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Foo20151013 2023 quzkes?1444774189
5
612

Hello World, I've been to London's Air Ambulance for a bit...

Hi. Or rather, #HelloMyNameIs Adam. I like trauma, emergency medicine, PHEC, #FOAMed, twitter and scuba diving (but only when there's sunshine involved afterwards). I also like teaching and education, and I'm one of the final year medical students here in Edinburgh. But for 2 months I wasn't. I was one of the London's Air Ambulance elective students down in Whitechapel at the Royal London Hospital. So as an opening gambit, and by some way of an introduction I thought you might want to hear about that. After all, they're much more interesting than I am, and I can't host you for your elective… I managed to swindle my way into a 2 month elective with LAA just before Christmas 2014 and in a word it was pretty great. For those of you thinking of doing it, just go, now, and apply. Then you can come back and read the rest of my ramblings. For the rest of you, here’s what happened. LAA electives are a bit different, unsurprisingly. To cover its 1800-odd missions a year, LAA runs both their trauma service in two flavours: a helicopter (G-EHMS, aka “Mike Sierra” or MEDIC 1) by day and a car (DA “Delta Alpha” 77 or MEDIC 1 NIGHT) by night, (because apparently, whilst sporting and enjoyable for the pilots, landing in metropolitan areas in the dark is too risky, especially with comparatively empty roads). Alongside the trauma service, there is also a Physician Response Unit (PRU) which responds locally to cardiac arrests to provide quality CPR (along with some advanced post-arrest care like cooling and delivery to a cath lab), but for the most part does jobs for the London Ambulance Service which have been deemed probably not to require hospital, but might benefit from a doctor. There’s a 5 year waiting list for day-time flying shifts, and not much less for the rest of their work, so you’re not going to spend 4, 6 or 8 weeks in a helicopter flying round London taking names and saving lives, in fact the helicopter schedule is totally off-limits to students. Instead you’ll start off scheduled for a couple of night shifts each month and there will be opportunities to see a lot of London Ambulance Service, from the “control” at the Emergency Operations Centre (EOC), to time spent with road crews, and, off the back of some of the folk you’ll meet, a route in to observing with some more specialist units too. (More on that in the future if I run out of other ideas!) As well as the “live” experience there are 5 very experienced senior registrars from a variety of backgrounds as well as the 4 full-time LAA consultants, and opportunities to learn both practical skills and theoretical knowledge from them abound. As it turned out, the PRU was probably my favourite part of the elective. You can read about all the trauma that LAA goes to elsewhere, its splashed all over their shiny new website for a start, and many things have been written about their work (I might even write some more later on!) and there’s even a (not great) telly program on Channel 5. But the PRU is just really cool. I hate that word but it is. It fits into a strange, but now expanding niche in emergency care. That is, it serves to lighten the load both on the ambulance service and on the Emergency Departments of London by going out to people who have called 999 and asked for an ambulance but might in fact be better managed in the community. The work is incredibly varied, you can see older folk with a nasty UTI who couldn’t get to see their GP, you can go to a school and glue the head of a kid who’s taken a nasty fall in the playground, or you can end up in some sheltered housing talking to a lady who’s having the roughest of times and trying to deal with borderline personality disorder to boot. The PRU is crewed about half the time by a small group of GPs and EM docs who have been doing it for a while, usually about once a week or so, and quite often in their own time (in between the rota is made up with the LAA docs who usually work the trauma service). They’re kept firmly in line by an experienced LAS paramedic who is seconded over to run this unit, 9-5, 5 days a week, usually for about a year. As a team, they have perfected their ability to assess a patient using the minimal resources available to them, and as we are so often reminded, quite rightly, it turns out to be all in the history. Some interventions are available to them that aren’t available to paramedics, prescribing antibiotics or other drugs to leave with the patient, bypassing the ED for referral straight to specialists, and doing urine dipsticks being the most used among them; but mostly it is the team’s experience and advanced clinical judgement which makes this unit tick, and empowers them to safely leave so many of their patients at home, with care delivered, advice given, and a plan arranged should anything deteriorate. This wasn’t my first rodeo, I’ve been lucky enough to spend some time with the Scottish Ambulance Service up here in Edinburgh, and have spent more than my fair share of time in our Emergency Department, but it was still impressive to see how these guys dealt with the delicate balance of who to leave at home and who might need a further investigation in hospital. Firstly, this is something that anyone who aspires to work in an emergency department should aspire to be comfortable to do. There are going to be a huge number of people who don’t need to be admitted coming through it every day, wherever it is. The faster and more confidently you can identify their problems, treat them, and crucially, reassure them with appropriate advice, good follow up and a safety net, the better experience they will have. Of course much of this comes with experience and training, but tagging along with teams like this is a fine way to start getting some. Secondly, and this is a bit of a stab in the dark, but I think this idea really might take off. The media is almost swamped with stories of A&E departments being overwhelmed, ambulance services are operating at or near capacity, and we’re struggling to work out how we get the public to access the right care provider for their problem at that time. So maybe this is a solution. Maybe doctors, have a new role to play in assessing people earlier rather than people going through so many steps down a potentially unsuitable line of care. We’re starting to see consultants running triage at A&Es, we’re starting to see doctors out in cars like this. Get in on the ground floor guys and girls, I think we’re going to start being “first on scene” a little more often than we might be used to, even if you never leave the hospital.  
Adam Collins
over 6 years ago
Preview 300x225
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The Ultimate OphthalmoloGAME

Players compete using their knowledge of Ophthalmology for the honour of the Ultimate OphthalmoloGAME trophy pictured in the centre of the board. Rules 1. Before rolling the die, players must complete an ophthalmology based challenge 2. The type of challenge the player must complete is dependent on the colour that their piece is on at the beginning of their turn 3. All players begin on Dark Purple (Multiple Choice Question 3. Categories are as follows Blue: Visual challenge, competitor looks into one of 5 randomly selected cups and must identify the type of retinal pathology as would be seen when using ophthalmoscopy Lilac: Case based question, clinical judgement question based on features of history and examinatio Silver: Eye Pictionary, other competitors must guess the ophthalmology related word via the competitor's artistic skill Dark purple: Multiple choice question, competitor must correctly select the answer to an ophthalmology based questio 4. If the competitor successfully completes their challenge, they are allowed to roll the die and move their piece forward accordingly 5. However, if the competitor fails to complete their challenge, they are not permitted to move forward and must complete a challenge of the same category on their next turn 6. The winner of the Ultimate Ophthalmology trophy is the first player to make a full circuit of the iris, reaching the pupil in doing so.  
Emma Papworth
almost 9 years ago
Foo20151013 2023 e7fpn8?1444774293
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339

The Importance Of Clinical Skills

In the USA the issue of indiscriminate use of expensive, sophisticated, and time consuming test in lieu of, rather than in addition to, the clinical exam is being much discussed. The cause of this problem is of course multifactorial. One of the factors is the decline of the teaching of clinical skills to our medical students and trainees. Such problems seem to have taken hold in developing countries as well. Two personal anecdotes will illustrate this. In the early nineties I worked for two years as a faculty member in the department of ob & gyn at the Aga Khan University Medical School in Karachi, Pakistan. One day, I received a call from the resident in the emergency room about a woman who had come in because of some abdominal pain and vaginal bleeding. While the resident told me these two symptoms her next sentence was: “… and the pelvic ultrasound showed…” I stopped her right in her tracks before she could tell me the result of the ultrasound scan. I told her: “First tell me more about this patient. Does she look ill? Is she bleeding heavily? Is she in a lot of pain and where is the pain? What are her blood pressure and pulse rate? How long has she been having these symptoms? When was her last menstrual period? What are your findings when you examined her ? What is the result of the pregnancy test?”. The resident could not answer most of these basic clinical questions and findings. She had proceeded straight to a test which might or might not have been necessary or even indicated and she was not using her clinical skills or judgment. In another example, the resident, also in Karachi, called me to the emergency room about a patient with a ruptured ectopic pregnancy. He told me that the patient was pale, and obviously bleeding inside her abdomen and on the verge of going into shock. The resident had accurately made the diagnosis, based on the patient’s history, examination, and a few basic laboratory tests. But when I ran down to see the patient, he was wheeling the patient into the radiology department for an ultrasound. "Why an ultrasound?" I asked. “You already have made the correct diagnosis and she needs an urgent operation not another diagnostic procedure that will take up precious time before we can stop the internal bleeding.” Instead of having the needless ultrasound, the patient was wheeled into the operating room. What I am trying to emphasize is that advances in technology are great but they need to be used judiciously and young medical students and trainees need to be taught to use their clinical skills first and then apply new technologies, if needed, to help them to come to the right diagnosis and treatment. And of course we, practicing physicians need to set the example. Or am I old fashioned and not with it? Medico legal and other issues may come to play here and I am fully aware of these. However the basic issue of clinical exam is still important. Those wanting to read more similar stories can download a free e book from Smashwords. The title is: "CROSSCULTURAL DOCTORING. ON AND OFF THE BEATEN PATH." You can access the e book here.  
DR William LeMaire
almost 6 years ago
29629
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Mental Status Examination (normal)

Mental Status Normal examinatio SECTION Orientation, Memory vide Attention-working memory vide Judgement-abstract reasoning vide Set generation vide Receptive language vide Expressive language vide Praxis vide Gnosis vide Dominant parietal lobe function vide Non-dominant parietal lobe function vide Visual recognition video With thanks to the authors and contributors to the NeuroLogic Exam website (http://medstat.med.utah.edu/neurologicexam) and Pediatric NeuroLogic Exam website (http://medstat.med.utah.edu/pedineurologicexam) retain copyright to all material, including movies, and request acknowledgement whenever it is used.  
Neurologic Exam
over 9 years ago
29748
2
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Cranial Nerves Examination - Normal

Orientation, Memor Asking questions about month, date, day of week and place tests orientation, which involves not only memory but also attention and language. Three-word recall tests recent memory for which the temporal lobe is important. Remote memory tasks such as naming Presidents, tests not only the temporal lobes but also heteromodal association cortices. Attention-working memory Digit span, spelling backwards and naming months of the year backward test attention and working memory which are frontal lobe functions Judgement-abstract reasoning These frontal lobe functions can be tested by using problem solving, verbal similarities and proverbs Set generation This is a test of verbal fluency and the ability to generate a set of items which are frontal lobe functions. Most individuals can give 10 or more words in a minute. Receptive language Asking the patient to follow commands demonstrates that they understand the meaning of what they have heard or read. It is important to test reception of both spoken and written language. Expressive language In assessing expressive language it is important to note fluency and correctness of content and grammar. This can be accomplished by tasks that require spontaneous speech and writing, naming objects, repetition of sentences, and reading comprehension. Praxis The patient is asked to perform skilled motor tasks without any nonverbal prompting. Skills tested for should involve the face then the limbs. In order to test for praxis the patient must have normal comprehension and intact voluntary movement. Apraxia is typically seen in lesions of the dominant inferior parietal lobe. Gnosis Gnosis is the ability to recognize objects perceived by the senses especially somatosensory sensation. Having the patient (with their eyes closed) identify objects placed in their hand (stereognosis) and numbers written on their hand (graphesthesia) tests parietal lobe sensory perception. Dominant parietal lobe function Tests for dominant inferior parietal lobe function includes right-left orientation, naming fingers, and calculations. Non-dominant parietal lobe function The non-dominant parietal lobe is important for visual spatial sensory tasks such as attending to the contralateral side of the body and space as well as constructional tasks such as drawing a face, clock or geometric figures. Visual recognition Recognition of colors and faces tests visual association cortex (inferior occiptotemporal area). Achromatopsia (inability to distinguish colors), visual agnosia (inability to name or point to a color) and prosopagnosia (inability to identify a familiar faces) result from lesions in this area.  
Neurologic Exam
about 9 years ago
Preview
2
39

The Ultimate OphthalmoloGAME

Players compete using their knowledge of Ophthalmology for the honour of the Ultimate OphthalmoloGAME trophy pictured in the centre of the board Rules 1. Before rolling the die, players must complete an ophthalmology based challenge 2. The type of challenge the player must complete is dependent on the colour that their piece is on at the beginning of their turn 3. All players begin on Dark Purple (Multiple Choice Question 3. Categories are as follows Blue: Visual challenge, competitor looks into one of 5 randomly selected cups and must identify the type of retinal pathology as would be seen when using ophthalmoscopy Lilac: Case based question, clinical judgement question based on features of history and examinatio Silver: Eye Pictionary, other competitors must guess the ophthalmology related word via the competitor's artistic skill Dark purple: Multiple choice question, competitor must correctly select the answer to an ophthalmology based questio 4. If the competitor successfully completes their challenge, they are allowed to roll the die and move their piece forward accordingly 5. However, if the competitor fails to complete their challenge, they are not permitted to move forward and must complete a challenge of the same category on their next turn 6. The winner of the Ultimate Ophthalmology trophy is the first player to make a full circuit of the iris, reaching the pupil in doing so.  
Emma Papworth
almost 9 years ago
Preview
2
10

Otitis media with effusion in under 12s: surgery | Guidance and guidelines | NICE

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.  
nice.org.uk
over 4 years ago
29746
1
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Mental Status Abnormal

Orientation, Memor This patient has difficulty with orientation questions. The day of the week is correct but he misses the month and date. He is oriented to place. Orientation mistakes are not localizing but can be due to problems with memory, language, judgement, attention or concentration. The patient has good recent memory (declarative memory) as evidenced by the recall of three objects but has difficulty with long term memory as evidenced by the difficulty recalling the current and past presidents. Attention-working memor The patient has difficulty with digit span backwards, spelling backwards and giving the names of the months in reverse order. This indicates a problem with working memory and maintaining attention, both of which are frontal lobe functions. Judgement-abstract reasoning The patient gives the correct answer for a house on fire and his answers for similarities are also good. He has problems with proverb interpretation. His answers are concrete and consist of rephrasing the proverb or giving a simple consequence of the action in the proverb. Problems with judgement, abstract reasoning, and executive function can be seen in patients with frontal lobe dysfunction. Set generatio Set generation tests word fluency and frontal lobe function. The patient starts well but abruptly stops after only four words. Most individuals can give more then 10 words in one minute. Receptive languag Patients with a receptive aphasia (Wernicke’s) cannot comprehend language. Their speech output is fluent but is devoid of meaning and contains nonsense syllables or words (neologisms). Their sentences are usually lacking nouns and there are paraphasias (one word substituted for another). The patient is usually unaware of their language deficit and prognosis for recovery is poor. This patient’s speech is fluent and some of her sentences even make sense but she also has nonsense sentences, made up of words and parts of words. She can’t name objects (anomia). She doesn’t have a pure or complete receptive aphasia but pure receptive aphasias are rare. Expressive languag This patient with expressive aphasia has normal comprehension but her expression of language is impaired. Her speech output is nonfluent and often limited to just a few words or phases. Grammatical words such as prepositions are left out and her speech is telegraphic. She has trouble saying “no ifs , ands or buts”. Her ability to write is also effected Patients with expressive aphasia are aware of their language deficit and are often frustrated by it. Recovery can occur but is often incomplete with their speech consisting of short phrases or sentences containing mainly nouns and verbs. Praxi The patient does well on most of the tests of praxis. At the very end when he is asked to show how to cut with scissors he uses his fingers as the blades of the scissors instead of acting like he is holding onto the handles of the scissors and cutting. This can be an early finding of inferior parietal lobe dysfunction. Gnosi With his right hand the patient has more difficulty identifying objects then with his left hand. One must be careful in interpreting the results of this test because of the patient’s motor deficits but there does seem to be astereognosis on the right, which would indicate left parietal lobe dysfunction. This is confirmed with graphesthesia where he definitely has more problems identifying numbers written on the right hand then the left (agraphesthesia of the right hand). Dominant parietal lobe functio This patient has right-left confusion and difficulty with simple arithmetic. These are elements of the Gertsmann syndrome, which is seen in lesions of the dominant parietal lobe. The full syndrome consists of right-left confusion, finger agnosia, agraphia and acalculia.  
Neurologic Exam
about 9 years ago
Preview
1
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Harry Burns: 'We need compassion, not judgments about poor people' | Peter Hetherington

Peter Hetherington: Scotland's retiring chief medical officer still wants to make the country a healthier place and stresses the connections between dire social conditions and ill health  
the Guardian
about 6 years ago
Www.bmj
1
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Deprivation of liberty in healthcare

The right to liberty in UK healthcare has been greatly strengthened this year. In March, the House of Lords Select Committee on the Mental Capacity Act (2005) published a report that severely criticised inconsistent safeguarding provisions for patients without mental capacity who are deprived of their liberty.1 Later that month, the UK Supreme Court gave judgment in a case “Cheshire West,” which involved three adults with severe learning disability and answered the general question “what is a deprivation of liberty?”2  
bmj.com
about 6 years ago
Www.bmj
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NHS is not (yet) in crisis, but what about school rugby?

If a crisis is the point of judgment, the nadir, the turning point, the NHS in England can’t yet be judged to be in crisis, said John Appleby of the health think tank the King’s Fund in a BBC interview this week, because things may well get worse (doi:10.1136/bmj.h50). This is hardly reassuring but probably realistic. Hospitals around the country are declaring “major incidents” because of a lack of beds or staff or both, emergency departments report that they are at breaking point, and general practice is under unprecedented pressure (doi:10.1136/bmj.h66, doi:10.1136/bmj.g7266, doi:10.1136/bmj.g6069, doi:10.1136/bmj.g6040). And there is little sign yet of things improving. Less realistic but more palatable is the belief of NHS England’s chief executive, Simon Stevens, that the £30bn (funding gap expected for 2020-21 can be narrowed to £8bn. This is magical thinking, says Nigel Hawkes (doi:10.1136/bmj.g7842).  
bmj.com
over 5 years ago
Preview
1
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Doctors should not cherry pick what information to give patients, court rules

Doctors should no longer decide what information a patient should be given before agreeing to treatment, the UK Supreme Court has ruled in a historic judgment.1  
bmj.com
about 5 years ago
Preview
1
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Guest Post: Agree to disagree? Why not? | Practical Ethics

Pedro Jesus Perez Zafrilla. (University of Valencia) In a previous post on this blog, David Aldridge questions the social convention of ending arguments by “agreeing to disagree.”, arguing that doing so “ends the dialogue at precisely the point where what is really at issue is beginning to emerge” . He also questions the motivations of those who seek to end an argument by offering to "agree to disagree" However, I think agreeing to disagree is a good idea and I will try to argue why. Debating could be characterized by three features: a context of disagreement, open-minded participants, and an expectation that one can rationally convince his/her interlocutor. Then, people who debate do so because they believe that agreement is possible. The achievement of agreement is the aim of  dialogue. Nevertheless, the desire to reach agreement shouldn’t lead us to forget that debate is fruitful only under certain conditions. Some of them include limitations of time and the number of participants, because the decision must be made, or agreement reached, within a reasonable span of time. But there are also other limitations in the debating process. We might begin with the expectation that one can rationally convince one’s interlocutor about the rightness of one’s position but we reach difficulties when incommensurable views are confronted. Some examples are found in debates on taxes, euthanasia or models of education. Here what is morally significant for some persons is not so for others. So, concepts such as “a dignified life” or “quality of education” have different meanings for each side of the debate. Accordingly, the arguments one side presents will not be convincing to the other side. In these cases, the expectation that one can rationally convince one’s interlocutor will generate polarization processes toward antagonist positions (see Haidt, J. “The Emotional Dog and its Rational Tail. A Social Intuitionist approach to Moral judgement”, Psychological Review, 108, 2001, p.823). Even more, each person will think that his/her interlocutor is not morally motivated (Schulz, Kathryn. Being wrong. Adventures in the margin of error. London: Portobello Books, 2010, pp.107-110). In that context, far from achieving agreement, debate leads to disagreement. For that reason, I think the more reasonable option to avoid this turn is to seek points of convergence between the interlocutors, whilst recognising the deep differences that remain between them, as Gutmann and Thompson suggest (Gutmann, A. and Thompson, D. Democracy and disagreement. Cambridge: Harvard University Press, 1996, pp.84-85). However, this recognition of the limitations of the agreement that can be reached doesn’t mean that the dialogue has failed. On the contrary, it is the most suitable way to maintain the effectiveness of dialogue and arrive at agreement. I think so for three reasons: the first is that agreeing to disagree avoids the frustration when our interlocutor doesn’t recognize the rightness of our arguments. Second, and as a consequence of the first, agreeing to disagree enables us to continue recognizing our interlocutor as an open-minded person. Finally, it enables us to set more realistic goals for deliberation. The opposite, blindly trusting the open-mindedness of our interlocutor, as Aldridge argues, seems a to be overly optimistic.. Then, answering to Aldridge’s question about what could motivate an offer to agree to disagree, an appropriate reason to offer to agree to disagree would be an awareness of the limitations that debate has in contexts of deep disagreement.  
blog.practicalethics.ox.ac.uk
almost 5 years ago
Preview
1
1

General =========================================================================

This information is intended for physicians and related personnel, who understand that medical information is often imperfect, and must be interpreted in the context of a patient's clinical data using reasonable medical judgment. This website should not be used as a substitute for the advice of a licensed physician. All information on this website is protected by copyright of PathologyOutlines.com, Inc. Information from third parties may also be protected by copyright. Please contact us at copyrightPathOut@gmail.com with any questions (click here for other contact information).  
pathologyoutlines.com
over 4 years ago
Preview
1
0

Multiple sclerosis in adults: management | Guidance and guidelines | NICE

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.  
nice.org.uk
over 4 years ago
Preview
1
7

Gallstone disease: diagnosis and initial management | Guidance and guidelines | NICE

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.  
nice.org.uk
over 4 years ago
Preview
1
0

Rehabilitation after critical illness in adults | Guidance and guidelines | NICE

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.  
nice.org.uk
over 4 years ago
Preview
1
6

Child maltreatment: when to suspect maltreatment in under 18s | Guidance and guidelines | NICE

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.  
nice.org.uk
over 4 years ago
Preview
1
0

Donor milk banks: service operation | Guidance and guidelines | NICE

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.  
nice.org.uk
over 4 years ago
7
1
0

Smoking: workplace interventions | Guidance and guidelines | NICE

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.  
nice.org.uk
over 4 years ago