Subcapsular Orchiectomy Under Local Anaesthesia Nursing Essay

Subcapsular Orchiectomy Under Local Anaesthesia Nursing Essay Prostate cancer underwent bilateral subcapsular orchiectomy at our Hospital. In every patient, we performed orchiectomy under spermatic cord block by injection of 8-10 ml anaesthetic mixture (1% lignocaine and 0.25 % bupivacaine hydrochloride) to each spermatic cord and infiltrate at skin incision site. During the operation we monitored blood pressure, pulse rate, and record abnormal symptoms such as abdominal pain, nausea, vomiting and pain score of the procedure was assessed at the end of the operation. Results: 96 patients underwent operation under local anesthesia, 91 patients tolerate the procedure well, while other 5 patients converted to general anaesthesia due to severe pain. 5patients developed scrotal hematoma, 2 patients developed infections one of them is admitted to control because the need for dressing and debridement Conclusion: Day case bilateral subcapsular orchiectomy in patient with advanced prostate adenocarcinoma under local anaesthesia is simple, save and coast effective Key words: Subcapsular orchiectomy, bupivacaine, lidocaine Correspondence should be addressed to:- Dr Awad Kaabneh. Tel +96277414388. email :- [emailprotected] P.O.POX:-Jordan-Mdaba 11710-986 Introduction: Huggins and Hodges (1941) described the androgen dependent nature of prostate cancer by the observation that surgical castration resulted in prompt relief of pain in patients with bone metastatic prostate cancer, and since that time hormonal manipulation in the treatment of prostate cancer has evolved(1,2, 3). Prostate cancer is the most frequent visceral malignancy and the second leading cause of death in American men. It has been estimated that approximately 184 500 new cases will be diagnosed and over 39 200 men will die from prostate cancer in the United States in 1998 (3, 4, 5, 6). The annual Medicare expenditure for prostate cancer is approaching $1.5 billion, of which a large portion is spent on androgen deprivation therapy. Androgen deprivation therapy can be achieved medically using luteinizing hormone releasing hormone (LH-RH) agonist or surgically by bilateral orchiectomy. While the two approaches have similar efficacy, medical therapy is significantly more expensive than surgical therapy (4, 7, 8). The trend towards day case surgery in many countries is increasing (9); it is an efficient way of using resources and reducing waiting lists. Intrascrotal operations are particularly suitable for day case surgery (2, 3, 7, 9). Regional block techniques have been used for minor urological procedures and one such technique is spermatic cord block (2, 3, 7, 9). This is a simple, cost-effective technique suitable for adults undergoing intrascrotal surgery. It is particularly appropriate when the patient is considered a poor risk for general anaesthesia (9, 10, 11, 12, 13). We report our successful experience with local anaesthesia for a series of 96 patients undergoing a bilateral Subcapsular orchiectomy in Prince Hussein Urology Center Materials and Methods: Of 96 patients from April 2004 October2008 who were diagnosed prostatic cancer. They were nonlocalized prostatic cancer or physical status not suitable for radical prostatectomy surgery. We excluded patients who were allergic to bupivacaine hydrochloride, or having severe hypertension, recent MI, unstable angina, uncorrected bleeding disorder, paraplegia and neuro- sensory deficit. During the pre-operation we explained to the patient the procedure and provided anesthesia only on the scrotal content and scrotal skin at the incision site; he would feel some pain initially during the injection of anesthetic agent, and he might have some abdominal discomfort during the cord manipulation, and postoperatively he could ambulate immediately .The patient was not allowed to take anything by mouth after midnight before the procedure. Every patient was given an intravenous line and an anaesthetist was on stand-by to give anesthesia if spermatic cord block did not work. The scrotum is prepared by pre-operative shaving and is cleansed using 10%povidone -iodine solution and draped in sterile fashion .The anaesthetic agent is a mixture of 1%lidocaine and 0.25 % bupivacaine hydrochloride was selected, the patient was in supine position. The pubic tubercle is palpated; the cord was trapped between the index and middle fingers of the surgeon; 1 cm below and medial to the tubercle was the injected point, infiltrate at skin and pass the needle vertically down to the anterior aspect of the pubic bone. In it course the needle, thus passes through the spermatic cord, 8 -10 ml of anesthetic solution is injected through the cord at slightly different angle and the needle entering the blood vessel be aware of. The instilled volume of anaesthetic solution causes visual ballooning of the grasped segment of the spermatic cord; this bulge is then gently squeezed between the thumb and index finger to disperse the anesthetic fluid within the spermatic cord. After the spermatic cord was blocked the skin at the incision site was infiltrated with 3-5 ml anesthetic fluid, 3 -5 minutes before the start of the operation so that drug became effective. Orchiectomy was performed in the midline raphae incision with epididymis sparing fashion to create a round structure mimic a small testis for cosmetic result. A longitudinal incision is made through the tunica albuginea of the testis along its free border, exposing the seminiferous tubules. The internal contents of the testis are quickly freed from the side walls by gentle squeezing the outside of the capsule. This is the most sensitive part of the procedure but if discomfort is experienced, more anesthetic fluid can be injected directly into the cord. The tubules can be disconnected at the testicular hilum using scissors. Any tissue remaining on the inside of the capsul e is removed and meticulous haemostasis is established by diathermy. The capsule is resutured with a continuous layer of 3 vicryl. The procedure is repeated on other side through the same skin incision and the wound closed using 3 vicryl to the tunica vaginalis and covering layers, and 4 subcuticular dexon to the scrotal skin. The procedure is completed by local dressing, a large gauze pressure pad and a scrotal support to prevent haematoma formation. During the operation, the patient was monitored and blood pressure, pulse rate and abnormal symptom were recorded; when surgery finished the patients pain score of the procedure (including pain of anaesthetic injection) was assessed immediately by using visual analog pain scale (0 = no pain, 5 = moderate pain and 10 = worst possible pain) . At 1-week follow-up, the patients symptom and wound were evaluated again. Discussion: An LHRH agonist is the preferred first option to treat patients with advanced prostatic cancer. However, clinical studies have suggested that an orchiectomy is superior to an LHRH agonist in that it more rapidly achieves castrate levels of testosterone, avoids the testosterone flare, is less expensive, and has superior therapeutic compliance (1, 8, 10, 14). If there were a castration procedure that did not adversely affect life satisfaction and the male image, this option might become more frequently recommended and chosen. Several attempts have been made to achieve this goal. In 1942, Riba pioneered the subcapsular orchiectomy, a procedure that involved the removal of the testicular parenchyma and the simple closure of the tunica albuginea (10, 13, 16, 17, 19). No difference was observed between patients who underwent a bilateral total orchiectomy and a subcapsular orchiectomy in preoperative and postoperative testosterone or luteinizing hormone levels( 5,17,19).Most importantly, serum PSA and 3-year survivals for patients undergoing a bilateral total orchiectomy and a subcapsular orchiectomy were determined to be similar (3,10). The technique of spermatic cord block is base on the anatomy 🙠 2, 3, 4, 18) .as the cord emerges from the external ring, it passes over the pubic tubercle and the shifted medially to the scrotum. In this region it is closely associated with the ilioinguinal nerve and the genital branch of genitofemoral nerve, which supply the testis and its covering, the epididymis and the vas deferens but not the scrotal skin. The scrotal skin receives sensory supply from the pudendal nerve and the perineal branch of the posterior cutaneous nerve of the thigh; therefore it needs to be infiltrated with the anesthetic agent separately from spermatic cord block (5, 9, 11, 12). Good result of spermatic cord block facilitates a successful orchiectomy. No complication related to anesthesia was detected in the series. The advantage of spermatic cord block is its short time of recover, low cost and may be performed in patient who has high risk of anesthesia (7, 11, 14, 18). 10 patients numbered thei r visual analog pain scale 10. Five had underlying anxiety disorder, while the other 5 one had severe pain that needed to be converted to general anesthesia which might have caused by his obesity (BW 86.5 kg, HT 165 cm, BMI 31.77 kg/m2; mean BW = 62.55 kg; patients who had success operation whose BW was in the range of 45 68 kg). other 4 patients have huge inguinal hernias that also make procedure more difficult .Obesity made it difficult to palpate the cord and inject anesthetic agent to the correct point, so the spermatic cord block did not work well. Three patients had bradycardia (pulse rate = 50|min. 49|min.54/ min) which might due to his vagovagal reflex when the cord was under traction; however they developed no other symptom or hypotension. Intrascrotal procedures can be performed easily with spermatic cord block rather than general anaesthesia. This offers advantages to both the patient and the treating hospital. For the patients the length of time spent in the recovery room, the chances of intraoperative anesthetic complications and the need for postoperative analgesia are all reduced. For the hospital the obvious advantages in terms of bed occupancy and cost saving may be realized (5, 9, 11, 12) We evaluated the cost-effectiveness of androgen suppression strategies for men with advanced prostate cancer. Our principal finding is that the effectiveness of orchiectomy is much less expensive. The subcapsular technique bypasses the need for prosthesis thus contributing to a lower cost when compared to total orchiectomy. Result: Of the 96 patients age 65 83 yr (mean =71.11 yr), operative time 20 55 min (mean 36.00 min), amount of anesthetic mixture 10 30 ml (mean = 20 ml) orchiectomy under spermatic cord block were successful in 91 96 (94.79 %). Five patients failed because they had so severe pain that needed to be converted to general anesthesia. Three patients had bradycardia (pulse rate = 50|min. 49|min.54/ min), 2 patients had tachycardia (pulse rate = 124/min, 102/min). None of patients had hypotension, nausea or vomiting. No complication related to the anesthesia nor the procedure was seen. Most of the patients felt little pain especially when monopolar electrocautery was used to cut the tissue or stop bleeding. Post-operatively, all of the patients ambulated immediately; 86 patients (89.47 %) rated their visual analog pain scale between 0 6; 10 patients (10.42%) numbered their visual analog pain 10 (5 of them converted from local to general anesthesia). When classify to mild (pain score 0-3/10), m oderate (pain score 4-6/10), and severe pain (pain score 7-10/10). 59 patients (61. 46 %) were in mild pain group, 27 patients (28.13 %) had moderate pain and severe pain in 10 patients (10.42 %) table-1. At 1-week follow-up, 2 patients suffer from surgical wound infection , one is admitted to hospital for dressing and debridement, the other treated as outpatient with wound dressing and oral antibiotic treatment; 5 patients had scrotal hematoma which improved with time and conservative treatment. Conclusion: Bilateral subcapsular orchiectomy is safely done under local anaesthesia, simple and coast effective. For preoperation, the patient needs to be explained the procedure and some symptoms that he may experience during the operation. Spermatic cord block is not suitable in patient with anxiety or obesity. They should receive general or spinal anesthesia.

Health Insurance Policy

HEALTH INSURANCE POLICY Normally the medical insurance will be available through employer. When the individual unable to get the medical insurance from the employer or seek separate coverage is advised to select individual health insurance plans. Such individual health insurance plan also known as private health insurance. The medical insurance coverage under such plans is ideal for the self employed persons. However who desires to have many options can also go for private health insurance.Long-term care insurance which is a different insurance product available in the United States. The product of LTC or Long Term care insurance helps to provide the cost of long-term care for a predetermined period. The LTI insurance not covered by health insurance, Medicare or Medicaid. The individuals who unable to perform the basic activities of daily living i. e. dressing, bathing, toileting, etc can choose the LTC. One advantage with the product is age is not determining factor to purchase the health insurance for Long Term care.The benefits of LTC include home care, assisted living, hospice care, assisted living etc. Even the product allows paying up to 7 days a week of 24 hours a day for rendering services by visiting care giver, housekeeper, duty nurse etc. Tax qualified and Non-tax qualified offered, hence the individual may choose according to availing tax benefits. Tax qualified policy requires the person to take care policy who are expected to require at least 90 days and unable to perform two activities of daily living.In case of Non-tax qualified policy, the person who is unable to perform one or activity of daily living can purchase the policy. Another insurance product is individual disability. Every disability insurance policy is will vary company to company. But it is not such product which can be purchased easily. Of course, the cheapest disability insurance policy can be purchased by just throwing money. It is such product designed to assist the individual when the income of the person is decreased by the illness in the occupation.The disability insurance also known as DI and the policy assures the holder against the risk that will arise from the work place. So paid sick leave, short-term disability benefits, long term disability benefits etc are covered under the product of DI. REFERENCE: 1. http://www. healthinsurancefinders. com/ 2. http://en. wikipedia. org/wiki/Long_term_care_insurance 3. http://www. about-disability-insurance. com/ 4. http://en. wikipedia. org/wiki/Disability_insurance

Vark Questionnaire Paper

VARK is a questionnaireâ€Å"VARK† is a questionnaire of about 16 questions that provides people with their preference of learning style. The learning styles that VARK offers can help people develop additional and effective strategies for learning and for making your communication skills better. The styles that this questionnaire determines are Visual, Aural, Read/Write, Kinesthetic, or you can be multimodal which means you have a multiple learning preference. In this paper I will summarize the results received after taking the questionnaire and the other learning styles.After taking the questionnaire it was learned that some individuals, such as this author are multimodal learners. What multimodal means is you have multiple preferences. Majority of the population fits into this category. The results after this author took the questionnaire showed a preference of a visual and kinesthetic learner. As visual learner VARK says that the learners want the whole picture therefore th ey are most likely holistic rather than reductionist in their approach. Visual learners prefer something because of the way it looks, the layout of it and the presentation catches their eye.When explaining something the learner/teacher is most likely to draw it out so they can visualize it. As a Kinesthetic learner VARK suggest that the learner uses all their senses; sight, touch, hearing, etc. Kinesthetic learners like hands on, trial and error. Relating things to real life experiences can help absorb the information. Using pictures can also help to remember the information. When taking notes kinesthetic learners should take notes that are relevant and concrete, reducing notes for every three pages to one page, and use color such as highlighting important information.Other learning styles that VARK include are Aural; meaning you would rather have things explained to. Information is better obtained when aural learners discuss is with others and hear it repeated instead of reading it from their notes. When aural learners teach or discuss something with others, they are practically teaching themselves because discussing it helps to better learn and retain it. The last learning style that VARK offers is read/write learning style. You prefer to write things down and receive handouts on new material.The library is a preferred area of study, and choice when gathering information on a topic. After completing the VARK questionnaire this author feels that the results were pretty accurate. She feels that she learns best when applying areas of study to real life experience and to personal experiences. She also finds herself writing many things down, high lighting, and drawing out things when trying to remember something. This author took another survey on another website to see what the preferred learning style showed.After completion it showed this author is a visual and tactile/kinesthetic learner, which matched the VARK results. In the future there are a few things th is author needs to work on to improve her study habits. Although this writer has in the past used the learning styles previously mentioned, she may have not been using them correctly. Why highlighting can help to pinpoint the main idea or important information, there is a thing as highlighting too much. This author needs to be able to determine what is pertinent and when something is not as important.In the past she has highlighted too much information, and perhaps has highlighted the same information twice. Also note taking so be minimized, and not writing everything down, which she has done in the past. In conclusion after taking the two different questionnaires they showed the same results. Both results revealed that this author is a visual learner as well as a tactile/kinesthetic learner. This author feels these results show how she has studied in the past. This author likes to try things out when learning new material and enjoys having people demonstrate what is being taught.Du ring nursing school this author learned best by the demonstrations in skills and clinical and then being able to perform the hands on task. These questionnaires are good guidelines to get a student headed in the right direction and to help them improve their study habits.ReferencesFleming, N. (n. d. ). a guide to learning styles. In VARK . Retrieved October 21, 2012, from http://www. vark-learn. com/english/page. asp? p=questionnaire Conner, M. (n. d. ). What is Your Learning Style?. In Marcia Conner Business Culture, Collaboration, and Learning.Retrieved October 21, 2012, from http://marciaconner. com/assess/learningstyle/ The VARK Questionnaire ResultsYour scores were:†¢Visual: 13†¢Aural: 1†¢Read/Write: 4†¢Kinesthetic: 13You can find more information about your learning preferences in our downloadable book: How Do I Learn Best? a student's guide to improved learning More Information†¦ You have a multimodal (VK) learning preference. Use the following helpsh eets for study strategies that apply to your learning preferences: multimodal visual kinesthetic.Personal Learning Profile Report The VARK questionnaire provides four scores and the various combinations of those scores are huge in number. You can order a report based on your specialized profile. Every attempt is made to personalize the report so that it addresses the meanings from your learning preferences in a unique way. You will receive a report personalised to your VARK scores, as a PDF file, immediately after purchasing. More Information Example Report Purchase

Bad Policing . When A Person Thinks Of A Policeman, A Variety

Bad Policing When a person thinks of a policeman, a variety of thoughts will probably come to his or her mind. Some people feel a sense of security or fear, while others have accomplished an actual camaraderie with policemen. Who feels safe? Who is fearful of police and why are they? The United States Constitution’s Fifteenth Amendment says, â€Å"The rights of citizens of the United States shall not be denied or abridged by the United States or by any state on account of race, color, or previous condition of servitude† (United States Constitution). Since the abolishment of slavery and the Civil Rights Movement, African Americans thought they would be equally treated in this country, but they have yet to have their wishes come true. Many†¦show more content†¦Today, there is a high number of black males that are incarcerated. People automatically assume when a police apprehends a black male that he will be going to jail. It is a well-established fact that racial and ethnic d isparities in arrest and incarceration are astronomical (Kutateladze and Lawson 980). Statistics show that despite making up only two percent of the total United States population, African American males between the ages of fifteen and twenty-four comprised more than fifteen percent of all deaths logged in 2015 by an ongoing investigation into the use of deadly force by police (alternet.org). Therefore, many black males no longer trust the police and think that the police are out to antagonize them. Even though the slavery of blacks ended in 1865, African Americans have since then still been mistreated and belittled. It is very scary situation once the people who are supposed to serve and protect begin enacting hate crime against blacks. The government may not say police brutality is a hate crime, but it is very much so. Deaths caused due to bad policing has dated all the way back to the early 1900s. Since Rodney King’s beating, up until the most recent victims, death changed the overall perspective of policemen. Some historians compare masters to modern day policemen because they show racial bias and kill many civilians as well. The

Ethics of Animal Testing - 754 Words

Ethics of Animal Testing For my paper I chose the topic of animal testing because I have always been very passionate for animals and against animal abuse. I have never believed in animal testing and that there were always other alternatives. I wanted to look further into and educate myself about what is being done about this and why it is an ethical issue. I have come up with an axiom to summarize this topic. Testing animals in research revolves around the relative or moral value of humans and animals, and many different viewpoints helped to contribute to the development of ethical principles of animal treatment. The use of animals in research, teaching and testing is an important ethical and political issue. Much of the discussion about this issue revolves around the relative value, often referred to as moral value, of humans and animals. How do you decide what is right when the needs of animals and humans come into conflict? It’s really difficult to make a moral decision when so many people have different morals regarding this topic (Animal testing and ethics). In today’s society, there is a wide spectrum of views on this subject. There are people who are with animal rights, and people who view animals only as a resource to be exploited. All of these viewpoints have contributed to the development of ethical principles of animal use. Because of these views, we now have different organizations such as AAALAC,AALAS and the AVMA (Animal testing and ethics).The positiveShow MoreRelatedThe Ethics Of Animal Testing1534 Words   |  7 Pagessucceed in many areas, but has also damaged the basic ethics and morals in some of us. Today on television, we see the over dramatized body spray commercials or a famous celebrity advertising their favorite shampoo and stating its claims, but what most do not know is that a couple or couple hundred, animals were killed to approve, by law, of that product. 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The Organization Of Trade Unions - 1514 Words

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Since it is beneficial, it is supposed to see that many employees have make good utilization of it, but quite a number of employees st ill lacks the awareness and skills of making response to trade unions for employees. If they know that, their welfare will acquire greater extent of guarantee. Two theories of employment relation In this essay, the employees are defined as the crowd of people that use their labor to exchange for salary. One mainstream viewpoint views the employees as a kind of economic men. 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Special Education Needs free essay sample

I will also write about the medical and social model, what they are and how they relate to SEN, I will then write about the SEN Code of Practice and special educational needs coordinators and touch upon the 1987 Warnock report. The definition of SEN according to the 1996 Education act is, a child has special educational needs if he/she has a learning difficulty which calls for special educational requirements to be made for them (Farrell, 2003). A child is said to have a learning difficulty if they have a considerably greater struggle in learning than most children of the same age and they have a disability which prevents or stops from making full use of their educational facilities provided for children of the same age in schools within the area of the local educational authority (Farrell, 2003). I have chosen to discuss how the education support has changed for children suffering from the autistic spectrum disorder. The word ‘Autism’ first came about in 1911 by a Swiss Dr named Eugen Bleuler (Freedman, 2009) the term was based on the Greek word ‘autos’ meaning self; the actual disorder he was referring to was schizophrenia. Autism was later identified in 1943 by Dr Leo Kanner (Freedman, 2009) he believed mental and biological element played a key role in autism. Autistic spectrum disorders are usually present from birth or early stages of development (NRC, 2001). Autism is a disability that affects how someone communicates and interacts with others (Brill, 2008). The disability arises due to problems in the nervous system; which is made up of the brain, spinal cord, and a network of nerves that permits us to move, think, and sense the world (Brill, 2008); how an individual with autism learns and develops will depend on how the nervous system interacts with the environment around them (Brill, 2008). Autism affects vital human behaviours e. g. social interaction, the ability to communicate ideas and feelings, imagination, and the ability to form close bonds and feelings (NRC, 2001). Children with autism look physically normal however they display a series of behaviours that are autism related (Brill, 2008); doctors usually identify autism by looking at a variety of signs that point to the condition and how it affects the way the person learns and develops; the signs can be mild or severe depending on the child as we are all different (Brill, 2008). Autistic disorders usually have long lasting effects on how children are as social beings, how they learn to look after their selves and participate in their community (NRC, 2001). A range of autistic behaviours is called autism spectrum disorder; at one end of the spectrum is Asperger syndrome which is the mildest form of autism those with the disorder function more self-reliantly unlike those with more severe autism (Brill, 2008) children with Asperger tend to speak by the time they are age four but their voices usually lack emotion. Children with Asperger normally have some trouble interacting with their peers (Brill, 2008). Asperger sufferers tend to test well but lack common sense; experts believe that Asperger is a different disability to autism (Brill, 2008). The most severe the type of autism the more it affects your learning and behaviour to the point that in some cases it can cause mental retardation which greatly slows the learning and progress of a young child (Brill, 2008). Many of those with autism have difficulties handling information through their senses; they usually hear, feel or see too much or too little arriving material which causes them to either under or over react (Brill, 2008). Some common signs of children suffering from autism are they tend to withdraw and become silent or unresponsive, they throw tantrums to block out smells, sounds, touch and sights which they find disturbing (Brill, 2008) and they take longer to reach the common stages of childhood e. g. walking and talking; autism halts normal progression (Brill, 2008). The autistic spectrum sometimes occurs along with mental retardation and language disorders therefore educational planning must address both autistic needs and the needs associated with accompanying disabilities (Brill, 2008). By the 1960’s autism was finally identified as a disorder of its own; in 1965, Dr O. Ivar Lovas and colleagues at a university developed a treatment for autism called applied behaviour of analysis (ABA) (Freedman, 2009); ABA is the use of techniques and principles to bring about a good change in behaviour (Freedman, 2009). ABA focuses on the principles that explains how learning takes place e. g. through positive reinforcement; if good behaviour is followed by a reward the behaviour is more likely to be repeated. This technique could be used not only in the classroom but at home by parents (Freedman, 2009). ABA has become a very popular and widely known treatment for autism through the years especially through the last decade where it has been used to help autistic people lead normal and productive lives. Another popular treatment for autism was discovered in the 1990s by Drs Serna Wieder and Stanley Greenspan called floortime which was based on brain research that showed human development is built on interactions with others (Freedman, 2009) in contrast to ABA which aims to change behaviour, floortime concentrates on improving social skills, imagination and emotional abilities. When discussing SEN we must touch upon the issue of labelling; there are both positive and negative aspects to labelling an autistic child. Some positives are it leads to the child getting the treatment and specialist help they need (Lauchlan, Boyle) , it raises awareness and the understanding of autism and it helps in supporting the families and children with autism by giving them more details about their condition (Lauchlan, Boyle) . Some negatives to labelling are it can sometimes lead to bullying by peers and the use of bad language to describe those with autism, which can sometimes lead to devastating consequences and it can make children with autism feel inferior to typically developing children (Lauchlan, Boyle). Labelling can also lead to social disadvantage and exclusion from mainstream society and also some people with disabilities use their impairment as an excuse or scapegoat for things they find difficult. The use of labels are useful to special educational needs children as if they were dropped it would mean that the specialist help they require would no longer be available to them as they would be given the same workload and support as typically developing children so labelling benefits more than hurts them. The SEN Code of Practice was made to give necessary advice and help to the LEA, schools, social services, and early education setting on how best to provide the help for children with disabilities (DfES, 2001). The Education act 1993 placed a duty on the secretary of state to issue a Code of Practice and make compulsory changes to it every few years. The first Code of Practice was written in 1994; schools, health, social services and settings must abide by the SEN Code of Practice (DfES, 2001) and although the Code of Practice does not tell professionals how to react or deal with every individual situation it advises and guides them on how best to deal with the situation (DfES, 2001). In 2001 the Code of Practice was revised; more rules were added e. g. more rights for children with SEN educated in mainstream schools, the LEA must offer parents more information help and advice on how best to give their child the best education and schools and early years settings must give each other more support (DfES, 2001). During the 1960’s people with autism were still very much viewed as ‘not normal’ this was not helped by the medical model (TOU, 2006). The medical model defines those with disabilities by their impairments.