Public Interest Law Initiative


By Y. Gorok. Thunderbird School of Global Management.

From this perspec- tive the here-and-now interpersonal relations could be explored toward the goal of insight 10 mg loratadine mastercard penicillin allergy treatment gonorrhea, communication purchase loratadine 10 mg with mastercard allergy treatment herbal, and productive methods of contact. To that end, I apply each individ- ual’s symbolic communication to the larger context of the family’s social system. The older son, Larry, was placed in a residential treatment facility due to an attempted theft during which he threatened a security guard. His younger brother, Jef- frey, had recently been referred to outpatient therapy for explosive bouts of rage following periods of guarded withdrawal. Family Therapy Directives wardly projecting two very different personalities (Jeffrey quiet and re- served, Larry loud and uncompromising), shared a need to conceal their orally aggressive feelings. By way of example, their father had lost a high-paying job some months earlier, and this loss had brought about numerous lifestyle changes. The family members sup- pressed their shame, while at the same time the family as a whole harbored unexpressed resentment against Mr. In this case Larry, playing his role of the irrepressible and disobedient child, disguised his aggression through verbal sarcasm and distrust aimed at his father, while Jeffrey defended against his anxiety by retreating from in- terpersonal relationships through an obsequious demeanor. However, his hostility lay just beneath the surface and was often projected onto his older sibling. Harrison was equally distressed over the recent loss, as she was ac- customed to both receiving and offering love through the transfer of mate- rial objects. This was the pattern of nurturance in her family of origin and one she expected from her husband and replicated with her sons. However, as the family savings were dwindling, this was no longer feasible; thus, her interpersonal relationships suffered, because she did not know how to please without offering a gift of substance. Harrison’s calm acquiescence contradicted the inten- sity of his feelings: He channeled emotional conflicts into intellectualized control. Harrison presented with a guarded demeanor, preferring to protect uncomfortable feelings through contain- ment. Following an initial interview I presented the directives for the family mural drawing. Harrison (upper center) and Larry (lower center) used the center of the mural, while the outside paper walls held Mr. Harrison’s render- ings (left side and middle right), with Jeffrey occupying the upper and lower right side of the paper. Assessed on an individual basis, each fam- ily member dominated his or her compartmentalized and unconsciously sanctioned-off space, which characteristically delineated common feelings of isolation. However, when working from a psychodynamic model, one must consider the family unit as a whole; an examination of how these individual personalities blend becomes vital when examining the inter- personal dynamics. For me it was one of unsettled turbulence, a tempestuous feeling of foreboding that was matched only by the inten- sity of the lower half of the drawing. This portion, rendered completely un- der water, metaphorically illustrates the dark depths of the unconscious. The emotional impact of the bottom half of this drawing, dominated by Larry and his father, symbolizes feelings of passive acquiescence, power- lessness, danger, and aggressiveness. In its totality, the art production metaphorically pointed toward this family’s long-standing pattern of concealing their true emotions, thoughts, and feelings in order to maintain outward appearances, while their indi- vidual concerns and needs remained either suppressed or disguised as fam- ily members employed maladaptive models of relating. Additionally, the symbolic separation of each member’s drawings repli- cated this family’s ineffective interactional process. I will examine each drawing individually, because the pictorial communication of the family mural drawing imparts both individual and interpersonal concerns. Harrison was having grave difficulties adapting to the changing circumstances and inherent stresses within the family system. The materialistic considerations of her childhood had joined with the unconscious expectation that her husband would provide her with the same care and protection that her own family had. How- ever, she outwardly denied the conflict that her husband’s unemployment had produced in accordance with the family’s tendency of emotional sup- pression. Family Therapy Directives where a winter tree is surrounded by a brooding skyline. The heavy line pressure throughout her form items suggests an inner tension, while the ag- gressive shading found at the bottom right of Figure 7. Addi- tionally, the tree, often viewed as a symbol of the self in relation to the en- vironment (Buck, 1966), has been rendered with exposed branches and a trauma scar.

The result of this means of giving birth without gravity has spawned a new generation of "superbabies" buy 10 mg loratadine free shipping best allergy medicine for 5 yr old, with memories of very happy birth order loratadine 10 mg without a prescription allergy levels. The children are much better and have a far higher intelligence quotient than the average for their age group, giving them many ad- vantages in school. These children are also psychologically superior: they are happier, more sociable and have a more peaceful tempera- ment. The Tomatis Method Alfred Tomatis heads the list of experts who have found a way to take advantage of all these fantasies that surround our birth. A former ear-nose-throat specialist, he was thrown out by the medical authori- ties in 1977. Tomatis played perfectly on the guilt feelings of parents and fu- 145 Healing or Stealing? Tomatis left no room for doubt: the baby recognizes the voice of the mother (and father), heard during the "long uterine night" that preceded the labor. He went on to elaborate a theory on the psycho-emotional dis- turbances of children and their relationship to the sound disturbances to which they were subjected during gestation, in particular focusing on such things as vocal outbursts during arguments, and the consecu- tive modifications of language in states of stress. Tomatis maintained that, starting in the first months of preg- nancy, the fetus is sensitive to the sounds coming from outside, mainly the voice of his or her mother, transmitted through the uterine and pla- cental barrier. After having reconstituted what he calls the "acoustic impressions" of the fetus, using filtered sounds recorded in water, To- matis has young children listen to these montages of sound, thereby conducting what he calls "sonic labor". This technique was never persuasive to music-therapists and spe- cialists in electro-acoustics, who point out (correctly) that the voice is muffled by the filter of the amniotic liquid combined with the various tissues that separate the fetus from the airspace where voluntary ma- ternal sounds are created (her voice, and song). Moreover, Tomatis skips over the issue of sound "parasites" that disturb the hypothetical fetal listening: the sound of heart beats, diges- tion, cracking joints, and muscular rustlings that make up the aural en- vironment of the fetus. Neither does he address the arguments of his former professional colleagues, who have pointed out to him that the ear of the fetus is blocked with a mucous plug that only disappears after birth. He defies the criticisms of the neurophysiologists who counter his beautiful theories with the fact that, since the nervous system is not yet mature, it is difficult to understand how already muffled sound im- pulses can make their way to an incompletely-formed brain through incomplete nervous connections. It is true that they are based on his personal interpretation of work carried out by the acoustic laboratory of physiology of Port-Royal. These experi- ments aim at proving that the fetus is sensitive to sound frequencies ranging between 800 and 2000 hertz, when these frequencies are played through the abdominal wall using a speaker placed on the mother’s belly. The sound from the speaker is transmitted by the vibra- tion of the abdominal wall, which acts as a resonator. But they don’t talk about the fact that the sound environment is not limited to these frequencies — far from it; that the voice human represents only a tiny part of the sound environment; and future mothers find walking awk- ward enough without having speakers strapped to their bellies. W hat really brought fame and fortune to the Tomatis method is that it uses a unique apparatus: the electronic ear. This is an apparatus that filters the sound of the maternal voice, and music, cutting out deeper frequencies and emphasizing higher tones above eight thousand hertz. The Tomatis treatment is intended for children who are autistic or emotionally disturbed, those with speech difficulties, behavioral problems, or learning disabilities. The treatment consists in listening to the mother’s voice, filtered — such as it is supposed to have been heard by the fetus during gestation. The objective is to bring the child back to the pre-natal period in order to encourage training in total lis- tening. After a first stage of listening to the filtered maternal voice, the child is subjected to sessions of listening to filtered music, alternating with sessions of language acquisition, then with sessions copied from more traditional speech therapy. The program is divided into two principal parts: In the first phase, the child receives auditory stimulation, using a helmet and a vibrator. Music is used as the initial stimulus and will be gradually filtered to reproduce the sonic universe corresponding to the 147 Healing or Stealing? If any positive results follow a Tomatis treatment, that is obvi- ously due to the closer attention and intensive training given to the young children, to the traditional speech therapy sessions, and to the psychological acceptance of responsibility — and not to the electronic ear, as the Tomatis documents implicitly acknowledge: The monitoring sessions. The consultant explains to the child what is happening, and advises the parents so that the family climate becomes increasingly harmoni- ous and thus contributes to the blossoming of the child’s personality. Tomatis wanted to make his technique universally applicable, and that is precisely what reveals the manipulative aspect of his efforts. The electronic ear was supposed to resolve all difficulties of communi- cation, psychological problems, delays in language and social develop- ment — it was even supposed to improve the vocal performances of singers!

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These injuries were judged to require treatment in approximately three fourths of those identified (13) order loratadine 10 mg free shipping allergy testing when pregnant. Much like cervical spine fractures order 10 mg loratadine amex allergy symptoms chills, a resulting neurologic deficit is noted in approximately one third of those with thoracolumbar injury (14,15). Given the potentially serious consequences of these injuries, it is unsettling to find that studies have noted a significant delay in diagnosis in 11% to 22% of patients with spine fractures (9,16,17). Overall Cost to Society There is enormous variability in the practice of cervical spine imaging (18,19), but in most centers, imaging is used liberally. Overall, the total cost of the imaging, evaluation, and care of patients with cervical spine trauma in the United States is an estimated $3. The yield of thoracolum- bar imaging is somewhat higher than cervical spine imaging, with posi- tive studies accounting for 7. The total societal cost of thoracolumbar spine injury has been estimated at $1 billion per year (24). Chapter 17 Imaging of the Spine in Victims of Trauma 321 Goals The overall goal of initial spine imaging is to detect potentially unstable fractures to enable immobilization or stabilization and prevent develop- ment or progression of neurologic injury. Additional imaging studies may be performed to inform prognosis and guide surgical intervention for unstable injuries. Methodology A Medline search was performed using PubMed (National Library of Medicine, Bethesda, Maryland) for original research publications dis- cussing the diagnostic performance and effectiveness of imaging strategies in the cervical and thoracolumbar spine. Clinical predictors of cervical and thoracolumbar spine fracture were also included in the literature search. The search for cervical spine–related publications covered the period 1966 to March 2002. The search strategy employed different combinations of the following terms: (1) cervical spine, (2) radiography or imaging or computed tomography, and (3) fracture or injury. The search for thoracolumbar spine– related publications covered the period 1980 to March 2004. The search strategy included the MESH headings (1) spine and diagnosis, and (2) imaging and trauma. Additional articles were identified by reviewing the reference lists of relevant papers. The authors performed an initial review of the titles and abstracts of the identified articles followed by review of the full text in articles that were relevant. Summary of Evidence: Determination of which blunt trauma subjects should undergo cervical spine imaging, and which should not undergo imaging, is a question that has been studied in detail in literally tens of thousands of subjects. The Canadian C-spine rule (Table 17-2) also has high sensitivity, and potentially higher specificity than the NEXUS. However, neither of these rules has been tested in an implementation trial to deter- mine their impact outside the research setting. NEXUS criteria: imaging of the cervi- cal spine is not necessary if all five of the NEXUS criteria are met 1. The Canadian C-spine rule If the following three determinations are made, then imaging is not indicated 1. No high-risk factor, including: Age >64 years Dangerous mechanism, including: Fall from >3m/5 stairs Axial load to head (diving) High-speed motor vehicle accident (60mph, rollover, ejection) Bicycle collision Motorized recreational vehicle Paresthesias in extremities 2. Low-risk factor is present Simple rear-end vehicular crash, excluding: Pushed into oncoming traffic Hit by bus/large truck Rollover Hit by high-speed vehicle Sitting position in emergency department Ambulatory at any time Delayed onset of neck pain Absence of midline cervical tenderness 3. Able to actively rotate neck (45 degrees left and right) Source: Adapted from Dickinson et al. Supporting Evidence: The low yield of cervical imaging has prompted a number of investigators to attempt to identify clinical factors that can be used to predict cervical spine fracture. Early studies of this question were largely level III (limited evidence) investigations consisting of unselected case series. For example, in 1988, Roberge and colleagues (25) studied 467 consecutive subjects who underwent cervical spine radiography and found that subjects with cervical discomfort or tenderness were more likely to have a fracture than those without such symptoms or signs. Additional investigators identified associations between cervical spine fracture and mechanism of injury (26,27), level of consciousness (20,21,27), and intoxi- cation (20,28). However, all of these investigations involved small numbers of subjects with fracture and a single or small number of centers.

This means that students of various ages should be accepted buy discount loratadine 10 mg online allergy luxe, not just those who have graduated from college at age 21 generic loratadine 10 mg visa juniper allergy treatment. Nurses, medical technicians, farmers, stockbrokers, military people, teachers and others add to the educational mix of a medical school, for example, and bring important perspectives to traditional medical students. In addition, a medical student body needs strong multicultural representation, not for the sake of the minorities accepted, but for the sake of other students also accepted and for the sake of the profession as a whole. Among "minorities" who should be encouraged to apply are, very importantly, the ill and the disabled, as well as those who have either survived serious illness or dealt with it in their families. Such students would bring to a medical class a much needed dose of realism about the experience of being a patient. They would bring, hopefully, some appreciation for what goes on in the lives of patients and families outside of the direct medical encounter, and of how that wider experience largely determines the value of that encounter. Given the great multiplicity of roles in medicine, including research, practice, teaching and community outreach, medical schools should seek undergraduates with interest and experience in the humanities and the social sciences, as well as those in engineering and the biomedical sciences. The efficacy of the healing professions of course depends on sound and well-learned science; but it also depends on engagement with patient and community facts and values. A profession dominated by people passionate for cell biology and genetics alone is not a profession which can reach whole persons and interface well with struggling communities. The profession needs diversity of interest for effective balance just as a person needs balance for health. Preclinical and clinical training could also better support sound informal reasoning, deliberation and judgment in the practice of medicine. There was once a tradition of future doctors acting as orderlies (now known as "technicians"). Potential physicians need to know first hand what patients experience in the halls while waiting for procedures, in the emergency department while waiting for help, and in their rooms after ringing the buzzer in distress. They need to see close up from the patients’ and families’ eye view what a hospitalization or outpatient experience means. This process of staying close to the patient should continue in the pre-clinical years. There should be chances for medical and nursing students to listen to the unstructured narratives of patients: to the stories of their illnesses and their efforts to cope; to their accounts of encounters with doctors and medical institutions; to their stories of seeking care and trying to find ways to pay for it. We need, in fact, a whole course in the preclinical years which is supplemental to the courses given on medical histories and physical diagnosis – a course on patient experiences. FULL SPECTRUM MEANS AND ENDS REASONING 163 Medical students by and large arrive at school with the idea that they should become skillful in order to serve patients. Unfortunately, the four years of medical school often communicate another idea: That students are learning to serve an ideal called "health" (assumed to be precise without having ever been precisely articulated), and that their job will be to foist this ideal on patients. We should not inculcate an ideal which has an abstract existence outside of actual patients. Such an agenda leads to the view that patients are obstacles to the external ideal, and not the very parties who ultimately determine what ideal goals should be in play. The perception that patients are difficult, stubborn, and foolish increases when ideals are anchored outside of those patients. This perception, whatever real justification it might sometimes have, becomes exaggerated and gets in the way of accomplishing anything. It would be well to replace the concept of ideal health with the concept of the possible, relative to particular patients. To facilitate wise decision making, the medical curriculum needs to focus on functioning with uncertainty, not arriving at premature certainty as though it was required for functioning. Professors should reveal the well-kept secret that not everything can be diagnosed to fit our existing categories of illness. They should admit that "illness" is not a univocal concept, but a vague one with borderline cases. They should acknowledge that triage is not something that happens only after a train wreck or a bomb explosion, but that it happens all day long every day, because not all concerns can be met at once – they have to be prioritized.

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