By: David Robertson MD
The X-vision model allows practice papil lotomy to purchase 5 mg glucovance with mastercard blood sugar 180 be performed on artificial papillae made of a special molded material . Ex vivo model allows for only one papillotomy unless modified using the Neopapilla. The trainer needs to be able to recognize and correct the errors (mistakes) made by the trainee in terms of technical operation as well as clinical judgment, and to do it in a sup portive and nonpunitive manner. The “Train the trainer” courses have been ben eficial in highlighting the key elements. In the British system, attendance at such courses is now mandated, and trainees are required to assess their teachers in the e-portfolio system. Whatever training methods are employed, the key issue clearly is how well the trainee can perform. Trainees should keep logs of their procedures (on simulators as well as patients), and some metrics are suggested in Tables 1. Objective assessment of performance is easier to document with practice on simulators (Table 1. Specific end points may include successful execution of the procedure and total procedure time taken including the use of simulated fluoroscopy time during the practice . Documentation during computer sim ulation training is more complete with tracking of the time taken and number of attempts made to perform a particular procedure. Adjustment or modification in training can be done by using different computer software programs with varying levels of complexity, whereas the mechanical simulator can incorporate a different setup including changing position of the papilla or level of the bile duct stricture. Such changes can cater for procedures with varying levels of dif ficulties from basic cannulation to papillotomy and to the more advanced proce dures such as multiple stents placement for a simulated bile duct stricture . In general, trainer assessment is more subjective based on a summation of the overall clinical performance of the trainees (Tables 1. The Australians have an even tougher criterion which requires trainees to have performed 200 successful solo procedures without trainer involvement . These assessments are usually made by a sympathetic trainer at “home base, ” and are a complex amalgam of subjective information. The only important numbers (in practice and in training) are the actual out comes, using agreed quality metrics, such as deep biliary cannulation success and pancreatitis rates. Thus, we have long recommended that practitioners collect these data (report cards) , and have the opportunity to compare them with peers (benchmarking) . These systems also include complexity levels, so that the spectrum of practice can be documented.
Code D642 (Secondary sideroblastic anemia due to order glucovance 5 mg line zinc diabetes type 1 drugs or toxins) when reported due to conditions listed in the causation table under address code D642. The code Y402 is listed as a subaddress to D642 in the causation table so this sequence is accepted. Thrombocytopenia (D696) Code D695 (Secondary thrombocytopenia) when reported due to conditions listed in the causation table under address code D695. Codes for Record I (a) Multiple hemorrhages R5800 (b) Thrombocytopenia D695 (c) Cancer lung C349 Code to C349. Hyperparathyroidism (E213) Code E211 (Secondary hyperparathyroidism) when reported due to conditions listed in the causation table under address code E211. Codes for Record I (a) Korsakoff psychosis F04 (b) Wernicke encephalopathy E512 (c) Code to E512. The code E512 is listed as a subaddress to F04 in the causation table so this sequence is accepted. The code I709 is listed as a subaddress to F09 in the causation table so this sequence is accepted. Mental Disorder (any F99) Code F069 (Organic mental disorder) When reported due to or on the same line with conditions listed in the causation table under address code F069. Codes for Record I (a) Cardiorespiratory arrest I469 (b) Heart failure I509 (c) Mental disorder F069 (d) Multiple sclerosis G35 Code to G35. Parkinson Disease (G20) Advanced Parkinson Disease (G2000) Grave Parkinson Disease (G2000) Severe Parkinson Disease (G2000) a. Code G214 (Vascular parkinsonism) when reported due to conditions listed in the causation table under address code G214. Code G219 (Secondary parkinsonism) when reported due to: A170-A179 B060 B949 R75 Y20-Y369 A504-A539 B200-B24 F200-F209 S000-T357 Y600-Y849 A810-A819 B261 G000-G039 T66-T876 Y850-Y872 A870-A89 B375 G041-G09 T900-T982 Y881-Y899 B003 B900 G20-G2000 T983 B010 B902 G218-G219 X50-X599 B021-B022 B91 G300-G309 X70-X84 B051 B941 I950-I959 X91-Y09 Codes for Record 1. I (a) Parkinsonism G214 (b) Arteriosclerosis I709 (c) Code to G214 (Vascular parkinsonism) when reported due to conditions listed in the causation table under G214. I (a) Parkinson disease G219 (b) Tuberculous meningitis A170 (c) Code to G219 (Secondary parkinsonism) when reported due to conditions listed in the causation table under G219. The code E149 is listed as a subaddress to I672 in the causation table so this sequence is accepted. Code (b) as cerebrovascular atherosclerosis since reported as causing a cerebral thrombosis. Code I850 (Bleeding esophageal varices): When reported due to or on same line with: Alcoholic disease classified to: F101-F109 Liver diseases classified to: B150-B199, B251, B942, K700-K769 Toxic effect of alcohol classified to: T510-T519, T97 Codes for Record I (a) Varices I859 (b) Cirrhosis of liver K746 Code to K746. The code K746 is listed as a subaddress to I859 in the causation table; therefore, this sequence is accepted. Pneumoconiosis (J64) Code J60 (Coalworker pneumoconiosis): When Occupation is reported as: Coal miner Coal worker Miner Codes for Record Occupation: Coal Miner I (a) Bronchitis J40 (b) Pneumoconiosis J60 Code to J60. The code Q790 is listed as a subaddress to Q336 in the causation tables; therefore, this sequence is accepted. Codes for Record I (a) Biliary cirrhosis K744 (b) Carcinoma pancreas C259 (c) Code to C259.
The airway should be assessed and cleared of fuid and birth debris if there are signs of obstruction buy glucovance 50 mg mastercard diabetes foot signs. Neonatal Resuscitation Textbook recommends “suctioning immediately following birth (including suctioning with a bulb syringe) should be reserved for babies who have obvious obstruction to spontaneous breathing or who require positive-pressure ventilation. The baby’s bottom should not be spanked; gentle stroking and rubbing of the skin of the legs and buttocks should suffce. A regular sequence of events occurs when an infant becomes hypoxemic and acidemic. Initially, gasp ing respiratory efforts increase in depth and frequency for up to 3 minutes, followed by approximately 1 minute of primary apnea (Fig. If oxygen (along with stimulation) is provided during the apneic period, respiratory function spontaneously returns. If asphyxia continues, gasping then resumes for a variable period of time, terminating with the “last gasp” and is followed by secondary apnea. During secondary apnea the only way to restore respiratory function is with positive pressure ventilation and high concentrations of oxygen. Thus a linear relationship exists between the duration of asphyxia and the recovery of respiratory function after resuscitation. The longer that artifcial ventilation is delayed after the last gasp, the longer it will take to resuscitate the infant. Clinically, however, the two condi tions are indistinguishable, although an infant’s cyanosis will become progressively worse over time. Airway, airway, airway—the most important aspect of neonatal resuscitation is managing the airway. How much pressure does it take to infate the lungs of a healthy infant at the moment of birth The frst breath of an infant has been measured in the delivery room and is reported to be between 30 and 140 cm H2O. As surfactant is deposited, however, subsequent breaths rapidly decrease to 4 to 10 cm H2O. With limited energy reserves this effort soon deteriorates, and respiratory failure ensues. The oral intubation school argues that because neonates are obligate nose breathers, they will demonstrate increased work of breathing and atelectasis after removal of nasotracheal tubes. On the other hand, nasal intubation proponents assert that orotracheal intubation results in grooving of the palate with subsequent orthodontic problems.
However buy 5 mg glucovance mastercard blood sugar over 300, the anatomical variation, that is, close proximity of the papilla to the pylorus in the porcine model makes scope positioning and cannu lation more difficult. Besides, there are separate biliary and pancreatic ductal openings, making it suboptimal to practice selective cannulation. To facilitate practice of biliary papillotomy, the porcine model is further improved by attach ing a chicken heart (Neopapilla model) to a separate opening created in the second portion of the duodenum, which corrects for the anatomical difference and allows multiple (up to three) papillotomy practices to be performed on each chicken heart (artificial papilla) . Both utilize a rigid model with special papillae adapted to a mechanical duodenum. Hospitals have the responsibility for ensuring that their credentialing and privileging systems allow only competent endoscopists into their units. The assessment at the end of training could be made by people other than their trainers, by a combination of logbooks, Training and assessment of competence (Preparing the endoscopist) 13 videos, references, and observation of procedures (live and simulated) in their home environment or elsewhere. Ideally, there should be some form of certification at the national level, incorporating the complexity levels. Taking deep biliary cannulation as a key metric, we know that experts achieve greater than 95% success, but not all cases can or should be done by experts. Professional societies have usually suggested 85 or 90% in gen eral, but much depends on the clinical circumstances and setting. A less expert endoscopist will be acceptable, and may be life-saving, in an emergency. Patients should not be afraid to quiz their potential interventionists about their experience, and ask to see the report card . Training and Credentialing in Gastrointestinal Endoscopy in Endoscopy Practice and Safety. The Erlangen Endo-Trainer: Lifelike Simulation for Diagnostic and Interventional Endoscopic Retrograde Cholangiography. Didactic Teaching and Simulator Practice Improve Trainees’ Understanding and Performance of Biliary Papillotomy. A Prospective Study of Training in Endoscopic Retrograde Cholangio-pancreatography. The key issues for endoscopists, trainees, nurses, anesthesia, radiology, and reporting are covered in separate chapters. Apart from issues of scheduling, there are several reasons why that arrangement may be problematic. In addition, it is tedious and inefficient to have to transport all of the potentially needed equipment for each case.
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