Hospice palliative care nurse practitioner jobs
Is proving people wrong a reason to study?
2023.06.04 20:19 darthluke11 Is proving people wrong a reason to study?
I'm a guy approaching 30 and I've worked minimum wage jobs all my life. I've been to college a couple of times and did relatively well; it wasn't a degree course but the course to gain entry to a degree. I left once because I didn't like the subject and just couldn't get interested in it whereas the 2nd time I left because I had to give presentations and I couldn't bring myself to do it. Public speaking is hard for me, I'm determined to improve but I'm quite introverted and shy so it's really difficult for me, which is embarassing.
I've dropped out of college twice and I think as a result of this my family and friends see me as stupid. My brother will make comments saying I'm dumb and seems to not respect my opinion on anything, my dad has never overtly called me stupid but it's just the impression I get from him when we talk about things. My friends from school who I hung out with until recently (I realized they are arseholes) constantly took the piss out of me for not having a degree and wouldn't respect anything i said and in their view I know nothing about anything. I found these people extremely arrogant and unkind so I disassociated with them.
I don't think I am the smartest person but I never tried in school or college when doing full time courses. I've done a couple of part time courses to gain some qualifications; English and Biology AS level. I managed to get an A in English but only received a C in biology. I was disappointed with my biology grade and the exam itself as it was 40% maths and I really suck at maths. I feel I knew the biology well but my maths let me down.
I've been looking in to courses for mature students and I'm considering doing a one year course focused on care/health professions, it gains me entry to a range of uni degrees such as physio, paramedic science, nursing, occupational therapy etc. The course involves biology, chemistry, immunology, care principles and many other topics to study. I'd like to gain entry to a physio degree next year.
However, the opinions of others has made me uncertain of my ability to achieve this and made me question whether to try at all. I think I could do it if I commit and put my mind to it, though it will be very challenging but rewarding at the same time. I wouldn't tell my family or friends about it. I want to help people and gain a good career but I also want to prove people who have always doubted me wrong. I want some respect from my family and friends.
All this has affected my self esteem massively; it's made me question myself and held me back as a person.
Do you have any experiences similar to this? Have you ever been motivated to do something educational or any difficult task for that matter simply to prove people wrong?
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2023.06.04 19:53 turkeypooo How to ask for a raise (first post here)
Hi everyone! Long time lurker, love all the posts, and I hope I am posting in the right place.
Bit of a background: I work in healthcare in Canada. Worked my way up from receptionist to overnight nurse in 10 years. Currently in med school (so that I can no longer have a boss telling me what to do... ha) and still work 27-32 hrs a week at an urgent care clinic. I have never had to ask for a raise. It always came automatically with each performance review roughly every 3-6 months. However, this field has notoriously high burnout and is desperately hiring.
My question is this: my clinic just posted a job for the same position as mine...offering 3$ more than they pay me. I have experience, well-liked by my patients and superiors, and an university degree. They lowered their standard to accept high school students who have some experience in the field. So naturally, I would like to ask for a raise. We have no HR. 4 doctors and an accountant.
Do I ask to have a sit down meeting with the doctors and put them on the spot/make my case? Do I write an email and send it to the doctors, give them xx hrs to respond? Do I type and print a letter and give a copy to each doctor? Any help is appreciated. I do want to stay. I like the doctors/hours/location/flexibility around my schooling.
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2023.06.04 19:32 RhubarbDangerous9378 Should I report my coworker?
I’ve been working at this nursing home for a few months now and have known my coworker since I started working there. She originally was a valet and watched a room of patients but was not allowed to do any CNA care. As of now, our nursing facility is removing the position of valet and is only keeping workers who plan on taking the CNA exam. So far, a lot of the people I’ve worked with have left since they only wanted to work as a valet, but this specific coworker of mine is staying and is planning to take the exam.
I don’t mind having extra help around the floor, but I, along with a few other coworkers of mine, have been upset and frustrated at how extremely lazy she is. There are moments where she suddenly leaves out of nowhere when I’ve asked her to help me with a patient that requires two people. She also goes to the break room for long periods of time on her phone and just talking to friends and roaming on social media.
From what I know she works the afternoon and usually the night shift. I worked overtime late at night and couldn’t find her for hours on end while all the other CNAs were taking care of their residents and answering call lights. I go to our nursing home’s library where both the doors are closed and find her completely asleep, sleeping completely on her back looking very comfortable, on the couch, while everyone else was working.
I don’t know if I should report her but clearly she is not a team player or actually does her job properly. If anything, I think she’s a danger to this nursing facility since she abruptly leaves patients and is ultimately very lazy. Should I report her to the DON?
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2023.06.04 19:30 No_Box2690 Local hospitals and safe medical care
If this formats weird it's because I'm on mobile. I'm not sure where else to post this somewhat anonymously, but here goes.
I'm a nurse. All of the local hospitals are short staffed and treated like shit from upper management. We aren't able to provide the best possible care because we're so short staffed that we have such high nurse to patient ratios that severely limit the time we have to provide the bare minimum expectations of our job. You as patients suffer and it's dangerous for everyone. New grad nurses are getting short, inadequate training because there simply isn't enough time and not enough staff.
The thing is, everyone in upper management knows about this, they just don't care.
Wesley’s staffing on 6/3 was that all ICUs 6 or more nurses were tripled. They are supposed to be one nurse to one patient, MAYBE two depending on acuity. They had three extremely critically ill patients. Remember- the ICU is where the sickest of the sick land and require the most monitoring and care.
The medical surgical units, where most admissions typically land depending on what's going on, they were flexed to 8 patients to 1 nurse. According to National Nurses United, a safe ratio on a med-surg floor is 1 nurse to no more than 4 patients.
We all work 12 hour shifts, so if we have 8 patients, we are only going to have 1.5 hours max for each patient in a day. That's 1.5 hours to do everything - meds, helping with basic activities of daily living, taking vital signs, and monitoring you in case your condition changes and you need either a different plan of care, or require more close monitoring and have to be shipped off to the ICU. Never mind that you as an individual person need to be educated on what's going on, you might be scared and lonely, your family might have questions, the doctor has questions, if your toilet is broken we have to fix it, your sheets are dirty we have to change them, etc etc. Plus getting yelled at and physically hit by patients and families. All of this falls on one nurse for eight different people. Let that sink in. Wichita sadly isn't alone in this either, it's all over the country.
Our community deserves better. Our nurses deserve better.
We are exhausted and burnt out and begging for help that is falling on deaf ears because profit is the only thing that matters to these hospitals. Nurses are trying to unionize at Ascension, but there's no guarantee that'll improve things either.
I guess this is partially a rant but also a cry for help, and also to alert the community of the BS that goes on in the background of healthcare here. Talk to your community leaders, write emails to the CEOs of the hospitals, the senators, anyone that will listen. If you find yourself in a hospital as a visitor or patient, please just be kind and give some grace to everyone.
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2023.06.04 19:29 feeling_threatened My ex husband (of several divorced years) ordered MY social security card for himself
I live in Texas.
He has a history of child abuse plus spousal abuse (see previous post). He’s also done horrible things since then he helpfully documented via text.
I asked him to provide the kids’ social security cards because I became a 100% disabled veteran and that means the kids would get free healthcare as long as I bring them to get dependent IDs. That’s a HUGE advantage and I wanted to take care of it as soon as possible.
Many months went by with me repeatedly asking for the cards over text, but instead of just letting me borrow the cards I left with him when we separated pre-divorce, he ordered new cards for the kids for me to have and also ordered MY Social Security Card since he was “already ordering them for the kids”. We’ve been divorced for years. For what it’s worth my kids were born overseas and I was born in America. He had to have gone well out of his way to create a new application for a domestic birth SS card since the application is different than those born overseas. I already have my own card and most certainly would never ask my ex spouse to order my own for me. With his abusive history this is 100% a power play.
He’s currently across the country working. He called me on my literal first day of my first job since 2017 (disabled military) to tell me he was leaving in a week and I was going to watch the kids for him despite the fact that he was obligated by the divorce decree (that he asked for!) to watch them over them during that time. No boss alive would approve significant hour changes 3 hours into your very first shift, that’s unreasonable. I love my kids and I’m glad to have them but I just wasn’t expecting to have them 24/7 for God knows how long, months at the very least.
I have no idea where he is right now other than I know he’s in California somewhere being a post-partum Nurse despite his child abuse charges in Texas.
What are my options regarding the forged documents and signatures that got him my social security card? If we can find him, would he be forced to return to Texas?
Edit: regarding the other things he’s done, the one that scared me the most was when he drove into my gated and secure apartment complex one day and texted me “I saw you in your neon green sports bra, I wish I would have taken a picture”. It’s a gated community and I live on the second floor. My balcony (that moves perspective outward) is covered in plants. My area of the state is also nearly exclusively built with retaining walls that further displace any viewers. You’d have to deliberately study my place for quite some time before catching even a glimpse at me. He’s not an authorized resident and has never been a resident. That really scared me.
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2023.06.04 19:16 Far_Scholar9240 Am I reading too much into the situation? What is going on here?
Hello people of Reddit, I need some help.
This is my first time here personally, but I have been listening to reddit stories for almost 2 years whether on Youtube, Insta, or any other platform. I made this account specifically because of this and I despratly need others' opinions as it has been eating at me for the past day.
*TW for talk of blood, illnesses, and implied pedophilia*
Some backstory first:
I am a high school student (so think in the age range of 15-18). I volunteer at a hospital every weekend: helping patients and nurses and showing visitors to their friends and loved ones. It can sometimes be a very sad job as I have met parents who children were dying, mentally ill patients who were being schedualed to be tranfered into mental hospitals, and watching bloody patients come out of ambulances.
One highlight of my job, however, is an older coworker who was being paid at the hospital, let's call him "G". G was a graduating college student (think in his mid 20s) who had been working at the hospital for a few years now. We worked together at the front of the hospital to greet and direct visitors. He was great, we had a lot of fun conversations, joked around, and he helped me become more confident when speaking with others. We became really good friends and I looked forward to seeing him every weekend for a few hours before I went to another part of the hospital to help out there.
Now to the actual story:
About 6 months into me volunteering around the hospital, G had told me he was quitting to find another higher paying job closer to his home. Of course, I was happy for him and supported him, wanting my now close friend to seceed. We exchanged numbers on his last day of the job and I never saw him again after that. I currently still work at hospital, but now with new people who I'm usually in charge of teaching because G is gone.
At first, we would talk once a week, mainly on my break at the hospital, as I had a small phase of hating the changes and wanting things to go back to normal. Of course, I soon got over that and stopping starting conversation a lot less as I had grown more busy with my daily life and wanted him to focus on his new job. He started texting me once or twice through the week, almost always texting first with a "hey" or "whats up". At first, I didn't think much of it until he started texting me even more. Of course I didn't mind, he was a good friend of mine and it seemed like he really cared about our friendship. The only problem is that he had and still currently has a girlfriend of three+ years (I'll call her "F"). I had known about G and F's relationship since G and I had started working together in the hospital. He talked about her pretty often.
I began to feel was possibly over stepping unknown boundries by talking with G too much. So, I started pushing back a bit to try and subtly force those boundries and respect their relationship, telling him things like "you've been talking to me a lot lol" and "Go check on your girlfriend, I'm sure she misses you rn". Keep in mind, this is all over text messages.
For a bit of context, I wasn't sure if F knew I was talking to G. over the phone, he never really mentioned her until I brought her up and asked about her.
Flash forward a few weeks until yesterday. Earlier in the day (around noon), G had texted me mention he was going out to celebrate his Dad's birthday. I tell him to have fun and go on with my day. later, I was going to a family event, both parents and my siblings in the car and we're driving to this event an hour away from our home.
I get a text from G around 6:30pm:
G: Yeah I'm drunk
Me [not completely sure if he's being serious or not]: Pfttt what
G: I'm drunk we went to a drinking festival [for his dad's birthday, he meant]
Me [laughing about it lightly to my family as I'm texting]: Lol you better not be driving home
G: I'm not
Me: okay good lol stay safe :>
G: I will don't worry
Me: Okayyy is you gf with you???
G: Yeah well she was with me but she went home, she was with us all day
Me [confused]: Oop- how come? Why did she leave early?
G: She was tired and it was getting late and she was drinking
Me in my head: huh........
Me on text [wanting to end the conversation]: Ooo well it sounds like you guys are having fun :)
G: It was
I was talking about it with my parents (I basically tell them everything) and they felt kind of off about it all. Like I had stated above, I am a minor, this dude is not. It especially didn't sit well with my dad who had implied that MANY older men had crushes on minors. Of course, because G is my friend, I defended him, but that comment had stuck with me and I'm now over thinking things.
To continue the story, after the conversation I had put down my phone for the event. When I got home around 9:30pm, I realized he had texted me again. I'll spare the finer details, but we had asked about each others' events, what we were both doing the next day, then our birthday came up (we have the same birthday). He asked how old I was turning. I got a weird vibe from that, but I told him and said "why do you ask?". His response was "Just asking", which I'm getting weird vibes from as I'm going through the texts again...
After that we spoke about things we want to do for our birthday, and then he asked if I wanted to hang out at some point.
For some more context, my parents are extreme planners, we practically already had the rest of the year planned out on your giant family callender. This mean I'm of course WAY to busy to make a 30 minute drive to his area so we can hang out for a few hours.
I told him this and our conversation was pretty normal after that.
It was around around 10pm when I really just wanted to end the conversation and told him: "Text your gf, make sure she's doing okay, I gtg to bed :P"
He didnt respond after that.
Knowing all of this information, what do you think is going on here? Is G just overly confortable with me??? Or was my dad right about something?? I don't freaking know and I need help. I not going to try and deny it, I'm not muture enough for these kinds of things. I just need help to figure out if I should cut him off or if I'm over reacting. All opinions are valid and will be looked over by me.
Thank you <3
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2023.06.04 18:54 piercecharlie I'm just so angry
My grandma died one week ago today at 96 years old. She would have been 97 in September.
She was my best friend and my favorite person. I saw her every week, multiple times a week if I could. I saw her more than anyone else.
She got Covid in March and then pneumonia. Earlier this year she found out she had a type of cancer but it was such a slow growing that realistically she would die of old age/other health issues before the cancer became an issue. But I wonder if that's why Covid hit her so hard. And then the pneumonia.
She had an increase of fluid build up, but there was nothing they could do. At the end of April they put her on comfort care. She qualified for hospice but they thought a diuretic and massaging her legs would help with the fluid build up. The massaging didn't because it had the fluid collect around her heart. She signed a DNR and didn't want any life support/feeding tubes.
Ultimately I suppose she died from heart failure but it doesn't take a genius to see it was due to the complications from Covid. We were all with her when she died and it was very peaceful. It was sudden. I had just seen her two days prior and while she wasn't in the best shape, I never would have guessed she was going to die so soon.
I'm just feeling really angry. I'm angry that no one cares about Covid anymore. I'm angry that the laws changed and you don't need masks in nursing homes. I'm angry that I don't know how safe the rest of my family was being with Covid. I have been hyper vigilant, because of my Grandma and because of me and society.
It just makes me so angry that people say oh well the only people that die from Covid are old. I don't care that she was 96. She was my best friend. And her goal has always been to live to be 100. At one point her doctor thought she would make that easily. She was very proud of her health and how well she took care of herself. It feels like she was robbed of that accomplishment of living to 100 because the US government stopped treating Covid seriously and protecting our most vulnerable.
I tagged this as Covid, but I also could have put vent. I'm not looking for advice. If anyone else is struggling with anger as apart of their grief, especially for Covid related deaths, I'd love to read your stories and feel a little less alone ❤️
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2023.06.04 16:53 MountainSnowClouds One of my Facebook friends shared this...
2023.06.04 16:13 WritingDrakon (EODAT Ch.5 REPOST) brewing legacies, and oversized weapons
(Hey everyone! Finally out of the shadow realm! Im reposting chapter five here as it got wiped last time, 6 is still percolating away in my head, but in the mean time, enjoy! Comments are appreciated!)
4-LOM rolled up to the holotable, the aging shipbuilder looking over the various fleet and division commanders.
4-LOM was an old Mk1 astro robot, his main body was a sphere, with four mechanical arms extending from his body, two large and bulky, and the other two smaller, more nimble and accurate, more dexterous, with a cylindrical lower body leading down to his treads, which were angular, tank like in shape, designed for heavy lifting. His head was flat, with a duo of square optics, a set of welding shields flipped up, ready to flip down when and where needed. His backpack was open, with tools sticking out, ready to be grabbed and used.
Looking around, he noted that the Saurians had their Admiral, a middle age Rox, their massive, tyrannasauric form still managing to tower over most of the others, even in holo, while Serano stood next to him. Nearby, Hota sat, nursing a coffee, rubbing his head, while one of the chief science officers hologram glanced at him nervously.
Another door entered, and a Mk12 frame entered, standing at the table. At first glance, the frame looked pristine, but 4-LOM wasn't fooled. He wasn't a shipwright for nothing, and he could see the pitting under the paint where plasma weaponry had uselessly splashed off, taking with it little layers of metal with it. Despite how new the frame looked, it was clear it had seen some action, recently as well, judging by the fresh coat of paint.
More holograms of fleet officials, and the bridges, or representations of their ships, flickered in above their shoulders. Serano looked like he had an old sailing ship floated there idly, a representation of the Enterprise. Some had wasps, while one captain had a cartoonish Barbus fish, with an old style white sailors cap and a belt of dynamite.
And then a small black hole flickered into view in front of his faceplate, making him roll back with a start. Getting a good look at the now pulsing black hole, he seemed to frown, one of his welding shields rising higher to simulate a eyebrow raise….. "Horizon? Is that you, little lass?" He said, with a thick, Scottish accent as his other shield rose up to join the other in shock.
The holographic black hole bobbed up and down in the air, two arms extending out from its corona and spun, as if to represent it, no, her, spinning in happiness. For a moment, 4-LOM was silent, before he began laughing, reaching up, even as his servo passed through the holo. "Ach, what I wouldn't give ta be in the Link with ye, lassie! I'm glad ye survived." He said, as the little ever hungry representation of the ship spun around him, before it shot off, floating near the Mk12, who looked at it.
The 12s head tilted more, as it listening to what the ship was saying, while 4-LOM felt a bit of possessiveness flair. Horizon was one of HIS creations, his and his wife's. Their ships were like children for them. Rolling over, he mentally began preparing a bit of what his wife would call the shovel talk, something they used to do with Captains that took on their vessels……
"Did you need something, Grandfather?" The machine said, domed head snapping to his, taking the wind out of his sails, and stare blankly at the taller, thinner machine.
Behind him, he heard Serano chuckle behind him, even as the Rox raised an eyeridge, while the Saline sat his mug down and placed his head in his hands.
"Grandfather- oh. I see…." He said, gaze turning flat as he gave a glare at Horizon. "I see the little gremlin is still able to make me short a fuse or two. Void knows Maria's hair turned white before she had to move bodies due to someone's antics." The little black hole pulsed sharply, as if squawking. "Would have appreciated a warning she made herself a captain…. Lassie, ye best be teaching him self preservation instincts." Catching the snort from the Rox and the sigh from Serano.
Slowly, his head turned around to face the two, one shield twitching, and finally saw Hota looking up with a flat look. "Too late on that one. I'll pass you the after action report later, AFTER the meeting." Serano said, hiding a smile. "If you want a first hand account, ask Hota. From what I understand, he had a front row seat for the Chaos the two caused."
She wasn't a little ship anymore, she wasnt- ah kriff it all. She was still his little lass. He'll talk with her later…preferably with Maria there…..after he grabbed his wrench and had a….. talk….. with whoever was their crew.
All the admirals and fleet commanders were soon in place, Asimov standing to the side, near the Admiral Serano, Horizons representation floating next to his head as his own panned about, looking at the assembled species. Several robotic ones, not Astro Robot series, called Glinch, looked at him curiously, while he picked out several different….Saurians, a few Roxes, several Trikes.
Several were pale, white skinned humans, bald, be they male or female. Clones, like himself, but with organic bodies, accompanied by nat-born humans, and several more advanced Astro Robot series units, these ones looking everything from near human, to large and bulky, armed with cannons, inbuilt missile launchers on their upper arms, and massive treads, or slimmer, almost skeletal ones with modules that could be swapped out at a moments notice.
"I appreciate ye all for coming on such short notice" 4-LOMs voice said, cutting over the gentle hubbub of the side conversations. "I had hoped that we wouldn't be facing them again, but here we are." The robot said as one of his smaller limbs tapes a command into the console, pulling up images of Everwatch stations current…condition. "Those of yeh from Federation space are more familar of the old stories, battle videos and the like. The Demons, as the Human Federation calls them, have been returned. It's only thanks to the work of Representative Hota that we have this information….. and had stumbled across an old Ace that had woken back up in time for this chaos." 4-LOM said, nodding to the Saline, getting the attention of his compatriots, who he shook his head to.
"Our opponents are equipped with biotech vessels, and are known for appropriating technology to forcibly integrate it with their own. Which means keep an eye out for a worse hodgepodge of weapons than a pirate vessel after its crew hits a pound of Spice and then gets drunk at a star port." 4-LOM said dryly, as various, old, images of the vessels and a few of the newer ones. "That being said, expect the sheer firepower jammed onto each of these ships to be on the higherside. However, they need long recharge periods, likely due to whatever power source used overloading, or the capacitor banks running dry and needing to recharge. Don't be fooled, they do have some form of biological armament, acid spitters, spike launchers, the works." He said, as images flicked up organic turrets, tentacles, and what looked like maws.
"As of right now, several of our larger vessels are being inspected and repaired, resupplied, and upgraded as needed. Several older vessels are being pulled out of mothball for the same reason. All civilian vessels are being drafted for emergency roles, receiving refit with hardware that will allow them to fight in a pinch, though their primary objective will be escorting transport ships and acting as emergency evacuation ships. We won't be expecting them to fight, but we need every ship we can get."
An image flickered into view of what amounted to the humans old museum of warships and deep space vessels, revealing it to be a hive of activity. Many other races had laughed at humanity for keeping their old vessels, rather than scrapping them, but now, now there was a reason why humanity had.
"Patrol fleets are to be at least one Saline Sensor ship, two to three Buckler class Trike Shield Bearers, one Rox Artillery ship, one Vohle capable human vessel, Two human PT ships, and three Raptor Swift claws." 4-LOM said, "these things aren't to be taken lightly. Sensors pick them up, call it in and engage. Stall for time if needed for reinforcements to arrive. Intercept fleets are to consist of five Trike Aegis class Shield Bearers, six Swift claws, one Rox supercarrier, three Rox artillery ships, two Saline Auxiliary ships, one Saline Medical cruiser, one Human Vohle Super-carrier, eight human PT ships, two Human Iowa class destroyers." The elderly bot belted out, making several Captains and admirals wince. Those weren't lightweight ships. The 'patrol' fleet could have been considered a planetary invasion force.
Before anyone could make any arguments or questions as to why the fleets were set to the Human classic of 'Maximum Overkill', and before any more ridiculous fleet deployments could be called out, a slightly panicking human sprinted into the room. "Sir! Confirmed hostile assault on Tisan-4" the human said, breathing heavily. "The Demons made planet fall, looks like a small invasion force that had left before the incursion field went up."
4-LOM stared….and then sighed. "Well, Caliburn had been itching for a fight." He sighed and placed a servo over his optics.
/-----------------------------------/ WARNING: Hostiles detected. Match confirmed; species D-65. Threat level:Apollyon. Combat systems:unlocked.
That was what appeared on the Colony Managers terminal as alarms screamed across the Colony, alerts screaming on PADDs, sirens spinning as bunkers opened up.
An aging Wargen bared his teeth as he rapidly tapped at his terminal, as the younger human clone stood grimly at her manager's terminal.
"Civilians are filling out the bunkers, tunneling charges are set and ready to clear escape routes." The elderly, wolf like Wargen said, his muzzle splitting into four as he spoke, one part vertical, the other horizontally. "Colonial militia are manning hard points and connecting to systems now."
"Understood." The Colony manager said and let out a long breath, before opening the PA system. "All hands, brace for Activation procedure. I repeat, all hands, brace for activation procedure." She said, before securing herself in on one of the chairs, even as the commander buckled himself in across from her, even as terminals all around them flickered and the building shuddered and shook, new lights came online all over.
"And the other races call our alliance insane for building the bunkers" The Wargen muttered under his breath as the command room became a flurry of activity, sensor teams working together in an attempt to get data on their opponents. "Our people are safe. That's what matters, commander." The clone said softly, looking at her long time friend, even as the hidden defense system of the Colony woke up.
Outside, the demonic army approached, on a slow, steady March, disgruntled at the lack of organics they had found to use. They needed biomass to fuel their war machine, to create their bases, their armies, their ships. And while they didn't care much about the sheer number of ships they lost during planet fall thanks to the orbital defenses, they needed to deal with the local defense computers. There had to be a way to broadcast an all clear signal and allow their other ships past.
Before them sat a large, fortified structure, looked like a massive cathedral, really. The irony was not lost on them as ports on the castle-like structure opened up, and began spitting metallic shells at them, exploding after punching through their infantry, leaving craters behind, destroying more of their forces.
The ground shook as their massive siege beast began forming from the splattered biomass, like some strange, oozing horror, slowly forming into a quadropodic creature.
The beast was mostly just a giant mouth in legs, with a long, worm like body lined with eyes, teeth, spikes, and tendrils, flinging said teeth at the structure.
Warlord Gistle ground his teeth as he stared at the cathedral as it held its own, his forces decimated by the attempted rain of metal. Said rain changed to one of scalding plasma as the castle changed tactics to try and burn the bodies to prevent them from forming additional, stronger units.
"Battle lord." Hissed one of the smaller battle chiefs said, as they stepped up next to Gistle. "The Seekers have not located where the miserable Frails have hidden themselves. Our efforts would be best put to entering the fortress ahead." The chief said, pointing at the massive fortress as the siege beast brushed off the weapons fire.
"No need, we will be inside soon en-" Came the guttural voice of the Warlord, before it was interrupted by a computerized voice, echoing out.
"THREAT ASSESSED. ASSUMING COMBAT MODE."
There was a rumble, everyone grabbing onto the stablest thing around them as the ground tore apart, the siege beast stumbling back, as the building tore up its own foundations as steam hissed out, and part of the building lifted up, and then slammed into the ground, and then the other side, slowly pulling itself up….and up…and up……
The structure wasn't a structure. Not any more. Towering over them, looking like a massive hunchback stood the cathedral, it's towers opening, revealing to be cowling around massive artillery cannons. It's arms, once covered with flat pillars, opened up to reveal a set rotating barrels, slowly spinning up, and a bulky duo of MAC batteries on the other arm. Sticking off the side of its upper arms were smaller hardpoints, each turret armed with four barrels, small and accurate, sniping ground units with horrifying accuracy, the soft metal shells ripping away to reveal their incendiary cargo held within steel mesh, allowing the coilguns to spit them out rapidly.
The head section looked like a sphere with three optics in a triangular formation, around a cannon that locked onto the siegebeast and whined, arcing brightly, before it fired, a bright flash seen as the cannon went off, it's round leaving behind a trail of fire as it raced through the air, punching through the beast, making it howl, and began trying to heal the injury that pierced it, ripping open a hole below it.
It's bipedal legs were thick, armored, and just as equally armed, it's lower legs armed with rotary cannons that spun, the lower pair foring a heavy stream of plasma, one barrel firing and then cooling as it spun, the others keeping the pace up, while above them, physical artillery was spat out, helping pierce armor for the plasma to scorch and burn to uselessness. More cannons sat on the sides and back of its legs in, taking aim at the surrounding armies, making sure to add on their screeches of rage.
Hanging off the underside of the platform that held the Cathederal sat more turrets, each swiveling around and adding to the chaos, their mini MAC armament chattering as they fired, picked a new target and fired again. On the top of the platform were AA cannons, taking aim and firing into the air, altering the timing of their rounds so that they acted as impromptu artillery, while more cannons, on four turrets, covered the monstrosities back, preventing them from sneaking up behind it, as if the cannons on the back of its legs weren't enough to cover it.
Warlord Gistle hissed in shock. The Frails had been LIVING in a Siege beast of their own!? Hidden partially underground, deceiving them to make it seem as if it was nothing more than a fortification!?
"Have all expendable units merge with our Siege beast, NOW! if the frails continue to pick our forces off one by one, they will never be able to reinforce our beast after they fall!" Gistle roared, even as around him the battle chiefs barked out the orders……..
The massive machine stared down at the hostile forces as they turned into a thick, biological slurry, short of the Demons themselves, and oozed towards the horror before it.
The monster seemed to absorb the substance on contact, growing larger and larger with each passing moment, howling and hissing.
He could feel his crew cursing in their heads, humans and otherwise, lighting the slurry up with plasmafire, burning some of it, but not enough. Caliburn agreed with them, as his Plasma getting cannon spun up, the five barrels glowing brightly, the heatsinks by the ends of the barrel glowing as the machine poured plasmafire from the barrels, searing into the beasts body, burning it up as it grew, stunting its growth heavily, and forcing it to consume more biomass to make heavy, chitenous armor, layers burning away under the assault.
Caliburn could feel the dust coming off as his gears spun, and he stepped forward, swinging the glowing arm as it cooled down, making the horror screech as he spun his upper body to add to the force of the blow, digging the glowing heating into the beast's face and knocking it back, buying time for his crew to deal with the horrific slurry around them, which still tried to fuse with the horror, chasing after it with a single minded determination.
As his upper body slowed down and he was facing forward again, he saw the beast setting up, snarling. His other arm came up, and he could feel his capacitors burning as he began firing his MAC arm at it, the massive, vehicle sized slugs punching into the beast, knocking it back farther, punching holes in the chitin it tried to grow as armor, making it hiss and move rapidly, trying to put distance between itself and the machine.
Unfortunately, the beast had the advantage in land speed, as it had four legs, while Caliburn only had two and lumbered slowly forward, his aging systems relishing the taste of combat after so long. And now he had far better weapons then a simple crane arm, like he had last time he fought a creature like this.
Because the beast had put distance between itself and him, it managed to absorb the last of the biomass, and began bounding forward, it's maw open, teeth spinning like some sort of Cuisinart….
A target he couldn't miss. His head cannon barked again, not as powerful as last time, but this time, he wasn't trying to rip it apart from the inside. The shell detonated on contact with the teeth, shredding them, tearing into the soft flesh within, making the beast howl and close its maw, it's chitin armor weathering the plasma splashing off, hardened to withstand the smaller weapons fire his crew spat at the creature.
His arms pulled their shrouding back around them, as he drew back and swung, hard, again using his body spinning to his advantage, striking the beast, the heavy weight of the heatsink and the weapon itself burying the shroud covered arm inside, the end opening up. Unfortunately, thanks to the partial shrouding, he wouldn't be able to spin his cannon, but all he needed was one shot inside it, and let it fly, ripping his arm out as it howled, smoke billowing from its new hole it tried rapidly to heal.
The tendrils it had tried to dig into his arm burned away as he kicked it up from below and began unloading both arms, fully unshrouded, the heat coming off both of them making steam hiss up into the air, as the beast took a heavy slug and then a plasma bolt, one after the other, deep into its stomach, sending it onto its back.
Loud popping sounds were heard as its limbs reoriented, allowing its former belly to become its back, the holes sealing slowly as it circled the walking cathedral, even as Caliburn scanned it, his upper body following its every movement. His command crew were breaking down every schematic and scan he gave them, working hard to figure out a way to kill the horror.
In the mean time, Caliburn and his crews would do their damndest to stall the beast and continue on their current plan. Burn it down, slowly.
He could feel his crews tracking the retreating demon forces, listening to the mental chatter within him as the artillery crews happily worked together to figure out their path, searching for the enemy command position, even as sensor crews watched as the rapidly approaching flood of biomass and machinery charged for them, some of the artillery crews already letting loose N-4 shells, the 'super-napalm', as the crews nicknamed them, impacting and exploding, burning into the biomass, unquenchable, even as the biomass attempted and failed to smother the burning substance, only serving to make it worse, melting the weaponry it carried with it.
The only reason why the crews could get away with it was because the biomass wasn't near the Bunkers exits or near infrastructure. Or Burnable items.
Command soon had a viable target, a sort of brain mass it had, separated throughout its body in a vain attempt to make sure it could still operate when a few of them were destroyed.
Several had been burned away by the plasma bolt going off inside of it, but many more remained, and it was attempting to make more/replace the burned away ones. They needed to eliminate the command signal….
Jubilation and grim satisfaction bloomed in his sensor and artillery crews, as he felt the mad scramble for bunker busting shells, before they were let loose into the air. Even as he blocked a tail strike from the beast and managed to crush its head under one foot, letting his landing engines ignite for the first time in decades to burn the creature more, his crews targeted the command bunker, shelling it with deadly accuracy, smoke rising from the hill they were tucked away behind in the distance, making Caliburn burn with satisfaction and praise for his crew.
Gistle ran as fast as his hooves could move him, teeth barred as he snarled.
Around him, their command temple shook and shuddered, veins bursting, cables arcing wildly as the biomass contracted involuntarily or simply sagged, turning to biomass.
"Warlord, they are heavily shelling our position, we won't be able to retreat at this rate!" Hissed one of the Battle Chiefs at his side, hissing in fear, even as he snarled at the Pitiful, compared to him, creature. "We won't be taking everyone, only the essentials. The Everlasting King must be notified of this development. King be damned, the frails took the time to prepare for our arrival again." He growled as he came out to a hanger area, and ran into a small, fast ship, even as the others ran into larger, bulkier, slower ships.
Soon, the chitin that served as the door opened, and they shot out, erratically flying, trying to avoid the artillery shells, and now AA fire joining the fray.
He kept close to his compatriots, using them as a living shield as he twisted the small vessel around, smirking as he dodged the fire while they took it..
They were almost to space, soon, they could tear a Gate and get the fleet-
Reality tore open above him as a massive ring shaped vessel pushed itself into real space, disgorging hundreds of smaller vessels, bearing down on their positions, others engaging the floating fleet around them with aggressive assault runs, the sudden appearance in the system allowing them to have the element of surprise.
Weapons fire began filling the space around f them, tearing at their vessels faster then they could repair them as little, frail vessels zipped in and out of line of fire faster then they could shoot, track, or react, unloading slugs, plasma, torpedoes in a flurry of activity before diving away, allowing their munitions to wreak havoc amongst them.
Already, the larger vessels were disabled before Gistle managed to sacrifice one, smirking as it warped, it's biomass fueling the Gate, as he flew through, hoping he was in friendlier territories, unaware of a sensor torpedo flying in behind him.
Down below, on the surface, Caliburn flung back his opponent again, arms blazing as he shelled it.
It was bigger then it had been, managing to absorb the biomass from the surviving landing ships and the remains of the command center they shelled out. It's armor was thicker, and was flinging out dozens, hundreds of calcium spikes, spitting its unknown energy weapons, only to splash off his shields, for the energy weapons, and his ar.or foe the calcium spikes, even as his weapons screeched.
The beast had holes all over its chitenous armor, from his shells punching in, or his artillery crews shelling the beast, his plasma following close behind as he sought to burn the creature out from the inside, going so far as to ram his plasma cannon inside and unload it, the rotating barrels helping tear it up from the inside as the heat sinks burned it.
Ships began dropping down from above, doing strafing runs, dropping smaller caliber explosives, distracting the beast as he tore another hole in it by spinning his upper body, one shrouded cannon arm striking the beast and ripping in, just as a gunship fired a Cleaner into it, just before it healed.
A burning flash of light, a horrific scream from the beast as it howled, body jerking as the explosive did its job…. Before it swung down, still alive, though just barely, it's armor shattering rather then buckling on the next strike from Caliburn, a facsimile of a uppercut, before the barrels let loose again, even as the plasma cannon dumped bolt after bolt into its lower body, searching for, burning the neural clusters as he found them.
The beast wrenched itself away from his grasp, snarling as it looked at him, the beast snarling as it tried to heal from the most recent injuries.
Caliburn felt his crew snarling back, his cannons swiveling around as they gave their response in munitions as he lumbered forward, the ground shaking from his steps and the escape ships erupting out of the ground around them, his rotary cannon screaming as it fired, the MAC on the other arm barking as he hit it again and again as it charged forward.
The beast no longer cared for its injuries, all it cared was to take the metal monster before it down, spitting acid out of it as it tried, and failed, to blind the machine, even as said machine swung its smoldering plasma cannon up and brought down the burning barrels down on its head, smashing it into the ground, pinning it there as it's crew continued shelling it out ruthlessly.
Caliburn refused to let the beast survive, he refused to let the thing get to the civilians. His crew snarled their agreement as the beast tore the pinned head off its body, even as it burned away to nothing, and tried to charge again, blindly, only to smash against the MAC arm and receive a pair of heavy slugs to the neck stump for its troubles, sending it somersaulting back, trying to reform its head.
It was much, much smaller now, now matching Caliburns size, due to all the biomass loss, it's head reforming as it snarled.
Caliburn seemed to roll his pauldrons and twitched his MAC, as if saying 'come at me'. The beast howled and charged forward, razor sharp tentacles erupting from its sides, whipping about wildly, only for turret crews to blast the tentacles off at the base, and for his artillery crews to shell it down from above, flattening it into the ground again with explosive shells.
Again, the beast began pulling itself out of the ground, only for another strafing run from aircraft , this time dropping standard napalm canisters onto the beast, making it howl as it healed around the canisters, and began burning from within.
It thrashed and writhed, tail and body whipping about, even as Caliburn kept firing, not letting up, shells puncturing the chitin bubble it was trying to form around the napalm to contain it, keeping it burning into the beasts body.
At last, the beast tried to fling itself at Caliburn, thinking that it could at least burn out the mechanical monster with it, only for Caliburn to swing and strike it, flinging it away again, the beasts body unable to get back up, and laid there, slowly burning away at last……………
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2023.06.04 15:35 AdHelpful3292 Rock and a hard place
So I’m getting to the point in my job where I am seeing the cons outweigh the positives. I disagree with the shady practices and how important matters are handled by being covered up. People who are trying to address important issues are gaslit into silence. The nurses have literally the weight of this hospital on their shoulders with little to no recognition or protection…I am trying to recover from the grief of a horrific loss(murder) of a kid I had cared for so much, and dread coming in even more now. I feel like the work I do means nothing despite all the responsibilities I have, and that my work is ultimately for no reason. Even when I have many days off I still never feel rested when I come back to work.
Ive been a nurse for a while now and I was used to sacrificing holidays and weekends but now it feels like they are just taking advantage of EVERYTHING. I used to love this job, and now I am so tempted to start looking for other jobs but let’s face it, most hospitals suck and may be even worse! I just got a raise at this place and love the money I make. I cannot stand office jobs, and love fast paced where you are able to LEARN and further your experience and knowledge base. I used to feel I was learning here and now it’s the same shit. What do I do? Should I see if this feeling subsides and see if it’s worth sticking it out or should I look for something else and try to salvage my sanity and happiness? Thanks.
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2023.06.04 14:39 Apprehensive_Menu393 Looking for opinions on a gift idea I have
I'm dating a nursing student and he's about to graduate with his LPN. He's also going to be working in palliative care. As a grad gift I want to make him a pouch (decent size) and have the lining of the pouch be nurse related but the exterior being something nice that doesn't scream I'm a nurse. I was thinking about getting him a small notebook, pens (black), sharpies (fine and medium), highlighters.
I'm looking for other ideas to add that could be useful and thoughtful. Thank you!!
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2023.06.04 14:34 Dirtclodkoolaid AMA RESOLUTION 235
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AMA RESOLUTION 235 November 2018 INAPPROPRIATE USE OF CDC Guidelines FOR PRESCRIBING OPIOIDS (Entire Document)
“Resolution 235 asks that our AMA applaud the CDC for its efforts to prevent the incidence of new cases of opioid misuse, addiction, and overdose deaths; and be it further, that no entity should use MME thresholds as anything more than guidance and that MME thresholds should not be used to completely prohibit the prescribing of, or the filling of prescriptions for, medications used in oncology care, palliative medicine care, and addiction medicine care: and be it further, that our AMA communicate with the nation’s largest pharmacy chains and pharmacy benefit managers to recommend that they cease and desist with writing threatening letters to physicians and cease and desist with presenting policies, procedures and directives to retail pharmacists that include a blanket proscription against filling prescriptions for opioids that exceed certain numerical thresholds without taking into account the diagnosis and previous response to treatment for a patient and any clinical nuances that would support such prescribing as falling within standards of good quality patient care; and be it further, that AMA Policy opposing the legislating of numerical limits on medication dosage, duration of therapy, numbers of pills/tablets, etc., be reaffirmed; and be it further, that physicians should not be subject to professional discipline or loss of board certification or loss of clinical privileges simply for prescribing opioids at a quantitative level that exceeds the MME thresholds found in the CDC Guidelines; and be it further, that our AMA encourage the Federation of State Medical Boards and its member boards, medical specialty societies, and other entities to develop improved guidance on management of pain and management of potential withdrawal syndromes and other aspects of patient care for “legacy patients” who may have been treated for extended periods of time with high-dose opioid therapy for chronic non-malignant pain.
RESOLVED, that our American Medical Association (AMA) applaud the Centers for Disease Control and Prevention (CDC) for its efforts to prevent the incidence of new cases of opioid misuse, addiction, and overdose deaths
RESOLVED, that our AMA actively continue to communicate and engage with the nation’s largest pharmacy chains, pharmacy benefit managers, National Association of Insurance Commissioners, Federation of State Medical Boards, and National Association of Boards of Pharmacy in opposition to communications being sent to physicians that include a blanket proscription against filing prescriptions for opioids that exceed numerical thresholds without taking into account the diagnosis and previous response to treatment for a patient and any clinical nuances that would support such prescribing as falling within standards of good quality patient care.
RESOLVED, that our AMA affirms that some patients with acute or chronic pain can benefit from taking opioid pain medications at doses greater than generally recommended in the CDC Guideline for Prescribing Opioids for Chronic Pain and that such care may be medically necessary and appropriate, and be it further
RESOLVED, that our AMA advocate against misapplication of the CDC Guideline for Prescribing Opioids by pharmacists, health insurers, pharmacy benefit managers, legislatures, and governmental and private regulatory bodies in ways that prevent or limit patients’ medical access to opioid analgesia, and be it further
RESOLVED, that our AMA advocate that no entity should use MME (morphine milligram equivalents) thresholds as anything more than guidance, and physicians should not be subject to professional discipline, loss of board certification, loss of clinical privileges, criminal prosecution, civil liability, or other penalties or practice limitations solely for prescribing opioids at a quantitative level above the MME thresholds found in the CDC Guideline for Prescribing Opioids.””
Pain Management Best Practices Inter-Agency Task Force - Draft Report on Pain Management Best Practices: Updates, Gaps, Inconsistencies, and Recommendations Official Health and Human Services Department Released December 2018
“The Comprehensive Addiction and Recovery Act (CARA) of 2016 led to the creation of the Pain Management Best Practices Inter-Agency Task Force (Task Force), whose mission is to determine whether gaps in or inconsistencies between best practices for acute and chronic pain management exist and to propose updates and recommendations to those best practices. The Task Force consists of 29 experts who have significant experience across the disciplines of pain management, patient advocacy, substance use disorders, mental health, and minority health.”
In addition to identifying approximately 60 gaps in clinical best practices and the current treatment of pain in the United States, HHS PMTF provided recommendations for each of these major areas of concern. In alignment with their original charter, the PMTF will submit these recommendations to Congress to become our ‘National Pain Policy’. The 60+ gaps and inconsistencies with their recommendations will serve to fill gaps in pain treatment at both the state and federal level; and the overwhelming consensus was that the treatment of pain should be multimodal and completely individualized based on the individual patient. The heart of each recommendation in each section was a resounding call for individualization for each patient, in regards to both non-pharmacological and pharmacological modalities; including individualizations in both opioid and non-opioid pharmacological treatments.
While each of the gap+recommendation sections of what is poised to become our national pain policy is extremely important, one that stands out the most (in regards to opioid prescribing) is the Stigma section. Contained in this section is one of the core statements that shows our Health and Human Services agency - the one that should have always been looked to and followed - knew the true depth of the relationship (or lack of) between the overdose crisis and compassionate prescribing to patients with painful conditions:
“The national crisis of illicit drug use, with overdose deaths, is confused with appropriate therapy for patients who are being treated for pain. This confusion has created a stigma that contributes to raise barriers to proper access to care.”
The recommendation that follows - “Identify strategies to reduce stigma in opioid use so that it is never a barrier to patients receiving appropriate treatment, with all cautions and considerations for the management of their chronic pain conditions” - illustrates an acknowledgment by the top health agency of the federal government that the current national narrative conflating and confusing compassionate treatment of pain with illicit drug use, addiction, and overdose death is incorrect and only serving to harm patients.
Since March of 2016 when the CDC Guidelines were released, advocates, patients, clinicians, stakeholders, and others, have began pointing out limitations and unintended consequences as they emerged. In order to address the unintended consequences emerging from the CDC Guidelines, this task force was also charged with review of these guidelines; from expert selection, evidence selection, creation, and continuing to current misapplication in order to provide recommendations to begin to remedy these issues.
“A commentary by Busse et al. identified several limitations to the CDC guideline related to expert selection, evidence inclusion criteria, method of evidence quality grading, support of recommendations with low-quality evidence, and instances of vague recommendations. In addition, the CDC used the criterion of a lack of clinical trials with a duration of one year or longer as lack of evidence for the clinical effectiveness of opioids, whereas Tayeb et al. found that that was true for all common medication and behavioral therapy studies.
Interpretation of the guideline, in addition to some gaps in the guideline, have led to unintended consequences, some of which are the result of misapplication or misinterpretation of the CDC guideline.
However, at least 28 states have enacted legislation related to opioid prescription limits, and many states and organizations have implemented the guideline without recognizing that the intended audience was PCPs; have used legislation for what should be medical decision making by healthcare professionals; and have applied them to all physicians, dentists, NPs, and PAs, including pain specialists.441–444 Some stakeholders have interpreted the guideline as intended to broadly reduce the amount of opioids prescribed for treating pain; some experts have noted that the guideline emphasizes the risk of opioids while minimizing the benefit of this medication class when properly managed.”
“The CDC guideline was not intended to be model legislation for state legislators to enact”
“In essence, clinicians should be able to use their clinical judgment to determine opioid duration for their patients” https://www.hhs.gov/ash/advisory-committees/pain/reports/2018-12-draft-report-on-updates-gaps-inconsistencies-recommendations/index.html
HHS Review of 2016 CDC Guidelines for responsible opioid prescribing
The Pain Management Task Force addressed 8 areas that are in need of update or expansion with recommendations to begin remediation for each problem area:
Lack of high-quality data exists for duration of effectiveness of opioids for chronic pain; this has been interpreted as a lack of benefit Conduct studies Focus on patient variability and response for effectiveness of opioids; use real-world applicable trials
Absence of criteria for identifying patients for whom opioids make up significant part of their pain treatment Conduct clinical trials and/or reviews to identify sub-populations of patients where long-term opioid treatment is appropriate
Wide variation in factors that affect optimal dose of opioids Consider patient variables for opioid therapy: Respiratory compromise Patient metabolic variables Differences in opioid medications/plasma concentrations Preform comprehensive initial assessment it’s understanding of need for comprehensive reevaluations to adjust dose Give careful considerations to patients on opioid pain regimen with additional risk factors for OUD
Specific guidelines for opioid tapering and escalation need to be further clarified A thorough assessment of risk-benefit ratio should occur whenever tapering or escalation of dose This should include collaboration with patient whenever possible Develop taper or dose escalation guidelines for sub-populations that include consideration of their comorbidities When benefit outweighs the risk, consider maintaining therapy for stable patients on long term opioid therapy
Causes of worsening pain are not often recognized or considered. Non-tolerance related factors: surgery, flares, increased physical demands, or emotional distress Avoid increase in dose for stable patient (2+ month stable dose) until patient is re-evaluated for underlying cause of elevated pain or possible OUD risk Considerations to avoid dose escalation include: Opioid rotation Non-opioid medication Interventional strategies Cognitive behavior strategies Complementary and integrative health approaches Physical therapy
In patients with chronic pain AND anxiety or spasticity, benzodiazepine co-prescribed with opioids still have clinical value; although the risk of overdose is well established When clinically indicated, co-prescription should be managed by specialist who have knowledge, training, and experience with co-prescribing. When co-prescribed for anxiety or SUD collaboration with mental health should be considered Develop clinical practice guidelines focused on tapering for co-prescription of benzodiazepines and opioids
The risk-benefit balance varies for individual patients. Doses >90MME may be favorable for some where doses <90MME may be for other patients due to individual patient factors. Variability in effectiveness and safety between high and low doses of opioids are not clearly defined. Clinicians should use caution with higher doses in general Using carefully monitored trial with frequent monitoring with each dose adjustment and regular risk reassessment, physicians should individualize doses, using lowest effective opioid dose that balances benefit, risk, and adverse reactions Many factors influence benefits and risk, therefore, guidance of dose should not be applied as strict limits. Use established and measurable goals: Functionality ADL Quality of Life
Duration of pain following acute and severely painful event is widely variable Appropriate duration is best considered within guidelines, but is ultimately determined by treating clinician. CDC recommendation for duration should be emphasized as guidance only with individualized patient care as the goal Develop acute pain management guidelines for common surgical procedures and traumas To address variability and provide easy solution, consideration should be given to partial refill system
Human Rights Watch December 2018 (Excerpt from 109 page report)
“If harms to chronic pain patients are an unintended consequence of policies to reduce inappropriate prescribing, the government should seek to immediately minimize and measure the negative impacts of these policies. Any response should avoid further stigmatizing chronic pain patients, who are increasingly associated with — and sometimes blamed for — the overdose crisis and characterized as “drug seekers,” rather than people with serious health problems that require treatment.
Top government officials, including the President, have said the country should aim for drastic cutbacks in prescribing. State legislatures encourage restrictions on prescribing through new legislation or regulations. The Drug Enforcement Administration (DEA) has investigated medical practitioners accused of overprescribing or fraudulent practice. State health agencies and insurance companies routinely warn physicians who prescribe more opioids than their peers and encourage them to reduce prescribing. Private insurance companies have imposed additional requirements for covering opioids, some state Medicaid programs have mandated tapering to lower doses for patients, and pharmacy chains are actively trying to reduce the volumes of opioids they dispense.
The medical community at large recognized that certain key steps were necessary to tackle the overdose crisis: identifying and cracking down on “pill mills” and reducing the use of opioids for less severe pain, particularly for children and adolescents. However, the urgency to tackle the overdose crisis has put pressure on physicians in other potentially negative ways: our interviews with dozens of physicians found that the atmosphere around prescribing for chronic pain had become so fraught that physicians felt they must avoid opioid analgesics even in cases when it contradicted their view of what would provide the best care for their patients. In some cases, this desire to cut back on opioid prescribing translated to doctors tapering patients off their medications without patient consent, while in others it meant that physicians would no longer accept patients who had a history of needing high-dose opioids.
The consequences to patients, according to Human Rights Watch research, have been catastrophic.”
Opioid Prescribing Workgroup December 2018
This is material from the Board of Scientific Counselors in regards to their December 12, 2018 meeting that culminated the works of a project titled the “Opioid Prescribing Estimates Project.” This project is a descriptive study that is examining opioid prescribing patterns at a population level. Pain management is a very individualized process that belongs with the patient and provider. The Workgroup reviewed work done by CDC and provided additional recommendations.
SUMMARY There were several recurrent themes throughout the sessions.
Repeated concern was voiced from many Workgroup members that the CDC may not be able to prevent conclusions from this research (i.e. the benchmarks, developed from limited data) from being used by states or payors or clinical care systems to constrain clinical care or as pay-for- performance standards – i.e. interpreted as “guidelines”. This issue was raised by several members on each of the four calls, raising the possibility that providers or clinical systems could thus be incentivized against caring for patients requiring above average amounts of opioid medication.
Risk for misuse of the analysis. Several members expressed concerns that this analysis could be interpreted as guidance by regulators, health plans, or clinical care systems. Even though the CDC does not plan to issue this as a guideline, but instead as research, payors and clinical care systems searching for ways to reign in opioid prescribing may utilize CDC “benchmarks” to establish pay-for-performance or other means to limit opioid prescribing. Such uses of this work could have the unintended effect of incentivizing providers against caring for patients reliant upon opioids.
…It was also noted that, in order to obtain sufficient granularity to establish the need for, dosage, and duration of opioid therapy, it would be necessary to have much more extensive electronic medical record data. In addition, pain and functional outcomes are absent from the dataset, but were felt to be important when considering risk and benefit of opioids.
...Tapering: Concerns about benchmarks and the implications for tapering were voiced. If tapering occurs, guidance was felt to be needed regarding how, when, in whom tapering should occur. This issue was felt to be particularly challenging for patients on chronic opioids (i.e. “legacy” patients). In addition, the importance of measuring risk and benefit of tapering was noted. Not all high-dose patient populations benefit from tapering.
General comments. Workgroup members noted that most patients prescribed opioids do not experience adverse events, including use disorder. Many suggested that further discussion of opioids with patients prior to surgery was important, with an emphasis on expectations and duration of treatment. A member suggested that take-back programs would be more effective than prescribing restrictions.
Procedure-related care. Members noted that patient factors may drive opioid need more than characteristics of a procedure.
Patient-level factors. Members noted that opioid-experienced patients should be considered differently from opioid-inexperienced patients, due to tolerance.
It was noted that anything coming out of the CDC might be considered as guidelines and that this misinterpretation can be difficult to counter. There was extensive discussion of the 50 and 90 MME levels included in the CDC Guidelines. It was recommended that the CDC look into the adverse effects of opioid tapering and discontinuation, such as illicit opioid use, acute care utilization, dropping out of care, and suicide. It was also noted that there are major gaps in guidelines for legacy patients, patients with multiple diagnoses, pediatric and geriatric patients, and patients transitioning to lower doses.
There were concerns that insufficient clinical data will be available from the dataset to appropriately consider the individual-level factors that weigh into determination of opioid therapy. The data would also fail to account for the shared decision-making process involved in opioid prescribing for chronic pain conditions, which may be dependent on primary care providers as well as ancillary care providers (e.g. physical therapists, psychologists, etc).
Patient-level factors. Members repeatedly noted that opioid-experienced patients should be considered differently from opioid-experienced patients, due to tolerance.
Members noted that the current CDC guidelines have been used by states, insurance companies, and some clinical care systems in ways that were not intended by the CDC, resulting in cases of and the perception of patient abandonment. One option raised in this context was to exclude patients on high doses of opioids, as those individuals would be qualitatively different from others. A variant of this concern was about management of “legacy” patients who are inherited on high doses of opioids. Members voiced concerns that results of this work has caused harm to patients currently reliant upon opioids prescribed by their providers.
Acute Non-Surgical Pain
Patient-level factors. Members felt that opioid naïve versus experienced patients might again be considered separately, as opioid requirements among those experienced could vary widely.
...Guidelines were also noted to be often based on consensus, which may be incorrect.
Cancer-Related and Palliative Care Pain
It was noted that the CDC guidelines have been misinterpreted to create a limit to the dose of opioids that can be provided to people at all stages of cancer and its treatment. It was also noted that the cancer field is rapidly evolving, with immunotherapy, CAR-T, and other novel treatments that affect response rates and limit our ability to rely upon historical data in establishing opioid prescribing benchmarks.
Concern that data would not be able to identify all of the conditions responsible for pain in a patient with a history of cancer (e.g. people who survive cancer but with severe residual pain). Further, it was noted that certain complications of cancer and cancer treatment may require the least restrictive long-term therapy with opioids.
The definition of palliative care was also complicated and it was suggested that this include patients with life-limiting conditions.
Overall, it was felt that in patients who may not have long to live, and/or for whom returning to work is not a possibility, higher doses of opioids may be warranted. https://www.cdc.gov/injury/pdfs/bsc/NCIPC_BSC_OpioidPrescribingEstimatesWorkgroupReport_December-12_2018-508.pdf
CDC Scientists Anonymous ‘Spider Letter’ to CDC
Carmen S. Villar, MSW Chief of Staff Office of the Director MS D14 Centers for Disease Control and Prevention (CDC) 1600 Clifton Road Atlanta, Georgia 30329-4027
August 29, 2016
Dear Ms. Villar:
We are a group of scientists at CDC that are very concerned about the current state of ethics at our agency. It appears that our mission is being influenced and shaped by outside parties and rogue interests. It seems that our mission and Congressional intent for our agency is being circumvented by some of our leaders. What concerns us most, is that it is becoming the norm and not the rare exception. Some senior management officials at CDC are clearly aware and even condone these behaviors. Others see it and turn the other way. Some staff are intimidated and pressed to do things they know are not right. We have representatives from across the agency that witness this unacceptable behavior. It occurs at all levels and in all of our respective units. These questionable and unethical practices threaten to undermine our credibility and reputation as a trusted leader in public health. We would like to see high ethical standards and thoughtful, responsible management restored at CDC. We are asking that you do your part to help clean up this house!
It is puzzling to read about transgressions in national media outlets like USA Today, The Huffington Post and The Hill. It is equally puzzling that nothing has changed here at CDC as a result. It’s business as usual. The litany of issues detailed over the summer are of particular concern:
Recently, the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) has been implicated in a “cover up” of inaccurate screening data for the Wise Woman (WW) Program. There was a coordinated effort by that Center to “bury” the fact that screening numbers for the WW program were misrepresented in documents sent to Congress; screening numbers for 2014 and 2015 did not meet expectations despite a multimillion dollar investment; and definitions were changed and data “cooked” to make the results look better than they were. Data were clearly manipulated in irregular ways. An “internal review” that involved staff across CDC occurred and its findings were essentially suppressed so media and/or Congressional staff would not become aware of the problems. Now that both the media and Congresswoman DeLauro are aware of these issues, CDC staff have gone out of their way to delay FOIAs and obstruct any inquiry. Shouldn’t NCCDPHP come clean and stop playing games? Would the ethical thing be to answer the questions fully and honestly. The public should know the true results of what they paid for, shouldn’t they?
Another troubling issue at the NCCDPHP are the adventures of Drs. Barbara Bowman and Michael Pratt (also detailed in national media outlets). Both seemed to have irregular (if not questionable) relationships with CocaCola and ILSI representatives. Neither of these relationships were necessary (or appropriate) to uphold our mission. Neither organization added any value to the good work and science already underway at CDC. In fact, these ties have now called into question and undermined CDC’s work. A cloud has been cast over the ethical and excellent work of scientists due to this wanton behavior. Was cultivating these relationships worth dragging CDC through the mud? Did Drs. Bowman and Pratt have permission to pursue these relationships from their supervisor Dr. Ursula Bauer? Did they seek and receive approval of these outside activities? CDC has a process by which such things should be vetted and reported in an ethics review, tracking and approval system (EPATS). Furthermore, did they disclose these conflicts of interest on their yearly OGE 450 filing. Is there an approved HHS 520, HHS 521 or “Request for Official Duty Activities Involving an Outside Organization” approved by Dr. Bauer or her Deputy Director Ms. Dana Shelton? An August 28, 2016 item in The Hill details these issues and others related to Dr. Pratt.
It appears to us that something very strange is going on with Dr. Pratt. He is an active duty Commissioned Corps Officer in the USPHS, yet he was “assigned to” Emory University for a quite some time. How and under what authority was this done? Did Emory University pay his salary under the terms of an IPA? Did he seek and receive an outside activity approval through EPATS and work at Emory on Annual Leave? Formal supervisor endorsement and approval (from Dr. Bauer or Ms. Shelton) is required whether done as an official duty or outside activity.
If deemed official, did he file a “Request for Official Duty Activities Involving an Outside Organization” in EPATS? Apparently Dr. Pratt’s position at Emory University has ended and he has accepted another position at the University of California San Diego? Again, how is this possible while he is still an active duty USPHS Officer. Did he retire and leave government service? Is UCSD paying for his time via an IPA? Does he have an outside activity approval to do this? Will this be done during duty hours? It is rumored that Dr. Pratt will occupy this position while on Annual Leave? Really? Will Dr. Pratt be spending time in Atlanta when not on Annual Leave? Will he make an appearance at NCCDPHP (where he hasn’t been seen for months). Most staff do not enjoy such unique positions supported and approved by a Center Director (Dr. Bauer). Dr. Pratt has scored a sweet deal (not available to most other scientists at CDC). Concerns about these two positions and others were recently described in The Huffington Post and The Hill. His behavior and that of management surrounding this is very troubling.
Finally, most of the scientists at CDC operate with the utmost integrity and ethics. However, this “climate of disregard” puts many of us in difficult positions. We are often directed to do things we know are not right. For example, Congress has made it very clear that domestic funding for NCCDPHP (and other CIOs) should be used for domestic work and that the bulk of NCCDPHP funding should be allocated to program (not research). If this is the case, why then is NCCDPHP taking domestic staff resources away from domestic priorities to work on global health issues? Why in FY17 is NCCDPHP diverting money away from program priorities that directly benefit the public to support an expensive research FOA that may not yield anything that benefits the public? These actions do not serve the public well. Why is nothing being done to address these problems? Why has the CDC OD turned a blind eye to these things. The lack of respect for science and scientists that support CDC’s legacy is astonishing.
Please do the right thing. Please be an agent of change.
CDC Spider (CDC Scientists Preserving Integrity, Diligence and Ethics in Research) https://usrtk.org/wp-content/uploads/2016/10/CDC_SPIDER_Letter-1.pdf
January 13, 2016
Thomas Frieden, MD, MPH Director Centers for Disease Control and Prevention 1600 Clifton Road Atlanta, GA 30329-4027
Re: Docket No. CDC-2015-0112; Proposed 2016 Guideline for Prescribing Opioids for Chronic Pain
Dear Dr. Frieden:
There is no question that there is an opioid misuse epidemic and that efforts need to be made to control it. The Centers for Disease Control and Prevention (CDC) is applauded for its steps to undertake this lofty effort. However, based on the American Academy of Family Physicians’ (AAFP’s) review of the guideline, it is apparent that the presented recommendations are not graded at a level consistent with currently available evidence. The AAFP certainly wants to promote safe and appropriate prescribing of opioids; however, we recommend that the CDC still adhere to the rigorous standards for reliable and trustworthy guidelines set forth by the Institute of Medicine (IOM). The AAFP believes that giving a strong recommendation derived from generalizations based on consensus expert opinion does not adhere to evidence-based standards for developing clinical guideline recommendations.
The AAFP’s specific concerns with the CDC’s methodology, evidence base, and recommendations are outlined below.
Methodology and Evidence Base
All of the recommendations are based on low or very low quality evidence, yet all but one are Category A (or strong) recommendations. The guideline states that in the GRADE methodology "a particular quality of evidence does not necessarily imply a particular strength of recommendation." While this is true, it applies when benefits significantly outweigh harms (or vice versa). When there is insufficient evidence to determine the benefits and harms of a recommendation, that determination should not be made.
When evaluating the benefits of opioids, the evidence review only included studies with outcomes of at least one year. However, studies with shorter intervals were allowed for analysis of the benefits of nonopioid treatments. The guideline states that no evidence shows long-term benefit of opioid use (because there are few studies), yet the guideline reports "extensive evidence" of potential harms, even though these studies were of low quality. The accompanying text also states "extensive evidence" of the benefits of non-opioid treatments, yet this evidence was from shorter term studies, was part of the contextual review rather than the clinical systematic review, and did not compare non- opioid treatments to opioids.
The patient voice and preferences were not explicitly included in the guideline. This raises concerns about the patient-centeredness of the guideline. https://www.aafp.org/dam/AAFP/documents/advocacy/prevention/risk/LT-CDC-OpioidGuideline011516.pdf
The Myth of Morphine Equivalent Daily Dosage Medscape Neuro Perspective
For far too many years, pain researchers and clinicians have relied on the concept of the morphine equivalent daily dosage (MEDD), or some variant of it, as a means of comparing the "relative corresponding quantity" of the numerous opioid molecules that are important tools in the treatment of chronic pain.
...And, most unfortunately, opioid prescribing guideline committees have relied on this concept as a means of placing (usually arbitrary) limits on the levels of opioids that a physician or other clinician should be allowed to prescribe. Although these guidelines typically bill themselves as "voluntary," their chilling effect on prescribers and adaptation into state laws makes calling them "voluntary" disingenuous.
Although some scientists and clinicians have been questioning the conceptual validity of MEDD for several years, a recent study has indicated that the concept is unequivocally flawed—thereby invalidating its use empirically and as a tool in prescribing guideline development.
The authors used survey data from pharmacists, physicians, nurse practitioners, and physician assistants to estimate daily morphine equivalents and found great inconsistency in their conversions of hydrocodone, fentanyl transdermal patches, methadone, oxycodone, and hydromorphone—illustrating the potential for dramatic underdosing or, in other cases, fatal overdosing.
Patients with chronic pain (particularly that of noncancer origin) who are reliant on opioid analgesia are already sufficiently stigmatized and marginalized to allow this type of practice to continue to be the norm.
Although the use of MEDD in research and, to a greater extent, in practice, is probably due to unawareness of its inaccuracy, we posit that the use of MEDD by recent opioid guideline committees (eg, the Washington State Opioid Guideline Committee and the Centers for Disease Control and Prevention Guideline Committee) in the drafting of their guidelines is based more heavily on disregarding available evidence rather than ignorance. Furthermore, their misconduct in doing so has been more pernicious than the use of MEDD by researchers and individual clinicians, because these guidelines widely affect society as a whole as well as individual patients with persistent pain syndromes. We opine that these committees are strongly dominated by the antiopioid community, whose agenda is to essentially restrict opioid access—irrespective of the lack of data indicating that opioids cannot be a useful tool in the comprehensive treatment of carefully selected and closely monitored patients with chronic pain.
Above 100% extracted from: Medscape Journal Brief https://www.medscape.com/viewarticle/863477_2
Actual Study https://www.dovepress.com/the-medd-myth-the-impact-of-pseudoscience-on-pain-research-and-prescri-peer-reviewed-article-JPR
Are Non-Opioid Medications Superior in Treatment of Pain than Opioid Pain Medicine? Ice Cream Flavor Analogy...
In the Oxford University Press, a November 2018 scientific white paper was released that examined the quality of one of the primary studies that have been used to justify the urgent call to drastically reduce opioid pain medication prescribing while claiming that patients are not being harmed in the process.
The study is commonly referred to as ‘the Krebs study’. “The authors concluded that treatment with opioids was not superior to treatment with non opioid medications for improving pain-related function over 12 months.”
Here is an excerpt from the first paragraph of the design section (usually behind a paywall) from the Krebs study that gives the first hint of the bias that led to them to ‘prove’ that opioids were not effective for chronic pain:
“The study was intended to assess long-term outcomes of opioids compared with non opioid medications for chronic pain. The patient selection, though, specifically excluded patients on long-term opioid therapy.”
Here is an analogy given in the Oxford Journal white paper to illustrate how the study design was compromised:
If I want to do a randomized control study about ice cream flavor preferences (choices being: vanilla, chocolate, or no preference), the results could be manipulated as follows based on these scenarios:
Scenario A: If a study was done that included only current ice-cream consumers, the outcome would certainly be vanilla or chocolate, because of course they have tried it and know which they like.
Scenario B: If a study was done that included all consumers of all food, then it can change the outcome. If the majority of study participants do not even eat ice-cream, than the result would certainly be ‘no preference’. If the majority do eat ice-cream it would likely be ‘chocolate’. Although this study is wider based, it still does not reflect real world findings.
Scenario C: In an even more extreme example, if this same study is conducted excluding anyone who has ever ate ice-cream at all, then the conclusion will again be ‘no preference’ and the entire study/original question becomes so ludicrous that there is no useful information to be extracted from this study and one would logically question why this type of study would even be conducted (although we know the answer to that)
Scenario C above is how the study that has been used to shift the attitudes towards the treatment of pain in our nation's medical community was designed. “One has to look deep into the study to find that they began with 9403 possible patients and excluded 3836 of them just because they had opioids in their EMR. In the JAMA article, they do not state these obvious biases and instead begin the explanation of participants stating they started with 4485 patients and excluded 224 who were opioid or benzo users.” That is the tip of the iceberg to how it is extremely misleading. The Oxford white paper goes into further detail of the studies “many flaws and biases (including the narrow focus on conditions that are historically known to respond poorly to opioid medication management of pain)”, but the study design and participant selection criteria is enough to discredit this entire body of work. Based on study design alone, regardless of what happened next, the result would be that opioids are no more effective than NSAIDs and other non-opioid alternatives.
The DEA Is Fostering a Bounty Hunter Culture in its Drug Diversion Investigators
A Good Man Speaks Truth to Power January 2019
Because I write and speak widely on public health issues and the so-called “opioid crisis”, people frequently send me references to others’ work. One of the more startling articles I’ve seen lately was published November 20, 2018 in Pharmacy Times. It is titled “Should We Believe Patients With Pain?”. The unlikely author is Commander John Burke, “a 40-year veteran of law enforcement, the past president of the National Association of Drug Diversion Investigators, and the president and cofounder of the International Health Facility Diversion Association.”
The last paragraph of Commander Burke’s article is worth repeating here.
“Let’s get back to dealing with each person claiming to be in legitimate pain and believe them until we have solid evidence that they are scamming the system. If they are, then let’s pursue them through vigorous prosecution, but let’s not punish the majority of people receiving opioids who are legitimate patients with pain.”
This seems a remarkable insight from anyone in law enforcement — especially from one who has expressed this view in both Pain News Network, and Dr Lynn Webster’s video “The Painful Truth”. Recognizing Commander Burke’s unique perspective, I followed up by phone to ask several related questions. He has granted permission to publish my paraphrases of his answers here.
“Are there any available source documents which establish widely accepted standards for what comprises “over-prescription?” as viewed by diversion investigators?” Burke’s answer was a resounding “NO”. Each State and Federal Agency that investigates doctors for potentially illegal or inappropriate opioid prescribing is pretty much making up their own standards as they go. Some make reference to the 2016 CDC Guidelines, but others do not.
- “Thousands of individual doctors have left pain management practice in recent years due to fears they may be investigated, sanctioned, and lose their licenses if they continue to treat patients with opioid pain relievers.. Are DEA and State authorities really pursuing the worst “bad actors”, or is something else going on?
Burke’s answer: “Regulatory policy varies greatly between jurisdictions. But a hidden factor may be contributing significantly to the aggressiveness of Federal investigators. Federal Agencies may grant financial bonuses to their in-house diversion investigators, based on the volume of fines collected from doctors, nurse practitioners, PAs and others whom they investigate.
"No law enforcement agency at any level should be rewarded with monetary gain and/or promotion due to their work efforts or successes. This practice has always worried me with Federal investigators and is unheard of at the local or state levels of enforcement.”
Commander Burke’s revelation hit me like a thunder-clap. It would explain many of the complaints I have heard from doctors who have been “investigated” or prosecuted. It’s a well known principle that when we subsidize a behavior, we get more of it. Financial rewards to investigators must inevitably foster a “bounty hunter” mentality in some. It seems at least plausible that such bonuses might lead DEA regulators to focus on “low hanging fruit” among doctors who may not be able to defend themselves without being ruined financially. The practice is at the very least unethical. Arguably it can be corrupting.
I also inquired concerning a third issue:
- I read complaints from doctors that they have been pursued on trumped-up grounds, coerced and denied appropriate legal defense by confiscation of their assets – which are then added to Agency funds for further actions against other doctors. Investigations are also commonly announced prominently, even before indictments are obtained – a step that seems calculated to destroy the doctor’s practice, regardless of legal outcomes. Some reports indicate that DEA or State authorities have threatened employees with prosecution if they do not confirm improper practices by the doctor. Do you believe such practices are common?”
Burke’s answer: “I hear the same reports you do – and the irony is that such tactics are unnecessary. Lacking an accepted standard for over-prescribing, the gross volume of a doctor’s prescriptions or the dose levels prescribed to their patients can be poor indicators of professional misbehavior. Investigators should instead be looking into the totality of the case, which can include patient reports of poor doctor oversight, overdose-related hospital admissions, and patterns of overdose related deaths that may be linked to a “cocktail” of illicit prescribing. Especially important can be information gleaned from confidential informants – with independent verification – prior patients, and pharmacy information.”
No formal legal prosecution should ever proceed from the testimony of only one witness — even one as well informed as Commander John Burke. But it seems to me that it is high time for the US Senate Judiciary Committee to invite the testimony of others in open public hearings, concerning the practice of possible bounty hunting among Federal investigators.
C50 Patient, Civil Rights Attorney, Maine Department of Health, and Maine Legislature Collaborative Enacted Definition of Palliative Care
One suggestion that our organization would like to make is altering the definition of “palliative care” in such a manner that it can include high-impact or intractable patients; those who are not dying this year, but our lives have been shattered and/or shortened by our diseases and for whom Quality of Life should be the focus. Many of our conditions may not SIGNIFICANTLY shorten my life, therefore I could legitimately be facing 30-40 years of severe pain with little relief; that is no way to live and therefore the concern is a rapidly increasing suicide rate.
This is a definition that one of our coalition members with a civil rights attorney and the Maine Department of Health agreed upon and legislators enacted into statues in Maine. This was in response to a 100mme restriction. This attorney had prepared a lawsuit based on the Americans with Disability Act that the Department of Health in Maine agreed was valid; litigation was never the goal, it was always patient-centered care.
A. "Palliative care" means patient-centered and family-focused medical care that optimizes quality of life by anticipating, preventing and treating suffering caused by a medical illness or a physical injury or condition that substantially affects a patient's quality of life, including, but not limited to, addressing physical, emotional, social and spiritual needs; facilitating patient autonomy and choice of care; providing access to information; discussing the patient's goals for treatment and treatment options, including, when appropriate, hospice care; and managing pain and symptoms comprehensively. Palliative care does not always include a requirement for hospice care or attention to spiritual needs. B. "Serious illness" means a medical illness or physical injury or condition that substantially affects quality of life for more than a short period of time. "Serious illness" includes, but is not limited to, Alzheimer's disease and related dementias, lung disease, cancer, heart, renal or liver failure and chronic, unremitting or intractable pain such as neuropathic pain.
Here is the link to the most recent update, including these definitions within the entire statute: https://legislature.maine.gov/statutes/22/title22sec1726.html?fbclid=IwAR0dhlwEh56VgZI9HYczdjdyYoJGpMdA9TuuJLlQrO3AsSljIZZG0RICFZc
January 23, 2019
The Board of Pharmacy has had an influx of communication concerning patients not able to get controlled substance prescriptions filled for various reasons, even when signs of forgery or fraudulence were not presented. As a result of the increased “refusals to fill,” the board is issuing the following guidance and reminders regarding the practice of pharmacy and dispensing of controlled substances:
- Pharmacists must use reasonable knowledge, skill, and professional judgment when evaluating whether to fill a prescription. Extreme caution should be used when deciding not to fill a prescription. A patient who suddenly discontinues a chronic medication may experience negative health consequences;
- Part of being a licensed healthcare professional is that you put the patient first. This means that if a pharmacist has any concern regarding a prescription, they should attempt to have a professional conversation with the practitioner to resolve those concerns and not simply refuse the prescription. Being a healthcare professional also means that you use your medication expertise during that dialogue in offering advice on potential alternatives, changes in the prescription strength, directions etc. Simply refusing to fill a prescription without trying to resolve the concern may call into question the knowledge, skill or judgment of the pharmacist and may be deemed unprofessional conduct;
- Controlled substance prescriptions are not a “bartering” mechanism. In other words, a pharmacist should not tell a patient that they have refused to fill a prescription and then explain that if they go to a pain specialist to get the same prescription then they will reconsider filling it. Again, this may call into question the knowledge, skill or judgment of the pharmacist;
- Yes, there is an opioid crisis. However, this should in no way alter our professional approach to treatment of patients in end-of-life or palliative care situations. Again, the fundamentals of using our professional judgment, skill and knowledge of treatments plays an integral role in who we are as professionals. Refusing to fill prescriptions for these patients without a solid medical reason may call into question whether the pharmacist is informed of current professional practice in the treatment of these medical cases.
- If a prescription is refused, there should be sound professional reasons for doing so. Each patient is a unique medical case and should be treated independently as such. Making blanket decisions regarding dispensing of controlled substances may call into question the motivation of the pharmacist and how they are using their knowledge, skill or judgment to best serve the public.
As a professional reminder, failing to practice pharmacy using reasonable knowledge, skill, competence, and safety for the public may result in disciplinary actions under Alaska statute and regulation. These laws are:
AS 08.80.261 DISCIPLINARY ACTIONS
(a)The board may deny a license to an applicant or, after a hearing, impose a disciplinary sanction authorized under AS 08.01.075 on a person licensed under this chapter when the board finds that the applicant or licensee, as applicable, …
(7) is incapable of engaging in the practice of pharmacy with reasonable skill, competence, and safety for the public because of
(A) professional incompetence; (B) failure to keep informed of or use current professional theories or practices; or (E) other factors determined by the board;
(14) engaged in unprofessional conduct, as defined in regulations of the board.
12 AAC 52.920 DISCIPLINARY GUIDELINES
(a) In addition to acts specified in AS 08.80 or elsewhere in this chapter, each of the following constitutes engaging in unprofessional conduct and is a basis for the imposition of disciplinary sanctions under AS 08.01.075; …
(15) failing to use reasonable knowledge, skills, or judgment in the practice of pharmacy;
(b) The board will, in its discretion, revoke a license if the licensee …
(4) intentionally or negligently engages in conduct that results in a significant risk to the health or safety of a patient or injury to a patient; (5) is professionally incompetent if the incompetence results in a significant risk of injury to a patient.
(c) The board will, in its discretion, suspend a license for up to two years followed by probation of not less than two years if the licensee ...
(2) is professionally incompetent if the incompetence results in the public health, safety, or welfare being placed at risk.
We all acknowledge that Alaska is in the midst of an opioid crisis. While there are published guidelines and literature to assist all healthcare professionals in up to date approaches and recommendations for medical treatments per diagnosis, do not confuse guidelines with law; they are not the same thing.
Pharmacists have an obligation and responsibility under Title 21 Code of Federal Regulations 1306.04(a), and a pharmacist may use professional judgment to refuse filling a prescription. However, how an individual pharmacist approaches that particular situation is unique and can be complex. The Board of Pharmacy does not recommend refusing prescriptions without first trying to resolve your concerns with the prescribing practitioner as the primary member of the healthcare team. Patients may also serve as a basic source of information to understand some aspects of their treatment; do not rule them out in your dialogue.
If in doubt, we always recommend partnering with the prescribing practitioner. We are all licensed healthcare professionals and have a duty to use our knowledge, skill, and judgment to improve patient outcomes and keep them safe.
Professionally, Richard Holt, BS Pharm, PharmD, MBA Chair, Alaska Board of Pharmacy
FDA in Brief: FDA finalizes new policy to encourage widespread innovation and development of new buprenorphine treatments for opioid use disorder
February 6, 2018
Media Inquiries Michael Felberbaum 240-402-9548
“The opioid crisis has had a tragic impact on individuals, families, and communities throughout the country. We’re in urgent need of new and better treatment options for opioid use disorder. The guidance we’re finalizing today is one of the many steps we’re taking to help advance the development of new treatments for opioid use disorder, and promote novel formulations or delivery mechanisms of existing drugs to better tailor available medicines to individuals’ needs,” said FDA Commissioner Scott Gottlieb, M.D. “Our goal is to advance the development of new and better ways of treating opioid use disorder to help more Americans access successful treatments. Unfortunately, far too few people who are addicted to opioids are offered an adequate chance for treatment that uses medications. In part, this is because private insurance coverage for treatment with medications is often inadequate. Even among those who can access some sort of treatment, it’s often prohibitively difficult to access FDA-approved addiction medications. While states are adopting better coverage owing to new legislation and resources, among public insurance plans there are still a number of states that are not covering all three FDA-approved addiction medications. To support more widespread adoption of medication-assisted treatment, the FDA will also continue to take steps to address the unfortunate stigma that’s sometimes associated with use of these products. It’s part of the FDA’s public health mandate to promote appropriate use of therapies.
Misunderstanding around these products, even among some in the medical and addiction fields, enables stigma to attach to their use. These views can serve to keep patients who are seeking treatment from reaching their goal. That stigma reflects a perspective some have that a patient is still suffering from addiction even when they’re in full recovery, just because they require medication to treat their illness. This owes to a key misunderstanding of the difference between a physical dependence and an addiction. Because of the biology of the human body, everyone who uses a meaningful dose of opioids for a modest length of time develops a physical dependence. This means that there are withdrawal symptoms after the use stops.
A physical dependence to an opioid drug is very different than being addicted to such a medication. Addiction requires the continued use of opioids despite harmful consequences on someone’s life. Addiction involves a psychological preoccupation to obtain and use opioids above and beyond a physical dependence.
But someone who is physically dependent on opioids as a result of the treatment of pain but who is not craving the drugs is not addicted.
The same principle applies to replacement therapy used to treat opioid addiction. Someone who requires long-term treatment for opioid addiction with medications, including those that are partial or complete opioid agonists and can create a physical dependence, isn’t addicted to those medications. With the right treatments coupled to psychosocial support, recovery from opioid addiction is possible. The FDA remains committed to using all of our tools and authorities to help those currently addicted to opioids, while taking steps to prevent new cases of addiction.”
Above is the full statement, find full statement with options for study requests: https://www.fda.gov/NewsEvents/Newsroom/FDAInBrief/ucm630847.htm
Maryland’s co-prescribing new laws/ amendments regarding benzos and opioids
Chapter 215 AN ACT concerning Health Care Providers – Opioid and Benzodiazepine Prescriptions – Discussion of Information Benefits and Risks
FOR the purpose of requiring that certain patients be advised of the benefits and risks associated with the prescription of certain opioids, and benzodiazepines under certain circumstances, providing that a violation of this Act is grounds for disciplinary action by a certain health occupations board; and generally relating to advice regarding benefits and risks associated with opioids and benzodiazepines that are controlled dangerous substances.
Section 1–223 Article – Health Occupations Section 4–315(a)(35), 8–316(a)(36), 14–404(a)(43), and 16–311(a)(8) SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND, That the Laws of Maryland read as follows: Article – Health Occupations (a) In this section, “controlled dangerous substance” has the meaning stated in § 5–101 of the Criminal Law Article.
Ch. 215 2018 LAWS OF MARYLAND (B) On treatment for pain, a health care provider, based on the clinical judgment of the health care provider, shall prescribe: (1) The lowest effective dose of an opioid; and (2)A quantity that is no greater than the quantity needed for the expected duration of pain severe enough to require an opioid that is a controlled dangerous substance unless the opioid is prescribed to treat: (a.) A substance–related disorder; (b.) Pain associated with a cancer diagnosis; (c.) Pain experienced while the patient is receiving end–of–life, hospice, or palliative care services; or (d.) Chronic pain
(C.) The dosage, quantity, and duration of an opioid prescribed under [subsection (b)] of this [section] shall be based on an evidence–based clinical guideline for prescribing controlled dangerous substances that is appropriate for: (1.) The health care service delivery setting for the patient; (2.) The type of health care services required by the patient; (3.) and The age and health status of the patient.
(D) (1) WHEN A PATIENT IS PRESCRIBED AN OPIOID UNDER SUBSECTION (B) OF THIS SECTION, THE PATIENT SHALL BE ADVISED OF THE BENEFITS AND RISKS ASSOCIATED WITH THE OPIOID.
(2) WHEN A PATIENT IS CO–PRESCRIBED A BENZODIAZEPINE WITH AN OPIOID THAT IS PRESCRIBED UNDER SUBSECTION (B) OF THIS SECTION, THE PATIENT SHALL BE ADVISED OF THE BENEFITS AND RISKS ASSOCIATED WITH THE BENZODIAZEPINE AND THE CO–PRESCRIPTION OF THE BENZODIAZEPINE. (E) A violation of [subsection (b) OR (D) of] this section is grounds for disciplinary action by the health occupations board that regulates the health care provider who commits the violation.
4-315 (a) Subject to the hearing provisions of § 4–318 of this subtitle, the Board may deny a general license to practice dentistry, a limited license to practice dentistry, or a teacher’s license to practice dentistry to any applicant, reprimand any licensed dentist, place any licensed dentist on probation, or suspend or revoke the license of any licensed dentist, if the applicant or licensee: (35) Fails to comply with § 1–223 of this article.
8–316. (a) Subject to the hearing provisions of § 8–317 of this subtitle, the Board may deny a license or grant a license, including a license subject to a reprimand, probation, or suspension, to any applicant, reprimand any licensee, place any licensee on probation, or suspend or revoke the license of a licensee if the applicant or licensee: (36) Fails to comply with § 1–223 of this article.
14–404. (a) Subject to the hearing provisions of § 14–405 of this subtitle, a disciplinary panel, on the affirmative vote of a majority of the quorum of the disciplinary panel, may reprimand any licensee, place any licensee on probation, or suspend or revoke a license if the licensee: (43) Fails to comply with § 1–223 of this article.
16–311. (a) Subject to the hearing provisions of § 16–313 of this subtitle, the Board, on the affirmative vote of a majority of its members then serving, may deny a license or a limited license to any applicant, reprimand any licensee or holder of a limited license, impose an administrative monetary penalty not exceeding $50,000 on any licensee or holder of a limited license, place any licensee or holder of a limited license on probation, or suspend or revoke a license or a limited license if the applicant, licensee, or holder:
(8) Prescribes or distributes a controlled dangerous substance to any other person in violation of the law, including in violation of § 1–223 of this article;
SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall take effect October 1, 2018.
Approved by the Governor, April 24, 2018.
2023.06.04 12:13 Thick_Mick_Chick M.O.N.S.T.E.R Nursery
Let me be the first to welcome you to the MotheOffspring, Nurturing/Support, Teaching/Education Resource Network, or? M.O.N.S.T.E.R. Nursery. My name is Sassy, short for Sasquatch. Yes, THAT sasquatch. Are there other kinds?! I'm a HCC (Healthcare Cryptid) here at the nursery. I also teach humans the survival basics of coming across a baby monster in the woods.
Anyhoo, you're probably wondering why Sasquatch are utilized as Labor and Delivery nurses. It's simple, really. We're natural born mothers. You see, we just love babies! We always have! All of that nonsense about whooping, tree knocking and vocalizations that we do in the woods when you guys are camping? Don't get scared! That's just us shouting out to our boys letting them know we have humans in the woods! Humans could possibly have a BABY with them. Now, I don't like to judge based on looks, but those bald human babies are so ugly? They're cute! Poor little things look like they have mange, though. Who would think a bald puppy is cute? Ew.
I digress. So, when it came to the M.O.N.S.T.E.R. Nursery? We were the natural choice. Even though I happen to be female? History tells us that male nursery nurses happen to have the best bonding with our little devils. Well, little devils and whoever else was born that day. Just look at Chewy over there bonding with that litter of werewolf pups born on the last full moon. He's so maternal? He's practically a breast.
Now, all babies are not created equal. Have you ever wondered which monster's baby is the loudest? I can promise you that you'd rather listen to that werewolf pup litter any day over being 5 minutes late with Baby Siren Head's bottle. I had a headache for a week. When Vlad and Countess Bathory had their little undead bundle of joy last month? You'd be surprised how quick a Bigfoot can prick and milk their finger to get a fresh bottle of nutritious blood for that adorable, pale little parasite. He definitely had a healthy appetite, especially if you were B positive. Vlad and Countess Bathory couldn't have been happier. Patient satisfaction has always been a priority for HCCs (Healthcare Cryptid) since day one! We've never gotten below a 5 on the Jack Link's scale of 0 - 5 jerkies. We are collectively very proud of this fact! It's such an accomplishment for Bigfoot and all of Sasquatch kind.
Okay, I could understand why you think we're a little full of ourselves. I, mean, when Sasquatch are the chosen ones to be the top requested HCC? It's a far fall to the 2nd position. Look, we can't all be God's Chosen Ones. Yes, he exists. Yes, he created us. You're getting distracted, again. We aren't all going to argue semantics on what is Creationism and what is Darwinism and all of that. I'm too busy trying to teach incompetent, um cough cough, INTERESTED humans how to provide the most basic care for any creature's neonates (medical term for newborn) that they might stumble across while enjoying hiking, camping, fishing, etc. The priority? The newborn. Additional concerns?
1) MotheFather finding humans around newborn and attacking them.
2) Humans treating the scenario like an episode of "Jack Ass" and thinking it's a good idea to "mess with" the newborn and? Again? Mom/Dad attacks them.
3) Basically? A human breathing will set Mom/Dad off. Most creatures just don't want humans around. They can't be trusted. Sorry, Guys. It's been that way every since you refused to credit Chewy in the '67 Patterson–Gimlin film.
So? Your first reaction, if you see a baby creature? Look for it's parents. If you see them? Run. Run fast. Like, put Forrest Gump to shame kinda runnin'. Those parents don't want you there for any reason at all. Pick 'em up and put 'em down the whole way back down the trail.
If you don't see the parents? Proceed slowly and with caution. Now, don't let everything I've said scare you into not helping a baby monster. They're babies, after all. Please, check on them. Just be aware of your surroundings so as not to frighten the wood creatures which will, in turn, attack you. Then? It's just a bad day for everyone involved.
So? Depending on the woodland creature? You'll want to know what action you need to take to help the baby and? Hopefully? Survive assisting. The first thing you'll want to do is call out/whistle, whatever you have to do to try to get someone's attention. Look around and listen. What do you see and hear? If it's nothing? Again, proceed with caution. If you hear howling, growling, tree knocking, whooping, any of these things? Leave, either their parents are still around or we're there and will then takeover. I know. It's confusing to try to tell when we're tree knocking hoping you have a baby with you or if we know there's a baby around and we don't want you around the baby. Really, if at all possible, just don't mess with the babies if you don't have to. With that having been said? Let's proceed!
As you cautiously approach? Keep making noise letting everyone know you're there. We don't want to scare the life, or afterlife, out of these little ones. They're at their most vulnerable right now. Let's use Chewy's patients today as an example. You traipse along and stumble over a werewolf den. Well, that's not something you see every day. You hear soft whimpering. About 4 or 5 little werewolf pup heads pop up out of the den. How's everyone looking? Is anyone hurt? No? Then check your supplies. It just so happens you were successful fishing earlier. Werewolf pups love fish almost as much as moonbathing and cutting their baby teeth on a human femur. They'll be thankful, the Alpha male and female will be thankful and you'll really be thankful. You get to walk away, karma and limbs intact.
Next? It would be highly likely that you'd come across a wendigo, skinwalker, rake slenderman, etc. besides just a litter of werewolf pups. Try to prepare yourself as much as possible for these encounters. The better prepared? The better off everyone will be. The best part? These creatures won't want your everlasting soul in infancy. Those challenges don't present until adolescence. So? Enjoy the respite for the moment. Now? No matter what the situation? You'll always want to approach with caution and announce your arrival. It's saved not only many a human? It's saved a lot of cryptids as well. Try to have some sort of food item on you that's rather filling. You'd prefer that over them making YOU the food item.
So, as we proceed down the trail, there's a cabin to the left and it's the last house but do not enter, please. The last good hearted Samaritan did and, well, let's just say he had a run in with a girl locked in the cellar who wasn't quite herself. That's probably about the most PC way of explaining demonic possession. Anyhoo, there was bad press for a year and visitors to the park fell off, it just was a big mess. They ended up doing some kind of cybernetic enhancement and now the good Samaritan has a chainsaw for an arm. He's done a great job keeping them all in line. Overall? That was one we got right.
Since I brought up Vlad and the Countess Bathory's bouncing little bundle of bloodsucker? It's important to know that if you are in your domicile, and R.V.'s count, vampires cannot enter without an invitation from you. So, if you are camping in your R.V. and someone comes knocking late at night? Don't answer. If they aren't a vampire? They can come back the next day. If they don't come back? You definitely made the right decision. Now, the problem is? If you encounter a vampire in the wild. Hopefully? They've already set their sights on whoever they picked that night to be their victim. If not? A dropper of Holy Water as perfume on either side of your neck is a nice deterrent. Again, if the little count is there by himself? He's clearly gotten away from the castle. He needs returned immediately. Go to the nearest tree that displays a "break in case of emergency" box. Break the glass, take the bag of beef jerky out, shake it. Every Sasquatch in a 5 mile radius will come running to you. Point the baby vampire out and we'll be glad to take it from there.
Something I should bring up to our do-gooders ready to risk it all: if you can't swim? Don't try to help aquatic creatures. It won't end well. It never does. Little fry just aren't acclimated to landlubbers. Merpups are tough for even us to handle. They get scared, you can't swim, bad things happen. So? If you're determined to help any baby monster no matter where they reside? Take swimming lessons. You'll thank me. Trust me on this.
Don't let the fae trip you up, either. They're mischievous. They'll also try to sneak a changeling in on you if you do bring your human babies to the forest. If you respect walking around fairy rings and respect mother nature? The fae shouldn't be an issue. If you don't? Well, you were warned.
So, what have we not covered? Flying creatures. Yes, they present a challenge even we Sasquatch find difficult. It's hard to assess the needs of a baby that's wrapped in the arms of a mother flying 75 feet above your head. Even though the task is daunting? It's a challenge we'll definitely take on. We just watch and wait for Mom to go on the hunt and we take a peak at that tiny little velociraptor in that nest, with it's mouth hanging wide open, just awaiting a morsel. Now, the Mothman's baby was an experience. Cocoons are just something you have to see for yourself, especially when they're 6 feet tall. It's truly fascinating!
I think that covers everything for today's lesson. Bear in mind, we're beginning the summer season here in the U.S. Encounters are going to increase between cryptids and humans so be aware and care when it comes to our babies. We're aware and care when it comes to yours. Stay safe and Sasquatch on!
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2023.06.04 12:12 Thick_Mick_Chick Windows to the Soul: Allie's Assimilation
Note: This is part 2 to Shiloh's Final Battle
Gomez and Tish pulled into their driveway and heard barking. They'd gotten a German Shepherd pup when Guillermo Del Toro's "The Strain" was on T.V. As a joke, but also because they loved the character? They named him Thomas Eichhorst after the Nazi vampire who was one of Guillermo Del Toro's most powerful villains ever created. No one put much thought into the name choice considering they loved all things horror. "What the hell has Eichhorst going off? He knows it's us!" Gomez couldn't understand why he'd bark at the 2 people he NEVER barks at. "I can honestly say I'm not even surprised after this day." Tish exhaled and proceeded to get out of the car. Eichhorst continued the call of his people. "IKE! EICHHORST! KNOCK IT THE HELL OFF!" Gomez yelled so Eichhorst could hear because he was behind the chain link fence in the backyard. He acted like he didn't hear a word. As they got closer to the house? They noticed Eichhorst was not barking at them. He was barking at the woods BEHIND them. "He sees something we don't." Tish matter-of-factly stated. She & Gomez simultaneously turned to look into the woods. Nothing. No noise. Nothing was there. Eichhorst stopped barking as soon as they turned towards the woods. Everything stopped. "What the hell is going on, Cara Mia?" Gomez was starting to experience what Tish had all day long. "I don't know, Mon Cher. I just know I don't like it." Tish continued glancing into the trees. "Probably time to sit back and relax. You've had a bad day that ended a rough week. It's time to just chill." As if knowing what Gomez had just said? His city issued phone started ringing. "NO. ABSOLUTELY not! I'm off tonight! What is so critical that Gomer & Goober can't handle it?" Gomez could feel his blood pressure start to rise. "Find out what it is 1st, Craig, before you go into a meltdown." Tish always called him Craig when she was irritated. "Hello?!" Gomez did a poor job hiding his inconvenience. "Man, it's Ol Shiloh! You gotta get over here, Gomez. It's bad! It's so bad!" Bubba was inconsolable. He was on the verge of tears. "Whoa, slow down, Bubba. What happened?" Gomez tried bringing levity. "We came by to check on him when we were on patrol. He was in the doorway, he was..." Bubba finally started crying. He hated it. The last thing he wanted to do was cry in front of his co-workers. He just simply could not process what the hell they'd rolled up on. "Wait? Ol Shiloh is hurt?" Gomez was trying to process what Bubba was saying. Tish's brow furrowed. She didn't like what she was hearing. "I mean, if you consider hurt dead with his fuckin' throat ripped out to his spinal cord? Then? Yeah, he's hurt." Bubba's anger at his own insecurities was boiling over onto Gomez. "Look, Bubba. Clearly you guys have been going through something over there. I'm headed that way. For future reference? Don't take your shit out on me. I didn't do anything to you." Gomez scolded. "Sorry, Gomez. It's just so..." and Bubba broke down further. Gomez hopped back into the car. "What's going on? Who was that? Don? Bubba?" Tish was concerned. "Hop in the passenger's side if you want to find out. I have to go." Gomez started the engine. Tish walked around and got in.
They pulled into Shiloh's driveway behind the Eerie, Indiana patrol car. Bubba came running out to greet them. "Don is in there with him. The paramedics just got here a few minutes ago." Bubba proceeded to catch Gomez up. He and Tish had been so busy looking at Bubba and the patrol car they didn't notice the bus parked to the side of the house ready to pick up Ol Shiloh.
Tish & Gomez entered the threshold where Ol Shiloh laid on his back, staring at the ceiling. His throat. Jesus, his throat. It was gone. They both were rocking back on their heels.
"We thought it was a big cat attack. It's not. Those bite marks on his throat? That's human not feline." Kennedy was an intelligent little bastard. Arrogant, condescending and holier-than-thou, but very intelligent. Not only would he inform all of the insubordinates around him about everything they didn't know? He'd do it with one hell of a cocky attitude. Ah, Kennedy, and his unsolicited lessons. Time to sit up and listen in class. ..
"When he opened the door? We thought it was an animal attack. Instead? He must've been attacked by humans. The bite marks definitely indicate human but the vicious nature of how deep the wounds went indicate something much more powerful. This was to his spinal cord." Kennedy didn't look like he knew-it-all. He looked perplexed.
"But how could a human bite that deep?" Gomez asked.
"I don't know. I honestly don't know." Kennedy was lost for the 1st time since becoming a paramedic 7 years ago. He'd never seen trauma of this caliber. He hadn't even seen this level of brutality and he'd rolled up on gang fights.
Don and Bubba were both on the front porch, looking in, mouths agape. Gomer & Goober indeed.
Kennedy loaded up Ol Shiloh's body with the assistance of a new EMT that Gomez was fairly certain Kennedy was banging. I mean, he was a total Chad so why wouldn't he?
Don put the camera away in the trunk of the patrol car. At least he had the presence of mind to get the pictures taken before emergency services hit the scene. This was going to rock Eerie, Indiana's foundation. Murder hadn't happened here in anyone's lifetime so this was a "big city" problem they weren't use to dealing with. Nosey people, scared kids, idiot media, this was not what Eerie needed right now. It certainly wasn't what he needed. He had enough of Allie putting out for anyone that would buy her a 6 pack or some cigarettes. Had he known he could've gotten off so cheaply? He sure as hell wouldn't have married her. Unfortunately, for his dumb ass? He actually fell in love with her. Why? He didn't know. Self esteem was never his strong suit. So? After dating 6 months, her only cheating 3 times, then getting pregnant with his baby? He made the perilous decision to try to make an honest woman out of her. Don sincerely doubted if Allie had ever been honest about anything in her life. Coincidentally? When they came back from their Honeymoon 2 weeks later? She'd miscarried. Well, she claimed she miscarried. Don never saw a pregnancy test nor would he have been 💯% sure the baby was his. He would've actually suspected the baby was not. Looking at all of it now, how did he not see it sooner?
"Get to those pics, ASAP Rocky, Don!" Gomez instructed. "Please, don't be an embarrassing Gen Xer who thinks he's so cool and up to date on all of the current lingo. They laugh at us only a little less than Boomers." Tish was still trying to get a handle on all of this and his Goofy antics weren't really in need right now.
The woods to the side of Ol Shiloh's place was the same as the woods to the back of Gomez & Tish's driveway. Eichhorst couldn't understand why his humans didn't acknowledge his bark. He never barked. He especially never barked at his humans. Why did they think he had? Didn't they see the kids in the woods? The little boy? The little girl? How could they not? As far away as the kids were? They smelled funny. He didn't understand. It was the same smell in the air that he sensed right before thunderstorms began and he hid under Gomez and Tish's bed. Humans don't smell like that. It's impossible to explain ozone to a German Shepherd.
The children watched as Ol Shiloh was loaded onto the ambulance and taken away. The couple were getting into their car and the deputies were already headed down the driveway.
"It has began." The dark-haired pale little girl spoke. "Indeed. It has. Let's see what Venerate has in store for the humans now." The boy replied and they headed towards town.
Eerie, Indiana was like any other Midwest, small town. You had your good ol boys & jerks. You had freaks and geeks. You had Bible thumpers and always humpers. Allie Hoff was the "always humpers" category. No one nor nothing could change that. The girl went through life bartering sex and blow jobs for anything she needed. It was a pitiful existence and she knew it. Unfortunately? She never learned and didn't know another way. With Eerie being so small? She was limited to the same "favor givers" over and over, again. Never any new blood. Never any fresh meat. It really stifled what few prospects she had. She looked up from where she was slumped over the bar, in her barstool, nursing a bottle of beer. She happened to look up to the front door. Who was that? She'd never seen him in here before. He was about 6'3" with dark wavy hair and ocean blue eyes. His skin was sun kissed and the muscles showcased the entire package. Wait. WTF? This dude doesn't belong here. Who the hell is he?
He appeared to glide and almost float towards her. He gestured to the empty bar stool next to her. "Is this seat taken?" He smiled with almost glowing white teeth. She locked up. Wait? He wants to sit next to me?
She just shook her head no because she was too shocked to speak. "Hi, I'm Vinny." He extended his hand and his gleaming smile never faltered. "Allie." She finally squeaked out. Guys like this didn't talk to girls like her. "Nice to meet you, Allie." Vinny swung around and attempted to get the bartender's attention. "I'll have a Jack & Coke. For the lady?" Vinny slyly smiled at Allie and she was entranced. "Same" was all Allie could say. He paid for their drinks and handed Allie hers. "I've never seen you before." Allie just finally came out with it. "No, I'm new to the area. You wouldn't have seen me around here." Vinny replied. "Oh? New from where?" Allie was trying to proceed with caution. She did not want to miss out on the opportunity that was this gorgeous specimen of a man. "You've never heard of it, trust me. No one ever has." Vinny still held his smile. "I'd still like to know." Allie returned a smile that was nowhere near as beautiful as Vinny's. "Maybe when we get to know each other better." Vinny conceded. "Oh? So we're going to be getting to know each other better, are we?" Allie coyly pressed. "If I have any say in it? Most definitely." Vinny winked. Damn. That boy was so fine she'd drink his bathwater if he peed in it. He was the perfect vision of the perfect man. It was as if he were tailor made just for Allie. How, though? How could she actually meet her real life Manic Pixie Dream boy? The one she'd dreamed about when she was a little girl. The one who laughed at everything she said. Listened attentively. The one who only had eyes for her no matter how many "rich bitch" girls were around. She'd treat him like a postage stamp. She'd lick every square inch of him and go back for 2nds on the important parts. "Allie, you strike me as a very straightforward girl." Vinny snapped her out of her daze. "I am. No bullshit." Allie replied. "Then? Allow me to be straightforward by telling you that I want to fuck you senseless." Vinny casually stated as if someone asked him for the time. "Well, that is certainly straightforward." Allie was stunned. She wasn't so stunned that she'd let an opportunity like this pass her by. She'd made up her mind that was going to happen as soon as she saw him. "And your answer?" Vinny inquired. "Anywhere. Any place. Any time Any day." Allie assured. With that? They stood from their barstools and headed outside. He even smelled good but not a typical smell. It was like the air at the beginning of a thunderstorm. He smelled like ozone. Ozone??? Was that even possible?
Gomez and Tish got home and plopped on the couch. Eichhorst came through the doggy door and trotted straight to Tish. "I've got leftovers, Piggy. Give me a sec." Tish opened her container from the restaurant. Eichhorst sat patiently waiting for his command.
"What a fuckin' day." Gomez exhaled exhaustedly. "Yeah. It has been. Poor Ol Shiloh. This is just too much." Tish's head continued to try to find rationality where there was one. "I'm getting in the shower and going to bed. You need anything?" Gomez slowly rose up from the couch, joints popping like a glow stick. "No. I'm probably gonna watch a movie and go to bed after." Tish answered. "Horror?" Gomez queried. "What else?" Tish smiled albeit a tired one. Eichhorst jumped up next to her on the couch and laid on her like a lap dog.
Vinny was walking Allie into their local little flop hotel room. It wasn't like she wasn't familiar with the place. The staff referred to her as "Frequent flier". She didn't particularly like the insensitive moniker but couldn't deny its accuracy, either. He closed the door behind them in one failed swoop. This was a practiced talent she noticed. Didn't matter. He was hers tonight.
"Make yourself comfortable." Vinny gestured to the only bed in the room. Allie took a seat. She looked up at him and noticed the ozone smell becoming stronger. Weird. He smelled good but she had never known someone to smell like a thunderstorm.
"I'm going to step into the bathroom for just a minute. I'll be right out." Vinny stepped into their adjacent bathroom. She heard loud music and laughter from somewhere down the hall but couldn't quite place where. It was for the best. Allie had always been, well, vocal. Normally? If a guy is hitting it right? She hit the vocal range of 2 stray cats screwing. She couldn't help it. She was like this every since puberty. It was all the girl thought about. She figured she was probably a nympho although she was never officially diagnosed. She couldn't hear what he was doing. It didn't matter. It wasn't going to affect her and what she was doing. She walked to the curtains and made sure they were completely closed. Although they were, why did she feel like she was being watched? She stripped down with the efficiency of a HazMat worker decontaminating. She heard the bathroom door opening. She kept her back turned so she could make the surprise last as long as possible. Was this the night? The night she could finally reach sexual satisfaction? Was this the dick that was going to change her life? There was a soft green glow coming from the bathroom. Must be a nightlight? She hadn't noticed before. Was it getting brighter? It looked like it was coming towards her. Was it Vinny? Maybe he's videoing me? Not like I'd care, but he could have asked. "Are you recording me?" She asked as she continued to look towards the window. His breathing was different. It seemed labored and, well, wet. It didn't sound like he did earlier, that was for sure. "You okay?" Allie asked. His breathing was raspier, louder, wetter. She decided to bail on her romantic idea of not turning around before he reached her. She turned around and her playful nature and smile fell away immediately.
Her brain couldn't process what her eyes were seeing. It couldn't be real. God knows along with banging any guy she could get her hands on, she used to hit hard drugs back in the day. This had to be a flashback. It had to be a "Fear and Loathing in Las Vegas" scenario. This? This "Mars Attacks!" bullshit right here? This is not reality.
It's bulbous head was transparent. It looked like a barrel eye fish that she saw on a nature show she used to blaze and chill to. That also explained the soft green glow. It sounded like and looked aquatic. That's where the wet sounds were coming from. It kept advancing. It had a white upper torso with arms and webbed fingers on each hand. What sent her over the edge? From the waist down? It was a human male. All the important parts and in working condition. How? She had no idea. But? When she meant working condition? It was working it's way right towards her. Wait, this thing is going to still have sex with me?! No. Absolutely not. "No. Stop." Allie feebly tried to resist. It did no good. Allie didn't know she was the reason he was even here. This was the whole gameplan all along. It was never a casual hook up.
Venerate had studied numerous different civilizations but Terrestrials always fascinated him. They were so primitive but also entertaining. The Alliance had tried many different hybrid trials between themselves and Terrestrials. They never made it out of infancy. There was a weakness that need strengthened in their own DNA to combine with humans. They worked on it until their resolution was Venerate himself. He has the best of what their kind has to offer with the malleable adaptivity to change himself into anything he needs to to be able to convince Terrestrials to trust him. It worked. Ol Shiloh thought Venerate was his deceased wife. Allie thought he was her dream man. He needs a human to impregnate. Beggars can't be choosers. It worked out perfectly. Allie took one look at his bulbous transparent head, his lower nontransparent stiff head and proceeded to pass out on the bed. It didn't matter. Venerate didn't need her awake to begin their hybrid breeding program. And? Begin the program he did. Everything was coming to fruition via the Alliance's vision. All of their hard work finally got them here. The pale, dark-haired children stood outside the hotel room window, peaking through the crack in the curtain. They were able to relay the mission a success with Venerate making first, second and third contact. Once the younglings come forth? The Alliance can begin occupation and what a glorious day that will truly be! Everything was going so perfectly. This just had to be fool proof. They walked off into the night, smiling so much those obsidian eyes even looked less demonic. This was the beginning of prosperity. This was the beginning of the end of humanity.
The Windows to the Soul: Allie's Assimilation
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2023.06.04 12:05 maraaa7 I really want my grandma to die
(You’re welcome to give advice) So my grandma (mother’s side) is 70 yrs old and she’s had arthritis that progressed into some other type of disease, and since her bones are so fragile she had already broken one of her hip bones and had it replaced which cost a fortune. Later she broke another bone in her leg and for the past 6 months she’s been in bed like a damn vegetable. My mom has to care for her, she goes to her house 2 times a day to change her diaper and honestly it’s just awful.
My grandma has become unbearable and it seems like she doesn’t want to do absolutely anything to get hersel out of bed and at least be able to stand/sit on her own. Because of her behavior my mom’s constantly super nervous and easily irritated, which affects our relationship.
Overall this situation made our lives harder because now we can’t even leave the city to go somewhere like a vacation which my mom really wants. She can’t even get a job because there’s no jobs available with the exact schedule my mom has. I suggested sending grandma to a nursing home and of course my mom snapped at me, somewhat understandable + we don’t have proper nursing homes in our country where the staff will actually care for her.
There’s no progress whatsoever, she is in the same state as she was in 6 months ago and it’s truly unbearable. I really started to dislike my grandma and honestly, I want her to die. That would be way less problematic that trying to keep alive a fucking vegetable that whines all day about how useless she is and ruins my mom’s health and nerves.
Every time I see angel numbers I make a wish for grandma to recover, but deep down I think that I want her to die because realistically, I don’t think there will be any progress at all and her dying would be for the best. Sometimes I even think about praying to God for her to die and end all of ours suffering including her, since for the past 6 months our prayers of healing her do not seem to be answered.
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2023.06.04 12:04 idunnosorrylol i’m think i’m miserable
extremely new to reddit. sorry. just really need a place to talk. this will probably be long.
10 years ago i lost my dad to stomach cancer. they found it very late so he died very quickly after being diagnosed. he chose hospice so i was there every part of the way to watch him die. i was 13 and it really messed me up. i still have unresolved trauma from it.
since then, i have suffered from very persistent and extreme depression and anxiety, and some ptsd. it obviously impacted my formative teenage years intensely negatively. i struggled with serious suicidal thoughts all through high school. since graduating in 2017, it slowly got less severe, but depending on life events could easily come back full force.
for the better part of this past decade i attempted to receive help through therapy, psychiatry, and many, many prescription medications. i have throughly exhausted these tools that i was lucky enough to receive thanks to my caring mother. however, it was never enough. i do not feel that with this help there was ever any noteworthy improvement. i have not been to therapy for over a year and i have not taken any medication for two. i do not intend to seek further help in either form.
the reason i have come here to talk now though is not because of any of this. about two months ago now, my mother died of cancer too. it wasn’t like my father’s. it was a much more torturous and cruel experience for my family and i in how slow and debilitating it was. she was first diagnosed with liposarcoma a few years ago. it’s a very rare form of cancer in which there is very little to do in way of treatment. she underwent a successful surgery to remove a huge tumor. the nurses and doctor admitted it was a miracle she survived. she was cancer free for a couple years, but another tumor formed. she needed surgery again, but she suffered a lot more from the ordeal this time. they removed a kidney and some muscle. she was much weaker afterwards. but still she fought to be healthier, so it wouldn’t come back. less than a year later, it came back anyway. too big a tumor for surgery in her current physical state. she was forced to choose between chemotherapy to attempt to shrink the tumor, or live like normal as long as she could until it killed her. she chose to take a chance with chemo. it ruined her. she couldn’t complete the full treatment plan. it wasn’t even working in the first place. she couldn’t undergo surgery. all that was left was for her to die. and just like my father i watched her rot. i watched as her body and mind failed her. an impossibly cruel fate for someone so beautiful and kind and loving. she deserved a much better life than what she got. and that is putting it egregiously lightly.
because of my mental state i made my mother suffer through my youth. i’m the youngest of four children so she already worried about me the most. i amplified her anxiety tenfold. at times i was cruel to her due to my struggles with anger management. i am not satisfied with my relationship with my mother. i always wanted to be much, much better for her. but the reality is that i’m not. i tried to step up past my limits for her during her final months, but i’m kidding myself if i thought even for a moment it could make up for the years of pain and disrespect i inflicted upon her. i always have and always will hate myself for it.
i was not ready to lose my mother, and i mean that in multiple ways. due to my extensive depression i spent almost all my days up until maybe 2021 doing absolutely nothing but finding distractions from reality. my life was consumed by pastimes like video games and anime. because of this, i have few life skills. my mother had immeasurable knowledge and talent. yet i never took the time to learn anything from her. i relied on her for much, much more than i ever realized. i moved out almost a year ago to rent a place with a couple of my very good friends. i work a minimum wage job because i dropped out of community college after 2 years. i can barely take care of myself. i make only enough money for rent and utilities. i can’t afford food. thus far my mom was helping me pay for extra things and if i’m lucky my roommates will buy me food but now that she’s dead i’m totally on my own with supporting myself and it’s just starting to hit me when i paid my credit card bill and have next to nothing left.
i have a very wonderful boyfriend. we’ve been dating for 2 years. he is genuinely perfect and has changed my life. up to this point we have shared the kind of love you think is fake or only exists in books and movies. i thought i would be able to survive my mother’s passing with his support. for a time i did. we are long distance but he came to visit right after she died. he stayed with me for more than a month and even though my loss was painful i still thought things would be okay because i want to share a future with him. however, since he left and since i’ve returned to work, i have felt my mental state rapidly decline. it is to the point i fear i’m straining our relationship. he is desperately trying to help, but his words don’t seem to comfort me anymore.
i cry every night now. even on nights where i’m too hopeless or numb to cry, i cry in my dreams. i have never, ever been at this low a point in my life. not even losing my father left me like this. my friends have all been laughably removed from my suffering. my two roommates who i considered my closest friends are so far removed from this that neither of them even spared a typical “sorry for your loss” when she died. it disgusts me. everyone in my friend group either has never lost a loved one, or has such a terrible relationship with their parent(s) that they couldn’t even imagine what it feels like to love a parent, let alone lose one. which means the lack of empathy is utterly horrendous and intolerable. even sympathy can be too much to ask from these people on this topic.
all of that is to say i am isolated in my own purgatory. i feel nothing anymore but anger and disgust. hobbies and pastimes i used to enjoy that would have helped me in the past mean nothing to me anymore. my suffering is amplified by the fact that i have been mildly lashing out at my boyfriend, the one person in my life right now who has been actively listening to me and caring for me through the entire unfiltered experience of watching my mother die. i reward his patience and positivity with contempt or blatant disregard in favor of misery. at times i am angry with him simply because i see him as an obstacle preventing me from killing myself. because if he wasn’t in my life, i 100% would be dead right now. and every day that i survive amplifies my desire for suicide just a bit more. i don’t know how long this will go on. it’s starting to affect my memory, because i feel like i can’t even remember the things about my boyfriend that make me happy. when i try to remember anything specific about us i can’t focus on it. nothing is there. i can’t remove myself from this numbness and it infuriates me. i don’t want to self sabotage this relationship but i’m afraid i can’t stop it from happening.
i guess a tldr would be hey i have watched both of my parents die from cancer and it has given me insurmountable trauma, i truly lack emotion now but i struggle with killing myself cuz there is a small sense of self that still worries about my godsend boyfriend. i just don’t know what i want from life anymore
submitted by idunnosorrylol
to depressed [link] [comments]
2023.06.04 11:04 TheGoobTM I don’t know where to post but I need to say this…
So my job is working with kids and one was sent to the hospital, he’s physically alright. So one of us gets assigned to come here for 12 hour shifts, it’s also and hour and a half drive and we get paid for that too…
Anyways he somehow sneakily tied the earlier staffs hands to the bed so now we have to sit in the hall…
I’m sitting hear and right behind me I hear a nurse talking to someone I’m not eavesdropping but I hear bits, “she wasn’t on chemo anymore… came in yesterday at 4:45… was going to be moved to hospice…” I’m not thinking anything of it just wasting time on my phone. Awhile later two male nurses are behind me, I hear giggling, I hear a lot of noise like plastic. Then I hear “you get the toe” followed by a really really long zipper noise. “I don’t think it’ll be too heavy”
I see them come buy and put a gown and sheets in the hazard bin…
Few minutes later they come back with one of those morgue tables…
I tried to look away… I know she was bagged, but I just don’t deal with death well. I stay out of funerals. I am just sitting here I dunno, heart pacing though… 3-4 more hours…
Edit: I just want to add, because after posting I felt it came off cold, I feel for the families loss, and I feel for her, there was no one here with her when she went. I should t be uncomfortable about it but it does.
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to TrueOffMyChest [link] [comments]
2023.06.04 10:25 sadbabylynn Advice on how to approach doctors
Hi all I am new to the sub and have a burning question regarding how honest I should be with my doctor. TLDR: I have a big nose and am trying to take advantage of my insurance. Should i tell my doctor?
Context I’m a lady who has a really big nose… I am really beautiful regardless and my nose suits me yada yada… I get nose filler to diminish the large hump on my nose and recently went to a new doctor for this (due to his experience on face balancing). Well, this doctor asked if i had a deviated septum, to which I said “a small one i think” (based on prior knowledge from visiting 2 plastic surgeons regarding my nose). This Doctor then proceeded to exam my face and stuck two q-tips up my nose opening my nasals to show me how i am suppose to breathe. I was in shock and didn’t realize how poor my breathing was. This Doctor then told me that my ‘nose bone’ is in the shape of an ‘S’ as well as telling me that i have an over growth of cartilage in the bulbous of my nose. This doctor recommended i go see a plastic surgeon named Dr. XYZ. I began noticing how gosh awful my breathing truly is and spoke to my personal practitioner telling him about what this doctor has told me and so my practitioner referred me to a nose/ears/throat doctor. The objective of the referral is to get me on the road to a septoplasty and/or deviated septum repair (covered by insurance). My main concern is I have taken what doctor #1 has told me to heart. I want a reduction on the bulbous of my nose as well as a shaved nasal bone- for aesthetic purposes though.
I understand I am taking advantage of the so called ‘system’ but the first time I wanted a nose job was when i was 3 years old.
I have always been the family favourite due to my “middle eastern nose”.
I have been teased my whole life, i would look in the mirror at age 6-8 and just cry asking the universe why me. in high school the popular boys use to say “she’d be so hot if she had a nose job”. I don’t know how many people know or care to know, but nose insecurities are linked to eating disorders and I currently weigh 93 pounds at age 27, my bmi is shameful.
I don’t mean to sound condescending and everyone is beautiful and unique but i feel so held back in life because of my nose. As awful as it is, i envy those woman that honour their prominent noses and look so strikingly beautiful. I wish they felt how ugly and disgusting i feel which is so wrong and horrible to say but i’ve been stuck in a loop of sadness and self pity since I was born.
I apologize for sounding condescending and vain, I apologize for victimizing myself and not being able to love this beautiful face of mine. my boyfriend has a big ol dominant nose and i’ve never seen anything sexier, but i just can’t live with mine. He loves mine, everyone does, it’s what makes me unique they say but i hate it.
On to my question, When i have the privilege of speaking to the Nose/Throat and Ear doctor should I honestly tell him my intentions? Should I truthfully tell him I would rather mouth breathe my whole life than to be stuck with this horrendous nose of mine? Should i tell him the personal information like how i have social anxiety and can’t look people in the eyes because my nose haunts me? Should I tell him I don’t even want kids because how dare I give them my big ugly nose? should i tell him that i want a deviated septum recovery in hopes that i come out of it “more beautiful”. I hate myself foe the words i have said abs the question I asked but I need help, i’ve tried to end my time here because of my nose twice now and i don’t want to have false hope going into this surgery just to be disappointed after the fact. (i understand 100% that i will never like or love my nose, before or after any surgery, i am aware that it will never be ‘small enough’ in my eyes, i know that this body dysmorphia that i will live with for the rest of my life)
I just need to know, if you were a doctor, would you help me if i shared this with you? would you go the extra mile to approve my appearance? would it be strictly for functionality of my nose?
submitted by sadbabylynn
to cosmeticsurgery [link] [comments]
2023.06.04 07:42 ThrowRA99988RFFGGGG My family and the family of my ex wife still want us to get together I am (30M) my ex wife (29F) what should I do?
I was told to post here by my friend I am from India and didn't knew about reddit till now the story is I am a male of 30 years and my ex wife is an year younger than me we dated when I was in my 3rd year of medical college (BHU UTTAR PRADESH) I was 22 then still studying when I met her at our hospital she was practicing as a nurse and this was her 2nd year studying we liked each other and kinda met and didn't told anything to anyone social standards are very high in my family like no dating or anything just straight up marriage we dated we dated till I completed my pg and 2 years of md total of 5 years then we decided to come clean to our parents about everything they agreed it become a love arranged marriage we got married but be had a prenup as proposed by my cousin brother after marriage she quit her job at the private hospital and I was able to get her a leverage at my government hospital as a nurse as she had 3 years of experience so it was easy for her we both had a good incomes in the same year she got pregnant we had a child and nothing much happened for 2 years till one of the nurses in my hospital told me one of the doctor in the other department was really close to my wife I didn't thought of it but when I asked her about it she got startled and asked how I knew him as he was from a really different branch from me and all at that moment I kinda got suspicious but still nothing as in India cheating is not very common and is despised in our society too so I didn't even though of this well nearly after a month when I was attending a seminar at a different state I was contacted by my maid that someone comes at my home with my wife at evening and leaves with her at the morning I was still confused and didn't thought of anything but was more suspicious when I came home I asked her who that was she was I would say horrified how i knew i told her our maid told me and I know he was a male I thought it would be her brother but at that moment I was sent into a shock as she told me it was the Dr from the trauma center and she suddenly told me everything I don't know why I guess she thought I knew everything she started crying and all even I started crying and sobbing but didn't know what to do so I just called a cab and left I started at a hotel for That night and took a few day of sick leave from my work I went to my hometown and told my parents about everything and I didn't knew what to do but my parents and his came together and made it so we don't get divorced and still get be a couple and hell I gave it a shoti got an std check and she told me she'll get job at a different hospital and our child was mostly cared by an aaya(maid for children I guess) I was in it for the him then but after 2 or 3 months after one of the cousins told me to have a paternity test for the baby so just to be sure and I was preety sure she cheated and it was all emotional she was hesitant of it but when the results came I was not the father it was maybe the biggest shock i ever had I was broken even wanted to die but made it though after that mine and her side of her family asked her who was it she finally confessed it was the other doctor but she said she was sure the baby was mine and how was this possible. I was still doing my job at the hospital now she quit till now and was living with her mother and father and my parents were with me at my home(I am a single child) when me and my father confronted the other doctors family they had nothing to say I guess all they said that they were sorry but how could my wife do this and I was kinda with them and when we told them the child was not mine but could be his like 99% chance they were shocked the real thing is that he was married for 7 years at that moment with twins we asked for paternity test they agreed if only we don't tell anyone else about this we agreed and after 3 months when the results came here he was the father if i remember he still is married but don't know much. We got divorced after that it took a few months and our parents were still against it but went along it's been an year since we divorced I went to a different state to continue my practice (I am an ophthalmologist if anyone is interested) but now my parents are inviting her every event that's happening and she still teachers maya the name of the child that I am her father and also dating in India is not as easy as outside if you are a divorce I tried bumble tinder and few others my parents still Want us to reconnect and all and she is all for it but how can I prevent it I don't want to cutoff my parents is there any other way please tell me if there is.
submitted by ThrowRA99988RFFGGGG
to relationship_advice [link] [comments]
2023.06.04 07:03 hilbilly1980 So many questions
My mother was recently diagnosed with stage four metastatic breast cancer and it has progressed rapidly to the point where she is not able to care for herself. My stepdad is basically unavailable physically or emotionally, so I have stepped in to be her caregiver. We just started hospice care, and they come to the house three times a week to assess her medically and once a week to bathe and clean her. My job has been incredibly supportive and flexible, so I have been working remote for the past two weeks, stepping away whenever I am needed. Over the past couple of days I have realized that this is going to be a full time job. I also should note I have a young family three states away that I am missing terribly and struggling to do this without any support, since I am an only child. I’m not sure exactly where I’m going, other than I am so scared this is going to last for months, and I’m already feeling emotionally and physically exhausted. I love my mom so incredibly much, I’m just in a bit of a panic trying to figure out how to best support her and also not lose my sanity in the process. Guess I’m just looking for support. Maybe some ideas on what to do if I need to go home for a few days. For reference, my mother is on Medicare and MediCal through the state.
So glad this group exists. 😮💨
submitted by hilbilly1980
to CaregiverSupport [link] [comments]
2023.06.04 06:35 Cool_ball999 Awaken 20/web of chaos
Corva fiddled with an empty medicine bottle, he looked at the labels and peeled them, only to stick it on the bottle again, he would screw off the cap and screw it back on repeatedly. It was an old habit of his, just looking at random things and playing with them like a fidget toy, he only does it when he has nothing to do, ever since he got a job that habit disappeared, but now, all he can do is lay down on the bed of a hospital tent, and he's also technically currently unemployed. Since no company is going to recruit anyone in the middle of an invasion from killer robots. He thought back to what happened yesterday, when Lavoss came into the tent and confronted Kawl.
"You're still awake?"
He was still curious about it, what did Lavoss mean by traitor? Did Kawl kill someone? He doesn't look like someone who would do such a thing, whatever it was that he did though, it was significant enough for Lavoss to hit him in the head with the stock of his gun knocking him out cold. It was shocking to see, he was awfully calm up until the point he said something about the traitor part and not a moment later Kawl was on the ground unconscious with a gun stock shaped dent on the chitin protecting his head. Everyone gasped, except Mari, the nurse, she looked like she expected it for a long time and stayed calm.
"Do you have trouble sleeping?"
She asked as she came back with another box of medical supplies.
"No, just… didn't feel like it"
"What do you mean you don't feel like sleeping?"
She put the box down and walked up to him.
"Well… i got plenty of sleep yesterday, spent the rest of it sleeping, didn't i? And most of today as well"
"With all due respect that doesn't justify staying up until the middle of the night, besides, you need rest"
"Same thing can be said about you… I haven't seen you take any kind of break, even the doctor's not here, why are you?"
"The downside of being the only qualified nurse left around, not the only one in the camp of course, just the only one left for this tent, besides… it's my duty to watch over the patients, and make sure they have enough sleep…"
She raised her voice a little on that last word, as well as throwing a glance at other patients that were already asleep.
"Right i am, now sleep"
"I've tried, i don't think i can"
"So you do
have trouble sleeping, hold on, i think i have something for that in stock"
"No thanks, can we just… talk? It's been some time since I've had a friendly talk with anyone, just… Not about anything in particular, you know? Just talk"
"Hmm… fine, when was the last time then?"
"Right before the invasion… right before he lost his life…"
"Let's… not talk about that…"
"Uhm… What's your job?"
"QC, for quality control, in an arms factory"
"A factory worker? You looked way cleaner than i thought you would"
"If i were working in the assembly i think you would change your mind about that, but no, QC's don't get their hand dirty often, maybe once in a while when a weapon explodes on them"
"Huh… ever had one?"
"Personally? No, have I seen it? Yes, funny story, when i first got accepted i had this instructor, telling us how to check the quality of products, the first rifle he picked up to show us how to check the pulse had a faulty wiring on it, too much energy, it blew up on his face while a group of new QC's was watching, safe to say he doesn't like it when some of us laughed"
"Poor guy, Reminded of someone"
"Oh don't worry, it's nothing sensitive, it's like your story, she's a teacher, been one for a while even before she got here, so when she got here to Rosan she was considered a senior teacher, and when new ones needs a tour of their workplace and know how to handle the kids they relied on her, now one day she was guiding a new teacher…"
"And she was like… maybe she wants to show off a little bit, I don't know, but from what she told me, she said to this new teacher something along the lines of: 'look at these children! So behaved! If you want to do that you have to learn from me' or something like that… and… not a second after that, one of the kids who were playing threw a wet ball of paper and it hit her right in the back of the head"
Corva had to spend some willpower trying not to laugh, remembering that he was the one who laughed when his instructor blew himself up along with Kasso didn't make it any easier.
"Oh the look of embarrassment on her face, didn't see it myself, but i wish i did, i can feel her esteem crumble every time i mention it, it was cute to see her just shrink and try to hide her face"
"Oh… you'll like it when you see how my friend acts around girls, Kasso, he…"
Mari was a bit confused why Corva suddenly fell silent, why he looked at the ground with a frown, until she remembered what he said, and it clicked on her. Right before he lost his life
"I'm sorry for your loss"
"It's fine, i'm sure he's in a better place… much better than this… hellhole"
She wanted to comment on his sudden pessimism, but decided that won't be so wise considering he's not wrong, no matter how many times she tries to ignore it, she has to admit, their current situation is a hellhole.
"I suppose that's enough talk for now…"
"I advise you sleep now, you'll get tired"
He didn't respond, and just went to sleep without another word, and an unchanged expression of sorrow. She sighed and returned to her work, sorting the type of medications into different containers.
"When will it all end?"
It was calm… and black… that is about all Schen can think about regarding his current state, he can't tell if he's dreaming, or if he's asleep or awake, it's just that he is aware. It was a strange feeling, like being asleep physically but not mentally, he feels like he's floating, without a body, like there's nothing that can limit him. And yet at the same time he can't do anything, he was just aware, and drifting away in this weird state of half dream. For some reason, he thought of those tales of people who 'died' , people who experienced long comas, and the tale of their supposed journey to this place between the mind and the world.
Ridiculous stories, barely believable, and uninteresting if you ask him. And yet, here he is now, aware of what's happening, he remembers everything, he passed out from blood loss, after fighting one of those things. He wants to wake up, check on his men, maybe meet up with Captain Vaiya and make up a plan on what to do next regarding their situation. But you can't wake up when you don't even have control over your eyes, so it was more of a waiting game, an annoying one, knowing what's happening and yet can't act on it. He'd rather be actually dead over this, at least if he's dead he doesn't have to worry about anything. The problem is, he knows he's alive, it's just that his body is not responding to him, nor can he feel it.
It took what felt like hours, since he wasn't actually asleep, he was paralyzed but still conscious. After an agonizing few hours, he felt the first bodily sensation, his finger, it graduated to the feeling of his hand resting on a soft surface, probably some sort of bed, he can feel his breath as well. He started feeling his body, little by little, unfortunately, now that he feels his body again, he can feel what his body feels, and that is pure unadulterated pain. On his head, on his leg, his back, his arm, everywhere, he doesn't remember getting hit that much, but apparently he did. His back arched from trying to suppress it, and he let out a grunt that was too loud for his standard.
"Calm down! Don't move just yet…"
A voice, good, that means he should be in a friendly area now. He opened one of his eyes with a considerable amount of struggle, and saw the face of an Enovian with a waterproof paramedic hat on through his blurry vision.
"I've had worse…"
What a word for him to say before his back gave up on him and suddenly went limp, triggering pain in many areas of his body.
He grunted with some exasperation and regret. Maybe he shouldn't be showing off at this kind of age, it's not good for his bones.
"Where's our painkillers?"
"For awhile, he needed some time to actually get up, thought we'll just wait for him before telling you"
"Alright, thank you, i'll be there, a wonder he survived though, and to wake up this early"
"It is, his wounds were near fatal, he was essentially one light tap away from a fractured skull"
"Tough little guy… you can go now, there are others no?"
"Oh…yes, sorry ma'am"
Vaiya turned off her personal datapad, and stood up from her command seat. She dusted some metal dust off her uniform and made her way to the recruitment office turned into a temporary medical bay. She walked through a collection of the remaining crew of the ship, some simply threw a glance at her, some greeted her, and some gave her a salute. She noted the look of despair in their eyes and sighed, but kept on walking as that isn't her goal right now. She arrived at a door with a plate next to it that says: 'recruitment', the plate had an electrical tape with a writing on it that says: 'medical bay now' stuck haphazardly on top of it.
It isn't a neon sign, but it works. She opened the door manually with her hand as most of the doors in administration are now unpowered, inside was simple, four 'beds' laid on the floor, with most of the desks removed, the remaining medical crews stay here now, treating anyone they can. Including the new security captain, Schon, who she spotted sitting on his bed half awake wrapped in blood caked bandages, while clearly struggling to drink from a glass cup. He looked oddly… calm, like he's not surprised he's here at all. Granted, she did rescue him from becoming minced meat, and it's only logical to assume there are survivors holding out somewhere, but he looks absolutely unfazed, as if he had this happen before.
She walked up to him, he gave an unsurprised look and went back to doing his best to drink.
"Nice to see you awake already, i figured it would take a long time but you prove me wrong…"
"About that status report you ask for-"
"I already know, stranded, no engine, almost all crew dead, ship's practically scrapped, light's dying, and surrounded by killer machines chewing on the hull, and Rosan IV isn't so lucky either"
"Yes… unfortunate is it?"
"Yes, but right now I don't care, how's my men?"
"Ah… they're… few, 50… down to you and two others, i'm sorry"
"I see… who?"
"Koern, and Ayuna"
Schen wasn't paying much attention to the captain, he simply stared off into the distance, but hearing the young Caevit's name roll off her tongue took his attention.
"Really?... Thank you, but you're not here just for that right?"
Now that he actually pays some attention to her, he noticed her face change, a bit more tense.
"You read my mind, come"
"I can barely move my lips and you want me to walk?"
She looks around for a minute before looking back at him.
"I don't mind carrying someone"
"If i have credit for every time a Tekit lady carries me in her arms while i can barely move, i'll have two"
Schen commented on his current position, it earned him a confused and curious look from the captain. She took him to an uninhabited room to talk, as it turns out most of the administration has been turned to some sort of holdout for whoever's left alive in the ship. She set him down on a chair and followed suit, sitting right in front of him.
"So what is this? Is there something you want to know? If it's about this whole thing then you're talking to a wall"
Her behavior was odd, Schen noted, she seems… agitated, not angry, just stirred, like something's bugging her. He can understand being scared, but the way she moves suggests whatever's currently happening isn't the case.
"Nothing much… i just want… confirmation"
"So… I heard that Koern asked you for help, is that so?"
"Yeah? Got to me after he said you can't help"
"Do you know what his issue was?"
"Yes, random images and voice recordings from his cousin"
"Okay… where does his cousin lives?"
"In Rosan IV and from what i heard, it's about as messed up as this ship"
"That is correct, do you-"
"Wait, can we just get to the point here? What's the issue? Why are you suddenly interested in Koern's problem?"
"...Because i've been having the same problem, what you said, random images, and voice recordings, now i know it's exactly the same, that is what i want to know"
"Huh… okay… so?..."
"There's one difference… his problem started today, during the jump, my problem has been going on for the last five cycles"
"And I want to know one more thing, please, answer this honestly… do you see it?"
He can feel her agitation increase tenfold as she asks the question. She was normal, now she's visibly shaking.
"Please tell me you saw it too, i… I've been thinking about it… for a long time… ever since I've peered into those images, there's a shape stuck in my eyes, it's burned itself into my mind, and I feel it…. Everyday i think i see something in the corner of my eyes, i hear noises that aren't there, closer and closer every time!…. It… it was getting closer… the shape…"
Her stare became intense, like the stare of a crazed person.
"i… don't know…"
"Oh but you know! You saw it!... Just as I did… it sees you, but you can barely see it, it's there… watching… First it stays in the image, then it creeps into you, haunts you, then you see it hide everytime you turn your head… it follows you, everywhere you go… in your sleep… when you work… all the time…"
Her breathing was rapid, almost uncontrolled.
"Perhaps… that's just you, i do not experience these"
"It may not now, but it will…. Because it has to me, it's like a tumor, and it won't go away, no matter how hard i try… it's still there…"
She calmed down slightly, her breathing was normal again, sort of, and she's no longer shaking, but the stare is still there, the stare of true fear, striking deep into his soul. As she calmed down more and thankfully finally averted her gaze elsewhere, Schen took the downtime to process what he just listened to, and his conclusion was: what the ////?
"Sorry… i… i just… i needed to know… i need to know if i'm not the only one… now i know it's in you too, not now, but soon, t-thank you"
"Should we return?"
He pondered about asking her to take him to the bridge, so he can look out and see what's happening outside the ship, but now he's reconsidering it, because of that… experience.
"...Yes, we should"
She let go of his arms, he didn't even realize it, but she was holding on to him tight the whole time.
"Of course… of course, let's make this quick…"
Schen observed Captain Vaiya as she left the medical room, he noted her sudden return to her previous well mannered behavior, he can still see a tinge of anxiety in her eyes and movements however, and realized how similar it was to Koern's behavior. Anxiety, unease, massive discomfort, moving around constantly, and eyes snapping to random positions as if they're trying to catch something on the move. It was unmistakable, Schen recalled back to his conversation with Koern, about something he said.
Koern did look at the images before coming to him, and it was clear the images caused it, if Vaiya had something similar or identical happen, he can assume the cause for her distress is the same. But one question remains that still baffles him: how? How do random images do that? Implanting irrational fear into someone, making them see things that aren't there, what is happening? And now that he considers it, he did see the images, is he going to fall victim to the same thing? Why hasn't he felt anything if those images can do that to someone through just a mere look at it?
One question leads to another, and it all gets more complicated the longer he tries to solve it. He wanted to ignore it, maybe they were just unstable and he misjudged the whole thing, but he can't help but feel there's something to it, it's clear those images and recordings somehow were sent by the creatures currently roaming the ship, he sees the connection, but why? And how? Psychological warfare? Maybe, that was the most rational answer he could come up with. With their clear situation of being in the middle of an invasion, he can only assume such an answer, but applying it to only a few specific targets seems beyond strange.
He pinched his snout in frustration, before taking a deep breath and exhaling it as slowly as he could. Perhaps he shouldn't think of it too much for now, maybe that's how it gets into you, the shape… whatever it is. He looked around his surroundings, a 'medical' room, previously an office, he watched the doctors treat the wounded as he thought of his next step. Looking outside the ship should be a good idea, he had asked a nurse about the whole situation before Vaiya showed up, they told him the entire star system has fallen, Rosan IV was silent, any attempts at communication and call for help were futile, the other planets around the system, some are yet to be named, are the same.
That means those things have been here for a while, and somehow stayed out of the union's radar. He remembered the emerging stories of Rosan IV, how it became a ghost, how communications were far and few between, how many ships that traveled to its system went missing and ones that returned had signs of heavy damage on them, and how their crews looked 'lifeless'. If Rosan's system has been like this for some time, wouldn't that mean any ship that comes here would suffer the same fate as his ship?.
Why would some return and look 'fine' was beyond him, but a thought nestled itself in his mind, a terrifying thought, it made his blood run cold, the thought that these things have spread beyond this solar system, spread silently, in cargo ships that travel to every corner of union space. Suddenly people seeing shapes and hearing sounds after they look at an image doesn't sound horrifying anymore.
Faen sat in his office, for the millionth time, he stared at his computer, for the millionth time, he opened the files containing the Qrid military spending, for the millionth time, he looked at the reports file, for the millionth time. It has always been like this, being a general wasn't all about giving orders and making war plans, most of his time was spent in front of his computer, looking at the passive activity of his army, and its spendings, receiving calls or calling someone to see if he can learn something new about someone else's army. Look at pirate reports, raiders, terrorists, radicalist, sometimes cultists, it has always been like this, looking away at the computer, looking at files, always has been.
He wouldn't say he couldn't make wartime decisions, if one were to ever occur, he's always confident he can, after all he has learned from both his father and many mentors. He trained for it, for war, he trained how to control an army in such a situation for pretty much his whole life, he doesn't have to, but it's better to know how to fight than not at all. You never know when it'll come, maybe now, maybe in years during your old days, maybe never, but if it ever does come, he knows what to do, whether he likes it or not. It's a part of his pride, his identity, though he couldn't say much about his son, and everyday he worries about not having a successor, not having someone to pass the torch to, and as time marches on indiscriminately, his worry can only grow.
Sometimes he wondered if should've been harsh, and not fulfill his wish to go to university so he can learn computer science, and put him in the very school he himself went through to become what he is now. But that's not a good father, isn't it? It would be against his wish, and he would've needed to force him, it's what his son's grandfather did… to him, he still thinks about it, about his original dream. A singer, a far cry from a supreme general, he remembered the angry face of his father upon learning what he wanted to be, it felt like it happened just yesterday. He never liked it, not once, despite managing to prove himself worthy as a leader of an army in the end of everything.
And to think, he was almost like that, to his own son, he couldn't handle the thought. Faen took his eyes off the screen, just for a moment, and looked at another one, a camera display, showing his son's room. Rana was sleeping, as usual and as he should be at a time like this, he looked at him through the screen, at his arm, and thought about his latest conversation with the woman he loved.
He felt a subtle pain in his chest out of nowhere, he opened the drawer on his desk through a motion that tells of excessive habit, and absentmindedly took his medication without looking. With a sigh, he looked at a small button to his right. There was a screen above it that had a list of people considered significant enough to be contacted by him directly, which ranged from the supreme generals of other species, to the head maiden that cleaned his and his son's bedroom. He looked for a specific one that he recently added, the surgeon that is the head of operation for the trials he had put Rana through for the last few cycles, the trials that he and his mother show complete disapproval to.
He found it and clicked the button, it was answered after some time and he entered a call with the surgeon.
"A pleasure to speak with you general
"Is there something you wish to ask of me?
"Yes… we should stop, no more trials"
"If that is what you want, then I will gladly comply, but may I ask why for the sudden stop? You seem invested in this when you first called me to arrange it
He cut the call short, and continued his work. Looking at the files, looking for differences every so often, making sure everything is stable and taken care of, and glancing at his son's monitor once in a while, and for the first time since his son graduated university, he smiled. Perhaps that's the right thing, to be a father, not a general. At least… for a moment, his smile disappeared as he received a call, it was marked as urgent, and was displayed on his screen instead of just a sound notification. He dusted his uniform and fixed any creases as he noticed the call wasn't just any call, it was a notice for him to join a discussion between supreme generals of each species and their respective leaders, that includes the matriarch.
It is odd he wasn't notified of this earlier, oftentimes these kinds of things have their own schedule that was discussed beforehand, a sudden meeting like this can only mean one thing. He accepted the call, and his screen changed to the display he's all too familiar with, a digital conference room, two lines of camera display, the bottom for the generals, the top for the leaders, they were all present, which is to be expected. The matriarch of Qrids, the Tekit queen, the Caevitan allfather, high empress of Enovia, and the Civean president, the current roster of union council, below them was him, and other generals, including general Cynte of the Civeans.
He still remembers his little offer to make an accident to highlight Rana's name, after the reveal of the Goels and the incident it was kept as a private thing between them that didn't really go anywhere. He doesn't want to talk about it, neither does Cynte, so it was technically a win-win situation, despite the unexpected and frankly out of their favor results. The call was oddly silent, no one was saying anything even the loud ones like his mother, they seemed to be waiting for something, or someone. Faen didn't question it, it would be considered stupid, so he too followed the silence. It was a strange and awkward few minutes of staring at each other not saying anything, up until what they waited for arrived in the call.
Another screen appeared above all ten screens, and on it was something he dreaded to see, the collection of red revolving rings, Cain. Practically every general present felt tense, including him, the leaders couldn't care less, except maybe for the Civean president who expressed the most worry as they all waited for Cain to speak. Sudden meeting, all members, and Cain, and considering their latest development with the Goels, this couldn't be good. The red rings assemble into the shape of a solar system like it did when it appeared on the monitors of his warship, and Cain spoke with his usual low pitched synthesized voice that everyone in the room knew quite well.
'it is no doubt all of you will question why I requested this urgent meeting, i apologize if any of you found it to be too sudden, but what I have to tell you will change your mind, and I will not waste your time, as we are in a race against time itself… the union has been breached by an invader, you are under attack, and in a process of galaxy wide invasion'
No, definitely not good.
"What do you mean by this?"
Faen immediately asked, as much as he distrust Cain, he must agree with his mindset that no time should be wasted. And it seems his question stopped a particular set of leaders trying to speak, stopping them from blurting out what are probably4 going to be pointless sarcastic remarks, so that was another benefit of speaking first.
'your union is currently under the invasion of a race that is arguably similar to me, we call them Shakran'
The display of red rings changed to a scrolling collection of images, images of… Faen doesn't know how to describe it, bipedal creatures, made of metal, and grossly disfigured bodies, with sharp claws and many eyes. Every single thing varies, some of the things in the images looked small and only had claws, some were massive and had what are clearly cannons as a weapon. He noted a certain detail about the images, they were blurry, and not straight, and some strange things were staring at the camera, while looking elsewhere. Something tells Faen these images were taken in the middle of active combat.
'They are a hivemind of machines, their sentience and sapience is debatable, but that does matter currently as their only goal is to destroy and conquer'
"Lies! If we were under an invasion from them, we would've known already! Besides… we already have an invader… we're talking to them right now
The Tekit queen spoke with clear passive aggresive energy in her voice. Faen sighed in annoyance but kept it to himself.
'i understand the distrust, but it is no reason to make a sarcastic remark, however, you need to trust me on this matter, because their return can only mean danger to the union, and the universe as a whole, they are-'
"Wait, what do you mean… their return?"
'you all must've wondered how and why i and my brother ended up the way we did on that desert planet, what you are seeing on my screen is the answer to your question'
It didn't click for any of the leaders, their annoyed expression stays the same as Cain finished his sentence, but it clicked for every single military leader in the room, and it horrified them.
'my kind have encountered them before, my creators, it led to a war, a million year war, between me and them, they are what wiped my creators out of existence, and soon will be the cause of extinction for every single species in this union if we don't take any actions, since you refused, i have personally tracked every ship that left Rosan IV for the last six cycles, here is the data'
The scrolling images turned into a detailed map of the galaxy, with every single star system currently under union control included in it, there were red lines all over the map, they were all traced back all the way to one specific system, Rosan IV. A heavy weight rested itself on Schen's mind as he realized how far the lines have gone, to a point it crosses itself, wrapping around the galaxy in a circle, like some sort of a chaotic web.
'Rosan is lost, it is highly likely they have turned it into a staging ground, i know that we all have strived to avoid this, but war is inevitable, i have send a complete data regarding the Shakrans to all of you, please review it as fast as you can, and take your moves, as i will mine right now, alert your fleets, if they see my fleet entering a system, tell them they are here as an ally, i have been defeated once, i will not repeat the same mistake again, i hope you can catch up and help me, because there is no telling of what they will do once their setup is complete, and there is no telling whether or not i can do this alone'
"Wait! What should we do?
'search and destroy, hunt down every ship that left the system, check every station, scan every inch of space, detonate stations, evacuate every planet they have visited then purge the cities and hammer the surface with orbital strikes if you might, but by all means… do not
let. them. develop. That is all i have to say, my reinforcements are coming, but i do not know if there is enough time, act now'
And with that, Cain left the conference room, and at that very moment, it shattered, every world leader was either furious or dead silent with a look of horrific realization, his fellow generals went into a panic and contacted their fleets. Except for him, he simply sat there, unmoving and very still, staring at the galaxy map Cain had brought up, looking at one particular star system, crossed several times by the red lines, and surrounded by it, Sheneae XI, isn't that?... The solar system his wife is visiting to look at a newly opened hospital?.
(a TON of RIC's)
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2023.06.04 05:33 bcmcfann551 Advice for CNA to MA (training on the job)
I an a CNA and just applied for a MA position (referred by a nurse I work with in long term care). They are supposed to train on the job so I wouldn’t have to go back to school! I’m nervous but ready to hear back from them. Any tips, tricks or helpful advice for the interview or if/when I start? Please and thank you in advance!
submitted by bcmcfann551
to MedicalAssistant [link] [comments]