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MARYLAND HEIGHTS, that site Mo lowest price viagra. €” Fans of the band Wilco could have reasonably interpreted frontman Jeff Tweedy singing “I Am Trying to Break Your Heart” at an Aug. 13 concert lowest price viagra at St.

Louis Music Park as the universe explaining the past year or so. For example, 30-year-old fan Lazarus Pittman had planned to see Wilco and co-headliner Sleater-Kinney in August 2020 at the open-air venue in this suburb west of St. Louis.

Then the show was postponed because of the erectile dysfunction treatment viagra. Pittman got sick with the erectile dysfunction. He quit his job as a traffic engineer in Connecticut to relocate to St.

Louis for his girlfriend — only to have her break up with him before he moved. But he still trekked from New England to Missouri in a converted minivan for the rescheduled outdoor show. €œerectile dysfunction treatment’s been rough, and I’m glad things are opening up again,” he said.

Yet hours before Pittman planned to cross off the concert from his bucket list, he learned the latest wrinkle. He needed proof of vaccination or a negative erectile dysfunction treatment test from the previous 48 hours to enter the concert. St.

Louis Music Park required attendees to show proof of erectile dysfunction treatment vaccination or a negative erectile dysfunction treatment test from the previous 48 hours to attend a Wilco and Sleater-Kinney concert on Aug. 13, 2021.(Eric Berger for KHN) The bands announced the requirements just two days earlier, sending some fans scrambling. It was the latest pivot by the concert industry, this time amid an increase in delta variant s and lingering concerns about the recent Lollapalooza music festival in Chicago being a superspreader event.

After more than a year without live music, promoters, bands and fans are eager to keep the concerts going, but uncertainty remains over whether the treatment or negative-test requirements actually make large concerts safe even if held outdoors. €œAbsolutely not,” said Dr. Tina Tan, a specialist in pediatric infectious diseases at Northwestern University.

€œThere is just too much erectile dysfunction treatment that is circulating everywhere in the U.S.” During the first months of summer, large outdoor venues such as Red Rocks Amphitheatre in Colorado and Ruoff Music Center in Indiana again hosted bands such as the String Cheese Incident and Phish, with sellout crowds of mostly maskless people inhaling marijuana or whatever other particles were possibly around. Then the delta variant surge in July prompted renewed concerns about large gatherings, even at such outdoor venues. Tan, and other doctors, warned that Lollapalooza, with an estimated 385,000 attendees from July 29 to Aug.

1, was a “recipe for disaster” even though organizers instituted a treatment or negative-test requirement. It turned out that Lollapalooza was not a superspreader event, at least according to Chicago Department of Public Health Commissioner Dr. Allison Arwady, who reported that only 203 attendees were diagnosed with erectile dysfunction treatment.

Tan said she is skeptical of those numbers. €œWe know that contact tracing on a good day is difficult, so think about a venue where you have hundreds of thousands of people,” Tan said. €œThat just makes contact tracing that much more difficult, and there always is a reluctance for people to say where they have been.” But Saskia Popescu, an infectious disease expert at the University of Arizona, said she sees the Lollapalooza data as “a really good sign.” Still, an outdoor concert with the new entrance rules is not without risk, she said, particularly in states such as Missouri, where the delta variant has thrived.

“If you are considering an event in an area that has high or substantial transmission, it’s probably not a great time for a large gathering,” Popescu said. Recently, two of the country’s largest live music promoters, AEG Presents and Live Nation Entertainment, announced they would begin requiring vaccination cards or negative erectile dysfunction treatment tests where permitted by law starting in October. But not all bands and venues are instituting such measures.

And some simply are postponing shows yet again. For the second straight year, organizers canceled the annual New Orleans Jazz &. Heritage Festival slated for October.

Theresa Fuesting, 55, wasn’t planning on coming to her first Wilco show, even though she had four tickets, until the bands announced the new rules. €œI still think it’s a threat even though I am vaccinated,” said Fuesting, who lives just over the river from St. Louis in Illinois.

For promoters, ensuring that people like Fuesting feel safe enough to use their tickets affects their bottom line, said Patrick Hagin, who promoted the Wilco concert and serves as a managing partner of The Pageant and Delmar Hall music venues in St. Louis. Even if the tickets are already purchased, bar and merchandise sales at the venue suffer if fans are no-shows.

€œAlso you worry. Is this person who purchased a ticket going to even come in the future?. € said Hagin.

In non-erectile dysfunction treatment times, more than 90% of ticket buyers ultimately attend, Hagin said. During the viagra, that number has been as low as 60%. Hagin said he is temporarily offering refunds for shows at his venues.

St. Louis Music Park did not offer refunds for the Wilco concert and told fans on its Facebook page that it was instituting the requirements “based on what each show wants.” The venue operators did not answer questions for this story. Jason Green, unable to get a refund for the Aug.

13 show, sold his two sixth-row tickets for $66 — which was $116 less than he paid for the pair in March 2020. He was concerned the venue’s new requirements weren’t enough. €œYou want to wait and see if that’s a legit thing that is keeping things from being spread,” said Green, 42, who lives in St.

Louis and is fully vaccinated against erectile dysfunction treatment. Lazarus Pittman converted his 2006 Toyota Sienna into his temporary home as he travels across the country, with a stop at St. Louis Music Park for a Wilco and Sleater-Kinney concert.

(Eric Berger for KHN) He skipped the concert even though he and friends in a comic book collective liked Wilco enough to name a recent comic after the band’s album “A Ghost Is Born.” The band enjoys a loyal local following. Tweedy is from Belleville, Illinois, just across the Mississippi River, and the band played its debut concert in 1994 in St. Louis.

Fuesting and Pittman took their chances. This was many fans’ first visit to the new venue, an open-air space beneath a curved roof. It was supposed to open last year but was delayed because of the viagra.

Fans passed through metal detectors and quickly showed their treatment cards or test results to people sitting at tables. Out of about 2,500 attendees, the venue had to turn only four people away. One of them left, got a test and then returned, Hagin said.

€œI was very encouraged just by how positive the compliance was,” he said. Fortunately, Pittman had a photo of his treatment card on his phone, which organizers accepted. €œIt was so much fun,” said Fuesting, who wore a mask for the whole show.

€œI just liked the energy of the crowd. They were all just such super fans and singing along to every song.” The band encored with their classic tune “Casino Queen,” the name of a riverboat casino in East St. Louis, Illinois.

€œCasino Queen,” Tweedy sang, “my lord, you’re mean.” So is erectile dysfunction treatment. But for Pittman, who didn’t wear a mask, the show was worth the gamble. He said he was so into the music, he could push the erectile dysfunction from his mind, at least for a bit.

€œThey just played all of my favorite songs, one after another,” Pittman said. €œI wasn’t even thinking about it.” Related Topics Contact Us Submit a Story Tip.

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Email us at [email protected].In an unexpected move, the Food and Drug Administration is reversing a decision by the Trump administration to end a controversial program that forces drug makers to win regulatory approval for medicines already on the market, but were never actually approved.At issue is the Unapproved Drugs Initiative, which was launched in 2006 to gather data on numerous medicines that had been available for years on a grandfathered basis because they predated stricter approval requirements. But the program prompted complaints that some companies established wellbutrin viagra monopolies after winning approval for a drug that, in some cases, led to big price hikes or shortages. Unlock this article by subscribing to STAT+ and enjoy your first 30 days free!. GET STARTED Log In | Learn More What is it?. STAT+ is STAT's premium subscription service for wellbutrin viagra in-depth biotech, pharma, policy, and life science coverage and analysis.

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They’ll be taking the virtual stage to explain their findings and take your questions live.Coverage supported by the Commonwealth Fund. Featured speakers:advertisement David Blumenthal, M.D., president of the Commonwealth Fund (introductory remarks) Erich S. Huang, M.D., Ph.D., director of Duke Forge, director of Duke Crucible, and chief data officer for quality, Duke Health at the Duke University School of Medicine Suchi Saria, Ph.D., M.Sc., founder and CEO of Bayesian Health. John C. Malone Associate Professor of Computer Science, Statistics, Nursing and Health Policy, director of machine learning, AI and Healthcare Lab, research director of the Malone Center for Engineering in Healthcare at Johns Hopkins UniversityKarandeep Singh, M.D., MMSc, assistant professor of learning health sciences, internal medicine, urology, and information, University of Michigan.

Chair, Michigan Medicine Clinical Intelligence CommitteeErin Brodwin, health tech correspondent, San Francisco, STAT (moderator)Casey Ross, national technology correspondent, STAT (moderator) If you’re looking for a version of this recording with closed captioning, please reach out to Julia Baker at [email protected].

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What's included?. Daily reporting and analysis The most comprehensive industry coverage from a powerhouse team of reporters Subscriber-only newsletters Daily newsletters to brief you on the most important industry news of the day STAT+ Conversations Weekly opportunities to engage with our reporters and leading industry experts in live video conversations Exclusive industry events Premium access to subscriber-only networking events around the country The best reporters in the industry The most trusted and well-connected newsroom in the health care industry And much more Exclusive interviews with industry leaders, profiles, and premium tools, like our CRISPR Trackr.AI has enormous potential to improve the quality of health care, enable early diagnosis of diseases, and reduce costs. But if implemented incautiously, AI can exacerbate health disparities, endanger privacy rights, and perpetuate bias. In a new STAT report, reporters Casey Ross and Erin Brodwin, examine the possibilities and pitfalls of artificial intelligence, and offer recommendations for future best practices.

They’ll be taking the virtual stage to explain their findings and take your questions live.Coverage supported by the Commonwealth Fund. Featured speakers:advertisement David Blumenthal, M.D., president of the Commonwealth Fund (introductory remarks) Erich S. Huang, M.D., Ph.D., director of Duke Forge, director of Duke Crucible, and chief data officer for quality, Duke Health at the Duke University School of Medicine Suchi Saria, Ph.D., M.Sc., founder and CEO of Bayesian Health. John C.

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A bag what do i need to buy viagra of Doritos, that’s all Princess wanted walmart viagra price 2020. Her mom calls her Princess, but her real name is Lindsey. She’s 17 and lives walmart viagra price 2020 with her mom, Sandra, a nurse, outside Atlanta. On May 17, 2020, a Sunday, Lindsey decided she didn’t want breakfast.

She wanted Doritos. So she walmart viagra price 2020 left home and walked to Family Dollar, taking her pants off on the way, while her mom followed on foot, talking to the police on her phone as they went. Lindsey has autism. It can be hard for her to communicate and navigate social situations.

She thrives on routine and gets walmart viagra price 2020 special help at school. Or got help, before the erectile dysfunction viagra closed schools and forced tens of millions of children to stay home. Sandra said that’s when their living hell started. €œIt’s like walmart viagra price 2020 her brain was wired,” she said.

€œShe’d just put on her jacket, and she’s out the door. And I’m chasing her.” On May 17, Sandra chased her all the way to Family walmart viagra price 2020 Dollar. Hours later, Lindsey was in jail, charged with assaulting her mom. (KHN and NPR are not using the family’s last name.) Lindsey is one of almost 3 million children in the U.S.

Who have a serious emotional or behavioral health condition walmart viagra price 2020. When the viagra forced schools and doctors’ offices to close last spring, it also cut children off from the trained teachers and therapists who understand their needs. As a result, many, like Lindsey, spiraled into emergency rooms and even police custody. Federal data shows a nationwide surge of kids in mental health crisis during the viagra — walmart viagra price 2020 a surge that’s further taxing an already overstretched safety net.

€˜Take Her’ Even after schools closed, Lindsey continued to wake up early, get dressed and wait for the bus. When she realized it had stopped coming, Sandra said, her daughter just started walking out of the house, wandering, a few times a week. In those situations, Sandra did what many families in crisis report they’ve had to walmart viagra price 2020 do since the viagra began. Race through the short list of places she could call for help.

First, her walmart viagra price 2020 state’s mental health crisis hotline. But they often put Sandra on hold. €œThis is ridiculous,” she said of the wait. €œIt’s supposed to walmart viagra price 2020 be a crisis team.

But I’m on hold for 40, 50 minutes. And by the time you get on the phone, [the crisis] is done!. € Then there’s the local hospital’s walmart viagra price 2020 emergency room, but Sandra said she had taken Lindsey there for previous crises and been told there isn’t much they can do. That’s why, on May 17, when Lindsey walked to Family Dollar in just a red T-shirt and underwear to get that bag of Doritos, Sandra called the last option on her list.

The police. Sandra arrived at the store before the police walmart viagra price 2020 and paid for the chips. According to Sandra and police records, when an officer approached, Lindsey grew agitated and hit her mom on the back, hard. Sandra said she explained walmart viagra price 2020 to the officer.

€œâ€˜She’s autistic. You know, I’m OK. I’m a nurse walmart viagra price 2020. I just need to take her home and give her her medication.'” Lindsey takes a mood stabilizer, but because she left home before breakfast, she hadn’t taken it that morning.

The officer asked if Sandra wanted to take her to the nearest hospital. The hospital wouldn’t be walmart viagra price 2020 able to help Lindsey, Sandra said. It hadn’t before. €œThey already told me, ‘Ma’am, there’s nothing we can do.’ They just check her labs, it’s fine, and they ship her back home.

There’s nothing [the hospital] can do,” she recalled telling the officer walmart viagra price 2020. Sandra asked if the police could drive her daughter home so the teen could take her medication, but the officer said no, they couldn’t. The only other thing they could do, the officer said, was take Lindsey to jail for hitting her mom walmart viagra price 2020. €œI’ve tried everything,” Sandra said, exasperated.

She paced the parking lot, feeling hopeless, sad and out of options. Finally, in tears, she told the officers, “Take walmart viagra price 2020 her.” Lindsey does not like to be touched and fought back when authorities tried to handcuff her. Several officers wrestled her to the ground. At that point, Sandra protested and said an officer threatened to arrest her, too, if she didn’t back away.

Lindsey was taken to jail, walmart viagra price 2020 where she spent much of the night until Sandra was able to post bail. Clayton County Solicitor-General Charles Brooks denied that Sandra was threatened with arrest and said that while Lindsey’s case is still pending, his office “is working to ensure that the resolution in this matter involves a plan for medication compliance and not punitive action.” Sandra isn’t alone in her experience. Multiple families interviewed for this story reported similar experiences of calling in the police when a child was in crisis because caretakers didn’t feel they had any other option. €˜The Whole System Is Really Grinding to a walmart viagra price 2020 Halt’ Roughly 6% of U.S.

Children ages 6 through 17 are living with serious emotional or behavioral difficulties, including children with autism, severe anxiety, depression and trauma-related mental health conditions. Many of these children depend walmart viagra price 2020 on schools for access to vital therapies. When schools and doctors’ offices stopped providing in-person services last spring, kids were untethered from the people and supports they rely on. €œThe lack of in-person services is really detrimental,” said Dr.

Susan Duffy, a pediatrician and professor of emergency medicine at Brown walmart viagra price 2020 University. Marjorie, a mother in Florida, said her 15-year-old son has suffered during these disruptions. He has attention deficit hyperactivity disorder and oppositional defiant disorder, a condition marked by frequent and persistent hostility. Little things — like being asked to do schoolwork — can send walmart viagra price 2020 him into a rage, leading to holes punched in walls, broken doors and violent threats.

(Marjorie asked that we not use the family’s last name or her son’s first name to protect her son’s privacy and future prospects.) The viagra has shifted both school and her son’s therapy sessions online. But Marjorie said virtual therapy isn’t working because her son doesn’t focus well during sessions and tries to watch TV instead. Lately, she has simply been walmart viagra price 2020 canceling them. €œI was paying for appointments and there was no therapeutic value,” Marjorie said.

The issues cut across socioeconomic lines — affecting families with private insurance, like Marjorie, as well as those who receive coverage through Medicaid, a federal-state program that provides health insurance to low-income people walmart viagra price 2020 and those with disabilities. In the first few months of the viagra, between March and May, children on Medicaid received 44% fewer outpatient mental health services — including therapy and in-home support — compared to the same time period in 2019, according to the Centers for Medicare &. Medicaid Services. That’s even after accounting for increased telehealth appointments walmart viagra price 2020.

And while the nation’s ERs have seen a decline in overall visits, there was a relative increase in mental health visits for kids in 2020 compared with 2019. The Centers for Disease Control and Prevention found that, from April to October last year, hospitals across the U.S. Saw a 24% increase in walmart viagra price 2020 the proportion of mental health emergency visits for children ages 5 to 11, and a 31% increase for children ages 12 to 17. €œProportionally, the number of mental health visits is far more significant than it has been in the past,” said Duffy.

€œNot only are we seeing more children, more children are being admitted” to inpatient care. That’s because there are fewer outpatient services now available to children, she said, and because the conditions of the children showing up walmart viagra price 2020 at ERs “are more serious.” This crisis is not only making life harder for these kids and their families, but it’s also stressing the entire health care system. Child and adolescent psychiatrists working in hospitals around the country said children are increasingly “boarding” in emergency departments for days, waiting for inpatient admission to a regular hospital or psychiatric hospital. Before the viagra, there was already a shortage of inpatient psychiatric walmart viagra price 2020 beds for children, said Dr.

Christopher Bellonci, a child psychiatrist at Judge Baker Children’s Center in Boston. That shortage has only gotten worse as hospitals cut capacity to allow for more physical distancing within psychiatric units. €œThe whole system is really grinding to a halt at a time when we walmart viagra price 2020 have unprecedented need,” Bellonci said. €˜A Signal That the Rest of Your System Doesn’t Work’ Psychiatrists on the front lines share the frustrations of parents struggling to find help for their children.

Part of the problem is there have never been enough psychiatrists and therapists trained to work with children, intervening in the early stages of their illness, said Dr. Jennifer Havens, a child psychiatrist at walmart viagra price 2020 New York University. €œTons of people showing up in emergency rooms in bad shape is a signal that the rest of your system doesn’t work,” she said. Too often, Havens said, services aren’t available until children are older — and in crisis.

€œOften for people who don’t have access to services, we wait walmart viagra price 2020 until they’re too big to be managed.” While the viagra has made life harder for Marjorie and her son in Florida, she said it has always been difficult to find the support and care he needs. Last fall, he needed a psychiatric evaluation, but the nearest specialist who would accept her commercial insurance was 100 miles away, in Alabama. €œEven when you have the money or you have the insurance, walmart viagra price 2020 it is still a travesty,” Marjorie said. €œYou cannot get help for these kids.” Parents are frustrated, and so are psychiatrists on the front lines.

Dr. C.J. Glawe, who leads the psychiatric crisis department at Nationwide Children’s Hospital in Columbus, Ohio, said that once a child is stabilized after a crisis it can be hard to explain to parents that they may not be able to find follow-up care anywhere near their home. €œEspecially when I can clearly tell you I know exactly what you need, I just can’t give it to you,” Glawe said.

€œIt’s demoralizing.” When states and communities fail to provide children the services they need to live at home, kids can deteriorate and even wind up in jail, like Lindsey. At that point, Glawe said, the cost and level of care required will be even higher, whether that’s hospitalization or long stays in residential treatment facilities. That’s exactly the scenario Sandra, Lindsey’s mom, is hoping to avoid for her Princess. €œFor me, as a nurse and as a provider, that will be the last thing for my daughter,” she said.

€œIt’s like [state and local leaders] leave it to the school and the parent to deal with, and they don’t care. And that’s the problem. It’s sad because, if I’m not here …” Her voice trailed off as tears welled. €œShe didn’t ask to have autism.” To help families like Sandra’s and Marjorie’s, advocates said, all levels of government need to invest in creating a mental health system that’s accessible to anyone who needs it.

But given that many states have seen their revenues drop due to the viagra, there’s a concern services will instead be cut — at a time when the need has never been greater. This story is part of a reporting partnership that includes NPR, Illinois Public Media and Kaiser Health News. Related Topics Contact Us Submit a Story TipFlorida, Colorado and several New England states are moving ahead with efforts to import prescription drugs from Canada, a politically popular strategy greenlighted last year by President Donald Trump. But it’s unclear whether the Biden administration will proceed with Trump’s plan for states and the federal government to help Americans obtain lower-priced medications from Canada.

During the presidential campaign, Joe Biden expressed support for the concept, strongly opposed by the American pharmaceutical industry. Drugmakers argue it would undercut efforts to keep their medicines safe. The Pharmaceutical Research and Manufacturers of America, an industry trade group, filed suit in federal court in Washington, D.C., to stop the drug-purchasing initiatives in November. That followed the Trump administration’s final rule, issued in September, that cleared the way for states to seek federal approval for their importation programs.

Friday is the deadline for the government to respond to the suit, which could give the Biden administration a first opportunity to show where it stands on the issue. But the administration could also seek an extension from the court. Meanwhile, Florida and Colorado are moving to outsource their drug importation plans to private companies. Florida hired LifeScience Logistics, which stores prescription drugs in warehouses in Maryland, Texas and Indiana.

The state is paying the Dallas company as much as $39 million over 2½ years, according to the contract. That does not include the price of the drugs Florida is buying. LifeScience officials declined to comment. Florida’s agreement with LifeScience came last fall, just weeks after the state received no bids on a $30 million contract for the job.

Florida’s importation plan calls initially for the purchase of drugs for state agencies, including the Medicaid program and the corrections and health departments. Officials say the plan could save the state in its first year between $80 million and $150 million. Florida’s Medicaid budget exceeds $28 billion, with the federal government picking up about 62% of the cost. On Monday, the Colorado Department of Health Care Policy and Financing issued a request for companies to bid on its plan to import drugs from Canada.

Unlike Florida’s plan, Colorado’s would help individuals buy the medicines at their local pharmacy. Colorado also would give health insurance plans the option to include imported drugs in their benefit designs. Kim Bimestefer, executive director of Colorado’s Health Care Policy and Financing agency, said she is hopeful the Biden administration will allow importation plans to proceed. €œWe are optimistic,” she said.

Her agency’s analysis shows Colorado consumers can save an average of 61% off the price of many medications imported from Canada, she added. Prices are cheaper north of the border because Canada limits how much drugmakers can charge for medicines. The United States lets the free market determine drug prices. The Canadian government has said it would not allow the exportation of prescription drugs that would create or exacerbate a drug shortage.

Bimestefer said that her agency has spoken to officials at the Canadian consulate in Denver and that officials there are mainly concerned about shortages of generic drugs rather than brand-name drugs, which is what her state is most interested in importing since they are among the most costly medicines in the U.S. Colorado plans to choose a private company in Canada to export medications as well as a U.S. Importer. It hopes to have a program in operation by mid-2022.

Other states working on importation are Vermont, New Hampshire and Maine. But skeptics say getting the programs off the ground is a long shot. They note Congress in 2003 passed a law to allow certain drugs to be imported from Canada — but only if the secretary of the Department of Health and Human Services agreed it could be done safely. HHS secretaries under Presidents George W.

Bush and Barack Obama refused to do that. But HHS Secretary Alex Azar gave the approval in September. Biden’s HHS nominee, Xavier Becerra, voted for the 2003 Canadian drug importation law when he was a member of Congress. HHS referred questions on the issue to the White House, which did not return calls for comment.

Trish Riley, executive director of the National Academy for State Health Policy, said states have worked hard to set up procedures to ensure drugs coming from Canada are as safe as those typically sold at local pharmacies. She noted that many drugs sold in the United States are already made overseas. She said the Biden administration could choose not to defend the importation rule in the PhRMA court case or ask for an extension to reply to the lawsuit. €œRight now, it’s murky,” she said of figuring out what the Biden team will do.

Ian Spatz, a senior adviser with consulting firm Manatt Health, questions how significant the savings could be under the plan, largely because of the hefty cost of setting up a program and running it over the objections of the pharmaceutical industry. Another obstacle is that some of the highest-priced drugs, such as insulin and other injectables, are excluded from drug importation. Spatz also doubts whether ongoing safety issues can be resolved to satisfy the new administration. €œThe Trump administration plan was merely to consider applications from states and that it was open for business,” he said.

€œWhether [HHS] will approve any applications in the current environment is highly uncertain.” Phil Galewitz. pgalewitz@kff.org, @philgalewitz Related Topics Contact Us Submit a Story Tip.

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Lindsey has autism. It can be hard for her to communicate and navigate social situations. She thrives on routine and gets special help at school lowest price viagra.

Or got help, before the erectile dysfunction viagra closed schools and forced tens of millions of children to stay home. Sandra said that’s when their living hell started. €œIt’s like her brain was wired,” lowest price viagra she said.

€œShe’d just put on her jacket, and she’s out the door. And I’m lowest price viagra chasing her.” On May 17, Sandra chased her all the way to Family Dollar. Hours later, Lindsey was in jail, charged with assaulting her mom.

(KHN and NPR are not using the family’s last name.) Lindsey is one of almost 3 million children in the U.S. Who have a serious emotional or behavioral lowest price viagra health condition. When the viagra forced schools and doctors’ offices to close last spring, it also cut children off from the trained teachers and therapists who understand their needs.

As a result, many, like Lindsey, spiraled into emergency rooms and even police custody. Federal data shows a nationwide surge of kids in mental health crisis during the viagra — a surge that’s further taxing an already lowest price viagra overstretched safety net. €˜Take Her’ Even after schools closed, Lindsey continued to wake up early, get dressed and wait for the bus.

When she realized it had stopped coming, Sandra said, her daughter just started walking out of the house, wandering, a few times a week. In those situations, Sandra did what many lowest price viagra families in crisis report they’ve had to do since the viagra began. Race through the short list of places she could call for help.

First, her state’s mental lowest price viagra health crisis hotline. But they often put Sandra on hold. €œThis is ridiculous,” she said of the wait.

€œIt’s supposed to lowest price viagra be a crisis team. But I’m on hold for 40, 50 minutes. And by the time you get on the phone, [the crisis] is done!.

€ Then there’s the local hospital’s emergency room, but Sandra said she had taken lowest price viagra Lindsey there for previous crises and been told there isn’t much they can do. That’s why, on May 17, when Lindsey walked to Family Dollar in just a red T-shirt and underwear to get that bag of Doritos, Sandra called the last option on her list. The police.

Sandra arrived at the store before the police and lowest price viagra paid for the chips. According to Sandra and police records, when an officer approached, Lindsey grew agitated and hit her mom on the back, hard. Sandra said she explained lowest price viagra to the officer.

€œâ€˜She’s autistic. You know, I’m OK. I’m a lowest price viagra nurse.

I just need to take her home and give her her medication.'” Lindsey takes a mood stabilizer, but because she left home before breakfast, she hadn’t taken it that morning. The officer asked if Sandra wanted to take her to the nearest hospital. The hospital lowest price viagra wouldn’t be able to help Lindsey, Sandra said.

It hadn’t before. €œThey already told me, ‘Ma’am, there’s nothing we can do.’ They just check her labs, it’s fine, and they ship her back home. There’s nothing [the hospital] can lowest price viagra do,” she recalled telling the officer.

Sandra asked if the police could drive her daughter home so the teen could take her medication, but the officer said no, they couldn’t. The only other thing lowest price viagra they could do, the officer said, was take Lindsey to jail for hitting her mom. €œI’ve tried everything,” Sandra said, exasperated.

She paced the parking lot, feeling hopeless, sad and out of options. Finally, in lowest price viagra tears, she told the officers, “Take her.” Lindsey does not like to be touched and fought back when authorities tried to handcuff her. Several officers wrestled her to the ground.

At that point, Sandra protested and said an officer threatened to arrest her, too, if she didn’t back away. Lindsey was taken lowest price viagra to jail, where she spent much of the night until Sandra was able to post bail. Clayton County Solicitor-General Charles Brooks denied that Sandra was threatened with arrest and said that while Lindsey’s case is still pending, his office “is working to ensure that the resolution in this matter involves a plan for medication compliance and not punitive action.” Sandra isn’t alone in her experience.

Multiple families interviewed for this story reported similar experiences of calling in the police when a child was in crisis because caretakers didn’t feel they had any other option. €˜The Whole System Is Really Grinding to a Halt’ Roughly 6% of U.S lowest price viagra. Children ages 6 through 17 are living with serious emotional or behavioral difficulties, including children with autism, severe anxiety, depression and trauma-related mental health conditions.

Many of lowest price viagra these children depend on schools for access to vital therapies. When schools and doctors’ offices stopped providing in-person services last spring, kids were untethered from the people and supports they rely on. €œThe lack of in-person services is really detrimental,” said Dr.

Susan Duffy, a pediatrician lowest price viagra and professor of emergency medicine at Brown University. Marjorie, a mother in Florida, said her 15-year-old son has suffered during these disruptions. He has attention deficit hyperactivity disorder and oppositional defiant disorder, a condition marked by frequent and persistent hostility.

Little things — like being asked to do schoolwork — can send him lowest price viagra into a rage, leading to holes punched in walls, broken doors and violent threats. (Marjorie asked that we not use the family’s last name or her son’s first name to protect her son’s privacy and future prospects.) The viagra has shifted both school and her son’s therapy sessions online. But Marjorie said virtual therapy isn’t working because her son doesn’t focus well during sessions and tries to watch TV instead.

Lately, she lowest price viagra has simply been canceling them. €œI was paying for appointments and there was no therapeutic value,” Marjorie said. The issues lowest price viagra cut across socioeconomic lines — affecting families with private insurance, like Marjorie, as well as those who receive coverage through Medicaid, a federal-state program that provides health insurance to low-income people and those with disabilities.

In the first few months of the viagra, between March and May, children on Medicaid received 44% fewer outpatient mental health services — including therapy and in-home support — compared to the same time period in 2019, according to the Centers for Medicare &. Medicaid Services. That’s even after accounting lowest price viagra for increased telehealth appointments.

And while the nation’s ERs have seen a decline in overall visits, there was a relative increase in mental health visits for kids in 2020 compared with 2019. The Centers for Disease Control and Prevention found that, from April to October last year, hospitals across the U.S. Saw a 24% increase in the proportion of lowest price viagra mental health emergency visits for children ages 5 to 11, and a 31% increase for children ages 12 to 17.

€œProportionally, the number of mental health visits is far more significant than it has been in the past,” said Duffy. €œNot only are we seeing more children, more children are being admitted” to inpatient care. That’s because there are fewer outpatient lowest price viagra services now available to children, she said, and because the conditions of the children showing up at ERs “are more serious.” This crisis is not only making life harder for these kids and their families, but it’s also stressing the entire health care system.

Child and adolescent psychiatrists working in hospitals around the country said children are increasingly “boarding” in emergency departments for days, waiting for inpatient admission to a regular hospital or psychiatric hospital. Before the viagra, there was already a lowest price viagra shortage of inpatient psychiatric beds for children, said Dr. Christopher Bellonci, a child psychiatrist at Judge Baker Children’s Center in Boston.

That shortage has only gotten worse as hospitals cut capacity to allow for more physical distancing within psychiatric units. €œThe whole system is really grinding to a halt at a lowest price viagra time when we have unprecedented need,” Bellonci said. €˜A Signal That the Rest of Your System Doesn’t Work’ Psychiatrists on the front lines share the frustrations of parents struggling to find help for their children.

Part of the problem is there have never been enough psychiatrists and therapists trained to work with children, intervening in the early stages of their illness, said Dr. Jennifer Havens, a child psychiatrist at New York lowest price viagra University. €œTons of people showing up in emergency rooms in bad shape is a signal that the rest of your system doesn’t work,” she said.

Too often, Havens said, services aren’t available until children are older — and in crisis. €œOften for people lowest price viagra who don’t have access to services, we wait until they’re too big to be managed.” While the viagra has made life harder for Marjorie and her son in Florida, she said it has always been difficult to find the support and care he needs. Last fall, he needed a psychiatric evaluation, but the nearest specialist who would accept her commercial insurance was 100 miles away, in Alabama.

€œEven when you have the money or lowest price viagra you have the insurance, it is still a travesty,” Marjorie said. €œYou cannot get help for these kids.” Parents are frustrated, and so are psychiatrists on the front lines. Dr.

C.J. Glawe, who leads the psychiatric crisis department at Nationwide Children’s Hospital in Columbus, Ohio, said that once a child is stabilized after a crisis it can be hard to explain to parents that they may not be able to find follow-up care anywhere near their home. €œEspecially when I can clearly tell you I know exactly what you need, I just can’t give it to you,” Glawe said.

€œIt’s demoralizing.” When states and communities fail to provide children the services they need to live at home, kids can deteriorate and even wind up in jail, like Lindsey. At that point, Glawe said, the cost and level of care required will be even higher, whether that’s hospitalization or long stays in residential treatment facilities. That’s exactly the scenario Sandra, Lindsey’s mom, is hoping to avoid for her Princess.

€œFor me, as a nurse and as a provider, that will be the last thing for my daughter,” she said. €œIt’s like [state and local leaders] leave it to the school and the parent to deal with, and they don’t care. And that’s the problem.

It’s sad because, if I’m not here …” Her voice trailed off as tears welled. €œShe didn’t ask to have autism.” To help families like Sandra’s and Marjorie’s, advocates said, all levels of government need to invest in creating a mental health system that’s accessible to anyone who needs it. But given that many states have seen their revenues drop due to the viagra, there’s a concern services will instead be cut — at a time when the need has never been greater.

This story is part of a reporting partnership that includes NPR, Illinois Public Media and Kaiser Health News. Related Topics Contact Us Submit a Story TipFlorida, Colorado and several New England states are moving ahead with efforts to import prescription drugs from Canada, a politically popular strategy greenlighted last year by President Donald Trump. But it’s unclear whether the Biden administration will proceed with Trump’s plan for states and the federal government to help Americans obtain lower-priced medications from Canada.

During the presidential campaign, Joe Biden expressed support for the concept, strongly opposed by the American pharmaceutical industry. Drugmakers argue it would undercut efforts to keep their medicines safe. The Pharmaceutical Research and Manufacturers of America, an industry trade group, filed suit in federal court in Washington, D.C., to stop the drug-purchasing initiatives in November.

That followed the Trump administration’s final rule, issued in September, that cleared the way for states to seek federal approval for their importation programs. Friday is the deadline for the government to respond to the suit, which could give the Biden administration a first opportunity to show where it stands on the issue. But the administration could also seek an extension from the court.

Meanwhile, Florida and Colorado are moving to outsource their drug importation plans to private companies. Florida hired LifeScience Logistics, which stores prescription drugs in warehouses in Maryland, Texas and Indiana. The state is paying the Dallas company as much as $39 million over 2½ years, according to the contract.

That does not include the price of the drugs Florida is buying. LifeScience officials declined to comment. Florida’s agreement with LifeScience came last fall, just weeks after the state received no bids on a $30 million contract for the job.

Florida’s importation plan calls initially for the purchase of drugs for state agencies, including the Medicaid program and the corrections and health departments. Officials say the plan could save the state in its first year between $80 million and $150 million. Florida’s Medicaid budget exceeds $28 billion, with the federal government picking up about 62% of the cost.

On Monday, the Colorado Department of Health Care Policy and Financing issued a request for companies to bid on its plan to import drugs from Canada. Unlike Florida’s plan, Colorado’s would help individuals buy the medicines at their local pharmacy. Colorado also would give health insurance plans the option to include imported drugs in their benefit designs.

Kim Bimestefer, executive director of Colorado’s Health Care Policy and Financing agency, said she is hopeful the Biden administration will allow importation plans to proceed. €œWe are optimistic,” she said. Her agency’s analysis shows Colorado consumers can save an average of 61% off the price of many medications imported from Canada, she added.

Prices are cheaper north of the border because Canada limits how much drugmakers can charge for medicines. The United States lets the free market determine drug prices. The Canadian government has said it would not allow the exportation of prescription drugs that would create or exacerbate a drug shortage.

Bimestefer said that her agency has spoken to officials at the Canadian consulate in Denver and that officials there are mainly concerned about shortages of generic drugs rather than brand-name drugs, which is what her state is most interested in importing since they are among the most costly medicines in the U.S. Colorado plans to choose a private company in Canada to export medications as well as a U.S. Importer.

It hopes to have a program in operation by mid-2022. Other states working on importation are Vermont, New Hampshire and Maine. But skeptics say getting the programs off the ground is a long shot.

They note Congress in 2003 passed a law to allow certain drugs to be imported from Canada — but only if the secretary of the Department of Health and Human Services agreed it could be done safely. HHS secretaries under Presidents George W. Bush and Barack Obama refused to do that.

But HHS Secretary Alex Azar gave the approval in September. Biden’s HHS nominee, Xavier Becerra, voted for the 2003 Canadian drug importation law when he was a member of Congress. HHS referred questions on the issue to the White House, which did not return calls for comment.

Trish Riley, executive director of the National Academy for State Health Policy, said states have worked hard to set up procedures to ensure drugs coming from Canada are as safe as those typically sold at local pharmacies. She noted that many drugs sold in the United States are already made overseas. She said the Biden administration could choose not to defend the importation rule in the PhRMA court case or ask for an extension to reply to the lawsuit.

€œRight now, it’s murky,” she said of figuring out what the Biden team will do. Ian Spatz, a senior adviser with consulting firm Manatt Health, questions how significant the savings could be under the plan, largely because of the hefty cost of setting up a program and running it over the objections of the pharmaceutical industry. Another obstacle is that some of the highest-priced drugs, such as insulin and other injectables, are excluded from drug importation.

Spatz also doubts whether ongoing safety issues can be resolved to satisfy the new administration. €œThe Trump administration plan was merely to consider applications from states and that it was open for business,” he said. €œWhether [HHS] will approve any applications in the current environment is highly uncertain.” Phil Galewitz.

pgalewitz@kff.org, @philgalewitz Related Topics Contact Us Submit a Story Tip.

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Start Preamble Agency for Healthcare buy viagra online no prescription http://www.tracyiperkins.com/2015/01/26/30-day-minimalism-challenge-day-15/ Research and Quality (AHRQ), HHS. Request for supplemental evidence and data submissions. The Agency buy viagra online no prescription for Healthcare Research and Quality (AHRQ) is seeking scientific information submissions from the public. Scientific information is being solicited to inform our review on Emergency Medical Service/911 Workforce Control and Prevention Issues, which is currently Start Printed Page 70128 being conducted by the AHRQ's Evidence-based Practice Centers (EPC) Program. Access to published and unpublished pertinent scientific information will improve the quality of this review.

Submission buy viagra online no prescription Deadline on or before January 10, 2022. Email submissions. Epc@ahrq.hhs.gov. Print submissions. Mailing Address.

Center for Evidence and Practice Improvement, Agency for Healthcare Research and Quality, ATTN. EPC SEADs Coordinator, 5600 Fishers Lane, Mail Stop 06E53A, Rockville, MD 20857. Shipping Address (FedEx, UPS, etc.). Center for Evidence and Practice Improvement, Agency for Healthcare Research and Quality, ATTN. EPC SEADs Coordinator, 5600 Fishers Lane, Mail Stop 06E77D, Rockville, MD 20857.

Start Further Info Jenae Benns, Telephone. 301-427-1496 or Email. Epc@ahrq.hhs.gov. End Further Info End Preamble Start Supplemental Information The Agency for Healthcare Research and Quality has commissioned the Evidence-based Practice Centers (EPC) Program to complete a review of the evidence for Emergency Medical Service/911 Workforce Control and Prevention Issues. AHRQ is conducting this technical brief pursuant to Section 902 of the Public Health Service Act, 42 U.S.C.

299a. The EPC Program is dedicated to identifying as many studies as possible that are relevant to the questions for each of its reviews. In order to do so, we are supplementing the usual manual and electronic database searches of the literature by requesting information from the public ( e.g., details of studies conducted). We are looking for studies that report on Emergency Medical Service/911 Workforce Control and Prevention Issues, including those that describe adverse events. The entire research protocol is available online at.

Https://effectivehealthcare.ahrq.gov/​products/​ems-911-workforce--control/​protocol. This is to notify the public that the EPC Program would find the following information on Emergency Medical Service/911 Workforce Control and Prevention Issues helpful. A list of completed studies that your organization has sponsored for this indication. In the list, please indicate whether results are available on ClinicalTrials.gov along with the ClinicalTrials.gov trial number. For completed studies that do not have results on ClinicalTrials.gov, a summary, including the following elements.

Study number, study period, design, methodology, indication and diagnosis, proper use instructions, inclusion and exclusion criteria, primary and secondary outcomes, baseline characteristics, number of patients screened/eligible/enrolled/lost to follow-up/withdrawn/analyzed, effectiveness/efficacy, and safety results. A list of ongoing studies that your organization has sponsored for this indication. In the list, please provide the ClinicalTrials.gov trial number or, if the trial is not registered, the protocol for the study including a study number, the study period, design, methodology, indication and diagnosis, proper use instructions, inclusion and exclusion criteria, and primary and secondary outcomes. Description of whether the above studies constitute ALL Phase II and above clinical trials sponsored by your organization for this indication and an index outlining the relevant information in each submitted file. Your contribution is very beneficial to the Program.

Materials submitted must be publicly available or able to be made public. Materials that are considered confidential. Marketing materials. Study types not included in the review. Or information on indications not included in the review cannot be used by the EPC Program.

This is a voluntary request for information, and all costs for complying with this request must be borne by the submitter. The draft of this review will be posted on AHRQ's EPC Program website and available for public comment for a period of 4 weeks. If you would like to be notified when the draft is posted, please sign up for the email list at. Https://www.effectivehealthcare.ahrq.gov/​email-updates. The technical brief will answer the following questions.

This information is provided as background. AHRQ is not requesting that the public provide answers to these questions. Guiding Questions 1. What are the characteristics, incidence, prevalence, and severity of occupationally-acquired exposures to infectious diseases for the EMS/911 workforce?. a.

How do the incidence, prevalence, and severity of exposures vary by demographic characteristics ( e.g., age, sex, race, ethnicity) of the workforce?. b. How do the incidence, prevalence, and severity of exposures vary by workforce characteristics ( e.g., training, experience, level of practice, geographic region)?. 2. What are the characteristics and reported effectiveness ( i.e., benefits and harms) in studies of EMS/911 workforce practices to prevent infectious diseases?.

a. How do workforce practices to prevent infectious diseases vary by demographic characteristics ( e.g., age, sex, race, ethnicity)?. b. How do workforce practices to prevent infectious diseases vary by workforce characteristics ( e.g., training, experience, geographic region etc.)?. c.

How do workforce practices to prevent infectious diseases vary by practice characteristics ( e.g., training, personal protective equipment (PPE), personnel, and budget requirements)?. d. What is the reported effectiveness ( i.e. Benefits and harms) in studies of EMS/911 workforce practices to prevent infectious diseases?. (Outcomes of interest include but are not limited to, incidence, prevalence, duration, severity, missed work, healthcare utilization, separation from the workforce, disability, and death from s.) 3.

What are the characteristics and reported effectiveness ( i.e., benefits and harms) in studies of EMS/911 workforce practices to recognize and control ( e.g., chemoprophylaxis, but excluding treatment) infectious diseases?. a. How do workforce practices to recognize and control infectious diseases vary by demographic characteristics ( e.g., age, sex, race, ethnicity) of the EMS/911 workforce?. b. How do workforce practices to recognize and control infectious diseases vary by workforce characteristics ( e.g., training, experience, level of practice, geographic region)?.

c. How do workforce practices to recognize and control infectious diseases vary by recognition and control practice characteristics ( e.g., training, PPE, personnel, and budget requirements)?. d. What is the reported effectiveness ( i.e., benefits and harms) in studies of EMS/911 workforce practices to recognize and control infectious disease?. (Outcomes of interest include but are not limited to, incidence, prevalence, duration, severity, missed work, healthcare utilization, separation from the workforce, disability, and death from s.) Start Printed Page 70129 4.

What are the context and implementation factors of studies with effective EMS/911 workforce practices to prevent, recognize and treat occupationally-acquired infectious diseases?. This description might include distinguishing factors such as workforce training, surveillance, protective equipment, pre- and post-exposure prophylaxis, occupational health services, preparedness for emerging infectious diseases, and program funding. 5. What future research is needed to close existing evidence gaps regarding preventing, recognizing, and treating occupationally-acquired infectious diseases in the EMS/911 workforce?. PICOTS (Populations, Interventions, Comparators, Outcomes, Timing, and Settings) Inclusion criteriaExclusion criteriaPopulation• Emergency medical service workforce including 911 dispatchers exposed to or at risk of exposure to an occupationally-acquired infectious disease as contact exposure, respiratory exposure, or blood-borne exposure.*• Fire fighters and police personnel not involved in medical care.Intervention• One or more of the following types of interventions:• NA. ○ Training or education ○ PPE protocols ○ Personnel policies ○ Budget allocations ○ treatments ○ EquipmentComparison• Any comparison group (for studies that evaluate the effectiveness of an EMS/911 workforce practice)• Studies without a comparison group (for studies that evaluate the effectiveness of an EMS/911 workforce practice).Outcomes• Incidence• NA. • Prevalence • Duration • Severity • Missed work • Healthcare utilization • Separation from the workforce • Disability • Death from sTiming• Published after 2006 and includes data after 2006Setting• Conducted in the United States• Military exercises and drills.

€¢ Live evacuations from another country.Study design• Experimental and non-experimental studies with comparison groups, including pre-post studies • Relevant systematic reviews.• No original data (Narrative reviews, commentaries, simulation studies).* Organisms of interest included but are not limited to SARS-COV2, influenza, tuberculosis, HIV, and Hepatitis B and C. Start Signature Dated. December 3, 2021. Marquita Cullom, Associate Director. End Signature End Supplemental Information [FR Doc.

2021-26630 Filed 12-8-21. 8:45 am]BILLING CODE 4160-90-PThe emergency alarm went off just before sundown. For the oil-field medics of Loving County, that sound means your world is about to get a shot of adrenaline. One minute you might be lounging on the couch with the guys on call, watching Lethal Weapon 4, nursing a post-brisket food baby, and the next you’re in the back of an ambulance, watching a ribbon of West Texas highway unspool behind you, cursing yourself for not using the restroom before hustling out of the clinic. Which is exactly where I found myself one stormy Friday evening last July.An emergency medical technician named Justin Esthay was behind the wheel.

Beside him, Anthony Luk, a paramedic trained for more-complex procedures, radioed to dispatch for directions. We were speeding toward a fire in a far-flung corner of the Permian Basin oil patch. Lightning had ignited a tank of crude, and a nearby drilling crew had called in the blaze. Several days of heavy rain had transformed the dry arroyos and bar ditches into churning rivers. A wind shear had blown through a few nights before and razed two dozen telephone poles like a sickle moving through hay.

Line crews had worked day and night to restore power and clean up the mess. Now the roads, already in bad shape, were washing away into the muddy desert.The ambulance we were in belonged to Occupational Health and Safety International, a company based in the Houston area that operates a scrappy medical network in this sparsely populated part of the patch, including the clinic we had just come from, near Mentone, about one hundred miles west of Midland. The medics and EMTs who work there treat everyone from oil-field workers with critical injuries to cowboys with broken bones to old-timers with indigestion. They also run Loving County’s ambulance service. If you’re sideswiped by a sand hauler or T-boned by a welder on one of the region’s few blacktop roads—one of which is known as “Death Highway” because of its lethal oil-field traffic—the members of an OHSI crew are your best shot at making it to a hospital alive.

But first they have to make it to the scene alive. On this call, I wasn’t sure we would.We were barreling north on County Road 300 when the driver’s side tire sank into a crater. The ambulance lurched to one side, and we skidded to a halt. Behind us, the lights of a semi grew closer and closer. The driver managed to stop before slamming into us, but just barely.

A little farther down the road, we passed another ambulance. It was hobbled on the shoulder with a blown tire and twisted rim. That crew, hailing from another OHSI clinic in nearby Culberson County, had been the first to respond to the alarm. But they’d been less lucky with that pothole. Lightning wraps around a telephone pole in the distance, seen from the OHSI ambulance dock in July 2021.Photograph by Jeff WilsonWe finally turned off the asphalt and drove for another half hour down mud-choked caliche roads.

At 10 p.m., just over an hour after the call came in, we arrived on the scene. Legs numb, I stumbled out and looked around. The drilling crew, smoking and chatting in dirty coveralls, was huddled around their company pickup waiting for the all clear to return to the rig. The only signs of fire were flares burning natural gas and the glow of the roughnecks’ cigarettes.There was no sign of a proper fire engine either. Just an ancient, battered brush truck with “Balmorhea Volunteer Fire Dept.” on the side.

We shook hands with two dudes leaning against the vehicle who were dressed more like farmers than firefighters. They’d come about a hundred miles from Balmorhea. Other departments nearer to the fire had refused to make the trip, unwilling to risk the flooded low-water crossings. Between thick streams of tobacco juice, the men told us the blaze had nearly burned itself out by the time they got there. A good thing, considering they had little more than a couple hundred gallons of water and some shovels on their truck.

The oil company had asked them to stick around until a drone equipped with a thermal camera flew over the area to look for hot spots. Having already made the trek, we were asked to stay as well.Even though I had worked as a roughneck for a short stint after college, this was the most remote and isolated place I’d ever been in the patch. There was no cell service. It was pitch-black save for our headlights, a few flares, and the glowing pillars of drilling rigs scattered across the dark desert floor. It was early summer, and I was nearing the end of the second week of three that I spent in Mentone, embedded with the medics of Loving County.

I knew that this was where we’d be spending the rest of our Friday night. I’d been on several ambulance runs at this point and had learned that out here a single call could last twelve hours. The previous weekend, Anthony had rushed two gunshot victims, one of whom had brain trauma, from the town of Pecos to two different hospitals, hours apart, in Lubbock and Midland. He’d left the clinic at 2 a.m. And hadn’t returned until 4:30 p.m.

The next day. This call was a cinch in comparison. I’d already been around long enough to appreciate our good fortune. Because when the emergency alarm rings, disasters far worse than snuffed-out fires often await the crews at OHSI.At last, after two and a half hours, a rep from the oil company confirmed that the drone had detected no heat. As members of the drilling crew piled into their truck to head back to the rig, one of them, as if acting in some oil-field drama, hollered, “Let’s make some hole!.

€As we loaded back into the ambulance, it occurred to me that the OHSI crews weren’t so different from the oil and gas workers they were here to help. The hard living, the time away from family, the macho culture, the insider lingo, the physicality of the job. Those who work in emergency medical services are essentially the roughnecks of health care. Although their job requires a high level of skill and knowledge, compared with other health-care gigs it is undeniably blue-collar and often treated as less than. But at least roughnecks are paid well, with many banking at least $75,000 a year.

The same can’t be said of EMS workers, who on average make less than half that. And yet here they were, EMTs and medics, proving their guts and grit in the heart of nowhere, their work known only to each other—and the people they save.The OHSI clinic in Loving County in July 2021.Photograph by Jeff WilsonI found OHSI by accident. Though I’d grown up in the oil patch, in the small town of Andrews, about eighty miles northeast of Mentone, I’d never heard of an outpost of oil-field medics. Most folks haven’t. OHSI doesn’t advertise, and it’s not the kind of outfit EMS workers flock to.But in October 2020, I was reporting a story on the last county in the U.S.

Without a single recorded erectile dysfunction treatment case, which happened to be Loving. A cashier at the Horseshoe, the only convenience store (or any kind of store) in the county, had mentioned a small clinic on the outskirts of Mentone where oil-field workers and locals could get tested for the viagra. When I drove out there, Cary Skelton, a fifty-year-old paramedic and OHSI’s West Texas program manager, was outside. He had on his typical uniform. A T-shirt, ball cap, cargo pants, and square-toed cowboy boots.

He was chain-smoking Kool menthols next to a parked ambulance. A gray cat named Tigger was curled up on the vehicle’s hood, and a shotgun named Bubba rested against the front bumper. Cary nodded at the gun. €œCoyotes been getting too close for ol’ Tigger here.”We talked as the sun went down—about the viagra, about how the clinic had been erectile dysfunction treatment-testing scores of workers every day, about the region. Loving County, Cary told me, is a tough sell.

The 677-square-mile county is best known for being the least populous in the entire United States. Just 64 souls claimed permanent residence there in the 2020 census. If it weren’t for the courthouse, you might mistake Mentone (population 22) for an oil-field junkyard. It’s quicker to rattle off what few amenities exist in town than to list everything that doesn’t. In addition to the courthouse and a few abandoned buildings, there’s the county annex, a tennis/basketball court, the Horseshoe, a post office (never locked), three food trucks, and one Tex-Mex restaurant that closes at three in the afternoon.

But to Cary, Loving County is more than a desolate frontier of sandstorms and creosote bush. This part of West Texas is his home. As a boy, he worked cattle on ranches, including his grandfather’s, across the region. And today you’d be hard-pressed to find a more entertaining source of regional history than Cary Skelton. When he tells stories, his posture shifts and his voice changes, depending on the character he’s enacting.

He affects a lisp to imitate the late Newt Keen, a droll cafe owner in Mentone who lost a few front teeth after he took a bullet to the face. And Cary’s eyes narrow when he takes on the role of Sheriff Elgin “Punk” Jones, the top lawman in the county from his first term, in 1965, till he hung up the badge in 1992.Cary lights up when he talks about growing up out here. Like the time he was nine or ten, when he and a buddy decided to drive a go-kart the thirty miles from the Red Bluff Reservoir to Mentone in the dead of night. This was in the early eighties, some three decades before the shale boom brought heavy traffic and thousands of itinerant workers to the area. The roads were mostly empty then, but they could still be dangerous.

Mexican cartels used them as improvised runways on which to land small aircraft loaded with cocaine or other illicit drugs. One night, Cary told me, the Texas Rangers were waiting for the traffickers. A plane landed, and, in the ensuing firefight, one of the narcos backed into its whirring propeller. €œIt was some straight-up Indiana Jones shit,” Cary said. (The bloodstain left on the pavement marked the spot where Cary said he used to turn off for his favorite fishing hole.)But the boys weren’t worried about narcos on the night they set out in a go-kart for Mentone.

They were on a mission. They strapped a five-gallon tank of gas to the tiny vehicle and clicked on a pair of Maglites to shine their way through the dark. €œWe were driving so fast,” Cary remembered, “we were outrunning our lights.” The boys had almost made it to Mentone when they got lit up by Punk Jones. Punk was the archetypal West Texas lawman. He tucked his jeans into high-topped boots, wore a silverbelly Stetson with a roguish curve, and kept a silver star pinned to his pearl-snap shirt.

His grim good looks gave off the same tough-as-leather vibe as Clint Eastwood. He strolled up to the go-kart.“What are you boys doing?. € he asked. €œWell, we’re driving around,” they told him. Punk shook his head.

€œI don’t know if riding around on a go-kart in this part of the country is very safe.” He loaded the boys and their go-kart into his truck and drove them back to their homes. Cary was sure he’d get a whupping for the stunt, but Punk never said a word about their adventure, not even to Cary’s dad.There have been a few changes since Cary was a kid. Thanks in part to the same Punk Jones, who drilled some of the county’s first non-brackish wells, you can now turn on a tap anywhere in town and get drinkable water. Still, potable water isn’t much of a selling point in 2022, and besides the lack of modern conveniences, the OHSI staff also faces all the dangers and discomforts of the oil field. When they’re out on a call, they might encounter poisonous gases, homicidal drivers, and high-pressure wells that sometimes blow up.

There are also the long hours and weeks away from home. The crew’s hitches are two weeks long, minimum. They’re on call 24 hours a day during that time, which means that consuming anything stiffer than Red Bull is prohibited. On top of this, they must meet Cary’s standards. “Look, I don’t have time to make someone an EMT or paramedic,” Cary said.

€œThey need at least five years of experience of doing this on the daily, thousands of patient contacts, before they come out here.” In an urban environment, new medics can cut their teeth with less risk of fatal mistakes. €œThey’re ten minutes away from a physician and an ER to get them out of a jam,” Cary said. Not so in Loving County, where the nearest level I trauma center is several hours away, in El Paso or Lubbock. €œWe have to bat a thousand. We have to get a base hit every single time,” he said.

€œOtherwise, we could have some bad outcomes. We could lose someone.” Cary snubbed out his cigarette. €œGive me another sweet,” he told one of the EMTs who’d joined us outside. Another Kool was produced. Cary lit it.

It was dark now. Above us, the Milky Way was smeared across the night sky as if someone had tried wiping chalk from a blackboard. The quiet was broken by a yelping chorus of coyotes not far from where we stood. €œOut here, you’ve gotta be the cavalry,” Cary said, exhaling smoke. €œBecause no one is going to come to help you.”Since the erectile dysfunction viagra began, politicians and corporations trying to gin up goodwill have heaped praise on first responders, including EMS workers like Cary.

But many on the front lines say it’s mostly a bunch of smoke. €œEMS is the bastard stepchild of the planet,” Cary told me.Today, most of us take for granted that we can pick up the phone, dial 911, and someone will be at our side in minutes, capable of keeping us alive during the brief trip to a hospital awaiting with teams of doctors. But this convenience is a relatively new development. Texas’s Department of State Health Services didn’t include an EMS division until 1973.In Texas and most other states, EMS, unlike police and fire departments, is not considered an “essential service.” Instead, EMS workers are dispatched through a haphazard patchwork of municipal and county operations, hospital-affiliated services, nonprofit and volunteer associations, and private enterprise. That’s where OHSI comes in.

Dustin Hoffpauir outside the OHSI clinic.Photograph by Jeff WilsonThe nutty idea of opening a for-profit clinic in the country’s least populated county was Dustin Hoffpauir’s. I met Dustin during my first week at the clinic. He arrived from Houston in his King Ranch Ford bearing a load of boiled crawfish, a nod to his Cajun roots. Dustin had come to EMS through the safety departments of several oil and gas companies. After graduating from the University of Louisiana at Lafayette in 1998, he worked as a fire watchman on offshore rigs in the Gulf of Mexico.He eventually migrated to dry land and a small Lafayette-based safety company, doing contract work for bigger oil and gas companies.

One of those was Anadarko Petroleum, which hired Dustin in 2005. For the next thirteen years, he served as one of its lead safety officers. The job frequently took him west to the Permian Basin, where he spent days driving the lease roads of Loving and its neighboring counties. Dustin was headed for a comfortable retirement with the company, but then a trip to West Texas made him change course.Several years ago, Dustin was on his way to tour a natural gas plant when an accident at the facility left two contract workers severely burned. Though he’d completed basic EMT training, when he arrived Dustin didn’t have any equipment with him to start caring for the victims.

He waited helplessly for EMS to get there. It took more than an hour and half, an eternity to Dustin resource. €œAnd that’s when I really started thinking about the challenges associated with providing medical care out here, and the lack of resources,” he said. €œThe same thing kept on reoccurring. Delayed response.

Unfortunately, some lives were lost.”“The same thing kept on reoccurring. Delayed response. Unfortunately, some lives were lost.”Three years ago, for instance, in Culberson County, just west of Loving, a worker died of an apparent heart attack. His coworkers were forced to sit with his body for more than two hours while waiting for the sheriff, who drove more than 150 miles on bad roads to get there. When no ambulance could be found, the sheriff had to haul the body back to Van Horn in his truck.

One of the coworkers later spoke at a county commissioners’ meeting, imploring the officials to invest in EMS, cut down on response times, and give the deceased a bit of dignity. €œMy God, people,” he said, his voice choked, “what have we come to!. €Dustin and his wife, Mandy Hoffpauir, a registered nurse, made a plan. Dustin recalled his time working in the Gulf. The challenges of providing medical care on offshore oil rigs mirrored those in the Permian Basin.

He figured he could replicate the model he’d learned out there.First, he tackled the economics. Most ambulance companies don’t get paid unless they transport a patient. Out in a rural area like Loving County, the relatively low volume of transports, compared with the number carried out by city services, can make it hard for a company to keep the lights on between calls. If a patient doesn’t have insurance and is deemed indigent, the ambulance company often eats the bill. But Dustin knew that the oil and gas industry was desperate to find solutions to the problems it had brought to the region.

The traffic accidents, the thousands of itinerant workers needing basic care for chronic conditions or medical emergencies, and the work-related incidents (well blowouts, rig injuries, flash fires, heat exhaustion, and so on) that are often more serious than those that occur in other industries. EMTs unload their medical bag from the OHSI ambulance. Photograph by Jeff Wilson Medical instruments at the OHSI clinic. Photograph by Jeff Wilson Left. EMTs unload their medical bag from the OHSI ambulance.

Photograph by Jeff Wilson Top. Medical instruments at the OHSI clinic. Photograph by Jeff Wilson Dustin pitched the idea for a remote medic service to some of the major companies operating in the region. They asked whether he could also open a clinic that would perform on-site drug testing, issue some medications, and perform basic medical procedures such as treating minor wounds and conducting X-rays. Dustin agreed to that.

In a rare move for fiercely competitive oil companies, several banded together to form a consortium. Their pooled resources guaranteed a steady income for OHSI, regardless of the volume of calls. In late 2017, Dustin leased land outside Mentone and hauled in an old army barracks to convert into OHSI’s flagship clinic. He and a friend did most of the remodeling themselves, spending nights in sleeping bags on the floor while they worked. The product was functional, if not exactly luxurious.Dustin knew that it wasn’t only oil-field workers who could benefit from OHSI’s services.

The locals of Loving County needed access to health care too. That’s where Cary Skelton came in.When the former manager at OHSI stumbled upon his résumé on a jobs listing site, Cary was working in El Paso and looking for a new gig. He was tired of the relentless pace of the city’s emergency rooms and urgent care centers. He’d never dreamed he’d be able to find work in Loving County, yet here was an opportunity to do something meaningful for his community. Cary jumped at the chance to come home.

€œBut the other part of it was, I had to produce. This is my granddad’s stomping grounds, and I cannot mess this up.” Cary understood Loving County. €œOil-field workers and rodeo cowboys, they don’t go the doctor unless something is sticking out,” he said. €œPeople don’t even take their prescriptions out here because it’s seen as a sign of weakness.” Cary’s dad is like that. He once showed up at the clinic with a busted head.

He refused to get out of his truck, so one of the medics had to staple the wound through the window. OHSI ultimately made inroads with county officials, including Judge Skeet Lee Jones, one of Punk Jones’s sons. The county purchased its first ambulance, and OHSI signed on to staff it around the clock. (OHSI also provides health care to Loving County residents for free.)Although the Mentone clinic is still the heart of its operations, OHSI has expanded. There are now two more small clinics, one in Culberson County, near the revived ghost town of Orla, and another in Pecos, 23 miles south of Mentone.

OHSI also dedicates an ambulance to serve Kermit and Monahans (55 miles east of Mentone), moving patients from one hospital to another.The presence of OHSI is a comfort to even the most treatment-hesitant locals and the itinerant workers who, however briefly, call Loving County home. But for the EMTs and medics who make their living and spend more than half the year at the clinic, their sacrifices add up. Dominic Sanchez, Steven Hutson, and Anthony Luk play poker in the clinic while waiting for a call.Photograph by Jeff WilsonMy first hitch, which would last two weeks, began in late June. On a Tuesday morning, I arrived at the clinic, a metal structure the same beige as desert camouflage. The clinic abuts a rodeo arena just to the east.

Otherwise there is little but sun-scorched pastures of mesquite and greasewood, the occasional pump jack, and a few rusted skeletons of old trucks and tractors. As Cary and I walked up the entrance ramp, Tigger and her kittens scattered from a heaping plate of food. In front of the door was a bloody rabbit’s foot. €œThat was probably Tigger,” Cary said, catching my stare as he swung open the door. €œNot the first time she’s gotten a cottontail.

And, hey, that’s good luck!. €Touring the clinic didn’t take long. The building is divided in half. One side includes an examination room, X-ray room, and dispatch office. The other side serves as the living quarters for the staff.

A cramped kitchen. A common room with an overstuffed brown sofa, an easy chair, and a TV on the wall. A bathroom. And two bedrooms, where the crew members sleep two to a room. There are plain white walls and scuffed linoleum floors throughout.

The vibe is a mix of college dorm and military medical outpost. As the fresh crew trickled in, the EMTs and medics who’d been on duty headed home, to El Paso, Lubbock, and as far away as Louisiana. One by one, I met the guys I’d be shadowing for the next two weeks. First was Steven Hutson, an EMT from the flyspeck of Kirvin, a town eighty miles southeast of Dallas. The youngest of the bunch at 25, he had a hefty frame and Bambi eyes that had earned him the nickname Baby Huey.

Next was Dominic Sanchez, a 26-year-old Albuquerque transplant with a boy-band smile and muscles on his earlobes. Dom was responsible for dispatching crews to calls for help, a duty he performed while wearing a pair of pearly white Crocs. And finally there was Anthony Luk, a 29-year-old paramedic who grew up far from West Texas, in the Asian grocery store his family managed in Houston. These three, along with Cary, would be responsible for running the clinic 24 hours a day for the next fourteen days, as well as responding to emergency calls.Texas Highway 302, which leads into Mentone from the clinic.Photograph by Jeff WilsonDays at the clinic varied wildly. One might be mind-numbingly slow.

Hardly anyone would show up for treatment, and the emergency alarm stayed quiet. The next, the team might be slammed from morning to night with workers dropping in for erectile dysfunction treatment screenings, for drug and alcohol tests, or with physical maladies. A welder came in with a metal shaving lodged in his eye. Another patient arrived needing an X-ray after falling from a catwalk between two tall tanks. Several workers, their accents suggestive of places a long way from Texas, came in suffering from dehydration.

And one evening a man hobbled in with severe burns on his leg. He and his wife had gotten sideways at dinner. She’d doused him with hot gravy.For the most part, evenings were peaceful. The guys would retreat to the living quarters after six or seven, offering a little prayer that no one else would show up or call 911. We’d make a family dinner, which could be Steve’s deer-sausage spaghetti or a Korean barbecue dish Anthony whipped up.

A game of Texas Hold ’Em might start up, one of the many firearms stashed around the clinic might be fetched for cleaning, or a haircut attempted, but more often than not, someone would turn on the television, and, after settling on a movie, the guys would sit shoulder to shoulder on the couch, eating off TV trays as if they were kicking back at a middle-school slumber party. “Everyone knows each other’s backstory so well,” Anthony told me, “we don’t really have to talk about that anymore.” They repeated some details for my sake. I learned that Anthony’s parents had immigrated from Hong Kong before he was born. He’d lived in Houston until he left for Lubbock to attend Texas Tech. Going from Houston’s humidity to the dry heat, he’d suffered nosebleeds constantly that first year.

I learned that Steve had gotten married just seven months prior and that he hated broccoli and loved Mel Gibson. (I was subjected to three Gibson films during my stay.) And Dom was the group’s Casanova, practicing his charms, without much success, on a clerk at the Horseshoe.Everyone caught hell for something. Steve for his diet (“He’d eat the ass out of a dead rhino”), Dom for his footwear, and Anthony for his skin-care routine, which revolves around his FaceTory, a small mint-green refrigerator he hauls with him that’s full of serums, oils, and face masks he wears at night. €œIf you can’t take the ribbing,” Cary said, shrugging, “this outfit ain’t for you.”Cary was at the center of it all. He acted as the group’s big brother, camp counselor, and, occasionally slipping back into his military background (he served overseas as a cavalry scout), drill sergeant.

He often quizzed the guys on what meds or protocols to use in various situations. €œThese are perishable skills,” he explained. Because OHSI doesn’t run calls every day like city ambulance services do, “you have to be studying. You have to be practicing. You have to be putting your hands on equipment.” But for all the grief he gives them, Cary is fiercely loyal to and proud of his crew.

€œA lot of people think that because we’re out here in Hickville, we’re going to deliver some type of substandard medicine. No way. I would put my guys up with anybody out there.” When that emergency phone rings—and eventually it does—life-and-death situations await the OHSI crews. Their memories are full of the kind of gore that most of us see only in horror films. A road-rage victim shot point blank in the belly, guts slopping out like uncooked sausage.

An F-150 crushed like a Coke can under an eighteen-wheeler. A three-man roustabout crew charred in a flash fire. One driver was covered in tar after his tanker exploded. Onlookers had poured water on him to relieve his pain, but that had only made the tar harden onto him. By the time OHSI delivered him to a hospital, his skin was peeling off in chunks.Just a couple of weeks before my hitch, a worker had been up on a catwalk removing a flange.

Maybe he had heard a hiss of pressure and realized he was in danger. He’d apparently turned to run, but before he could get to the stairs nearby, the enormous pressure now leaking from the loosened bolts blew the metal cover off the flange. It struck him smack in the back of the head. He was dead by the time OHSI arrived on scene, but before the site could be opened back up, Cary had to scrape gray brain matter off the railing of the catwalk. Because the area is so remote, the OHSI crews are also the de facto biohazard team in this part of the patch.This tension between normal life at the clinic and the arrival of the next emergency was something I could never quite adjust to during my time at OHSI.

It was hard to sleep, knowing that at any minute the alarms could call us out into the night. Luk reads an EKG at the clinic. Photograph by Jeff Wilson The examination room at the OHSI clinic in Loving County in July 2021. Photograph by Jeff Wilson Left. Luk reads an EKG at the clinic.

Photograph by Jeff Wilson Top. The examination room at the OHSI clinic in Loving County in July 2021. Photograph by Jeff Wilson You won’t find much sympathy talking about the woes of a forty-hour week with EMS workers. For them, long hours are the norm. Justin Esthay, the EMT driving the ambulance on the call that took us to the flare fire, told me he regularly worked sixteen-hour shifts and once put in twenty hours straight for an ambulance service in Louisiana.

The schedule at OHSI, with its occasional stretches of downtime, was a relief. Still, it was hard not to notice the dark circles around Justin’s eyes. Anthony explained that EMTs and medics work such ungodly hours in part because the pay for EMS workers is shockingly low and they need the overtime. With the mean annual wage for Texas EMS workers clocking in at about $37,550, many work two or even three jobs to eke out a living.As an EMT in Lubbock, Anthony had started out making $11 an hour. €œBut I also picked up a lot of overtime.

That’s the thing. In EMS, picking up overtime is where we make our money. It’s also a big reason why there’s a lot of burnouts.” The annual turnover rate for EMS workers is about 30 percent.“You’re constantly working,” Anthony continued. €œIt’s hard on marital life, social life, all life outside of work. Relationships are hard to sustain because, like, for us here, you’re gone for two weeks.

It’s terrible to say, but out of the guys who’ve had partners or were married, a good forty to fifty percent are no longer.”Anthony’s fiancé, William, is a composer in Lubbock. I met him briefly when he made the three-hour one-way trip to deliver a set of keys Anthony had accidentally left at their apartment. It was the only time William had ever set foot in the clinic where Anthony spends more than half the year.“When you go home, you don’t want to do anything,” Anthony said, speaking generally. €œYou just want to rest, and your partner doesn’t always understand. Plus, you don’t want to tell them everything because you don’t want to relive it.

Like, if you had a bad day at work where you had to do CPR on a kid who drowned. . . That’s traumatizing. Even though most people seem to shake it off and move on, you’re still overwhelmed with sadness.” According to one study, EMTs and medics are about ten times more likely to have suicidal thoughts than workers in other professions.

And yet many first responders never seek professional help for their mental health. Cary chalks this up in part to EMS culture, in which the ability to put on a tough front and “silently suffer” is highly valued. Others don’t seek counseling because they can’t afford it. (A couple of the OHSI workers I spoke with said they’d opted out of the company’s plan because they felt the premiums were too high.) This means EMS workers find other ways to deal with their trauma. €œI know a lot of EMS guys who have pretty bad vices,” Anthony said.

€œThat’s the way that they wind down, whether it be a massive amount of alcohol or a massive amount of partying.”According to one study, EMTs and medics are about ten times more likely to have suicidal thoughts than workers in other professions.While the crews are on call at OHSI, they temper certain bad habits they might indulge at home. A couple of them funneled their energy into working out at Mentone’s only gym, a tiny collection of weights set up inside a shipping container. Some dipped tobacco, smoked, and guzzled an endless stream of energy drinks to ward off stress, boredom, and weariness. But without exception, all the guys leaned heavily into a dark humor specific to their profession.That night in Culberson County, for instance, as we stood around waiting for the drone to finish its search for any lingering hot spots from the fire, Justin told a story from a few years back. He’d just finished an ambulance shift and was walking out to the parking lot to head home.

€œThis car comes hauling ass in, pulls right up, and almost hits me. The window rolls down, and the driver leans over. €˜This guy just OD’d on heroin.’ ” The man in the passenger seat was barely breathing. Justin got him out of the car. €œI start doing CPR on this dude.

I’m dripping sweat, absolutely drenched because it’s so hot.” Justin managed to get the guy to the hospital alive. The patient woke up, “and he’s thanking me, blah, blah, blah. For a while, I felt like, ‘Wow, I really saved somebody.’ I felt kind of good about it, even though the circumstances were crappy. So I come back to work the next day. The EMT I’m relieving is like, ‘Hey, remember that guy you saved yesterday?.

€™ I’m like, ‘Yeah.’ ‘He left the hospital and immediately OD’d again and died.’ I’m thinking, ‘I sweat my ass off, and it was all for nothing.’ ” He and Anthony both laughed at the irony.As an outsider, I was initially horrified by stories like this. But I came to understand their necessity. Anthony and Justin didn’t think the story was funny. They laughed because that’s how they deal with the grief and suffering they witness all the time. For EMS workers, black humor is the shared tongue, a coping mechanism, a survival tool.EMT Steven Hutson in the field in Loving County in July 2021.Photograph by Jeff WilsonAfter my hitch ended, the price of oil climbed and the patch got busier—and so did OHSI.

They’d had some rough calls. A few bad wrecks and a fire that had burned a crew of three. Plus, a surge in erectile dysfunction treatment cases had forced the crews to work even longer hours, as they had to transfer patients to hospitals farther and farther away. There had been some personnel changes too. Dominic Sanchez had left OHSI for a medical gig nearer to his home in Killeen.

And Steven Hutson had found work with an ambulance service close to his wife and family in Kirvin. Anthony Luk is still at OHSI but has been preparing to apply to medical school. He hopes to start later this year. Cary hates to lose good workers, but he doesn’t blame anyone for leaving.Sometimes when we spoke on the phone, Cary sounded bone tired. Finding replacements hadn’t been easy, and the crews were stretched thin.

At times he felt as if OHSI were barely hanging on. And lately, bigger ambulance companies have started to home in on the Permian Basin. Cary explained that big companies can choke out a small independent operation by offering their services more cheaply—at least until they run the competition out of business. He knows how precarious the state of rural EMS is right now. He’s seen companies come and go.For Cary, the mission goes beyond the balance sheet.

It’s about the camaraderie of doing a difficult job in an unforgiving desert. It’s about providing his community the comfort of knowing that someone will answer when they have an emergency.It was Cary who answered the alarm one cold, windy day last January. Punk Jones had been ill for going on a month, but he’d told his family, “I ain’t going to the hospital.” The nearest was in Kermit, half an hour away, and to get advanced care, he’d have to travel all the way to Lubbock, nearly two hundred miles northeast. Most of the wards were overloaded with erectile dysfunction treatment patients anyway. But Punk did acquiesce to his wife Mary Belle’s urging to visit the OHSI clinic.The 93-year-old former lawman had been diagnosed with pneumonia.

And so twice a day, every day, Cary or another OHSI medic drove out to Punk’s ranch to check on him. On that cold Saturday morning, Cary had been on his way back to the clinic from Kermit when he received a panicked call from Punk’s family. €œHe’s not breathing well. He’s doing bad.”Cary and the family started making calls. They finally managed to find a hospital bed for Punk in Amarillo, about three hundred miles away.

Cary sent an ambulance to Punk’s house and summoned a plane to Winkler County Airport, outside Kermit, to transport Punk the rest of the way. Meanwhile, Cary had been speeding toward Punk’s place. He arrived just before the ambulance and went inside. Punk’s daughter, Mozelle Carr, was there with him. So was Mary Belle.

She told Cary, “I want you to do everything you can.” “I will,” he promised.The ambulance dock at the OHSI clinic in Loving County in July 2021.Photograph by Jeff WilsonHe and the OHSI medics got Punk on the stretcher and into the ambulance. They were flying down the road, hooking him up to monitors, starting an IV, when Punk squeezed Cary’s hand. He wagged a finger up at Cary. Then he pointed down. Punk Jones had made it clear.

He wanted to die in Loving County.Cary knew Punk wouldn’t make it to Amarillo. He told the EMT driving the ambulance to pull over in the parking lot of the county courthouse. There, Cary did as he promised. He and his fellow medics tried everything they could to save Punk. They intubated him and gave him fluids through an IV.

When Punk’s heart stopped, Cary did compressions on his chest until it started thumping again. Eight times he was able to get the heart rate monitor to register a rhythm.Cary phoned Punk’s family. The Jones clan trickled into the parking lot, congregating at the ambulance. Cary held Mozelle’s hand, and they cried together. Punk’s heart stopped again.

This time, Cary could not bring him back.At OHSI, Cary and his crews fight every day to keep folks from dying in Loving County. Of course, they can’t save everybody. And being able to provide dignity at death, to allow someone to die in the place they call home, can be just as important. It’s these moments, however weighted with tragedy, that keep Cary working overtime in Loving County, making plans to ensure that basic health care is here to stay—no matter what happens at OHSI or to the fortunes of the oil patch.A week later, Punk was laid to rest at his ranch. During the funeral, Cary offered his condolences to the Jones family.

Tom, one of Punk’s sons, told him, “I’m glad you were with him, Cary.”Cary nodded. €œIt was an honor.” This article originally appeared in the January 2022 issue of Texas Monthly with the headline “There Will Be Blood.” Subscribe today..

Start Preamble Agency for Healthcare Research and Quality (AHRQ), viagra for women price HHS lowest price viagra. Request for supplemental evidence and data submissions. The Agency for lowest price viagra Healthcare Research and Quality (AHRQ) is seeking scientific information submissions from the public. Scientific information is being solicited to inform our review on Emergency Medical Service/911 Workforce Control and Prevention Issues, which is currently Start Printed Page 70128 being conducted by the AHRQ's Evidence-based Practice Centers (EPC) Program.

Access to published and unpublished pertinent scientific information will improve the quality of this review. Submission Deadline on or lowest price viagra before January 10, 2022. Email submissions. Epc@ahrq.hhs.gov.

Print submissions. Mailing Address. Center for Evidence and Practice Improvement, Agency for Healthcare Research and Quality, ATTN. EPC SEADs Coordinator, 5600 Fishers Lane, Mail Stop 06E53A, Rockville, MD 20857.

Shipping Address (FedEx, UPS, etc.). Center for Evidence and Practice Improvement, Agency for Healthcare Research and Quality, ATTN. EPC SEADs Coordinator, 5600 Fishers Lane, Mail Stop 06E77D, Rockville, MD 20857. Start Further Info Jenae Benns, Telephone.

301-427-1496 or Email. Epc@ahrq.hhs.gov. End Further Info End Preamble Start Supplemental Information The Agency for Healthcare Research and Quality has commissioned the Evidence-based Practice Centers (EPC) Program to complete a review of the evidence for Emergency Medical Service/911 Workforce Control and Prevention Issues. AHRQ is conducting this technical brief pursuant to Section 902 of the Public Health Service Act, 42 U.S.C.

299a. The EPC Program is dedicated to identifying as many studies as possible that are relevant to the questions for each of its reviews. In order to do so, we are supplementing the usual manual and electronic database searches of the literature by requesting information from the public ( e.g., details of studies conducted). We are looking for studies that report on Emergency Medical Service/911 Workforce Control and Prevention Issues, including those that describe adverse events.

The entire research protocol is available online at. Https://effectivehealthcare.ahrq.gov/​products/​ems-911-workforce--control/​protocol. This is to notify the public that the EPC Program would find the following information on Emergency Medical Service/911 Workforce Control and Prevention Issues helpful. A list of completed studies that your organization has sponsored for this indication.

In the list, please indicate whether results are available on ClinicalTrials.gov along with the ClinicalTrials.gov trial number. For completed studies that do not have results on ClinicalTrials.gov, a summary, including the following elements. Study number, study period, design, methodology, indication and diagnosis, proper use instructions, inclusion and exclusion criteria, primary and secondary outcomes, baseline characteristics, number of patients screened/eligible/enrolled/lost to follow-up/withdrawn/analyzed, effectiveness/efficacy, and safety results. A list of ongoing studies that your organization has sponsored for this indication.

In the list, please provide the ClinicalTrials.gov trial number or, if the trial is not registered, the protocol for the study including a study number, the study period, design, methodology, indication and diagnosis, proper use instructions, inclusion and exclusion criteria, and primary and secondary outcomes. Description of whether the above studies constitute ALL Phase II and above clinical trials sponsored by your organization for this indication and an index outlining the relevant information in each submitted file. Your contribution is very beneficial to the Program. Materials submitted must be publicly available or able to be made public.

Materials that are considered confidential. Marketing materials. Study types not included in the review. Or information on indications not included in the review cannot be used by the EPC Program.

This is a voluntary request for information, and all costs for complying with this request must be borne by the submitter. The draft of this review will be posted on AHRQ's EPC Program website and available for public comment for a period of 4 weeks. If you would like to be notified when the draft is posted, please sign up for the email list at. Https://www.effectivehealthcare.ahrq.gov/​email-updates.

The technical brief will answer the following questions. This information is provided as background. AHRQ is not requesting that the public provide answers to these questions. Guiding Questions 1.

What are the characteristics, incidence, prevalence, and severity of occupationally-acquired exposures to infectious diseases for the EMS/911 workforce?. a. How do the incidence, prevalence, and severity of exposures vary by demographic characteristics ( e.g., age, sex, race, ethnicity) of the workforce?. b.

How do the incidence, prevalence, and severity of exposures vary by workforce characteristics ( e.g., training, experience, level of practice, geographic region)?. 2. What are the characteristics and reported effectiveness ( i.e., benefits and harms) in studies of EMS/911 workforce practices to prevent infectious diseases?. a.

How do workforce practices to prevent infectious diseases vary by demographic characteristics ( e.g., age, sex, race, ethnicity)?. b. How do workforce practices to prevent infectious diseases vary by workforce characteristics ( e.g., training, experience, geographic region etc.)?. c.

How do workforce practices to prevent infectious diseases vary by practice characteristics ( e.g., training, personal protective equipment (PPE), personnel, and budget requirements)?. d. What is the reported effectiveness ( i.e. Benefits and harms) in studies of EMS/911 workforce practices to prevent infectious diseases?.

(Outcomes of interest include but are not limited to, incidence, prevalence, duration, severity, missed work, healthcare utilization, separation from the workforce, disability, and death from s.) 3. What are the characteristics and reported effectiveness ( i.e., benefits and harms) in studies of EMS/911 workforce practices to recognize and control ( e.g., chemoprophylaxis, but excluding treatment) infectious diseases?. a. How do workforce practices to recognize and control infectious diseases vary by demographic characteristics ( e.g., age, sex, race, ethnicity) of the EMS/911 workforce?.

b. How do workforce practices to recognize and control infectious diseases vary by workforce characteristics ( e.g., training, experience, level of practice, geographic region)?. c. How do workforce practices to recognize and control infectious diseases vary by recognition and control practice characteristics ( e.g., training, PPE, personnel, and budget requirements)?.

d. What is the reported effectiveness ( i.e., benefits and harms) in studies of EMS/911 workforce practices to recognize and control infectious disease?. (Outcomes of interest include but are not limited to, incidence, prevalence, duration, severity, missed work, healthcare utilization, separation from the workforce, disability, and death from s.) Start Printed Page 70129 4. What are the context and implementation factors of studies with effective EMS/911 workforce practices to prevent, recognize and treat occupationally-acquired infectious diseases?.

This description might include distinguishing factors such as workforce training, surveillance, protective equipment, pre- and post-exposure prophylaxis, occupational health services, preparedness for emerging infectious diseases, and program funding. 5. What future research is needed to close existing evidence gaps regarding preventing, recognizing, and treating occupationally-acquired infectious diseases in the EMS/911 workforce?. PICOTS (Populations, Interventions, Comparators, Outcomes, Timing, and Settings) Inclusion criteriaExclusion criteriaPopulation• Emergency medical service workforce including 911 dispatchers exposed to or at risk of exposure to an occupationally-acquired infectious disease as contact exposure, respiratory exposure, or blood-borne exposure.*• Fire fighters and police personnel not involved in medical care.Intervention• One or more of the following types of interventions:• NA. ○ Training or education ○ PPE protocols ○ Personnel policies ○ Budget allocations ○ treatments ○ EquipmentComparison• Any comparison group (for studies that evaluate the effectiveness of an EMS/911 workforce practice)• Studies without a comparison group (for studies that evaluate the effectiveness of an EMS/911 workforce practice).Outcomes• Incidence• NA. • Prevalence • Duration • Severity • Missed work • Healthcare utilization • Separation from the workforce • Disability • Death from sTiming• Published after 2006 and includes data after 2006Setting• Conducted in the United States• Military exercises and drills.

€¢ Live evacuations from another country.Study design• Experimental and non-experimental studies with comparison groups, including pre-post studies • Relevant systematic reviews.• No original data (Narrative reviews, commentaries, simulation studies).* Organisms of interest included but are not limited to SARS-COV2, influenza, tuberculosis, HIV, and Hepatitis B and C. Start Signature Dated. December 3, 2021. Marquita Cullom, Associate Director.

End Signature End Supplemental Information [FR Doc. 2021-26630 Filed 12-8-21. 8:45 am]BILLING CODE 4160-90-PThe emergency alarm went off just before sundown. For the oil-field medics of Loving County, that sound means your world is about to get a shot of adrenaline.

One minute you might be lounging on the couch with the guys on call, watching Lethal Weapon 4, nursing a post-brisket food baby, and the next you’re in the back of an ambulance, watching a ribbon of West Texas highway unspool behind you, cursing yourself for not using the restroom before hustling out of the clinic. Which is exactly where I found myself one stormy Friday evening last July.An emergency medical technician named Justin Esthay was behind the wheel. Beside him, Anthony Luk, a paramedic trained for more-complex procedures, radioed to dispatch for directions. We were speeding toward a fire in a far-flung corner of the Permian Basin oil patch.

Lightning had ignited a tank of crude, and a nearby drilling crew had called in the blaze. Several days of heavy rain had transformed the dry arroyos and bar ditches into churning rivers. A wind shear had blown through a few nights before and razed two dozen telephone poles like a sickle moving through hay. Line crews had worked day and night to restore power and clean up the mess.

Now the roads, already in bad shape, were washing away into the muddy desert.The ambulance we were in belonged to Occupational Health and Safety International, a company based in the Houston area that operates a scrappy medical network in this sparsely populated part of the patch, including the clinic we had just come from, near Mentone, about one hundred miles west of Midland. The medics and EMTs who work there treat everyone from oil-field workers with critical injuries to cowboys with broken bones to old-timers with indigestion. They also run Loving County’s ambulance service. If you’re sideswiped by a sand hauler or T-boned by a welder on one of the region’s few blacktop roads—one of which is known as “Death Highway” because of its lethal oil-field traffic—the members of an OHSI crew are your best shot at making it to a hospital alive.

But first they have to make it to the scene alive. On this call, I wasn’t sure we would.We were barreling north on County Road 300 when the driver’s side tire sank into a crater. The ambulance lurched to one side, and we skidded to a halt. Behind us, the lights of a semi grew closer and closer.

The driver managed to stop before slamming into us, but just barely. A little farther down the road, we passed another ambulance. It was hobbled on the shoulder with a blown tire and twisted rim. That crew, hailing from another OHSI clinic in nearby Culberson County, had been the first to respond to the alarm.

But they’d been less lucky with that pothole. Lightning wraps around a telephone pole in the distance, seen from the OHSI ambulance dock in July 2021.Photograph by Jeff WilsonWe finally turned off the asphalt and drove for another half hour down mud-choked caliche roads. At 10 p.m., just over an hour after the call came in, we arrived on the scene. Legs numb, I stumbled out and looked around.

The drilling crew, smoking and chatting in dirty coveralls, was huddled around their company pickup waiting for the all clear to return to the rig. The only signs of fire were flares burning natural gas and the glow of the roughnecks’ cigarettes.There was no sign of a proper fire engine either. Just an ancient, battered brush truck with “Balmorhea Volunteer Fire Dept.” on the side. We shook hands with two dudes leaning against the vehicle who were dressed more like farmers than firefighters.

They’d come about a hundred miles from Balmorhea. Other departments nearer to the fire had refused to make the trip, unwilling to risk the flooded low-water crossings. Between thick streams of tobacco juice, the men told us the blaze had nearly burned itself out by the time they got there. A good thing, considering they had little more than a couple hundred gallons of water and some shovels on their truck.

The oil company had asked them to stick around until a drone equipped with a thermal camera flew over the area to look for hot spots. Having already made the trek, we were asked to stay as well.Even though I had worked as a roughneck for a short stint after college, this was the most remote and isolated place I’d ever been in the patch. There was no cell service. It was pitch-black save for our headlights, a few flares, and the glowing pillars of drilling rigs scattered across the dark desert floor.

It was early summer, and I was nearing the end of the second week of three that I spent in Mentone, embedded with the medics of Loving County. I knew that this was where we’d be spending the rest of our Friday night. I’d been on several ambulance runs at this point and had learned that out here a single call could last twelve hours. The previous weekend, Anthony had rushed two gunshot victims, one of whom had brain trauma, from the town of Pecos to two different hospitals, hours apart, in Lubbock and Midland.

He’d left the clinic at 2 a.m. And hadn’t returned until 4:30 p.m. The next day. This call was a cinch in comparison.

I’d already been around long enough to appreciate our good fortune. Because when the emergency alarm rings, disasters far worse than snuffed-out fires often await the crews at OHSI.At last, after two and a half hours, a rep from the oil company confirmed that the drone had detected no heat. As members of the drilling crew piled into their truck to head back to the rig, one of them, as if acting in some oil-field drama, hollered, “Let’s make some hole!. €As we loaded back into the ambulance, it occurred to me that the OHSI crews weren’t so different from the oil and gas workers they were here to help.

The hard living, the time away from family, the macho culture, the insider lingo, the physicality of the job. Those who work in emergency medical services are essentially the roughnecks of health care. Although their job requires a high level of skill and knowledge, compared with other health-care gigs it is undeniably blue-collar and often treated as less than. But at least roughnecks are paid well, with many banking at least $75,000 a year.

The same can’t be said of EMS workers, who on average make less than half that. And yet here they were, EMTs and medics, proving their guts and grit in the heart of nowhere, their work known only to each other—and the people they save.The OHSI clinic in Loving County in July 2021.Photograph by Jeff WilsonI found OHSI by accident. Though I’d grown up in the oil patch, in the small town of Andrews, about eighty miles northeast of Mentone, I’d never heard of an outpost of oil-field medics. Most folks haven’t.

OHSI doesn’t advertise, and it’s not the kind of outfit EMS workers flock to.But in October 2020, I was reporting a story on the last county in the U.S. Without a single recorded erectile dysfunction treatment case, which happened to be Loving. A cashier at the Horseshoe, the only convenience store (or any kind of store) in the county, had mentioned a small clinic on the outskirts of Mentone where oil-field workers and locals could get tested for the viagra. When I drove out there, Cary Skelton, a fifty-year-old paramedic and OHSI’s West Texas program manager, was outside.

He had on his typical uniform. A T-shirt, ball cap, cargo pants, and square-toed cowboy boots. He was chain-smoking Kool menthols next to a parked ambulance. A gray cat named Tigger was curled up on the vehicle’s hood, and a shotgun named Bubba rested against the front bumper.

Cary nodded at the gun. €œCoyotes been getting too close for ol’ Tigger here.”We talked as the sun went down—about the viagra, about how the clinic had been erectile dysfunction treatment-testing scores of workers every day, about the region. Loving County, Cary told me, is a tough sell. The 677-square-mile county is best known for being the least populous in the entire United States.

Just 64 souls claimed permanent residence there in the 2020 census. If it weren’t for the courthouse, you might mistake Mentone (population 22) for an oil-field junkyard. It’s quicker to rattle off what few amenities exist in town than to list everything that doesn’t. In addition to the courthouse and a few abandoned buildings, there’s the county annex, a tennis/basketball court, the Horseshoe, a post office (never locked), three food trucks, and one Tex-Mex restaurant that closes at three in the afternoon.

But to Cary, Loving County is more than a desolate frontier of sandstorms and creosote bush. This part of West Texas is his home. As a boy, he worked cattle on ranches, including his grandfather’s, across the region. And today you’d be hard-pressed to find a more entertaining source of regional history than Cary Skelton.

When he tells stories, his posture shifts and his voice changes, depending on the character he’s enacting. He affects a lisp to imitate the late Newt Keen, a droll cafe owner in Mentone who lost a few front teeth after he took a bullet to the face. And Cary’s eyes narrow when he takes on the role of Sheriff Elgin “Punk” Jones, the top lawman in the county from his first term, in 1965, till he hung up the badge in 1992.Cary lights up when he talks about growing up out here. Like the time he was nine or ten, when he and a buddy decided to drive a go-kart the thirty miles from the Red Bluff Reservoir to Mentone in the dead of night.

This was in the early eighties, some three decades before the shale boom brought heavy traffic and thousands of itinerant workers to the area. The roads were mostly empty then, but they could still be dangerous. Mexican cartels used them as improvised runways on which to land small aircraft loaded with cocaine or other illicit drugs. One night, Cary told me, the Texas Rangers were waiting for the traffickers.

A plane landed, and, in the ensuing firefight, one of the narcos backed into its whirring propeller. €œIt was some straight-up Indiana Jones shit,” Cary said. (The bloodstain left on the pavement marked the spot where Cary said he used to turn off for his favorite fishing hole.)But the boys weren’t worried about narcos on the night they set out in a go-kart for Mentone. They were on a mission.

They strapped a five-gallon tank of gas to the tiny vehicle and clicked on a pair of Maglites to shine their way through the dark. €œWe were driving so fast,” Cary remembered, “we were outrunning our lights.” The boys had almost made it to Mentone when they got lit up by Punk Jones. Punk was the archetypal West Texas lawman. He tucked his jeans into high-topped boots, wore a silverbelly Stetson with a roguish curve, and kept a silver star pinned to his pearl-snap shirt.

His grim good looks gave off the same tough-as-leather vibe as Clint Eastwood. He strolled up to the go-kart.“What are you boys doing?. € he asked. €œWell, we’re driving around,” they told him.

Punk shook his head. €œI don’t know if riding around on a go-kart in this part of the country is very safe.” He loaded the boys and their go-kart into his truck and drove them back to their homes. Cary was sure he’d get a whupping for the stunt, but Punk never said a word about their adventure, not even to Cary’s dad.There have been a few changes since Cary was a kid. Thanks in part to the same Punk Jones, who drilled some of the county’s first non-brackish wells, you can now turn on a tap anywhere in town and get drinkable water.

Still, potable water isn’t much of a selling point in 2022, and besides the lack of modern conveniences, the OHSI staff also faces all the dangers and discomforts of the oil field. When they’re out on a call, they might encounter poisonous gases, homicidal drivers, and high-pressure wells that sometimes blow up. There are also the long hours and weeks away from home. The crew’s hitches are two weeks long, minimum.

They’re on call 24 hours a day during that time, which means that consuming anything stiffer than Red Bull is prohibited. On top of this, they must meet Cary’s standards. “Look, I don’t have time to make someone an EMT or paramedic,” Cary said. €œThey need at least five years of experience of doing this on the daily, thousands of patient contacts, before they come out here.” In an urban environment, new medics can cut their teeth with less risk of fatal mistakes.

€œThey’re ten minutes away from a physician and an ER to get them out of a jam,” Cary said. Not so in Loving County, where the nearest level I trauma center is several hours away, in El Paso or Lubbock. €œWe have to bat a thousand. We have to get a base hit every single time,” he said.

€œOtherwise, we could have some bad outcomes. We could lose someone.” Cary snubbed out his cigarette. €œGive me another sweet,” he told one of the EMTs who’d joined us outside. Another Kool was produced.

Cary lit it. It was dark now. Above us, the Milky Way was smeared across the night sky as if someone had tried wiping chalk from a blackboard. The quiet was broken by a yelping chorus of coyotes not far from where we stood.

€œOut here, you’ve gotta be the cavalry,” Cary said, exhaling smoke. €œBecause no one is going to come to help you.”Since the erectile dysfunction viagra began, politicians and corporations trying to gin up goodwill have heaped praise on first responders, including EMS workers like Cary. But many on the front lines say it’s mostly a bunch of smoke. €œEMS is the bastard stepchild of the planet,” Cary told me.Today, most of us take for granted that we can pick up the phone, dial 911, and someone will be at our side in minutes, capable of keeping us alive during the brief trip to a hospital awaiting with teams of doctors.

But this convenience is a relatively new development. Texas’s Department of State Health Services didn’t include an EMS division until 1973.In Texas and most other states, EMS, unlike police and fire departments, is not considered an “essential service.” Instead, EMS workers are dispatched through a haphazard patchwork of municipal and county operations, hospital-affiliated services, nonprofit and volunteer associations, and private enterprise. That’s where OHSI comes in. Dustin Hoffpauir outside the OHSI clinic.Photograph by Jeff WilsonThe nutty idea of opening a for-profit clinic in the country’s least populated county was Dustin Hoffpauir’s.

I met Dustin during my first week at the clinic. He arrived from Houston in his King Ranch Ford bearing a load of boiled crawfish, a nod to his Cajun roots. Dustin had come to EMS through the safety departments of several oil and gas companies. After graduating from the University of Louisiana at Lafayette in 1998, he worked as a fire watchman on offshore rigs in the Gulf of Mexico.He eventually migrated to dry land and a small Lafayette-based safety company, doing contract work for bigger oil and gas companies.

One of those was Anadarko Petroleum, which hired Dustin in 2005. For the next thirteen years, he served as one of its lead safety officers. The job frequently took him west to the Permian Basin, where he spent days driving the lease roads of Loving and its neighboring counties. Dustin was headed for a comfortable retirement with the company, but then a trip to West Texas made him change course.Several years ago, Dustin was on his way to tour a natural gas plant when an accident at the facility left two contract workers severely burned.

Though he’d completed basic EMT training, when he arrived Dustin didn’t have any equipment with him to start caring for the victims. He waited helplessly for EMS to get there. It took more than an hour and half, an eternity to Dustin. €œAnd that’s when I really started thinking about the challenges associated with providing medical care out here, and the lack of resources,” he said.

€œThe same thing kept on reoccurring. Delayed response. Unfortunately, some lives were lost.”“The same thing kept on reoccurring. Delayed response.

Unfortunately, some lives were lost.”Three years ago, for instance, in Culberson County, just west of Loving, a worker died of an apparent heart attack. His coworkers were forced to sit with his body for more than two hours while waiting for the sheriff, who drove more than 150 miles on bad roads to get there. When no ambulance could be found, the sheriff had to haul the body back to Van Horn in his truck. One of the coworkers later spoke at a county commissioners’ meeting, imploring the officials to invest in EMS, cut down on response times, and give the deceased a bit of dignity.

€œMy God, people,” he said, his voice choked, “what have we come to!. €Dustin and his wife, Mandy Hoffpauir, a registered nurse, made a plan. Dustin recalled his time working in the Gulf. The challenges of providing medical care on offshore oil rigs mirrored those in the Permian Basin.

He figured he could replicate the model he’d learned out there.First, he tackled the economics. Most ambulance companies don’t get paid unless they transport a patient. Out in a rural area like Loving County, the relatively low volume of transports, compared with the number carried out by city services, can make it hard for a company to keep the lights on between calls. If a patient doesn’t have insurance and is deemed indigent, the ambulance company often eats the bill.

But Dustin knew that the oil and gas industry was desperate to find solutions to the problems it had brought to the region. The traffic accidents, the thousands of itinerant workers needing basic care for chronic conditions or medical emergencies, and the work-related incidents (well blowouts, rig injuries, flash fires, heat exhaustion, and so on) that are often more serious than those that occur in other industries. EMTs unload their medical bag from the OHSI ambulance. Photograph by Jeff Wilson Medical instruments at the OHSI clinic.

Photograph by Jeff Wilson Left. EMTs unload their medical bag from the OHSI ambulance. Photograph by Jeff Wilson Top. Medical instruments at the OHSI clinic.

Photograph by Jeff Wilson Dustin pitched the idea for a remote medic service to some of the major companies operating in the region. They asked whether he could also open a clinic that would perform on-site drug testing, issue some medications, and perform basic medical procedures such as treating minor wounds and conducting X-rays. Dustin agreed to that. In a rare move for fiercely competitive oil companies, several banded together to form a consortium.

Their pooled resources guaranteed a steady income for OHSI, regardless of the volume of calls. In late 2017, Dustin leased land outside Mentone and hauled in an old army barracks to convert into OHSI’s flagship clinic. He and a friend did most of the remodeling themselves, spending nights in sleeping bags on the floor while they worked. The product was functional, if not exactly luxurious.Dustin knew that it wasn’t only oil-field workers who could benefit from OHSI’s services.

The locals of Loving County needed access to health care too. That’s where Cary Skelton came in.When the former manager at OHSI stumbled upon his résumé on a jobs listing site, Cary was working in El Paso and looking for a new gig. He was tired of the relentless pace of the city’s emergency rooms and urgent care centers. He’d never dreamed he’d be able to find work in Loving County, yet here was an opportunity to do something meaningful for his community.

Cary jumped at the chance to come home. €œBut the other part of it was, I had to produce. This is my granddad’s stomping grounds, and I cannot mess this up.” Cary understood Loving County. €œOil-field workers and rodeo cowboys, they don’t go the doctor unless something is sticking out,” he said.

€œPeople don’t even take their prescriptions out here because it’s seen as a sign of weakness.” Cary’s dad is like that. He once showed up at the clinic with a busted head. He refused to get out of his truck, so one of the medics had to staple the wound through the window. OHSI ultimately made inroads with county officials, including Judge Skeet Lee Jones, one of Punk Jones’s sons.

The county purchased its first ambulance, and OHSI signed on to staff it around the clock. (OHSI also provides health care to Loving County residents for free.)Although the Mentone clinic is still the heart of its operations, OHSI has expanded. There are now two more small clinics, one in Culberson County, near the revived ghost town of Orla, and another in Pecos, 23 miles south of Mentone. OHSI also dedicates an ambulance to serve Kermit and Monahans (55 miles east of Mentone), moving patients from one hospital to another.The presence of OHSI is a comfort to even the most treatment-hesitant locals and the itinerant workers who, however briefly, call Loving County home.

But for the EMTs and medics who make their living and spend more than half the year at the clinic, their sacrifices add up. Dominic Sanchez, Steven Hutson, and Anthony Luk play poker in the clinic while waiting for a call.Photograph by Jeff WilsonMy first hitch, which would last two weeks, began in late June. On a Tuesday morning, I arrived at the clinic, a metal structure the same beige as desert camouflage. The clinic abuts a rodeo arena just to the east.

Otherwise there is little but sun-scorched pastures of mesquite and greasewood, the occasional pump jack, and a few rusted skeletons of old trucks and tractors. As Cary and I walked up the entrance ramp, Tigger and her kittens scattered from a heaping plate of food. In front of the door was a bloody rabbit’s foot. €œThat was probably Tigger,” Cary said, catching my stare as he swung open the door.

€œNot the first time she’s gotten a cottontail. And, hey, that’s good luck!. €Touring the clinic didn’t take long. The building is divided in half.

One side includes an examination room, X-ray room, and dispatch office. The other side serves as the living quarters for the staff. A cramped kitchen. A common room with an overstuffed brown sofa, an easy chair, and a TV on the wall.

A bathroom. And two bedrooms, where the crew members sleep two to a room. There are plain white walls and scuffed linoleum floors throughout. The vibe is a mix of college dorm and military medical outpost.

As the fresh crew trickled in, the EMTs and medics who’d been on duty headed home, to El Paso, Lubbock, and as far away as Louisiana. One by one, I met the guys I’d be shadowing for the next two weeks. First was Steven Hutson, an EMT from the flyspeck of Kirvin, a town eighty miles southeast of Dallas. The youngest of the bunch at 25, he had a hefty frame and Bambi eyes that had earned him the nickname Baby Huey.

Next was Dominic Sanchez, a 26-year-old Albuquerque transplant with a boy-band smile and muscles on his earlobes. Dom was responsible for dispatching crews to calls for help, a duty he performed while wearing a pair of pearly white Crocs. And finally there was Anthony Luk, a 29-year-old paramedic who grew up far from West Texas, in the Asian grocery store his family managed in Houston. These three, along with Cary, would be responsible for running the clinic 24 hours a day for the next fourteen days, as well as responding to emergency calls.Texas Highway 302, which leads into Mentone from the clinic.Photograph by Jeff WilsonDays at the clinic varied wildly.

One might be mind-numbingly slow. Hardly anyone would show up for treatment, and the emergency alarm stayed quiet. The next, the team might be slammed from morning to night with workers dropping in for erectile dysfunction treatment screenings, for drug and alcohol tests, or with physical maladies. A welder came in with a metal shaving lodged in his eye.

Another patient arrived needing an X-ray after falling from a catwalk between two tall tanks. Several workers, their accents suggestive of places a long way from Texas, came in suffering from dehydration. And one evening a man hobbled in with severe burns on his leg. He and his wife had gotten sideways at dinner.

She’d doused him with hot gravy.For the most part, evenings were peaceful. The guys would retreat to the living quarters after six or seven, offering a little prayer that no one else would show up or call 911. We’d make a family dinner, which could be Steve’s deer-sausage spaghetti or a Korean barbecue dish Anthony whipped up. A game of Texas Hold ’Em might start up, one of the many firearms stashed around the clinic might be fetched for cleaning, or a haircut attempted, but more often than not, someone would turn on the television, and, after settling on a movie, the guys would sit shoulder to shoulder on the couch, eating off TV trays as if they were kicking back at a middle-school slumber party.

“Everyone knows each other’s backstory so well,” Anthony told me, “we don’t really have to talk about that anymore.” They repeated some details for my sake. I learned that Anthony’s parents had immigrated from Hong Kong before he was born. He’d lived in Houston until he left for Lubbock to attend Texas Tech. Going from Houston’s humidity to the dry heat, he’d suffered nosebleeds constantly that first year.

I learned that Steve had gotten married just seven months prior and that he hated broccoli and loved Mel Gibson. (I was subjected to three Gibson films during my stay.) And Dom was the group’s Casanova, practicing his charms, without much success, on a clerk at the Horseshoe.Everyone caught hell for something. Steve for his diet (“He’d eat the ass out of a dead rhino”), Dom for his footwear, and Anthony for his skin-care routine, which revolves around his FaceTory, a small mint-green refrigerator he hauls with him that’s full of serums, oils, and face masks he wears at night. €œIf you can’t take the ribbing,” Cary said, shrugging, “this outfit ain’t for you.”Cary was at the center of it all.

He acted as the group’s big brother, camp counselor, and, occasionally slipping back into his military background (he served overseas as a cavalry scout), drill sergeant. He often quizzed the guys on what meds or protocols to use in various situations. €œThese are perishable skills,” he explained. Because OHSI doesn’t run calls every day like city ambulance services do, “you have to be studying.

You have to be practicing. You have to be putting your hands on equipment.” But for all the grief he gives them, Cary is fiercely loyal to and proud of his crew. €œA lot of people think that because we’re out here in Hickville, we’re going to deliver some type of substandard medicine. No way.

I would put my guys up with anybody out there.” When that emergency phone rings—and eventually it does—life-and-death situations await the OHSI crews. Their memories are full of the kind of gore that most of us see only in horror films. A road-rage victim shot point blank in the belly, guts slopping out like uncooked sausage. An F-150 crushed like a Coke can under an eighteen-wheeler.

A three-man roustabout crew charred in a flash fire. One driver was covered in tar after his tanker exploded. Onlookers had poured water on him to relieve his pain, but that had only made the tar harden onto him. By the time OHSI delivered him to a hospital, his skin was peeling off in chunks.Just a couple of weeks before my hitch, a worker had been up on a catwalk removing a flange.

Maybe he had heard a hiss of pressure and realized he was in danger. He’d apparently turned to run, but before he could get to the stairs nearby, the enormous pressure now leaking from the loosened bolts blew the metal cover off the flange. It struck him smack in the back of the head. He was dead by the time OHSI arrived on scene, but before the site could be opened back up, Cary had to scrape gray brain matter off the railing of the catwalk.

Because the area is so remote, the OHSI crews are also the de facto biohazard team in this part of the patch.This tension between normal life at the clinic and the arrival of the next emergency was something I could never quite adjust to during my time at OHSI. It was hard to sleep, knowing that at any minute the alarms could call us out into the night. Luk reads an EKG at the clinic. Photograph by Jeff Wilson The examination room at the OHSI clinic in Loving County in July 2021.

Photograph by Jeff Wilson Left. Luk reads an EKG at the clinic. Photograph by Jeff Wilson Top. The examination room at the OHSI clinic in Loving County in July 2021.

Photograph by Jeff Wilson You won’t find much sympathy talking about the woes of a forty-hour week with EMS workers. For them, long hours are the norm. Justin Esthay, the EMT driving the ambulance on the call that took us to the flare fire, told me he regularly worked sixteen-hour shifts and once put in twenty hours straight for an ambulance service in Louisiana. The schedule at OHSI, with its occasional stretches of downtime, was a relief.

Still, it was hard not to notice the dark circles around Justin’s eyes. Anthony explained that EMTs and medics work such ungodly hours in part because the pay for EMS workers is shockingly low and they need the overtime. With the mean annual wage for Texas EMS workers clocking in at about $37,550, many work two or even three jobs to eke out a living.As an EMT in Lubbock, Anthony had started out making $11 an hour. €œBut I also picked up a lot of overtime.

That’s the thing. In EMS, picking up overtime is where we make our money. It’s also a big reason why there’s a lot of burnouts.” The annual turnover rate for EMS workers is about 30 percent.“You’re constantly working,” Anthony continued. €œIt’s hard on marital life, social life, all life outside of work.

Relationships are hard to sustain because, like, for us here, you’re gone for two weeks. It’s terrible to say, but out of the guys who’ve had partners or were married, a good forty to fifty percent are no longer.”Anthony’s fiancé, William, is a composer in Lubbock. I met him briefly when he made the three-hour one-way trip to deliver a set of keys Anthony had accidentally left at their apartment. It was the only time William had ever set foot in the clinic where Anthony spends more than half the year.“When you go home, you don’t want to do anything,” Anthony said, speaking generally.

€œYou just want to rest, and your partner doesn’t always understand. Plus, you don’t want to tell them everything because you don’t want to relive it. Like, if you had a bad day at work where you had to do CPR on a kid who drowned. .

. That’s traumatizing. Even though most people seem to shake it off and move on, you’re still overwhelmed with sadness.” According to one study, EMTs and medics are about ten times more likely to have suicidal thoughts than workers in other professions. And yet many first responders never seek professional help for their mental health.

Cary chalks this up in part to EMS culture, in which the ability to put on a tough front and “silently suffer” is highly valued. Others don’t seek counseling because they can’t afford it. (A couple of the OHSI workers I spoke with said they’d opted out of the company’s plan because they felt the premiums were too high.) This means EMS workers find other ways to deal with their trauma. €œI know a lot of EMS guys who have pretty bad vices,” Anthony said.

€œThat’s the way that they wind down, whether it be a massive amount of alcohol or a massive amount of partying.”According to one study, EMTs and medics are about ten times more likely to have suicidal thoughts than workers in other professions.While the crews are on call at OHSI, they temper certain bad habits they might indulge at home. A couple of them funneled their energy into working out at Mentone’s only gym, a tiny collection of weights set up inside a shipping container. Some dipped tobacco, smoked, and guzzled an endless stream of energy drinks to ward off stress, boredom, and weariness. But without exception, all the guys leaned heavily into a dark humor specific to their profession.That night in Culberson County, for instance, as we stood around waiting for the drone to finish its search for any lingering hot spots from the fire, Justin told a story from a few years back.

He’d just finished an ambulance shift and was walking out to the parking lot to head home. €œThis car comes hauling ass in, pulls right up, and almost hits me. The window rolls down, and the driver leans over. €˜This guy just OD’d on heroin.’ ” The man in the passenger seat was barely breathing.

Justin got him out of the car. €œI start doing CPR on this dude. I’m dripping sweat, absolutely drenched because it’s so hot.” Justin managed to get the guy to the hospital alive. The patient woke up, “and he’s thanking me, blah, blah, blah.

For a while, I felt like, ‘Wow, I really saved somebody.’ I felt kind of good about it, even though the circumstances were crappy. So I come back to work the next day. The EMT I’m relieving is like, ‘Hey, remember that guy you saved yesterday?. €™ I’m like, ‘Yeah.’ ‘He left the hospital and immediately OD’d again and died.’ I’m thinking, ‘I sweat my ass off, and it was all for nothing.’ ” He and Anthony both laughed at the irony.As an outsider, I was initially horrified by stories like this.

But I came to understand their necessity. Anthony and Justin didn’t think the story was funny. They laughed because that’s how they deal with the grief and suffering they witness all the time. For EMS workers, black humor is the shared tongue, a coping mechanism, a survival tool.EMT Steven Hutson in the field in Loving County in July 2021.Photograph by Jeff WilsonAfter my hitch ended, the price of oil climbed and the patch got busier—and so did OHSI.

They’d had some rough calls. A few bad wrecks and a fire that had burned a crew of three. Plus, a surge in erectile dysfunction treatment cases had forced the crews to work even longer hours, as they had to transfer patients to hospitals farther and farther away. There had been some personnel changes too.

Dominic Sanchez had left OHSI for a medical gig nearer to his home in Killeen. And Steven Hutson had found work with an ambulance service close to his wife and family in Kirvin. Anthony Luk is still at OHSI but has been preparing to apply to medical school. He hopes to start later this year.

Cary hates to lose good workers, but he doesn’t blame anyone for leaving.Sometimes when we spoke on the phone, Cary sounded bone tired. Finding replacements hadn’t been easy, and the crews were stretched thin. At times he felt as if OHSI were barely hanging on. And lately, bigger ambulance companies have started to home in on the Permian Basin.

Cary explained that big companies can choke out a small independent operation by offering their services more cheaply—at least until they run the competition out of business. He knows how precarious the state of rural EMS is right now. He’s seen companies come and go.For Cary, the mission goes beyond the balance sheet. It’s about the camaraderie of doing a difficult job in an unforgiving desert.

It’s about providing his community the comfort of knowing that someone will answer when they have an emergency.It was Cary who answered the alarm one cold, windy day last January. Punk Jones had been ill for going on a month, but he’d told his family, “I ain’t going to the hospital.” The nearest was in Kermit, half an hour away, and to get advanced care, he’d have to travel all the way to Lubbock, nearly two hundred miles northeast. Most of the wards were overloaded with erectile dysfunction treatment patients anyway. But Punk did acquiesce to his wife Mary Belle’s urging to visit the OHSI clinic.The 93-year-old former lawman had been diagnosed with pneumonia.

And so twice a day, every day, Cary or another OHSI medic drove out to Punk’s ranch to check on him. On that cold Saturday morning, Cary had been on his way back to the clinic from Kermit when he received a panicked call from Punk’s family. €œHe’s not breathing well. He’s doing bad.”Cary and the family started making calls.

They finally managed to find a hospital bed for Punk in Amarillo, about three hundred miles away. Cary sent an ambulance to Punk’s house and summoned a plane to Winkler County Airport, outside Kermit, to transport Punk the rest of the way. Meanwhile, Cary had been speeding toward Punk’s place. He arrived just before the ambulance and went inside.

Punk’s daughter, Mozelle Carr, was there with him. So was Mary Belle. She told Cary, “I want you to do everything you can.” “I will,” he promised.The ambulance dock at the OHSI clinic in Loving County in July 2021.Photograph by Jeff WilsonHe and the OHSI medics got Punk on the stretcher and into the ambulance. They were flying down the road, hooking him up to monitors, starting an IV, when Punk squeezed Cary’s hand.

He wagged a finger up at Cary. Then he pointed down. Punk Jones had made it clear. He wanted to die in Loving County.Cary knew Punk wouldn’t make it to Amarillo.

He told the EMT driving the ambulance to pull over in the parking lot of the county courthouse. There, Cary did as he promised. He and his fellow medics tried everything they could to save Punk. They intubated him and gave him fluids through an IV.

When Punk’s heart stopped, Cary did compressions on his chest until it started thumping again. Eight times he was able to get the heart rate monitor to register a rhythm.Cary phoned Punk’s family. The Jones clan trickled into the parking lot, congregating at the ambulance. Cary held Mozelle’s hand, and they cried together.

Punk’s heart stopped again. This time, Cary could not bring him back.At OHSI, Cary and his crews fight every day to keep folks from dying in Loving County. Of course, they can’t save everybody. And being able to provide dignity at death, to allow someone to die in the place they call home, can be just as important.

It’s these moments, however weighted with tragedy, that keep Cary working overtime in Loving County, making plans to ensure that basic health care is here to stay—no matter what happens at OHSI or to the fortunes of the oil patch.A week later, Punk was laid to rest at his ranch. During the funeral, Cary offered his condolences to the Jones family. Tom, one of Punk’s sons, told him, “I’m glad you were with him, Cary.”Cary nodded. €œIt was an honor.” This article originally appeared in the January 2022 issue of Texas Monthly with the headline “There Will Be Blood.” Subscribe today..

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(4) Finally, ensuring guideline implementation and providing regular our website updates are essential.In the accompanying editorial, Otto, Kudenchuk and Newby2 compare the NICE teva generic viagra methodology with the current approach of our cardiovascular professional societies, as well as to established reporting criteria for clinical practice guidelines (figure 1).3 They propose several areas for improvement including cooperative development of a common evidence database. A rigorous transparent process based on established standards. A more diverse group of stakeholders. Minimising conflicts of interest teva generic viagra. Support by information specialists, medical writers and other relevant experts.

Regular updates. Adaptation for regional considerations teva generic viagra. And improved methods for dissemination and access. As they conclude. €˜Current cardiovascular society guidelines fall short of best practice teva generic viagra.

We can and must do better.’Visual summary of reporting criteria for clinical practice guidelines as detailed in the Appraisal of Guidelines, Research and Evaluation (AGREE) checklist." data-icon-position data-hide-link-title="0">Figure 1 Visual summary of reporting criteria for clinical practice guidelines as detailed in the Appraisal of Guidelines, Research and Evaluation (AGREE) checklist.In patients with atrial fibrillation (AF) at moderate or high risk of stroke, randomised controlled trials (RCTs) have shown superiority or non-inferiority of non-vitamin K oral anticoagulants (NOACs) over vitamin K anticoagulants (VKA) for prevention of stroke or systemic embolism along with reduced rates of intracranial haemorrhage. However, patients in RCTs may not be representative of the full range of patients seen in clinical practice. In order to address this issue, Camm and colleagues4 used a method called overlap propensity matching to compare the effectiveness of VKA and different NOACs for mortality, stroke/systemic embolism teva generic viagra and major bleeding in patients with newly diagnosed AF and an indication for oral anticoagulation. Based on 25 551 patients in the Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF) study, they confirmed that ‘Important benefits in terms of mortality and major bleeding were observed with NOAC versus VKA with no difference among NOAC subtypes’ (figure 2).Adjusted* HRs and corresponding 95% CIs for selected outcomes at 2 years of follow-up by OAC treatment at baseline. The reference considered is the treatment reported as second.

*Obtained using an overlap-weighted teva generic viagra Cox model. Variables included in the weighting scheme are. Country and cohort enrolment, sex, age, ethnicity, type of AF, care setting specialty and location, congestive heart failure, acute coronary syndromes, vascular disease, carotid occlusive disease, prior stroke/TIA/SE, prior bleeding, venous thromboembolism, hypertension, hypercholesterolaemia, diabetes, cirrhosis, moderate to severe chronic kidney disease, dementia, hyperthyroidism, hypothyroidism, current smoking, heavy alcohol consumption, body mass index (BMI) heart rate, systolic and diastolic blood pressure at diagnosis and baseline antiplatelet use. DTI, direct teva generic viagra thrombin inhibitor. FXaI, factor Xa inhibitors.

NOAC, non-vitamin K oral anticoagulants. OAC, oral teva generic viagra anticoagulants. SE, systemic embolism. TIA, transient ischaemic attack. VKA, vitamin K antagonists." data-icon-position data-hide-link-title="0">Figure 2 Adjusted* HRs teva generic viagra and corresponding 95% CIs for selected outcomes at 2 years of follow-up by OAC treatment at baseline.

The reference considered is the treatment reported as second. *Obtained using an overlap-weighted Cox model. Variables included teva generic viagra in the weighting scheme are. Country and cohort enrolment, sex, age, ethnicity, type of AF, care setting specialty and location, congestive heart failure, acute coronary syndromes, vascular disease, carotid occlusive disease, prior stroke/TIA/SE, prior bleeding, venous thromboembolism, hypertension, hypercholesterolaemia, diabetes, cirrhosis, moderate to severe chronic kidney disease, dementia, hyperthyroidism, hypothyroidism, current smoking, heavy alcohol consumption, body mass index (BMI) heart rate, systolic and diastolic blood pressure at diagnosis and baseline antiplatelet use. DTI, direct thrombin inhibitor.

FXaI, factor teva generic viagra Xa inhibitors. NOAC, non-vitamin K oral anticoagulants. OAC, oral anticoagulants. SE, systemic teva generic viagra embolism. TIA, transient ischaemic attack.

VKA, vitamin K antagonists.In the accompanying editorial, Choi and Lee5 point out the strengths of this study including a clinically diverse international patient cohort with regular audits and a low rate of loss to follow-up, a sophisticated matching method, and results consistent with previous RCTs. However, limitations teva generic viagra include the possibility of residual confounders. Possible discontinuation or switching of medications during this study period. Lack of detailed data on types of major bleeding, and regional or ethnic differences in outcomes. And any effects due teva generic viagra to lack of adherence to therapy.

As they conclude ‘The GARFIELD-AF registry has reported valuable clinical practice patterns in AF worldwide, but it will also play a role as a pragmatic study for real-world practice-based RCTs.’The prevalence and outcomes of adults over age 65 years with more than mild mitral regurgitation (MR) or tricuspid regurgitation (TR) was studied in 4755 subjects who had undergone echocardiography in the Oxford Valvular Heart Disease Population Study (OxVALVE).6 Overall, the prevalence of moderate or greater MR was 3.5% and TR was 2.6% with only about half these patients having previously diagnosed valve disease. Subjects with regurgitation identified by screening were less likely to be symptomatic than those with known valve disease. The aetiology of MR was most often primary although 22% had teva generic viagra secondary MR due to left ventricular systolic dysfunction (figure 3). Surgical intervention was rarely undertaken (2.4%) during the 64-month median follow-up.Mechanism of mitral regurgitation (MR). The mechanisms of valve dysfunction in patients with moderate or greater MR are shown, according to Carpentier classification.

Type 1, normal leaflet motion and position teva generic viagra. Type 2, excess leaflet motion. Type 3a, restricted leaflet motion in systole and diastole. Type 3b, restricted leaflet motion in systole." data-icon-position data-hide-link-title="0">Figure 3 Mechanism of mitral regurgitation (MR) teva generic viagra. The mechanisms of valve dysfunction in patients with moderate or greater MR are shown, according to Carpentier classification.

Type 1, normal leaflet motion and position. Type 2, teva generic viagra excess leaflet motion. Type 3a, restricted leaflet motion in systole and diastole. Type 3b, restricted leaflet motion in systole.In an editorial, Bouleti and Iung7 point out that the prevalence of MR and TR increases even further in those over age 75 years and that the number of patients with secondary MR and a low left ventricular ejection fraction is of concern given the association with impaired long-term survival. They conclude teva generic viagra.

€˜These findings highlight the need for educational programmes to increase the awareness on heart valve disease, for evaluation of the adherence to guidelines and for the continuous development and evaluation of less invasive interventions targeting elderly patients.’The Education in Heart article in this issue summarises the recommended approach to screening for cardiovascular disease in healthy individuals.8 A state-of-the-art review article on nuclear cardiology9 provides an overview of myocardial perfusion imaging techniques and clinical applications for ischaemic heart disease, heart failure, and myocardial disease and . Newer nuclear imaging approaches include 18F-fluorodeoxyglucose positron emission tomography scans for diagnosis of infective endocarditis, particularly in patients with prosthetic valves, and the use of nuclear approaches as adjuncts for the diagnoses of sarcoidosis and amyloidosis.Our Cardiology in Focus series continues with an article10 on pregnancy during cardiology training which will be helpful for women considering pregnancy during cardiology training (or as a consultant cardiologist) for those providing training and support to those women (figure 4).Concerns of the pregnant cardiologist." data-icon-position data-hide-link-title="0">Figure 4 Concerns of the pregnant cardiologist.Clinical guidelines play an increasingly important role in care of patients with cardiovascular disease. Approaches to guideline development reflect the need to integrate a complex and ever-expanding evidence base with new treatment options and clinical expertise to formulate recommendations that then can be implemented both by individual healthcare providers and across healthcare systems teva generic viagra. All guidelines for a specific disease condition start with the same evidence base, yet guidelines are developed in many different ways, by many different organisations, often addressing the same or overlapping types of cardiovascular disease, typically leading to at least subtle (and sometimes major) divergences in the resultant recommendations.Professional society recommendations, such as those generated by the European Society of Cardiology (ESC) and by the American Heart Association/American College of Cardiology (AHA/ACC), predominate, but many geographic regions have their own guidelines, tailoring recommendations to specific regional requirements.1 Government agencies and insurance providers also generate guidelines either directly in published documents or indirectly by restricting reimbursement. Online medical textbooks, such as Up-to-Date, attempt to integrate and reconcile recommendations from multiple guideline sources, filling any gaps in clinical management with recommendations based on clinical expertise alone.

Another approach is to convene an independent group of experts to address new practice changing evidence rapidly, focusing on a specific question, such as the BMJ Rapid Recs or Magic Evidence Ecosystem Foundation.2 3Why are there so many guidelines?.

Support by Where to get cialis pills information specialists, lowest price viagra medical writers and other relevant experts. Regular updates. Adaptation for regional considerations. And improved methods for lowest price viagra dissemination and access.

As they conclude. €˜Current cardiovascular society guidelines fall short of best practice. We can and must do better.’Visual summary of reporting criteria for clinical practice guidelines as detailed in the Appraisal of Guidelines, Research and Evaluation (AGREE) checklist." data-icon-position data-hide-link-title="0">Figure 1 Visual summary of reporting criteria for clinical practice guidelines as detailed in the Appraisal of Guidelines, Research and Evaluation (AGREE) checklist.In lowest price viagra patients with atrial fibrillation (AF) at moderate or high risk of stroke, randomised controlled trials (RCTs) have shown superiority or non-inferiority of non-vitamin K oral anticoagulants (NOACs) over vitamin K anticoagulants (VKA) for prevention of stroke or systemic embolism along with reduced rates of intracranial haemorrhage. However, patients in RCTs may not be representative of the full range of patients seen in clinical practice.

In order to address this issue, Camm and colleagues4 used a method called overlap propensity matching to compare the effectiveness of VKA and different NOACs for mortality, stroke/systemic embolism and major bleeding in patients with newly diagnosed AF and an indication for oral anticoagulation. Based on 25 551 patients in the Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF) study, they confirmed that ‘Important benefits in terms of mortality and major bleeding were observed with NOAC versus VKA with no difference among NOAC subtypes’ (figure 2).Adjusted* HRs and corresponding 95% CIs for selected outcomes at 2 years of lowest price viagra follow-up by OAC treatment at baseline. The reference considered is the treatment reported as second. *Obtained using an overlap-weighted Cox model.

Variables included in lowest price viagra the weighting scheme are. Country and cohort enrolment, sex, age, ethnicity, type of AF, care setting specialty and location, congestive heart failure, acute coronary syndromes, vascular disease, carotid occlusive disease, prior stroke/TIA/SE, prior bleeding, venous thromboembolism, hypertension, hypercholesterolaemia, diabetes, cirrhosis, moderate to severe chronic kidney disease, dementia, hyperthyroidism, hypothyroidism, current smoking, heavy alcohol consumption, body mass index (BMI) heart rate, systolic and diastolic blood pressure at diagnosis and baseline antiplatelet use. DTI, direct thrombin inhibitor. FXaI, factor Xa lowest price viagra inhibitors.

NOAC, non-vitamin K oral anticoagulants. OAC, oral anticoagulants. SE, systemic lowest price viagra embolism. TIA, transient ischaemic attack.

VKA, vitamin K antagonists." data-icon-position data-hide-link-title="0">Figure 2 Adjusted* HRs and corresponding 95% CIs for selected outcomes at 2 years of follow-up by OAC treatment at baseline. The reference considered is the lowest price viagra treatment reported as second. *Obtained using an overlap-weighted Cox model. Variables included in the weighting scheme are.

Country and cohort enrolment, sex, age, ethnicity, type of AF, care setting specialty and location, congestive heart failure, acute coronary syndromes, vascular disease, carotid occlusive disease, lowest price viagra prior stroke/TIA/SE, prior bleeding, venous thromboembolism, hypertension, hypercholesterolaemia, diabetes, cirrhosis, moderate to severe chronic kidney disease, dementia, hyperthyroidism, hypothyroidism, current smoking, heavy alcohol consumption, body mass index (BMI) heart rate, systolic and diastolic blood pressure at diagnosis and baseline antiplatelet use. DTI, direct thrombin inhibitor. FXaI, factor Xa inhibitors. NOAC, non-vitamin K oral anticoagulants lowest price viagra.

OAC, oral anticoagulants. SE, systemic embolism. TIA, transient lowest price viagra ischaemic attack. VKA, vitamin K antagonists.In the accompanying editorial, Choi and Lee5 point out the strengths of this study including a clinically diverse international patient cohort with regular audits and a low rate of loss to follow-up, a sophisticated matching method, and results consistent with previous RCTs.

However, limitations include the possibility of residual confounders. Possible discontinuation or switching of medications during lowest price viagra this study period. Lack of detailed data on types of major bleeding, and regional or ethnic differences in outcomes. And any effects due to lack of adherence to therapy.

As they conclude ‘The GARFIELD-AF registry has reported valuable clinical practice patterns in AF worldwide, but it will also play a role as a lowest price viagra pragmatic study for real-world practice-based RCTs.’The prevalence and outcomes of adults over age 65 years with more than mild mitral regurgitation (MR) or tricuspid regurgitation (TR) was studied in 4755 subjects who had undergone echocardiography in the Oxford Valvular Heart Disease Population Study (OxVALVE).6 Overall, the prevalence of moderate or greater MR was 3.5% and TR was 2.6% with only about half these patients having previously diagnosed valve disease. Subjects with regurgitation identified by screening were less likely to be symptomatic than those with known valve disease. The aetiology of MR was most often primary although 22% had secondary MR due to left ventricular systolic dysfunction (figure 3). Surgical intervention was rarely undertaken (2.4%) during the 64-month median follow-up.Mechanism of mitral lowest price viagra regurgitation (MR).

The mechanisms of valve dysfunction in patients with moderate or greater MR are shown, according to Carpentier classification. Type 1, normal leaflet motion and position. Type 2, excess leaflet lowest price viagra motion. Type 3a, restricted leaflet motion in systole and diastole.

Type 3b, restricted leaflet motion in systole." data-icon-position data-hide-link-title="0">Figure 3 Mechanism of mitral regurgitation (MR). The mechanisms of valve dysfunction in lowest price viagra patients with moderate or greater MR are shown, according to Carpentier classification. Type 1, normal leaflet motion and position. Type 2, excess leaflet motion.

Type 3a, restricted leaflet motion in systole and diastole lowest price viagra. Type 3b, restricted leaflet motion in systole.In an editorial, Bouleti and Iung7 point out that the prevalence of MR and TR increases even further in those over age 75 years and that the number of patients with secondary MR and a low left ventricular ejection fraction is of concern given the association with impaired long-term survival. They conclude. €˜These findings highlight the need for lowest price viagra educational programmes to increase the awareness on heart valve disease, for evaluation of the adherence to guidelines and for the continuous development and evaluation of less invasive interventions targeting elderly patients.’The Education in Heart article in this issue summarises the recommended approach to screening for cardiovascular disease in healthy individuals.8 A state-of-the-art review article on nuclear cardiology9 provides an overview of myocardial perfusion imaging techniques and clinical applications for ischaemic heart disease, heart failure, and myocardial disease and .

Newer nuclear imaging approaches include 18F-fluorodeoxyglucose positron emission tomography scans for diagnosis of infective endocarditis, particularly in patients with prosthetic valves, and the use of nuclear approaches as adjuncts for the diagnoses of sarcoidosis and amyloidosis.Our Cardiology in Focus series continues with an article10 on pregnancy during cardiology training which will be helpful for women considering pregnancy during cardiology training (or as a consultant cardiologist) for those providing training and support to those women (figure 4).Concerns of the pregnant cardiologist." data-icon-position data-hide-link-title="0">Figure 4 Concerns of the pregnant cardiologist.Clinical guidelines play an increasingly important role in care of patients with cardiovascular disease. Approaches to guideline development reflect the need to integrate a complex and ever-expanding evidence base with new treatment options and clinical expertise to formulate recommendations that then can be implemented both by individual healthcare providers and across healthcare systems. All guidelines for a specific disease condition start with the same evidence base, yet guidelines are developed in many different ways, by many different organisations, often addressing the same or overlapping types of cardiovascular disease, typically leading to at least subtle (and sometimes major) divergences in the resultant recommendations.Professional society recommendations, such as those generated by the European Society of Cardiology (ESC) and by the American Heart Association/American College of Cardiology (AHA/ACC), predominate, but many geographic regions have their own guidelines, tailoring recommendations to specific regional requirements.1 Government agencies and insurance providers lowest price viagra also generate guidelines either directly in published documents or indirectly by restricting reimbursement. Online medical textbooks, such as Up-to-Date, attempt to integrate and reconcile recommendations from multiple guideline sources, filling any gaps in clinical management with recommendations based on clinical expertise alone.

Another approach is to convene an independent group of experts to address new practice changing evidence rapidly, focusing on a specific question, such as the BMJ Rapid Recs or Magic Evidence Ecosystem Foundation.2 3Why are there so many guidelines?. What are the lowest price viagra limitations of our current approach?. How can we optimise guideline development to improve care of patients with cardiovascular disease?. All guidelines share two common purposes.

First, to review, assess quality, summarise and interpret the published evidence base, and second, to provide clear recommendations for patient management.

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