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Objetivo: describir las competencias profesionales de los enfermeros que trabajan en urgencias y emergencias y comprender la percepción que tienen sobre las competencias esenciales para el desempeño y la actualización profesional. Método: estudio secuencial explicativo de métodos mixtos, realizado con enfermeros de urgencias y emergencias. Para obtener datos cuantitativos, se utilizó un cuestionario con 78 ítems, respondido por 39 enfermeros, que fueron analizados mediante estadística descriptiva y pruebas no paramétricas. Los datos cualitativos se obtuvieron a través de entrevistas semiestructuradas con 17 enfermeros, que fueron interpretados mediante el análisis temático de contenido inductivo. Los datos se combinaron por conexión. Resultados: se obtuvo un alto nivel de competencia en la autoevaluación de los enfermeros de urgencias y emergencias en el factor 2 - relaciones en el trabajo y un nivel más bajo en el factor 6 - excelencia profesional (p=0,036). Los datos cualitativos coincidieron positivamente con el factor relaciones en el trabajo, identificando la asociación entre conocimiento y experiencia práctica con las competencias, además de un escenario que carece de educación continua. Conclusión: a pesar de los altos niveles de competencia identificados en los enfermeros de urgencias y emergencias, el fortalecimiento de las estrategias educativas favorece el desarrollo y reconocimiento profesional. Objective: to describe the professional competencies of nurses working in urgency and emergency services and to understand their perception of the essential competencies for professional performance and updating. Method: a sequential, mixed-methods and explanatory study, conducted with emergency nurses. To obtain the quantitative data, a questionnaire with 78 items was used, answered by 39 nurses and analyzed using descriptive statistics and non-parametric tests. In turn, the qualitative data were obtained through semi-structured interviews with 17 nurses, whose interpretation was based on inductive content thematic analysis. The data were combined by connection. Results: a high level of competence was obtained in the self-assessment of urgency and emergency nurses in Factor 2 - Relations at work and a lower level in Factor 6 - Professional excellence (p=0.036). The qualitative data corroborated positively with the “Relations at work” factor, identifying the association of knowledge and practical experience, with competencies beyond a scenario devoid of permanent education. Conclusion: despite the high levels of competence identified in emergency nurses, the strengthening of educational strategies favors professional development and recognition. Objetivo: descrever as competências profissionais dos enfermeiros que atuam em urgência e emergência e compreender sua percepção a respeito das competências essenciais para a atuação e a atualização profissional. Método: estudo sequencial explanatório de métodos mistos, realizado com enfermeiros de urgência e emergência. Para a obtenção dos dados quantitativos, utilizou-se um questionário com 78 itens, respondidos por 39 enfermeiros, que foram analisados mediante estatística descritiva e testes não paramétricos. Já os dados qualitativos, foram obtidos por entrevista semiestruturada realizada com 17 enfermeiros, cuja interpretação deu-se pela análise temática de conteúdo indutiva. Os dados foram combinados por conexão. Resultados: obteve-se alto nível de competência na autoavaliação dos enfermeiros de urgência e emergência no fator 2 – relações no trabalho e menor nível no fator 6 - excelência profissional (p=0,036). Os dados qualitativos corroboraram de forma positiva com o fator relações no trabalho, identificando a associação do conhecimento e experiência prática com competências, além de um cenário desprovido de educação permanente. Conclusão: apesar de altos níveis de competência identificados nos enfermeiros de urgência e emergência, o fortalecimento de estratégias educacionais favorece o desenvolvimento e o reconhecimento profissional.

An earthquake measuring 7.7 magnitude on the Richter scale occurred at 04:17am on February 6, 2023 in the Pazarcık district of Kahramanmaraş province Turkey. In the hours following the 7.7 magnitude event in Kahramanmaraş, a second 7.6 magnitude earthquake struck the region and a third 6.4 magnitude earthquake struck Gaziantep, causing extensive damage and death. A total of ten provinces directly experienced the earthquake, including Kahramanmaraş, Hatay, Gaziantep, Osmaniye, Malatya, Adana, Diyarbakır, Şanlıurfa, Adıyaman, and Kilis. The official figures indicate 31,643 people were killed, 80,278 were injured, and 6,444 buildings were destroyed within seven days of the earthquakes (as of 12:00pm/noon on Monday, February 13th). The area affected by the earthquake has been officially declared to be 500km in diameter. This report primarily relies on observations made by pioneer Emergency Physicians (EPs) who went to the disaster areas shortly after the first earthquake (in the early stages of the disaster). According to their observations: (1) Due to winter conditions, there were transportation problems and a shortage of personnel reaching disaster areas on the first day after the disaster; (2) On the second day of the disaster, health equipment was in short supply; (3) As of the third day, health workers were unprepared in terms of knowledge and experience for the disaster; and (4) The subsequent deployment of health personnel to the disaster area was uncoordinated and unplanned on the following days, which resulted in the health personnel working there not being able to meet even their basic needs (such as food, heating, and shelter). During the first week, coordination was most frequently reported as the most significant problem.

Cardiogenic shock (CC) is the most advanced and severe stage of heart failure. Its management requires a rapid diagnosis, an etiological evaluation and the initiation of an adapted treatment as soon as possible. Even if ischemic etiology remains preponderant, the prevalence of other causes, notably valvular, is constantly increasing. In our industrialized countries, aortic stenosis is the most frequent valve disease, followed by mitral insufficiency, aortic insufficiency and mitral stenosis. While the management of these valvulopathies is well codified and has been evolving over the last few years, acute management is less clear. Inotropic treatments and mechanical circulatory support are part of the therapeutic arsenal available, but the correction of the valve disease remains the main problem. Conventional surgery is unfortunately difficult to consider because of its high moribidity and mortality. Percutaneous techniques are therefore an alternative, even if few data are available and their development according to the type of valve disease is uneven. This update provides an overview of the different valve diseases in the context of CC and summarizes the different therapeutic options available in such a critical situation.

Le TRALI (transfusion-related acute lung injury) est une insuffisance respiratoire aiguë hypoxémique, due à un œdème pulmonaire lésionnel, survenant dans les six heures suivant l’administration de produits sanguins labiles. Il peut être d’origine immunologique, médié par des anticorps anti-HLA ou anti-HNA ou d’origine non immunologique, secondaire à la présence de modificateurs de la réponse biologique. Les mesures d’éviction des donneurs à risque ont permis de diminuer l’incidence du TRALI immunologique. Sa physiopathologie est dominée par le modèle de la double agression avec un facteur donneur et un facteur receveur. Les patients de réanimation sont particulièrement à risque de TRALI. La classification du TRALI de 2019 adopte la dernière définition du SDRA et met en lumière le fait que le TRALI puisse survenir chez des patients ayant un SDRA préexistant ou d’autres causes concomitantes de SDRA. Le diagnostic de TRALI est un diagnostic clinico-radiologique où le facteur temps est un élément majeur. La distinction entre TRALI et œdème pulmonaire post transfusionnel de surcharge ou TACO (transfusion associated circulatory overload) se fait sur un faisceau d’arguments. La prise en charge du TRALI est symptomatique et seules des mesures préventives sont actuellement accessibles pour prévenir cette complication dont la mortalité peut atteindre 50%.

L’arsenal pharmacologique est responsable de près de 25% des cas d’insuffisance rénale aigüe (AKI) survenant en réanimation [1]. Parmi les médicaments à l’origine d’AKI les traitements anti-infectieux occupent une place significative. De tous les compartiments rénaux, le tubule, situé au carrefour des voies excrétrices des agents pharmacologiques et leurs métabolites, est la cible principale de la toxicité des anti-infectieux. Le tubule contourné proximal (TCP) remplit les fonctions d’une véritable plaque tournante : capable à la fois de réabsorber les traitements filtrés depuis la lumière tubulaire ou de participer à leur élimination dans les urines. L’accumulation de ces agents survient à la fois au sein des cellules tubulaires et dans leur lumière où ils peuvent précipitent sous forme de cristal ou d’agrégat. Ils constituent alors des micro-obstructions interrompant le flux urinaire. D’autre agents anti-infectieux interfèrent avec la sécrétion tubulaire causant ainsi des « pseudo- insuffisance rénale aiguë ». Des mécanismes immuno-allergiques peuvent également survenir. Dans ce cas l’agent pharmacologique anti-infectieux déclenche une activation lymphocytaire T et une inflammation interstitielle. Enfin certains agents pharmacologiques sont susceptibles de provoquer une insuffisance rénale aiguë par un mécanisme plus indirect, en étant à l’origine d’une hémolyse ou d’une rhabdomyolyse.

Les transfusions de produits sanguins labiles sont indispensables pour la prise en charge adéquate de diverses pathologies. Toutefois, elles ne sont pas sans risques, si bien que leur usage doit être raisonné. Pour les globules rouges, une stratégie transfusionnelle restrictive, privilégiant des seuils transfusionnels plus bas (hémoglobine 70 g/L) que ce qui était historiquement recommandé (hémoglobine 90-100 g/L), peut être recommandée pour la plupart des enfants admis en réanimation : elle permet de réduire la consommation de concentrés érythrocytaires sans affecter le pronostic des patients. Bien qu’une stratégie plus libérale puisse être envisagée sur base du jugement clinique dans certaines circonstances (incluant l’hypoxémie sévère, l’instabilité hémodynamique, le traumatisme crânien grave ou encore la dysfonction myocardique sévère), aucune donnée solide n’appuie l’intérêt d’une transfusion si l’hémoglobine est supérieure à 100g/L. Les données de la littérature sont beaucoup plus pauvres pour les transfusions de plasma et de plaquettes en réanimation pédiatrique, si bien que les experts ne peuvent recommander formellement une transfusion qu’en cas d’hémorragie massive, alors qu’ils invitent à utiliser le jugement clinique dans la plupart des autres situations. La recherche en médecine transfusionnelle doit être poursuivie afin d'obtenir des données permettant de développer des recommandations transfusionnelles davantage basées sur l'évidence.

Introduction: In Japan, evacuation at home is expected to increase in the future as a post-disaster evacuation type due to the pandemic, aging, and diverse disabilities of the population. However, more disaster-related indirect deaths occurred in homes than in evacuation centers after the 2011 Great East Japan Earthquake (GEJE). The health risks faced by evacuees at home have not been adequately discussed. Study Objective: This study aimed to clarify the gap in disaster health management for evacuees at home compared to the evacuees at the evacuation centers in Minamisanriku Town, which lost all health care facilities after the 2011 GEJE. Methods: This was a retrospective cross-sectional and quasi-experimental study based on the anonymized disaster medical records (DMRs) of patients from March 11 through April 10, 2011, that compared the evacuation-at-home and evacuation-center groups focusing on the day of the first medical intervention after the onset. Multivariable Cox regression analysis and propensity score (PS)-matching analysis were performed to identify the risk factors and causal relationship between the evacuation type and the delay of medical intervention. Results: Of the 2,838 eligible patients, 460 and 2,378 were in the evacuation-at-home and evacuation-center groups, respectively. In the month after the onset, the evacuation-at-home group had significantly lower rates of respiratory and mental health diseases than the evacuation-center group. However, the mean time to the first medical intervention was significantly delayed in the evacuation-at-home group (19.3 [SD = 6.1] days) compared to that in the evacuation-center group (14.1 [SD = 6.3] days); P Conclusion: This study suggested, for the first time, the causal relationship between evacuation at home and delay in the first medical intervention by PS-matching analysis. Although evacuation at home had several advantages in reducing the frequencies of some diseases, the delay in medical intervention could exacerbate the symptoms and be a cause of indirect death. As more evacuees are likely to remain in their homes in the future, this study recommends earlier surveillance and health care provision to the home evacuees.

Introduction: The ever-growing penetration of internet and mobile technologies into society suggests that people will increasingly use web searches to seek health-related information, including advice on first aid in medical emergencies. When a bystander is incompetent in first aid and has no immediate support from Emergency Medical Services (EMS), as it happens in low-resource settings or in disasters, instructions found online could be the sole driver for administering first aid before arrival of professional help. Study Objective: The aim of this study was to evaluate quality of advice on first aid generated by a web search engine’s question-answering system (QAS) in response to search queries concerning provision of help in common health emergencies. Methods: In December 2022-January 2023, an English-language search was carried out in Google with ten queries based on the keyword combinations (what to do OR how to help) AND (bleeding OR chest pain OR choking OR not breathing OR seizure). The search engine’s QAS responses (up to 11 per search query) were evaluated for compliance with the International Federation of Red Cross First Aid Guidelines 2020 using the pre-developed checklists. Results: Out of 98 QAS items generated by Google, 67.3% (n = 66) were excluded, mainly because the QAS answers did not address original queries. Eligible unique QAS responses (n = 27) showed poor coverage of the guideline-compliant instructions on first aid. Mean percentage of QAS responses providing a first aid instruction with complete adherence to the guidelines varied from 0.0 for choking to 19.5 for seizure. Only three (11.1%) QAS responses contained an explicit instruction to access EMS, while 66.7% (n = 18) included directions either contradictory to the guidelines and potentially harmful (eg, use of home remedies in chest pain) or inapplicable for an untrained person (eg, use of tourniquet in bleeding). Conclusion: Although the search engine’s QAS responds to user’s inquiries concerning assistance in health emergencies, the QAS-generated answers, as a rule, omit potentially life-saving evidence-based instructions on first aid and oftentimes give advices noncompliant with current guidelines or inadequate for untrained people, and thus create risks for causing harm to a victim.

Background: During a major earthquake, escape attempts or collapsed buildings can result in injury, disability, and even death for victims. The aim of this study is to examine the demographic characteristics, clinical outcomes, and injuries of victims admitted to the emergency department within the first week after an earthquake. Methods: This is a retrospective observational study conducted on earthquake victims who were admitted to the emergency services of a tertiary medical faculty and a training and research hospital in the city of Diyarbakir, located in the Southeastern Anatolia Region of Turkey, from February 6 through February 12, 2023. Results: Of the eligible 662 earthquake victims, the mean age was 10.66 (SD = 4.78 [min 0, max 17]) in children, 36.87 (SD = 4.78 [min 18, max 63]) in adults, and 72.85 (SD = 5.83 [min 65, max 84]) in the elderly. Women constituted 52.8% of the victims, 19.7% were children, and 8.0% were elderly. Sixty-one percent (61.0%) of earthquake victims were admitted to emergency services in the first three days following the disaster; 37.7% of all victims were transferred from other affected cities to Diyarbakır. In all, 80.2% of the victims were admitted as survivors to the emergency services (36.8% were rescued under rubble, 40.1% with injuries while attempting to escape the earthquake, and 3.3% with nontraumatic reasons) and 19.8% were deceased under rubble. The majority of the 131 deceased victims were women (52.7%), 20.6% were children, and 7.6% were elderly. An estimated 38.3% of victims were hospitalized (20.9% in the ward and 17.4% in the intensive care unit [ICU]). For all age groups that survived under the rubble, the extremities were most injured (53.6% for children, 53.1% for adults, and 55.5% for the elderly). Of adult survivors, 26.6% needed only fluid therapy, renal replacement treatment (hemodialysis) was required 20.7%, and 11.8% required amputation. Of children survivors under the rubble, renal replacement treatment (hemodialysis) was required for only four, seven required amputation, and 12 needed only fluid resuscitation for crush injury. Of elderly survivors, two needed only fluid therapy, renal replacement treatment (hemodialysis) was required for two, and no amputation was required. Six patients survived under the rubble and died in the ICU. Conclusion: The definition of the demographic characteristics and clinical outcomes of earthquake patients is critical to the development of preparedness, response, and recovery policies for future disasters.

Aim: This scoping review explored the main environmental factors in the workplace that contribute to nursing resilience in respiratory infectious pandemic events. Background: There is strong evidence in the literature about the influence of individual factors on nurses’ resilience and a growing interest on the impact of the workplace environment on these factors. Therefore, a review that synthesizes environmental factors that support nurses’ resilience in pandemic events is timely. Method: A scoping review of publications written in English, Spanish, and Portuguese of registered publications until December 2020 in MEDLINE, Embase, PubMed, Scopus, SciELO, CINAHL, WoS, BVS, and APA identified 10,767 potential papers. Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines were used during the literature review process. The Health Services Workplace Environmental Resilience Model (HSWERM) was used to guide exploration and synthesis. Results: Thirty-two (32) publications met inclusion criteria. Most of the HSWERM workplace factors were mentioned in the literature. The main workplace environmental factors that were identified included communication, inter-professional collaboration, access to equipment, targeted training, and supporting well-being. Conclusions: Recognition of these key environmental factors in the workplace will help to implement more effective actions to promote resiliency prior to and during emergency situations. It will also enable managers to include, in any preparation planning, contingencies to protect these factors with the view of sustainable resilience of nursing staff throughout the emergency event.

Background: Incorporating emerging knowledge into Emergency Medical Service (EMS) competency assessments is critical to reflect current evidence-based out-of-hospital care. However, a standardized approach is needed to incorporate new evidence into EMS competency assessments because of the rapid pace of knowledge generation. Objective: The objective was to develop a framework to evaluate and integrate new source material into EMS competency assessments. Methods: The National Registry of Emergency Medical Technicians (National Registry) and the Prehospital Guidelines Consortium (PGC) convened a panel of experts. A Delphi method, consisting of virtual meetings and electronic surveys, was used to develop a Table of Evidence matrix that defines sources of EMS evidence. In Round One, participants listed all potential sources of evidence available to inform EMS education. In Round Two, participants categorized these sources into: (a) levels of evidence quality; and (b) type of source material. In Round Three, the panel revised a proposed Table of Evidence. Finally, in Round Four, participants provided recommendations on how each source should be incorporated into competency assessments depending on type and quality. Descriptive statistics were calculated with qualitative analyses conducted by two independent reviewers and a third arbitrator. Results: In Round One, 24 sources of evidence were identified. In Round Two, these were classified into high- (n = 4), medium- (n = 15), and low-quality (n = 5) of evidence, followed by categorization by purpose into providing recommendations (n = 10), primary research (n = 7), and educational content (n = 7). In Round Three, the Table of Evidence was revised based on participant feedback. In Round Four, the panel developed a tiered system of evidence integration from immediate incorporation of high-quality sources to more stringent requirements for lower-quality sources. Conclusion: The Table of Evidence provides a framework for the rapid and standardized incorporation of new source material into EMS competency assessments. Future goals are to evaluate the application of the Table of Evidence framework in initial and continued competency assessments.

Sheganew Fetene Tassew,1 Betlhem Amha Haile,2 Tekalign Amera Birlie3 1Department of Emergency Medicine and Critical Care Nursing, College of Health Science, Debre Tabor University, Debre Tabor, Ethiopia; 2Department of Human Nutrition, Institute of Public Health, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia; 3Department of Adult Health Nursing, College of Health Science, Debre Tabor University, Debre Tabor, EthiopiaCorrespondence: Sheganew Fetene Tassew, Department of Emergency Medicine and Critical Care Nursing, Debre Tabor University, P.O. Box 272, Debre Tabor, Amhara Regional State, Ethiopia, Tel +251 918511768, Email sheganewabeba@gmail.comIntroduction: Rodenticides are pesticides used to eradicate rodents. It is a common reason for visits to the emergency department and hospitalization, and it is a major public health concern. Intentional or unintentional intoxication can result in severe consequences with a high fatality rate. In Ethiopia, studies on the outcome of rodenticide poisoning are scarce. The goal of this study was to assess the outcomes of rodenticide poisoning and its associated factors in adult patients admitted to the emergency unit of Debre Tabor Comprehensive Specialized Hospital in North Central Ethiopia.Methods: A retrospective record review institutional-based cross-sectional study design was used on 156 adult patients treated with rodenticide poisoning at Debre Tabor Comprehensive Specialized Hospital’s emergency unit between May 1, 2017 and April 30, 2022. To collect data from patient medical documents and the Health Management Information System, an abstraction sheet was employed. The information was entered into EPI data version 4.6, then exported and analyzed using STATA version 14 software. To analyze the relationship between the dependent and independent variables, bivariable and multivariable regression were used.Results: A total of 156 participants were involved in the study. The majority of them 55.13% were in the age group of 19– 37 years with the median age of 23 years. Three-fourth of the cases were suicidal poisoning. Overall, 49.35% patients presented to Debre Tabor Specialized Hospital had poor outcome. Having suicidal poisoning (AOR = 10.64; 95% CI: 2.43, 46.53), having tachycardia (AOR = 5.41; 95% CI: 1.54, 18.98), being referred from other health center (AOR = 5.78; 95% CI: 1.97, 16.95) were factors associated with poor outcome.Conclusion: Rodenticide poisoning had a poor overall outcome. Suicidal poisoning, tachycardia, and referral from other health facilities were all important predictors in poor rodenticide poisoning outcomes.Keywords: rodenticide, poisoning, emergency

The implementation of paediatric intensive care unit (PICU) diaries has been reported as feasible in routine care. To date no feasibility study has compared PICU healthcare providers' (HCPs) and parents' opinions on this tool.The aim of this study is to describe the feasibility and perception of PICU diaries in an Italian PICU from the point of view of parents and HCPs.This is a single-centre, prospective, observational study conducted in a tertiary care paediatric hospital from August 2020 to May 2021. Children admitted to the emergency department PICU, intubated, and sedated for ≥48 h were enrolled. To explore their perceptions and attitudes with the PICU diary, parents were interviewed at 30 days from their child's discharge from the PICU, whereas PICU HCPs were surveyed at the end of the study. Data were analysed as proportions for categorical variables and means and medians for continuous variables according to the distribution, whereas qualitative data were summarised in categories by two independent researchers.Twenty families were enrolled in this study. A total of 275 daily PICU diary entries were collected. Children's median age was 9 years (interquartile range = 2-13.25), and the length of stay ranged from 6 to 39 days. PICU diary applicability was rated high by parents and HCPs (8 on a 1-10 Likert scale). Parents and HCPs perceived PICU diaries as beneficial for communication between staff and families, for parents by expressing their emotions and for staff by becoming aware of how parents experienced their child's admission. Reported barriers were the lack of a private environment, the risk of exposure to public reading, and PICU workload.PICU diaries were feasible and perceived as beneficial both by parents and HCPs. Future research is warranted to understand the effect of PICU diaries on post-PICU outcomes.

Workplace violence remains a significant threat to the United States health care workforce. With increasingly aggressive patients, emergency nurses reported that the increased prevalence of workplace violence impacted their professional and personal lives.This study employed a qualitative, descriptive phenomenological approach with purposive sampling. Participants were asked to describe their lived experience with workplace violence while working as emergency nurses and how this affected them personally and professionally.Eleven experienced emergency registered nurses from 3 mid-Atlantic hospitals participated in the study. After reviewing, clustering, and validating significant statements, 4 major themes were identified: walking wounded to wounded healer, unexpected shock, betrayal, and resilient but changed.Our findings were consistent with other studies exploring the effects of workplace violence in emergency departments. We validated that trauma has long-lasting effects. Organizations should ensure that programs and processes are in place to support the nurse or health care worker when workplace violence events occur.

In 2020, during the first wave of the COVID-19 pandemic in Melbourne, visitor access to acute hospitals including intensive care units (ICUs) was initially barred, followed by a limit of one person per patient for one hour per day. This study explores the care and communication experienced by family members of ICU patients during this time.This qualitative descriptive study was conducted at an Australian quaternary hospital. Semistructured phone interviews were conducted using an aide-memoire designed to understand participants' experiences as family of a patient during this time. Interviews were recorded, transcribed, and thematically analysed.Twenty family members of patients in the ICU participated. Three major themes were identified: 'impact of restricting visiting procedures', 'family experiences of communication', and 'care and support'. Inflexible visiting restrictions had a momentous impact on families. Participants objected to having to nominate only two people to visit during the admission and the short visiting time limit. Some family members suffered extreme stress and anxiety during their absence from the bedside. Additional challenges were experienced by rural families, visitors with disabilities, and the young children of patients who were excluded. Communication with clinicians varied. Telehealth was valued by some but not universally embraced. The relationship between staff members and families and involvement in decision-making were unaffected.Families experienced significant psychological distress from being separated from their critically ill relatives. Patient care and involvement in decision-making appeared to be unchanged, but communication with staff felt to be lacking. Better alternatives to face-to-face communication must be sought to limit the impact of family separation on mental health. Families are a key link between the patient and clinicians and often play a major role in patient support and recovery after discharge. There is an urgent need to support them and facilitate meaningful engagement despite the obstacles.

Nurses in the emergency department often encounter patients exhibiting signs of aggressive behavior. Nurses need to know the pharmacologic treatment appropriate for the patient scenario to ensure safety for the patient and the emergency department team. This case review examines 4 common scenarios where a patient exhibits aggressive behavior. After each case review is a discussion about the appropriate pharmacologic therapy for that patient. The cases portrayed are fictional but based on experience and previous observations.