McDonald’s is now accepting job applications through Alexa and Google Assistant.
Not me !
the High school dropouts of today can not even fill out a job application obviously.
hope they can say their names correctly for Alexa
Wednesday, September 25, 2019
Why are doctors writing prescriptions for costly drugs when there are less expensive products that are equally effective and Safe?
Why are doctors writing prescriptions for costly drugs when there are less expensive products that are equally effective and Safe?
TO begin With, doctors frequently do not take cost into consideration when prescribing. Even when they do. there is good evidence that for the most part they are unaware of the cost of drugs, either in absolute terms (how much individual drugs cost) or in relative 21.22 terms (What different drugs cost in relation to one another
TO begin With, doctors frequently do not take cost into consideration when prescribing. Even when they do. there is good evidence that for the most part they are unaware of the cost of drugs, either in absolute terms (how much individual drugs cost) or in relative 21.22 terms (What different drugs cost in relation to one another
Tuesday, September 24, 2019
STD hell
A type of patient that was truly a patient from hell was the young, adolescent girl-type that all-too-frequently came into our OB ward for delivery. Most were victims of dysfunctional homes where there was little love and attention given to them, much less any guidance into the matters of sexuality and growing up. lt is a sad fact of our society that young people are allowed to experiment in sexuality long before they are able to make mature decisions about the consequences of that experimentation. And it is not only the baby that is the outcome of such behavior. Many times the outcome is also sexually transmitted diseases and the sequelae that those diseases cause. Not only do some diseases cause suffering, but some (such as HIV and herpes) are incurable and may cause death. The particular case that I want to tell about here is the story of
a fifteen-year-old black girl who, after the experimentation in Sex that she and her boyfriend did, found herself pregnant and totally unable to care for herself. As it turned Out, her parents had been neglectful and abusive to the point that the state intervened and took her out Of her parents' home. This girl was also, I believe, mildly mentally retarded as well as emotionally disturbed. At her age and level of maturity, she was totally incapable of tolerating the physical and hormonal changes in her body associated With pregnancy. Because of her mental State, she was not capable of tolerating any but the most minor changes associated With life and its associated painful circumstances. She came in to the OB ward several times long before she was due to deliver. She came in because she thought she was having contractions or her water bag had broken. On most of these occasions, we found her cornplaints to be unfounded (after several hours Of monitoring her by myself and expbe unfounded (after several hours of monitoring her by myself and experienced fernale nurses). We would then send her horne With instructions to rest and take Benadryl (to calm her down and make her drowsy) and see her obstetrician in a day or two. However, on one occasion she came in With her social worker (the State took care of her) and I found that indeed she was having fairly vigorous early contractions, making it necessary to give her medication to stop them. We generally tried to make sure patients reached the level of thirty -Six weeks' gestation before delivery, making it necessary to give her rnedication to stop them. After consultation With her obstetrician over the phone (they usuatly loved being called at late hours of the night as this was), I determined that it was necessary to give her the drug terbutaline subcutaneously. When I went into the room to advise the patient and her caretaker of this, just the mention of the name of the drug stirred up this patient. She beganabout on the bed, the very definition of hysterical behavior. As it turned Out, this patient was also an asthmatic and had been given terbutaline before, resulting in some untoward Side effects. Apparently, it had made this patient become wildly agitated With its previous administration. Just mentioning it sent her into that state again, reflective of her extreme emotional instability. The social worker attempted to calm her down, saying, "We've talked about this before and you need to relax." But to say that this had no effect was an understatement, because if anything, the patient became more agitated. lt was apparent to me that giving her this drug was not an Option. I then called the obstetrician back (you can imagine how much he loved this) to inform him of this and he advised me to give her some Procardia, a blood pressure medication that has been found to also stop contractions. This worked, and, after several more hours Of Observation, we let her go horne. I was hoping Copyfish With tru
hoping and praying that I was not on duty when this girl came in With true labor, anticipating that the pain and suffering associated With that event would be a horrible thing to deal With in this girl. I guess God was amenable to this prayer, because I wasn't on duty when she came in With real Labor. A young lady resident was on duty, as it turned Out. When I asked her the next day how the delivery went, the resident just groaned and walked away, actions that spoke volumes. Precipitous deliveries were not an uncommon event in Our obstetric ward. A precipitous delivery is defined as delivery of the baby within two hours of arrival in the obstetrics unit. Many were much faster than that. These are very stressful events for the OB staff as well as the doctors because you don't have much time to prepare for them. And since obstetrics is a field where joyous occasions can turn into screami ncies in minutes if not
seconds, we did not like having Little time to get things ready. However, Of all the precipitous deliveries I was involved in, only one had a complication, which was mercifully minor and brief. Usually, a delivery occurring this fast is a comforting sign to me as a doctor that everything is OK With the mother and baby, otherwise it wouldn't occur so quickly. However, that doesn't mean that they are easy. A classic example was the case of the fifteen-year-old white girl who, after her experimentations With her sexuality, discovered herself to be pregnant. Big surprise! Fortunately, her pregnancy progressed pretty normally until she appeared in our obstetrics ward in Labor. At first, I thought that this was just another case Of an immature adolescent in false labor. First pregnancies typically have labor lasting twelve to eighteen hours and this patient had only been having contractions about half an hour before she presented to the OB ward. However, upon checking her cervix, I discovered that
not only was she completely dilated With 100 percent effacement (cervix thinned Out), but the baby's head was well down into her pelvis. These facts meant that delivery was imminent. The hell for us was that the patient was crying inconsolably and begging to have something for pain. At this point in time, I had no doubt that the patient was in severe, unrelenting pain. Unfortunately, With the limited time we had before delivery, there was no time for us to give her an epidural anesthetic, the safest modality. Epidurals are injections into the nerves coming off of the spinal cord that cause the patient to become largely nurnb below the diaphragm. This takes about thirty minutes to do and it was clear that we were going to have a delivery before then, making it a moot point. Other treatments such as narcotics were out of the question—they were not safe for the baby since they would cause the baby to be sedated at a crucial time when it needed to respond aggressively
to Our Stimulation to prevent brain damage. So, white we were getting the emergency delivery kit out and getting the staff ready for imminent delivery, we tried to calm her down by telling her that the pain wouldn't last long (very true). She was screaming bloody murder throughout the delivery, which indeed only took about ten or fifteen minutes. To make it worse for it was apparent that we were going to have to cut an episiotomy into her perineal tissue for the baby to come Out. This procedure always makes me uncomfortable, since I can imagine someone taking a pair of scissors and cutting that part of my anatomy. I know What the textbooks say about it; namely that at that point in Labor, the patient is in so much pain and there is so much pressure on that area that they don't feel it, but I still cringe at the thought of doing it. I did it in this instance and the baby virtually shot out of the woman (girt). Delivery Of the lacenta wasn't nearl as ainful and I finished u n
Delivery Of the placenta wasn't nearly as painful and I finished up by giving a local anesthetic injection into her perineal tissue to sew up the cut I had to make. The patient's screams had subsided and she relaxed and basked in the temporary security of someone else taking care of her baby while she recovered. From my experience With this kind of patient, this part is the easy part, since they have about eighteen years of pain and emotional suffering raising the product of their immature behavior, frequently With little or no help from the male partner and both the mother's and father's families. A delivery that wasn't really precipitous, but certainly put me at risk, happened With one of my patients. As resident doctors, we had private patients of Our own. This was done to teach us how to manage patients from conception to post-parturn (after delivery). We each got a certain number Of patients from the outpatient practice in the family practice clinic. Most of these
women were really adolescents With Medicaid insurance and were single.. Most were very immature and, as in the previous cases cited, were women Who did not plan their pregnancies. Many came frotn broken, abusive, or neglectful homes and had no idea What becoming a mother involved. This was beneficial for us in many ways because it taught us how to manage patients in far less than optimal circumstances. But the downside was that these Women were usually high risk for sexually transmitted diseases, drug and alcohol use, and poor nutrition. I have to say that overall, we generally did a great job of handling these patients from hell. But we had to be very careful because in the process of managing them, we were put at risk of accidentally catching any diseases they had. This could happen in the process of examining them if we got a needle stick from a needle used on them or came into contact With their body fluids in any way. This was relatively early in the
With their body fluids in any way. This was relatively early in the beginning Of the AIDS epidemic, and heterosexual patients were beginning to be a major population catching this dread, deadly disease. This was always in the back of our minds, so we were very careful With "Universal Precautions," a set of procedures by which we protected ourselves With gloves, masks, and extreme care With needles. This was the setting in which I got the patient whose story I am about to tell. This was an eighteen-year-otd black woman Who became unexpectedly pregnant from her unprotected sexual activity. She couldn't tell me how many sexual partners she had had in the past and the father of her baby was long gone, as was sadly and frequently the case. Even With her high-risk behavior, her pregnancy progressed pretty normally. All the tests for sexually transmitted diseases came back ne ative but I knew that could be Copyfish
in these circumstances frequently continued their high-risk sexual behavior even after testing and being told the risks. When she was within a week or two of her due date (inexact in the best of circumstances) she came into the OB ward With contractions about five or Six minutes apart. We placed her in Observation status and, within about one hour, her contractions Were about three minutes apart and clearly showing a pattern that was indicative of true labor. I was on call and since she was my patient, it was clearly my responsibility to take care of her though we had several residents on duty at the time. This was this patient's first baby and I expected the labor to take twelve to eighteen hours, as is typical of first pregnancies. lt was not to be so. After about five or Six hours, the patient was completely dilated and her cervix effaced (thinned Out) completely, indicating it was time to Start the patient pushing. We had given her an epidural anesthetic at about three hours
pushing. We had given her an epidural anesthetic at about three hours into her labor because she was having substantial pain, so she could not feel much by this time. Since I was still a resident, I had to be supervised doing deliveries by a fully qualified family practice doctor. So I called the family practice attending doctor on call and told him he needed to come in to supervise. White I had him on the phone, he asked me to have the patient push one time to see if the baby's head would come down easily. He didn't want to come in and sit around for several hours White we had the patient pushing. When I had the patient push, the baby's head instantly came down to where it was showing through the vagina, What we call "crowning," a sign that delivery is imminent. I conveyed this knowledge to the attending doctor and suggested strongly that he hustle in quickly. He said that he was on his way and I hung up the phone. That is when the problems began in a hurry, as th usuall did. I noticed that the bab 's head was
continuing to Slide out of the woman in spite of the fact that she, at my request, had stopped pushing. I realized that we were going to have a delivery within minutes no matter What I did. So I quickly took off my exam gloves With the intent of putting on the longer sterile gloves we used for deliveries, as well as the gown and mask needed for precautions in these circunstances. As I turned around to the instrument table to grab the gown, gloves, and mask, the elderly, wise black nurse standing behind the table yelled, "Dr. Baker, you don't have time for that! " I quickly turned around to the patient, Who was up in stirrups for delivery. The baby's head was completely out of the woman and I could see the shoulders rapidly following. In that instant, I knew that my only option was to catch the baby barehanded, putting me at risk for whatever diseases this woman was carrying. If I didn't, within seconds the baby's body was going to be completely out and the baby was going to fall
was going to be completely out and the baby was going to fall about two feet and hit a hard wooden floor. This would obviously not be good for the baby's health. I grabbed the baby's head and supported it and the body as it shot out of the patient. I suctioned the baby's mouth, then clamped and cut the umbilical cord and handed the baby off to the nurse. I then had time to get on my gloves and gown before delivering the placenta and finishing up all post-delivery actions. White doing this, I was wondering What I might have caught. We all have minute breaks in Our Skin that can allow bacteria, viruses, fungi, and parasites to enter. After I was done caring for the patient, the nurse wisely told me that I should wash my hands and arms With alcohol, Betadine (surgical scrub Soap), and regular Soap for at least thirty minutes. After I was through, my arms and hands felt and looked like I had gotten a sunburn. But now, as Paul Harvey would say, came the "rest of the
About Six weeks later, I began having fevers up to 102, feeling sick at my stomach all of the time, and feeling exhausted all the time, even after a full night's sleep. Even doctors can get into denial and for Six more weeks I kept telling myself that it was just a "virus" that would resolve soon. I was trying to squelch the internal fear that it could be the human immunodeficiency virus or some Other dread disease, particularty after that mornentous delivery. After Six weeks of this and working every day With about one hundred hours per week, I began to realize that it wasn't going away and I needed to get evaluated. One reason that I didn't get evaluated before was that I was the head resident on obstetrics, responsible for supervision of Other residents. We were very short of residents and I kept telling myself that the hospital and residency couldn't afford another resident's absence. About that time, another symptom appeared, which gave partial reassurance that it wasn't that dread
appeared, which gave partial reassurance that it wasn't that dread disease. But the symptom indicated What my illness probably was while also giving me something else to fear, though not as bad. My urine began to turn very dark, which is frequently a symptom of hepatitis. Though that was comforting to Some extent, I knew that some forms of hepatitis were not curable and some did lead to death. We had gotten some residents back from Christmas vacation and were fully manned, so I fett that I could indulge my own illness. I went to See one Of the family practice attending doctors and told her my Story. She said the comforting words "Uh, oh," and immediately ordered some lab tests, including liver function tests. The liver function tests came back very high, as expected, but the tests for hepatitis A, B, and C came back negative, creating more questions as to What was causing my hepatitis(hepatitis can be caus Copyfish tests
and lead to death. I took a week off work at the insistence of the attending doctor and, With time to recover instead of using all my energy to work, got well. There was only one clue as to What had caused my hepatitis, which only took my interest one Year later when I began to get the same symptoms, which again lasted Six weeks. This time I couldn't blame a bare-handed delivery for my problems. When I got checked, I had hepatitis again! Blood tests were again unrevealing except for the same atypical lymphocytes in my complete blood count, suggesting infectious mononucleosis- induced hepatitis. A Monospot test for infectious mononucleosis (mono) came up positive, so this time we knew the cause. With the same atypical lymphocytes as the year before, I had to think it was possible that I had had the same thing then, though one infection With that virus usually confers lifetime immunity. lt is also possible that I had an infection With cytomegalovirus the first year, which
I understand can cause the same atypical lymphocytes. But the bottom line was that I was exposed to and may have gotten my first infection from that barehanded delivery from hell. A precipitous delivery that is burned in my memory forever occurred one Saturday or Sunday afternoon when there was absolutely nothing going on in the obstetrics ward. We had no one in labor and the patients and their babies previously delivered were all doing well without any problems. I was sitting at the front desk of the nursing station twiddling my thumbs. The only nurse around the immediate area was sitting about ten feet behind me, also doing nothing important. In these circumstances, I had quickly learned never, but never, to utter the dread words, "lt sure is quiet around here." The nurses were somewhat superstitious about that particular sentence and would immediately start chewing
ordered to immediately get off of the ward. The belief was that, someone having uttered those terrible words, we would get some catastrophic occurrence such as an emergency caesarean section or other incident causing blood pressures and heart rates (ours, of Course) to rise precipitously, along With the risk of a bad outcome. They believed it wholeheartedly and though I didn't harbor such superstitions, I learned fast to keep my mouth shut. This was because those nurses could make my life a living hell if I offended them in any way. But back to the Story at hand. As we were sitting there, I heard the elevator doors at the end Of the hall open, and, half a second later, the most ungodly screaming you could ever imagine. I also heard about three pairs of running feet and the squeaking wheels of a gurney being pushed at near lightning speed down said hall. I leaned over the desk to See What was going on (yeah, like I didn't know!) and Saw three hospital
a fifteen-year-old black girl who, after the experimentation in Sex that she and her boyfriend did, found herself pregnant and totally unable to care for herself. As it turned Out, her parents had been neglectful and abusive to the point that the state intervened and took her out Of her parents' home. This girl was also, I believe, mildly mentally retarded as well as emotionally disturbed. At her age and level of maturity, she was totally incapable of tolerating the physical and hormonal changes in her body associated With pregnancy. Because of her mental State, she was not capable of tolerating any but the most minor changes associated With life and its associated painful circumstances. She came in to the OB ward several times long before she was due to deliver. She came in because she thought she was having contractions or her water bag had broken. On most of these occasions, we found her cornplaints to be unfounded (after several hours Of monitoring her by myself and expbe unfounded (after several hours of monitoring her by myself and experienced fernale nurses). We would then send her horne With instructions to rest and take Benadryl (to calm her down and make her drowsy) and see her obstetrician in a day or two. However, on one occasion she came in With her social worker (the State took care of her) and I found that indeed she was having fairly vigorous early contractions, making it necessary to give her medication to stop them. We generally tried to make sure patients reached the level of thirty -Six weeks' gestation before delivery, making it necessary to give her rnedication to stop them. After consultation With her obstetrician over the phone (they usuatly loved being called at late hours of the night as this was), I determined that it was necessary to give her the drug terbutaline subcutaneously. When I went into the room to advise the patient and her caretaker of this, just the mention of the name of the drug stirred up this patient. She beganabout on the bed, the very definition of hysterical behavior. As it turned Out, this patient was also an asthmatic and had been given terbutaline before, resulting in some untoward Side effects. Apparently, it had made this patient become wildly agitated With its previous administration. Just mentioning it sent her into that state again, reflective of her extreme emotional instability. The social worker attempted to calm her down, saying, "We've talked about this before and you need to relax." But to say that this had no effect was an understatement, because if anything, the patient became more agitated. lt was apparent to me that giving her this drug was not an Option. I then called the obstetrician back (you can imagine how much he loved this) to inform him of this and he advised me to give her some Procardia, a blood pressure medication that has been found to also stop contractions. This worked, and, after several more hours Of Observation, we let her go horne. I was hoping Copyfish With tru
hoping and praying that I was not on duty when this girl came in With true labor, anticipating that the pain and suffering associated With that event would be a horrible thing to deal With in this girl. I guess God was amenable to this prayer, because I wasn't on duty when she came in With real Labor. A young lady resident was on duty, as it turned Out. When I asked her the next day how the delivery went, the resident just groaned and walked away, actions that spoke volumes. Precipitous deliveries were not an uncommon event in Our obstetric ward. A precipitous delivery is defined as delivery of the baby within two hours of arrival in the obstetrics unit. Many were much faster than that. These are very stressful events for the OB staff as well as the doctors because you don't have much time to prepare for them. And since obstetrics is a field where joyous occasions can turn into screami ncies in minutes if not
seconds, we did not like having Little time to get things ready. However, Of all the precipitous deliveries I was involved in, only one had a complication, which was mercifully minor and brief. Usually, a delivery occurring this fast is a comforting sign to me as a doctor that everything is OK With the mother and baby, otherwise it wouldn't occur so quickly. However, that doesn't mean that they are easy. A classic example was the case of the fifteen-year-old white girl who, after her experimentations With her sexuality, discovered herself to be pregnant. Big surprise! Fortunately, her pregnancy progressed pretty normally until she appeared in our obstetrics ward in Labor. At first, I thought that this was just another case Of an immature adolescent in false labor. First pregnancies typically have labor lasting twelve to eighteen hours and this patient had only been having contractions about half an hour before she presented to the OB ward. However, upon checking her cervix, I discovered that
not only was she completely dilated With 100 percent effacement (cervix thinned Out), but the baby's head was well down into her pelvis. These facts meant that delivery was imminent. The hell for us was that the patient was crying inconsolably and begging to have something for pain. At this point in time, I had no doubt that the patient was in severe, unrelenting pain. Unfortunately, With the limited time we had before delivery, there was no time for us to give her an epidural anesthetic, the safest modality. Epidurals are injections into the nerves coming off of the spinal cord that cause the patient to become largely nurnb below the diaphragm. This takes about thirty minutes to do and it was clear that we were going to have a delivery before then, making it a moot point. Other treatments such as narcotics were out of the question—they were not safe for the baby since they would cause the baby to be sedated at a crucial time when it needed to respond aggressively
to Our Stimulation to prevent brain damage. So, white we were getting the emergency delivery kit out and getting the staff ready for imminent delivery, we tried to calm her down by telling her that the pain wouldn't last long (very true). She was screaming bloody murder throughout the delivery, which indeed only took about ten or fifteen minutes. To make it worse for it was apparent that we were going to have to cut an episiotomy into her perineal tissue for the baby to come Out. This procedure always makes me uncomfortable, since I can imagine someone taking a pair of scissors and cutting that part of my anatomy. I know What the textbooks say about it; namely that at that point in Labor, the patient is in so much pain and there is so much pressure on that area that they don't feel it, but I still cringe at the thought of doing it. I did it in this instance and the baby virtually shot out of the woman (girt). Delivery Of the lacenta wasn't nearl as ainful and I finished u n
Delivery Of the placenta wasn't nearly as painful and I finished up by giving a local anesthetic injection into her perineal tissue to sew up the cut I had to make. The patient's screams had subsided and she relaxed and basked in the temporary security of someone else taking care of her baby while she recovered. From my experience With this kind of patient, this part is the easy part, since they have about eighteen years of pain and emotional suffering raising the product of their immature behavior, frequently With little or no help from the male partner and both the mother's and father's families. A delivery that wasn't really precipitous, but certainly put me at risk, happened With one of my patients. As resident doctors, we had private patients of Our own. This was done to teach us how to manage patients from conception to post-parturn (after delivery). We each got a certain number Of patients from the outpatient practice in the family practice clinic. Most of these
women were really adolescents With Medicaid insurance and were single.. Most were very immature and, as in the previous cases cited, were women Who did not plan their pregnancies. Many came frotn broken, abusive, or neglectful homes and had no idea What becoming a mother involved. This was beneficial for us in many ways because it taught us how to manage patients in far less than optimal circumstances. But the downside was that these Women were usually high risk for sexually transmitted diseases, drug and alcohol use, and poor nutrition. I have to say that overall, we generally did a great job of handling these patients from hell. But we had to be very careful because in the process of managing them, we were put at risk of accidentally catching any diseases they had. This could happen in the process of examining them if we got a needle stick from a needle used on them or came into contact With their body fluids in any way. This was relatively early in the
With their body fluids in any way. This was relatively early in the beginning Of the AIDS epidemic, and heterosexual patients were beginning to be a major population catching this dread, deadly disease. This was always in the back of our minds, so we were very careful With "Universal Precautions," a set of procedures by which we protected ourselves With gloves, masks, and extreme care With needles. This was the setting in which I got the patient whose story I am about to tell. This was an eighteen-year-otd black woman Who became unexpectedly pregnant from her unprotected sexual activity. She couldn't tell me how many sexual partners she had had in the past and the father of her baby was long gone, as was sadly and frequently the case. Even With her high-risk behavior, her pregnancy progressed pretty normally. All the tests for sexually transmitted diseases came back ne ative but I knew that could be Copyfish
in these circumstances frequently continued their high-risk sexual behavior even after testing and being told the risks. When she was within a week or two of her due date (inexact in the best of circumstances) she came into the OB ward With contractions about five or Six minutes apart. We placed her in Observation status and, within about one hour, her contractions Were about three minutes apart and clearly showing a pattern that was indicative of true labor. I was on call and since she was my patient, it was clearly my responsibility to take care of her though we had several residents on duty at the time. This was this patient's first baby and I expected the labor to take twelve to eighteen hours, as is typical of first pregnancies. lt was not to be so. After about five or Six hours, the patient was completely dilated and her cervix effaced (thinned Out) completely, indicating it was time to Start the patient pushing. We had given her an epidural anesthetic at about three hours
pushing. We had given her an epidural anesthetic at about three hours into her labor because she was having substantial pain, so she could not feel much by this time. Since I was still a resident, I had to be supervised doing deliveries by a fully qualified family practice doctor. So I called the family practice attending doctor on call and told him he needed to come in to supervise. White I had him on the phone, he asked me to have the patient push one time to see if the baby's head would come down easily. He didn't want to come in and sit around for several hours White we had the patient pushing. When I had the patient push, the baby's head instantly came down to where it was showing through the vagina, What we call "crowning," a sign that delivery is imminent. I conveyed this knowledge to the attending doctor and suggested strongly that he hustle in quickly. He said that he was on his way and I hung up the phone. That is when the problems began in a hurry, as th usuall did. I noticed that the bab 's head was
continuing to Slide out of the woman in spite of the fact that she, at my request, had stopped pushing. I realized that we were going to have a delivery within minutes no matter What I did. So I quickly took off my exam gloves With the intent of putting on the longer sterile gloves we used for deliveries, as well as the gown and mask needed for precautions in these circunstances. As I turned around to the instrument table to grab the gown, gloves, and mask, the elderly, wise black nurse standing behind the table yelled, "Dr. Baker, you don't have time for that! " I quickly turned around to the patient, Who was up in stirrups for delivery. The baby's head was completely out of the woman and I could see the shoulders rapidly following. In that instant, I knew that my only option was to catch the baby barehanded, putting me at risk for whatever diseases this woman was carrying. If I didn't, within seconds the baby's body was going to be completely out and the baby was going to fall
was going to be completely out and the baby was going to fall about two feet and hit a hard wooden floor. This would obviously not be good for the baby's health. I grabbed the baby's head and supported it and the body as it shot out of the patient. I suctioned the baby's mouth, then clamped and cut the umbilical cord and handed the baby off to the nurse. I then had time to get on my gloves and gown before delivering the placenta and finishing up all post-delivery actions. White doing this, I was wondering What I might have caught. We all have minute breaks in Our Skin that can allow bacteria, viruses, fungi, and parasites to enter. After I was done caring for the patient, the nurse wisely told me that I should wash my hands and arms With alcohol, Betadine (surgical scrub Soap), and regular Soap for at least thirty minutes. After I was through, my arms and hands felt and looked like I had gotten a sunburn. But now, as Paul Harvey would say, came the "rest of the
About Six weeks later, I began having fevers up to 102, feeling sick at my stomach all of the time, and feeling exhausted all the time, even after a full night's sleep. Even doctors can get into denial and for Six more weeks I kept telling myself that it was just a "virus" that would resolve soon. I was trying to squelch the internal fear that it could be the human immunodeficiency virus or some Other dread disease, particularty after that mornentous delivery. After Six weeks of this and working every day With about one hundred hours per week, I began to realize that it wasn't going away and I needed to get evaluated. One reason that I didn't get evaluated before was that I was the head resident on obstetrics, responsible for supervision of Other residents. We were very short of residents and I kept telling myself that the hospital and residency couldn't afford another resident's absence. About that time, another symptom appeared, which gave partial reassurance that it wasn't that dread
appeared, which gave partial reassurance that it wasn't that dread disease. But the symptom indicated What my illness probably was while also giving me something else to fear, though not as bad. My urine began to turn very dark, which is frequently a symptom of hepatitis. Though that was comforting to Some extent, I knew that some forms of hepatitis were not curable and some did lead to death. We had gotten some residents back from Christmas vacation and were fully manned, so I fett that I could indulge my own illness. I went to See one Of the family practice attending doctors and told her my Story. She said the comforting words "Uh, oh," and immediately ordered some lab tests, including liver function tests. The liver function tests came back very high, as expected, but the tests for hepatitis A, B, and C came back negative, creating more questions as to What was causing my hepatitis(hepatitis can be caus Copyfish tests
and lead to death. I took a week off work at the insistence of the attending doctor and, With time to recover instead of using all my energy to work, got well. There was only one clue as to What had caused my hepatitis, which only took my interest one Year later when I began to get the same symptoms, which again lasted Six weeks. This time I couldn't blame a bare-handed delivery for my problems. When I got checked, I had hepatitis again! Blood tests were again unrevealing except for the same atypical lymphocytes in my complete blood count, suggesting infectious mononucleosis- induced hepatitis. A Monospot test for infectious mononucleosis (mono) came up positive, so this time we knew the cause. With the same atypical lymphocytes as the year before, I had to think it was possible that I had had the same thing then, though one infection With that virus usually confers lifetime immunity. lt is also possible that I had an infection With cytomegalovirus the first year, which
I understand can cause the same atypical lymphocytes. But the bottom line was that I was exposed to and may have gotten my first infection from that barehanded delivery from hell. A precipitous delivery that is burned in my memory forever occurred one Saturday or Sunday afternoon when there was absolutely nothing going on in the obstetrics ward. We had no one in labor and the patients and their babies previously delivered were all doing well without any problems. I was sitting at the front desk of the nursing station twiddling my thumbs. The only nurse around the immediate area was sitting about ten feet behind me, also doing nothing important. In these circumstances, I had quickly learned never, but never, to utter the dread words, "lt sure is quiet around here." The nurses were somewhat superstitious about that particular sentence and would immediately start chewing
ordered to immediately get off of the ward. The belief was that, someone having uttered those terrible words, we would get some catastrophic occurrence such as an emergency caesarean section or other incident causing blood pressures and heart rates (ours, of Course) to rise precipitously, along With the risk of a bad outcome. They believed it wholeheartedly and though I didn't harbor such superstitions, I learned fast to keep my mouth shut. This was because those nurses could make my life a living hell if I offended them in any way. But back to the Story at hand. As we were sitting there, I heard the elevator doors at the end Of the hall open, and, half a second later, the most ungodly screaming you could ever imagine. I also heard about three pairs of running feet and the squeaking wheels of a gurney being pushed at near lightning speed down said hall. I leaned over the desk to See What was going on (yeah, like I didn't know!) and Saw three hospital
The purple smoke and cooking soda costing $ 344 !/Omeprazole/sodium — generic Zegerid (Salix) zegerid OTC (Bayer) 20.40 mg packets for susp•; 20 mgn.l g. 40 mgn.l g capsE 20 g capsw 20—40 mg 344.70 16.10'
Proton pump inhibitors (PPIs) have become a mainstay of therapy not only in the practice of gastroenterology, but also for general medicine and even for the general public. Recently, proton pump inhibitors have been associated with a number of potential complications including impaired vitamin and mineral absorption, altered drug metabolism and increased risk for infections.
All five PPIs on the market are equally effective at equivalent doses; no trials have demonstrated an intrinsic therapeutic advantage 01 the newest PPI, Nexium, over other PPls at equivalent doses. The initial choice 01 agent should therelore depend on cost. In Canada, Ihe PPIs Pariet and Apo-OmeprazoleU represent a reduction in cost of approximately 40% over other PPI drugs. We have used as a comparator a DDD of 20 mg of rabeprazole (Pariet) which is priced almost exactly at the generic Price of omeprazole.
'All PPIs appear to be similarly effective and well tolerated for treatment of peptic ulcer disease and GERD. Most are available generically and over the counter for a fraction of the cost of Nexium or other expensive brand name products"
This was the conclusion of The Medical letter in it's June 22 2015 issue.
But still the 'purple pill" myth lingers among physician and patient population and
Astrazeneca made many millions even after 2015
Omeprazole/sodium — generic 20.40 mg packets for susp•;
Zegerid (Salix) 20 mgn.l g. 40 mgn.l g capsE $ 344.70
zegerid OTC (Bayer) 20—40 mg 16.10'
The book color purple
Purple in Business
In using purple in business applications you need to understand the traits, qualities and mood of the color along with the psychological meaning. The messages the color sends to your customer base can have a major impact on your business success.
Purple suggests wealth and extravagance, fantasy and the world of dreams. It enhances spiritual pursuits and enlightenment.
Physiologically, it heightens people's sense of beauty and their reaction to more creative ideas.
It is often used to denote a high quality or superior product, such as Cadbury's chocolate or some women's cosmetics.
If you are in a service business, use some purple in your marketing to denote your premium service.
All five PPIs on the market are equally effective at equivalent doses; no trials have demonstrated an intrinsic therapeutic advantage 01 the newest PPI, Nexium, over other PPls at equivalent doses. The initial choice 01 agent should therelore depend on cost. In Canada, Ihe PPIs Pariet and Apo-OmeprazoleU represent a reduction in cost of approximately 40% over other PPI drugs. We have used as a comparator a DDD of 20 mg of rabeprazole (Pariet) which is priced almost exactly at the generic Price of omeprazole.
Excessive Medical Spending: Facing the Challenge
By Norman J. Temple, Andrew Thompson, Anwar Khan'All PPIs appear to be similarly effective and well tolerated for treatment of peptic ulcer disease and GERD. Most are available generically and over the counter for a fraction of the cost of Nexium or other expensive brand name products"
This was the conclusion of The Medical letter in it's June 22 2015 issue.
But still the 'purple pill" myth lingers among physician and patient population and
Astrazeneca made many millions even after 2015
Omeprazole/sodium — generic 20.40 mg packets for susp•;
Zegerid (Salix) 20 mgn.l g. 40 mgn.l g capsE $ 344.70
zegerid OTC (Bayer) 20—40 mg 16.10'
The book color purple
Purple in Business
In using purple in business applications you need to understand the traits, qualities and mood of the color along with the psychological meaning. The messages the color sends to your customer base can have a major impact on your business success.
Purple suggests wealth and extravagance, fantasy and the world of dreams. It enhances spiritual pursuits and enlightenment.
Physiologically, it heightens people's sense of beauty and their reaction to more creative ideas.
It is often used to denote a high quality or superior product, such as Cadbury's chocolate or some women's cosmetics.
If you are in a service business, use some purple in your marketing to denote your premium service.
Positive Color Meanings in Business:
- unusual and individual, creative and inventive
- psychic and intuitive
- humanitarian, selfless and unlimited
- mystery, fantasy and the future
Negative Color Meanings in Business:
- immaturity
- impractical
- cynical and aloof, pompous and arrogant
- fraudulent and corrupt
- delusions of grandeur and the social climber
Table 1. Oral Proton Pump Inhibitors
Drug Some Available Formulations Usual Adult Dosage1,2 Cost3
Dexlansoprazole – Dexilant (Takeda) 30, 60 mg DR caps 30-60 mg once/d $222.10
Esomeprazole magnesium – generic 20, 40 mg DR caps 20-40 mg once/d 204.50
Nexium (AstraZeneca) 20, 40 mg DR caps4
250.90
Nexium 24HR (OTC) (Pfi zer) 22.3 mg DR caps5 16.406
Lansoprazole – generic 15, 30 mg DR caps 15-30 mg once/d 64.60
Prevacid (Takeda) 333.70
Prevacid Solutab (Takeda) 15, 30 mg ODT 333.70
Prevacid 24HR (OTC)7
(Novartis) 15 mg DR caps 17.806
Omeprazole – generic 10, 20, 40 mg DR caps 20-40 mg once/d 16.30
Prilosec (AstraZeneca) 10, 20, 40 mg DR caps4
218.70
Prilosec OTC7 (AstraZeneca/P&G) 20 mg DR tabs 16.806
Omeprazole/sodium bicarbonate8
– generic 20, 40 mg packets for susp9
; 20-40 mg once/d 344.70
Zegerid (Salix) 20 mg/1.1 g, 40 mg/1.1 g caps10 383.40
Zegerid OTC (Bayer) 20 mg/1.1 g caps10 16.106
Pantoprazole – generic 20, 40 mg DR tabs 40 mg once/d 6.40
Protonix (Pfi zer) 20, 40 mg DR tabs4
274.20
Rabeprazole – generic 20 mg DR tabs 20 mg once/d 52.40
Aciphex (Eisai) 419.70
Aciphex Sprinkle (Eisai) 5, 10 mg DR sprinkle caps11 699.80
DR = delayed-release; OTC = over the counter; ODT = orally disintegrating tablets
1. The lower end of the range is generally used for initial treatment of GERD. Higher or more frequent doses may be needed for patients with erosive
esophagitis, peptic ulcer disease, hypersecretory conditions such as Zollinger-Ellison syndrome, or for treatment of Helicobacter pylori infection.
2. PPIs are generally taken 30-60 minutes before the fi rst meal of the day. Taking one before the evening meal or taking the drug twice daily may be more
effective for nocturnal acid control. PPIs should generally be swallowed whole and should not be crushed or chewed. Omeprazole/sodium bicarbonate
(Zegerid) should be taken on an empty stomach at least 1 hour before a meal. Dexlansoprazole (Dexilant) can be taken with or without food.
3. Approximate WAC for 30 days’ treatment with the lowest usual adult dosage. WAC = wholesaler acquisition cost or manufacturer’s published price to
wholesalers; WAC represents a published catalogue or list price and may not represent an actual transactional price. Source: AnalySource® Monthly. June 5,
2015. Reprinted with permission by First Databank, Inc. All rights reserved. ©2015. www.fdbhealth.com/policies/drug-pricing-policy.
4. Also available in delayed-release powder or granules for suspension.
5. Equivalent to 20 mg of esomeprazole.
6. Cost for 28 tablets or capsules.
7. Also available generically.
8. Immediate-release formulation that contains sodium bicarbonate as a buffer; it should be used with caution in patients on a low-sodium diet.
9. Each packet also contains 1680 mg of sodium bicarbonate.
10. Each capsule contains 1.1 g of sodium bicarbonate; therefore, two 20-mg caps are not equivalent to one 40-mg cap.
11. Contents of the capsule should be sprinkled on soft food or liquid and taken within 15 minutes
snitchiest technology/single digital ID card for every Indian.
First was PAN card
Then came Adhar card now this guy Amit shah wants a single digital ID card for every Indian.
"I got back to class and sat down again, Ms. Galvez warmly welcoming me back. I unpacked the school's standard-issue ma- chine and got back into classroom mode. The SchoolBooks were the snitchiest technology of them all, logging every keystroke, watching all the network traffic for suspicious keywords, counting every click, keeping track of every fleeting thought you put out over the net. We'd gotten them in my junior year, and it only took a couple months for the shininess to wear off. Once people figured out that these "free" laptops worked for the man—and showed a never-ending parade of obnoxious ads to boot—they suddenly started to feel very heavy and burdensome."
Then came Adhar card now this guy Amit shah wants a single digital ID card for every Indian.
"I got back to class and sat down again, Ms. Galvez warmly welcoming me back. I unpacked the school's standard-issue ma- chine and got back into classroom mode. The SchoolBooks were the snitchiest technology of them all, logging every keystroke, watching all the network traffic for suspicious keywords, counting every click, keeping track of every fleeting thought you put out over the net. We'd gotten them in my junior year, and it only took a couple months for the shininess to wear off. Once people figured out that these "free" laptops worked for the man—and showed a never-ending parade of obnoxious ads to boot—they suddenly started to feel very heavy and burdensome."
Little Brother
By Cory Doctorow
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