By A. Rozhov. State University of New York College at Oswego.

It is one thing to treat a patient as a machine buy mobic 7.5mg on-line, ignoring a rich store of infor­ mation that is related to health and functioning generic 7.5mg mobic with mastercard, and yet another to further subdivide the machine into its constituent parts. In the forpier medicine, at least the possibility existed for holistic treatm ent. T he technologies o f today’s medicine reflect its impervi­ ousness to factors conducive to health. Drugs flow nearly un­ im peded from doctor to patient, and are often prescribed for conditions like viral disorders, for which there is no chemical cure. T he delivery system has become large, un­ wieldy, and complex—an industry in search of newer and refined products. Some of the m ore elaborate technologies illustrate the preoccupation o f the system with technical en­ gineering. T he coronary care unit and the kidney dialysis machine link the patient, the machine, into a fixed feedback loop with another machine. M odern medicine is only one approach to health—a wholly disease-oriented approach. Its paradigm of healing assumes that highly refined techniques and profound inter­ ventions into the body can produce health by eliminating the The Eras of Medicine 211 symptoms o f disease. This has led to the neglect of popula­ tion medicine because there is no paying consumer; the neglect of social and environm ental conditions, because physicians are only trained to intervene at the individual level; the neglect of a blizzard of phenom ena about the hum an being, because it does not fit the paradigm ; and finally neglect of the role o f the individual in achieving health, because if health is a commodity it must be delivered to a manipulable public. This is because to the physician the hum an being is simply a machine with interchangeable parts. A given disease can be treated identically in Peoria or in Phoenix; it is the disease that is being treated, not the per­ son. Aside from its convenience to the harried doctor, immobi­ lization is the same as turning o ff the engine in a car and leaving it in a stall at the mechanic’s shop. While we do not know enough about what produces health we know some things—com- monsense things. For example, we know that a nutritious diet, recreation, fresh air, and sunlight are related to health. But because the hospital is a factory for the repair o f disease, none o f these things are readily available. Hospital food is not only tasteless, it is not nutritious— nothing is fresh, everything is frozen, white bread and butter are served, and so on. T here could be gyms and exercise rooms, but a person doing yoga or any other bodily exercise faces deri­ sion, even prohibition. And there is little opportunity to be 212 The Transform ations of Medicine outdoors; hospitals are hermetically sealed chambers. The only way a patient can get outdoors (if there are any grounds) is to grope his or her way to the front door and then face the possibility o f alarm from the m atrons at the admissions desk. Today’s medicine has succeeded where the medicines of the past have failed: it has succeeded in equating medical care with health. T hrough biological adaptation m an has survived; and through adaptation, not medical care, man has achieved im proved health. T he environm ental insults of the industrial age—contam inated water and lack o f sanita­ tion, the unavailability of basic nutrients, uncontrolled epidemics and an inadequate understanding of infectious transmission— have been mostly m anaged. These include air quality, chemical treat­ ments o f foodstuffs and other products, overindulgence in food and drugs, stress, the pace of life, congestion, noise, and the lack of recreation and exercise. T he contribution of medical care was m inor in the adaptation o f man to the industrial threats to health; and similarly, it has only a m inor role to play in the adaptations that now face us. T he reason lies in the paradigm o f health that medicine has con­ A New Paradigm 213 ceived—the “science of the organized individual,” to use A. Crombie elaborates: The biology of the individual is more like engineering than physics, in that each type of living organism is a solution to a specific set of engineering problems—problems of intake and conversion of fuel, locomotion, communication, replication and so on which it has to solve to survive. This subject matter has imposed on physiology its characteristic program: to find out how an organism works by taking it to pieces and trying to put it together again from knowledge of the parts. As a result it has sought to engineer hum an health through the m anipulation o f hum an parts. John Powles has examined this question in some detail in his paper “O n the Limitations of M odern Medicine”: The engineering approach to the improvement of health has been dominant over an alternative approach which would em­ phasize the importance of way of life factors in disease—an approach which could be described as “ecological. Curative medicine has not been very successful in reducing the impact of diseases of maladaptation. Despite the evidence to the contrary, it is widely believed by both patients and their doctors that industrial populations owe their high health standards to “scientific medicine,” that such medi­ cal technology as currently exists is largely effective in coping with the tasks it faces and that it offers great promise for the future. There was only one question Ivan Illyich wanted answered: was his condition dangerous or not?

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Unfortunately the numbers studied were small generic 7.5mg mobic with mastercard, and confirmation in a larger group of patients is required purchase mobic 15 mg otc. Patient preparation 131 Patients being considered for I-Lipiodol must have a full understanding of the risks and possible benefits of the procedure, including the angiographic as well as the Lipiodol therapy. If a biopsy is required, a laparoscopic rather than a transdermal approach is generally recommended. The patient should not have a blocked portal vein and should have a tumour that is deemed non-resectable by a specialist liver surgeon. The patient should be clinically staged using the Okuda staging (or the Child–Pugh staging). In patients with a large right lobe tumour that is greater than 50% of the right lobe, evidence should be sought of a shunt, which would allow tracer to pass into the right lung. The patient should have normal clotting and a platelet count of more than –3 100 000 mm. Platelet infusions can be given but should be discontinued two hours before the angiogram. Since the Lipiodol very rarely leaves the liver, and given the very high ratio of non-radioactive to radioactive Lipiodol, no blockage of the thyroid is required for this treatment. Pharmaceutical preparation Although it is possible to produce radioiodinated Lipiodol by passing 131I gas through Lipiodol, it is not without danger as the gas is not only radioactive but highly corrosive. This volume is too small for most liver tumours and it is advisable that the 131I-Lipiodol be diluted in non-radioactive Lipiodol, to give a total volume of 6–12 mL depending on tumour size. If stored in a syringe, a polypropylene variety is recommended since it is important that the syringe does not dissolve in Lipiodol. If in doubt, non- radioactive Lipiodol should be placed in a syringe and the time taken for the plastic to melt measured. Administration The patient should be prepared for angiography in the radiology department. The syringe 131 containing the I-Lipiodol is taken to the angiography room in a lead container. The Lipiodol can then be given over a period of three to five minutes via a non- dissolvable three way tap, attached between the syringe containing the 131 I-Lipiodol and the Luer lock of the indwelling catheter. The rate should be sufficient to ensure delivery of the dose in five minutes, but not fast enough to cause reflux 131 of the I-Lipiodol into the gastroduodenal artery. As it is radiolucent, the distri- bution of the 131I-Lipiodol can be seen in fluoroscopic examinations. This infusion is performed with a plastic sheet between the syringe and the patient so that any spills will not result in contamination of the patient. The infusion should be completed within five minutes or there is a danger of the catheter dissolving in the Lipiodol. If this starts to happen at any point during the infusion, the catheter should be removed and the infusion of Lipiodol stopped. When the last Lipiodol has been given, the catheter should be flushed with 10 mL saline and gently removed. As is the case with all angiograms, haemostasis is achieved, although the radiologist should not stand close to the liver to do this. Once the patient is removed from the fluoroscopy room, the drapes used on the patient are collected and put in a sealed plastic bag. This is monitored for contamination; if clear the drapes can be laundered, if not they should be stored until the activity is low enough for them to be cleaned. Monitoring of the room for contamination is also performed and any spills cleaned up. Post-procedure care Patients should remain in a supine position for eight hours after an angiogram. Vital signs should be monitored hourly; automatic monitoring devices are ideal for this purpose. After this time, patients may move around, eat and drink normally, and do as they wish within the confines of local radiation protection legislation. There may be some pain and fever 48–72 hours after a procedure, which can be treated with pain relievers and anti-pyrogens such as paracetamol. Discharge will depend on the radiation levels allowed for discharge of 131 patients who have received I. If more than 15% of the activity has passed into the lungs, this means that there is a significant shunt and re-treatment is not advised. Unless previously irradiated, the chance of radiation pneumonitis is low even at 1.