emergency ward/A&E department to deal with immediate threats to health and the capacity to dispatch emergency medical services. A general hospital is typically the major health care facility in its region, with large numbers of beds for intensive care and long-term care; and specialized facilities for surgery, plastic surgery, childbirth, bioassay laboratories, and so forth. Larger cities may have many different hospitals of varying sizes and facilities. Very large hospitals are often called Medical Centers and usually conduct operations in virtually every field of modern medicine. Types of specialized hospitals include trauma centers, children's hospitals, seniors' hospitals, and hospitals for dealing with specific medical needs such as psychiatric problems (see psychiatric hospital), pulmonary diseases, and so forth. A hospital may be a single building or a campus. Some hospitals are affiliated with universities for medical research and the training of medical personnel. Within the United States, many hospitals are for-profit, while elsewhere in the world most are non-profit. Many hospitals have hospital volunteer programs where people (usually students and senior citizens) can volunteer and provide various ancillary services. A medical facility smaller than a hospital is called a clinic, and is often run by a government agency for health services or a private partnership of physicians (in nations where private practice is allowed). Clinics generally provide only outpatient services.

History

In ancient cultures religion and medicine were linked. The earliest known institutions aiming to provide cure were Egyptian temples. Greek temples dedicated to the healer-god Asclepius might admit the sick, who would wait for guidance from the god in a dream. The Romans adopted his worship. Under his Roman name Æsculapius, he was provided with a temple (291 BC) on a island in the Tiber in Rome, where similar rites were performed. The first institutions created specifically to care for the sick appeared in India. Brahmantic hospitals were established in Sri Lanka by 431 BC, and King Ashoka founded 18 hospitals in Hindustan c. 230 BC The latter were provided with physicians and nurses, and supported from royal funds. The first teaching hospital, however, where students were authorized to methodically practice on patients under the supervision of physicians as part of their education, was the Academy of Gundishapur in the Persian Empire. Moreover, "to a very large extent, the credit for the whole hospital system must be given to Persia".(A medical history of Persia, C. Elgood, Cambridge Univ. Press, p. 173.) The Romans created valetudinaria for the care of sick slaves, gladiators and soldiers around 100 BC. The adoption of Christianity as the state religion of the empire drove an expansion of the provision of care, but not just for the sick. The First Council of Nicaea in 325 A.D. urged the Church to provide for the poor, sick, widows and strangers. It ordered the construction of a hospital in every cathedral town. Among the earliest were those built by the physician Saint Sampson in Constantinople and by Basil, bishop of Caesarea. The latter was attached to a monastery and provided lodgings for poor and travelers, as well as treating the sick and infirm. There was a separate section for lepers. Medieval hospitals in Europe followed a similar pattern. They were religious communities, with care provided by monks and nuns. (An old French term for hospital is hôtel-Dieu, "hostel of God.") Some were attached to monasteries. Others were independent and had their own endowments, usually of property, which provided income for their support. Some were multi-function. Others were founded specifically as leper hospitals, or as refuges for the poor or for pilgrims. Not all cared for the sick. Meanwhile Muslim hospitals developed a high standard of care between the eighth and twelfth centuries A.D. Hospitals built in Baghdad in the ninth and tenth centuries employed up to twenty-five staff physicians and had separate wards for different conditions. State-supported hospitals also appeared in China during the first millennium A.D. In Europe the medieval concept of Christian care evolved during the sixteenth and seventeenth centuries into a secular one, but it was in the eighteenth century that the modern hospital began to appear, serving only medical needs and staffed with physicians and surgeons. Britain led the field. Guy's Hospital was founded in London in 1724 from a bequest by wealthy merchant Thomas Guy. Other hospitals sprang up in London and other British cities over the century, many paid for by private subscriptions. In the British American colonies the Pennsylvania General Hospital was chartered in Philadelphia in 1751, after £2,000 from private subscription was matched by funds from the Assembly. In Continental Europe the new hospitals were generally built and run from public funds. The Charité was founded in 1710. Whatever the financing, by the mid-nineteenth century most of Europe and the United States had established a variety of public and private hospital systems. In the United States the traditional hospital is a non-profit hospital, usually sponsored by a religious denomination. One of the earliest of these "almshouses" in what would become the United States was started by William Penn in Philadelphia in 1713. These hospitals are tax-exempt due to their charitable purpose, but provide only a minimum of charitable medical care. They are supplemented by large public hospitals in major cities and research hospitals often affiliated with a medical school. In the late twentieth century chains of for-profit hospitals have arisen.

External links

- [http://www.ricwoods.com/ Murals in the John Hunter Children's Hospital Newcastle by Australian artist ric woods create a healing envoirnment]
- [http://www.building-history.pwp.blueyonder.co.uk/Articles/Heritage.htm Jean Manco, The Heritage of Mercy] covers medieval hospitals in Britain.
- [http://www.musee-mccord.qc.ca/en/keys/webtours/VQ_P2_10_EN.html Last Resort: Hospital Care in Canada] — Illustrated Historical Essay Category:Healthcare Category:Buildings and structures ja:病院

Paramedic

right A paramedic, is a highly trained medical professional who responds to medical & trauma emergencies in the pre-hospital setting ("in-field") for the purpose of stabilizing a patient's condition before and during transportation to an appropriate medical facility. Paramedics most often will transport patients to an Emergency Department, but "Treat-and-Release" practice can occasionally occur, state protocols permitting. The paramedic is the most advanced level of training as an Emergency Medical Technician (EMT), and they are designated as an EMT-P. A Paramedic can also be a NREMT-P (Nationally Registered Emergency Medical Technician-Paramedic). In the United States, emergency medical technicians are classified according to their level of training. The National Registry of EMTs is a private, central certifying entity who's main purpose is to maintain a national standard and assist in the ability of paramedics to perform their job functions should they relocate from the state which has certified them. Individual states set their own standards of certification, often based on or identical to, the National Registry. All EMTs must meet the minimum requirements as set forth in the Department of Transportation's standards for EMT curriculum. The National Registry of Emergency Medical Technicians recognizes three levels of EMT: EMT-B (Basic), EMT-I (Intermediate) and EMT-P (Paramedic). In the field, the levels of training are separated into BLS (Basic Life Support), ILS (Intermediate Life Support) and ALS (Advanced Life Support) units. In addition to the basic-level skills CPR, first aid, airway management, oxygen administration, spinal immobilization, traction splinting, bleeding control and splinting, as well as the intermediate skills of IV therapy, endotracheal intubation and initial cardiac drug therapy, the paramedic is also educated in EKG interpretation, advanced respiratory support and airway skills including RSI, pharmacology, trauma resuscitation, pediatric life support and advanced cardiac life support. Some states, and the National Registry, require ongoing continuing education and verification of clinical skills capability to maintain a paramedic certification. While some other states have permanant certification, except for issues involving gross negligence and malpractice. A Paramedic cannot perform advanced life support maneuvers while off-duty. Since all paramedics operate under the command of a medical doctor, any advanced life support techniques performed while not under medical command can be considered practicing medicine without a liscence.

Issues

advanced cardiac life support Paramedics are employed by various public and private emergency services providers. These include private ambulance services (non-911), fire departments & the 9-1-1 system, hospitals, law enforcement agencies, the military, or various EMS-specific, or "third service" public safety agencies. Paramedics may respond to medical incidents in an ambulance, rescue vehicle, helicopter, fixed-wing aircraft, and increasingly in fire suppression apparatus. As nursing shortages become more and more prevalent, paramedics are increasingly used in Emergency Departments and Intensive Care Units of hospitals. Often, paramedics operate with greater lattitude and autonomy than many nurses. In addition, paramedics are often used as chief medical personnel on offshore drilling platforms and on MEDEVACs and airplanes. However, paramedics may be employed in many different medical fields that do not necessarily involve transportation of patients. Such positions may include phlebotomy, blood banks, research labs and educational fields. In the U.S., paramedic salaries can range anywhere from unpaid, volunteer positions to as much as $90,000 a year, depending on location and experience. It should be noted that volunteer paramedics can generally provide the same level of care as those performing the service in a career capacity, depending on the local scope of practice.

History

Prior to the 1970s, ambulances were staffed with advanced first-aid level responders and were frequently referred to as "ambulance drivers." There was little regulation or standardized training for those staffing these early emergency response vehicles. However, after the release of the National Highway Traffic Safety Administration's "White Paper" on motor vehicle fatalities, a concentrated effort was undertaken to improve emergency medical care in the prehospital setting. Pittsburgh, Pennsylvania, Portland, Oregon and Seattle, Washington were early pioneers in prehospital emergency medical training. Pittsburgh's Freedom House paramedics are credited as the first EMT trainees in America. Portland's Leonard Rose, M.D., in cooperation with Buck Ambulance Service, instituted a cardiac training program and began to train other paramedics. In Seattle, the Medic One program at Harborview Medical Center and the University of Washington Medical Center, started by Leonard Cobb, M.D., began training firefighters in CPR in 1970. At the same time, the Los Angeles County Fire Department also began training some of their firefighters in emergency care. This was vividly portrayed in the television show, Emergency! which helped popularize the emergency medical service around the world. The first paramedics began operating in the 1970's with expansion throughout the country since that time. A few years later, emergency medical helicopters or MEDEVACs were put into service in the Denver and [http://www.krmc.org/ A.L.E.R.T.] Kalispell, Montana areas. It is now routine to have paramedic and nurse staffed EMS helicopters in most major metropolitan areas. The vast majority of these aeromedical services are utilized for critical care air transport (inter-hospital) in addition to emergency medical services (pre-hospital). Critical care transports are usually requested when a medical treatment facility (usually a smaller hospital) does not have the personell, equipment, and/or services to properly treat a patient. The patient is then rapidly transported to another medical treatment facility (usually a large hospital or health system located in close proximity to or within highly populated areas) that has the capability to either definitively treat or to extend or enhance treatment to a higher level. These critical care transports can occur by ground ambulance or aircraft. They are usually the reason why a nurse is needed in addition to a paramedic in the transport team. The nurse usually has experience and may be credentialled in critical care medicine. Recently, paramedics have received critical care medical training both in the initial paramedic certification course as well as continuing education courses such as the Critical Care Emergency Medical Transport Program (CCEMTP). The employment of paramedics depends on the organizations that operate the ambulances and other emergency vehicles which they are deployed in. Paramedics responding to a typical emergency may work for the local fire department and arrive in a fire truck or an ambulance bearing the department's insignia, work for a private organization such as a private ambulance and medical transport company, or work for a hospital or health care system.

Training

Paramedic training programs can last as little as 8 months or as long as 4 years. The national average of curriculum time is 2 years. Many universities now offer four-year degrees in emergency medical services, but as a relatively young industry, professional standards and training levels are still evolving. The difference bewteen the 4 year degree and 2 year technical training is minor. The main difference being a more "formal" college education, consisting of traditional classes in English, Math, etc. The 2 year technical training is focused completely on the education relavent to paramedicine. Regardless of educational path, the paramedic student must meet the same State requirements (course hours) to be eligible to take the certification exams as well as the National Registry exams. It is debatable that a 4 year education makes much of a difference, as the skills of a paramedic are heavily based in the experience and aptitude of their instructor(s), the students own natural talent/intelligence, and the amount of clinical experience they are exposed to during their education and training. Paramedics are trained to deal with a broad range of emergency medical situations. These include: obstetrics, cardiac, airway and breathing, a vast array of medical emergencies, orthopedics, psychological and mental health emergencies, pediatrics, trauma, vehicle extrication, communications, intravenous therapy, pharmacology, and advanced cardiac life support. In addition, most locales require paramedics to attend an ongoing schedule of refresher courses in order to maintain their license and/or certification. Specifically, paramedics are trained in airway management, such as intubation, including pharmacologically assisted intubation and increasingly in rapid sequence induction, advanced cardiac life support, including cardiac monitoring, 12-lead electrocardiograms, synchronized cardioversion and transcutaneous pacing; pediatric advanced life support, intravenous cannulation, needle chest decompression, needle cricothyroidotomy, and the administration of a wide range of medications such as morphine sulfate, benzodiazepines such as lorazepam, opioids and dextrose. In addition to certification (both state and National registry), most Paramedics are required to be certified in PALS (Pediatric Advanced Life Support) or PCC (Pediatric Prehospital care), PHTLS (Prehospital Trauma Life Support), and ACLS (Advanced Cardiac Life Support). All require additional education and certification from organizations such as the American Heart Association The National Registry requires continuing education and clinical skill verification for biannual recertification of both EMT-Basic and paramedic-level personnel. Many states offer reciprocity to individuals who obtain licensure through the National Registry by offering, through a nominal fee or examination, a state equivalent emergency provider license without the need to repeat formal training.

The Future

Gone are the days, at least in the urban setting, of untrained ambulance drivers. Those in need of emergency medical care have come to expect highly trained medical professionals within four to six minutes of the onset of their emergency. Rapid treatment and transport to a qualified medical facility follow the care given by paramedics in the field. Paramedics may arrive by fire truck or ambulance and may be involved in initial care and/or transportation, depending on local response strategies and funding levels. In some areas, fire departments and law enforcement agencies provide a "first response" capability, that includes use of automatic external defibrillators, or AED's. In the future, we will see fire agencies provide increasing levels of emergency medical services. Granted, even now, due to the success of fire prevention activities, 80% of the services provided by most fire departments were medical responses. Nontraditional agencies such as the Highway Patrol may also increase their involvement in providing paramedic-level emergency medical services.

References

- Meisel, Zachary (Nov. 8, 2005). [http://www.slate.com/id/2129684/ "Ding-a-Ling-a-Ling"]. Slate.

External links

- [http://www.talkems.com TalkEMS.com - The premier community forum to discuss topics related to Emergency Medical Services]
- [http://www.paramedic.ca/nocp National Occupation Competency Profile] for Paramedics
- [http://www.paramedic.ca Paramedic_Association_of_Canada]
- [http://www.healthservices.gov.bc.ca/bcas British Columbia Ambulance Service]
- [http://www.torontoparamedicassociation.com Toronto Paramedics Association]
- [http://www.city.toronto.on.ca/ems/ Toronto_EMS]
- [http://www.emslive.com] Category:Healthcare practitioners and technical occupations Category:Healthcare occupations Category:Emergency services Category:prehospital care

Catheter

In medicine, a catheter is a tube that a health professional may insert into part of the body. The process of inserting a catheter is catheterization. In most uses it is a thin, flexible tube: a "soft" catheter; in some, it is a larger, solid tube: a "hard" catheter. It was first invented by Benjamin Franklin. Placement of a catheter into a particular part of the body may allow:
- draining urine from the urinary bladder as in urinary catheterization, i.e. Foley catheter or even when the urethra is damaged as in suprapubic catheterization. By comparison, a Texas catheter is not inserted into the urethra, but connects to the penis via a condom-like envelope with a drainage tube at its tip.
- drainage of fluid collections, e.g. an abdominal abscess
- administration of intravenous fluids, medication or parenteral nutrition
- angioplasty
- direct measurement of blood pressure in a artery or vein A central venous catheter is a conduit for giving drugs or fluids into a large-bore catheter positioned either in a vein near the heart or just inside the atrium. A Swan-Ganz catheter is a special type of catheter placed into the pulmonary artery for measuring pressures in the heart.

Arm

In anatomy, the arm is the upper limb of a bipedal mammal, specifically the segment between the shoulder and the elbow. Arm can also refer to any analogous structure, such as one of the paired forelimbs of a quadruped, or any muscular hydrostat similar to a tentacle, as seen on some cephalopods, such as octopuses. The term arm also refers to the entire upper limb in an organism. Anatomically, the segment between the elbow and wrist is properly called the forearm. In primates the arms are richly adapted for both climbing and for more skilled, manipulative tasks. The ball and socket shoulder joint allows for movement of the arms in a wide circular plane, while the presence of two forearm bones which can rotate around each other allows for additional range of motion at this level.

Anatomy of the human arm

The human arm contains bones, joints, muscles, nerves and blood vessels. Many of these muscles are used for everyday tasks. There are clinical uses for the arm, including venepuncture and peripheral venous cannulation in the cubital fossa.

Bony structure and joints

cubital fossa The humerus is the (upper) arm bone. It articulates with the scapula above at the glenohumeral joint (shoulder) and with the ulna and radius below as the elbow joint.

Shoulder joint

The shoulder is the ball-and-socket joint between the proximal end of the humerus and the clavicle and scapula.

Elbow joint

The elbow joint is the hinge joint between the distal end of the humerus and the proximal ends of the radius and ulna.

Osteofascial compartments

The arm is divided by a fascial layer (known as lateral and medical intermuscular septa) separating the muscles into an anterior and posterior osteofascial compartments. The fascia merges with the periosteum (outer bone layer) of the humerus. The compartments contains muscles which are innervated by the same nerve and perform the same action. The anterior compartment is known as the "flexor compartment" as flexion is its main action. The muscles contained therein are:
- Biceps brachii
- Brachialis
- Coracobrachialis They are all supplied by the musculocutaneous nerve, which has nervous origins of C5,C6,C7 (see brachial plexus).
- the deltoid muscle is considered to have part of its body in the anterior compartment. This huge muscle is the main adductor of the upper limb and extends over the shoulder.
- the brachioradialis muscle originates in the arm but inserts into the forearm. This muscle is responsible for supination. The posterior compartment contains muscles which are all supplied by the radial nerve. This compartment is also known as the "extensor compartment", extension being its main action. Muscles of this compartment are:
- Triceps brachii, a huge muscle which contains three heads, the lateral, medial and middle.
- Anconeus, a tiny muscle which some embryologists suggest may be the fourth head of the triceps brachii muscle. This muscle stabilizes the elbow joint during movements. As the upper and lower limbs have similar embryological origins and the lower limb contains the quadriceps femoris muscle (the lower limb equivalent of the triceps), which has four heads, this would seem to make sense.

Cubital fossa

This important area is clinically important for venepuncture and for blood pressure measurement. It is an imaginary triangle with borders being:
- Laterally, the medial border of brachioradialis muscle.
- Medially, the lateral border of pronator teres muscle.
- Superiorly, the intercondylar line, an imaginary line between the two condyles of the humerus
- The floor is the brachialis muscle
- The roof is the skin and fascia of the arm and forearm The structures which pass through the cubital fossa are vital. The order from which they pass into the forearm are as follows, from medial to lateral:
- Median nerve, which starts to branch
- Brachial artery
- Tendon of the biceps brachii muscle
- Radial nerve
- Median cubital vein - this important vein is where venepuncture occurs. It connects the basilic and cephalic veins.
- lymph nodes

Nervous supply

The musculocutaneous nerve, root value C5,C6,C7 is the main supplier of muscles of the anterior compartment. It originates from the lateral cord of the brachial plexus of nerves. It pierces the coracobrachialis muscle and gives off branches to the muscle, as well as to brachialis and biceps brachii. It terminates as the anterior cutaneous nerve of the forearm. The radial nerve, root value C5-T1, originates as the continuation of the posterior cord of the brachial plexus. This nerve enters the lower triangular space (an imaginary space bounded by, amongst others, the shaft of the humerus and the triceps muscle) of the arm and lies deep to the triceps muscle. Here it travels with the profunda brachii artery (deep artery of the arm), lying on the radial groove of the humerus. This fact is very important clinically, as a fracture of the bone at the shaft of the bone here can cause lesions or even transections in the nerve. Other nerves passing through give no supply to the arm. These include:
- The median nerve, nerve origin C5-T1, which is a branch of the lateral and medial cords of the brachial plexus. This nerve continues in the arm, travelling in a plane between the biceps and triceps muscles. At the cubital fossa, this nerve is deep to the pronator teres muscle and is the most medial structure in the fossa. The nerve passes into the forearm.
- The ulnar nerve, origin C8-T1, is a continuation of the medial cord of the brachial plexus. This nerve passes in the same plane as the median nerve, between the biceps and triceps muscles. At the elbow, this nerve travels posterior to the medial epicondyle of the humerus. This means that condylar fractures can cause lesion to this nerve.
Blood supply and venous drainage
The main artery in the arm is the brachial artery. This artery is a continuation of the axillary artery. The point at which the axillary becomes the brachial is distal to the lower border of teres major. The brachial artery gives off an important brach, the profunda brachii (deep artery of the arm). This branching occurs just below the lower border of teres major. The brachial artery continues to the cubital fossa in the anterior compartment of the arm. It travels in a plane between the biceps and triceps muscles, the same as the median nerve and basilic vein. It is accompanied by venae comitantes (accompanying veins). It gives branches to the muscles of the anterior compartment. The artery is in between the median nerve and the tendon of the biceps muscle in the cubital fossa. It then continues into the forearm. The profunda brachii travels through the lower triangular space with the radial nerve. From here onwards it has an intimate relationship with the radial nerve. They are both found deep to the triceps muscle and are located on the spiral groove of the humerus. Therefore fracture of the bone may not only lead to lesion of the radial nerve, but also haematoma of the internal structures of the arm. The artery then continues on to anastamose with the recurrent radial branch of the brachial artery, providing a diffuse blood supply for the elbow joint. The veins of the arm carry blood from the extremities of the limb, as well as drain the arm itself. The two main veins are the basilic and the cephalic veins. There is a connecting vein between the two, the median cubital vein, which passes through the cubital fossa and is clinically important for venepuncture (withdrawing blood). The basilic travels on the medial side of the arm and terminates at the level of the 7th rib. The cephalic travels on the lateral side of the arm and terminates as the axillary vein. It passes through the deltopectoral traingle, a space between the deltoid and the pectoralis major muscles.
See also

- Terms for anatomical location Category:Upper limb anatomy ko:팔 ja:腕 simple:Arm

Hand

The hand (med./lat.: manus) is the portion of the arm or anterior limb of a human or other primate, where the appendage terminates. This part of the limb is especially used in grasping and holding. Each hand is a mirror image of the other.

What constitutes a hand?

Although many mammals and other animals have grasping appendages similar in form to a hand, these are scientifically not considered to be so, and have other varying names, including paws. Using the term hand is merely a scientific usage of anthropomorphization, to distinguish the terminations of the front paws from the hind ones. The only true hands appear in the mammalian order of primates. Hands must also feature opposable thumbs, as described later in the text.

Human anatomy of the hand

The human hand consists of a broad palm (metacarpus) with five digits, attached to the forearm by a joint called the wrist (carpus).

Digits

The Five Fingers

Five fingers on the hand are located at the outermost edge of the palm. These four digits can be folded over the palm, this allows for the holding of objects, and furthermore the grasping of small objects. Each finger, starting with the one closest to the thumb, has a colloquial name to distinguish it from the others:
- thumb
- index finger, pointer finger, or forefinger
- middle finger
- ring finger
- little finger or 'pinky'

The thumb

The thumb (connected to the trapezium) is located on one of the sides, parallel to the arm. The thumb can be easily rotated 90º, on a perpendicular level compared to the palm, unlike the fingers which can only be rotated approximately 45º. A reliable way of identifying true hands is from the presence of opposable thumbs. Opposable thumbs are identified by the ability to be brought opposite to the fingers. opposable thumb]]

Bones

The human hand has at least 27 bones: the carpus or wrist account for 8; the metacarpus or palm contains 5; the remaining 14 are digital bones.

Bones of the wrist

The wrist has eight bones, arranged in two rows of four. These bones fit into a shallow socket formed by the bones of the forearm.

Bones of the palm

The palm has 5 bones, one to each of the 5 digits.

Digital bones

Also called phalanx bones. Human hands contain 14 of them; 2 in the thumb, and 3 in each of the four fingers, called;
- distal phalanx, carrying the nail,
- middle phalanx and
- proximal phalanx. (The thumb has no middle phalanx).

Sesamoid bones

Sesamoid bones are small ossified nodes embedded in the tendons to provide extra leverage and reduce pressure on the underlying tissue. Many exist around the palm at the bases of the digits, but the exact number varies between different people. The patella is the largest example of a sesamoid bone in the human body.

Muscles and tendons

The movements of the human hand are accomplished by two sets of each of these tissues. They can be subdivided into two groups: the extrinsic and intrinsic muscle groups. The extrinsic muscle groups are the long flexors and extensors. They are called extrinsic because the muscle belly is located on the forearm.

Intrinsic hand muscles

The Intrinsic muscle groups are the thenar and hypothenar muscles (thenar referring to the thumb, hypothenar to the small finger), the interosseus muscles (between the metacarpal bones, four dorsally and three volarly) and the lumbrical muscles. These muscles arise from the deep flexor (and are special because they have no bony origin) and insert on the dorsal extensor hood mechanism.

The extrinsic muscles of the hand

The flexors

The fingers have two long flexors, located on the underside of the forearm. They insert by tendons to the phalanges of the fingers. The deep flexor attaches to the distal phalanx, and the superficial flexor attaches to the middle phalanx. The flexors allow for the actual bending of the fingers. The thumb has one long flexor and a short flexor in the thenar muscle group. The human thumb also has other muscles in the thenar group (opponens- and abductor muscle), moving the thumb in opposition, making grasping possible.

The extensors

Located on the back of the forearm and a connected in a more complex way then the flexors to the dorsum of the fingers. The tendons unite with the interosseous and lumbrical muscles to form the extensorhood mechanism. The primary function of the extensors is to straighten out the digits. The thumb has two extensors in the forearm; the tendons of these form the anatomical snuff box. Also, the index finger and the little finger have an extra extensor, used for instance for pointing.

Variation

Some people have more than the usual number of fingers or toes, this is normally caused by a genetic condition called Polydactyly.

Articulation

Polydactyly Also of note is that the articulation of the human hand is more complex and delicate than that of comparable organs in any other animals. Without this extra articulation, we would not be able to operate a wide variety of tools and devices. The hand can also form a fist, for example in combat, or as a gesture. See also: Common uses of the word hand in the English language, hand (clock), hand (unit), hand (mechanisms), hand (language).

Common uses in the English language

I know it like the back of my hand - English phrase used to say that the subject knows the matter perfectly, as if it were part of their body, or that they were born with the knowledge. Related: Second hand. Second hand - Similar to "I know it like the back of my hand," in that it is definitely known by the subject. Similar to something being described as second nature. Not to be confused with second-hand goods, which have already been used before, and are being resold. In the U.S., at least, second hand means indirect--almost the opposite. "She told me walking everyday is good for the brain" indicates second hand knowledge. A person may also describe somebody as his right hand man, which means that he relies heavily on this person, deriving from the importance and superiority place on the right over the left by many civilizations. Exemplified by phrases such as 'he is my right hand' and 'to be seated at the right hand of the gods when Judgment comes'. The hand is also an archaic unit of measurement.

Phalanx Bones

measurement The name Phalanges is commonly given to the bones that form fingers and toes. In primates such as humans and monkeys, the thumb and big toe have two phalanges, while the other fingers and toes consist of three. The phalanges do not really have individual names but are named after the digit, and their distance from the body. Distal phalanges are at the tips of the fingers and toes, the proximal phalanges are closest to the hand (or foot) and articulate with the metacarpals or metatarsals. Middle phalanges are between the distal and proximal. The thumb and big toe do not have middle phalanges. The phalanges of the foot correspond with those of the hand. They differ from them in their size (the bodies being much reduced in length) and being laterally compressed. First Row, The body of each is compressed from side to side, convex above, concave below. The base is concave; and the head presents a trochlear surface for articulation with the second phalanx. Second Row, The phalanges of the second row are remarkably small and short, but rather broader t