Professional Documents
Culture Documents
Recognizing and Reporting Red Flags For The Physical Therapist Assistant 1St Full Chapter PDF
Recognizing and Reporting Red Flags For The Physical Therapist Assistant 1St Full Chapter PDF
Recognizing and Reporting Red Flags For The Physical Therapist Assistant 1St Full Chapter PDF
https://ebookmass.com/product/orthopaedics-for-the-physical-
therapist-assistant-2nd-edition/
https://ebookmass.com/product/pathology-for-the-physical-
therapist-assistant-1st-edition-ebook-pdf/
https://ebookmass.com/product/duttons-introductory-skills-and-
procedures-for-the-physical-therapist-assistant-1st-edition-mark-
dutton/
https://ebookmass.com/product/pathology-for-the-physical-
therapist-assistant-2nd-edition-ebook-pdf-version/
Pathology for the Physical Therapist Assistant E Book
2nd Edition, (Ebook PDF)
https://ebookmass.com/product/pathology-for-the-physical-
therapist-assistant-e-book-2nd-edition-ebook-pdf/
https://ebookmass.com/product/guide-to-evidence-based-physical-
therapist-practice-4th-edition/
https://ebookmass.com/product/earlys-physical-dysfunction-
practice-skills-for-the-occupational-therapy-assistant-4th-
edition-mary-elizabeth-patnaude/
https://ebookmass.com/product/guide-to-evidence-based-physical-
therapist-practice-4th-edition-ebook-pdf/
https://ebookmass.com/product/textbook-for-the-veterinary-
assistant-kara-m-burns/
Recognizing
& Reporting
Red Flags
for the Physical
Therapist
Assistant
This page intentionally left blank
Recognizing
& Reporting
Red Flags
for the Physical
Therapist
Assistant
All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means,
electronic or mechanical, including photocopying, recording, or any information storage and retrieval system,
without permission in writing from the publisher. Details on how to seek permission, further information about
the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance
Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our understanding, changes in research methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds, or experiments described herein. In using such informa-
tion or methods they should be mindful of their own safety and the safety of others, including parties for
whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be
administered, to verify the recommended dose or formula, the method and duration of administration, and
contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of
their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient,
and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume
any liability for any injury and/or damage to persons or property as a matter of products liability, negli-
gence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained
in the material herein.
Printed in China.
In a rare departure from my usual approach, I am going individuals who have a clearly identified NMS problem
to “tell on myself ” and do so in hopes that you, the that is clearly within the scope of the PT/PTA practice—
reader, will see why I think this text is so important. because people often have more than one condition or
You see, I have never worked with a physical therapist problem and even many more comorbidities.
assistant (PTA) before now. My past experience was Using features such as The PTA Action Plan, Points
limited to occasional interactions only with on-the-job- to Ponder, and Picture the Patient, the material in this
trained aides or assistants. And that was years ago. first-time-ever presented text will bring the student or
So I never fully realized the need for the PTA to have working PTA up to date with current best practice
an instructional/reference text like this. across all health care disciplines. The methods and
In fact, I am embarrassed to admit even now that I clinical decision-making model for recognizing red
once questioned why in the world did Montana (where flags presented in this text apply to all practice settings.
I live) have a school to train PTAs? And how was As you will soon read and see in the Introduction to
that going to affect the jobs of physical therapists (PTs)? Recognizing and Reporting Red Flags for the Physical
Yes, I had fallen into the trap of seeing the PTA as Therapist Assistant (Chapter 1), we clearly delineate and
“competition.” differentiate the roles of the physical therapist versus
And then I met Charlene Marshall, who is a PTA the physical therapist assistant in this area of patient/
(and at the time that this text was written, she was client observation.
PTA Faculty and Clinical Coordinator at Great Falls The role of the PTA in performing ongoing assess-
College–Montana State University). She was able to ments and providing accurate information to the PT
clearly, carefully, and collegially educate me. And now is an important one. This is especially true regarding
she has helped me provide the information in this text any red flags or new or developing signs and/or
about recognizing yellow or red flags of systemic dis- symptoms.
ease and instruct the PTA in how to identify (and then Another skill that is important for the PTA to de-
report to the PT) anything suspicious. velop early on is to provide effective and efficient treat-
This is so important to the health of our patients/ ments to the patient/client. With the changes in health
clients. All health care workers must have this informa- care today, it is crucial that the PT and PTA can work
tion. It is in the best interest of our patient/client that together to provide adequate therapeutic interventions
everyone who has contact with that individual is on his in fewer treatment sessions. We believe that the infor-
or her toes and always watching for yellow or red flags. mation provided in this text will not only teach the
Some conditions will be missed even with proper student PTA, but will also provide important knowl-
screening by any health care professional because the edge to the working PTA with any amount of clinical
condition is early in its presentation and has not pro- experience. We hope this text will adequately highlight
gressed enough to be recognizable. In some cases, early this information for you.
recognition makes no difference to the outcome, either And we want to be clear that the purpose of this text
because nothing can be done to prevent progression of is to help the PTA recognize areas that are beyond the
the condition or there is no adequate treatment avail- scope of his or her practice or expertise. The aim is to
able. But most of the time, early recognition and report- provide a step-by-step method for PTAs to identify
ing by the PTA to the PT with follow-up evaluation clients who need further evaluation by the PT or refer-
by the PT and/or referral to a more appropriate health ral or consultation as appropriate with other health care
care professional can yield better outcomes for the professionals.
patient/client.
Any patient or client can present with red flags Catherine C. Goodman, MBA, PT, CBP
requiring reevaluation and at any time—even those Charlene Marshall, BS, PTA
vii
This page intentionally left blank
CONTENTS
5 Recognizing and Reporting Red Flags in the Head, Neck, and Back, 141
ix
This page intentionally left blank
Recognizing
& Reporting
Red Flags
for the Physical
Therapist
Assistant
This page intentionally left blank
CHAPTER
1
Introduction to Recognizing and Reporting Red
Flags for the Physical Therapist Assistant
1
2 CHAPTER 1 Introduction to Recognizing and Reporting Red Flags
Clinical presentation, especially typical red flag signs, The Case Examples and Critical Thinking Activities
and symptoms of emerging problems are included. provide opportunities for students and instructors to
The PTA Action Plan gives the PTA student an op- engage in dialogue and discussion about the role of
portunity to see the clinical application of the text ma- the PTA as a team member and in relation to the super-
terial. These sections include the “how tos” of observ- vising PT when observing, documenting, and reporting
ing, documenting, and reporting red (or yellow) flags potential red (or yellow) warning/cautionary flags.
to the physical therapist (or other health care provider
when appropriate). Follow-up Questions, Points to
Ponder, What to Watch For, and Communication
YELLOW OR RED FLAGS
with the Physical Therapist are just a few examples of The role of the PTA in identifying yellow (caution) or
the components included throughout the text in this red (warning) flag histories and signs and symptoms is
section. important (Box 1-1). A yellow flag is a cautionary or
Even as we write this, the focus on red flags in assess- is a placebo effect. Perhaps there is a physiologic effect
ment has been called into question, so this remains an of movement on the diseased state. The physical ther-
evolving practice.5,6 It has been reported that in the apy intervention may exert a positive influence on the
primary care (medical) setting, some red flags have body as it tries to regain a balance of health and homeo-
high false-positive rates and have very little diagnostic stasis. You may have experienced this phenomenon
value when used by themselves.7,8 Efforts are being yourself when coming down with a cold or symptoms
made to identify reliable red flags that are valid based of a virus. You felt much better and even symptom free
on patient-centered clinical research. Whenever possi- after exercising.
ble, those yellow/red flags are reported in this text.7,9,10 Movement, physical activity, and moderate exercise
Yellow and red flags are only one tool the PTA will aid the body and boost the immune system,11-16 but
monitor. In addition, the PT will review the patient/cli- sometimes such measures are unable to prevail, espe-
ent’s history, presenting pain pattern, and possible asso- cially if other factors are present such as inadequate
ciated signs and symptoms along with results from treat- hydration, poor nutrition, fatigue, depression, immu-
ment administered by the PTA in making a decision to nosuppression, and stress. In such cases the condition
modify treatment or consult with other disciplines. will progress to the point that warning signs and symp-
toms will be observed or reported and/or the patient/
client’s condition will deteriorate. The need for consul-
PTA Action Plan tation with the PT will become much more evident.
Key Factors to Consider
PICTURE THE PATIENT
Three key factors the PTA should always keep in mind
(because these create red flag signs and symptoms) are: The PTA must always keep in mind that medical condi-
• Side effects of medications tions can cause pain, dysfunction, and impairment of the:
• Comorbidities • Back/neck
• Visceral pain mechanisms • Shoulder
If the medical diagnosis is delayed, the correct diagno- • Chest/breast/rib
sis is eventually made when: • Hip/groin
1. The patient/client does not get better with physical • Sacroiliac (SI)/sacrum/pelvis
therapy intervention. But for the most part, the back and shoulder represent
2. The patient/client gets better, then worse. the primary areas of referred viscerogenic pain patterns. In
3. Other associated signs and symptoms eventually essence, anytime a patient or client is being treated for
develop. shoulder or back pain, a yellow flag is raised. These two
areas are the most commonly affected because the organs
are located in the central portion of the body and refer
At time, a patient/client with NMS complaints is symptoms to the nearby major muscles and joints. This
actually experiencing the side effects of medications. In concept will be explained in greater detail in Chapter 2.
fact, this is probably the most common source of asso-
ciated signs and symptoms observed in the clinic. Side PTA Action Plan
effects of medication as a cause of associated signs and
symptoms, including joint and muscle pain, is dis- Monitoring Vital Signs
cussed more completely in Chapter 2. Visceral pain Monitoring vital signs is a quick and easy way to iden-
mechanisms are also discussed in Chapter 2. tify the need for medical conditions that require further
As for comorbidities, many patient/clients are af- evaluation by the PT. Vital signs are discussed more
fected by other conditions such as depression, diabetes, completely in Chapter 4. Asking about the presence of
incontinence, obesity, chemical dependency, hyperten- constitutional symptoms is important, especially when
sion, osteoporosis, and deconditioning, to name just a the cause is unknown. Constitutional symptoms refer
few. These conditions can contribute to significant mor- to a constellation of signs and symptoms present when-
bidity (and mortality) and must be documented as part ever the patient/client is experiencing a systemic illness.
of the problem list. Physical therapy intervention is of- No matter what system is involved, these core signs and
ten appropriate to address the effects of these comor- symptoms are often present.
bidities, but sometimes these problems have not been
recognized and addressed yet, so the PTA brings them
to the PT’s attention as needed.
Finally, consider the fact that some clients with a
REASONS THAT RED FLAGS POP UP
systemic or viscerogenic origin of NMS symptoms get The practice of physical therapy has changed many
better with physical therapy intervention. Perhaps there times since it was first started with the Reconstruction
CHAPTER 1 Introduction to Recognizing and Reporting Red Flags 5
Aides. Clinical practice, as it was shaped by World War health care providers function as a team observing and
I and then World War II, was eclipsed by the polio epi- reporting any unusual, new, or suspicious signs and/or
demic in the 1940s and 1950s. With the widespread use symptoms.
of the live, oral polio vaccine in 1963, polio was eradi- Because today’s health care environment is complex
cated in the United States and clinical practice changed and highly demanding, the PT/PTA team must be alert
again (Fig. 1-1). to red flags of systemic disease at all times. Warning
Today, most clients seen by therapists have impair- flags may come in the form of reported symptoms or
ments and disabilities that are clearly related to NMS observed signs. It may be a clinical presentation that
(Fig. 1-2). Most of the time, the client history and does not match the recent history. It may be someone
mechanism of injury point to a known cause of move- who has been given early release from the hospital or
ment dysfunction. But changes in technology, the vast transition unit. Specific red and yellow flags are dis-
amount of information about health problems now cussed in greater detail later in this chapter, but an un-
available, and the aging of America (and subsequent derstanding of why we must watch out for these may be
needs of the older adults) have changed the way health helpful.
care is delivered and the way PTs function. These fac-
tors are making it more important than ever that all Quicker and Sicker
“Quicker and sicker” is a term used to describe
patients/clients in the current health care arena
(Fig. 1-3).17,18 Quicker refers to how health care delivery
has changed in the last 10 years to combat the rising
costs of health care. In the acute care setting, the focus is
on rapid recovery protocols. As a result, earlier
mobility and mobility with more complex patients are
allowed.19-22 Better pharmacologic management of agi-
tation has allowed earlier and safer mobility. Hospital
inpatients/clients are discharged much faster today than
they were even 10 years ago. Patients are discharged a natural result of the primary condition (e.g., cerebral
from the intensive care unit (ICU) to rehab, step-down palsy) or long-term effects of treatment for other prob-
or transition units, or even home. Outpatient/client sur- lems (e.g., chemotherapy, biotherapy, or radiotherapy
gery is much more common, with same-day discharge for cancer).
for procedures that would have required a much longer
hospitalization in the past. Patients/clients on the medi- Signed Prescription
cal-surgical wards of most hospitals today would have Clients who obtain a signed prescription for physical
been in the ICU 20 years ago. therapy from their primary care physician or other
Sicker refers to the fact that patients/clients in acute health care provider, based on similar past complaints
care, rehabilitation, or outpatient/client setting with any of musculoskeletal symptoms, without actually seeing
orthopedic or neurologic problems may have a past the physician or being examined by the physician will
medical history of cancer or a current personal history of require close observation for red flags.
diabetes, liver disease, thyroid condition, peptic ulcer,
and/or other conditions or diseases. Any of these can get Medical Specialization
worse or spiral out of control—and the first sign of trou- In addition, with the increasing specialization of medi-
ble may be one of the many red flags discussed in this text. cine, clients may be evaluated by a medical specialist
The number of people with at least one chronic dis- who does not immediately recognize the underlying
ease or disability is reaching epidemic proportions. systemic disease, or the specialist may assume that the
According to the National Institute on Aging,23 79% of referring primary care physician has ruled out other
adults over 70 have at least one of seven potentially causes. This type of situation is a yellow (cautionary)
disabling chronic conditions (arthritis, hypertension, flag, again requiring close observation of the client dur-
heart disease, diabetes, respiratory diseases, stroke, and ing the physical therapy intervention.
cancer).24 The presence of multiple comorbidities em-
phasizes the need to view the whole patient/client and Progression of Time and Disease
not just the body part in question. Sometimes in the early presentation, there are no red
In addition, the number of people who do not have flags or associated signs and symptoms to suggest an
health insurance and who wait longer to seek medical underlying systemic or viscerogenic cause of the client’s
attention are sicker when they access care. This factor, NMS symptoms or movement dysfunction. But with the
combined with the American lifestyle that leads to passage of enough time, an untreated disease process can
chronic conditions such as obesity, hypertension, and eventually progress and get worse (Case Example 1-1).
diabetes, results in a sicker population base.25 Not until the disease progresses does the clinical picture
change enough to raise a red flag. In some cases, exercise
Natural History stresses the client’s physiology enough to tip the scales.
Improvements in treatment for neurologic and other Previously unnoticed, unrecognized, or silent symptoms
conditions previously considered fatal (e.g., cancer, cys- suddenly present more clearly.
tic fibrosis) are now extending survivorship and life Symptoms may become more readily apparent or
expectancy for many individuals. Improved interven- more easily clustered. In such cases, the alert PTA may be
tions bring new areas of focus, such as quality-of-life the first to ask the patient/client pertinent questions to
issues. With some conditions (e.g., muscular dystrophy, determine the presence of underlying symptoms requir-
cerebral palsy), the artificial dichotomy of pediatric ing further evaluation by the PT or medical personnel.
versus adult care is gradually being replaced by a life- The PTA must know what follow-up questions to ask
style approach that takes into consideration what is clients in order to identify the need for reevaluation by
known about the natural history of the condition. the therapist. Knowing what medical conditions can
Many individuals with childhood-onset diseases cause signs or symptoms suggestive of NMS involve-
now live well into adulthood. For them, their original ment (especially in the shoulder, neck, or back) is help-
pathology or disease process has given way to second- ful. Familiarity with risk factors for various diseases,
ary impairments. These secondary impairments create illnesses, and conditions is an important tool for early
further limitations and issues as the person ages. For recognition in the assessment process. All of the com-
example, a 30-year-old with cerebral palsy may experi- ponents of assessment and follow-up appropriate for
ence chronic pain, changes or limitations in ambulation the PTA are included in this text.
and endurance, and increased fatigue.
These symptoms result from the atypical movement Patient/Client Disclosure
patterns and musculoskeletal strains caused by chronic Finally, sometimes patients/clients tell the PTA things
increase in tone and muscle imbalances that were origi- about their current health and social history that are
nally caused by cerebral palsy. The PTA’s assessment unknown or unreported to the PT or physician. The
may identify signs and symptoms that have developed as content of these conversations can reveal red flags and
CHAPTER 1 Introduction to Recognizing and Reporting Red Flags 7
hold important clues to point out a systemic illness or symptoms, and/or a clinical presentation that do not fit
viscerogenic cause of musculoskeletal or neuromuscu- the expected picture for NMS dysfunction, this informa-
lar impairment. tion must be communicated effectively to the therapist.
The PTA may hear the client relate new onset of
symptoms that were not present during the initial ex- PTA Action Plan
amination. Such new information may come forth any
time during the episode of care. If the patient/client PT/PTA Team Communication Style
does not progress in physical therapy or presents with Each PT/PTA team will develop their own unique com-
new onset of symptoms unreported before, the screen- munication style. With time and experience, the PTA
ing process may have to be repeated by the therapist. will learn what is appropriate for each situation. One
way to maintain a positive, balanced relationship with
DECISION-MAKING PROCESS the PT is to present the situation and then ask:
• How do you want to handle this? or
This text is designed to help PTAs recognize when it is • How do you want me to handle this?
appropriate to document and report red-flag signs and Unless directed otherwise by the supervising thera-
symptoms. The hallmark of professionalism in any pist, when providing written documentation, the PTA
health care practitioner is the ability to understand the can include in a note to the therapist (or in the medical
limits of his or her professional knowledge. The PTA, record) a short paragraph of findings followed by a list
either on reaching the limit of his or her knowledge or of concerns.
on reaching the limits prescribed by the client’s condi-
tion, should not hesitate to consult with the PT. In this
way, the PTA will work within the scope of his or her Documentation and Liability
level of skill, knowledge, and practical experience. Documentation is any entry into the patient/client
Knowing when to consult with the therapist is just record. Documentation may include the PTA’s observa-
as important as carrying out the plan of care. Once the tions and assessment, progress notes, recap of discus-
PTA recognizes red-flag histories, risk factors, signs and sions with the therapist or other health care professionals,
Another random document with
no related content on Scribd:
I would I had not come.
FALSTAFF
Nay, this is but a feeble grieving you have awakened. For,
madam, you whom I loved once—you are in the right. Our
blood runs thinner than of yore; and we may no longer, I
think, either rejoice or sorrow very deeply.
LADY SYLVIA
It is true.... I must go ... and indeed I would to God, that I
had not come. (Falstaff bows his head and remains
silent. Presently she goes on) Yet, there is something here
which I must keep no longer; for here are all the letters
you ever writ me. (She hands him a little packet. He turns
them awkwardly in his hands once or twice; stares at them
and then at her.)
FALSTAFF
You have kept them—always?
LADY SYLVIA
Yes, but I must not be guilty of continuing such follies. It is
a villainous example to my grandchildren.... Farewell.
(Falstaff draws close to her and takes both her hands in
his. He looks her in the eyes and draws himself very
erect.)
FALSTAFF
How I loved you!
LADY SYLVIA
I know and I thank you for your gift, my lover, O brave,
true lover, whose love I was not ever ashamed to own!
Farewell, my dear, yet a little while, and I go to seek the
boy and girl we know of.
FALSTAFF
I shall not be long, madam. Speak a kind word for me in
Heaven; for I have sore need of it.
LADY SYLVIA
(By this time she has reached the door) You are not sorry
that I came?
FALSTAFF
There are many wrinkles now in your dear face, my lady,
the great eyes are a little dimmed, and the sweet laughter
is a little cracked; but I am not sorry to have seen you
thus. For I have loved no woman truly save you alone; and
I am not sorry. Farewell. (He bends over and reverently
kisses her fingers. Then she leaves as quietly as a cloud
passes.)
FALSTAFF
(he goes back to the chair by the fire and sits at ease)
Lord, Lord, how subject we old men are to the vice of
lying.... Yet it was not all a lie;—but what a coil over a
youthful greensickness ’twixt a lad and a wench more than
forty years syne.... I might have had money of her for the
asking, yet I am glad I did not; which is a parlous sign and
smacks of dotage.... Were it not a quaint conceit, a merry
tickle-brain of Fate that this mountain of malmsey were
once a delicate stripling with apple cheeks and a clean
breath, smelling of civit and as mad for love, I warrant you
as any Amadis of them all? For, if a man were to speak
truly, I did love her. I had special marks of the pestilence.
Not all the flagons and apples in the universe might have
comforted me; I was wont to sigh like a leaky bellows; to
weep like a wench that is lost of her granddam; to lard my
speech with the fagends of ballads like a man milliner; and
did indeed indite sonnets, cazonets and what not of mine
own elaboration.... And Moll did carry them, plump, brown-
eyed Moll that hath married Hodge, the tanner and reared
her tannikins and died long since.
Lord, Lord, what did I not write (He draws a paper from the
packet and leaning over deciphers the faded writing by the
fire light.)
Have pity, Sylvia! Cringing at thy door
Entreats with dolorous cry and clamoring
That mendicant who quits thee nevermore;
Now winter chills the world, and no birds sing
In any woods, yet as in wanton Spring
He follows thee; and never will have done
Though nakedly he die, from following
Whither thou leadest. Canst thou look upon
His woes and laugh to see a goddess’ son
Of wide dominion, and in strategy
More strong than Jove, more wise than Solomon,
Inept to combat thy severity?
Have pity Sylvia! And let Love be one
Among the folk that bear thee company.
Is it not the very puling speech of your true lover? Faith,
Adam Cupid, hath forsworn my fellowship long since; he
hath no score chalked up against him at the Boar’s Head
Tavern; or if he have, I doubt not the next street beggar
might discharge it.
And she hath commended me to her children as a very
gallant gentleman and a true knight. Jove that sees all
hath a goodly commodity of mirth; I doubt not his sides
ache at times, as if they had conceived another wine-god.
“Among the folk that bear thee company” Well well, it was
a goodly rogue that wrote it, though the verse runs but
lamely! A goodly rogue.
(Bardolph steals back into the room.)
BARDOLPH
Well, Sir John?
FALSTAFF
(He addresses Bardolph. As the speech goes on
Bardolph’s jaw drops lower and lower as he gapes his
astonishment) Look you, he might have lived cleanly and
forsworn sack, he might have been a gallant gentleman
and begotten grandchildren and had a quiet nook at the
ingleside to rest his old bones; but he is dead long since.
He might have writ himself armigero in many a bill or
obligation or quittance or what not; he might have left
something behind him save unpaid tavern bills; he might
have heard cases, harried poachers and quoted old saws;
and slept in his own family chapel through sermons yet
unwrit, beneath his presentment, done in stone, and a
comforting bit of Latin but he is dead long since.
(Mistress Quickly too steals in.)
MISTRESS QUICKLY
Well, Sir John?
FALSTAFF
(Continues his meditation, unaware of them) Zooks, I
prate like a death’s head. A thing done hath an end, God
have mercy on us all! And I will read no more of the
rubbish. (He casts the papers into the heart of the fire;
they blaze up and he watches them burn to the last spark.
Then he gives himself a mighty shake) A cup of sack to
purge the brain! And I will go sup with Doll Tearsheet.
(The curtain falls quickly, it also is happy the play hath
ended.)
TRANSCRIBER’S NOTES:
Obvious typographical errors have been corrected.
Archaic or variant spelling has been retained.
*** END OF THE PROJECT GUTENBERG EBOOK POOR JACK: A
PLAY IN ONE ACT ***
1.D. The copyright laws of the place where you are located also
govern what you can do with this work. Copyright laws in most
countries are in a constant state of change. If you are outside
the United States, check the laws of your country in addition to
the terms of this agreement before downloading, copying,
displaying, performing, distributing or creating derivative works
based on this work or any other Project Gutenberg™ work. The
Foundation makes no representations concerning the copyright
status of any work in any country other than the United States.
1.E.6. You may convert to and distribute this work in any binary,
compressed, marked up, nonproprietary or proprietary form,
including any word processing or hypertext form. However, if
you provide access to or distribute copies of a Project
Gutenberg™ work in a format other than “Plain Vanilla ASCII” or
other format used in the official version posted on the official
Project Gutenberg™ website (www.gutenberg.org), you must, at
no additional cost, fee or expense to the user, provide a copy, a
means of exporting a copy, or a means of obtaining a copy upon
request, of the work in its original “Plain Vanilla ASCII” or other
form. Any alternate format must include the full Project
Gutenberg™ License as specified in paragraph 1.E.1.
• You pay a royalty fee of 20% of the gross profits you derive from
the use of Project Gutenberg™ works calculated using the
method you already use to calculate your applicable taxes. The
fee is owed to the owner of the Project Gutenberg™ trademark,
but he has agreed to donate royalties under this paragraph to
the Project Gutenberg Literary Archive Foundation. Royalty
payments must be paid within 60 days following each date on
which you prepare (or are legally required to prepare) your
periodic tax returns. Royalty payments should be clearly marked
as such and sent to the Project Gutenberg Literary Archive
Foundation at the address specified in Section 4, “Information
about donations to the Project Gutenberg Literary Archive
Foundation.”
• You comply with all other terms of this agreement for free
distribution of Project Gutenberg™ works.
1.F.
Most people start at our website which has the main PG search
facility: www.gutenberg.org.