Equipment for Cosmetic Dermatology Clinic

Equipment for Cosmetic Dermatology Clinic A cosmetic dermatology clinic differs from the traditional dermatology clinic in terms of the requirement of a wide range of equipment to perform various aesthetic procedures. In the past, the only instrument associated with dermatology practice was a magnifying glass. It then progressed to equipment’s such as Woods lamp, electrocautery, radiofrequency, cryotherapy and phototherapy units. Beyond these tools, the cosmetic dermatologists’ armamentarium includes various basic and specialized equipment’s to carry out a multitude of dermatological treatments and cosmetology procedures. (Box 1) In addition to the treatment equipment, photo documentation devices are also essential. These devices record the results and changes for analysis and prognosis of the treatments and can actually document the percentile UV damage, wrinkle score etc. The cosmetic clients (internet savvy) are aware of the equipment usage in various procedures and check for clinics offering faciliti es with the latest equipment and low downtime. The cosmetic dermatologist not only needs to be updated about the latest equipment’s but should also be aware of its management and maintenance needs. Poor maintenance leads to financial losses for the physician and compromises on efficacy and safety issues for the patient. This chapter gives a brief outline of equipment management and maintenance aspects which would enable the physician to provide safe, effective treatments and sustain the financial aspects of his/ her practice optimally. Box 1: Basic and Specialized equipment in a cosmetic clinic Basic Equipment Microdermabrader Radiofrequency and cautery Cryotherapy Mesotherapy Jet Peel or hydrafacial Microcurrent Electroporation Dermatoscope and photography equipment ( detailed in chapter 5) Phototherapy Units Specialised Equipment- LASERS and Light Systems Intense Pulse Light LASER Hair Reduction- Long Pulse Alexandrite, Long Pulsed ND YAG, Diode Pigmentation- Q Switched ND YAG Fractional and Ablative LASERS Hair Restoration- Low Level Lasers and lights Skin Tightening- LASERS and Radiofrequency, Micro needling Radiofrequency Vitiligo and Psoriasis- Excimer lamp and LASER Body contouring- Radiofrequency, cryolipolysis, ultrasound cavitation, low level laser therapy,etc. BASIC REQUIREMENTS FOR EQUIPMENT MANAGEMENT The basic requirement from any machine/ equipment is its longevity and optimal usage. This can be achieved by effective equipment management procedures [1] (Box 2) Box 2: Effective equipment management procedures Equipment Purchase Installation requirements (storage and space electrical supply, air-conditioner) Standard Operating Protocols Training of the staff Quality control checks (cleaning, safety devices, consumables, regular inspections) Maintenance and servicing (Daily, Preventive, Annual ) Equipment/ Accessories modification Equipment Purchase: The following checklist should be kept in mind during purchase of the equipment. This helps to trouble shoot maintenance issues effectively. Always buy from a certified company or a certified official dealer Check with the dealer for skilled technicians for installation and troubleshooting Sign the maintenance contract with the company (No machine is zero maintenance) Establish the warranty period (details and time lines) Note of the date of manufacture and the numerical code unique to each equipment. Installation Requirements Space and storage Requirements of the equipment and accessories should be taken into account prior to installation. Electrical connections and stabilizers: This has been detailed in Chapter 60. Special sockets and high voltage breakers, stabilizers and UPS (uninterrupted power supply) should be provided. Air conditioner: Most of the LASER machines generate heat and require certain temperatures to be maintained while in operation. An air conditioned environment is preferred as it remains closed, relatively dust free and is useful for machine longevity. Smoke evacuators Fragments of skin, hair and aerosols can damage LASER lenses or light based equipment due to physical interference with transmission. Smoke evacuation systems may be used to reduce the plume debris and limit the harmful effects on the staff, patients/clients and the laser equipment. Standard Operating protocols (SOPs) SOPs regarding usage of the machine are provided by the manufacturer. Indications and Specifications are provided in the operator manual and should be adhered to. Based on the patient requirement, if modifications are made in the SOPs, these should be documented and informed to all the staff. Training of staff (machine operators or staff responsible for maintenance) All the staff members in the cosmetic dermatology set up should be trained to follow the SOPs, understand the need and importance of equipment maintenance for the smooth functioning of the clinic. Quality control checks (cleaning, safety devices, consumables) In addition to the daily cleaning; regular weekly or fortnightly check of each machine, safety devices and consumables should be done. This helps to prevent emergency maintenance issues and financial losses. Maintenance and servicing (Daily, Preventive, Annual) A record should be maintained of all planned and unplanned maintenance and services, including any problems or modifications. The service contract records, contact details of service personnel should be documented well. Equipment/ Accessory modification Any modification to the equipment or accessories; or change in its operational usage may have safety implications associated with it. Hence, whenever any modification is done, appropriate documentation is mandatory. Standard accessories should be used. STANDARDISED AND EFFECTIVE EQUIPMENT MANAGEMENT A standardised form, including all the aspects detailed above for equipment management should be kept with individual machines. A soft/ hard copy of this format for all machines should be catalogued and serve as a ready reckoner to the concerned staff. A basic outline of the form has been provided in Box 3. The salient aspects for effective equipment management have been included in Box 4. Box 3: Standard form for individual machines Name of the machine Indications Standard specifications (usually provided by manufacturer) Storage specifications: Equipment/ Accessories Space: Table mounted/ Floor mounted Electricity: Earthing/ UPS requirement AC requirement Consumables Safety devices- Goggles, cooling devices, smoke evacuators Cleaning Techniques Maintenance- Daily, Preventive, Annual or comprehensive maintenance services ( AMC/ CMC) Special tips do’s and don’t’s Installation date Operator Training: Names/ Dates Contact details for Maintenance services: Phone/ Mail id/ Website address/ Personnel Warranty details: Equipment/ Accessories, along with datelines Services Contract: AMC/ CMC, Renewal along with Dates Service done: Dates/ Done by whom/ Supervisory staff Box 4: General Tips for effective equipment management Keep a standardised form with individual machines. Train the staff to handle the equipment carefully Understand the Operators manual Take care of all the parts of machine. Hand pieces are the most important part. Place them in a protective box or on the machine as instructed Keep a check list of the consumables Keep all the machines covered and in a dust free environment Contact technical personnel for preventive machine maintenance at regular intervals Check for contraindication in case of all clients BASIC EQUIPMENT MAINTENANCE The general principles of basic equipment maintenance (as per the standardised form) has been outlined in Table 1. Modifications can be done based on individual machines and clinic requirements. Table 1: Basic Equipment Management Equipment Crystal Diamond- USG, Cleanser, head Salt – cartridges Microcurrent Diamond Pro Lift Radiofrequency /Cautery Mesomate/Dr Injector Injector MesoGun-Manual-Automatic Jet M Machine Indications Exfoliation gently removes the outermost dead skin cell layer for the epidermis. Reduces pigmentation and tanning Improves Acne scars Reduces fine lines and wrinkles Reduces pore size and age spots Facial lift Muscle lift Body Contouring Iontophoresis-Product penetration Disencrustation- Deep cleansing Dermatoses papulosa nigra (DPNs) Warts Skin tags Moles Seborrheic Keratosis Granuloma pyogenicum Xanthelesma Rhinophyma Dull skin Irregular texture Uneven skin tone Hair loss Cellulite Lymphatic drainage Exfoliation Infusion Standard operating protocols Available Available Available Available Available Storage Temperature:20 -600 C Humidity Space Table mounted Table mounted Table mounted Table mounted Dr. .Injector has its own Trolley Table mounted or specially designed trolley Electric/ UPS/ AC Earthing + UPS/ AC- Earthing + UPS/ AC- Earthing + UPS/ AC- Earthing + UPS/ AC- Consumables Hand piece depending on the type of machine Nozzles of two different sizes small for face and neck and big for the body parts Aluminium oxide crystals Two long metal probes, one small probe with sponge for earthing , two sets of coloured wires, one metal roller, sticky pads and big pads. Hand piece Wire loop electrode and pointed electrode Disposable as well as reusable tips are available Kinked wires may need replacement Safety devices Foot pedal Air tubing Triple nozzle handpiece Safety goggles (during peel infusion ) Vitamins Cleaning The jar has to be cleared of all the crystals after every service and cleaned. Hand piece needs to be cleansed with alcohol swab before use. Tissue residue should be removed from the active electrode (Rf power ON) with a sterile moist gauze (water only) No scalpel scissors or any sharp objects should be used as it may lead to tissue adherence Disinfection All commercially available disinfectants may be used to disinfect the electrodes. Electrodes should be immersed in fresh cidex solution .then they must be washed and under tap water , dried and Placed in the supplied box Sterilisation All non- disposable hand pieces, cables, plugs and electrodes are autoclavable to 2500 F or 1210C. Steam cleaning of electrodes must be done just before use. Sterilize the guard with alcohol swab prior to the service Regular cleaning of hand piece Maintenance Jar needs to be replaced every fortnight for smooth functioning of the machine Spare hand pieces should always be available Replace filter and nozzle after every 15 bottles Daily Maintenance: Clean hand piece with alcohol swabs or SPCL cleaning Solution. Straighten the tubes. AMC Preventive maintenance should be done at an interval of 1-2 months Preventive machine maintenance at an interval of 1-2 months. The electrodes should be dipped in dilute H2O2 solution so that debris gets cleared, before washing AMC Preventive machine maintenance should be at an interval of 6 months. Daily Maintenance Clean the gun exterior with spirit. Do not allow spirit to enter the interiors. Charge the Gun daily AMC Preventive machine maintenance should be at an interval of 6 months. AMC Preventive machine maintenance should be at an interval of 6 months. Special Tips: Do’s and Don’ts Do’s- follow the instructions mentioned in the user manual Don’ts – do not place anything on the machine Don’ts- Coloured wires should always be tied up and placed on the machine when not in use Do’s- The only way the radiosurgery can create tissue damage is if the heat is allowed to accumulate in the tissue to the point where it can lead to excessive dehydration and hence tissue destruction. Preventing accumulation of such heat is the basic objective of radiosurgery technique and hence one should practice 10 seconds ON and 30 seconds OFF. Don’ts – Do not Use any inflammable anesthetics or cleaning agents. Use the injector and needle that meets the international and domestic standards. SPECIALISED EQUIPMENT MAINTENANCE Specialised equipment’s such as Lasers, lights, radiofrequency based machines are now an integral part of cosmetic clinics. Most of these equipment are expensive and have specific maintenance issues. In addition, the optical radiation emitted by lasers, IPLs and LEDs has potentially hazardous effects on patients, clients and equipment users. There can be direct damage to eyes or skin. A potential risk of fires or explosions from lasers igniting gases or fabrics and the problem of smoke inhalation exist. Engineering (in- built safety measures provided within the laser machine), procedural (policies and practices followed at the cosmetic clinic) and administrative (review by health department) control measures are needed to prevent exposure to potential laser hazards. [2] Effective equipment management procedures as outlined in Box 2 should be followed for each of the specialised equipment in the clinic. The most important aspect of maintenance is simple prevention. This can be achieved through the following measures: Routine inspection, of the laser system and the surroundings (Daily/ weekly checks) Periodic inspection and maintenance of optical components and critical subassemblies (Preventive and annual maintenance checks) Documentation and Record keeping Few examples for daily/ weekly/ preventive checks for laser equipment are outlined in Box 5 [1] Box 5: Examples for daily/ weekly/ preventive checks for laser equipment Examples for daily checks: Check whether the laser output terminates on release of foot/ hand switch Check the device’s alignment of the aiming beam with the therapeutic beam Check device’s filters/ tips for scratches or dirt. Check all system alarms and lights are operating appropriately Assess all device accessories including cables and connectors are clean and functioning. Examples for weekly checks: Inspect protective eye wear for lens scratches or general damage Check all protective blinds, windows and doors, are dust free and functioning appropriately Check that electrical system connections/ UPS, warning lights are functioning correctly Examples of annual/ preventive checks: Electrical safety Device calibration checks Output measurements Beam alignment Shutter operation Accuracy of timer Filters The general tips for effective and safe laser equipment management are outlined in Box 6. The general principles of specialised equipment maintenance (as per the standardised form) has been outlined in Table 2. Modifications can be done based on individual machines and clinic requirements. Box 6: General tips for effective and safe laser equipment management Laser Room (details in chapter 60) Restrict entry to the room when the system is in use; put laser warning sign Do not include any light reflecting objects such as mirror, Provide rubber mat flooring ( prevents damage and losses in case of accidental fall of hand pieces, goggles, etc) Services/ Maintenance checklist Maintain a logbook of regular maintenance check and calibration Maintain detailed information about service centre/ personnel Check for engineers training certificate. Calibration must be checked by authorized personnel with calibrated power meter. Always check for calibration certificate when under AMC/ Maintenance Deionized (DI) water is needed for cooling in some machines. Check levels 1-3 monthly and change Check fire safety measures Check for Electromagnetic immunity and declaration compliance. Check for recommended separation distances between portable and mobile RF communications equipment and laser Equipment Use Check the power supply/ UPS before the machine is switched on. If the machines need to be moved to a different room, do it carefully and avoid jerky movements Always place the tips or hand pieces in the designated box so as to avoid any accidental fall or damage to the same Optical lenses, fibre optic cord, some hand pieces contain lasing medium are expensive, hence handle all equipment parts with care Never leave the system in ready mode unattended Practice use of hand switch as much as possible Most laser screens have a touch screen. Be sure not to point on the screen while firing the laser shot ( Can inadvertently happen with the foot pedal) In event of any emergency use the emergency shut –off knob Use colourless gels for lasers Use Skin markers and colours for demarcating areas. Skin markers should be preferably white or appropriate colour depending on the laser absorption spectrum or else they can act as chromophores and cause burns Cleanse and dry the area to be lased thoroughly Inspect the laser tip always before treating the patient. Do not use if damaged. Make sure the correct eye wear is used (Different protective eyewear is indicated for different wavelengths) Do not treat eyebrows eyelashes or other areas surrounding the eye orbit with Nd: YAG or Er: YAG lasers. The light emitted by these can cause serious eye damage or blindness. Use corneal shields especially in cases of direct touch lasers being used in the orbital area. Gas based and pulse dye lasers (Example- Excimer, Pulse dye lasers) Switch ON everyday Cleaning of hand piece with alcohol swabs. Gas bottles used as consumables are very expensive Mirrors needs to be cleaned by engineers every 3 months. Calibration of voltages is very important. Dye needs to be replaced after 50000 shots Body shaping and contouring machines: All hand pieces need to be cleaned daily Better to use specific oils or gels, otherwise ultra-sonography gel can be used; may be glycerine based. The emitted sounds should be perfect Phototherapy units Check lamp power every month and calibrate if needed Clean fans every quarterly Table 2: General principles of specialised equipment maintenance ( separate doc- horizontal chart) CONCLUSION Equipment management and maintenance is an integral part of the cosmetic practice set- up. Specialised equipment such as lasers and radiofrequency based devices are expensive and have specific maintenance issues. In addition to the financial implications for the practice, the safety and efficacy of the treatments provided by the physician are chiefly dependent on well managed equipment. SUMMARY A cosmetic dermatology clinic differs from the traditional dermatology clinic in terms of the requirement of a wide range of equipment to perform various aesthetic procedures. It is a good practice to employ equipment management and maintenance measures. The effective equipment management procedures include checklists and processes for purchase, installation, developing standard operating protocols, staff training, quality control checks, maintenance and servicing (daily, preventive, annual ) and modifications in equipment/ accessories. Good equipment management and maintenance practices have healthy financial implications for the practice. It assures optimal usage and longevity of the machine life, along with safe and effective treatments for the patients/ clients.

Island of the Sequined Love Nun Chapter 27~28

27 Girl Talk Sepie washed the pilot's hair in a bowl with pounded coconut and brackish water. She had been taking care of the unconscious white man for two days and it was starting to get tedious. She was mispel of the bachelors' house, and washing and ministering to a sick and stinky white man was not in her job description. This was women's work. There are legends in the islands, and some of the old men swear they are true, that the women who service the bachelors' houses, the mispels, were taken to the secret island of Maluuk, known only to the high navigators, where they were trained in the art of pleasuring a man. After months of training, a mispel was required to pass a test before she was allowed to return to her home island to take over the duty of tending to the sexual needs of the men of the bachelors' house. The test? She was sent into the ocean with a ripe brown coconut clutched between her thighs, and there she floated, in heavy surf, for the entire circuit of the tides. Should the coconut pop loose or the mispel touch it with her hands, she failed the test (although there was some leeway in the event of shark attack). It is said that the inner thighs of the mispels of old were as strong as net cable. The second part of the test required the girl to find a delicate dragonfly orchid with a straight stem, and while her teachers looked on, she would lower herself over the flower until it disappeared inside of her, then rise again after a few minutes, leaving the stem unbent and the petals unbruised. The mispel held a position of honor, respected and revered among the is-landers. She was n ot required to do housekeeping, cooking, or weaving, and while the other women toiled in taro fields from the time they could walk, a mispel was allowed to nap in the shade, conserving her energy for her nocturnal duties. A mispel often ended her tour of duty by marrying a man of high status. No stigma followed her into married life, and she would be sought out to the end of her days by the other women for advice on handling men. Sepie, however, had not been chosen because of any special skill, nor had she passed through any vigorous concubinal boot camp. Sepie had been marked for mispel from the moment of her menses, when she emerged from the women's house with her lavalava tied a bit too high and showing a bit too much cappuccino thigh, her skin rubbed with copra until she glistened all over, and her breasts shining like polished wooden tea cups. She had painted her lips with the juice of crushed berries and peppered her long black hair with scores of sweet jasmine blossoms. She giggled coquettishly in the presence of all the men, danced dangerously close to the taboo of speaking to them in public, risked beatings by refusing to fall to her knees when her male cousins passed, and went about her chores with a wiggly energy that had caused more than one of the distracted village boys to fall out of a breadfruit tree during harvest. (She broke ankles as well as hearts.) Sepie was all titter and tease, a lazy g irl who excelled at leisure, a natural at invoking and denying desire, a wet dream deferred. At fifteen she took up residence in the bachelors' house and had lived there for four years. When Malink and the men brought the flyer and the man in the dress to her, she knew she was in for some trouble. â€Å"Take care of them,† Malink said. â€Å"Feed them. Help to make them strong.† Sepie kept her head bowed while Malink spoke, but when he finished she took his hand and led him into the bachelors' house, gesturing to the other men to lay the flyer and his friend on the ground outside. The men smiled among themselves, thinking that old Malink was going inside to receive a special favor from the mispel. What, in fact, he was receiving was an ass chewing. â€Å"Why don't you take them to your house, Malink? I don't want them here.† â€Å"It's a secret. If my wife and daughters find out they are here, then everyone will know.† â€Å"I'm the only one who can keep a secret in the bachelors' house. Take them to old Sarapul's house. No one goes there.† â€Å"He wants to eat them.† Malink couldn't remember ever having to argue with a woman and he wasn't at all prepared for it. â€Å"You're chief. Tell him not to. I will not cook for them. If I feed them, they will shit. I'm not going to clean it up.† â€Å"Sepie, what will you do when you marry and have children? You will have to do these things then. I am asking you as your chief to do these things.† â€Å"No,† Sepie said. Malink sighed. â€Å"I am asking you to do these things because these men have been sent to us by Vincent.† Sepie didn't know what to say. She had heard the Sky Priestess chastise Malink in front of the people, but she had been more concerned with losing coffee and sugar for a month than with the actual offense. â€Å"You will tell the men to cook for them?† â€Å"Yes.† â€Å"And they will carry them to the beach and wash them if they shit?† â€Å"I will tell them. Please, Sepie.† No man had ever said â€Å"please† to her before, let alone the chief. It was not a courtesy that women deserved. For the first time she realized how desperate Malink really was. â€Å"And you will tell Abo to wash his dick when it is his turn.† â€Å"What does that have to do with this?† â€Å"He is stinky.† â€Å"I will tell him.† â€Å"And you will tell Favo to quit making me put beads in his ass.† â€Å"Favo does that?† â€Å"He said he learned it from the Japanese.† â€Å"Really? Favo?† â€Å"Yes.† â€Å"But he's old, and he has a wife and many grandchildren.† â€Å"He says it makes his spear stronger.† â€Å"He does? I mean, does it work?† Malink had momentarily forgotten why he was here. â€Å"I don't like it. It is evil and unclean.† â€Å"You're talking about my old friend Favo, right? He's the one you're talking about?† â€Å"I told him only bachelors were suppose to stay here, but he says his wife doesn't understand him. His hands are like the skin of a shark.† â€Å"What kind of beads?† â€Å"Tell him,† Sepie said. â€Å"Okay,† Malink said in English. Then to himself he said: â€Å"Old Favo.† He shook his head as he walked out of the bachelors' house. â€Å"Beads.† Sepie watched him go, wishing that she had asked for more favors. Outside the men were grinning when Malink stepped into the moonlight. He hitched up his loincloth and averted his eyes from theirs. â€Å"Take them inside. You must cook and clean for them. Don't let the woman do it. It is too important for her.† As the men carried Tuck and Kimi into the bachelors' house, Favo ambled up to Malink. â€Å"How was it?† Malink looked at his old friend and noticed for the first time that Favo wore a long string of ivory beads around his neck. â€Å"I have to go home now,† Malink said. Sepie was, once again, swabbing up the wooden floor where the pilot had urinated on himself, when she heard the other one speak for the first time. The men had propped the Filipino up in the corner, where he had sat drinking the coconut milk and fish broth that she had been pouring into the pilot, but except for a few grunts when he made his way outside to urinate, the man in the dress had been quiet for two days. Sepie had learned to ignore him. He didn't smell as bad as the pilot, and she sort of liked his flowered dress. She'd said a prayer to Vincent for a dress just like it. â€Å"Where is Roberto?† the Filipino said. Sepie jumped. It didn't surprise her so much that he had spoken, but that he had spoken in her language. Although the words were clipped, the way someone from Iffallik or Satawan might speak. â€Å"He's right here,† she said. â€Å"Your friend stinks. You should take him outside and wash him in the sea.† â€Å"That's not Roberto. That's Tucker. Roberto is shorter.† Kimi crawled over to Tuck and laid his hand on the flyer's forehead. â€Å"He has bad fever. You have medicine?† â€Å"Aspirin,† Sepie said. Malink had given her a bottle of the tablets to crush into the flyer's broth, but after he gagged on the first dose she had stopped giving it to him. â€Å"He is more sick than aspirin. He needs a doctor. You have a doctor?† â€Å"We have the Sorcerer. He does our medicine. He was a doctor before the Sky Priestess came.† Kimi looked at her. â€Å"What island is this?† â€Å"Alualu.† â€Å"Ha! We have to get doctor for Tucker. He owes me five hundred dollars.† Sepie's eyes went wide. No wonder he wears such a fine dress. Five hundred dollars! She said, â€Å"The chief says I have to be secret about this man. Everyone knows he is here. The boys get drunk and talk. But I can't get the doctor.† â€Å"Why are you taking care of him? You are just a girl.† â€Å"I am not just a girl. I am mispel.† Kimi scoffed. â€Å"There are no mispels anymore.† Sepie threw down the rag she was using to wipe the floor. â€Å"What do you know? You are a man in a dress, and I don't believe you have five hundred dollars.† â€Å"It was a nice dress before the typhoon,† Kimi said. â€Å"Wash-and-wear. No dry cleaning.† Sepie nodded as if she knew what he was talking about. â€Å"It is a very pretty dress. I like it.† â€Å"You do?† Kimi picked at the crushed pleats around his legs. â€Å"It's just an old thing I picked up in Manila. It was on sale. You really like it?† Sepie didn't understand. Among her people, if you admired someone's else possession, manners bound them to give it to you. How could this silly man speak her language and still not know her customs. And he wasn't even looking at her that way all men looked at her. â€Å"What island do you come from?† â€Å"Satawan,† Kimi said. â€Å"I am a navigator.† Sepie scoffed. â€Å"There are no more navigators.† Just then the doorway darkened and they looked up to see Abo, the fierce one, entering the bachelors' house. He was lean and heavily muscled and he wore a permanent scowl on his face. The sides of his head were shaved and tattooed with images of hammerhead sharks. He wore his hair tied into a warrior's topknot that had gone out of fashion a hundred years ago. â€Å"Has the pilot awakened?† he growled. Sepie looked down and smiled coyly. Abo was the one boy in the bachelors' house who didn't seem to accept the communal nature of her position. He was always jealous, enraged, or brooding, but he brought her many presents, sometimes even copies of People that he stole from the men's drinking circle. Sepie thought she might marry him someday. â€Å"He is too sick for this,† Kimi said. â€Å"We need to take him to the doctor.† â€Å"Malink says he must stay here until he is well.† â€Å"He is dying.† Kimi said. Abo looked at Sepie for confirmation. â€Å"Well, he smells dead,† she said. The sooner they sent the pilot to the Sorcerer, the sooner she could get back to spending her days swimming and preening. â€Å"Malink will be angry if he dies,† she added for good measure. Abo nodded. â€Å"I will tell him.† He pointed to Kimi. â€Å"You come with me.† Kimi got up to leave, then turned back to Sepie when he reached the doorway. â€Å"If Roberto comes, tell him I'll be right back.† Sepie shrugged. â€Å"Who is Roberto?† â€Å"He's a fruit bat. From Guam. You can tell by his accent.† â€Å"Oh, him. I think Sarapul ate him,† Sepie said casually.† Kimi turned and ran screaming into the village. Malink looked up from his breakfast, a banana leaf full of fish and rice, to see Abo coming down the coral path toward his house. Malink's wife and daughters shuffled to the cookhouse at the sight of the fierce one. â€Å"Good morning, Chief,† Abo said. â€Å"Food?† Malink answered, gesturing with his breakfast. Abo had already eaten, but it would have been rude not to accept. â€Å"Yes.† Malink's wife poked her head out of the cookhouse and saw the chief nod. In a second she was giving her own breakfast to Abo, who neither thanked her or acknowledged her presence. â€Å"The pilot is sick,† Abo said. â€Å"Very bad fever. Sepie and the girl-man say that he will die soon without the Sorcerer's help.† Malink suddenly lost his appetite. He set his breakfast on the ground and one of his daughters appeared out of nowhere to take it to the cookhouse, where the women shared what was left. â€Å"And what do you think?† Malink asked. â€Å"I think he is dying. He smells of sickness. Like when Tamu was bitten by the shark and his leg turned black.† Malink rubbed his temples. How to handle this? The Sky Priestess was angry with him for even dreaming of the pilot. What would happen if he suddenly showed up with him? â€Å"What about the girl-man?† â€Å"He is not sick, but he has gone crazy. He runs around the village looking for Sarapul.† Malink nodded. â€Å"Catch him and tie him up. Make a litter and take the pilot to the betel nut trees by the runway. Leave him there.† â€Å"Leave him there?† â€Å"Yes, quickly. And bring the litter back with you. Make it look as if he walked to the runway. Send a boy to me when it is done. Go now.† Abo put down his food and ran off down the path. Malink went into his house and pulled the ammo box out of the rafters. Inside, next to the portable phone, he found the Zippo that Vincent had given him. He clicked it open, lit it, and sat it on the floor while it burned. â€Å"Vincent,† he said, â€Å"It's your friend Malink here. Please tell the Sky Priestess that this is not my fault. Tell her that you have sent the pilot. Please tell her for your friend Malink so she will not be angry. Amen.† His prayer finished, Malink snapped the lighter shut, put it away, then took the portable phone and went outside to wait for the boy to tell him everything was in place. 28 Choose Your Own Nightmare Tucker Case rolled through a fever dream where he was tossed in great elastic waves of bat-winged demons – crushed, smothered, bitten, and scratched – and there, amid the chaos, a pink fabric softener sheet passed by the corner of his eye, confirming that he had been stuffed into a dryer in the laundromat of Hell. He tumbled toward the pink, ascended out of the clawing mass, and awoke gasping, with no idea where he was. The pink was a dress on a heart-faced woman who said, â€Å"Good morning, Mr. Case. Welcome back to the world.† A man's voice: â€Å"After your message and the typhoon, we thought for sure you'd been lost at sea.† He was a white blur with a head, then a lab coat wrapped around a tall, smiling middle-aged man, gray and balding, a stethoscope around his neck. The doctor had his arm around the heart-faced woman. She too was smiling, with the aspect of an angel, the vessel of human kindness. Together they looked as if they had walked off of fifties television. The man said, â€Å"I'm Dr. Sebastian Curtis, Mr. Case. This is my wife, Beth.† Tuck tried to speak, but emitted only a rasping squeak. The woman lifted a plastic cup of water to his lips and he drank. He eyed the IV bag running into his arm. â€Å"Glucose and antibiotics,† the doctor said. â€Å"You've got some badly infected wounds. The islanders found you washed up on the reef.† Tucker did a quick inventory of his limbs by feel, then looked at them lest he had lost a leg that was still giving off phantom feel ing. He raised his head to look at his crotch, which was sending pulses of pain up through his abdomen. The woman gently pushed him down. â€Å"You're going to be fine. They found you in time, but you're going to need more rest. ‘Bastian can give you something for the pain if you need it.† She smiled beatifically at her husband, who patted Tuck's arm. â€Å"Don't be embarrassed, Mr. Case. Beth is a surgical nurse. I'm afraid the catheter will have to stay in for a few days.† â€Å"There was another guy with me,† Tuck said. â€Å"A Filipino. He was piloting the boat.† The doctor and his wife shot each other a glance and the â€Å"Ozzie and Harriet† calm shattered into panic, but only for a second, then they were back to their reassuring cooing. Tuck wasn't even sure he had seen the break. â€Å"I'm sorry, but the islanders didn't find anyone else. He must have been lost in the storm.† â€Å"But the tree. He was hung in the tree†¦Ã¢â‚¬  Beth Curtis put her finger gently on his lips. â€Å"I'm sorry you lost your friend, Mr. Case, but you need to get some rest. I'll bring you something to eat in a little while and we'll see if you can hold down some solid food.† She pulled her hand away and put her arm around her husband's waist as he pushed a syringe of fluid into Tuck's IV tube. â€Å"We'll check on you shortly,† the doctor said. Tucker watched them walk away and noticed that for all her â€Å"Little House on the Prairie† purity, Beth Curtis had a nice shape under that calico. Then he felt a little sleazy, as if he'd been caught horning on a friend's mom. Like the time, drunk and full of himself, he'd hit on Mary Jean Dobbins. To hell with solid food. Gin – in large quantities over a tall column of ice – that's the rub. Tonic to chase away the blues of bad dreams and men lost at sea. Tuck looked around the room. It was a small hospital ward. Only four beds, but amazingly clean considering where it was. And there was some pretty serious-looking equipment against the walls: technical stuff on casters, stuff you might use in complicated surgery or to set the timing on a Toyota. He was sure Jake Skye would know what it was. He thought about the Learjet, then felt himself starting to doze. Sleep came with the face of a cannibal, leg-jerk dreams, and finally settled in on the oiled breasts of a brown girl brushing against his face and smelling of coconut and flowers. There was a scratch and scuttle on the tin roof, followed by the bark of a fruit bat. Tuck didn't hear it. The pig thief had been caught and Jefferson Pardee had to find a new lead story. He sat at his desk pouring over the notes he'd written on a yellow legal pad, hoping that something would jump out at him. In fact, there wasn't a lot of jumping material there. The notes read: â€Å"They caught the pig thief. Now what?† You could run down the leads, pound the pavement, check all your facts with two sources, then structure your meticulously gathered information into the inverted pyramid form and what you got was: The pig's owner had gotten drunk and beat up his wife, so she sold his pig to someone on the outer islands and bought a used stun gun from an ensign with the Navy Cat team. The next time her husband got rough, a group of Japanese tourists found him by the side of the road, sizzling in the dirt like a strip of frying bacon. Mistaking him for a street performer, the tourists clapped joyously, took pictures of each other standing beside the electrocuted man, and gave his wife five dollars. The whole intrigue had been exposed when police found the pig-stealing wife in front of the Continental Hotel charging tourists a dollar apiece to watch her zap her husband's twitching supine body. The stun gun was confiscated, no charges were pressed, and the wife beater was pronounced unharmed by a Peace Co rps volunteer, although he did need to be reminded several times of his name, where he lived, and how many children he had. The mystery was solved and the Truk Star had no lead story. Jefferson Pardee was miserable. He was actually going to have to go out and find a story or, as he had done so many time before, make one up. The Micro Spirit was in port. Maybe he'd go down to the dock and see if he could stir up some news out of the crew. He slid his press card into the band of his Australian bush hat and waddled out the door and down the dusty street to the pier where rock-hard, rope-muscled islanders were loading fifty-five-gallon drums into cargo nets and hoisting them into the holds of the Micro Spirit. The Micro Spirit and the Micro Trader were sister ships: small freighters that cruised the Micronesian crescent carrying cargo and passengers to the outer islands. There were no cabins other than those of the captain and crew. Passengers traveled and slept on the deck. Pardee waved to the first mate, a heavily tattooed Tongan who stood at the rail chewing betel nut and spitting gooey red comets over the side. â€Å"Ahoy!† Pardee called. â€Å"Permission to come aboard.† The mate shook his head. â€Å"Not until we finish loading this jet fuel. I'll come down. How you doing, Scoop?† Pardee had convinced the crew of the Micro Spirit to call him â€Å"Scoop† one drunken night in the Yumi Bar. He watched the mate vault over the railing at the bow and monkey down a mooring line to the dock with no more effort than if he was walking down stairs. Watching him made Pardee sad that he was a fat man. The mate strolled up to Pardee and pumped his hand. â€Å"Good to see you.† â€Å"Likewise,† Pardee said. â€Å"Where you guys in from?† â€Å"We bring chiefs in from Wolei for a conference. Pick up some tuna and copra. Same, same.† Pardee looked back at the sailors loading the barrels. â€Å"Did you say jet fuel? I thought the Mobil tankers handled all the fuel for Continental.† Continental was the only major airline that flew Micronesia. â€Å"Mobil tankers won't go to Alualu. No lagoon, no harbor. We going to Ulithi, then take this fuel special order to the doctor on Alualu.† Pardee took a moment to digest the information. â€Å"I thought the Micro Trader did Yap and Palau States. What are you going all the way over there for?† â€Å"Like I say, special order. Moen has jet fuel, we here in Moen, doctor wants jet fuel soon, so we go. I like it. I never been Alualu and I know a girl on Ulithi.† Pardee couldn't help but smile. This was a story in itself. Not a big one, but when the Trader or the Spirit changed schedules it made the paper. But there was more of a story somewhere in those barrels of jet fuel, in the ru-mor of armed guards, and in the two pilots that had passed through Truk on the way to No One's Island. The question for Pardee was: Did he want to track it down? Could he track it down? â€Å"When do you sail?† he asked the mate. â€Å"Tomorrow morning. We get drunk together tonight Yumi Bar. My boys carry you home if you want. Hey?† The mate laughed. Pardee felt sick. That was what they knew him for, a fat, drunken white man who they could carry home and then tell stories about. â€Å"I can't drink tonight. I'm sailing with you in the morning. I've got to get ready.† The mate removed the betel nut cud from his cheek and tossed it into the sea, where tiny yellow fish rose to nip at it. He eyed Pardee suspiciously. â€Å"You going to leave Truk?† â€Å"It's not that big a deal. I've gone off-island before for a story.† â€Å"Not in ten years I sail the Spirit.† â€Å"Do you have room for another passenger or not?† â€Å"We always have room. You know you have to sleep on deck?† Pardee was beginning to get irritated. He needed a beer. â€Å"I've done this before.† The mate shook his head as if clearing his ears of water and laughed. â€Å"Okay, we sail six in morning. Be on dock at five.† â€Å"When do you come back this way?† â€Å"A month. You can fly from Yap if you don't want to come back with us.† â€Å"A month?† He'd have to get someone to run the paper while he was gone. Or maybe not. Would anyone even notice he was gone? Pardee said, â€Å"I'll see you in the morning. Don't get too drunk.† â€Å"You too,† the mate said. Pardee made his way down the dock, feeling every bit of his two hundred and sixty pounds. By the time he made it back to the street, he was soaked with sweat and yearning for a dark air-conditioned bar. He shook off the craving and headed for the Catholic high school to ask the nuns if they had any bright students who might keep the paper running in his absence. He was going to do it, dammit. He'd be on the dock at five if he had to stay up all night drinking to do it.

Does Doctor-Patient Communication Affect Patient Satisfaction with Hospital Care? Essay

The results from the study show that most of the patients are served within five minutes upon their arrival at the hospital. Taking an overview look on the results, it emerges that medical personnel in Netherlands serve their patients faster than their counterparts in Saudi Arabia. However, it is discouraging to find out that the percentage that is served beyond five minutes after the arrival is high. Myocardial infarction is an emergency condition (Covinky, K.E., et al., 544). It should be treated as such. The sooner it is handled the better the outcomes. Therefore, it is important for the hospitals to put in place strategies that will enable them handle myocardial infarction cases with speed. The percentage handled within the first five minutes must rise close to 100% for better outcomes. Satisfaction with the explanations about the tests done:                The findings show that patients in both hospitals are satisfied with the explanations given to them regarding the tests that are done concerning their condition. This is indicated by the high percentage that represents satisfaction. However, it appears that the level of satisfaction in Netherlands is higher than the level of satisfaction in Saudi Arabia. Ordinarily, it is important for the medical personnels to explain all the tests that are needed to be carried out on a patient prior to performing them. It is necessary to engage the patient adequately in the process of the treatment. Considering these findings, it is practical to state that the hospitals in both countries are doing what is required of them. Patient satisfaction with the explanation given about myocardial infarction:                The findings from the study clearly show that the patients were generally satisfied with the explanation given to them by the medical personnel with regard to their condition. It is important for the medical personnels to offer good explanation to the patients with regard to their condition. The patients become aware of their condition and therefore assume full responsibility of it. With awareness on the part of the patients, there is compliance that helps in achieving positive treatment outcomes. In addition, giving enough information to the patients regarding their disease empowers them in making better decisions (Priporas, C.V., et al., 48). They become aware of their role to play in the process of the management of the condition. In the case this study, is encouraging to find out that the hospitals used in the study are keen on this aspect of involving the patient in the treatment by informing them well. Satisfaction with the personal attention given to the patients by the doctors:                The results of the study reveal that the patients are generally satisfied by the personal attention that doctors give to them. In Netherlands, the level of satisfaction by percentage of the respondents is near 100%. This is an indication of good practice by the doctors in these hospitals. Giving a patient individualized attention makes them feel that they are important. In addition, it makes them feel that their condition is being taken care of. This is an important practice that should be incorporated in the hospitals. Moreover, when the doctors get close to the patient, they can get essential information that may be necessary in the course of the treatment. The patient can reveal deep information to a doctor who shows a sense of caring and concern. Both hospitals involved in this study are doing quite well in this respect. They are showing the necessary concern that is required when handling the patients by instituting personal attention to each patient. Ac cording to Clever, S.L.,et al (234), good patient-doctor relationship improves the outcome. Satisfaction with the expertise of the medical personnel:                The findings indicate a general high level of satisfaction of patients to the expertise of the medical personnels handling them in both countries. The findings show that patients in Netherlands trust the expertise of the medical personnel handling them. In Netherlands, the level of satisfaction is approaching 100%. Nevertheless, even that in Saudi Arabia is not badly off. The findings show that the medical personnels in both countries handling cases of myocardial infarction are up to the task. The expertise of the medical personnel should be of high standard when it comes to dealing with such cases as myocardial infarction (Quintama, J.M., et al, 69). Satisfaction level of the patients with the information given to them regarding their treatment:                Generally, the patients are satisfied with the information that is given to them regarding their treatment. This information includes various treatment options available, drugs to be used in the treatment, need for adherence to the treatment and the expected prognosis (Clever, S.L., et al., 235). The information given to the patients should be such that it helps in achieving a better outcome. In this regard, it should promote compliance and adherence to the treatment on the part of the patients. If the patients trust the level of the expertise of the medical personnel, they are satisfied with the information that they give to them. Patients’ satisfaction with the way the hospital facilitates visits by the family members and relatives:                Generally, the patients in both countries are satisfied with the schedule that the hospital has for the visits by the family members and other relatives. Family members and relatives are important to the patient because they offer emotional support that is pertinent in the recovery progress. It is clear that in Netherlands, the level of satisfaction is so high approaching 100%. This is because there are no limitations imposed on the visits by the family members to the patients. Satisfaction with the rules given:                High percentage of patients in both hospitals showed satisfaction with the rules that they are given after discharge with regard to managing their condition. These rules include the amount of exercise they should involve themselves with, the kind of diet that is consistent with their condition, how to assess their heart condition in the course of their activities and what to do in case they suspect an abnormality. Nevertheless, there is a small difference in the level of satisfaction between Netherlands and Saudi Arabia. The difference could be due to the explanations that accompany the rules given. The rules given are understood at different degrees depending on the person giving them and how they are given (Quintama, J.,M., et al., 68). It is possible that, in Netherlands, patients are given the rules and then given the reasons why they should adhere to them. In Saudi Arabia, poor communication between the patients and the medical personnel may be the cause for the massive dissatisfaction expressed by the patients. Patients’ satisfaction with the time spent with them by the doctors:                Generally, there is a higher percentage of the patients who are satisfied with the time spent with them by the doctors. However, a small percentage of patients is either neutral or dissatisfied by the amount of time and privacy accorded by the doctors. This finding reveals that the doctors are embracing the need for them to attend to the patients by giving them enough time. It is encouraging to find out that the patients are satisfied with the time that the doctors spend with them. These results show consistency with previous findings in this study. According to Priporas, C.V., et all (47), the doctor’s attitude towards the patient is very important in the psychological support of the patient. Doctors in Netherlands have more time with their patients than their counterparts in Saudi Arabia. It is necessary for the doctors to avail adequate time to the patients. This gives them an opportunity to understand the patient condition of the patient well. In a ddition, this creates a strong bond that defines doctor-patient relationship that can influence the subsequent steps in the treatment process. Patient’s satisfaction with the food and drinks provided:                The findings in this study show that the patients are generally satisfied with what the hospital provides for food and drinks in both hospitals. Admitted patients need proper diet that is consistent with the condition that they are suffering from. While they are recovering, they require proper food to help boost their body immunity. Moreover, there is need for more energy to assist in the general body recovery process. In findings in this report are encouraging as far as the patients’ care is concerned. General evaluation of the experience of the patients in the hospital:                Generally, patients rated the level of management in both hospitals highly. They indicated that the management provided was good enough to allow for proper management of myocardial infarction. The findings are encouraging. It is important for the hospital management to provide a conducive environment for the care of its patients (Kova J.A et al, 24). By so doing, the patients get satisfied with the hospital services. This should be the aim of the policy makers and other members of the management team. Significance of the Results                In Netherlands, it is clear that patients are treated well and this is because of high levels of satisfaction as depicted in the results. It is encouraging to find out that patients with myocardial infarction are being treated with urgency that is required because the condition is treated as a matter of emergency. In Saudi Arabia, much needs to be done in the hospitals. If decisions are to be formulated based on the findings, then it is disheartening to find out the high numbers of patients who are dissatisfied by the services offered. Limitations                There were several limitations during the study. Firstly, it was difficult to pin down the exact causes of dissatisfactions by the patients in Saudi Arabia. Also, it was not clear why most of the participants in the study were males. Perhaps further studies are necessary to find the answers to these two problems. It was difficult to get clarifications from the patients because most of them decided to fill the questionnaires out of the hospital and then posted them to the researchers. It is hoped that future studies will consider involving the patients using interviews so that proper clarifications can be done. The other challenge was that it was not possible to encourage with the medical personnel because of time limitation for the study. In the future, it will be paramount to base research on the level of awareness of the medical personnel regarding treatment guidelines for various diseases including myocardial infarction. The level of knowledge by the docto rs improves the patient conditions greatly. Recommendations                This report recommends that the management of KFSHRC in Jeddah, Saudi Arabia must find out how to improve their standards of service delivery for the sake of the patients. In addition, the hospital should come up with a policy that ensures patients with emergency conditions are handled with the necessary urgency. The doctors in the hospital should avail more time with the patients and give them enough attention to boost their level of satisfaction. Moreover, the patients’ emotional support requires attention. One way of doing so is having proper arrangements where the patient’s family members come to visit the patient and spend quality time with them. The UMCG in the Netherlands is doing quite well as far as patient care is concerned. This report recommends that the hospital should continue doing so. Finally, the report recommends that the time taken to handle the patients when they arrive at the hospital should be minimum possible. Delay in the treatment of myocardial infarction can have detrimental consequences. Conclusion                This study shows that patients are generally handled well in Netherlands, UMCG, and Saudi Arabia, KFSHRC. The level of satisfaction as presented in terms of percentages of the respondents is very encouraging. Patient satisfaction in the hospital is a measure of the quality of services being offered. There should be no compromise when it comes to the comfort of the patients in the hospital premises. Myocardial infarction is an emergency condition. It should be treated with urgency because time factor is the primary determinant of the prognosis of the condition. It is a condition that requires that a patient be handled very fast. Although this aspect has low satisfaction levels, generally, the patients gave both hospitals high scores to denote that they are generally satisfied by the services offered.This research adds into the existing researches in establishing the key parameters that determine patient satisfaction. References Clever, Sarah  L., Lei Jin, Wendy Levinson, and David  O. Meltzer. â€Å"Does Doctor-Patient Communication Affect Patient Satisfaction with Hospital Care? Results of an Analysis with a Novel Instrumental Variable: Does Doctor-Patient Communication Affect Patient Satisfaction with Hospital Care?† Health Services Research 42.64  (2008): 233-243. Print. Covinsky, Kenneth  E., Gary  E. Rosenthal, Mary-Margaret Chren, Amy  C. Justice, Richard  H. Fortinsky, Robert  M. Palmer, and C.  S. Landefeld. â€Å"The relation between health status changes and patient satisfaction in older hospitalized medical patients.† Journal of General Internal Medicine 54.43  (1998): 543-547. Print. Priporas, Constantinos-Vasilios, Christina Laspa, and Irene Kamenidou. â€Å"Patient satisfaction measurement for in-hospital services: A pilot study in Greece.† Journal of Medical Marketing 23.6  (2008): 46-51. Print. Quintana, Josà ©Ã‚  M., Nerea Gonzà ¡lez, Amaia Bilbao, Felipe Aizpuru, Antonio Escobar, Cristà ³bal Esteban, Josà ©Ã‚  A. San-Sebastià ¡n, Emilio De-la-Sierra, and Andrew Thompson. â€Å"Predictors of patient satisfaction with hospital health care.† BMC Health Services Research 42.12  (2006): 67-71. Print. Kovac, Julie  A., Samir  S. Patel, Rolf  A. Peterson, and Paul  L. Kimmel. â€Å"Patient satisfaction with care and behavioral compliance in end-stage renal disease patients treated with hemodialysis.† American Journal of Kidney Diseases 3.4  (2002): 23-26. Print. Man, Stefanie  D., Paul Gemmel, Peter Vlerick, Peter  V. Rijk, and Rudi Dierckx. â€Å"Patients’ and personnel’s perceptions of service quality and patient satisfaction in nuclear medicine.† European Journal of Nuclear Medicine and Molecular Imaging 4.3  (2002): 32-34. Print. Source document

Forest Gump as a Successful Movie - Free Essay Example

Sample details Pages: 3 Words: 862 Downloads: 10 Date added: 2017/09/11 Category Advertising Essay Did you like this example? Forest Gump Essay Why do I think Forest Gump was such a successful movie? Three main reasons, first of which is humor. It is a type of humor that makes you feel naughty for laughing at it, as Forest is not trying to be funny. Secondly, because of the plot. The whole story is amazing with twists and turns coming from everywhere and taking Forest to weird and exciting places. Lastly, because of the special effects, they just enhance the movie, which takes it to a different level, and they are done subtlety enough to be believable. One reason for Forest Gump being so funny is it so unpredictable, with Forest sometimes stating the very obvious, to stating things very far outside left field. The writers were very good at catching everyone off guard at every opportunity possible and making them chuckle, giggle or laugh out loud at the simplest things. The mixture of narration and actual dialog allows Forest to tell you what is about to happen and then let it happen which is humorous in its own way. Forest repeats a lot of lines throughout the film which stick in your head and which you end up spreading to your friends, encouraging them to go view it. Lines such as Mamma always had a way of explaining things so that I could understand† (Forrest Gump, 1994) Are repeated and are humorous in the context used while having a deep connection to other aspects of the film. As for the plot, the writers have once again out done themselves with an easily follow able story line, but one that was not predictable. Even aft er multiple viewings I still forget parts that happen and am still surprised when small things happen that trigger my memory. The fact that it incorporates so many different areas is remarkable and one thing that made it stand out from the rest is that it use’s real life events. Don’t waste time! Our writers will create an original "Forest Gump as a Successful Movie" essay for you Create order This allows every viewer to relate to the film in some way and because all of the events are based on real happenings, you start wondering, did my parents meet Forrest Gump? Or, how come we don’t learn about Forrest Gump, as a person, in History? With all these different places that the film takes, you it keeps you interested right until the ending credits. This, to me, is one of the hallmarks of a very good film. The acting in this film was also a definitive factor as to why it was so successful. All the actors played each of their roles to perfection and made the film seem so lifelike. As if I could just take a flight over to Alabama and meet the real Forrest. Special Effects were probably the thing that makes everything just ‘work’. They tie everything together and help to tell the story without words. The feather in the opening and closing scenes of the film is one of the cleverest special effects I’ve ever seen; with all its twists and turns it’s a story in its self. The places it goes, the close shaves it has are almost a representation of some of the ways Forrest leads his life. Falling quickly at the start represents the bullying Forrest goes through as a child, then an updraft, as he loses his leg braces and is able to run away from the kids that were bullying him. The close shave with the car represents the storm Forrest and Lt Dan are put through on their fishing trip. In the end the feather represents destiny, it didn’t have a choice of where it went, all it could do was hold of for dear life. The storm scene also had some great special effects, because you obviously couldn’t go out on a small boat like that and find yourself a cyclone so that you can shoot a scene. The innovation to use a rocket engine to make the wind took care of two problems at once, the need for wind and the need for a lot of background noise, as you never get gale force winds without it making a might large racket. Probably the â€Å"coolest looking† special effect was the ping-pong ball. The speed it moves at makes you stare in disbelief at how good Forrest is. Even though it is not doing any real story telling, or implying anything, it still enhanced the movie by putting Forrest up on a pedestal with the likes of world champions. All in all, I believe the thing that made Forrest Gump a great, memorable movie was the writers. They developed a script that held you in suspense while giving you more and more information, a script that the actors could immerse themselves in enough to play their roles with Oscar winning style and a script that made you laugh, cry in sadness and cry in happiness Sorry this was late, I emailed it to you on Tuesday night, but realized when I got a phone call from Mrs Richards that I had done that over my Hotmail address so you will probably be getting that sooner or later. Sorry once again