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By R. Kurt. Belmont University. 2019.

Liquid feeds either as a supplement or replacement pletion purchase genuine viagra capsules online, renal failure order viagra capsules line, poor cardiac output or urinary may be taken orally purchase viagra capsules 100 mg on line, via a nasogastric tube or via a gas- obstruction. Liquid feeds may be whole protein, oligopep- isation (or flushing of the catheter if already in situ) tide or amino acid based. These also provide glucose, and a clinical assessment of cardiovascular status in- essential fats, electrolytes and minerals. Mixed Early postoperative complications occur in the subse- preparations of amino acid, glucose and lipid are used quent days. Parenteralnutritionishypertonic,irritantandthrom- High-risk patients should receive prophylaxis (see bogenic. Patients may 16 Chapter 1: Principles and practice of medicine and surgery present with painful swelling of the legs, low-grade Surgical site infection pyrexia or with signs and symptoms of a pulmonary embolism. Definition r Confusion due to hypoxia, metabolic disturbance, in- Surgical site infections include superficial site infections fection, drugs, or withdrawal syndromes. Intestinal fistulae may be managed con- including cannulae) and Streptococci or mixed organ- servatively with skin protection, replacement of fluid isms. The organisms responsible for organ or space and electrolytes and parenteral nutrition. If such con- infections are dependent on the site and the nature servative therapy fails the fistula may be closed surgi- of the surgical condition, e. The risk of surgical perioperative atelectasis unless a respiratory infection site infection is dependent on the procedure performed. Prophylaxis and treatment Contaminated wounds such as in emergency treatment involves adequate analgesia, physiotherapy and hu- for bowel perforation carry a very high risk of infection. Respiratoryfailure Patients at particular risk include the elderly, mal- may occur secondary to airway obstruction. Laryn- nourished, immunodeficient and those with diabetes geal spasm/oedema may occur in epiglottitis or fol- mellitus. In Clinical features the absence of obstruction hypoxia may result from Superficial infections appear as a cellulitis (redness, drugs causing respiratory depression, infection, pul- warmth, swelling and tenderness) around the wound monary embolism or exacerbation of pre-existing margin, there may be associated lymphadenopathy. Respiratory support may be may be of value to draw round the area of erythema to necessary. Deeper r Acute renal failure may result from inadequate infections and collections may present as pyrexia with perfusion, drugs, or pre-existing renal or liver disease. Specific presentations depend on the Once hypovolaemia has been corrected any remaining site, e. Treatmentinvolvesdebridement,treat- is preceded by a high volume serous discharge from the ment of any infection, application of zinc paste and in wound site and necessitates surgical repair. Late postoperative complications, which may occur Investigations weeksoryearsaftersurgery,includeadhesions,strictures Pyrexial patients require investigations. Injury or abnormal func- or isotope bone scanning to identify the source of infec- tion within the nervous system causes neuropathic pain. Itmaybe triggered by non-painful stimuli such as light touch, so- Management calledallodynia. Examplesofcausesincludepostherpetic r Prophylaxisagainstinfectionincludesmeticuloussur- neuralgia, peripheral neuropathy, e. Neuropathic pain is often diffi- Severely contaminated wounds may be closed by de- culttotreat,partlybecauseofitschronicbutepisodicna- layed primary suture. The principal reason for treating pain is to relieve suf- r Superficial surgical site infections may respond to an- fering. It improves patients’ ability to sleep and their tibiotics (penicillin and flucloxacillin, depending on overall emotional health. Deeper surgical site infections may re- can also have other benefits: postoperatively it can im- quire the removal of one or more skin sutures to al- prove respiratory function, increase the ability to cough low drainage of infected material. Abscesses generally and clear secretions, improve mobility and hence reduce require drainage either by surgery or radiologically the risk of complications such as pneumonia and deep guided aspiration alongside the use of appropriate an- vein thromboses. Assessing pain Pain control To diagnose and then treat pain first requires asking the Many medical and surgical patients experience pain. Often, if pain is treated aggres- Surgery causes tissue damage leading to the release of sively and early, it is easier to control than when the pa- localchemicalmediatorsthatstimulatepainfibres. Ischaemia, be asked to score their pain on a scale from none to very obstruction, infections, inflammation and joint disease severe (sometimes a 10-point scale is useful, where 0 also cause pain. In Pain may be induced by movement, which is sometimes some cases where verbal communication is not possible unavoidable, e. In contrast, immobility can cause pain due to resenting degrees of pain is useful. In addition, a patient’s what precipitates pain, such as movement or breathing, perception of pain is altered by many factors, including and whether the pain prevents or interrupts sleep. It is the patient’s overall physical and emotional well-being, important to establish whether the pain is nociceptive, cultural background, age, sex and ability to sleep ade- neuropathic or both. Depressionandfearoftenworsentheperception and these may require separate treatment plans. In a patient who is already taking analgesia, it is use- ful to assess their current use, the effect on pain and any Types of pain side-effects. Thepatientshouldalsobeaskedabouthisor Tissue damage causes a nociceptive pain, which can be her beliefs about drugs they have been given before. The further divided into a sharp, stabbing pain, which is patients should be involved as far as possible in the man- conveyed by the finely myelinated Aδ fibres, and a dull, agement of their pain. Adverse effects such as nausea 18 Chapter 1: Principles and practice of medicine and surgery and constipation are predictable, patients should be of their analgesia. A loading dose is given first, then the alerted to these and provided with means by which these patient presses a button to deliver subsequent small bo- can be treated early. This prevents respiratory depression due to acci- method for choosing appropriate analgesia depending dental overdose by the patient repeatedly pressing the on the severity of pain. If the patient becomes overly sedated, the de- cancer patients but is useful for many types of pain. If patients are not adequately tially, analgesia may be given on an as needed basis, but analgesed, the bolus dose is increased. This system is if frequent doses are required, regular doses should be not suitable for patients who are too unwell or confused given, so that each dose is given before the effect of the to understand the system and be able to press the button. Acombinationofdifferentdrugs often improves the pain relief with fewer adverse effects. Local and regional anaesthetic After analgesia is initiated, if it is ineffective at maximal Local anaesthetic is useful perioperatively. Certain drugs givenaround the wound or as a regional nerve block are contraindicated or used with caution in patients with to provide several hours of pain relief. Postoperative patients may descend the sia is useful for surgery of the lower half of the body. However, complications codeine, dihydrocodeine or tramadol orally or intra- include hypotension due to sympathetic block, urinary muscularly are added to regular paracetamol or an retention and motor weakness. Co-analgesics Modes of delivery of opioids These are other drugs that are not primarily analgesics, The oral route is preferred for most patients, but for but can help to relieve pain.

Plots of the residuals showed no evidence of nonlinear patterns of bias (although there was a general increased magnitude of residuals with in- creasing values of each variable) cheap viagra capsules online american express. Basal metabolism increases during pregnancy due to the metabolic contribution of the uterus and fetus and increased work of the heart and lungs cheap viagra capsules 100mg without prescription. The increase in basal metabolism is one of the major components of the increased energy requirements during pregnancy (Hytten purchase generic viagra capsules, 1991a). In late pregnancy, approximately one-half the increment in energy expenditure can be attributed to the fetus (Hytten, 1991a). The fetus uses about 8 ml O2/kg body weight/min or 56 kcal/kg body weight/d; for a 3-kg fetus, this would be equivalent to 168 kcal/d (Sparks et al. The basal metabolism of pregnant women has been estimated longitu- dinally in a number of studies using a Douglas bag, ventilated hood, or whole-body respiration calorimeter (Durnin et al. Marked variation in the basal metabolic response to pregnancy was seen in 12 British women measured before and through- out pregnancy (Goldberg et al. Energy-sparing or energy-profligate responses to pregnancy were dependent on prepregnancy body fatness. Nonpregnant prediction equations based on weight are not accurate during pregnancy since metabolic rate increases disproportion- ately to the increase in total body weight. In late gestation, the anti-insulinogenic and lipolytic effects of human chorionic somatomammotropin, prolactin, cortisol, and glucagon contrib- ute to glucose intolerance, insulin resistance, decreased hepatic glycogen, and mobilization of adipose tissue (Kalkhoff et al. Although levels of serum prolactin, cortisol, glucagon, and fatty acids were elevated and serum glucose levels were lower in one study, a greater utilization of fatty acids was not observed during late pregnancy (Butte et al. These observations are consistent with persistent glucose production in fasted pregnant women, despite lower fasting plasma glucose concentrations. After fasting, the total rates of glu- cose production and total gluconeogenesis were increased, even though the fraction of glucose oxidized and the fractional contribution of gluco- neogenesis to glucose production remained unchanged (Assel et al. Until late gestation, the gross energy cost of standard- ized nonweight-bearing activity does not significantly change. In the last month of pregnancy, the energy expended while cycling was increased on the order of 10 percent. The energy cost of standardized weight-bearing activities such as treadmill walking was unchanged until 25 weeks of gesta- tion, after which it increased by 19 percent (Prentice et al. Stan- dardized protocols, however, do not allow for behavioral changes in pace and intensity of physical activity, which may occur and conserve energy during pregnancy. Gestational weight gain includes the products of conception (fetus, placenta, and amniotic fluid) and accretion of maternal tissues (uterus, breasts, blood, extracellular fluid, and adipose). The energy cost of deposition can be calculated from the amount of protein and fat deposited. The total energy deposition between 14 and 37+ weeks of gestation was calculated based on an assumed protein deposition of 925 g of protein, and energy equivalences of 5. Total energy deposition during pregnancy was estimated from the mean fat gain of 3. Lactation Evidence Considered in Determining the Estimated Energy Requirement Basal Metabolism. The increased energy expenditure is consistent with the additional energy cost of milk synthesis. Theoretically, the energy cost of lactation could be met by a reduction in the time spent in physical activity or an increase in the efficiency of performing routine tasks. The energetic cost of nonweight-bearing and weight-bearing activities has been measured in lac- tating women (Spaaij et al. Adaptations in the level of physical activity are not always seen in lactating women. Reduc- tions in physical activity have been reported in early lactation (4 to 5 weeks postpartum) in the Netherlands (van Raaij et al. Physical activity increased in the lactating Dutch women from 5 to 27 weeks post- partum (van Raaij et al. While a decrease in moderate and discretionary activities appears to occur in most lactating women in the early postpartum period, activity patterns beyond this period are highly variable. These sources of error may be attributed to isotope exchange and sequestration that occurs during the de novo synthesis of milk fat and lactose, and to increased water flux into milk (Butte et al. Milk energy output is computed from milk pro- duction and the energy density of human milk. Beyond 6 months post- partum, typical milk production rates are variable and depend on weaning practices. The energy density of human milk has been measured by bomb calorimetry or proximate macronutrient analysis of representative 24-hour pooled milk samples. The changes in weight and therefore energy mobilization from tissues occur in some, but not all, lactating women (Butte and Hopkinson, 1998; Butte et al. In general, during the first 6 months postpartum, well-nourished lactating women experience a mild, gradual weight loss, averaging –0. Changes in adipose tissue volume in 15 Swedish women were measured by magnetic resonance imaging (Sohlstrom and Forsum, 1995). In the first 6 months postpartum, the subcutaneous region accounted for the entire reduction in adipose tissue volume, which decreased from 23. Mobilization of tissue reserves is a general, but not obligatory, feature of lactation. In the 10 lactating British women, the total energy requirements (and net energy requirements, since there was no fat mobilization) were 2,646, 2,702, and 2,667 kcal/d (11. In 23 lactating Swedish women, the total energy requirement at 2 months postpartum was 3,034 kcal/d (12. In nine lactating American women, the total energy requirement was 2,413 kcal/d (10. The women in the above studies were fully breastfeeding their infants, who were less than 6 months of age. In these studies, mean milk energy outputs during full lactation were similar (483 to 538 kcal/d or 2. During the first 6 months of lactation, milk production rates are increased (Butte et al. Customary milk pro- duction rates beyond 6 months postpartum typically vary and depend on weaning practices (Butte et al. Because adap- tations in basal metabolism and physical activity are not evident in well- nourished women, energy requirements of lactating women are met par- tially by mobilization of tissue stores, but primarily from the diet. In the first 6 months postpartum, well-nourished lactating women experience an average weight loss of 0. The coefficients and standard error derived for only overweight and obese men and women are provided in Appendix Table I-10. For the combined data sets, the standard deviations of the residuals ranged from 182 to 321. Persons who do not wish to lose weight should receive advice and monitoring aimed at weight maintenance and risk reduction. This could be due to a reduction in energy expenditure per kg body weight or to a decrease in physical activity. These values can be used to estimate the anticipated reduction in metabolizable energy intake necessary to achieve a given level of weight loss, if weight loss is achieved solely by a reduction in energy intake and there is no change in energy expenditure for physical activity.

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The following are examples of practices or actions that are considered dishonest acts in academic pursuit order viagra capsules without prescription. There are numerous ways and methods of cheating and they include:  Copying from others during a test or an examination order 100mg viagra capsules amex. Tampering with marks /grades after the work has been returned viagra capsules 100mg for sale, then re-submitting them for re-marking/re-grading. Plagiarism means to produce, present or copy others’ work without authorization and acknowledgment as the primary source in the form of articles, opinions, thesis, books, unpublished works, research data, conference and seminar papers, reports, paper work, website data, lecture notes, design, creative products, scientific products, music, music node, artefacts, computer source codes, ideas, recorded conversations and others materials. In short, it is the use, in part or whole, of others’ words or ideas and then claiming them as yours without proper attribution to the original author. It includes:  Copying and pasting information, graphics or media from the Internet into your work without citing the source. The non-acknowledgment of an invention or findings of an assignment or academic work, alteration, falsification or misleading use of data, information or citation in any academic work constitute fabrication. Some examples of collusion include:  Paying, bribing or allowing someone else to do an assignment, test/examination, project or research for self-interest. Examples of unfair advantage are:  Gaining access to reproduce or circulate test or examination materials prior to its authorised time. If under any circumstances a student comes to know of any incident that denotes a violation of academic integrity, the student must report it to the relevant lecturer. The lecturer is then responsible for investigating and verifying the violation and then reporting the matter to the Dean of the School. If the investigation reveals that a violation has been committed, the student will be referred to the University Student Disciplinary Committee (Academic Cases). This programme manages psychosocial issues in a more effective manner and finally could improve the well-being of individuals in order to achieve life of better quality. Ideally, students are encouraged to participate in the exchange programme within their third to fifth semester (3 year degree programme) and within the third to seventh semester (4 year degree programme). However, as a condition for the conferment of a degree the student gives this right unconditionally, directly but not exclusively, and free of royalties to the university to use the contents of the work/thesis for teaching, research and promotion purposes. In addition, the student gives non-exclusive rights to the University to keep, use, reproduce, display and distribute copies of the original thesis with the rights to publish for future research and the archives. Students from the School of Medical Sciences and School of Dentistry are required to register for two (2) units of Co- Curriculum course in year Two. Students from the School of Health Sciences are required to register for one (1) unit of Co-Curriculum course. Students may obtain advice from the School of Languages, Literacies and Translation if they have different Bahasa Malaysia qualifications from the above. International students in this category are required to take and pass three Intensive Malay Language courses before they commence their Bachelor’s degree programmes. Note: • Students are required to accumulate four (4) units of English for graduation. They can also take foreign language courses to replace their English language units but they must first obtain written consent from the Dean of the School of Languages, Literacies and Translation. With academic exposure to cultural issues and civilization in Malaysia, it is hoped that students will be more aware of issues that can contribute to the cultivation of the culture of respect and harmony among the plural society of Malaysia. Among the topics in this course are Interaction among Various Civilizations, Islamic Civilization, Malay Civilization, Contemporary Challenges faced by the Islamic and Asian Civilizations and Islamic Hadhari Principles. This course is designed with 3 main objectives: (1) to introduce students to the basic concept and the practices of social accord in Malaysia, (2) to reinforce basic understanding of challenges and problems in a multi-ethnic society, and (3) to provide an understanding and awareness in managing the complexity of ethnic relations in Malaysia. At the end of this course, it is hoped that students will be able to identify and apply the skills to issues associated with ethnic relations in Malaysia. The mode of teaching is through interactive lectures, practical, business plan proposals, execution of entrepreneurial projects and report presentations. Practical experiences through hands-on participation of students in business project management will generate interest and provide a clearer picture of the world of entrepreneurship. The main learning outcome is the assimilation of culture and entrepreneurship work ethics in their everyday life. This initiative is made to open the minds and arouse the spirit of entrepreneurship among target groups that possess the potential to become successful entrepreneurs. By exposing entrepreneurial knowledge to all students, it is hoped that it will accelerate the effort to increase the number of middle-class entrepreneurs in the country. Emphasis will be given both to current issues in Malaysian politics and the historical and economic developments and trends of the country. An analysis of the formation and workings of the major institutions of government – parliament, judiciary, bureaucracy, and the electoral and party systems will follow this. The scope and extent of Malaysian democracy will be considered, especially in the light of current changes and developments in Malaysian politics. The second part of the course focuses on specific issues: ethnic relations, national unity and the national ideology; development and political change; federal-state relations; the role of religion in Malaysian politics; politics and business; Malaysia in the modern world system; civil society; law, justice and order; and directions for the future. It is compulsory for students from the School of Education to choose a uniformed body co-curriculum package from the list below (excluding Seni Silat Cekak). Students who do not enrol for any co-curriculum courses or who enrol for only a portion of the 3 units need to replace these units with skill/option courses. Students are not allowed to register for more than one foreign language course per semester. They must complete at least two levels of a foreign language course before they are allowed to register for another foreign language course. However, students are not required to complete all four levels of one particular foreign language course. However, in certain cases (for example, the student is repeating his academic year and needs only several units to graduate), the Dean can recommend that the student register for units below the minimum number required. Students need to accumulate only a specific number of the outstanding units for graduation purposes. However if the School wishes to accredit only one course at the diploma level for unit exemption for one course at the degree level, the said course at the diploma level must be equivalent to that at the degree level and carry the same number of units or more. If the student has completed Industrial Training while pursuing the programme of study at the diploma level, he/she must have at least one year’s work experience. In addition, the student should also submit a report on their work performance and the type of work performed. Dean’s List Guidelines (i) Students who achieve academic excellence at the end of a semester will be placed in the Dean’s List. University Courses University courses are offered to students as part of the requirement for graduation. Compulsory (10 units) a) Malay Language 108 b) English Language c) Islamic and Asian Civilisations d) Ethnic Relations 2.

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The trainee– has heard the surgeons lament that hospital politics will supervisor relationship is fraught with challenges ranging from once again mean cutbacks order discount viagra capsules online, reduced operating room time inconsistent evaluation standards buy viagra capsules 100mg with visa, to intergenerational misun- and fewer nurses available after hours buy generic viagra capsules 100 mg online. In a survey of over ing that, although they seem to be getting home earlier, 1200 residents in the United States, 93 per cent of respondents the resident is losing the ability to remember details about had experienced maltreatment at some point in their residency; each patient, is less interested in their stories and, frankly, further, they believed this to have signifcantly affected their enjoys their days less. Perpetrators of resident abuse fnish residency and start practicing that they might have can be faculty but include other residents and health care pro- the inclination and infuence to do things differently. In a survey of stress experienced in residency training in Alberta, nurses were Introduction identifed as the greatest source of intimidation and harass- Healthy workplaces support their employees in achieving ment (Cohen and Patten 2005). Most trainees do not report healthy lifestyles, behaviours and adaptive coping skills. Ironically, health care settings can be among the least healthy Residents are not the only recipients of disruptive behaviours. Experiences of medical trainees, Some report witnessing what they feel are derogatory acts particularly in their clinical years, can have detrimental effects directed at other health care professionals, patients and their on their personal well-being, professional behaviours and aca- families. Although residents are generally resilient dents, who are caught between wanting to be part of the team individuals who cope well with change and uncertainty, they while not compromising the standards they were encouraged are at risk of the effects of stress, some of which are common to hold in their formal medical education. Nor does postgraduate education necessarily The resident struggling with multiple environmental infu- support the development of these competencies. The resident’s superior of immature coping skills range from the temporary crisis in communication skills are waning, and this loss is rein- confdence that many residents experience over the course of forced by colleagues and faculty. The resident is receiving their training, to mood, anxiety and substance abuse disorders, messages from faculty that suggest there is little control burnout, potential impairment and, tragically, suicide. As commonly happens conducted in the United States has reported rates of burnout as when physicians feel they have limited infuence on their high as 76 per cent among internal medicine residents (Thomas work situation, the resident appears to be losing some of 2004). The idea that physicians can be burned out in a career the joy and motivation initially brought to training and the they have yet to actually start should be of great concern for resident may be developing a complacency that is threaten- medical educators. Residents who demonstrate increased unprofessional behaviours are prone to making more medical At this point, the resident needs to reconnect with the errors than the average and to providing suboptimal patient core values and beliefs that led to the decision to become care (West and Shanafelt 2007). Attending academic half-days on physician the development of active coping skills positively infuence self-care or workshops that offer active coping strategies the well-being of trainees on many levels (Shapiro et al 2000). However, these are frequently not aligned with, or reinforced Regular, informal, small-group discussions with his peers by, the informal and hidden curricula in which residents learn. Such reconnection will, in turn, foster of the faculty role models they work with every day, (e. Few medical schools a survey examining resident physician satisfaction both within have wellness programs to support their faculty, not only in and outside of residency training and mental health in Alberta. Sources of stress for residents and recom- temic aspect of the hidden curriculum, and this also infuences mendations for programs to assist them. The infuence of personal and environmental factors on professionalism in medical edu- Strategies to promote a healthy working and learning environ- cation. Some faculties of medicine have done just this by developing innovative, bottom-up, relational-centred care and teaching models that are transforming the environment in which all physicians and health care teams function. They emphasize mentorship, communication and compassion, and increased “face time” between residents and faculty in order to promote healthy role modelling and reduce trainee distress (Mareiniss 2005, and Cottingham et al 2008). In addition, postgraduate Case medical education offces have taken steps to develop health A third-year resident who provides on-call services at a and safety policies specifcally for their trainees, presumably to mid-sized community hospital is called to the emergency delineate appropriate local responses to identifed inadequacies room to consult on a patient. Environmental health risks include accidents confrmed the resident’s confdence in their expanding and exposures to hazardous agents such as chemicals and knowledge and skills. Occupational risks include exposures to blood and other bodily fuids and to respiratory pathogens. Personal safety The triage nurse directs the resident to the room where the risks include exposure to violence perpetrated by patients or patient is waiting and closes the door behind her. The resident To ensure the protection of their residents, postgraduate concludes that the environment is no longer safe and gets medical education offces are required to collect immunization up to leave the room, at which point the patient blocks the data on their trainees and to adhere to a communicable disease door, shoves the resident, and picks up the chair in front policy for residents who have or present a risk of transmissible of him with a motion to throw it directly at the resident. In addition, programs traditionally offer orientation in working safely with hazardous materials and in communicable Many minutes later, when the resident manages to calm disease precautions and protocols. Individual programs that the patient to the point where the resident can make a safe involve specifc and frequent environmental exposures (e. Although they discuss the appropriate man- training to minimize risks of special relevance to these residents. These include but are not limited to exposures A further challenge of preparing residents to protect their own to hazardous materials and communicable pathogens, aggres- safety is that some risks are not immediately apparent, or may sive and violent patients, and repetitive strain injuries. Many of same time, elements of postgraduate training put residents at these are related to the number of hours spent in the health care additional risk of which trainees and their programs or institu- setting, very often at the least secure times. On-call residents tions may not be suffciently aware and so may not adequately and their nursing colleagues are frequently in the position of address. This, combined with their relative inexperience in identifying when a situation is getting out of hand, can increase their risk of assault by a patient. Like many mid-level residents, this resident is trying to bal- ance the confdence gained from working more indepen- These incidents can be extremely stressful to residents, who dently with the limitations of their experience. Residents may feel inadequately trained to deal with them on their own may not consider that they will be placed in situations that and may be unfamiliar with reporting protocols. Accreditation could cause them harm, and therefore rely on hospital poli- visits routinely examine the physical layout where residents cies and procedures to ensure their safety needs are met. In train to ensure they are properly equipped, for example by this case, such procedures were fawed. The resident was means of alarms and proximity to support staff, to prevent focused on making a proper diagnosis and management violent assaults by patients. However, these assessments might plan, rather than on assessing the risk of the situation. The not examine other less controllable settings were residents resident began the patient encounter without considering see patients, such as community clinics and patients’ homes. Additionally, the resident may not have had the skills Where specifc education and training programs exist to and training to calm an increasingly agitated patient, and manage workplace violence, residents and students are more did not have a supervisor present to review the situation likely to report incidents and get the support they need. Intimidation and harassment by faculty, staff and colleagues can present safety risks that An additional risk for this resident was inherent in the residents are, generally speaking, reluctant to disclose. In addi- location of the call room in a portable building outside the tion, excessive fatigue from long work hours can affect judg- main hospital where the resident could have been isolated ment and reaction times, leading to increased risk of needle from any security back-up, and from which the resident stick injuries, adverse events, medical error and motor vehicle was required to travel in the dark to get to the work site. Protecting Residents are aware that certain risks are associated with the the safety of medical students and residents [editorial]. Trainee miss out on a great learning opportunity, or fear of repercus- safety in psychiatric units and facilities: The position of the sion if they appear too hesitant or dependant, residents may Canadian Psychiatric Association. A pilot survey that residents are trained in risk assessment and in policies and of patient-initiated assaults on medical students during clinical procedures to follow when breaches occur. In different parts of the world, including our own, health and Case education systems have struggled with the issue of resident One of the nurses has made a complaint about a senior work hours. In Canada, we have typically negotiated work resident’s level of irritability, and another is questioning hours on a provincial/territorial basis, in keeping with the whether the resident is practising safely: apparently, the fundamental structure of our health care system. The Europe and the United States, considerable attention has been resident requests a meeting with the program director, paid to resident work hours on a larger scale; this has had the who notes they look exhausted.

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