Pagmumuni-muni ni Manang

Hives again part 2

2011-01-15T10:59:00.001-05:00

Yesterday, after stopping my clindamycin and taking the first dose of prednisone 60 mg, I had high hopes the hives would subside. However, the apparent improvement on my chest was short-lived. Last night, despite my Benadryl (both before bedtime and at 330am), I found it hard to sleep. I itched everywhere. That same itch that prevented me from sleeping good. I got up at 530 am to subject my arms to hot water treatment. I had a few hours of relief after that, although my legs kept itching. My skin was sensitive everywhere even to cotton clothes. When I got up this morning, my neck and my face were red again. I took a hot shower to "scratch" my skin without traumatizing. It dawned on me that I could possibly be allergic to prednisone as ell. Good thing I blogged about my first bad case, wherein I was also just treated with cephalexin and prednisone when I developed very itchy rashes. I could rule out it was not cephalexin that caused it because I had no history of allergy to cephalexin, and that a second treatment course of cephalexin without the prednisone actually led to resolution of the swelling I had in my arms that time. The remainder of my skin healing depended on keeping it moist and applying vaseline petroleum jelly for barrier.

So, now I am thinking, after discontinuing my clindamycin yesterday, maybe I should hold off on the prednisone for now and see if I get better without it. I will continue with Benadryl instead. Type here

Hives again

2011-01-14T09:16:00.042-05:00

Rarely a year comes without me suffering from some form of skin allergy manifestation. Usually it is something environmental, and would happen anytime from spring to fall. This time it is winter, and the only culprits I can pinpoint were possibly (1) the colossal shrimps I got from WalMart and ate for supper on that night the rashes appeared or (2) the clindamycin which I had been taking since 1/1/11. That was the second time I ate that brand/type of shrimps. The only other things I ate that supper were fruit cocktail (canned, plus fresh apples and kiwis, with the dressing made with condensed milk, cream cheese and mayonnaise -- nothing suspicious and nothing new to me), and a Knorr brand fetuccine alfredo which I cooked with bacon. I doubt that the pasta and the flavoring that came with it caused my hives. No new soaps or shampoos or perfume that would correlate with the appearance of this rash.

1/11/11 first night of rash on torso

So, since 1/11/11 (10 days after my first dose of clundamycin), I have had the hives, which has rapidly spread now all over my skin that you will only see pinpoints of normal skin amidst the red skin. I feel tight and, of course, itchy, although the itch this time is nothing compared to my itch that happened in 2008. It was not that itchy so I could sleep okay. In fact, with Benadryl's help, I can sleep very well.

1/14/11 fourth day of rash on torso

I am just worried that the hives keep getting worse even after 3 days already, despite taking benadryl and zyrtec. I decided to visit my PCP for a prednisone prescription perhaps, and I did get that prescription. The doctor thinks it is the clindamycin that caused it. Now, if this subsides by Monday, probably I can proceed with my CAT scan on Tuesday, and my follow up appointment with the surgeon on Wednesday for a possible FNAB.

1/14/11 rash on my left arm

It's a good thing my allergies manifest only on the skin and not on the airways.

Neck Mass = Lymphadenitis

2011-01-12T12:29:00.004-05:00

I have been suffering from body malaise since Christmas, with some lymph nodes enlarged. However, on the day of the blizzard, 12/27/2010, my lymph nodes enlarged suddenly to this size after I slept for about 4 hours from 8am-12nn.

So I went to my PCP and was seen by Dr. Lambke. He did some tests (CBC, sed rate and cat-scratch) and basically found nothing. I was scheduled to see Dr. Shankar for assessment (he's the head of surgery at RFGH) on 1/5/11. However on 1/1/11, after my 12-hr duty, I had fever, and another set of CBC, sed rate, plus chest AP-lat were done. I was started on clindamycin. I had ato see Dr. Forster on 1/3/11 for increase in my clindamycin dose because it was prescribes as OD when it should have been q6h. She increased my dose and even extended the treatment to 10 days.

My lymph nodes are better now, and I was supposed to have the CAT scan done, after Dr. Shankar saw me last 1/5/11. However, because of rashes that started yesterday, it was postponed for 1/18, hopefully by the time I would have no more rashes.
Type here type the rest here

Dear Hubby: Happy Father's Day!

2009-06-21T07:53:00.000-04:00

Make a Smilebox scrapbook

Mother Nanny

2009-06-18T10:03:00.002-04:00

I was delighted to see Tagalog movies on Netflix (I have unlimited account). Last night I watched the very first Tagalog movie I got from Netflix - Mother Nanny. A yaya torn between taking care of her own daughter versus that of a rich couple whom she raised since infancy. My stepd and younger son both sat with me through the whole movie, so I had to translate from time to time for them to catch the gist. My stepd even appreciated it well. My eyes were boggy after the movie from the crying I did. I told my stepd, "Tthat situation is something you will never see in this country. I can relate to it, though, knowing the plight of many children in the Philippines.

I recall having worked a whole weekend in Makati then going home to Bulacan to my kids during the weekend. Of treating sick kids while one of mine was sick as well, but was taken care of by my Nanay (and sister on some occasions). It was not a good feeling at all.

I may not be working now as a doctor, and consequently I am earning much less than my potential earning as one, but the time I get to spend with my own kids is priceless.

Firefox Crashes and IE7 freezes - enter Chrome

2009-05-04T01:52:00.002-04:00

Lately my firefox crashes on certain websites (including my kusina)...it was very exasperating. So even if I do not want to use IE (since it is so vulnerable), I had no choice but to resort to it to browse my site and answer comments. However, tonight even IE just could not even open up google.com (my default homepage for both browsers)....I so wanted so much to answer comments (long overdue!), and was getting kinda hopeless...I searched for same problems, but the latest I saw was way back in Dec 2008. Is it just me, or my website apps? I read about incompatibilities with add-ons, as well, but I wanted a quick-fix...

Then I saw someone mentioned chrome comparing its popularity with IE and google and opera. Of course, it is way below as it is new...But I thought I'd try.

Well, so far, so good! It has not crashed on any of those sites that used to crash on firefox (including my kusina). I have updated my slides (baking and cooking) and answered comments.

I think I will be able to post some in kusina (but I have to sleep first and continue with my spring cleaning...rewards will be my playtime on blogging at night tomorrow.

Type here

type the rest here

US Immigration: Medical Examination - What do they look for?

2009-03-28T13:31:00.005-04:00

I thought I'd post it here for quick reference when someone asks me what do medical examiners actually look for when they are examining immigrants/aliens prior to going to the USA for immigration purposes.

Below is a set of guidelines that tells the medical examiners specifically what to look for:
http://www.cdc.gov/ncidod/dq/pdf/ti-alien.pdf

If you are planning to immigrate and are having medical exam, having a high BP is not a reason for you to be banned from immigrating to the US, although the doctors will feel safer to "clear" you if you are being managed appropriately, taking your medications, and your BP is controlled. That way, even if you suddenly suffer from a stroke on your first day upon setting a foot on the US soils, the medical examiner will not be apprehended for "clearing" you.

However, the major concerns are:
1. Communicable diseases - Tuberculosis is easily transmittable. However, if just diagnosed, based usually on x-ray (presents as nodule at the apex), then you will be required to have treatment for 9 mos, but they can clear you, I believe, as early as after two weeks upon starting treatment, but you have to continue treatments.
2. STDs - HIV, AIDS, syphilis, gonorrhea, etc. Of course, there is no treatment yet for HIV or AIDS so don't bother if you have this. With other treatable STDs, have them treated first.
3. Mental or Psychological issues - No to drug abuse! Psychological problems that will pose threat to the public safety or yours (e.g. suicidal, homicidal tendencies), or will be a burden (I believe mental retardation used to be a factor to prevent one from coming to the US since this will be of so much burden to the government, but I did not find that anymore in the guidelines, probably it is now acceptable unless there is homicidal/suicidal/violent tendency).

Of course, vaccination requirements must also be met as part of preventive measures of the government, especially for minor immigrants.

For a full set of information, check out http://www.cdc.gov/ncidod/dq/panel_1991.htm

Now, if you are already in the US and is currently applying for permanent residency, you will probably need another medical exam (or not; I believe it depends on how long you had the last medical exam done by panel physician), here is the link to the guidelines that medical examiners use to examine the applicant:
http://www.cdc.gov/ncidod/dq/pdf/ti-civil.pdf

DEFINITION of TERMS in my simple words:
Panel physicians are the medical examiners in the Philippines designated by US embassy to conduct your medical screening prior to immigration
Civil surgeons are the medical examiners in the US designated by US embassy to conduct your medical screening prior to approval of your application for permanent residency or citizenship(?)

Got on sale!

2009-03-21T22:04:00.001-04:00

Got this from JC Penney last week (it's almost spring! This light winter coat = shearling = was the last piece, size small. I was very hopeful it would fit me, and IT DID!
Original price: $200.00
Sale Price: $9.97

mas mahal pa yung panties na binili ko...on sale din at 3 for $21.00

Citizen Eco-Drive Watches

2009-03-16T19:50:00.002-04:00

I got this Citizen Men's Eco-Drive Perpetual Calendar Chronograph Watch #BL5250-02L
as Valentine's gift for hubby. He was not expecting it, and he is not used to having "expensive" watches (only wore something like $10 worth of watches). He loved it. Of course, I had to get Citizen Women's Eco-Drive Silhouette Crystal Accented Gold-Tone Watch #EW8842-57D
for myself as well (he gave me a different toy as his gift for me).

I had been eyeing these Citizen Eco-Drive at amazon.com and they sound so high-tech, not requiring batteries; only exposure to some light, sun or artificial.
However, after two weeks from purchase, mine had scratches all over. It was supposed to be scratch-resistant! My husband's had no scratch whatsoever (he was impressed!), and he had been subjecting his to more "trauma." I rarely wore my watch.

I made a phone call to amazon. They had me return it for a full refund. I got my money back. Too bad. I wanted it so much. I want to make another purchase of the same watch, but it was a disappointing experience. Should I trust Citizen again???

My New Toy

2009-01-03T15:10:00.003-05:00

We finally got a family plan for our cellphone needs now that our kids are into adolescence. The kids are going to more games, and keeping in touch via cellpones with reliable network is a must. I was the only one who got a cellphone with features more complicated than just being a phone and a cam. They all got the same motorola phone with cam feature, and it can be used also to send email. But I chose to have this blackberry curve not only because I have internet with it, but mainly for the PDA applications. I had been using the PDA Palm TX before, but I felt so limited with that in that I could not use it for internet purposes unless I am at home, and I do sometimes need internet while at work.

I was thinking that with this blackberry curve as my cellphone/PDA, I probably will be more inclined to study for USMLE. :)

I did not realize ER can be boring at times

2008-10-26T19:36:00.000-04:00

Yeah, we all heard about ER nurses being adrenaline junkies...I was quite anxious I would be too tired every time I come home from work. However, lately, I realize that the norm here where I work is that we get slow during the hours from 2am to 5am...usually.

Not that I do not like that. I actually enjoy that extra time because now I can make blog posts during those hours. And for those blogs that usually require photos, I just upload the photos to my picasa web album then later embed them as I make a new post during work hours.

My charge nurses do not care as long as our work is done. Or in cases where we have patients, we should make sure we have done all that we have to do before we "play." They themselves play online games when they get bored.

I used to do my online ENA training. But right now I am caught up with all online trainings. I should also try to make use of the time for reviewing for NCLEX...but how do I hide from my co-workers about me planning to take the USMLE?

It is not that concrete yet. I am just trying to see if I can actually find the time to prepare, and if I will indeed be prepared in a year to take the step 1...So far no luck. I have had my Kaplan reviewers for 2 months now, and I have just finished chapter 1. Pathetic...

Pediatrics

2008-08-14T03:52:00.000-04:00

I might have said I never wanted to be in Pedi. I still feel that way.

But I had a child patient tonight accompanied by mom who is a med asst somewhere. Child was shy but cooperative with a little coaxing. MD and PA did their stuff. I did mine with some PE as well. After administering a PO med, she was ready to go. MD came for the last time while I was there, to hand me the discharge instruction. Mom said, "[Child] is usually shy, but she did great tonight. She (referring to me) must have done something right at the start, that made her comfortable enough to do good with all of you."

I said, "I connect." with a smile. Child smiled back at me every time I winked at her. Cute.

I still do not want to be in pedi.

The story of B

2008-08-14T03:00:00.000-04:00

It's not the book by Daniel Quinn...It's about the charge nurse I worked with one night (I was still in my orientation). Let's call him BAH.

Scenario: 10 year old patient who came in with abdominal pain, diffuse, persistent. Nausea. Patient vomited once in the ER. Given GI cocktail. No relief. IVF NS 600 mL/hr.

Easy IV start. Prominent veins on AC.

I used regular tube, and ran it around 2-3 drops per minute (600 ml/hr divided by four equals 150 drops per minute. Or 150 drops per 60 seconds. Or 15 drops in 6 seconds. Or 5 drops in 2 seconds. Or 2-3 drops in 1 second. And I am talking about MACRO drops.

BAH later on calls me into the med room and shows me a pediatric buret. Told me to use that on Pedi pts to avoid overloading. I'm an orientee, so I said...."Okay."

Okay convert that 600 ml/hr to microdrops and it turns to 600 microdrops per minute. Or 600 microdrops per 60 seconds. Or 10 microdrops per second. Can you count that fast? I cannot convert that to smaller units. So I made it fast drip using microdrop. Who can count 10 in 1 sec???

Both parents of this kid were MDs (physiatrists). They should have an idea of what's going on.

Later on, BAH, while seated behind the ordering MD, was lecturing me about how given the rate ordered, I should get the idea that MD did not want to overload pt with fluid (Duh....that's even a faster rate than what we give to many adults. I kept my mouth shut.). MD seemed ready to chuckle...

Anyway, later on, IV antibiotics was started. My fave co-RN started it for me but told me she would use a regular tube. I told her about the incident with BAH. She said, "Oh, BAH is stupid." So we were on the same footing there.

An introduction

2008-08-14T02:13:00.000-04:00

I used to work as a general medical practitioner in the Philippines before coming to the US. Having said that, I can safely say I know very little in everything medical. I am not a specialist, so I do no really know much. I admit that.

Now allow me to brag some. I graduated with BS Biology degree from UP Diliman, had 97%ile ranking in NMAT, got a scholarship for Medicine in Fatima (my parents were very happy!!! Free tuition, books, board and lodging, including free review books for boards), got pregnant at age 24, struggled to finish Medicine despite having a baby and a husband afflicted with CHF, graduated 1st among 200++ Med grads but without honors, had my internship at EAMC, passed the boards without landing in the top 10 (my school would have wanted me to land in top 1 so they subjected me to 1 yr of (useless) review classes.

Despite some friends (and other patients I had later) who would have wanted me to go through IM residency because of "my brains"m (what brains they were talking about, I have no idea), I wanted to be in OB-Gyn. Less morbid. Less problems with patient compliance. Less headaches. More surgical skills. But at the time I was going to apply, the QUERT (qualifying exam for residency training) came into effect. So the powers that be in the DOH now had a say where their babies could get into for residency training. I did not know anyone in DOH. Can you guess??? That's right, I ended up not going into residency. Later on I got pregnant again and became a widow, so that now I had two kids to support, and I was alone (save for my Nanay and sister, that is).

I practised in a very busy clinic in Makati that was like urgent care type serving patients from annual/pre-employment medical exam types to common community illnesses to NSDs and D&Cs. Nothing medically/surgically complicated. Some of the consultants working there have actually offered to back me up if I applied for residency in the private hospital they were affiliated with. But with two kids to support, the salary I would get just would not cut it. So I stayed moonlighting for 5 years, with Quality Assurance Management on the side. (If you are familiar with JCAHO, you must know about quality assurance.)

I got to the US with a BSN from Philippines. Got a job as a Medical Transcriptionist and saved some money for NCLEX. Passed NCLEX and got a job at a nursing home. Stayed there for barely two months (never enjoyed it) and got a job at a hospital. Rehab unit.

It was a good introduction to the hospital culture here, with all the high-tech equipment and the new people, new set of policies and rules.

I got bored after a year, applied at the ER and got accepted. Now on my 5th month. First two months were spent during day shift I applied for night shift) and it was like hell...I got rattled because, even as I was still trying to learn the ins and outs of flow of patients here, the rules and policies, etc., they were throwing Category 2s and 1s at me, and I got too busy I was ready to scream when they would tell me I had another patient to get (uhhh...can I chart first on my other two patients?). Finally, against my first preceptor's recommendation to prolong my orientation on days (for purposes of exposing me to more cases), I was started on my orientation on night shifts. After a week there I was really considering applying for another job (even medical transcription), but as I was slowly released to be on my own with only a resource nurse to go to for questions, I became more comfortable and the clinician in me re-surfaced. My doctor-thinking came into play in trying to predict the management of patients, so that I easily got into the flow of when to start IV's and EKG's etc., without fear of being scolded by the MD for doing so without an order. Well, actually, the reason I was hesitant before to just jump into action was that I was not sure what my limitations were as a nurse. Apparently, the nurses here have enough autonomy, and even if the MD did not order, let's say, an IV line, it would be pretty safe for me to start one and draw blood (then dispose of them if they would not be used anyway). No big deal.

Because of being more comfortable, my resource nurses (usually the charge nurse) have observed the marked improvement, that everyone now says they are hearing good things about me from other CNs. Even my clinical manager and ED educator told me, "Finally, it has kicked in! I told you so."

So now I am enjoying the ER. It is quite a good exposure in my plan to pursue the MD license. Somehow, I am getting an idea of their treatment protocols, how the ED MDs proceed with consulting for possible admission. I am also getting a chance to review things indirectly, and I find myself doing the critical thinking again. Interpreting lab results mainly, in correlation with the presenting symptoms/complaints. However, my main disappointment is that I do not see the imaging results (the MD's see the images and make their "wet readings" then wait for official reading from offshore -- Australia, I heard). The official results usually come up the next day when the Radiologists of our hospital are able to officially read and sign electronically to make the report available on the computer.

I will be off orientation by the end of August. Some patients are quite needy, but most of the time it is the usual abdominal pain, chest pain, altered mental status that I see. Sometimes those brought by EMS are not really high categories. I have learned once again the art of being cool in the middle of this chaos.

Behavioral patient

2008-08-14T00:08:00.000-04:00

I inherited AF from an outgoing nurse. I went in and introduced my self. Patient wanted some medication before going to the BH hospital ce. MD did not want to give her any as she was not anxious when she came in. Then she began saying things like, "Ok, I don't even want this lady in my room. Please." in front of her mother. I did not even get a chance to do some therapeutic communication.

I swear, if this was my child, and she does this to me, I am gonna slap her on the face and ground her for at least a week. More so if she does this to a stranger who is trying to be helpful.

Glad the EMS personnel came right away.

Brat.

That's why I never considered to be in Pedi.

On my First Month of Orientation

2008-05-28T22:29:00.000-04:00

One thing I love about my hospital is that we have a very good orientation program. Having been exposed to Quality Systems Management while I was in PI, I could see my hospital addressing the elements of a quality system. And knowing so, I have the confidence to voice out any dissatisfaction in a constructive manner, for purposes of quality improvement (it is always a good reason) which will have patient satisfaction as an end-result.

First week of my training was spent working on my competencies, mainly the paperwork. Second week, I had my Basic EKG interpretation training, a prerequisite (aside from BLS- Basic Life Support) for ACLS, which I took and passed yesterday (yehey). Of course I have been going on duty with my wonderful preceptor. Whoever told me ER nurses here ate their young, well, I do not see that happening. I have the most wonderful preceptor (even better than the one I had in rehab, I would say). I'd say we do have a good chemistry. I had exposure in the triage room, and I actually am contemplating on sending copies of the triage flow diagram back to the Philippines for nurses to learn. I had a case of AMI (acute myocardial infarction) on my first day there, which was the highlight of my day.

Next I should sign up for PALS (Pediatric Advance Life Support), then sometime before the end of my first year, I plan to have the TNCC (Trauma Nursing Core Curriculum, if I remember it right) at least.

I have been trying to involve my kids to at least know how to do basic CPR...I gave them a lecture before, along with video viewing, several months ago. Yesterday, I kinda gave them a quiz, asking them what to do if they see me on the floor unconscious and unresponsive...Ben gave the best answer, then I recounted to them how they should approach it.

I told them they might someday consider ER nursing, but then I said they might not like seeing blood and what not, but both the boys seem not to fear that at all...hmmmm...we surely need more male nurses...

I will sign up for ENA (Emergency Nurses Association) on the next payday.

Emergency Department - my new area

2008-05-28T21:38:00.000-04:00

OK, I dunno why I looked for new openings in other departments...maybe because at the rehab, we usually would be RIF'ed (reduction in force when the census is low), or maybe because I was getting bored with the routine no-challenge type of work there (the only challenge was physically because we RNs also needed to help the techs prepare the patient for the rehab day -- i.e., bathing and dressing of patients, which could mean from the independent hip replacement patient to the bedridden stroke patient).

In any case, I looked in the employment opps in our website -- OR nurse. I guess I applied too late. One of my co-workers applied ahead of me and got accepted I guess even before I got the chance for my resume to be reviewed...OK...on to other opps...

Behavioral Health...nah...I always fear for my own sanity. I believe there is a very thin line between sanity and insanity, and that can easily break when you are surrounded by pathologic personalities.

CCU (Critical Care Unit)...too morbid for me...I have never liked taking care of very sick people...that would be too stressful.

MCH (Maternal Child Health)...I would have loved to be here but they required current OB-Gyn experience in any of the areas in L&D and Nursery. I have experience, but whether they are current per their standards, I don't know. I don't even know how to use the fetal monitor, but I can do it manually, including manual monitoring of labor. But they do it here with machines. I heard from another Pinay nurse (old-timer) that they wanted the experienced nurses because they were desperate to find ones who needed minimal training, as they were expecting 400++ deliveries for the month of May. Oh well...

ED (Emergency Department)...well, it's not exactly the kind of stress you would have in CCU, but the kind of cases, the variety, the surprises, the critical thinking, the more practical applications towards my own life...the similarity with my past experience while I was a GP in the Philippines, I guess I don't have much to fear. There may be different equipment that I needed to learn, but I am quite a gadget junkie so equipment do not intimidate me, nor computers. The one thing that almost stopped me from trying that one was the circulating reputation of the ED personnel: that they eat their young. Well, I guess that is not entirely different from the scenario I suffered in the hands of senior nurses when I was undergoing my clerkship and internship rotations before getting my MD license in the Philippines. Given the past circumstances of my life where I have had humbling experiences, and have come to accept that whatever I know now or understand now just made me realize how little I actually do understand (as in, God's work is just so amazing I cannot pretend that I understand exactly how He designed the human body), I have learned to get along well with people, and have converted several toughies into softies when they interact with me. Not that I suck up, I just make them realize I am not someone who will challenge them or intimidate them, that I will willingly accept whatever they can and will teach me and I will be very appreciative of that, because I know I DO NOT KNOW EVERYTHING.

Well, despite the warnings I received from friends and co-workers, I went ahead and applied. Not sure that I would like it. But I did think that if I would get stuck in rehab for another year, I would get stagnant mentally and skills-wise. ER, on the other hand, is such a very good experience to have, because after a year or so (or even less), I can find work virtually anywhere. One thing that attracts me to nursing is the TRAVEL NURSING opportunities, and the per diem rates. The hospital closest to me always have ER openings, both for per diem and regular positions. ALWAYS. And since ER nurses are in demand, I will never fear of becoming RIF'ed. Rather, I might always be called to fill in for one who calls out. Plus, I want to get all those certifications that are a requirement of other in demand departments -- ACLS, EKG interpretation, PALS...

I got an interview, and there was instant feeling of being at home. I had positive vibes with the two interviewers (manager and educator). I got the job (well, according to one of my co-workers, ER's are always desperate for nurses). After learning more about my past experiences, they even went as far ahead as me probably being a mentor, taking the TNCC and other higher trainings. (I was thinking, hey...slow down...one at a time). Anyway, maybe I looked confident enough that they became confident about my abilities, although I was quite upfront about the lack of abilities for the more complicated cases that really warranted a hospital (not clinic) visit, but they knew I could be trained. Ain't that the most important trait anyway? --- trainable. Another area they were concerned about was the use of the new computer system. I assured them I was, as a matter of fact, a superuser back in rehab. I was one of the few who had to walk others through the new system, simply because training for that was a breeze to me.

I started 1st week of May, when I was suffering from severe allergy that I almost feared I would be very vulnerable if I worked in the ER because my skin was so damaged (and on this very day I am posting this, is the first day I saw and felt my skin come back to an almost normal state that now I can expose it to air without sloughing skin and itching). It was a nightmare allergic attack-turned to atopic dermatitis event. Luckily, today I realized I am not that immunocompromised, and I can continue to enjoy the ER.

Why I like it: some days are busy, some days are not. Never boring. Variety of cases and people. Critical thinking developed. My clinical skills will be put back into practice, and they will probably benefit from skills I gained in IV insertion and blood draws (I used to stick even neonates without much problems). What I hated when I was a GP in PI was that I did not develop the skills needed to respond to emergencies such as stroke and acute MI (heart attack), and that I did not really learn much beyond treating common community acquired illnesses, etc. I wanted more...although I would not be the one who would actually treat (doctors would be) at least I would be exposed as to how they do it here...I can easily learn the why's. I can easily follow the rationale for the treatment because of my background, but learning their protocols will be great. I might in the end consider taking the USMLE, or maybe become an NP, who knows?...But this ER experience will surely be a gem in my resume...

Contact Allergic Dermatitis that turned into a NIGHTMARE!!!

2008-05-21T20:26:00.007-04:00

Are you like me, who, after having immigrated to the US, have encountered a lot of new things to which you react (i.e., allergic to)?

During my first year in the US, it was the year of exposure to new trees, new bacterial/viral strains, etc. That first exposure made my immune system create a counter-attack force for future re-exposures...

On my second year I had a brief episode of urticaria, which lasted 3 days. I could only think of having eaten Chinese food as a culprit. I used Benadryl and Aveeno oatmeal baths to help soothe the itching.

On the third year, I suffered another episode of urticaria for almost two weeks. Aveeno oatmeal did not help much to soothe. I was glad it was over by the end of the second week.

Fourth year here, I seemed to have succeeded avoiding re-exposure to whatever triggered my urticaria (I avoided gardening).

This year I attempted gardening during the first nice weekend of spring, and suffered from a new type of allergy that led to the nightmare depicted on the photo. As of this posting, the whole event is now on its 5th week. Yap! That's how long I have been suffering from this predicament.

As I mentioned in my previous post, I was suffering from dishydrotic eczema and was on prednisone treatment. I was at the last days of my prednisone taper when my allergic dermatitis started.

See my slide presentation for the series of events explaining the whole thing. I will keep updating this slide show as I progress.

UPDATE:
The flare-ups of my skin inflammation apparently was caused by my alternating use of petroleum jelly then lotions (which I would dare use once I felt my skin was getting better). Upon my derma's suggestion, I stopped all lotions or special soap for sensitive skin and stick to petroleum jelly, soak for at least 15 minutes in shower or tub (to engorge my skin cells and close the cracks), then slather a thick layer of the petroleum jelly to trap the moisture. Also, he prescribed desonide lotion which I had to apply to affected areas twice a day. I did that, and the desonide use had immediate effect on inhibiting the itching and inflammation of my arms/hands, and with showers twice a day at least, using the (self-prescribed) hot water treatment (counter-intuitive, the treatment regimen was effective for me. I believe that the increased rush of inflammatory chemicals like histamine, bradykinins, interleukins, etc. overload the receptors so that after the initial sensation like that of being scratched when in fact it was heated water, comes pain, then relief from itchiness for at least 4 hours (so finally I would get at least 4 hrs of straight sleep). Increased sleep boosts health and immune system. Less irritation (use only petroleum jelly) and more hydration of my skin (showers soaks)...finally my skin was back to normal after 6 months. When I mean back to normal, there is no longer that thin layer of skin with fast turnover, which was very very prone to losing moisture.

Well, during the first few months when I thought I would never get my pre-morbid skin, I was getting depressed because not only could I not wear tank tops/shorts without being so self-conscious, I also was not sure if there was ever an end to that suffering. I also felt so vulnerable since my skin was not intact and I was working at the ER (skin is the biggest organ of defense, so I felt defenseless). I even recorded songs for my hubby (although I did not tell him then that those were in case my skin issue would lead to my early demise eventually).

Now, I am happy with my skin, even if I still suffer from itchiness and cracks every time I go on duty at the hospital and have to wash my hands often.

Dishidrotic eczema

2008-05-04T18:54:00.013-04:00

It all began when I started working as a nurse in April of 2007-- the soap (I thought) irritated my skin so that at the end of my shift, I would drive home constantly scratching on my hands. I developed maculopapular rashes by May 2007 and sought an appointment with the Employee Health for an alternative soap (upon my Manager's suggestion). Okay, so I used a gentler soap, but continued to use the hand sanitizer (which seemed to be better despite making my skin red; it did not cause itching).

However, I did develop dryness, flaking, and eventually cracks on my skin. Once you have skin cracks, washing (especially with hot water) was agony. I almost was quite phobic of handwashing, and was using the sanitizer more. I also decided to use an OTC soap that was moisturizing, without the approval of the Employee Health. My symptoms were controlled, although I still got dried flaky hands on duty days. I also went to my family doctor and asked her to write a note that I can show at work that I was to avoid the hospital soaps to control my dishidrosis (aka pomphylox).

Then I was contacted by EH, and was asking if I was doing ok with the soap, to which I said yes. And that they would send a whole box, which I received that week. My manager told me to keep the used up bottles in the utility room so they could count. Oops...so I started using it again. My condition worsened again, and I would get cracks during duty days, which would heal during days off. It was torture every time I washed my hands or used the sanitizer because of the cracks! Despite use of lotion, I could not help the progression of my condition.

Then our manager started implementing a handwashing program, targeting 50 handwashes per shift! I tried to stick to it as much as I could, which led to soreness and swelling of my fingers, it was just too painful to even bend them because of too much swelling, and forcing to bend led to cracks and bleeding. Too thin because of flaking, my skin would also bleed at the slightest touch of a side of a paper...That bad. The EH nurse arranged for me to see the Workplace Health doctor. Nothing new prescribed aside from what my family doctor did. Nothing new suggested; just keep trying new soaps until I found one that would not exacerbate my condition. I did, but I still had the problem. After a week, I called the EH nurse to arrange another visit, because I could no longer sleep straight with all the itching and pain and severe dryness, and this time, even 5 days off did not result to healing. I knew the soreness/pain was due to infection already. I felt like amputating my fingers...

A nurse practitioner saw me the next time, and I liked his approach. He listened well, suggested specific creams/soaps, treated the infection and gave me prednisone and topical steroid. As expected, it cleared up. I was quite happy, but he had reservations, because he knew (and I knew) that eczema can flare up again, and is a chronic condition. We would have to see whether once off prednisone, the use of mild soap and cream would help control the issue.

These are before and after shots (not all have corresponding photos, though.)


























row 1, cell 1 row 1, cell 2
row 2, cell 1 row 2, cell 2
row 2, cell 1 row 2, cell 2
row 2, cell 1 row 2, cell 2
That crack was extremely painful!!! day 3 of commencing antibiotics
row 2, cell 1 row 2, cell 2

I was happy to be finally free of pain, and during the final followup, I had no problems anymore...but then at the end of my shift, when the EH nurse called me to remind me to have follow ups with her, I told her it was starting again...but then I had some more prednisone tabs to finish, and one more week of topical steroid cream plus the barrier cream to apply...

I was hoping the problem would go away, especially that I would have one week off before I make the transfer to ER...

PalmTX

2008-02-17T20:02:00.005-05:00

Sometime in January 2007 when I was busy preparing and submitting resumes and getting ready for interviews, I bought this PDA because of the hype I have been hearing about it being a necessary tool when you are a clinician (doctors, nurses, etc.). I was excited when I got it, downloaded several (medical and nursing) freeware, and bought programs online to download (nursing procedures, drug guide, etc.).

The reality is, I barely use it. Most of what I do at the hospital as a Rehab nurse can be easily learned hands-on. I have used it more to remind me of appointments, etc. But to remind me to follow up on something? No. It takes a lot of time to type (and I do not want to carry around a keyboard to attach to it.

It would probably be of more use if I were a doctor or NP who had training including the application of PDA in the practice.

It can be used to store photos and music, though, but I go to work basically to work, not to boast about how cool my gadget is...And even if I could, in theory, use this to browse the web, first I would need access to hour hospital network (how would I justify that when we have access to the internet using our own work station?). Second, the screen is small that I really would prefer the desktop whenever I could use it.

I am thinking at this time of selling this, but I do not know if any of the doctors at the hospital would be interested. They seem not to be too computer savvy and I have not seen any of them techie enough to carry such gadgets. Or maybe they are using Blackberry already...

PalmTX

Chitika Owna

Maybe I should sell it on Uncle Henry's...or ebay...or amazon...anyone interested here???

What I would want to replace it with is Nokia N810. It uses Linux (not Windows) so it is more secure, has less trash and is faster. It has built-in Skype, webcam and mic so you can use it for VoIP applications and talk to others (free if it is another Skype user, minimal fee if landline). You can browse the internet, including playing youtube videos on a screen with satisfactory resolution and size. It has a good-sized slide-out keyboard. It even has built-in GPS (additional purchase of $120? if you want the voice guide as well, although I already received a GPS from my husband last Christmas that he bought on sale).

Well, I am quite the gadget-lover, although I do not see myself geeky in any way (not in the same breath as my hubby). I had been trying to avoid posting about them on my blogs, for fear of sounding like I am boasting. But hey, sometimes you read about these gadgets you never heard of before, and become interested, so why not? It is quite nice to hear about a gadget you have been considering of getting if you get the info from someone you trust --- another consumer -- both the mediocre and the geeky types. So this post and the next few ones will probably focus on what I/we own and have experienced using.

Nokia N810

Chitika Owna

And yes, I feel that some of my ad affiliates would be more applicable for posts related to these gizmos. I figure, if I can earn additional revenue posting about a gadget I actually own and have used for some time, it will not be too bad.

Why do some people easily dismiss a case as something so simple???

2008-01-07T23:35:00.000-05:00

As I was saying in my earlier post, it was a toxic duty day.

I had a patient: in rehab for deconditioning following a colectomy after infection of her bowels post polypectomy. History of COPD, asthma, anxiety. She had a skin graft on her abdomen, with graft donor site from her thigh. Both had dressings. It was my first day to take care of her.

Early in the morning I changed her dressing on the thigh. She was so sensitive there, but I was gentle enough for her not to scream.

Around 10 am, she complained of abdominal cramping. Her colostomy bag usually had minimal output, since she also had very very poor appetite, per the report I received from the night nurse. Her prn meds for abdomen-related symptoms only had dulcolax supp ...what the??? What for? She does not use her rectal ampulla anymore. Everything goes to the colostomy bag. Even if you stimulate the rectal vault, that would not help. Possibly it was a protocol order entered by a nurse.

anyway, though there were other protoco laxatives, given the complicated nature of her condition and her colostomy, I wanted to make sure it was okay for her to receive a laxative. The doctor okayed. So she got it, and after a while, she felt better.

Lunchtime, her children came, and while her lunchtray was there, they were encouraging her to eat more. I dropped by to check on her...She was hyperventilating and complaining of neck pain. She wanted to lie down on the bed, and promised to eat. I got her pain pills, and in the process, checked if she had anything for anxiety. I wondered whether it was real anxiety or psychological only, as in acting like a baby in front of her children...in any case, I gave the pain pills and antianxiety. I also asked a CNA to help me lay her down on the bed using the Hoyer lift.

She was already calmer when we were transferring her. Upon laying her down we made her turn side to side to remove the pad that we used for lifting her. Soon after that she turned pale, eyes rolled upward, skin got cold, and she was unresponsive. We called a code.

Briefly she responded to my call while I was trying to measure her BP. She was breathing, quite a different pattern, though. Not as rapid as prior to lying down, but quite rapid and shallow. But we were afraid she was having a stroke or a seizure, although there were no such history. BP initially I could not get, but at second attempt was 80/50, with tachycardia. Then the two nurses from 5th floor came and saw that the patient was already responding and pinker. They easily dismissed with CONFIDENCE, after asking me what the diagnosis was, that it was probably a vasovagal complex. I could not easily dismiss it. Delta team came (EMS) and continued monitoring and evaluating the patient, while I went out to talk to the doctor. Delta team rep followed and talked with the doctor. Initially, we were asked to just monitor the patient. But Delta team went back to her, then I followed, and learned that she had another episode, BP going down, O2 sat could not be measured because she was too cold. They finally decided to transfer her to the ER, and started a mask and IV.

I notified the doctor. I called the ER nurse to give report about the patient they will be seeing. As I gave report and reviewed the history, I saw she had an episode of torsades in November 07. That was probably it, I said.

I stayed an hour and 1/2 more to catch up with my charting on my 6 patients that day.

I received a call this afternoon as an update on that patient. It turned out she had a pulmonary embolism. Nothing that I had done (basically medications administered) could have caused it, I was assured by the unit secretary.

But I wonder how she is doing now??? The therapists in our unit who have worked with her have said that she is not a candidate for rehab.

BUT THE THING THAT REALLY IRKED ME: Those two nurses who so quickly dismissed it as vasovagal syncope. NEVER EVER consider something to simple in a complicated case unless you have observed the patient for some time after the event.

Those nurses were orienting at the same time I was. I have been working more than 6 months now in rehab, but never acted like I know everything. I know a lot more and deeper than they do because of my medical background and experience, and I could not ever allow myself to think in such simplistic terms, especially where life is concerned.

I wonder how many are like that????

It was a very toxic duty today

2008-01-06T23:15:00.000-05:00

I work at a Rehab unit...so most of my patients are stable, undergoing rehab to get back to their optimum function. If they do get unstable, we send them to the ER, and if ER deems appropriate, the patient is sent back to acute care units (Med-Surg, ICU, etc.)

I love Rehab. For many new nurses, they will probably get bored in this unit, because they are eager to learn new things, eager to put into use what they learned from school, and eager to hone their skills. Here in rehab, there are not such skills you will learn. You basically give medications, period.

I love it because you see the patient's progress from debilitated to well. Fast.

I love it because I have had my taste of "toxicity" from my days of medical clerkship and internship, in the Philippines, both private and public hospitals...overworked, no pay. Very stressful...I learned a lot, but for now, when I have a family to take care of as well, I do not like to have more stress. I like it when I go home and just forget about work. I like that I do not ever fear of going to work in the mornings.

The story would have been different if I were single.

6 months into the RN experience

2007-11-10T20:09:00.000-05:00

Well, nothing that exciting, really...

(KK, this post is dedicated to you.)

I started out in a Rehab Dept (after 2 mos of being in a nursing home, that is). Big hospital, 45-50 minute-drive but it is worth it. Very pleasant environment, where I get the respect, and none of too much expectation. I am quite frank and humble about my limited nursing experience, anyway.

Rehab nursing offers very little opportunity for learning nursing skills outside of giving meds, occasional IV therapies/insertion, occasional special wound treatment. In other words, it is not TOXIC (a term med students/residents coined in PI for duties that really drained your energy). Boring, if I may say, but, as I told my manager, I am past the stage of wanting to immerse myself in "toxicity" as I have had that during my medical clerkship/internship. Do I miss it? Not really, especially during this period of my life when I have a family to attend to, and wanting enough time to enjoy life with them.

My penchant for computers came in handy during the transition to a new computer system. Needless to say, learning the old system on the job was a breeze, but the new system we have is Windows-based (and you may guess that, like Windows, it has a lot of garbage that came with the package, and a lot of holes that needed patching). Since I was one of the very few staff personnel with ease in using computers, I was chosen among the "superusers." Higher rate, less back-breaking job, more interesting, but that is a temporary phase. As soon as everyone gets more comfortable navigating the system, I won't have much use as a superuser.

Back to being a Rehab RN, the best thing probably is seeing the patients progress from debilitated to fully functional (within their limits) status. I get to know them better as well. However, most of them label us nurses as "pill nurse" and sometimes I am being asked whether I am a CNA or an RN.

I do have some thoughts of perusing USMLE-review books...

Endorsement and Verification

2006-10-06T21:48:00.000-04:00

Well, I have received my license from Vermont BON, then I proceeded to do the verification through Nursys as instructed on Maine's BON re endorsement. Nursys could be done (supposedly) online or by mail. Because I wanted to expedite things, I chose to do the online thing.

Well, my name was not in their database...yet. The reason (according to FAQ) is that for new nurses, it usually take 4 WEEKS to get the info into the system!

I figured it might be better to go through the snail mail route. I had cashier's checks prepared for both entities concerned, mailed the snail mails for both agencies. the one going to Maine BON contained not only the application form, copy of my license, and the fee payment, but also certified copies of my TOR and RLE. I hope I missed nothing.

Now I will just wait for approval for endorsement, then I would be all set to work as a nurse here with a temporary 90-day validity license as RN.

Problem is, I want to visit my mom in Canada (with my older sister) first before I go working full time. I have submitted an application to the PCGNY for renewal of my passport. As soon as I receive it, I will schedule a flight to Burnaby.

LP 14: A La Espanyola - Panaderya

2006-09-30T07:04:00.000-04:00

Panaderya, hurnuhan, pan de sal, pan de coco, pan de limon, biscocho -- it is obvious that these terms are of Spanish origin. If there was a certain Spanish influence in our foods that touched my life greatly and early, it was the staple bread and rolls that we Filipinos have during breakfast and merienda, the ones typically sold at the bakeries just around the corner every two or three blocks in a relatively congested area in Metro Manila.

My father started "working" as a tricycle driver in MM, and was delivering baked goods (especially pan de sal) to houses in the wee hours of the morning. The bakery was in Bagong Pag-asa in Quezon City where I lived as a child. My father had this dream of putting up his own bakery someday, and he took me once on a "tour" of the bakery, which was then using the old-fashioned brick-style oven that was as big as a wall, with a hole big enough to maneuver a baking pan easily.

My father was able to raise enough money to buy his own oven (the modern-style made of metal, not brick), and some baking tools like the wooden dough cutter, and a dough boat (yeah, the bakers knead dough as big as 4 big pillows combined, and had muscles and bodybuilt that could qualify for bodybuilding competition). Since it was meant to be for commercial purposes, everything looked big to me, and I kinda stereotyped baking doughs as a manly thing.

At first we only made pan de sal, with our workshop within our apartment unit, but there was such a great demand, we expanded and had to rent another apartment unit along a busier road, and also put up a general merchandise store. We added and added more staple breads and rolls, and had a display of baked goods which were pang-masa that typically would include ensaymada, Spanish bread, pan de coco, monay, pan de limon, pianono (?) ( a jelly roll-type of bread although this one we made then had no jelly; I am not sure what the filling was, but it was one of my favorites), "kababayan", biscocho,

I have received my certificate!

2006-09-29T15:35:00.000-04:00

I got it...from State of Vermont. It felt kinda weird to see my name Lxxx Txxxxxxx, RN (instead of the Lxxx Gxxxxxxxxx, MD). I will get used to it, I know.

Next step: Apply for endorsement to the state of Maine BON, with application also for verification via Nursys.

Meanwhile, I should prepare my (functional) resume...

I feel daunted...I admit. How will the US nurses perceive and treat me (a previous foreign MD). Well, if I indeed feel that they are discriminating against me and making my RN life miserable, I just might consider pursuing the MD path, and later look them in the eye and...(let your imagination run).

I have just passed the NCLEX

2006-09-06T20:43:00.000-04:00

Now I am just waiting for my certificate. I want to take ACLS/PALS certification programs but they require I attend the prep first. That would amount to $440.

I wonder if I can apply for a job even without a certificate yet?

I should prepare my resume and think about applying.

UPDATE 09/29/06

I have read in a forum that some hospitals provide free training for these certification programs. Maybe I should just look into that first and save the $$. I badly need it anyway.

What's next?

2006-09-05T09:30:00.000-04:00

I posted this question in a forum thread for MD-RNs and and also at a yahoogroup for my batch in MD-RN program:

Can anybody give me an advice on the best next step? My NCLEX was filed in another state, and I plan to seek endorsement to my current state, but my certificate will come later pa, around one month daw. Does anyone suggest that I seek employment right away while waiting for my certificate and even prior to seeking endorsement? As what (e.g., patient technician??? or should I just submit application for purposes of getting my name on file?) I am still holding on to my MT job only to see me through the waiting period, but I wonder if I should be doing something else with my time (like do you suggest I take some refresher course, or do they usually offer training in hospitals to fill in the gap in your knowledge? Or are these issues safe to discuss with the HRD? Kasi, 3 years na akong walang exposure sa clinical/hospital setting, parang napupurol na ako).

Answers:

I'm sure that with the shortage of Nursing in so many states (including Maine) that you will find some hospitals there that will be willing to give you some hands-on training while waiting for your license. It does not hurt to ask HRD's as you have the upper hand with an NCLEX out of the way. Of course if you can get the basic certifications (even from Red Cross) like BLS/CPR (would help). You are a gold mine for these hospitals so they will accomodate you and many of these hospitals have their own orientation and training period as long as you tell them the areas wherein you are not confident.
Looking ahead and if you dont want to take USMLE, CRNA might be an option (but it takes a longer path). I have a sister-in-law who is an NP and they do well also.

with a followup:

This advice is golden. Consider seriously the CRNA route manang. Its longer but certainly its going to be rewarding in the long run. On getting a job as a nurse, wag ka ng mag floors (para short cut), ask around for hospitals that need ICU nurses. There are hospitals that accept even fresh graduates for ICU, this is after training them for 3 months. Shop around, network with filipino nurse managers, and do this for 1-2 years. During your stay in the ICU, pass the CCRN, mani na lang yan sayo dahil MD tayo. Most CRNA school prefer CVICU experience (kasi dito me Swan cath, intra aortic baloon pump, lots of pressors, arterial lines etc.....) trabaho mo parang intern sa Pilipinas.

After 1-2 years, you can apply to CRNA school, mandatory kasi 1 year ICU experience. Impress them during interviews. You need to pass din pala the GRE (kayang kaya to! dont worry bout it! kung kaya nga ng mga 40 year old na puti mas kaya mo!). The CCRN is a certification for Critical Care Nursing, kayang kaya din ito. Same principle din ang application for schools, parang MLE apply broadly and early so you have more interviews.

Now for tuition fees, you can loan them. School is around 2 1/2 years parang residency na walang bayad. With the salary the CRNA makes, sus wala pang kalahating taon bayad na loan mo. Tutal when you are doing ICU experience, me sweldo kana, medyo mataas pa nga ata ang rate mo kesa floor nurses, pwede ka ng mag-ipon, if you dont have family restrictions, overtime ng overtime para makaipon at makabawi!

After school theres a certification exam, boards ba...Again, we've been there, your experience as an MD should help you. Of course this is not to say you dont have to study. This is serious stuff for them, so take it seriously din.

I know you can make it! Proud of all the MD-RN's who take up this route!

The thing about being an NP, oks lang pero sa halos same time commitment with school pero lower pay parin siya compared to CRNA, there's also the issue of respectability. We'll yeah this is just me. I figured kasi kung pareho lang ang pagod e dun kana sa mas more compensated ka.

Mahaba nato.....Sige manang congratulations and goodluck to your future endeavors....

Another advice:

I do not know if pareho ang situation natin, but when I passed the NCLEX last year I cannot get my licince as wala pa akong SSS no at tourist lang ako so with the Notice fron the BON that I passed I walked in to some big Medicval centers and asked if they could pititioin me and when finally one of them responded and had thier corporate lawyer work on my application, I got my work permit and that is the time I got my licence, mentime I took PALS, BLS and NRP to wjile my time.

I have looked into certification programs for ACLS/PALS...and of course, employment opps in nearby hospitals and their requirements.

It is unofficially out!

2006-09-03T09:15:00.000-04:00

gotta have a new plan for a new career...

2006-08-20T21:48:00.000-04:00

BANIG TV SHOWS

I was singing videoke with my kids this afternoon, then suddenly the image of Banig performing and winning in the International Star Search popped into my head. I had the idea of trying to see a video of her in You Tube. So I saw this video.
It was fun to see her evoloving through the years, up to age 16, then I wondered what has become of her after that.
A search for Banig videos did not give me much, until I checked out the other videos uploaded by doubleplayent (who uploaded this one), and I got a glimpse of Banig the Diva.
I wish there were videos of whole songs that she sang during those moments as shows in this video clips. They will surely give me the goose bumps.
I checked out banigonline.com but it seems outdated. I would like to have a Video CD of her albums (if there is any, instead of just an audio CD).
Banig has truly grown up to be a very sultry pop singer. I won't be surprised if she had now become a wife/mother. Any white (or black) male will surely have the hots for her, given her looks and talents. I noticed also from the links in her (outdated) website that there is a Japanese site (though I could not understand) devoted to her, so it is indeed a possibility that she finally made her vows.
Googling her name either as Banig or as Josephine Roberto did not help much in my search for an update on her.

A Filipina MD turned researcher

2006-08-02T12:08:00.000-04:00

I feel so proud of being an online friend of Dr. Florita C. Henderson, another MD (worked as GP in England before she married her then boyfriend, an American). She now lives in Iowa, and has been working in Univ of I as a researcher. Her first paper where she is the first author (there have been papers where she had been a contributor, of course) is:

Proapoptotic effects of P. aeruginosa involve inhibition of surfactant phosphatidylcholine synthesis

Click on the link to see the abstract as featured in Journal of Lipid Research. Mabuhay ang mga Pinay!

Congratulations are also in order for her being a new mom since June, having given birth prematurely (probably out of work-related stress) to a tisay (Hay, inggit ako!)

I hope I can someday find a research-related job where I can apply my medical knowledge, so as to avoid a mediocre career. The main problem is my location...rural Maine? Malabo...

I had my second road test today...

2006-07-11T17:13:00.000-04:00

The first time I had my road test, I had so many goof-offs. Well, I knew I had little practice. I had enough long-distance (well, 15 miles is long enough for me as a permit holder) driving practice, but I knew I needed more exposure to the busy streets downtown. As expected, I failed the first. But my in-laws said they, too, had to take the test either two or three times before they had their licenses. Okay, that made me feel better. I was not alone. My friends also had to take the road test twice or thrice. My MIL believes nobody gets it the first time.

Okay, so it was my second time today. I still did not have much practice, and truth be known, I had little enthusiasm practising in the interim, because I was still trying to squeeze in time to study for NCLEX and take care of the family and help Gary with the kitchen.

I was ready to fail again this time. We went out two hours earlier than my schedule for a brief practice downtown, and some practice on parallel parking and pulling up. During my first road test, I did good on parallel parking, although I mostly used the side mirror and rearview mirror, which I had been using perfectly in backing up. After I failed that test, the officer told me to always look behind over my right shoulder while backing up ALL THE WAY until I stopped. Oops, Gary never corrected me on that. I had to retrain myself to use the "looking my right shoulder to see the back" method, which I only did this morning, when doing the backing up straight and parallel parking. So many tries and frustrations. We finally went to the office 10 minutes prior to my schedule. The officer was there waiting for someone. When Gary got off the car to talk to him, he came back to me, telling me that the officer had to test one other applicant before he could attend to me. So I had to wait.

I had some anxiety vented off during the waiting time, I actually got teary eyed. I was ready to fail because I knew I had little practice, but I could care less because I had to pass my NCLEX more than this within a limited time (I have up to Sep 5 for that, while I could re-take the road test as many times as I need to. Maybe that waiting period and venting did some to calm me down. I was a bit laughing about some silly nonsense we were talking about, like our cat Midnight. By the time the officer was ready for me, I was a bit more calm.

I tried to relax, and I did...somehow. I avoided hyperventilating and concentrated on other motorists, much in the same way I would drive when with Gary. Went through the same downtown streets which were busy with construction and all cars coming from every direction. I managed to stay or end up in the right lane, stop where I should, wait where I should (sometimes over did it, being too cautious, but that was no big deal to the officer). I had some forgivable mistakes when I forgot to turn my right signal on when he asked me to pull up behind a car on the right (where he asked me later to back up straight until he told me to stop). But I did remember to signal when I did the same thing (pulling up) in front of the office when we finally went back to it. I did remember to let another car into my lane before proceeding, remembered who had the right of way, etc. , etc.

I PASSED!!!! I now hold a temporary license and have to have my picture taken before Sept 10th for the license.

HOORAY!

No, I won't spend the following weeks trying to acquaint myself with the roads and the town. I will stay at home and study for NCLEX (that is one item ticked off my to-do list). I have rescheduled that for Aug (because I had been dividing the past month between kids and garden and kitchen building, the past days being spent mostly on mudding and sanding. Gary applied the first coat of primer today. I (and the kids) still have to clean the whole house to rid it of the fine dust particles that have landed on most surface and which will linger for quite some time in the air. Particularly affected was the living room, which is most contiguous with the kitchen. Since I did not (and had none anyway) cover the furnitures with linen, we have to vacuum them all, wash the removable covers, remove the furnitures , vacuum the floor, wipe and mop it before putting all furnitures back in. Then I can study for NCLEX.

It's so good and considerate of Ana to offer to have the kids with her so I can study during days.

NCLEX ATT

2006-06-06T22:49:00.000-04:00

Betcha by golly bow-wow-wow! Natanggap ko na ang NCLEX ATT ko! I received the email from Pearson-Vue, and the ATT was attached, valid from 6/7/2006 to 9/5/2006!

Nangangatog ang tuhod ko!

I have to take a break from blogging, and concentrate on review. Work in the mornings, review in the afternoons.

I might even stop working in the garden, but that is quite a good diversion after long hours of studying.

Arrgh! I do not really know what to do! I hope to finish at least the Saunder's Comprehensive Review within a month, then practise answering test questions the rest of the time. The earlier I finish, the better.

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VR bloopers

2006-06-01T13:24:00.000-04:00

Initials are the VR draft - regular are the corrections

jammed fibers ill 600 mg - gemfibrozil 600 mg

denies drinking alcohol. The hernial legal drug use - denies drinking alcohol or any illegal drug use

apparently her vehicle guardian - apparently her legal guardian

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Applying for NCLEX

2006-05-31T13:11:00.000-04:00

This post is for those who, like me, have joined the bandwagon of MD-RNs and are already in the US, trying to see the fastest way to get licensed. I first saw the "quickest way" in a forum but that pointed out to the NY way for those who are residing abroad.

I asked about my case, because I am already a permanent resident. And the suggestion by the generous lady there was for me to inquire at Vermont instead of NY, which I did. I went to the vtprofessionals.org and clicked on the drop down menu for nursing, then clicked on application link for foreign nurses. I emailed the contact personnel.

Here was the exchange of emails:

ME:

Dear Ms. Patty Sartelle:

I am a Filipino immigrant who finished my nursing course in October 2003 in the Philippines, but did not have enough time to take the licensure examination there because of immigration processing. I now hold a permanent resident status and would like to pursue a career in nursing here.

I visited your website to see the requirements for foreign nurses, but one of them is the license from the country of origin. Kindly advise me on the next step I should take to proceed.

Appreciatively yours,

REPLY:
You have up to 5 years to take the exam. If you took you nursing courses in English than you may qualify to take the exam. The application is on the web at www.vtprofessionals.org go to drop down bar, nursing and the application that you need is foreign exam/endorsement – where it calls for licensure just put the date you graduated and that you never took the exam in the Philippines. Pat

ME:

Dear Ms. Sartelle:

I have browsed over the application instructions, and I have a question about #3 where the nursing school is to complete the" Verification of Education" form and it says to return the form along with a certified copy of the Transcript. My question is, will the school return the form to you, or will I have to ask them to return it to me first then I will include these with the other documents that I will submit to your office?

Thank you for your patience.

REPLY:

I prefer that they return it to you and you forward the complete application onto me. Pat

So I have asked my friend AJ in the PI (another MD-RN) to process my papers (the application form from Vermont BON site) and send them to me. I then submitted my Application, the fee ($150 on check), the TOR, and then later, they asked for my documents showing hours of lab and theoreticals (which was what we termed in PI as RLS - related learning subjects?). I should have included those in the first place, but it was not mentioned in the application instructions, so I did not think of it. I included other documents that would prove my identity since my name on the TOR was different from my present name.

It took them about a total of 1month to process everything (considering the delay regarding my RLS, that was fast!). When I received my approval to sit for NCLE, I was instructed to register at Pearson-Vue ($200) then to mail them back a form to tell them that I had registered. Then they would send a notice to PV about my eligiblity to sit for the NCLEX, then I could schedule my test.

So now, puspusan ako with my NCLEX review (dilly-dally kasi eh!)

I bought the following books from amazon:

More books (USMLE, Kaplan, etc.) are available at amazon. You can search for new and used ones using the below search engine.

Got the go-signal for NCLEX!

2006-05-22T19:05:00.000-04:00

I just received a mail from the Vermont Board of Nursing, that I am eligible to take the NCLEX (Yehey!!! No need for the CGFNS!). So I registered at Pearson-Vue and Paid $200. Then I will have to return a paper to the BON to notify them that I have registered. Then they will inform Pearson-Vue that I am registered, and I have to take the NCLEX within 90 days from there.

Now I really have to seriously review for the exam!

Tags: nursing, nclex, nclex review, Pearson-Vue

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I posted in a forum about GDI as a way out of having to send money to the Philippines

2006-05-09T15:54:00.000-04:00

This was the exchange...

Thank you for taking your time to read and respond to my post. It took me a while to weave a response to your post, because I had to suppress my initial reaction of rage, and so I hope the below post is civil enough. I apologize beforehand if it may sound condescending. My intent is to clarify my lack of desire to involve people in a "scheme."

JamboME wrote:

You sign your family up for a pyramid scheme? Nice.

I signed up my sister so she can have a job.

The job: Promote webhosting services for personal or business use.

Potential clients/market: Small business owners in PI (clinics with branches; small private hospitals; crafts-related industry; specialty stores, etc.; private use by people who want to put up their own website to feature weddings, baptismal, and other significant events in their lives. (Examples of businesses in PI which have their own websites are http://www.jumbonet.com/ and http://www.garmentsasia.com/garments.shtml)

Their options: Either continuously pay ~P 500/month to keep the website online and running, or get back the money by actively participating in the referral system (which you call pyramid scheme).

For a free start-up, I now have a business, with monthly expense of $10/month, with my own website and free use of website building tool and URL forwarding. I plan to employ my sister (since she will be jobless by the end of this month) to market the webhosting service GDI provides, instead of plainly sending her $200/month (I will lessen what I send to my mother). If she turns out to be successful, I might not have to be her "employer" (no longer need to send her money) after several months, and she might not have to do marketing while still earning. I will also task her to find a freelance website designer, who can offer his web design services to potential clients for a one-time fee (up to him how much he will charge), if clients do not know/intend to build their own website.

Now if other people there in PI will do the same thing, I might be indirectly contributing to job production in my country, with a mere investment of $10 for the business itself and my sister's salary of $200/month (which I would still give nonetheless if I have not come across this opportunity). Meaning, if more people there will sign up to market the webhosting services to business owners, and more people will see the need for web designers, I am sure it will fill in a void in the job market for these type of workers.

JamboME wrote:

I believe the secret to riches in Multi-Level Marketing (MLM) (ie pyramid schemes) is to be the one who starts the idea. Collect $1 for every new person that signs up. New members collect $1 for every new member they sign up etc etc etc.

Yeah, that is the secret to riches. But I do not want to be rich. I just want to earn a little extra, and would want my sister to do the same. If it turns out to be highly successful by virtue of this "pyramid scheme," then that would be an added bonus.

JamboME wrote:

I know it seems easy for someone outside to just dismiss the idea offhand, but thats because these are so easy to spot.

I signed up because it was a free trial, and during that period, I had a chance to observe and see the potential of the business. I myself tried to build my own website, and I liked what I saw, hence, the decision to give it a try. I can cancel anytime, anyway, but I doubt, because I have also enrolled in other affiliate programs which I will be advertising in my website.

I also think I have more imagination than most people who see such "pyramid schemes" in such a shallow manner. I always try to investigate things, and while some people have become rich concentrating on the pyramid scheme itself, I focus on the product and service and see if there is a need for such. I do not expect to make much if only based on the pyramid compensation plan.

JamboME wrote:

A company that cannot succinctly describe their product or service in one paragraph on their home page is not worth a second look.

Since I am now legally allowed to market the webhosting services, I treat myself "the company" and in one sentence, here is my product/service:
We offer webhosting services with website builder tool at no start-up cost and free trial period of 7 days.

JamboME wrote:

You seem like an intelligent, educated person with a good job.

Thank you for that observation. I am also beautiful and slim...Haha! Kidding! Modesty aside, I am a physician by profession when I was in PI, a blogger by hobby, a wannabe website builder, a work-at-home medical transcriptionist quality assurance personnel by trade here in the USA. While my income in my job is not that high, it is above average for the residents in this rural area where I live since my employer hires people from all over US, and because I work from home using the internet, I do not have expenses for gasoline, wardrobe, and make-up, unless they are non-work-related.

JamboME wrote:

I believe you have already lost your investment, and are putting more in every month. Put your cash in a proper investment, or invest in your OWN business venture (not someone elses idea).

I believe otherwise. Because of putting up my own website with my own domain, I realized there are a lot of other residual income that I can get involved with, businesses where I do not even have to be awake and will still earn, at no cost.

JamboME wrote:

If you can afford to send $300/month, you are doing pretty good! How many people in the PI will that feed?

I work and my husband work. Living in a rural area with low cost of living, living a simple life devoid of luxuries like SUVs, fancy vacations, fancy wardrobe, or a fancy home, not engaging in vices such as alcohol, drugs, or gambling, we do make enough and then some.

azcactus wrote:

Hey I have one question for you? Who was sending your family $300 a month fron the USA before you did? Just curious.

Pardon me if I am wrong, but I sense that your question is tinged with malice, and as such, initially I did not intend to answer it, but then I thought, why not?

To satisfy your curiosity, I worked as a physician then. My sister was a marketer for imported beef. I was a widow with two sons, she a separated mother with two children. Together we worked almost like husband and wife. As a physician, I was making a little bit more the $300 a month, enough to pay for monthly bills and groceries and give some to my parents, but not enough to buy myself a car.(See http://www.geocities.com/lrg1212/medprac.html)

WE DID NOT NEED ANYONE TO SEND US MONEY, although when I was in college, my aunt who lives in California, married to another Pinoy who works in the US Navy, was sending me money to pay for my tuition in University of the Philippines Diliman. When I was studying for my medical degree, she did not have to send me help, because I had an academic scholarship. (See http://www.geocities.com/lrg1212/medgrad.html)

I tried to put up my own clinic, but it was hard to start. It was then that I took a second course in nursing, to join the bandwagon of MD-RNs. (See http://www.geocities.com/lrg1212/nursing.html) During that time, I met my then fiance on the internet. My fiance was a divorcee with a daughter, is intelligent, very capable, not wordly, simple, loving, and only 5 years my senior. He was unemployed when I met him; nevertheless, I fell in love with him. We fell in love with each other and are now happy with our blended family.

Now I only have one wish that I want to fulfill: help generate jobs for Pinoys.

(At first, I thought I needed to be wealthy before I can do that, but now, maybe I can start with this webhosting service by GDI.)

One other affiliate program (which, to me, is another form of economic pyramid, whether you accept it or not) which I enrolled in recently is Speedypin.com where I purchase my phone cards online ($5 for 41 minutes to Metro Manila landline, 25 minutes for cellphone)). I buy 4 $5-denominations to get a discount. I will also put that in my website.

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Strep Throat and Vaginal Candidiasis

2006-05-08T12:48:00.000-04:00

More than a week ago, I diagnosed myself with Strep sore throat (streptococcal pharyngitis). It started with painful swallowing, right-sided cervical (neck) lymph node tenderness, and, when viewed on the mirror, right tonsil was inflamed (red) with some tiny pinpoint exudates (white spots). I was also starting to feel muscle pains on my thighs (the kind of soreness when you have sudden physical effort exerted). The next day it got worse, and the exudates were more and larger. The right one was also getting affected. Body aches and joints pains spread quite fast, involving headache. I knew it was another bout of strep.

Of course, even without the benfits of lab, it was easy to treat -- penicillin type of medications, first in line is amoxicillin. Can be intramuscular penicillin (one shot) or other penicillin-type antibiotics like cefalexin.

But, since I am not a licensed physician here in the US, I have to seek consultation with one to get the Rx, which I did, and the throat swab confirmed my diagnosis. I spent $60 for the cosultation, inclusive of the $15 lab test, which were unnecessary but inevitable expenses for me when I only needed a valid prescription (that is what a miss in my life in PI. Then the cefalexin (Duracef) was $70 for the 10-day course of treatment (it was cheaper when I had the penicillin shot at $50 At Reddington Fairview General Hospital when I went there during emergency hours. The bill then was higher because of the "emergency" hours. (It is cheaper to go to a clinic at an appointment. Our family clinic, Skowhegan Family Medicine, could immediately accomodate us usually, if we call during office hours on weekdays. Hence, when I had my symptoms on Thursday night that progressed the next day, I did not waste time. I called them rather than go to ER during weekend/night. Strep is, anyway, cured only with antibiotics.

Now, I have finished the course of cefalexin, and I have a new problem, as a result of altered vaginal flora (the normal bacteria residing in the vaginal mucosa), the environment within my vaginal canal was also altered (mainly pH), and it was an opportunity for a yeast infection (moniliasis). Symptoms: pruritus (itchiness) at the vulva and perineum (private parts) plus white cottage-cheese like discharge that is adherent (you can't go wrong with that -- once you have these symptoms, and knowing the predisposing factors, you may not need a laboratory done. Treatment: Monistat or Clotrimazole are very good first line of treatment.

Of course, the best way to prevent is practising good feminine hygiene, but that was not my problem. I was predisposed to it because of my prior intake of the wide-spectrum antibiotic cefalexin.

More info on vaginal candidiasis here.

Tags: strep throat, penicillin, antibiotics, cefalexin, vaginal candidiasis, monistat, infection, feminine hygiene

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Online Businesses

2006-05-05T21:40:00.000-04:00

My number #1 online business at present is offering my service as medical transcription quality assurance to MT companies as an independent contractor (self-employed). IC is a glorified term for those who are "employed" without benefits. The only perk in this job, aside from not having to travel and wear make up and buy a new set of wardrobe annually or every season, is that I get to set my own hours (that depends on the MT company, though). Realistically speaking, it is still a sort of twisted employee-employer situation (twisted to benefit the employer).

# 2: I recently signed up for an online business that revolves around promoting the GDI web hosting services by having my own domain/website Sign up is free, and the service is free for a trial period of 7 days.

I am not really a business person -- I am not out to try to rake in as much money as I can. But, after seeing freedom.ws and the Pinoys already involved in this business, I could see that it could be a good way for Filipinos to earn $$ without leaving the Philippines.

My sister who was a probee call center agent has found the end of her contract before this month ends. When I talked to her about the business, she thought it might be what would save her and her children (and what would save me from feeling guilty if I would not be able to send more than I could afford to send).

And I thought it could be a good way for me to provide her a chance to be self-sufficient, instead of waiting for my monthly "padala."

For those who will be interested in this, please go to freedom.ws and enter manangkusinera in the access code field. Watch the DVD and the Pinoys' testimonials. If you have any questions, please feel free to email me.

#3. Another online income generator by means of blogs is joining the network of advertisers. In my case, as evident in this post, not only am I making use of the Qumana blogging tool to make posting easier, but also to take part in their advertising scheme where I might be able to generate income by promoting websites of products related to my post.

#4. Also, I am considering of putting up an online store using my website. I am not sure yet what to offer (suggestions would be welcome). I just know I would not want to sell food items, as that involves a complicated set of regulations to follow (in the same way that health professions are highly regulated). I have looked into the process of putting up an online store (filing application at the town office for "Doing Business As" and applying for a license to resell, then signing up an account with paypal to facilitate online payments).

All these are potential sources of income without me having to spend every waking moment working.

Tags: online business, GDI, blogging, blog ads, qumana, blogging tool, web hosting, PayPal, e-commerce

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Circumcision

2006-05-04T06:36:00.000-04:00

I have just finished editing this report.

This is why I have long since decided to be anti-circumcision and pro-intactness...There are many more other untold stories. I myself have seen some tragic outcomes, and I could only wonder how the boy would grow up to be...Tags: circumcision, Gomco, anti-circumcision, pro-intactness

PREOPERATIVE DIAGNOSIS: Circumcision complication.

POSTOPERATIVE DIAGNOSIS: Circumcision complication.

OPERATION: Reconstructive penoplasty surgery complex.

INDICATIONS AND FINDINGS: This 2-day-old baby boy underwent a Gomco-type circumcision earlier in the day. Had persistent and intermittent bleeding and silver nitrate was applied. We found that the inner prepucial skin was still in place on the glans penis. Approximately half of the urethral meatus was exposed, but the remainder of the glans remained covered by the inner prepucial skin. The outer penile shaft skin had approximately 1-cm length on the dorsum, but on the ventrum was possibly only 1 to 2 mm from penoscrotal junction. By report, a Gomco clamp had been used with a 1.1 diameter "bell" and explanation has to be that a partial dorsal slit was performed and the bell portion of the Gomco clamp must have been inadvertently placed between the prepucial skin layers.

For a picture of Gomco clamp, go to http://www.circlist.com/instrstechs/gomco.html. You will also learn more about the horrors of circumcision.

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Circumcision

2006-05-04T06:34:00.000-04:00

PREOPERATIVE DIAGNOSIS: Circumcision complication.

POSTOPERATIVE DIAGNOSIS: Circumcision complication.

OPERATION: Reconstructive penoplasty surgery complex.

INDICATIONS AND FINDINGS: This 2-day-old baby boy underwent a Gomco-type circumcision earlier in the day. Had persistent and intermittent bleeding and silver nitrate was applied. We found that the inner prepucial skin was still in place on the glans penis. Approximately half of the urethral meatus was exposed, but the remainder of the glans remained covered by the inner prepucial skin. The outer penile shaft skin had approximately 1-cm length on the dorsum, but on the ventrum was possibly only 1 to 2 mm from penoscrotal junction. By report, a Gomco clamp had been used with a 1.1 diameter "bell" and explanation has to be that a partial dorsal slit was performed and the bell portion of the Gomco clamp must have been inadvertently placed between the prepucial skin layers.

For a picture of Gomco clamp, go to http://www.circlist.com/instrstechs/gomco.html. You will also learn more about the horrors of circumcision.

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Our Newly Bought 96 Dodge Caravan

2006-03-19T20:09:00.000-05:00

My driver's permit will expire on 06/08/06. So we were really quite in an urgent state to get a second-hand vehicle for me to practise with. We always kept our eyes on what were for sale in Uncle Henry's booklet. Last week we called several sellers, but they were all sold. This time, we could not find one that we really liked. Gary would have wanted something newer, but then we worried about those 99 Dodge Caravan allegedly having problems with transmission. Since it was basically for me to get used to driving (so that we could predict some dents/minor accidents within the first two years of me driving), we decided to go for this one. Not bad at $1500. Looked nice save for that rusty part at the bottom, smelled nice, and well-kept. The previous woman owner was a car racer (she had four trophies in her apartment to boast) so I figured she was in the know of how to take care of cars. She was also an EMT (Emergency Medical Technician) so that she did not smoke, and the car smelled nice.

Everything that should be automatic was still working -- adjustment of mirrors, auto-locking mechanism, power windows, etc. Plenty of room (7-seater) with two built-in baby seats.

Of course, Gary tried it on the road before we made the purchase. He said it handled nicely. He had had experience before with a Dodge Caravan so he somehow knew what it was behind the wheel of such, and he did not find any fault while driving it.

I had my first on-the-road practice this noontime with Gary. He was predicting a major carsickness attack, but luckily I drove it smoothly enough that he did not have that repercussion. He said I was a natural, and that I would have no problems after some time of practice.

I hope so...

We plan to spend the afternoons (when he comes home) for practice sessions on the road, about 30 minutes each time (so he won't get carsick).

A new set of Logitech speakers

2006-03-19T19:50:00.000-05:00

Last Friday we received a package which Gary had ordered from mwave.com. I knew he did order some computer parts to complete our computer server, which will also serve as a second computer for me to work with to maximize my time doing MT (I will work on one file while on one computer while the other computer downloads another audio file; I will have to be logged in on two accounts to do that).

So when I got the package, that was what I thought it contained. I waited for Gary to come home to open it.

When he got home, he went upstairs to my office and stopped at the hallway, told me he had a surprise for me...(I felt the same way I did when he was about to give me his Valentine's Day gift, but I could not help but wonder what it was this time...I could not remember telling him or hinting at anything that I wished to have...

And so he presented me this...
I asked him how he knew I wanted that...He said he did not know I wanted it; just that he knew I needed it.

Did I mention how thoughtful my hubby is?

To prevent osteoporosis, women need both diet and exercise

2006-02-15T08:34:00.000-05:00

This is what I like about my job. It is low-paying, but it is very mentally-stimulating. The only regret I have is not having enough time to read on the subjects discussed.

Anyway, I had posted before in another of my blogs about the importance of exercise supplementing diet.

Recently, my SIL noticed I had an exercise ball (aside from my elliptical) and she said, I did not have to exercise as I was already thin (to her). I told her, those were not to make me lose weight, but to keep my muscle toned. You see, muscles not used waste away (atrophy of disuse). If I continue to just sit here all day (as what my work requires), I will, in time, lose my legs' shape (which many have found to be quite sexy). I actually have been feeling aches in my upper limbs as they are most of the time in a typing position, and not subject to exercise as much as I would like them to be. I have been meaning to add dumbbells or resistance bands to my exercise gadget. I want to keep my muscle mass.

Now what has muscle got to do with bones and osteoporosis? Well, every time we use our muscles, the bones to which they are attached are put under stress. LIke I previously mentioned in another blog, there is a reaction to every action. The bones react to the stress by building mass as well.

I just thought about posting this here because I was editing a transcript where the doctor said the following:

"it is imperative for her bone health that she maintain weightbearing exercise including weights, not just using the elliptical trainer. I also discussed the importance in terms of maintaining muscle mass after the age of 50 or menopause. Once a woman loose their muscle mass, it is almost impossible for them to regain it, and the muscle mass is not only important for the basal metabolic rate and weight maintenance or control, it is also important for osteoporosis prevention, bone protection should one slip for fall, and it is also makes women over the age of 50 less likely to fall because they have better muscle strength and a better righting reflex and greater stability on their feet."

A lot of women in their 60's wonder why they have severe osteoporosis. I can only say, while it is still early and while we still are mentruating (we have enough estrogen), we drink milk (with calcium), expose ourselves to the sun (vit D activates dietary calcium for utilization by the body), and of course, exercise (our body reacts to the physical stress by building mass). Because even with the raw materials for building muscles and bones, we will not build them unless our body sees the need to (to be able to react to physical stress).

I also saw once in Discovery Science channel about astronauts who spent more than a year in space (weightless), who experience atrophy of muscles and weakening of bones (because of osteoporosis) simply because the gravity force was no longer there to stimulate these bodily structures. They came home having the need to be supported by several colleagues once alighting their space shuttle, as they could barely support themselves.

Benefits of exercise? Weight loss/maintenance is just one of them...

Happy Valentine's Day Indeed!

2006-02-14T19:50:00.000-05:00

I had been trying to make my hp photosmart 7760 work (ran out of ink; we refilled; could not work now), because I wanted to make a card for my hubby. That is usually how I remind him during this special day how much I love him. I do not want to spend money on holidays as much as possible. Call me kuripot, but these special days have been so commercialized.

I tried my old hp photosmart 7350 (I gave it to Patrick once I got hold of Gary's 7760 because he got himself a new Epson photo printer recently). Ink cartridges needed to be replaced as well. Aaaargh!

I gave up. I just thought I would make myself super bango and ganda for Gary's arrival from work. So I showered while baking chicken in mushroom soup/sour cream and cooking the Rice-A-Roni.

I was still in the bathroom brushing my teeth (in preparation for torrid kissing -- hehe), when he came. He handed me this beautifully wonderful flowers which he himself picked. I, of course, kissed him and thanked him.
Then I was waiting for the heart-shaped box of Stover Russell chocolates...nothing.

Then he led me out of the room...I was already anticipating he got me something else as a gift...I was ready to throw a fit! I wanted no luxurious spending!

Then he gave me a Valentine-decorated bag with a box that contained this:
Fujifil FinePix F10 6.3 Mega Pixels, 18.5 x total zoom, 2.5 inch LCD.

He forewarned me not to give a fit. I wanted to, but how could I? I was so pleased with this gadget (I would always prefer such things over a car, if I can help not having a car.)

Gary told me I was always able to come up with a very good picture using my obsolete digicam, so he got me a newer one of the same brand.

So this photo here is the last picture I took with my old Fujifilm FinePix 1.0 Mega Pixel digicam, which I have now handed to Patrick.

And that photo of flowers is the first I took with my brand-new digicam.

I was teasing him about drooling...his is a 4 MegaPixel Sony. While it took pictures, it was not quick enough to capture snapshots due to high-resolution.

Now, mine has better resolution, and is equipped with the technology to take snapshots without much delay despite the superior quality of photos.

I really love my husband...and my new digicam.

Sample calendar pages I made from hp's activity center

2005-12-24T19:23:00.000-05:00

For those who might want to consider giving family calendars as gifts to relatives/in-laws next Christmas, this is a good idea.

You will need photos to feature for each month, a pack of brochure n flyer paper from hp (free overnight shipping this season, $12.99, 50 sheets, double-sided), Adobe reader, a high-quality photo printer, and lots of ink (I recommend refilling instead of buying the cartridges).

Go to hp Activity Center page to start creating your calendar online (before you do this, you should have edited your photos -- cropping, effects, noise-reduction, red-eye fix, etc) using their very own software. Each month is created as one Adobe PDF file. Warning -- quite a long process, so better do one month at a time and save in your computer. Then just print near Christmas time.

Here is a sample month of my output using this method:

You may also want to consider downloading templates from Microsoft Office. One I particulaly liked was the Word photo 2006 calendar but it is so time-consuming to change the photos to use my own. (It can be done if you know how to manipulate the picture formatting and all that).

Also, if you like giving personalized birthday cards, you can buy HP photo greeting cards (which also ships overnight for free this season, $9.99 20 sheets, pre-scored, with envelopes). Either you use their software online like what I did with the calendar, or you may use the software that comes with the pack (a pleasant surprise for me! I used it to send cards to friends. It was easy to use and the photos came out nice too!).

Naku ha, dapat bayaran ako ng HP for plugging their products!

I am having fun!

2005-12-02T10:46:00.000-05:00

Starting November, I started taking online review classes for NCLEX (Kaplan). At first I was so enthusiastic, spending hours listening to the boring, at times ridiculously wrong, lectures of the speaker (I would often fall asleep!). Then I started taking "breaks" by revamping my resume and applying to every MT company that would allow satellite users, with work either using FTP and Word, or ASP platform.

After more than 6 months of doing clinic work in various specialties and various accents, I felt more confident that I would easily breeze through any type of dictation, as long as the dictator is reasonably clear. So I revised the experience part of my MT experience, saying that I had more than two years of transcribing clinic work (2 in PI, >6 mos here). That way, even with online MT tests (service provided by mtttest.com for several MT companies), I was able to pass the screening and personal info stages, and got through to the most important part of the tests, the objective and the audio/transcription. Some of these MT companies delayed the audio testing until they have reviewed the results of the preliminary stages, then they let me go on to the audio. Some allowed med to go straight to the audio as soon as I passed the preceding portion of the exam. I must admit that the audio is always the most daunting part for me, not because of lack of knowledge on the subject, because I can easily research them on the net as long as the dictator is clear, whether American or ESL. But I have had dictators who are American mumblers/sighers whose words I could only guess at...(they always give me migraine attacks!)

Anyway, I spent the past two weeks doing mostly that and neglecting my NCLEX review (or doing half an hour at a time -- I should be guilty!).

Two small companies called me and gave me false hopes of audio testing...never materialized and never heard any more from them.

One BIG company emailed me with a job offer already. Of course, I accepted that right away. Although I was skeptic at first, as I went on with their process, the more respect I developed for the company. Theirs was really stat-of-the-art technology! I had an online training yesterday, seeing my trainor's desktop superimposed on my own as she demonstrates using her cursor how she does things on her end and how I should do things. She was talking with me on the phone while explaining the features of the software. Of course, I had to login to the web conference that we had to be granted access to her desktop. That was the most awesome online training I have experienced so far. I was thinking, other small MT companies might lose their businesses if they do not ride this wave of technology. In the meantime, I am keeping myself updated with these kind of technological advancement in health information.

Prior to that training I received an email from another company where I applied either as an MT (despite my lack of years in experience; they required min of 3 yrs), or as MT editor for which I was fully qualified (medical background). I believe I received a message on the phone from them the next day upon submission of my online application (no tests whatsoever, as far as I can remember). I had been returning their call in the subsequent days, but was answered only by an answering machine. I gave up, only to receive an email after a week asking me if I was still interested. Of course, I was interested to know if they could give a better offer than the one I have now.

This morning I received a call from the same person (if I heard him right), and he said I passed their test (I was stumped, as I do not recall testing with them at all! But then again, I have tested several times, and only later did I make a printed copy of every test I did with each company I applied to that did allow me to test.). He arranged for a 15-minute talk on Tuesday next week. I have to get ready as to what I could possibly ask him. Time to post in the forums again.

It's nice to know that I can get a job (no matter how low the pay is) while staying at home and reviewing for NCLEX (I still believe that nursing is a more stable and more financially rewarding job than MT), or reviewing for USMLE (if and when I decide to pursue the medical career).

I am predicting more phone calls next week.

Oh, BTW, they never checked my past employment in PI. In this MT job, the important thing is that you can deliver.

PRACTICE FILES FOR THE MT-WANNABEs

2005-12-01T13:26:00.000-05:00

If you are a doctor who is considering doing MT as a sideline, below are some links from which you can download several audio files to see whether you have what it takes to do this job.

But before that, download first the Express Scribe to play the digital files. Once you have downloaded this software, then download the audio files from the below links and save them in a folder in your computer (make sure you know where you save them).

Here are the links:

http://www.qmedtranscription.com/testpage.htm

http://www.transrs.com - you must answer first the written portion to get to the audio (don't worry, that part is the easiest!).

http://www.enrightcorp.com/newtrans/enright_medical_test.wav

http://www.cnctranscription.com/OnLineTest.html

http://www.absoluteexperience.com/AudioSamples.html - these are zipped folders. Once you have downloaded the zipped files, unzip them first (rt-click then "Extract all...")

Once you have all (or even just one if you would just like to try this and not seriously considering doing this as a sideline) the audio files downloaded and unzipped as needed, open the Express Scribe and LOAD the dictations from the folder where you saved them, and type away! You can type directly onto Word while listening to the audio, and see the final outcome of your work. If you were the client, ask yourself this: "Would I want the medical records of my patients appear and filed like this?" That is your true assessment if you have done a good job or not.

Caution: Pangtawid lang ang MT for a more stable healthcare job. I'd go for either RN or MD pa rin. Truth is, either ma-offshore most of the MT work, or pag pinagbawal ng HIPAA regulations any offshoring of medical records eh wala nang mag-offshore (which I doubt will happen). So pag sinwerte kayo, you might be able to do this as a sideline directly hired by one MT company here in the US (wag na as employee ng middleman MT company in PI), as an at-home job.

2005-07-20T21:51:00.000-04:00

the sizing and lubricating equipment

reloading die sets

another view of the die sets

mold for the lead bullets on the right, melting pot on the left

melting pot with lead bars in preparation for modling

straining off the sandy material to isolate the "cleaned" shells

This is the catcher of the reloaded bullets

Winchester and Hornady bullets

Ako yan...

Hubby and boys

Me and my first son target shooting (lipas na anag hunting season)

target with the pile of wood behind to stop bullets...we make sure either these wood pieces will stop the bullet, or that there are no houses/people in the range where the bullets can go.

2005-07-20T21:38:00.000-04:00

a closer look at the bullet seat

Hubby operating the reloader

2005-07-20T21:36:00.000-04:00

Gary's gun collection

Gary's reloading tools

melting pot for lead bullets

Some lead bullets made

This itself is the reloading tool, with the primer on the left, and the powder measure holding the gunpowder, bullet seat

tumbler to clean the shells

These are lead bullets at the center, reloading press on the right, and the powder scale on the left (Lyman)

powder scale and a reloaded bullet

IntelliPoint 5.0 sucks!

2005-05-25T08:50:00.000-04:00

My husband, having been so excited that I am now earning a significant amount of money even as I stay at home, surprised me with a new set of wireless keyboard and optical mouse (I had been using the Logitech wireless kb and op mouse). I was thrilled at his thoughtfulness. He installed it last weekend. I had the whole weekend off.

I started work Monday morning, and noticed the glitches with my new hardware. I thought it was just because I had not learned all the ins and outs and the troubleshooting.

I tried to check out the help section on trooubleshooting when I was finally convinced that it was not just because of unfamiliarity.

Now, I had used it for 2 whole days typing for more than 8 hrs each day. I loved the padded keyboard (protects my wrists), BUT I HATE THE MOUSE!

It has delayed response to my dragging, pauses at one point where I did not intend it to go, which would make me react in such a manner that I would be exerting more effort to drag it to make it move, and when it did move, it went flying in all directions (either that or it disappears), and I would spend several seconds locating where it went, and would finally find it. Sometimes I would want to bring it to a certain point on the screen (like a button or a link), and as I slowed down it would get stuck, usually just before that point where I wanted it to be, so that when I finally clicked, I did not hit the right point! Then I would drag violently again to make it move (again, with a delayed response)...I finally had it.

I woke my hubby up earlier today before he went to work, asked him to put back my old Logitech mouse (Of course I was apologetic, but I would not want to waste any more time in this prodcution-based job of mine! I could have typed a lot of medical reports during those wasted seconds!)

Things are getting better...

2005-05-19T18:38:00.000-04:00

So many events have passed in my present work, but I haven't had the time to post here lately because of "addiction" with what I am doing, and the goodness of my superiors.

I had an unexpected partial raise in pay rate last week of April...I was kinda "promised" by my QA that I will be off QA at the end of April so I would get the full raise...

I had been on a QA-optional status, hence the partial raise, since that time.

When 100% QA-optional, it will be a full raise, then would follow production-based incentives.

Last week I sent an email to my QA re my status (i.e., when I would be completely QA-optional). No reply until this afternoon.

We had a brief chat. Definitely things are looking better and going faster than I anticipated.:

QA: Hi Manang- this is QA, I am logged in under Boss' IM for right now- I am at her house- I had to get away from my home very quickly as it was a violent situation. I just want to apologize for not being responsive lately and wanted to let you know I am back. I apologize if I appeared rude or unprofessional. I had a very rough few days as I had toXpXeXrXsXnXalX- but I hope to be on the mend soon!
md_mt032305: Oh...no problem! I hope things will get better for you soon...
md_mt032305: I feel like hugging you
md_mt032305: take your time...I am doing fine...
QA: you are doing better than fine!! you are one of our Superstars!!! Thank you for the hug- much needed and appreciated! I am not used to depended on other people for things. Today I would like to work just with you on your work que issues and see if we can resolve them today! I hate to ask you this again, but my mind is still not all there with me! Please let me know- you can IM or email. The first three docs and from then out- your next options to help with you productivity. Has your line count gone up? It seems that it has. Also, are you still in QA on anyone or optional only if you have a question? I am ready to get you 100% QA free
md_mt032305: you don't have to if you don't feel like it, but thanks for opting to attend to my issues..Here's the list of my most fave dictators from my highest priority: Dr1, Dr2,Dr3, Dr4, Dr5, Dr6, Dr7 and Dr8. I am not yet QA-op on the last 4. I can accomodate the other 5 doctors in my pool if you badly need help finishing them (Dr9, Dr10, Dr11, Dr12, and Dr13 in that order).
md_mt032305: I want to express my appreciation for taking good care of me.
md_mt032305: btw, I am not yet QA-op on the 3Drs from the last list.
QA: okay sweetie- I am going to have Boss take you off QA on those last four- you dont need it- or actually on all of them. I know you will send if you need to for QA. As soon as Boss gets back down here- I will get your work pool in order! You are just fantastic! After doing the transcription for a while, I really believe that you should look into moving into QA/editing- your skill and knowledge level would lend itself very nicely to this.
md_mt032305: Thanks for the praises, but I don't have the confidence yet to do that...
md_mt032305: and my past work as QA editor was quite traumatic for me...I don't feel like dealing with that kind of stress again...
QA: In time you will. There is a potential to make greater income- perhaps as we grow, that is something you will keep in mind. It is not stressful if you work for the right company.
md_mt032305: well, yes...the company does matter a lot...but I did learn a lot from you when you were doing QA on me...
md_mt032305: you knew exactly how to deliver feedback that encourages an MT
QA: just something to keep in mind! I had some TERRIBLE QA people in the past who made me feel like I needed to go work at Burger King!
md_mt032305: yes, I will keep that in mind...I just know that this is a great company, and I would be glad to be a part of/contributor to its growth!
QA: It is booming now and we have accounts lined up and ready to go with us as soon as we can staff them
md_mt032305: and that is sad...this work requires a great deal of skills and knowledge...it is not easy to find techie people with a strong medical background
QA: too bad too- it is such a great opportunity to be able to work at home
md_mt032305: I read fromBoss' last email about check crossing Canada. I have a friend who recently moved there, another doctor from PI, who is also interested in doing MT. Can I ask her to try applying?
QA: OH YES PLEASE DO!! I would be very happy to work to help her get accomodated to the system and the work! Ask her to please at her convenience send me an e-mail and we could get her on the road to working! How exciting! Can you not practice medicine when you move here?
md_mt032305: I have read enough horror stories about the medical practice
QA: The state of our health care system is shameful
md_mt032305: so many doctors get out of a state/city (ex. Chicago) or the profession itself (OB to teaching high school)
md_mt032305: disillusioned with the system
md_mt032305: insurance companies earning the big bucks
QA: no longer about the patients
md_mt032305: right...
md_mt032305: it is sad...treating patients for free gives us a different kind of high...but nowadays very few people appreciate that...can't blame them bec lots of drs also have become indifferent to make both ends meet, or just being arrogant
QA: and the frivoulous law suits and malpractice.... just terrible! So many doctors have become very callous and uncaring toward the patients beacause of the system
md_mt032305: yeah...but I am observing a trend -- online patient care...not sure if that will work fine...maybe then I will consider going back...in any case, this is a very good business on the side...Who knows? Maybe in time I wll have an income from this good enough to allow me to practice medicine without sacrificing patient care just so to earn enough to pay the insurance premium?...
QA: I had the opportunity to work for some of the large pharmeceutical companies on drug studies for Oncology (worked on the pahse three of Arimidex) and although it was very grattifying work, the amount of money the drug companies spent on nonsense and to entertain the doctors- when prices for prescriptions are so high that many cannot afford the medications needed was very alarming
md_mt032305: I am emailing my friend in Canada now...
QA: Great! Online medicine is becoming a very intriguing area of medicine-especially in rural areas.
md_mt032305: that too...I am uncomfortable knowing that a lot of pharma companies are manipulating doctors...just take a look at the latest guidelines on cholesterol and bp levels...I am not sure how much of that is honest...maybe they just want more sale for their drugs (pharm companies sponsor most of these studies anyway...). I can't help but think of doing Homeopathic Med if I will practice
md_mt032305: ok...done calling on other Filipino MDs (nonpractising like me) from Canada and US
QA: I absolutely agree- I have high cholesterol but did not want to try statins and am a big believer in vitamins and herbs and have reduced my greatly with red rice yeast and fish oil in conjunction with flax seed oil
md_mt032305: have you heard abt coconut oil (see Dr. Mercola's website and other scientific articles there written by PhD Chem...). I am a great cholesterol skeptic...recently saw a website of same people refuting the claims that cholesterol is bad for us...I still have reservations, though, but I try to eat foods as close as possible to their natural state.
QA: yes- that is what I have gone to as well- very little processed food. I try not to pay attention to a lot of the studies beacause I know how that whole system works with the drug companies manipulating the docs.
md_mt032305: well...i love chatting with you...lol...but I have to work now... Cheer up!
QA: Thank you have a wonderful day!
md_mt032305: you too! And thanks for everything that you have done for me...

Got my first paycheck!

2005-05-03T20:58:00.000-04:00

It is not that big yet...but that is only because it was only a week instead of two weeks' pay. Also, my production then was at it's lowest, and the pay in this job is production-based.

Just $ 142.24, and that is my pay from March 25-31, which I got one month after. My next paycheck will come on the 2nd half of May, which I have computed to be $ 482.44, then followed by $ 608.91 (yeah, that's how production jumps when you are starting your career as an MT, although my acceleration exceeds that of an ordinary MT who has no medical background that I have. I rarely have to check medical spellings/terms/procedures/drugs, whereas a new MT would always need that, and a medical terminology software such as Stedman's SmartType is such a big help to these laypeople, but which I doubt would help me). I have been focusing on building my autotext database to make my job quicker and easier. YOu can very well see the sharp upward slope in my production...from 200++ lines ($ 142.24 first paycheck for 2032 lines) to 600++ lines per day (so I will be getting that $ 608.91 for 8582 lines)...

Golly, this can be so addicting! The pay is not too great compared to being a nurse or a doctor, but then I won't have to worry about wardrobe and kissing somebody else's a-- just to stay hired. No worries about the weather and slippery roads, accidents during travel (do commuters get paid driving? and what about their driving time?). Most of all, I still get to cook, do household chores during my break, garden, and I am planning this summer to use the mornings for driving lessons.

Now I have to figure out how to pay my taxes. I can use some deductions like use of home for business, also equipment.

I think I will stick with this job. Then when I am ready, I will have my own MT business, using offshore talents...from the Philippines, of course!!! People there need good-paying jobs badly.

Increase in pay

2005-05-03T20:53:00.000-04:00

The last week of April was very exciting for me. I had been asking around at Scribera forum about when is the right time to ask for a raise if I have been proving myself an asset to the company...Some wise advise was that I wait for a month or two after getting out of QA to ask for a raise.

But surprise! I started getting (partially) out of QA last week of April, so I got a partial raise (It was also just about a month after starting my work in this company. I am hoping to get out of QA 100% by the end of this week so I will have the full raise of 5 cpl per line, then from thereon I can produce and produce and show consistency so I can ask for a raise depending on my production.

God is good...

It is inspiring to hear these words from your superior...

2005-04-20T12:55:00.000-04:00

I just wanted to take a moment out of the day to recognize [Manang]'s EXCELLENT WORK on two of our tougher doctors, Dr. Xxx and Dr. Xx. She types them like a pro!! It is so nice to have someone who is very dedicated to professinalism and perfection on tough ones like these two.

Thank you and have a great evening!

That's from one of my QAs that was emailed to me last night.

Then my boss made this offer:

I am considering completely pulling over Xxx or Xx for you to type since you seem to do very well with them both. That way, you should not continue to have the problem with light days etc. Right now another company has been handling those and the plan is for me to slowly transition them over here anyway. Which one do you like the best? You would still be hooked up to the other docs, but the doc you pick here will be your priority as you will be the only one working on it for the short term anyway. Eventually, I will get someone else on them for backup, etc. Until then, you will have to let me know ASAP if you are not going to be able to finish their load. I am going to look a the numbers and make sure the one you pick does not exceed the commitment you have made on a line basis so we can ensure coverage…. Just let me know!

That offer was in an attempt to solve my dilemma when I would spend several hours here without a file to transcribe, primarily because of the 3-hour difference in time from where my clients are (California). I have been asking my boss if I should work on additional accounts to fill in this vacancy, as I spend my early morning hours working on leftover files from the previous day.

I really think that my employer is VERY VERY ACCOMMODATING and is indeed CONCERNED with her employees.

My superiors (from employer to the QAs) have been very supportive and they know when to listen and really gives answers.

I think I would really want to grow in this team.

Guidelines for OB report etc.

2005-04-15T19:34:00.000-04:00

Obstetrics and Gynecology is a clerkship in a class all its own. You are usually caring for young, healthy patients, have a fair amount of responsibility, get to do procedures on your own, do deliveries, and participate in some surgery. In addition, in this clerkship you'll rarely have trouble making a diagnosis. Patients usually present appearing pregnant, feeling pregnant, and smelling pregnant. Yep, you got it - they are pregnant.

As in most other clerkships, you'll start of with an orientation: "Welcome to OB-GYN. In this clerkship you are graded on technical skill as well as knowledge. Therefore, when you are delivering babies, you are not to drop them." You'll also get a brief demonstration on scrubbing and sterile gown and glove techniques. While this works well in theory, you'll soon discover that occasionally from the time the mother is transferred into the delivery room to the time you have to be in position to catch the baby, there are often only a few seconds - not much time for perfect sterile technique. If, as you are racing to the delivery room, you should happen to spill a glass of water and get your fingertips wet, you will probably be considered sufficiently "scrubbed." Almost without exception, though,, there IS time to wear a gown, gloves, and mask with a fluid shield. Plan for this each time you are part of a delivery and it will become second nature. This is a part of OSHA (Occupational Safety and Health Administration) regulations that have been mandated for your safety Don't take unnecessary risks - it isn't worth it!

Some general advice for OB

Tips: Get to know the nurses working during your shifts. They are typically your lifeline to deliveries and a fantastic resource. Let them know that you would like to do the cervical checks, but remember not to check a pt after SROM without asking your intern or resident. Be sure to give the nurses your pager #. If they like you, you will be called when things start moving, if not... NOT.

Carry a standardized copy of each type of note . Since many of the cases in OB are relatively routine, the write ups are fairly standard - this includes admission notes, delivery notes, postpartum notes, and discharge papers. The residents will be impressed with you if you do this. See the attached Copy Me! pages or use the format used by the residents in your rotation.

As in surgery, practice your knot tying. OB-GYN's tend to be less forgiving when a student asks to do some suturing and hasn't at least practiced tying knots. If you don't know how yet, ask! The residents will be happy to show you how. The one-handed tie is used more often in OB relative to the surgery rotation.

Sites

Tucson

University Medical Center Students divide themselves into 3 groups, in which they spend 3 weeks on OB and 1 _ on GYN and 1 _ on GYN-ONC. Call is approximately every fourth night depending on the number of students on the rotation. Hours are approximately 6:3OAM-6:30 PM on both services. On OB, you are in clinic every morning and on Tuesday through Friday afternoons (Tuesday and Thursday afternoons are spent at the St. Elizabeth Clinic-Bring a Spanish/English dictionary if you are not bilingual). Basically, you will spend all day in OB Clinic, unless you are on call, then you are "on the deck" admitting patients and catching babies. Don't check cervix without intern being present. On GYN, students are in clinic in the afternoons, with the rest of the time for surgery, rounds, and studying. Generally speaking, at UMC you'll see a lot of high-risk patients on OB. Don't expect as much direct involvement in surgery as you had, or will have, in general surgery. You will learn more by showing interest. You will get less deliveries than in Phoenix but if you pay attention, you will get to do a lot. On GYN-ONC you pre-round, round with residents, scrub for the surgeries and do clinic (pre-op, follow-up, oncology).

The residents/interns are for the most part very good and really enjoy teaching. The main complaint at UMC is there are fewer deliveries than other sites, but most students get to do 2 to 8 on their own. Be assertive! UMC usually affords students more GYN experience than the other sites, so students usually become proficient at the pelvic exam. It doesn't hurt to ask the Thomas-Davis and Cigna attendings if you can assist if things are slow. Many times they will let you do the delivery if their patient doesn't mind.

Phoenix

Maricopa Medical Center- While doing OB-GYN at Maricopa, you may be confused for the entire 6 weeks, but when it's over, you'll realize you have a great deal of confidence when it comes to examining women and delivering babies. This place is a baby factory! You will have the opportunity to deliver many babies on your own, repair several episiotomies, and assist on all kinds of GYN surgery. The best piece of advice we can give is to be assertive (can you see a theme developing?) - they really do believe in "see one, do one, teach one." Also, don't, whatever you do, cross the nurses. They have the power to make or break the rotation. At Maricopa you'll work hard. Twelve hour days are the norm. Call is every 3rd to 5th night for 8 calls in six weeks. You can count on going without sleep, but the post call team tries to go home by noon. You may want to review clinical GYN in your "spare time." Be aware that the long hours leave minimal time for studying. In addition, those of you wishing to work with a Spanish-speaking population will have a terrific opportunity to do so at MMC. All in all, Maricopa is a great place to learn "hands-on" OB-GYN. The experience, confidence, and skill you'll gain are well worth it. It your goal is to deliver lots of babies... this is the place. Dr. Glen Kishi is a very enthusiastic teacher and a valuable resource.

St. Joseph's Hospital and Medical Center - As the residencies are combined, the MMC and St. Joe's experiences are similar, although it tends to be a little less hectic here "on the deck." The main difference is the droves of private attendings that care for patients. Many of them will be more than willing to let you catch their patient's kids. Others are less receptive. Again, be assertive. The worst that can happen is that they'll say NO! Call is the same as at Maricopa but students make their own schedule. The clinic experiences are much more limited at St. Joe's that at the other Phoenix sites. There is however, plenty of opportunity for GYN surgery.

Good Samaritan Regional Medical Center- GSRMC is a regular baby factory. It's not unusual for a student to deliver 10-20 babies in 6 weeks. The rotation is split between L&D, GYN, Clinic and subspecialty. Call is every fourth to fifth night, and you must do 8 nights with a couple of weekend days. Students make their own call schedule here, as well. Call nights take place in L&D and are extremely valuable. This is when you'll catch most of your babies and assist in C-sections. Some students have commented that it is easy for a student to be "ignored" when on L&D and on-call, because there is so much going on. The nurses here are great about waking you up to check on patients - but you have to ask! Assertiveness is important. Tip - check the triage board (there are TV monitors to do this with) and anticipate when a normal patient is coming up to L&D, then SNAG IT! It might pay to follow the second-year resident around as well. For some reason this is not encouraged, but this is where you'll work the ER, do some cross-cover and maybe watch some high risk OB. You will meet with your personal preceptor once a week. You will attend lectures (which are excellent) and conferences with the residents almost every afternoon. The evaluations of the students are often short and generic. An honors grade is difficult, but possible. GSRMC has a lot going for it - the residents are friendly, the teaching is outstanding, and the food is plentiful. Just be ASSERTIVE!!!

OB Exam

The final is an NBME exam which is challenging, but passable. Get in as much studying as you can, using lecture notes, handouts, and the books you may have. You may actually get the day off before this exam. The department is changing the required text for the rotation and will likely have it to borrow as they did with this year's book.

Pearl Books OB-GYN
Obstetrical Pearls, A practical Guide for the Efficient Resident (Benson). ESSENTIAL. READ THIS BOOK BEFORE YOU START THE ROTATION. The hours it takes to read it will be invaluable!! Borrow or buy it. An excellent practical guide to being on the OB-GYN rotation.
PRE-TEST - Obstetrics and Gynecology Great overview of OB-GYN. Helpful for the NBME exam.
NMS and Board Review Series were also helpful for exam preparation and NMS can be borrowed from the OB office.

Copy Me!

OB/GYN history and physical

H&P for Labor and Delivery, actual format

ID/HPI: Patient is a 24 yo. G2PlOOl African-American female with an EDC of 07/05/93 by U/S (07/06/93 by L.M.R) Gestational Age is 39 3/7 weeks. Patient presents with uncomfortable contractions since 06/30/93 at q 10 minutes. Patient presented to triage today with painful contractions (ctx's) q 4'. Patient denies any SROM (spontaneous rupture of membranes), bloody show h/a (headache), epigastric pain, edema, visual changes, N/V/ F/C. Patient intends to bottle (vs. breast) feed. Pediatrician is Dr. Moreno. (Optional: Birth control method used during conception, pregnancy was planned/unplanned) (You may add a paragraph here describing any significant complications during the pregnancy)

Prenatal Hx: First prenatal visit on 01/05/93 at 16 weeks gestation. Patient received prenatal care at the office of Dr. Mary King. Ultrasound was performed at 18 and 24 weeks and demonstrated a singleton fetus without abnormalities. Patient was diagnosed with a yeast infection which resolved with administration of Metronidazole ointment on 3/23/93.
Labs: Blood Type A pos, H&H 14.3/41.9 on 5/25/93.
Antibody screen neg., G.C. neg, RPR non-reactive,
Chlamydia neg., Rubella reactive, Pap smear negative,
HBsAg neg., Glucola 89, serum AFP not performed.
Amniocentesis not performed.
OB Hx:
(1) 1990 - S.V.D. of an 8# 4.5 oz. male at 40 weeks gestation, without
complications. Midline episiotomy performed.
(2) Current
GYN Hx: No history of abnormal Pap smears. Denies any history of STD's (you will want to specifically ask patient if she's had chlamydia, syphilis, gonorrhea, HPV, trichamonas or exposure to HIV)

PMH : Denies Asthma, DM, HTN, Immunological deficiencies, Cancer
Allergies: NKDA
Meds: PNV (Prenatal vitamins) with Fe 325 mg QD
Past Surgical Hx: Appendectomy, 1988, St. Joseph's
Hospital, Phoenix, Arizona
Fam Hx: Maternal grandmother with Breast Cancer, otherwise no significant family history. Denies fam Hx of DM, Immunological deficiency HTN, CHD, twins, mental illness, stillborns, or congenital or chromosomal anomalies.
Soc Hx: Denies TOB, Denies ETOH, 1 cup coffee QD. Patient is married x 3 years. At Maricopa always ask about hx of sexual abuse. Drugs.
ROS: Denies chest pain, visual changes, HA, edema, N/ V/F/C, calf pain, back pain.

PE: A WDWN African-American Female with apparent discomfort during contractions.
BP 11 6/71 HR 77
HEENT No thyromegaly
Breasts: Not engorged
Lungs: CTA Bilateral
Heart: Sl and S2 normal, without murmur, gallop, or rub
FHt 38 cm. Leopold's with vertex position. FHT's 150's and reactive.
Ctx's q 4-5 min.
VE: 6/80%/O (that's 6 cm dilated, 80% effaced, 0 station - always ask a
resident or nurse to check after you)
Ext: No edema, calf tenderness. DTR's 2/4 bilat patellar (Don't forget DTR's!),
no clonus.

A/P: TIUP 39 3/7 weeks with ctx's x 1 day and no SROM.
(1) Admit to L&D with monitoring
(2) Expectant managemnt ( you'll write this ALOT)
(3) Consider artificial rupture of membranes (this is not
always indicated)
(4) Discussed with Dr. Montis

Prenatal H&P - Initial visit

This H&P is similar to the one above, with the exception that you won't be as rushed as you are in Labor and Delivery. The HPI is essentially the same - you may want to ask the patient about things like low back pain and constipation (iron in prenatal vitamins is a major culprit), visual changes, vaginal discharge, and head aches. In the Gyn history, ask about age at menarche, information about menstrual periods (length, regularity or lack thereof, days of heavy/light flow). You will also want a more complete sexual history, including number of partners, whether they are "men, women, or both" and STD's. One way to elicit accurate information about STD's is to ask, "Have you ever had any bumps, rashes, sores, ulcers, etc......" Under Social History, get information about occupation. Your physical is much more complete, and the clinic may have a form for you to fill out. Make sure and find out the pregestational weight. You will be performing a pap and pelvic on the first visit. You will also want to perform a thorough breast exam, as many women receive their primary care at these visits. Remember DATING (of the pregnancy, that is) IS KEY! ALWAYS recalculate dates on every prenatal visit, even if gestational dates are listed in the chart!

Copy Me!

OB/GYN delivery Note
OB/GYN Post partum note

A controlled spontaneous vaginal delivery over an intact perineum (or midline episiotomy anesthetized with 5% lidocaine) of a viable male/female infant, weight 6 pounds 1 0 oz, apgars 9/9. Bulb suction on the perineum. Clear amniotic fluid. Spontaneous expulsion (or manual extraction) of an intact placenta with a 3VC (3 vessel cord make sure there are 3 vessels in the cord - a 2VC is associated with abnormalities 18% of the time). Cervix, vagina, and side walls inspected and intact with no tears appreciated.

Episiotomy repaired with 3-0 vicryl. EBL 300 cc. No other complications. Blood type is A pos. Rubella reactive. Delivered by Joseph Montes, M.D. and Mary Falls, MSIII.

NOTE: Certain residents/attendings prefer different formats. Refer to your OB/GYN orientation packet for different formats.

Post Partum Note

I.D.: [Age] [Race] Female G- P - - - - estimated gestational age-
This is a regular SOAP note, but you need to pay special attention to:
Level of uterine fundus (in relation to umbilicus)
Is the uterus firm (i.e., contracted down)?
Lochia (this is the postpartum bleeding) - quality and quant.
Episiotomy - intact? edematous?
HCT
LE edema/tenderness (for DVT's)- review Homan's sign.
Rubella status, Blood type (Does the mother need Rhogam?)
f/u care and discharge instructions (ask your resident)
Ask about contraceptio, breast/bottle feeding.

Source: http://studentaffairs.medicine.arizona.edu/TheBook/obgyn.html

Line production

2005-04-07T20:35:00.000-04:00

I recently posted about what could be the realistic line production for a newbie like me...So far, I am averaging 500++ lines per day, but my back and legs and hands are really crying...

Still I want to set a goal, but while I have set it at 1000 lines (at least) per day, I am not sure that is realistic.

But this is the jump:

FRom day 1 to day 5 my production increased from a bare 200++ lines to 400++ lines.

On my first week I made "Total Records: 100 and Total Lines: 2187" (mainly due to "gettin to know my dictators" stage and finding the right matches for me to come up with a pool that will fill my time and not leave me waiting here indefinitely for a dictation to download).

On my second week, with dictators pretty much established (though I still had new ones added to my pool for another 2 days and so I had to orient myself with their styles), my production rose to "Total Records: 156 and Total Lines: 3031 lines."

We will see if there will be improvement in the next weeks as I get a firm grip of my dictators' styles, and do less of researching for vague/unheard terms.

Somehow I have made improvements with my autotext and templates/macros to make transcribing easier, but still, when I am about to reach my daily goal of 600 lines, my hands are already stiff and slow, and my eyes are strained, my back and legs feeling numb...

Maybe I should relax a little bit. Anyway, I did not mean for this to be a major income source, but only to push myself to study more about medicine, to be able to save some for a possible USMLE, to help pay the bills, to raise money for buying a second-hand car, to be able to buy gifts for my husband, to be able to send some money to my Nanay...

Maybe I should start working on my garden...work there from 5:30 am to 10:30, take a break, have lunch then start work at 11:00, stop at 5:00, cook supper, work again for another 2 hours (if I would not be too tired by then), hit the sack at around 10 or 11 at night...

Somehow, this extra feature of counting lines in the software that I am using is making me obsessive-compulsive in reaching a certain number of lines...But hey...I should be wary. I might end up with CTS if I am not careful.

What QAs look for in a transcription (How can an MT get out of QA stage?)

2005-04-05T11:03:00.001-04:00

I started my MT career as an MT, primarily just knowing how it is on the client's end, but not having any knowledge on how it is to properly address the MTs (correcting them, giving suggestions on researching techniques and hoping to get them out of the need for QA). I decided to do transcribing itself not only for higher net pay, but also to avoid having bad relations with the MTs and my boss. I searched for a new employer to start anew, willing to learn every level, before I finally (I hope) embark on setting up my own business (or an option is to do some marketing and receive commissions).

I found this series of posts at a forum very helpful.

-----

I am new working for a company and I want to make life as easy as possible for me and for QA. I try very hard not to leave blanks and spend a lot of time researching before I leave a blank. What is really expected by QA? What would you consider a good employee versus a bad one? Do you get paid for anything that comes through QA? Do you QA all work or just certain MTs?
I'm just trying to get some insight into a world unseen to me.

----

QA procedures differ from company to company.

We do full audio review for two weeks on new MTs, new accounts, MTs assigned to accounts new to them, and accounts on which we have received customer complaints. If the MT is performing at 98% or better after two weeks, the account is released from QA; if not, we continue with review until we see improvement.

MTs are reviewed randomly once a month on 5% of their work and are given a score of accuracy.

We provide instructions for each account which include account specifics and client preferences.

QA editors are paid per line. They are not assigned to specific accounts. They do jobs in order that they come in.

My advice to you is to find out what your company's QA policies and procedure are and exactly what they expect from you.

First and foremost, you need to know whether your company adheres to a particular style guide, such at the AAMT Book of Style. Some companies use their own style guides which are usually an adaptation from the BOS.

Secondly, clarify your account preferences, i.e., does your dictator prefer verbatim transcription, etc. If you don't have the account specs in writing, get a copy. (You never know when you might need these to defend yourself.)

It would also help if you could see a QA worksheet that shows the point system your company uses to determine your QA score. For instance 2 points for a medical word error, 1 point for an English word error, 2 points for an omission, etc. If you could get a copy of this list, you would know what types of mistakes we are looking for.

Next, proofread, proofread, proofread. Most errors can be avoided by taking the time to proofread. I realize we are paid on production, but proofreading is a step that cannot be omitted.

Regarding blanks, as many of the other posters have said, I would rather see 10 blanks than 1 guess. NEVER, ever guess at medical terms. I follow the 5-minute rule for blanks--search all your resources for 5 minutes, then leave a blank and move on. (This applies to editors are well.) If the audio quality is horrendous, don't waste time trying to figure it out. Leave a blank and let your manager know if the audio is consistently poor. Sometimes the dictators are using a bad phone or a bad phone line or they need to adjust their handheld settings. Your manager or customer service people can handle those issues.

And also, as others have stated, develop a system to record all of the feedback, corrections, and blanks that are sent to you so that you can refer to the feedback and review it frequently during the first few weeks/months.

Lastly, develop a good relationship with your QA staff. Most of us are willing to answer questions and help out if we can. Hopefully your QA editors will provide clear, constructive feedback that will help you continue to grow as an MT. I realize that some editors enjoy their perceived "power" and are hard to get along with, but most of us enjoy the teaching aspect of our jobs and are willing to do what we can to help.

If I were your editor, I would appreciate your professionalism and your concern about doing a good job. Good luck.

-------

For those considering of making the shift from MT to editing/QA, here were some tips given:

Tests vary a lot and can include a little bit of everything ("sound-alikes," English/grammar, punctuation, AAMT style, terminology, anatomy, etc.) For example, the test may consist of several sentences that contain errors, and the instructions are to find the errors and correct them. I have taken a few tests that were very extensive and tested every possible aspect of editing, while others were very brief. I actually appreciate the tests that are more comprehensive because it shows me that the company places a high emphasis on finding qualified people. (I took a test recently and the test itself contained two errors. I decided they probably wouldn't be the most quality-minded company to work for!)

Personally, I like editing much more than transcribing. I think I am just more cut out for editing/proofreading than I am transcribing. I genuinely like the challenge and I like the teaching aspect of the job. In addition to working in QA, I also teach part-time at a college, and I try to incorporate a "teaching mindset" into the feedback that I provide for MTs.

I always had a difficult time making any serious money transcribing on a production basis because I spent so much time looking up obscure words, reading articles and proofreading my work. And now, even though I work on a production basis doing QA, I have found that I can make a lot more money.

Another thing to consider is your wrists. I was starting to have the classic tingling and wrist fatigue. I'm sure switching to QA saved me from carpal tunnel. (Now my eyes are tired at the end of the day, but my wrists don't hurt!)

-------

I found these helpful. so right now, my first aim would be to be out of QA, then I will slowly work on my production.

What QAs look for in a transcription (How can an MT get out of QA stage?)

2005-04-05T11:03:00.000-04:00

I started my MT career as an MT editor, primarily just knowing how it is on the client's end, but not having any knowledge on how it is to properly address the MTs (correcting them, giving suggestions on researching techniques and hoping to get them out of the need for QA. I also partly used the AAMT, but I am not inclined to follow every guideline they have, which are, to my point of view as a doctor, ridiculous.). I decided to do transcribing itself not only for higher net pay, but also to avoid having bad relations with the MTs and my boss. I searched for a new employer to start anew, willing to learn every level, before I finally (I hope) embark on setting up my own business (or an option is to do some marketing and receive commissions).

I found this series of posts at a forum very helpful.

-----

I am new working for a company and I want to make life as easy as possible for me and for QA. I try very hard not to leave blanks and spend a lot of time researching before I leave a blank. What is really expected by QA? What would you consider a good employee versus a bad one? Do you get paid for anything that comes through QA? Do you QA all work or just certain MTs?
I'm just trying to get some insight into a world unseen to me.

----

QA procedures differ from company to company.

We do full audio review for two weeks on new MTs, new accounts, MTs assigned to accounts new to them, and accounts on which we have received customer complaints. If the MT is performing at 98% or better after two weeks, the account is released from QA; if not, we continue with review until we see improvement.

MTs are reviewed randomly once a month on 5% of their work and are given a score of accuracy.

We provide instructions for each account which include account specifics and client preferences.

QA editors are paid per line. They are not assigned to specific accounts. They do jobs in order that they come in.

My advice to you is to find out what your company's QA policies and procedure are and exactly what they expect from you.

First and foremost, you need to know whether your company adheres to a particular style guide, such at the AAMT Book of Style. Some companies use their own style guides which are usually an adaptation from the BOS.

Secondly, clarify your account preferences, i.e., does your dictator prefer verbatim transcription, etc. If you don't have the account specs in writing, get a copy. (You never know when you might need these to defend yourself.)

It would also help if you could see a QA worksheet that shows the point system your company uses to determine your QA score. For instance 2 points for a medical word error, 1 point for an English word error, 2 points for an omission, etc. If you could get a copy of this list, you would know what types of mistakes we are looking for.

Next, proofread, proofread, proofread. Most errors can be avoided by taking the time to proofread. I realize we are paid on production, but proofreading is a step that cannot be omitted.

Regarding blanks, as many of the other posters have said, I would rather see 10 blanks than 1 guess. NEVER, ever guess at medical terms. I follow the 5-minute rule for blanks--search all your resources for 5 minutes, then leave a blank and move on. (This applies to editors are well.) If the audio quality is horrendous, don't waste time trying to figure it out. Leave a blank and let your manager know if the audio is consistently poor. Sometimes the dictators are using a bad phone or a bad phone line or they need to adjust their handheld settings. Your manager or customer service people can handle those issues.

And also, as others have stated, develop a system to record all of the feedback, corrections, and blanks that are sent to you so that you can refer to the feedback and review it frequently during the first few weeks/months.

Lastly, develop a good relationship with your QA staff. Most of us are willing to answer questions and help out if we can. Hopefully your QA editors will provide clear, constructive feedback that will help you continue to grow as an MT. I realize that some editors enjoy their perceived "power" and are hard to get along with, but most of us enjoy the teaching aspect of our jobs and are willing to do what we can to help.

If I were your editor, I would appreciate your professionalism and your concern about doing a good job. Good luck.

-------

For those considering of making the shift from MT to editing/QA, here were some tips given:

Tests vary a lot and can include a little bit of everything ("sound-alikes," English/grammar, punctuation, AAMT style, terminology, anatomy, etc.) For example, the test may consist of several sentences that contain errors, and the instructions are to find the errors and correct them. I have taken a few tests that were very extensive and tested every possible aspect of editing, while others were very brief. I actually appreciate the tests that are more comprehensive because it shows me that the company places a high emphasis on finding qualified people. (I took a test recently and the test itself contained two errors. I decided they probably wouldn't be the most quality-minded company to work for!)

Personally, I like editing much more than transcribing. I think I am just more cut out for editing/proofreading than I am transcribing. I genuinely like the challenge and I like the teaching aspect of the job. In addition to working in QA, I also teach part-time at a college, and I try to incorporate a "teaching mindset" into the feedback that I provide for MTs.

I always had a difficult time making any serious money transcribing on a production basis because I spent so much time looking up obscure words, reading articles and proofreading my work. And now, even though I work on a production basis doing QA, I have found that I can make a lot more money.

Another thing to consider is your wrists. I was starting to have the classic tingling and wrist fatigue. I'm sure switching to QA saved me from carpal tunnel. (Now my eyes are tired at the end of the day, but my wrists don't hurt!)

-------

I found these helpful. so right now, my first aim would be to be out of QA, then I will slowly work on my production.

Setting goals as a newbie MT

2005-04-05T10:10:00.000-04:00

In a forum I frequent, I posted this:

What is the realistic goal of # lines/day for a newbie?

How fast usually is the rate of increasing production (say, an increase of 200 lines per day more than the previous production shuld be achievable in how many days/weeks/months?)

Accordingly, how much should the increase in pay to accompany such increase in production, and also increase in quality (i.e., getting out of QA stage)?

Thanks for the info.

To which another forumer answered:

Too many variables to say. Your own base of knowledge and the clarity of your dictation will have a big impact on what you do. If you need to be spending many many minutes replaying fuzzy dictation and/or searching for unheard of words, drugs, etc. in all your references and online, it can really eat up a large part of your day and cut into your production. Also, the familiarity you have with your software will have a lot to do with how fast you crank out files, too.

I won't even comment on the pay because you usually stay at that post-newbie level for quite a long time as a search will show. The companies pay what they want to pay. If you don't like it, you pretty much have to move on. Good luck!

then I replied:

When I was applying, I have seen companies outlining pay based on productivity based on certain ranges, like 400-600/day at 0.05 cpl, moving up as one improves. I have read that some companies require MTs to make 1,200 lines/day to qualify for benefits. I have read MTs making 2000lines per day, and recently there was a post of making 15,000 lines per pay period.

I am getting confused as to what is realistic. I was not sure if those 15,000 to 20,000 lines per pay period were meant to be sarcastic.

I have set a goal for me to reach at least 1000/day to 1200 lines /day, to achieve a pay equivalent to $9/hour on an 8-hr period basing on my current pay level. Right now, having started learning about a new software and quickly learning to utilize its features, I have jumped from 200 plus lines to 600 lines per 8-hr workday within 5 days. This increase is mainly due to the autotext feature, but I think my initial entry of new autotexts for new accounts also slowed me down. Neverthelss, I can foresee this investment of time having its benefits of escalating my production once I have all my autotext and macros etup for all the 10 accounts (mostly ESLs, multi-specialty clinics) I have. Will it be realistic for me to even set my goal to, say, 2000 lines/day?

Plus, though I started at an entry level, I have received feedback from my QAs that I am doing a fantastic job, that my medical terminology is excellent, and that I am very skilled (I have 7 years of previous hospital/multispecialty non-MT job aside from a medical course which included 2 yrs of basic medical sciences plus 1 year of clinical sciences)...and that some of my work (where I left no blanks) needed no change, so, modesty aside, I am predicting I might get out of QA in a matter of few months if not few weeks...I have been observing (through the software feature) that my most of my transcriptions are delivered to the client within 2 hours upon my submission to QA.

I am just trying to arrive at what I should expect that is fair both to me and to my employer, although right now I am very very pleased with my company's system, and would not ever wish to get to the point of hopping to another company (which I might do if I think I am not being paid fairly)...I may sound dumb to you, but I really have no idea...your input will be highly appreciated. Thanks.

Another newbie posted:

That is a lot to chew on. I am about to begin my first job as a recent grad. I am interested in what software your using. I need to buy something. Thanks for the misc. info on line production also.

I emailed her with this:

thought I'd email you in case you didn't read my reply...

The software I use is provided by the company. Nowadays, I think most companies have their own platform, so I would suggest you don't buy a software yet, as some companies require their MTs to buy their software once hired. I also suggest before you sign any contract, verify if you have to purchase/rent anything from the company. I think it is very unfair to us, and they profit not only from their clients but also from MTs. Our pay is not at all decent enough. They should consider that with this business they don't even have to pay for internet, office, telephone lines, etc. A company that requires you to purchase hardware and reference materials is a no-no in my opinion. The internet itself is a very useful tool for researches.

If you want to familiarize yourself with the autotext, I suggest you do something like the following:

I wanted to print the autotext that I have made so far with the sofware I am using. However, the program does not have such a feature (I wish they will come up in the next version), so per dictator, I made a listing of autotext. Some of the "codes" I made were meant for short words such as "hs" to be converted automatically to h.s., to "tpci" to convert automatically to "The patient is coming in." In wanting to customize my autotext to a particular dictator, I wanted to print them accordingly (per dictator). What I did was, while transcribing and using and adding new autotext (which makes me slow at this initial period), I would also make a table in Word of such, The Word automatically corrected my codes by capitalizing the first letter, which I did not want it to do. So I clicked on the help button in Word, and asked how to remove that feature. I then learned that it was the autocorrect feature. I realized it can be used the same way, to build macros and autotext, if you happen to be working for a company that does not have such a software that helps MTs increase productivity. From what I have read, such Word autotexts can be imported into software provided by the company, if they do have addressed that concern.

Honestly, I still don't know at this point if I will be able to achieve that. I am giving myself one month to familiarize myself with all my accounts and prepare macros and templates and atutotext, hoping that I will indeed reach at least 1000 to 1200 lines per day, or more, without having to have a 100 wpm typing speed. I only have 45-65, and I doubt that that will change. I can type faster if I am typing my own thoughts, but not when I have to listen to a dictation and pause and type and play and listen and pause and type.

Right now while still getting acquainted with the autotext I have made and trying to create a method for me to organize my approach in typing for certain dictators, I am making barely above 400 to less than 600 lines per day, sometimes working more than 8 hours in a day.

Sample Endocrine transcriptions by ALT

2005-04-03T20:26:00.000-04:00

Among my accounts, this is the most interesting and fascinating...

HISTORY OF PRESENT ILLNESS: The patient is 59-year-old woman who was diagnosed with hypothyroidism in October xxxx. She presented with fatigue and weight gain. She was started on Synthroid 0.2 mg once a day. At the time, her TSH was 35.04. Repeat laboratory testing in December showed a TSH at 0.07 and her dose was reduced to 125 mcg. Her repeat thyroid function tests in February showed a TSH of 0.16. She is currently complaining of continued fatigue, total weight gain of 25 pounds since October, difficulty losing weight, cold intolerance, and dry skin. She takes her medication in the morning with her other medications but no supplements. She waits for an hour before eating breakfast. She was apparently started on a generic preparation, developed the rash to this, but is now on the brand Synthroid. She has never had any previous thyroid disorder, no history of nodules or lumps in her neck. She has had no compressive symptoms. She has noted a significant increase in the size of her neck, but this is in the area below her chin.

The patient also had her estrogen level reduced about 1 year ago. She had been on 2 mg daily since 1982 when she had a hysterectomy. The dose was cut in half to 1 mg about 1 year ago. She believes some of her symptoms began at that time as well, particularly the dryness and reduction in temperature.

PAST MEDICAL HISTORY:

Hypothyroidism, diagnosed xx/xx.
Postmenopause, on HRT.
Depression, on Wellbutrin.
Urinary incontinence.
Hearing loss requiring hearing aid in the left ear.
PAST SURGICAL HISTORY:

Hysterectomy with ovaries intact in xxxx.
Hemorrhoid surgery xx years ago.
Breast augmentation.
Pregnancies, x, with x children.

ALLERGIES: Unknown, except for the generic thyroxine.

FAMILY HISTORY: Father died at60 with heart valve problems. The mother is 88; she is recently diagnosed with hypothyroidism and osteoporosis. She has 2 brothers, age 53 and 57; they are healthy. She has 4 children, 27 through 40, who are also healthy, no diabetes, no other tyroid disease, cancer, or heart disease in the family.

MEDICATIONS:

Synthroid 125 mcg daily.
Wellbutrin 150 mg SR daily
Detrol LA 2 mg daily.
Estradiol 1 mg daily.
Bextra 10 mg as needed.
Super B-complex with flaxseed supplement.

SOCIAL HISTORY: She is originally from California. She is a retired puppeteer. She is married.

HABITS: Nonsmoking. Consumes 1 alcohol a day. Caffeine none.

REVIEW OF SYSTEMS: General: Overall, the patient feels well, but she is very unhappy about not being able to lose weight. HEENT: Negative. Cardiorespiratory: Negative. Gastrointestinal: Negative. Genitourinary: Her symptoms are controlled with Detrol. Endocrine: Amenorrhea, cold intolerance and dry skin ; she has never had an elevated glucose. She had a bone density scan done many years ago and has lost 2 inches in height. She is not following any diet at this time, but is contemplating on a weight-loss diet. She did look into Madura. She exercises 5 times a week, going to Curves for 30 to 45 minutes. Musculoskeletal: She has some osteoarthritis. She is on occasional Bextra. Vascular: She has had varicosities, and some end-of-the-day edema in her ankle. Neurologic: She occasionally can feel some numbness in her feet. Hematologic: Negative. Psychiatric: Her depression has been under good control.

PHYSICAL EXAMINATION: General: The patient is a healthy-appearing 59-year-old woman. She is no apparent distress. Vital signs: Blood pressure 126/70, pulse 64 and regular. Weight 159 1/2 pounds. Integument: Cool and dry. Normal texture, smooth and some old stretch marks on her abdomen, nothing new. Hair: Normal in distribution, no hirsutism and balding. HEENT: There is no Cushingoid appearance. There is increased soft tissue under the chin in the midline, but no supraclavicular increase in fat or subcervical fat pad or facial cheek fat distribution. EOMI PERRLA. Normal eyes and nose. There is no periorbital edema. Oropharynx is unremarkable. Neck: The thyroid gland is small with no nodule. Lymph nodes: Negative. Chest: Clear to auscultation on anterior and posterior. COR: Regular rate and rhythm. No murmur, gallop or rub heard. Abdomen: Soft, flat and normoactive bowel sounds. No hepatosplenomegaly and nontender. Extremities: No edema. Neurological: Cranial nerves intact. DTR is 2+/2 with normal sensation and motor intact.

LABORATORY DATA: From October laboratory testing included a normal CBC, a chemistry panel with a fasting glucose of 75.

IMPRESSION:

Hypothyroidism.
Recent low TSH.
Fatigue.
Cold intolerance.
Postmenopause on estrogen.
Abnormal weight gain.

DISCUSSION: At this time we will recheck thyroid function test to see if the dose needs to be adjusted. I discussed with her the lag in time for normalization of thyroid function once the dose is changed, as well as the lag in time for clinical symptoms to improve as well. Autoantibodies are supposed to have been drawn today to see whether or not this is consistent with Hashimoto's thyroiditis. We will recheck her estrogen level as well. I am reluctant at this point to increase her estrogen to help relieve some of her symptoms until the thyroid level has been completely normalized. We will also order a bone densitometry at this time as it has been many years since she had one.

We briefly discussed weight loss, dieting, and exercise principles. She is going to work on this on her own and is contemplating on program at this time.

We will have her return to the office in 3 months. We will contact her concerning her laboratory results.

******************

HISTORY OF PRESENT ILLNESS: The patient reports that she was recently diagnosed with pituitary adenoma in June of 1999 when she presented for an annual Pap examination. She had galactorrhea of both breasts at the time. Her prolactin level was checked and it was high at 100. An MRI was done, which demonstrated a 5-mm pituitary adenoma. She was started on bromocriptine; however, she had a poor response in her prolactin level. This has been switched to Dostinex 0.5 mg 2 times a week. She has been on this since then. She reports good control of her prolactin when she is on the Dostinex. Her results will go down to below 10. Her menstrual cycles are also regular when on Dostinex. When she was originally diagnosed, she was on oral contraceptives. Her menstrual cycles have remained normal on this. Birth control pills were discontinued, and she had irregular cycles until she was placed on the Dostinex. She had a lack in medication last year due to a change in the insurance. During that time, her prolactin level increased to 190. Her menstrual cycles were also irregular at that time. Recently she has gone off the Yasmin to become pregnant. Her last menstrual cycle was on February 20th, which was at the end of the last pack of Yasmin dose. She has not had a menstrual cycle since then, but has had a repeated home pregnancy test negative. She missed Dostinex for 1 week while she was traveling on spring break, and attributes the irregularity to this, too. She has been back on the Dostinex for 1 to 2 weeks. She has had repeated MRI throughout the year. I have a report from the most recent one, which was in 5/04. The pituitary tumor measured 78 mm. It was in the right aspect of the gland and it showed no significant change from prior MRIs. She reports that the size does vary on MRI between 5 to 8 mm. In addition, she has seen an ophthalmologist on a regular basis and has never had any problems with her visual field. She has never had any symptoms such as headache or change in vision. She has no galactorrhea.

PAST MEDICAL HISTORY:

Pituitary tumor.
Hyperprolactinemia.
No surgeries, no fracture or injuries.
Gravida 1 para zero, 1998.

ALLERGIES: None known

FAMILY HISTORY: Her father is 46 and had a brain aneurysm a number of years ago. Her mother is 40 and is doing well. She has 3 siblings, all well, ages 7, 18 and 20. Her maternal grandfather had prostate cancer and a stroke. Her maternal grandmother had glaucoma. There is no thyroid disease, diabetes, endocrinopathies, or pituitary tumors in this family.

MEDICATIONS: Dostinex 0.5 mg twice a week. Multivitamins daily.

SOCIAL HISTORY: She is originally from xxxx. She is married. She is currently working as a substitute teacher and recently graduated.

HABITS: No cigarettes, no alcohol, 1 caffeine a day.

REVIEW OF SYSTEMS: General: Overall, the patient feels well. HEENT: Negative. Cardiorespiratory: Negative. Gastrointestinal: Negative. Genitourinary: Negative, except for as in history of present illness. Endocrine: She is complaining of hair loss at this point in time. Her weight has been stable. She exercises 30 minutes 3 days a week. Musculoskeletal: Negative. Vascular: Negative. Neurologic: Negative. Hematologic: Negative. Psychiatric: Negative.

PHYSICAL EXAMINATION: General: The patient is a healthy-appearing 24-year-old woman. She is no apparent distress. Vital signs: Blood pressure 120/72, pulse 72 and regular. Weight 182 1/2 pounds. Integument: Cool and dry. Normal texture and color. Palms were dry. Nails are normal. Hair: Normal in distribution, no hirsutism and no hair loss noted. HEENT: No Cushingoid appearance. EOMI PERRLA. Normal eyes and nose. There is no periorbital edema. Oropharynx is unremarkable. Neck: The thyroid gland is normal with no nodule. Lymph nodes: Negative. Chest: Clear to auscultation on anteriorly and posteriorly. Back: No dorsocervical fat pad. [5:23] COR: Regular rate and rhythm. No murmur, gallop or rub heard. Abdomen: Soft, flat with normoactive bowel sounds. No hepatosplenomegaly, no stria and nontender. Extremities: No edema. Neurological: Grossly intact. DTR is 2+/2 with normal relaxation phase, no tremors. The visual fields were intact to confrontation.

IMPRESSION:

Microprolactinoma.
Irregular menstrual cycle.

DISCUSSION: The patient probably has a prolactin-secreting adenoma given the degree of elevation of prolactin and the size of the tumor being under 1 cm. It has responded well to Dostinex when the patient has been on the medication. We will check prolactin level. At this time, it may be mildly elevated given the fact that she has not been on the Dostinex regularly in the last months or so. We also will check a serum pregnancy test as her menstrual cycle is late at this point in time. She will continue on the Dostinex at this time. Should she become pregnant, it will be discontinued and she will notify our office. I have recommended that she wait a total of 3 months prior to getting pregnant off of the contraceptive pills. She is to keep track of her cycle, and from the day that her cycle is due, she will need to begin her pregnancy test until she resumes her period or the test is positive. We will also check other pituitary functions at this time, including thyroid, IGF-1, and gonadotropins, and estrogen.

I would like to thank you for having referred this patient for evaluation and I have requested her to follow up with us in 3 months. She is to call us if she becomes pregnant. Please let me know if you have any questions or concerns regarding her.

I love the software that I am using to transcribe dictations

2005-04-03T13:16:00.000-04:00

My present employer has partnered with [EMR service] to facilitate the smooth flow of work from the doctors to them, with a good distribution of accounts to the several MTs (including me), back to QA, then delivered to the clients, without worrying about filing and archiving. The [EMR service] prives those services; my employer only worries about transcription per se and anything related to it: hiring MTs, assisting and communicating with her MTs.

The dictation files can be pulled in by the MTs, and work on them only while online. I (MT) have no way (or have not found a way and not planning to) to store the dictation files in my computer to work on it offline. When the MT does not work on those files right away, the company has the option to pull them back in for the others to transcribe. This way, TAT is ensured, and contingency measures are taken care of in case an MT suddenly has an emergency. One MT has 6-8 accounts to transcribe, but there are 2-3 MTs assigned to a particular account, in case an MT goes on vacation or is sick. Good contingency measure.

I love using the [software]in that templates are already there, dictator-specific, as prepared by my employer and, of course, approved by the client. (Client has the option to type in the template themselves or just dictate it so the MT can choose from the different templates.) MT has the option to check demographic data from the database or enter those as dictated. Employer builds a database of doctors and associates to facilitate easy CCing of reports, and if there are new associates to add, MT can add that to the database; no need to look for and to enter addresses and all everytime that associate comes in for CCs. Autotext features enables MT to enter such codes as "tpic" to mean "The patient is coming in," or the code "rsmb" as "I reinforced multi-self breast examination, daily calcium needs, and regular exercise," so that by building up my autotext during my initial weeks for such "canned" (de-kahon) sentences/reports/paragraphs will eventually maximize my production and the overall production of the company. The [software] also has the Spellchecker, which not only has a central database like the addresses of the associates, but an MT can also add a new term/acronym/abbreviation there . Before final submission/uploading for QA, spellchecker is run again automatically. Comment box is separate. When empty, the QA is notified as such, and when there are comments, QAs also are automatically notified.

I can also check my lines transcribed or the actual # of lines delivered, any time! I can check from and to any point in time. The counting is done automatically. In my first week of transcribing using this system, my one-week production was 2187, of which 2032 were delivered. It is so motivating to keep track of how I am improving daily with my line count. My productivity from day 1 jumped from 200/day to 500/day on day 5, and only because I kept adding doctors/accounts to my list, from an initial 3 dictators to 11, and I guess that is enough to keep me busy during the day (I won't have to waste time waiting for dictations). As soon as the doctor start their day and start seeing patients, they dictate right away, I get the files right away and work on them one by one and check them back in, usually within 20 minutes for a 1-2 minute dictation.

I am about to enter my second week, and without additional doctors to get used to and to build my autotext for, I am foreseeing a jump in my productivity, hopefully to at least double my initial production.

From the MT's point of view, I love using this [software]. It is soooo user-friendly. It is easy to use, and best of all, my employer DID NOT REQUIRE ME TO BUY THE SOFTWARE nor to have high-speed internet connection ([EMR service feaures are sooo flexible!). When I was looking for a new company to work for, most of them required their MTs to purchase their software, which is BS, if you ask me. Companies save a lot already on overhead costs, not having to provide a working environment with computers and telephones/internet lines having shouldered by the MT themselves. Some even ask the MTs to purchase their own pedal and/or lease their computer! Well, I certainly don't need additional computers. We have a total of 4 computers at home now! Almost one for each member of the family. We are just saving money or wait for some "donations of parts" to build another one. We always have a use for thrown away keyboard, modem, CPU, etc. My hubby only buys the second-to-the-latest computer parts that are critical for upgrades like the motherboard, DVD player/burner, video card and audio card, etc. So I don't really need unnecessary expenses for those.

I cannot speak for the company/QA and the client itself, but I can imagine how efficient and simple the system is, given that this [EMR service] can configure several dictation hardware for the client's end, who have the option to enter the data themselves or just dictate. If they just dictate, which they usually prefer, MTs have work to do. Filing is made easy and taken care of by the [EMR service], not on the shoulders of the MT company nor the client, and I am pretty sure a back-up system has been addressed by as well.

I can only think that if I do get enough experience as an MT, I might embark on my own MT business and use the same [EMR servcice] as well, or, I am exploring with my employer the possibility of marketing for my company, offering this service to the doctors around here in my state, getting commission (say 1%) for all clients I introduce to the company, and taking direct responsibility for doing QA on these accounts and direct personalized communication with the clients to keep them in our client database and in my account.

If I also find the motivation to practice here myself (these cases I am typing just gives me some kind of high that I feel like I am working as a doctor myself! Reminds me of those days when I used to manage patients. It also gives me the motivation I need to review things that might be useful for the USMLE so I just might take up those tests to be licensed.), then I am pretty sure that when I do practise here as a doctor, I will use this [EMR service]for my dictations and even recommend it to others.

So I'd say, a lot of headaches will be taken care of if an MTSO will go for this [EMR services]. Your focus, as an MTSO, will be on the transcription itself. The [EMR service] takes care of everything else. My employer even told me that this [EMR service] sometimes add to their pool of clients (she mentioned that to me when I asked about the possibility of incentives for marketing for new clients). Doesn't that sound too good to be true?

Sample IM, SNF transcription by ACU

2005-04-03T09:32:00.000-04:00

SUBJECTIVE: Mr.xxx has multiple questions and problems.

He states that his ears may be full of wax. He uses a liquid but he still feels that he has some problems there.
Pain in his knee, especially over the patella, also when he puts pressure on it, such as kneeling. He has left knee pain when he flexes his leg at times, but this is intermittent and none of these are disabling.
He needs a refill on medications.
He also requests a complete physical examination.
He has some various reactions when he takes his blood pressures. He gets anxious, and his blood pressure stays elevated.

OBJECTIVE:

General: This is an alert and orient male aged 57.

Vital signs: Blood pressure 148/84; retake is 150/84; temperature 98.4; pulse 78; respiration 16. Weight 222 pounds. Height 5 feet 11 inches.

Skin: Warm and dry.

HEENT: Cranium is normocephalic and atraumatic. Ears have increased cerumen bilaterally.

Chest/Lungs: Clear.

Heart: Regular rate and rhythm.

Abdomen: Soft.

Extremities: No peripheral edema.

ASSESSMENT: Hypertension, obesity and hyperlipidemia.

PLAN: Refill hydrochlorothiazide and lisinopril. Add atenolol 25 mg 1 tab daily to the regimen of hydrochlorothiazide and lisinopril 40 mg. He is also taking Zocor 20 mg, and he will return for a complete physical exam. Also, the patient's ears were irrigated, and he was advised regarding his ears.We will follow up.

********

SUBJECTIVE: The patient presents with a complaint of low back pain. She states that she is feeling much better. Emotionally she is in therapy. She still has a great deal of problems with family, etcetera, but it is definitely better. Regarding her complaint of low back pain, she was seen by Dr. XXX. She is taking medications. She still has sacroiliac discomfort, and we discussed this with regard to therapies.

OBJECTIVE:

Vital signs: Blood pressure 170/90; retake 160/90. Temperature 98.6. Pulse 64. Respiration 12. Weight 228 pounds.

Skin: Warm and dry.

Cranium: Normocephalic.

HEENT: Benign.

Neck: Supple.

Chest/Lungs: Clear.

Heart: Regular rate and rhythm.

Abdomen: Obese and nontender.

Extremities: There is no peripheral edema. The feet were examined, and they show no lesions which may be aggravated by her diabetes.

ASSESSMENT:

Diabetes mellitus, non-insulin dependent.
Obesity.
A case of chronic heart disease with status post coronary artery bypass graft (CABG).
Hyperlipidemia.
Hypertension.

PLAN: The patient's chart is not available at this time. She will return for a complete physical exam in 2 weeks, but she is having laboratory work done. We have not done this in quite a while. She is having SMA 20, with repeat UA, CBC, TSH, HbA1c in 12-hour, microalbumin done. Her medications are atenolol and lisinopril plus the medicines which I do not have listed. She will bring all her medications, and hopefully we will find her chart prior to her being examined.
********

SUBJECTIVE: XXX is here for medication refill and also have her lipids evaluated. She is feeling well; there are no specific complaints at this time.

OBJECTIVE:
General: The patient is a 54-year-old white female, alert, oriented, and in no distress.
Vital signs: Blood pressure 140/80; temperature 98.6; pulse 97; respiration 16. Weight 167 pounds. Height 5 feet 3 inches.
Skin: Warm and dry.
HEENT: Benign.
Neck: Supple.
Chest/Lungs: Clear to auscultation.
Heart: Regular rate and rhythm.
Abdomen: Soft.
Extremities: No peripheral edema.

ASSESSMENT:
1. Hyperlipidemia.
2. History of fibromyalgia.
3. Lactose intolerance with irritable bowel syndrome.

PLAN: New prescription for Vytorin 10/20. She will get #30 to try, and then if no side effects such as diarrhea, she will get the 90-day supply. If that is not covered by her insurance, we will order Zocor. We need to follow. The patient is asked to return in 3 to 4 months.

**********

SUBJECTIVE: Mr. XXX is here for followup. He complains that he is getting severe back spasms upon rising from bed or even getting out of his chair at times. It may last 3 to 4 days where he is incapacitated. He has had at least twice in the past month, and before that he had this several times during the month. He failed to make any mention of it. The patient had no history of trauma; it is just moving from one area to another, or arising from a sitting position.

OBJECTIVE:
General: This 84-year-old gentleman is alert and oriented in no severe distress
Vital signs: Blood pressure today was 130/60, temperature is 97, pulse is 60, and respiration is 14. Weight is 190 pounds. He is 6 feet 3 inches tall.
Skin: Warm and dry.
HEENT: Benign.
Neck: Supple.
Chest/Lungs: Clear to auscultation.
Heart: Regular rate and rhythm.
Abdomen: Flat and nontender.
Extremities: There is no peripheral edema at this time.
Musculoskeletal: On examination of the spine, there is some muscle of the right lower lumbar area, but it is not tender. I am not certain if this is a normal finding in this gentleman's case. He is muscular in general.

ASSESSMENT:
1. Hypertension, with history of atrial fibrillation, diabetes mellitus, osteoarthritis, spinal stenosis, hyperlipidemia, and glaucoma.
PLAN: He has Vicodin for the severe pain. He has several conditions definitely predisposing him to these problems, one of which is his arthritis, and the other is his spinal stenosis. I will discuss this more in the future. We will follow.

*********

SUBJECTIVE: The patient is here for a review of her blood pressure and to review diabetic standing. She is doing quite well. Her only problem is that she is having difficulty with sleeping.

OBJECTIVE:
General: The patient is a 52-year-old white female. She is alert, oriented and in no distress.
Vital signs: Blood pressure 130/68; temperature 97.6; pulse 88; respiration 20. Weight 166 pounds. Height 5 feet 2 1/2 inches.
Skin: Warm and dry.
HEENT: Benign.
Neck: Supple.
Chest/Lungs: Clear to auscultation.
Heart: Regular rate and rhythm.
Abdomen: Soft. There is no mass nor tenderness.
Extremities: There is no peripheral edema. The patient denies any sores on her feet or any other significant changes.

ASSESSMENT:
1. Diabetes mellitus.
2. Hypertension, controlled.
3. Hyperlipidemia.

PLAN: We will continue to monitor. The patient is to return in 6 weeks or as necessary.

*********

SUBJECTIVE: Xxx presents with the complaint that she has had chest pain, which is oppressive, as somebody is sitting on her chest, and difficulty in getting her "ear". She says that she gets pain in the right arm and also cervical spine pain when this occurs. There is some difficulty with the history. This is because of the nature of the problem and also of the patient's prohistorian as well. This has occurred in 4 episodes, which is disconcerting. She also has abdominal pain; it is a chronic pain, which keeps her from employment. She also a right upper quadrant pain. Whether this is GI or cardiovascular remains to be seen. She was taken to the emergency room and they gave her a clean bill of health and sent her home a week ago.

MEDICATIONS:
1. Naprosyn.
2. Vicodin.
3. Voltaren.
4. Prozac.
5. Tylenol.
6. Some medications for her eyes.

She is not to take Voltaren and Naprosyn at the same time. If she does, she may have stomach problems from that. She shakes her head no, she is not taking both medications.

OBJECTIVE:
General: This is an obese 53-year-old asthenic female, alert, and in no distress at this time.
Vital signs: Blood pressure 120/90; temperature 98.6; pulse 76; respiration 16. Weight 232 pounds. Height 5 feet 1 inches.
Skin: Warm and dry.
HEENT: Benign.
Neck: Supple.
Chest/Lungs: Clear to auscultation.
Heart: Regular rate and rhythm.
Abdomen: Rounded, obese and nontender.
Extremities: There is no peripheral edema.

ASSESSMENT: Chest pain, etiology secondary to psychophysiologic reaction versus esophagitis versus cardiovascular complications.

PLAN: Repeat electrocardiogram; have cardiology re-evaluate, and consider an upper GI and esophagram to rule out any esophageal problem. I will treat the esophagus at the present time with mild antacid medication and possibly proton-pump medications to prevent her symptoms, and then await referral to cardiology. We will follow.

*******

SUBJECTIVE: He has no specific complaints. He has some concerns about his skin as he was a surfer and exposed to the sun. However, we examined him last year and again this year, and we will evaluate the skin areas. He has physical examination a year; he is gainfully employed, and he is a hardworking gentleman. There is a history of asthma, but he has been asymptomatic for some time. The patient is a nonsmoker, and drinks alcohol only very socially. There is no family history of chronic disease. His parents are in their 80s, living and in good health.

REVIEW OF SYSTEMS: He denies constitutional symptoms. He has gained 5 pounds over the past years. He has no fever or night sweats.
Thyroid or throat: He denies visual or hearing difficulties.
Respiratory: He does not complaint upper respiratory infections or chronic cough, etcetera. He denies shortness of breath or chest pain. There is no cardiovascular symptoms of fatigue, palpitations or chest pains either. The asthma has been asymptomatic for a long time.
Gastrointestinal: He denies nausea, vomiting, diarrhea, and constipation. There are no changes in bowel habits.
Genitourinary: There is no history of dysuria. He has occasional back aches in the past, but has been asymptomatic over the past years or so.

OBJECTIVE:
General: The patient is a healthy-appearing, good-looking 6 ft 4 in 43-year-old Caucasian weighing 187 pounds.
Vital signs: His blood pressure is 120/80; temperature 97.2; pulse 64; respiration 16. Weight 187 pounds. Height 6 feet 3 1/2 inches tall.
Skin: Warm and dry. There are no lesions of note on his back or elsewhere.
HEENT: [2:40 hyro-per-cream] normocephalic, atraumatic. Pupils round and equally reactive to light, accomodation and distance. There is increased cerumen in the right ear which will be lavaged. Contaminants were localized on the left but not on the right. Nares slight congestion. Pharynx benign.[02:59] No oral lesions.
Neck: Supple. No bruits, thyromegaly, or retinopathy. No restriction in motion.
Chest/Lungs: Symmetrical. Lungs clear to auscultation without adventitious breath sounds.
Heart: Regular rate and rhythm. No murmurs, friction, rub, or gallop.
Abdomen: Flat and nontender. No masses. No hepatosplenomegaly. No tenderness noted. There is no hernia, either ventral or inguinal.
Genitalia: Circumcised male without penile [3:24 sl circumferential?] lesions.
Rectal: Prostate is normal in size and shape, flat, nonindurated. Stool is negative for occult blood.
Musculoskeletal: Spine has no asymmetry. No paraspinal muscle splinting.
Extremities: Intact. No clubbing.
Neuro: Cranial nerves are grossly intact. Deep tendon reflexes were not tested, but the patient had no difficulty in ambulation and walking, or any other physical activities. The patient has a [3:51 sl terse?] sensorium.

ASSESSMENT: Healthy male. History of asthma, asymptomatic. History of back pain, asymptomatic. Cerumenosis in the

PLAN: Lavage of the right ear. Laboratory studies have been ordered. We will follow.

My 1st week of job...

2005-04-01T09:51:00.000-05:00

I have spent a total of 1 week in this job from Friday of last week, and I'd say that our software is amazing and really meant to increase productivity.

Well, Friday was "getting-to-know" more about the software and my initial 4 dictators. My production that time was so sliw, but I was maximizing my autotext feature (embedded in the software) and that added to my slowness. Building up my autotext database may be slow, but it will be my tool to make my production explode later.

Monday morning, theres wa not much to do, and I was asking my employer about it. Well, since my dictators are in CA, and I am in ME, that means we have a 3-hour difference in time. What were available to me early in the morning were leftover from the weekend. Then I had to wait til 11 a.m. before the dictation files came pouring in.

However, on Tuesday, I stil found a lot of vacant times, and I had a dictator that talked rapidly, that I asked my employer whether she could try to match me to other dictators who were dictating more slowly. I specifically asked to be tried on their ESLs, since I am an ESL myself, that I thought I might find it eaay to listen to them, since I am so used to hearing foreign tongues, even had Chinese, Japanese, British, Pakistani, Indian and Bangladeshi patients/correspondents before, aside from exposure to American tongues, thanks to western movie and TV shows.

Hence it was because of such a correspondence with my employer that the next day, Wednesday, she did give me a trial flow on several dictators, both ESLs and Americans, which kept me glued to the computer the whole day. The good thing is I found these dictators to be rather easy, such that, instead of having only 6-8 dictators in my pool, I now have 11 (minus the difficult rapid talker) in my pool! Now I will never run out of dictation files to transcribe! The most recent addition was a podiatrist, and that is soooo easy! Imagine concentrating on the feet! Anatomy of the foot is easy for me to listen to (though I vaguely recall the exact anatomy of it, hearing the terms brings them back to memory). Anyway, I got a goooood flow of work that Tuesday, trying new dictators. I made about 400+ lines that day. That night I printed out several reports for each dictator and familiarized myself with their styles, and made some shortcuts (autotext) for phrases that they routinely use. I love the autotext feature. Imagine, I can type something like "rsmb" and the text will automatically be converted to "I reinforced self multi-breast examination, daily calcium needs and exercise," or "tcph" for "The patient is coming in with a history of." Isn't that cool? Now it is not too puzzling for me to read in forums and employer requirements of making 2000 lines per day. Imagine, if you are making a radiology transcription and they have a template for every report where you only have to enter values for measurements, that would be easy to reach! However, at the end of my 1st week, I only came to about 600 lines. I hope that with the autotext feature I will be able toa chieve my targeted goal of at least 1000 lines per day, or even 1200 per day, plus I also hope that my QAs will recommend my removal from QA stage, meaning they won't have to edit my work, only to fill in blanks, which will then also lead to increase in pay.

Thursday was slow, and apparently it had something to do with the spring break in CA, such that most of the drs might be out with their kids. I had some dictation that came pouring in more regularly later that afternoon, but I had to prepare supper.

With the schedule in mind, my thoughts went to planning ahead for the summer, particularly working on my garden. I thought that I could use the early hours in the morning to transcribe leftover of the previous day, then go out and attend to the garden, have lunch before 11, start working from 11 a.m. through 5 p.m., take a break for cooking and eating supper, then work some more for additional 2 hours to make it an 8-hr job. If I would be too tired to do that, I have the option to just be lazy at night.

Friday, since I had not much to do in the morning, I checked my production. The software also has an automatic counting-line feature based on a 65-cpl (characters per line), and I transcribed 2187 in my first week, and of these, the delivered transcriptions were 2032, which at $0.07/65-cpl would translate to $142.24 in my first week of work. Not bad for a ramp-up period, especially that I don't have to buy wardrobe and gasoline and, best of all, don't have to kiss somebody else's ass. Just plain work and that's it. My first paycheck would come, however, at the end of April, then it will be bimonthly. My employer is also working on a direct-deposit method of payment. I really like her, and I am very satisfied with the system; I only now need to see how good my boss is when it comes to giving the salary of her MTs (i.e., on time) .

The rest of the day went quite smoothly with all these dictators, but since I started at 11, I felt it was still early when my boys were back from school. You know how it feels to want to go on, but you have to stop because you have to attend to your family's needs first. AT least, it is a good thing that after supper, I can go back and work some more, pile the dishes in the sink filled with water to keep the debris soft, attend to it the next morning when there is less work (actually optional work on a weekend). Before I was to conclude my work that night, I noted I made about 513 in 8 hours, but I noticed the appearance of a new dictator, the podiatrist, and I got intrigued as to how I would do with him. So I extended some more, made extra 35 lines and achieved a total of 602 lines in 9 hours. Hmmm...podiatrist dictator may be easy, but his notes are so short that I spend more time verifying and entering the demographics than transcribing the actual case. So he is not much of an increase in my productivity. But then, more of my slowness also could be attributed to my researching effort to familiarize myself with his style, his terms, especially for procedures and what he uses, but once I learned, I made autotext of these again, also of phrases such as "ico" for "Informed consent was obtained for," "spd" for "sterilely prepped and draped," and "aisd" for "alcohol irrigation, sterile dressing." I'm sure he will be easier.

The next day, Saturday, my ever-loving sweet and thoughtful hubby went to Wal-Mart and surprised me with an ergonomic chair (he even bought me a gel pad to protect my wrist after I complained about it that night after my first day of working. What can I say? Life may not be so easy, but I sure don't feel empty.

My work is exciting enough that I am learning and reviewing medical cases, akin to being an apprentice of these doctors, only without having to be their assistant. My researching on the net about their cases is like reviewing the pathophysiology of these illnesses and seeing the logic in the management. Very good exposure to the system here. I also learn their brands of drugs which are the equivalent of what I used to prescribe in PI for such common symptoms as fever, headache, joint pains, etc.

But I am not considering this to be a long-term career unless it becomes my own business. I am just using this jobs as a means to an end: to get either in a medical practice or in a medical teaching (clinical instructor or public health) position. I am still considering the possibility of being a doctor and having the MT business on the side. Having this MT job as a bridge for me to reach the other side just made me realize I do have a lot of options there waiting for me...

I made 571 lines today!

2005-03-30T21:25:00.000-05:00

Not bad for a day where I had to start learning again about some new (6 or 7) dictators without any sample to use a basis of their style. I have so far a total of 9 or 10 (?) dictators in my pool, enough to keep me occupied during my vacant hours, I hope. Although I might request to remove two of these, who are hard dictators and therefore, they waste my tim e(they require double the time I do the other dictators. If my employer will request I keep them, she should give me more financial reward for these.)

My target is 1000 to 1200 lines per day, to give me a salary of equivalent to 9/hr. I thin it is possible once I got the hang of using the autotext feature of the software I am using, and of course, the most important is to get used to the style of the various dictators in my pool. To give you an idea of how fast I am improving, last Friday I made around 400 lines working for about 8 to 9 hours (I was not able to keep track) on 3 dictators, and had a hard time on a 4th dictator.

Then yesterday morning I worked on the leftover dictations from yesterday, and made 200 lines for just 2 hours! However, siince I am 3 hours behind the CA's timeframe, I had ato wait until the dictators submit their files to the ftp. The internet was also crappy, that I was not sure if it was really only during lunchtime when files started streaming in. I also had to request to my employer for more dictators/accounts to keep me occupied. Then I think during the afternoon I made a total of 412 lines (either that or plus the previous 200 of the morning work.)

So my 571 lines today was only lower than what I could have accomplished mainly because of slowing down by the two hard dictators. Two dictators in particular was so easy, that I transcribed their dictations of 22 lines for less than 20 minutes and another of 25 lines for 26 minutes! (That could translate to around $12/hour salary if I only transcribed their dictations!)

Not to mention I still am looking forward to elevating my status from an entry-level, but I will have to wait for the QA to make the recommendation to the employer.

I hope I can land on a 10 cpl at least.

DJR's sample transcriptions

2005-03-29T10:33:00.000-05:00

SUBJECTIVE: The patient presents for follow up. She saw Dr.XXXX yesterday. She had a positive pregnancy test. She had some cramping on 3/22 but is doing fine now. Her last menstrual period was 12/18/04; however, she does have a history of irregualar menses. She just recently started having nausea and some breast tenderness about 3 to 4 weeks ago.

PAST MEDICAL HISTORY: Negative for chronic illnesses or operations.

ALLERGIES: None.

CURRENT MEDICATIONS: None

OBJECTIVE:

Vital signs: Blood pressure 110/70; temperature 98; pulse 68; respirations 19; weight 149 pounds; height 5 feet 3 inches.

Pelvic: Vulva: no lesions. Vagina: clear. Cervix: nulliparous, nonfriable, no cervical motion tenderness. Uterus: slightly enlarged and globular, nontender. Adnexa: no masses or tenderness.

ASSESSMENT: Growing pregnancy

PLAN: The patient was advised for starting prenatal multivitamins, Novonatal 1 tab p.o. daily, advised to avoid medicines or other substances. She will have pelvic ultrasound on 8th dating of the pregnancy. Schedule new OB appointment. Follow up p.r.n..

**************

SUBJECTIVE: The patient presents for refill on Ortho Tri-cyclen low. She is currently a pharmacy student back at University of Illinois, Chicago, and will be graduating in May. She will be getting married in June, hence, has recently started on Ortho Tri-cyclen low. She denies problems.

PAST MEDICAL HISTORY: Negative for chronic illnesses. She has a history of appendectomy.

ALLERGIES: None

CURRENT MEDICATIONS: Ortho Tri-cyclen low.

OBJECTIVE:

Vital signs: Blood pressure 100/60; temperature 98; pulse 56; respirations 19; weight 108 pounds; height 5 feet.

ASSESSMENT: Family planning.

PLAN: Questions were answered in regard to oral contraceptives. In particular the patient wanted to know how she can avoid menses at the time of her waning. I advised her to skip placebos in the pack that month, and just start the next pack. She will follow up p.r.n. and in July after her marriage so she can have her first Pap smear.
*********

SUBJECTIVE: The patient presents for the first time to our office for annual examination and Pap smear, and also wants to discuss birth control. Her last menstrual period was 3/1/05.

PAST MEDICAL HISTORY: Negative for chronic illnesses or operations.

ALLERGIES: None.

SOCIAL HISTORY: The patient is a nonsmoker.

FAMILY MEDICAL HISTORY: The father is alive and well. The mother has hypertension.

GYN HISTORY: Menarche at age 15, with regular cycles. Her last Pap smear was two years ago. She has history of Chlamydia approximately 2 to 3 years ago during her last pregnancy.

OB HISTORY: The patient is a gravida 6 para 6; all of pregnancies were normal with vaginal deliveries.

OBJECTIVE:

Vital signs: Blood pressure 110/70; temperature 98.2; pulse 76; respirations 19; weight 172 pounds; height 5 feet 2 1/2 inches.

Thyroid: Within normal limits.

Breasts: Within normal limits.

Lungs: Clear to auscultation.

Heart: Normal sinus rhythm.

Abdomen: Soft and nontender.

Pelvic: Vulva: No lesions. Vagina: Clear. Cervix: Parous, nonfriable, no cervical motion tenderness. Uterus: Normal size, shape and consistency, mobile and nontender. Adnexa: No masses or tenderness.

Extremities: Within normal limits.

ASSESSMENT:

Stress incontinence.
Family planning.

PLAN: Pap smear was done. The patient was scheduled for mammogram. I reinforced multi-self breast examination, daily calcium needs, and regular exercise. Also teaching was done and a handout was given regarding Kegel exercises as the patient was complaining of losing urine when she coughs or sneezes. I also answered questions in regard to birth control. The patient is very interested in IUD. She cannot use oral contraceptives of Depo-Provera because she has extensive varicose veins. Handouts were given in regard to IUD and other birth control methods. We will submit referral to determine her insurance coverage with this method. She will also screen today for gonorrhea and chlamydia. The patient is to call me in one week to check authorization for IUD. Follow up p.r.n. and yearly.
**********

SUBJECTIVE: The patient presents for annual examination and Paps smear. Her last menstrual period was 3/24/05. There has been no change in her health status since examination one year ago except for recent treatment of pneumonia.

ALLERGIES: None.

CURRENT MEDICATIONS: None.

OBJECTIVE:

Vital signs: Blood pressure 120/70; temperature 96.8; pulse 72; respirations 20; weight 160 pounds; height 5 feet 1 inches.

Thyroid: Within normal limits.

Breasts: Within normal limits.

Lungs: Clear to auscultation.

Heart: Normal sinus rhythm.

Abdomen: Soft and nontender.

Pelvic: Vulva: No lesions Vagina: Clear. Cervix: Parous, nonfriable, no cervical motion tenderness. Uterus: Normal size, shape and consistency, mobile and nontender. Adnexa: No masses or tenderness.

Rectum: No masses.

Extremities: Within normal limits.

ASSESSMENT: Normal well-woman examination.

PLAN: Paps smear was done. The patient was scheduled for mammogram. I reinforced multi-self breast examination, daily calcium needs, and regular exercise. Return to the clinic p.r.n. and yearly.
***********

SUBJECTIVE: The patient presents for annual examination and Paps smear and refill of Ortho Evra patch. Her last Pap smear was 11/20/02 and normal. Her last menstrual period was 3/21/05. She denies problems.

ALLERGIES: None.

CURRENT MEDICATIONS: Ortho Evra patch.

OBJECTIVE:

Vital signs: Blood pressure 110/68; weight 138 pounds.

Thyroid: Within normal limits.

Breasts: Within normal limits.

Lungs: Clear to auscultation.

Heart: Normal sinus rhythm.

Abdomen: Soft and nontender.

Pelvic: Vulva: No lesions. Vagina: With small amount of menstrual blood. Cervix: Parous, nonfriable, no cervical motion tenderness. Uterus: Normal size, shape and consistency, mobile and nontender.. Adnexa: No masses or tenderness.

Extremities: Within normal limits.

ASSESSMENT:

Normal well-woman examination.
Family planning.

PLAN: Pap smear done. I reinforced multi-self breast examination. Ortho Evra patch refill was given. Return to the clinic p.r.n. and yearly. I stressed the importance of annual examination and Pap smear screening.
*****

SUBJECTIVE: The patient presents for annual examination and Paps smear. Her last menstrual period was 3/09/05. She is complaining of vulvar and vaginal irritation and discharge. Her health status is unchanged since her last examination 12/08/03, except that after she was screened by this office and found to have elevated blood sugar. She was referred to Dr. XXX who advised her to go on a low-carbohydrate diet and also started her on oral medication for diabetes. The patient took the medications for a while and then stopped about 6 months ago. She has an appointment tomorrow with Dr. Echeverri for followup and will go in fasting so that she can have followup blood sugar studies done.

ALLERGIES: None.

CURRENT MEDICATIONS: None.

OBJECTIVE:

Vital signs: Blood pressure 112/74; temperature 99.6; pulse 96; respirations 16; weight 243 pounds; height 5 feet 8 inches.

Thyroid: Within normal limits.

Breasts: Within normal limits.

Lungs: Clear to auscultation.

Heart: Normal sinus rhythm.

Abdomen: Soft and nontender.

Pelvic: Vulva: With mild erythema, however, with no lesions. Vagina: Positive for frothy discharge. Cervix: Parous, nonfriable, no cervical motion tenderness. Uterus: Normal size, shape and consistency, mobile and nontender. Adnexa: No masses or tenderness.

Extremities: Within normal limits.

DIAGNOSTIC STUDIES: Wet mount shows positive clue cells.

ASSESSMENT:

Bacterial vaginosis.
Adult-onset diabetes/poor compliance with therapy.

PLAN: Pap smear was done. I reinforced multi-self breast examination, daily calcium needs, regular exercise and low-carbohydrate diet. I stressed the importance of the patient's good compliance with diet and therapy to avoid long-term complications, such as cardiovascular disease, renal disease, and eye problems. The patient agreed that she would follow up with Dr. XXX as scheduled. Metronidazole 500 mg #14 1 tab orally b.i.d. for 7 days. The patient was advised to take it after meals, and also to refrain from alcohol during treatment and up to 3 days after finishing. Teaching reinforced in regard to prevention of vaginal infections. Return to the clinic p.r.n. and yearly.
*******
SUBJECTIVE: The patient presents for annual examination and Paps smear. She denies problems. Her last menstrual period was approximately 1999.

PAST MEDICAL HISTORY: Significant for hypercholesterolemia.

CURRENT MEDICATIONS:

Zantac 150 mg b.i.d.
Lipitor and Gennin were discontinued recently after the patient was found to have anemia.

OBJECTIVE:

Vital signs: Blood pressure 90/50; temperature 97.8; pulse 64; respirations 16; weight 115 pounds; height 4 feet 11 inches.

Thyroid: Within normal limits.

Breasts: Within normal limits.

Lungs: Clear to auscultation.

Heart: Normal sinus rhythm.

Abdomen: Soft and nontender.

Pelvic: Vulva: No lesions. Vagina: Clear. Cervix: Parous, nonfriable, no cervical motion tenderness. Uterus: Normal size, shape and consistency, mobile and nontender. Adnexa: No masses or tenderness.

Rectum: No masses and heme-negative.

Extremities: : Within normal limits.

ASSESSMENT:

Normal well-woman examination.
Premature menopause.

PLAN: Pap smear was done.The patient was scheduled for mammogram. I reinforced multi-self breast examination, daily calcium needs, and regular exercise. I stressed the importance of the patient getting sufficient calcium in her diet, as with early menopause she is at a higher risk for osteoporosis changes. Return to the clinic p.r.n. and yearly.
******
SUBJECTIVE: The patient presents for annual examination and Paps smear. Her last menstrual period was January 2005. Her menses continue to be kind of sporadic.The patient complains of recent episodes of feeling tired; otherwise, there is no change in has health status since her examination one year ago.She already has mammogram scheduled for next week.

OBJECTIVE:

Vital signs: Blood pressure 110/60; temperature 98; pulse 76; respirations 19; weight 174 pounds; height 5 feet 2 inches.

Thyroid: Within normal limits.

Breasts: Within normal limits.

Lungs: Clear to auscultation.

Heart: Normal sinus rhythm.

Abdomen: Soft and nontender.

Pelvic: Vulva: No lesions. Vagina: Clear. Cervix: Parous, nonfriable, no cervical motion tenderness. Uterus: Normal size, shape and consistency, mobile and nontender. Adnexa: No masses or tenderness.

Rectum: No masses.

Extremities: Within normal limits.

ASSESSMENT:

Fatigue.
Normal well-woman examination.

PLAN: Pap smear was done. The patient is to go to the laboratory in the morning fasting for comprehensive metabolic panel, lipid panel, CBC and TSH. I reinforced multi-self breast examination, daily calcium needs, and regular exercise. I will call the patient with laboratory results. To follow up p.r.n. and yearly.
****
SUBJECTIVE: The patient presents for annual examination and Paps smear. Her last menstrual period was 3/20/05. She denies problems. There is no change in her health status since examination one year ago.

ALLERGIES: PENICILLIN

CURRENT MEDICATIONS:

Synthroid 125 mcg daily.
Vitamin B12 1 tablet daily.
Multivitamins occasionally.

OBJECTIVE:

Vital signs: Blood pressure 102/64; temperature 97.4; weight 122 1/2 pounds; height 5 feet 2 inches.

Thyroid: Within normal limits.

Breasts: Within normal limits.

Lungs: Clear to auscultation.

Heart: Normal sinus rhythm.

Abdomen: Soft and nontender.

Pelvic: Vulva: No lesions. Vagina: Clear. Cervix: Parous, nonfriable, no cervical motion tenderness. Uterus: Normal size, shape and consistency, mobile and nontender. Adnexa: No masses or tenderness.

Rectum: No masses.

Extremities: Within normal limits.

ASSESSMENT: Normal well-woman examination.

PLAN: Pap smear was done. The patient was scheduled for mammogram. I reinforced multi-self breast examination, daily calcium needs, and regular exercise. Return to the clinic p.r.n. and yearly.
********
SUBJECTIVE: The patient presents for annual examination and Paps smear. Her last menstrual period was 3/22/05. She is currently under the care of infertility specialist as she has been trying to get pregnant for over a year. She was previously on [0:30]. She has now a full battery of tests, including bloodwork and hysterosalpingogram which were normal. Infertility specialist has advised her to have in vitro fertilization so she is doing all her annual screening tests before this is done, including her Pap smear and will also need a mammogram. She needs several prescriptions written for medications that she will take at least during that one month after the in vitro fertilization.

PAST MEDICAL HISTORY: Significant for hyperthyroidism.

ALLERGIES: None.

CURRENT MEDICATIONS: PTU 1 tab daily

OBJECTIVE:

Vital signs: Blood pressure 118/68; temperature 96.8; weight refused; height 5 feet 5 inches.

Thyroid: Within normal limits.

Breasts: Within normal limits.

Lungs: Clear to auscultation.

Heart: Normal sinus rhythm.

Abdomen: Soft and nontender.

Pelvic: Vulva: No lesions. Vagina: Clear. Cervix: Nulliparous, nonfriable, no cervical motion tenderness Uterus: Normal size, shape and consistency, mobile and nontender. Adnexa: No masses or tenderness.

Extremities: Within normal limits.

ASSESSMENT: Normal well-woman examination.

PLAN: Pap smear was done. The patient was scheduled for mammogram. I reinforced multi-self breast examination, daily calcium needs, and regular exercise. The patient was given prescriptions for dexamethasone 0.5 mg 1 tab PO daily, doxycycline 100 mg 1 tab PO daily for 30 days, Vivelle transdermal patch 0.1 mg one patch thrice a week, and Medrol 8 mg #8 1 tab PO times 8 days. Return to the clinic p.r.n. and yearly.
*****

I am now officially tied up with a better MT company!!!

2005-03-23T17:53:00.000-05:00

I had a lot of mistakes when I agreed to work for my first employer. Well, it was a learning process for me. But as soon as I realized that that company was rotten, and it was such a waste of my talents and time to work for them, I made my announcement of leaving them as early as just beyond one week of working for them. They were not worth my time and effort. I abided by the two-week notice I was required before such notices as termination of service or vacation. During those last two weeks of working for them I was actively seeking other potential employers. This new one was the one most satisfying company among those who replied positively to my application. I interrogated their systems, addressing all those concerns that made me want to quit my previous company, and when I was satisfied, I then took their tests. Obviously, I passed with flying colors. I was satisfied with all their answers (two weeks of corresponding through emails, plus the final phone conversation to conclude the terms), and they were satisfied with my performance in their tests. As early as now I have developed a deep sense of respect for these professional people who obviously knew how to value their employees. My previous employer should learn from my new employer, but then, they are not the type of people who listen to their most important resources.

Below is a copy of the contract between me and my new employer. One thing I can say is that this new employer is very professional and knows how to listen to their greatest asset, their MTs. My new employer is miles far ahead my previous employer. I am so glad to make this shift at a very early phase of my MT career.

SECTION 1. PARTIES AND TERM OF CONTRACT

This Contract for Medical Transcription Services (hereinafter called "Agreement") is made this 23rd day of March, 2005, by and between [ME], the subcontractor, an independent contractor (hereinafter called "Subcontractor"), whose address is xxxx,and telephone number is #####, and [employer(hereinafter called "Contractor"), whose address is [address].

WHEREAS Subcontractor desires to contract with Contractor to perform work and/or services in accordance with the contract between Contractor and its Client(s) (hereinafter called "Client(s)"), and

WHEREAS the parties herein desire to set forth their contractual and business arrangement(s)

THEREFORE, this Agreement constitutes said contractual and business arrangement(s), and the parties hereto contract and agree as follows:

THAT THE SUBCONTRACTOR agrees to perform, abide by and follow the stipulations listed in this Agreement:

1. Client Contracts. During the course of performing work and/or other services in accordance with the contract between Contractor and any of its Client(s), Subcontractor agrees to adhere to the terms of said contract, which are considered pertinent by the Contractor to insure Contractor's compliance to the terms of said contract.

2. Equipment, Supplies, Materials. The independent Subcontractor will provide his/her own transcription and word processing equipment, reference materials, and supplies. Contractor will provide any supplies specifically indigenous to the Client(s). The Subcontractor is responsible for all repairs on his/her own equipment. Any equipment, supplies, or materials (i.e., doctor’s lists, drug lists, etc.) provided to the Subcontractor by the Contractor will not be distributed to any third party by the Subcontractor.

3. Work Hours. Subcontractor's work hours are set at the Subcontractor's discretion with consideration for the terms and conditions of the listed hereinabove contract between Contractor and his/her Client.

4. Compensation. Compensation for all work will be paid at a rate of $0.07 per 65-character line by electronic character count.

Contract for Medical Transcription Services
Page 2

5. Invoices/Billing Statements. Based on the work performed by the Subcontractor from the 16th through the 31st of the previous month, compensation will be issued on the 16th of the following month. For the 1st through the 15th of a month, compensation will be issued on the 1st of the following month. Subcontractor may verify the character/line count within the EMDAT software. Any discrepancies between the Subcontractor and Contractor counts are to be settled within two weeks of statement issue. EMDAT software is used to calculate compensation owed to Subcontractor.

6. Payment. Contractor will only compensate Subcontractor for work completed which meets the requirement(s) of the Client(s) in accordance with the contract(s) between Contractor and Client(s), which includes missed deadlines. The Subcontractor will be given an opportunity to correct any unacceptable work and will receive compensation for the final and correct product.

Contractor is not responsible to remunerate Subcontractor for work that must be reprocessed due to losses caused by power outages or equipment failure. It is the responsibility of Subcontractor to keep equipment in working order and to provide backup emergency services should a technical problem occur.

7. Confidentiality. It is Subcontractor's responsibility to refrain from violating any confidence of the patients or their families through indiscriminate discussion pertaining to patients, their treatment, diagnosis, or progress. Erroneous and nonpublic information released by Subcontractor shall result in legal liability. The Subcontractor understands and agrees that all patient names, patient records and patient information are strictly confidential and will not make any disclosures.

8. Communication with Clients. Subcontractor may not communicate with Client(s) directly regarding billing or pricing structure or anything other than a question directly applying to the production of reports or documents, or work procedure, such as terminology, spelling, etc. When communicating with Client(s), Subcontractor must identify self as being from the agency of Contractor, and in no way represent self as an independent.

9. Noncompete Clause. The Client(s) of the Contractor shall remain the Client(s) of the Contractor unless and until the contract between such parties is terminated or expires without renewal in accordance with such contract. The Subcontractor will not contract or attempt to contract directly with Clients of Contractor unless and until the contract between such parties is terminated or expires without renewal, and only with the express written consent of Contractor.

10. Quantity of Work. Subcontractor understands Contractor cannot guarantee the quantity of work that will be made available to Subcontractor, as work volume is beyond the control of Contractor, and is set by the Client(s).

Contract for Medical Transcription Services
Page 3

11. Termination of this Contract.

Contractor may terminate this Agreement by providing Subcontractor with seven days written notice.

Subcontractor may terminate this Agreement by providing Subcontractor with seven days written notice. Anything less than a seven-day written notice may result in a 50 percent penalty fee assessed against Subcontractor's final billing statement, payable to the Contractor, and subtracted from the final payment due to the Subcontractor.

Upon termination of this Agreement, Subcontractor is to surrender to Contractor, all tapes, reports, documents, computer disks, Client(s) stationary, and any other supplies and/or equipment belonging to or loaned by or borrowed from Contractor.

Upon termination of this Agreement, Subcontractor is responsible for supplying the Contractor with a copy of all work performed for Client(s) during the previous two-week period.

12. Entire Agreement. This Agreement supersedes any and all other agreements, either oral or in writing, between the parties hereto with respect to the hiring of Contractor by client, and contains all of the covenants and agreements between the parties with respect to that hiring in any manner whatsoever. Each party to this Agreement acknowledges that no representation, inducements, promises, or agreements, orally or otherwise, have been made by any party, or anyone acting on behalf of any party, which are not embodied herein, and that no other agreement, statement, or promise no contained in this agreement shall be valid or binding on either party, except that any other written agreement dated concurrent with or after this Agreement shall be valid as between the signing parties thereto.

13. Modifications or Amendments. No amendment, change or modification of this Agreement shall be valid unless in writing signed by the parties hereto.

14. Waiver. The failure of either party to insist on strict compliance with any of the terms, covenants, or conditions of this Agreement by the other party shall not be deemed a waiver of that term, covenant, or condition, nor shall any waiver or relinquishment of any right or power at any one time or times be deemed a waiver or relinquishment of that right or power for all or any other times.

15. Partial invalidity. If any provision in this Agreement is held by a court of competent jurisdiction to be invalid, void, or unenforceable, the remaining provisions shall nevertheless continue in full force without being impaired or invalidated in any way

16. Governing Law. This Agreement shall be governed by the laws of the State of Alabama. The laws of the State of Alabama shall govern the validity of this Agreement, the construction of its terms and the interpretation of the rights and duties of the parties hereto.

Contract for Medical Transcription Services
Page 4

17. Notices. Any and all notices, demands, or other communications required or desired to be given hereunder by any party, shall be in writing and shall be considered validly given or made to another party if personally served, or if deposited in the United States mail, certified or registered, postage prepaid, return receipt requested. If such notice, demand or other communication is given by mail, such notice shall be conclusively deemed given five days after deposit thereof in the United States mail addressed to the party to whom such notice, demand or other communication is to be given as follows:

If to the Contractor: XXXXXX

If to the Subcontractor: XXXXXX

This Agreement is via Internet and mail on this 23rd day of March 2005.

.

_______________________________________
My Signature

________________________________________
Employer's Signature

It is quite ironic that most of the companies seek MTs with 2-3 years of experience. Even this new employer of mine wanted experienced MTs. I lacked experience, but I got to the stage, despite annoying queries regarding methods of work distribution and payment system, of finally taking their tests to show what I can offer to their company. I even had the vision, upon being so impressed with the efficient system of this particular company, of promoting this service in my area, and giving more clients to my company, meaning to distribute more work to the MTs. I was thinking that if MTs are nationwide, we can get clients nationwide as well, if such efforts are rewarded by incentives (say 1% of all work done for the client marketed will go to the marketer, with the marketer trying her best, of course, to meet customer satisfaction to keep her incentives coming). An MT can only type so fast and do so much in a day's work, but with marketing, the income is augmented exponentially. My new employer is trying to discuss such possibilities with their partner (EMR). If approved and once working, I will be ready to use my Filipina charm to the doctors around here.

Haha...as soon as I received the contract copy to sign, I got an email from another company that says they saw my CV at MTWanted.com and are interested to learn more. They gave their salary payscale, which was so low (starting pay of 4 cpl, when I will start here with my new employer at 7 cpl despite lack of experience -- what a joke!!!)as well as a list of equipment that an IC MT must possess (I wondered whether they required their MTs to buy the software, pedal and reference materials.) I knew I corresponded before to this other company, and they replied, giving me the same information, to which I sent several queries addressing some concerns, such as the need to buy the equipment (or can I use mine?), etc. I got no replies to my queries. Then I got their email...Hahahaha! Some companies are now so desperate to get good MTs, yet they are not too keen on giving pay commensurate to the abilities of MTs. Plus some of them even try to make a business out of it, by demanding that the MT pay for such and such equipment or pay a deposit! Some say such arrangements are justifiable because MTs are given work to do in the comfort of their homes...Helloooo! This companies save a lot not to have to put up an office, and with IC status, they even have nothing to worry about benefits!!! The least they can do is compensate the MTs with a good salary!!!

I know I can save enough money with this new employer for me to take the USMLE or process whatever papers I have to prepare for an RN life, or even obtain a certification as a Phlebotomist...There are so many options available, once I have saved the money to proceed.

What are the prospects of progress in this type of job?

2005-03-16T11:18:00.000-05:00

In the past nights, after work, I have been testing for my prospective employers.

Golly, I was not prepared for the difficult dictators. I even stopped applying to other companies to give time to these test files (while at the same time working in my present job editing).

This job is easy IF the dictator is clear and slow enough. Accent is not a problem. But recently with my test files, I have encountered dictators who won't even slow down on findings that really matter: (e.g., CV findings on a CVA patient; lab result of a Rheumatoid Arthritis suspect--I got the WBC count, not the Hgb and Hct if those were dictated, got the sed rate and ANA and RF). Some dictations, particularly SOAP in clinics, have sentences that make no sense, and which I could have researched on IF ONLY I knew what the case is all about (I wish all doctors doing SOAP will at least dictate the Working Diagnosis, so that by the time they dictate the medications, workup and plan, I can try to guess the mumbled words and come up with sentences that make sense and is related to the case.)

One thing I can say, the more I learn about how difficult this job is for MTs, the more I see how strong the net community built by MTs, and the more respect I develop for them (us). All the more reason for me to wonder why MTs salary (based on forums/chats I have witnessed) is going downhill. This is not at all an easy task! While some nurses (especially CNAs) may be doing back-breaking dirty tasks, we face the same dillemma of acquiring CTS, scoliosis/kyphosis, and poor eyesight, often at our own expense. If not for my present need to stay at home, I would have applied even for an NA position and slowly work my way up.

Furthermore, I believe that while MTs have the burden of making their transcriptions as close to error-free as possible for these to be considered quality documents, I also believe that doctors should produce quality documents in the form of their quality dictations as well. This whole quality assurance and proper documentation are intended to enhance quality medical service through continuity of care made possible by such quality documents (i.e., if a patient is attended to by different doctors--ER to admitting to attending primary care to specialists--proper documentation will make it easy for these doctors to manage the patient).

Ergo, don't MTs have a voice to make such demands from the doctors to provide us with quality dictations?

I used to work in a clinic where the nurses only had to ask me (assistant to the med director) to tell my fellow drs to make their handwriting more legible, so the nurses could properly log the cases in their ER/admissions logbook. I did, and everyone cooperated, so the nurses were happy. Needless to say, the ultimate beneficiary was the clinic and, indirectly, the patients.

I thinks MTs should also have this kind of feedback system with their clients (hospital QAM, by principles of quality assurance, can address such problems at the root cause by sending a notice to their doctors to improve their dictations, even to the point of sending the doctor who got more complaints from the MTS to a dictation workshop, to avoid erroneous documentations. If these are carried out, then the burden of errors will be on the MTs.) In true quality assurance, communication is important to come up with the least errors, and targeting the root cause is the best way to tackle problems.

I wonder if that is possible?

I can see now why individual MTs working on accounts of doctors within their vicinity have better work relations with the clients. If the client is a hard dictator, the MT has the right to demand a higher pay (because she uses more time and effort to transcribe) for a job well done. Either the client agrees to pay more, or make his dictations easier to transcribe.

But I don't see the same thing with MTs working for companies, especially when these MT companies are competing against each other, and trying very hard to please their clients by always promising at least 98% accuracy. Do they also have a means to address the problems of difficult dictators at the root cause? I have no idea...but I hope they do. I hope it is one of the issues tackled by AAMT. After all, MTs are part of the healthcare system, not mere typists.

Just a note about MT jobs in PI (you are aware that there are indeed some MT companies with offshore MTs): I have read a post in another forum where they say that MTs earn less than call center agents, and they (MTs) don't get it, when employers look for qualifications that are higher--allied health professions, typing speed of 45 wpm or more, and the rest is the same for both jobs (English proficiency, listening skills, computer skills).

I just might look for local clients sometime in the near future if the situation becomes so depressing, but then that would mean that I will not address issues on EMR (electronic medical records) handling, but purely just transcribing what the doctor dictates, then sending them copies (both hard and soft, as they desire); they will be responsible for filing and archiving their documents.

In any case, I will use this MT job to force me to study and to raise the money for USMLE. I hope I will make it, and if I do, I will remember the plight of many MTs.

I have read posts about MTs praying for the patients. Sometimes I have the same tendencies. In addition, I can't help asking whether the PCP did a previous workup for a differential diagnosis that I had in mind, or whether aside from referring to the ortho, did the PCP also refer the patient to the cardio?...things like that...

Well, I hope I will learn more about case management through these transcripts. It is like undergoing an apprenticeship. I hope that by the end of 2 or 3 years I will have studied enough to pass the USMLE, and learned enough insights from the specialists to add to my wisdom.

I honestly don't think that MTs will be regarded as that valuable in the coming years. Companies and clients will always use the competition to haggle for the price, and will use the VR technology to threaten the MTs and force them to bow down.

I think it is best to be on the client side -- be a doctor/health practitioner. There is no way one will run out of job in this profession.

Interesting Cases Today

2005-03-16T11:01:00.000-05:00

1. Reflex Sympathetic Dystrophy
2. Fibromyalgia

These were things I only encountered in Pathology class during med school but not during practice...sigh.

The links prove these are indeed common here.

Major corrections I made

2005-03-14T10:56:00.000-05:00

These are only some major errors.
I.
From
A well (29:03) in a (29:03) splint. Her fingers are warm and well-profused. She does have a normal sensory exam, but in the median of this, she reports it is tingling. She has full motion of her right hip without pain. She does have pain when I try to extend her leg. She is tender at the posterior thigh. The knee has no effusion. There is tenderness medially. No instability. Normal neurological exam distally.

To:
Physical examination reveals a well forearm which is in a sugartong splint. Her fingers are warm and well-perfused. She does have a normal sensory exam, but in the median nerve distribution, she reports it is tingling. She has full motion of her right hip without pain. She does have pain when I try to extend her leg. She is tender at the posterior thigh. The knee has no effusion. There is tenderness medially, with no instability. Normal neurological exam distally.

(Things that an ordinary MT, inexperienced, would not comprehend...Did she know that the carpal tunnel syndrome assessment in this case was brought forth by that PE finding of tingling sensation on the median nerve distribution? Only a doctor can understand that. Now, if only MT companies who turned down my application would understand that...Well, it's their loss.)

II.
from "culture insensitivity" to culture and sensitivity"

Other errors were minor.

I will be better off working at Wal-Mart as a cashier!

2005-03-13T11:21:00.000-05:00

I made an observation.

After editing and making comments for further revision of the intial medical letter (see previous post), and editing another transcription, I calculated my compensation for a job done over a period of 3 hours, with pay depending on the lines I produced (including the document and the comments I gave. No compensation for THINKING.)

I came to $4 for working for three hours...using my own computer, own electricity, and paying for my own internet connection.

Is this job worth my time?

That is the reason I am quitting this job in this particular company! They don't know how to properly compensate a reliable worker.

I hope my next company will be better. If the pay is better, I will see if it is worth the time and effort, and if there are possibilities of relying on it fully and going up the ladder. If not, I still might just use this job as a means to earn while reviewing for USMLE.

A Medical Letter related to worker's compensation

2005-03-13T08:51:00.000-05:00

I won't post the medical letter here. It was a letter in reponse to one given by an attorney acting on behalf of an insurance company.

This is the kind of editing that I do, which might probably be considered aggressive by some MTs, and, I predict, is way above some MTs.

I had minor revisions on the letter itself, but I raised the following issues to the doctor who wrote it:

Before finalizing this letter, please verify with Dr. XYZ the following:

(1) if this phrase "should discontinue" meant that the insurance company asked whether Ms. XXX is to discontinue work (and what is this work specifically?)

(2) Dr. XYZ said, "I do not believe she will have any permanent functional impairment with regards to her left shoulder when and if she progresses through physical therapy and without difficulties."

--I believe the insurance company's concern then would also include if Ms. XXX should be temporarily disabled and approximately for how long, and if not, if she would require to be given none or light to moderate task through time as she undergoes PT. I believe that this letter does not address those concerns clearly and would put the insurance company and the employer at a loss on how to proceed giving Ms. XXX her benefits, or on how to continue employing her.

(3) On this phrase:"With regards to the second statement that Mrs. XXX suffers from similar problems in her right shoulder, she did complain of right shoulder pain the last time I saw her." -- Is this statement as Dr. XYZ himself said, or is there a statement also by the insurance company or the attorneys that referred to a similar problem in her right shoulder? Basing on the letter, it seems that this is not presently the concern of the most recent letter, although it is quite okay to bring it up as this also has work compensation implications. The objective findings of the right shoulder exam are of no concern to the insurance company and to the lawyers; what they would be interested in is how this condition will affect her work proclusions and her compensations. It will be better for Dr. XYZ to state a tentative schedule of the observation period, during which, in what work conditions should Ms. XXX be, then an approximate date of followup, and so on.

I am predicting Dr. XYZ will have major changes done in this letter to address those concerns.

I wonder how many MTs are that brave to make such comments to the doctors?

My observation is that this doctor is a novice to worker's compensation issues. I am no expert in that, but I had enough exposure to pre-employment, annual medical exams, and compensation issues, have educated myself on the DOH's rating system for such pre-employment exams, also to the seafarer's med exam as per ILO guidelines. I know enough about it to point out the inconsistencies and innacuracies of the doctor's letter to the attorneys. I am sure he will overhaul that letter.

And I am confident he will probably inwardly thank me for the indirect education.

Learning more about the MT job

2005-03-06T08:58:00.000-05:00

For more than a week now I have been doing MT editing, and I realized that the pay I agreed to was not worth the effort and time I devote to doing the job. I am now convinced to just do MT instead of editing; that way, the pay is more commensurate to the effort and time I put into it. But, because of disgruntlement with my present employer, plus the replies I am getting from some companies to which I applied, I am now considering other MT companies and am leaving my present employer.

Why do I want to work as an MT?

First, it is a job which will not change my mindset from a doctor-thinking to a nursing-thinking (like what happens to those MD-RNs. Remember, I took a one-year crash course in nursing before coming here.)

Second, I am a stay-at-home mother and has no driver's license yet.

Third, I am somewhat of a techie. I love techno gadgets and internet.

Fourth, it keeps my mind medically-oriented.

Fifth, there is a GREAT DEMAND for good MTs.

And lastly, I need the money to help pay the bills.

Because of my recent employment, I gained confidence enough to submit application to 19 companies Saturday of last week. So far, responses have been varied: from "your application is in processing" to "you do not meet the requirements for the position" to "please take our online test files."

I TURNED ONE DOWN after realizing they are doing mostly acute care. Why? Because the dictators are in such a hurry they tend to produce dictations that are a garbled mess; therefore, production-wise, I will be on a losing end, unless they pay me more per line.

As I have been learning the flaws of my employer, I have now engaged another company in a series of discussion, meaning to let the employer know that I am studying thoroughly what I am getting myself into this time.

I am quickly learning that these companies are in dire need of good MTs. They have a lot of jobs that they can't catch up with, because there simply are not enough MTs whose work do not need editing.

Then I got a latest reply from a company that said they "have no good fit" for me, "but in the interim, another service took interest in my skill set. For privacy reasons, I cannot forward your resume to her, so I am referring you to the above contact person for submission of your resume."

That got me excited. It seems I will be offered a job that is above the MT level.Of course, I quickly submitted to her my resume. Still waiting for her reply. (I realized now that I only need to make myself known to these companies, then the employer/HR who has the vision can think of the best way to make use of my talents.)

But then, with my recent experience in MT editing, I realized another thing; it gave me a whole new perspective of MT as a way to earn while reviewing for the USMLE.

You see, with the recent transcripts of actual practice here, I had been forcing myself to study more about drugs, their indications and dosages. I had to recall the anatomy, examination techniques and management of illnesses of the shoulder, knee, leg and hand. I discovered websites that had "Guidelines for Reporting on Musculoskeletal Imaging" and some "Operative Technique" samples. I realized that instead of paying for a review for USMLE, this is a good way to earn while reviewing, using the internet for updated information on medicine that is relevant to today's practice (no need to buy expensive reviewers; no need to enrol in expensive review centers! I don't have the money nga eh!). I am exposing myself to actual cases even without a residency training.

I had been thinking...with MT jobs (not managerial position in an MT company), I can then review while earning. At the end of 2 or 3 years when my children might probably want to spend less time with their parents, I can then probably seriously consider registering with the ECFMG and taking the USMLE and to practice medicine in this rural area where doctors are needed.

I will make it a goal to be prepared for those at the end of at most 3 years. Then I can make the MT business as a sideline. If government regulations permit, I will use offshore talents (MD-MTs as well as allied health professionals in PI, of course!) for that.

No, ain't that a smart move?

Wish me luck.

I am now officially an MT Editor!

2005-02-24T15:41:00.000-05:00

I am excited...This is just so great, being a stay-at-home mom and working, earning, making use of my time productively, with a job that makes use of what I have learned in Medicine, without malpractice lawsuits lurking in the backgound...

I started revamping my resume last week, around Feb 16. Then out of the 4 or so companies to which I applied (through Monster and CareerBuilder as well as JobsinME) one immediately replied to me, gave me their number so we can discuss the details.

It was a small company, and after studying my capabilities, they decided they needed me more with the proofing of transcriptions done by their other girls. Of course I agreed, because that is easier! However, I won't be able to hone my typing skills, but that would give me immediate exposure to the style/format, names and addresses, the way certain American doctors pronounce drugs and other words and names which would have been easier for an American transcriptionist to decipher, without spending too much time just looking for it. It fells like a fast-forward training. The best part is, I am training my ear with the various accents, and orienting myself with their protocol in medical management. I get updated with the US style of management without really meaning to.

I feel lucky to have been given such a break. In the past I have been trying to apply but most companies need MTs with 1 or 2 yrs experience transcribing (nurses, PTs, etc, allied health professionals were advised to take an MT course first). I have self-studied with the help of sherry (PT-MT in PI who transcribes mostly ortho notes from a US-based client) about the MT tools like ExpressScribe and foot pedal, that the only lacking thing was training my ear with the dictation and typing at the same time. Sherry provided the initial tapes and edited the first actual transcriptions that I made. I saw it useless to enrol in an MT school, especially if what they are going to offer are mostly things that I already know about. I know that the technical tools MT use varies from company to company. Would the schools provide a single student with all those types? I don't see that happening. I can only predict that these schools will teach the technical aspect with what they have on hand. Any company should train their employee with what they have and use. The technical aspect of MT is easy to learn for a technologically-inclined student. I have something to offer that most MT's don't have: intensive knowledge in medicine and medical management. Of course! I am a doctor by heart!

Anyway, I was beginning to feel desperate...I actually considered enrolling in a course just to get hired, but then I could not help but think that upon graduation, if these companies still would like to hire only those with 1-2 yrs of experience, then how can I have that? It is a vicious cycle, and that's what many new MT grads are facing now.

But alas! I got this editorship job! I am actually going to have my experience with a higher position! And without a formal MT course at that!

When my then employer-would-be explained that proofers have lower rates because it is an easier job (I agreed), I was just too ecstatic at the opportunity they are giving me! Though the job is low-paying at present, I consider it not only as a free training, but as PAID! Good thing I did not enrol! (I was planning on enroling by March of this year).

God is really good, I'd say.

I am still submitting my resume to other bigger companies, eyeing in particular the MT company based in Portland, where they said in their ad that there is the possibility of working at home upon training...

Of course I updated my resume and included my latest position: Medical Transcription Editor/Quality Assurance Specialist.

Bongga...

Vaccination supplement

2005-01-04T15:24:00.000-05:00

I have spent the past few days arguing with myself on whether to have a medical examination by a civil surgeon prior to the AOS interview or not. I was told by a friend who had her interview then was asked to undergo a medical exam, which caused delay in the approval of her AOS. But she told me that she had to take anti-PTb prophylaxis for 3 months.

The INS website says that:

2. Ks: If you were admitted to the United States as a finacee (K-1), child of a fiancee (K-2), Spouse of a U.S. citizen (K-3), or child of K-3 (K-4), and received a medical examination prior to admission, then you do not require another medical examination as long as your application for adjustment of status (Form I-485) is filed within one year of your overseas medical examination. You will, however, be required to submit a vaccination supplement with your adjustment of status application. The vaccination supplement must be completed by a designated civil surgeon.

My interview notice says:

If you have not already submitted it, bring a completed medical examination (Form I-693) and vaccination supplement in a sealed envelope.

Putting them together,

I came with a K-1 visa, and submitted my medical exam to the INS officer at the port of entry.

I filed my application for AOS June 12, 2004. I had my medical exam July 4, 2003, which would be valid for AOS application filing purposes up to July 4, 2004. I take it I do not need to undergo another medical examination.

I had incomplete vaccination in PI and had a waiver because of insufficient time. I continued my vaccinations during my last months of stay there. Now I have to present to the INS a vaccination supplement signed by the civil surgeon, but I have to show him first my records of vaccination, both from the St. Luke (vaccination documentation worksheet) and from my personal physician.

I hope I am making the right move. Medical exam here can cost anywhere from $175-350 depending on the extent of the tests as determined by the CS. Signing of the vaccination supplement, on the other hand, is only $10, granting that the requirements are already met. If there's a need for additional vaccines, a Td vaccine is another $10, a Hepa A (not routinely required of adults 19-50 y.o.) costs $64, and so on. I called the nearest designated civil surgeon (got it from the INS website) for the figures.

I am preparing myself in case the CS requires me to undergo the whole med exam. I have printed the above quote from INS website, ready to show my receipt and x-ray film (left with me at the POE) that shows my previous medical, my AOS interview notice (showing my filing date) to rebuff whatever attempts the CS might want to make more money (if he does intend to; I have heard of such stories). I am going to tell him that if the INS will require me to undergo another med exam, then I will come back to him for such.

I think that's wise for me, and fair enough for him.

Got my Driver's Permit!

2004-12-09T10:49:00.000-05:00

Golly! Been lazily studying the handbook for 1 whole week (with a lot of internet breaks, of course! I finally had the gumption to take the test yesterday. Gary went with me to Waterville's Bureau of Motor Vehicles Office.

$10 fee, photo ID (I used my EAD card, but they were not familiar with this less-often-used government issued ID, so I showed my passport, marriage certificate and birth certificate. They need not see anymore IDs.

My eye exam was done first, using something that I thought was computerized but not really. It's more like an electronic version of Snelle's chart for the visual acuity, with small lights flashing vaguely on either side. One eye tested first before the other. My left eye apparently was weaker than the right, but I could be allowed to drive in such eye condition, as long as I am comfortable with my vision. However, if I feel the need to wear glasses, I may do so.

Then the written exam. To get the driver's permit, I should be able to answer 24 out of 30 questions correctly. During checking, I was counting...1,...2,......6!...Another mistake and I'm toast!

Lucky enough, I had no more mistakes. I barely made the exam! All is well now...I was issued the permit, and was advised to take at least 4 months of practice before applying for the road test, which was valid for 18 months. I should have had 35 hours of driving by then, with 5 night driving, before I should consider the road test.

Haha! Now on to borrowing Ana's old car for me to practice on...Good thing she and Jake are still maintaining that car though they seldom use it. Now they are actually glad to have me use it for practice! Blessing in disguise.

I love my friend Ana...

Target Shooting

2004-11-28T21:52:00.000-05:00

After Thanksgiving Day, the kids were scheduled to spend the weekend at Mom's. So while we waited in the morning for them to pick up the kids, Gary thought to make use of the time to practice shooting. When Mom and Dad came, we let them get the younger kids first, since they are not old enough to be responsible in handling guns.

It had been a long time since we did this (last year, actually). Gary loves collecting guns, but hunting never appealed to him. Of course I was excited to have my turn too!

Now it is Patrick's turn. Gary made sure that the trajectory of the bullet is such that it would not hit anywhere near our neighbors, and that it would either hit the pile of firewood or go deep into the forest (which is part of our property).

Gary is re-loading the guns now, where on the same spot lies the target sheets .

So now he is trying his .480 Ruger, his favorite handgun (because it is powerful, and the kick gives him a high.

Josh even tried to shoot from a farther distance, using the flat boulder to make a good stable aim.

When he stood, Patrick was mimicking him.

Here Gary tries to check how he did with the AR 15.

Shannon and Ann, upon hearing the gunshots, came over to join the fun, using their muzzle loaders.

Now they are loading their guns,

with these different bullet parts that they have to load piece by piece into the muzzle.

Gary checked out their guns. Both guys were saying gunshooting is a sure fun way to spend cold days, rather than sit in front of the TV or do drugs or drink alcohol.

Dad also heard the gunshots and joined in, himself tyring that muzzle loader. I myself tried it upon Ann's coaxing. The magnifier was cool, but it was so hard to stabilize my hold of the gun that I would easily lose the target at the center, I had to rest the gun on the big boulder.

That was a fun day! It made me think whether I would want to work in the future...

AOS Interview Notice

2004-11-25T20:19:00.000-05:00

Received it yesterday, set for February 16 at 2:00 pm.

AOS interview notice

Guess I will have to have a medical examination by a civil surgeon before that...

Luncheon Meeting with 2 Filipino Doctors

2004-11-17T10:06:00.000-05:00

I am so elated! I have been corresponding through emails with the Filipino doctor couple, DR. and Dra. Amurao, and they agreed to meet me tomorrow for lunch!

While Dr. Guillermo Amurao works as a hospitalist/pulmonologist at the Redington Fairview General Hospital, Dra. Christine Amurao works as a senior medical researcher at the Occupational Health Research near the RFGH. She also used to be a stay-at-home mom, and when their kids got old enough for daycare services, she volunteered as assistant to well-known dermatologists here (she is a certified dermatologist in PI, with PGH training). Then both of them got a master's degree in Public Health. She was then given the position in the Occupational Research Hospital, as they were too happy to have a clinical doctor doing research.

I still don't know where I am heading, but this is a good start. I don't even mind being at an entry-level position, be it in a clinical, teaching, or research setting. The important thing is to start working, put my talents into use, earn some money, and personally GROW!

*******
UPDATE (o eto na, MsT):

I went first to Dra. Cristine's office at the Occupational Health Research (it is a company started by a Dr. at the Redington GFH to develop a software which would be usefule in occupational health applications). Then we went together to the RFGH to meet Dr. Amurao at the canteen.

Small world. Dr. Guillermo Amurao is the son of a couple, Dra. and Captain Amurao, owners of the Airlink Aviation school in Malibay, and are good friends my with uncle-employer in the clinic where I used to work. I even joined twice the medical missions that they regularly sponsor in Lubang! They introduced me to the other Filipino doctors who also had their lunch there: Dr. Cielo Maca, another hospitalist like DR. Amurao; and Neurologist Dr. Amelito Malapira, who was surprisingly quite young for his specialty. All of them are probably around 3 yrs my senior, or probably just the same age as me.

They were simple, down-to-earth. I told them what I wanted to know (where I could possibly fit it given my background and experience), what I wanted to do (can start with an entry-level position; would be willing to be trained even with low pay just to get me started, but would rather end up working from home). I asked them whether a medical practice was worth the investment in exam fees and the troubles of residency training, given the high malpractice insurance costs, not to mention the malpractice lawsuits. Dr. Amurao actually had an experience on that, but it was dismissed because the complaint was misdiagnosis, yet records showed he was the first to make the correct diagnosis! Dra. Amurao said that the pay is good even at the residency level, $30/hr, which, of course, will go up the higher I go up the ladder, but she herself did not pursue that for the children's sake, despite the coaxing by colleagues. I told her I have the same considerations, and that that was the reason why I still would want to pursue medical transcription in the future, when I have enough money to enrol in the online course. Well, we were both mothers, and we understood one another. She said her husband works daily from 7am to 6pm and still on-call outside of those hours, that if she decides to be on the same boat, she could not imagine what would become of her kids.

They were very kind and accomodating. They accompanied me to the HDR to hear first-had whether there was any way I can fit in any of the vacant positions. Understandably and expectedly, since health-care professions are highly-regulated, I still have yet to acquire some sort of certifications for them to accept me.

There, I heard what I needed to hear straight from the people in the trade. If I will consider the nursing path, I will have to start at the CNA level, but I will try to see if I can make use of my credentials in nursing to bypass that stage, probably start at a higher level. But I will have to wait first for my friend in PI to send me those credentials. I will do some research first on scholarships/supports for such.

I have also submitted an application for scholarship in Med Trans. I am quite nervous as to what effect my being an immigrant will be, and my being a medical practitioner (they might think I can easily find a job to have the money to enrol in their course).

meanwhile, I intend to study the driving handbook and hopefully get a permit. Gotta learn how to drive around...Hopefully by next spring I will have my driver's license...

Hay...konting tiis na lang...

My Blog on Our House...

2004-11-10T13:29:00.000-05:00

...is a way for me to document how we slowly build our house, with our own hands, using our own skills (well, primarily my husband's).

But hubby, upon knowing that I am blogging about it, and whenever I report to him how another person has been impressed by it, his eyes would glow...So it was another way for me to show to my hubby how proud I am of him. He might not be a professional...he's "just" a high-school graduate with some college courses in engineering robotics, yet I can honestly say that he has a brain that has a lot of stored knowledge and still has lots of potentials. He can learn anything that he puts his heart into. That, to me, is a very good gauge of intelligence: the capacity to learn and retain information. There was even a time I blogged about me telling my kids to try to learn as much as they can from us (their parents) while they are with us. I never told them to study hard to be a professional. I just see that education is another screwed-up institution wherever.

Another purpose is to update my family back in PI how we are sloooooowly building our house. Initially, just so we can share our excitement with them, but now, also so that they may know that we have our own expenses to think about. Recently my sister and mother informed me that they have renovated their house upon the prodding of several relatives from the province. They borrowed money from my aunt and grandmother in California and spent around P100,000 already. Now they want to rent out spaces to students and are contemplating on offering laundry job and cooking to them, asking now some money from me and my sister in Canada for capital. I have no work yet, and we are still tight financially, especially with our unfinished house which we also want finished. Did they think I could just dip my hand into my pocket and pull out a thick wad of $$$??? Even if I did work, I would not work for them, but mainly for my family, so that we (especially my kids) can live a decent (not luxurious) life.

One offshoot of my tahanan blog is that Gary seems inspired to work on the house as rapidly yet carefully as he can, knowing that people all around the world might get a glimpse of it. This is the best part for me.

My hubby may not always be able to take me out because of our house...he always apologizes and promises that when it is done, we can spend more time going out. I don't know if he understands that whenever I go out and come back to the house, I stare in amazement and wonder of how my hubby could almost single-handedly build this "castle". My chest swells and almost explodes with unexplained elation (words will never be enough to convey the emotions I feel) thinking "THIS IS MY HOUSE..."It may not be much to other people, but to me, it is probably the best gift a husband could ever give to his wife.

And he wonders why I almost never ask him anything aside from groceries kept to the minimum...

Oh I love my husband so much.

Plans for the Immediate Future

2004-11-10T11:14:00.000-05:00

Wow...I went out to mail some letters, one for Dr. Guillermo Amurao (an introduction of myself and asking if I could visit him at the hospital for a friendly chat), another to a decline for a promo offer, and another my complaint to SS using their survey form. It was soooo cold outside. I could feel my facial muscles stiffening.

If Dr. Amurao agrees to see me by next week, Gary will drive me to the hospital, then probably we can also apply for a driver's license on the same day.

Can't wait to explore my work options. I badly badly need it to maintain my sanity.

Fe's birthday celebration

2004-10-28T13:50:00.000-04:00

Oct 5 was Fe's birthday. The surprise party was planned by her business partner, Janis, who is a huntress as well. This is how surprised Fe was, when she entered Janis' house, expecting to meet a customer (they have a housekeeping business).

The two hugged after the shock has subsided...

Me, Fe and Ana...

The cake that Ana made for Fe. Look at the elaborate weave-style frosting at the side of the cake.

Fe reads here one of the cards that came with the gifts that she received.

Mary (a Burmese) on the left, and Janis' sister (?) (I have forgotten her name) on the right. It was a very warm group of people. Not snobbish or proud. Very accomodating, I felt at home with them. Wish we could have more time to get together.

Social Security Administration Waterville Office is so Incompetent!

2004-10-25T13:02:00.000-04:00

I filed my application on the last Thursday of August. Prior to that I downloaded a PDF application form, which also included instructions on how to fill it up, as well as the statement that said my card would be received 10-14 days from the date of filing.

A month and two weeks had passed, and I was wondering about my application. I called the 1-800-7721213 and the 8722723 numbers but I just got exasperatd by the answering machine and the endless loop of answers it gives. I decided to pay the office a visit for follow-up, but I had to coordinate with my friend Ana, as I myself have no means of transportation.

I showed to the officer my EAD card, which was the same ID I used to show the SS office that I was legally allowed to work, aside from my passport, marriage certificate and birth certificate for identity verification purposes. In fact, I brought all these with me again.

The man asked whether it was the woman (there were only two of them attending to us) who accepted my application, and I affirmed. He talked with her then came back to me. He told me that they are still verifying with the INS. I should expect notice of receipt after two weeks. I should just "hang on."

I asked when after the notice would I receive my card. He said two weeks after that (calculating a total of 4 weeks from my follow-up visit, equivalent to 2 months and a half from my date of filing). I asked whether I should follow up again or would they send me my card. He said I would receive it in my mailbox.

I said okay, thinking, "What is there to verify with the INS when my EAD card issued by the INS is already proof that I am cleared with them?" But I dared not argue. I did not want to jeopardize my status here in any way.

But I brought home with me the form for Customer Satisfaction. INS already uses Quality Assurance in their offices and sub-offices. The SSA, apparently, has not yet adopted it fully, basing on the lack of means for their customers to have a documentation of some sort that an application has been filed, and a follow-up had been made. However, their customer service questionnaire is one step towards that. I wonder if they really pay attention to it.

The application form I downloaded said 10-14 days, the questionnaire said their commitment is within 5 working days. These alone show a discrepancy in practices, and the actual scenario is not promising either.

I plan to send to them the questionnaire with my comments and complaints once I have my card already. And I want them to know that even non-government workers or immigrants like me have an idea of how quality management should be.

I was trained with ISO 9000:2000, and I have an international certification for Internal Quality Audit. I made a quality manual for a clinic applying the elements of QSR as per ISO 9000:2000.

These alone can already land me in a very good position in any hospital or clinic, not to mention my medical background and my 1-yr nursing course.

But I have to have my SS card first. Sighhhh....

row 1, cell 1	row 1, cell 2
row 2, cell 1	row 2, cell 2
row 2, cell 1	row 2, cell 2
row 2, cell 1	row 2, cell 2
That crack was extremely painful!!!	day 3 of commencing antibiotics
row 2, cell 1	row 2, cell 2