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Emphasis is on California law generic levitra 20mg visa impotence etymology, although reference also is made to comparable laws in other states; however discount levitra 10 mg line erectile dysfunction pills canada, the objective is less to understand the details of the rules than the dynamic interplay between them that can and does occur when you try to navigate the rough shoals of litigation. The game3 played is, to be sure, a high stakes one in which you can affect the outcome to win, lose, or draw (i. To my mind, “winning” in the context of malpractice litigation means getting out of it as early as possible with no judgment of liability against you. If you have to go to trial, even if you eventually win your case, you will pay such a heavy price that the victory will seem pyrrhic. That is because preparing for trial, let alone going through it, is a lengthy and arduous process that consumes your time and physical and emotional resources to the neglect of your present and future life. In preparing for trial, you will be forced to put much of your present life on hold while you concentrate on reliving an event that happened in the past, frequently several years in the past. Dwelling on the past in a defensive way prevents you from realizing the present and planning for the future; it is by all accounts a draining process. The storytelling aspect of litigation requires your defense team to put a consistent “spin” or interpretation on the known and unknown facts that is a more persuasive explanation of what happened than the interpretation provided by the plaintiff. These “facts” will emerge in varying degrees of clarity from medical records and witness testi- 3 Use of the term “game” is not meant to trivialize or minimize the impor- tance of the litigation process, but rather to get the reader to better understand how to maneuver within it by “seeing” it in the sense that Wittgenstein sees what all games share: “You will not see something that is common to all, but similarities, relationships and a whole series of them at that. Additionally, 40 percent undergo a major depression as a result and 60 percent state that being sued for malpractice has altered their lives and practices completely. Chapter 2 / Litigation 15 mony, but they must be constantly placed in a context that will make sense to those deciding your case. This presupposes that although much can be learned about what happened to someone else in the course of medical treatment that is related to some injury that befalls the plaintiff, there will invariably be ambiguity about many aspects of what is learned. The longer litigation persists and the closer it gets to trial, the more facts will be known to both sides that require explana- tion as to why they do or do not add up to the defendant’s liability. Ultimately, if one must go to trial, the audience that hears and judges what is the best or most credible story will be the court and jury or arbitrator(s). Whatever attempts are made along the way to dispose of the case before trial will require a nonfiction narrative that is more believable than your opponent’s story, that makes better sense of what is known and not known factually than a contrary explanation pointing to your liability. Stories you tell along the way to trial must be consistent with each other even if the latest spin is, as expected, more detailed than earlier versions you present. Conflicting stories or interpretations of facts will, if they are known to court or jury, hurt your credibility and increase the risk of a finding of liability against you. With this sketch of the big litigation picture in mind, let us turn to rules of the game and then discuss what you should do from the time you are first forced to play the game. THE IMPORTANCE OF THE RULES IN THE LITIGATION GAME To win or avoid losing in any game other than one of pure chance, a player must be generally familiar with the rules of that game and the moves, likely and actual, of other players in it. That familiarity should not be on the detailed nuances of the rules, which is the responsibility of your lawyers, but on the importance and dynamics of the interplay between them. Rules of litigation fall into three categories: substan- tive, procedural, and evidentiary. The Substantive Liability Rule of Negligence and Its Four Constituent Elements of Duty, Breach, Causation, and Compensable Injury Substantive rules are those that define the conditions necessary to find liability. When it comes to professional liability or medical mal- practice, the most common substantive rule is negligence. Negligence 16 Hiestand is comprised of four essential elements, and the absence of any one element defeats liability. The first element is that a defendant must be shown to owe a duty to the plaintiff. This means that there must be a defined and accepted standard of care that the defendant is required to adhere to in treating the plaintiff, something the defendant should not have done that he or she did or some act that he or she did that should not have been done. Standards of care can be found in statutes, regulations, court decisions, published professional articles, and tes- timony by expert medical witnesses. When the standard of care is a statute, regulation, or rule of a professional organization, its violation is called negligence per se. The second element that must be proved to successfully prosecute a medical malpractice case is that the defendant breached this stan- dard of care, which is to say that he or she acted contrary to or in violation of it. This is usually an evidentiary matter where each side presents whatever testimony or documentary evidence that shows conduct by the defendant in conformity with or in violation of the standard of care.

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An equilibrium potential is not shown Mixed cation channel V Carries Na (mostly) and for Ca2 because order levitra 10mg amex drugs for treating erectile dysfunction, unlike Na and K purchase levitra 10mg fast delivery erectile dysfunction quality of life, it changes during the ac- (funny, I )f inward when tion potential. This is because cytosolic Ca2 concentration activated by hyperpolarization. During the plateau of the action potential, the equilibrium potential for Ca2 Contributes to is approximately 90 mV. K channel (delayed V Contributes to phase 3 of outward rectifier, iK) action potential. Depolarization occurs when the membrane potential moves away from the K equilibrium potential and toward the Na equilibrium po- tential. In ventricular cell membranes, this occurs passively at first, in response to the depolarization of adjacent mem- meable only to K (potassium equilibrium potential). Once the ventricular cell mem- contrast, when open Na channels predominate (as occurs brane is brought to threshold, voltage-gated Na channels at the peak of phase 0 of the action potential), the measured open, causing the initial rapid upswing of the action poten- potential is closer to the potential that would exist if the tial (phase 0). The opening of Na channels causes Na membrane were permeable only to Na (sodium equilib- permeability to increase. The opening of Ca chan- permeability to K , the membrane potential approaches nels causes the membrane potential to be closer to the cal- the Na equilibrium potential, and the inside of the cell be- cium equilibrium potential, which is also positive; this comes positively charged relative to the outside. Specific changes in the number of open Phase 1 of the ventricular action potential is caused by a channels for these three cations are responsible for changes decrease in the number of open Na channels and the in membrane permeability and the different phases of the opening of a particular type of K channel (see Fig. The Opening and Closing of Cation Channels Late Depolarization (Plateau): Selective Opening of Cal- Causes the Ventricular Action Potential cium Channels and Closing of Potassium Channels. In the normal heart, the sodium-potassium pump and cal- The plateau of phase 2 results from a combination of the cium ion pump keep the ionic gradients constant. These chan- 222 PART IV BLOOD AND CARDIOVASCULAR PHYSIOLOGY Area of depolarization resulting in their absence, serious disorders of cardiac electrical ac- from artificial stimulus or pacemaker tivity can develop. The pacemaker potential results from Depolarization Phase changes in the permeability of the nodal cell membrane to Membrane potential 3 + all three of the major cations (see Table 13. First, K approaches K equilibrium potential channels, primarily responsible for repolarization, begin to close. Second, there is a steady increase in the membrane Threshold is reached Na+ channels open Phase Membrane potential 0 + Ca2+ channels open approaches Na +20 1 equilibrium potential and ito1 channels close 2 then: 0 Ca2+ channels close -20 Phase and iK1 channels close Membrane potential -40 0 3 2 (mV) -60 Membrane potential -80 4 stays near zero -100 ito + High Na channels inactivated + i * iK1 K permeability K1 Phase and ito1 channels open iKs 1 Low Membrane potential nears zero iKr High FIGURE 13. High Ca2+ permeability Repolarization: Selective Opening of Potassium Channels. This relative increase in permeability to K drives the membrane potential toward Changes in cation permeabilities during a FIGURE 13. The rise in action potential (phase 0) is caused by rapidly increasing Na current carried by voltage-gated Na Resting Membrane Potential: Open Potassium Channels. Na current falls rapidly because voltage-gated Na channels are inactivated. K current rises briefly because of open- ventricular cells is maintained primarily by K channels ing of ito1 channels and then falls precipitously because iK1 chan- that are open at highly negative membrane potentials. Ca They are called inward rectifying K channels because, channels are opened by depolarization and are responsible, along when the membrane is depolarized (e. K current begins to in- K1 voltage-gated Na channels), they do not permit outward crease because iKr and iKs channels are opened by depolarization, movement of K. Once repolarization occurs, Na channels are acti- bilize the resting membrane potential (see Table 13. CHAPTER 13 The Electrical Activity of the Heart 223 40 Neurotransmitters and Other Ligands Can Influence Membrane Ion Conductance a b c 20 The normal pacemaker cells are under the influence of parasympathetic nerves (vagus) and sympathetic nerves 0 (cardioaccelerator). The vagus nerves release acetylcholine (ACh) and the cardioaccelerator nerves release norepi- nephrine at their terminals in the heart. ACh slows the 20 heart rate by reducing the rate of spontaneous depolariza- tion of pacemaker cells (see Fig. Slowed heart rate is called bradycardia, or when the heart rate is below 60 beats/min.

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Almost all absorption and digestion is accomplished in the small intestine buy cheap levitra 10 mg on-line erectile dysfunction causes in early 20s. The small intestine absorbs water and sodium and secretes mucus cheap levitra 10 mg amex impotence workup, potassium, and bicarbonate for stool formation. The cecum is 6 cm in length and lies below the terminal ileum, forming the first part of the large intestine. The colon is the division of the large intestine that extends from the cecum to the rectum. In the colon, fluids and electrolytes are reabsorbed and feces are stored so that defecation can occur at an acceptable time. Defecation is affected by peristalsis, anorectal sensory aware- ness, anal sphincter function, and abdominal muscle func- tion and strength. The rectum is the 12 cm segment of the large bowel between the sigmoid colon and the anal canal. Striated muscle in the anal canal and pelvic floor provides sup- port to the rectal wall and anus, thus maintaining continence. Neurogenic bowel results from the interruption of neural pathways that supply the rectum, external sphincter, and accessory muscles involved in defecation. Nerve impulses that are disrupted may impede cerebral recognition of anal contents and the need to empty stool at a desired or planned time. Decreased activity related to altered mobility, fatigue, or a sedentary lifestyle may contribute to slow bowel function. Constipation has been defined as less than or equal to two bowel movements per week; or the need for stimulation, the use of laxatives, enemas, or suppositories more than once a week. Constipation has also been characterized by hard, dry stool, causing straining or painful defecation and resulting in a delay of passage of food residue. Medications contributing to constipation may include analgesics anticholinergics anticonvulsants antidepressants diuretics psychotherapeutics iron opiates muscle relaxants 9. Other neurologic factors that contribute to neurogenic bowel conditions: lack of exercise inadequate fluid intake inadequate dietary fiber effects of medication 10. Diarrhea may result from gastrointestinal influenza, dietary irritants, and gastrointestinal disorders. Diarrhea (loose, liquid stools) and frequent discharge of fluid fecal matter may be secondary to fecal impaction diet or irritating foods inflammation or irritation of the bowel stress, anxiety medications overuse of laxatives or stool softeners dietary intolerance of milk products, chocolate 2. Diarrhea may be accompanied by urgency, cramping, abdominal pain, increased bowel sounds, or increased volume of stools. In MS, involuntary bowel or fecal incontinence is the result of interruption in the neural pathways and impaired cortical awareness of the urge to defecate. Questions to ask include the use of medications that influence bowel activity, such as diuretics, antacids, nonsteroidal anti-inflammatory agents, anticholinergics, antidepressants, antibiotics, laxatives, and enemas. Fluid and dietary history should include fluid intake, daily intake of fiber, and type of food or snacks eaten. Objective assessment of the abdomen should include aus- cultation, palpation, and percussion. Assessment should include patient’s functional ability to ambulate and transfer, the use of assistive devices, the ability to remove clothing, and the accessibility of toilet facilities. Goals of bowel training program include: normalizing stool consistency establishing a regular pattern for defecation stimulating rectal emptying on a routine basis avoiding complications of diarrhea, constipation, or incontinence improving the patient’s quality of life C. Constipation should be first treated with nonpharmacologic interventions: 1. The use of stool softeners or bulk formers with fluids and fiber may help. Oral stimulants provide a chemical stimulation and a localized mechanical stimulation and lubrication to promote elimination of stool. Dulcolax® suppositories and Therevac® mini enemas con- tain medications that stimulate strong, involuntary, wavelike movement that facilitates the elimination of stool.

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