#she was a normal nurse before a dental nurse so i suspect shes one of THOSE nurses

[slumbering-shadows]

Went to the dentist today to get a temporary crown on my poor root canal tooth and they had a new nurse

And I explained to her I just had my wisdom teeth out and was still healing so please be careful and she didn't even bat an eye she like completely fucking ignored me, GRABBED my cheek as hard as she could and shoved the numbing shot DIRECTLY into one of my incision sites. And then spent five minutes like SQUEEZING my STILL VERY TENDER FROM SURGERY CHEEK FLESH as hard as she possibly could. It's been 12 hours and my cheek is literally still throbbing. If she ever gets near me again I'm fucking biting her I don't care. The entire time my bf was like she just had SURGERY right there PLEASE be careful and she was just not listening. NO PART OF THAT WAS NECESSARY. like yes numbing shots are uncomfortable because they have to go in uncomfortable spots but a) she was in the wrong spot anyway because it DIDN'T numb the area it needed to and b) under no circumstance was the manhandling warranted! nobody else in the office has ever had to grab my face like that and I've had that tooth numbed before!

[eloquent-vowel]

Part 5 "Comfortable" Bucky X OFC (#043)

Description: A series of attacks on Russian diplomats lead to Fury dispatching some members of the avengers to defend them. There they meet a very new threat- one they have never seen before.

Tags: Angst, Fluff, Slow burn, very much a slow burn. Bucky Barnes x OFC, Winter Soldier X OFC

Warnings: Canon typical violence

Thank you all for reading this far! Here is a little time skip for you and the first time some of the Avengers meet Eris. Time is probably going to be very disjointed after this part! <3

Part 4

Bruce stared out of the Avenger's tower window, New York looked so small from up here. Looking down everyone seemed so unimportant, there were hundreds of people walking to the same place they always did, dressed in the same clothes they always wore. Were they happy with their lives? Were they living their dreams? What did they regret?

"See anything interesting Doc?" Tony's voice broke Bruce's trance. "Seen any muggings? Street fights? You know, I once saw a pigeon fly down and steal someone's sandwich right from their hand, the whole thing." Tony came into view, two cups of coffee in his hands. His eyes sparkled with the usual joy but under it all there was the slightest hint of concern.

Bruce took the offered coffee cup. "Buff pigeon."

"Perhaps it was a tiny pigeon hulk."

Bruce huffed a laugh before sipping is coffee. "The Incredible Squawk?" Despite Bruce's attempt at humour his voice came out as bitter as his coffee. Bruce watched the steam slowly rise before letting out a broken sigh. "She would have been 24 today."

Tony placed a hand on Bruce's shoulder, there was silence for a while. He had to think about what to say next, "We'll find her, Bruce. We won't stop looking I can pro-"

"Tony." Bruce turned to face Tony, the bags under his eyes were deeper than usual. "Thank you for trying to cheer me up but, let's be realistic, its been 20 years. The truth is either she doesn't want to be found or never will be."

"You are aloud to be realistic, Bruce, but don't lose hope."

The two shared an understanding stare, Bruce looked like he was going to say something but was interrupted by Natasha entering the room.

"We have a problem."

"When do we not?"

"Funny, Tony." Nat approached the two of them, she was staring down at the tablet in her hand very intently, eyebrows furrowed in concentration. "A Russian diplomat was murdered at his safe house last week."

"And this concerns us how." Tony's tone was flippant.

"Because he as an informant for Shield but before he could talk he was beaten so badly they had to use dental records to confirm his identity."

Nat handed over the tablet to Tony who flicked through the photos of the crime scene. It was brutal. The guards that were put in to defend the diplomat were beaten to death, violently. It was obvious, even to his untrained eye, that whoever did this used their fists and no other weapon. Most of the guards had dents in their temples and some had broken knees. The path of the killer was followed by a nice trail of beaten corpses. Until they lead to the bedroom of the diplomat. Just like the other corpses, his body was beaten with blunt objects but unlike the others the killer really wanted to make sure he was dead. There was practically no skull that remains intact and there was blood everywhere. Tony blanched a bit and returned the tablet to Nat.

"What exactly do you want us to do? Bring a guy back from the dead?"

"No." Nat sounded tired, stressed, Tony kicked himself slightly for not being able to be serious. "We are being tasked for protecting someone we strongly suspect to being a second target." She turned the tablet around to show another angry looking man.

"Who pissed in his cornflakes?"

Nat ignored Tony. "This is Panin Rostislavovich, Russian ambassador here in America and more importantly mole for Shield. We think there is a large possibility he will be attacked at some point this week. Fury has asked that we personally see to guarding him. Something about improving relations with Russia."

"So, we sit in a room with someone and get paid for it?"

Nat just raised her eyebrow.

-----------------------------------------------------------------------------

"Getting comfortable there, Mr. Rostislavovich?"

Tony quipped to the stern man who was currently pacing violently up and down the length of the room. Normally he wouldn't have commented on it but his footfalls were terribly annoying and Tony was nursing one hell of a hangover.

"Would you be comfortable in this situation? Would you Mr. Stark." Tony fought the urge to roll his eyes. "When your colleague has been beaten to death in his apparently 100% secure and safe house!"

"Panin, buddy, listen- we are just here on a hunch no one said for certain that they were after you."

Tony made eye contact with Natasha and Steve who were standing guard by the door. They both shook their heads, no signs of intrusion at the moment. They were in direct contact with the guards outside the house and inside of the house, if Tony said so himself, this place seemed pretty impenetrable.

"Team Delta. Team Delta, report."

Him and his big mouth,

Nat's voice was panicked as she began to check in with all the teams around the perimeter of the house. She got more and more intense with each team name.

"No one on the perimeter is responding. Tony get him to the safe room, be ready to take the back exit."

"You don't have to tell me twice, come on buddy, let's not get you killed."

With that the escorted Panin to the solid metal safe room leaving Steve and Nat to do what they did best, beat people up.

--------------------------------------------------------------------------

Natasha turned to Steve, he looked calm but the tight grip he had on his shield gave him away. The sound of fighting and violence started to be heard through the door.

"Hide and we get the jump on them." Nat whispered as she ducked behind one of the large sofas, Steve look up place adjacent to her. She began to count her bullets, double checking that she had enough ammunition.

There was silence for a moment.

Then a massive crash as the door flew off its hinges and into the wall behind Steve. She couldn't help the slight gasp that she let out as Steve slowly moved away from the rubble.

"I can hear you." A female voice, gravelly and harsh spoke in perfect Russian. It sent shivers down Nat's spine, Steve looked at her questionably. She just gritted her teeth and shot at the doorframe. She watched as Steve leapt out once she ran out of bullets. She reloaded as quickly as possible to cover Steve, as soon as she aimed her pistol over the couch she was stunned into inaction.

She could hardly keep track of who was hitting who as Steve fought the intruder. It was evident that this person was the same as Steve, they were a super soldier. Nat tried to find a pattern in their movements, an opening to fire a shot but every move they made was unexpected and chaotic. They were covered almost head to toe in black tactical gear, the only exception being their legs that reflected in the low lights of the room, metal legs? Whatever they were made of their legs were definitely strong as one well placed kick threw Steve back against the wall to joint the door.

Nat didn't hesitate to engage. Vaulting over the couch and throwing her gun by the window, she went immediately for a choke hold, swinging her legs over the other woman's neck. Nat felt some sort of pride as she succeeded to bring the intruder down to the floor, she squeezed tightly in an effort to choke them. Until the glint of metal over the intruder's fists slammed right into the back of Nat's knee, it didn't quite dislocate as intended but the force was enough to let the intruder get free.

The two women stood up once more and took a moment to size each other up. Nat realised that this woman was as tall as Steve and looked as strong. The bottom half of her face was covered in a protective mask and her hair was wild, perhaps from a previous scuffle? Now that Natasha had a good look she realised that both of the woman's legs were made of a shining metal, they whirred and clicked as she stood up. She glanced at Steve who was just beginning to stand up, clutching his ribs- the two exchanged a quick nod and together began to try and take down this new threat.

Unfortunately it was not as easy as either of them thought. Their opponent was brutal, unpredictable and yet seemed to predict every move they made. Steve would attack from behind and she was sidestep, only to throw a devastating punch at her. It was down right terrifying that one woman was able to take on both Steve and herself at once. Even worse was that this woman didn't seem to tire, while Steve and the woman were able to breathe normally Nat was beginning to falter. The intruder saw this and with one well timed switch kick Nat saw stars as a metallic leg collided with her temple.

Steve watched in horror as Nat fell, his opponent showed no sense of regret and did not hesitate to begin her brutal assault on him once more. Thrown by Natasha bleeding from the head it didn't take long for the woman to have her arms around his neck in a less than friendly way. Black spots danced in his vision, he thought this was it. He began to run through ways to get out of this but every time he struggled the edge of the brass knuckles dug deeper into his throat.

He thought he was gone until he felt her shift slightly and then let go of him altogether. He fell on the floor gasping and turned to see where the woman had gone. He saw her pick up Natasha's pistol and making a running leap out of the window. Shattering the glass into a hailstorm of chaos.

---------------------------------------------------------------------------

Tony had little warning other than the sound of glass shattering and the violent bang of a gunshot. The man who he had previously been talking to about his plans for the future fell to the ground, a bullet hole directly through the centre of his brain.

Tony turned around violently to just catch the sight of some meta glinting under streetlights and a figure darting off into the dark.

Fury was going to be so mad at him.

Part 6

[notgonnarememberthis]

Through the Valley - Chapter One

IT’S FINALLY HERE. The long awaited murder family au that I promised back in February is finally in motion. This chapter takes place seven months after Jessica killed Endicott and from here we’re completely throwing out the canon arc of season 2. This is the direct response to my first fic of the series Playtime’s Over, which acts as a prologue to this AU. I will be linking that just below. I hope y’all enjoy this first chapter and I’m so excited to jump into this new story with y’all.

Playtime’s Over

It’s been seven months since Endicott died, since Jessica killed him. She thought it was over. She knows it isn’t.

It had been seven months. Seven months since Gil was stabbed, seven months since her family was irreparably torn to shreds, seven months since Nicolas Endicott died.

Since Jessica killed him.

Her life settles back into normal with far too much ease. She takes the role as Gil’s caretaker, nursing him back from his injury. He stays with her longer than either of them expected. Ainsley moves back in after the incident. If she suspects anything, she doesn’t tip her hand.

Jessica taught her far too well to give away information too carelessly.

Malcolm, however.

He’s absolutely beside himself. The longer time stretches, the longer they go without hearing from a dead man. The more it hurts him. The more she hurts him.

She wonders when is the last time he had slept for more than 2 hour increments. He hasn’t sat down and had a proper meal with them since. She doubts he’s feeding himself properly. If hearing from Gil is any indication, he’s just as bad at work too. Falling asleep on the job, springing up in a terror, excessive use of his favorite phrase I’m fine.

Guilt gnaws at her stomach every time she looks at him.

She arrives at the hospital again, hours after. Eyes more vacant than when she left.

It changes the second Ainsley crashes into her arms. “Mom, thank god.” She returns the hug, squeezing her daughter close with all her might. Knowing she’s safe, that they both are safe. It almost loosens the tension in her chest. “Malcolm’s with Gil. He’s ok, surgery had some complications but it’ll just be a longer recovery. He’s going to make it.”

She lets out a breath, at least something is going right. Less so than Adolpho who’s cleaning the house as they speak. Ridding of the blood stained rug before any of them are the wiser. “Thank god.”

“What happened? I thought-” Her voice catches in her throat and Jessica pulls back. Sure enough Ainsley’s bottom lip quivers.

“I was not letting Nicolas Endicott take our family down. Certainly not me.” She strokes her chin with the best comforting grin she can muster. “I kept him busy long enough. I was trying to get authorities there but I couldn’t just reach for a phone.” She tucks a loose strand of hair behind her ear. “He got away before I could. I actually believe I managed to scare him.”

Ainsley’s smile tells her enough. She believes the story. Malcolm will be a harder sell. “He’s running?”

“For now.”

“Good. We’ll be ready when he comes back.” She kisses Ainsley on the forehead, the weight of lying to her settling into her bones. He won’t be back. Not now. Not ever.

“Mom.” Malcolm’s voice cuts her spiraling thoughts. He’s wrapping his arms around the both of them before she can even turn to face him. She frees her arm from between them, looping it around his shoulders. She clutches the back of his coat holding both of her children close.

If she’d just been a second too late. If she’d have hesitated.

But she didn’t.

Malcolm breaks the embrace first. Eyes already ablaze with questions. “Where is Endicott?”

It only got worse. Constant questions forcing her to recall the night over and over. Dani, JT, hell even Gil had questioned her when he was finally cleared to return to duty again. All worried about the lingering threat, all more worried about Malcolm unraveling at the seams.

Her fingers hover over the phone. One call.

An anonymous tip. 

This could all be over with. She could end the agony after all this time.

One call.

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

The knock startles her. She’d been waiting for it, waiting for him. Yet, ever since Endicott she jumps at loud noises. She’s good at masking it, for others. When she’s alone it’s harder. She gets stuck into a whirlpool of thoughts and-

“Gil.” She smiles at him when she opens the door. “I didn’t know you were coming, I would have put on something nicer.”

“You look beautiful, Jess.” Her chest swells with the compliment. They put this on hold while he recovered. Despite the many times she’d helped him up, how many times she fell asleep beside him. They hadn’t moved past the first kiss. God she desperately wanted to move forwards.

“What brings you here unannounced?” She knows exactly why. She’s been waiting for the news to circulate.

“Have you watched Ainsley’s broadcast?”

“No?” She hadn’t. It hurt too much. She tried. Yet the second Ainsley’s face appeared, glee filled eyes and a dazzling smile, she clicked the television off.

She would be happy, Jessica thinks. Happy that the man who haunted her family for the past 7 months is dead. Finally found and free of the fear he carried in his grasp. “Jess,”

“Gil.” She takes a breath. “You found him, didn’t you?”

He nods in confirmation. Jessica wishes she could say she was faking her reaction, exaggerating it somehow. Yet the fear is too real, her relief that the secret is finally out is too real. “A camper called in skeletal remains at a clearing a couple of hours from here. We ran the dental records, they’re a match for Nicholas Endicott.”

“He’s dead.” It’s not a question.

“Yes. I wanted to get the news to you before you saw anything.”

“Thank you, Gil.” It hurts when he looks at her like she’s bound to shatter. His movements are careful when his hands settle on her shoulders. “How’s Malcolm?”

“He’s gonna be ok.” She smiles sadly. That’s not entirely true. They both know it. “He’s relieved. He can finally take a breath for the first time in months.” He won’t. He doesn’t know how to. Gil’s hands run down her arms until he is holding hers. His touch sends a shiver up her spine. “It’s over Jess.”

His words make her breath catch in her throat. For months she’d worried, she paced, sprung up from nightmares. He’d witnessed it all. He pulls her to him, his arms wrapping tightly around her and everything gives. Tears she didn’t know were there slid down her cheeks as she buried her face in his shoulder. 

“It’s over.” He repeats, pressing a kiss to the side of her head. She wants to tell him. She wants to tell him so badly that for her, it will never be over. The smell of smoke lingered on her with every passing breath. His unseeing eyes watched her in every reflection.

As her shoulders shake, Gil holds her tighter. As if trying desperately to hold her together.

And she thinks this could be enough.

[ohmyprodigalson]

Oooh. The team rescues the reader, who was kidnapped and kept there pretty much her whole life. She's kind of like eleven from stranger things. She doesn't talk much, and and shes bad at controlling her emotions. He lies to her, and she gets really angry, asking him "why he lies". This is really specific, sorry about that.

Here you go 😊

Trigger Warnings: Mentions of kidnapping and child abuse.

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(Y/N) was sitting on the bed in her hospital room, with her legs crossed. She was holding her doll, made of fabric scraps tied together in knots, tightly against her chest as her eyes darted frantically around the room. Her hair was matted and there was still dirt under her fingernails. She shivered a little, not from the cold but from her fear. The lights in the room were dimmed, and she wasn't wearing any of the monitors usually required by the hospital. Everything scared her because it was so new and strange.

Malcolm stood outside her room, peering in through the window, arms crossed. He was the one to find her, not even five hours ago. Gil walked up to Malcolm, hands in his pockets. He spoke low and quiet. "There's nothing else we can do for her today. Why don't you go home and get some rest?"

"She hasn't said a single word." Malcolm's voice was so quiet, it almost sounded like a whisper. "The only reaction she's had to this whole thing was her screaming when we tried to take her doll from her. I should have known better."

When the team raided the suspect's house, they never expected to find a prisoner in his basement. They were running her face through the database of missing persons, but they had no luck yet.

A nurse went into the room and attempted to put the blood pressure cuff on her and start an IV. Just like the other times before, (Y/N) started screaming. But she didn't fight; she cowered and hid behind her arms.

"Seriously." Gil reached out and placed a hand on Malcolm's shoulder. "We aren't going to learn anything tonight. Go home, get some rest, and we'll be back tomorrow to talk to her and figure things out." Malcolm turned to look at Gil. He had a sad look in his eyes as he paused before nodding.

The next morning Malcolm was at the hospital bright and early. One of the hospital's psychologists was there to help talk to (Y/N), but Malcolm wanted to be there, too.

They were all in her hospital room, and the psychologist had set out manipulatives, dolls, pens, and papers on the hospital bedside table pulled in front of her. Gil stood outside of the room, watching from the other side of the window.

The psychologist had a soothing voice when she finally spoke. "Let's start at the very beginning. Can you tell me your name?"

(Y/N) still clung to her doll, and she stared at the wall in front of her. She made no eye contact with anyone and she had no facial expressions whatsoever. Both were signs of extreme abuse, especially as a child. She was broken.

They waited in silence for an answer as the clock on the wall ticked away. The psychologist continued to work with her, and sometimes she would respond with a drawing or an escaped moan. After an hour, they decided to take a break. The psychologist left the room, and Malcolm was compelled to walk over to (Y/N).

He slowly moved to sit down on the bed beside her, so that if she started to freak out, he could stop. She made no movement, so he sat down gently. He spoke quietly. "I know you must be filled to the brink with emotion that you haven't been allowed to show, and I know you must be filled with so much pain." Malcolm paused as he tried to make eye contact. (Y/N) kept her eyes on the bed before her.

"But there's one thing no one has asked you yet." Malcolm paused before continuing. "Is there anything you want? You haven't been able to ask for anything in so long." He bent his head down to tempt her into looking at him. "Is there anything at all that you want?"

He waited patiently for her answer, exuding a sense of calm so that the silence wouldn't feel weird for her. Then he heard her voice for the very first time; it was so soft and meek. "Mom."

Malcolm's heart was immediately shattered. This was no longer a woman before him, but a little girl, asking for her mother. He confirmed this by asking, "You want your mom?" She gave a very small nod. Malcolm looked away from her, up towards the ceiling, and he closed his eyes. He was trying to fight his tears because that was not what she needed right now. Malcolm returned his gaze to her. He was emphatic with every word he spoke. "I promise, I will find your family."

Malcolm went back to the precinct with this goal in mind. He talked to Dani about the progress in finding (Y/N)'s identity, and she had no luck. That's when Edrisa walked up to them with a solemn look on her face. Even Malcolm's smile couldn't put the light back in her eyes.

"I know who the kidnapped woman is." She let the file in her hand drop with a thud on Dani's desk. Dani opened it as Edrisa continued. "I was running the dental records on the skeletons we found in has back yard, and I came across this man, and this woman." She was pointing at the picture in Dani's hands. "They were married, and they had a daughter. I looked them up and found that they went missing twenty-five years ago, but I didn't find any bones that would belong to a child." She paused as Malcolm looked at her seriously, waiting for the dreaded words. "I believe the woman you found was their daughter."

Malcolm's heart sank. He just promised (Y/N) that he would find her family, and he did. They just weren't alive. He took a copy of the family picture from Edrisa and went back to the hospital.

He found everyone exactly as they were before. The psychologist was talking with (Y/N) and Gil was watching from the doorway. "Gil, can I talk to you for a minute?" He stepped away from the room and followed Malcolm down the hall a few paces.

"What is it? What did you find?"

"Long story short, Edrisa found the remains of the couple in this picture, but not the little girl. She thinks that's her, in there." Malcolm motioned back towards the door.

"So we have a name?"

"Yes, it's (Y/N), but that's not the point." Malcolm shifted his weight as he looked away for a moment, and then back at Gil. He leaned in and became animated when he spoke. "I just promised her that I would find her family. They are the only thing she wants in the world right now, and I can't give them to her."

Gil saw the worry in Malcolm's eyes, but he remained calm. "There's nothing we can do about that right now. Yes, it's sad, but let's focus on getting her to talk first. All she's done is scream when someone tries to touch her." His face remained calm and serious as he clapped Malcolm on the back before turning to walk back towards the room.

They watched as the psychologist continued to work with her. When they took another break and everyone had left, she spoke softly again. "Mom?"

Malcolm had feared this. He walked across the room and sat on the bed with her. He pulled Edrisa's photo from his suit pocket and gave it to (Y/N). "Is this your mother?"

She gripped the photo tightly as her eyes grew wide. She nodded.

Malcolm's voice cracked when he spoke. "I'm sorry, but... We found their remains." He paused before clarifying. "They're dead."

(Y/N) shot her head up and made eye contact with him for the first time. It was the first time she had made eye contact with anyone. Then she spoke with force. "No."

All he could do was look back into her broken eyes.

"No! You lied! You lied!!" Her soft voice escalated to yelling and then screeching as she became incoherent. Malcolm jolted off the bed as she started to thrash and a nurse rushed in. She sedated (Y/N), and her sessions with the psychologist were over for the day.

Over the next week, if Malcolm tried to visit, she would start screaming the same words until she was either sedated or restrained until he left. He couldn't see her ever again, because it was detrimental to the progress she was making with the psychologist.

***

A year later, Gil handed Malcolm a small envelope with no address on the front. "Hey, Bright, this is for you."

Malcolm took it and turned it over in his hands. It was made of nice paper, not like the generic ones you find in the store. "What is it?"

"Do you remember that case last year where we rescued the woman who was kidnapped as a little girl? She left it for you. She specifically said, 'Please give this to the nice man in the suit.'"

Malcolm couldn't hide the shock on his face, and he hurriedly opened the envelope as he thanked Gil. The world faded away as he read the handwritten letter.

"I don't know if you remember me, but you saved me a little over a year ago from a very bad man. I hadn't been allowed to see the sun since he took me, and I never had any friends. But that all changed after you and your partners found me.

Looking back, I lashed out at you when I shouldn't have. You were only trying to help me, but I was too hurt to see that. I'm very sorry for the way I treated you, and I hope some day you can forgive me.

If you would like, I thought we could get lunch or drinks some time. I am so very grateful to you for saving me, and I would love to get to know you."

Later that week he met her at a little café for lunch, and he couldn't believe his eyes. She was so beautiful and radiantly happy, like a normal woman her age. What a huge difference a year can make.

[12-3amproductions]

Sudden Death Syndrome (SADS)

Sudden Death Syndrome is an umbrella term used for the many different causes of cardiac arrest in young people. Usually, they are caused by abnormal heart rhythms called arrhythmias. The most common life-threatening arrhythmia is ventricular fibrillation, disorganized firing of impulses from the ventricles (the heart’s lower chambers). In today’s article, we will be discussing a similar case that happened in Singapore, as well as a story regarding this.

Case description:  Elise Fitzpatrick, 24, was found dead in September last year (2016), with the dental nurse student perfectly healthy before her unexpected death.

Her family has now spoken out about the struggle to come to terms with Elise's death, remembering her as a "kind and caring" young woman who "lived her 24 years to the full".

Mum Kirsty told The Sun Online: "There was nothing physically wrong at all with her, she was perfectly healthy.

"She did the normal things a 24-year-old did."

Mum Kirsty said she usually heard from Elise the morning after her daughter had gone out, but on the morning of September 3 last year, quickly realised something was wrong.

She said: "She always texted me in the morning to let me know she was OK.”

"I hadn't heard from her by 10am, which was fine, but I texted her through the day and still didn't hear back."

The worried mum raced to Elise's groundfloor flat, with dad Sean quickly realising something "wasn't right."

Kirsty said: "I jumped in the window and we found her on the sofa. She had just gone to sleep and didn't wake up."

Paramedics and police arrived at the flat soon after but it took weeks for the family to be told what had caused their daughter's death - "Sudden Adult Death Syndrome".

But Kirsty said: "To me, that's still not a reason, is it.”

"You have someone fit, healthy and living their life to the maximum and then for some reason, that's it.

"It still to me doesn't make any sense whatsoever."

Since Elise's death, Kirsty herself has been diagnosed with Brugada Syndrome, which sees an increased risk of sudden cardiac arrest.

While doctors are still looking into whether Elise had a link to the syndrome, Kirsty said the other family members including younger siblings, Macie, 11, Tilly, 8, Isla, 5, and Connor, 17, will be tested.

She said it was not clear what caused her daughter's death, saying: "There was nothing physically wrong with her heart. It just stopped.

"Now, it's like a ticking time bomb for our family.

"I just want as many people as possible to be aware of this - people are aware of cot death but we just don't know enough about this.

"It's a silent killer."

The family, of Rayne, Essex, is now working to raise money for Cardiac Risk in the Young charity, taking part in a bridge walk next month to keep their daughter's memory alive.

Admins: Rest in peace Elise. Life is short so do cherish what is around us before it is long gone....

Case description: A total of 235 cases of sudden unexpected death syndrome (SUDS) among apparently healthy male Thai migrant workers in Singapore were reported between 1982 and 1990. Most of the deaths occurred during sleep and 13% were not sleep-related.

The median age at the time of death was 33 years and the median interval between arrival and death was 8 months. These deaths occurred singly and sporadically throughout the year. Post-mortem examination revealed few abnormal findings except for hemorrhagic congestion or oedema of the lungs. There were moderate to severe intra-alveolar haemorrhages with some evidence of myocarditis or pneumonitis.

Preliminary findings of serial sections of the hearts indicate evidence of anomalies in the cardiac conduction system. Epidemiological investigations showed that a family history of similar deaths and serological evidence of current or recent infection with Pseudomonas Pseudomallei were significantly associated with SUDS. Extensive biochemical and toxicological investigations were inconclusive. There was no evidence of chronic deficiency in thiamine or potassium among the healthy Thai workers living and working in the same conditions as the cases, and no significant abnormalities were detected on electrocardiographic examination. As these migrant workers experienced various psychosocial problems which could stem from maladjustment to an urban environment, separation from the family, burden of debts and long hours of work, stress could be a precipitating factor for SUDS.

Which really means that they don’t know what is going on. However the Thais have a theory which will be explain in this story.

Site supervisor, male, 52

I’ve been working with Thai construction workers for some time and I’m friendly with some of them. There’s a story that’s going around about one Thersak which terrifies them. Thersak apparently woke up just before daybreak to the feeling of soft feminine hands all over his body. He became excited and stretched out his arms to embrace his “lover”. It was still dark and though none of his fellow workers sleeping nearby had woken up, they could hear loud grunts and groans. They thought he was merely dreaming. A few hours later, however, he lay dead.

This is one of many horror stories spreading like wildfire among Thai workers. In 1990, many Thai workers in Singapore died in their sleep from no obvious illness. Terrified of the phenomenon, the Thais have taken to uttering a silent prayer before going to bed. They claim that more than five thousand young Thai men have died since 1993 and there’s no way of knowing who will be next.

Various theories to explain the deaths have been put forward: the use of PVC pipes for cooking glutinous rice(a Thai staple), genetic factors,stress from work, unsanitary living conditions, an over starchy diet, vitamin B deficiency, even a tropical soil disease. But the most popular reason offered is “ghosts”. My friends are convinced a female ghost is stalking virile Thai men.

Thai folklore tells of a sex-starved ghost which is said to seduce males and sap them of their energy. That would explain why there’s no sign of disease or foul play, why they die only when asleep. Most Thais here come from northeastern Thailand where the ghost is said to originate from - the Khorat Plateau region with its blood-red soil.

One workers claims he managed to fight off the ghost. Pretending to be asleep one night, he saw a misty shape with a beautiful woman’s face forming above him. When it floated downwards almost touching his body, he yelled. The spirit vanished.

It is stories like this that caused widespread panic in the community. In May, there was a report that up to seventy percent of Thai workers threatened to leave. They said a monk from Bangkok had to be sent down to hand out amulets and pray for their lives. Some of them, however, have turned to witchcraft to protect themselves. You can find phallic charms made of wood, painted bright red, hanging in their doorways and some Thai men even sleep in women’s nightgowns and stockings, and paint their fingernails in bold colours to mislead the ghost into thinking that they are women.

That is the end of the personal story. We will be posting our conclusion here and before we do that, we would like to mention that SADS does not happen only among Thai workers. It does happen among other regions as well. Can this happen again? Definitely. It might not be to a mass number. It can even happen in individuals and even some of us! Reason being, people do pass out and die for no apparent reasons, and with medical reports that do not state any forms of abnormalities. We believe that a supernatural cause could happen in a form of black magic. Dirt or soil are widely used by witches or in any magic spells either to bless or harm people. Whatever insider stories the Thai workers have, we suspect that it is an art of evil from the story of ‘Blood-red Soil’. It could be during the time when there were about to travel to Singapore and needed to do a blood test beforehand. Blood collected then was probably not properly disposed and were used for black magic purposes, causing the supernatural phenomenon. It is also possible that the medical research was not advanced during that point of time and doctors couldn’t rule out any possible health issues.

Couldn’t it be coincidence that it happened to the Thais only? Despite having other foreigners from different countries staying together as well? One thing for sure, death is definitely inevitable.

Thank you for all the support! We hope you enjoy the case and we wish you all the best ahead. Till the next time, goodbye!

[vetdownunder]

That’s Gutsy!

Compared to the last couple of placements, the one and a half hour drive on Monday morning was nothing, and I arrived long before I resorted to playing ‘I spy’ with myself! It was a public holiday, but I agreed to be in town and available in case there were any emergencies. I spent the day wandering through the quaint little shops on the main road, visiting second hand bookstores and antique markets. Once I’d exhausted everything the town had to offer, I headed ten minutes out of town to the ‘vet house’ where I’d be staying for the week. I was greeted by a very bold kitten who marched right up to me and meowed very loudly until I patted her. I let myself in and found my room, which was small but clean and private. The house had a beautiful garden that gave it a very homely feel, and was conveniently located next to the stables where they hospitalise the horse patients. I sat out in the garden studying until one of the vets, Alice, arrived home with her dog, Issy. Issy was a rescue mutt who looked quite like a border terrier - appropriate, Alice said, as that was the breed James Herriot had.

In the evening I received a message saying there was a colic horse at the stables, so I went over and introduced myself to the practice owner, Therese, and the new grad, Ollie, who was shadowing her for the week. The horse was in a little bit of discomfort from suspected sand ingestion, but overall the colic seemed pretty mild. We gave him an anti-inflammatory and drenched him via a naso-gastric tube.

On Tuesday I went to their small sister clinic in a nearby town with a vet named Simon and one of the nurses. It was a pretty quiet morning of consultations and one dog castration. In the afternoon, Simon and I drove out to a hobby farm to do a horse power float (a routine dental procedure), which was interesting to watch. Afterwards, we visited a pony on another property for a corneal ulcer recheck. Once back at the main clinic, we joined the other vets and headed down the road to the pub for the monthly vet meeting. First on the agenda: vet students! Therese wanted to make it quite plain that if vet students didn’t answer their phones after hours, they’d fail the placement. Hint taken! The vets shared some of their recent interesting cases and discussed new products and recent discoveries. I was able to contribute a little by sharing what I’d seen in other clinics. Therese bought us all chicken parmigiana which was delicious, but I felt like a failure for not finishing the gigantic portion!

The following morning at the clinic was filled with surgery. There was a cat spey, a double dew claw amputation and a dog fight stitch up. The colic horse from Monday returned to the hospital having taken a turn for the worst. The owners couldn’t afford to send him to Perth or keep him in hospital overnight, so they opted to bring him back first thing in the morning for ongoing monitoring and treatment. I met them at the stables first thing in the morning and helped unload the horse from the float ready for when Ollie arrived. The poor horse was not looking very flash today. We treated him again and then had to head to the clinic for the start of the day. It was my job, as the student, to periodically drive back to check on him and report back to the vets. He went downhill steadily throughout the day. The signs were textbook and easily recognised even by a non-horsey person like myself. He was pawing at the ground, turning around to bite his flank, and repeatedly lying down and getting up again. In the afternoon, I went with Therese to see a horse that had lacerated his heel bulb. She explained that these sorts of injuries have the potential to be very serious, but luckily this wound was superficial and had missed all the tendons. We clipped and cleaned the wound, cut off the flap and bandaged the limb. On my next visit to the colic horse, he was looking even more distressed and suddenly collapsed to the ground in front of me. I tried to get him up, but he was too painful and determined to stay down. When I called Therese to inform her that his heart rate had reached 80 beats per minute (normal is up to 36!), she decided it was time to call it quits. We followed the distraught owner back to her property, and I helped Therese with the euthanasia. She taught me that the best method is to place a large gauge jugular catheter, sedate the horse until the head drops right down, and then whack in two 60 mL syringes of lethobarb as quickly as possible. The procedure went quite smoothly, although not perfectly (I’m told this is very difficult to achieve!). It was the first time I’d seen a horse euthanasia and it was a little confronting. It’s not the same peaceful and dignified ending as with dog and cat euthanasias. There are a lot of logistics involved in dropping half a tonne to the ground and ensuring everyone’s safety. It was an upsetting end to the case and I was disappointed we couldn’t do more for him.

On Friday morning, I was invited to join the vets at the clinic bright and early for a haematology tutorial from my clinical pathology lecturer. It was very informative and I learnt some new things that weren’t covered at uni. We also played around with the new microscope system which lets you to view the slide and take photos from a smartphone, allowing easy sharing for second opinions. We discussed a case of megacolon in a cat where the vet ended up surgically removing the entire colon. Therese unintentionally exclaimed, “phwoar, that’s gutsy!”, which caused us all to burst out laughing. In the afternoon I went with Simon to see a beautiful Andalusian horse with lameness in all four feet. I learnt a lot from this case about treatment and management options for lameness. Back at the clinic, someone entrusted me with the keys to the monster vet vehicle, so I got to pretend to be a vet while I drove down the main road to get fuel! The final call of the day was to a farm to test five rams for Brucellosis. This involves taking a blood sample and palpating the testicles for any lumps and bumps. Once back in town, I thanked the vets for a great week and hit the road back to Perth. That’s a wrap on three weeks of placement and my grand tour of Western Australia!

[queenmercurys]

My health anxiety thoughts - week 1

Hi! So, I’ve been thinking about doing this for a while, and I’m finally getting to it. I’ve been suffering from hypochondria (I suppose) for some months now, and I’m trying very hard to shake it off, but I thought it would be useful for me to write down some of the things I’m feeling in the hopes that writing it down will give me a different perspective on it. And maybe to be able to actually get over these feelings. So yeah, just my own ramblings, I’m not looking for reassurance or anything like that, I just kind of need to do this. I’m putting it all under the cut because this is not something I feel anyone’s going to be too interested in. But if you do read this, please don’t judge me. I know it’s silly, but I can’t exactly help it. Yet, anyway.

I’m not entirely sure when exactly this started, but I reckon it was around March when I noticed this discoloration on my stomach and back, very mild, my mother couldn’t even see it in the picture I sent to her in panic, but it was there. I googled around for ages (big, big mistake, but I didn’t realize that at the time) and found multiple results, from casual to fatal, but all urged me to get a doctor’s appointment. I went to see the nurse at my university (the thing about Finland is that you almost always get a nurse’s appointment first, I’ve hardly ever gotten straight to the doctor, which just adds to the anxiety) and she said that it was simply dry skin, and would disappear eventually. It was not, and it did not. I did go to the doctor a few weeks ago about it, finally, and it turned out to be harmless pigmentation that will go away on its own. But a part of me still thinks that maybe she was wrong about the diagnosis. 

My next source of anxiety came some time later when I noticed a dark spot on my tooth. I’ve had a fear of dentists for a while now, so my panic at that time was understandable (to me, I mean). I booked a dentist’s appointment, but as my university’s dentist is always so booked, it got pushed to August, even though I did the booking in May. So I had a good few months to dwell on it, panic about my teeth and the possibility of having cavities for the first time in my entire life. I have now had the dentist’s appointment, and everything is fine. But as I spent most of the appointment asking questions about teeth and all that, I have to go to a dental hygienist separately to get the standard teeth cleaning, because I wasted so much time pleading for the dentist to explain it all to me. Luckily for me, she was very sweet and did just that. 

Some other things came soon after, the biggest one being a fear of melanoma. I’m very fair-skinned, and apparently melanoma is “more common” with people who share my skin type, so naturally, I panicked. I have now gone to both a nurse specializing in spotting melanoma, and a surgeon who removed two moles (for convenience's sake, they were in an uncomfortable spot), and they both declared my moles perfectly normal. And yet, I still find myself staring at random moles and picturing that they’ve changed rapidly, that they don’t look like they used to, that they weren’t there before. It’s a lot more exhausting than it sounds. 

I almost forgot to mention these next two things that were the center of my attention for a while. One, a strange lump that moves under my ribs on the left side. I went to the doctor about this twice. First, one from the university, who didn’t know what it was, but claimed that it could be nothing more than a lipoma. Nevertheless, she scheduled an ultrasound I’ll be going to next week. The second one was a different doctor from a different hospital who pressed down on my stomach for ages, and said that there’s nothing there except the back of my ribs from the back side, poking through as I’ve become so skinny. In other words, harmless. And the other problem that plagued my thoughts for over a week was this horrible chest and throat pressure I first put down to a heart attack (naturally), then heartburn and finally, after the doctor’s examination, back pain due to tense muscles around my back and ribcage. At one point I did suspect it could be throat cancer, and cancer of the esophagus. Again, naturally. 

And even more recently, on top of these, I have “discovered” two more things to stress over. One, a strange feeling in my left eye, as if something is stuck there. I googled, and naturally, I feel I have a rare condition which starts from such symptoms and eventually leads to blindness. Ad the other thing is that, today, I spotted a tiny (as if done by an ink pen) black spot on the back of my gums in my mouth. I googled, again, and got to know a little disease called melanoma of the mouth. I actually lucked out, because a while ago I booked a dental hygienist’s appointment, and it happens to be this week, so this particular paranoia will be answered as soon as Wednesday. But that’s not usually the case. Usually I find a symptom, worry about it, google it, think about it constantly... until I find a new one to worry about, google and observe. 

I find that the disease that I keep coming back to, always, is cancer. Every single time. Perhaps it’s because my mother had cancer, or maybe it’s because it’s such a deadly disease no one seems to understand, or because it remains undetected for so long. No matter how small the odds are, no matter how vague my symptoms are, I always go back to cancer. And that’s really terrifying, because when I do that, I convince myself that I’m dying, and I have no choice but to repeat the harmful process of going to the doctor to get the reassurance I so desperately need. Maybe one day I will get cancer, and die. I hope not, but it’s as possible for me as for everyone else. But the idea of it happening now, now that I’m still so young and have done basically nothing with my life, it’s terrifying. 

All of this can probably also be linked to the fact that I am generally a person who worries a lot, and someone with mild anxiety in other forms, too. It sucks that this is something I’m putting myself through, but I really am trying everything I can to get over it. I didn’t have it before, so I can not have it again. At least I really hope so.

[freewhispersmaker]

case study

  92434 Professional Identity 2017

ASSESSMENT 2

Case Study, (40%)

  Sandy Wilson

Assignment

Read the following scenario carefully

Provide an analysis of the case by answering the questions that follow

Submit into Turnitin when you have completed the assignment. It will be marked in Turnitin and grades will appear in ‘My Grades’ on UTSOnline

  The Scenario

Sandy Wilson, fifteen years old, had just completed a three-month check-up for a fractured ankle. The fracture had healed completely without complications, but her haemoglobin level was in the low-normal range. As a precautionary measure, she was sent to Mary Jones, a nurse practitioner, for diet counselling.

Not long after Sandy had met in Mary’s office, she confided that she thought she was pregnant, but that she did not want anyone else to know, especially her mother. After some questioning, however, it became clear to Mary that Sandy had no clear idea of what she was going to do about the suspected pregnancy.

Before Mary could begin to think the situation through, Mrs Wilson knocked on the door and asked to come because she wanted to speak to Mary. Mrs Wilson entered and told Mary that Sandy had been nauseated and very tired lately, and asked Mary ‘Do you have any idea what could be causing this?

As Mary prepared to respond, Sandy remained silent and glared at her.

______________________________________________________________

  Professional judgement requires that Mary, the Nurse Practitioner [NP] recognises the full range and complexity of issues involved in the ‘Sandy Wilson’ scenario and be able to ‘weigh these in the balance’ and come to a considered decision about what is best given the circumstances. In the scenario, there are legal, ethical and clinical issues which the nurse must attend to. Such judgement improves with experience and reflective attention to that experience.

  All the following questions must be attempted. Please note that the majority of time should be spent on section 4 as this carries the highest percentage of marks. The word limit is 1200 words.

Case Study Questions

1. Briefly note the ‘problem’ that exists for Mary [what is the most basic thing ethically that the nurse must address]

Make a list of the things YOU think are the most ethically/legal significant factors in the scenario. In other words what things would have to take into account if thinking and decisions are to be ethically and legally appropriate in this situation?]

List 2 (two) options available to Mary, which are the most obvious courses of action, given what she takes the problem to be. Then choose ONE course of action

Develop an argument/rationale for the stance (course of action) taken by Mary.

  The argument should:

Clear reasons for the nominated option

Give clear reasons why the other option is not recommended

The argument must relate to points 1-3 above

The criteria is present through ‘Assessment’ tab and assessment 1 case study

Further Points to note about this assignment:

This is not a formal essay. The best way to ‘format’, the assignment is simply to address questions 1-4 in that order

Use the headings supplied

The portal for ‘Turnitin’ is in the Assessment folder via Assessment button on the blue side bar

Please remember to ‘SAVE’ a copy of your work before submitting to your tutor

It is important to address your assignment to the appropriate tutor

You can submit into Turnitin before the due date and the previous copy will be over ridden. However, I suggest that you limit your submission as your previous work remains in the system

If you submit prior to the date to check your similarity index allow time to resubmit

Benefit of this exercise:

The exercise is designed to help you develop your own capacity for informed, analytical and appropriate critical appraisal of the ethical texture of nursing work. You develop these skills by building on your own current views through reading and classroom discussion. Use the readings given to SHAPE your thinking however it is YOUR thinking about the situation that is important. We want you to be a credible participant in the argument. Not merely a reporter of what others have said.

Acknowledgement Aileen Wylle

92434 Professional Identity ASSESSMENT 2 CASE STUDY

     CRITERA

DESCRIPTION

POSSIBLE MARKS

GRADE Problem Ø  Problem noted with consideration of ethical issues

Ø  Demonstrates basic facts of the case are understood

Ø  Provides a relevant ethical consideration for the nurse

5 Ethical-legal

considerations

Ø  Ethical and legal issues mentioned are linked to the problem

Ø  Demonstrates depth of understanding in identification of ethically and legally significant factors related to the case

Ø  Relevance of nominated ethical issue is made clear

Ø  Basic facts of the case correctly understood

5 Courses of Action Ø  Highlights no more than two courses of action that are relevant to the case

  5 Chosen Course of Action Ø  Provides a rationale and argues why you chose that particular course of action

Ø  Recognises important implications and consequences of the recommended course of action

Ø  Evidence that the ‘Problem’ and ‘Ethical & Legal Considerations’ are integrated throughout the discussion

Ø  Offers analysis and evaluation of the course of action that was not chosen

20 Presentation and Referencing Ø  Argument well supported with current and relevant literature

Ø  Clear writing style with accurate grammar and referencing

5 Overall Mark and Grade  Z= Below 50%

P= 50% and above

C= 65% and above

D= 75% and above

H = 85% and above

Total marks 40%

(100%)

Student Name: __________________________________________ ID_________________

Marker Name: ______________________________________________________________

Marker Signature: ___________________________________________________________

92434 Professional Identity

STUDENT FEEDBACK FOR ASSESSMENT 2

  The Sandy Wilson Case Study

Professional judgement requires that the nurse recognise the full range and complexity of issues involved in the ‘Sandy Wilson’ scenario, be able to ‘weigh these in the balance’ and come to a considered decision about what was [most] important, what she needs to do, how she should go about these things etc … in order to be properly ‘available’ to Sandy. In the scenario, there are legal, ethical and clinical issues which the nurse must attend to. Such judgement improves with experience – and reflective attention to that experience. Following are a few comments on clinical skills and related legal and ethical matters.

  Some specific law and ethics

Children and consent

Unless Maria had reason to believe otherwise, it seems clear that Sandy is an ordinarily legally competent girl. She will be able to consent to ‘ordinary medical and dental treatment’, which is what is initially involved here. If this is the case, then Sandy has status as a patient, and therefore has the right to confidentiality. An implication is this: that it is up to Sandy to decide whether her mother is to be informed of her situation. Maria has no obligation to say anything about Sandy to the mother, nor would she have any right to say anything without Sandy’s permission.

Sexual relations and 15-year old’s

You will be aware of what the Crimes Act (NSW) has to say about sexual intercourse with 15- year- old girls. However, the following points should be noted:

If the nurse, having discussed things with Sandy, learns that Sandy has been sexually involved with a boyfriend, and that this was consensual, then normal practice is to simply note this and move on to whatever therapeutic business might be necessary, This practice shows that the law is no longer viewed as applying absolutely and without exception: gradual changes in sexual mores have resulted in a more restricted application of the law.

Suppose the nurse learns that there has been coerced sex – forced by a family member: father, brother, uncle. The nurse is required by law to notify welfare authorities – under the provisions of the children and Young Persons (Care and Protection Act) (NSW). Note that the nurse would be indemnified in this situation: she is required to report even suspected abuse, but cannot be prosecuted if it turns out that no abuse actually occurred, in this situation, Sandy’s right to confidentiality is overridden by the requirements to notify.

If the nurse learns that Sandy was raped by someone outside the home, then while this is a clearly criminal matter, its handling involves complexity. Even if Sandy is in her care at home. The question of whether the police are to be notified, and by whom, is also complicated. Much would depend, for example, on whether the rapist was a stranger, or someone known to Sandy, and therefore identifiable to the police.

  How to respond to the mother

Mother’s question to Maria [“Do you have any idea…?”] is very awkward for the nurse. She has a very clear idea of the possibilities here, even if she does not know for sure about any one of them.  However, Sandy is owed confidentiality [already established], and given the delicacy of the issue she has raised, would need ‘protective space’ for the moment so that she can make use of the help she has sought from the nurse. Maria has a dilemma: either she answers truthfully – in which case she opens up a conversation which would likely expose Sandy: or she answers by deception [even lying] – which could afford protection for Sandy, but at the cost of an ethically troubling act. Note that some ‘in between’ action – evasion, but not deception, yet not the truth about Sandy’s concerns- would likely only stimulate further questions from the concerned mother… questions which would ultimately bring Maria back to the basic dilemma.

General nursing Overview:

A useful guiding framework for Maria in approaching such a situation is that of patient centredness. Here the patient has a status and ‘rights’ as a patient and these ought to be observed:

It implies recognition of the important person (Sandy)

shows respect to the patient (Sandy appears to be the patient)

fosters a therapeutic relationship with Sandy and others such as her mother when appropriate

in turn gains trust

Sandy will feel ‘empowered’/ a partnership perhaps better/ boundaries set though

leads into caring and a way forward

Abilities for the clinician (Maria) to observe in order to achieve the above dot points:

open mindedness

self-aware: considerate, empathetic

values individuals

motivated to help

advocate

The framework of ‘patient centred’ and the abilities required assist in the approach and the skills necessary for Maria to meet the situation as  ‘professional’ i.e. a NP who is registered to:

diagnose and treat acute health problems e.g. infections, minor injuries,

monitor and treat chronic diseases such as diabetes and hypertension

order , perform and interpret specific diagnostic tests

possess, supply and prescribe some medications

refer and accept referrals for other health professional

(See the competency requirements necessary for NPs)

To be able to diagnose, monitor, treat, order and treat Maria would require the following skills

effective communication skills which are your attending, listening, questioning technique as appropriate e.g. direct questions can elicit information but may need to establish a trust or person at ease first.

use supportive behaviours: see notes below on the approach to Sandy

Sound judgement: avoid assumptions, making judgements too quickly, false reassurance

Making unnecessary decisions for Sandy

assessment skills to assist in making the ‘best’ possible decisions

authority to practice through professional bodies

knowledge related to that which she is registered

Source: © AcademicWritersBay.com

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[yesilovehorses-blog1]

Caring for the Equine Colic Survivor

New Post has been published on http://lovehorses.net/caring-for-the-equine-colic-survivor/

Caring for the Equine Colic Survivor

Every colic case is different—and certainly not all stories can have such happy endings—but veterinarians agree that the care we give our horses after a colic episode, surgical or not, can play a major role in their recovery.

Photo: Anne M. Eberhardt/The Horse

Special maintenance and nutrition can help your horse get back to (and stay in) good health after a colic episode

Ouragan was in a critical state. Four days after colic surgery, the regional show jumping champion was suffering from postoperative ileus (a lack of gut motility) and facing a mere 5% chance of survival. To make matters worse, Ouragan (French for “Hurricane”) reacted to his hospital surroundings with severe stress. The 12-year-old half-Thoroughbred was naturally high-strung, and being confined to an unfamiliar stall and surrounded by foreign sights, sounds, and smells pushed him beyond his limits. 

But one thing calmed him—his owner. Every day after work and on weekends, Claire Boillin, of Auxonne, France, would make the 200-km (124-mile) drive to see Ouragan at the clinic. It provided a moment of relief for the horse, as well as the staff. 

“He wouldn’t sleep and just kept refluxing (expelling fluid when veterinarians tubed him), and I was sure he wouldn’t make it through the night,” she says of that pivotal fourth day in his healing. “When I went in his stall, he was so exhausted, he just lay down. I sat next to him and put his head on my lap, and he fell asleep.”

Thankfully, the next morning the gelding had made a miraculous turn for the better. And today, Ouragan is back to winning show jumping medals under Boillin in the Burgundy region of France. 

Every colic case is different—and certainly not all stories can have such happy endings—but veterinarians agree that the care we give our horses after a colic episode, surgical or not, can play a major role in their recovery. 

By preventing relapses, encouraging healthy gut motility, protecting incision sites in postop horses, and seeing to horses’ welfare during their convalescence, we can help patients get back to all the things they were doing before colic—and more. 

Best-Case Scenario: No Surgery

Perhaps you’ve made it through this colic experience without sending your horse to surgery. Lucky you! Chances are he is in for a full recovery within a few days—maybe even a few hours. 

A horse whose colic resolves without surgery can go back to his normal routine within 12 to 24 hours of the episode, says Louise Southwood, BVSc, MS, PhD, Dipl. ACVS, ACVECC, associate professor of emergency medicine and critical care at the University of Pennsylvania School of Veterinary Medicine’s New Bolton Center, in Kennett Square.

In fact, the sooner the better. “The more time horses spend in the stall, the more gastrointestinal problems they’ll have,” she says. “Getting them out and getting exercise is good for them. Just treat them like any other horse that’s had a short time off work, and gradually increase their workload over a couple of days.”

When There’s an Incision Site

Let’s say surgery was necessary, but your horse is on the other side of it. The good news is he’s among the approximately 80% that get to go home afterward. The bad news? He’s got a major incision in his abdominal wall. Colic surgery incisions range from 20 to 40 cm in length (8 to 16 inches), depending on the kind of surgery performed. Several layers of tissue—skin, subcutaneous fatty tissue, peritoneal lining (the membrane lining the abdominal cavity), and especially the body wall—need to heal. That body wall, composed of muscles, ligaments, and other fibrous tissues, is what essentially “holds everything in,” says Southwood. And getting that wall to heal well enough to withstand the forces of ridden exercise can take up to 12 weeks. That’s if all goes well.

Surgeons and medical staff perform the necessary wound treatment in the week or so before your horse comes home. Then, your job is to make sure he doesn’t burst that incision open with excessive movement. That means four weeks of strict stall rest (with some hand-walking and -grazing), followed by another four weeks of small turnout time, alone. 

What to Expect After Colic Surgery

“We don’t want them running and playing and bucking with other horses, but we do want them to be able to have just a little more exercise at this point,” Southwood says. After eight weeks they can be in a pasture with other horses. If the incisional scar is small and looks good, they can start some very light, unridden exercise after Week 10, she adds. 

Unfortunately, that incision site can get infected, even if you’ve been careful about keeping it clean and protected. Infections can delay wound healing and postpone return to work, Southwood says. 

They can also lead to hernias, in which the intestines protrude through the incision, which can reduce athletic potential, says Debra Archer, BVMS, PhD, CertES (soft tissue), Dipl. ECVS, FHEA, MRCVS, of the University of Liverpool’s School of Veterinary Science, in the U.K. “The vast majority of horses (around 86%) that are discharged home following colic surgery return to (or start) work, and one of the key factors that limits this is formation of an incisional hernia,” she says. 

Veterinarians can sometimes repair a hernia via a second surgery, but it’s best to try to prevent it from happening by adhering to the rest protocol and using a hernia belt if your veterinarian suspects any weakening of the body wall at the incision site, says Archer. 

Getting That Gut Moving

Surgery or not, a critical aspect of returning to health post-colic is getting the intestines to work actively again. The two keys to gut motility? Exercise and eating. 

You can (and should) hand-walk and -graze your horse within hours of a complication-free surgery to get his gut moving again.

Photo: Anne M. Eberhardt/The Horse

You can hand-walk and -graze your horse on the hospital lawn within hours of surgery, our sources say. “We like to get them out to grass after about 12 hours following uncomplicated surgery, just for five minutes at a time,” Archer says. “That’s what they’re designed to eat, and it’s a great way to get their guts moving again, eating little and often.”

Southwood adds that she likes to restart horses on complete senior feeds, an easily palatable source of nutrients that gets them chewing and salivating, which encourage intestinal movement.

In some cases owners of nonsurgical horses might need to withhold feed following the colic episode, says Archer. “If it’s an impaction of the large colon, you don’t want to add to that traffic jam of feed ­material … by bringing in more food to get stuck there,” she explains. “These type of cases will need repeated tubing of fluids via the stomach until the impacted feed starts to move through.”

Even so, feeding a handful of hay or a few bites of grass might stimulate the gut to move that traffic jam along, she adds. But that decision should be made with a veterinarian’s advice. 

Owners can also, in certain situations, feed their horses certain small treats, with veterinarian approval.

The Isolation Blues

Horses dealing with colic are in enough pain as it is. But when they recover, they often find themselves locked up—­sometimes for weeks, sometimes in unfamiliar environments—and separated from herdmates. Such confinement and isolation can be hard on these social, mobile animals. 

Again, get the horse out and walking in hand and grazing as often as your v­eterinarian recommends, our sources say. Nothing beats fresh air and open space for these animals. 

“Getting them out and moving a bit helps keep edema (fluid swelling) down and really brightens the horse up,” Archer says. “That nursing care is really important for them.”

The Cost of Colic

No doubt about it, colic surgery is expensive. A basic, complication-free surgery can cost around $5,000 depending on the clinic, while an extensive resection (removing part of the intestine), for instance, can cost double that. To keep you from colicking over the expenses you’re running up, keep an open dialogue with your veterinarian and remain realistic. 

“We want to save them all, and that’s why we do what we do. But that doesn’t mean all we do is within everyone’s budget,” says Louise Southwood, BVSc, MS, PhD, Dipl. ACVS, ACVECC, associate professor of emergency medicine and critical care at the University of Pennsylvania School of Veterinary Medicine’s New Bolton Center, in Kennett Square.

Be sure you discuss costs with veterinarians, even before going to the clinic. “If you can’t spend a thousand dollars for a nonsurgery hospital stay, it’s okay to say so,” Southwood says. “If you can get the horse to the hospital but can’t spend $10,000 if he develops postoperative reflux and needs a second surgery, it’s okay to say so.”

You can also inquire about therapy options to keep costs down, she adds, as possible nonsurgical treatments are often available.

Christa Lesté-Lasserre, MA

Not Again!

Now that he’s out of the woods, let’s make sure your horse doesn’t end up there again. Claire Scantlebury, BSc, BVSc, PhD, MRCVS, of the University of Liverpool, says as many as 30% of post-colic horses colic again within a year. While sometimes it’s secondary to the first colic (such as adhesions in the intestines caused by scar tissue after surgery), a repeat colic might happen because whatever caused the first colic never resolved.

To make sure you’re reducing the risk of repeat colics, first look at some common culprits, says Archer. The exact cause of colic is complex and likely involves many factors. She says dental problems that prevent chewing properly are risk factors for colic, and horses should have good, regular dental care to prevent these from developing. Parasites, especially tapeworms, are still far too often a cause of colic, Archer adds. Not all dewormers target tapeworms, and it is difficult to know if they have built up high levels. “It’s really disappointing when you take a horse into surgery when a simple dewormer (effective against tapeworms) could have prevented this,” she says. 

Free access to fresh palatable water is also important, says Archer. Make sure it’s clean and not iced over, because dehydration can cause impaction colic. So can sudden stall rest, since exercise keeps the gut moving. And if you’ve got a colic-sensitive horse (and some just are), make management and feeding changes slowly and with caution. “We’re not talking about hours or days, but something like two to three weeks for feed and management changes with these horses,” Archer says.

Generally speaking, keep horses that have colicked on their normal routine as much as possible as soon as it’s permitted by their vet, says Scantlebury. 

Communicate, Communicate

Good care for your horse includes good communication with your veterinarian. “It’s really important to keep an open dialogue,” says Archer. “Knowing how things are going, getting questions answered, making sure we’re following the right care plan as things progress for each horse. And also keeping up with the bill, which is really necessary.”

My Horse’s Vet Bill is How Much?

She encourages owners of hospitalized horses to visit frequently, which also helps with communication between the owner and veterinary staff (although she cautions that lengthy visits can interrupt regular clinic workflow). 

Owners should refrain from getting too wrapped up in the dialogue on internet forums or getting information online from unreliable sources, she adds. “People can feel really overwhelmed and might be tempted to go to the internet, but there are endless websites out there with ridiculous, unscientific advice and lots of anecdotes,” she says. “The best information will come from your vet, so don’t hesitate to pick up the phone.”  

When All We Do Just Isn’t Enough

Despite our best efforts and care, sometimes horses just can’t beat the challenges of colic. Some horses, like Ouragan, develop postoperative reflux, which can lead to serious complications and a vicious cycle that often (but not always) requires a second surgery. Others develop a second bout of colic requiring additional surgery. Some can have serious wound infections or painful intestinal adhesions. 

When the suffering goes on too long, or when the bills get too high, euthanasia can be an ethical ending. “It’s okay to say it’s time to stop trying,” says Archer. 

Southwood agrees. “Sometimes things don’t work out, and it’s entirely acceptable to make that decision, even for financial reasons,” she says. “No veterinarian would pass judgment on owners for such a decision.”

Take-Home Message

Colic can be taxing on the horse’s body, as can the recovery process. But with good after-colic care—whether the horse has had surgery or not—and preventive measures to ward off recurrence, we can help our horses safely transition back to their healthy and active lives, minimizing stressors along the way. 

About the Author

Christa Lesté-Lasserre, MA

Christa Lesté-Lasserre is a freelance writer based in France. A native of Dallas, Texas, Lesté-Lasserre grew up riding Quarter Horses, Appaloosas, and Shetland Ponies. She holds a master’s degree in English, specializing in creative writing, from the University of Mississippi in Oxford and earned a bachelor’s in journalism and creative writing with a minor in sciences from Baylor University in Waco, Texas. She currently keeps her two Trakehners at home near Paris. Follow Lesté-Lasserre on Twitter @christalestelas.

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  92434 Professional Identity 2017

ASSESSMENT 2

Case Study, (40%)

  Sandy Wilson

Assignment

Read the following scenario carefully

Provide an analysis of the case by answering the questions that follow

Submit into Turnitin when you have completed the assignment. It will be marked in Turnitin and grades will appear in ‘My Grades’ on UTSOnline

  The Scenario

Sandy Wilson, fifteen years old, had just completed a three-month check-up for a fractured ankle. The fracture had healed completely without complications, but her haemoglobin level was in the low-normal range. As a precautionary measure, she was sent to Mary Jones, a nurse practitioner, for diet counselling.

Not long after Sandy had met in Mary’s office, she confided that she thought she was pregnant, but that she did not want anyone else to know, especially her mother. After some questioning, however, it became clear to Mary that Sandy had no clear idea of what she was going to do about the suspected pregnancy.

Before Mary could begin to think the situation through, Mrs Wilson knocked on the door and asked to come because she wanted to speak to Mary. Mrs Wilson entered and told Mary that Sandy had been nauseated and very tired lately, and asked Mary ‘Do you have any idea what could be causing this?

As Mary prepared to respond, Sandy remained silent and glared at her.

______________________________________________________________

  Professional judgement requires that Mary, the Nurse Practitioner [NP] recognises the full range and complexity of issues involved in the ‘Sandy Wilson’ scenario and be able to ‘weigh these in the balance’ and come to a considered decision about what is best given the circumstances. In the scenario, there are legal, ethical and clinical issues which the nurse must attend to. Such judgement improves with experience and reflective attention to that experience.

  All the following questions must be attempted. Please note that the majority of time should be spent on section 4 as this carries the highest percentage of marks. The word limit is 1200 words.

Case Study Questions

1. Briefly note the ‘problem’ that exists for Mary [what is the most basic thing ethically that the nurse must address]

Make a list of the things YOU think are the most ethically/legal significant factors in the scenario. In other words what things would have to take into account if thinking and decisions are to be ethically and legally appropriate in this situation?]

List 2 (two) options available to Mary, which are the most obvious courses of action, given what she takes the problem to be. Then choose ONE course of action

Develop an argument/rationale for the stance (course of action) taken by Mary.

  The argument should:

Clear reasons for the nominated option

Give clear reasons why the other option is not recommended

The argument must relate to points 1-3 above

The criteria is present through ‘Assessment’ tab and assessment 1 case study

Further Points to note about this assignment:

This is not a formal essay. The best way to ‘format’, the assignment is simply to address questions 1-4 in that order

Use the headings supplied

The portal for ‘Turnitin’ is in the Assessment folder via Assessment button on the blue side bar

Please remember to ‘SAVE’ a copy of your work before submitting to your tutor

It is important to address your assignment to the appropriate tutor

You can submit into Turnitin before the due date and the previous copy will be over ridden. However, I suggest that you limit your submission as your previous work remains in the system

If you submit prior to the date to check your similarity index allow time to resubmit

Benefit of this exercise:

The exercise is designed to help you develop your own capacity for informed, analytical and appropriate critical appraisal of the ethical texture of nursing work. You develop these skills by building on your own current views through reading and classroom discussion. Use the readings given to SHAPE your thinking however it is YOUR thinking about the situation that is important. We want you to be a credible participant in the argument. Not merely a reporter of what others have said.

Acknowledgement Aileen Wylle

92434 Professional Identity ASSESSMENT 2 CASE STUDY

     CRITERA

DESCRIPTION

POSSIBLE MARKS

GRADE Problem Ø  Problem noted with consideration of ethical issues

Ø  Demonstrates basic facts of the case are understood

Ø  Provides a relevant ethical consideration for the nurse

5 Ethical-legal

considerations

Ø  Ethical and legal issues mentioned are linked to the problem

Ø  Demonstrates depth of understanding in identification of ethically and legally significant factors related to the case

Ø  Relevance of nominated ethical issue is made clear

Ø  Basic facts of the case correctly understood

5 Courses of Action Ø  Highlights no more than two courses of action that are relevant to the case

  5 Chosen Course of Action Ø  Provides a rationale and argues why you chose that particular course of action

Ø  Recognises important implications and consequences of the recommended course of action

Ø  Evidence that the ‘Problem’ and ‘Ethical & Legal Considerations’ are integrated throughout the discussion

Ø  Offers analysis and evaluation of the course of action that was not chosen

20 Presentation and Referencing Ø  Argument well supported with current and relevant literature

Ø  Clear writing style with accurate grammar and referencing

5 Overall Mark and Grade  Z= Below 50%

P= 50% and above

C= 65% and above

D= 75% and above

H = 85% and above

Total marks 40%

(100%)

Student Name: __________________________________________ ID_________________

Marker Name: ______________________________________________________________

Marker Signature: ___________________________________________________________

92434 Professional Identity

STUDENT FEEDBACK FOR ASSESSMENT 2

  The Sandy Wilson Case Study

Professional judgement requires that the nurse recognise the full range and complexity of issues involved in the ‘Sandy Wilson’ scenario, be able to ‘weigh these in the balance’ and come to a considered decision about what was [most] important, what she needs to do, how she should go about these things etc … in order to be properly ‘available’ to Sandy. In the scenario, there are legal, ethical and clinical issues which the nurse must attend to. Such judgement improves with experience – and reflective attention to that experience. Following are a few comments on clinical skills and related legal and ethical matters.

  Some specific law and ethics

Children and consent

Unless Maria had reason to believe otherwise, it seems clear that Sandy is an ordinarily legally competent girl. She will be able to consent to ‘ordinary medical and dental treatment’, which is what is initially involved here. If this is the case, then Sandy has status as a patient, and therefore has the right to confidentiality. An implication is this: that it is up to Sandy to decide whether her mother is to be informed of her situation. Maria has no obligation to say anything about Sandy to the mother, nor would she have any right to say anything without Sandy’s permission.

Sexual relations and 15-year old’s

You will be aware of what the Crimes Act (NSW) has to say about sexual intercourse with 15- year- old girls. However, the following points should be noted:

If the nurse, having discussed things with Sandy, learns that Sandy has been sexually involved with a boyfriend, and that this was consensual, then normal practice is to simply note this and move on to whatever therapeutic business might be necessary, This practice shows that the law is no longer viewed as applying absolutely and without exception: gradual changes in sexual mores have resulted in a more restricted application of the law.

Suppose the nurse learns that there has been coerced sex – forced by a family member: father, brother, uncle. The nurse is required by law to notify welfare authorities – under the provisions of the children and Young Persons (Care and Protection Act) (NSW). Note that the nurse would be indemnified in this situation: she is required to report even suspected abuse, but cannot be prosecuted if it turns out that no abuse actually occurred, in this situation, Sandy’s right to confidentiality is overridden by the requirements to notify.

If the nurse learns that Sandy was raped by someone outside the home, then while this is a clearly criminal matter, its handling involves complexity. Even if Sandy is in her care at home. The question of whether the police are to be notified, and by whom, is also complicated. Much would depend, for example, on whether the rapist was a stranger, or someone known to Sandy, and therefore identifiable to the police.

  How to respond to the mother

Mother’s question to Maria [“Do you have any idea…?”] is very awkward for the nurse. She has a very clear idea of the possibilities here, even if she does not know for sure about any one of them.  However, Sandy is owed confidentiality [already established], and given the delicacy of the issue she has raised, would need ‘protective space’ for the moment so that she can make use of the help she has sought from the nurse. Maria has a dilemma: either she answers truthfully – in which case she opens up a conversation which would likely expose Sandy: or she answers by deception [even lying] – which could afford protection for Sandy, but at the cost of an ethically troubling act. Note that some ‘in between’ action – evasion, but not deception, yet not the truth about Sandy’s concerns- would likely only stimulate further questions from the concerned mother… questions which would ultimately bring Maria back to the basic dilemma.

General nursing Overview:

A useful guiding framework for Maria in approaching such a situation is that of patient centredness. Here the patient has a status and ‘rights’ as a patient and these ought to be observed:

It implies recognition of the important person (Sandy)

shows respect to the patient (Sandy appears to be the patient)

fosters a therapeutic relationship with Sandy and others such as her mother when appropriate

in turn gains trust

Sandy will feel ‘empowered’/ a partnership perhaps better/ boundaries set though

leads into caring and a way forward

Abilities for the clinician (Maria) to observe in order to achieve the above dot points:

open mindedness

self-aware: considerate, empathetic

values individuals

motivated to help

advocate

The framework of ‘patient centred’ and the abilities required assist in the approach and the skills necessary for Maria to meet the situation as  ‘professional’ i.e. a NP who is registered to:

diagnose and treat acute health problems e.g. infections, minor injuries,

monitor and treat chronic diseases such as diabetes and hypertension

order , perform and interpret specific diagnostic tests

possess, supply and prescribe some medications

refer and accept referrals for other health professional

(See the competency requirements necessary for NPs)

To be able to diagnose, monitor, treat, order and treat Maria would require the following skills

effective communication skills which are your attending, listening, questioning technique as appropriate e.g. direct questions can elicit information but may need to establish a trust or person at ease first.

use supportive behaviours: see notes below on the approach to Sandy

Sound judgement: avoid assumptions, making judgements too quickly, false reassurance

Making unnecessary decisions for Sandy

assessment skills to assist in making the ‘best’ possible decisions

authority to practice through professional bodies

knowledge related to that which she is registered

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