Difficult Intubation And Post Tonsillectomy Bleeding

Difficult Intubation And Post Tonsillectomy Bleeding A six year old boy with Downs syndrome is on his way to the childrens hospital by ambulance with post-tonsillectomy bleeding. He underwent adeno-tonsillectomy because of recurrent tonsillitis and enlarged adenoids under general anesthesia the day before, some 22 hours ago. Despite being overweight at 37 kilograms and enlarged adenoids he did not suffer from sleep apnea. Prior to his original surgery, the child was uncooperative necessitating an inhalation induction with some struggling. Venous access was difficult even post induction requiring several attempts, and finally being achieved in the left saphenous vein at the ankle. Because of possible atlanto-occipital instability associated with Downs syndrome, laryngoscopy was performed with C-spine precautions. Direct laryngoscopy presented a Grade 3 view due to an enlarged tongue. Bag-mask-ventilation with an oro-pharyngeal airway was easy throughout the preintubation phase. Indirect laryngoscopy using the GlideScopeÂÂ ® revealed a Grade 1 view followed by the placement of a styletted, uncuffed 5 mm ID oral RAE tube. Adeno-tonsillectomy was performed i n the usual fashion and the child was discharged home after an uneventful 20 hour overnight observation period. Apparently, while momentarily unattended at home, the boy ate a hard tea biscuit. The child immediately experienced a sharp pain and an intra oral bleeding started. The emergency physician on duty is confronted with an overweight boy, sitting on a stretcher and spitting blood frequently into a kidney basin. The child is in moderate distress with the following vital signs (HR 152, BP 97/57). The child will not tolerate nasal prong oxygen and the pulse oximeter reading is 94% on room air. Auscultation of the chest is clear. Examination of the mouth reveals brisk bleeding in the right tonsillar bed. An attempt to start an intravenous line in the right saphenous vein is not successful, but blood is obtained for a CBC, coagulation parameters and a cross match for blood. The child is then transferred to the operating room. 45.2 INTRODUCTION: 45.2.1 What is the incidence, Morbidity and Mortality of pediatric post-tonsillectomy bleeding? Tonsillectomy is one of the most frequently performed surgical procedures in children. Rates in children aged 0-14 vary considerably within and between countries. In 1998, they varied from 19 per 10,000 children in Canada to 118 per 10,000 in Northern Ireland, so a very common procedure in both countries (1). The most common post-tonsillectomy complications include postoperative nausea and vomiting and pain. Dehydration may occur in children due to delayed and poor oral intake, nausea and fever. Delayed post-operative bleeding is the most significant complication and though uncommon, is not rare (2). Many estimates of the incidence of post-tonsillectomy bleeding exist in the literature varying widely from 0 to 11.5 percent (3). Typically, however, the rate ranges between 2.9 and 3.4% (4). Mortality rates are rarely reported in the literature. Two large studies reported 0 out of 15,996, and 1 out of 16,381 tonsillectomies in 1979 and 1970 (5). On the other hand, there are many published case reports. Sixty-seven percent of post-adeno-tonsillectomy bleeding originates in the tonsillar fossa and 27% in the nasopharynx. There are two major time frames for post operative bleeding. Most often, the bleeding occurs within the first 24 hours after surgery (primary bleeding) (5). Primary bleeding is generally related to surgical technique, and incidence is declining. Twenty five percent of all post tonsillectomy hemorrhage occurs after 24 hours. This secondary bleeding is not related to surgical technique, is rare and of unchanged prevalence over the years (5). It is mainly observed between the 5th and 10th postoperative day, although it may occur at any time (6). Infection of the tonsillar bed with clot sloughing is believed to be the major cause of secondary bleeding. It tends to occur more commonly in older pediatric patients, because the indication for tonsillectomy in this age group is usually related to recurrent infections rather than airway obstruction, the most common indication in the younger pediatric age group.(5). Since tonsillectomy is usually performed to improve the quality of life in otherwise healthy, young children, any death is unacceptable. 45.3 PATIENT EVALUATION: 45.3.1 What are the initial clinical steps one should take in the patient with post-tonsillectomy bleeding? The diagnosis of post-tonsillectomy bleeding is usually made by a quick history. Parents or patients will mention right away the previous surgery. Differential diagnosis is blunt or sharp trauma to the oropharynx. Rare cases are bleeding tumors of the oropharynx, like hemangioma. The child will present with fresh blood in the mouth and frequent swallowing of blood. Nausea with or without emesis of fresh blood is common. Newer and more potent antiemetic medications may mask or suppress vomiting. Therefore, the amount of blood swallowed may be underestimated. It is not uncommon for children to have been bleeding silently for a prolonged period of time with extensive blood loss. The child is often restless, diaphoretic and pale. The vital signs may show an increased heart rate, because of pain and hypovolemia. In awake children, hypotension following blood loss is a very late sign and then indicates significant hypovolemia. Intravenous access must be established as soon as possible followed by initial volume resuscitation with crystalloid or colloid solutions or. A blood sample for baseline hematocrit or hemoglobin is necessary as well as for blood type and cross match. An intra oral examination will show blood and blood clots. A bleeding source may be seen in the tonsillar bed. Bleeding from the tonsillar bed may initially be controlled using pharyngeal packs and cautery. But children with post tonsillectomy bleeding should be taken back to the operating room for exploration and surgical hemostasis. Repeated attempts to stop bleeding on the ward or in the emergency department should be avoided, except if exsanguination is imminent. A questionnaire of children undergoing tonsillectomy with or without postoperative bleeding showed an increased incidence of post-traumatic stress disorder if the children with bleeding were treated on the ward compared to children without bleeding or if the bleeding was treated in the operating room (7). 45.4 AIRWAY MANAGEMENT 45.4.1 How is the airway usually managed in post-tonsillectomy bleeding? Large volumes of blood may be swallowed, and blood or blood clots are often present in the oral cavity of these children. Despite the fact that the aspiration of blood is not similar in severity to aspiration of gastric acid, it remains an undesirable occurrence. In addition to hypovolemia, patients with post tonsillectomy bleeding present two major problems: Aspiration: These patients must be considered to have a full stomach and are at an increased risk of aspiration. Difficult airway: Blood and blood clots may impair visualization to the vocal cords. In addition swelling of the oropharynx may have occurred because of surgery or infection. This may lead to a changed laryngeal anatomy. Because of the risk of aspiration, a mask induction maintaining spontaneous breathing is not desirable and a rapid sequence induction should be considered. The efficacy and use of cricoid pressure, especially in children is currently controversial. It is noteworthy that cricoid pressure can distort the laryngeal anatomy and worsen the view of the larynx. In addition, it can induce vomiting in the partially anesthetized patient. The blood and blood clots in the oropharynx can impair vision during laryngoscopy or cause plugging of the endotracheal tube. A working suction apparatus is lifesaving and must be prepared in duplicate. One should be a large bore, rigid surgical suction and the other mounted with a flexible endotracheal suction catheter. If one becomes blocked with a blood clot, another is readily available. If large amounts of clot are present, it may be necessary during the initial laryngoscopy to manually remove them with a finger or gauze. A Magill forceps should be available to grab clots deeper in the pharynx, recognizing that these clots may be too fragile to be grasped and removed from the oral cavity using the Forceps. A past history of difficult laryngoscopy is helpful, although this never precludes preparations for a difficult and failed airway. Different sized curved and straight blades as well as a flex tip blade (McCoy laryngoscope) should be readily available. Different sized cuffed endotracheal tubes, with one size up and down of the calculated size must be prepared. They should be preloaded with a well lubricated intubating stylet, as is standard for a rapid sequence induction. A tracheal introducer (Bougie) may be helpful in the presence of a grade 3 view. If the epiglottis is visible, but no laryngeal entrance can be appreciated, a stroke of chest compression may help find the glottic opening by creating air bubbles. The pediatric lightwand represents an elegant technique for intubation in the case of a glottic view obscured by secretions or blood. The extremely bright light can shine easily through blood and blood clots. However experience is necessary when using this device. Indirect laryngoscopy using the video-laryngoscope (GlideScopeÂÂ ® or the AirtraqÂÂ ®) can be difficult. Blood and secretions may block the optical lenses and impair the view to the vocal cords. The lens in the AirtraqÂÂ ® with its position between the lightsource on one side and the guide channel for the endotracheal tube on the other side might be more protected than the lens of the GlideScopeÂÂ ®. Case reports or studies, however, have not been published in this regard. The laryngeal mask plays an accepted role as an alternative airway device in managing the difficult pediatric airway (see Chapter 42). It is used frequently in primary adeno-tonsillectomies. It can be placed quickly and can be used as a conduit for a flexible bronchoscope to guide intubation if required. On the positive side, a laryngeal mask may briefly tamponade the bleeding site, and therefore protect the airway and the optical lens of the bronchoscope. Though, on the other hand, it may not provide sufficient airway protection in situations with increased risk of aspiration like post tonsillectomy bleeding. A case report recently described the successful use of a laryngeal mask for a failed intubation in a post tonsillectomy bleed (8). The use of a flexible bronchoscope alone is not recommended in cases of oropharyngeal bleeding. Experts recommend that the practitioner should rely on the alternative techniques with which they have the most experience and skill. Preparation for the unexpected is essential. An experienced otolaryngologist or other qualified rigid laryngoscopist/bronchoscopist should be in the OR for all of these cases. If direct laryngoscopy fails, a rigid device wielded by the otolaryngologist may just be successful. An appropriately sized, lubricated and tested rigid laryngoscope/bronchoscope connected to a light source and suction must be readily available at the head of the child. Preparation for a surgical airway is also essential (e.g. tracheotomy tray opened and ready). To reduce the risk of postoperative nausea and vomiting the stomach content of the child should be suctioned using an orogastric tube at the end of the procedure, recognizing that this does not guarantee an empty stomach as much of the blood may be clotted. 45.4.2 What are the airway management options for this patient? This patient presents several issues regarding anesthesia induction and airway management: high risk of aspiration difficult intravenous access suspected atlanto-occipital instability known difficult direct laryngoscopy with easy facemask ventilation expected difficult view of the larynx due to blood and secretions Several options for the anesthetic and airway management of this child need to be weighed and considered in light of their risks and benefits: Intravenous induction versus inhalation induction without IV access: This child is undergoing a second surgical procedure within 24 hours. Due to the frightening emergency situation, pain, bleeding and his mental impairment he is distressed and uncooperative. While a smooth inhalation induction with a facemask was preferred for his first surgery, a stomach potentially full of blood mitigates against this approach and for a rapid sequence induction to minimize the duration of an unprotected airway. One might even hope for a rapid venous access following a mask induction to permit medication administration but we know in this case that is not likely. Anesthesia induction with cervical spine precautions versus no C-spine precautions: Downs syndrome is associated with atlanto-occipital instability in up to 20% of cases. It can occur in children as young as 4 years of age. The large head of the Downs child coupled with this atlanto-occipital instability places them at increased risk for cervical spine injury during anesthetic induction. Radiographic findings of cervical spinal instability in Downs syndrome remain controversial. Lateral radiographs of the neck in flexion and extension do not reliably detect atlanto-occipital instability. Due to impaired cognition and anxiety, positioning of the patient can be difficult. Old lateral neck radiographs are not available for this child. Due to the emergency situation, a current neck radiograph is not possible. Therefore cervical spine precautions should be performed. Extreme neck extension should be avoided in this child. Awake tracheotomy versus anesthesia induction with attempted laryngoscopy: The fact that this child has a known difficult direct laryngoscopy together with a documented Grade 3 view favors an awake tracheotomy under local anesthesia. This approach would maintain a protected airway at all times. Awake tracheotomy in adults and children are challenging. Optimal surgical positioning with neck extension is crucial for successful procedure. It is not expected, that this child will tolerate this procedure. This fact, together with the required c-spine precautions would exclude an awake tracheotomy as an option for this child. The plan is to perform an intravenous rapid sequence induction employing indirect laryngoscopy to place an endotracheal tube. Preparations for rigid laryngoscopy are in place and the surgeon is prepared to embark immediately with a surgical airway (in this case a triple set up). 45.4.3 How should you prepare for this case? Following the failed attempt to start an intravenous line in the emergency department, the child was brought to the operating room. As previously outlined, venous access is crucial for induction and fluid resuscitation. Placement of a central line in the awake child is a possible option. For internal jugular vein access, the head may need to be rotated with increased risk associated with the presumed atlanto-occipital instability. The subclavian approach has the risk of a pneumothorax. An ultrasound guided femoral vein approach is an alternative. On the other hand, several studies have shown that an intraosseos cannula can be placed within 60 seconds and that this line provides an excellent access for the administration of medications and fluids. Because of the risks associated with central line placement, the child was prepared for an intraosseous cannula. The right leg was prepped with antiseptic solution, and local anesthetic injected at the tibial plateau. An intraosseous canula was placed without incident. A normal saline solution flowed freely permitting the administration of 20ml.kg-1 bodyweight. Atropine 0.1 mg IV was administered to reduce additional secretions and mitigate vagal responses secondary to laryngoscopy. The usual monitors were applied (pulse oximetry, noninvasive blood pressure and EKG). The surgeon was prepared as was his equipment; the rescue airway cart was in the room. 45.4.4 Management of this child Concurrent with the placement of the intraosseous canula, the child was prepared for a rapid sequence induction. The child was denotrogenated with 100% FiO2 for 3 minutes employing a facemask that was reasonably tolerated with much cajoling. Considering the possibility of significant hypovolemia a 50/50 mix of Ketamine and Propofol (ketofol) was selected for induction and Succinylcholine for neuromuscular blockade. Cricoid pressure during induction was not applied to avoid stimulating vomiting in the already agitated child. It was applied after the child was deeply anesthetized. As soon as the child was deeply asleep and paralyzed, the mouth was suctioned easily and several clots were removed with the Magill Forceps. Again the brisk bleeding from the right tonsillar bed was noted. Since the previous direct laryngoscopy showed a Grade 3 view, a repeated direct laryngoscopy was not attempted. Because the oral cavity seemed to be free of clot, it was decided to proceed with indirect laryngoscopy with the GlidescopeÂÂ ®. Unfortunately, blood obscured the lens and following a prolonged laryngoscopy the attempt to intubate was abandoned. Oxygen saturations fell from 100% to 94% and despite the risk of aspiration, mask ventilation was begun and cricoid pressure was maintained.The saturations recovered nicely. At this point, faced with a failed intubation, rather than a failed airway it was decided to insert a ProSealÂÂ ® laryngeal mask. The oral cavity was once again suctioned with a rigid catheter under direct laryngoscopy and a number 3.0 ProsealÂÂ ® laryngeal mask was easily placed. No air leak was noted and pressure controlled ventilation with a pressure limit of 15 cm H2O was started. A number 5.5 uncuffed endotracheal tube was loaded on a pediatric flexible bronchoscope. Using the LMA ProSealÂÂ ® as a conduit, the bronchoscope was advanced into the trachea. Blood and secretions where present in the LMA and in the trachea but did not obscure the view through the bronchoscope. The ETT was placed easily. With a small air leak at 20 cm H2O airway pressure, it was decided not to change the ETT over a pediatric Cook airway exchanger to a cuffed ETT. Since the LMA did not obscure the surgeons view, it was decided to leave the LMA in place and remove it together with the endo tracheal tube at the end of the procedure after emerge of anesthesia. With a secured airway, the ENT surgeon cauterized the tonsillar bed, and the bleeding artery could be ligated. At the end of the procedure, a large bore nasogastric tube was placed through the suction port of the ProsealÂÂ ® laryngeal mask and the stomach suctioned. The child was taken to the pediatric ICU where he was extubated fully awake one hour later. 45.5 OTHER CONSIDERATIONS 45.5 1 What is the current thinking with respect to the surgical management of post-tonsillectomy bleeding? Life threatening post-tonsillectomy bleeding requires an aggressive approach to surgical management. Initially pressure on the bleeding tonsillar fossa with a clamped gauze or the index finger may give sufficient time to start an intravenous line for blood work and cross match, and to provide for fluid resuscitation or blood transfusion if indicated. If intraoperative localization of the bleeding source is time consuming and local treatment is ineffective, ligation of the external carotid artery at an early stage may be required. Aberrant arterial blood supply to the tonsillar region deriving from the internal carotid artery or the carotid bulb may be present. In cases such as these, packing of the pharynx and angiographic embolization of the feeding artery may be necessary(9). 45.5.2 Are there specific measures that one ought to employ to reduce the postoperative morbidity and mortality of patients following tonsillectomy? The focus on post-tonsillectomy bleeding is on preventive measures, both by the surgeon and the anesthesia practitioner. Tonsillectomy technique: In comparison to the cold knife technique, hot techniques employing bipolar diathermy or coblation tonsillectomy are associated with an increased rate of secondary bleeding (4, 9). The duration, frequency and surgical extent of these techniques are linked to the amount of damage to the surrounding tissue. This damage leads to deeper zones of local necrosis which is vulnerable to bacteria- and enzyme-containing saliva, and therefore at increased risk of secondary bleeding (4, 5). Effects of postoperative, nonsteroidal, antiinflammatory drugs: Nonsteroidal anti-inflammatory drugs (NSAIDs) inhibit platelet cyclo-oxygenase (COX). A recent meta-analysis showed an increased risk of re-operation for hemostasis post-tonsillectomy if conventional NSAIDs such as ketorolac, ibuprofen or ketoprofen were used for postoperative pain control in children (10). On the other hand ketorolac has been proven to be an effective treatment for post tonsillectomy pain, and as a non-opioid delivers an intraoperative opioid sparing effect and leads to a reduction in postoperative respiratory depression, nausea and vomiting. A most recent meta-analysis did not find an altered number of perioperative bleeding events in patients given an NSAID (11). Still, the use of these drugs should be discussed with the surgeon and used with precautions. Effects of dexamethasone for postoperative nausea and vomiting (PONV): Postoperative nausea and vomiting increases the risk of primary hemorrhage and unexpected postoperative hospital admission. Dexamethasone has antiemetic properties in the perioperative setting. However, dexamethasone may inhibit wound healing, attenuate the inflammatory response to local infection and as a result perhaps increase the risk of postoperative bleeding. A recent study in children undergoing tonsillectomy and administered dexamethasone was prematurely terminated because of an increased bleeding rate (12). Similar to NSAIDs, the use of dexamethasone should be discussed with the surgeon und used with caution. Tonsillectomy as outpatient surgery: Traditionally, tonsillectomy has been associated with a hospital inpatient admission. Economic imperatives have pushed hospitals to perform tonsillectomies as outpatient day surgery procedures. The evidence has shown that this can be safely performed with the following exceptions: age under 3 years medical disorders that increase anesthetic and surgical risk craniofacial abnormalities abnormal coagulation, with or without an identifiable bleeding disorder obstructive sleep apnea acute peritonsillar abscess family conditions that prevent easy and rapid return to a medical facility Patients should always be observed for a minimum of 6 hours. They should be able to tolerate oral fluids and be pain free of prior to discharge. As an alternative to hospital admission, a 23 hour overnight observation period can be considered. 45.6 SUMMARY Post-tonsillectomy bleeding is a rare event, which occurs most often within 24 hours following tonsillectomy. However, it may be delayed for up to 14 days postoperatively. The amount and severity of bleeding along with the need to ensure patient comfort and a still surgical field most often make operative revision under general anesthesia necessary. The insidious and continuous nature of the bleeding may lead to significant hypovolemia which is often difficult to assess. Blood work and cross match as well as preoperative intravenous access with fluid resuscitation are crucial in the management of these children. Aspiration and a difficult airway are ever-present risks during the induction of anesthesia in these patients. Rapid sequence induction with direct laryngoscopy and endotracheal intubation is the accepted first choice in the management of these children. An array of pediatric airway management devices need to be immediately available. Blood and secretions can obscure the laryngeal view and can make some devices more useful than others. A surgeon experienced in rigid broncoscopy and establishment of a surgical airway must be present during anesthesia induction. Cautious use of nonsteroidal inflammatory drugs and steroids is advocated. Any death related to a tonsillectomy is a unacceptable bleeding in otherwise healthy children.

Profile of Henri Fayol, a Founding Father of Management

Profile of Henri Fayol, a Founding Father of Management Background and Carrier Henri Fayol was a French industrialist and manager, working in the mine industry and looking for applicable solution to business management. He went to school in Lyon (the second largest city of France) and enrolled at the engineering school of Saint-Etienne (Ecole Nationale des Mines). He received an education as a mine engineer and graduated in 1860 from this school at the age of 19. He was first employed as an engineer at Boigues, Rambourg and Co. In 1874, this company became Commentry-Fourchambault SA or Comambault). It is important to notice he spend all his professional life in the same company experiencing its expansion and knowing well its structure and production methods. Fayol was first remarked as an engineer when he wrote a paper proposing a solution to fire hazard, fire fitting and spontaneous combustion in mine, destructing men and installations. In 1866, he was appointed director of a single mine of Commentry at the age of 25. The company was going through expansion an d added several other mines to the company in other part of France such as Monvicq coal mine and Berry Iron Ore Mine. He became the directors of those mines as well at the age of 31. In the same time, those expansions did not translated in increase of dividend. Quite the contrary, Fayol had to face the fact that Comambault was in dire financial straits. In the late 1880s, the company had failed to pay dividends for at least 4 years. In 1888, at the age of 47 he became the CEO of the Comambault conglomerate. The objective of his mission as a CEO was to make the company viable again which he did. He worked closely with his managers to turn the company around, closing inefficient units, investing in research and technology and expanding the geographical base of the company. In 1908, in a discourse he gave he reminded this episode of industrial history: In 1888, the company Commentry-Fourchambault was on the verge of disappearing in abandoning its plants and in resuming the exhaustion of the mine stocks, when a change of head office came. Since then, the company prospered again. The companys history shows that its fall and rising are uniquely an effect of the administrative process employed. This is with the same mines and the same plants, with the same financial resources, in the same commercial situation, the same board of directors, and the same personal that the company raises again to this moment. Therefore, some administrative methods leave the company to its ruin; other methods give it its prosperity back. Work, experience, knowledge and good will of several thousands of people had been sterilized by some dysfunctional administrative process. And other administrative processes emphasize all its strength. Fayol was head of a very large business with over 10,000 employees, which at the time, was comparable to todays international companies. He remained CEO until his retirement at the end of WWI, in 1918. Before his retirement in 1916, Fayol published his main book Administration Industrielle et Generale in the professional publication called Bulletin de la Socià ©tà © de lindustrie minà ©rale. In 1917, he sets up the Centre for Administrative Studies (CAS) in Paris. His reflections were published as a book only in 1925, the year of his death. This centre was important in diffusing his ideas. It organised seminars and colloquium with industrialists, public sector officials of the French state, engineers, the military, and various academics. The CAS was a platform from which collaboration and further works could be done. From 1921 to 1925, he collaborated to several studies on behalf of the Frenchs public sector. Notably, he produced a study of the Post and Telecom Department as well as the French Tobacco and Match monopoly. Why a founding Father of Management? One remarkable feature about Henri Fayols influence in management is the fact that he is little known compared to Taylor (1856-1915) who lived roughly at the same time. The epoch of the great development of the XIX century industry does not explain why one hits more fame than the other. In 1912, Charles de la Poix de Frà ©minville met Taylor and stated to spread the principles of Taylorian organisation of work. Taylors work dealt with the workshop of manufacturing and Fayols with the mining industry and its general management. One must say that one aspects of the relative slow diffusion of Fayols ideas, is due to timing. In 1916 and 1918, France was dealing with the WWI and its aftermath. Although many of Fayols principles he developed in studies during 1921-25 could have been used for bettering the management of the French state agencies and enterprises were not followed. The reason have to be found in the institutional change of France at the time, whereby France was separating th e church from the state in education, the growth of the public sector, labour union and large businesses correlated with the rise of professional managers and the interest in technology development. My view is that, for ideological reason, when the French state was trying to reinforce itself (by establishing national system of education, nationalisation of companies (train system, post telecom, etc.) but also vis-à  -vis the threat of Germany), Fayols pragmatic criticism and suggestion to change the states forms of management were not always welcome. The reinforcement of the state own industry and the regulation of market by state agencies went well until 1986. That is in the large part, the reason why the French themselves did not consider Henri Fayols work the convenient resource to deal with the management of the Frenchs state agencies and industries. The US business school considered Henri Fayols works worth teaching their undergraduates. It only since the last 10 years (around the end of the 1990) Frenchs scholars have been studying back their own managerial roots. Despite the history of how Fayols ideas come about, one may ask us what is important in them to be consider foundational to management thought. In fact, there is, as any classical management thinker, a basic originality in Fayols proposition on the need of management regarding the dealing of the industry. Fayols Originality To a large extend, all management thinkers and practitioners view the management function as the means to organise technical function of the business toward an optimal economic efficiency. In this respect, Henri Fayol, Frederick Taylor or Alfred Sloan do not differ in their aim. One can find Fayols formulation of the role of management in the industry in a talk he gave in 1900 at the Congrà ©s International des Mines et de la Metallurgie. Fayol makes the following remarks: The technical and commercial services are rather well defined, which is not the case of the administrative services. The way it is built and the attribution it fulfils are not well known, its operations are not immediately clear. It does not visibly built, forge, sell or buy but nevertheless, everybody knows that if it does not work well, the company goes downhill. [Something on] recruitment: It is necessary to link theory and practice in engineers education. But it is about the proportion of each we may differ. Some think one needs to overcharge the programs as well as the lectures given in the engineering schools, other think that we have already reached the limit of theoretical teaching and that one waist our elites youth one or two years that would be better employed in active life. He also make clear in his Book, General and Industrial Management, the difference of skills and attention one needs to deal with engineering work and management work. Fayol drew attention to the need for schools and universities to educate people about administration as a topic of its own right (in conjunction to engineering, and not engineering alone). The point of his reflection on the education needs of the engineers was trying to deal with the qualities required to make a good manager rather than relying on the formal rules of engineering, its aura amongst the bourgeoisie to provide good job to their kids. For that matter, the list of qualities needed to get effective manager is rather dissimilar to what is required to be an engineer alone: Physical qualities: health, vigor, address (manner of behaving) Mental qualities: ability to understand, judge and adapt Moral qualities: energy, firmness, willingness to accept responsibility, initiative, tact, loyalty and dignity General education Special knowledge: pertaining to the functional context of work, function, technical and so on. Experience: knowledge of work, recollection of lessons from experience. Fayol take the need of education very seriously. He indicates three main sources of issues that can potentially trouble the good education of managers: (a) the problem of industrial concentration, (b) the role of higher technical education and its abuse of mathematics and (c) intellectual curiosity. The problem of industrial concentration Managing great business has always presented great difficulties. To get a grasp of it, suffice to glimpse over the various charges a CEO has to take into account. Those difficulties are inherent to the nature of things and have existed at all time. But what did not exist all the time was the recent industrial development and industrial concentration which increased considerably the proportion of big deals and show the lack of good CEO. The role of higher education and the abuse of mathematics We abuse mathematics in the belief that more one knows it, more one is able to govern businesses. Also, [we are in the belief that] their study, more than anything else, develops and makes the judgement correct. Those are mistakes which cause serious issues to our country and which seems to me useful to fight. () A long personal experience taught me that the use of higher mathematics is worthless in business management, and that engineers, pitworkers or steelworkers almost never use it. I firmly believe that elementary mathematics contribute to form your judgement, as all other branches of general culture. I nevertheless do not believe that an intense higher mathematical culture, imposed without necessity to future engineers has the same effect. The excessive culture of any kind of science is unhealthy to both the physic and the intellect. The studies of mathematics do not make exception. Studied at length with intensity, it leaves intact only the well balanced brains. One sees transcending mathematicians without common sense and we see numerous men of common sense who are not mathematicians. Intellectual curiosity You are not prepared to take the direction of a company, even small. School did not give you the administration, commercial and accountancy notions you need to be a CEO. Even if school would have provided them, you will still lack practice and experience that can only be acquired by the contact of men and things. () one asks you to bring with you your diploma, reflection, logic and a spirit of observation and dedication to the accomplishment of your task. Work to complete your professional knowledge, but do not neglect general instruction. Directors inspiring high esteem and admiration never stopped, you will see, to learn through constant effort. () You belong to the intellectual elite, so you should not be uninterested in news, you should be aware of the general ideas agitating modern society in all domains. One sees that Fayol saw that the engineering education (such as he received with its predominance of mathematics) did not answer the challenge one is facing when dealing with organisation and human matters. He saw in management the field of practice and reflection that was needed in the domain where engineering, although provide efficient techniques for dealing with materials, was unable to address the human aspects. It does not mean that management was a sort of humanism but the normal counter-part of the rationalisation of an organisation (private or public) having in mind that one needs to take a special attention to the question of human organisation if one wants an industry to function. Fayols Administrative Theory As a result of his experience and of a continuous reflection on the way to make corporation work best, in situation of change, he reckons one needs to establish an administrative theory which takes into account: The need of projections. It demands to establish a system of yearly projections for the long term objectives and monthly projections for special activities in the company fitting the global planning. The role of projection for the personal is to be able to assess what has been achieved as people go on working. To fight bureaucracy by facilitating the face to face relations, avoiding the multiplicity of hierarchies which increase the irresponsibility of the directors. Also one needs to stability in hierarchy and the possibility to reward or penalize the use of power. Pragmatism has to be applied in the division of labour by controlling decisions to be always balanced with the situation. The need to use control managers to be able to take decisions rapidly before it turns to be catastrophic. In the general literature in management, Fayol is often seen as the top-down manager that worked out the tools of governance to the distribution of task. In fact, his main focus was not to formalise the tools of decision making in a simple chart to follow. Fayols point was that an organisation could not be managed with a simplest view concerning both the function of the organisation and its human components. And for that matter, it is first necessary to consider the organisation, not simply from the tasks analysis view following technology application the industry, but as an integration of several key functions. In other words, Fayol invites us to grasp at once the complexity of the management of business organisation by taking into account the following functions: Techniques (production, transformation), commerce (business and sales), finance (capital management and research), security (protection of goods and persons), accounting (balance sheet, inventory, factory price, statistics, etc) and administration (foresight, organisation, command, coordination and control). Donald Reid (in his paper on Fayol called Fayol: From Experience to Theory) make clear that Fayol, as a practitioner, did accumulate a number of industrial and managerial experience before putting his ideas on paper. He kept copious notes of his observations, having a particular interest in organisational failure and the nature of responsibility and authority among key decision makers. In 1861, Fayol write in his notebook an example of management failure. In one mine, he saw that all work had to be stopped because of an injury to a working horse. The mine manager was absent and the stable manager had no authority to obtain the replacement of the injured horse. In the case of the horse replacement, it was the inability of the company structure to deal with this technical problem that causes inefficiency. Fayol did identify that authority was required to overrun narrow conception of decision making that did not keep the final objective in mind. Fayol was able to overrun the absence of the stable manager in order to get things done. In this case, one sees that authority is neither authoritative nor working without the flexibility demanded by the condition of the situation (the production of coal in this case). In his work, General and Industrial Management, he reviewed all aspects of management involved in the running of a business. Concerning the authority, he came with a list of principles: Unity of command Hierarchical chain of command Separation of powers (authority, subordination, responsibility and control) Centralisation Order. But he did not concentrate only on authority since his interest was about the functioning of the industrial business in its entirety. Since most of the problems he encountered were not technical in the sense of related to engineering skill; but mostly managerial, he came to the conclusion that one needed a certain element of creativity in the managerial practices in order to accommodate industrial realities. For example, he gave the possibility of experienced workers to become supervisors of work groups. In developing working teams with the authority to act and make decisions in the mines, it improved both motivation and effectiveness. The objective was to make them responsible for quality and the timing of work. He observed that all employees are involved in the administration of the business to a greater or lesser degree. In his book General and Industrial Management, he draws a comprehensive perspective of all his experience. One may call this a general theory. But it is clear that in Fayols words, it is an attempt to generalise the sum of experiences he has observed in managing Comambault in order to deliver a compendium of his ideas that could transcend industry and organisational types. One sees that in keeping the area of management large (from the decision making, the work relationship as well as the selection of human resources) Fayol identified the following principles of management (see text 1 of the reading list): Division of work specialisation of labour Authority the right to direct the work of others but requiring commensurate responsibility for actions and performance Discipline obedience and respect for the organisation and fellow workers Unity of command one superior rather than many in contrast to F W Taylor Unity of direction one agreed plan of action leading to focus and coordination of effort Subordination of individual interest to the general interest Remuneration to incentivise and make employees more valuable Centralisation to achieve the right proportion of centralised and decentralised decision making to optimize personnel Scalar chain the chain of authority from top to bottom, allowing also for lateral communication and decision making (the gang plank) Order people and resources in their appropriate place Equity equitable employee relations based on respect and kindliness Stability of tenure of personnel to assist in resources planning Initiative encouraging energy and zeal throughout the organisation Esprit de Corps building a sense of belonging and team work

The Guitar and Its Effect on My Life Essay -- Papers Personal Narrativ

The Guitar and Its Effect on My Life The time was Christmas morning 2003, the ambience was silent and tranquil; not a sound could be heard. All of a sudden, I was woken from my eternal slumber. With awareness of the significance of the time and event, I leaped out of bed and rushed into the living room where a Christmas tree stood tall. Beneath the tree there lay my precious presents. Rummaging through these random gifts that had been awarded to me, I was disappointed to see that there were few that specifically appealed to me. Yet being the foolish child I was, I had overlooked one of them. In the corner of the room was one unwrapped box; upon it labelled â€Å"Electric Guitar and Amplifier†. Although it had not appeared to be something as momentous at first, little had I known that this object was something that would soon turn out to have a highly significant effect on my life†¦ From that point on, the guitar seemed to turn the tables for me. It was highly unlike any other musical instruments I have ever played before, it had seemed to be something that I had become completely attached and addicted to. In spite of all the offers my father had given to me about guitar lessons, I had intentionally turned them down. As puzzled as my father was to my decision, I explained to him that this was an instrument I wanted to play in the form of an enjoyable activity. Having a guitar teacher would give me consistent blocks of homework on specific set pieces, thus turning practice into a task. I wanted to learn to play this instrument at my own pace and I wanted to learn to play this instrument in a manner that I would regard it as something ... ...sion with practicing the guitar has almost reached the point that my parents have had no choice but to enforce a maximum practice time of 3 hours per day on the guitar. They have also warned me that should my grades drop, my guitar would be the first possession of mine that would be confiscated. This in one sense could also be a good thing considering the fact that it does give me more incentive to achieve higher academic grades. After weighing out the pros and cons, I would definitely say that playing the guitar has had a favourably positive effect both psychologically and physically upon my life. With aid of my guitar I was able to release the stresses of everyday life, learn new ideas about music and make new friends. Of all the greatest gifts that anyone has ever bought me, my guitar is definitely among the top.

walmart :: essays research papers

Wal-Mart’s everyday low prices gives an edge over other retailers. †¢ Efficient IT infrastructure enables to smoothen inbound and outbound logistics. †¢ Distribution efficiencies reduces the dependency on the suppliers inefficiencies. †¢ Wide range of products provides customer anything and everything under one roof. †¢ Current dominating market position gives advantage in market development and penetration. †¢ economies of scale of scale Weaknesses- †¢ The weakness is that their overhead is expensive to run store facilities all over the world. †¢ Hierarchical corporate structure may impair decision-making. †¢ In an attempt to succeed by means of low prices, may possibly portray Walmart as a cheap store. †¢ Market maturing †¢ Concentration in a low margin industry †¢ †¢ Zoning issues are the store real estate problems. Just because a company has the ability to build a huge store anywhere it wants to, it does not necessarily mean that it is possible to build one anywhere it wants to. The real estate issue becomes more evident in crowded cities such as Japan where there is a major concern over the availability of real estate. Opportunities †¢ Expansion into emerging International markets †¢ Societal trend towards environmental friendly and American –made products †¢ Move toward value for money products in the slower economic growth Threats- †¢ Even though Wal-Mart is the largest retailer and most successful, they can still be threatened by many factors ranging from their main competitors, environmental, and economic factors. †¢ In many places in USA, Wal-Mart has faced the Anti Wal-Mart activists. According to them having Wal-Mart in the neighborhood kills the local retailers, increases the property taxes to pay for sewage, roads, utilities, and sidewalks. †¢ Regulations and political stability in the international markets †¢ Exchange rate fluctuations †¢ A union problem for ex.Germany has one of the highest degrees of unions and this has a profound effect on hiring, retaining, and laying off employees. Once an employee is hired, it costs more in Germany to keep the employee on payroll and to lay off the employee. German workers are one of the highest paid workers in the world. †¢ Capital intensive for expansion †¢ Challenges The main challenge for Walmart in the years to come is to make sure they continue to keep their customer’s and associates satisfied. In addition, to be a profitable corporation for their investors who own stock in Walmart.