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For example purchase 100 mg cefpodoxime fast delivery infection, patient outcome- due to increased numbers of paramedics gaining an undergrad- based measures will require better information sourced from uate degree and postgraduate qualifications also being achieved generic cefpodoxime 100 mg mastercard antibiotic plants. Improved funding and stronger collaborations between prehospital As in other areas of practice buy cefpodoxime 200mg lowest price bacteria exponential growth, implementation of research and care and academic institutions is also making prehospital research knowledge translation is slow. Research priorities Barriers and facilitators Research priorities identified through in the literature can be found in Box 38. Historically there have been a number of barriers to undertaking research in emergency settings (Box 38. As in many areas of health care, there are tensions between delivering services and undertaking research. The ambulance service is no longer Conflicting priorities seen as a ‘scoop and run’ service and has expanded its scope of Lack of interest care to include the assessment and treatment of patients on scene Inadequate capacity and capability with appropriate signposting to services where required. Numer- Poor organization ous studies have shown that this can be effective, for example Limited funding. The context of diverse or rapidly changing health systems or Systems organization of care is another barrier, particularly when studies Prehospital care should not be considered in isolation. Although patient outcomes are dependent pered by local and regional differences in pathways, the numbers of on the whole system rather that the component parts, the process organizations involved and changes in systems and processes of care of care within the prehospital setting is an important contributor due to national guidance. The ability to evaluate process and outcomes methods employed – for example a randomized controlled trial in the emergency care system is challenging, but appealing. System evaluating a service or pathway may be impossible if that service is performance, quality and safety of care are key drivers for change, already fully established. Normally where capacity for consent the impact on patients and services of bypassing local emergency is not present the legislation allows for personal or professional departments in favour of specialized centres such as trauma centres legal representatives to give consent on behalf of the patient. While policy is driving emergency situations where capacity is present but the patient has the changes, the evidence supporting it is lacking and research is little time for fully informed consent as a result of their condition needed to address these deficiencies. Drugs and devices Specific methods such as cluster randomization, where random- The use of new technologies within prehospital care should ideally ization of groups of patients treated by one or more ambulance be evaluated within that setting. It is no longer sufficient to translate clinicians rather than randomization of individual patients may findings from other clinical settings and assume the effects will be reduce some of the requirements for individual patient consent in similar. However, in many such studies individual consent proves one of the most challenging for researchers and therefore is still required for individual level data such as quality of life or drug or device trials are rarely undertaken in these settings. Pre- data requiring review of subsequent clinical and service utilization viously successful trials demonstrated the benefit of interventions records. The knowledge and expertise needed to consent patients such as prehospital thrombolysis, and more research of this quality by front line staff is often lacking, particularly in ambulance services should be undertaken. Such training requires resources Future directions and considerable effort but should be considered as an investment in future capacity for research. Therearecontinuingchallengesforprehospitalcareresearchworld- New systems for ethical review and approval of research studies wide. The setting and often urgent nature of the clinical conditions have been developed to enable more efficient processes but many presented make research in this area challenging. However, this ethical and other complexities of prehospital research are prob- should not act as a deterrent, but be utilized to develop strong and lematic for research ethics committees and health organizations effective collaborations that can deliver a sound research evidence responsible for research governance. The future of prehospital care should focus on developing a diverse service that takes healthcare to the patient and directs ongo- New technologies ing care from that point. This means that healthcare professionals Evaluating the clinical and cost effectiveness of new technologies in will need to have a range of skills, equipment and pathways open order to inform their integration into healthcare is essential. In the to them in order to deliver the most appropriate and cost-effective past, the evidence for what we do has been scanty. A mobile intensive care unit in the management of • Recent evidence reviews have highlighted priorities for future myocardial infarction. Supporting research • The context of prehospital medicine makes research challenging; and development in ambulance services: research for better health care in especially clinical trials where interventions can have a significant prehospital settings. Prehospitalthrombolytic Tips from the field therapy in patients with suspected acute myocardial infarction. London: Department and data collection may seem arduous but it will lead to of Health, 2010. S p e c i a l I m a g i n g S t u d i e s E m e r g e n c i e s f o r t h e E m e r g e n c y D e p a r t m e n t : A n g i o g r a p h y M R I V / Q 1 0. I n f e c t i o u s D i s e a s e E m e r g e n c i e s T h e V a d e m e c u m s e r ie s in c l u d e s s u b j e c t s g e n e r a l l y n o t c o v e r e d in o t h e r h a n d b o o k s e r i e s , e s p e c i a l l y m a n y t e c h n o l o g y - d r i v e n t o p i c s t h a t r e f l e c t t h e i n c r e a s i n g Digitally signed by in f l u e n c e o f t e c h n o l o g y in c l in ic a l m e d ic in e. T h e n a m e c h o s e n f o r t h is c o m p r e h e n s iv e m e d ic a l h a n d b o o k s e r ie s is V a d e m e c u m , malina a L a t in w o r d t h a t r o u g h l y m e a n s “ t o c a r r y a l o n g ”. I n t h e M id d l e A g e s , t r a v e l in g c l e r ic s c a r r ie d p o c k e t - s iz e d b o o k s , e x c e r p t s o f t h e c a r e f u l l y t r a n s c r ib e d c a n o n s , k n o w n a s V a d e m e c u m. T h e L a n d e s B io s c ie n c e V a d e m e c u m b o o k s a r e in t e n d e d t o b e u s e d b o t h in t h e Date: 2006. S p e c i a l I m a g i n g S t u d i e s E m e r g e n c i e s f o r t h e E m e r g e n c y D e p a r t m e n t : A n g i o g r a p h y M R I V / Q 1 0. I n f e c t i o u s D i s e a s e E m e r g e n c i e s T h e V a d e m e c u m s e r ie s in c l u d e s s u b j e c t s g e n e r a l l y n o t c o v e r e d in o t h e r h a n d b o o k s e r i e s , e s p e c i a l l y m a n y t e c h n o l o g y - d r i v e n t o p i c s t h a t r e f l e c t t h e i n c r e a s i n g in f l u e n c e o f t e c h n o l o g y in c l in ic a l m e d ic in e. T h e n a m e c h o s e n f o r t h is c o m p r e h e n s iv e m e d ic a l h a n d b o o k s e r ie s is V a d e m e c u m , a L a t in w o r d t h a t r o u g h l y m e a n s “ t o c a r r y a l o n g ”. I n t h e M id d l e A g e s , t r a v e l in g c l e r ic s c a r r ie d p o c k e t - s iz e d b o o k s , e x c e r p t s o f t h e c a r e f u l l y t r a n s c r ib e d c a n o n s , k n o w n a s V a d e m e c u m. I n t h e 1 9 t h c e n t u r y a m e d ic a l p u b l is h e r in G e r m a n y , S a m u e l K a r g e r , c a l l e d a s e r ie s o f p o r t a b l e m e d ic a l b o o k s V a d e m e c u m. T h e L a n d e s B io s c ie n c e V a d e m e c u m b o o k s a r e in t e n d e d t o b e u s e d b o t h in t h e t r a in in g o f p h y s ic ia n s a n d t h e c a r e o f p a t ie n t s , b y m e d ic a l s t u d e n t s , m e d ic a l h o u s e s t a f f a n d p r a c t ic in g p h y s ic ia n s. Department of Emergency Medicine Keck School of Medicine University of Southern California Los Angeles, California, U. No part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publisher.

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As far as communication policies are concerned order cefpodoxime 200mg on line infection on finger, while the Italian and German clinics seem to prefer more ‘private’ channels cefpodoxime 100mg line antibiotic resistance due to overuse of antibiotics in agriculture, which imply a direct contact by phone or email buy cefpodoxime 100mg low cost antibiotic resistance vs tolerance, the Dutch clinics attach great importance to online information, aware of the fact that web-mediated communication “has qualified as a powerful strategic resource in healthcare settings”, creating a “new type of self-informed patient” (Vicentini 2013: 53, 54). When considering textual strategies, however, the distinction should be drawn rather between Italy, on the one hand, and Germany and the Netherlands, on the other. The Italian Gender Dysphoria 183 texts appear to be heavily doctor-centered and monological, they present many instances of opacity of medical communication and are definitely not in line with the main functions of patient brochures, i. On the contrary, the German and Dutch websites demonstrate to be aware of the fact that patient brochures are typically used to bridge communication gaps (Montalt-Resurrecció/ González Davies 2007: 59). They show multiple efforts to compensate mismatches of knowledge, through simple syntax, the frequent use of explanations and paraphrases, the combination of specialized and popular terms. Their communication style is more comprehensible for potential patients, and thus more efficient – although comprehensibility is not the only yardstick for measuring the effectiveness of a text (Renkema 2004: 180). This seems to be the background against which the German and Dutch texts have been produced, and it is in line with what we already observed in the field of vaccination programs, where the two language communities have been demonstrated to give much more consideration than the Italian health sector to proper communication for the sake of health literacy and social inclusion (Ross/Magris 2012: 147). In the present study we have also observed that the German and Dutch texts show more empathy with potential patients and adopt a more positive attitude when describing the surgical treatment, often emphasizing the competence of the medical staff and the high success rate of surgery. The Italian texts, on the contrary, tend to highlight possible difficulties and negative consequences, often failing – at least in our opinion – to strike the right balance between the necessary cau- tion in informing the patients and due consideration of the emotional impact of this information. Against the background of social acceptance and human rights, translators and other language experts could play an important role in disseminating the best communicative approaches. On the one hand, Critical Applied Linguistics turns out to be 184 Mariella Magris / Dolores Ross far more than the addition of a critical dimension to applied linguistics, but rather opens up a whole new array of questions and concerns, issues such as identity, sexuality, access, ethics, disparity, difference, desire, or the re- production of Otherness that have hitherto not been considered as concerns related to applied linguistics. First of all, an important step in the translation process is the mastering of drafting techniques, and translators are commonly re- quired to be familiar with “different types of target readers, their moti- vations, their expectations and their purposes in written medical communication” (Montalt-Resurrecció/González Davies 2007: 37). Secondly, these developments are also related to the fact that, generally speaking, the translators’ operating environments “are signi- ficantly shifting, giving rise to new ways of working” (O’Hagan 2011: 21). In this new context, the translators’ traditionally invisible role is not realistic anymore, giving way to a different status: that of an infor- mation broker with language counselling tasks. The development of technologies has changed the ways of producing, translating and distributing texts, with far reaching consequences for the integrity of the source text, which is increasingly a product of “multiple author- ing” (Jiménez-Crespo 2013: 51, 53). In the translation of website information, user interaction is becoming an important parameter of communicative success, at the detriment of linguistic accuracy (Pym 2011: 424). With their terminological, interlinguistic and intercultural competences, translators can become active participants in the communication process instead of silent mediators, performing the language counselling functions which are increasingly required by modern society. A public service translator capable of handling va- rious text types and facilitating communication between public Gender Dysphoria 185 services and persons may offer promising perspectives in the field of medical translation, particularly in the sector of patient information. Should the second stage of analysis confirm the first results, translators and other lan- guage experts could indeed play an important role in disseminating best practices, as mastering communicative skills constitutes commu- nicative – and social – capital. In the context of the growing number of sites related to health issues and online conversation, statistical research tends to confirm that com- munication through health message boards has a significant role to play in the era of online counseling (Eysenbach/Diepgen 1999; Mulholland 1999; Anderson et al. Previous studies have explored how people discussing health issues use health-related online communities or doctor-answer support facilities to access information and support. In fact, one of the main worries concerning these spaces has been the uncontrolled information that is provided by users with no defined roles and who do not/cannot take responsibility for what they say. This research questions whether health forums may represent a new means of co-construction (Fage-Butler/Nisbeth Jensen 2013, 2014) and self-appropriation of (quality) knowledge based on credibility. Authentic examples from health forum boards are analysed by means of Discourse Analysis in order to understand how participants construct attitude and commitment toward advice, opinions and suggestions (Bybee et al. Finally, a survey is undertaken in order to understand whether this credibility works, and if so how it affects people’s beliefs and behaviour in relation to their health. This participatory web phenomenon has emerged so quickly and widely that research has generally focused much more on various features, user responses, and design characteristics than on theoretical explanations for the causes and effects associated with their use. In particular, forum benefits include providing support, understanding, praise, and reinforcement as well as a place to find intervention options, negotiating plans, and/or general assistance. Although it is unlikely to supplant the role of trusted healthcare- providers, the Internet has found an important place in people’s reper- tory of health information sources. The Internet offers confidential and convenient access to an unprecedented level of information about a diverse range of subjects, and over time its perceived credibility has increased. Unsurprisingly, children and adolescents also use the Credibility and Responsibility in User-generated Health Posts 193 Internet as a resource for health information (Borzekowski/Rickert 2001), since the Internet enables users to explore topics (like sexual health) in a confidential and anonymous manner, which is an additional comfort for them. Behind the label ‘doctor’, there is either an individual person with a medical training or a group of general practitioners/specialists, who run these pages and offer their help in response to users’ posts. The net works as a source for a new medical support system, in which health-care professionals help with the translation of codified information, the validation of self-care practices and with biosocial symptoms. Doctors certainly still need to see and speak with the patient in order to diagnose or prescribe remedies, but the medical support is evolving into a different model on the net, represented by a mutually respectful one-to-many dis- course. Forums provide advice, exempla (when presenting personal history to illustrate a point), interpretations (in the case of re-description of others’ narratives, and possible (self-) diagnosis), recommendations and medical questions/requests for help. Participation varies between one- to-one, one-to-many and many-to-many structures, which are mostly public although there is a high degree of nicknames that guarantee anonymity. People participating in these communities generally have very heterogeneous roles and statuses in real life, but it is very rare for participants to introduce themselves or 194 Marianna Lya Zummo talk about their job in real life, unless it is specifically asked or they need it to support their claim (“since I’m a nurse”, “I’m a registered nurse”). Most participants tend to socialise when the goal of their interaction is seeking support, but when the goal is seeking information, they use the site in a very personal way, and once they have obtained it there is no further active participation. In this way, the activity evolves from information exchange to problem solving, and it is regulated with norms established by moderators, who ensure language appropriateness and balance in participants’ behaviour. In his study of online groups dealing with disabilities, Finn (1999) divided posts into two domains: socio-emotional messages (including expres- sion of feelings, provision of support, and friendship) and task-orien- tated messages (including requests for or provision of information, and problem solving).

It is therefore necessary buy cefpodoxime 200 mg otc antibiotics for streptococcus viridans uti, may be undertaken via the right atrium directly if necessary order cefpodoxime 100mg mastercard bacteria 7th grade science. Evidence of need to be administered in order to maintain the patient in a longstanding death such as rigor mortis 200mg cefpodoxime amex antibiotics for sinus infection wiki, dependent livido or state of adequate anaesthesia prior to transport to the receiving putrefaction are obvious indicators of futility. Injuries incompatible Care must be taken when calculating effective doses of medi- with survival such as hemicorporectomy, severe head trauma cations and fluid administration in the post-traumatic cardiac and emaceration do not warrant resuscitation. Ventricular fibrillation Once the pulse returns, it may be prudent to adopt a ‘permissive or pulseless electrical activity would indicate potential viability hypotension’ approach, maintaining the systolic blood pressure as opposed to an asystolic rhythm. Opening, maintaining and protecting the airway in a traumatic 7 Evacuation to hospital cardiac arrest victim may present challenges due to distortion The post-traumatic cardiac arrest victim who has a return of of normal anatomy caused by the mechanism of injury. This spontaneous circulation, or who has a specific in-hospital medi- may lead to the necessity of providing spinal protection and the cally or surgically correctible cause of cardiac arrest, will require early use of supraglottic, glottic or infraglottic devices to provide transportation to the nearest and most appropriate emergency adequate oxygenation. Associated severe head injury ◦ Inadequate rescuer training, equipment, assistance or system resources Haemorrhage control en route, particularly following return Inadequate emergency department or specialist surgical support within a of spontaneous circulation. Large rescue-type scissors Large sharp-pointed scissors Artery forceps or equivalent Prehospital emergency thoracotomy Foley catheter 3/0 non-absorbable suture on a curved needle or staples Introduction Numerous large abdominal type swabs. Prehospital emergency thoracotomy, although still a controversial subject, has a definitive role in the resuscitation of the critically injured patient when performed by an appropriately trained and Table 22. Curved Mayo scissors This systemized approach ensures that guidance is available in the Toothed forceps Large vascular clamp (e. Satinsky) decision-making process, safety is maintained during the operative Aortic clamp (e. De Bakey) procedure, adequate assistance is always on-hand, and hospital Needle holders (long and short) definitive care is activated timeously, all of which is geared towards Selection of sutures patient resuscitation, stabilisation and hospital discharge neurolog- ically intact. In this type of setting, the generally quoted success rates of 9–12% for penetrating trauma can be increased to as high as 38%. Operative technique Aleftanterolateralsurgicalapproachistheclassicalmethodofentry, Indications and relative contraindications extending from the left parasternal costochondral junction in the The indications and relative contraindications for prehospital fifth or sixth intercostal space to the mid-axillary line laterally, emergency thoracotomy are listed in Table 22. However, it is far more practical to extend the incision across the sternum Equipment (clamshell incision) into a bilateral anterior thoracotomy because The equipment required for on-scene resuscitative thoracotomy of the access that it provides to the pericardium, pleura and rest of must be safe, simple and effective for use in an environment which the mediastinum, thus facilitating surgical release of a pericardial is limited in resources, generally unsterile, and open to the elements. Once spontaneous cardiac rhythm has been restored, haemorrhage from incised vessels, including the internal mammary Table 22. Individual decisions will be exsanguination en route to the delegated emergency department required for blunt polytrauma patients where survival rates approximate nearby. The travel duration from injury to specialist surgical hospital care is greater than 10 minutes. Resus- sions, as hypoxia is the main determinant of cardiac arrest in citation should not be started if the patient has a valid Do Not children. If • The depth of compressions should be at least one-third of the this has been unequivocally established, then there is no reason- anterior-posterior diameter of the chest wall. However, while any to approximately 5 cm in the child and approximately 4 cm in an withdrawal of existing treatment which could hasten the patient’s infant. Always err on the side of quent shocks at 4 joules/kg or higher (up to a maximum of 10 commission when it comes to resuscitation decisions. If paediatric pads or attenuator An ‘advance directive’ is an expression of a person’s thoughts, is not available, then the adult pads should be used. The legal validity of the various forms darone (5 mg/kg) may be given after the third shock and repeated of advance directives varies, but courts tend to consider written after the fifth and seventh shock if necessary (not to exceed advance directives to be more trustworthy than recollections of 300 mg/dose or a maximum total dose of 2. Prehospital providers must be thoroughly familiar • If a pulse is detected but the child is not breathing, ventilations with their own local protocols and regulations. A ‘living will’ is a patient’s written directive to physicians about Post-resuscitation induced (therapeutic) hypothermia should be medical care the patient would approve when the patient can no considered where appropriate. It constitutes clear evidence of the patient’s wishes, spelling out exactly the type of The ethics of resuscitation: difficult interventions allowed. Remember to take excellent Has an intercostal drain been inserted and is it notes and record your actions. Is sonography available to confirm and to facilitate dictors of poor outcome and clinical decision aids can be found decompression? Toxins Antidotes or prolonged resuscitation may be indicated: Is the patient taking any drugs (orally, rectally, Box 22. Hypoxia A systematic search for hypoxia extends from the Has the patient been given any medications oxygen source to the alveolus: recently? Thrombosis Look for evidence of cardiovascular pathology: Is the bag-valve resuscitator intact? The pupils should be fixed and dilated with no response to Is the chest visibly rising? Although the family’s permission to terminate the resuscitation Evidence of distributive shock (anaphylactic / septic is not ordinarily required, it is wise to involve them in the pro- / neurogenic)? Hypothermia Obtain an accurate temperature reading and Invariably onlookers will appreciate your labours more than you re-warm as necessary: realize, and will be assured that everything possible was attempted. The rescuer’s efforts are thereafter directed at comforting and Was a core temperature reading taken? American Heart Association Guidelines for Cardiopulmonary Resuscitation Circulation 2010; 122: S665–S675). No cardiac activity on prehsopital ultrasound at any point during International Consensus on Cardiopulmonary Resuscitation and Emergency resuscitation Cardiovascular Care Science with Treatment Recommendations, 2010.

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But paradoxically order 200mg cefpodoxime mastercard xylitol antibiotic, they will also seek to preserve the flow of benefits from providers to consumers purchase 200 mg cefpodoxime fast delivery vyrus 985. T he en­ trenchm ent o f a bureaucracy that feeds off a service by serving as an interm ediary between provider and consum er will then frustrate if not prevent change in the service sys­ tem of the future buy cefpodoxime 100mg visa antibiotic nasal irrigation. As the governm ent assumes larger obligations for services and as the economy gradually shifts to a service economy, bureaucracies will swell in power as well as size. In the past, a key problem has been the rapacity of the private sector which controlled the resources necessary for a decent life. But in the future, control over the flow o f resources will rest m ore with 132 Medicine: a. Evidence is available that medical care has less impact on health than a variety of other factors. T he growth and strength of service bureaucracies will frustrate attem pts to reallocate resources—to shift re­ sources from services to other program s with a potentially greater impact on health. Today’s com puters are already deployed in medical care; scores o f software salesmen visit doctors’ offices and hospital corridors. T he com puter, one example of high medical technology, can improve medical care, but there are hazards as well. Decisions regarding the kind and the am ount of medical care are made by the physician, but also to an increasing extent by government. Currently, federal and state governments together purchase about 40 percent of the medical care provided in this country. However, it is equally possible that the com puter will facilitate despotic m anipulation o f consumers; it could dramatically lessen con­ sum ers’ opportunities to affect decisions about health care services. T he com puter might make possible instantaneous interaction between pa­ tient and provider without the necessity of an office or The Com puter Revolution: The High Technology of the Future 133 hospital visit. For example, a person experiencing certain symptoms may be able to take advantage o f a com puter link with a physician’s office. A com puter could be utilized for interrogation o f the patient and instantaneous coding of the patient responses. This is an example o f how medical care might be m ade m ore accessible to the consumer. G reater use of the com­ puter in the provision o f care will accelerate this trend. The use of the com puter in triage—situations in which decisions m ust be m ade as to who will receive life-saving medical care—has occurred. In a hospital in Salt Lake City, Utah, that is almost entirely com puterized, use of the com puter system presumably makes a physician’s diagnosis m ore accu­ rate. Reliance on the com puter will undoubtedly increase m arkedly in the next 20 to 30 years. A nother product of further developm ent of com puter technology is the patient com puter console. Patients could be provided with hom e consoles that would be program m ed with inform ation relating to their own condition and past treatm ent, and perhaps linked with the physician’s com puter system. T hrough use o f the console, patients would be able to retrieve inform ation relating to their conditions almost instantaneously. Since they pose an obvious threat to professional prerogatives, providers will probably resist the use of hom e consoles. One potentially adverse consequence o f increased use of the com puter in medical care derives from the fact that com puters cost money. W idespread deploym ent o f com put­ ers will drive up the costs of care and foster further speciali­ zation. T he recent history o f medical care reflects the unabating sophistication of medical care technology and the rapid specialization of practitioners. As m ore sophisticated technology is im plemented, substantial num bers of citizens will be deprived of care which only the rich will be able to 134 Medicine: a. T he alternative is the subsidy of costly procedures under a national health insurance program. But limits on the public purse will soon be reached, and a private m arket for the most costly procedures will undoubtedly develop. O ne of the dualities in medicine referred to in C hapter 3 is the schism between the an­ thropologic and technical approaches to care. If future use of the com puter is dictated by the proponents of technical care, an even greater erosion in the anthropologic approach can be expected. W hen intelli­ gently used by the physician and the patient, the com puter might lead to m ore accuracy in both diagnosis and treat­ ment. Further deemphasis in the hum an or an­ thropologic approach may have unforeseen costs that far outweigh the benefits of the use o f the com puter. T he com puter, as one o f the most powerful and allur­ ing tools for technicians, will contribute to its demise. T he alienation of individuals when grappling with large and complex organizations is conveyed in an extensive literature. T he scale and complex­ ity of the medical care system have im portant implications for health. T here is no definitive evidence correlating health with the scale of the treatm ent system, but the scale o f the delivery system is growing, irrespective of the means taken to finance care, or the nature of structural reform s within the system. Increasing sophistication o f the medical hard­ ware and superspecialization by practitioners has led to larger units for the delivery of care. Since the com puter increases the potential for control o f larger and m ore complex operations and feeds the specialization craze, m ore extensive use of the Work 135 com puter will facilitate the evolution o f larger and more complex units for care. Increases in the size o f institutions further attenuates the patient’s responsibility for health. Historically, with the rise of the professions of health, the individual has been relieved o f responsibility for health.

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