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of blown ber techniques in which the cable is pushed, not pulled, using air ow. A typical such mechanism is shown in Figure 4.8. In earlier installations, the compressed air propelled a bobbin down the duct, which in turn pulled the ber attached to it. It was then realized that the concentrated strain on the leading portion of the ber could be reduced considerably by manufacturing the ber jacket with dimples in it to transfer the air ow forces into a completely distributed pulling force on the ber. Such dimpled ber cable is now widely available. For ve 5- to 8-mm inner-diameter subducts, up to 12 SMF or MMF bers can be blown simultaneously down each one. Blowing distances between manholes or other points of access of up to 1000 m are now routinely available, and ber installation can take as little as 90 min. Fiber can also be blown vertically, as is necessary in tall of ce or apartment buildings. Vertical blowing distances up to 300 m have been reported [Blolite]. One interesting wrinkle is that ducts and subducts can be pressurized so as to provide security alerts in case tampering or tapping is attempted.

In the step from i to (i + 1) the clique with attribute set Mi+1 is added to Gi . If we can show that Mi+1 Si pU Ui Si | Si , where Si = Mi+1 Ui ,

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Dennis does not start at the green layer, but with the blue core His analysis goes like this He sets out to consider each blue box in turn, to see how it relates to the case in question He begins with create autonomy, and decides there is no question that the autonomy of both Michael and Caroline is being impeded by the supervisor s decision The requirement to create autonomy by removing obstacles from people s physical and intellectual paths, to enable them to take greater charge of their own destinies, is a foundational feature of health work The question is: can the impairment of two people s autonomy be justi ed, either by pointing to greater future autonomy gain, or by showing that the beliefs and wishes of Michael and Caroline are somehow de cient, or both.

A model for conceptualizing individuals or couples we treat appears in Table 6.1. The model helps focus on the dimension(s) most likely to foster change as quickly as possible.

1. Check that the patient s airway is clear, that breathing is satisfactory, and that the patient s colour is good. 2. Assess the level of coma, looking at vital functions, pupils and items of the Glasgow Coma Scale as mentioned above. 3. Try to establish the cause of the coma by taking a history from relatives or witnesses, physical examination and appropriate tests. It is obviously important to have the common causes of coma (A, E, I, O, U) clearly in one s mind whilst questioning, examining and ordering investigations. 4. Remember the danger of lumbar puncture in patients in whom coning is imminent or present (see p. 44). Reduction of the CSF pressure below the foramen magnum may encourage further downward herniation at the tentorial or foramen magnum level, so no lumbar puncture if papilloedema is present, or until a head scan has excluded a mass lesion or any brain swelling. 5. Treat the speci c cause of the coma as soon as this is established, e.g. anticonvulsants for epilepsy, antibiotics for meningitis, intravenous glucose for hypoglycaemia, speci c antagonists for speci c CNS depressant drug poisonings. 6. Establish the routine care of an unconscious patient regardless of the cause (Fig. 11.7). (a) Observations: assessment every 15 30 minutes of vital functions, pupils and Glasgow Coma Scale, to monitor improvement or deterioration in the patient s condition. (b) Airway, ventilation, blood gases. (c) Blood pressure, to maintain adequate perfusion of the body, particularly of the brain and kidneys. (d) Fluid and electrolyte balance. (e) Nutrition and hydration. (f) Avoidance of sedative or strong analgesic drugs. (g) General nursing care of eyes, mouth, bladder, bowels, skin and pressure areas, passive limb mobilization to prevent venous stagnation and contractures, chest physiotherapy.

In this case the ideas of creating and respecting autonomy are not far apart Unless their beliefs can be shown to be clearly mistaken it can hardly be denied that Michael and Caroline s choices are not being respected As he considers the box respect persons equally it becomes clear to Dennis that this is the key consideration He thinks that neither Michael nor Caroline are being afforded the basic respect due to persons Caroline in particular is being abused To use Kant s terminology, she is being used as a means rather than an end She is not being treated as a person, but as an object She has been used to train the health visitor Her personal circumstances and needs are immaterial (indeed they always were to the supervisor), all that was necessary was that somebody was available to allow Michael to develop health visiting experience.

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