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However generic 10mg maxalt amex, if the researcher has an interest in this parti- cular issue buy discount maxalt 10mg online, or is perhaps on a media studies course, there are a number of ways in which this research could become more manageable. The researcher could focus in on a particular type of programme and/or a particu- lar type of person. For example, she could decide to show an Open University programme to potential OU students and find out what they thought about the pro- 10 / PRACTICAL RESEARCH METHODS gramme in a series of focus groups. Or she could choose children’s programming and find out what tea- chers think about the educational value of these pro- grammes. Or she could ask business people what they think about a programme aimed specifically at the busi- ness community. Finally, maybe she could ask fellow students to keep a diary of their television viewing over a week and then interview them about their viewing ha- bits. The researcher needs to decide exactly where her inter- ests lie and focus in on those interests. Statement 2: My project is to do some research into Alz- heimer’s disease, to find out what people do when their relatives have it and what support they can get and how nurses deal with it. The topic itself is more focused as the researcher has mentioned, specifically, the areas he wishes to consider – nurses’ attitudes, carers’ experiences and available support. His topic is immediately more manageable be- cause he is only considering nurses or carers who come into contact with sufferers of Alzheimer’s disease. How- ever, he needs to think about whether he is going to consider hospitals, residential homes, or both, and in what areas. Also, is he going to contact people who look after their relatives at home? HOW TO DEFINE YOUR PROJECT / 11 Although, on the surface, this project appears more manageable, this researcher has a major point to con- sider. In the UK all social research which is carried out on health care premises comes under the jurisdic- tion of Research Ethics Committees. These committees were set up to ensure that research does not harm pa- tients in any way and that it is done in their best inter- ests. In the USA a similar function is carried out by Institutional Review Boards. This means that the re- searcher would have to get his project approved by the appropriate committee before he could go ahead with the research, and it is not guaranteed that his pro- ject would be given approval. As he would have to sub- mit a full and detailed proposal to the committee, he could be conducting a lot of preliminary work, only to be turned down. Researchers need to think carefully whether this is a route they wish to take, and if so, ob- tain the appropriate advice before committing them- selves. Statement 3: We want to find out how many of the local residents are interested in a play scheme for children dur- ing the summer holiday. This project put forward by a tenants’ association ap- pears to be straightforward and manageable, although there are still several issues which need addressing. My first question for this topic would be: do you really want to find out how many of the local residents are inter- 12 / PRACTICAL RESEARCH METHODS ested, or do you want to find out the interests of resi- dents with children of the appropriate age who would ac- tually use the scheme? If the latter is the case, this narrows down the research population and makes it more manageable. Finding out whether someone is interested in something is not actually the same as finding out whether someone would use the service. For example, I might think a play scheme is a good idea for other children as it might keep them off the streets, but not for my little darlings who are too occupied with their computer. If I said ‘yes, I am interested’, this could be misleading as I have no in- tention of using the service. However, if the purpose of the research is to obtain funding for the scheme, then the more people who express an interest, the better, although the tenants’ association would have to be careful not to produce misleading information. I would also find out whether the tenants’ association was interested only in the issue of how many people were interested in it and would use the play scheme.

Emission Sympathetic T11 to L2 (hypogastric Erections nerve) Ejaculation Somatic S2 best 10mg maxalt, 3 order 10mg maxalt with visa, 4 Most patients with complete upper motor neurone lesions of (pudendal nerve) the cord have reflex, but not psychogenic, erections. However, 67 ABC of Spinal Cord Injury the erections are not always sustained or strong enough for penetrative sex. In patients with complete lower motor neurone lesions parasympathetic connections from the S2 to S4 segments of the cord to the corpora cavernosa are interrupted, so that reflex erections are usually impossible. Difficulty in achieving a satisfactory erection has been revolutionised by the introduction of sildenafil, which has often replaced the use of intracavernosal drugs such as alprostadil or vacuum erection aids and compressive retainer rings. Insertion of a penile implant is also possible, but carries a small risk of infection or erosion of the implant which will necessitate its removal. Some men with a sacral anterior nerve root stimulator are able to achieve stimulator-driven erections, in addition to using the stimulator primarily for micturition. For seminal emission to occur the sympathetic outflow from T11 to L2 segments of the cord to the vasa deferentia, seminal vesicles, and prostate must be intact. Emission infers a trickling leakage of semen, with no rhythmic contractions of the pelvic floor muscles as in true ejaculation. Some patients with complete cord lesions at lumbar or sacral level may have both psychogenic erections and emissions. If ejaculation is not possible during penetrative sexual intercourse, it may be induced by direct stimulation of the fraenum of the penis by masturbation or by using a vibrator. If this is unsuccessful, rectal electroejaculation may produce what is actually an emission. In men who cannot ejaculate using the vibrator, or where electroejaculation is difficult, a hypogastric plexus stimulator can be implanted to obtain seminal emission, using a single Figure 13. Men with lesions above T6 are at courtesy of Professor SWJ Seager, Washington DC, USA. If this occurs activity should be curtailed, the man sat upright, and if necessary given sublingual nifedipine. For erection: • Oral sildenafil • Intracavernosal drugs Preparation for sexual intercourse • Vacuum erection aid and compressive retainer ring • Penile implant (small risk of infection or extrusion) Preparation for sexual intercourse includes ensuring that the • Sacral anterior root stimulator bladder is as empty as possible. A man with an indwelling For ejaculation or seminal emission: catheter should preferably remove it, but it may be strapped • Vibrator back on to the shaft of the penis. The able-bodied partner tends to be the more • Hypogastric plexus stimulator active, and this has a bearing on the positions used for To collect spermatozoa: intercourse. The quality of the (possible in men during ejaculation, and in women during labour, if seminal fluid may improve with repeated ejaculations, however, lesion above T6) and successful insemination has been reported both with the • Sublingual nifedipine or vibrator and by electroejaculation. It is essential to obtain • Glyceryl trinitrate (potentially fatal interaction with sildenafil) microbiological cultures of the seminal fluid and to eradicate 68 Later management and complications—I any infection prior to proceeding with any attempt at Box 13. The success rate has recently improved with the use of assisted conception techniques, including enhancement • If lesion complete above T10, labour may be painless, therefore of seminal fluid, intrauterine insemination, and assisted admit to hospital early, before labour commences reproductive technology, such as in vitro fertilisation (IVF) and • Increased risk of assisted delivery because of paralysis of intracytoplasmic sperm injection (ICSI). Autonomic dysreflexia during labour is a risk in patients with lesions at T6 and above, but this complication can be prevented by epidural anaesthesia. Fulfilment in relationships It should be emphasised that emotional and psychological factors are as important as physical factors in a satisfying relationship and that such a relationship is possible even after severe spinal cord injury. This needs reiterating, particularly to young men who are otherwise apt to see their altered sexual function as a profound loss. Although sensation in the sexual organs may be reduced or absent, imaginative use can be made of touching and caressing, as areas of the body above the level of the spinal cord lesion may develop heightened sensation as erogenous zones. Some couples find that the extra time and effort required for sexual expression after one of them has suffered a spinal cord injury enriches their lives and results in a more understanding and caring relationship. Transrectal electroejaculation combined with in-vitro fertilization: effective treatment of anejaculatory infertility due to spinal cord injury. Human Reproduction 1997;12:2687–92 • Cross LL, Meythaler JM, Tuel SM, Cross AL. Sexual problems associated with spinal and may develop heightened sensation cord disease.

Nurses 43 Ten Things Doctors Do That Nurses Hate 1 Leave sharps lying around – this is a sackable offence order maxalt 10mg online. Likewise generic 10 mg maxalt with mastercard, do not clear up someone else’s sharps, as if you are unlucky enough to sustain a sharps injury you may not be able to trace the donor. The most effective way to decrease National Health Service (NHS) expenditure is to improve communication. This in turn decreases clinical error and thus, litigation (see the section on giving instructions). This is extremely dangerous and one of the most common causes of clinical mistakes. Most nurses expect junior doctors to answer within approximately five to ten seconds (as we have nothing better to do and will obviously be sitting by the telephone in the doctor’s mess). However unrealistic their expectations, you should not take longer than one minute to answer your bleep unless you are performing a procedure or talking to relatives, etc. In this situation, try and ask someone to hold your bleep until you are finished. If there is a good night sister on (and they usually are) then they will amass a num- ber of non-urgent jobs that need doing before you turn in, for example cannula- tion, reading electrocardiographs and checking observation readings. They will often not bleep you for these as they are not ‘urgent’, but require doing before bed. It is good practice to drop in to each of your wards before bed to (i) clear up any jobs and (ii) let the nurses know so they do not bleep you too much. Most nurses appreciate that doctors need their sleep too and will try to minimise the number of bleeps they make if they know you have gone to bed. You will often want to wring someone by the neck after a long difficult day but this really will get you nowhere. Do not forget that they probably asked the right person who conveniently‘forgot’ to do it. You will quickly establish which of your peers consistently ‘forget’ to complete certain tasks such as rewriting drug charts or prescribing TTA sheets, leaving it instead for the on-call doctor to do. A polite but firm request for some help normally will suffice, but if you are rude you will find that next time they will not bother to help at all (it can be a bit of a Catch 22 situation sometimes). When I was a pre-registration house officer (PRHO) in respiratory medicine, I was bleeped near midnight to come to the ward to see one of the elderly patients. I knew the gentleman well, a very pleasant man who used to rivet the bodywork of aircraft together in the Second World War. The nurse had been going around the ward performing the routine observations on all the patients (pulse, blood pressure, temperature, etc. She related to me over the phone ‘he is tachycardic and his blood pressure is up and he is really out of breath. I ran up to the ward to see the patient who looked at me and said ‘I don’t know what all the fuss is about’. When I explained the nurse was worried as he was out of breath and his heart was pounding away Nurses 45 he replied ‘of course it is. I was having a cigarette outside the entrance and the lift wasn’t working so I had to walk up the stairs! If the nurse had simply asked the patient some questions instead of relying purely on numbers on the chart then I would have had a peaceful night. Giving Instructions Communication or lack of it is the chief cause of litigation within the NHS today. Lack of effective communication is particularly noticeable in some doctors compared to others. Most of us find it relatively easy to talk to fellow doctors or patients, but the worst communica- tion is usually to nursing staff or peer-level doctors when‘handing over’ (I will come to this in a moment). All through medical school we are taught to converse with other doctors and with our patients in order to take histories. We are never taught how to communicate with nurses effectively and for this reason most doctors do not actu- ally know what information nurses need to do their job.