Quality Management in Healthcare

Introduction The need for quality management in healthcare facilities is an issue that many stakeholders have been fighting for over the years. According to Arias (2000, p. 87), quality healthcare is one of the major pillars of the economic development within a given country. People should have access to quality and affordable healthcare in order to remain strong and healthy.Advertising We will write a custom case study sample on Quality Management in Healthcare specifically for you for only $16.05 $11/page Learn More In the current society, there are numerous diseases that may affect people of different social classes, and this may reduce their productivity. It is because of this that many stakeholders, including the government and nongovernmental agencies, have been able to come up with ways of improving service delivery at various healthcare institutions within the country. In the United States, the federal government, in close connection with private non-profit making organisations such as Mayo Clinics, has improved the healthcare standards within the country. Mayo has been using numerous quality management tools in order to improve its service delivery. Currently, the hospital is using ISO 9001 principles to improve the quality of its services. Background of Mayo Clinic Mayo Clinic is one of the largest non-profit making private healthcare institutions in the world that offers a wide range of medical services to various people across the country. In defining Mayo Clinics, Charantimath (2006, p. 78) says, â€Å"The Mayo Clinic is the world’s oldest and largest integrated multispecialty group medical practice, combining clinical practice, education, and research at the regional, national, and international levels for the benefit of individuals with routine as well as complex health care needs.† From this definition, it is clear that The Mayo Clinic offers more than just medical services to the American population. It is an integrated team of multispecialty medical practitioners who are focused on offering medical services, educating young people interested in joining the medical practice, and maintaining a high level of research in various areas of health.Advertising Looking for case study on health medicine? Let's see if we can help you! Get your first paper with 15% OFF Learn More Founded in 1889 by William Worrall Mayo and his sons, this foundation currently employs over 3,800 physicians, and about 60,000 allied health staffs in various hospitals within the United States and all over the world. It has experienced massive growth over the years to become the largest and one of the most reputable healthcare centres in the world. As stipulated in their mission statement, Mayo is not just focused on offering quality healthcare to the people, but it is also concerned with finding the best ways of managing some of the emerging health complications by engaging its staffs in research . With its headquarters in Rochester, Minnesota, Mayo Clinic has become one of the most reliable healthcare institutions in North America. Its efforts in research and development has enabled it become one of the most successful non-profit making healthcare organisations in the entire region. Quality Management System at Mayo Clinic (Strengths) At Mayo, the management has always been focused on offering quality healthcare to all the patients who visit the facility with various health complications. When William and his sons started this facility, they were interested in offering quality healthcare services to the American people. However, this organisation experienced numerous challenges as the field of medicine started experiencing changes due to technological advancements (Donabedian 2003, p. 34). The organisation had to adapt to the emerging technologies in order to maintain the quality service provision to the patients. The dynamic leadership at this organisation has seen it tran sform in line with the technological advancement and various other changes in this field to become one of the most reputable organisations in the world. Always emphasising on quality delivery of healthcare services, this organisation has six attributes of an ideal healthcare delivery system as defined by the Commonwealth Fund which forms its main strength (Charantimath 2006, p. 44).Advertising We will write a custom case study sample on Quality Management in Healthcare specifically for you for only $16.05 $11/page Learn More Information Continuity Information continuity is one of the most important ingredients of quality healthcare provision within a healthcare facility (Wheeler Grice 2000, p. 81). At Mayo clinic, all departments are interconnected using personal computers and local area networks that make information transfer very efficient. Once a client’s information is fed into the system at the reception, all the relevant departments can ac cess the information on demand. Any adjustment made in the information at any of the departments will be reflected in other relevant departments. This means that the speed and reliability of data transfer has become highly efficient. It has helped improve the quality of services offered within the facility. The information is managed from a central database as shown in the diagram below. Care Coordination and Transitions At Mayo, there is a clear system that allows for patient care coordination among various practitioners. There are cases where a patient suffers from multiple health complications that may require practitioners in different fields. The management has developed a system where this cannot be done without any form of strain. A medical doctor in one department can easily communicate with another doctor in a different area of specialty of the medication that has been offered, and the steps that should be taken to address other complications. Such closely coordinated comm unication between the practitioners eliminates any possibility of misunderstanding among the doctors. System Accountability Mayo Clinics have adopted a total care policy on all the patients who visit their facility as a way of improving the quality of services they deliver. According to Lighter (2011, p. 33), many medical practitioners have worsened the health of their patients through careless acts due to relaxed management systems at the institutions. This is not the case at Mayo Clinic.Advertising Looking for case study on health medicine? Let's see if we can help you! Get your first paper with 15% OFF Learn More At this facility, every medical officer is held accountable for any service rendered, and if any mistake arises from any of the departments visited by the patient, then the officer who offered the service is always held responsible as per the organisation’s policies and principles. Peer Review and Teamwork for High-Value Care The peer review and teamwork system was introduced at this facility to help promote teamwork and responsibility within various departments. Under this system, practitioners in a specific field have the responsibility to review works of peers in that department with the aim of maintaining the best practice in their field. Any changes taking place in that specific field would be shared by the members in order to enhance its application within the facility. The focus of this strategy is to offer high value care by improving skills and competencies of the individual members of the staff. Continuous Innovation In the current dynamic world, innovation is one o f the most important tools that an organisation can use in order to ensure that it offers continuous quality care to its clients (Kelly 2003, p. 45). At Mayo Clinic, the management knows that the only way of achieving its vision is to maintain innovativeness in its service delivery. This has been made possible by the research unit of this firm. The researchers have been interested to identify the emerging trends in this field of healthcare and to develop mechanisms of dealing with it in order to ensure that this firm remains dynamic. It has come up with new ways of addressing various issues that at the facility in order to maintain superior quality delivery (Lighter Fair, 2000, p. 44). Easy Access to Appropriate Care According to Horch (2003, p. 78), healthcare is one of the basic needs in the modern society, and it should be easily accessible to members of the public. When offering healthcare services, it is necessary to ensure that clients have the capacity to access their informa tion and understand their health conditions as soon as it is determined by the practitioners. This is one of the factors that Mayo Clinic has been determined to improve its service quality in the market. The Clinic has developed a communication system in all its clinics for easy retrieval of information and reliable communication with the patients. The above attributes have been considered ideal for a standard healthcare facility such as Mayo Clinic. This has made this healthcare facility one of the most preferred institutions in North America. The above strengths have seen a rise to the Mayo brand in the healthcare sector within this region. They are considered an integrated team of medical experts who are focused on identifying any health complication, informing their patients about their complication, suggesting ways through which such complications can be addressed, and using the strategy that the patients chooses to address the problem. This creates a feeling among the patients that at this facility, they have a voice, and can make their own independent choices about how they should be treated based on their personal preferences. This strength has helped this firm expand its operations beyond the United States. It has also made it easy for it to raise funds from the well wishers who have now trusted it as one of the leading healthcare provider in North America. In most of its campaigns, this firm has received massive support from the public, not just because of the fact that it is a non-profit making healthcare facility, but also because of the quality of care it offers (Lighter Fair 2004, p. 67). The management of Mayo Clinic knows that its strengths in offering quality healthcare largely relies on its ability to retain highly qualified and motivated team of experts who are specialised in various fields. Although this is a non-profit making organisation, maintaining this kind of staff needs a strategy that would help in making them comfortable so that t hey do not consider quitting the facility. This can only be achieved through good remuneration. Mayo Clinic is one of the best paying private hospitals to various health experts. The working environment is positively designed to promote integration, socialisation and teamwork among all the employees, creating a community where everyone has an emotional attachment with other members of the organisation. This has helped minimise the rate of employees’ turnover, the fact that has helped it to retain its highly qualified staff. Using Principles in ISO 9001 to Improve Quality of Services at Mayo Clinic From the discussion above, it is clear that Mayo Clinic is one of the best non-profit making private healthcare firms in service delivery within North America. The firm has been determined to embrace the best practice principles in the industry in order to match or even exceed the quality of healthcare offered at some of the best hospitals in the world. The management of this facili ty has been benchmarking its services with that of the leading hospitals in the world such as John Hopkins Hospital and Cleveland Clinic (Lloyd 2004, p. 44). In 2010, CNN, one of the leading news agencies in the world, ranked it as the third best healthcare facility in the world in overall medical treatment and quality services to its clients. Despite this success, it is a fact that this facility needs to maintain continuous improvement in order to maintain its glorious position as one of the leading healthcare facility in the world. Although this firm is ISO certified, it needs to give more focus to the principles of ISO 9001:2008 as it seeks to improve on its quality of service in the market. There are nine principles that will help Mayo Clinic to advance its current systems, and find ways of expanding its capacity to offer improved services to all the patients that visit the facility. The principles of ISO 900:2008 that have been applied by Mayo Clinic include the following. Cust omer focus This is the first principle of ISO 9001:2008 that Mayo Clinic has been using to improve the quality of services offered to its customers. Mayo Clinic clearly understands that all other healthcare facilities in the regions where it operates are competitors. For this reason, it has always found ways of attracting customers to its facility. To achieve this, it has taken a customer-centric approach in its management. It focuses on ways through which its clients can be offered customised quality healthcare whenever they visit the facility (McLaughlin, Johnson Sollecito 2012, p. 77). This involves active engagement of the clients when offering them care in order to ensure that they get the service in the manner they consider appropriate. Every client is always treated as a unique entity with unique needs. This way, the firm has been able to develop a personal relationship with clients who visit the facility. Leadership Leadership is the second principle that Mayo Clinic has us ed in order to improve the quality of its service delivery to the clients. As stated previously, this facility has a responsibility of managing its top doctors in a manner that would convince them to remain loyal to the firm. This can only be achieved through effective leadership (Mohanty, 2008, p. 56). The management unit has embraced transformational leadership characteristics in order to maintain high moral and loyalty of every member of the organisation. The leaders have developed best approaches of positively challenging the current capacity of its workers with the view of making them reinvent themselves into better service providers in their respective field. The management realizes that it has a responsibility of making every employee feel valued within the firm. It is only through this that employees will feel committed to the firm and develop a responsibility of coming up with new approaches of undertaking their duties. The managers at Mayo appreciates that their position i s meant to offer service to the employees. They seek to offer guidance in case of challenging factors in the environment, and in all the cases, they ensure that they integrate easily with all the employees of different ranks within the organisation (Geisler, Krabbendam Schuring, 2003, p. 66). There is an open communication system at Mayo Clinic as shown in the model below. Involvement of people One of the basic principles of ISO 9001:2008 used at Mayo Clinic is the need for involvement of people in undertaking various tasks and in making decisions. According to Morfaw (2009, p. 97), every human being has his or her worth that makes him or her special over the rest. The problem is that in most of the cases, some people are always belittled to the extent that they feel useless. The management at Mayo Clinic appreciates the fact that the firm can only become innovative if people are involved actively in the development of plans and in their execution. Creativity and innovation is no t a preserve for the top managers, the intelligent staff or any other special groups within an organisation. It is a natural force that comes out of a person irrespective of the position held or academic excellences when faced with new challenges in the workplace (Okeyo Adelhardt 2003, p. 78). By involving every member of the organisation in decision making, the management of Mayo Clinic has given them the opportunity to be creative in their respective fields in order to come up with superior ways of addressing various issues in the workplace. This has helped in improving the quality of services that are offered in this organisation at various levels. Process approach The process approach is another principle of ISO 9001:2008 that Mayo Clinic has been using to improve the quality of its services. Success and failure are two possibilities that an organisation can experience when dealing with various issues in its normal operations. One of the factors that separate failure from succe ss is the approach that is taken in the process of undertaking a specific activity. Many organisations have failed to implement good plans because they used wrong approaches. Deciding on the best approach to use will involve embracing technology and innovativeness whenever it is necessary. Oleske (2009, p. 96) advises that it is important to ensure that the management devolves decision making to the departments. At Mayo Clinic, each departmental heads has a plan that is always followed when implementing various policies within their departments based on their local needs. This hospital has been focused on choosing the process approach when implementing new policies (Sollecito Johnson 2013, p. 89). System approach to management The principle of system approach to management has gained popularity in many successful organisations around the world, and Mayo Clinic is one of the firms that have actively used this principle in their operations. According to Spath (2009, p. 78), an organi sation is a system of people with different skills, experience, knowledge, and talents. All these factors define an organisation and the approach it takes when addressing various activities in the market. System approach to the management is a principle in ISO 9001:2008 that emphasises on the need to involve other members of the organisation in the management process. At Mayo Clinic, before coming up with a decision on how different tasks should be undertaken, the responsible managers always make efforts to understand the ideas of other people, especially those that are directly involved in the implementation of some of these policies are very important. They always form part of the management system, especially in decision making. Their views are regarded as important when making decisions that will affect them or their tasks. This not only motivates them, but also ensures that the approach taken is the most practical one. This approach has helped this giant organisation to devolve some of the operational and tactical plans to departmental levels in order to help find local solutions to local problems at these facilities. Continual improvement Continual improvement is probably one of the most important principles in the ISO 9001:2008 that Mayo Clinic has emphasised on at all its departments. According to Stamatis (1996, p. 63), success should not be considered a destination because it is a process that has no end. Continuous success is what should be regarded as a true success because any missteps that a successful firm makes would lead to a failure that may wipe away past successes. With this in mind, Mayo Clinic has maintained continuous improvement in its service delivery in order to retain its prestigious position as one of the best hospitals in the world. All the good strategies that this firm uses have been under continuous improvement to enable it offer even better services. If this firm was ranked third in 2010 among the best hospitals, it means that there are other areas that it should improve on in order to become the best. Continual quality improvement that has been embraced by Mayo Clinic may be a challenging task, especially when a firm believes that it has exploited some of the best imaginable strategies. However, Steiger (2001, p. 68) says that there is always a way of improving the best, and the only difficult task is to identify how this should be done. This should be a continual process as shown in the diagram below, and the management at Mayo Clinic has been determined to apply it in order to improve its customers’ experience whenever they visit the facility. Factual approach to decision making Factual approach to decision making has been another popular principle of ISO 9001:2008 that Mayo Clinic has been using to enhance its ability to offer quality products. Some policies can appear very attractive on a piece of paper, but when it comes to implementation, they may become impractical. This is one of the reas ons why some firms fail to achieve their objectives in the market. When the plan lacks the factual information, or practicality, then it will remain a plan that cannot be implemented (Wan Connell 2003, p. 56). This simply means that the plan will be useless to the organisation, and all the resources that were used in its development will be a waste. The management at Mayo Clinic acknowledges the importance of ensuring that its decision making process is based on factual information. Care has always been taken to ensure that only the practical plans based on the factual information from the field are developed. This means that decision making should not be a preserve of the top executives. The main role of the top executive when planning for operational and tactical plans would be to ensure that the operational and tactical plans are in line with the strategic plans of the firm. If they realise that a section of the plan does not work within the strategic objectives of the organisat ion, they should give advices on how to make adjustments in order to realise the desired goals. As Kelly (2003, p. 75) notes, this will help in coming up with practical and realistic plans that can easily be implemented by respective departments. Mutually beneficial supplier relationships This is the last principle of ISO 9001:2008 that Mayo Clinic has actively used to improve the quality of its products. The research by Charantimath (2006, p. 32) shows that one of the major challenges that firms face in the current market is the increasing strength of the suppliers. Dealing with a strong supplier may be a serious challenge to a firm, especially if the supplier controls a major share of the market for the supplies. Such a supplier may set terms which are unfriendly to the firm as a way of gaining quick success before the industry is invaded by other players. Mayo Clinic has found ways of developing a mutually beneficial relationship with all its suppliers in order to ensure that it is able to get all the needed products at friendly terms. To achieve this, the firm has always created a partnership with these suppliers. It strives to make these suppliers feel that they are in a form of relationship where they need each other’s support. This way, their suppliers always view them as partners that need their protection, other than customers that should be exploited. Through this strategy, this firm has been able to deliver its products to the clients at reduced prices. Previous Quality Management Tools at Mayo Clinic The above nine principles are very vital for Mayo Clinic when implementing ISO 9001:2008 in its management strategies. This does not mean that other strategies that this firm was using previously will be discarded when implementing the above recommendations. Some of the strategies that this firm was using before included Six Sigma. Although some scholars claim that Six Sigma is a complicated quality management strategy that is gradually being ou tdated, it still remains to be one of the important tools that should not be ignored by the management. At Mayo, this has been an important quality management tool for many years. This tool could probably provide the answer to the question on how to improve the current best practices within this firm. Mayo Clinic has also found the Commonwealth Fund Commission to be an important quality management tool that has helped it remain competitive in the market. The six principles that have enabled this firm become strong in the market, as discussed on the section above, were based on the best practices as defined by the Commonwealth Fund Commission. Other important principles that this firm has been using in the past include John Ovretveit’s Principles, which the firm has since reduced its application within its system preferring to emphasise on ISO 9001:2008. Conclusion Quality management in the field of healthcare has become one of the most important tasks that define the success of a firm. Mayo Clinic has realised that it has a responsibility to its clients to offer quality healthcare to all the patients. To achieve this, the organisation has been using the industry’s best practice in order to ensure that its services meet the industry standards. It has been determined to employ some of the important quality measures in its management system. The Commonwealth Fund Commission principles on quality management have been one of the major quality management tools used by the firm in the past. However, the firm must now fully implement the principles of ISO 9001:2008 in order to achieve even greater success in this competitive industry. List of References Arias, K 2000, Quick reference to outbreak investigation and control in health care facilities, Aspen Publishers, Gaithersburg. Charantimath, P 2006, Total quality management, Pearson Education, New Delhi. Donabedian, A 2003, An introduction to quality assurance in health care, Oxford University Press, Ne w York. Geisler, E, Krabbendam, K Schuring, R 2003, Technology, health care, and management in the hospital of the future, Praeger, Westport. Horch, J 2003, Practical Guide to Software Quality Management, Artech House, Norwood. Kelly, D 2003, Applying quality management in healthcare: A process for improvement, Health Administration Press, Chicago. Lighter, D Fair, D 2000, Principles and methods of quality management in health care, Aspen Publishers, Gaithersburg. Lighter, D Fair, D 2004, Quality management in health care: Principles and methods, Jones and Bartlett, Sudbury. Lighter, D 2011, Advanced performance improvement in health care: Principles and methods, Jones and Bartlett Publishers, Sudbury. Lloyd, R 2004, Quality health care: A guide to developing and using indicators, Jones and Bartlett Publishers, Sudbury. McLaughlin, C, Johnson, J Sollecito, W 2012, Implementing continuous quality improvement in health care: A global casebook Sudbury, Jones and Bartlett Publishers, Sudbury. Mohanty, R 2008, Quality management practices, Excel Books, New Delhi. Morfaw, J 2009, Total quality management (TQM): A model for the sustainability of projects and programs in Africa, University Press of America, Lanham. Okeyo, T Adelhardt, M 2003, Health professionals handbook on quality management in healthcare in Kenya, Centre for Quality in Healthcare, Nairobi. Oleske, D 2009, Epidemiology and the delivery of health care services: Methods and applications, Springer, New York. Sollecito, W Johnson, J 2013, McLaughlin and Kaluzny’s continuous quality improvement in health care, Jones Bartlett Learning, Burlington. Spath, P 2009, Introduction to healthcare quality management, Health Administration Press, Chicago. Stamatis, D 1996, Total quality management in healthcare: Implementation strategies for optimum results, McGraw-Hill, New York. Steiger, H 2001, Risk control and quality management in neurosurgery, Springer, Wien. Wan, T Connell, A 2003, Monitoring t he quality of health care: Issues and scientific approaches, Kluwer Academic, Boston. Wheeler, N Grice, D 2000, Management in health care, Stanley Thornes, Cheltenham. This case study on Quality Management in Healthcare was written and submitted by user Malice to help you with your own studies. You are free to use it for research and reference purposes in order to write your own paper; however, you must cite it accordingly. You can donate your paper here.

Left Ventricular Failure Causing Hypoxemia and Low Blood Pressure †Nursing Management Essay

Left Ventricular Failure Causing Hypoxemia and Low Blood Pressure – Nursing Management Essay Free Online Research Papers Left Ventricular Failure Causing Hypoxemia and Low Blood Pressure Nursing Management Essay In this essay the author will analyse the normal and pathologic physiology of left ventricular failure (LVF) and how this is related to hypoxemia and low blood pressure (BP). The nursing management will be discussed as well. John had two myocardial infarctions (MI) during the last five years and was waiting for coronary artery bypass graft (CABG) surgery. The angiogram showed severe triple vessels coronary artery disease with poor left ventricular (LV) function. John was admitted to critical care presenting low peripheral saturations, symptoms of respiratory distress and low blood pressure. Ten litres of oxygen were administered by nasal mask; a central venous catheter and an arterial line were inserted in order to continuously monitor John’s BP and central venous pressure (CVP), and to obtain arterial blood gases (ABG’s). John’s mean arterial pressure (MAP) was 55 mmHg and the ABG showed a Partial pressure of arterial oxygen (PaO2) of 7.8 kPa, a partial pressure of arterial carbon dioxide (PaCO2) of 5.5 kPa and an arterial oxygen saturation of haemoglobin (SaO2) of 86%. A urinary catheter was inserted and a chest X-ray was performed. Pulmonary oedema was diagnosed. The oxygen supplied was changed to humidified oxygen at 50% of inspired fraction of O2 (FiO2) and afterwards increased to 60% according to the ABG results; 40 milligrams (mg) of furosemide IV were given as a bolus and continuous intravenous infusion of dopamine was started at 3 micrograms/ kilogram/minute ( µg/kg/min). After 3 hours of treatment, an Intra-aortic Balloon Pump (IABP) was inserted and a furosemide infusion was started at 10 mg/h. PHYSIOLOGY OF BLOOD PRESSURE AND MYOCARDIUM. BP is defined as the force per unit area exerted on a vessel wall by the contained blood, and is expressed in millimetres of mercury (mmHg) (Marieb 2004). The mechanisms that are involved to regulate BP are: neural control of vasoconstriction and contractility, capillary fluid shift mechanism altering blood volume and renal excretory and hormonal mechanisms which alter blood volume and vasoconstriction (Adam Osborne 1997). Marieb (2004) and Thibodeau Patton (1993) state that the neural controls of peripheral resistance act by redistributing blood in respond to specific demands of the body and maintaining adequate MAP by altering blood vessels diameter. These changes are controlled by baroreceptors (located in the carotid sinusis, the aortic arch and in the large arteries of the neck and thorax) and chemoreceptors (activated by an increase in CO2 or decrease in O2 or pH). The renal regulation of BP acts altering blood volume by a direct mechanism, filtrating more or less water in the kidney tubules; or by an indirect mechanism called renin-angiotensin. If the BP drops, the kidneys release an enzyme called renin which triggers a series of reactions that produce angiotensin II (potent vasoconstrictor). It also stimulates the secretion of aldosterone by the adrenal cortex which enhances renal reabsorption of sodium, and stimulates the posterior pituitaria to release anti-diuretic hormone (ADH) which promotes more reabsorption (Marieb 2004, p725-729). During normal homeostasis, the above described physiology maintains normal BP. However, as a consequence of the myocardial infarction, John developed left ventricular failure (LVF) that resulted in low blood pressure. The normal physiology of the myocardium, left ventricular function and the terms related to it are stated below. The bulk of the heart wall is the thick, contractile, middle layer of specially constructed and arranged cardiac muscle cells called myocardium (Thibodeau Patton 1993). Although equal volumes of blood are pumped by the two ventricles, the workloads are totally different. The walls of the left ventricle are three times as thick as those of the right, and its cavity is more circular, this is because the left ventricle has to pump the blood through the systemic circuit and there is five times more resistance than in the pulmonary system. Myocardial function is determined by three factors: Preload: Refers to the amount of blood in the heart before contraction begins and it is the amount of stretch placed on a cardiac muscle fiber just before systole; is related to Starling’s law of the heart, which states that â€Å"the force of myocardial contraction is determined by the length of the muscle cell fibers† (Hudak, Gallo Morton 1998). Afterload: Is the pressure that must be overcome by the ventricles to eject blood (Marieb 2004). The most critical factor determining afterload is the resistance imposed by the vascular bed on blood flow. There are three sources of resistance: blood viscosity, vessel length and vessel diameter. Contractility: Is defined as an increase in contractile strength that is independent of muscle stretch and end diastolic volume (EDV) (Marieb 2004). The more vigorous contractions are a direct consequence of a greater calcium influx into the cytoplasm from the extracellular (EC) fluid and the sarcoplasmic reticulum (SR). PATHOPHYSIOLOGY OF LOW BLOOD PRESSURE John suffered two MI during the past 5 years, the changes that occur in the myocardium after a MI are very important to understand the mechanisms that lead to LVF, and consequently, to low BP. According to Gheorghiade Bonow (1998) recurrent episodes of myocardial ischemia, producing repetitive myocardial stunning, may contribute to the overall magnitude of LV dysfunction and heart failure symptoms. It has been shown (Woods et al, 1995) that changes in LV contractility and compliance precipitate sympathetic compensation by increasing the heart rate in order to maintain cardiac output and elevating the systemic vascular resistance (SVR) to sustain BP. Immediately after an infarction, blood flow ceases in the coronary vessels beyond the occlusion except for small amounts of collateral flow. Guyton Hall (2000) maintain that when the area of ischemia is large, some of the muscle fibers in the middle of the area die rapidly. Immediately around it is a non-functional area because there is nor contraction or is diminished. Extending circumferentially around the non-functional area is an area that is still contracting but that weakly. During the next days after the infarction, the borders of the non-functional area either become functional again or die, depending on the enlargement of the collateral arterial channels. In the meantime, fibrous tissue begins to develop among the dead fibers because the ischemia stimulates growth of fibroblasts; therefore, the dead muscle tissue is replaced by fibrous tissue. Finally, the heart gradually hypertrophies to compensate the loss of cardiac muscle. After a large myocardial infarction, the heart’s capability of pumping is permanently decreased below that of a healthy heart. LV failure due to inadequate contractility results in a decreased cardiac output leading to a poor tissue perfusion as well as to an increase in the volume remaining in the ventricle at the end of systole. That results in a low BP and high pressures in the left atrium that could cause pulmonary oedema (Hansen1998, p379). PHYSIOLOGY OF HYPOXEMIA RELATED TO PULMONARY OEDEMA Adam Osborne (1997) defined hypoxemia as a low concentration of oxygen in the blood (10 µg/kg/min) ? adrenergic receptors are stimulated increasing peripheral resistance, and therefore, increasing the BP (Kenry Salerno, 2003). The author recognizes the controversy of renal-dose dopamine, and on analyzing the literature, there is no conclusive evidence to support either one point of view or another. Vovan Brenner (2000) and Ichai et al (2000) defend the use of renal-dose dopamine and Friedrich (2001) and Bracco Parlow (2002) criticize its use. Both groups concur that further studies should be undertaken in order to clarify the true effect of renal-dose dopamine. Low blood pressure: When an arterial line was inserted, John’s MAP was 55 mmHg and the CVP was 14 mmHg. Initially, 250 ml of gelofusine was administered over 30 min. John’s BP increased to 62 mmHg. It is important to note that the CVP increased to 17 mmHg following the 250 ml of gelofusine. Because John was already in pulmonary oedema, doctors were cautious to not compromise his condition by administering further fluids and decided to wait, considering that John’s urine output was adequate despite his BP. At this point, it is relevant to emphasize the discussion that exists in the literature comparing crystalloids and colloids in fluid therapy. After a systematic review of 105 articles, Choi et al (1999) concluded that there are no apparent differences in pulmonary oedema, mortality or length of stay when using either crystalloid or colloid. Nonetheless, Cook (2003) argues that crystalloids increase hydrostatic pressure but decrease colloidal pressure and could enhance pulmonary oedema. After 3 hours, John’s BP decreased to 50 mmHg and his urine output diminished to 60 ml/h. How it has been mentioned in the pathophysiology chapter, John’s low BP was due to poor LV function, thus decreasing cardiac output (CO). Therefore, to resolve the hypotension it needs to be improved CO. Aggressive inotropic therapy would be unsuitable because the cause of John’s low BP could be masked behind the inotropes. Considering it, IABP therapy commenced, triggering the balloon 1:1 and on maximum augmentation. The IABP consists of a 25cm balloon that is inserted, via the femoral artery, in the descending aorta with its tip at the distal aortic arch. Inflation and deflation is synchronized to John’s cardiac cycle (Overwalder 1999). The IABP is set to inflate at the beginning of diastole displacing blood above the balloon (forcing the blood up and into the coronary arteries, improving myocardial perfusion and oxygen supply) and below the balloon (the blood is forced into the systemic circulation). When the balloon deflates, it creates a relative space to accommodate the blood before systole, resulting in a full load ejection. With less resistance to pump against, the heart requires less oxygen to function (Metules 2003). Summing up, when IABP therapy is started an increase in MAP, CO, and ejection fraction, along with a decrease in heart rate, pulmonary artery diastolic and capillary wedge pressure should be observed (Metules 2003). Upon IABP therapy, John’s BP increased to 65 mmHg during the first 30 min, and to 75 after 90 min of treatment. In addition, renal perfusion was improved and the urine output was observed to increase, as well as a decrease in John’s heart rate (from 100 beats per minute (bpm) to 85 bpm). John didn’t have a pulmonary artery catheter in situ, it is therefore inaccurate to comment on any suspected change in CO, SVR or pulmonary artery wedge pressure (PAWP). Overwalder (1999) states that IABP therapy is not exempt from complications such as artery injury perforation, aortic perforation, femoral artery thrombosis, peripheral embolization and limb ischemia. Nursing care involved the evaluation of John’s skin colour and temperature on the legs, and the presence of infection, pain or bleeding. Pedal pulses were recorded every two hours in order to avoid limb ischemia, which can occur because of a reduced blood flow to the leg, thrombosis formed around the catheter or arterial spasm (Metules 2003). CONCLUSION The author has analysed how John’s LVF caused hypoxemia and low BP. The therapy and treatment provided (although not always supported by the literature) was effective in resolving John’s low PaO2 and low BP. It may have been beneficial to provide John with a higher concentration of FiO2 (80%) humidified oxygen via facial mask or using non-invasive mechanical ventilation on admission, instead of 40% humidified oxygen that was administered, in order to correct as quickly as possible John’s hypoxemia. IABP seems a very aggressive therapy to correct John’s low BP, taking into account the risks and complications inherent to this therapy; perhaps increasing the dopamine to a cardiac dose could have been an option in order to increase John’s BP. However, the insertion of a pulmonary artery catheter would have been useful to monitor the haemodynamic status (CO, SVR, PAWP), guiding the treatment. The author has achieved a better understanding of both physiology and pathophysiology whilst analysing in detail the treatment administered and other possible interventions that could improve John’s care. REFERENCE LIST Adam S Osborne S (1997) Critical care nursing science practice. Bath: Oxford. Badcott S. (1998) Inotropes- choosing the right agent for the right job. MKCPA Critical Care Group study day. September 29th. Bracco D Parlow JL (2002) Prevention: dopamine does not prevent death, acute renal failure, or need for dialysis. Canadian journal of anesthesia 49:417-419. Chadda K .et al (2002) Cardiac and respiratory effects of continuous positive airway pressure and non-invasive ventilation in acute cardiac pulmonary edema. Critical Care Medicine. Nov; 30(11):2457-61. Choi P et al (1999) Crystalloids vs. colloids in fluid resuscitation: A systematic review. Critical care medicine January 1999 27(1):200-210. Cook L (2003) IV fluid resuscitation. Journal of infusion nursing Sept/Oct 2003 26(5):296-303. Cotter et al (2001). Pulmonary edema: new insight on pathogenesis and treatment. Current opinion in cardiology May 16(3): 159-163. Friedrich A (2001) The controversy of â€Å"renal-dose dopamine†. International anaesthesiology clinic Winter 2001 39(1):127-139. Gheorghiade M Bonow RO (1998) Chronic heart failure in the United States: a manifestation of coronary artery disease. Circulation 97: 282-289 Grahame-Smith DG Aronson JK (2002) Clinical pharmacology and drug therapy. 3rded. New York: Oxford University. Guyton A. Hall J (2000) Textbook of medical physiology. 10th ed. Philadelphia, Pennsylvania: W.B. Saunders. Hansen M (1998) Pathophysiology: foundations of disease and clinical intervention. Philadelphia, Pennsylvania: W.B. Saunders Company Ichai C et al (2000) Comparison of the renal effects of low to high doses of dopamine and dobutamine in critically ill patients: A single-blind randomized study. Critical care medicine April 2000 28(4):921-928. Kenry LM Salerno E (2003) Mosby’s pharmacology in nursing. St. Louis, Missouri: Mosby. L’Her E. (2003). Non-invasive mechanical ventilation in acute cardiogenic pulmonary edema. Current opinion critical care 9(1):67-71. Marieb E (2004) Human anatomy physiology. 6th ed. San Francisco: Pearson Education Mc. Mervyn Singer (2003) Decompensated heart failure. European Society of Anaesthesiologists (refresher course) May 31 Euroanaesthesia 2003 – Glasgow. Metules T, BSN. IABP therapy: getting patients treatment fast. RN May 66(5):56-62, 64. Overwalder PJ (1999) Intra aortic balloon pump (IABP) counterpulsation. The internet journal of thoracic and cardiovascular surgery. Volume 2 number 2. Silverthorn U (2001) Human physiology: an integrated approach. 2nd ed. San Francisco: Pearson. Thibodeau G Patton K (1993) Anatomy physiology. 2nd ed. St. Louis: Mosby Vovan T Brenner M (2000) Controversy: Is there a â€Å"renal dose† dopamine? Critical care medicine April 28(4):1220. Webb A, Shapiro M, Singer M and Sutter P (1999). Oxford textbook of critical care. Oxford: Oxford. Woods S. L. et al (1995) Cardiac nursing. 3rd ed. Pennsylvania: J.B. Lippincott. BIBLIOGRAPHY Hobsley M Imms FJ (1992) Physiology in surgical practice. 1st ed. London: Edward Arnold. Mattera C (2000) Heart failure and pulmonary edema. Jems May 25(5): 36-47. Schierhoud G Roberts I (1998) Fluid resuscitation with colloid or crystalloid solutions in critically ill patients: a systematic review of randomised trials. BMJ March 316: 961-964. Stevenson LW (2003) Clinical use of inotropic therapy for heart failure: looking backward or forward? Part I: Inotropic infusions during hospitalization. Circulation July 22: 367-372. Kellum JA Bellomo R (2000) Low-dose dopamine: What benefit? Critical care medicine March 28(3): 907-908. Research Papers on Left Ventricular Failure Causing Hypoxemia and Low Blood Pressure - Nursing Management EssayDefinition of Export QuotasThe Relationship Between Delinquency and Drug Use19 Century Society: A Deeply Divided EraAnalysis Of A Cosmetics AdvertisementThe Project Managment Office SystemGenetic EngineeringBionic Assembly System: A New Concept of SelfOpen Architechture a white paperEffects of Television Violence on ChildrenPersonal Experience with Teen Pregnancy

Literary criticism over madness and symbols in Edgar Allan Poe short Essay

Literary criticism over madness and symbols in Edgar Allan Poe short stories - Essay Example As he tells his frequently bizarre and frightening tales, Poe presents his readers with symbol-rich imagery and descriptions based on binary oppositions to help build the suspense and horror of his tale. As Mowery explains, binary oppositions are things such as hot and cold, male and female, dark and light. â€Å"It is in the subtle shifts in our expectations of the character that tension and conflict are developed† (1997). This concept is frequently illustrated in terms of the madness that comes upon characters as they experience deep feelings that had potential to overwhelm. In â€Å"The Tell-Tale Heart,† â€Å"The Black Cat† and â€Å"Ligeia,† Edgar Allan Poe uses madness and symbolism to convey love and hate. Poe employs two primary objects in â€Å"The Tell-Tale Heart† to illustrate the cause of his narrator’s madness. The old man’s eye is the first of these symbols to appear within the text of the story. As the narrator attempts to explain why he felt led to murder, he says, It is impossible to say how first the idea entered my brain; but once conceived, it haunted me day and night. Object there was none. Passion there was none. I loved the old man. He had never wronged me. He had never given me insult. For his gold I had no desire. I think it was his eye! yes, it was this! He had the eye of a vulture – a pale blue eye, with a film over it. Whenever it fell upon me, my blood ran cold; and so by degrees – very gradually – I made up my mind to take the life of the old man, and thus rid myself of the eye for ever. (156). Basic medical knowledge to the modern reader quickly identifies this condition as symptoms of a cataract, a film that gradually creeps over the eye of an elderly person, eventually rendering him or her blind while also changing the color of the eye to a pale bluish color. It is this encroachment that seems to so bother the narrator,

White Collar Crime Essay Example | Topics and Well Written Essays - 3000 words

White Collar Crime - Essay Example This paper is a review of white collar crimes in an Australian context and will specifically address the collapse of the HIH Insurance Group, considered to be one the biggest corporate failures ever in the country. The study will cover the crime/ misbehaviour, regulatory failure, the existing literature relevant to the area of crime and regulation, and provide a case analysis, explaining how and why the failure of regulation occurred. According to Sutherland, â€Å"white collar crime may be defined approximately as a crime committed by a person of respectability and high social status in the course of his occupation† (The evolution of white-collar crime, n.d.). The book, Encyclopedia of white-collar & corporate crime states that Sutherland implicitly makes it clear that crime results not just out of poverty, but due to other reasons as well. Sutherland developed the theory of differential association primarily to state that criminality includes â€Å"the social and business influences that caused persons of high status to violate the law through occupation† (Salinger, 2005, p. 775) One of the earliest among similar researchers was Edward Alsworth Ross, who coined the term criminals, intentionally done to sound familiar with words like an asteroid, crystalloid or anthropoid. Ross feels that such acts were not seen as serious by the general public and the perpetrators themselves. (Geis, 2006, p. 26). Ross adds that there is a ‘shocking leniency’ by the public towards such crimes and the people who perpetrate or are a part of the crime. What is interesting is that the article which originally appeared in The Atlantic Monthly was written in 1907. Over the years, the term white-collar crime has come to be primarily associated with business alone. Hartung undertook a study on violations in price control of wholesale meat in Detroit in 1950. According to him white collar crimes are those committed by a firm or its agent by the violation of statutes and regulations.

How Were Workhouses Run so That Only Those in Need of Genuine Help Would Apply Essay Example for Free

How Were Workhouses Run so That Only Those in Need of Genuine Help Would Apply Essay Workhouses, tried many things to stop those in need of help applying for help; this was because they soon became to expensive to run which is why the owners of the workhouse began to try to put the public off applying for help. I am going to cover all of the main reasons that tell you why the poor were ‘put off’. To begin, the workhouses soon introduced separation, they had different classifications. These were: Infirm men, able-bodied men and youths above fifteen, boys above the age of seven and under fifteen, infirm women, able-bodied women and girls above fifteen, girls above the age of seven and under fifteen and children under seven (however they were allowed in the same workhouse as either their mother or father). This would mean that if you were classified to a different class than someone else in your family, for instance; you would be separated and not allowed to communicate. This encourage those in need of slightly less help not to apply, as they may have believed that scraping a living with their family and friends would be better than getting separated in a work house. Next, the living conditions may be considered to have been better outside the workhouse, scraping a living, the living conditions were horrific! Firstly, all the women and babies were all living in the same room; this meant that when one baby awakened, apart from a heavy sleeper, everyone woke up. They also slept in square, coffin-like beds, which will have been hardly comfortable to sleep in. For me, if workhouses wanted their employees to perform to their full potential they would have given them good living conditions, however they didn’t want people coming in on demand. Because the workhouses mad the living conditions so horrific, would have encouraged many to not apply for help. This is because they may have believed they would get a longer, more comfortable sleep outside the workhouse. To continue, the food provided was terrible, the food was cooked terribly for a few reasons, two examples would be because the workhouses wanted to save money and buy the cheapest food, for the cheapest possible price and they may have purposely cooked the food badly. They also gave each of the same food for each food break causing people to have a bad diet. Again, people in poverty would not apply for help. People wouldn’t apply because word would spread about the terrible food and people wouldn’t apply because again they could think that they could get better food elsewhere. The workhouse owners probably knew that word of this would spread and less people would apply for help, like they wanted. Next, punishments were very harsh and barely taken into consideration, for instance the workhouse owners would judge whether someone was ill or not ill, for instance, if they judged someone to be well and fit when they were ill the would punish the ill person, for no reason when they should be treating their employee well so that as soon as they had recovered, they would be able to perform at a high standard again. This would have put people off because they would be scared of the owners and if they were a parent, they may feel that they were the person to hand out punishments to child not the owners. The owners most possibly knew again that word would spread and would be ruthless to any parent try who tried to have authority. Working conditions, like living conditions were poor. Some people may have applied sot they may get a more enjoyable job with good earnings, instead they were allocated with jobs such as rope picking, this was where a worker had to get old, battered rope, and individually take each thread off the rope and then put it back together to make good rope. This would have put the poor off because they may feel that the jobs they were doing were more enjoyable plus they may feel that they should be doing better jobs if they were to apply for help because workhouses had been advertised to be the ‘way out’ of problems. My final point is on the fact that the workers had no individuality. The workhouse owners had some rules which were strict and if broken would show no tolerance. An example of this is in a picture, it shows how each of the women in the workhouse are having their meal, everyone’s food is exactly the same food, which for lunch was commonly beef and vegetable soup, so vegetarians would be forced to eat the food, not necessarily by the workhouse owners but by their own hunger because they were served such a small amount, they would be extremely hungry. They were also sat in rows, they were not allowed to socialise and they all had to wear uniforms. This would make employees feel worthless and as if they were in prison and ultimately they would feel demoralised and wouldn’t feel excited for the job they would do after their lunch, for example. Word would have spread about this (Like the owners would have wanted) and the poor would feel that the joy of socialising was worth m ore than living a poor lifestyle. To conclude this essay, I feel the most important factor that people would have taken into consideration would be the fact that families were split; the workhouse owners would have found that this was the biggest blow to a family thinking of applying because they would have wanted to be together.

The Search for Self and Identity in Jack Kerouac’s On The Road :: On The Road essays

Quest for Identity in On the Road In Jack Kerouac's novel On the Road, the author tries to convey to the audience that everybody is naturally dishonest and morally deceitful. Morals are defined by one's religion, the laws of the country, or some combination of the two. One's identity captures and plays out that individual’s moral. My morals follow the Christian beliefs, Texas state laws, and the laws of the United States. Although one's own morals can change, basic things such as stealing and murder are wrong and illegal by federal law. Numerous characters performed many acts proving this point such as Montana Slim, who says in order to get money, follow a man down an alley and rob him, or Dean, who never feels remorse for beating Mary Lou after a fight. These along with other characters display such actions that show that everyone is morally deceitful. In Part 1, Chapter 4, Sal tells Montana Slim that he only has enough money to buy some whiskey. Slim says to Sal, "I know where you can get some." "Where?" "Anywhere. You can always folly a man down an alley, can't you? ...I ain't beyond doing it when I really need some dough." (27) At this early point in the novel, Sal is still figuring out who he is and what life is like on the road. He seems like a young naive schoolboy being bullied by an older, wiser kid. Slim knows what he is talking about because he has been on the road for some time now. He has probably robbed quite a few people throughout his experience on the road. This act is, by law, wrong and dishonest. In Part 2, chapter 6, while Dean, Mary Lou, Ed Dunkel, and Sal stopped at a gas station on the way to New Orleans, Dunkel casually steals three packs of cigarettes. The way the narrator says it is that he stole them without even trying. He then justifies it by saying that they were fresh out (139). The language used is just so "non-chalant," as if stealing was no big deal. Stealing, like robbing, is illegal and morally wrong. The part that is most disturbing is that Dunkel feels that stealing cigarettes is okay, that it is necessary for survival just like food or water. Stealing food or water in order to survive can be justified, but not cigarettes.

Fool Chapter 7

SEVEN A BROTHER TRAITOR Am I to be forever alone? The anchoress told me it might be so, trying to comfort me when I felt pushed aside by the sisters of Dog Snogging. â€Å"You're gifted with wit, Pocket, but to cast jibe and jest you must stand separate from the target of your barbs. I fear you may become a lonely man, even in the company of others.† Perhaps she was right. Perhaps it is why I am such an accomplished horn-beast and eloquent crafter of cuckoldry. I seek only succor and solace beneath the skirts of the soft and understanding. And so, sleepless, did I make my way to the great hall to find some comfort among the castle wenches who slept there. The fire still blazed, logs the size of oxen set in before bed. My sweet Squeak, who had oft opened her heart and whatnot to a wayfaring fool, had fallen asleep in the arms of her husband, who spooned her mercilessly as he snored. Shanker Mary was not to be seen, no doubt servicing the bastard Edmund somewhere, and my other standard lovelies had fallen into slumber in proximity too close to husbands or fathers to admit a lonely fool. Ah, but the new girl, just in the kitchen a fortnight, called Tess or Kate or possibly Fiona. Her hair was jet and shone like oiled iron; milky skin, cheeks brushed by a rose – she smiled at my japes and had given Drool an apple without his asking. I am relatively sure that I adored her. I tiptoed across the rushes that lined the floor (I had left Jones in my chamber, his hat bells no help in securing stealthy romance), lay down beside her, and introduced my personage to the nether of her blanket. An affectionate nudge at the hip woke her. â€Å"Hello,† said she. â€Å"Hello,† said I. â€Å"Not a papist, are you, love?† â€Å"Christ, no, Druid born and raised.† â€Å"Thank God.† â€Å"What are you doing under my blanket?† â€Å"Warming up. I'm terribly cold.† â€Å"No you're not.† â€Å"Brrrr. Freezing.† â€Å"It's hot in here.† â€Å"All right, then. I'm just being friendly.† â€Å"Would you stop prodding me with that?† â€Å"Sorry, it does that when it's lonely. Perhaps if you petted it.† Then, praised be the merciful goddess of the wood, she petted it, tentatively, almost reverentially at first, as if she sensed how much joy it could bring to all who came in contact with it. An adaptable lass, not given to fits of hysteria or modesty – and soon a gentle surety in her grip that betrayed some experience in the handling of manly bits – simply lovely she was. â€Å"I thought it would have a little hat, with bells.† â€Å"Ah, yes. Well, given a private place to change, I'm sure that can be arranged. Under your skirt, perhaps. Roll to the side, love, we'll be less obvious if we keep the cuddle on a lateral plane.† I popped her bosoms out of her frock, then, freed the roly-poly pink-nosed puppies to the firelight and the friendly ministries of this master juggler, and thought to burble my cheeks softly between them, when the ghost appeared. The spirit was more substantial now, features describing what must have been a most comely creature before she was shuffled off to the undiscovered country, no doubt by a close relative weary of her irritating nature. She floated above the sleeping form of the cook Bubble, rising and falling on the draft of her snores. â€Å"Sorry to haunt you while you're rogering the help,† said the ghost. â€Å"The rogering has not commenced, wisp, I have barely bridled the horse for a moist and bawdy ride. Now, go away.† â€Å"Right, then. Sorry to have interrupted your attempted rogering.† â€Å"Are you calling me a horse?† asked Possibly Fiona. â€Å"Not at all, love, you pet the little jester and I'll attend to the haunting.† â€Å"There's always a bloody ghost about, ain't there?† commented Possibly, a squeeze on my knob for emphasis. â€Å"When you live in a keep where blood runs blue and murder is the favored sport, yes,† said the ghost. â€Å"Oh do fuck off,† said I. â€Å"Thou visible stench, thou steaming aggravation, thou vaporous nag! I'm wretched, sad, and lonely, and trying to raise a modicum of comfort and forgetting here in the arms of, uh – â€Å" â€Å"Kate,† said Possibly Fiona. â€Å"Really?† She nodded. â€Å"Not Fiona?† â€Å"Kate since the day me da tied me belly cord to a tree.† â€Å"Well, bugger. Sorry. Pocket here, called the Black Fool, charmed I'm sure. Shall I kiss your hand?† â€Å"Double-jointed, then, are ye?† said Kate, a tickle to my tackle making her point. â€Å"Bloody hell, would you two shut up?† said the ghost. â€Å"I'm haunting over here.† â€Å"Go on,† said we. The ghost boosted her bosom and cleared her throat, expecto-rating a tiny ghost frog that evaporated in the firelight with a hiss, then said: â€Å"When a second sibling's base derision, Proffers lies that cloud the vision, And severs ties that families bind, Shall a madman rise to lead the blind.† â€Å"What?† said the former Fiona. â€Å"What?† said I. â€Å"Prophecy of doom, innit?† said the ghost. â€Å"Spot o' the old riddly foreshadowing from beyond, don't you know?† â€Å"Can't kill her again, can we?† asked faux Fiona. â€Å"Gentle spook,† said I. â€Å"If it is a warning you bring, state it true. If action you require, ask outright. If music you must make, play on. But by the wine-stained balls of Bacchus, speak your bloody business, quick and clear, then be gone, before time's iron tongue licks away my mercy bonk with second thoughts.† â€Å"You are the haunted one, fool. It's your business I do. What do you want?† â€Å"I want you to go away, I want Fiona to come along quietly, and I want Cordelia, Drool, and Taster back – now, can you tell me how to make those things come about? Can you, you yammering flurry of fumes?† â€Å"It can be done,† said the ghost. â€Å"Your answer lies with the witches of Great Birnam Wood.† â€Å"Or you could just fucking tell me,† said I. â€Å"Nooooo,† sang the ghost, all ghosty and ethereal, and with that she faded away. â€Å"Leaves a chill when she goes, don't she?† said formerly Fiona. â€Å"Appears to have softened your resolve, if you don't mind my sayin'.† â€Å"The ghost saved my life last evening,† said I, trying to will life back into the wan and withered. â€Å"Kilt the little one, though, didn't she? Back to your bed, fool, the king's leaving on the morrow and there's a wicked lot of work to do in the morning to prepare for his trip.† Sadly, I tucked away my tackle and sulked back to the portislodge to pack my kit for my final journey from the White Tower. Well, I won't miss the bloody trumpets at dawn, I can tell you that. And sod the bloody drawbridge chains rattling in my apartment before the cock crows. We might have been going to war for all the racket and goings-on at first light. Through the arrow loop I could see Cordelia riding out with France and Burgundy, standing in the stirrups like a man, like she was off to the hunt, rather than leaving her ancestral home forever. To her credit, she did not look back, and I did not wave to her, even after she crossed the river and rode out of sight. Drool was not so fickle, and as he was led out of the castle by a rope round his neck, he kept stopping and looking back, until the man at arms to whom he was tethered would yank him back into step. I could not bear to let him see me, so I did not go out onto the wall. Instead I slunk back to my pallet and lay there, my forehead pressed to the cold stone wall, listening as the rest of the royals and their retinues clomped across the drawbridge below. Sod Lear, sod the royals, sod the bloody White Tower. All I loved was gone or soon to be left behind, and all that I owned was packed in a knapsack and hung on my hook, Jones sticking out the top, mocking me with his puppety grin. Then, a knock at my door. Like dragging myself from the grave, was making my way to open it. There she stood, fresh and lovely, holding a basket. â€Å"Fiona!† â€Å"Kate,† said Fiona. â€Å"Aye, your stubbornness suits you, even in daylight.† â€Å"Bubble sends her sympathies over Taster and Drool, and sends you these sweet cakes and milk for your comfort, but says to be sure and remind you to not leave the castle without saying your farewells, and further that you are a cur, a rascal, and a scurvy patch.† â€Å"Ah, sweet Bubble, when kindness shagged an ogre, thus was she sired.† â€Å"And I'm here to offer comfort myself, finishing what was started in the great hall last night. Squeak says to ask you about a small chap in a canoe.† â€Å"My my, Fi, bit of a tart, aren't we?† â€Å"Druish, love. My people burn a virgin every autumn – one can't be too careful.† â€Å"Well, all right, but I'm forlorn and I shan't enjoy it.† â€Å"In that we shall suffer together. Onward! Off with your kit, fool!† What is it about me that brings out the tyrant in women, I wonder? â€Å"The next morning† stretched into a week of preparation for departure from the White Tower. When Lear pronounced that he would be accompanied by one hundred knights it was not as if one hundred men could mount up and ride out of the gates at sunrise. Each knight – the unlanded second or third son of a noble – would have at least one squire, a page, usually a man to tend his horses, and sometimes a man at arms. Each had at least one warhorse, a massive armored beast, and two, sometimes three animals to carry his armor, weapons, and supplies. And Albany was three weeks' journey to the north, near Aberdeen; with the slow pace set by the old king and so many on foot we'd need a crashing assload of supplies. By the end of the week our column numbered over five hundred men and boys, and nearly as many horses. We would have needed a wagon full of coin to pay everyone if Lear had not conscripted Albany and Cornwall to maintain his knights. I watched Lear pass under the portislodge at the head of the column before going downstairs and climbing on my own mount, a short, swayback mare named Rose. â€Å"Mud shall not sully my Black Fool's motley, lest it dull his wit as well,† said Lear, the day he presented the horse. I did not own the horse, of course. She belonged to the king – or now his daughters, I suppose. I fell in at the end of the column behind Hunter, who was accompanied by a long train of hounds and a wagon with a cage built on it, which held eight of the royal falcons. â€Å"We'll be raiding farms before we get to Leeds,† said Hunter, a stout, leather-clad man, thirty winters on his back. â€Å"I can't feed this lot – and they've not enough stowed to last them a week.† â€Å"Cry calamity if you will, Hunter, but I'm the one to keep them in good spirits when their bellies are empty.† â€Å"Aye, I've no envy for you, fool. Is that why you ride back here with we catch-farts and not at the king's side?† â€Å"Just drawing plans for a bawdy song at supper without the clank of armor in my ear, good Hunter.† I wanted to tell Hunter that I was not overburdened by my duties, but by my disdain for the senile king who had sent my princess away. And I wanted time to ponder the ghost's warnings. The bit about daughters three and the king becoming a fool had come to pass, or at least was in the way of it. So the girl ghost had predicted the â€Å"grave offense† to â€Å"daughter's three† even if all the daughters had not seen the offense yet – when Lear arrived at Albany with this rowdy retinue, offense would soon follow. But what of this: â€Å"When a second sibling's base derision, proffers lies that cloud the vision†? Did it mean the second daughter? Regan? What did it matter if her lies clouded Lear's vision? The king was nearly blind as it was, his eyes milky with cataract – I'd taken to describing my pantomimes as I performed them so the old man would not miss the joke. And with no power, what tie could be severed that would make a difference now? A war between the two dukes? None of it about me, why do I care? Why then would the ghost appear to this most irrelevant and powerless fool? I puzzled it, and fell far behind the column, and when I stopped to have a wee, was accosted by a brigand. He came up from behind a fallen tree, a great bear of a fiend, his beard matted and befouled with food and burrs, a maelstrom of grey hair flying about under a wide-brimmed black hat. I may have screamed in surprise, and a less educated ear might have likened my shriek to that of a little girl, but be assured it was most manly and more for the fair warning of my attacker, for next I knew I had pulled a dagger from the small of my back and sent it flying. His miserable life was saved only by my slight miscalculation of his distance – the butt of my blade bounced off his behatted noggin with a thud. â€Å"Ouch! Fuck's sake, fool. What is wrong with you?† â€Å"Hold fast, knave,† said I. â€Å"I've two more blades at the ready, and these I'll send pointy end first – the quality of my mercy having been strained and my ire aroused by having peed somewhat upon my shoes.† I believed it a serviceable threat. â€Å"Hold your blades, Pocket. I mean you no harm,† came the voice under the hat brim. Then, â€Å"Y Ddraig Goch ddyry gychwyn.†[22] I wound up to send my second dagger to the scoundrel's heart, â€Å"You may know my name, but that gargling with catsick that you're doing will not stop me from dropping you where you stand.† â€Å"Ydych chi'n cymryd cerdynnau credid?†[23] said the highwayman, no doubt trying to frighten me further, his consonants chained like anal beads strung out of hell's own bunghole. â€Å"I may be small, but I'm not a child to be afraid of a pretended demon speaking in tongues. I'm a lapsed Christian and a pagan of convenience. The worst I can do on my conscience is cut your throat and ask the forest to count it as a sacrifice come the Yule, so cease your nonsense and tell me how you know my name.† â€Å"It's not nonsense, it's Welsh,† said the brigand. He folded back the brim of his hat and winked. â€Å"What say you save your wicked sting for an enemy true? It's me, Kent. In disguise.† Indeed, it was, the king's old banished friend – all of his royal trappings but his sword gone – he looked like he'd slept in the woods the week since I'd last seen him. â€Å"Kent, what are you doing here? You're as good as dead if the king sees you. I thought you'd be in France by now.† â€Å"I've no place to go – my lands and title are forfeit, what family I have would risk their own lives to take me in. I have served Lear these forty years, I am loyal, and I know nothing else. My thought is to affect accents and hide my face until he has a change of heart.† â€Å"Is loyalty a virtue when paid to virtue's stranger? I think not. Lear has misused you. You are mad, or stupid, or you lust for the grave, but there is no place for you, good greybeard, in the company of the king.† â€Å"And there is for you? Or did I not see you restrained and dragged from the hall for that same offense: truth told boldly? Don't preach virtue to me, fool. One voice can, without fear, call the king on his folly, and here he stands, piss-shoed, two leagues back from the train.† Fuckstockings, truth is a surly shrew sometimes! He was right, of course, loudmouthed old bull. â€Å"Have you eaten?† â€Å"Not for three days.† I went to my horse and dug into my satchel for some hard cheese and an apple I had left from Bubble's farewell gift. I gave them to Kent. â€Å"Come not too soon,† said I. â€Å"Lear still fumes about Cordelia's honest offense and your supposed treason. Follow behind to Albany's castle. I'll have Hunter leave a rabbit or a duck beside the road for you every day. Do you have flint and steel?† â€Å"Aye, and tinder.† I found the stub of a candle in the bottom of my bag and handed it to the old knight. â€Å"Burn this and catch the soot upon your sword, then rub the black into your beard. Cut your hair short and blacken it, too. Lear can't see clearly more than a few feet away, so keep your distance. And carry on with that ghastly Welsh accent.† â€Å"Perhaps I'll fool the old man, but what of the others?† â€Å"No righteous man thinks you a traitor, Kent, but I don't know all of these knights, nor which might reveal you to the king. Just stay out of sight and by the time we reach Albany's castle I'll have flushed out any knave who might betray your cause.† â€Å"You're a good lad, Pocket. If I've shown you disrespect in the past, I'm sorry.† â€Å"Don't grovel, Kent, it doesn't wear well on the aged. A swift sword and a strong shield are allies I can well use with scoundrels and traitors weaving intrigue about like the venomous spider-whore of Killarney.† â€Å"Spider-whore of Killarney? I've never heard of her?† â€Å"Aye, well, sit on that downed tree and eat your lunch. I'll spin the tale for you like it was web from her own bloody bum.† â€Å"You'll fall behind the column.† â€Å"Sod the column, that tottering old tosspot so slows them they'll be leaving a snail trail soon. Sit and listen, greybeard. By the way have you ever heard of Great Birnam Wood?† â€Å"Aye, it's not two miles from Albany.† â€Å"Really? How do you feel about witches?†