Public Interest Law Initiative


By S. Osmund. Virginia Union University.

Presence of signifi- cant thermal injury to the larynx makes it more prone to injury by an endotracheal tube buy 150mg fluconazole with amex antifungal hair loss. When possible purchase 200mg fluconazole free shipping fungus lips, early extubation reduces the risk of exacerbating a laryngeal injury. When extubation is not possible tracheostomy is another option that may help to limit laryngeal injury. The early popularity of tracheostomies for initial airway management in burn-injured patients gave way to reports of unacceptably high rates of complications. In the most often quoted study regarding the risks of tracheostomy in burn patients, Eckhauser et al. Moreover, a 100% correlation was found between cultures of the burn wound and cultures of the endotracheal aspirate. Presence of a tracheostomy stoma, especially through a burn injury, was assumed to facilitate contamination of the respiratory tract with microorganisms from the burn wound. Tracheosto- mies were considered an increased risk in burn patients and a more conservative approach was recommended, with tracheostomies reserved for specific indications rather than for so-called prophylactic airway control [6,7]. More recently many clinicians have published comparisons of clinical out- comes for burn patients managed with translaryngeal endotracheal tubes and tracheostomy tubes. These studies indicate that the risk of pneumonia for patients with tracheostomies is the same as the risk for patients with translaryngeal endo- tracheal tubes [8,9]. The general consensus now is that with current methods of supportive care, the risk of pneumonia appears similar in patients with tracheostomies and those with translaryngeal endotracheal tubes. Tracheostomy offers several advantages over a translaryngeal endotracheal tube in certain patients. For those requiring prolonged mechanical ventilation, the tracheostomy tube has been reported to reduce dead space, improve compli- ance, lower peak inspiratory pressures, and facilitate airway suctioning. Tracheos- tomy also offers protection from laryngeal and tracheal injury. Prolonged transla- ryngeal intubation is associated with laryngeal injury. Tracheostomy is especially beneficial for patients who have sustained inhalation injury to the larynx. Mechan- ical irritation to the larynx by an endotracheal tube exacerbates inhalation injury to the larynx caused by heat or chemical irritants. Several recent studies have described very low rates of morbidity associated with tracheostomy in small study groups of burn patients, especially young pa- tients. Some of these authors have recommended earlier and more aggressive use of tracheostomy in burn patients. A conservative reluctance to use tracheos- tomy in burn patients is now frequently replaced with a broader application of Inhalation Injury 75 this technique, often in patients with normal airways and without need for long- term mechanical ventilation. Reluctance to perform tracheostomy in burn patients may increase risk of laryngeal injury in these patients, especially in those who have also sustained an inhalation injury to the larynx. At the same time, burn patients may experience an increased risk of morbidity when tracheostomy is performed in patients who will not benefit from the procedure (risk without benefit). Many patients who have sustained major burn injury require intubation and mechanical ventilation soon after their injury. For most of these patients, intuba- tion is only required for a short duration, often only until upper airway obstruction due to edema resolves. Even when inhalation injury is diagnosed endoscopically and pulmonary gas exchange is impaired, intubation and mechanical ventilation are not necessary unless there is profound respiratory failure. Under theses cir- cumstances, tracheostomy offers little advantage over a translaryngeal endotra- cheal tube. In fact, in some burn patients initial management with tracheostomy presents an additional serious risk. A specific concern about the use of tracheos- tomy in burn patients is that, soon after burn, pronounced edema from cutaneous neck burns may cause dislodgment of the tracheostomy tube. Under these circum- stances, loss of the airway may be life-threatening. Even in the presence of facial burns, an oral endotracheal tube may be more secure than a tracheostomy when thermal injury to the neck results in extensive edema.

Studies such as this highlight the power of the media in influencing beliefs about pain and people’s response to it safe fluconazole 200mg antifungal laundry. Level 4: Higher Order Factors Level 4 represents the higher order factors affecting social and psychologi- cal processing that influence the response to pain purchase 200 mg fluconazole visa fungus easy definition, such as health culture, history, ideology and politics, quality of life, and economic beliefs about health. For health culture we must ask how particular cultural beliefs foster sickness and wellness in the community. There was a Western cultural tra- dition of prescribing extended bed rest for all low back pain sufferers until the results of Deyo’s seminal study (Deyo, Diehl, & Rosenthal, 1986) showed how this recommendation was contraindicated for those without malig- nancy or herniated disc and indeed, could be iatrogenic. In a wider sense of the word, this issue is also about whether culture en- courages or discourages people from, for example, taking up and maintain- ing exercise that would prevent or retard the onset of a painful condition, or enable people to better cope with it when present. In a recent commu- nity study conducted in a town in northern England noted for its high immi- grant population, a health promotion scheme was set up to enable Bangla- deshi women to cultivate vegetables in publicly owned plots. At the end of the project these formerly housebound women had improved physical, psy- chological, and social health and quality of life: in particular, a boost to their confidence relating to self-efficacy, and less depression. This was as a result of regular contact with other Bangladeshi women, participating in culturally acceptable forms of physical exercise through gardening, and im- proving their family’s diet by cultivating fresh vegetables suited to Asian dishes, to take home (NHS Health Development Agency, UK, 2001). By pro- viding a rationale for exercise, distraction, and social support, such commu- nity pilot projects have the potential to retard the onset of pain, and where pain and disability are present, to maintain mobility, and other aspects of quality of life including good mental health. Health history encompasses the sociocultural history of seeking medical care for pain and other problems, and the reactions of health professionals and significant others on each event, not simply the traditional record of previous illnesses. These higher order factors also relate to the apparent legitimacy of a person’s complaint and help-seeking behavior, that is, whether or not a person’s symptoms are deemed severe enough to justify seeking professional help, particularly when dealing with a phenomenon that other people cannot see. SOCIAL INFLUENCES ON PAIN RESPONSE 197 Health ideology and politics at an individual differences level have rarely been studied in detail in pain research but are necessarily reflected by the predominant premises adopted by the very different health services deliv- ery systems that have been implemented around the world. Those who be- lieve in a socialist medical system, such as the National Health Service in Britain, may wait uncomplainingly on a waiting list for a physiotherapy ap- pointment or scan, despite having trouble sleeping, walking, and working, because they believe that health care should be free at the point of use— that in the current politico-economic context of limited resources and with the assumption of a fair system, they must necessarily wait their turn. In countries where health care is provided through fee for service or health in- surance, those without financial resources or health insurance often suffer without professional care. An individual assessment of health economics, within the ideology of a patient-centered system, might include an evalua- tion of how people in pain believe the resource should be shared out. There is likely to be a continuum from those who hold highly individualistic views, to those who believe that the resources should be used to benefit the great- est number of those in pain. Here, government policy and funding are perti- nent issues and are likely to impact indirectly on how people respond to symptoms, like pain. Policies to withdraw formerly available treatments on the grounds of inconclusive findings of evidence-based medicine may, in the psychological terms of reactance theory (Brehm, 1966; Brehm & Brehm, 1981), make the treatment all the more attractive, and the pain worse as a result of the treatment’s newly inaccessible status. Indeed, recent research has shown a link between patient noncompliance and reactance (Fogarty, 1997; Fogarty & Youngs, 2000). Thus, people are inclined to react adversely when told they must do something. Global inequities in pain relief arising from different governmental poli- cies, have been extensively documented by Stjernsward (1993). This is par- ticularly evident in the field of palliative care concerning the use or with- holding of morphine. Recently McQuay argued that politics, prejudice, and ignorance prevent the most appropriate use of opioid analgesics (McQuay, 1999). Fears of addiction have hindered the effective use of strong pharma- ceuticals for pain relief. This has some resonance with the question of indi- vidual response to pain, not only at a physiological or biochemical level, but also psychologically, as dominant attitudes toward the prescription of strong analgesics can influence the beliefs, attitudes, and behavior of peo- ple with acute and chronic pain. We must also include a consideration of the variable impact of pain on quality of life in health. Without knowing how satisfying or problematic the pain and disability can be, and how much it affects many different aspects of life, we can barely begin to evaluate individual problems. Too often re- searchers and clinicians have erroneously subscribed to a deficit theory, in 198 SKEVINGTON AND MASON the erroneous assumption that the greater the pain intensity, the poorer is the quality of life. There is now substantial empirical data for the quality-of- life literature to show that many of the patients who are in intense pain do not necessarily also have very poor quality of life. This is because the meaning of pain is very different for different people; for some, pain is very threaten- ing and debilitating, whereas for others with the same level of intensity, it plays a less significant role and does not appear to greatly impair their well- being or lifestyle. We need to invest in understanding the variables that me- diate this and other important factors and elucidate the impact that living with pain has on a person’s quality of life. Ultimately, quality of life is about people’s “goals expectations, standards and concerns” (WHOQOL Group, 1995) and how far these are satisfied.

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