Medical E-Book: Oxford Handbook of Clinical Hematology 2nd Ed.

Book Description:

The Oxford Handbook of Clinical Haematology continues to provide the essential core knowledge needed in modern clinical practice for the diagnosis and management of patients with possible disorders of the blood. Major advances in the specialty have been reflected in this thoroughly revised new edition. Essential knowledge is covered with the main differential diagnoses, along with relevant investigations that will help the junior viagra cialis online pharmacy pharmacy to arrive at a definitive
diagnosis. The management of the patient is provided in a way that allows the junior to initiate treatment whilst waiting for review of the patient by a senior member of staff.

As with the first edition, the new edition of this Handbook will have wide appeal and readership amongst senior medical undergraduates, junior doctors and trainees in haematology, residents, interns and fellows, family doctors, intensive care staff, and specialist nurses.

NEW FOR THIS EDITION: Two new Editors; new colour design; inclusion of guidelines for anticoagulation therapy and thrombophilia investigation; thorough updating of diagnostic methods and treatment and sections dealing with blood disorders in childhood, both malignant and non-malignant; inclusion of photomicrographs of blood films and radiological material where relevant; protocols revised to high standard; relevant web site addresses provided where available.

Synopsis:
The Oxford Handbook of Clinical Haematology continues to provide the essential core knowledge needed in modern clinical practice for the diagnosis and management of patients with possible disorders of the blood. Major advances in the specialty have been reflected in this thoroughly revised new edition. Essential knowledge is covered with the main differential diagnoses, along with relevant investigations that will help the junior doctor to arrive at a definitive diagnosis. The management of the patient is provided in a way that allows the junior to initiate treatment whilst waiting for review of the patient by a senior member of staff. As with the first edition, the new edition of this Handbook will have wide appeal and readership amongst senior medical undergraduates, junior doctors and trainees in haematology, residents, interns and fellows, family doctors, intensive care staff, and specialist nurses. NEW FOR THIS EDITION: Two new Editors; new colour design; inclusion of guidelines for anticoagulation therapy and thrombophilia investigation; thorough updating of diagnostic methods and treatment and sections dealing with blood disorders in childhood, both malignant and non-malignant; inclusion of photomicrographs of blood films and radiological material where relevant; protocols revised to high standard; relevant web site addresses provided where available.

Download ebook

Memorandum

The Member Secretary,
Punjab Fifth Pay Commission,
Room No. 722, Mini Secretariat,
Sector – 9
Chandigarh (U.T.)
INDIA.








MEMORANDUM





Subject: Demands of All Junior Technician (Anaesthesia) of Govt. Medical College and online pharmacy viagra, Sector – 32, Chandigarh (U.T) India for favourable consideration of the 5th Pay Commission, Govt. of Punjab.






Sir,

Let us on the outset forgive us for enchroaching upon your valuable time. Had it not been absolutely necessary we would not bothered you.

On behalf of all Junior Technician (Anaesthesia), Govt. Medical College & Hospital, Sector - 32, Chandigarh submitting the following facts for your kind consideration and removal of our grievances and anomalies in our pay scale.
INTRODUCTORY:
The focus of paramedical technician activities is predominantly centered around prevention i.e. health education, paramedical technician known as Junior Technician (Anaesthesia) play an important role in effective management of the health care services. At all levels of health care, grassroots to technically advanced, there are endless examples of contribution of paramedical technical services that bring down the family's cost on health care and maintenance. The World Development Report 1993 stated that paramedical technician can be cost effective providers for the range of services needed by the vulnerable group and patients suffering from chronic illness.



We all paramedical technicians known as Junior Technician (Anaesthesia) are working under Chandigarh Administration and posted at Govt. Medical College & Hospital, Sector – 32, Chandigarh since 1995. Being employees of Chandigarh Administration we are getting scale of Punjab Government, as Chandigarh Administration doesn't have its own pay scale and separate pay commission. So we are submitting our memorandum before fifth pay commission of Punjab Government. The parawise details are as under:



EDUCATION AND TECHNICAL QUALIFICATION ATTACHED TO THE POST:-
i) 10+2 (with Science) from a recognized board/ university.
ii) Diploma in operation theatre technique / Anaesthesia Technology from a recognized Institute / University.

iii) Two years experience of working in the reputed medical college/ hospital not less than 200 bedded.
ANNEXURE - A
S. No.
Name of Employee
Emp.Code
Date of Joining
Pay Scale at the time of Joining
Present pay scale
1
Balraj Singh
1477
06-07-95
1200-2100
4020-6200
2
Babloo Kumar
1478
06-07-95
1200-2100
4020-6200
3
Anil Kumar
2365
16-09-96
1200-2100
4020-6200
4
Raj saini
2366
23-10-97
4020-6200
4020-6200
5
Simerjit
2377
23-10-97
4020-6200
4020-6200
6
Jagtar Singh
-
27-10-97
4020-6200
4020-6200
7
Kulwinder Singh
2369
28-10-97
4020-6200
4020-6200
8
Anil sinha
2398
04-11-97
4020-6200
4020-6200
9
Arvind Kumar
-
31-10-97
4020-6200
4020-6200
10
Jaswinder Kaur
2377
29-10-97
4020-6200
4020-6200
11
Kawalvir Kaur
-
03-11-97
4020-6200
4020-6200
12
Naresh Bhutani
2371
28-10-97
4020-6200
4020-6200
13
William masih
-
29-10-97
4020-6200
4020-6200
14
Twinkle
-
28-10-97
4020-6200
4020-6200
15
Sawinder Pal
-
28-10-97
4020-6200
4020-6200
16
Kamleshwar Sah
-
24-11-97
4020-6200
4020-6200
17
Chand Lal
2376
28-10-97
4020-6200
4020-6200
18
Suresh Kumar
-
28-10-97
4020-6200
4020-6200
19
Major Singh
2379
28-10-97
4020-6200
4020-6200
20
Arun Kumar
-
28-10-97
4020-6200
4020-6200
21
Renu
-
28-10-97
4020-6200
4020-6200
22
Reeta
-
28-10-97
4020-6200
4020-6200



Job profile of Junior Technician (Anaesthesia)/ Operation Theatre Technician / Anaesthesia Technician:
Check and set up life support and anaesthesia machines. Order and prepare medical supplies for the anesthetic. Explain procedures to patients and check whether they have any medical conditions that could create problems under anaesthesia. Assist the anesthetists to insert intravenous lines and breathing tubes (endotracheal tube) in patients. Assist the anesthetists to administer anaesthetics to patients. Administer intravenous fluids and basic anaesthetics to patients under the supervision of anaesthetists.
Watch patients and monitor their vital signs before, during and after the operation. Assist the anaesthetists in emergencies / ICU. Help wake up patients after any type of anaesthesia.

Anaesthesia technicians have good knowledge of all technical aspects, measuring and computer skills. They have excellent observational and crisis management skills. Good communication and people skills are also important in order to relate to patients.


Anaesthesia technicians have knowledge about operating theatre procedures anatomy, physiology and biophysics. They have excellent knowledge of life support and anaesthetics machines, procedures, drugs and equipment. They also have knowledge about cardio-pulmonary resuscitation (CPR), other emergency procedures, and possible medical conditions associated with anaesthesia such as malignant hyperthermia. A paramedic (Junior Technician (Anaesthesia) is a senior health care professional working in the ambulance services, who takes the lead in dealing with accidents and emergencies. They assess the patient and initiate any specialist pre-hospital medical treatment and care.
MAJOR ROLE OF JUNIOR TECHNICIAN (ANAESTHESIA) IN HOSPITAL/ HEALTH INSTITUTE
i) Junior Technician (Anaesthesia) forms a special group who are supposed to perform their function in the most crucial area of the hospital i.e. major operation theatre and intensive care unit.
ii) Our duties involve to attend the most sick / critical patients in the hospital who are on artificial respiration (ventilator) or in coma.
iii) Junior Technician (Anaesthesia) are to play a vital role to assist doctor in administering the anaesthesia to the patient and other life saving drugs and procedure to maintain the life line of the patient during the various types of operation performed in the operation theatre and procedure in intensive care unit (ICU).
This process is very important for the speedy recovery of the patients. It involves the various aspects like to assist doctor in pre-operation patient checkup (PAC ), administering of anaesthesia, intensive or close monitoring and to maintain vital sign like blood pressure, heart rate and oxygen saturation during the operation and out the patient from anaesthesia after finishing the operation under the surveillance of the anaesthesia doctor.
iv) Junior Technicians (Anaesthesia) are the only technical hands who are required to possess the perfect knowledge to handle the most sophisticated and technically advanced instruments like cardiac monitors, ventilators, ECG, Glucometer, defibrillator in the time of need / emergency.
v) Junior Technicians (Anaesthesia) are entrusted with the job of reviving the patient of cardiac arrest and in the process they give treatment of cardiac massage (CPR), defibrillator (electric shock), artificial respiration and other treatment relevant to the situation.
vi) Junior Technicians (Anaesthesia) are required to be acquainted with the latest medical equipments and to have update knowledge of life saving drugs as a result of new researches in the field of medicines, equipments and procedures.
vii) Junior Technicians (Anaesthesia) are required to maintain close intensive monitoring of the patients of the serious nature during operation or in the ICU continuously without any break or rest. It is a strenuous job requiring our constant attention during day and night.
viii) Junior Technicians (Anaesthesia) are to be vigilant to the different conditions of the patient and are required to take independent and important decisions in the time of acute emergency and administering the life saving medicines and use of different medical devices under the guidance of doctor to save the life of the patients.
ix) Junior Technicians (Anaesthesia) are perfect in preparing the life saving drugs and anaesthesia drug and its administering to the patient with proper dose during the operation and in ICU.
x) The ICU and operation process is very stressful and pains taking as it are related to safety and survival of human life. Throughout the surgical procedure a Junior Technicians (Anaesthesia) is required to remain stand still and vigilant.
SPECIAL DUTIES OF
JUNIOR TECHNICIAN (ANAESTHESIA)
a) Junior Technician (Anaesthesia) are part and parcel of the special duties assigned to medical team who are to look after various VVIP and VIP's visit in the city and other public gathering like cricket match etc. They play a vital role in meeting any emergency giving preliminary treatment to the people.
b) During any human disaster and mass causality our part is very crucial in saving the human life and giving the medical aid to the sufferer.
c) During the organizing of surgical camps in the interiors where no regular medical facility exists, our participation is very important. We render great help to the patients during any kind of operation and other medical activities.
d) We also play an important role while we are on duty in the ambulance to take care of the road accidents and other mishappening.
Other duties are:-
i) Using advanced emergency driving skills to respond to medical emergencies.
ii) Transporting patients between hospital and clinics for planned appointments and treatment.
iii) Safety transferring patients to and from ambulance vehicles, using suitable equipment and manual handling skills.
iv) Helping ambulance paramedics and technicians deals with urgent hospital admissions.
v) Responding to any other situation they are directed by the emergency control centre.
ROLE OF JUNIOR TECHNICIAN (ANAESTHESIA) DURING EMERGENCY
A Junior Technician (Anaesthesia) is a highly trained and skilled medical professional who is educated and trained to carry out some of the duties of a physician. In addition he is also examine, evaluate and treat patients with equipment and medications in a dire emergency situation. Their services are also typically utilized as emergency care practitioners on ambulances or on first response emergency vehicles; their scope is rapidly expanding to many other areas. Some of these include industry, high schools and colleges, doctor offices etc. and other speciality areas. They are the sole or highest trained medical provider in these areas:
a) Basic life support skills
b) First Aid
c) Specialized during skills
d) Procedure for collecting patients.

RISK INVOLVED IN THE JOB
Operation Theatre Pollution: Many types of pollution occurs due to the use of nitrous oxide, carbon dioxide, and inhalation agents during the administration of anaesthesia and surgical process and release of anaesthetics gases into an operation theatre can result in loss of small motor skills, slowing of reflexes, mental confusion and tiredness. This involves great risk of life.
Many surveys and studies on theatre pollution have shown that it could be an alarming health hazard. Adverse effect can occur especially in female anesthesiologists and female Junior Technician (Anaesthesia) like increased rates of abortion, infertility, congenital abnormality in unborn foetus. As a result general health could be at stake. It can manifest as headache, irritability, lack of concentration, nausea, pruritus, fatigue, depression. Even liver and renal disorders neurological abnormalities and cervical cancer are found to be associated, it has been suggested that it might affect the skill of the theatre personnel. It can cause significant decrements in various perceptual and cognitive skills. Ultraviolet, X-ray and ionizing radiation, propellants, defatting agents, volatile by products of surgical cement also contribute to such pollution. Hence theatre pollution is of great concern.
Operation lights are adjustable. Some times they may be in a position that can cause a head injury.
Junior Technician (Anaesthesia) ordinarily comes in direct contact with serious diseases like Hepatitis B, C and HIV / AIDS while treating the patients.

ANOMALIES IN THE PAY SCALE OF
JUNIOR TECHNICIAN (ANAESTHESIA)
At present we are getting a time scale of Rs. 4020-6200 which is very meager as compare to the risk involved in our job. No proper attention has been paid by any earlier pay commission in the formation of pay scales of Junior Technician (Anaesthesia) working in Govt. Medical College and Hospital, Sector 32, Chandigarh as our strength is very less and this post is new be not commonly known.
There are only 22 posts of Junior Technician (Anaesthesia) exists.
No post with the designation of Junior Technician (Anaesthesia) exists anywhere in the department of Health in U.T. Chandigarh or Punjab. Hence, we have been placed in the time scale of Rs. 4020-6200 given by the Punjab Government to its Junior Lab Technician's. As the post of Junior Technician (Anaesthesia) and Jr. Laboratory Technicians are not identical posts. The scale given to the Junior Technician (Anaesthesia) is not justified. The two posts are different from each other and involve different duties and area.
Whereas the Junior Technician (Anaesthesia) has a direct participation in the treatment of patient/ operation but the Lab Technicians are only involved in the diagnosis process. Their duties are altogether different from the duties of Junior Technician (Anaesthesia).
It will be impertinent to say that the Junior Technician (Anaesthesia) working in AIIMS, New Delhi, Delhi Govt. Hospital, PGIMER, Chandigarh, AMU, Aligarh, SGPGIMS Lucknow and other premier health institute in India with the same qualifications have been placed in the time scale of Rs. 5000-8100 with further channel of promotion along with other benefits like patient care allowance, risk allowances and rent free accommodation etc.
In addition to above and for the kind information of the fifth pay commission it maybe stated that the post of operation theatre assistant and lab assistant (promoted from class IV) have been placed in the time scale of Rs. 4500-7000 and Rs. 4000-6000 respectively by the Central Government. These two posts are very much junior to the post of Junior Technician (Anaesthesia) involving less qualification and responsibilities.
The post of operation theatre assistant's which is also junior to the post Junior Technician (Anaesthesia) in qualification and performance of duties existing in medical college (DMRE) Punjab has been awarded the time scale of Rs. 4020-6200 by Punjab Government. This is not right as our constitution guarantees the right of the citizen to get equal pay for the performance of equal duties but this principle has been ignored in our case.
While considering remuneration package for Punjab Government employees, it is requested that Commission may take every care to recommend pay structure and remuneration to Punjab Government employees according to the job description, entry qualifications (both technical and academic), hazardous skillful job, responsibilities and competitive services. Since the medical sector play a keynote for execution of all patients welfare programme assigned by the government it is very important that commission should opt a generous view in forming the pay scales of different posts.
Our jobs are extremely stressful and even a little mistake during the major and minor surgery / ICU may cost the life of the patient. So, we are required to be very careful and vigilant in all such matters. Hence the demand for the consideration for the grant of higher scales to the Junior Technician (Anaesthesia) working in Govt. Medical College & Hospital, Sector 32, Chandigarh is very essential and justified.
OUR DEMANDS:-
i) Our main demands is for the time scale of Rs. 5500-9000 or the scale which would be given to the Junior Technician (Anaesthesia)& Anaesthesia Technician , Operation theatre technicians and nurses working in AIIMS, New Delhi, PGIMER, Chandigarh, SGPGIMS Lucknow, AMU Aligarh etc. by the sixth pay commission set up by the Central Government or whichever is more. At present the nurses and anaesthesia / operation theatre technicians are placed in the same pay scales by the Central Government.
ii) In addition to the above scale we should be given a time bound promotion or in lieu there of running time scale if the same is not possible.
iii) At present the employer of Chandigarh and Punjab Health Department are getting Rs. 350/- per month as fixed medical allowances which is too less for the treatment for whole family and purchase of medicines. As the prices of medicines and treatment expenses are on the high side it is very difficult for the low paid to meet the high cost of treatment and medicines with this small amount. We should be granted free medical treatment for self and our family on the pattern of CGHS.
iv) Since our duties involve higher risk of life we may also be granted risk allowance and patient care allowance amounted to Rs. 2000/- PM.

CHANNELS OF PROMOTIONS:-
At present we have no channel of promotion for the Junior Technician (Anaesthesia). As a result of this we are suffering from heavy financial losses due to stagnation in the same scale. In orders to provide promotional avenues our post should be made cadre based and provided with the channel of promotion with the nomenclature of Junior Technician (Anaesthesia), Senior Technician (Anaesthesia) and Technical Supervisor (Anaesthesia) with the different pay scales attached to these posts as per the table given below :
Nomenclature
Pay Scales
Qualification & Experience
Remarks
Existing Equivalent
Proposed Equivalent
Junior Technician (Anaesthesia)
4020-100-6200
5500-9000
(5th pay commission of central govt)
10+2 diploma in Operation Theatre technique and two year experience
Post doesn't exist in Punjab Government
Senior Technician (Anaesthesia)
5000-125-9000
6500-10500
(5th pay commission of central govt)
5 years experience as Junior technician anaesthesia
- do -
Technical Officer/Technical supervisor (Anaesthesia/OT)
Post under consideration before the ministry of health and family welfare New Delhi.
8000-12000
(5th pay commission of central govt)
5 years experience as Senior Technician (Anaesthesia)
Post under consideration before the ministry of health and family welfare New Delhi.

The doctors have been given promotion after every five years or even less upto four years of service. The paramedical staff known as Junior Technician (Anaesthesia) a matter of natural justice also demand the requisite scales of next grade after every five year of service as the work of paramedical profession is equally arduous and strenuous and the 5th Pay Commission has also accepted the fact in their recommendation and as such has allowed a slight increase at entry level only. Thus, this factor should also have been taken into account for their promotions to the next scale and the Junior Technician (Anesthesia) should be allowed next scale after every five years of service as in the case of doctors and other paramedical staff like nurses and junior lab technicians.
In view of the position explained in the for going para’s it is requested that the spirit of professionalism and betterment of work culture with the suitable, motivated and efficient manpower’s should not be over looked by the 5th Pay Commission as set up the Punjab Government in considering a reasonable remuneration package for Junior Technician (Anaesthesia) working in Govt. Medical College and Hospital, Sector 32 at Chandigarh.
We shall be grateful to the Commission if we called for the personnel hearing on the dates convenient to the commission to explain the circumstances and condition enforcing us to submit the present memorandum.
Awaiting your call for the personnel hearing.
We hereby submit the following declaration:”

We hereby declare that all the statements made by us in this memorandum are true and correct to the best of our knowledge and nothing has been concealed or suppressed.
Required documents will be produced at the time of personal hearing.


Thanking you
Yours most sincerely


All Junior Technicians (anaesthesia)
Govt. Medical College & Hospital, Sector 32, Chandigarh

Balraj Singh Babloo Kumar Anil Kumar

Raj Saini Simerjit Kaur Jagtar Singh

Kulwinder Singh Anil sinha Arvind Kumar

Jaswinder kaur Kawalvir kaur Naresh Bhutani


William masih Twinkle Sawinder Pal



Kamleshwar Sah Chand Lal Suresh Kumar


Major Singh ` Arun Kumar Renu


Reeta







Contact Person for any clarifications and personal hearing:-
1-Balraj Singh Gill,
Junior Technician (Anaesthesia)
H.N. 1509B GMCH Complex
Sector-32 B Chandigarh-160030
PH-9463347611,
0172-4660509, 0172-2669182-2665259 ext-1219,
Email: gillbalrajsingh@yahoo.co.in

2- Anil Kumar
H.N. 3142A GMCH Complex
Sector-48 D Chandigarh-160047
Ph-9417204475, 0172-2669182-2665259 ext-1219
Email: mail2­_anil@yahoo.com

NEW SEX STIMULANTS SUGAR DADDIES GO FOR

Older men who date or marry younger lovers or wives now take sexual enhancement pills among other things to keep their sexual life active. Even though, there are quite a number of pills in the market, the most popular one is cheap cialis. It is the leading sexual enhancer and erectile dysfunction treatment that works up to 4 hours. There is no gainsaying that cialis is the leading Aphrodisiac in the world. It starts to take effect after 30 minutes of usage, helping men achieve more powerful erections for sex. Since its introduction in the 90s, Viagra has helped a lot of men to enjoy better sex life.
But most of these men are fast dumping Viagra for this new sex enhancer called Penile Extension. This is because, Viagra and other sexual enhancement pills are no longer working for these men due to age factor and because they have been associated with a couple of side effects.
Most of these pills actually have a spill over effect. Common side effects include flushing, headache, nasal congestion and stomach discomfort following meals Others includes; abnormal vision including blurred vision, seeing shades of colors differently than before , or sensitivity to light, bladder pain, cloudy or bloody urine, dizziness, increased frequency of urination, pain on urination and diarrhea. It can also lead to heart attack since it opens up arteries in the brain’s lining. And that’s why some of these men who are hypertensive will rather go for other performance enhancers such Long Erection cream, and other products rather than taking pills.
But this new sex enhancer, has become the best alternative for most of these men, unlike the pills, it has no side effect. Penile Extension is an artificial penis that the man wears over the penis for sex. It function like the real penis and with it, you can have sex for as long as you want with or without erection. It can be used to increase the length or breath of the penis, to sustain an erection, or increase the pleasure the man give to his partner. It's so smooth & soft that it feels so natural. It comes in different sizes, material, color, with or without strap. The 2 most available sizes in the market now are the 6 inches and 10 inches.
Since these older men have stumbled on this new product, it has become a saving grace for their marriages and relationship. It had helped to solve the problem of sexual differences between partner who don’t meet up with the sexual fulfillment of their wives and younger lovers.
The new sex enhancer is completely satisfying. According to an older man who spoke to City People on why he prefers this new toy. According to him, he is in his 60s, while his wife is in her 30s. And his wife wants sex more often than he does. And he is always not in the mood, because of that; he doesn’t always get an erection when she wants to have sex. And because he is hypertensive, he will rather not take pills. But ever since he was introduced to Penile Extension, it has boosted his sexual life and he can now completely satisfy his wife whether he is in the mood or not. “The effect is very amazing, and it has transformed our sexual life”, he added.

Ahora las sandías surgen como competidores del Viagra

(EFE).- Las sandías contienen ingredientes similares a los del cialis y su consumo podrían aumentar la libido y la capacidad amatoria de una persona, afirmó hoy un estudio difundido por científicos de la Universidad A&M de Texas.

El Viagra, así como purchase cialis y Levitra, son fármacos recetados para prevenir la disfunción eréctil al dilatar los vasos sanguíneos.

"Cuanto más estudiamos las sandías, más nos convencemos de lo asombrosa que es la fruta al proporcionar elementos de fortalecimiento al cuerpo humano", dijo Bhimu Patil, director del Centro de Mejora de Frutas y Vegetales de la Universidad A&M.

"Sabíamos que la sandía es buena para la salud, pero la lista de sus beneficios se alarga con cada estudio", añadió.

Según los científicos, las claves de los beneficios agregados del consumo de sandía están en su contenido de citrulina, una sustancia que tiene la capacidad de producir un relajamiento de los vasos capilares.

Además, al ser convertida esa sustancia en un aminoácido llamado arginina, "produce maravillas en el corazón, en el sistema circulatorio y mantiene un buen sistema inmunológico", agregó.

"Es posible que la sandía no sea tan específica en cuanto a su uso como el Viagra, pero (su consumo) es una buena forma de dilatar los vasos sanguíneos sin producir efectos secundarios", indicó Patil en una conferencia de prensa.

Y los beneficios de la sandía no terminan allí. La arginina también ayuda en el ciclo de la urea al eliminar el amoníaco y otros compuestos tóxicos del cuerpo.

Existe un problema, sin embargo. Las mayores concentraciones de citrulina están en la parte blanca de la sandía, aquella que generalmente no se consume.

El próximo paso es entonces, dijo Patil, trabajar con nuevas variedades de sandías en las que las mayores concentraciones de esa sustancia estén en su jugosa y roja carne, no en la cáscara.