By Q. Jack. Appalachian School of Law.

Plaintiff attorneys are not going to win cases against doctors who are kind to their patients quibron-t 400 mg with mastercard allergy group, try to help them purchase quibron-t 400 mg on line latex allergy symptoms underwear, and take responsibility when an adverse outcome occurs. If you avoid discussing a complication with your patients, they will try to get answers either from other doctors, who may be critical of your care, or from an attorney. From a plaintiff attorney’s perspective, nothing lowers your risk of being sued success- fully as much as your documented frank explanation to the patient regarding what happened. The jury sees that something went wrong through no one’s fault and that the doctor then worked hard to help the patient recover. From an attorney’s point of view, a doctor who has a complication but communicates openly and works to help his or her patient recover makes a very strong defendant. However, plaintiff attorneys usually do not have to worry about this scenario because many doctors avoid discussing complications with their patients. This makes the physician appear guilty and they become a very weak defendant. Thus, my advice is to practice medicine with your patients’ best interests in mind and treat them as you would like to be treated if you were the patient—especially when there is a com- plication. If a claim is filed against you, the first thing you must be concerned about, after informing your insurance carrier, is the attorney who will defend you. You must feel comfortable with that individual in terms of his or her experience and interest in you. Do not worry if the attorney tells you he or she is busy; however, be certain that you feel he or she can focus on your case and provide you with the attention you will need. You will need to educate your attorney about the case and to be honest with yourself about the quality of the care you have provided. Review a textbook and the recent literature on the subject matter; then give it to your attorney to review. You must understand that your efforts in educating your attorney about the medical aspects of the case will be worthwhile. You can be certain that the plaintiff attorney is doing the same research. Chapter 3 / Risk Reduction 39 However, no one knows your case like you do. Make certain that the basic medical information that the plain- tiff attorney certainly will have has been provided to your attorney. From the plaintiff attorney’s perspective, when doctors work closely with their attorneys, are not in denial about a lawsuit, and discharge their responsibilities to their patients, the chances of winning are diminished. ONCE YOUR DEPOSITION IS SCHEDULED, THE PLAINTIFF ATTORNEY IS LOOKING FOR SPECIFIC THINGS The order of the information the plaintiff attorney seeks is as impor- tant as their content. Thus, it is important for you to react to people in an accommodating manner. The effort you make in relating to those around you during the deposition and during the trial will be key to whether you are successful in the litigation. If you do not respect your attorney, ask your insurance carrier for another one. Do not show your contempt or lack of respect for the justice system through your lack of respect for your attorney. Plaintiff attorneys are allowed to ask you questions during a deposi- tion. If you are courteous and respectful when asked questions, the plaintiff attorney will conclude that you will behave that way in trial as well. To show respect and be the kind of caring doctor that jurors will love is not how a plaintiff attorney wants you to behave. Study the medical aspects of the case and then teach them to your attorney. You may think you will remember the facts of the case simply by having experienced them, but you will be surprised at the details you have forgotten. However, you still must understand that this is the least important thing the plaintiff attorney is looking for when he or she assesses your ability to fight a potential suit. The most important thing is you and the impression you will makeon a jury. If you are honest and straightforward with your patients when there is a complication and you are honest and straightforward to a jury, you have maximized your risk reduction.

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The control of free (unbound) calcium ion concen- protect the brain during surgical procedures in which its tration in skeletal muscle cytoplasm is severely impaired in circulation is occluded or the heart is stopped cheap 400 mg quibron-t with amex allergy treatment for eyes. Much of our susceptible individuals; and when an attack is triggered purchase quibron-t 400 mg line allergy vs sinus infection, knowledge about the physiological effects of hypothermia calcium concentration rises abnormally, activating myosin comes from observations of surgical patients. ATPase and leading to an uncontrolled hypermetabolic During the initial phases of cooling, stimulation of shiv- process that rapidly increases core temperature. Treatment ering through thermoregulatory reflexes overwhelms the with dantrolene sodium, which appears to act by reducing Q10 effect. Metabolic rate, therefore, increases, reaching a the release of calcium ions from the sarcoplasmic reticulum, peak at a core temperature of 30 to 33 C. At lower core has dramatically reduced the mortality rate of this disorder. Other velops, wherein a fall in core temperature depresses metab- than producing specific disorders, heat exposure aggravates olism and allows core temperature to fall further, so that at several other diseases. Epidemiological studies show that 17 C, the O2 consumption is about 15%, and cardiac out- during unusually hot weather, mortality may be 2 to 3 times put 10%, of precooling values. Deaths ascribed to specific heat disorders account poses is called accidental hypothermia (Clinical Focus Box for only a small fraction of the excess mortality (i. It occurs in individuals whose defenses are impaired crease above the expected mortality). Most of the excess by drugs (especially ethanol, in the United States), disease, mortality is accounted for by deaths from diabetes, various or other physical conditions and in healthy individuals who diseases of the cardiovascular system, and diseases of the are immersed in cold water or become exhausted working blood-forming organs. REVIEW QUESTIONS DIRECTIONS: Each of the numbered (D) Antipyretics increase skin blood Threshold for items or incomplete statements in this flow so as to dissipate more heat, Core Sweating Cutaneous Temperature Threshold Vasodilation section is followed by answers or by increasing circulatory strain during (A) Unchanged Higher Lower completions of the statement. Select the exercise (B) Unchanged Unchanged Unchanged ONE lettered answer or completion that is (E) The increased heat production (C) Higher Higher Higher BEST in each case. A surgical sympathectomy has person, one who is acclimatized to but they are not used to counteract the completely interrupted the cold has increase in core temperature that sympathetic nerve supply to a patient’s (A) Higher metabolic rate in the cold, occurs during exercise. How would one expect the to produce more heat following best explains why it is thermoregulatory skin blood flow and (B) Lower metabolic rate in the cold, inappropriate to use antipyretics for sweating responses on that arm to be to conserve metabolic energy this purpose? Which statement best describes how preventing it temperature is tested in the early the elevated core temperature during (C) Antipyretics are ineffective during morning at 4:00 AM, and again in the fever affects the outcome of most exercise because they act on a afternoon at 4:00 PM. Harrison’s Principles of Internal infection concentration and ECF volume after he Medicine. New York: Mc- (C) Fever is harmful because the has replaced all the water that he lost? Cytokines as endogenous reduces the availability of amino acids (mmol/L) ECF Volume (L) pyrogens. In: Braunwald E, Fauci AS, growth of the bacteria responsible for (D) 113. Our subject is bicycling on a long road New York: McGraw-Hill, 2001;91–94. A manual laborer moves in March from metabolic rate (M in the heat-balance heat biophysics and physiology. In: Canada to a hot, tropical country and equation) is 800 W (48 kJ/min). Handbook becomes acclimatized by working performs mechanical work (against of Physiology. New York: Oxford his responses on the first few days in at a rate of 140 W. Interaction of body temperatures activity level after acclimatization one transfer coefficient, is 15 W/(m2• C). In: Fregly MJ, Blatteis (A) Core temperature is 34 C, all the sweat he secretes is CM, eds. Cardiovascular In questions 7 to 8, assume a 70-kg (Remember that 1 W 1 J/sec adjustments to heat stress. Our subject begins an 8-hour hike in SUGGESTED READING and Electrolyte Metabolism.

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The crossbridge cycle stops 400mg quibron-t overnight delivery allergy treatment dallas, and myosin purchase quibron-t 400 mg on-line allergy shots cpt code, changing it to an active form (myosin-P or Mp). Because of the importance of Another possible secondary mechanism in some smooth smooth muscle relaxation in physiological processes, this muscle tissues involves the protein caldesmon. While the process is phorylation to control smooth muscle activation, second- not well understood, it is possible that caldesmon, under ary regulatory mechanisms are present in some types of the control of calcium, could form crosslinks between actin smooth muscle. One of these provides long-term regula- and myosin filaments and, thus, aid in bearing force during tion of contraction in some tissues after the initial calcium- a long-maintained contraction. It is likely that several such mechanisms exist in var- force of contraction may be maintained for long periods. Even during the latch state, increased Mechanical Activity in Smooth Muscle Is Adapted cytoplasmic calcium appears to be necessary for force to be for Its Specialized Physiological Roles maintained. Not all smooth muscle tissue can enter a latch state, however, and the details of the process are not com- The contraction of smooth muscle is much slower than that pletely understood. The source of these and this ion pumping requires a significant portion of the differences lies largely in the chemistry of the interaction cell’s energy supply. Internal pumping of calcium ions into between actin and myosin of smooth muscle. Recall that the the SR during relaxation also requires energy, and the crossbridges of muscle form an actin-myosin enzyme system processes that result in phosphorylation of the myosin light (actomyosin ATPase) that releases energy from ATP so that chains consume a further portion of the cellular energy, as it may be converted into a mechanical contraction (i. The inherent rate of this ATPase corre- Smooth muscle contains both glycolytic and oxidative lates strongly with the velocity of shortening of the intact metabolic pathways, with the oxidative pathway usually muscle. Most smooth muscles require several seconds (or the most important; under some conditions, a transition even minutes) to develop maximal isometric force. A may temporarily be made from oxidative to glycolytic me- smooth muscle that contracts 100 times more slowly than a tabolism. In terms of the entire body economy, the energy skeletal muscle will have an actomyosin ATPase that is 100 requirements of smooth muscle are small compared with times as slow. The major source of this difference in rates is those of skeletal muscle, but the critical regulatory func- the myosin molecules; the actin found in smooth and skele- tions of smooth muscle require that its energy supply not be tal muscles is rather similar. Smooth muscle contractile activ- degree of myosin light-chain phosphorylation. In some cases, smooth muscle makes rapid to 500 times greater than that in skeletal muscle, is vital to phasic contractions, followed by complete relaxation. Economy, as other cases, smooth muscle can maintain a low level of ac- used here, means the amount of metabolic energy input tive tension for long periods without cyclic contraction and compared to the tension produced. In smooth muscle, relaxation; a long-maintained contraction is called tonus there is a direct relationship between isometric tension and (rather than tetanus) or a tonic contraction. The economy is related to the ba- of smooth muscle activated by hormonal, pharmacological, sic cycling rate of the crossbridges: Early in a contraction or metabolic factors, whereas phasic activity is more closely (while tension is being developed and the crossbridges are associated with stimulation by neural activity. The force-veloc- Compared with skeletal muscle, the crossbridge cycle in ity curve for smooth muscle reflects the differences in smooth muscle is hundreds of times slower, and much more crossbridge functions described previously. Although time is spent with the crossbridges in the attached phase of smooth muscle contains one-third to one-fifth as much the cycle. Because the cells are so small produce as much force per unit of cross-sectional area as and numerous, smooth muscle tissue contains a large cell does skeletal muscle. Maintenance of the proper ionic concen- muscle on the force axis would be similar, while the maxi- trations inside the cells requires the activity of the mem- mum (and intermediate) velocity values are very different brane-based ion pumps for sodium/potassium and calcium, (Fig. A and B, Typical peak forces may be similar, the maximum shortening velocity of length-tension curves from skeletal and smooth muscle. Note smooth muscle is typically 100 times lower than that of skeletal the greater range of operating lengths for smooth muscle and muscle. C, CHAPTER 9 Skeletal Muscle and Smooth Muscle 173 force-velocity curves, each corresponding to a different Elastic material Elastic material level of myosin light-chain phosphorylation. Other mechanical properties of smooth muscle are also 5 related to its physiological roles. While its underlying cel- 4 Viscoelastic Viscoelastic lular basis is uncertain, smooth muscle has a length-tension 3 material material curve somewhat similar to that of skeletal muscle, although 2 there are some significant differences (Fig. At lengths 1 at which the maximal isometric force is developed, many 0 smooth muscles bear a substantial passive force. This is 0 5 10 0 5 mostly a result of the network of connective tissue that sup- Time Time ports the smooth muscle cells and resists overextension; in some cases, it may be partly a result of residual interaction between actin and attached but noncycling myosin cross- 5 Slow stretch Rapid stretch bridges. Compared to skeletal and cardiac muscle, smooth muscle can function over a significantly greater range of lengths.

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