What would you do? Keep them in a lab? How would you justify that?
Public safety.
Because humans never kill, maim, or torture other humans. We'd um.... you know.... legitimately worry that H. neanderthalensis would... um, definitely be, um, more dangerous than H. sapiens.
And most Unix nerds also prefer DIY when it comes to their laptops. However should they develop appendicitis, most would want a little help from a surgeon (even if they themselves were a surgeon).
The reasons you choose an OS seem like they would be a teensy bit different than the reasons you'd choose a system of government.
Yes. Rural areas should not be held hostage by urban ones just because they happen to have more votes. This is the entire point of the US Senate and Electoral College.
So by your reasoning if there was a national (winner-take-all) vote for president, people who live in rural areas should have 1.5 votes (or some number >1.0). Your reasoning seems to be that they are a minority so they should have disproportionate power since they are otherwise vulnerable to the tyranny of the majority. If that is the case, why just use being rural as a minority status worthy of having ones vote count more than others? How about we also give 1.5 votes to the disabled? African Americans? LGBT people? Left-handed people? People with type AB-negative blood? Gingers?
So if you were from Iowa and Iowa's popular vote was different from the national popular vote, your vote counts even less. How would this make someone from Iowa, or any state adopting this, feel like their vote counts more?
It would only make their vote count less if you think that every American's vote counts equally now. But that isn't the case. My vote as a California voter holds less weight than the vote from a resident of Delaware or Iowa. This measure would make the Iowa or Delaware votes equal to mine.
So the question is really would you prefer that every American have the same say in electing the president or should some get more say. If you feel the former is true, support electoral college reform. If you agree with the later support the status quo.
Honestly, I love my fucking job, and would still do it, even if I won the lottery. Just would work less than 50 hours a week, instead of 80.
Exactly. I would soooo be a hobbydoc if I won the lottery. I would still do 10-15 hours a week at the ER because its fun (for the most part), but I would open a private general practice out of my house. I would see people who don't otherwise have access to care and see them the way I want to: 60 minute visits over a cup of tea, maybe even sitting in the garden if its a nice day. And I would even make a house call when its really needed. I wouldn't take money or insurance (in fact I wouldn't see insured people unless we get universal access and everyone is insured). Though I would take a pie or some fried chicken, or a bird feeder, or a nice plant for my garden.
You can't seriously believe that there aren't scads of premeds thinking exactly what you are? And unless cardiology practices some serious birth control like Anesthesia did, there will be a glut. Though if they do practice serious birth control to avoid a glut, a cards fellowship will be harder to come by than an ENT spot.
I'm not in it for seven figures, six figures is the goal.
Good. You'll probably make well over 100,000 by the time you graduate. However as I said, that's not a ton if you are entering it for the money (given that you'll first spend 8 years going into debt unless you've got rich parents) followed by 5 years making around minimum wage (you'll make a small salary as a resident, but because of the hours you work it ends up being for crap hourly.) And with debts in the 200-300k range common, you won't break even with your friends who entered a career after undergrad till you are a decade out from finishing your training.
Plus, I'd rather be private practice than in the cath lab. It's also a disease that is pretty much supported by our lifestyle here in the US and abroad in first world countries.
Ah, that's almost cute in its naivete. If you spend a day in the cath lab (now) doing procedures you'll make $5000. If you spend the day in clinic (which is I think what you mean by 'private practice') you will be lucky to clear $1000. The whole reason that people enter fields like cardiology to make money is that they are procedure heavy. Seeing grandma in clinic gets you squat (except the chance that grandma might need a cath or a pacer from you.)
As an example from my own practice, if I spend 60 minutes with you assessing and diagnosing your abdominal pain, doing a big work-up, and admitting you to the hospital for appendicitis, I make less than if I pull a bean out of a toddlers nose. Procedures are the cash cow of medicine and you will be a pretty poor cardiologist indeed if you keep the attitude that you'd rather be in clinic than the cath lab.
Of course those figures are today, and the well will be drier when you come out. Insurers and the government are seriously putting the clamps on high ticket procedure-monkeys. For example, CA just recently enacted a rule that says hospital based physicians can't bill HMO patients the balance of what their insurer doesn't pay for. So if you do a cath at a hospital in CA and bill Ms Smith's HMO $2000, they can pay you $500 and your only real recourse is a lawsuit against the insurer. And that's just one example. Making money from procedures is going to be far less guaranteed than it is now.
I see little evidence to suggest that I won't be making bank by the time I'm out. Thanks for the condescending "sport" though.
Well as Carl Sagan said: "The absence of evidence is not evidence of absence." This is especially the case when you don't seem to have looked at the abundance of evidence out there suggesting you're projected income will be significantly less than you seem to think. But at least you were a nice young man and demonstrated that my use of 'Sport' was in fact, appropriate.
People are more likely to do something when they have a higher risk to be effected.
Not always. Sometimes people take a defeatist attitude. It depends on how you frame that risk to the patient and how the patient sees it. A good example of such defeatism (and general adolescent 'fuck you' attitude) is kids with CF who start smoking.
1) If you are going into medicine for the money and are pre-med now, you are basically going to end up in the same situation that all those kids coming out of Harvard with MBAs expecting to make millions on Wall Street. Once you finish 4 years of med school, three of IM residency, and 2 of Cards fellowship, the well will have dried up significantly for specialists who don't do fee for service (which few people are for a cath and stent). Have you considered plastics?
2) If you insist on persisting with your career plans, take Spanish now. You're going to be amazed how being bilingual in a useful language in the US sells on your med school and residency application. Because while you are going to be making less money, you are going to have a lot more Spanish speaking patients when you get out. Maybe if you grow a sense of moral responsibility to your fellow men (which should be a pre-rec for med school but sadly isn't) you'll be glad you took my advice and can converse with your patients in their native language in a culturally competent way.
Or better yet, childhood diagnosis with this particular condition would merit lifetime treatment with statins and aggressive control of other modifying factors. Prevent these kids from smoking, get them in a daily exercise habit, teach them a good diet, and monitor and aggressively treat for diabetes and hypertension if/when they appear. Except for the genetic test itself, the rest of that is cheaper than spit. Even in the US, the real cost of the blood tests and medicines would be less than $200 annually. Add two NP visits and its maybe $400 annually. The cost in India would obviously be even cheaper.
However what is expensive is the political will to prevent smoking in children. Its also politically expensive to have cheap and effective public health prevention programs. Heaven forbid you give medicines or pap smears to people who don't have insurance or money.... why.... it.... would be an ENTITLEMENT!
Ok, then when was separation of Church and State added to the constitution? I can't find it in there anywhere.
Actually you are right in one way. It wasn't added, it was there from the beginning in Article 1 of the Bill of Rights. "Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof; or abridging the freedom of speech, or of the press; or the right of the people peaceably to assemble, and to petition the Government for a redress of grievances."
The phrase 'separation of church and state' was originally coined by Jefferson referring as establishing a 'wall of separation' between church and state.
What you may be referring to is the issue that there are two things implied by separation of church and state: 1) freedom of religion and 2) the secularity of government. However given that the founders and the SCOTUS on numerous occasions has interpreted Article 1 to mean both those concepts, I feel pretty safe in stating yes, its in there.
And before anyone claims these are never used, I can honestly say that I actually use them.
Though I work as a physician at a clinic in San Francisco that treats a large population of transgender patients. So if you have reason to use it, the terms actually (well almost) start to come naturally. I see them as sort of a technical jargon from my perspective. Though it does come in useful when you are talking about Chris Jones whose gender is not obvious before you meet hir (or maybe not even after.)
Yes, I always find that same argument to be inane. Those with at least an order of magnitude greater financial and capital power (Israel) complain that the far less well funded and enfranchised group (Hamas) doesn't fight fair because they are not respecting the 'rules of engagement'.
If I were forced to fight someone substantially larger and more powerful, I would feel no qualms about 'fighting dirty'. Its not a fair fight to start with and whining about someone not being 'fair' is ridiculous.
1) Commandeer the newsmedia and make the following policy announcements:
2) All major highways out of the area in question will be made unidirectional for 5 days (with a one lane exception for police/military/fuel supply). If you have a car/van/MC/etc and wish to leave with it, you must do so within the next 5 days.
3) National guard/army/police will be at crucial checkpoints inspecting vehicles. Any vehicle without one passenger for every seat will not be allowed to pass. However, people without vehicles (such as the poor who were left during Katrina) may assemble at these sites and will be offered a seat in your car/van/etc if it is not full.
4) If you refuse to take assigned passengers and/or refuse to eject possessions to do so, your vehicle will be commandeered and given to a car-less driver.
5) On the 6th day all roads will be shut down to personal vehicles and the roads become bidirectional.
6) On days 6-10 buses (and semis capable of hauling people in the trailer) will begin making round trips to evacuate as many of the remaining people as possible. Only vehicles capable of carrying at least 10 people will be allowed on the road.
7) Continued refusal to comply and/or seriously disruptive behavior will result in you being shot on site (both because the delay or misuse of resources you are causing will threaten the lives of others and absolute order is essential to getting as many people out as possible.)
8) The seriously infirm (i.e. nursing home patients, people in the ICU/on vents in hospitals, people who have a less than 6 month life expectancy due to cancer/etc) will not be transported out. If supplies are available and these people consent, euthanasia should be offered by health care workers. To prevent too much hysteria though, during the first 5 days, if you can schlep your family member, they can go in your car/van/suv.
9) All people living outside the 1000km radius will have people assigned to inhabit their living spaces and will be required to accommodate them until more habitable space is available for them. (#7 applies outside of the 1000km radius as well.)
Of course this assumes I have those dictatorial powers. And this certainly would not get everyone out, but I think it would do the most good for the most possible. Though just instituting #3 would have saved hundreds of lives and the suffering of thousands during Katrina.
I don't think it is unreasonable to use the Communist Manifesto to answer the question "What is communism?".
That is like using On the Origin of Species to answer questions about evolution. Of course quote mining Creationists like to do just that since it weakens the argument, which is I suspect why you use Marx rather than contemporary communist theorists.
You took a guess. Educated, but a guess. And you guessed right. What if you had guessed wrong? He might be dead and you wouldn't be bragging here but signing an affidavit in a lawsuit.
Absolutely I took an educated guess. And absolutely had I been wrong I could quite readily been sued (or even if I had been right and he'd had a complication of the TPA.) However, since he was coding the myriad of other things it could have been would have ultimately killed him regardless. I basically had the choice to bet I was right and if he dies, I am hosed OR do standard ACLS and he would die either way (but I would not be considered at fault or been nearly as vulnerable as I hadn't strayed from the beaten path.)
The point wasn't to 'perpetuate the mystique of the Doctor as Omniscient' (since as I said it was a guess based on limited data - the opposite of omniscient). The point was to illustrate that following checklists as an absolute (as they are often touted) can be to the detriment of patient care and safety.
Everyone in the studies in TFA (you did read it, didn't you?) was a highly trained professional. They KNEW how to do their jobs. But they still made mistakes. And when they implemented checklists, the rate of adverse outcomes dropped. Dramatically. This is basic stuff, but you act like it's all handwaving and a plot to take away your autonomy.
Actually I read TFA but I also read TFS when it came out about a year ago. And the whole thing could easily have been a Hawthorne Effect as they did a single group pre and post design.
So we took him to the Doctor's office and THEY diagnosed the ear infection.
And as I said most middle ear infections are VIRAL. Though I don't blame your provider for practicing defensive medicine given your responses in this thread.
The medical profession is the only one in which the practitioners can make repeated mistakes, costing people their health and their lives, and still retain their positions of status and respect.
Oh absolutely. I've heard of that... my brother is a Civil Engineer who does traffic engineering and he's never made a single serious mistake since he still has his license. Oh, wait.... no my bad. He's told me that they make mistakes and misjudgements all the time. Small ones frequently and major ones rarely. And fortunately for him (and the people in the city where he works,) he understands that mistakes are possible - which you apparently don't. And who was it again that had the god complex?
Another point about checklists not being a procedure is that, if you can't check off all the boxes, you STOP and fix the problem or abort the procedure. So if a checklist says "Verify the IV machine is operating correctly" and it isn't, you go get a new one, and THEN you check it off as done. That checklist won't go into the procedure for swapping out equipment (there would be a different procedure), but is simply waiting for the check box to be initialed.
Yet another reason that they can be ill suited to critical care settings. Often you don't have time to 'stop and fix the problem'. I treated a man about two years ago who came in to the ER screaming "I can't breathe" repeatedly. I got report from EMS that he had collapsed at home and that he had prostate cancer. 30 seconds after he arrived his blood pressure dropped like a rock and his pulse disappeared. That's ALL the info I had to go on.
I made the literally split second decision to use a medicine called TPA because I thought it was quite likely given that scenario that he has a pulmonary embolus. There are other things that could have been going on, but this was likely and treatable with TPA. The check-list before administration of TPA is as long as your arm, and the nurses are 'empowered to' refuse to give it unless the checklist has been completed.
Fortunately the nurses that night trusted my judgment and gave the medicine. If we'd waited for the checklist he would be brain dead by the time he received it. He regained his pulse but wasn't breathing, so he was intubated and he was place in the ICU that night. I went up to check on him a day later and he was awake in bed, sipping juice. Three days later he was out of the hospital on long term blood thinners to prevent another clot like the one that almost killed him.
Check lists can be helpful, but they are not a panacea and can themselves cause injury, illness, and death. What is most important is to have a skilled practitioner who knows when you should use them and when not to.
With regard to your son.... what you describe is the classic scenario for a viral syndrome. Most otitis media is viral. Most pinkeye is viral. And almost always infectious mouth ulceration is viral. When you get those three together the likelihood that its viral is almost certain. And to top it off, the rash he had could quite likely have been viral as well.
If you look at adults who claim allergy to penicillin antibiotics based on a childhood rash after an antibiotic, the percent who have an actual allergy is about 10%. The rest are often kids who had a viral syndrome that included a rash who were inappropriately prescribed antibiotics (often due to parental demand) who then had a rash that correlates with but was not caused by an antibiotic.
So checklist or not, assuming your kid is otherwise healthy and fully immunized he would have been best served by no antibiotics at all and just symptomatic treatment. That is my practice (even though I don't use a checklist) because its evidence based. And that's the difference. Evidence based medicine is definitely better, but EBM != checklists. You can have a checklist that is based on granola, crystals, and woo that is shitty care. You can have EBM that is based on a fund of knowledge and clinical acumen rather than a checklist and its great care.
Here's the bad news... a lot of women really appreciate whiney emogoth fag-boys. Emotional connection, eldritch and compelling androgyny, plus you can play dress-up with them. And 3somes ftw - without all the tedious 'aw man I thought you meant with another *girl*' shit (tho it's always an option).
Um, in high school the aforementioned whiney emogoth fag-boys will date you. But generally by college we came out of the closet and while we all love a good hag, we aren't really interested in sex with you. The willingness to do it with another guy should be a big clue.;)
Though as a disclaimer I am really only a fag-boy.... the closest I will get to emogoth is a black tee shirt and some hair gel.
Users tend to be resistant about checklists for 2 reasons:
1) "I know better than the checklist" (your ACE-Inhibitor example)
2) "I don't have time" ("if I spend all my time inputting data into the EMR it becomes more of a hindrance than a help.)
Um, do you want your doctor to prescribe a medicine for you that may be contraindicated because a checklist told her so? Similarly, would you rather your doctor spend time typing and starting at a monitor or talking to you? Given the realities of the current health care system where doctors are expected to see 3 patients an hour, what percentage of your 20 minutes do you want spent actually talking to you?
Aside from the fact that the current types of EMR's are NOT the checklists the study examined
Uh, no. The EMR we use at my hospital prompts you all the time for things like that. The EMR we're implementing for inpatient care now is exactly that. And there are others that I've seen who go even further than ours. I don't know where you're getting your facts for this comment, but that's not what I've experienced interacting with real EMRs on the market today. Hell, that's what the guys selling you the system tout as the most beneficial aspect!
I had the same thing happen when I slipped a disk in my lower back and required an ambulance. Although in excruciating pain, I had to recite my history and present circumstances to each staff member I came in contact with. It was like watching the old telephone game, where the original spoken message to the first person rarely matches by the time it makes it to the last person.
That's actually what's supposed to happen. In fact often when I interview a patient after the nurse or paramedic, newer details come out. Then if I admit you and you talk to the hospitalist, even more details emerge. I can't count the times that the nurse asked the patient if they had allergies to any medicines and the patient says none. Then I ask and the answer changes to 'oh yeah, when I was in the hospital for pneumonia they gave me an antibiotic and I got a bad rash and my lips swelled up...'
Though I often encounter people with the complaint you have: I already told the nurse, ask her or better yet I talked to my doctor on the phone about it, so look in the computer. That is about as useful as a wet kleenex and will actually delay things even more because I won't simply ask the nurse or look in the computer. I always do look at that data, but I don't base my care on it. In fact, you wouldn't want me to.
If they just had a way to not only capture the patient background and case history but easily convey it to next nurse or doctor, I would bet it would reduce plenty of mistakes.
Actually it perpetuates them and numerous studies have demonstrated this. If you have an electronic medical record, instead of getting their own history from the patient people tend to cut and past whats already in the EMR. So that notation of the nurse that the patient has no allergies is entered by the doctor instead of asking themselves and getting the different answer.
By the way, I almost lost her and it was just a kidney stone that was stuck. Don't ever buy the line "oh, they are painful but they will just pass".
Um, they do pass most of the time. I've passed over a dozen myself with nothing more than oral pain and nausea meds with lots of water. However it is correct that a small percentage of stones don't pass and either require removal or breaking the stone into smaller pieces so it passes or that are complicated by infection.
So in the ER I tell people most of the time they pass, but if you get X, Y, or Z symptom come back to the ER. Which is precisely what happened to your wife, I suspect. The problem is that some people are unable to accept diagnostic or therapeutic limitations and uncertainty. And when (inevitably if you come to the doctor enough) you are one of the 3% who don't get better with X treatment you assume that it is due to malice and/or incompetence. Then you do two things which shoot you in the foot:
1) You take a permanently adversarial attitude with people in the health care system. Instead of an appropriate level of concern that manifests as asking things like 'what is this medicine you are giving me and what does it do?' when the nurse brings in a medicine you become hypervigilant and every time the nurse gives you a tylenol (that says tylenol on the pill,) you ask to see the bottle it was from and write down the lot number, expiration date, and the nurses name in your notebook. Just a clue for you: this is going to breed contempt. If you treat the nurses like crap and imply they are malicious and/or incompetent, often your wife may get the standard of care, but she won't get the little extras that make a hospital tolerable and even improve outcomes. Fortunately for people like you, most nurses will treat you decently even if you do that because most of them entered nursing to help people and they understand that prior bad experiences can breed that kind of attitude. However providers are human and don't be surprised if they react li
Just the effect of studying errors will decrease errors. So unless they did a RCT with some patients getting 'checklisted' and some not, its not a study I would change care based on.
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What would you do? Keep them in a lab? How would you justify that?
Public safety.
Because humans never kill, maim, or torture other humans. We'd um.... you know.... legitimately worry that H. neanderthalensis would... um, definitely be, um, more dangerous than H. sapiens.
Sure.
No. Really. I'm serious.
And most Unix nerds also prefer DIY when it comes to their laptops. However should they develop appendicitis, most would want a little help from a surgeon (even if they themselves were a surgeon).
The reasons you choose an OS seem like they would be a teensy bit different than the reasons you'd choose a system of government.
Yes. Rural areas should not be held hostage by urban ones just because they happen to have more votes. This is the entire point of the US Senate and Electoral College.
So by your reasoning if there was a national (winner-take-all) vote for president, people who live in rural areas should have 1.5 votes (or some number >1.0). Your reasoning seems to be that they are a minority so they should have disproportionate power since they are otherwise vulnerable to the tyranny of the majority. If that is the case, why just use being rural as a minority status worthy of having ones vote count more than others? How about we also give 1.5 votes to the disabled? African Americans? LGBT people? Left-handed people? People with type AB-negative blood? Gingers?
It would only make their vote count less if you think that every American's vote counts equally now. But that isn't the case. My vote as a California voter holds less weight than the vote from a resident of Delaware or Iowa. This measure would make the Iowa or Delaware votes equal to mine.
So the question is really would you prefer that every American have the same say in electing the president or should some get more say. If you feel the former is true, support electoral college reform. If you agree with the later support the status quo.
Exactly!
Because he's a terrorist who hates freedom and downloads copyrighted material illegally.
He probably also regularly tosses kittens in a woodchipper.
Honestly, I love my fucking job, and would still do it, even if I won the lottery. Just would work less than 50 hours a week, instead of 80.
Exactly. I would soooo be a hobbydoc if I won the lottery. I would still do 10-15 hours a week at the ER because its fun (for the most part), but I would open a private general practice out of my house. I would see people who don't otherwise have access to care and see them the way I want to: 60 minute visits over a cup of tea, maybe even sitting in the garden if its a nice day. And I would even make a house call when its really needed. I wouldn't take money or insurance (in fact I wouldn't see insured people unless we get universal access and everyone is insured). Though I would take a pie or some fried chicken, or a bird feeder, or a nice plant for my garden.
I may just jizz in my pants thinking about that.
I seriously doubt that by the time I would be done with my fellowship that there will be an over abundance of cardiologists.
Well, you'd be wrong. There is a strong and increasing trend for medical students to avoid primary care. The lifestyle and affluent specialties are ballooning. http://www.nytimes.com/2008/12/12/health/11doctors.html?partner=permalink&exprod=permalink
You can't seriously believe that there aren't scads of premeds thinking exactly what you are? And unless cardiology practices some serious birth control like Anesthesia did, there will be a glut. Though if they do practice serious birth control to avoid a glut, a cards fellowship will be harder to come by than an ENT spot.
I'm not in it for seven figures, six figures is the goal.
Good. You'll probably make well over 100,000 by the time you graduate. However as I said, that's not a ton if you are entering it for the money (given that you'll first spend 8 years going into debt unless you've got rich parents) followed by 5 years making around minimum wage (you'll make a small salary as a resident, but because of the hours you work it ends up being for crap hourly.) And with debts in the 200-300k range common, you won't break even with your friends who entered a career after undergrad till you are a decade out from finishing your training.
Plus, I'd rather be private practice than in the cath lab. It's also a disease that is pretty much supported by our lifestyle here in the US and abroad in first world countries.
Ah, that's almost cute in its naivete. If you spend a day in the cath lab (now) doing procedures you'll make $5000. If you spend the day in clinic (which is I think what you mean by 'private practice') you will be lucky to clear $1000. The whole reason that people enter fields like cardiology to make money is that they are procedure heavy. Seeing grandma in clinic gets you squat (except the chance that grandma might need a cath or a pacer from you.)
As an example from my own practice, if I spend 60 minutes with you assessing and diagnosing your abdominal pain, doing a big work-up, and admitting you to the hospital for appendicitis, I make less than if I pull a bean out of a toddlers nose. Procedures are the cash cow of medicine and you will be a pretty poor cardiologist indeed if you keep the attitude that you'd rather be in clinic than the cath lab.
Of course those figures are today, and the well will be drier when you come out. Insurers and the government are seriously putting the clamps on high ticket procedure-monkeys. For example, CA just recently enacted a rule that says hospital based physicians can't bill HMO patients the balance of what their insurer doesn't pay for. So if you do a cath at a hospital in CA and bill Ms Smith's HMO $2000, they can pay you $500 and your only real recourse is a lawsuit against the insurer. And that's just one example. Making money from procedures is going to be far less guaranteed than it is now.
I see little evidence to suggest that I won't be making bank by the time I'm out. Thanks for the condescending "sport" though.
Well as Carl Sagan said: "The absence of evidence is not evidence of absence." This is especially the case when you don't seem to have looked at the abundance of evidence out there suggesting you're projected income will be significantly less than you seem to think. But at least you were a nice young man and demonstrated that my use of 'Sport' was in fact, appropriate.
People are more likely to do something when they have a higher risk to be effected.
Not always. Sometimes people take a defeatist attitude. It depends on how you frame that risk to the patient and how the patient sees it. A good example of such defeatism (and general adolescent 'fuck you' attitude) is kids with CF who start smoking.
Let me give you two bits of advice, Sport:
1) If you are going into medicine for the money and are pre-med now, you are basically going to end up in the same situation that all those kids coming out of Harvard with MBAs expecting to make millions on Wall Street. Once you finish 4 years of med school, three of IM residency, and 2 of Cards fellowship, the well will have dried up significantly for specialists who don't do fee for service (which few people are for a cath and stent). Have you considered plastics?
2) If you insist on persisting with your career plans, take Spanish now. You're going to be amazed how being bilingual in a useful language in the US sells on your med school and residency application. Because while you are going to be making less money, you are going to have a lot more Spanish speaking patients when you get out. Maybe if you grow a sense of moral responsibility to your fellow men (which should be a pre-rec for med school but sadly isn't) you'll be glad you took my advice and can converse with your patients in their native language in a culturally competent way.
Or just go into plastics.
Can you mod parent complete utter fucking douchebag?
Or better yet, childhood diagnosis with this particular condition would merit lifetime treatment with statins and aggressive control of other modifying factors. Prevent these kids from smoking, get them in a daily exercise habit, teach them a good diet, and monitor and aggressively treat for diabetes and hypertension if/when they appear. Except for the genetic test itself, the rest of that is cheaper than spit. Even in the US, the real cost of the blood tests and medicines would be less than $200 annually. Add two NP visits and its maybe $400 annually. The cost in India would obviously be even cheaper.
However what is expensive is the political will to prevent smoking in children. Its also politically expensive to have cheap and effective public health prevention programs. Heaven forbid you give medicines or pap smears to people who don't have insurance or money.... why.... it.... would be an ENTITLEMENT!
Shudder! Aiiigh! No, not that!
Wait, did that sound bitter?
Ok, then when was separation of Church and State added to the constitution? I can't find it in there anywhere.
Actually you are right in one way. It wasn't added, it was there from the beginning in Article 1 of the Bill of Rights. "Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof; or abridging the freedom of speech, or of the press; or the right of the people peaceably to assemble, and to petition the Government for a redress of grievances."
The phrase 'separation of church and state' was originally coined by Jefferson referring as establishing a 'wall of separation' between church and state.
What you may be referring to is the issue that there are two things implied by separation of church and state: 1) freedom of religion and 2) the secularity of government. However given that the founders and the SCOTUS on numerous occasions has interpreted Article 1 to mean both those concepts, I feel pretty safe in stating yes, its in there.
Ze or Sie. http://en.wikipedia.org/wiki/Gender-neutral_pronoun
And before anyone claims these are never used, I can honestly say that I actually use them.
Though I work as a physician at a clinic in San Francisco that treats a large population of transgender patients. So if you have reason to use it, the terms actually (well almost) start to come naturally. I see them as sort of a technical jargon from my perspective. Though it does come in useful when you are talking about Chris Jones whose gender is not obvious before you meet hir (or maybe not even after.)
Yes, I always find that same argument to be inane. Those with at least an order of magnitude greater financial and capital power (Israel) complain that the far less well funded and enfranchised group (Hamas) doesn't fight fair because they are not respecting the 'rules of engagement'.
If I were forced to fight someone substantially larger and more powerful, I would feel no qualms about 'fighting dirty'. Its not a fair fight to start with and whining about someone not being 'fair' is ridiculous.
1) Commandeer the newsmedia and make the following policy announcements:
2) All major highways out of the area in question will be made unidirectional for 5 days (with a one lane exception for police/military/fuel supply). If you have a car/van/MC/etc and wish to leave with it, you must do so within the next 5 days.
3) National guard/army/police will be at crucial checkpoints inspecting vehicles. Any vehicle without one passenger for every seat will not be allowed to pass. However, people without vehicles (such as the poor who were left during Katrina) may assemble at these sites and will be offered a seat in your car/van/etc if it is not full.
4) If you refuse to take assigned passengers and/or refuse to eject possessions to do so, your vehicle will be commandeered and given to a car-less driver.
5) On the 6th day all roads will be shut down to personal vehicles and the roads become bidirectional.
6) On days 6-10 buses (and semis capable of hauling people in the trailer) will begin making round trips to evacuate as many of the remaining people as possible. Only vehicles capable of carrying at least 10 people will be allowed on the road.
7) Continued refusal to comply and/or seriously disruptive behavior will result in you being shot on site (both because the delay or misuse of resources you are causing will threaten the lives of others and absolute order is essential to getting as many people out as possible.)
8) The seriously infirm (i.e. nursing home patients, people in the ICU/on vents in hospitals, people who have a less than 6 month life expectancy due to cancer/etc) will not be transported out. If supplies are available and these people consent, euthanasia should be offered by health care workers. To prevent too much hysteria though, during the first 5 days, if you can schlep your family member, they can go in your car/van/suv.
9) All people living outside the 1000km radius will have people assigned to inhabit their living spaces and will be required to accommodate them until more habitable space is available for them. (#7 applies outside of the 1000km radius as well.)
Of course this assumes I have those dictatorial powers. And this certainly would not get everyone out, but I think it would do the most good for the most possible. Though just instituting #3 would have saved hundreds of lives and the suffering of thousands during Katrina.
That is like using On the Origin of Species to answer questions about evolution. Of course quote mining Creationists like to do just that since it weakens the argument, which is I suspect why you use Marx rather than contemporary communist theorists.
Absolutely I took an educated guess. And absolutely had I been wrong I could quite readily been sued (or even if I had been right and he'd had a complication of the TPA.) However, since he was coding the myriad of other things it could have been would have ultimately killed him regardless. I basically had the choice to bet I was right and if he dies, I am hosed OR do standard ACLS and he would die either way (but I would not be considered at fault or been nearly as vulnerable as I hadn't strayed from the beaten path.)
The point wasn't to 'perpetuate the mystique of the Doctor as Omniscient' (since as I said it was a guess based on limited data - the opposite of omniscient). The point was to illustrate that following checklists as an absolute (as they are often touted) can be to the detriment of patient care and safety.
Actually I read TFA but I also read TFS when it came out about a year ago. And the whole thing could easily have been a Hawthorne Effect as they did a single group pre and post design.
And as I said most middle ear infections are VIRAL. Though I don't blame your provider for practicing defensive medicine given your responses in this thread.
Oh absolutely. I've heard of that... my brother is a Civil Engineer who does traffic engineering and he's never made a single serious mistake since he still has his license. Oh, wait.... no my bad. He's told me that they make mistakes and misjudgements all the time. Small ones frequently and major ones rarely. And fortunately for him (and the people in the city where he works,) he understands that mistakes are possible - which you apparently don't. And who was it again that had the god complex?
Yet another reason that they can be ill suited to critical care settings. Often you don't have time to 'stop and fix the problem'. I treated a man about two years ago who came in to the ER screaming "I can't breathe" repeatedly. I got report from EMS that he had collapsed at home and that he had prostate cancer. 30 seconds after he arrived his blood pressure dropped like a rock and his pulse disappeared. That's ALL the info I had to go on.
I made the literally split second decision to use a medicine called TPA because I thought it was quite likely given that scenario that he has a pulmonary embolus. There are other things that could have been going on, but this was likely and treatable with TPA. The check-list before administration of TPA is as long as your arm, and the nurses are 'empowered to' refuse to give it unless the checklist has been completed.
Fortunately the nurses that night trusted my judgment and gave the medicine. If we'd waited for the checklist he would be brain dead by the time he received it. He regained his pulse but wasn't breathing, so he was intubated and he was place in the ICU that night. I went up to check on him a day later and he was awake in bed, sipping juice. Three days later he was out of the hospital on long term blood thinners to prevent another clot like the one that almost killed him.
Check lists can be helpful, but they are not a panacea and can themselves cause injury, illness, and death. What is most important is to have a skilled practitioner who knows when you should use them and when not to.
With regard to your son.... what you describe is the classic scenario for a viral syndrome. Most otitis media is viral. Most pinkeye is viral. And almost always infectious mouth ulceration is viral. When you get those three together the likelihood that its viral is almost certain. And to top it off, the rash he had could quite likely have been viral as well.
If you look at adults who claim allergy to penicillin antibiotics based on a childhood rash after an antibiotic, the percent who have an actual allergy is about 10%. The rest are often kids who had a viral syndrome that included a rash who were inappropriately prescribed antibiotics (often due to parental demand) who then had a rash that correlates with but was not caused by an antibiotic.
So checklist or not, assuming your kid is otherwise healthy and fully immunized he would have been best served by no antibiotics at all and just symptomatic treatment. That is my practice (even though I don't use a checklist) because its evidence based. And that's the difference. Evidence based medicine is definitely better, but EBM != checklists. You can have a checklist that is based on granola, crystals, and woo that is shitty care. You can have EBM that is based on a fund of knowledge and clinical acumen rather than a checklist and its great care.
Wait. What?
I'm a registered green. But I'm also gay. And while political positions change teh gay don't.
Paper? Plastic? How about both!
Um, in high school the aforementioned whiney emogoth fag-boys will date you. But generally by college we came out of the closet and while we all love a good hag, we aren't really interested in sex with you. The willingness to do it with another guy should be a big clue. ;)
Though as a disclaimer I am really only a fag-boy.... the closest I will get to emogoth is a black tee shirt and some hair gel.
^ != *
Thus 2*0 != 2^0.
And unfortunately while I have skills to attract women, I bat for the other team.
Um, do you want your doctor to prescribe a medicine for you that may be contraindicated because a checklist told her so? Similarly, would you rather your doctor spend time typing and starting at a monitor or talking to you? Given the realities of the current health care system where doctors are expected to see 3 patients an hour, what percentage of your 20 minutes do you want spent actually talking to you?
Uh, no. The EMR we use at my hospital prompts you all the time for things like that. The EMR we're implementing for inpatient care now is exactly that. And there are others that I've seen who go even further than ours. I don't know where you're getting your facts for this comment, but that's not what I've experienced interacting with real EMRs on the market today. Hell, that's what the guys selling you the system tout as the most beneficial aspect!
That's actually what's supposed to happen. In fact often when I interview a patient after the nurse or paramedic, newer details come out. Then if I admit you and you talk to the hospitalist, even more details emerge. I can't count the times that the nurse asked the patient if they had allergies to any medicines and the patient says none. Then I ask and the answer changes to 'oh yeah, when I was in the hospital for pneumonia they gave me an antibiotic and I got a bad rash and my lips swelled up...'
Though I often encounter people with the complaint you have: I already told the nurse, ask her or better yet I talked to my doctor on the phone about it, so look in the computer. That is about as useful as a wet kleenex and will actually delay things even more because I won't simply ask the nurse or look in the computer. I always do look at that data, but I don't base my care on it. In fact, you wouldn't want me to.
Actually it perpetuates them and numerous studies have demonstrated this. If you have an electronic medical record, instead of getting their own history from the patient people tend to cut and past whats already in the EMR. So that notation of the nurse that the patient has no allergies is entered by the doctor instead of asking themselves and getting the different answer.
Um, they do pass most of the time. I've passed over a dozen myself with nothing more than oral pain and nausea meds with lots of water. However it is correct that a small percentage of stones don't pass and either require removal or breaking the stone into smaller pieces so it passes or that are complicated by infection.
So in the ER I tell people most of the time they pass, but if you get X, Y, or Z symptom come back to the ER. Which is precisely what happened to your wife, I suspect. The problem is that some people are unable to accept diagnostic or therapeutic limitations and uncertainty. And when (inevitably if you come to the doctor enough) you are one of the 3% who don't get better with X treatment you assume that it is due to malice and/or incompetence. Then you do two things which shoot you in the foot:
1) You take a permanently adversarial attitude with people in the health care system. Instead of an appropriate level of concern that manifests as asking things like 'what is this medicine you are giving me and what does it do?' when the nurse brings in a medicine you become hypervigilant and every time the nurse gives you a tylenol (that says tylenol on the pill,) you ask to see the bottle it was from and write down the lot number, expiration date, and the nurses name in your notebook. Just a clue for you: this is going to breed contempt. If you treat the nurses like crap and imply they are malicious and/or incompetent, often your wife may get the standard of care, but she won't get the little extras that make a hospital tolerable and even improve outcomes. Fortunately for people like you, most nurses will treat you decently even if you do that because most of them entered nursing to help people and they understand that prior bad experiences can breed that kind of attitude. However providers are human and don't be surprised if they react li
Two words: Hawthorne effect.
Just the effect of studying errors will decrease errors. So unless they did a RCT with some patients getting 'checklisted' and some not, its not a study I would change care based on.