The Consultant grants to the City and the Task Force a non-exclusive anxiety or heart problem discount atarax 25mg on-line, irrevocable anxiety 5 point scale discount 25mg atarax otc, unlimited, royalty-free license to use aggregate data or research reports prepared by the Consultant for the City under this Agreement. If requested by the City and or the Task Force, a copy of all documents or materials, that do not violate Section 19 of this document, that are developed solely for, and paid for by, the City in connection with the performance of the Work, shall be promptly delivered. The City and or the Task Force may make and retain copies of such documents for its information and reference in connection with their use on the project. This Request for Proposal (Long Version) Page 25 of 29 68 will be considered extra work, supplemental to this Agreement, and shall not proceed unless authorized by an amendment. Any costs incurred due to the performance of extra work prior to execution of an amendment will not be reimbursed under this Agreement or an amendment. If such officials do not agree upon a decision within a reasonable period of time, the parties may pursue other legal means to resolve such disputes, including but not limited to alternate dispute resolution processes. Notice: Notice of termination pursuant to this section shall be given by the party terminating this Agreement to the other not less than thirty (30) days prior to the effective date of termination. Actions Upon Termination: In the event of termination not the fault of the Consultant, the Consultant shall be paid for the services properly performed prior to termination, together with any reimbursable expenses then due, bu t in no event shall such compensation exceed the maximum compensation to be paid under the Agreement. The Consultant agrees that this payment shall fully and adequately compensate the Consultant and all subconsultants for all profits, costs, expenses, losses, liabilities, damages, taxes, and charges of any kind whatsoever (whether foreseen or unforeseen) attributable to the termination of this Agreement. Upon termination for any reason, the Consultant must notify the City and all members of the Task Force of the new secure location of all medical record, data, and reports. The City and other members of the Task Force shall have the same rights to use these materials as if termination had not occurred. The Consultant has received overall performance evaluations of deficient, inadequate, or substandard performance on three or more City of Contracts. The Consultant has failed to comply with Fire Department ordinances or Contract terms, including but not limited to , ordinance or Contract terms relating to small business utilization, discrimination, or equal benefits. The Consultant has abandoned, surrendered, or failed to complete or to perform work on or in connection with a Fire Department Contract. The Consultant has failed to comply with Contract provisions, including but not limited to quality of workmanship, timeliness of performance, and safety standards. The Consultant has submitted false or intentionally misleading documents, reports, invoices, or other statements to the Fire Department in connection with a Contract. The Consultant has committed fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a Contract for the Fire Department or any other government entity. The rights and remedies of the City of under these debarment provisions are in addition to any other rights and remedies provided by law or under the Agreement. Amendments: No modification of this Agreement shall be effective unless in writing to the City and the Task Force and signed by an authorized representative of each of the parties hereto. Binding Agreement: this Agreement shall not be binding until signed by both parties. The provisions, covenants, and conditions in this Agreement shall bind the parties, their legal heirs, representatives, successors, and assigns. Applicable Law/Venue: this Agreement shall be construed and interpreted in accordance with the laws of the State of. The venue of any action brought hereunder shall be in the Superior Court for County. Remedies Cumulative: Rights under this Agreement are cumulative and nonexclusive of any other remedy at law or in equity. Captions: the titles of sections or subsections are for convenience only and do not define or limit the contents. Severability: If any term or provision of this Agreement is determined by a court of competent jurisdiction to be invalid or unenforceable, the remainder of this Agreement shall not be affected thereby, and each term and provision of this Agreement shall be valid and enforceable to the fullest extent permitted by law. Waiver: No covenant, term or condition or the breach thereof shall be deemed waived, except by written consent of the party against whom the waiver is claimed, and any waiver of the breach of any covenant, term or condition shall not be deemed to be a waiver of any preceding or succeeding breach of the same or any other covenant, term or condition. Neither the acceptance by the City of any performance by the Consultant after the time the same shall have become due nor payment to the Consultant for any portion of the Work shall constitute a waiver by the City of the breach or default of any covenant, term or condition unless otherwise expressly agreed to by the City, in writing. Entire Agreement: this document, along with any exhibits and attachments, constitutes the entire agreement between the parties with respect to the Work.
Role of dietary vitamin K intake in chronic oral anticoagulation: prospective evidence from observational and randomized protocols anxiety 30002 purchase 10mg atarax with mastercard. Patients with unstable control have a poorer dietary intake of vitamin K compared to patients with stable control of anticoagulation anxiety symptoms returning purchase 10 mg atarax visa. Controlled vitamin K content diet for improving the management of poorly controlled anticoagulated patients: a clinical practice proposal. Constituents Aloe vera gel is contained in the mucilaginous tissue that is found in the inner leaf, and should not be confused with aloes, page 27, which is the latex stored in tubules along the leaf margin. Aloe vera gel may be produced by a handfilleted technique to remove the inner leaf, or by a whole-leaf extraction process where the aloes constituents (anthraquinones) are now usually subsequently removed. The principal constituents of the gel are polysaccharides consisting mainly of polymannans, of which acemannan is the major one. Other constituents include glycoproteins such as aloctins, and various carboxypeptidases, sterols, saponins, tannins, organic acids, vitamins and minerals. It is reported to possess anti-inflammatory, antitumour, immunomodulatory and antibacterial properties. Internally, aloe vera is thought to be immunostimulatory and to have mild analgesic, antioxidant and antidiabetic effects. Interactions overview Aloe vera contains only traces of anthraquinone glycosides, and would therefore not be expected to have any of the interactions of aloes, page 27, or similar herbal medicines, which occur, or are predicted to occur, as a result of their anthraquinone content. Aloe vera may have blood-glucose-lowering properties and may therefore be expected to interact with conventional drugs that have the same effect. Aloe vera appears to enhance the absorption of some vitamins but the clinical significance of this is not clear. Use and indications Aloe vera is used topically to aid wound healing from cuts 24 Aloe vera 25 Aloe vera + Antidiabetics Aloe vera juice reduces blood-glucose levels in patients with diabetes taking glibenclamide. Clinical evidence In placebo-controlled clinical studies, aloe vera juice (80%), one tablespoonful twice daily for 42 days, reduced blood-glucose in patients with diabetes, either taking glibenclamide,1 or not taking oral antidiabetic drugs,2 from an average of 14 to 16 mmol/L down to 8 mmol/L over a period of 6 weeks. However, it should be noted that, in the study in patients taking glibenclamide, there was, unexpectedly, no response to the use of glibenclamide alone. In these studies, the aloe vera juice (80%) was prepared from aloe gel and additional flavours and preservatives. Experimental evidence There is extensive literature (not cited here) on the possible bloodglucose-lowering effect of various extracts of aloe vera in animal models of diabetes, with some studies showing an effect and others not. Importance and management It seems possible that some oral preparations of aloe vera might have a clinically important blood-glucose-lowering effect. It might therefore be prudent to increase the frequency of blood-glucose monitoring if patients taking antidiabetic medication wish to try oral aloe vera preparations. The authors suggest that a possible interaction between sevoflurane and aloe vera contributed to the excessive bleeding seen. Experimental evidence Aloe vera gel extracts inhibited prostaglandin synthesis in vitro,2 and might therefore have antiplatelet activity. Mechanism Sevoflurane can inhibit platelet aggregation by inhibiting thromboxane A2, and aloe vera affects prostaglandin synthesis, which may also impair platelet aggregation. Therefore additive antiplatelet effects may have contributed to the excessive bleeding. Perioperative considerations in the management of the patient taking herbal medicines. A Aloe vera + Vitamins Aloe vera might delay, and enhance, the absorption of vitamin C and vitamin E. However, this difference was not statistically significant: it was attributed to the large interindividual differences. There was a second maximum plasma ascorbate level at 8 hours with the gel, and plasma ascorbate was still detectable at 24 hours, suggesting that aloe vera gel might delay, as well as enhance, absorption. Conversely, aloe vera whole leaf extract 60 mL had no significant effect on the absorption of vitamin C.
Providers must be trained on and competent with the airway device they will be using anxiety help order atarax 25 mg with amex. For devices inserted into the esophagus: o the patient has known esophageal disease anxiety natural treatment trusted 25 mg atarax. Confirm appropriate placement by symmetrical chest-wall rise, auscultation of equal breath sounds over the chest and a lack of epigastric sounds with bag valve mask ventilation, and quantitative waveform capnography, if available. Advance the bougie into the trachea feeling for "clicks" of tracheal rings and until "hangup" when it cannot be advanced any further. Assess tracheostomy tube: Look for possible causes of distress which may be easily correctable, such as a detached oxygen source. If on a ventilator, remove the patient from the ventilator prior to using bag valve mask device as there may be a problem with the ventilator or oxygen source. If the patient remains in severe distress, continue ventilation attempts using bag valve mask with high-flow oxygen via the tracheostomy. Consider underlying reasons for respiratory distress and refer to the appropriate protocol for intervention. If another tube is available from caregivers, insert into stoma and resume ventilation (a standard endotracheal tube may be used or the used tracheostomy tube, after being cleaned). If unable to replace tube with another tracheostomy tube or endotracheal tube, assist ventilations with bag valve mask and high-flow oxygen. To optimize oxygenation and ventilation of endotracheally intubated patients as well as patients with supraglottic airways. The use of ventilators in the pre-hospital interfacility transport environment is not addressed by this protocol. Adult and pediatric patients on their own ventilator: o If the ventilator is operational, transport patient with their ventilator and caregiver on previously prescribed ventilator settings. Be alert for causes of artifact: dry or sweaty skin, dried out electrodes, patient movement, cable movement, vehicle movement, electromagnetic interference, static electricity. According to manufacturers, dried out electrodes are a major source of artifact; keep in original sealed foil pouches; plastic bags are not sufficient; use all the same kind of electrodes; press firmly around the edge of the electrode, not the center. This includes physical, sexual, or emotional abuse, neglectful acts or omissions by self or others, and/or the illegal use of a person or property for profit or advantage. Procedure for Assessment Treat and document assessment findings using appropriate medical treatment protocols without causing undue emotional trauma. Whenever possible, secure and bag (in paper) clothing or items needed as evidence. Interview patient in a calm, respectful, and private manner, while observing for: o Mental status. Do not interrogate, accuse, or otherwise address specifics of abuse or neglect to patient, caregiver or parent. Document verbatim any patient statements of instances of rough handling, sexual abuse, alcohol/drug abuse, verbal or emotional abuse, isolation or confinement, misuse of property, threats, and gross neglect such as restriction of fluids, food, medications, or hygienic care. Note any potential indicator of an abusive or neglectful circumstance or environment: o Unsolicited history provided by the patient. If a parent/guardian refuses treatment of a minor child whom you feel needs medical attention, contact law enforcement immediately. Written documentation is vital because the "story" often changes as investigation proceeds. Abuse to Elders** Report suspected abuse immediately To report cases of suspected abuse, neglect or exploitation, call the toll-free In State referral line at 1-888-385-4225 during normal business hours or 211 after hours. Operational Considerations When a patient meets the defined clinical criteria listed below and the ground transport time to the closest hospital capable of providing definitive care. Clinical Considerations Severe respiratory compromise with respiratory arrest or abnormal respiratory rate. Circulatory insufficiency: sustained systolic blood pressure <90 mmHg in both children and adults or other signs of shock. Trauma: All penetrating injuries to head, neck, torso, and extremities proximal to elbow or knee; chest wall instability or deformity.
Administer Aspirin to every patient with suspected acute coronary syndrome unless they have: Patients with acute coronary syndrome (especially women and the elderly) may present with signs and symptoms other than chest pain including shortness of breath anxiety medications atarax 25mg visa, weakness anxiety symptoms body purchase 10mg atarax with amex, syncope and nausea. In the un-intubated patient, analgesics may not be administered in combination with benzodiazepines without Direct Medical Oversight. Consider administration of one of the following prior to/during pacing, if feasible: o Midazolam 0. For symptomatic beta blocker or calcium channel blocker overdose, consider glucagon 0. After 4 cycles (8 minutes): o Continue 2 minute cycles of uninterrupted chest compressions. Consider treatable causes: hypoxia, overdose/poisoning, hypothermia, hypoglycemia, and hypovolemia-treat as per specific protocol. Consider termination of efforts or not attempting resuscitation (see Do Not Resuscitate Orders 6. After 4 cycles (8 minutes): o Consider endotracheal intubation or use of an alternative airway without interrupting chest compressions. Minimize interruptions in chest compression, as pauses rapidly return the blood pressure to zero and stop perfusion to the heart and brain. Perform chest compressions while defibrillator is charging and resume compressions immediately after the shock is delivered. Move furniture or get the patient in a position that will allow a rescuer space to kneel on both sides of them, and where there is sufficient room at the head. Therefore resuscitate the patient as close to the scene as operationally feasible. Ventilate 1 breath every 10 compressions during recoil without interrupting chest compressions. With the goal of immediate uninterrupted chest compressions, if a mechanical device is used, it should not lead to delay or interruption in chest compressions; consider delayed applications. Pre-charge manual defibrillators prior to rhythm check to ensure rapid defibrillation if a shockable rhythm is present. Consider treatable causes: hypoxia, overdose/poisoning, hypoglycemia, hypothermia, and hypovolemia (treat as per specific protocol). If Return of Spontaneous Circulation occurs see Post Resuscitative Care Protocol 3. Placement of an advanced airway during cardiac arrest should not interrupt chest compressions. Avoid nitroglycerin in any patient who has used a phosphodiesterase inhibitor such as: sildenafil (Viagra, Revatio), vardenafil (Levitra, Staxyn), tadalafil (Cialis, Adcirca) which are used for erectile dysfunction and pulmonary hypertension. Allow the patient to be in their position of comfort to maximize their breathing effort. Avoid hyperventilation as it increases intrathoracic pressures, potentially worsening hemodynamic instability. Consider administer of one of the following prior to or during cardioversion, if feasible: o Midazolam 2. Medications should be administered cautiously in frail or debilitated patients; lower doses should be considered. Wide complex tachycardia should be considered Ventricular Tachycardia until proven otherwise Signs and symptoms of hemodynamic instability: Hypotension Acutely altered mental status Signs of shock Signs of acute heart failure Ischemic chest pain Adenosine should be administered rapidly though a proximal. If adenosine is ineffective or for wide complex, perform synchronized cardioversion: Consider administration of one of the following prior to or during cardioversion, if feasible: o Midazolam 0. If a partial thickness burn (2nd degree) is <10% body surface area, apply roomtemperature water or room-temperature wet towels to the burned area for a maximum of 15 minutes. If the patient has respiratory difficulty, stridor at rest, burns about the mouth or neck, or is producing carbonaceous sputum, consider advanced airway management, see Airway Management Protocol 5. Rule of Nines Head & Neck: Left arm: Right arm: Chest: Abdomen: Upper back: Lower back: Front left leg: Front right leg: Back left leg: Back right leg: Genital region: 9% 9% 9% 9% 9% 9% 9% 9% 9% 9% 9% 1% 4. Consider spinal motion restriction for electrical burns that result in hand to hand flow. If a partial thickness burn (2nd degree) is <10% body surface area, apply room-temperature water or room-temperature wet towels to the burned area for a maximum of 15 minutes.
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