By C. Hernando. Worcester Polytechnic Institute.

Anglo-American patients sought pills and injections finax 1 mg on line treatment 4 hiv, denial of pain 1mg finax amex medicine 750 dollars, and reassuring clinical contacts. In contrast, the Chinese patients preferred salves, oils, creams, and com- 164 ROLLMAN presses and nontraditional medicine, although Chinese dentists (and the Scandinavian ones) shared the American preference for using pharmaceuti- cal treatments. Interestingly, although Scandinavian patients did not want to be treated with local anesthetics, many volunteered that they accepted this treatment for their dentist’s peace of mind. It is rare for anthropologists to go into the field in order to study pain behavior within an isolated cultural group. One exception is Sargent’s (1984) study, conducted in the mid-1970s, of the Bari- ba, a major group of about 400,000 persons living in Benin and Nigeria who are “notable for consistently demonstrating an ‘absence of manifest behav- ior’ when confronted with apparently painful stimuli such as childbirth, wounds, or initiation ordeals” (p. Sargent interviewed 120 women of reproductive age in a small village regarding their behavioral ideals and ac- tual behavior during delivery, spoke to numerous indigenous midwives and village leaders, and attended a number of deliveries. Tellingly, one local physician explained that the Bariba equate pain with cowardice, a source of enormous shame. They pride themselves on the courage of their men in war and their women in childbirth and disparage the behavior of other groups that express pain openly through complaints or behavioral expres- sions. Not surprisingly, the Bariba have few words with which to describe pain, although they do distinguish between pain sensation and suffering. Social modeling (Craig, 1986), from childhood, appears to shape the behav- ior of tribal members. Stoicism is not limited to pain; Bariba are expected to suppress grief and other negative emotions. Honeyman and Jacobs (1996) went into the Australian outback to study pain behavior and beliefs among the members of a small aboriginal commu- nity. They observed that aboriginal children show few signs of distress and that adults minimize any overt pain behaviors. When questioned individu- ally, community members acknowledged pain, including long-term low back pain, but none showed public pain or illness behaviors of the sort seen in Western society. Also, it was extremely rare for any of them to seek medical attention for pain problems. Honeyman and Jacobs proposed that: the concept of illness as a social process, separate from a biological malfunc- tion termed disease, allows us to see these people as acting appropriately to their cultural setting. In this society there are strong community expectations about tolerating and not expressing or displaying pain. This was evidenced by the few public back pain reactions we saw and the reluctance to talk about pain in front of others. ETHNOCULTURAL VARIATIONS IN PAIN 165 The findings emphasize the need for sensitive questioning of patients about their symptoms, particularly when they may come from a group where emotional expression of symptoms is discouraged. Given the psychosocial perspective on cultural differ- ences in pain, it would be interesting to look for evidence concerning ethno- cultural variation in children’s pain. The task is not easy because of problems in assessing pain in young children. Recent years have seen numerous ad- vances in developing physiological measures, behavioral observations, and self-report measures (McGrath, 1995; McGrath et al. Little attention has been paid to the need to validate these scales in dif- ferent cultural settings. Villarruel and Denyes (1991) developed alterna- tive versions of the “Oucher” scale for Hispanic and African American chil- dren. The Oucher comprises a series of six photographs of a 4-year-old White boy showing facial expressions indicating various levels of pain. A pediatric patient is asked to point to the picture that best reflects his or her own level of hurt. Using photographs of Hispanic and African Ameri- can children, taken when they were or were not experiencing pain, the au- thors established an ordering of six photographs that other children could agree represented a progression of pain expression. It remains to be established whether this particular measure will reveal any cross- cultural differences in children’s pain levels, whether scales tailored to ethnic origin or race, although culturally sensitive, aid in either pain as- sessment or in strengthening communication between medical practition- ers and children of different cultural groups, and whether culture-free measures (such as a series of face drawings; Chambers & Craig, 1998; Chambers, Giesbrecht, Craig, Bennett, & Huntsman, 1999) can achieve both validity and universality in pain assessment. Abu-Saad (1984) interviewed Arab American, Asian American, and Latin American school children, asking what caused pain for them, what words they used to describe pain (“like a hurt” was the most common descriptor in each group), how they felt when they are in pain, and how they coped with pain. Given that all lived in the same urban environment, the finding that the similarities among the subjects are considerably greater than the differences is not surprising.

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During massive blood transfusion finax 1mg low cost medicine 377, citrate can accumulate in the circulation discount 1mg finax amex symptoms queasy stomach and headache, resulting in a fall in ionized calcium. Hypocalcemia can result in hypotension, reduced cardiac function, and cardiac arrhythmias. However, the level of calcium required for adequate coagulation is much lower than that necessary to maintain cardiovascular stability. Therefore, hypotension and decreased cardiac contractility occur long before coagulation abnormalities are seen. During massive blood transfusion it is generally prudent to monitor ionized calcium, especially if hemodynamic instability is present in the hypocalcemic patient. During the storage of whole blood or packed red cells, potassium leaks from erythrocytes into the extracellular fluid and can accumulate at concentrations of 40–80 mEq/L. Once the RBCs are returned to the in vivo environment, the potassium quickly re-enters RBCs. However, during rapid blood transfusion tran- sient hyperkalemia may result, particularly in patients with renal insufficiency. The transient hyperkalemia, particularly in the presence of hypocalcemia, can lead to cardiac dysfunction and arrhythmias. In patients with renal insufficiency, potassium load can be minimized by the use of either freshly obtained blood or washed packed RBCs. Hypokalemia can also result from massive blood transfusion due to re- entry of potassium into RBCs and other cells during stress, alkalosis, or massive catecholamine release associated with large volume blood loss. Therefore, potas- sium levels should be monitored routinely during large-volume blood transfu- sions. During the storage of whole blood, an acidic environment occurs due to the accumulation of lactate and citrate with a pH in the range of 6. Rapid transfusion of this acidic fluid can contribute to the metabolic acidosis observed during massive blood transfusion. However, metabolic acidosis in this setting is more commonly due to relative tissue hypoxia and anaerobic metabolism due to an imbalance of oxygen consumption and delivery. The anaerobic metabolism that occurs during states of hypovolemia and poor tissue perfusion results in lactic acidosis. The re-establishment of tissue perfusion and homeostasis is a much more important factor in re-establishing acid–base balance. In contrast, many patients receiving massive blood transfusion will experi- ence a metabolic alkalosis during the posttransfusion phase. This is due to the conversion of citrate to sodium bicarbonate by the liver and is an additional reason to avoid sodium bicarbonate administration during massive blood transfu- sion, except in cases of severe metabolic acidosis (base deficit 12). Rapid infusion of large volumes of cold (4 C) blood can result in significant hypothermia. When added to the already impaired thermoregulatory mechanisms in burn patients, this can result in significant hypothermia. Potential complications Anesthesia 131 of hypothermia include altered citrate metabolism, coagulopathy, and cardiac dysfunction. During large-volume blood transfusion in burn patients, fluids should be actively warmed with systems designed to warm large volumes of rapidly transfused blood effectively. In addition, the room temperature should be elevated and the patient’s extremities and head covered to minimize heat loss. Body tem- perature should be maintained at or above 37 C in burn patients. Thermoregulation The skin plays an important role in maintenance of body temperature. The skin contains sensory receptors to monitor surface temperature, subcutaneous fat that serves as insulation, blood vessels that dilate or contract to dissipate or retain heat, and it acts as a barrier to evaporation of body fluids, which is another potential source of heat loss. Large burn injuries also alter the central regulation of temperature control. The hypermetabolic state that occurs within days of burn injury is associated with an increase in the skin temperature that is perceived as cold and that elicits homeo- static reflexes to maintain body temperature. Burn patients respond to perceived cold with a brisk increase in heat generation by shivering and increased oxidative metabolism. Since the metabolic rate is already accelerated, this response causes additional catabolic stress.

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