Lying Essay Example | Topics and Well Written Essays - 500 words

Lying - Essay Example However, sometimes in life, one is faced with situations that require some amount of lying, or rather twisting the truth. For instance, parents do relate white lies to children, by saying that a demon would come and kidnap the baby, if he or she does not eat. A teacher might threaten a student, to prevent him or her from getting attuned to what is not morally right. One is, sometimes, forced to lie due to the turn around of circumstances. At such a juncture, one might be troubled by the question, as to whether it is right to lie or not. When is it alright, to lie and when is it not This question is one that is ethically quite perception-oriented. What might seem right to some might not to the rest. In the Indian epic of Mahabharatha, Lord Krishna says that it is alright to lie, if it translates into being committed for the welfare of the others. This, is considered ethically appropriate. If lying does not bring about harm and is more so, good for the majority, it is alright to lie. According to Buddhist scriptures, there ar

Concert report Essay Example | Topics and Well Written Essays - 500 words - 3

Concert report - Essay Example Seven pieces were played in the concert, of which Salve Venere, Salve Marte, and Sonata were played before the intermission whereas Apres un Reve, Improvisation XIII in A Minor, Nuit dà ©toiles, Eccentric Dances, and Pearls III were performed after the intermission. Since it was a concert centered around tuba, the program’s overview was performed in a low tune. In this concert, I happened to experience some very good Baroque style of music. Bruce Broughton’s Sonata was the best piece among all in the concert. I particularly liked it more because that piece combined tuba with piano. In that piece, I could figure out a variety of element that we were taught before in the class. Kathy started the piece by playing piano in a low volume that gradually rose as she started playing the key harder. Piano was followed by tuba that although was played in a low moderato tempo, yet its deep and grave timbre blanketed the sound of piano. The example that Kate and Kathy set during the piece’s coda was second to none which was why, the piece had had such a lasting effect on me, and I am sure, on most of the audiences too. I found Salve Venere, Salve Marte by John Stevens relatively boring and mismatched with the energy level of the rest of the pieces. I would not regret if that piece was not included into the concert. The reason I didn’t like it was because it was a tuba solo with a moderato tempo and that too, continued for full 8 minutes. Particularly, the deep timber of tuba made a not-so-pleasing sound. Perhaps, it would have played the effect of a break had it been shorter in time-span. The high pitch of the piece by Bruce Broughton was quite overwhelming and sent pleasant goose-bumps down my spine as I listened to that wonderful music. I could feel the rise in the energy level of the audience as they listened to the music. John

Milgram Obediance Study Essay Example for Free

Milgram Obediance Study Essay In May of 1962 Stanley Milgram, a Social Psychologist at Yale University, conducted a study on â€Å"Obedience and Human Nature† that was influenced by his curiosity of the WWII German Nazi Holocaust and concentration camps. Milgram asked â€Å"How could it be, that ordinary German people could allow the extermination of the Jews† and wanted to know under what circumstances would a person disobey authority? The study took place in the greater New Haven area and consisted of 40 male participants that were recruited after responding to a newspaper ad. Each participant was compensated for their participation, and were given $4.50. It was thought by many professors that only 3 out of 100 participants might deliver the maximum shock. After the recruitment, Milgram conducted a series of controversial experiments with his invention of a shock generator. The switches were labeled and ranged from slight shock, stong shock, very strong shock, moderate shock, intense shock, extream intense shock, to Danger Severe Shock and the last two only stating â€Å"XXX†. The voltage began at 30, increasing by 15 volt increments for each switch, all the way up to 450 volts. The purpose of Milgrams experiment was to try and answer,â€Å"How far would you be willing to go?† Prior to the experiment the professor explained the procedure to each participant. The â€Å"Student† was hooked up to the shock machine with leads that were connected by a paste that was supposed to protect the skin from being damaged or burned. The proctor explained that the shocks would be painful, but would not cause harm to the subject. The role of the â€Å"Teacher† was to ask the â€Å"Student† a series of questions. With each wrong answer the â€Å"Teacher† was to deliver a shock to the â€Å"Student†. However, what Milgram did not reviel was that the study was in fact, rigged. The â€Å"Student† had been given a script, and was instructed to pretend to be shocked. During the experiment, with each stagged wrong answer, the â€Å"Student† complained about the pain. As the intensity increased, the â€Å"Student† began to complain about having heart problems. Begging for the â€Å"Teacher† to stop. Pleading and demanding to be let out of the room over and over again. All the while the â€Å"Teacher† was prompted by the proctor to continue. Throughout the exam, most of the â€Å"Teachers† began to doubt if they should continue. Asking the proctor â€Å"how far should I go†, or â€Å"what will happen if I continue†. Each time, the proctor would encourage the teacher to â€Å"please continue† telling them â€Å"you have no choice but to continue, the experiment depends on you†. With each shock the â€Å"Teacher† became increasingly agitated. Demonstrating mental anguish, and struggled with the their emotions of inflicting pain with the next shock. Eventually after hitting the 300 volt mark the â€Å"Student† got to the point that he stopped responding to the questions. By this point the â€Å"Teachers† were angry and refused to continue. The proctor advised the â€Å"Teacher† to treat the silence as a wrong answer and instructed to proceed with the experiment and to administer another shock. This caused increased severe mental anguish and suffering on the â€Å"Teachersâ€Å" behalf. Some would refuse again to continue, stating that they â€Å"wouldnt go on if I thought I were harming them†. One even shouted, â€Å"Im not going to be responsible, Im not going to kill the man.† The proctor simply responded, â€Å"you have too, you have no other choice but to continue.† Many of the phrases used to prompt the â€Å"Teacher† to continue included, â€Å"The experiments require you to continue†, and â€Å"Its absolutely essential that you continue.† The results of the Milgram experiment tested his theories of why people were willing to go against their conscious and demonstrated just how far people were willing to go to stay in compliance with an authoritative figure. In 1974 Milgram published his book ,â€Å"Obedience to Authority† which raised controversial, ethical, and moral issues of his experimentation on Obedience. Many believed that it was cruel and several professors stated it was â€Å"in humane† and questioned his use of human subjects, due to the cruel nature that caused mental anguish, unnecessary stress, grief, and turmoil on the so called â€Å"Teacher†. After the experiment, Milgram purposed the question, â€Å"Why did so many agree to and perform the shock treatment, if they felt it was wrong?† I believe that there are many factors that influenced the participants to continue to deliver the shock treatment, some of which include the following; 1. Human nature to be pleasing. I believe that Authority is seen to be powerful and insurmountable and having the authoritative figure presence, tromping them to continue even when they wanted to stop had a huge influence on the participants and affected the â€Å"teachers† decision to continue even though they wanted to stop. 2. Fear of non-compliance. I believe the participant felt an obligation to continue because of the agreement they made with the University to participate. I think that some may of thought their might be consequences if they disobeyed the proctor. 3. Curiosity and sadistic behaviors. I think that some participants wanted to see just how tolerant the â€Å"Student† could be. 4. The experiment was held at the highly esteemed Yale University. I believe this peeked the interest of the participants and many wanted to be a part of a highly accredited institutional study group. 5. Many believed it was safe. They were told that it was not dangerous, it was painful but would not harm the participant receiving the shocks and this allowed the participants to continue administering the shocks because they trusted what they were told. 6. Ability to redirect responsibility onto the Authoritative figure, in order to relieve the guilt they may feel- stating â€Å"I was only following orders.† I found the results of the Milgram Obedience study astounding. Of the 40 participants, 26 delivered the maximum shock and 14 participants stopped at various levels throughout the experiment, siting they â€Å"just couldnt go on.† While watching the video, I found myself feeling anxious, and thought about how I would of reacted. The Milgram experiment demonstrates exactly how people actually react when placed in certain circumstances, rather than a hypothetical situation, stating how they feel they would react. I believe this study revels how some humans can detach themselves emotionally in order to remain obedient. So after thinking about the statistics of the experiment I shouldnt have been so surprised that 65% delivered the maximum shock. I would of never believe so many of them would have gone thru with the experiment and felt that the number would have been much lower. There are many examples throughout history of how dangerous it can be to take obedience to the extrema. One example is during WWII. The Germans treatment of the Jews was horrific and unimaginable. It was estimated that during the Holocaust, the Nazis used the concentration camps to murder approximately 11 million people. So you ask, yourself, how could such a horrific event take place?, How could people be so EVIL? These conditions were real and the answer to these questions are highly debated throughout the world by Psychologist, Analysis, Universities and amongst people sitting at dinner tables everywhere. It lies deep within the dark places of evil minds. It unleashes its wrath and destroys. In conclusion, I believe we are taught to be obedient from birth. As parents we teach our children to obey us, so that they learn consequences and grow into respectable, responsible adults. God expects us to obey his commandments. Police officers expect us to obey traffic laws. Employers expect us to obey rules and regulations, and office policies On a daily basis we are told to follow instructions, directions, commands and orders. Obedience involves power and status and is influenced by social pressure and conformity. As a society we are conditioned and expected to be obedient.

Difficult Intubation And Post Tonsillectomy Bleeding

Difficult Intubation And Post Tonsillectomy Bleeding A six year old boy with Downs syndrome is on his way to the childrens hospital by ambulance with post-tonsillectomy bleeding. He underwent adeno-tonsillectomy because of recurrent tonsillitis and enlarged adenoids under general anesthesia the day before, some 22 hours ago. Despite being overweight at 37 kilograms and enlarged adenoids he did not suffer from sleep apnea. Prior to his original surgery, the child was uncooperative necessitating an inhalation induction with some struggling. Venous access was difficult even post induction requiring several attempts, and finally being achieved in the left saphenous vein at the ankle. Because of possible atlanto-occipital instability associated with Downs syndrome, laryngoscopy was performed with C-spine precautions. Direct laryngoscopy presented a Grade 3 view due to an enlarged tongue. Bag-mask-ventilation with an oro-pharyngeal airway was easy throughout the preintubation phase. Indirect laryngoscopy using the GlideScopeÂÂ ® revealed a Grade 1 view followed by the placement of a styletted, uncuffed 5 mm ID oral RAE tube. Adeno-tonsillectomy was performed i n the usual fashion and the child was discharged home after an uneventful 20 hour overnight observation period. Apparently, while momentarily unattended at home, the boy ate a hard tea biscuit. The child immediately experienced a sharp pain and an intra oral bleeding started. The emergency physician on duty is confronted with an overweight boy, sitting on a stretcher and spitting blood frequently into a kidney basin. The child is in moderate distress with the following vital signs (HR 152, BP 97/57). The child will not tolerate nasal prong oxygen and the pulse oximeter reading is 94% on room air. Auscultation of the chest is clear. Examination of the mouth reveals brisk bleeding in the right tonsillar bed. An attempt to start an intravenous line in the right saphenous vein is not successful, but blood is obtained for a CBC, coagulation parameters and a cross match for blood. The child is then transferred to the operating room. 45.2 INTRODUCTION: 45.2.1 What is the incidence, Morbidity and Mortality of pediatric post-tonsillectomy bleeding? Tonsillectomy is one of the most frequently performed surgical procedures in children. Rates in children aged 0-14 vary considerably within and between countries. In 1998, they varied from 19 per 10,000 children in Canada to 118 per 10,000 in Northern Ireland, so a very common procedure in both countries (1). The most common post-tonsillectomy complications include postoperative nausea and vomiting and pain. Dehydration may occur in children due to delayed and poor oral intake, nausea and fever. Delayed post-operative bleeding is the most significant complication and though uncommon, is not rare (2). Many estimates of the incidence of post-tonsillectomy bleeding exist in the literature varying widely from 0 to 11.5 percent (3). Typically, however, the rate ranges between 2.9 and 3.4% (4). Mortality rates are rarely reported in the literature. Two large studies reported 0 out of 15,996, and 1 out of 16,381 tonsillectomies in 1979 and 1970 (5). On the other hand, there are many published case reports. Sixty-seven percent of post-adeno-tonsillectomy bleeding originates in the tonsillar fossa and 27% in the nasopharynx. There are two major time frames for post operative bleeding. Most often, the bleeding occurs within the first 24 hours after surgery (primary bleeding) (5). Primary bleeding is generally related to surgical technique, and incidence is declining. Twenty five percent of all post tonsillectomy hemorrhage occurs after 24 hours. This secondary bleeding is not related to surgical technique, is rare and of unchanged prevalence over the years (5). It is mainly observed between the 5th and 10th postoperative day, although it may occur at any time (6). Infection of the tonsillar bed with clot sloughing is believed to be the major cause of secondary bleeding. It tends to occur more commonly in older pediatric patients, because the indication for tonsillectomy in this age group is usually related to recurrent infections rather than airway obstruction, the most common indication in the younger pediatric age group.(5). Since tonsillectomy is usually performed to improve the quality of life in otherwise healthy, young children, any death is unacceptable. 45.3 PATIENT EVALUATION: 45.3.1 What are the initial clinical steps one should take in the patient with post-tonsillectomy bleeding? The diagnosis of post-tonsillectomy bleeding is usually made by a quick history. Parents or patients will mention right away the previous surgery. Differential diagnosis is blunt or sharp trauma to the oropharynx. Rare cases are bleeding tumors of the oropharynx, like hemangioma. The child will present with fresh blood in the mouth and frequent swallowing of blood. Nausea with or without emesis of fresh blood is common. Newer and more potent antiemetic medications may mask or suppress vomiting. Therefore, the amount of blood swallowed may be underestimated. It is not uncommon for children to have been bleeding silently for a prolonged period of time with extensive blood loss. The child is often restless, diaphoretic and pale. The vital signs may show an increased heart rate, because of pain and hypovolemia. In awake children, hypotension following blood loss is a very late sign and then indicates significant hypovolemia. Intravenous access must be established as soon as possible followed by initial volume resuscitation with crystalloid or colloid solutions or. A blood sample for baseline hematocrit or hemoglobin is necessary as well as for blood type and cross match. An intra oral examination will show blood and blood clots. A bleeding source may be seen in the tonsillar bed. Bleeding from the tonsillar bed may initially be controlled using pharyngeal packs and cautery. But children with post tonsillectomy bleeding should be taken back to the operating room for exploration and surgical hemostasis. Repeated attempts to stop bleeding on the ward or in the emergency department should be avoided, except if exsanguination is imminent. A questionnaire of children undergoing tonsillectomy with or without postoperative bleeding showed an increased incidence of post-traumatic stress disorder if the children with bleeding were treated on the ward compared to children without bleeding or if the bleeding was treated in the operating room (7). 45.4 AIRWAY MANAGEMENT 45.4.1 How is the airway usually managed in post-tonsillectomy bleeding? Large volumes of blood may be swallowed, and blood or blood clots are often present in the oral cavity of these children. Despite the fact that the aspiration of blood is not similar in severity to aspiration of gastric acid, it remains an undesirable occurrence. In addition to hypovolemia, patients with post tonsillectomy bleeding present two major problems: Aspiration: These patients must be considered to have a full stomach and are at an increased risk of aspiration. Difficult airway: Blood and blood clots may impair visualization to the vocal cords. In addition swelling of the oropharynx may have occurred because of surgery or infection. This may lead to a changed laryngeal anatomy. Because of the risk of aspiration, a mask induction maintaining spontaneous breathing is not desirable and a rapid sequence induction should be considered. The efficacy and use of cricoid pressure, especially in children is currently controversial. It is noteworthy that cricoid pressure can distort the laryngeal anatomy and worsen the view of the larynx. In addition, it can induce vomiting in the partially anesthetized patient. The blood and blood clots in the oropharynx can impair vision during laryngoscopy or cause plugging of the endotracheal tube. A working suction apparatus is lifesaving and must be prepared in duplicate. One should be a large bore, rigid surgical suction and the other mounted with a flexible endotracheal suction catheter. If one becomes blocked with a blood clot, another is readily available. If large amounts of clot are present, it may be necessary during the initial laryngoscopy to manually remove them with a finger or gauze. A Magill forceps should be available to grab clots deeper in the pharynx, recognizing that these clots may be too fragile to be grasped and removed from the oral cavity using the Forceps. A past history of difficult laryngoscopy is helpful, although this never precludes preparations for a difficult and failed airway. Different sized curved and straight blades as well as a flex tip blade (McCoy laryngoscope) should be readily available. Different sized cuffed endotracheal tubes, with one size up and down of the calculated size must be prepared. They should be preloaded with a well lubricated intubating stylet, as is standard for a rapid sequence induction. A tracheal introducer (Bougie) may be helpful in the presence of a grade 3 view. If the epiglottis is visible, but no laryngeal entrance can be appreciated, a stroke of chest compression may help find the glottic opening by creating air bubbles. The pediatric lightwand represents an elegant technique for intubation in the case of a glottic view obscured by secretions or blood. The extremely bright light can shine easily through blood and blood clots. However experience is necessary when using this device. Indirect laryngoscopy using the video-laryngoscope (GlideScopeÂÂ ® or the AirtraqÂÂ ®) can be difficult. Blood and secretions may block the optical lenses and impair the view to the vocal cords. The lens in the AirtraqÂÂ ® with its position between the lightsource on one side and the guide channel for the endotracheal tube on the other side might be more protected than the lens of the GlideScopeÂÂ ®. Case reports or studies, however, have not been published in this regard. The laryngeal mask plays an accepted role as an alternative airway device in managing the difficult pediatric airway (see Chapter 42). It is used frequently in primary adeno-tonsillectomies. It can be placed quickly and can be used as a conduit for a flexible bronchoscope to guide intubation if required. On the positive side, a laryngeal mask may briefly tamponade the bleeding site, and therefore protect the airway and the optical lens of the bronchoscope. Though, on the other hand, it may not provide sufficient airway protection in situations with increased risk of aspiration like post tonsillectomy bleeding. A case report recently described the successful use of a laryngeal mask for a failed intubation in a post tonsillectomy bleed (8). The use of a flexible bronchoscope alone is not recommended in cases of oropharyngeal bleeding. Experts recommend that the practitioner should rely on the alternative techniques with which they have the most experience and skill. Preparation for the unexpected is essential. An experienced otolaryngologist or other qualified rigid laryngoscopist/bronchoscopist should be in the OR for all of these cases. If direct laryngoscopy fails, a rigid device wielded by the otolaryngologist may just be successful. An appropriately sized, lubricated and tested rigid laryngoscope/bronchoscope connected to a light source and suction must be readily available at the head of the child. Preparation for a surgical airway is also essential (e.g. tracheotomy tray opened and ready). To reduce the risk of postoperative nausea and vomiting the stomach content of the child should be suctioned using an orogastric tube at the end of the procedure, recognizing that this does not guarantee an empty stomach as much of the blood may be clotted. 45.4.2 What are the airway management options for this patient? This patient presents several issues regarding anesthesia induction and airway management: high risk of aspiration difficult intravenous access suspected atlanto-occipital instability known difficult direct laryngoscopy with easy facemask ventilation expected difficult view of the larynx due to blood and secretions Several options for the anesthetic and airway management of this child need to be weighed and considered in light of their risks and benefits: Intravenous induction versus inhalation induction without IV access: This child is undergoing a second surgical procedure within 24 hours. Due to the frightening emergency situation, pain, bleeding and his mental impairment he is distressed and uncooperative. While a smooth inhalation induction with a facemask was preferred for his first surgery, a stomach potentially full of blood mitigates against this approach and for a rapid sequence induction to minimize the duration of an unprotected airway. One might even hope for a rapid venous access following a mask induction to permit medication administration but we know in this case that is not likely. Anesthesia induction with cervical spine precautions versus no C-spine precautions: Downs syndrome is associated with atlanto-occipital instability in up to 20% of cases. It can occur in children as young as 4 years of age. The large head of the Downs child coupled with this atlanto-occipital instability places them at increased risk for cervical spine injury during anesthetic induction. Radiographic findings of cervical spinal instability in Downs syndrome remain controversial. Lateral radiographs of the neck in flexion and extension do not reliably detect atlanto-occipital instability. Due to impaired cognition and anxiety, positioning of the patient can be difficult. Old lateral neck radiographs are not available for this child. Due to the emergency situation, a current neck radiograph is not possible. Therefore cervical spine precautions should be performed. Extreme neck extension should be avoided in this child. Awake tracheotomy versus anesthesia induction with attempted laryngoscopy: The fact that this child has a known difficult direct laryngoscopy together with a documented Grade 3 view favors an awake tracheotomy under local anesthesia. This approach would maintain a protected airway at all times. Awake tracheotomy in adults and children are challenging. Optimal surgical positioning with neck extension is crucial for successful procedure. It is not expected, that this child will tolerate this procedure. This fact, together with the required c-spine precautions would exclude an awake tracheotomy as an option for this child. The plan is to perform an intravenous rapid sequence induction employing indirect laryngoscopy to place an endotracheal tube. Preparations for rigid laryngoscopy are in place and the surgeon is prepared to embark immediately with a surgical airway (in this case a triple set up). 45.4.3 How should you prepare for this case? Following the failed attempt to start an intravenous line in the emergency department, the child was brought to the operating room. As previously outlined, venous access is crucial for induction and fluid resuscitation. Placement of a central line in the awake child is a possible option. For internal jugular vein access, the head may need to be rotated with increased risk associated with the presumed atlanto-occipital instability. The subclavian approach has the risk of a pneumothorax. An ultrasound guided femoral vein approach is an alternative. On the other hand, several studies have shown that an intraosseos cannula can be placed within 60 seconds and that this line provides an excellent access for the administration of medications and fluids. Because of the risks associated with central line placement, the child was prepared for an intraosseous cannula. The right leg was prepped with antiseptic solution, and local anesthetic injected at the tibial plateau. An intraosseous canula was placed without incident. A normal saline solution flowed freely permitting the administration of 20ml.kg-1 bodyweight. Atropine 0.1 mg IV was administered to reduce additional secretions and mitigate vagal responses secondary to laryngoscopy. The usual monitors were applied (pulse oximetry, noninvasive blood pressure and EKG). The surgeon was prepared as was his equipment; the rescue airway cart was in the room. 45.4.4 Management of this child Concurrent with the placement of the intraosseous canula, the child was prepared for a rapid sequence induction. The child was denotrogenated with 100% FiO2 for 3 minutes employing a facemask that was reasonably tolerated with much cajoling. Considering the possibility of significant hypovolemia a 50/50 mix of Ketamine and Propofol (ketofol) was selected for induction and Succinylcholine for neuromuscular blockade. Cricoid pressure during induction was not applied to avoid stimulating vomiting in the already agitated child. It was applied after the child was deeply anesthetized. As soon as the child was deeply asleep and paralyzed, the mouth was suctioned easily and several clots were removed with the Magill Forceps. Again the brisk bleeding from the right tonsillar bed was noted. Since the previous direct laryngoscopy showed a Grade 3 view, a repeated direct laryngoscopy was not attempted. Because the oral cavity seemed to be free of clot, it was decided to proceed with indirect laryngoscopy with the GlidescopeÂÂ ®. Unfortunately, blood obscured the lens and following a prolonged laryngoscopy the attempt to intubate was abandoned. Oxygen saturations fell from 100% to 94% and despite the risk of aspiration, mask ventilation was begun and cricoid pressure was maintained.The saturations recovered nicely. At this point, faced with a failed intubation, rather than a failed airway it was decided to insert a ProSealÂÂ ® laryngeal mask. The oral cavity was once again suctioned with a rigid catheter under direct laryngoscopy and a number 3.0 ProsealÂÂ ® laryngeal mask was easily placed. No air leak was noted and pressure controlled ventilation with a pressure limit of 15 cm H2O was started. A number 5.5 uncuffed endotracheal tube was loaded on a pediatric flexible bronchoscope. Using the LMA ProSealÂÂ ® as a conduit, the bronchoscope was advanced into the trachea. Blood and secretions where present in the LMA and in the trachea but did not obscure the view through the bronchoscope. The ETT was placed easily. With a small air leak at 20 cm H2O airway pressure, it was decided not to change the ETT over a pediatric Cook airway exchanger to a cuffed ETT. Since the LMA did not obscure the surgeons view, it was decided to leave the LMA in place and remove it together with the endo tracheal tube at the end of the procedure after emerge of anesthesia. With a secured airway, the ENT surgeon cauterized the tonsillar bed, and the bleeding artery could be ligated. At the end of the procedure, a large bore nasogastric tube was placed through the suction port of the ProsealÂÂ ® laryngeal mask and the stomach suctioned. The child was taken to the pediatric ICU where he was extubated fully awake one hour later. 45.5 OTHER CONSIDERATIONS 45.5 1 What is the current thinking with respect to the surgical management of post-tonsillectomy bleeding? Life threatening post-tonsillectomy bleeding requires an aggressive approach to surgical management. Initially pressure on the bleeding tonsillar fossa with a clamped gauze or the index finger may give sufficient time to start an intravenous line for blood work and cross match, and to provide for fluid resuscitation or blood transfusion if indicated. If intraoperative localization of the bleeding source is time consuming and local treatment is ineffective, ligation of the external carotid artery at an early stage may be required. Aberrant arterial blood supply to the tonsillar region deriving from the internal carotid artery or the carotid bulb may be present. In cases such as these, packing of the pharynx and angiographic embolization of the feeding artery may be necessary(9). 45.5.2 Are there specific measures that one ought to employ to reduce the postoperative morbidity and mortality of patients following tonsillectomy? The focus on post-tonsillectomy bleeding is on preventive measures, both by the surgeon and the anesthesia practitioner. Tonsillectomy technique: In comparison to the cold knife technique, hot techniques employing bipolar diathermy or coblation tonsillectomy are associated with an increased rate of secondary bleeding (4, 9). The duration, frequency and surgical extent of these techniques are linked to the amount of damage to the surrounding tissue. This damage leads to deeper zones of local necrosis which is vulnerable to bacteria- and enzyme-containing saliva, and therefore at increased risk of secondary bleeding (4, 5). Effects of postoperative, nonsteroidal, antiinflammatory drugs: Nonsteroidal anti-inflammatory drugs (NSAIDs) inhibit platelet cyclo-oxygenase (COX). A recent meta-analysis showed an increased risk of re-operation for hemostasis post-tonsillectomy if conventional NSAIDs such as ketorolac, ibuprofen or ketoprofen were used for postoperative pain control in children (10). On the other hand ketorolac has been proven to be an effective treatment for post tonsillectomy pain, and as a non-opioid delivers an intraoperative opioid sparing effect and leads to a reduction in postoperative respiratory depression, nausea and vomiting. A most recent meta-analysis did not find an altered number of perioperative bleeding events in patients given an NSAID (11). Still, the use of these drugs should be discussed with the surgeon and used with precautions. Effects of dexamethasone for postoperative nausea and vomiting (PONV): Postoperative nausea and vomiting increases the risk of primary hemorrhage and unexpected postoperative hospital admission. Dexamethasone has antiemetic properties in the perioperative setting. However, dexamethasone may inhibit wound healing, attenuate the inflammatory response to local infection and as a result perhaps increase the risk of postoperative bleeding. A recent study in children undergoing tonsillectomy and administered dexamethasone was prematurely terminated because of an increased bleeding rate (12). Similar to NSAIDs, the use of dexamethasone should be discussed with the surgeon und used with caution. Tonsillectomy as outpatient surgery: Traditionally, tonsillectomy has been associated with a hospital inpatient admission. Economic imperatives have pushed hospitals to perform tonsillectomies as outpatient day surgery procedures. The evidence has shown that this can be safely performed with the following exceptions: age under 3 years medical disorders that increase anesthetic and surgical risk craniofacial abnormalities abnormal coagulation, with or without an identifiable bleeding disorder obstructive sleep apnea acute peritonsillar abscess family conditions that prevent easy and rapid return to a medical facility Patients should always be observed for a minimum of 6 hours. They should be able to tolerate oral fluids and be pain free of prior to discharge. As an alternative to hospital admission, a 23 hour overnight observation period can be considered. 45.6 SUMMARY Post-tonsillectomy bleeding is a rare event, which occurs most often within 24 hours following tonsillectomy. However, it may be delayed for up to 14 days postoperatively. The amount and severity of bleeding along with the need to ensure patient comfort and a still surgical field most often make operative revision under general anesthesia necessary. The insidious and continuous nature of the bleeding may lead to significant hypovolemia which is often difficult to assess. Blood work and cross match as well as preoperative intravenous access with fluid resuscitation are crucial in the management of these children. Aspiration and a difficult airway are ever-present risks during the induction of anesthesia in these patients. Rapid sequence induction with direct laryngoscopy and endotracheal intubation is the accepted first choice in the management of these children. An array of pediatric airway management devices need to be immediately available. Blood and secretions can obscure the laryngeal view and can make some devices more useful than others. A surgeon experienced in rigid broncoscopy and establishment of a surgical airway must be present during anesthesia induction. Cautious use of nonsteroidal inflammatory drugs and steroids is advocated. Any death related to a tonsillectomy is a unacceptable bleeding in otherwise healthy children.

The Verdict on Albert Camus’s The Fall Essay example -- Literature The

The Verdict on Albert Camus’s The Fall As if to mock the crumbling principles of a fallen era, â€Å"The Just Judges† preside over a solemn dumping ground of earthly hell. This flimsy legion of justice, like the omnipresent eyes of Dr. T.J. Eckleburg in F. Scott Fitzgerald’s The Great Gatsby, casts a shadow of pseudo-morality over a land spiraling towards pathos. But Albert Camus’s The Fall unfolds amidst the seedy Amsterdam underground--a larger, more sinister prison than the Valley of Ashes, whose center is Mexico City, a neighborhood bar and Mecca for the world’s refuse. The narrator and self-proclaimed judge-penitent, Jean-Baptiste Clamence, presides over his subjects every night to â€Å"offer his services,† although partially dissembled and highly suspect, to any who will listen. More artfully than a black widow preying on her unsuspecting mate, he traps us in his confessional monologue, weaving a web so intricate and complete that no one can escape its clutches. Clamence points out that â€Å"Holland is a dream†¦of gold and smoke† whose residents are â€Å"somnambulists in the fog’s gilded incense† who â€Å" have ceased to be† (13-14). Peopled by the living dead, where â€Å"hundreds of millions of men†¦painfully slip out of bed, a bitter taste in their mouths, to go to a joyless work,† â€Å"Amsterdam’s concentric canals resemble the circles of hell,† as in Dante’s Inferno (144, 14). Holland’s lost souls are the forsaken ones, machines who go through the motions of life but never really live, the modern men, who fornicate and read the papers, with good intentions and bourgeois dreams never realized. These are the men capable of tolerating the â€Å"Liebestod† and the Holocaust in the same breath, who wait for something to happen, â€Å"even loveless sla... ...risk your life. You yourself utter the words that for years have never ceased echoing through my nights and that I shall at last say though your mouth: â€Å"O young woman, throw yourself into the water again so that I may a second time have the chance of saving us both!† (147) For Clamence it was too late, will always be †(t)oo late, too far† for him (70). But we are not he. We do not need to suffer from the paralysis of inaction. We need not relive unlucky Hamlet’s indecision each and every day nor question whether to dare disturb the universe. We have a choice—we will always have a choice. It is never too late for us, for we are endowed with freedom, and more importantly, a responsibility to be free. By all means, â€Å"Do not go gentle into that good night,/ Rage, rage against the dying of the light† (Dylan Thomas). Works Cited: Camus, Albert. The Fall.

Lord Of The Flies - Discovery :: essays research papers

Lord Of Flies( The Importance of self-discovery) 1Human should understand the importance of self-discovery. In the Lord of the Flies, Ralph, Simon and Samneric learned the weaknesses and darkness within the human hearts. People grows up when they faces a challenge. Ralph ‘s challenge is how to be a good and responsible leader. Simon’s challenge is how to speak at front of people. Samneric’s challenge is how to make right choice. The truth about self-discovery may be cruel, but it is worth to learn from it. 2Ralph is being a playful, innocent child in the beginning of the story, but towards the end he matures significantly. Excluding Piggy, Ralph is the most mature and responsible member of the boys, for he is concerned throughout the book with keeping the fire on the mountain going, and building shelter. " If a ship comes near the island they may not notice us. So we must make smoke on top of the mountain. We must make a fire." pg,37 Ralph always has the strong belief that all the children will be saved from the island sooner or later, but at middle part of the story he begins to doubting it. At end of the story, after the death of Piggy, Ralph’s encounter with the Lord of the Flies, he knocks over the pig’s skull. " A sick fear and rage swept him. Fiercely he hit out at the filthy thing in front of him that bobbed like a toy and came back, still grinning into his face, so that he lashed and cried out in loathing." pg206 Ralph realize the evil is part of him and just as to other boys. However, he is the only person who acknowledges the importance of being responsible, and he takes over as a true leader even though he is not necessarily good at it. 3Sam and Eric represents the crowd in modern society, just like every ordinary human. They are faithful and mostly good. They can be described as loyalist in the story. Their rule is to serve whomever is the leader. For example when Jack says " Grab them! No one moved. Jack shouted angrily. I said " grab them"! " Samneric finally give into his threats on their travel to Castle Rock. Later, then betray Ralph, by showing his hiding place to Jack. " You’re sure he meant in there? The twin moaned faintly and then squealed again. " " He meant he’d hide in there?" pg. 214 In this way, Samneric symbolize the weakness of human nature. They have lose any real sense of loyalty to others.

Ethical Decision Making In Business Essay

The term often used to describe the system or principles by which we choose right from wrong is ethics. Conflicts in ethics arise when one person or a group of people impede the beliefs of another person or group of people. It would not be possible to decide who is right or wrong when a conflict arises, but it is our moral responsibility to resolve the dilemmas to the best of our ability. This paper is going to explore the topic of ethical decision making and establish ground rules for the process and analyze possible ethical implications that may arise. What are the ground rules? Making an ethical decision, at times, can be extremely difficult, as emotions tend to hinder ones judgment. For example, if a husband came upon his wife being beat to death, his first impulse would likely be to bring as much pain to the attacker as the attacker brought to his wife. On the other hand, the husband would know that would not be the ethical thing to do. For that reason, the process of making an ethical decision should be similar to making a normal decision. There are five possible steps that can be taken in order to ensure an ethical and reasonable decision. The first step is to clarify the issue and determine precisely what must be decided. This involves gathering as much information as possible and clearly recognizing the problem. At this step, one should be forced to develop at least three ethically justifiable options and determine which ethical principles and values are involved (Five Steps, 2001). The next step is to evaluate the issue. Evaluation involves exploring the options created in step one and realizing if they require the sacrifice of any ethical principle. Evaluation would also involve deciphering facts from beliefs and theories, or past experiences. When a person is emotionally involved, as the man was in the example above, all commonsense tends to fade. The evaluation step forces a person to ensure they are not allowing their emotions to get involved and they are purely making their decision based on facts (Five Steps, 2001). The third step in the decision-making process is to decide what is or is not true and to make a judgment regarding what consequences are most likely to  occur. At this stage, if an ethical dilemma was discovered, this is the time to evaluate the alternatives of each option and decide which would be the most ethical. For example, for the man in the example, the most ethical decision would be to restrain the man and free his wife and then call the authorities and let them handle punishing the man. It would not be to take the law into his own hands and punish the man himself, even though that is mostly like what he wants to do (Five Steps, 2001). At this third step, it is important to incorporate the three â€Å"ethic guides† when trying to make a decision. The first guide is the golden rule, which believes that a person should treat others as they would want to be treated. The second guide is publicity. A person would need to consider how they would feel if their decision were presented to the public. Finally, the third guide is called the â€Å"kid on your-shoulder.† This forces the person to imagine following through with their decision with their children watching (Five Steps, 2001). The fourth step in the decision-making process is developing a plan to implement the decision. If all the steps above have been followed properly, this step should be relatively easy since all the ethical risks have already been established. Finally, the fifth step is to monitor the effects of the decision. This involves being willing to change their decision if it appears their first choice is not successful. This is a constant process until the issue has been resolved (Five Steps, 2001). What could the ground rules be? Ethical decision-making is something that varies from person to person. Not everyone has the same beliefs of what is right and wrong. Some people believe the death penalty is inhumane and cruel while others believe it’s justice. Who is to say which person is right or wrong? No one can since ground rules and ethical behavior are subjective. The ground rules explained above are broad enough as to not force a person to overrule their own beliefs, however it is enough to make them realize, at least to them, what is right and wrong in any given situation. What should the ground rules be? Deciding what should the ground rules be is also subjective. Each individual is going to have their own feedback and decisions on how ethical decisions should be made. I believe the best way to improve on the decision-making process would be to involve others. Even if a person follows the ground rules mentioned above, there is still going to be emotion involved. If a person could ask for another point of view, they might learn or think of something they hadn’t before. For example, going back to the man who found his wife being beat, if there were another person present at the time, that person could help reason with the husband and realize the unethical aspect of what he wanted to do to the man. I know when I have a difficult decision to make that involves ethics I immediately involve another person. I am able to realize that I am too emotional about the situation and cannot make a reasonable decision on my own. Therefore, that is how I believe the ground rules should be changed. What are the ethical implications of the decision? The fifth step in the decision-making process is to monitor and modify the decision if any problems arise. This will allow the person who made the decision to either live with the implications or select another solution. If they stay with their first option, even if there are implications, at least the person can be sure they followed the steps, weighed all of the options, and this is the most appropriate solution for the issue. Making a decision not only involves implementing it, but also living with the outcome. Conclusion Ethical norms and principles have developed over time and across all different cultures (Shanks, 1997). People have been raised to weigh the difference between right and wrong when making a decision. Therefore, I believe people utilize the ground rules described above without even realizing it. That leads me to believe that ethical decision-making is an innate trait for most people, and something they make the most of on a regular basis. The sad reality is not all people have these skills or even  have the ability to understand the difference between right and wrong. The challenge for us would be to share our knowledge, help others to learn the ground rules of ethical decision-making; and maybe, just maybe, our world would become a little safer. References: Five steps of principled reasoning. (2001). [Online]. Available: http://www.josephsoninstitute.org (September 25, 2002). Shanks, Thomas. (1997, Winter). Everyday ethics: morality requires regular reflection on the day-to-day decisions that confront us. Issues in Ethics. 8(1). [Online]. Available: http://www.scu.edu (September 28, 2002).