Month: June 2016

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adult Oral Sedation dental office

adult Oral Sedation as part of dentistry can be a wonderful addition to the services provided to your patients. This article is not intended to provide any training in oral sedation, you are encouraged to take such approved courses.

The ability to treat patients that otherwise go without proper care can be very rewarding for you, your team and your patients. Currently, California, licenses acquired through the Dental Board is required. Part 1004 defines an adult as conscious in all patients over the age of 13, although I personally just treat patients over 18 This permission is only needed if the dentist is going to give medication doses that exceed FDA daily recommended dose. A dentist can apply either by submitting 10 board approved sedations completed before Dec. 31, 2005, have 25 hours of classroom instruction and examination of the patient first live experience of a Board approved CE provider. The license must be renewed every 2 years to a minimum of 7 hours of CE in sedation. Just training the whole dental team, monitoring equipment, emergency training and equipment is required.

Usually in our work, our sedation patients fall into two categories- fear based and time based. Patients fear base are just as you would think, they usually have some previous dental experience that has kept them form a dental office. It is not uncommon for us to see a patient who has not had a dental visit for 10, 20, 30 years in some cases. Typical concerns are bad childhood experience, pain treatment, fear of needles, sound, smell, difficulty getting numb, gag reflex or bad rapport with the dentist. Time based patients usually have at least some fear, but also want to have as few commands as possible to get back to maintenance visit. Patients with hectic work schedules and frequent business travel are examples of patients based on time. The entire dental team must be highly skilled, compassionate, well trained and have excellent communication skills to properly handle patient sedation. Increased patient fears or needs require the team go the extra mile to put the patient at ease.

As before, we treat only patients 18 years or older. Generally, ASA I or ASA II are good candidates and advanced training ASA III can be treated. We consult with each patient a doctor for treatment. Also, a complete medical history and pre-op vitals taken. Oral sedation is very safe, but there are some contraindications – pregnancy, allergy medicine is used, the interaction of some drugs the patient is already taking – I will not go into all that now. Triazolam is the main drugs we use for sedation mouth. Triazolam is a benzodiazepine sedative-hypnotic in the family. Amnesia is natural and welcomed side effect for my patients. Usually the patient takes a small dose of diazepam sleep and we can also complement triazolam with hydroxyzine. We also, quite often, additional sedative with a low dose of nitric oxide during the administration of local anesthetic and oral. Typical sedation appointment is 5-6 hours. We can carry out the treatment of simple restorative, crown and bridge and periodontal treatment (with one trained Hygienists our) full mouth reconstruction, endodontic treatment, oral and laser gum treatment. Our patients are constantly monitored by a pulse oximeter / pulse / blood pressure monitor. We do not put our patients to sleep. They are in a relaxed state that allows them to complete the requested treatment. We can communicate with patients about their appointments as needed. At the conclusion of the appointment, escort the patient is given after surgery and teaching the patient will return home to nap the rest of the afternoon. Patients appreciate amnesiac effect of triazolam. I’ve had patients call the office later in the day, upset that they have slept through and missed their appointments only to be told they were in the office from 7:30 to 1:00 pm.

I hope this give you a brief insight into adult sedation intake and how this can be a wonderful service to provide your patients.

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Source by Craig Johnson DDS

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When you can sue the hospital or its employees for negligence?

A hospital can be sued for negligent mistakes that harm or kill the patient. When an employee of the hospital is guilty of negligence, you can sue the hospital. When a physician working for the hospital makes mistakes, both personal doctor and the hospital as a whole can be sued. However, doctors can only be sued if they were available and could have prevented the failure. You can not sue every doctor in the emergency room or surgical floor, only the one who is or oversaw treatment. Hospitals can also sue the doctor with a history of medical negligence and mistakes were kept on the payroll, thus enabling them to continue to harm patients.

What constitutes neglect?

Neglect occurs when someone is not doing his job as a normal and competent professional would. Failure does not establish guidelines, not a checklist, not to assist patients in need and do not take immediate action in an emergency. There is more tolerance for mistakes made in life-threatening emergencies and general conditions care. Malpractice and negligence can arise from failure to properly diagnose a condition or injury. Neglect can occur when someone is given inappropriate treatment or appropriate treatment is given incorrectly. Nurses administer the wrong medication and treatment protocols are following the wrong example.

Failing to stop patients from the negative results of the medical treatment or side effects of treatment is also negligent. Recommend surgery to cure cataracts that can also leave the patient blind is an example of this concept. To sue for negligence, the risk to be significant enough that the patient could have chosen to have the procedure or treatment if they had known and must have suffered a negative result.

Can Sue professionals other than physicians in the hospital?

Yes. Every medical professional connected with a hospital can be sued for negligence. This includes nurses, physical therapists, medical technicians and pharmacists. First responders such as paramedics and firefighters have a high level of protection against medical negligence claims, because of the difficulty in acting during emergencies, unless they are employees of the hospital and provide care at the facility. Good Samaritans are rarely sued for negligence unless their actions are reckless.

What types of damage are available when someone sues hospital for negligence?

There will be a specific injury as well as actual damages to sue for negligence. You can not sue the hospital because you were unhappy with the level of service.

• The physical pain and suffering
• Medical bills with other primary care or specialists in treating conditions due to the negligence of the hospital, injuries hospital or analyzing what hospital failed to find.
• Lost revenue due to inability to work or lost income of the person who died
• Medical bills for further treatment in a hospital if the patient had received a proper course of treatment.
• The cost of physiotherapy or assisted care while level

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Source by Michael Krillman

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automated appointment reminder system can safely send large amounts of personal appointment reminders to patients with little effort and in a fraction of the cost of manual methods. The effortful part of the process is extracting patient appointment information and send it to the seller. For some practices, reminder system can automatically extract patient appointment information from the job management system, forming appointment reminders, send reminders, and track responses. In other practices, staff need to create a file with patient appointment information. This is usually easy. If practices do not store appointment information electronically, they can send this information by inputting command information online.

Advantages of sending automatic appointment reminders

more comfort for patients. Since the front Office is limited to call the office, they usually reach an answering machine. Automatic reminder system can make reminder calls at night and on weekends, when patients are more likely to be home. While the message left on the answering machine can serve as effective reminders, this message lacks an important feature: interactivity. By reaching the patient, the patient can easily confirm or cancel the appointment during a call.

Reliable, effortless, consistent reminders. Making reminder call for a reminder call is tedious chore for the staff. Fatigue make the routine reminder call can adversely affect the other person’s tone of voice. However, a reminder call is consistent in tone and content. The messages are pre-recorded in the studio with professional voice actors. The recipient can easily repeat the message and call the office if further assistance is required.

Relying on staff to call or send out reminder postcards are burdened not only staff but also have other projects they may or may not get around to complete. Certainly a few days, they forget to take all alerts or calls they just run out of time to do it. However, this is not the case for automatic reminder system.

releases time for other tasks. Other but the time it takes for an employee to a command system information and to view reports, good automatic reminder system requires little interaction and minimal training. Although practices are naturally hesitant to adopt a new tool that can disrupt current workflow, automated appointment reminder system very easy to use and can save hours a day.

Small manual process to make reminder calls. Someone needs to call the number, track responses, keep track of those who need to be called back, try again a few numbers, spending time in answering other questions that come up in conversation, etc. Automated alerts are much more efficient.

Tips for using the automatic appointment reminders

Although most practices that accept appointment reminders are satisfied with the results, there are some potential pitfalls to use Automatic reminder. To avoid these pitfalls, consider setting expectations and ask for feedback.

Set expectations. It is important that staff and patients know what to expect when you switch to automatic reminder system. Explain how reminders work for all employees so that they can field questions from patients. At least, the use of signs and handouts to explain the new reminder services to patients. Most patients are used to receive automatic messages and will appreciate the service.

Ask for feedback. If you are concerned that your patients will not like to receive automatic appointment reminders, do not sign long-term contract with a service provider. Consider the first months of service as a trial period. Ask staff how they feel about the service reminder and whether they have had a positive and / or negative comments from patients. You might want to ask patients directly, especially if you already sent out patient satisfaction surveys.

Listen carefully to feedback. If the majority are happy with the service, you should continue to send automatic reminders. If many express dissatisfaction with the service, it may be time to consider another reminder service.

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Source by Susan Linton

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Healthcare practice owners and managers are often astounded to realize that it can cost as much as $ 6 or $ 7 to successfully collect payment patients with traditional accounts through email. Based employee time, plus postage paid envelopes, the cost adds up truly already sending dozens of accounts each week. Working hours preparing accounts also reduces other efforts around the office – valuable time that could be focused on improving patient flow, document management, etc. – not to mention that most patients are sent two or even three accounts before they return payment. Establishing formal payment policies with your patients can improve collections and reduce training costs.

Design Patient Payment Policy:
When designing a payment strategy, spend some time talking to staff, responsible for the collection and colleagues in other practices. These resources often provide insightful information from direct personal experience of what works and what does not. Consider the history of your job to define how far you should pick a payment policy; there are variations from one locale to the next in terms of age, economic status, and so on. In some areas a written statement that insurance policies you agree and that “payment is due in full at the time services” may be sufficient. Other areas may need detailed information about payment plans, minimum payments and your use of collection agencies to set appropriate expectations.

Just remember to keep it simple. The more simple strategy, the more effective it will be. Be upfront about your rules, explain how you will handle free of charge, and driving with enforcement. Too many practices have found out the hard way it is much easier to offer a well-written policy in advance but it is shocked to calm the patient down when asked to make a large payment on site.

some items
The simple, direct payment policy would require all patient obligations are met at the time of service, but it is not always an option. What about patients “forget” their defense? How about those patients who just do not have enough money to cover expensive process? Below are several options that you might want to consider.

collect fees
Some practices offer to send out patient accounts instead of payment in the office, but add a “collection fee” for each mailed statement. These fees often range anywhere from $ 1 $ 5 per statement and help cover some costs, but rarely less than that. While billing charges can be effective in getting patients to render payment of the first bill, they can reflect negatively in a saturated market with strong competition between practices, not to mention the new practices seek to build a patient base.

Payment Plans:
Payment plans can be a good alternative for patients who can not meet the full obligations at the time service, but the exact parameters are important. Keep in mind payment plans that run too long, increase the risk of default. Some practices have found the best approach is to limit the terms of six months or less.

For some practices, an example payment plan strategy could bring a minimum of say $ 100 due at the time of service, with the balance divided in equal installments over the next 6 months. Or, you could change the overall balance in six monthly installments, with the first installment due at the time of service.

Regardless of how the payment plan is built, it should focus on two equally important goals. First, keep it simple to avoid confusion. Second, to find a reasonable balance between collecting as much as possible up front, at the time of visit, and what the patient can bear. If patients too far upfront, they may not be able to make payments for the next period, resulting in a worst case scenario for everyone – the default.

Interest:
Most offices offer payment plans do not charge interest, but it is not unheard of practice. Interest charges, such as billing charges may be negative determining factor in competitive markets, and new routines. Charging interest also requires more staff time to calculate bills for mailing rarely offset the added cost. Another important factor to remember with interest is to follow the principles of truth in lending law. This can add a few more layers of requirements for administrative training, creating further unnecessary complications.

Gallery Agencies
team with a collections agency can provide you with some recourse if patients fall into arrears, but consider your options carefully and collection agencies can charge anywhere from 15% to 50 % of receivables. Any such cooperation should be carefully studied in advance, described in detail in the policy, including the establishment Contact information for your patients.

No Shows:
Patients who fail to attend a visit without notice is true, annoying and rude. But the collection of no show can turn patients from future visits, not to mention they usually reach very low rate. If you’re collecting no show, keep both these things in mind that the overhead costs of collection can give you enough reason to write it off completely.

Alternate Payment Methods:
Consider that offer as many payment options as possible. In recent years, a reduction in credit card processing fee, which makes them more attractive even for practices with modest traffic patient. Credit cards can also be used to bill monthly installments and payment plans if signed authorization. This will also help circumvent the proverbial ‘check in the mail, “and you will know immediately if the bid is rejected.

Communication
What parameters are defined in the policy of payment, communication is key to ensure smooth implementation. Remember that office staff is on the front line when it comes to dealing with policies to patients and should give clear instructions on all aspects. office wide meeting can benefit all, offer the opportunity for employees to ask questions before implementation. Provide front office with “internal” copy of the policy recommendations on when and how to remind patients of policy.

the relaying new strategy for patients sign the check-in counter stating “Any patient responsibilities must be resolved at the time of service” is an easy first step. Second, create a detailed flyer outlining policy and keep a stack visible in the waiting area, and for the first few months, each patient should to have a copy of your pilot check. The front office staff should advise patients when they call for an appointment and remind them verbally when we came. If steps are necessary, you may need one patient sign a “contract Payment Policy” and keep it in their records.

Some practices now even send “new information patient package” command is planned far in advance. This is an excellent opportunity to include billing policy with other information about the exercises. Practice could also basic information providers, healthy living suggestions intended to practice specialty, or information on how patients should prepare for an office visit.

Implementation:
Create your strategy is the first step to improve the pockets museums, but it will only be as effective as implementation and follow-through. A few small changes to procedures office will ensure this is carried out successfully.

First, it should be standard procedure for employees to obtain prior authorization from the insurance carriers – before the appointment, not just the time the claim is filed. Create a list of steps in relation to the timing of patient visit that includes investigating co-pays, deductibles, the time benefits, etc. directly to the carrier. While pre-authorizations can be done over the phone, “self-serve” online with many airlines is much quicker. Common carrier websites might even be bookmarked on workstations for easy access.

Second, the state staff to take advantage of information from pre sources and in patients obligations age. All parties should be fully aware of their responsibilities and patients are expected to advise how they will render payment.

Third, to ensure patients do not “get away” without paying everyone should be required to check out, and check. All your workers – doctors, nurses, aides, who is the last to visit with the patient – should clearly remind them to cancel the receipt or cashier to handle co-pays on the way out, and get detailed instructions on balance that will be charged to them.

Finally, review the performance strategy. Allow one to two weeks for changes to take effect and begin the evaluation of the results. Arm yourself with detailed information about the collections rates for the weeks and months before the change and bear against the weeks immediately after. Take note of what is happening around the office; assess staff to manage the new policy and make changes as necessary. If something does not seem to be working, make sure that you have given enough time to fully measure the performance, and not be afraid to make another change. Remember, maximizing the pocket portfolios is an ongoing task, but if done properly it can yield improvements in the overall profitability of your practice.

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Source by K Allen

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Receivables management is the art of keeping track of how much credit the company has given its customers, and the company can expect to return. Typically these include the amount the customer owes the company for the sale of any product or service. Doctors provide patients with the best care possible and expect to pay for their services from insurance companies and patients. The healthcare insurance system works in curious ways in which hand carry services and re-imbursed at a much later date.

Whether we like it or not, the insurance model is here to stay and it is important for both small providers like doctors offices and physician groups and large providers like large hospitals to diligently follow up the payments that are due. The receivables management has developed in the most important department in this organization as they help in recovering money from patients and insurance companies and help to keep the business running.

Projects standard payment management has evolved from a mere head of department activities of specialized skill center by itself and requires professionals so that doctors can focus on providing the best care to their patients. These activities have become an important and integral part of the total collection of services that are offered by Medical Billing companies. The process of accounts receivable follow-up is before the entry charge, verification and claim status. The process to enter a charge code in healthcare claim sheet is called charge transfer. This includes determining the procedure codes and diagnosis codes based on the treatment performed by a doctor. There are special rules defined by the insurance companies on what constitutes a valid claim and there are hundreds of rules some simple and others complex to determine the value of the claim. The audit team reviews usually claim based on the rules and accept the requirement of submission. This is a very important step as this significantly lowers the risk of claim denials. Claims are then submitted to the insurance company for processing. Insurance claim processes and sends the remittance of the billing company’s response time is unpredictable and there is a need separate accounts team. This year the team takes the requirements and the insurance payments.

The AR team analyzes the requirement of denial, payment and non-payment if the claim has been filed incorrectly, the claim is adjusted and re-submitted. The AR team constantly develops communication system with the insurance company, patient and physician office and meticulously follow to ensure prompt and full payment. The skill sets and qualities expected from members accounts receivable management team are good analytical skills, attention to detail, hard work and above all, patience. Team members with these characteristics are valuable assets to the organization and will ensure that the medical office receives payments instead.

The aging report is the most common tool for measuring the efficiency of accounts receivable team. This shows the amount that is due to hand and is broken down into different periods – 0 to 30 days, 31 to 60 days, 61 to 90 days and more than 90 days. An aging report that less than 5% of the total amount pending for more than 30 days is considered very efficient.

Finally, accounts receivable management is an important service offered by Medical Billing companies and the performance of this team will determine the financial health of the company as well as the collection of medical practice. If you have any questions regarding accounts receivable and how to receive prompt payment from insurance companies.

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Source by Ryan Wayne

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I’ve stopped with pre-shift religious meditation parked my car along with soothing piece of music. No more prayers to God the way to work asking for more patience, more humanitarian, more understanding. I have noted the fact that it will be no different than any other night in the emergency department, whether I blare Rancid piano YANNI’s Etudes or make a promise to God to go beyond their own body parts to release my patients as they go. Nothing will change. I used to look forward to making a difference in someone’s life, help the poor soul that the body has issued. Those moments are few and far between now. Instead, I tell myself that in the next 12 hours will be spent fake smile pasted on a tired body, going through the motions concern, repeating lines ready false concern and issue medical falling on deaf ears. I used to feel important in my role as a Charge Nurse in the main by the inner-city charity hospitals. Now, as I sit in my car at 6:45 in the evening, gangster rap blaring, I sent out a quick impromptu message to God ….. “Please God, allow me the opportunity to be gainfully employed for 12 hours from now. “

7:02 PM-

I get a quick report on clingons and leftovers that have not made it out of the department with the change of shift and no surprise to me and the night crew, some names all too familiar and the latest reports of “illness” recitable easily from memory. The usual apologies from the day the crew to get them out before we get to go unnoticed. A shrill Shri from one of psych beds startles no. We all look just within “safe” limits of the nursing station from, confirm that obesity safety of our force is camped out next to the room, shaking his head briefly in and go about our business. We go through the ritual take our own baseline vital signs, some popping Xanax and remove sharp objects from our pockets. patient safety is important and we would not want to accidentally stab one of them repeatedly in the chest.

7:17 PM-

main my job aside from direct patient care is Triage. Initial interview, vital signs, short medical history, current medical problems, current medications, height, weight etc etc my first 35 or so matches the typical information on this or any other in the country. 40 years old, female, morbidly obese, diabetes, hypertension, multiple Psych meds, very little Enska, less common sense, no way to pay. She complains of the usual nausea, vomiting, diarrhea and general pain. She has already spent thousands of dollars of other people’s money last week for the same complaint. She did not complete her manuscripts, not monitor gastroenterologist her request and was not at this 300 + £, truffle hunting leech going to change their diet one iota in order to prevent another attack of diverticulitis. her idea of ​​”Clear Liquid Diet” was a bucket of chicken and a bowl of Menudo hour for her arrival. So here she is, totally unaware of why she is still weak. Non-compliant with its meds, non-compliant with discharge instructions, or follow the dietary guidelines, which included gentle, low-fat, liquid diet for a few days until she was able to endure the semi-solid / or solid food.

She bitches profusely when it is brought straight back and put to bed, instead it is sent back out to the waiting area for the long wait. We are very busy and the truly “floating” patients, but she can not seem to fathom this. She barrels through the exit door in the waiting area calling me every name in the book (in Spanish) and swearing never to return. “Pendejo!”, She mutters. Oh, she’ll be back.

“NEXT”!

7:31 PM-

3 My patient is a 23 year old mother of three, the oldest being 10. She has somehow mistaken our “emergency unit” for children clinic and wants her young “checked out “because they feel” hot “. No heat ever taken home, no Tylenol or Motrin given before the decision was made to spend $ 1,500.00 on other people’s money and spend our time Babysitting 3 snot-nosed, unkempt Ankle-Biters are not more sicker than a man in the moon. I usher them one by one on the scale of the plot and is not surprised that anyone is twice the size they should be limited to their age. One, I have to pry finger foods and “Big Gulp” from their stubborn little mitts before the weight so as not to inadvertently add 5 lbs to the triple-digit reading his. Electronic scale beeps incessantly and says: “one at a time, PLEASE.” (Ok, not quite) With all their vitals are normal they are started out of the hold where they eagerly jump on the furniture and run around like defense for attention deficit.

I verbally assault obese stomach pain my wife, who has “been waiting time” (uh, how about 20 minutes). I immediately took the “Cheetos positive signal” on her fingers and around her lips and remind her of the sickest are seen first and to have a seat. She throws me “Pinch pendejo” and rumbles back to his or her seat. I sneak in a quick call to God, praying that he makes sure she looks before she plops back down in his chair (s). I hear intercom announcer now, “CODE BLUE trauma, ER waiting room.” I mentally picture the scenario of the code team spend the next hour remove the child Julio rectal 300-lb verbally abusive Hispanic woman.
“NEXT” !!

9:21 PM-

I’ve lived dinner crowd with my work intact and make my way back to the treatment area to assist the rest of my team in the treatment of patients who were lucky enough to do it again before non-liquid riff-raff. I make my way to EMS radio station when I hear ….. “Unit 842 number 2 patients report” …. we have 102 years of nursing home patient, …. found unresponsive on the floor .. ..not IV .. .. she is now awake, combative, confused, falling into a chair, urinary incontinence, bla, bla, bla … “the report from the nursing home before its EMS transport reveals that this patient had a tendency to” dig out stool rectal when their constipation. “” Oh, it’s just friggin lovely “

9:25 PM-

waiting room intercom buzz ……” I beeen waiting for 10 hours, pendejo you … you piece of …. “click!

9:33 PM

wonderful our elderly finger painter comes, covered in poop from head to toe. EMS personnel that smirk they wheel her in, updating us that any change in the way. no, no changes, except that now she has given up the fight and return unresponsive and her breathing shallow. an instant her breathing stops and immediately rushed to the trauma 1 where CPR is started. “CODE BLUE IS-1, CODE BLUE IS-1.”

9:57 PM-

“Time of death, 9:55” is belted out by the code team leader. “She never stood a chance.” “It was her time.” “She had a long and good life.” Bla bla bla bla. She had a horrendous death. Born fall into the amniotic fluid, but certainly proud parents can be sure of. She died, however, covered in shit, piss and bedsores. Nursing home where she spent her remaining days in perpetual anguish and loneliness must be burned to the ground. No family, no attention, nowhere near as prominent and proud as she once was. Left to spend while understaffed employees Mary Perpetual petri dish were able fraction of them and plundered through her personal belongings. A courtesy call to the nursing home is placed to tell them that Mrs. Mullins will not come back and have been transferred to the ECU (Eternal Care Unit). I hear, “Whew, thank God ….. CLICK.”

10:22 PM-

our usual group of drug-seeking, bipolar disorder, depression, suicidal thoughts, Xanax, Vicodin, Demerol dogs arrive as scheduled with many and varied complaints, migraine, chronic back pain , stress, anxiety, fibromyalgia, bla, bla, bla .. ..!
They are easy to spot, almost always familiar with the history Same Ole ‘. Most people we know on a first name basis. They are all, incidentally, the same allergy medications; Tylenol, Motrin, will save, Toradol, Aspirin or other drugs or not harmless placebo we have tried to quell the “pain” of the past. The only thing that works is “Demerol” and they must have a large supply of Vicodin in the form of a prescription when they leave. (Vicodin have Tylenol in it but does not seem to cause severe allergic reactions when mixed with euphoria, …. go figure!)

Security is usually called, to tell them “no drugs Tonight” is just asking for fighting. $ 1,000.00 later other peoples money and they usually go with their noise and their script for Vicodin. But usually not before asking for “shots for the road” or more scripts for anxiety (preferably Xanax) or sleep aids. 30 pills are often given the number of pills, depending on the frequency of the prescribed dose. This typically last a few days for typical agents found and then they usually return with more “pain” and hungry monkey.

In an age when doctors are sued for both the treatment of pain or to prescribe too many drugs and “get them addicted”, the medical personal are caught up in the proverbial “Catch 22”. More often than not, I’ve been written up several times and was a place where my work was in danger because I challenge sad their lies when the low life drug addicts undertaken is ours. Now I just shut up, shaking his head and asking for overdose.

11:12 PM

Waiting Room PTT ring in the wall. “… How long will I ……. can you tell me where I am on the list …… Donde esta su Doctor ……. I can not find my baby … ….. is Dingo ate my baby ….. pinche PEDEJO, I have been Heer goes for two days and my ASS feel like someone poured salsa right up my ………. click.

midnight in the garden of good (good for nothings) and evil (doers) –

After a flurry of non triage liquid, (sore toe, “shakes”, anal abscess, foreign body in the nose, ears and stomach of 2 years, blah, blah) I call the astute, well-dressed, middle-aged white male, who is walking quite gingerly and refuse to sit. Differential diagnoses race through my head, back pain, abdominal pain, rectal abscess or ,. maybe …. no! …. No! …… NOOOOOOOOOOO!

Yes!

story goes (and it is common) that he and his wife were “attempts “in bed (against his wishes, no doubt) when the vibrator was stuck in his keester and is now painfully out of reach. Given the nature of “injury” he is whisked back private room, put on his side, Kent like a 57 Chevy, and valiant efforts are required to attend 12-inch “perpetrator with ribs” from his colon. All to no avail. At one point we had to keep the foreign body (actually, it was done in the US) colon would not let go of it’s new found friend cylindrical. We pulled, twisted, yanked, pulled, all efforts prove futile. Finally, the doctor stopped, exhausted by the tug-o-war game, with forceps, commonly used to remove large headed children, protruding from prominent lawyers butt, he made the decision to call the surgery team. All efforts to be a professional, however, fell by the wayside when in a moment of silence, the low noise found in the room. Had the blood pressure cuff inflated? Incandescent lights were buzzing? Was on TV?

No, no and no. We looked at the tongs and took them were vibrating uncontrollably, instead realize at the time that this article was still on. A mad rush of nearly crew to close the door of the private room was not trying to humiliate this local experts with boisterous laughter us. No dice.

We will all end up writing and apologies made for “unprofessionalism and disregard for the privacy of the patient and mental well-being” our.
It’s okay. We had to preserve their own spiritual welfare. Still true that laughter is still the best medicine.

1:02

Ten triage and later dinner time for this mentally worn crew. We apply our food, locate it in the middle of the nursing station and we eat. Not all at once, mind you, but usually bite at a time. Eating French fry, go wipe ass in ER-1, a bite of the Big Mac, go clean up cherries cool-Aid flavored success of ER-4, a sip of Dr Pepper, then physically restrain a combative patient Scitzo-effective. By 2:15 we have polished off the last bite tighten hamburgers, ate the last old French fry us and sucked down the last sip of our watered down soda. A soda is now as hot as fresh urine and food which is as cold as Mrs. Mullins in ER13.

2:30 the AM

Ahhh, my favorite time of the entire shift is upon us. The “Last Call at the local bar group” (LCLBC) start pouring in the front entrance, but EMS brings those who got the shit kicked out of them through the back of the ambulance entrance. “Santa Rosa, this is unit 842 …. we are coming Code 2 trauma 19 years Male ….. closed head injury …. drown … combative …. dirty …. bloody. …. no guarantees ….. bla, bla, bla.

the Same Ole Song and dance spews from these patients grow bloodied as he is wheeled into trauma-2 ….. . “I was just minding my own business” …… “I only had two beers” … .. “I do not do drugs” ….. “Can I get something to eat?” “RAALLLLLLPHHH ! “” Housekeeping to trauma-2, cleaning …. “

2:31 the AM

” Dear Lord, if anyone can make time travel possible, it’s you, God. “” Pleeeese, send me on to 7 AM.

3:03 the AM

Patient waiting room intercom is screaming ……….. “Click” ……. “BANG, BANG, BANG “.

3:15 the AM

I started in the staff break room for “time out” and reminded the night supervisor that the cost of intercom will be deducted from my paycheck.

4:18 the AM

Portly our female animal woman finally began again in the room, but not before mumbling under her breath as she brushed past me, “pendejo”! Large “abdominal work up” is ordered. 40 lab tests, urine tests, stool culture, abdominal x-rays, Cat Scans, bla, bla, bla …… It is set in a gown that looks like curtains stolen from the Grand Ole Opry, and given a reprimand “opening on the back, please, “thrown in for good measure. ( “Lord, give me strength ……….. Oh forget it, never mind”)

She is given urine cup as she bounces his way to the bathroom. She fills it with a chair. “Offered in ER, STAT.”

Can not find the blood pressure cuff large enough so we have to take a chance on an erroneous reading by placing it around her calf or forearm. The fluid bed grunts and groans with some twitch and shift from this woman substances. She continues to bitch and moan and will eventually complaint with (a) human resources, I’m sure. Many attempts IV access provider finally vein that has not been choked off by a mass of arm fat and IV fluids are initiated. After a quick assessment is a doctor she’s off to radiology, with a slight 120 pounds technology pushing £ 600 of the patient bed and the third floor for a series of $ 3,000.00 radiologic examinations. X-rays was done just last week and it has no intention or means to pay for. It would have been easier (and cheaper) that she had driven to Sea World instead. Certainly more accommodating to a woman of her stature.

5:57 the AM

Many early morning stragglers are classified and sent to wait. The foul odor of urine, poop, BO, booze, vomit, etc, permeates the air. “One Hour Left”, I thought. We get all the test results voluptuous Ms. Hinojosa is back and surprise, surprise …. “diverticulitis.” Maybe this time it will be in accordance with the meds her, according to her diet, according to her guide, in accordance with life. “Fat chance,” I thought. (Pun intended).

IV it is removed and a half liters of fat globules ooze from harpoon hole. She pulled off the bed with the help of several departments within the hospital; half of which will call in sick the morning with severe back spasms. The battered stretcher which now resembles a low rider after disaster is withdrawn for repairs. Ms. Hinojosa is drained but not before asking for breakfast tray. Request denied.

Off she goes to the local “Taco Cabana” for a flurry of various breakfast tacos and a bowl of Menudo. “She you in a few days, Ms. Hinojosa.”

“pinche pendejo!”

6:47 the AM

miserable face morning crew are obvious as they make there way into reluctantly, some still in the middle of town, new nurses with the Walkman is, listening to the ocean waves or cricket noise saturated with Muzac. A quick report is given to the mentally exhausted night crew and made an apology for missing bed in the ER 3 and the body of IS-12.

7:07 the AM

Each member of the night crew, each with a phone in hand, waiting for the moment the clock strikes 7:08 in with lightning speed, the flurry of buttons will be punched in the clock out, end another horrendous but typical night in the ER.

7:47 the AM

I pull up to my apartment and sit quietly in my car. I recall the events of the night and wonder if I had made no major errors in care or court. I prepare mentally for answers to complaints the night before of this unique culture is ignorant, non-compliant, offensive, poor, helpless, drugged up, psychosis, dregs of society.

I say a prayer for Mrs. Mullins and her family and curse all those who have abused the system in the last 12 hours, spending thousands upon thousands of dollars of other people’s money while contributing nothing to society what- so-ever. When I think that I will have a job to come 6:45 in the evening, I relieve the tired body and mind shattered out of my vehicle, meander up my apartment and in bed, hungry, frustrated, angry. Since I will fight the evil spirits in an hour or so until I’m able to sleep. Not me. I awakened from a dream in which workers of all patients in the waiting room on a busy night. I called back as 500-lb female nurse is ripping my clothes off with one hand and swing 6 foot rectal scope in other like a pair of numchucks in a Bruce Lee movie. The alarm sounds and I immediately spring up and grab my ass, asking for a 6-foot proctoscope is not hanging precariously from it. It is not. I breathe a sigh of relief and make my way in the shower and another fateful night of chaos and mayhem.

6:43 PM-

I pull up to the ER, park my car and sit. I clip on my name badge, giggle as I read our “Mission statement” tattooed on his back. “To extend the healing ministry of Christ,” it reads, and I take a minute to reflect on that statement. I smile, admit it is a powerful and significant activity and turning my head to pray.
“Lord, today, give me divine authority to accept my responsibility in this service. I pray …”

Just then enter a Delta 88 rolls of two-wheeled, with a certain slope aside. I watch as they take up two parking spaces in the “staff” full and out pops Ms Hinojosa. I cringe. She leaves a trail of urped a Fajita and Menudo patient through the parking lot, parking in the brook, toward the ER entrance. Anger byltist inside me and I hang my head, looking down at my shield and the instructions on the back. I try desperately to find peace, and I felt proud just 2 minutes earlier and I continue my prayer …… “Sir, I just …. ……. if you could only find it in your heart ………… oh forget it !!!!! ……. never mind. “

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Source by Michael Wayne Brown

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There are certain misconceptions about psychology that people have lived with over the years simply because either they do not understand the nature of mental illness or because they are firmly rooted in their cultural attitudes.

These beliefs have been proven to be inaccurate as they really are unfounded and can not be supported by scientific evidence. They have been partly responsible for neglect psychiatric patient is sometimes exposed to.

1. What mental illness is unique and different from physical illness: The World Health Organisation (WHO) defines health as “physical, mental and social well-being and not merely the absence of disease or infirmity”

Illness clearly, in different forms. Physical illness appeared in the form of headache, fever, pain, cough, etc. So also is a mental illness in the form of obvious irrational behavior. The above characteristics are known as symptoms of the disease: it does not matter whether they are physical or otherwise; disease is a disease.

2. Psychiatric patients are violent and dangerous: This is not always true and quite a number of these patients less violent than some of those who are perceived to be well.

3. Patients Psychiatric never get well when they go on the market: This is false as many of them have been selected from the market and taken to hospital for treatment they received well by proper management.

4. mental illness is a punishment for sin: Illnesses are caused by bacteria, toxins, hormonal imbalance, stress, genetic problems, etc. The same applies to mental illness. They are not caused by curses or sins they are caused by any of the above.

5. Psychiatric disease is incurable: Treatment of psychiatric problems could take a long time before the patient gets well. The same applies to diseases such as peptic ulcer disease, tuberculosis, kidney disease, heart disease, etc …

Mentally ill patients may suffer setback as also seen in malaria, eczema, asthma, gastric ulcer, etc. and they could also have persistent . The same thing occurs in other forms of physical disorders.

6. mental illness is contagious: mental illness is safest to stay close as they are not infectious. Unlike some forms of physical diseases, they are not transmitted through contact with the patient or contact with bodily discharges.

7. psychiatric nurses are only trained to handle psychiatric patients: This is the only area of ​​specialization. Every nurse trained in basic patient care and can work in any hospital or healthcare installed.

8. mental illness is seasonal: This is also wrong. Patients may have a regular setbacks but their illness is not open.

9. psychiatric nurses behave like their patients: The environment can influence the behavior of people in some ways. Exposure nurse with mentally ill patients helps the nurse to develop emotionally and understand the importance of interpersonal relationships.

10. One must be mentally ill if bitten by a psychiatric patient: Illness can not be transmitted through saliva or human bite. It is a disease of the mind and so can not infect another person.

The understanding of these misunderstandings would enable us to better connect with patients with mental illness and be well equipped to lend a helping hand when needed to reduce their plight.

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Source by Joseph Ezie Efoghor

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A hospital is driven by the goal of saving lives. It can range in size and service from a small unit that provides general care and low-risk treatments to large, specialized centers offering dramatic and experimental treatments. You can be a limited choice of hospital by factors beyond your control, including insurance, hospital affiliation to the doctor, and the type of care available.

Before hospital, you should be aware of possible dangers. Well-known dangers hospitals are unnecessary features, unexpected adverse reaction, harmful or even fatal blunders and hospitals have infection. The Institute of Medicine recently three areas where the health care system in general, and hospitals and their staff, in particular often fall short: The use of unnecessary or inappropriate care (too many antibiotics), underused actual care (too few immunizations or Pap smear) and shortcomings in technical and interpersonal skills. More than one risk of hospital infection presents, which is largely preventable.

What can make people do to ensure proper and safe care while in the hospital? The following guidelines should be considered.

If you have a choice of hospitals, inquire about their accreditation status. Hospitals are under review to make sure they are in compliance with federal standards. Rules implemented in 1989 requires the release of information on request to state health departments of death in the hospital, the accreditation status, and major deficiencies.

Before checking into the hospital, you need to decide on your accommodations. Do you want to pay extra for a single room? Want nonsmoker for a roommate? Do you need a special diet? Do you need a place to store refrigerated medicine? If someone would be with you, they will need a cot? You should try to avoid going into the weekend when few procedures are performed. When you get to your room, you should speak up immediately if it is unacceptable.

You need to be familiar with rights as a patient. Hospitals should provide information booklet which includes patient bill of rights. The booklet will tell you that you have the right to considerate and respectful care; Information about tests, drugs, and procedures; dignity; courtesy; respect; and the opportunity to make decisions, including when to go to the hospital.

You should make informed decisions. Before the permit procedure, the patients about their condition, treatment options, expected risks, prognosis state, and name of the person responsible for treatment. This is called informed consent. The only times hospitals are not getting informed consent are cases involving life-threatening emergency, unconscious patients when no relatives are present, and / or compliance with law or court order, such as examination of sexually transmitted diseases. If you are asked to sign a consent form, you should read it first. If you want more information, you should ask before signing. If you are skeptical, you have the right to post pone the procedure and discuss it with your doctor.

Source of a medical procedure can be given nonverbally, such as the appearance of a clinic for treatment, cooperative during the administration of the test, or failure to object when consent can easily rejected. This is called implied consent.

You have to weigh the risks of drug treatment, x-ray examinations and laboratory tests with their anticipated benefits. When tests or treatments are ordered, you should ask about their purpose, potential risks, and possible actions if a test finds something wrong. For example, injection or consumption x-ray dyes makes body more visible and greatly facilitates the ability of the doctor to make the correct diagnosis. However, pigments can cause allergic reactions extending from a skin rash circulatory failure and death. Finally, you should inquire about prescribed drugs. You should avoid taking drugs, including pain and sleep medication, unless you feel confident about their benefits and are aware of their dangers.

When timetable for action, preparing anesthesia. In rare cases, anesthesia can cause brain damage and death. One cause of such disasters is vomiting while unconscious. To reduce the risk, refuse food or drink that may be available for error 8 hours before surgery.

You need to know who is in charge of care and record the office number and when you can expect a visit. If your doctor is moving care to someone else, you need to know who it is. If your doctor is not available and you do not know what’s going on, you can ask the nurse in charge of your case.

You should keep a daily log of procedures, medications, and doctor visits. When you get your bill, compare each item with a written record. Insist on itemized bill.

You have to be active within the limits of medical problem. Many features of the body begin to suffer from inactivity few days. Moving about, walking, bending, and contracting muscles help to clean the body fluids, reduce the risk of infections (especially of the lungs), and deal with stress procedures that improve hospital for depression and distress in the hospital.

You should be wary. Of your stay, you can keep asking questions until you know everything you need to know. According to some experts, the biggest improvement in health care has not been technological advances; it’s been patients asking questions. The more questions, fewer mistakes and the more power patients have a doctor-patient relationship

Selecting a healthcare

The choice of doctor for general health is an important and necessary duty. Only physicians are discussed here, but this information applicable to the selection of all health care professionals. You have to choose one that will listen carefully to your problems and analyze them accurately. At the same time, you need to have a doctor who can move through the maze of modern medical technology and experts.

For most people, good health means to have a primary care physician, specialists will help you as you responsible for your overall health and directs you when specialized care is necessary. primary-care physician should be familiar with your complete medical history, as well as at home, work and other environments. You are better understood during periods of illness when the doctor sees you also during periods of well-being. Find a primary care physician, however, can be difficult. Of the 700,000 physicians in the United States, only 200,000 (less than 30%) in health care.

For adults, the primary-care doctors usually family practitioners, once called “Writing” and internists, specialists in internal medicine. Pediatricians often serve as primary-care doctors for children. Gynecologists and obstetricians who specialize in pregnancy, childbirth and the female reproductive system diseases, often serve as primary care physicians for women. In some places, general surgeons may offer health care as well as function they perform. Some osteopathic physicians also engaged in Family Medicine. A doctor of osteopathy (DO) is focused on the treatment of the body to treat the symptoms.

There are several sources of information to get the names of doctors in your area:

Local and state medical societies can identify doctors by specialty and tell you the basic credentials doctor is. You should check the relationship of the hospital doctor and make sure the hospital is recognized. Another sign of status is made by the communities where physician membership. Eligibility surgeon, for example, are enhanced by the community in the American College of Surgeons (FACS abbreviated by name surgeon). An Internist community in the American College of Physicians is abbreviated F ACP. Membership in academies indicates a special interest medical.

All physicians board certified in the United States are listed in the American Medical Directory published by the American Medical Association and available in larger libraries. About a quarter of practicing physicians in the US are not board certified. This could mean that the doctor failed the exam, never completed training, or is incompetent. It could also mean that the doctor simply has not taken the test.

The American Board of medical specialists (ABMS) publishes the Compendium of Certified specialties, which lists physicians by name, specialty, and location. Pharmacists may be asked to recommend names.

Hospitals can give you the names of staff physicians also engaged in the community.

Local medical schools can identify faculty members who also practice privately.

Many colleges and universities have clinics that maintain a list of doctors for referrals of students.

Friends may have recommendations, but you should allow for the possibility that your opinion of a doctor may vary.

Once you have identified a leading candidate, you can order. You need to check with the Office of office hours, the availability of emergency care at night or on weekends, backup doctors, procedures when you call for advice, hospital associations, and payment and insurance procedure.You should schedule the first visit while in good health. Once you have seen your doctor, consider this: Did the doctor seem to be listening to you? Were your questions answered? History was made? Were you informed about possible side effects of medications or tests? The respect shown for your need of privacy? Was a doctor open to the proposal a second opinion?

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Source by Prahalad Singh

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Obamacare, even the title is an oxymoron. There is nothing that I can see in my review and analysis of the “PPACA” HR 3590 that resembles “care”.

Nancy Pelosi put “local framework” of this legislation in connection with the infamous her statement, “we need to pass this bill in order to find out what is in it.” Talk about ready, fire, aim!

Unfortunately for us in medicine and medical support service areas, PPACA is now law. Rather than burying our heads in the sand, it is important to understand and prepare for the direct and indirect effects of the PPACA will have a medical provider revenue cycle.

What percentage of the total A phone / R is patient A / R?

The national average for patient A / R ratio of the total A / R for non-hospital medical practices is 16.4%.

How much are you collecting as of Patient A / R?

Although it varies by specialty, on average, do not collect Hospital Medical practices 17.8% of the money owed patients.

• gastroenterologists 26.9%
• urologists 24.9%
• radiology 19.6%
• oncology 07.9%
• surgeons 14.7%
• Cardiologists 12.8%

When “prototype program for Obamacare,” Romney Care, was introduced in MA for some years ago, the second increase in patient accounts were on average 30%.

is expected to predict patient A / R increases due Obamacare General to be 27.5%.

If you are collecting less than half of outstanding patient phone / R, you can actually afford to have insurance A / R reduction and patient A / R increased by 27.5%?

In recent years, even before Obamacare, patient receivable A / R for most health care has become a growing problem.

5 years: Medical experts were conditioned to survive in the co-pay and insurance reimbursement. Very little thought or effort was put into collecting the responsibility of the patient.

Today, 83% of doctors interviewed said A / R part of their overall trade has gone up more than 15% in the last 5 years. Lower insurance reimbursements and much higher deductibles patients, providers have expressed that they can no longer afford to live of insurance reimbursement and co-pay one.

Medical providers have found that they can no longer simply write off the unpaid balance of the patient and expect to stay in business. Obamacare will only intensify this as a growing problem. Cooperation with the revenue cycle company specializing in billing and collections patient will significantly reduce this threat.

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Source by Samara L Keaton

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Part of the problem in dealing with dementia patients is “attitude”, they are usually negative. Due care requires a major effort already in day-to-day demands, any negativism is just one thing to face. Understanding its origin can help to make it more acceptable and sometimes even avoid it.

The article “notion of time in dealing with dementia patient”, I say to live without short-term memory obliges the dementia patient to live only in the present moment. That means they have little sense of why things happen because they can not remember what was just happening. The whole idea of ​​cause and effect disappears so they come to believe that anything can happen. Memory loss is so destabilizing that it is difficult for these patients to be positive. Then, with no memory, they can not prepare themselves for the upcoming event, they have the impression that things keep happening to them against their will. This is especially true of “control freaks” like my mother. Since she can no longer control things, her idea of ​​the perfect day is one where we stay home all day. Her sigh of pleasure is audible when I announce that there are no plans for that day.

For caregivers, this can be a little depressing because it means that each proposed activity is going to be met with various reactions go from reluctant “OK” to all the “Not today, my back is killing me “. In my case, I have learned that my mother will always say yes to the breakfast table, but then try to take down the last moment. Knowing this, even I can be surprised. The other day I saw that it was a book sale in the library 30 min. away. I knew my mother could handle this length of trip where we were doing just the same trip last week just to buy yarn. My mother also used to be a librarian and is / was an avid reader. (It’s hard to read a novel when you can not remember what you just read.) The breakfast table she was very enthusiastic although she did keep focused on that I was the one who wanted to go and she wanted to do something for me. I heard the alarms go off in my head but decided to push on; after all, my pile of thrillers had indeed reduced to nothing and spend the whole day in the house is not my idea of ​​entertainment.

After two reminders, my mother was finally dressed and we left. I was convinced that she would come up with the usual claim her to return home before we get to the highway, but she did not. 10 minutes into the ride we had run out of conversation, 20 minutes journey she began to ask how much longer it would be and I could sense her starting to tense up. I suggested that we stop for coffee and she snapped at me that it was better to get this over with. On the side, I was trying to be Zen; after all, we had the pleasure; any books would be a luxury. As soon as possible, I started oohing and aahing on how well the library was given the size of the book sales return, etc. When we pulled into the handicapped parking space right next to the door, I thought she might actually refuse to get out of the car. I could see that she was seething.

For me, of course, there was no reason for her reaction, but it was pretty clear what was going on in her mind, this was not the usual our library, ride in a place she did not know was scary, the time it took was like an eternity. I “cheerfully” took out Walker and its our reusable bags shopping, chatting all the time about how great this was and how I had really run out of books etc. When we first went in, she was looking so angry that I decided to go for it on her own, so she could feel more independent and I could get down to my own choice; I knew my time was limited. As expected, she chose only books that were familiar (ie we have them at home). Fortunately, she had decided to budget herself to $ 4 so that meant only 8 books. (She groused to me at “our” library, secondhand books are only 25c.) When I saw originally her choice, I decided to mention that we had two of them at home so she said to take them out of the pile and she would choose another. I did little fingers would be (my father was a wizard) and spent two more. This was of course replaced with 4 more “repeats”, but now she feels much safer. Walking among the tables allowed her to present themselves with the place in half an hour we were there and she does love books. Then, too, the fact that I finished choosing my books at the same time she did, it was very pleasing to her. Learning that we had got 33 books for $ 16.50 amazed her and put a very positive light on our little outing.

So was it worth it? After all, I had spent the entire trip wondering if we’d actually get a sale. The time of the sale was spent trying to keep an eye on my mother and still trying to choose books for me. On the other hand, my mother’s relief on the way back that everything had gone well, the obvious. Gone was the silence that had marked the outward journey: She spoke of scattered rain showers that we kept going through, she spoke about the agreement that we had (each time asking me numbers), she talked about the restaurant where we were going to eat (we ate finally home). Even a few days after, when she saw me reading a book, she would ask if it was from the “journey”. How she remembered the trip, I do not know, but it would definitely be a good stimulus and every little thing helps.

So yes, it is worth it when you become a caregiver, you have decided that the other person is worth to care. Caring for someone with dementia means trying to keep them as much themselves as they once were, allowing them to connect to their former selves as long as possible. (Short-term memory may be gone but basic knowledge and long-term memory often subsist to a good degree.) This requires that you gently push them to do what they used to enjoy. Again it will not stimulate them, they are just terrible. When these patients say no to your recommendations, you must remember that it really is not that they are being negative, it is often that they do not understand what is going to happen or how else to express their fears. It is not really negativism, it just looks pretty much like it.

I have adapted the way I talk to my mother:

– I do not usually ask her if she would like to go to the grocery store. Despite the fact that this is an activity that she enjoys (the only one in which she is very comfortable because she knows the store as well), she will try to delay. I say more: we need this or that, shall we go to Publix or Walmart? This is good because it focuses her thoughts (rather than her fear) function and gives her the feeling that she is the one to decide, which is positive.

– I avoid imposing a choice of 3 things because she can definitely get lost. I noticed early on that when I invited her to choose from two, she would usually choose another. Obviously! It requires less thought to say the last word she heard. So now, to balance out the two types of ice to keep, I just edit a series I invite them in. Funny how it keeps our stock evenly balanced!

– I was not going anywhere for no reason because my mother has not forgotten how to ask why? (Since she does not want to venture out anyway). Personally, I think some of my excuses are pretty flimsy, but without my mother has difficulty evaluating it and is willing to accept the idea of ​​my value, importance and urgency. With no sense of time and no less, it is difficult to prioritize things or events. This allows me to get us out of the house to buy one skein of yarn for a baby blanket that I’m going to do next for my grandchild due in 6 months!

Recall that NO is an expression of fear or ignorance but a no, is a good way to learn how to circumvent the problem. In the beginning, it may feel like lying or deception, but when you see what you can do with it, it can solve a lot of problems. The most important person in the caregiver / patient relationship is the caregiver, so give yourself a break when you can. The patient is certainly not going to remember the little falsehoods and you may even start to feel that you are master of the situation. Do not let the NO defeat you, but consider it a challenge!

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Source by Catherine Warner