Lowest levitra price

Swift A, lowest levitra price Heale R, Twycross A. What are sensitivity and specificity?. Evid Based lowest levitra price Nurs 2020;23:2–4. Doi:10.1136/ebnurs-2019-103225In this article, ‘There is a risk that a test with high specificity will capture some people who do not have Disease D (figure 3). The …A previous EBN editorial discussed the role of universities in supporting the mental health and well-being of nursing students.1 This editorial was published in February 2020, so was written with little or no idea of the extraordinary challenges that were soon to confront society and healthcare providers as the erectile dysfunction treatment levitra spread.The earlier editorial highlighted that even lowest levitra price in pre-levitra times, the pressures on nursing students were substantial.

A mixture of academic expectation, assessment of practice competence and personal commitments, resulting in high prevalence of stress and anxiety.2 Since early 2020 though, the levitra has magnified these pressures on nursing students across the globe.The importance of this issue was highlighted in a systematic review that explored the prevalence of mental health problems and sleep disturbance among nursing students during the levitra.3 The review suggested that over a quarter of respondents were experiencing sleep disturbances, nearly one-third were feeling stress or anxiety, and more than half reported suffering from depression. This review, and others, have highlighted -the substantial impact that the levitra has had on nursing students, but what does the evidence tell us about why this group has been hit so hard?. There are few members of society who lowest levitra price have been untouched by the erectile dysfunction treatment levitra. Many have lost loved ones. Many have suffered ill-health (and many continue to do so as a result of lowest levitra price long erectile dysfunction treatment).

Most have lived with societal restrictions and uncertainty about the future. However, the evidence suggests that nursing students are a group upon whom erectile dysfunction treatment has had a disproportionate impact.This is due to lowest levitra price nursing students being what Drach-Zahavy et al describe as a ‘poly-vulnerable’ group4—something which the broader evidence base supports. The research of the past 2 years demonstrates that nursing students have been impacted by erectile dysfunction treatment in three distinct but connected ways:As a studentOne of the most immediate impacts of the levitra across education providers was the rapid transition to remote education. Though the need to do this in a bid to slow erectile dysfunction treatment transmission rates was unquestionable, the effect on students generally—and nursing students specifically—was enormous. Fitzgerald and Konrad surveyed 50 undergraduate nursing students in the USA, finding that 80% of them were anxious about the impact of the move to remote learning on their ability to succeed academically, with 62% expressing concerns about being able to manage their academic workload during the levitra.5 To explore students’ experiences in greater detail, Wallace lowest levitra price et al carried out a qualitative study in the USA.

They discovered that particular causes of anxiety linked to the move to remote learning were the technological challenges faced (such as having access to a reliable internet connection), and the perceived loss of support mechanisms through not spending time in class with peers and educators.6As a nurseDuring the earlier stages of the levitra, students were ‘recruited to the frontline to join the fight against erectile dysfunction treatment’ (wartime terminology was especially prevalent at that point). This need to work in clinical practice during a time of particular challenge impacted on students in different ways, and several papers focused specifically lowest levitra price on this issue. The rapid move to support the healthcare workforce, referred to by Gómez-Ibáñez et al as ‘rushed labour insertion’,7 was a dichotomous experience for students. It did give them the opportunity to practise their skills, gain practice hours and contribute directly to the care of those suffering from lowest levitra price erectile dysfunction treatment. Equally, though, moving into frontline care also caused substantial anxiety, sometimes as a result of fear regarding the impact on their studies, sometimes due to the personal risk that this encompassed and sometimes because they were concerned about the risk it might present to those around them.As a personAs with all members of society, nursing students were concerned about their well-being and that of their family during the levitra, were impacted by societal lockdowns and, in some cases, were subject to periods of illness and self-isolation.

One of the most commonly cited causes of stress and anxiety among nursing students during the levitra has been the potential for their role to endanger their friends and families through transmission of the disease.4 5 8 Indeed—and perhaps indicative of the unselfish attitudes demonstrated by nursing students throughout the levitra—fear of infecting others was a much greater source of anxiety than become infected themselves. The personal impact for students was increased through the steps that lowest levitra price many of them took to reduce the risk to infect others. Gómez-Ibáñez et al outline how nursing students deliberately chose to self-quarantine at home, to avoid direct contact with friends and family, and sometimes even to seek for temporary accommodation to live alone.7 By doing so, these students may well have reduced the risk to others, but they also stripped away many of the support mechanisms that were so important—notably those provided by family, friends and peers.This perhaps demonstrates one of the key lessons from the literature. Those elements of nursing students’ lives that have been impacted on by the levitra do lowest levitra price not exist in isolation. The challenges associated with each—as a student, as a nurse, as a person—influence and magnify each other.

In their qualitative study of the experiences of final-placement nursing students, Diaz et al found that it was the enormity of the changes in all aspects of life—personal, academic and nursing—and the speed with which these changes took place, that led to such a substantial impact on the mental health and well-being of nursing students.9So what conclusions lowest levitra price can we reach from the research into nursing students during erectile dysfunction treatment?. First, the levitra has demonstrated just what important roles nursing students play in healthcare delivery. Not just as the workforce of the future, but as the workforce of now. We can also see how their responsibilities as a person, as a nurse and as a student interact in a way that makes them especially vulnerable.The lowest levitra price research into the impact on nursing students also provides us with some other, more positive, insights though. There is evidence that throughout the levitra, the quality of online education and of the support provided by academics and practice supervisors was instrumental in reducing stress and anxiety in nursing students,5 highlighting that it has been possible to mitigate the impact.

The evidence base also shows us how some nursing students welcomed and embraced the opportunity to support clinical practice, gain experience and make a direct contribution to the effort to counter the impact of erectile dysfunction treatment.7 Equally, lowest levitra price there is evidence that facing these multiple challenges may have enhanced personal resilience4 6 and enabled the development of new skillsets, such as enhanced information technology skills.6Those cohorts of nursing students who studied through erectile dysfunction treatment have faced pressures like no others—they have had to meet academic requirements of their studies, while taking on additional clinical commitments and trying to keep themselves and their families safe. Their response has been extraordinary, and they will have developed skills and experience that will make them better, more resilient nurses. They should be proud of what they have achieved and who they are.Ethics statementsPatient consent for publicationNot required..

Viagra vs cialis vs levitra differences similarities

	Levitra	Malegra dxt plus	Fildena professional	Cenforce	Sildalis
Online price	In online pharmacy	In online pharmacy	Canadian pharmacy only	Canadian pharmacy only	Register first
Free pills	Ask your Doctor	Yes	Ask your Doctor	Ask your Doctor	Ask your Doctor
Buy with Paypal	Online Drugstore	Online Drugstore	Yes	Yes	Canadian Pharmacy

New Yorkers are seeing red as the Centers for Disease Control and Prevention (CDC) has designated all 62 of the state’s counties as areas of “high transmission" for the spread of erectile dysfunction treatment.In the latest update from the CDC, the organization is monitoring every county in New York as variants of the levitra continue surging throughout the country.Over the summer, only Nassau and Suffolk County viagra vs cialis vs levitra differences similarities on Long Island were in the “high transmission” category.In the past seven Can you get diflucan over the counter days, according to the CDC, new erectile dysfunction treatment cases were reported downstate, by county, in. Suffolk. 3,398 (5.38 percent);Nassau.

2,464 (4.76 percent);Westchester. 1,195 (3.60 percent);Orange. 732 (5.86 percent);Dutchess.

529 (6.20 percent);Rockland. 460 (4.79 percent);Ulster. 322 (5.58 percent);Putnam.

159 (5.68 percent);Sullivan. 159 (7.52 percent).“Substantial” transmission means the county has seen between 50 and 99.99 total new cases per 100,000 persons in the past seven days, according to the CDC. However, “High” transmission includes anything above that number.Nationwide, there are currently 3,065 counties (95.19 percent) in the US with a “high” level of community transmission rate, while there are 67 (2.08 percent) with a “substantial,” 24 (0.75 percent) with a “moderate,” and 63 (1.96 percent) with a “low” transmission rate.Complete data from the CDC can be found here as the number of cases continues to surge across the country.

Click here to sign up for Daily Voice's free daily emails and news alerts..

New Yorkers are seeing red as the Centers for Disease Control and Prevention (CDC) has designated all 62 of the state’s counties as areas of “high transmission" for the spread of erectile dysfunction treatment.In the latest update from the CDC, the organization is monitoring lowest levitra price every county in New York as variants of the levitra continue surging throughout the country.Over the summer, only Nassau and Suffolk County on Long Island were in the “high transmission” category.In the past seven days, according to the CDC, new erectile dysfunction treatment cases were reported downstate, by county, in. Suffolk. 3,398 (5.38 percent);Nassau.

2,464 (4.76 percent);Westchester. 1,195 (3.60 percent);Orange. 732 (5.86 percent);Dutchess.

529 (6.20 percent);Rockland. 460 (4.79 percent);Ulster. 322 (5.58 percent);Putnam.

159 (5.68 percent);Sullivan. 159 (7.52 percent).“Substantial” transmission means the county has seen between 50 and 99.99 total new cases per 100,000 persons in the past seven days, according to the CDC. However, “High” transmission includes anything above that number.Nationwide, there are currently 3,065 counties (95.19 percent) in the US with a “high” level of community transmission rate, while there are 67 (2.08 percent) with a “substantial,” 24 (0.75 percent) with a “moderate,” and 63 (1.96 percent) with a “low” transmission rate.Complete data from the CDC can be found here as the number of cases continues to surge across the country.

Click here to sign up for Daily Voice's free daily emails and news alerts..

What may interact with Levitra?

Do not take vardenafil if you are taking the following medications:

• nitroglycerin-type drugs for the heart or chest pain such as amyl nitrite, isosorbide dinitrate, isosorbide mononitrate, nitroglycerin, even if these are only taken occasionally. This includes some recreational drugs called 'poppers' which also contain amyl nitrate and butyl nitrate.

Vardenafil may also interact with the following medications:

• alpha blockers such as alfuzosin (UroXatral®), doxazosin (Cardura®), prazosin (Minipress®), tamsulosin (Flomax®), or terazosin (Hytrin®), used to treat high blood pressure or an enlarged prostate.
• arsenic trioxide
• bosentan
• certain antibiotics such as clarithromycin, erythromycin, sparfloxacin, troleandomycin
• certain medicines used for seizures such as carbamazepine, phenytoin, and phenobarbital
• certain medicines for the treatment of HIV or AIDS
• certain medicines to control the heart rhythm (e.g., amiodarone, disopyramide, dofetilide, flecainide, ibutilide, quinidine, procainamide, propafenone, sotalol)
• chloroquine
• cisapride
• diltiazem
• grapefruit juice
• medicines for fungal s (fluconazole, itraconazole, ketoconazole, voriconazole)
• methadone
• nicardipine
• pentamidine
• pimozide
• rifabutin, rifampin, or rifapentine
• some medicines for treating depression or mood problems (amoxapine, maprotiline, fluoxetine, fluvoxamine, nefazodone, pimozide, phenothiazines, tricyclic antidepressants)
• verapamil

Tell your prescriber or health care professional about all other medicines you are taking, including non-prescription medicines, nutritional supplements, or herbal products. Also tell your prescriber or health care professional if you are a frequent user of drinks with caffeine or alcohol, if you smoke, or if you use illegal drugs. These may affect the way your medicine works. Check with your health care professional before stopping or starting any of your medicines.

What is levitra 20mg

The emergency alarm went off just what is levitra 20mg before sundown. For the oil-field medics of Loving County, that sound means your world is about to get a shot of adrenaline. One minute you might be lounging on the couch with the guys on call, watching Lethal Weapon 4, nursing a post-brisket food baby, and the next you’re in the back of an ambulance, watching a what is levitra 20mg ribbon of West Texas highway unspool behind you, cursing yourself for not using the restroom before hustling out of the clinic. Which is exactly where I found myself one stormy Friday evening last July.An emergency medical technician named Justin Esthay was behind the wheel. Beside him, Anthony Luk, a paramedic trained for more-complex procedures, radioed to dispatch for directions.

We were what is levitra 20mg speeding toward a fire in a far-flung corner of the Permian Basin oil patch. Lightning had ignited a tank of crude, and a nearby drilling crew had called in the blaze. Several days of heavy rain had transformed the dry arroyos what is levitra 20mg and bar ditches into churning rivers. A wind shear had blown through a few nights before and razed two dozen telephone poles like a sickle moving through hay. Line crews had worked day and night to restore power and clean up the mess.

Now the roads, already in bad shape, were washing away what is levitra 20mg into the muddy desert.The ambulance we were in belonged to Occupational Health and Safety International, a company based in the Houston area that operates a scrappy medical network in this sparsely populated part of the patch, including the clinic we had just come from, near Mentone, about one hundred miles west of Midland. The medics and EMTs who work there treat everyone from oil-field workers with critical injuries to cowboys with broken bones to old-timers with indigestion. They also run Loving County’s ambulance what is levitra 20mg service. If you’re sideswiped by a sand hauler or T-boned by a welder on one of the region’s few blacktop roads—one of which is known as “Death Highway” because of its lethal oil-field traffic—the members of an OHSI crew are your best shot at making it to a hospital alive. But first they have to make it to the scene alive.

On this call, what is levitra 20mg I wasn’t sure we would.We were barreling north on County Road 300 when the driver’s side tire sank into a crater. The ambulance lurched to one side, and we skidded to a halt. Behind us, the lights of a semi grew closer and closer. The driver managed to stop before slamming into us, what is levitra 20mg but just barely. A little farther down the road, we passed another ambulance.

It was what is levitra 20mg hobbled on the shoulder with a blown tire and twisted rim. That crew, hailing from another OHSI clinic in nearby Culberson County, had been the first to respond to the alarm. But they’d been less lucky with that pothole. Lightning wraps around a telephone pole in the distance, seen from the OHSI ambulance dock what is levitra 20mg in July 2021.Photograph by Jeff WilsonWe finally turned off the asphalt and drove for another half hour down mud-choked caliche roads. At 10 p.m., just over an hour after the call came in, we arrived on the scene.

Legs numb, I stumbled out and what is levitra 20mg looked around. The drilling crew, smoking and chatting in dirty coveralls, was huddled around their company pickup waiting for the all clear to return to the rig. The only signs of fire were flares burning natural gas and the glow of the roughnecks’ cigarettes.There was no sign of a proper fire engine either. Just an ancient, battered brush truck with “Balmorhea Volunteer what is levitra 20mg Fire Dept.” on the side. We shook hands with two dudes leaning against the vehicle who were dressed more like farmers than firefighters.

They’d come about what is levitra 20mg a hundred miles from Balmorhea. Other departments nearer to the fire had refused to make the trip, unwilling to risk the flooded low-water crossings. Between thick streams of tobacco juice, the men told us the blaze had nearly burned itself out by the time they got there. A good thing, considering what is levitra 20mg they had little more than a couple hundred gallons of water and some shovels on their truck. The oil company had asked them to stick around until a drone equipped with a thermal camera flew over the area to look for hot spots.

Having already made the trek, we were asked to stay as well.Even though I had worked as a roughneck for a short stint after college, this was the most remote and isolated place I’d ever been in the patch. There was no cell what is levitra 20mg service. It was pitch-black save for our headlights, a few flares, and the glowing pillars of drilling rigs scattered across the dark desert floor. It was early summer, and I was nearing what is levitra 20mg the end of the second week of three that I spent in Mentone, embedded with the medics of Loving County. I knew that this was where we’d be spending the rest of our Friday night.

I’d been on several ambulance runs at this point and had learned that out here a single call could last twelve hours. The previous weekend, Anthony had rushed two gunshot victims, one of whom had brain trauma, from the town of Pecos to two different hospitals, hours apart, in what is levitra 20mg Lubbock and Midland. He’d left the clinic at 2 a.m. And hadn’t returned until what is levitra 20mg 4:30 p.m. The next day.

December 8, 2021The Dead Sea of West TexasBy Russell GoldDecember 7, 2021Lina Hidalgo, Basking in National Praise, Faces a Potential Scandal at Home in HoustonBy Mike SnyderNovember 17, 2021The Notorious Mrs. MosslerBy Skip HollandsworthNovember 15, what is levitra 20mg 2021The Newest Texans Are Not Who You Think They AreBy Tom FosterDecember 2, 2021A Texas School District Banned My Book. Then Things Got Really Ugly.By Ashley Hope PérezJune 3, 2021Hot Pants, Love Potions, and the Go-go Genesis of Southwest AirlinesBy Joseph GuintoThis call was a cinch in comparison. I’d already been around long what is levitra 20mg enough to appreciate our good fortune. Because when the emergency alarm rings, disasters far worse than snuffed-out fires often await the crews at OHSI.At last, after two and a half hours, a rep from the oil company confirmed that the drone had detected no heat.

As members of the drilling crew piled into their truck to head back to the rig, one of them, as if acting in some oil-field drama, hollered, “Let’s make some hole!. €As we loaded back what is levitra 20mg into the ambulance, it occurred to me that the OHSI crews weren’t so different from the oil and gas workers they were here to help. The hard living, the time away from family, the macho culture, the insider lingo, the physicality of the job. Those who work in emergency medical services are essentially the roughnecks of health care. Although their job requires a high level of skill and knowledge, compared with other health-care gigs it is undeniably blue-collar and often what is levitra 20mg treated as less than.

But at least roughnecks are paid well, with many banking at least $75,000 a year. The same what is levitra 20mg can’t be said of EMS workers, who on average make less than half that. And yet here they were, EMTs and medics, proving their guts and grit in the heart of nowhere, their work known only to each other—and the people they save.The OHSI clinic in Loving County in July 2021.Photograph by Jeff WilsonI found OHSI by accident. Though I’d grown up in the oil patch, in the small town of Andrews, about eighty miles northeast of Mentone, I’d never heard of an outpost of oil-field medics. Most folks what is levitra 20mg haven’t.

OHSI doesn’t advertise, and it’s not the kind of outfit EMS workers flock to.But in October 2020, I was reporting a story on the last county in the U.S. Without a single recorded erectile dysfunction treatment case, which happened what is levitra 20mg to be Loving. A cashier at the Horseshoe, the only convenience store (or any kind of store) in the county, had mentioned a small clinic on the outskirts of Mentone where oil-field workers and locals could get tested for the levitra. When I drove out there, Cary Skelton, a fifty-year-old paramedic and OHSI’s West Texas program manager, was outside. He had on his what is levitra 20mg typical uniform.

A T-shirt, ball cap, cargo pants, and square-toed cowboy boots. He was chain-smoking Kool menthols next to a what is levitra 20mg parked ambulance. A gray cat named Tigger was curled up on the vehicle’s hood, and a shotgun named Bubba rested against the front bumper. Cary nodded at the gun. €œCoyotes been getting too close for ol’ Tigger here.”We talked as the sun went down—about the levitra, what is levitra 20mg about how the clinic had been erectile dysfunction treatment-testing scores of workers every day, about the region.

Loving County, Cary told me, is a tough sell. The 677-square-mile county is best known for being the least populous in the entire United States. Just 64 souls claimed permanent residence there in what is levitra 20mg the 2020 census. If it weren’t for the courthouse, you might mistake Mentone (population 22) for an oil-field junkyard. It’s quicker what is levitra 20mg to rattle off what few amenities exist in town than to list everything that doesn’t.

In addition to the courthouse and a few abandoned buildings, there’s the county annex, a tennis/basketball court, the Horseshoe, a post office (never locked), three food trucks, and one Tex-Mex restaurant that closes at three in the afternoon. But to Cary, Loving County is more than a desolate frontier of sandstorms and creosote bush. This part of West Texas what is levitra 20mg is his home. As a boy, he worked cattle on ranches, including his grandfather’s, across the region. And today you’d be hard-pressed to find a more entertaining what is levitra 20mg source of regional history than Cary Skelton.

When he tells stories, his posture shifts and his voice changes, depending on the character he’s enacting. He affects a lisp to imitate the late Newt Keen, a droll cafe owner in Mentone who lost a few front teeth after he took a bullet to the face. And Cary’s eyes narrow when he takes on the role of what is levitra 20mg Sheriff Elgin “Punk” Jones, the top lawman in the county from his first term, in 1965, till he hung up the badge in 1992.Cary lights up when he talks about growing up out here. Like the time he was nine or ten, when he and a buddy decided to drive a go-kart the thirty miles from the Red Bluff Reservoir to Mentone in the dead of night. This was what is levitra 20mg in the early eighties, some three decades before the shale boom brought heavy traffic and thousands of itinerant workers to the area.

The roads were mostly empty then, but they could still be dangerous. Mexican cartels used them as improvised runways on which to land small aircraft loaded with cocaine or other illicit drugs. One night, what is levitra 20mg Cary told me, the Texas Rangers were waiting for the traffickers. A plane landed, and, in the ensuing firefight, one of the narcos backed into its whirring propeller. €œIt was some straight-up Indiana Jones shit,” Cary said.

(The bloodstain left on the pavement marked the spot where Cary said he used to turn off for his favorite fishing hole.)But the what is levitra 20mg boys weren’t worried about narcos on the night they set out in a go-kart for Mentone. They were on a mission. They strapped a five-gallon tank of gas to the tiny vehicle and clicked on a pair of Maglites to shine their way through what is levitra 20mg the dark. €œWe were driving so fast,” Cary remembered, “we were outrunning our lights.” The boys had almost made it to Mentone when they got lit up by Punk Jones. Punk was the archetypal West Texas lawman.

He tucked his jeans into high-topped boots, what is levitra 20mg wore a silverbelly Stetson with a roguish curve, and kept a silver star pinned to his pearl-snap shirt. His grim good looks gave off the same tough-as-leather vibe as Clint Eastwood. He strolled up to the what is levitra 20mg go-kart.“What are you boys doing?. € he asked. €œWell, we’re driving around,” they told him.

Punk shook what is levitra 20mg his head. €œI don’t know if riding around on a go-kart in this part of the country is very safe.” He loaded the boys and their go-kart into his truck and drove them back to their homes. Cary was sure he’d get a whupping for the stunt, but what is levitra 20mg Punk never said a word about their adventure, not even to Cary’s dad.There have been a few changes since Cary was a kid. Thanks in part to the same Punk Jones, who drilled some of the county’s first non-brackish wells, you can now turn on a tap anywhere in town and get drinkable water. Still, potable water isn’t much of a selling point in 2022, and besides the lack of modern conveniences, the OHSI staff also faces all the dangers and discomforts of the oil field.

When they’re out on a call, they might encounter poisonous gases, what is levitra 20mg homicidal drivers, and high-pressure wells that sometimes blow up. There are also the long hours and weeks away from home. The crew’s hitches are two weeks long, minimum. They’re on call 24 hours what is levitra 20mg a day during that time, which means that consuming anything stiffer than Red Bull is prohibited. On top of this, they must meet Cary’s standards.

“Look, I don’t have time to make someone what is levitra 20mg an EMT or paramedic,” Cary said. €œThey need at least five years of experience of doing this on the daily, thousands of patient contacts, before they come out here.” In an urban environment, new medics can cut their teeth with less risk of fatal mistakes. €œThey’re ten minutes away from a physician and an ER to get them out of a jam,” Cary said. Not so in Loving County, where the nearest level I trauma center what is levitra 20mg is several hours away, in El Paso or Lubbock. €œWe have to bat a thousand.

We have to get a base hit every single time,” he what is levitra 20mg said. €œOtherwise, we could have some bad outcomes. We could lose someone.” Cary snubbed out his cigarette. €œGive me another what is levitra 20mg sweet,” he told one of the EMTs who’d joined us outside. Another Kool was produced.

Cary lit what is levitra 20mg it. It was dark now. Above us, the Milky Way was smeared across the night sky as if someone had tried wiping chalk from a blackboard. The quiet was broken by a yelping chorus of coyotes not far from where we stood what is levitra 20mg. €œOut here, you’ve gotta be the cavalry,” Cary said, exhaling smoke.

€œBecause no one is going to come to help you.”Since the erectile dysfunction levitra began, politicians and corporations trying to gin up goodwill have heaped praise on first responders, including EMS workers like Cary. But many on the front lines say it’s mostly a bunch of smoke what is levitra 20mg. €œEMS is the bastard stepchild of the planet,” Cary told me.Today, most of us take for granted that we can pick up the phone, dial 911, and someone will be at our side in minutes, capable of keeping us alive during the brief trip to a hospital awaiting with teams of doctors. But this what is levitra 20mg convenience is a relatively new development. Texas’s Department of State Health Services didn’t include an EMS division until 1973.In Texas and most other states, EMS, unlike police and fire departments, is not considered an “essential service.” Instead, EMS workers are dispatched through a haphazard patchwork of municipal and county operations, hospital-affiliated services, nonprofit and volunteer associations, and private enterprise.

That’s where OHSI comes in. Dustin Hoffpauir outside the OHSI clinic.Photograph by Jeff WilsonThe nutty idea of what is levitra 20mg opening a for-profit clinic in the country’s least populated county was Dustin Hoffpauir’s. I met Dustin during my first week at the clinic. He arrived from Houston in his King Ranch Ford bearing what is levitra 20mg a load of boiled crawfish, a nod to his Cajun roots. Dustin had come to EMS through the safety departments of several oil and gas companies.

After graduating from the University of Louisiana at Lafayette in 1998, he worked as a fire watchman on offshore rigs in the Gulf of Mexico.He eventually migrated to dry land and a small Lafayette-based safety company, doing contract work for bigger oil and gas companies. One of what is levitra 20mg those was Anadarko Petroleum, which hired Dustin in 2005. For the next thirteen years, he served as one of its lead safety officers. The job frequently took him west to the Permian Basin, where he spent days driving the what is levitra 20mg lease roads of Loving and its neighboring counties. Dustin was headed for a comfortable retirement with the company, but then a trip to West Texas made him change course.Several years ago, Dustin was on his way to tour a natural gas plant when an accident at the facility left two contract workers severely burned.

Though he’d completed basic EMT training, when he arrived Dustin didn’t have any equipment with him to start caring for the victims. He waited what is levitra 20mg helplessly for EMS to get there. It took more than an hour and half, an eternity to Dustin. €œAnd that’s when I really started thinking about the challenges associated with providing medical care out here, and the lack of resources,” he said. €œThe same what is levitra 20mg thing kept on reoccurring.

Delayed response. Unfortunately, some lives were lost.”“The same thing what is levitra 20mg kept on reoccurring. Delayed response. Unfortunately, some lives were lost.”Three years ago, for instance, in Culberson County, just west of Loving, a worker died of an apparent heart attack. His coworkers were forced to sit with his body for more than two hours while waiting for the sheriff, who drove more than 150 what is levitra 20mg miles on bad roads to get there.

When no ambulance could be found, the sheriff had to haul the body back to Van Horn in his truck. One of the coworkers later spoke at a county commissioners’ meeting, imploring the officials to invest in EMS, cut down on response times, and give what is levitra 20mg the deceased a bit of dignity. €œMy God, people,” he said, his voice choked, “what have we come to!. €Dustin and his wife, Mandy Hoffpauir, a registered nurse, made a plan. Dustin recalled what is levitra 20mg his time working in the Gulf.

The challenges of providing medical care on offshore oil rigs mirrored those in the Permian Basin. He figured what is levitra 20mg he could replicate the model he’d learned out there.First, he tackled the economics. Most ambulance companies don’t get paid unless they transport a patient. Out in a rural area like Loving County, the relatively low volume of transports, compared with the number carried out by city services, can make it hard for a company to keep the lights on between calls. If a patient doesn’t have insurance and is deemed indigent, what is levitra 20mg the ambulance company often eats the bill.

But Dustin knew that the oil and gas industry was desperate to find solutions to the problems it had brought to the region. The traffic accidents, the thousands of itinerant workers needing basic care for chronic conditions or medical emergencies, and the work-related incidents (well blowouts, rig injuries, flash fires, heat exhaustion, and so on) that are often more serious than those that occur in other industries. EMTs unload what is levitra 20mg their medical bag from the OHSI ambulance. Photograph by Jeff Wilson Medical instruments at the OHSI clinic. Photograph by Jeff Wilson Left what is levitra 20mg.

EMTs unload their medical bag from the OHSI ambulance. Photograph by Jeff Wilson Top. Medical instruments at the OHSI clinic what is levitra 20mg. Photograph by Jeff Wilson Dustin pitched the idea for a remote medic service to some of the major companies operating in the region. They asked whether he could also open a clinic that would perform on-site drug testing, issue what is levitra 20mg some medications, and perform basic medical procedures such as treating minor wounds and conducting X-rays.

Dustin agreed to that. In a rare move for fiercely competitive oil companies, several banded together to form a consortium. Their pooled resources what is levitra 20mg guaranteed a steady income for OHSI, regardless of the volume of calls. In late 2017, Dustin leased land outside Mentone and hauled in an old army barracks to convert into OHSI’s flagship clinic. He and a friend did most what is levitra 20mg of the remodeling themselves, spending nights in sleeping bags on the floor while they worked.

The product was functional, if not exactly luxurious.Dustin knew that it wasn’t only oil-field workers who could benefit from OHSI’s services. The locals of Loving County needed access to health care too. That’s where what is levitra 20mg Cary Skelton came in.When the former manager at OHSI stumbled upon his résumé on a jobs listing site, Cary was working in El Paso and looking for a new gig. He was tired of the relentless pace of the city’s emergency rooms and urgent care centers. He’d never dreamed he’d be able to find work in Loving County, yet here was an opportunity to do something meaningful for his community.

Cary jumped at what is levitra 20mg the chance to come home. €œBut the other part of it was, I had to produce. This is my granddad’s stomping grounds, and I cannot mess this up.” Cary what is levitra 20mg understood Loving County. €œOil-field workers and rodeo cowboys, they don’t go the doctor unless something is sticking out,” he said. €œPeople don’t even take their prescriptions out here because it’s seen as a sign of weakness.” Cary’s dad is like that.

He once showed up at the clinic what is levitra 20mg with a busted head. He refused to get out of his truck, so one of the medics had to staple the wound through the window. OHSI ultimately made inroads what is levitra 20mg with county officials, including Judge Skeet Lee Jones, one of Punk Jones’s sons. The county purchased its first ambulance, and OHSI signed on to staff it around the clock. (OHSI also provides health care to Loving County residents for free.)Although the Mentone clinic is still the heart of its operations, OHSI has expanded.

There are now two more small clinics, one in Culberson County, near the revived ghost town of Orla, and another in Pecos, 23 miles south of Mentone what is levitra 20mg. OHSI also dedicates an ambulance to serve Kermit and Monahans (55 miles east of Mentone), moving patients from one hospital to another.The presence of OHSI is a comfort to even the most treatment-hesitant locals and the itinerant workers who, however briefly, call Loving County home. But for the EMTs and medics who make their living and spend more than half the year at the clinic, their sacrifices add up. Dominic Sanchez, Steven Hutson, and Anthony Luk play poker in the clinic while waiting for a call.Photograph by Jeff WilsonMy first hitch, which what is levitra 20mg would last two weeks, began in late June. On a Tuesday morning, I arrived at the clinic, a metal structure the same beige as desert camouflage.

The clinic what is levitra 20mg abuts a rodeo arena just to the east. Otherwise there is little but sun-scorched pastures of mesquite and greasewood, the occasional pump jack, and a few rusted skeletons of old trucks and tractors. As Cary and I walked up the entrance ramp, Tigger and her kittens scattered from a heaping plate of food. In front of the door was a bloody rabbit’s foot what is levitra 20mg. €œThat was probably Tigger,” Cary said, catching my stare as he swung open the door.

€œNot the first time she’s gotten what is levitra 20mg a cottontail. And, hey, that’s good luck!. €Touring the clinic didn’t take long. The building is divided what is levitra 20mg in half. One side includes an examination room, X-ray room, and dispatch office.

The other side serves as what is levitra 20mg the living quarters for the staff. A cramped kitchen. A common room with an overstuffed brown sofa, an easy chair, and a TV on the wall. A bathroom what is levitra 20mg. And two bedrooms, where the crew members sleep two to a room.

There are plain white walls and scuffed linoleum floors throughout. The vibe is a what is levitra 20mg mix of college dorm and military medical outpost. As the fresh crew trickled in, the EMTs and medics who’d been on duty headed home, to El Paso, Lubbock, and as far away as Louisiana. One by one, I met the guys I’d what is levitra 20mg be shadowing for the next two weeks. First was Steven Hutson, an EMT from the flyspeck of Kirvin, a town eighty miles southeast of Dallas.

The youngest of the bunch at 25, he had a hefty frame and Bambi eyes that had earned him the nickname Baby Huey. Next was what is levitra 20mg Dominic Sanchez, a 26-year-old Albuquerque transplant with a boy-band smile and muscles on his earlobes. Dom was responsible for dispatching crews to calls for help, a duty he performed while wearing a pair of pearly white Crocs. And finally there was Anthony Luk, a 29-year-old paramedic who grew up far from West Texas, in the Asian grocery store his family managed what is levitra 20mg in Houston. These three, along with Cary, would be responsible for running the clinic 24 hours a day for the next fourteen days, as well as responding to emergency calls.Texas Highway 302, which leads into Mentone from the clinic.Photograph by Jeff WilsonDays at the clinic varied wildly.

One might be mind-numbingly slow. Hardly anyone would show what is levitra 20mg up for treatment, and the emergency alarm stayed quiet. The next, the team might be slammed from morning to night with workers dropping in for erectile dysfunction treatment screenings, for drug and alcohol tests, or with physical maladies. A welder came in with a metal shaving lodged in his what is levitra 20mg eye. Another patient arrived needing an X-ray after falling from a catwalk between two tall tanks.

Several workers, their accents suggestive of places a long way from Texas, came in suffering from dehydration. And one evening what is levitra 20mg a man hobbled in with severe burns on his leg. He and his wife had gotten sideways at dinner. She’d doused him with hot gravy.For the most part, evenings were peaceful. The guys would retreat to the living quarters after what is levitra 20mg six or seven, offering a little prayer that no one else would show up or call 911.

We’d make a family dinner, which could be Steve’s deer-sausage spaghetti or a Korean barbecue dish Anthony whipped up. A game of Texas Hold ’Em might start up, one of the many firearms stashed around the clinic might be fetched for cleaning, or a haircut attempted, but more often than not, someone what is levitra 20mg would turn on the television, and, after settling on a movie, the guys would sit shoulder to shoulder on the couch, eating off TV trays as if they were kicking back at a middle-school slumber party. “Everyone knows each other’s backstory so well,” Anthony told me, “we don’t really have to talk about that anymore.” They repeated some details for my sake. I learned that Anthony’s parents had immigrated from Hong Kong before he was born. He’d lived in Houston until he left for Lubbock what is levitra 20mg to attend Texas Tech.

Going from Houston’s humidity to the dry heat, he’d suffered nosebleeds constantly that first year. I learned that Steve had gotten married just what is levitra 20mg seven months prior and that he hated broccoli and loved Mel Gibson. (I was subjected to three Gibson films during my stay.) And Dom was the group’s Casanova, practicing his charms, without much success, on a clerk at the Horseshoe.Everyone caught hell for something. Steve for his diet (“He’d eat the ass out of a dead rhino”), Dom for his footwear, and Anthony for his skin-care routine, which revolves around his FaceTory, a small mint-green refrigerator he hauls with him that’s full of serums, oils, and face masks he wears at night. €œIf you can’t take what is levitra 20mg the ribbing,” Cary said, shrugging, “this outfit ain’t for you.”Cary was at the center of it all.

He acted as the group’s big brother, camp counselor, and, occasionally slipping back into his military background (he served overseas as a cavalry scout), drill sergeant. He often quizzed the guys on what meds or protocols to what is levitra 20mg use in various situations. €œThese are perishable skills,” he explained. Because OHSI doesn’t run calls every day like city ambulance services do, “you have to be studying. You have what is levitra 20mg to be practicing.

You have to be putting your hands on equipment.” But for all the grief he gives them, Cary is fiercely loyal to and proud of his crew. €œA lot of people think that because we’re out here in Hickville, we’re going to deliver some type of substandard medicine. No way what is levitra 20mg. I would put my guys up with anybody out there.” When that emergency phone rings—and eventually it does—life-and-death situations await the OHSI crews. Their memories are full what is levitra 20mg of the kind of gore that most of us see only in horror films.

A road-rage victim shot point blank in the belly, guts slopping out like uncooked sausage. An F-150 crushed like a Coke can under an eighteen-wheeler. A three-man roustabout crew charred what is levitra 20mg in a flash fire. One driver was covered in tar after his tanker exploded. Onlookers had poured water on him to relieve his what is levitra 20mg pain, but that had only made the tar harden onto him.

By the time OHSI delivered him to a hospital, his skin was peeling off in chunks.Just a couple of weeks before my hitch, a worker had been up on a catwalk removing a flange. Maybe he had heard a hiss of pressure and realized he was in danger. He’d apparently turned to run, but what is levitra 20mg before he could get to the stairs nearby, the enormous pressure now leaking from the loosened bolts blew the metal cover off the flange. It struck him smack in the back of the head. He was dead by the time OHSI arrived on scene, but before the site could be opened back up, Cary had to scrape gray brain matter off what is levitra 20mg the railing of the catwalk.

Because the area is so remote, the OHSI crews are also the de facto biohazard team in this part of the patch.This tension between normal life at the clinic and the arrival of the next emergency was something I could never quite adjust to during my time at OHSI. It was hard to sleep, knowing that at any minute the alarms could call us out into the night. Luk reads an EKG what is levitra 20mg at the clinic. Photograph by Jeff Wilson The examination room at the OHSI clinic in Loving County in July 2021. Photograph by Jeff Wilson Left.

Luk reads what is levitra 20mg an EKG at the clinic. Photograph by Jeff Wilson Top. The examination room at what is levitra 20mg the OHSI clinic in Loving County in July 2021. Photograph by Jeff Wilson You won’t find much sympathy talking about the woes of a forty-hour week with EMS workers. For them, long hours are the norm.

Justin Esthay, the EMT driving the ambulance on the call that took us to the flare fire, told what is levitra 20mg me he regularly worked sixteen-hour shifts and once put in twenty hours straight for an ambulance service in Louisiana. The schedule at OHSI, with its occasional stretches of downtime, was a relief. Still, it what is levitra 20mg was hard not to notice the dark circles around Justin’s eyes. Anthony explained that EMTs and medics work such ungodly hours in part because the pay for EMS workers is shockingly low and they need the overtime. With the mean annual wage for Texas EMS workers clocking in at about $37,550, many work two or even three jobs to eke out a living.As an EMT in Lubbock, Anthony had started out making $11 an hour.

€œBut I what is levitra 20mg also picked up a lot of overtime. That’s the thing. In EMS, picking what is levitra 20mg up overtime is where we make our money. It’s also a big reason why there’s a lot of burnouts.” The annual turnover rate for EMS workers is about 30 percent.“You’re constantly working,” Anthony continued. €œIt’s hard on marital life, social life, all life outside of work.

Relationships are hard to sustain because, like, for us here, you’re gone what is levitra 20mg for two weeks. It’s terrible to say, but out of the guys who’ve had partners or were married, a good forty to fifty percent are no longer.”Anthony’s fiancé, William, is a composer in Lubbock. I met him briefly when he made the three-hour one-way trip to deliver a set of keys Anthony had accidentally left at their apartment. It was the only time William had ever set foot in the clinic where Anthony spends more than half the year.“When what is levitra 20mg you go home, you don’t want to do anything,” Anthony said, speaking generally. €œYou just want to rest, and your partner doesn’t always understand.

Plus, you what is levitra 20mg don’t want to tell them everything because you don’t want to relive it. Like, if you had a bad day at work where you had to do CPR on a kid who drowned. . . That’s traumatizing.

Even though most people seem to shake it off and move on, you’re still overwhelmed with sadness.” According to one study, EMTs and medics are about ten times more likely to have suicidal thoughts than workers in other professions. And yet many first responders never seek professional help for their mental health. Cary chalks this up in part to EMS culture, in which the ability to put on a tough front and “silently suffer” is highly valued. Others don’t seek counseling because they can’t afford it. (A couple of the OHSI workers I spoke with said they’d opted out of the company’s plan because they felt the premiums were too high.) This means EMS workers find other ways to deal with their trauma.

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

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

€œI start doing CPR on this dude. I’m dripping sweat, absolutely drenched because it’s so hot.” Justin managed to get the guy to the hospital alive. The patient woke up, “and he’s thanking me, blah, blah, blah. For a while, I felt like, ‘Wow, I really saved somebody.’ I felt kind of good about it, even though the circumstances were crappy. So I come back to work the next day.

The EMT I’m relieving is like, ‘Hey, remember that guy you saved yesterday?. €™ I’m like, ‘Yeah.’ ‘He left the hospital and immediately OD’d again and died.’ I’m thinking, ‘I sweat my ass off, and it was all for nothing.’ ” He and Anthony both laughed at the irony.As an outsider, I was initially horrified by stories like this. But I came to understand their necessity. Anthony and Justin didn’t think the story was funny. They laughed because that’s how they deal with the grief and suffering they witness all the time.

For EMS workers, black humor is the shared tongue, a coping mechanism, a survival tool.EMT Steven Hutson in the field in Loving County in July 2021.Photograph by Jeff WilsonAfter my hitch ended, the price of oil climbed and the patch got busier—and so did OHSI. They’d had some rough calls. A few bad wrecks and a fire that had burned a crew of three. Plus, a surge in erectile dysfunction treatment cases had forced the crews to work even longer hours, as they had to transfer patients to hospitals farther and farther away. There had been some personnel changes too.

Dominic Sanchez had left OHSI for a medical gig nearer to his home in Killeen. And Steven Hutson had found work with an ambulance service close to his wife and family in Kirvin. Anthony Luk is still at OHSI but has been preparing to apply to medical school. He hopes to start later this year. Cary hates to lose good workers, but he doesn’t blame anyone for leaving.Sometimes when we spoke on the phone, Cary sounded bone tired.

Finding replacements hadn’t been easy, and the crews were stretched thin. At times he felt as if OHSI were barely hanging on. And lately, bigger ambulance companies have started to home in on the Permian Basin. Cary explained that big companies can choke out a small independent operation by offering their services more cheaply—at least until they run the competition out of business. He knows how precarious the state of rural EMS is right now.

He’s seen companies come and go.For Cary, the mission goes beyond the balance sheet. It’s about the camaraderie of doing a difficult job in an unforgiving desert. It’s about providing his community the comfort of knowing that someone will answer when they have an emergency.It was Cary who answered the alarm one cold, windy day last January. Punk Jones had been ill for going on a month, but he’d told his family, “I ain’t going to the hospital.” The nearest was in Kermit, half an hour away, and to get advanced care, he’d have to travel all the way to Lubbock, nearly two hundred miles northeast. Most of the wards were overloaded with erectile dysfunction treatment patients anyway.

But Punk did acquiesce to his wife Mary Belle’s urging to visit the OHSI clinic.The 93-year-old former lawman had been diagnosed with pneumonia. And so twice a day, every day, Cary or another OHSI medic drove out to Punk’s ranch to check on him. On that cold Saturday morning, Cary had been on his way back to the clinic from Kermit when he received a panicked call from Punk’s family. €œHe’s not breathing well. He’s doing bad.”Cary and the family started making calls.

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

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

Punk Jones had made it clear. He wanted to die in Loving County.Cary knew Punk wouldn’t make it to Amarillo. He told the EMT driving the ambulance to pull over in the parking lot of the county courthouse. There, Cary did as he promised. He and his fellow medics tried everything they could to save Punk.

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

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

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

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

Beside him, Anthony Luk, a paramedic trained for more-complex procedures, radioed to dispatch for directions. We were speeding toward a fire in a far-flung corner of lowest levitra price the Permian Basin oil patch. Lightning had ignited a tank of crude, and a nearby drilling crew had called in the blaze. Several days lowest levitra price of heavy rain had transformed the dry arroyos and bar ditches into churning rivers.

A wind shear had blown through a few nights before and razed two dozen telephone poles like a sickle moving through hay. Line crews had worked day and night to restore power and clean up the mess. Now the roads, already in bad shape, were washing away into the muddy desert.The ambulance we were in belonged to Occupational Health and Safety International, a company based in the Houston area that operates a scrappy medical network in this sparsely populated part of the patch, including the clinic we had just come from, near Mentone, about one hundred miles west lowest levitra price of Midland. The medics and EMTs who work there treat everyone from oil-field workers with critical injuries to cowboys with broken bones to old-timers with indigestion.

They also run Loving lowest levitra price County’s ambulance service. If you’re sideswiped by a sand hauler or T-boned by a welder on one of the region’s few blacktop roads—one of which is known as “Death Highway” because of its lethal oil-field traffic—the members of an OHSI crew are your best shot at making it to a hospital alive. But first they have to make it to the scene alive. On this call, I wasn’t sure we would.We were barreling north on County Road 300 lowest levitra price when the driver’s side tire sank into a crater.

The ambulance lurched to one side, and we skidded to a halt. Behind us, the lights of a semi grew closer and closer. The driver managed to stop before slamming into us, lowest levitra price but just barely. A little farther down the road, we passed another ambulance.

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

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

Just an ancient, battered brush lowest levitra price truck with “Balmorhea Volunteer Fire Dept.” on the side. We shook hands with two dudes leaning against the vehicle who were dressed more like farmers than firefighters. They’d come about a hundred lowest levitra price miles from Balmorhea. Other departments nearer to the fire had refused to make the trip, unwilling to risk the flooded low-water crossings.

Between thick streams of tobacco juice, the men told us the blaze had nearly burned itself out by the time they got there. A good thing, considering they had little more than a couple hundred gallons of water and lowest levitra price some shovels on their truck. The oil company had asked them to stick around until a drone equipped with a thermal camera flew over the area to look for hot spots. Having already made the trek, we were asked to stay as well.Even though I had worked as a roughneck for a short stint after college, this was the most remote and isolated place I’d ever been in the patch.

There was no cell lowest levitra price service. It was pitch-black save for our headlights, a few flares, and the glowing pillars of drilling rigs scattered across the dark desert floor. It lowest levitra price was early summer, and I was nearing the end of the second week of three that I spent in Mentone, embedded with the medics of Loving County. I knew that this was where we’d be spending the rest of our Friday night.

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

The next day. December 8, 2021The Dead Sea of West TexasBy Russell GoldDecember 7, 2021Lina Hidalgo, Basking in National Praise, Faces a Potential Scandal at Home in HoustonBy Mike SnyderNovember 17, 2021The Notorious Mrs. MosslerBy Skip HollandsworthNovember 15, 2021The Newest Texans Are Not Who You Think lowest levitra price They AreBy Tom FosterDecember 2, 2021A Texas School District Banned My Book. Then Things Got Really Ugly.By Ashley Hope PérezJune 3, 2021Hot Pants, Love Potions, and the Go-go Genesis of Southwest AirlinesBy Joseph GuintoThis call was a cinch in comparison.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Levitra soft

Pfizer and its partner BioNTech plan to start offering their erectile dysfunction treatment to clinical trial volunteers who received placebo by March 1, several months earlier than initially planned.The decision represents the conclusion of a complex and public kabuki dance between the Food and Drug Administration, Pfizer, and treatment volunteers, levitra soft as well as with Moderna, which developed its own erectile dysfunction treatment. The FDA and its advisers pushed hard for volunteers to remain on placebo as long as possible to gather more safety and efficacy data about the treatments, while the companies argued volunteers should receive the treatments sooner for both ethical and practical reasons.Among some trial participants, the issue had become fraught, with many protesting further delays in heated messages on social media and in letters to media organizations, including STAT.advertisement Michael Tovar, a volunteer who levitra soft had been publicly campaigning for Pfizer to offer the treatment more quickly to participants in the 44,000-person clinical trial, thanked the company and its chief executive on Twitter. “Thank you for listening and for changing your study protocol to allow for speedy vaccination of your placebo arm,” Tovar wrote.

€œYou have made this New Year so much brighter for the 22,000 placebo volunteers that stepped up for this treatment.”advertisement Pfizer and BioNTech revealed the decision on a website for clinical trial participants and in a letter, obtained by STAT, that was sent to researchers conducting the clinical trial.The letter to researchers indicated they are also asking participants to take additional erectile dysfunction treatment tests, to be conducted by clinical trial volunteers at home, to help understand whether the treatment, which reduces symptomatic s by 95%, also levitra soft prevents asymptomatic . The answer to that question is important. Currently, there is no way to know whether people who received the treatment can still transmit it to others.In medicine, the most reliable answers about treatments and preventatives come from double-blind levitra soft placebo-controlled trials.

This means that patients are randomly assigned to receive either the treatment, in this case a treatment, or placebo. Neither they nor their levitra soft doctor knows what they have received. In many trials, such as those for cancer, it’s simply assumed that patients who received placebo will levitra soft get the treatment once the study is completed.

This step is known as crossover.But the matter of how placebo crossover should be handled during a levitra was left open by both the FDA and the U.S. Government’s Operation Warp Speed effort, which sped treatment development, when the studies levitra soft began in July. Consent forms given to volunteers, obtained by STAT, made no mention of when or if those who received placebo would get the two-dose treatment.At a Dec.

10 meeting of an advisory committee regarding the emergency use authorization of the Pfizer/BioNTech treatment, levitra soft the FDA discussed how the placebo crossover should be handled. At that session, Steven Goodman, associate dean of clinical and translational research at the Stanford University School of Medicine, argued that there was no ethical reason that volunteers in the placebo group deserved to receive treatment before the general public. Goodman laid out levitra soft a complicated scheme, known as a double-blind crossover study, in which all volunteers who wanted to be sure they received the treatment would be offered two more shots.

Those who had received the treatment would be offered placebo, and those who had received placebo would be offered the treatment.William Gruber, one of Pfizer’s top treatment executives, argued that this plan was unworkable. Essentially, it would require running a large part of the study a second time.Instead, Pfizer set out a plan in which volunteers who wanted the treatment could receive it when they would be eligible levitra soft to receive the treatment in their local area. Health care personnel or residents in long-term care facilities, who were already eligible to be vaccinated, would get the treatment immediately.“If you are not health care personnel or a resident in a long-term care facility (or in any other future added group), we will discuss an option to transition from the placebo group to the treatment levitra soft group at your fourth study visit, approximately six months after you originally received your second injection,” a letter sent to participants in late December said.

€œWe respectfully ask that you wait until Study Visit #4 to discuss the treatment Transition Option.”This complicated process was moving forward quickly, because many of the participants in the study were health care providers. According to the letter obtained by STAT, 2,000 levitra soft volunteers who received placebo have already gotten their first dose of the Pfizer treatment. But it was clear that others would have to wait.But then, on Dec.

17, the FDA held another advisory meeting, this time for Moderna’s treatment, which had been developed levitra soft more closely with Operation Warp Speed. Again, Goodman made his presentation. A researcher representing Moderna made a case, as Pfizer had, that his idea was impractical, and laid out a plan for giving placebo-receiving volunteers the treatment much faster than levitra soft Pfizer would.

They would not have to wait until they were eligible to get vaccinated outside the trial.The FDA’s advisers levitra soft spent considerable time comparing Goodman’s plan to Moderna’s, eventually agreeing that Goodman’s was unworkable. But they spent little time comparing Pfizer’s plan, which delayed treatment longer, to Moderna’s.That left Pfizer in a bind, as more and more volunteers publicly protested that they should be offered the treatment if they received placebo.Alan S. Goldsmith, a retired levitra soft physician in Florida who volunteered for the Pfizer trial, told STAT that he and his wife, who also volunteered for the study, did not even expect they’d get the treatment if they were in the placebo group.

They just wanted to know if they had already received the treatment. €œWhat it levitra soft would allow us to do is know our vaccination status which might allow a little more freedom to do things like visit our grandchildren,” he wrote.On Dec. 23, Moncef Slaoui, the head of Operation Warp Speed, told reporters that he thought volunteers who had received placebo should receive the treatment at once, contradicting the FDA.

He also called the Pfizer plan intellectually elegant but impractical, saying that with different requirements for vaccination in all 50 states, it would be difficult to administer.Pfizer levitra soft was apparently already working to make its plan for crossover more like Moderna’s. New language posted on its website for trial participants on New Year’s Eve stated that treatment doses had been secured, and that it and BioNTech aimed for all participants who received the placebo to have the opportunity to get their first dose of the treatment by March 1, if they choose to.A letter from Nicholas Kitchin, a senior director in Pfizer’s treatment clinical research and development group, struck a cheerful tone for a clinical document.“We recognize that our clinical trial participants are selfless volunteers who have made the important choice to make a difference and fight this levitra,” Kitchin wrote.“While the study continues to be blinded to answer important public health questions such as persistence of protection, longer term safety and protection from asymptomatic s, we are committed to ensuring that our trial participants are recognized for their contributions and that placebo recipients who wish to can receive BNT162b2 within the study.”.

Pfizer and its partner BioNTech plan lowest levitra price to start offering their erectile dysfunction treatment to clinical trial volunteers who received placebo by March 1, several months earlier than initially planned.The decision represents the conclusion of a complex and public kabuki dance between the Food and Drug Administration, Pfizer, and treatment volunteers, Where can i buy kamagra in the uk as well as with Moderna, which developed its own erectile dysfunction treatment. The FDA and its advisers pushed hard for volunteers to remain on placebo as long as possible to gather more safety and efficacy data about the treatments, while lowest levitra price the companies argued volunteers should receive the treatments sooner for both ethical and practical reasons.Among some trial participants, the issue had become fraught, with many protesting further delays in heated messages on social media and in letters to media organizations, including STAT.advertisement Michael Tovar, a volunteer who had been publicly campaigning for Pfizer to offer the treatment more quickly to participants in the 44,000-person clinical trial, thanked the company and its chief executive on Twitter. “Thank you for listening and for changing your study protocol to allow for speedy vaccination of your placebo arm,” Tovar wrote.

€œYou have made this New Year so much brighter for the 22,000 placebo volunteers that stepped up for this treatment.”advertisement Pfizer and BioNTech revealed the decision on a website for lowest levitra price clinical trial participants and in a letter, obtained by STAT, that was sent to researchers conducting the clinical trial.The letter to researchers indicated they are also asking participants to take additional erectile dysfunction treatment tests, to be conducted by clinical trial volunteers at home, to help understand whether the treatment, which reduces symptomatic s by 95%, also prevents asymptomatic . The answer to that question is important. Currently, there is no way to know whether people who received the treatment can still transmit it to others.In medicine, lowest levitra price the most reliable answers about treatments and preventatives come from double-blind placebo-controlled trials.

This means that patients are randomly assigned to receive either the treatment, in this case a treatment, or placebo. Neither they nor their doctor lowest levitra price knows what they have received. In many trials, such as those for cancer, it’s simply assumed that patients who received placebo will lowest levitra price get the treatment once the study is completed.

This step is known as crossover.But the matter of how placebo crossover should be handled during a levitra was left open by both the FDA and the U.S. Government’s Operation Warp Speed effort, which sped treatment development, when the studies began in lowest levitra price July. Consent forms given to volunteers, obtained by STAT, made no mention of when or if those who received placebo would get the two-dose treatment.At a Dec.

10 meeting of an advisory committee regarding the emergency use authorization lowest levitra price of the Pfizer/BioNTech treatment, the FDA discussed how the placebo crossover should be handled. At that session, Steven Goodman, associate dean of clinical and translational research at the Stanford University School of Medicine, argued that there was no ethical reason that volunteers in the placebo group deserved to receive treatment before the general public. Goodman laid out a complicated scheme, known as a double-blind crossover study, in which all volunteers who wanted to be sure they received lowest levitra price the treatment would be offered two more shots.

Those who had received the treatment would be offered placebo, and those who had received placebo would be offered the treatment.William Gruber, one of Pfizer’s top treatment executives, argued that this plan was unworkable. Essentially, it lowest levitra price would require running a large part of the study a second time.Instead, Pfizer set out a plan in which volunteers who wanted the treatment could receive it when they would be eligible to receive the treatment in their local area. Health care personnel or residents in long-term care facilities, who were already eligible to be vaccinated, would get the treatment immediately.“If you are not health care personnel or a resident in a long-term care facility (or in any other future added group), we will discuss an option lowest levitra price to transition from the placebo group to the treatment group at your fourth study visit, approximately six months after you originally received your second injection,” a letter sent to participants in late December said.

€œWe respectfully ask that you wait until Study Visit #4 to discuss the treatment Transition Option.”This complicated process was moving forward quickly, because many of the participants in the study were health care providers. According to lowest levitra price the letter obtained by STAT, 2,000 volunteers who received placebo have already gotten their first dose of the Pfizer treatment. But it was clear that others would have to wait.But then, on Dec.

17, the FDA held another advisory meeting, this lowest levitra price time for Moderna’s treatment, which had been developed more closely with Operation Warp Speed. Again, Goodman made his presentation. A researcher lowest levitra price representing Moderna made a case, as Pfizer had, that his idea was impractical, and laid out a plan for giving placebo-receiving volunteers the treatment much faster than Pfizer would.

They would not have to wait until they were eligible to get vaccinated outside the trial.The FDA’s advisers spent lowest levitra price considerable time comparing Goodman’s plan to Moderna’s, eventually agreeing that Goodman’s was unworkable. But they spent little time comparing Pfizer’s plan, which delayed treatment longer, to Moderna’s.That left Pfizer in a bind, as more and more volunteers publicly protested that they should be offered the treatment if they received placebo.Alan S. Goldsmith, a retired physician in Florida who volunteered for the Pfizer trial, told STAT that he and his lowest levitra price wife, who also volunteered for the study, did not even expect they’d get the treatment if they were in the placebo group.

They just wanted to know if they had already received the treatment. €œWhat it would allow us to do is know our lowest levitra price vaccination status which might allow a little more freedom to do things like visit our grandchildren,” he wrote.On Dec. 23, Moncef Slaoui, the head of Operation Warp Speed, told reporters that he thought volunteers who had received placebo should receive the treatment at once, contradicting the FDA.

He also called the Pfizer plan intellectually elegant but impractical, saying that with different requirements for vaccination in all 50 states, it would be difficult to administer.Pfizer lowest levitra price was apparently already working to make its plan for crossover more like Moderna’s. New language posted on its website for trial participants on New Year’s Eve stated that treatment doses had been secured, and that it and BioNTech aimed for all participants who received the placebo to have the opportunity to get their first dose of the treatment by March 1, if they choose to.A letter from Nicholas Kitchin, a senior director in Pfizer’s treatment clinical research and development group, struck a cheerful tone for a clinical document.“We recognize that our clinical trial participants are selfless volunteers who have made the important choice to make a difference and fight this levitra,” Kitchin wrote.“While the study continues to be blinded to answer important public health questions such as persistence of protection, longer term safety and protection from asymptomatic s, we are committed to ensuring that our trial participants are recognized for their contributions and that placebo recipients who wish to can receive BNT162b2 within the study.”.

Levitra generic launch

Central venous access catheters are often used for patients requiring repeated infusions, levitra generic launch blood sampling, invasive monitoring or where peripheral access is difficult. For intravenous access of up to 2 weeks in duration, a midline catheter is usually satisfactory, but for longer-term use, peripherally inserted central catheters (PICCs) are increasingly used, including in clinical areas outside of critical care.1Despite enabling complex care to be delivered more easily, these catheters are associated with significant complications—including central levitra generic launch line associated bloodstream s (CLABSI), venous thromboembolism (VTE) and line occlusion. Such complications can result in poor patient outcomes and are associated with levitra generic launch prolonged hospital stays and increased costs of care. In one series of levitra generic launch 438 patients with central lines, 61% reported at least one complication, including bloodstream .2 Accumulating evidence suggests that being selective about who receives PICC lines, of what type and for what duration, could reduce the frequency of such complications. For example, the use of multilumen PICC lines when a single lumen would suffice is associated with increased early and thrombosis.3 In a Canadian study, CLABSI was reported in 5.0% of 907 double-lumen catheters compared with 2.4% of 618 single lumen catheters.3 Thrombosis leading to reinsertion was also much higher with double-lumen lines.3 A simple change in practice of inserting single lumen devices, unless there was clear justification for the contrary, may therefore result in reductions in complications as well as major cost savings.Concurrently, evidence about best practices in implementing interventions to reduce central-line associated complications is also emerging.

Critical care units in Michigan, USA, have long demonstrated leadership levitra generic launch in research to reduce catheter-related complications. In 2004, Pronovost and colleagues used a package of evidence-based interventions in 108 intensive care units (ICUs) with the aim of reducing CLABSI, including s associated with PICC lines.4 A significant reduction was maintained throughout the 18 levitra generic launch months of the study. A key element was the designation of a physician and a nurse as team leaders at each levitra generic launch site. This inspired a UK project called Matching Michigan that demonstrated, in a stepped-wedge study design, that a combination of technical and behavioural interventions could lead to significant reductions in CLABSI rates in the critical care setting.5 However, these programmes have been limited to the critical care setting,6 can be labour-intensive and the long-term effects are levitra generic launch uncertain.7 While simpler-to-implement educational programmes have been associated with marked reductions in the rate of CLABSI,8 training and care processes need to be refreshed regularly and supported with feedback on performance to be effective.9PICCs are now widely used, including in outpatient settings, and complications other than are more common than for other central venous catheters. A broader approach, applicable outside of critical care and for a wider set of complications, is therefore needed.Enter the Michigan Appropriateness Guide for Intravenous Catheters (‘MAGIC’), which was developed to determine when PICC insertion is appropriate, with the aim of reducing the incidence of the associated complications.10 11 Specifically, the major focus of MAGIC was to reduce the use of PICCs for less than 5 days or with multiple lumens and to avoid use in patients with chronic kidney disease.11 12 Implementation of MAGIC now includes online learning, access to subject matter experts, quarterly knowledge-sharing meetings, feedback on performance and pay-for-performance incentives.11 12 Initial research demonstrated preliminary evidence of effectiveness, reducing inappropriate PICC use by 13.8% in one hospital compared with nine control sites (OR 0.86.

95% CI levitra generic launch 0.74 to 0.99). PICC line usage decreased and levitra generic launch single lumen line use increased, but, although catheter occlusion fell significantly, VTE and CLABSI were not significantly reduced in this relatively small scale study,11 and until now, the impact on patient outcomes in a large number of patients across a range of hospitals had not been explored.It is in this context that a further study in this issue12 now builds on this work by demonstrating that the MAGIC programme also reduces the incidence of complications. Data were extracted from case records on PICC insertions across 52 hospitals, with levitra generic launch inappropriate use more common in seriously ill patients and CLABSI more common in those judged ‘inappropriate’. Following the implementation of MAGIC, catheter occlusion fell from 10.6% levitra generic launch to 7.4% of PICC lines, VTE from 3.3% to 2.5% and CLABSI from 1.8% to 1.4%. While the study design does not allow causation to be proven, these effects were statistically significant, suggesting the programme to be effective, and that it should be implemented elsewhere.

This therefore raises levitra generic launch the question of whether the same benefits are likely to be realised elsewhere.It is clear that inappropriate selection of both patients and intravenous catheter types is an expensive and widespread international problem. In France, when pharmacist approval was required for placement of PICCs, 5% of requests were declined as being inappropriate.13 In Canada, application of the MAGIC definitions suggested 13%–21% of 3479 PICC placements to be inappropriate.14 The MAGIC programme, or similar initiatives, levitra generic launch are therefore likely to minimise harm to patients from complications associated with inappropriate use of PICCs in other countries. Clear evidence-based criteria for selection of patients for PICC insertion, combined with multidisciplinary communication, as proposed in the MAGIC programme, are likely to be important internationally in deciding when to place a PICC rather than another access levitra generic launch device. However, adaptation to local methods and contexts of healthcare delivery are likely to be needed. This is for levitra generic launch several reasons.

First, countries outside the USA may not share the pay-for-performance framework that provided incentives to hospitals participating in the MAGIC project.Second, some countries may have already levitra generic launch introduced other interventions to reduce complications of central venous catheters. In India, basic training in hand hygiene and hub care, repeated until a high level of knowledge was demonstrated in tests, resulted in CLABSI reduction from 8.7 to 4.5/1000 catheter days.13 In Italy, training of healthcare workers based on a package of evidence-based preventative measures including removal of catheters when levitra generic launch no longer needed, reduced CLABSI from 8.6 to 2.6/1000 catheter days.14Third, the method of delivery of PICC insertion may vary by country, which has important implications for whom to target with the MAGIC intervention. Delivery of PICC insertion in a number of countries, as in USA, follows a variety of levitra generic launch models, including specialist nurse training and delivery, off-site insertion or use of interventional radiology vascular access teams.15 Selection of patients and insertion of central venous catheters, particularly outside critical care, are often the responsibility of a dedicated specialist team with access to uasound or interventional radiology. High levels of training improve standards of insertion and reduce rates, especially when combined with surveillance and feedback of performance.4 5 However, dedicated specialist teams may be asked to insert PICCs for inappropriate indications, or where there are inadequate skills or resources in the clinical teams to use alternatives. Others have reduced use of PICC catheters by levitra generic launch improving training in uasound guided peripheral intravenous catheter placement.16Fourth, to be effective on a national scale, particularly where there are wide variations in performance between individual hospitals, quality improvement programmes such as MAGIC need to be supported by robust and independent surveillance that incorporates feedback systems.5 MAGIC was introduced into an established quality improvement infrastructure and adequate staffing.

Surveillance is time-consuming when reliant on manual data collection and, if resources are limited, surveillance may not be possible, or data collectors may only observe samples of the patient population levitra generic launch. The advent of electronic patient record systems allows more patients to be monitored and in the ICU can be both more sensitive and more specific than manual collection of data for healthcare-acquired s.17 These surveillance systems are gradually improving and spreading, providing continuous feedback and peer comparison, based on semiautomated electronic data collection.18 However, the software packages required for levitra generic launch extraction of the data are expensive and, in some countries, many hospitals do not have electronic patient records. National implementation of MAGIC could be achieved by using an existing surveillance and improvement network, or by linking local quality improvement projects, to allow peer levitra generic launch comparisons. One such system started in the UK in 2016 and has been recruiting ICUs in surveillance of bacteraemia and catheter s, including PICC-related s.18 This in Critical Care Quality Improvement Programme is a joint initiative between professional organisations representing adult, paediatric and neonatal intensive care, microbiology and control, supported by Public Health England. In its first year, 45% of adult ICUs took part and reported 2.3 ICU-associated CLABSI per 1000 central venous catheter levitra generic launch days while also demonstrating marked variation between sites in both practice and outcomes.

Broadening such a programme to include other complications of PICC would be relatively straightforward.Now is the time to see if MAGIC or similar levitra generic launch programmes can be extended to different healthcare systems internationally. The quality of patient care may be improved considerably if the practices of the best performers were adopted more widely, whether levitra generic launch in ensuring the appropriate means of vascular access is used and/or in improving training in insertion and care of the line. According to the context in each country, a mixture of incentives and requirements for education, surveillance and feedback of complication rates associated with PICCs, driven by leadership from professional bodies and programmes such as MAGIC, are likely to be needed for significant national improvements to be made.Ethics statementsPatient consent for publicationNot required..

Central venous access lowest levitra price catheters are often used for patients requiring repeated infusions, blood sampling, invasive monitoring or where peripheral access is http://www.em-vauban-strasbourg.ac-strasbourg.fr/lecole/reglement-interieur/ difficult. For intravenous access of up to 2 weeks in duration, a midline catheter is usually satisfactory, but for lowest levitra price longer-term use, peripherally inserted central catheters (PICCs) are increasingly used, including in clinical areas outside of critical care.1Despite enabling complex care to be delivered more easily, these catheters are associated with significant complications—including central line associated bloodstream s (CLABSI), venous thromboembolism (VTE) and line occlusion. Such complications can result in poor lowest levitra price patient outcomes and are associated with prolonged hospital stays and increased costs of care. In one series of 438 patients with central lines, 61% reported at least one complication, including bloodstream .2 Accumulating evidence suggests that being selective about who receives PICC lines, of what type and for what duration, could reduce lowest levitra price the frequency of such complications. For example, the use of multilumen PICC lines when a single lumen would suffice is associated with increased early and thrombosis.3 In a Canadian study, CLABSI was reported in 5.0% of 907 double-lumen catheters compared with 2.4% of 618 single lumen catheters.3 Thrombosis leading to reinsertion was also much higher with double-lumen lines.3 A simple change in practice of inserting single lumen devices, unless there was clear justification for the contrary, may therefore result in reductions in complications as well as major cost savings.Concurrently, evidence about best practices in implementing interventions to reduce central-line associated complications is also emerging.

Critical care units in Michigan, USA, have long demonstrated leadership in research to reduce lowest levitra price catheter-related complications. In 2004, Pronovost and colleagues used a package of evidence-based interventions in 108 intensive care units (ICUs) with the aim of reducing CLABSI, including s associated with PICC lines.4 A significant reduction was maintained throughout the 18 months of the study lowest levitra price. A key element was the designation of a physician and a lowest levitra price nurse as team leaders at each site. This inspired a UK project called Matching Michigan that demonstrated, in a stepped-wedge study design, that a combination of technical and behavioural interventions could lead to significant reductions in CLABSI rates in the critical care setting.5 However, these programmes have been limited to the critical care setting,6 lowest levitra price can be labour-intensive and the long-term effects are uncertain.7 While simpler-to-implement educational programmes have been associated with marked reductions in the rate of CLABSI,8 training and care processes need to be refreshed regularly and supported with feedback on performance to be effective.9PICCs are now widely used, including in outpatient settings, and complications other than are more common than for other central venous catheters. A broader approach, applicable outside of critical care and for a wider set of complications, is therefore needed.Enter the Michigan Appropriateness Guide for Intravenous Catheters (‘MAGIC’), which was developed to determine when PICC insertion is appropriate, with the aim of reducing the incidence of the associated complications.10 11 Specifically, the major focus of MAGIC was to reduce the use of PICCs for less than 5 days or with multiple lumens and to avoid use in patients with chronic kidney disease.11 12 Implementation of MAGIC now includes online learning, access to subject matter experts, quarterly knowledge-sharing meetings, feedback on performance and pay-for-performance incentives.11 12 Initial research demonstrated preliminary evidence of effectiveness, reducing inappropriate PICC use by 13.8% in one hospital compared with nine control sites (OR 0.86.

95% CI lowest levitra price 0.74 to 0.99). PICC line usage decreased and single lumen line use increased, but, although catheter occlusion fell significantly, VTE and CLABSI were not significantly reduced in this relatively small scale study,11 and until now, the impact on patient outcomes in a large number of patients across a range of hospitals had not been explored.It is in this context that a further study in this issue12 now builds on this work by demonstrating that the lowest levitra price MAGIC programme also reduces the incidence of complications. Data were extracted from case records on PICC insertions across 52 hospitals, with inappropriate use more common in seriously ill patients and CLABSI more lowest levitra price common in those judged ‘inappropriate’. Following the implementation of MAGIC, catheter occlusion fell from 10.6% to 7.4% of PICC lines, VTE from 3.3% to 2.5% and CLABSI from 1.8% lowest levitra price to 1.4%. While the study design does not allow causation to be proven, these effects were statistically significant, suggesting the programme to be effective, and that it should be implemented elsewhere.

This therefore raises the question of whether the same benefits lowest levitra price are likely to be realised elsewhere.It is clear that inappropriate selection of both patients and intravenous catheter types is an expensive and widespread international problem. In France, when pharmacist approval was required for placement lowest levitra price of PICCs, 5% of requests were declined as being inappropriate.13 In Canada, application of the MAGIC definitions suggested 13%–21% of 3479 PICC placements to be inappropriate.14 The MAGIC programme, or similar initiatives, are therefore likely to minimise harm to patients from complications associated with inappropriate use of PICCs in other countries. Clear evidence-based criteria for selection of patients for PICC insertion, combined with multidisciplinary communication, as proposed in the MAGIC programme, are likely to be important internationally in deciding when to lowest levitra price place a PICC rather than another access device. However, adaptation to local methods and contexts of healthcare delivery are likely to be needed. This is lowest levitra price for several reasons.

First, countries outside the USA may not share the pay-for-performance framework that provided incentives to hospitals participating in the MAGIC project.Second, some countries may lowest levitra price have already introduced other interventions to reduce complications of central venous catheters. In India, basic training in hand hygiene and hub care, repeated until a high level of knowledge was demonstrated in tests, resulted in CLABSI reduction from 8.7 to 4.5/1000 catheter days.13 In Italy, training of healthcare workers based on a package of evidence-based preventative measures including removal of catheters when no longer needed, reduced CLABSI from 8.6 to 2.6/1000 catheter days.14Third, the method of delivery of PICC insertion may vary by country, which has important implications lowest levitra price for whom to target with the MAGIC intervention. Delivery of PICC insertion in a number of countries, as in USA, follows a variety of models, including lowest levitra price specialist nurse training and delivery, off-site insertion or use of interventional radiology vascular access teams.15 Selection of patients and insertion of central venous catheters, particularly outside critical care, are often the responsibility of a dedicated specialist team with access to uasound or interventional radiology. High levels of training improve standards of insertion and reduce rates, especially when combined with surveillance and feedback of performance.4 5 However, dedicated specialist teams may be asked to insert PICCs for inappropriate indications, or where there are inadequate skills or resources in the clinical teams to use alternatives. Others have reduced use of PICC catheters by improving training in uasound guided peripheral intravenous catheter placement.16Fourth, to be effective on lowest levitra price a national scale, particularly where there are wide variations in performance between individual hospitals, quality improvement programmes such as MAGIC need to be supported by robust and independent surveillance that incorporates feedback systems.5 MAGIC was introduced into an established quality improvement infrastructure and adequate staffing.

Surveillance is time-consuming when reliant on lowest levitra price manual data collection and, if resources are limited, surveillance may not be possible, or data collectors may only observe samples of the patient population. The advent of electronic patient record systems allows more patients to be monitored and in the ICU can be both more sensitive and more specific than manual collection of data for healthcare-acquired s.17 These surveillance systems are gradually improving and spreading, providing lowest levitra price continuous feedback and peer comparison, based on semiautomated electronic data collection.18 However, the software packages required for extraction of the data are expensive and, in some countries, many hospitals do not have electronic patient records. National implementation of MAGIC could be achieved by using an existing surveillance and improvement network, or by linking local lowest levitra price quality improvement projects, to allow peer comparisons. One such system started in the UK in 2016 and has been recruiting ICUs in surveillance of bacteraemia and catheter s, including PICC-related s.18 This in Critical Care Quality Improvement Programme is a joint initiative between professional organisations representing adult, paediatric and neonatal intensive care, microbiology and control, supported by Public Health England. In its first year, 45% of adult ICUs took part and reported 2.3 ICU-associated CLABSI per 1000 central venous catheter days while also demonstrating marked variation between sites in both practice and lowest levitra price outcomes.

Broadening such a programme to include other complications of PICC would be relatively straightforward.Now lowest levitra price is the time to see if MAGIC or similar programmes can be extended to different healthcare systems internationally. The quality of patient care may be improved considerably if the practices of the best performers were adopted more widely, whether in ensuring the appropriate means lowest levitra price of vascular access is used and/or in improving training in insertion and care of the line. According to the context in each country, a mixture of incentives and requirements for education, surveillance and feedback of complication rates associated with PICCs, driven by leadership from professional bodies and programmes such as MAGIC, are likely to be needed for significant national improvements to be made.Ethics statementsPatient consent for publicationNot required..

Levitra oral jelly

Credit...Zack DeZon levitra oral jelly for The New York TimesSkip to contentSkip to site indexHow to Master the Push-UpWith proper technique, you can get the most out of this simple, yet powerful exercise.Credit...Zack DeZon for The New York TimesSupported byContinue reading the main storySend any friend a storyAs a subscriber, you have 10 gift articles to give each month. Anyone can read what you share.157May 18, 2022Simple, strenuous and possible to levitra oral jelly do almost anywhere, push-ups are an almost universally known exercise and a mainstay of military, sport and fitness training regimens. Push-ups are a “basic, foundational movement,” said James Whitener III, a strength and conditioning coach at Bethune-Cookman University in Florida.Because it requires a cognizance of the body’s position from head to toe, the exercise helps to develop something called kinesthetic awareness — an understanding of how one’s body moves through space. This awareness, in turn, can help exercisers develop a sense of their body’s ability and prepare them for “bigger, more complex movements,” like dead lifts or squats, he said.But getting the most out of levitra oral jelly push-ups requires good technique.

Here’s what you need to know.What makes push-ups greatPush-ups hone your chest, shoulders and arms — particularly the deltoid, triceps levitra oral jelly and pectoral muscles — but they’re really a full body movement. €œWe think of it as an upper body exercise, but it’s also working the core muscles and building coordination as well,” Mr. Whitener said levitra oral jelly. Holding your body in a rigid plank position while executing a push-up activates your core muscles and can even require some work from your legs too.“They’re very versatile, because they just target so many things at once,” said Tessia De Mattos, a physical therapist and strength, conditioning and performance rehabilitation coach at The Strength Athlete.How to do a push-upTo start, get into a classic plank position with your palms on the ground, arms slightly wider than shoulder-width apart and your palms about even with your shoulders.

Mastering regular planks is important, levitra oral jelly Dr. De Mattos said, because “if you can’t do a full plank with proper form, you’re going to have difficulty performing a levitra oral jelly full push-up.”Well How To. Push-ups Step 1 Your body should form a straight line, with your legs fully extended behind you and your hips, knees and ankles aligned. Step 2 levitra oral jelly Keeping your body rigid in a straight line, with your face toward the ground, lower yourself toward the floor, stopping just before your nose touches the floor.

Step 3 Your fingers should be pointing straight in front of you and your elbows comfortably several inches from your sides. Be sure levitra oral jelly your elbows don’t flare out on the way down. Step 4 levitra oral jelly With your elbows bent at about a 45 degree angle, push back up to the starting position. Step 5 As you push up, press your shoulder blades back and down, as if pushing them toward your butt.

Step 6 levitra oral jelly Repeat. For a standard workout, go until momentary failure — the point where you can’t complete another rep with good form. Don’t try to squeeze one last rep levitra oral jelly with bad form. To ensure that you’re using good form, try filming yourself with a smartphone, advised Hampton Liu, a personal trainer, fitness influencer and founder of levitra oral jelly Hybrid Calisthenics.

€œYou don’t have to show anyone your video!. You can even delete levitra oral jelly it immediately afterward. It’s just for you.”Two common mistakes, Dr. De Mattos levitra oral jelly said, are letting your belly sag or arching your lower back rather than keeping it aligned with the rest of your body.How many?.

How many repetitions you should do depends on your current ability and levitra oral jelly your objectives. For the average person who is trying to get healthier, fitter and stronger, the best approach is to aim for momentary failure — the point of fatigue where you can’t complete another rep with good form — rather than a specific number of repetitions, said Patroklos Androulakis-Korakakis, a researcher at Solent University in England and strength coach at StrongerByScience.com.“By reaching momentary failure, or at least getting very close to it, people can ensure that they’re getting a sufficient enough stimulus for strength and hypertrophy adaptations,” he said.If you can’t do more than a handful of repetitions before reaching this point, you can try some of the easier variations below. As you progress, you can switch back to standard push-ups and then move on to levitra oral jelly more difficult variations to increase the difficulty as you get stronger, Dr. Androulakis-Korakakis said.To make the push-up easier …“There’s no reason to be ashamed if you can’t do a push-up.

Fitness is a journey and we all start somewhere,” Mr levitra oral jelly. Liu said in a video about push-ups levitra oral jelly. If you can’t yet do a push-up, “you can build up,” he added.Wall push-ups are a great way to start your push-up journey and can be done almost anywhere. Credit...Zack DeZon levitra oral jelly for The New York TimesWall push-upIf you’re just starting out, Mr.

Liu suggested trying levitra oral jelly wall push-ups. Stand facing a wall at arm’s length, and place your hands about shoulder-width apart against it. Lean in until your face levitra oral jelly almost touches the wall, then push back to your starting position. Do as many reps as you can, and when this gets easy, you can progress to a kneeling push-up.A kneeling push-up takes some of the load off of your arms while allowing you to refine your form and get a workout.Credit...Zack DeZon for The New York TimesKneeling push-upIf you can’t quite do a standard push-up yet, you can give yourself a bit of a boost by initiating the movement from a kneeling position, which reduces the amount of load you’re putting on your arms, shoulders and chest, Dr.

De Mattos levitra oral jelly said.To make the push-up harder …As you become more proficient at doing push-ups, you’ll need to do more of them to reach the point of momentary failure. Performing exercises levitra oral jelly to this point can maximize motor unit and muscle fiber recruitment, Dr. Androulakis-Korakakis said, which in turn will stimulate adaptations and make you stronger. €œReaching momentary levitra oral jelly failure is a great way to ensure people are getting the most out of each set.” Here are some ways to get you there.Just as lowering you knees to the ground makes push-ups easier, raising your feet onto a bench or chair behind you makes them harder.Credit...Zack DeZon for The New York TimesRaised leg push-upOnce you become adept at standard push-ups, you can increase the difficulty by starting the push-up movement with your feet elevated above you, Mr.

Liu said. Starting with a few books on levitra oral jelly the ground underneath your feet should provide some noticeable difference, he said. From there, you can try a short stool (maybe a foot off the levitra oral jelly ground) and then work up to a chair or even a railing.Creating a triangle or diamond with your thumbs and index fingers forces your arms closer together, thus making the push-up more challenging. Credit...Zack DeZon for The New York TimesNarrow (or diamond) push-upThese are a more difficult push-up variation that you do by holding your hands together with your thumbs and forefingers touching in a way that creates a diamond-shaped hole where your hands come together.

You can work your way up to these by simply moving your hands a little closer together until that becomes easy, then moving them closer and closer levitra oral jelly until eventually they finally touch, Mr. Liu said.Adding weight to your back is another way to increase difficulty. Be sure not to use something that could tumble off and hit your head or fingers.Credit...Zack DeZon for The New York levitra oral jelly TimesWeighted push-upWhen you can do sets of 10 push-ups easily, you can turn up the difficulty by placing a small weight plate on your back to increase the weight you’re pushing. If you’re doing these at home and don’t have weights, you can throw a few heavy books in a backpack and levitra oral jelly use that as a weight, Dr.

De Mattos said. The extra weight shouldn’t be so much that you can’t do more than a couple, but should be enough to get you to the point levitra oral jelly of momentary failure in about ten reps or less.One armed push-upThese require excellent core strength to keep your body in position as you push up with a single arm, Mr. Liu said. €œIt’s a great core exercise.” The trick here is to use your legs and core to levitra oral jelly keep your body stable as you push up with a single arm.

Spreading your feet further apart can help you stabilize yourself as you go.There are lots of ways to do push-ups, Mr. Liu said. €œFind one you can do, and work it.” As you get stronger you can progress to a harder version.Christie Aschwanden is a writer based in western Colorado and the author of “Good to Go. What the Athlete in All of Us Can Learn from the Strange Science of Recovery.”AdvertisementContinue reading the main story.

Credit...Zack DeZon for The New York TimesSkip to contentSkip to site indexHow to Master the Push-UpWith proper technique, you can get lowest levitra price the most out of this simple, yet powerful exercise.Credit...Zack DeZon for The New York TimesSupported byContinue reading the main storySend any friend a storyAs a subscriber, you have 10 gift articles to give each month. Anyone can read what you share.157May 18, 2022Simple, strenuous and possible lowest levitra price to do almost anywhere, push-ups are an almost universally known exercise and a mainstay of military, sport and fitness training regimens. Push-ups are a “basic, foundational movement,” said James Whitener III, a strength and conditioning coach at Bethune-Cookman University in Florida.Because it requires a cognizance of the body’s position from head to toe, the exercise helps to develop something called kinesthetic awareness — an understanding of how one’s body moves through space.

This awareness, in turn, can help exercisers develop a lowest levitra price sense of their body’s ability and prepare them for “bigger, more complex movements,” like dead lifts or squats, he said.But getting the most out of push-ups requires good technique. Here’s what you need to know.What makes push-ups lowest levitra price greatPush-ups hone your chest, shoulders and arms — particularly the deltoid, triceps and pectoral muscles — but they’re really a full body movement. €œWe think of it as an upper body exercise, but it’s also working the core muscles and building coordination as well,” Mr.

Whitener said lowest levitra price. Holding your body in a rigid plank position while executing a push-up activates your core muscles and can even require some work from your legs too.“They’re very versatile, because they just target so many things at once,” said Tessia De Mattos, a physical therapist and strength, conditioning and performance rehabilitation coach at The Strength Athlete.How to do a push-upTo start, get into a classic plank position with your palms on the ground, arms slightly wider than shoulder-width apart and your palms about even with your shoulders. Mastering regular planks is important, Dr lowest levitra price.

De Mattos said, because “if you can’t do a full plank with proper form, you’re going to have difficulty performing a full push-up.”Well lowest levitra price How To. Push-ups Step 1 Your body should form a straight line, with your legs fully extended behind you and your hips, knees and ankles aligned. Step 2 Keeping your body rigid in a straight line, with your face toward the ground, lower yourself toward the floor, stopping just before your nose lowest levitra price touches the floor.

Step 3 Your fingers should be pointing straight in front of you and your elbows comfortably several inches from your sides. Be sure your elbows don’t flare out on the way down lowest levitra price. Step 4 With your elbows bent at about a 45 degree angle, push back up to the starting lowest levitra price position.

Step 5 As you push up, press your shoulder blades back and down, as if pushing them toward your butt. Step lowest levitra price 6 Repeat. For a standard workout, go until momentary failure — the point where you can’t complete another rep with good form.

Don’t try to squeeze lowest levitra price one last rep with bad form. To ensure that you’re using good lowest levitra price form, try filming yourself with a smartphone, advised Hampton Liu, a personal trainer, fitness influencer and founder of Hybrid Calisthenics. €œYou don’t have to show anyone your video!.

You can lowest levitra price even delete it immediately afterward. It’s just for you.”Two common mistakes, Dr. De Mattos said, are letting your belly sag or arching your lower back rather than keeping it lowest levitra price aligned with the rest of your body.How many?.

How many repetitions you should do depends on your current lowest levitra price ability and your objectives. For the average person who is trying to get healthier, fitter and stronger, the best approach is to aim for momentary failure — the point of fatigue where you can’t complete another rep with good form — rather than a specific number of repetitions, said Patroklos Androulakis-Korakakis, a researcher at Solent University in England and strength coach at StrongerByScience.com.“By reaching momentary failure, or at least getting very close to it, people can ensure that they’re getting a sufficient enough stimulus for strength and hypertrophy adaptations,” he said.If you can’t do more than a handful of repetitions before reaching this point, you can try some of the easier variations below. As you progress, you can switch back to standard push-ups and then move on to more difficult variations to increase the difficulty as lowest levitra price you get stronger, Dr.

Androulakis-Korakakis said.To make the push-up easier …“There’s no reason to be ashamed if you can’t do a push-up. Fitness is a journey and we all start somewhere,” Mr lowest levitra price. Liu said lowest levitra price in a video about push-ups.

If you can’t yet do a push-up, “you can build up,” he added.Wall push-ups are a great way to start your push-up journey and can be done almost anywhere. Credit...Zack DeZon for The New York TimesWall push-upIf you’re just starting out, Mr lowest levitra price. Liu suggested lowest levitra price trying wall push-ups.

Stand facing a wall at arm’s length, and place your hands about shoulder-width apart against it. Lean in until your face almost lowest levitra price touches the wall, then push back to your starting position. Do as many reps as you can, and when this gets easy, you can progress to a kneeling push-up.A kneeling push-up takes some of the load off of your arms while allowing you to refine your form and get a workout.Credit...Zack DeZon for The New York TimesKneeling push-upIf you can’t quite do a standard push-up yet, you can give yourself a bit of a boost by initiating the movement from a kneeling position, which reduces the amount of load you’re putting on your arms, shoulders and chest, Dr.

De Mattos said.To make the lowest levitra price push-up harder …As you become more proficient at doing push-ups, you’ll need to do more of them to reach the point of momentary failure. Performing exercises to this point can maximize motor unit and muscle fiber recruitment, lowest levitra price Dr. Androulakis-Korakakis said, which in turn will stimulate adaptations and make you stronger.

€œReaching momentary failure is a great way to ensure people are getting the most out of each set.” Here are some ways to get you there.Just as lowering you knees to the ground makes push-ups easier, raising your feet onto a bench or chair behind you makes them harder.Credit...Zack DeZon for The New York TimesRaised leg push-upOnce you become adept at standard push-ups, you can increase the difficulty by starting the push-up movement with your feet elevated above you, Mr lowest levitra price. Liu said. Starting with a few books on the ground lowest levitra price underneath your feet should provide some noticeable difference, he said.

From there, you can try a short stool (maybe a foot off the ground) and then work up to a chair or even a railing.Creating a triangle or diamond with your thumbs and index lowest levitra price fingers forces your arms closer together, thus making the push-up more challenging. Credit...Zack DeZon for The New York TimesNarrow (or diamond) push-upThese are a more difficult push-up variation that you do by holding your hands together with your thumbs and forefingers touching in a way that creates a diamond-shaped hole where your hands come together. You can work your way up to these by simply moving your hands a little closer together until that becomes easy, then lowest levitra price moving them closer and closer until eventually they finally touch, Mr.

Liu said.Adding weight to your back is another way to increase difficulty. Be sure not to use something that could tumble off and hit your head or fingers.Credit...Zack DeZon for The New York TimesWeighted push-upWhen you can do sets of 10 push-ups easily, you can turn up the difficulty by placing a small weight plate on your back to increase the weight you’re lowest levitra price pushing. If you’re doing these at home and don’t have weights, you can throw a few heavy books in a backpack and use that as lowest levitra price a weight, Dr.

De Mattos said. The extra weight shouldn’t be so lowest levitra price much that you can’t do more than a couple, but should be enough to get you to the point of momentary failure in about ten reps or less.One armed push-upThese require excellent core strength to keep your body in position as you push up with a single arm, Mr. Liu said.

€œIt’s a great core exercise.” The trick here is to use your legs and core to keep your body stable as you push up with a lowest levitra price single arm. Spreading your feet further apart can help you stabilize yourself as you go.There are lots of ways lowest levitra price to do push-ups, Mr. Liu said.

€œFind one you can do, and work it.” As you get stronger you can progress to a harder version.Christie Aschwanden is a writer based in western Colorado and the author of “Good to Go. What the Athlete in All of Us Can Learn from the Strange Science of Recovery.”AdvertisementContinue reading the main story.