The Economic Essay Example | Topics and Well Written Essays - 250 words

The Economic - Essay Example Aside from the education sector, the construction segment also suffered from a major cut due to the slowdown in public construction projects. Irwin also mentions Obama’s response to America’s unemployment problem, which is the $447 billion American Jobs Act. The Act aims to channel money to the state governments to avoid more job cuts (Irwin 2). This Act however is facing a lot of resistance from Congress who deem it unacceptable for the federal government to rescue the state and local governments. This article by Irwin presents a bird’s eye view of the current unemployment situation of the US. It is very informative, citing valuable data on the labor front. One thinks that even if the public sector does not create new jobs or cuts on its employment, the unemployment figure could still improve provided that the private sector is able to take in those who lost their jobs from the state and local governments. The question though that persists in one’s mind is whether the private sector is ready to hire more with the current state of the

Ethical Dilemmas and Cultural Issues Essay Example for Free

Ethical Dilemmas and Cultural Issues Essay 29 year old Sakura has been brought to counseling by a concerned neighbor because she believes Sakura is suffering from depression. She is listless and silent, and prone to staring in to space. During the course of the counseling sessions, it was discovered that Sakura’s husband has been violent towards her recently. Sakura is Japanese and has migrated to California two years ago, here she met and married an American husband. Sakura refuses to tell authorities because she is ashamed that her family in Japan would discover the failure of her marriage. She clearly tells the counselor that no one should know of the state of her relationship with her husband. A counselor is ethically obligated to inform authorities about the abusive nature of the relationship but she is also obligated to respect her client’s wishes. Framework for Ethical Decision Making (Velasquez, M. , Moberg, D. , Meyer, M. J. , Shanks, T. ,. McLean, M. R. , DeCosse, D. , Andre, C. , and Hanson, K. O. , 2009) Recognize an Ethical Issue Psychologists cannot break client-therapist confidentiality; Sakura has clearly expressed that her problems in marriage must be kept confidential and believes that her husband’s temperament is just being affected by his problems at work and the situation between them can be resolved. The counselor feels conflicted because the situation involves actual and potential risk for the client. Get the Facts Sakura is being verbally and physically abused when her husband is incited to anger by small things, like unwashed laundry or bland food. She sometimes gets bruises when her husband grabs he arms and shakes her or pushes her around. Sakura feels miserable at the state of her marriage but she was raised to be a loyal wife to her husband. The Japanese value a good marriage and frown upon divorce and marital problems. The Japanese believe marital problems must be resolved at home and must not be publicly acknowledged. This must be dealt with in therapy sessions sensitive to her culture and to her way of thinking. She must learn to value herself more than valuing the opinion of others. Evaluate Alternative Actions The counselor may decide to first try to convince Sakura of the unreasonable aspects of her situation. An establishment of a high sense of self-worth in therapy can ideally enable her get out of the abusive relationship by her own accord. However, when the danger is imminent and when it is clear that her husband is escalating in violence towards Sakura then the first area of concern would be to notify authorities to stop the abuse. Make a Decision and Test It The therapist can decide to tell the authorities about the nature of the situation, testing a decision can involve looking at the possible outcomes should the decision be executed. All other approaches must be considered; a useful exercise would be asking the question â€Å"what If I told someone I respect-or told a television audience-which option I have chosen, what would they say? † considering different perspectives is vital in making the choice. Act and Reflect on the Outcome Implement the decision, tell the authorities and monitor the outcome, Sakura must be guided in therapy and offered psychological support at all times. Reference: Velasquez, M. , Moberg, D. , Meyer, M. J. , Shanks, T. ,. McLean, M. R. , DeCosse, D. , Andre, C. , and Hanson, K. O. , (2009). A framework for ethical decision making. Markkula Center for Applied Ethics at Santa Clara University.

Incorporating Telemedicine into a Surgical Practice

Incorporating Telemedicine into a Surgical Practice Kristen Harkey Complex wounds can create a challenge for the patient as well as the surgeon. The challenges faced include operative management, cosmesis, long-term management, effects on lifestyle for patient and caregiver, and self-image (Park, Copeland, Henry Barbul, 2010). Hospitalized patients will have the surgical team, the wound care specialist, and a bedside nurse to assist them in their daily care. When these patients are ready to leave the hospital they can feel anxiety about providing care for themselves, especially if they have a complex wound present. This anxiety can decrease once they learn how to care for themselves at home while having the readily available supplies, but then they must leave their homes to travel to come to the surgical office for a wound check. This can be a burden to not only the patient but their primary caregiver. The purpose of this paper is to introduce an evidence-based change project that focuses on providing patients with the option of telemedicine office visits. Background In 2010, approximately 51.4 million inpatient surgeries were performed in the US according to the National Center for Health Statistics (CDC/NCHS, 2010). Wound complications can be an important cause of postoperative morbidity following a laparotomy (Mizeell, Sanfrey, Collins, 2014). Acute wound care is needed in all patients with surgical and traumatic wounds, when an incision is made this creates a wound which will need further attention. There are a multitude of ways to address these wounds such as wet to dry dressings, dry packing strips, wound vac systems, and if needed further surgery such as a skin graft. These wounds can then become chronic when they have failed to proceed through the reparative process to produce anatomic and functional integrity in 12 weeks (Sen, 2009). Both acute and chronic wounds can become a significant financial burden on both the healthcare system and the patient’s themselves. Significance With the sheer number of surgeries listed above, this will create wounds that need to be managed appropriately. Not only are wounds created by surgery, they can also be created by trauma or massive soft tissue infections (Park, Copeland, Henry Barbul, 2010). Part of this management may be further surgical interventions to restore the fascia or possibly watchful waiting. In our facility in 2014, 3349 patients were evaluated by our wound care specialist. Of these 695 patients had surgically created wounds and approximately 656 were managed with wound vacs (G. Caldwell, personal communication, January 20, 2015). These patients will need to be followed in the outpatient setting for ongoing wound assessments, possible change in wound management, or further surgical intervention if indicated. The outpatient care to these patients will include discussions on proper nutrition to promote wound healing, activity levels, timing of dressing changes, and ongoing assessments of the wounds. It can create a significant burden to patient and caregiver to travel to office visits for ongoing assessment of the wounds which can take as little as ten to fifteen minutes to examine once they have arrived back to the exam room. This short office visit can create a significant burden to the patient and their caregiver, this burden can include ability to keep themselves clean throughout the trip, financial, and time-strain. PICO Question and Components Evidence-based practice (EBP) can be described as a â€Å"life-long problem solving approach to clinical decision-making that involves the conscientious use of the best available evidence with one’s own clinical expertise and patient values and preferences to improve outcomes for individuals, groups, communities, and systems† (Melnyk Fineout-Overholt, 2011). EBP will help to ensure high quality, safe, relevant, and up-to-date care while at the same time improving patient outcomes (Robb Shellenbarger, 2014). One of the ways to create EBP in a way that will yield the most relevant information from a search is to form a question in the PICOT format. The PICOT format is composed of the following: â€Å"P† will describe the patient population, â€Å"I† will reveal the intervention or issue of interest, â€Å"C† will reveal the comparison intervention or status, â€Å"O† will reveal the outcome, and â€Å"T† will reveal the time frame in w hich the intervention/issue of interest will accomplish the outcome (Melnyk Fineout-Overholt, 2011). For the purpose of this paper, the author will include all components listed except for time which will be addressed at another juncture. Population The population of focus will be outpatient postoperative patients in the home health setting. The patient population will be those with acute/chronic wounds, ages eighteen and up, both male and female patients with no restrictions on ethnicity. The wounds will likely be compromised of complex abdominal wounds, however no limit will be placed on the type/cause of the wound. The patient’s will live in North Carolina or South Carolina and reside within a 4 hour drive from Charlotte, NC. No restrictions will be placed on the agency providing home health services to the patient. Intervention Telemedicine is defined by the World Health Organization (WHO) to be the practice of healthcare using video, interactive audio, and/or data communications (Chanussot-Deprez Contreras-Ruiz, 2008). With the use of telemedicine the patients will be able to stay in their own home. This will also provide an enhanced team based approach because we will have both the patient, patient’s caregiver if applicable, and the home health nurse. This will provide accurate documentation of wound measurements. The appropriate wound care will then be provided by the home health nurse, and if applicable the wound vac will be re-applied. Comparison The comparison group will be a standard office visit. The standard office visit will consist of the patient and their caregiver coming to our surgical practice, in one of our two locations. The patient will be required to wait for their appointment time and wait as required for the provider to see them. If a wound vac is present, this will be removed in the office and will not be re-applied per standard operating procedures. The patient will have a temporary dressing replaced and will then need the home health nurse to come to their home upon their arrival to re-apply the wound vac. This consists of a standard office visit in our practice. Outcome The anticipated outcome, will be no effect on wound healing when using telemedicine. For the practitioner, one important aspect of examination of the wound is not only using your sense of sight but also your sense of smell. The smell of a wound can be indicative of necrotic tissue that requires further debridement or possibly a wound infection. This sense will be missing with telemedicine and the practitioner will need to rely heavily on the home health nurse for this aspect of assessment. Another outcome for this study will be increased patient satisfaction. The patient with a complex abdominal wound may have difficulty at baseline maintaining adequate coverage for the drainage, this is more of a challenge when you add frequent position changes associated with traveling to a health care provider’s office. In summary, a postoperative surgical patient will require care for the surgical wound in an outpatient setting. This care can be frustrating for the patient, the patient’s caregiver, and the home health nurse. With the addition of telemedicine to a surgical practice this will decrease the burden of traveling to a standard office visit as well as enhance multi-disciplinary care for the patient. It is the hope of the author that for complex wounds that remain difficult to manage in the outpatient setting, the inpatient wound ostomy nurses who provided care inpatient will be able to assist more in the outpatient setting by providing continuity of care. Conclusion With every surgery performed a resultant wound is created. Wounds can also be created by trauma or massive necrotizing soft tissue infections (Park, Copeland, Henry Barbul, 2010). The surgical wound can heal without difficulty and the patient returns to his activities of daily living, however a multitude of wound complications can occur delaying wound healing. Some wound complications will require further surgery, however due to the nature of these wounds surgery may need to be delayed for up to one year or longer. This can cause caregiver strain and for the patient can take away many of the freedoms we enjoy on a daily basis. As part of a standard office visit the patient is expected to arrange transportation to our office, wait for his/her appointment time, have their wound examined, and then if a wound vac is used they are expected to have this re-applied when they get back to their home by the home health nurse. With the addition of telemedicine to the patient’s postopera tive care, they would be able to have a multidisciplinary team visit them in the home using telemedicine resources. This would significantly decrease the burden travel can create for these patients with complex wounds. References CDC/NCHS National Hospital Discharge Survey (2010). Retrieved from  http://www.cdc.gov/nchs/data/nhds/4procedures/2010pro4_numberprocedureage.pdf Chanussot-Deprez, C. Contreras-Ruiz, J. (2008). Telemedicine in wound care. International  Wound Journal, 5(5), 651-654. Melnyk, B. Fineout-Overholt, E. (2011). Evidence-based practice in nursing healthcare: A  guide to best practice (2nd ed.). Philadelphia, PA: Wolters Kluwer|Lippincott Williams   Wilkins. Mizell, J., Sanfrey, H., Collins, K. (2014). Complications of abdominal surgery. Retrieved  from http://www.uptodate.com. Park, H., Copeland, C., Henry, S., Barbul, A. (2010). Complex wounds and their  management. The Surgical Clinics of North America, 90(6), 1181-1194.  doi: 10.1016/j.suc.2010.08.001 Rob, M., Shellenbarger, T. (2014). Strategies for searching and managing evidence-based  practice resources. The Journal of Continuing Education in Nursing, 45(10), 461-466. Sen, C. K., Gordillo, G. M., Roy, S., Kirsner, R., Lambert, L., Hunt, T. K., Longaker, M. T.  (2009). Human skin wounds: A major and snowballing threat to public health and the  economy. Wound Repair Regeneration, 17(6), 763-771. doi:10.1111/j.1524-475X.2009.00543.x Incorporating Telemedicine into a Surgical Practice Incorporating Telemedicine into a Surgical Practice Kristen Harkey Imagine presenting to the hospital for your planned cesarean section, a time of great anxiety and joy. During the procedure you unfortunately have a complication and an enterotomy (cut into the intestines) is made, but missed at the time. Hours later you develop increasing abdominal pain and a rash spreads quickly across your abdomen. Your healthcare providers explain you have an infection called necrotizing fasciitis and this requires further surgery to treat the condition. The individual then wakes up possibly weeks later with most of their abdominal wall, upper thigh skin, some muscle layers missing of both the abdomen and thigh, as well as stool draining from the middle of the wound. The individual is informed they have an enterocutaneous fistula that will likely not be able to be repaired for several months to a year. This person is finally able to transition home with their newborn, a gaping abdominal wound, stool draining from the wound, not allowed to have anything to eat or drink, and are attached to intravenous nutrition twenty-four hours a day. This would be overwhelming for the most health literate patient, much less an individual with limited resources and low health literacy. Our health can change quickly with an unexpected surgery that causes a complex surgical wound. This wound must be monitored closely in the outpatient setting to prevent further complications including loss of limb or possibly life. Typically the patient’s wound care has been provided in the home by a home health nurse. Subsequently the patient and family caregiver are then expected to travel to the doctor’s office for intermittent follow-up examinations of the wound over a weekly to monthly schedule which could last up to one year or more postoperatively. Leaving the patient’s home with these complex wounds can be a burden due to factors such as increased pain, time-consumption, financial costs, and possible embarrassment if the wound or ostomy appliance leaks. Some of this burden could be relieved with virtual visits. Overview of Problem of Interest In the United States 6.5 million individuals are affected with chronic wounds that require ongoing care (Sen et al., 2009). Patients are expected to travel to their healthcare provider’s office for follow-up examinations and sometimes this requires a long care ride, wait in the office, and then travel home. It is difficult to maintain a dressing on the wound in the most basic of circumstances, such as during times of everyday activity in their home. With the addition of traveling this can become an overwhelming and untidy endeavor while the healthcare provider will likely only spend minutes examining you. Due to this some patients will not come to their follow-up appointment and this can be detrimental to their health by prolonging wound healing, increasing risk for infection, and delay future surgical repairs. When the individual is at home, they require home health services for ongoing wound care as well as provision of supplies. The home health nurse sees the patient on a m ore regular basis than the healthcare provider and will call the providers’ office with important changes they note. Unfortunately this process may take several phone calls which takes valuable time for the home health nurse and increases wait time for care of the patient. Most patients have an expectation that surgery will help them heal or cure their disease. Unfortunately approximately 22% of patients may experience moderate to complete postoperative disability (Shulman et al., 2015). Home health nursing will provide some relief for the patient and a multidisciplinary approach is necessary to manage complex treatment modalities (Wilkins, Lowery, Goldfarb, 2007). In Carolinas Medical Center Main in 2014, 3229 patients had wound care provided by our wound ostomy care nurse team and of those 820 were surgical patients (G. Caldwell, personal communication, January 25, 2015). These are many of the patients that require ongoing care in the outpatient setting to prevent further complications. In the United States (US) in 2000, forty million inpatient surgical procedures were performed and at that time the need for post-surgical wound care was sharply on the rise (Chittoria, 2012). In the US the amount of money spent on wound care, diminished quality of life, and the loss of productivity for the individual and caregiver comes at a great cost to our society (Sen et al., 2009). Therefore it is in our best interest as providers to provide safe and effective care to our patients in the most convenient format for both the patient, caregiver, home health nurse, and the healthcare provider. Review of Literature One of the first steps to address a problem is reviewing evidence available to support the proposed intervention. Virtual care is currently being used in many different platforms such as urgent care, psychiatric care provided in ER’s, preventing readmissions in heart failure patients, and many other venues. The examination of acute and chronic wounds is one venue that has found success. In the plastic surgery population where visual exam is heavily relied upon for decision-making, telemedicine has been shown to have great potential. Gardiner and Hartzell (2012) performed a systematic review of twenty-nine articles. Twenty-eight of the articles noted a benefit including improved access to expertise and cost reduction through conserving hospital resources and avoiding unnecessary transfers (Gardiner Hartzell, 2012). Wallace, Hussain, Khan and Wilson (2012) had similar findings in the burn population where they noted improved assessment and triage, avoidance of unnecessary trans fers and a potential for health care savings when using virtual care. In the trauma population a 90% accuracy was noted in assessing traumatic plastic surgery injuries whether the practitioner was using bedside visual exam or transmitted digital images (Gardiner Hartzell, 2012). Wilkins, Lowery, and Goldfarb (2007) used their initial investigation to determine the feasibility of virtual wound care and then moved forward with performing a pilot study using a store and forward technique. At the time of initial referral the mean wound surface area was noted to be 5.85 cm2. Using virtual care the authors noted in 58.2% of the wounds, the diagnosis or treatment plan was changed. This change in diagnosis or treatment plan resulted in an average decrease of 58% from the initial wound size over an average time period of 40.2 days. The authors went on to note 95.5% of patients found telemedicine consultation more convenient than traveling and 98.2% of patients were either satisfied or very satisfied with the care they received (Wilkins, Lowery, Goldfarb, 2007). An article published in 2014 by Kidholm, Dineseen, Dyrvig, Rasmussen, and Yderstraede was noted to be the largest and most comprehensive research project to evaluate telemedicine effectiveness and costs for patients with chronic diseases. The results revealed telehealth reduced mortality with an odds ratio of 0.54. Mortality in the control group was noted to be 8.3% while the intervention group was 4.6%. The authors also noted a 10.8% lower hospital admission rates in the intervention group with an odds ratio of 0.82 (Kidholm, Dinessen, Dyrvig, Rasmussen, Yderstraede, 2014). Telemedicine may be applied to many different aspects of medicine, but a benefit has been shown in the examination and long-term treatment of wounds (Wilkins, Lowery, Goldfarb, 2007). Telemedicine has been shown to satisfy both the clinician as well as the patient, while continuing to provide quality care. Therefore a solution to the burden of traveling to the doctor’s office, decreasing financial strain, decreasing caregiver strain, and improving access to care are all potential benefits of providing care using virtual visits. Purpose of Project The purpose of incorporating telemedicine into our surgical practice is to provide our patients with the most efficient high quality care in the most appropriate setting for the patient. A standard office visit consists of the patient traveling to our office, being evaluated by the medical team, and then having to travel back to their home. This evidenced based project will allow the patient to stay in their own home and have the providers visit them via a virtual visit. Upon discharge from the hospital the patient will be evaluated for inclusion into the virtual visit program. If the patient is determined to meet the criteria including living in NC, using Healthy at Home to provide home health services and have a complex surgical wound; then an appointment will be made for the virtual visit. The home health nurse will proceed to the patient’s home at the assigned appointment time and use their tablet for the visit. The provider will then join the home health nurse in the virt ual setting and the patient’s wound will be evaluated. Appropriate changes in the treatment plan for the wound will occur and the provider will assure all questions/concerns are addressed with the patient, caregiver, and home health nurse. One desired outcome for this project will be to maintain a high level of patient satisfaction, as we do in our office. As providers, we would like to provide more efficient care and this may be possible by having one provider performing postop visits virtually while another provider evaluates new consults in the office. It will be important for this project to provide the same level of care that we provide in the brick and mortar office, as well as following all current standards of care. Project Management The facility where this project takes place is a Magnet facility. To receive this designation an organization must prove they have several key characteristics including empirical outcomes as well as integrating evidenced based practice and research into operational and clinical processes (American Nurses Credentialing Center, 2014). An important goal for our organization this year will be to provide care in new ways, one of which will be providing more opportunities for our patients to experience virtual care. This innovative project is meant to assure that we are improving quality, enhancing value and dealing with the complexity of health care today (Harris, Roussel, Walters, Dearman, 2011). Implementation Team The backbone of quality improvement work is the team and their teamwork (Ogrinc et al., 212). The team for this project will include individuals from different disciplines to ensure success. The author of this paper will serve as the operational lead on the project, assuring all aspects of the project are coordinated. Our administrative lead will be the practice manager for our outpatient sliding scale clinic. He will be able to assist the project in assuring we meet meaningful use standards as we do in the office, as well as building templates in our scheduling software, and facilitate changes in the organization. A management associate with the virtual care division will remain part of the team, as she has had past experience with implementing similar projects and has provided invaluable support. The next member of the team will be a member of the IT department and will assist the team in choosing the right technology/platform for this project. He will not only assist in the beginn ing stages of this project but will be a constant resource for ongoing IT support. The administrator for the home health agency will be a member of this team, she will provide information regarding her organization and provide us with establishing workflow for the home health nurse. This will be an important step as this project is meant to provide multidisciplinary care, however it will not be beneficial for it to provide more efficiency for our team but not the home health team. The chairman of surgery who also serves as the interim lead of the acute care surgery team, as well as the two surgeons who practice on the same service. This team will serve to bring virtual care visits to our surgical practice. Risk Management Strategy It is important to examine every project to identify external and internal items that either positively or negatively affect the project. One type of assessment that can be performed is the strengths, weaknesses, opportunities, and threats analysis (SWOT analysis). During the SWOT analysis the system is fully examined from the clinical micro to the macrosystem perspective (Harris, Roussel, Walters, Dearman, 2011). For this project some strengths noted include other departments within the facility using virtual visits and a department dedicated to assisting new groups to use this technology. Another strength is the patients included in this project will remain in the global ninety day postoperative fee which will not require reimbursement from insurance companies and keep the cost incurred limited. It is important to then examine some of the weaknesses which include removing a provider from an already overbooked clinic to participate in this project, the additional cost of the techno logy, and surgical postoperative care has not been provided in this manner in our facility prior to this. When further evaluating opportunities associated with this project, the ability to be the only surgical providers providing care virtually will set this team apart and appeal to more consumers and home health agencies. Another opportunity would be to include all home health care providers in our area and obtain licensure to be able to provide virtual visits in South Carolina. Some threats to this project include newer technology that hasn’t been tested, a good working relationship with the home health agency must be in place, and is it possible for the team to provide confidential care to our patients using virtual visit technology. Organizational Approval Process Initially this project was approved at the departmental level after multiple discussions with the chairman of surgery for the metro division of our healthcare system. Prior to proceeding to the IRB process, the facility requires submission of your proposal to the Nursing Scientific Advisory Council (NSAC). Once NSAC has evaluated a proposal fully and any revisions have been completed you may move forward with your submission to the IRB. Role of Information Technology in this Project Information technology will play an integral part of this project. Although virtual visits are used throughout the hospital system, they have not been incorporated into the surgical practices within our system. This project will include an IT tech to assist in choosing the best platform to serve our patient population while being user friendly for our home health nursing colleagues. It will be important for our platform to work well with the technology available to the home health nursing team. This will assure we are able to provide the best quality visit and address not only the provider’s needs, but also the home health team, patient, and caregiver. The project needs IT support for both the onsite provider as well as the home health team in the patient’s home. Plans for IRB Approval An institutional review board (IRB) is a committee that is mandated by the National Research Act, Public Law 93-948 and is required in institutions that conduct biomedical or behavioral research that involves human subjects (Harris, Roussel, Walters, Dearman, 2011). IRB approval will be sought for this project using the Carolinas Healthcare System’s IRB. The submission type will be expedited. This approach was chosen because it is evidenced based research and poses minimal human risk to the participants (Chatham University). Prior to approval by the IRB this project must be submitted to the NSAC therefore this will be performed in September 2015. Once approval has been obtained by the NSAC the information will then be submitted to the IRB for approval, likely in November 2015. This letter can be reviewed in Appendix A of this paper. References American Nurses Credentialing Center. (2014). Magnet model. Retrieved  fromhttp://www.nursecredentialing.org/Magnet/ProgramOverview/New-Magnet-Model Chatham University. (n.d.). Institutional Review Board (IRB). Retrieved from  http://my.chatham.edu/tools/irb/ Chittoria, R. (2012). Telemedicine for wound management. Indian Journal of Plastic Surgery,  45(2), 412-417. Gardiner, S., Hartzell, T. L. (2012). Telemedicine and plastic surgery: A review of its  applications, limitations and legal pitfalls. Journal of Plastic, Reconstructive   Aesthetic Surgery: JPRAS, 65(3), 47–53. doi:10.1016/j.bjps.2011.11.048 Harris, J., Roussel, L., Walters, S., Dearman, C. (2011). Project planning and management:  A guide for CNLs, DNPs, and nurse executives. Sandbury, MA: Jones Bartlett  Learning. Kidholm, K., Dinesen, B., Dyrving., A, Rasmussen, B., Yderstraede, K. (2014). Results from  the worlds largest telemedicine project-The whole system demonstrator. EWMA journal,  14(1), 43-48. Ogrinc, G., Headrick, L., Moore, S., Barton, A., Dolansky, M., Madigosky,  W. (2012).Fundamentals of health care improvement: A guide to improving your  patients’ care(2nded.). Oakbrook Terrace, IL: The Joint Commission and the Institute  for Healthcare Improvement. Sen, C. K., Gordillo, G. M., Roy, S., Kirsner, R., Lambert, L., Hunt, T., . . . Longaker, M. T.  (2009). Human skin wounds: A major and snowballing threat to public health and the  economy. Wound Repair and Regeneration, 17, 763-771. Shulman, M. A., Myles, P. S., Chan, M. V., McIlroy, D. R., Wallace, S., Ponsford, J. (2015).  Measurement of Disability-free Survival after Surgery.Anesthesiology,122(3), 524-536.  doi:10.1097/ALN.0000000000000586 Wallace, D., Hussain, A., Khan, N., Wilson, Y. (2012). A systematic review of the evidence  for telemedicine in burn care: With a UK perspective. Burns, 38, 465-480. Wilkins, E., Lowery, J, Goldfarb, S. (2007). Feasibility of virtual wound care: A pilot study.  Advances in Skin Wound Care, 20(5), 275-278.

Nazis Pursuit of the Perfect Race :: Marriage Germany Nazis History Essays

Nazis' Pursuit of the Perfect Race The organization of the argument of this paper is not particularly imaginative since this writer â€Å"lists† elements in a strictly sequential order, but he or she demonstrates familiarity with a wide range of documents and concepts of the Reader while working closely with the specific language of the document he or she is presenting. 1. Remember that you are a German. 2. If you are genetically healthy you should not remain unmarried. 3. Keep your body pure. 4. You should keep your mind and spirit pure. 5. As a German choose only a spouse of the same or Nordic blood. 6. In choosing a spouse ask about his ancestors. 7. Health is also a precondition for physical beauty. 8. Marry only for love. 9. Don't look for a playmate but for a companion for marriage. 10. You should want to have as many children as possible." (CR 286) This document, the "Ten Commandments for Choosing a Spouse" from the "Advice Center for the Improvement of Genetic and Racial Health" of the Aryan society, is a compilation of recommendations to reinforce the position of the "Nazi policy of pursing racial purity" (Ellis, Esler 365). It was published in 1934 as Nazi propaganda to influence the public to move towards the Nazi government's ideal society of Aryans. The problem in executing this plan was that the restrictions placed by the Nazi government against non-citizens caused the marriage rate to decline. In achieving this dream, Hitler tried to redefine gender roles in Nazi Germany in order to return the woman to the household and "restore her to her true profession - motherhood" (Ellis, Esler 365). The "Ten Commandments for Choosing a Spouse" is an example of Hitler's campaign towards his Aryan utopian society. Even though the high school textbook claims that women took secondary roles in Nazi Germany, women were so important to the

Faith and Greer

As Faith and Greer grow closer, Faith wants to know what Greer truly thinks. As Greer starts talking, she gives all these suggests which never felt like she could do, and someone actually listen. â€Å"Tell me your impressions about what we're doing here,† Faith said. â€Å"Be honest. Don't worry about my ego. I'm curious how it seems to you so far.† (Wolitzer 201). The thing about activism is to she what you think is right and will help. Faith pressures Greer to speak her mind but in a good that will help the company rise. She want to makes sure that she does her part to Faith's grand venture. Greer want to experience the success that Faith does. Now that Faith tooken the suggests of Greer it, they both demonstrate the truths of activism. Greer realizes the she values her individualism more that sisterhood, she wants to ensure her own success, even though she would be keeping Zee from success, now that is little selfish. At this point Faith is reflecting back to the past, and she recalls supporting Greer over the years. Faith sees a lot of herself in Greer, they have reflected upon how they share a sense of disappointment in their parents and that is what has bond them together. â€Å"Greer had been so bright and filled with feeling, but beyond that she had also been upset with her parents. Of course Faith had been reminded of being upset with her own parents at that age. Both sets of parents had held their daughters back, even as they loved them.†(Wolitzer 442). Faith feels for what Greer had to go through, and now Faith wants to see Greer be successful. Faith can see Greer's potential as an activist, a feminist, and a leader. Faith is using her power to help other women find their own. Greer and Faith are a lot alike and they deeply bond over that, because of that demonstration of the disappointment of both their parents. When Faith talks to Greer about the mentorship program, Greer tells Faith that it does not exist. So Faith asks if the rescue was at least real and Greer responses that yes it was. Faith's realization that the mentorship program was not real made her wonder what was actually going on at the ShraderCapital. â€Å"Exactly what isn't true?† Greer managed to say. â€Å"The whole thing?† â€Å"The rescue was real. The security group apparently went in and saved those girls.† â€Å"Well, good. That's a relief.† â€Å"But the mentor part never happened. They just pretend it did.† (Wolitzer 464). The whole thing is messed up what they are doing is wrong, but Faith is so caught up in being preoccupied with the public's perception of her than in make sure that everything in her organization is running smoothly. Although Faith would have lived with ignoring the whole situation and now even though she knows what is going on Faith is not planning to take any action. Knowing Faith that is just not how she does things, but she seem that she just have no idea of how to handle it. Now Faith has confronted Emmett Shrader which has been long overdue. Emmett have not a very good excuse of the whole thing. â€Å"So the mentor program really doesn't exist?† He paused, thrown, trying to be careful. â€Å"It was supposed to have existed,† he tried. â€Å"We had every intention. Does that count for anything?† (Wolitzer 523). Emmett had totally ignored the thing of the mentorship program as well of the severity of Faith's struggle. Faith couldn't afford to tune out of her own life, and she could afford to make mistakes. Where Emmet just goes through life with not a thought to what consequences his actions could have. This just shows the contrast between the power of men and women. Although Emmett had claimed to of had a hazy memory of what was actually discussed that day of what happened to the mentorship program. What he actually remembers shows his total lack of interest in an important contribution of time, and resources. Emmett is clearly not an activist and putting his name on an activist company has definitely not made him a better feminist or a better member of the community. Even though the severity of the situation or even perhaps, because of it Emmett didn't think that it was important enough to solve the Ecuador crisis. â€Å"I should have listened better in that meeting, and I shouldn't have let them switch out that woman you liked, and I should have shut down the fund and announced the whole thing publicly.† (Wolitzer 550) Emmett now longing for the simpler times of the earlier days of Loci of when he connected with Faith Frank with any of the damage of this sandal between them. Though Emmett doesn't remember what happened, he knew that there were strings being pulled and people were urged to keep the truth of the whole thing quiet. During that time he tried to convince himself that he was doing the right things to make Faith happy even when it was a bad situation by keeping the money for Faith to use on another project. The realization sets in that Faith Frank is an activist and mentor a lot of reasons. Some were more selfish than others, but Faith felt rewarded and loved by receiving gifts and notes from people she had mentored. â€Å"Dear Faith, This book was my favorite when I was a little girl, and I wanted you to have it. Love, Denise Manguso (from that dinner in Chicago!)† (Wolitzer 555). Her importance has been threatened many time throughout the year, but it is her fans that keep her going not her work, and that keep her in the world. That is Faith's rensurence that she will remain adored and relevant as she once was at the start of her career. Although Emmett had messed up, he feels awful about how things went between him and Faith. He realizes that things haven't been all that bad and that he has given Faith that greatest gift of all, and influential platform. He has done perhaps more of the work than anyone else in Faith's life. Greer is now at a point in her life where her career has taken off, her career is almost a direct mirror of Faith's. â€Å"Tonight they were celebrating the fact that Greer Kadetsky's book Outside Voices had just spent one full year on the bestseller list.† (Wolitzer 602). Greer finally got the success she has been looking for. Greer has manifested so much attention, but she still gets criticized and often publicly. She gets criticized for her privileged idealism and inattention to worse issues that face the modern of feminism. It seems like Greer gets the same kind of adoration, attention, and praise as Faith Frank once did. This fills Greer with a sense of personal fortitude and socio political power. This all of what Greer wanted she worked hard for it and success found its way to her. Now that Greer is marry to Cory, has a baby named Emilia, and a babysitter name Kay. Greer finds that she sees a lot of herself in Kay, it seems that she sees a similar dynamic blossoming between her and Kay, like what she once had with Faith. â€Å"I want you to know I think you're great, Greer. I totally do. My friends and I have read all your book and they're impressed that I sit for you,† said benevolently† (Wolitzer 607). Although Kay is unlike the shy Greer who was willing to change her personality and opinions to better align with Faith. Kay has her own independent thoughts about feminism and is not afraid to express herself. With that Greer often wishes that she could contact her former mentor, but with things that ended badly between them. â€Å"But lately, Greer had been wishing she could say something different to Faith.† (Wolitzer 623). Greer still deeply admires Faith, and with the realization that her hero was just an ordinary person like the rest of us with flaws too. Greer realizes that even with the complicated or with the moments that were upsetting with Faith were ultimately a service of goodness and advancement. Greer's ability to be grateful for the way Faith had called her out on things has shown Greer that she has matured considerably and is able to see her past mistake a lot more cleary . Greer now wonders if Kay will one day take her place as the mentor, that Kay will be the mentor to her daughter Emila. â€Å"Who is going to replace me? She though, shocked at first at the idea, and the finding it kind of funny, and relaxing into it.† (Wolitzer 624). By wondering, Greer wonders if she will slowly out live them all, Greer shows that the power dynamics and politics are constantly shifting. Impling that even as Greer has risen to fame, she will always feel a deep sense of loss for Faith. The cycle continues of mentors, because it is destined to repeat it, with Greer's daughter Emilia most likely to be mentor by Kay.

Writing with Speech Recognition Software

Writing with Speech Recognition Software Writing with Speech Recognition Software Writing with Speech Recognition Software By Michael A professional writer might add a thousand words a day to their rough draft. With speech recognition software, some writers can add several thousand. Thats one reason why more writers are choosing to dictate their books. Today the error rate of speech recognition software has improved to within a percentage point of a human being. According to IBM, even a human transcriptionist hears the wrong word 4 or 5 percent of the time. IBM reached 5.5 percent in 2017. Google claims even lower than that 4.9 percent in 2017. Speech recognition can be found in Google Docs, Windows 10, your smartphone and in various home devices. Dragon Naturally Speaking is the only commercially-available speech recognition software for consumers, mostly because they bought all their competitors. According to their website, Dragon is 3x faster than typing and its 99% accurate. For higher accuracy, Dragon can be trained to recognize your own voice and vocabulary. Tips for writing with speech recognition Dictate in complete phrases or sentences. Recent advances in accuracy have come not so much from speech recognition (thats a buh not a duh) as from language recognition (after the words eat or peel the sounds buh nah nuh are probably banana). I can sometimes see my software rewrite a sentence once Ive completed it, because it now has more of the context and so can recognize more of the words. Pause between phrases, not words. Thats mostly what I just said, but it bears repeating. Separating parts of speech with pauses (It was the best of times) can really confuse the software. It likes to sense the sentence structure as you speak. Pausing between phrases is also a good habit for public speaking, or for speaking in general, for that matter. Yes, you need to pause while you think, but you dont need to keep talking while you do it. Watch the screen. If there are any errors or omissions, you want to make sure theyre not so serious that you cant remember what you really meant to say. I can handle Dragon spelling to instead of too or member instead of remembering. But sometimes the software provides a perfectly spelled word that would make no sense later. In that case, I can usually dictate the correct word again, perhaps preceding it with or rather as a newscaster might. Or you may be able to train Dragon (and yourself) that you pronounce to as tu and too as te-yoo. Or restate your sentence in different words. Dont worry about polluting your masterpiece with synonyms its probably faster than hemming and hawing for the perfect word. You can perfect it when you edit it. Keep a consistent tone, speed, and volume. Shouting, whispering or pretending youre Robin Williams will make the software work harder. It doesnt appreciate or even recognize histronics. I did a stint as a professional voice transcriptionist, repeating the speech of another person more clearly so that Dragon could understand it better. We maintained a cheerful tone as we worked, but we werent dramatic. Dont stop for mistakes. Keep a consistent flow, where words come out of your mouth at approximately the same speed they come into your mind. Your mind will appreciate that. Dont stop to fix typos or punctuation errors. Talk around any blatant mistakes restate anything thats unclear but keep dictating. Your first transcription may not be smooth or free of mistakes. But mistakes inspire creativity, because they beg you to fix them. So dont worry about making mistakes when dictating. Dont try to speak the keyboard. Youre better off just dictating words and not trying to operate your computer with your voice. Yes, Dragon has many editing commands: Scratch that, Scratch that n times, Go back, Go to top, Stop listening, Search eBay for text (NOTE TO SELF: DO NOT TRY TO WRITE NOVEL AND SHOP ON EBAY AT THE SAME TIME.) But the main commands I use are Period and New line Im supposed to be writing not editing remember? and Ive turned off my internal editor. Dragons commands are great for people who cant use a keyboard they can say Open Google Chrome or Post to Facebook but the extra learning curve can sour other people on trying the software. Hands-free editing I keep Dragon in Dictation Mode, which ignores commands as long as Im dictating quickly. Otherwise, if one of my paranoid characters shouts, Stop listening, Dragon might take me literally and not transcribe anything else. So how do you edit without using editing commands? Dictate the section again, without the mistakes. Really. Its probably faster than using the commands. It may be faster than using a keyboard. Many writers with repetitive stress injuries say that what hurt their wrists was not the typing, it was the constant cutting, pasting and mousing. With dictation, the only movement is your mouth and your eyeballs. Dictation lets you hear your words again, which lets you decide if you really like them. It even lets you combine several versions. You could have both versions open on your computer and switch your eyes between them as you read your favorite paragraph with each. Or you could print out both versions, lay the pages all over the floor, rearrange them as you like, edit them with a fat marker pen, and then smoothly read them back into your microphone. When I first tried this technique, though, the new version wasnt much better than the old. I hoped that as I reread the passage, my mind would naturally find things to correct, as a storyteller does. But seeing the text in front of me made it harder to see areas of improvement. A better strategy might be to silently read both versions again, then close my eyes and retell the story into the microphone. Dictation software works better for some writers than others, and for some types of writing than others. At first you may miss the feel of the keyboard or the pen, or you may be distracted by the sound of your voice. But for many writers, speech recognition software can set their creative process free. Want to improve your English in five minutes a day? Get a subscription and start receiving our writing tips and exercises daily! Keep learning! Browse the Writing Basics category, check our popular posts, or choose a related post below:75 Contronyms (Words with Contradictory Meanings)Among vs. AmongstOppose and Opposed To