Some disagreements are serious, others are footling. There are two disagreements about dreaming. They concern the questions ‘Do we wake or dream?’ and ‘Should we have confidence in dreams or in waking experience?’. The answer, said the Sceptics, is in each case: ‘Who knows?’. According to Galen, the sceptics aren’t serious, and no-one is genuinely puzzled by the questions — the disagreements are of the footling sort. That is true, and philosophically uninteresting. But the sceptical arguments which have exercised philosophers are, as Galen suggests, trifles; and in this case at least it is not difficult to let the fly out of the fly-bottle.

Key Learning Points

1. 1. Ultrasound guidance can, in trained hands, improve success of venous cannulation in difficult patients.

2. 2. Different techniques exist, with none clearly superior to the other.

3. 3. Find a technique that works for you and stick with it.

4. 4. An understanding of vascular anatomy is essential to successful cannulation.

5. 5. Differentiating between arteries and veins can be done in various ways and is an essential skill.

Key Learning Points

1. 1. Patients with epidurals need careful and close monitoring.

2. 2. It is the dose of local anaesthetic, not the volume, that is of most importance in ensuring adequate analgesia.

3. 3. If the block is too low or absent, try topping up the epidural before removing it.

4. 4. If the block is too high or off to one side, try changing the patient’s position to use gravity to help you alter the block.

5. 5. Always be wary of the hypotensive patient with an epidural. Do not assume it is always down to the epidural, but rather rule out other possible causes.

Key Learning Points

1. 1. A Sengstaken–Blakemore tube (SBT) should only be employed as a rescue technique.

2. 2. In practice, the four-lumen Minnesota tube is often encountered, not a classical SBT. However, insertion and aftercare are the same.

3. 3. In most cases, only the gastric balloon will need inflating.

4. 4. Monitor pressures regularly, and be careful to avoid complications.

5. 5. An SBT is only a temporising measure, and having inserted one, it is vital to make a definitive management plan early.

Key Learning Points

1. 1. A lumbar puncture (LP) is a useful and extremely valuable investigation and should always be considered early.

2. 2. LPs carry a morbidity risk, and patients should be screened for contraindications before performing the procedure.

3. 3. Performing an LP in the sitting-up position is likely to be easier than in the lateral position; however, it does prevent all the tests from being done and may not be as well tolerated by the patient (particularly the acutely meningitic patient).

4. 4. The risk of post-dural puncture headache can be minimised by using the smallest possible ‘non-cutting’ needle.

5. 5. Ensure to send all samples that may be required and do not forget a paired serum glucose.

Key Learning Points

1. 1. Abdominal drains should be inserted under ultrasound guidance.

2. 2. Use the ‘Z-track’ technique to minimise complications.

3. 3. Pay attention to volume replacement, particularly in the critically unwell patient.

4. 4. Antibiotic administration should not be delayed in cases of suspected spontaneous bacterial peritonitis.

5. 5. Differentiating transudative from exudative ascites is achieved by calculating the serum–ascites albumin gradient.

Key Learning Points

1. 1. There are different types of tubes for different indications.

2. 2. For ease of insertion, keep the tubes in the fridge, ensure good lubrication and optimise head positioning.

3. 3. Use the pH of the aspirate, and/or a chest radiograph, to check positioning.

4. 4. On a chest radiograph, a correctly sited nasogastric tube should pass down the midline and bisect the carina, before passing below the diaphragm.

5. 5. If initiating nasogastric feeding, start thinking about long-term feeding plans early, as in practice, these can take a while to sort out.

Key Learning Points

1. 1. Clear British Thoracic Society guidelines exist for optimal management of a pneumothorax.

2. 2. Different techniques exist for chest drain insertion, each with its own advantages and disadvantages.

3. 3. Chest drains must be secured adequately, otherwise they will fall out.

4. 4. Be careful to avoid re-expansion pulmonary oedema.

5. 5. Always send samples if a fluid is drained.

All medical procedures, be they therapeutic or investigative, touch on the issue of consent – that is a measure of willingness on the part of the patient to undertake the procedure proposed. In this, ECT is no different to other therapeutic interventions. However, ECT has a particular status both within psychiatry and within the law that makes specific discussion of issues with regard to consent necessary.

General issues regarding consent

Electroconvulsive therapy is unusual in that consent obtained is for a course of treatments rather than for an individual procedure. It is also customary that the person seeking the consent will not be the person giving the treatment. The fact that the person receiving treatment has a psychiatric disorder sufficiently severe for ECT to be considered raises questions about their capacity; this makes it particularly important that consent is properly obtained and valid. It is unlawful and unethical to treat a patient who is capable of understanding the nature of any procedure, its purpose and implications, the anticipated benefits and any reasonably foreseeable adverse effects without first explaining it. The patient must then agree. Even if patients choose not to be informed of the full details of their diagnosis and treatment, they must be given the option of receiving this information. Guidance on good practice in consent can be found in publications from the Department of Health in England and Wales (2009), the Department of Health, Social Services and Public Safety in Northern Ireland (2003) and the Scottish Executive (2006), as well as from the General Medical Council (2008).

Obtaining valid consent should be considered a process rather than an event and it is necessary for patients to be given an adequate length of time to consider the benefits and drawbacks of the proposed treatment before making an informed decision. Patients should be informed of the risks and unwanted effects of ECT (Chapters 7–9) and they need to realise that a general anaesthetic is involved. If there are specific anaesthetic risks, the anaesthetist should explain these and obtain the necessary consent.

It is helpful for patients and carers to be provided with information obtained from different sources. Written information sheets may be useful (e.g. Appendix V); these need to be accompanied by the opportunity to discuss issues with members of the therapeutic team, family members, carers, advocates, etc.

Introduction

The concept of literacy has become a well-used term of late, applied to over 30 areas of study and practice, ranging from the functional (financial, digital) to the description of current trends (emotional, environmental) and the more abstract (philosophical, critical). Like many of these, religious literacy is an attempt to define and modernise a pursuit for understanding our world that is as ancient as creation stories. In this chapter we look at one such traditional model – at once ancient and yet new in the sense that it seeks to renew and re-energise one of the most important of contemporary debates.

The chapter is divided into three sections. The first articulates the ancient philosophical concept of lokahi from its Hawaiian roots to its post-modern relevance. The second engages with four key aspects of the definition of religious literacy as proposed by Dinham and Jones (2010), and proposes a contested definition of religious literacy as lokahi, in response. The third presents three case studies of religious literacy in practice in different professional contexts and continents. A brief conclusion brings us back to the ‘new’ contribution that an ancient tradition can offer to the contemporary world.

Concept of lokahi

The Lokahi Foundation, like many interreligious organisations that have sprung up in the UK in recent years, aims to deepen public understanding of religion and increase its sophistication. Most agencies recognise that the promotion of religious literacy as a civic practice, while neither simple nor straightforward, is primarily a matter of broadening the sense of human religiosity as a significant phenomenon for all spheres of modern society. Lokahi, however, is distinctive in seeing religious diversity not as a problem to be managed but as an inevitable and rich source of human diversity. In probing the foundations of religious beliefs and values of all kinds, lokahi begins with the conviction that diversity is inherent in individuals and communities of faith. The task is not to elide but to value difference and embrace it as part of working with others for the common good.

Simply put, the concept of lokahi means ‘harmony through diversity’. It draws on and weaves together a number of ideas. The most remote, yet arguably the most important, is the religious culture of Hawaii and, quite literally, the Hawaiian geology and the volcanic landscape that supports it.

All medical procedures, be they therapeutic or investigative, touch on the issue of consent – that is a measure of willingness on the part of the patient to undertake the procedure proposed. In this, ECT is no different to other therapeutic interventions. However, ECT has a particular status both within psychiatry and within the law that makes specific discussion of issues with regard to consent necessary.

General issues regarding consent

Electroconvulsive therapy is unusual in that consent obtained is for a course of treatments rather than for an individual procedure. It is also customary that the person seeking the consent will not be the person giving the treatment. The fact that the person receiving treatment has a psychiatric disorder sufficiently severe for ECT to be considered raises questions about their capacity; this makes it particularly important that consent is properly obtained and valid. It is unlawful and unethical to treat a patient who is capable of understanding the nature of any procedure, its purpose and implications, the anticipated benefits and any reasonably foreseeable adverse effects without first explaining it. The patient must then agree. Even if patients choose not to be informed of the full details of their diagnosis and treatment, they must be given the option of receiving this information. Guidance on good practice in consent can be found in publications from the Department of Health in England and Wales (2009), the Department of Health, Social Services and Public Safety in Northern Ireland (2003) and the Scottish Executive (2006), as well as from the General Medical Council (2008).

Obtaining valid consent should be considered a process rather than an event and it is necessary for patients to be given an adequate length of time to consider the benefits and drawbacks of the proposed treatment before making an informed decision. Patients should be informed of the risks and unwanted effects of ECT (Chapters 7–9) and they need to realise that a general anaesthetic is involved. If there are specific anaesthetic risks, the anaesthetist should explain these and obtain the necessary consent.