wathe
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Posts posted by wathe
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On 3/10/2023 at 2:51 PM, Corraleno said:
People from other countries must read these threads with their mouths hanging open.
The idea that access to healthcare should be controlled by private insurance companies, who can not only charge outrageous fees but also maximize profits by denying necessary treatment, is so dystopian it beggars belief.
The US healthcare system is just insane.
Yes. It is insane.
The out-of-pocket cost to the patient for removing and imbedded IUD here is $0. Well, if you park, you would have to pay for parking....
Major surgery: $0
Emergency department visits: $0
Family doctor visits $0
Specialist MD visits $0
Hospitalizations: $0
Hospitals charge for room upgrades, parking, phone service, internet access and other extra amenities, but the cost of care and basic hospital stay is $0 out-of-pocket. No forms. No insurance claims. You pay your taxes and register for a free health card, which require periodic (free) renewal every 5 years or so. The card is your ticket to $0 out-of-pocket hospital care.
Canadians love to complain about their healthcare, but it's actually pretty great.
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Coach might send out a notice to all families, indicating that a child on the team has a court order of protection and please do not share photos or video that contain images of any child other than your own. There is no reason for the other families to know which kid, or protection from whom.
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12 minutes ago, HomeAgain said:
I'd be calling all my medical friends to help me convert dosage if it came down to it.
Fortunately, the math is not complicated. Weight-based dosing for acetamonophen and ibuprofen of page 2 of this chidren's hospital handout. Once you've calculated the child's dose in mg, then just have to figure out what fraction of an adult tablet will give the right number of mg
ETA: Ooops, forgot link. Fixed it
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2 hours ago, KSera said:
Embark is the one who always comes out the most accurate, which is backed up by this. The people submitting don't seem to understand the "Village Dog" classification, which is one of the things that makes Embark more accurate than the others. You can't have a result made up of modern domesticated dog breeds with a dog from a region where those aren't the dog breeds that have gone into their village dog population. Ridiculous the two cheap companies that couldn't even tell they had human DNA 🙄.
Oh for sure. The Embark results make sense.
But, the 2 companies that matched the human DNA to dog breeds was super funny. And the company that matched the pure-breed great dane to 100% chihuahua, because the submitted form stated the dog was suspected to be chihuahua (it's a trap!)...... Oh my goodness.
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Totally frivolous post.
This news article on DNA dog testing had me laughing out loud. Obviously, some of these companies are more reliable that others (and one of them seems straight out scammy!). CBC Marketplace is a national consumer watchdog news series.
ETA: They sent DNA for 2 mixed-breed dogs of unknown ancestry, one known pure-breed, and human DNA from the show's host, to 4 different testing companies. With wildy varied results.
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CYA training modules is a hospital administration specialty. We do hours and hours of these every year at re-appointment time. And every year, they tack on a few more. There is no evidence to suggest that they make any difference in outcomes that I am aware of (other than CYA legal box ticking; staff-had-trraining-and-we-can-prove-it.
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I have the same struggle.
3 main strategies:
1) Things that go in the crock pot or pressure cooker well ahead of time and can just sit until dinner: Chili, beef stew, pulled pork etc
2) Things that go in the oven well ahead of time, for a long time, aren't fussy about being overdone, and can be left in the oven to stay warm: Lasagne, shepherd's pie, cabbage rolls (pre-made, cook from frozen)
3) Meat that is quick to cook up in a frying pan (sausage, chicken chunks, chicken chunks with butter chicken sauce), with rice made ahead in the rice cooker and left to keep warm, and raw veg - either cucumber slices or carrot sticks.
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15 minutes ago, MercyA said:
"Products of conception?" Now that's some purposefully dehumanizing language.
It's literally the formal medical term for placental and/or fetal tissue that remains in the uterus after a spontaneous pregnancy loss (miscarriage), planned pregnancy termination, or preterm/term delivery.
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23 minutes ago, MercyA said:
A D&C is a D&C, but a D&C is not always an abortion.
It technically is, when products of conception are being removed. As in this case.
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2 hours ago, Brittany1116 said:
I think it's... intellectualy dishonest?... to act as though anyone outside of a medical establishment would casually refer to surgical removal of an already dead fetus as an abortion. No one is doing that.
Legislators literally are doing that. But not casually. And that's the problem.
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On 2/19/2023 at 2:49 PM, SKL said:
I do appreciate that recommendation to make sure the doc will take measures to reduce potential pain.
I talked to my kid and, for now, we agree to do the Pill temporarily to see if she has any concerning reactions to the hormones. (Though, if she does, how would we know whether it was the Estrogen or the Progesterone?)
If the hormones don't pose a problem, we're looking at the Mirena, mainly because it lasts longer than the arm implant and various other methods.
If the hormones do pose a problem, I guess we have a difficult discussion regarding the copper IUD, kuz what else is there that doesn't involve hormones?
I think thats a good plan, in that the pill in non-invasive, and if she can remember to take them regularly, it's a reliable and easy choice.
Using the pill as a way to test whether or not she will tolerate a Mirena doesn't really make sense though. Standard combination Pill and Mirena are very different hormonally. People who don't tolerate the pill often tolerate Mirena just fine (progestin only, systemic progestin 1/10th that of the pill)
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Also important to note that hormonal IUD's (mirena, kylena) deliver much less progesterone that pills and implants, something like 1/10th as much systemic progesterone than the pill and 1/4 as much as implants. Because IUD progesterone acts locally, rather than systemically.
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On 2/19/2023 at 4:19 PM, Corraleno said:
There's a progestin-only pill. Also, some people who don't do well on the pill due to fluctuating hormone levels (especially if they sometimes forget to take them) may do fine with methods like the implant or mirena that continuously release low levels of progestin, so response to the pill doesn't always predict how well someone would do with a different hormonal method.
Yes.
Adding though: Important not note though that the minipill (progesterone only pill) is less forgiving than standard combination pill ---- only it's 91% effective with typical, real-world use. It would not be a great choice for a teen, I don't think.
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3 hours ago, TCB said:
Does anyone know if they have presented any verifiable evidence to support this? I know they are talking about the VAERS site, but do they have verifiable data.
I have tried to keep up with as much of the anti vaccine stuff that I can, and I have not seen much of anything that includes verifiable data. Almost everything I’ve seen is opinion based. I have seen various accounts of blood clots etc, but have seen follow ups that photographs used were reused pre Covid photos, or possibly even plant roots??
How do they deal with the data showing reduced Covid deaths, and even reduced all cause mortality in those who have been vaccinated- other than saying they don’t believe it and it’s a government conspiracy? How do they deal with the Uk ONS data released a few days ago?
I ask this because I live in the US and I would like to believe that something so consequential to peoples lives must be decided on some sort of hard facts. If you know of any, please let me know because it all feels very bleak to me.
They don't deal with data, period. This is all political grandstanding, and nothing to do with reality. Sadly.
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4 hours ago, KSera said:
What if the thought experiment is shifted to your older, not particularly well parents?
Fully vaccinated and immune-competent, I would think hard, but still probably not. More co-morbidities increase the risk of drug complications: potential drug-drug interactions, regular meds that would need to be stopped or adjusted, and renal failure. EPIC-SR included patients with "at least one characteristic or underlying medical condition associated with an increased risk of developing severe illness from COVID-19 and were fully vaccinated against COVID-19 OR no characteristics associated with risk of severe COVID-19 and were unvaccinated". These were not low risk patients.
Not fully vaccianted, or immune-compromized, then yes.
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I'm back. Sorry to post and run earlier.
Re evidence:
We have exactly one RTC on paxlovid for vaccinated people, EPIC-SR. It was halted for futility and never formally published. Results were communicated by press release.
All of the other studies on vaccinated people are observational cohort studies. Many of them show a correlation with paxlovid and decreased hospitalization for covid in older patients (exact age range depends on the study). But these need to be interpreted with a extreme caution. Observational studies cannot eliminate confounders. These studies show that older people who were prescribed paxlovid did better than those who weren't, but that might not be because of the drug. Another way to put it is that these studies showed that patients who seek paxlovid do better than those who don't. Which I didn't need a study to know! Pts who seek paxlovid tend to be those who have social determinants of health in their favour; they are well organized/supported enough to acknowledge covid sx, test, be aware that paxlovid exists, seek care, have had blood drawn in the past 3 months or get blood drawn, get to a pharmacy that stocks paxlovid --- all within a 5 days window. Those same favourable social determinants of health mean that they were going to do better anyway, whether they got paxlovid or not. Those whose social determinants of health are against them tend not to be able to pull it off, and because of those same social determinant of health, they were going to do worse anyway, whether they got paxlovid or not. Authors of observational studies do their best to erase confounders with fancy math and statistical manipulation, but it's not actually possible.
The only way to eliminate confounders from a drug efficacy study is to do a double-blinded, randomized controlled trial. Of which we have exactly one for vaccinated patients (EPIC -SR, above). Which did not show benefit.
Another issue with most of the trials and studies is that they tend to use disease-specific hospitalization (hospitalization for covid) as an endpoint. Which means that non-covid hospitalizations due to paxlovid (like, say, for drug-drug interaction, or for worsening of chronic disease due to stopping regular meds that interact with paxlovid, or acute process like a stroke due to stopping or adjusting anticoagulant because it interacts with paxlovid) aren't captured. Risk of harm from paxlovid treatment is missed.
The Paxlovid story echos the Tamiflu story in a way that makes many of us uncomfortable. EPIC-SR was pharma-funded and pharma-run. Publishing it properly would not be in the drug company's financial best interest. So they didn't.
Anyway, long story short: It is very reasonable to conclude that paxlovid likely does not benefit vaccinated patients, and to prescribe very judiciously.
My very EBM focused ED group is skeptical. The litmus test/thought experiment of "would you recommend paxlovid to your own older, fully-vaccinated, immune-competent, otherwise well parents?" gets an answer of "probably not" from most of us.
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6 hours ago, EKS said:
My almost 86yo mother has covid. She is in generally good health, no risk factors other than being elderly (she is thin, not immunocompromised, and does not have diabetes, for example). She is 5x vaccinated including the bivalent booster. She also had a very mild case of covid over the summer.
Her doctor does not seem to be a fan of Paxlovid, but at the moment I don't know why.
Am I nuts in thinking that she should be taking Paxlovid?
Any information, experience, or opinions you may have about the Paxlovid thing or covid in the elderly in general would be much appreciated.
In short, because the state of the evidence for paxlovid for vaccinated people remains very, very poor, and it's very reasonable to conclude that she likely won't benefit.
You've caught me right before work. I'll respond more fully later.
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It's casual misogyny.
I find it offensive.
Our culture is deeply steeped in misogyny. This sort of behaviour is just the tip of the iceberg, a bit that shows in a culture that is deeply unfair to women. And these sorts of casual misogynistic behaviours and attitudes add up to very big inequities that are pervasive and affect all of us. I am offended by the death-by-a-thousand-cuts daily microaggressions and unconsiously gender biased behaviours and expectations of others that prevent me from ever being able to earn as much as my male colleagues. I am offended that the gender pay gap that exists in my sector is not unique -- it's the norm across sectors.
It may seem like a just silly prank, but it represents the tip of a giant societal iceberg of misogyny.
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I don't think that n95 and hepa are going to do anything for VOC's/paint vapors. I think you would need a chemical cartridge respirator for that.
Does the building have mechanical ventilation? Could you speak with the custodian and management to request that ventilation be increased while painting? Absent that, probably your best option is a big fan at the door to keep the air moving
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Regarding migraine with aura and estrogen containing contraceptives and stoke:
The state of the evidence is not strong. We know that women who have migraine with aura alone are at increased risk of stroke (small but real). We know that OCP alone increased the risk of thromobosis and ischemic stroke (small but real). It is not clear that OCP + migraine with aura increases the risk in combination any more that each would increase the risk alone. Migraine without aura does not seem to be correlated with stroke risk at all. OCP decreases lots of other risks - all cause mortality is lower for women who've used OCP than for women who haven't - so it's important to consider all risk and benefits specific to each user.
Combined hormonal contraceptives and migraine: An update on the evidence plain language paper
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5662520/ technical paper
UpToDate recommendation (paywalled, but links to references are not): Patients experiencing migraine withoutaura (MO) can safely use estrogen-containing contraceptives, including oral pills, transdermal patches, and vaginal rings. Individuals with migraines with aura (MA) are generally not candidates for estrogen-containing contraceptives [17-19]. However, the absolute risk of stroke in women with MA on combined hormonal contraceptives (CHC) is small, and good quality studies specific to low-dose estrogen products are lacking [20]. Therefore, the use of CHCs in women with MA should be individualized. For those with a clear indication for CHCs, such as endometriosis or those who desire this method after a clear discussion of the risks, their use is reasonable.
I am a person who has infrequent migraine with aura. I was on the pill for about 15 years as a teen and young woman. The overall risk/benefit balance worked out in favour of the pill for me (and, of course, the state of the evidence was different then, in the 80's and 90's)
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Link to Society of Obstetricians and Gynaecologists of Canada contraception booklet, that has details for every method going. Their https://www.sexandu.ca/ is comprehensive.
Other options besides pills, implants and IUD's, include patches and vaginal rings - both non-invasive, and require less remembering than a daily pill.
I love my Mirena. Insertion was a bit pinchy but not terrible. Insertion under sedation or anesthesia is an option here. Not having periods is very freeing.
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1 hour ago, TCB said:
I work in an ICU and I would like us to wear masks for the foreseeable future as it is at least something we can do to protect the patients. I’ve seen figures showing a 30% increase in mortality for someone with a hip fracture who catches Covid while in hospital, and also worse outcomes for trauma patients who coincidentally are infected with Covid.
Most of the people I work with are quite careful to wear masks in the patient rooms, which is the rule at the moment, but some are not. I’ve discussed the above mentioned increased risks with some of them but it does not seem to change what they do. I find it really hard to understand and it’s hard to see. Puts me off working more hours as I find it upsetting. I try to safeguard my allocated patients as much as possible by asking anyone coming in their rooms to mask up properly. I’m sure I’m not very popular with some people because of that.Coincidentally I don’t think I’ve had Covid yet myself. I wear a mask everywhere at work and don’t eat in the break room. I’ve also had 2 booster vaccinations, including the bivalent. Some of the people I work with have had 3 infections, and just about everyone else has had at least one, so I am probably on borrowed time as far as that goes.
All of this. I am also diligent with n95, avoid the break room, and haven't had covid yet.
In my hospital, masks are still required everywhere, except when alone in a private office, or when eating/drinking in a designated break space. There are staff who pull their masks down at the desk; this annoys me.
I will mask at work for the rest of my career, I think.
Regarding non-compliance: It's a bit like handwashing. I don't think we will ever have perfect compliance with that either. It's human nature to take short-cuts, especially when working under tremendous stress in really quite terrible conditions.
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6 minutes ago, Spy Car said:
The actor Julian Sands went missing in the same spot where I did the ice-axe training component a Basic Mountaineering course I took in high school. He still hasn't been found.
I try hard not to be an "alarmist" type. But do respect nature. A bunch of newbies getting out into backcountry who lack basic skills, who may have the wrong gear and clothes, who can't read topo maps and properly use a compass, who don't know basic knots or how to (potentially use ropes), who are not trained in survival skills, don't know how to deal with bears, or do first aid, etc., can get into trouble. Or not.
It is better to have skills. Training.
Bill
Yes, safety is a big concern. There is a lot that can go wrong, and it can go very wrong, very, very fast. Knowledge and experience are essential for back-country safety
A co-trainee of mine (back in residency) was killed on a wilderness trip. I am ever mindful.
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I think the group trip is a good idea.
$200 for transport, permits, food, all equipment and a guide is a reasonable price.
You will learn a ton from an experienced guide. I would not go on a first trip without an experienced person in the group - that's a recipe for disaster.
It's also a good opportunity to try before you buy for equipment. Backpacking equipment is expensive. sleeping pad + sleeping bag + tent + pack, then water treatment equipment, stove and cook kit, animal resistant food storage (bear bag or canister). Well over $1000. Probably more for quality and lightweight.
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My rant for today: teens and school trip medicine policies
in The Chat Board
Posted · Edited by wathe
I totally understand the reasons for such a policy. Teens may be near-adults, but the point is that they are not adults. They are legally children. Who are in the care of the school staff while on an overnight trip away from home -- staff, who, (here at least), are loco parentis.
Teens get up to all kinds of shenanigans. Stealing meds, abusing meds, overdosing on meds, sharing-meds-with-good-intentions-scenarios-that-go-sideways. The school is legally liable for all of it. And also genuinely cares for children and wants to reduce the risk dead or injured kids.
It's annoying but necessary.
The weird part of the policy to me is that a doctor is dispensing meds. Medication administration would usually be a nursing task. But, I've never heard of bringing a doctor along on a school trip (and even less likely, an out of state field trip, where a doc from home would likely not even be licensed to practice -- licensing is by state, right?), never mind for the purpose of dispensing meds. But, I'm not American, so take that for what it's worth, I guess. Maybe USA school trip culture is different than here.
ETA - I realize that OP did not specify whether or not the trip is out of state. I am assuming based on balance of probabilities.
ETA again - sounds like nightmare gig for the doc. I would not want that job!