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July 1, order viagra online our website 2021Contact. Office of CommunicationsPhone. 202-693-1999OSHA urges fireworks/pyrotechnics industry employersto protect workers as the Fourth of July holiday approaches WASHINGTON, DC – As people nationwide plan to celebrate the Fourth of order viagra online July holiday, the U.S. Department of Labor's Occupational Safety and Health Administration reminds fireworks/pyrotechnics industry employers to protect their workers from hazards in the processes of manufacturing, storing, transporting, displaying and selling fireworks for use at public events.

"This industry's hazards are well-known, but necessary precautions can prevent injuries or worse when working with these volatile devices," said Acting Assistant Secretary of Labor for order viagra online Occupational Safety and Health Jim Frederick. "Employers are responsible for taking preventive measures and making sure they train all workers properly in a language they understand." OSHA's web page on the pyrotechnics industry addresses retail sales of fireworks and fireworks displays. The page provides information on common hazards and solutions found in both areas of the industry, and downloadable safety posters for workplaces. It also includes a training video demonstrating best industry practices for retail sales and manufacturers based on National Fire Protection Association consensus standards order viagra online.

Learn more about OSHA. # # # U.S order viagra online. Department of Labor news materials are accessible at http://www.dol.gov. The department's Reasonable Accommodation Resource Center converts departmental information and documents into alternative formats, which include Braille and large print.

For alternative format requests, please contact the department at (202) 693-7828 (voice) or (800) 877-8339 (federal relay).July 1, 2021US Department of order viagra online Labor orders CSX Transportation Inc. To pay worker who raised safety concerns nearly $222K in back wages, damagesOSHA investigation finds pattern of retaliation NEW ORLEANS – An investigation by the U.S. Department of Labor’s Occupational Safety and Health Administration has found that CSX Transportation violated the Federal Railroad Safety Act and demonstrated a pattern of retaliation after firing a worker in December 2019 for reporting safety order viagra online concerns. OSHA ordered the company to pay $71,976 in back wages, interest, and damages, and $150,000 in punitive damages.

“CSX Transportation’s actions are unacceptable,” said OSHA Regional Administrator Eric Harbin in Dallas. €œFederal law protects employees who report hazards in the nation’s transportation sector and OSHA is committed to enforcing these rights to keep workers safe.” This investigation is the latest example of CSX retaliating against order viagra online workers for reporting safety concerns. In October 2020, OSHA ordered CSX to reinstate an employee who reported an unsafe customer gate and an on-the-job injury and pay more than $95,000 in back wages and $75,000 in punitive damages. Similar whistleblower investigations resulted in reinstatements and payment of back wages and damages in order viagra online the New York region in 2016 and 2010.

Based in Jacksonville, Florida, CSX Transportation Inc. Is one order viagra online of the nation’s leading transportation suppliers. The company provides rail-based transportation services including traditional rail service, intermodal containers and trailers, and operates on about 20,000 route miles of track in 23 states. OSHA’s Whistleblower Protection Program enforces the whistleblower provisions of 25 whistleblower statutes protecting employees from retaliation for reporting violations of various workplace safety and health, airline, commercial motor carrier, consumer product, environmental, financial reform, food safety, health insurance reform, motor vehicle safety, nuclear, pipeline, public transportation agency, railroad, maritime, securities and tax laws, and for engaging in other related protected activities.

For more information on whistleblower protections, visit OSHA’s Whistleblower order viagra online Protection Programs webpage. # # # Editor’s note. The U.S order viagra online. Department of Labor does not release the names of employees involved in whistleblower complaints.

Media Contacts. Chauntra Rideaux, 972-850-4710, order viagra online [email protected] J. Rodríguez, 972-850-4709, [email protected] Release Number. 21-889-DAL U.S order viagra online.

Department of Labor news materials are accessible at http://www.dol.gov. The department’s Reasonable Accommodation Resource Center converts departmental information and documents into alternative formats, which include Braille and large print. For alternative format order viagra online requests, please contact the department at (202) 693-7828 (voice) or (800) 877-8339 (federal relay).California Healthline producer Lydia Zuraw told of her experience with long erectile dysfunction treatment and how singing helped her shortness of breath on Newsy’s “Morning Rush” on Thursday. California Healthline reporter and producer Heidi de Marco discussed a clinic treating migrants at the Mexican border on KCET’s “SoCal Update” on Wednesday.

KHN Colorado correspondent Rae Ellen Bichell spoke about the order viagra online erectile dysfunction treatment delta variant on Illinois Public Media’s “The 21st Show” on Tuesday. Related Topics Contact Us Submit a Story TipIn the past two weeks, many medical experts started to question whether the Johnson &. Johnson treatment, which is administered in a single dose, would be as effective as the two-dose Pfizer-BioNTech or Moderna treatment in protecting against the new, order viagra online highly transmissible delta variant that is poised to become the dominant strain in the U.S. The reason for their doubts were studies showing that the J&J treatment was less effective at preventing disease than the other two treatments and also less protective against variants.

In recent days, several scientists and even members of the public who originally got J&J decided to get a “booster dose” of an mRNA treatment, Pfizer-BioNTech or Moderna, to bolster their immune systems. But data order viagra online released Thursday night by Johnson &. Johnson showed that the treatment remains highly protective against the delta variant and immunity may be long-lasting. €œThose who got J&J should be less worried than they may have been before order viagra online about delta,” said Dr.

David Diemert, a professor of medicine at George Washington University who was not involved in J&J’s research. €œIt is reassuring.” The Food and Drug Administration granted the J&J treatment emergency use authorization in February on the heels of the Pfizer-BioNTech and Moderna treatments. After a 10-day pause in April, order viagra online triggered when the treatment was found to be associated with rare but severe blood clots, distribution resumed. About 12 million Americans have received it so far.

Experts say the delta variant, first identified in India, is 40% to 60% more transmissible than other variants, meaning that unvaccinated people can more easily catch erectile dysfunction treatment and that those who have been vaccinated face a higher risk order viagra online of breakthrough s. The delta variant has also been associated with greater disease severity than other variants. In the U.S., it now accounts for about 25% of erectile dysfunction treatment cases. The Johnson order viagra online &.

Johnson data released Thursday offered the first window into how well the J&J shot holds up against the delta variant. EMAIL SIGN-Up Subscribe to California Healthline's free Daily Edition. “We believe that our treatment offers durable protection against erectile dysfunction treatment and elicits neutralizing order viagra online activity against the Delta variant,” Dr. Paul Stoffels, chief scientific officer at Johnson &. Johnson, said in a press release.

The data order viagra online comes from two small-sample preprint studies, which have not yet been peer reviewed and were both conducted in laboratories. One of the new studies showed that the J&J treatment continued to produce a high number of antibodies in the presence of the delta variant. And the order viagra online number was actually higher than what recent data had shown for antibody levels against the beta variant (first identified in South Africa). The second study showed that the J&J treatment’s immune response lasted at least eight months and that some types of immune cells increased over time.

This immune response was found to provide protection even against the delta variant order viagra online and other variants of concern. This builds onto research from J&J’s clinical trial before its treatment received authorization from the FDA. In that study, the treatment was found to be 72% effective at preventing severe and moderate disease in the U.S. Part of the trial was also conducted in South order viagra online Africa and Brazil, where variants were circulating as the treatment was being tested.

Those results were slightly lower than in the U.S. Trials — 57% in South Africa and 66% in Latin American nations — but, overall, those percentages confirm a high degree order viagra online of protection. Still, those percentages were lower than what Pfizer-BioNTech and Moderna had reported in their trials — 95% and 94% effectiveness, respectively, at preventing symptomatic disease. Recent data suggests the two treatments also protect against the delta variant.

That means that, while there is now some evidence that J&J is protective against the delta variant, its overall efficacy is still lower than that of order viagra online Pfizer-BioNTech or Moderna, said John Moore, a professor of microbiology and immunology at the Weill Cornell Medical College in New York. €œI don’t think anything has changed about that,” said Moore. He had previously told KHN he order viagra online thought J&J should be a two-dose treatment, since it provides less protection than Pfizer and Moderna. He also pointed out that, if you look closely at one of the new J&J studies, a single person did elect to get an mRNA dose after receiving J&J, which strongly boosted that person’s antibody response.

€œThat is just a one-off result,” said Moore. €œBut it is consistent with emerging data.” Indeed, data from studies in the United Kingdom shows that following a single dose of the Oxford-AstraZeneca shot with a Pfizer-BioNTech shot order viagra online offered an immunity boost. (The Oxford-AstraZeneca treatment, authorized for use in the U.K. But not the U.S., operates through a similar mechanism as J&J, although two doses are required.) Experts, order viagra online though, also maintain that all the erectile dysfunction treatments authorized for emergency use in the U.S.

Are very effective, especially compared with other types of treatments. Flu treatments have been found to have an average of 33% to order viagra online 61% effectiveness, depending on the strain they protect against. Still, Moore said those who got J&J should not pursue booster shots on their own but instead wait for guidance from the Centers for Disease Control and Prevention and FDA. €œIf and when FDA and CDC approve a change in policy, then it looks to me entirely appropriate to consider using the mRNAs as a boost for J&J,” said Moore.

In a statement, the FDA said that J&J remains a single-dose shot and that no data is available yet order viagra online on its interchangeability with other erectile dysfunction treatments. The CDC said the agency is continuing “to monitor and evaluate erectile dysfunction treatment effectiveness.” Diemert said the data from J&J’s studies supports his view that at this time a booster shot isn’t necessary for those who got J&J. €œNow that we have data that is encouraging that the treatment might be protective against delta and order viagra online that the duration of protection is a thing, those two together are encouraging that a booster might not be needed,” said Diemert. Dr.

Robert Wachter, chair of the Department of Medicine at the University of California-San Francisco, said he doesn’t think an mRNA booster is necessary either — but he would still caution those who got J&J to be a bit more careful than those who received Pfizer-BioNTech or Moderna. €œThe main difference would be definitely masking indoors (unless certain that everybody was vaccinated), whereas for mRNA vax recipient, I see that as order viagra online more elective,” Wachter wrote in an email. As for those who got J&J and have already gotten an mRNA booster shot?. For some, the new findings order viagra online come as a relief.

€œThese results are great news. I don’t find them surprising, but they are some of the data that was missing when I decided to take an mRNA booster,” said Jason Gallagher, a clinical pharmacy specialist in infectious diseases at Temple University Hospital in Philadelphia. He got a dose of the Pfizer-BioNTech treatment order viagra online after receiving the J&J treatment because he was concerned about a U.K. Study that indicated one dose of the Oxford-AstraZeneca or Pfizer-BioNTech treatment was much less effective against the delta variant than two doses.

Gallagher said he might not have gotten a booster if the J&J results had been available order viagra online a month ago, but he doesn’t regret his decision. €œThis is an immunologic study suggesting that the treatment will work against the delta variant, not a clinical study describing whether it did. I’m looking order viagra online forward to learning more about that,” said Gallagher. For those who are still considering getting an mRNA booster, it’s important to know that treatment sites may ask whether you have already been vaccinated against erectile dysfunction treatment.

These sites have been instructed to administer treatments according to CDC and FDA guidelines and have not been authorized to give additional shots to those who have already received a complete treatment regimen. Experts also emphasized that the best way to protect against the highly transmissible delta order viagra online variant is to achieve a high vaccination rate across the U.S. When more people are vaccinated, the amount of circulating viagra is reduced, which means everyone is better protected, including those who got the J&J shot. Almost 67% order viagra online of U.S.

Adults have received at least one treatment dose, but only 47% of the total population is fully vaccinated. Rates of vaccination also vary widely by state. In other words, location has a lot to do with risk order viagra online. Several Southeastern and Midwestern states, for instance, have less than 55% of their population vaccinated, meaning the delta variant could more easily sweep through those areas.

“All order viagra online of the evidence on our currently authorized treatments in the U.S. Suggests they remain highly effective against preventing severe disease even against the variants,” said Dr. William Moss, executive director of the International treatment Access Center at Johns Hopkins University in Baltimore. This story was produced by KHN (Kaiser Health News), a national newsroom that produces in-depth journalism about health order viagra online issues.

Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation order viagra online. Victoria Knight. [email protected], @victoriaregisk Related Topics Contact Us Submit a Story Tip.

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To the like it Editor is viagra otc. Figure 1 is viagra otc. Figure 1. erectile dysfunction Variants among Symptomatic is viagra otc Health Workers.

Shown is the distribution of the B.1.1.7 (alpha), delta, and other erectile dysfunction variants according to vaccination status and month of diagnosis is viagra otc among health workers at University of California San Diego Health, March through July 2021. The number of workers indicates those who were symptomatic and had available variant data, and the number of positive tests indicates those that included data on variants. In December 2020, the is viagra otc University of California San Diego Health (UCSDH) workforce experienced a dramatic increase in severe acute respiratory syndrome erectile dysfunction 2 (erectile dysfunction) s. Vaccination with mRNA treatments began in mid-December 2020.

By March, 76% of the workforce had been fully vaccinated, and by July, the percentage had risen to is viagra otc 87%. s had decreased dramatically by early February 2021.1 Between March is viagra otc and June, fewer than 30 health care workers tested positive each month. However, coincident with the end of California’s mask mandate on June 15 and the rapid dominance of the B.1.617.2 (delta) variant that first emerged in mid-April and accounted for over 95% of UCSDH isolates by the end of July (Figure 1), s increased rapidly, including cases among fully vaccinated persons. Institutional review board approval was obtained for use of administrative data is viagra otc on vaccinations and case-investigation data to examine mRNA SARS CoV-2 treatment effectiveness.

UCSDH has is viagra otc a low threshold for erectile dysfunction testing, which is triggered by the presence of at least one symptom during daily screening or by an identified exposure, regardless of vaccination status. From March 1 to July 31, 2021, a total of 227 UCSDH health care workers tested positive for erectile dysfunction by reverse-transcriptase–quantitative polymerase-chain-reaction (RT-qPCR) assay of nasal swabs. 130 of the 227 workers (57.3%) were is viagra otc fully vaccinated. Symptoms were present in 109 of the 130 fully vaccinated workers (83.8%) and in 80 of the 90 unvaccinated workers (88.9%).

(The remaining 7 is viagra otc workers were only partially vaccinated.) No deaths were reported in either group. One unvaccinated person was hospitalized for erectile dysfunction–related symptoms is viagra otc. Table 1. Table 1 is viagra otc.

Symptomatic erectile dysfunction and mRNA treatment Effectiveness among is viagra otc UCSDH Health Workers, March through July 2021. treatment effectiveness was calculated for each month from March through July. The case definition was a positive PCR test and one or more symptoms among persons with no previous erectile dysfunction treatment (see the Supplementary Appendix) is viagra otc. treatment effectiveness exceeded 90% from March through June but fell to 65.5% (95% confidence interval [CI], 48.9 to 76.9) in July (Table 1).

July case is viagra otc rates were analyzed according to the month in which workers with erectile dysfunction treatment completed the vaccination series. In workers completing vaccination in January or February, the attack rate was 6.7 per 1000 persons (95% CI, 5.9 to 7.8), whereas the attack rate was 3.7 per 1000 persons is viagra otc (95% CI, 2.5 to 5.7) among those who completed vaccination during the period from March through May. Among unvaccinated persons, the July attack rate was 16.4 per 1000 persons (95% CI, 11.8 to 22.9). The SARS CoV-2 mRNA treatments, BNT162b2 (Pfizer–BioNTech) and mRNA-1273 (Moderna), have previously shown efficacy rates of 95% and 94.1%,2 respectively, in their initial clinical trials, and for the BNT162b2 treatment, sustained, albeit slightly decreased effectiveness (84%) 4 months after the second dose.3 In England, where an extended dosing interval of is viagra otc up to 12 weeks was used, Lopez Bernal et al.

Reported a preserved treatment effectiveness of 88% against symptomatic disease associated with the delta variant.4 As observed by others in populations that received mRNA treatments according to standard Emergency Use Authorization intervals,5 our data suggest that treatment effectiveness against any symptomatic disease is considerably lower against the delta variant and may wane over time since vaccination. The dramatic change in treatment effectiveness from June to July is likely to be due to both the emergence of the delta variant and waning immunity over time, compounded by the end of masking requirements is viagra otc in California and the resulting greater risk of exposure in the community. Our findings underline the importance is viagra otc of rapidly reinstating nonpharmaceutical interventions, such as indoor masking and intensive testing strategies, in addition to continued efforts to increase vaccinations, as strategies to prevent avoidable illness and deaths and to avoid mass disruptions to society during the spread of this formidable variant. Furthermore, if our findings on waning immunity are verified in other settings, booster doses may be indicated.

Jocelyn Keehner, M.D.Lucy is viagra otc E. Horton, M.D., M.P.H.UC San Diego Health, is viagra otc San Diego, CANancy J. Binkin, M.D., M.P.H.UC San Diego, La Jolla, CALouise C. Laurent, M.D., Ph.D.David is viagra otc Pride, M.D., Ph.D.Christopher A.

Longhurst, M.D.Shira R. Abeles, M.D.Francesca is viagra otc J. Torriani, M.D.UC San Diego Health, San is viagra otc Diego, CA [email protected] Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org. This letter was published on September 1, 2021, and updated on September 3, 2021, at NEJM.org.

Dr. Laurent serves as an author on behalf of the SEARCH Alliance. Collaborators in the SEARCH Alliance are listed in the Supplementary Appendix, available with the full text of this letter at NEJM.org. Drs.

Keehner and Horton and Drs. Abeles and Torriani contributed equally to this letter. 5 References1. Keehner J, Abeles SR, Torriani FJ.

More on erectile dysfunction after vaccination in health care workers. Reply. N Engl J Med 2021;385(2):e8.2. Baden LR, El Sahly HM, Essink B, et al.

Efficacy and safety of the mRNA-1273 erectile dysfunction treatment. N Engl J Med 2021;384:403-416.3. Thomas SJ, Moreira ED Jr, Kitchin N, et al. Six month safety and efficacy of the BNT162b2 mRNA erectile dysfunction treatment.

July 28, 2021 (https://www.medrxiv.org/content/10.1101/2021.07.28.21261159v1). Preprint.Google Scholar4. Lopez Bernal J, Andrews N, Gower C, et al. Effectiveness of erectile dysfunction treatments against the B.1.617.2 (Delta) variant.

N Engl J Med 2021;385:585-594.5. Israel A, Merzon E, Schäffer AA, et al. Elapsed time since BNT162b2 treatment and risk of erectile dysfunction in a large cohort. August 5, 2021 (https://www.medrxiv.org/content/10.1101/2021.08.03.21261496v1).

Preprint.Google Scholar10.1056/NEJMc2112981-t1Table 1. Symptomatic erectile dysfunction and mRNA treatment Effectiveness among UCSDH Health Workers, March through July 2021.* MarchAprilMayJuneJulyUCSDH workforce — no. Of persons18,96418,99219,00019,03519,016Vaccination status — no. Of personsFully vaccinated†14,47015,51016,15716,42616,492mRNA-1273 (Moderna)6,6087,0057,3407,4517,464BNT162b2 (Pfizer–BioNTech)7,8628,5058,8178,9759,028Unvaccinated3,2302,5092,1872,0591,895Percentage of workers fully vaccinated76.381.785.086.386.7Symptomatic erectile dysfunction treatmentFully vaccinated workers343594Unvaccinated workers1117101031Percentage of cases in fully vaccinated workers21.419.023.133.375.2Attack rate per 1000 (95% CI)Fully vaccinated workers0.21 (0.21–0.47)0.26 (0.26–0.50)0.19 (0.21–0.40)0.30 (0.31–0.53)5.7 (5.4–6.2)Unvaccinated workers3.4 (2.1–5.9)6.8 (4.5–10.6)4.6 (2.6–8.2)4.9 (2.9–8.7)16.4 (11.8–22.9)treatment effectiveness — % (95% CI)93.9 (78.2–97.9)96.2 (88.7–98.3)95.9 (85.3–98.9)94.3 (83.7–98.0)65.5 (48.9–76.9)Study Sample A total of 103,199 hospitalizations of patients with erectile dysfunction treatment–like illness who were 50 years of age or older were identified by the seven VISION partners.

Of these hospitalizations, 64,400 (62%) occurred after the dates of age-specific erectile dysfunction treatment eligibility and the time required for vaccination records to be updated (Table S3). The hospitalizations occurred during the period from January 1 through June 22, 2021. Among unvaccinated patients who were hospitalized, the median duration from treatment eligibility to the index date was 39 days (interquartile range, 16 to 70) (Table S4). erectile dysfunction testing with a molecular assay ordered by clinicians was conducted for 74% of the patients who were hospitalized (range across network partners, 55 to 99).

During the period from January 1 through June 22, a total of 121,709 visits to emergency departments or urgent care clinics for erectile dysfunction treatment–like illness were identified by three partners. 76,220 visits (63%) occurred after treatment age eligibility and updates to vaccination records (Table S5). Among the patients who visited an emergency department or urgent care clinic, the median duration from treatment eligibility to the index date was 39 days (interquartile range, 15 to 70). 30% (range, 25 to 41) of these patients were tested by means of molecular assay.

Across the partners, 1872 hospitalizations and 1350 emergency department or urgent care clinic visits were excluded because the index dates occurred 1 to 13 days after the patient received the first dose of erectile dysfunction treatment and immunity was considered indeterminant. Table 2. Table 2. Characteristics of the Patients According to erectile dysfunction Test Results and Vaccination Status.

Our analytic sample included 41,552 hospitalizations and 21,522 emergency department or urgent care clinic visits. 3% of the hospitalizations and 14% of the emergency department or urgent care clinic visits were repeat medical visits by the same patient (Table 2). Characteristics of the patients are listed in Table 2, and characteristics of the patients according to network partner are provided in Tables S6 through S11. The median age was 74 years (interquartile range, 66 to 82) among hospitalized patients and 70 years (interquartile range, 61 to 78) among those who visited an emergency department or urgent care clinic.

Black patients and Hispanic patients accounted for a larger percentage of medical visits in the hospitalization sample (9% and 11%, respectively) than in the emergency department or urgent care sample (4% and 5%). These findings reflect in part the differing demographic characteristics of the network partners that contributed data on emergency department or urgent care clinic visits. The percentage of patients with underlying medical conditions was higher among hospitalized patients than among those who visited an emergency department or urgent care clinic. erectile dysfunction treatment–Associated Medical Care We identified 4321 patients with erectile dysfunction treatment who had laboratory-confirmed erectile dysfunction among 41,552 patients who were hospitalized (10%.

Range across network partners, 5 to 21). The remaining 37,231 hospitalized patients (90%) had discharge codes for erectile dysfunction treatment–like illness but were erectile dysfunction–negative. Laboratory-confirmed erectile dysfunction was identified in 3251 of 21,522 patients who visited an emergency department or urgent care clinic (15%. Range across network partners, 9 to 19).

The remaining 18,271 patients who visited an emergency department or urgent care clinic (85%) were erectile dysfunction–negative (Table 2). The percentage of erectile dysfunction–positive patients also varied among network partners (Tables S12 and S13). The percentage of patients with laboratory-confirmed erectile dysfunction decreased with age among hospitalized patients and among those with emergency department or urgent care clinic visits. In both care settings, the percentage of infected patients was higher among unvaccinated patients and lower among White patients, non-Hispanic patients, and those with chronic nonrespiratory conditions.

The numbers of both erectile dysfunction–positive patients and erectile dysfunction–negative patients with medical visits on each day are provided in Figures S1 through S10. erectile dysfunction treatment Vaccination Status On the index date, unvaccinated patients composed approximately half the patients who were hospitalized (49%. Range across network partners, 26 to 73) or visited an emergency department or urgent care clinic (55%. Range, 45 to 65) (Table 2).

In both samples, the largest differences between vaccinated and unvaccinated patients were age, network partner, calendar time, and local erectile dysfunction circulation on the index date. These same differences were noted when the sample was limited to erectile dysfunction–positive patients only (Tables S14 and S15). As described in the Supplementary Appendix, the application of inverse propensity-to-be-vaccinated weighting reduced the differences between vaccinated and unvaccinated patients with respect to these factors and other patient characteristics to a standard mean difference of less than 0.2. Among vaccinated patients, 53.4% of those who were hospitalized and 53.7% of those who visited an emergency department or urgent care clinic had received the BNT162b2 treatment, 43.3% and 41.6%, respectively, had received the mRNA-1273 treatment, and 3.3% and 4.7%, respectively, had received the Ad26.COV2.S treatment.

The median days from full vaccination to the index date were similar with the three types of erectile dysfunction treatments and with both samples (hospitalization and emergency department or urgent care clinic) (range, 42 to 53). Among the patients who received the BNT162b2 treatment, the median duration from partial vaccination (one dose) to the index date of hospitalization was 21 days and the median duration from partial vaccination to the index date of an emergency department or urgent care visit was 20 days. Among patients who received the mRNA-1273 treatment, these durations were 26 days and 24 days, respectively. These findings reflected the different dosing schedules of these treatments.

MRNA-Based treatment and Hospitalization Figure 1. Figure 1. Estimated treatment Effectiveness against erectile dysfunction Leading to Hospitalization or an Emergency Department or Urgent Care Clinic Visit, According to the Type of treatment. Patients who were partially vaccinated with one dose of a messenger RNA (mRNA)–based treatment received the first dose at least 14 days before the index date for the medical visit and had not received the second dose by the index date.

Patients who were partially vaccinated with two doses of an mRNA-based treatment received the second dose 1 to 13 days before the index date. Fully vaccinated patients received a single dose of the Ad26.COV2.S treatment or the second dose of an mRNA-based treatment at least 14 days before the index date. CI denotes confidence interval, and erectile dysfunction severe acute respiratory syndrome erectile dysfunction 2.Figure 2. Figure 2.

Estimated Effectiveness of Full Two-Dose mRNA Vaccination against erectile dysfunction Leading to Hospitalization, According to Age, Race or Ethnic Group, and Underlying Medical Conditions. Among adults who were 50 years of age or older, the effectiveness of full two-dose mRNA-based vaccination (≥14 days after the second dose) was 89% (95% confidence interval [CI], 87 to 91) against laboratory-confirmed erectile dysfunction leading to hospitalization. The treatment-effectiveness point estimates were similar (differences, ≤5 percentage points) with the BNT162b2 and mRNA-1273 treatments (Figure 1 and Figure 2). The effectiveness of full mRNA-based vaccination was 83% (95% CI, 77 to 87) among patients who were at least 85 years of age, 86% (95% CI, 75 to 92) among Black patients, 90% (95% CI, 85 to 93) among Hispanic patients, 90% (95% CI, 88 to 92) among patients with chronic respiratory conditions, and 88% (95% CI, 86 to 90) among patients with chronic nonrespiratory conditions (Figure 2).

When the hospital sample was limited to 7283 admissions to an ICU, the effectiveness of full mRNA-based vaccination against laboratory-confirmed erectile dysfunction leading to ICU admission was 90% (95% CI, 86 to 93) (Table S16). Patients who were partially vaccinated with one dose of mRNA-based treatment received the first dose at least 14 days before the index date and had not received the second dose by the index date. Patients who were partially vaccinated with two doses of mRNA-based treatment received the second dose 1 to 13 days before the index date. Among patients who received an mRNA-based treatment, the effectiveness of partial one-dose vaccination (≥14 days after the first dose, but without the second dose) was 54% (95% CI, 47 to 61) against erectile dysfunction leading to hospitalization, and the effectiveness of partial two-dose vaccination (1 to 13 days after the second dose) was 73% (95% CI, 66% to 79).

With both the BNT162b2 and mRNA-1273 treatments, the effectiveness of full vaccination with respect to erectile dysfunction treatment–associated hospitalization was higher than that of partial vaccination (first dose) (with 95% confidence intervals that did not overlap) (Figure 1). A similar pattern of higher treatment-effectiveness point estimates for full mRNA-based vaccination than for partial mRNA-based vaccination was noted in all stratified analyses (Table S17). The effectiveness after partial vaccination (first dose) was lower with BNT162b2 than with mRNA-1273 (Figure 1). The estimates of the effectiveness of full mRNA-based vaccination were similar when stratified according to the six network partners that contributed the most data on hospitalizations (range, 82 to 97%).

However, heterogeneity was observed among the partners in the estimates of effectiveness of partial vaccination (first dose). treatment effectiveness also remained consistent in the other sensitivity analyses (Section S5). Our simulation model suggested that if both misclassification of outcome and of exposure occur, treatment effectiveness could be underestimated by as much as 10 percentage points, given the rates of clinical testing, percent positivity, and vaccination coverage observed in our hospitalization sample. Figure 3.

Figure 3. Estimated Effectiveness of mRNA-Based Vaccination against erectile dysfunction Leading to Hospitalization or an Emergency Department or Urgent Care Visit, According to the Days since the Most Recent Dose Was Administered. The total number of hospitalizations shown is higher than the total number in the main analysis because this secondary analysis was conducted weeks after the main analysis and incorporated updated information from vaccination records and registries. Specifically, an additional 212 hospitalizations among unvaccinated patients and 831 hospitalizations among vaccinated patients with confirmed vaccination status were included.In secondary analyses, we stratified mRNA-based treatment exposure according to 14-day intervals after administration (Figure 3) and according to type of treatment (Table S18).

treatment effectiveness with respect to erectile dysfunction treatment–associated hospitalization was null 0 to 13 days after the first dose, and treatment-effectiveness point estimates increased through 55 days after the first dose. treatment-effectiveness point estimates for full mRNA-based vaccination remained consistently high (>80%) through at least 112 days after the second dose. MRNA-Based treatment and Emergency Department and Urgent Care Visits Figure 4. Figure 4.

Estimated Effectiveness of Full Two-Dose mRNA-Based Vaccination against erectile dysfunction Leading to an Emergency Department or Urgent Care Clinic Visit, According to Age, Race or Ethnic Group, and Underlying Medical Conditions. The effectiveness of full two-dose mRNA-based vaccination was 91% (95% CI, 89 to 93) against laboratory-confirmed erectile dysfunction leading to emergency department or urgent care clinic visits (Figure 4). The treatment-effectiveness point estimates were similar (3 percentage points) with the BNT162b2 and mRNA-1273 treatments (Figure 1). The effectiveness of full mRNA-based vaccination was 84% (95% CI, 73 to 91) among adults who were 85 years of age or older, 95% (95% CI, 84 to 98) among Black patients, 81% (95% CI, 70 to 88) among Hispanic patients, and 90% (95% CI, 86 to 93) and 90% (95% CI, 87 to 92) among patients with chronic respiratory conditions and those with chronic nonrespiratory conditions, respectively (Figure 4).

The effectiveness of partial (one-dose) mRNA-based vaccination (both types) against erectile dysfunction leading to emergency department or urgent care clinic visits was 68% (95% CI, 61 to 74), and the effectiveness of partial (two-dose) vaccination was 80% (95% CI, 73 to 85) (Table S19). With both the BNT162b2 and mRNA-1273 treatments, the effectiveness of full vaccination against erectile dysfunction leading to emergency department or urgent care clinic visits was higher than the effectiveness with partial vaccination (one dose) (Figure 1). In sensitivity analyses, treatment-effectiveness point estimates for full mRNA-based vaccination against erectile dysfunction leading to emergency department or urgent care clinic visits ranged from 89 to 97% across the three network partners. Estimates of treatment effectiveness also remained consistent in other sensitivity analyses (Section S5).

In secondary analyses, treatment effectiveness against erectile dysfunction leading to emergency department or urgent care clinic visits was null 0 to 13 days after the first dose, and then treatment-effectiveness point estimates increased through 55 days after the first dose. treatment-effectiveness point estimates for full mRNA-based vaccination remained consistently high (≥86%) through at least 112 days after the second dose (Figure 3). Estimates of effectiveness according to the type of erectile dysfunction treatment are provided in Table S20. Effectiveness of Ad26.COV2.S treatment Estimates of the effectiveness of Ad26.COV2.S treatment were limited to five network partners with Ad26.COV2.S treatment recipients (CUIMC, Intermountain Healthcare, KPNC, KPNW, and Regenstrief Institute).

These analyses included 11,468 hospitalizations and 8917 emergency department or urgent care clinic visits that occurred after the index date for the first patient who was fully vaccinated with Ad26.COV2.S for each network partner (Figure 1). The effectiveness of the full one-dose Ad26.COV2.S treatment was 68% (95% CI, 50 to 79) with respect to erectile dysfunction treatment–associated hospitalization. The effectiveness of full vaccination against erectile dysfunction leading to emergency department or urgent care clinic visits was 73% (95% CI, 59 to 82) (Figure 1)..

To the Editor order viagra online. Figure 1 order viagra online. Figure 1. erectile dysfunction Variants among Symptomatic Health Workers order viagra online. Shown is the distribution of the B.1.1.7 (alpha), delta, and other erectile dysfunction variants according to vaccination status and order viagra online month of diagnosis among health workers at University of California San Diego Health, March through July 2021.

The number of workers indicates those who were symptomatic and had available variant data, and the number of positive tests indicates those that included data on variants. In December 2020, the University of California San Diego Health (UCSDH) workforce experienced a order viagra online dramatic increase in severe acute respiratory syndrome erectile dysfunction 2 (erectile dysfunction) s. Vaccination with mRNA treatments began in mid-December 2020. By March, 76% of the workforce order viagra online had been fully vaccinated, and by July, the percentage had risen to 87%. s had decreased order viagra online dramatically by early February 2021.1 Between March and June, fewer than 30 health care workers tested positive each month.

However, coincident with the end of California’s mask mandate on June 15 and the rapid dominance of the B.1.617.2 (delta) variant that first emerged in mid-April and accounted for over 95% of UCSDH isolates by the end of July (Figure 1), s increased rapidly, including cases among fully vaccinated persons. Institutional review board approval was obtained for use of administrative data on vaccinations and order viagra online case-investigation data to examine mRNA SARS CoV-2 treatment effectiveness. UCSDH has a low threshold for erectile dysfunction testing, which is triggered order viagra online by the presence of at least one symptom during daily screening or by an identified exposure, regardless of vaccination status. From March 1 to July 31, 2021, a total of 227 UCSDH health care workers tested positive for erectile dysfunction by reverse-transcriptase–quantitative polymerase-chain-reaction (RT-qPCR) assay of nasal swabs. 130 of the 227 workers (57.3%) were fully vaccinated order viagra online.

Symptoms were present in 109 of the 130 fully vaccinated workers (83.8%) and in 80 of the 90 unvaccinated workers (88.9%). (The remaining 7 workers order viagra online were only partially vaccinated.) No deaths were reported in either group. One unvaccinated person was hospitalized for erectile dysfunction–related symptoms order viagra online. Table 1. Table 1 order viagra online.

Symptomatic erectile dysfunction and mRNA treatment order viagra online Effectiveness among UCSDH Health Workers, March through July 2021. treatment effectiveness was calculated for each month from March through July. The case definition was a positive PCR test and one or more order viagra online symptoms among persons with no previous erectile dysfunction treatment (see the Supplementary Appendix). treatment effectiveness exceeded 90% from March through June but fell to 65.5% (95% confidence interval [CI], 48.9 to 76.9) in July (Table 1). July case rates were analyzed according to the month in which workers with erectile dysfunction treatment completed the vaccination order viagra online series.

In workers completing vaccination in January or February, the attack rate was 6.7 per 1000 persons (95% CI, 5.9 to order viagra online 7.8), whereas the attack rate was 3.7 per 1000 persons (95% CI, 2.5 to 5.7) among those who completed vaccination during the period from March through May. Among unvaccinated persons, the July attack rate was 16.4 per 1000 persons (95% CI, 11.8 to 22.9). The SARS CoV-2 mRNA treatments, BNT162b2 (Pfizer–BioNTech) and mRNA-1273 (Moderna), have previously shown efficacy rates of 95% and 94.1%,2 respectively, in their initial clinical trials, order viagra online and for the BNT162b2 treatment, sustained, albeit slightly decreased effectiveness (84%) 4 months after the second dose.3 In England, where an extended dosing interval of up to 12 weeks was used, Lopez Bernal et al. Reported a preserved treatment effectiveness of 88% against symptomatic disease associated with the delta variant.4 As observed by others in populations that received mRNA treatments according to standard Emergency Use Authorization intervals,5 our data suggest that treatment effectiveness against any symptomatic disease is considerably lower against the delta variant and may wane over time since vaccination. The dramatic change in treatment effectiveness from June to July is likely to be due to both the emergence of the delta variant and waning immunity over order viagra online time, compounded by the end of masking requirements in California and the resulting greater risk of exposure in the community.

Our findings underline the importance of rapidly reinstating nonpharmaceutical interventions, such as indoor masking and intensive testing strategies, in addition to continued efforts to increase vaccinations, as strategies to prevent avoidable illness and order viagra online deaths and to avoid mass disruptions to society during the spread of this formidable variant. Furthermore, if our findings on waning immunity are verified in other settings, booster doses may be indicated. Jocelyn Keehner, order viagra online M.D.Lucy E. Horton, M.D., M.P.H.UC San Diego Health, San order viagra online Diego, CANancy J. Binkin, M.D., M.P.H.UC San Diego, La Jolla, CALouise C.

Laurent, M.D., order viagra online Ph.D.David Pride, M.D., Ph.D.Christopher A. Longhurst, M.D.Shira R. Abeles, M.D.Francesca order viagra online J. Torriani, M.D.UC San Diego Health, San Diego, CA [email protected] Disclosure order viagra online forms provided by the authors are available with the full text of this letter at NEJM.org. This letter was published on September 1, 2021, and updated on September 3, 2021, at NEJM.org.

Dr. Laurent serves as an author on behalf of the SEARCH Alliance. Collaborators in the SEARCH Alliance are listed in the Supplementary Appendix, available with the full text of this letter at NEJM.org. Drs. Keehner and Horton and Drs.

Abeles and Torriani contributed equally to this letter. 5 References1. Keehner J, Abeles SR, Torriani FJ. More on erectile dysfunction after vaccination in health care workers. Reply.

N Engl J Med 2021;385(2):e8.2. Baden LR, El Sahly HM, Essink B, et al. Efficacy and safety of the mRNA-1273 erectile dysfunction treatment. N Engl J Med 2021;384:403-416.3. Thomas SJ, Moreira ED Jr, Kitchin N, et al.

Six month safety and efficacy of the BNT162b2 mRNA erectile dysfunction treatment. July 28, 2021 (https://www.medrxiv.org/content/10.1101/2021.07.28.21261159v1). Preprint.Google Scholar4. Lopez Bernal J, Andrews N, Gower C, et al. Effectiveness of erectile dysfunction treatments against the B.1.617.2 (Delta) variant.

N Engl J Med 2021;385:585-594.5. Israel A, Merzon E, Schäffer AA, et al. Elapsed time since BNT162b2 treatment and risk of erectile dysfunction in a large cohort. August 5, 2021 (https://www.medrxiv.org/content/10.1101/2021.08.03.21261496v1). Preprint.Google Scholar10.1056/NEJMc2112981-t1Table 1.

Symptomatic erectile dysfunction and mRNA treatment Effectiveness among UCSDH Health Workers, March through July 2021.* MarchAprilMayJuneJulyUCSDH workforce — no. Of persons18,96418,99219,00019,03519,016Vaccination status — no. Of personsFully vaccinated†14,47015,51016,15716,42616,492mRNA-1273 (Moderna)6,6087,0057,3407,4517,464BNT162b2 (Pfizer–BioNTech)7,8628,5058,8178,9759,028Unvaccinated3,2302,5092,1872,0591,895Percentage of workers fully vaccinated76.381.785.086.386.7Symptomatic erectile dysfunction treatmentFully vaccinated workers343594Unvaccinated workers1117101031Percentage of cases in fully vaccinated workers21.419.023.133.375.2Attack rate per 1000 (95% CI)Fully vaccinated workers0.21 (0.21–0.47)0.26 (0.26–0.50)0.19 (0.21–0.40)0.30 (0.31–0.53)5.7 (5.4–6.2)Unvaccinated workers3.4 (2.1–5.9)6.8 (4.5–10.6)4.6 (2.6–8.2)4.9 (2.9–8.7)16.4 (11.8–22.9)treatment effectiveness — % (95% CI)93.9 (78.2–97.9)96.2 (88.7–98.3)95.9 (85.3–98.9)94.3 (83.7–98.0)65.5 (48.9–76.9)Study Sample A total of 103,199 hospitalizations of patients with erectile dysfunction treatment–like illness who were 50 years of age or older were identified by the seven VISION partners. Of these hospitalizations, 64,400 (62%) occurred after the dates of age-specific erectile dysfunction treatment eligibility and the time required for vaccination records to be updated (Table S3). The hospitalizations occurred during the period from January 1 through June 22, 2021.

Among unvaccinated patients who were hospitalized, the median duration from treatment eligibility to the index date was 39 days (interquartile range, 16 to 70) (Table S4). erectile dysfunction testing with a molecular assay ordered by clinicians was conducted for 74% of the patients who were hospitalized (range across network partners, 55 to 99). During the period from January 1 through June 22, a total of 121,709 visits to emergency departments or urgent care clinics for erectile dysfunction treatment–like illness were identified by three partners. 76,220 visits (63%) occurred after treatment age eligibility and updates to vaccination records (Table S5). Among the patients who visited an emergency department or urgent care clinic, the median duration from treatment eligibility to the index date was 39 days (interquartile range, 15 to 70).

30% (range, 25 to 41) of these patients were tested by means of molecular assay. Across the partners, 1872 hospitalizations and 1350 emergency department or urgent care clinic visits were excluded because the index dates occurred 1 to 13 days after the patient received the first dose of erectile dysfunction treatment and immunity was considered indeterminant. Table 2. Table 2. Characteristics of the Patients According to erectile dysfunction Test Results and Vaccination Status.

Our analytic sample included 41,552 hospitalizations and 21,522 emergency department or urgent care clinic visits. 3% of the hospitalizations and 14% of the emergency department or urgent care clinic visits were repeat medical visits by the same patient (Table 2). Characteristics of the patients are listed in Table 2, and characteristics of the patients according to network partner are provided in Tables S6 through S11. The median age was 74 years (interquartile range, 66 to 82) among hospitalized patients and 70 years (interquartile range, 61 to 78) among those who visited an emergency department or urgent care clinic. Black patients and Hispanic patients accounted for a larger percentage of medical visits in the hospitalization sample (9% and 11%, respectively) than in the emergency department or urgent care sample (4% and 5%).

These findings reflect in part the differing demographic characteristics of the network partners that contributed data on emergency department or urgent care clinic visits. The percentage of patients with underlying medical conditions was higher among hospitalized patients than among those who visited an emergency department or urgent care clinic. erectile dysfunction treatment–Associated Medical Care We identified 4321 patients with erectile dysfunction treatment who had laboratory-confirmed erectile dysfunction among 41,552 patients who were hospitalized (10%. Range across network partners, 5 to 21). The remaining 37,231 hospitalized patients (90%) had discharge codes for erectile dysfunction treatment–like illness but were erectile dysfunction–negative.

Laboratory-confirmed erectile dysfunction was identified in 3251 of 21,522 patients who visited an emergency department or urgent care clinic (15%. Range across network partners, 9 to 19). The remaining 18,271 patients who visited an emergency department or urgent care clinic (85%) were erectile dysfunction–negative (Table 2). The percentage of erectile dysfunction–positive patients also varied among network partners (Tables S12 and S13). The percentage of patients with laboratory-confirmed erectile dysfunction decreased with age among hospitalized patients and among those with emergency department or urgent care clinic visits.

In both care settings, the percentage of infected patients was higher among unvaccinated patients and lower among White patients, non-Hispanic patients, and those with chronic nonrespiratory conditions. The numbers of both erectile dysfunction–positive patients and erectile dysfunction–negative patients with medical visits on each day are provided in Figures S1 through S10. erectile dysfunction treatment Vaccination Status On the index date, unvaccinated patients composed approximately half the patients who were hospitalized (49%. Range across network partners, 26 to 73) or visited an emergency department or urgent care clinic (55%. Range, 45 to 65) (Table 2).

In both samples, the largest differences between vaccinated and unvaccinated patients were age, network partner, calendar time, and local erectile dysfunction circulation on the index date. These same differences were noted when the sample was limited to erectile dysfunction–positive patients only (Tables S14 and S15). As described in the Supplementary Appendix, the application of inverse propensity-to-be-vaccinated weighting reduced the differences between vaccinated and unvaccinated patients with respect to these factors and other patient characteristics to a standard mean difference of less than 0.2. Among vaccinated patients, 53.4% of those who were hospitalized and 53.7% of those who visited an emergency department or urgent care clinic had received the BNT162b2 treatment, 43.3% and 41.6%, respectively, had received the mRNA-1273 treatment, and 3.3% and 4.7%, respectively, had received the Ad26.COV2.S treatment. The median days from full vaccination to the index date were similar with the three types of erectile dysfunction treatments and with both samples (hospitalization and emergency department or urgent care clinic) (range, 42 to 53).

Among the patients who received the BNT162b2 treatment, the median duration from partial vaccination (one dose) to the index date of hospitalization was 21 days and the median duration from partial vaccination to the index date of an emergency department or urgent care visit was 20 days. Among patients who received the mRNA-1273 treatment, these durations were 26 days and 24 days, respectively. These findings reflected the different dosing schedules of these treatments. MRNA-Based treatment and Hospitalization Figure 1. Figure 1.

Estimated treatment Effectiveness against erectile dysfunction Leading to Hospitalization or an Emergency Department or Urgent Care Clinic Visit, According to the Type of treatment. Patients who were partially vaccinated with one dose of a messenger RNA (mRNA)–based treatment received the first dose at least 14 days before the index date for the medical visit and had not received the second dose by the index date. Patients who were partially vaccinated with two doses of an mRNA-based treatment received the second dose 1 to 13 days before the index date. Fully vaccinated patients received a single dose of the Ad26.COV2.S treatment or the second dose of an mRNA-based treatment at least 14 days before the index date. CI denotes confidence interval, and erectile dysfunction severe acute respiratory syndrome erectile dysfunction 2.Figure 2.

Figure 2. Estimated Effectiveness of Full Two-Dose mRNA Vaccination against erectile dysfunction Leading to Hospitalization, According to Age, Race or Ethnic Group, and Underlying Medical Conditions. Among adults who were 50 years of age or older, the effectiveness of full two-dose mRNA-based vaccination (≥14 days after the second dose) was 89% (95% confidence interval [CI], 87 to 91) against laboratory-confirmed erectile dysfunction leading to hospitalization. The treatment-effectiveness point estimates were similar (differences, ≤5 percentage points) with the BNT162b2 and mRNA-1273 treatments (Figure 1 and Figure 2). The effectiveness of full mRNA-based vaccination was 83% (95% CI, 77 to 87) among patients who were at least 85 years of age, 86% (95% CI, 75 to 92) among Black patients, 90% (95% CI, 85 to 93) among Hispanic patients, 90% (95% CI, 88 to 92) among patients with chronic respiratory conditions, and 88% (95% CI, 86 to 90) among patients with chronic nonrespiratory conditions (Figure 2).

When the hospital sample was limited to 7283 admissions to an ICU, the effectiveness of full mRNA-based vaccination against laboratory-confirmed erectile dysfunction leading to ICU admission was 90% (95% CI, 86 to 93) (Table S16). Patients who were partially vaccinated with one dose of mRNA-based treatment received the first dose at least 14 days before the index date and had not received the second dose by the index date. Patients who were partially vaccinated with two doses of mRNA-based treatment received the second dose 1 to 13 days before the index date. Among patients who received an mRNA-based treatment, the effectiveness of partial one-dose vaccination (≥14 days after the first dose, but without the second dose) was 54% (95% CI, 47 to 61) against erectile dysfunction leading to hospitalization, and the effectiveness of partial two-dose vaccination (1 to 13 days after the second dose) was 73% (95% CI, 66% to 79). With both the BNT162b2 and mRNA-1273 treatments, the effectiveness of full vaccination with respect to erectile dysfunction treatment–associated hospitalization was higher than that of partial vaccination (first dose) (with 95% confidence intervals that did not overlap) (Figure 1).

A similar pattern of higher treatment-effectiveness point estimates for full mRNA-based vaccination than for partial mRNA-based vaccination was noted in all stratified analyses (Table S17). The effectiveness after partial vaccination (first dose) was lower with BNT162b2 than with mRNA-1273 (Figure 1). The estimates of the effectiveness of full mRNA-based vaccination were similar when stratified according to the six network partners that contributed the most data on hospitalizations (range, 82 to 97%). However, heterogeneity was observed among the partners in the estimates of effectiveness of partial vaccination (first dose). treatment effectiveness also remained consistent in the other sensitivity analyses (Section S5).

Our simulation model suggested that if both misclassification of outcome and of exposure occur, treatment effectiveness could be underestimated by as much as 10 percentage points, given the rates of clinical testing, percent positivity, and vaccination coverage observed in our hospitalization sample. Figure 3. Figure 3. Estimated Effectiveness of mRNA-Based Vaccination against erectile dysfunction Leading to Hospitalization or an Emergency Department or Urgent Care Visit, According to the Days since the Most Recent Dose Was Administered. The total number of hospitalizations shown is higher than the total number in the main analysis because this secondary analysis was conducted weeks after the main analysis and incorporated updated information from vaccination records and registries.

Specifically, an additional 212 hospitalizations among unvaccinated patients and 831 hospitalizations among vaccinated patients with confirmed vaccination status were included.In secondary analyses, we stratified mRNA-based treatment exposure according to 14-day intervals after administration (Figure 3) and according to type of treatment (Table S18). treatment effectiveness with respect to erectile dysfunction treatment–associated hospitalization was null 0 to 13 days after the first dose, and treatment-effectiveness point estimates increased through 55 days after the first dose. treatment-effectiveness point estimates for full mRNA-based vaccination remained consistently high (>80%) through at least 112 days after the second dose. MRNA-Based treatment and Emergency Department and Urgent Care Visits Figure 4. Figure 4.

Estimated Effectiveness of Full Two-Dose mRNA-Based Vaccination against erectile dysfunction Leading to an Emergency Department or Urgent Care Clinic Visit, According to Age, Race or Ethnic Group, and Underlying Medical Conditions. The effectiveness of full two-dose mRNA-based vaccination was 91% (95% CI, 89 to 93) against laboratory-confirmed erectile dysfunction leading to emergency department or urgent care clinic visits (Figure 4). The treatment-effectiveness point estimates were similar (3 percentage points) with the BNT162b2 and mRNA-1273 treatments (Figure 1). The effectiveness of full mRNA-based vaccination was 84% (95% CI, 73 to 91) among adults who were 85 years of age or older, 95% (95% CI, 84 to 98) among Black patients, 81% (95% CI, 70 to 88) among Hispanic patients, and 90% (95% CI, 86 to 93) and 90% (95% CI, 87 to 92) among patients with chronic respiratory conditions and those with chronic nonrespiratory conditions, respectively (Figure 4). The effectiveness of partial (one-dose) mRNA-based vaccination (both types) against erectile dysfunction leading to emergency department or urgent care clinic visits was 68% (95% CI, 61 to 74), and the effectiveness of partial (two-dose) vaccination was 80% (95% CI, 73 to 85) (Table S19).

With both the BNT162b2 and mRNA-1273 treatments, the effectiveness of full vaccination against erectile dysfunction leading to emergency department or urgent care clinic visits was higher than the effectiveness with partial vaccination (one dose) (Figure 1). In sensitivity analyses, treatment-effectiveness point estimates for full mRNA-based vaccination against erectile dysfunction leading to emergency department or urgent care clinic visits ranged from 89 to 97% across the three network partners. Estimates of treatment effectiveness also remained consistent in other sensitivity analyses (Section S5). In secondary analyses, treatment effectiveness against erectile dysfunction leading to emergency department or urgent care clinic visits was null 0 to 13 days after the first dose, and then treatment-effectiveness point estimates increased through 55 days after the first dose. treatment-effectiveness point estimates for full mRNA-based vaccination remained consistently high (≥86%) through at least 112 days after the second dose (Figure 3).

Estimates of effectiveness according to the type of erectile dysfunction treatment are provided in Table S20. Effectiveness of Ad26.COV2.S treatment Estimates of the effectiveness of Ad26.COV2.S treatment were limited to five network partners with Ad26.COV2.S treatment recipients (CUIMC, Intermountain Healthcare, KPNC, KPNW, and Regenstrief Institute). These analyses included 11,468 hospitalizations and 8917 emergency department or urgent care clinic visits that occurred after the index date for the first patient who was fully vaccinated with Ad26.COV2.S for each network partner (Figure 1). The effectiveness of the full one-dose Ad26.COV2.S treatment was 68% (95% CI, 50 to 79) with respect to erectile dysfunction treatment–associated hospitalization. The effectiveness of full vaccination against erectile dysfunction leading to emergency department or urgent care clinic visits was 73% (95% CI, 59 to 82) (Figure 1)..

What may interact with Viagra?

Do not take Viagra with any of the following:

• cisapride
• methscopolamine nitrate
• nitrates like amyl nitrite, isosorbide dinitrate, isosorbide mononitrate, nitroglycerin
• nitroprusside
• other sildenafil products (Revatio)

Viagra may also interact with the following:

• certain drugs for high blood pressure
• certain drugs for the treatment of HIV or AIDS
• certain drugs used for fungal or yeast s, like fluconazole, itraconazole, ketoconazole, and voriconazole
• cimetidine
• erythromycin
• rifampin

This list may not describe all possible interactions. Give your health care providers a list of all the medicines, herbs, non-prescription drugs, or dietary supplements you use. Also tell them if you smoke, drink alcohol, or use illegal drugs. Some items may interact with your medicine.

When do you take viagra

Ask them and they’ll likely say it’s, “I can hear, but I can’t understand.” If this is what you’re experiencing, you may have hearing when do you take viagra loss.Hearing loss involves not only the ears, but also the brain where sound is translated into meaningful words. Symptoms vary between people. Hearing loss comes in all degrees from mild to profound. But most people, especially older adults, when do you take viagra have mild-to-moderate hearing loss, especially the type that makes it harder to hear high-pitched sounds.

In this case, the chief symptom may be difficulty with word understanding, especially in noisy situations. Hearing vs. Understanding When your hearing is tested, the results are when do you take viagra plotted on an audiogram. People with high-frequency hearing loss are said to have a “sloping” hearing loss.

If you have a sloping hearing loss, it means you are able to hear low-pitched sounds (such as thunder), sometimes even as clearly as someone with normal hearing. But, high-pitched sounds (such as children's voices) need to be much when do you take viagra louder before you can hear them. While not always the case, high-frequency hearing loss is often the cause of feeling like you can hear but can’t understand. Did you say parrot or ferret?.

In speech, the vowel sounds (A, E, I, O and when do you take viagra U) are low in pitch while consonant sounds like S, F, Th, Sh, V, K, P and others are high in pitch. Being able to hear vowel sounds is helpful and will alert you that speech is present, but it’s the consonant sounds that give speech meaning and help you distinguish one word from another. Without being able to hear subtle differences between consonants, words like “cat” and “hat,” “parrot” and “ferret” and “show” and “throw” can be hard to differentiate. This is why so many when do you take viagra people with age-related hearing loss or excessive noise exposure have difficulty understanding even when they know sound is present.

Trouble hearing with background noise If you feel like you can hear but notunderstand speech, it may be an earlysign of hearing loss. If you have a high-frequency hearing loss, you may notice problems understanding speech even in a relatively quiet environment, but when background noise is present or several people are talking at once, it can become nearly impossible to follow a conversation. People with hearing loss may begin to avoid lively social situations or public places they once enjoyed because interacting when do you take viagra with others is too difficult. Signs of high-frequency hearing loss When you have a high frequency hearing loss, you may.

struggle to follow conversations (hear but can’t understand). Sturggle to hear people when do you take viagra on the phone. Find it hard to watch TV shows or movies even when you turn the volume up. Mishear female and young children’s voices not enjoy music because it sounds distorted, especially at higher volumes.

Feel like everyone is mumbling more often feel exhausted from listening, known as listening fatigue Family members, friends and work colleagues when do you take viagra can get frustrated and feel you aren’t listening to them when they speak to you. Your spouse may accuse you of having “selective hearing.” You may accuse others of mumbling. Sometimes, you will answer questions inappropriately and miss the punch lines of jokes. Other times, you may resort to smiling and nodding when someone speaks to give the impression you are listening when in fact, you do not understand what was just said (see when do you take viagra this woman's story for how that plays out in real life).

Untreated hearing loss can take a toll on relationships, careers and your daily life. Pass a hearing test but still feel like you can't hear?. If you've taken a hearing test and were told your hearing is fine, don't give up when do you take viagra trying to get answers just yet. Your ears may be fine—but your auditory nerve or your brain may have problems processing sounds or other sensory input.

For example. Hidden hearing loss Hidden hearing loss is defined as hearing loss that's not detectable on standard hearing tests, which zero when do you take viagra in on problems within the ear. Hidden hearing loss is not a problem with the ears—instead, it originates in the brain. Auditory processing disorders (APD) For some people, hearing but not understanding may signal an auditory processing disorder (APD).

This means the nervous system—not the when do you take viagra ears—struggles to make sense of the sounds coming in from the ears. APD is often diagnosed in children, but it also can be diagnosed in adults. Attention deficit disorder (ADD) Attention deficit hyperactivity disorder (ADHD) also can make it hard to understand—in the sense that the brain can't quite keep up with all incoming sensory inputs, including and sometimes especially noise. If you have undiagnosed and untreated ADD, you may pass a hearing test just fine, yet feel like you can't understand people, or struggle to when do you take viagra follow conversations.

In either case, a hearing aid may help a person with APD or ADD focus on the conversation they want to hear most, allowing them to amplify the voice of their preferred speaker (such as a professor). It's worth noting that some people may have ADD or autism and an auditory processing disorder. Don't accept difficult hearing If your hearing test reveals hearing loss, hearing aids can amplify the high pitches you’ve been missing without amplifying when do you take viagra low-pitched sounds. Once you begin wearing hearing aids, you will notice improvement with understanding speech and you may even notice you’re hearing sounds that have long been forgotten.

For instance, some new hearing aid wearers are pleasantly surprised to hear the soft chirping of songbirds for the first time in years. You will once again be able to hear that beeping sound your microwave makes, your car’s turn signal and your when do you take viagra phone ringing. If you can hear, but can’t understand, you’re not alone. This is what hearing care professionals hear almost every day from their patients, and they are highly skilled at getting to the root of the problem, listening to your concerns and finding a solution that meets your needs.

Don’t give up on enjoying conversations when do you take viagra at work, home and play. Find a hearing center near you with our directory, and make the call today.A growing body of research suggests that hearing loss contributes to falls. For older people, falls are a big fear. As we age, our hearing and balance naturally when do you take viagra decline.

More than one in four Americans age 65 or older falls every year, the Centers for Disease Control and Prevention (CDC) reports. Even if you’re not hurt, a tumble is frightening. People tend to retreat when do you take viagra to their chairs, which sets off a bad cycle. You move less, you become weaker, and are more likely to fall again.

Here’s a simple test of your risk. Stand on one leg when do you take viagra. In a small study of women in their 70s, the chance of a hip fracture dropped by 5 percent for every second they could stand on one leg with their eyes open. Hearing and balance.

How they're connected How when do you take viagra does hearing fit in?. What you hear (and don’t hear) directly affects your balance, according to a research overview led by Anat Lubetzky, PhD, assistant professor in the Physical Therapy Department at New York University, with a team at New York Eye and Ear Infirmary. This is especially important if your balance isn’t the best. €œMost of us in the field believe that people with poor balance benefit a lot from auditory cues,” Timothy Hullar, MD, a professor of otolaryngology at Oregon Health and Science University, told me.

Hearing loss increases the risk of falls when do you take viagra I know this from experience. I have hearing loss, and I’ve fallen twice on hikes. I have a bit of reputation with my hiking group. A few when do you take viagra years ago, I tripped on a small stone—and fell over what looked like a cliff.

Once I landed, I recall a flood of relief. As I looked up at the horrified faces of my hiking companions, I saw a large boulder with a sharp edge coming my way. I had dislodged when do you take viagra it. It was worse for them than for me.

I recall thinking, “So that was my life!. Maybe there is a heaven.” The rock landed on my neck and because it wasn’t my time to die, when do you take viagra it only left a scratch. Even mild hearing loss can affect fall risk My hearing loss is mild—but that counts. A 25-decibel hearing loss—equivalent to going from normal to mild hearing loss—triples your chance of falling according to a study of people aged 40 to 69.

That’s when hearing loss often first develops and you’re less likely to when do you take viagra guard against falls. Another study, from a team at the University of Michigan, analyzed data on nearly 115,000 seniors newly diagnosed with hearing loss (but otherwise healthy). It found that 13 percent had an injury in a fall within three years, compared to 7.5 percent of the general population their age. Reasons hearing loss may increase risk of falling when do you take viagra 1.

Hearing taps your brain reserves. If you’re concentrating harder to interpret sound, you may have less mental resource available for balance. "Gait and balance are things most people when do you take viagra take for granted, but they are actually very cognitively demanding," says otologist Frank Lin, MD, PhD, from the Johns Hopkins School of Medicine. 2.

Aging affects both hearing and balance. Age-related hearing loss may be linked to declines in the when do you take viagra vestibular sense, a set of receptors in your inner ear, which comes into play whenever you move your head. It’s also activated by the downward force of gravity, giving you a sense of where you are. Your grounding.

If you’ve ever had an of when do you take viagra the inner ear, you’ll recall you were dizzy. However, you don’t need to be dizzy to have vestibular issues. Some evidence suggests the vestibular sense may begin to decline at about the age of 40. More than a third of all Americans older than 40 are unable to pass a balance test—standing on foam when do you take viagra with their eyes closed—that is linked to a higher risk of falling.

(To test your balance, check out this test.) Loud low-frequency sounds (think pounding drums) may damage the inner ear, over time affecting our balance (and hearing). To be clear, age-related hearing loss and inner ear problems are not the same thing and don't always occur simultaneously. €œMany people with vestibular disorders have excellent hearing and not all when do you take viagra people with hearing loss will have vestibular weakness,” Lubetzky told me. 3.

Sounds help us balance. If you try to balance when do you take viagra on one leg in a yoga class, for example, your teacher will tell you to stare at one spot. Stable sounds may work the same way, Lubetzky explained, as a kind of “auditory anchor.” But you have to hear them. This process may be especially important if you have hearing loss.

For example, when people with when do you take viagra hearing loss hear stable background sounds, their posture improves. Balance arises from the contributions of several senses. Vision, the coordination between our head and our eyes, our muscle and joint coordination—and, possibly, what we hear. 4.

Hearing loss is linked to mood. People may be less alert when caught up in a fog of misery or anxiety. Hearing loss increases the risk of depression. Depression is linked to more falls and those falls tend to deepen depression in another classic bad cycle.

How to prevent falls Keep moving. Walking, balance exercises and resistance exercises to strengthen muscles can keep seniors on their feet. You can build strength and improve your balance in as little as two 15-20 minute sessions a week, Finnish researchers report. Staying active and exercising regularlyhelps keep your sense of balance healthy.

Tai-chi classes, an ancient Chinese practice, are popular among older people. An hour of tai chi from one to three times a week can cut the risk of a bad fall by half, according to a review of 10 randomized controlled trials. The National Council on Aging recommends a program called “Tai Chi for arthritis” for older people. You may feel more comfortable in a tai chi (or any kind of class) if you can easily hear the teacher and converse with other students.

Or consider a water aerobics class. If you do fall, strength-training will make you less to break a bone. Working out with resistance bands or weights or doing resistance exercises makes your bones denser and therefore stronger. Squats, for example, built bone mass in a group of post-menopausal women with deteriorating bones in one study.

When did you have your last eye checkup?. Tint-changing lenses and bifocals are less appropriate for older people and you may need to change prescriptions. Fall proof your home. Have you done a walk-through, making sure that the bottom and top of all stairs are well-lit and the carpeting and railing secure?.

Secure any loose carpeting, especially in hallways. Install grab bars near the toilet and bath or shower. The CDC offers a home assessment checklist. Consider physical therapy, if you or your older loved one have trouble walking or getting up from a chair.

In this case, the chief order viagra online symptom may be difficulty with word understanding, especially in noisy situations. Hearing vs. Understanding When your hearing is tested, the results are plotted on an audiogram.

People with order viagra online high-frequency hearing loss are said to have a “sloping” hearing loss. If you have a sloping hearing loss, it means you are able to hear low-pitched sounds (such as thunder), sometimes even as clearly as someone with normal hearing. But, high-pitched sounds (such as children's voices) need to be much louder before you can hear them.

While not always the case, high-frequency hearing loss is often the cause of order viagra online feeling like you can hear but can’t understand. Did you say parrot or ferret?. In speech, the vowel sounds (A, E, I, O and U) are low in pitch while consonant sounds like S, F, Th, Sh, V, K, P and others are high in pitch.

Being able to hear vowel sounds is helpful and will alert you that speech is present, but it’s the consonant sounds order viagra online that give speech meaning and help you distinguish one word from another. Without being able to hear subtle differences between consonants, words like “cat” and “hat,” “parrot” and “ferret” and “show” and “throw” can be hard to differentiate. This is why so many people with age-related hearing loss or excessive noise exposure have difficulty understanding even when they know sound is present.

Trouble hearing with background noise If you feel like you can hear but notunderstand speech, it may be an earlysign of hearing order viagra online loss. If you have a high-frequency hearing loss, you may notice problems understanding speech even in a relatively quiet environment, but when background noise is present or several people are talking at once, it can become nearly impossible to follow a conversation. People with hearing loss may begin to avoid lively social situations or public places they once enjoyed because interacting with others is too difficult.

Signs of high-frequency hearing loss When you have a high frequency hearing loss, you may order viagra online. struggle to follow conversations (hear but can’t understand). Sturggle to hear people on the phone.

Find it hard to watch TV order viagra online shows or movies even when you turn the volume up. Mishear female and young children’s voices not enjoy music because it sounds distorted, especially at higher volumes. Feel like everyone is mumbling more often feel exhausted from listening, known as listening fatigue Family members, friends and work colleagues can get frustrated and feel you aren’t listening to them when they speak to you.

Your spouse may accuse you of having “selective hearing.” You may order viagra online accuse others of mumbling. Sometimes, you will answer questions inappropriately and miss the punch lines of jokes. Other times, you may resort to smiling and nodding when someone speaks to give the impression you are listening when in fact, you do not understand what was just said (see this woman's story for how that plays out in real life).

Untreated hearing order viagra online loss can take a toll on relationships, careers and your daily life. Pass a hearing test but still feel like you can't hear?. If you've taken a hearing test and were told your hearing is fine, don't give up trying to get answers just yet.

Your ears order viagra online may be fine—but your auditory nerve or your brain may have problems processing sounds or other sensory input. For example. Hidden hearing loss Hidden hearing loss is defined as hearing loss that's not detectable on standard hearing tests, which zero in on problems within the ear.

Hidden hearing loss is order viagra online not a problem with the ears—instead, it originates in the brain. Auditory processing disorders (APD) For some people, hearing but not understanding may signal an auditory processing disorder (APD). This means the nervous system—not the ears—struggles to make sense of the sounds coming in from the ears.

APD is often diagnosed order viagra online in children, but it also can be diagnosed in adults. Attention deficit disorder (ADD) Attention deficit hyperactivity disorder (ADHD) also can make it hard to understand—in the sense that the brain can't quite keep up with all incoming sensory inputs, including and sometimes especially noise. If you have undiagnosed and untreated ADD, you may pass a hearing test just fine, yet feel like you can't understand people, or struggle to follow conversations.

In either case, a hearing aid may help a person with APD or ADD focus on the conversation they want to hear order viagra online most, allowing them to amplify the voice of their preferred speaker (such as a professor). It's worth noting that some people may have ADD or autism and an auditory processing disorder. Don't accept difficult hearing If your hearing test reveals hearing loss, hearing aids can amplify the high pitches you’ve been missing without amplifying low-pitched sounds.

Once you begin wearing hearing aids, you will notice improvement with understanding speech and you may even order viagra online notice you’re hearing sounds that have long been forgotten. For instance, some new hearing aid wearers are pleasantly surprised to hear the soft chirping of songbirds for the first time in years. You will once again be able to hear that beeping sound your microwave makes, your car’s turn signal and your phone ringing.

If you can hear, order viagra online but can’t understand, you’re not alone. This is what hearing care professionals hear almost every day from their patients, and they are highly skilled at getting to the root of the problem, listening to your concerns and finding a solution that meets your needs. Don’t give up on enjoying conversations at work, home and play.

Find a hearing center near you with our directory, and make the call today.A growing body of research suggests that hearing loss order viagra online contributes to falls. For older people, falls are a big fear. As we age, our hearing and balance naturally decline.

More than one in four Americans age 65 or older order viagra online falls every year, the Centers for Disease Control and Prevention (CDC) reports. Even if you’re not hurt, a tumble is frightening. People tend to retreat to their chairs, which sets off a bad cycle.

You move less, order viagra online you become weaker, and are more likely to fall again. Here’s a simple test of your risk. Stand on one leg.

In a small study of women in their 70s, the chance of a hip fracture dropped by 5 percent for every second they could stand on one leg with their eyes open order viagra online. Hearing and balance. How they're connected How does hearing fit in?.

What you hear (and don’t hear) directly affects your balance, according to a research overview led by Anat Lubetzky, order viagra online PhD, assistant professor in the Physical Therapy Department at New York University, with a team at New York Eye and Ear Infirmary. This is especially important if your balance isn’t the best. €œMost of us in the field believe that people with poor balance benefit a lot from auditory cues,” Timothy Hullar, MD, a professor of otolaryngology at Oregon Health and Science University, told me.

Hearing loss increases the order viagra online risk of falls I know this from experience. I have hearing loss, and I’ve fallen twice on hikes. I have a bit of reputation with my hiking group.

A few years ago, I tripped on a small stone—and fell over what looked like a cliff. Once I landed, I recall a order viagra online flood of relief. As I looked up at the horrified faces of my hiking companions, I saw a large boulder with a sharp edge coming my way.

I had dislodged it. It was order viagra online worse for them than for me. I recall thinking, “So that was my life!.

Maybe there is a heaven.” The rock landed on my neck and because it wasn’t my time to die, it only left a scratch. Even mild hearing loss can affect fall risk My hearing loss is mild—but that counts order viagra online. A 25-decibel hearing loss—equivalent to going from normal to mild hearing loss—triples your chance of falling according to a study of people aged 40 to 69.

That’s when hearing loss often first develops and you’re less likely to guard against falls. Another study, from a team at the University of order viagra online Michigan, analyzed data on nearly 115,000 seniors newly diagnosed with hearing loss (but otherwise healthy). It found that 13 percent had an injury in a fall within three years, compared to 7.5 percent of the general population their age.

Reasons hearing loss may increase risk of falling 1. Hearing taps order viagra online your brain reserves. If you’re concentrating harder to interpret sound, you may have less mental resource available for balance.

"Gait and balance are things most people take for granted, but they are actually very cognitively demanding," says otologist Frank Lin, MD, PhD, from the Johns Hopkins School of Medicine. 2. Aging affects both hearing and balance.

Age-related hearing loss may be linked to declines in the vestibular sense, a set of receptors in your inner ear, which comes into play whenever you move your head. It’s also activated by the downward force of gravity, giving you a sense of where you are. Your grounding.

If you’ve ever had an of the inner ear, you’ll recall you were dizzy. However, you don’t need to be dizzy to have vestibular issues. Some evidence suggests the vestibular sense may begin to decline at about the age of 40.

More than a third of all Americans older than 40 are unable to pass a balance test—standing on foam with their eyes closed—that is linked to a higher risk of falling. (To test your balance, check out this test.) Loud low-frequency sounds (think pounding drums) may damage the inner ear, over time affecting our balance (and hearing). To be clear, age-related hearing loss and inner ear problems are not the same thing and don't always occur simultaneously.

€œMany people with vestibular disorders have excellent hearing and not all people with hearing loss will have vestibular weakness,” Lubetzky told me. 3. Sounds help us balance.

If you try to balance on one leg in a yoga class, for example, your teacher will tell you to stare at one spot. Stable sounds may work the same way, Lubetzky explained, as a kind of “auditory anchor.” But you have to hear them. This process may be especially important if you have hearing loss.

For example, when people with hearing loss hear stable background sounds, their posture improves. Balance arises from the contributions of several senses. Vision, the coordination between our head and our eyes, our muscle and joint coordination—and, possibly, what we hear.

4. Hearing loss is linked to mood. People may be less alert when caught up in a fog of misery or anxiety.

Hearing loss increases the risk of depression. Depression is linked to more falls and those falls tend to deepen depression in another classic bad cycle. How to prevent falls Keep moving.

Walking, balance exercises and resistance exercises to strengthen muscles can keep seniors on their feet. You can build strength and improve your balance in as little as two 15-20 minute sessions a week, Finnish researchers report. Staying active and exercising regularlyhelps keep your sense of balance healthy.

Tai-chi classes, an ancient Chinese practice, are popular among older people. An hour of tai chi from one to three times a week can cut the risk of a bad fall by half, according to a review of 10 randomized controlled trials. The National Council on Aging recommends a program called “Tai Chi for arthritis” for older people.

You may feel more comfortable in a tai chi (or any kind of class) if you can easily hear the teacher and converse with other students. Or consider a water aerobics class. If you do fall, strength-training will make you less to break a bone.

Working out with resistance bands or weights or doing resistance exercises makes your bones denser and therefore stronger. Squats, for example, built bone mass in a group of post-menopausal women with deteriorating bones in one study. When did you have your last eye checkup?.

Tint-changing lenses and bifocals are less appropriate for older people and you may need to change prescriptions. Fall proof your home. Have you done a walk-through, making sure that the bottom and top of all stairs are well-lit and the carpeting and railing secure?.

Secure any loose carpeting, especially in hallways. Install grab bars near the toilet and bath or shower. The CDC offers a home assessment checklist.

Consider physical therapy, if you or your older loved one have trouble walking or getting up from a chair. Do hearing aids help prevent falls?. The University of Michigan study found that a first-time hearing aid cut the risk of a fall-related injury by 13 percentage points in the next three years.

Research has not yet supported the idea that people are more stable when wearing hearing aids. But it’s possible that treating “hearing loss (with hearing aids or other implants) will also serve as a type of 'balance aid' like a cane," says otolaryngologist Maura Cosetti, MD, co-author of the New York Eye and Ear Infirmary study.

Women and viagra

V-safe Surveillance women and viagra Can you buy kamagra without a prescription. Local and women and viagra Systemic Reactogenicity in Pregnant Persons Table 1. Table 1. Characteristics of women and viagra Persons Who Identified as Pregnant in the V-safe Surveillance System and Received an mRNA erectile dysfunction treatment.

Table 2. Table 2 women and viagra. Frequency of women and viagra Local and Systemic Reactions Reported on the Day after mRNA erectile dysfunction treatment Vaccination in Pregnant Persons. From December 14, 2020, to February 28, 2021, a total of 35,691 v-safe participants identified as pregnant.

Age distributions were similar among the participants who received the Pfizer–BioNTech treatment and those who received the Moderna treatment, with the majority of the participants being 25 to 34 years of women and viagra age (61.9% and 60.6% for each treatment, respectively) and non-Hispanic White (76.2% and 75.4%, respectively). Most participants (85.8% and 87.4%, respectively) reported being pregnant at the time of vaccination (Table 1). Solicited reports of injection-site pain, fatigue, headache, and myalgia were the most frequent local and systemic reactions women and viagra after either dose for both treatments (Table 2) and were reported more frequently after dose 2 for both treatments. Participant-measured temperature at or above 38°C was reported by less than 1% of the participants on day 1 after dose 1 and by 8.0% after dose 2 for both treatments.

Figure 1 women and viagra. Figure 1 women and viagra. Most Frequent Local and Systemic Reactions Reported in the V-safe Surveillance System on the Day after mRNA erectile dysfunction treatment Vaccination. Shown are solicited reactions in pregnant persons and nonpregnant women 16 to women and viagra 54 years of age who received a messenger RNA (mRNA) erectile dysfunction disease 2019 (erectile dysfunction treatment) treatment — BNT162b2 (Pfizer–BioNTech) or mRNA-1273 (Moderna) — from December 14, 2020, to February 28, 2021.

The percentage of respondents was calculated among those who completed a day 1 survey, with the top events shown of injection-site pain (pain), fatigue or tiredness (fatigue), headache, muscle or body aches (myalgia), chills, and fever or felt feverish (fever).These patterns of reporting, with respect to both most frequently reported solicited reactions and the higher reporting of reactogenicity after dose 2, were similar to patterns observed among nonpregnant women (Figure 1). Small differences in women and viagra reporting frequency between pregnant persons and nonpregnant women were observed for specific reactions (injection-site pain was reported more frequently among pregnant persons, and other systemic reactions were reported more frequently among nonpregnant women), but the overall reactogenicity profile was similar. Pregnant persons did not report having severe reactions more frequently than nonpregnant women, except for nausea and vomiting, which were reported slightly more frequently only after dose 2 (Table S3). V-safe Pregnancy women and viagra Registry.

Pregnancy Outcomes and Neonatal women and viagra Outcomes Table 3. Table 3. Characteristics of V-safe Pregnancy Registry women and viagra Participants. As of March 30, 2021, the v-safe pregnancy registry call center attempted to contact 5230 persons who were vaccinated through February 28, 2021, and who identified during a v-safe survey as pregnant at or shortly after erectile dysfunction treatment vaccination.

Of these, 912 were unreachable, 86 declined to participate, and 274 did not meet inclusion criteria (e.g., were never pregnant, were pregnant but received vaccination more than 30 days before the last menstrual period, or did not provide enough information to women and viagra determine eligibility). The registry enrolled 3958 participants with vaccination from December 14, 2020, to February 28, 2021, of whom 3719 (94.0%) identified as health care personnel. Among enrolled participants, most were 25 to 44 years of age (98.8%), non-Hispanic White (79.0%), and, at the time of interview, did not report a erectile dysfunction treatment women and viagra diagnosis during pregnancy (97.6%) (Table 3). Receipt of a first dose of treatment meeting registry-eligibility criteria was reported by 92 participants women and viagra (2.3%) during the periconception period, by 1132 (28.6%) in the first trimester of pregnancy, by 1714 (43.3%) in the second trimester, and by 1019 (25.7%) in the third trimester (1 participant was missing information to determine the timing of vaccination) (Table 3).

Among 1040 participants (91.9%) who received a treatment in the first trimester and 1700 (99.2%) who received a treatment in the second trimester, initial data had been collected and follow-up scheduled at designated time points approximately 10 to 12 weeks apart. Limited follow-up calls had been made at the time of women and viagra this analysis. Table 4. Table 4 women and viagra.

Pregnancy Loss and Neonatal Outcomes in Published Studies and V-safe Pregnancy Registry Participants. Among 827 participants who had a completed pregnancy, the pregnancy resulted in a live birth in 712 (86.1%), in a spontaneous abortion in 104 (12.6%), in stillbirth women and viagra in 1 (0.1%), and in other outcomes (induced abortion and ectopic pregnancy) in 10 (1.2%). A total of 96 of 104 spontaneous abortions (92.3%) occurred before 13 weeks of gestation (Table 4), and 700 of 712 pregnancies that resulted in women and viagra a live birth (98.3%) were among persons who received their first eligible treatment dose in the third trimester. Adverse outcomes among 724 live-born infants — including 12 sets of multiple gestation — were preterm birth (60 of 636 among those vaccinated before 37 weeks [9.4%]), small size for gestational age (23 of 724 [3.2%]), and major congenital anomalies (16 of 724 [2.2%]).

No neonatal deaths were reported at the women and viagra time of interview. Among the participants with completed pregnancies who reported congenital anomalies, none had received erectile dysfunction treatment in the first trimester or periconception period, and no specific pattern of congenital anomalies was observed. Calculated proportions of pregnancy and neonatal outcomes appeared similar to incidences published in the peer-reviewed literature (Table women and viagra 4). Adverse-Event Findings on the VAERS During the analysis period, the VAERS received and processed 221 reports involving erectile dysfunction treatment vaccination among pregnant persons.

155 (70.1%) involved women and viagra nonpregnancy-specific adverse events, and 66 (29.9%) involved pregnancy- or neonatal-specific adverse events (Table S4). The most frequently reported pregnancy-related adverse events were spontaneous women and viagra abortion (46 cases. 37 in the first trimester, 2 in the second trimester, and 7 in which the trimester was unknown or not reported), followed by stillbirth, premature rupture of membranes, and vaginal bleeding, with 3 reports for each. No congenital women and viagra anomalies were reported to the VAERS, a requirement under the EUAs.1.

Global Initiative on Sharing All Influenza Data (GISAID). HCoV-19 tracking of women and viagra variants. 2021 (https://www.gisaid.org/).Google Scholar2. World Health women and viagra Organization.

WHO erectile dysfunction women and viagra (erectile dysfunction treatment) dashboard. 2021 (https://erectile dysfunction treatment19.who.int/).Google Scholar3. Volz E, Mishra S, Chand M, et women and viagra al. Assessing transmissibility of erectile dysfunction lineage B.1.1.7 in England.

Nature 2021;593:266-269.4 women and viagra. Faria NR, Mellan TA, Whittaker C, et al. Genomics and women and viagra epidemiology of the P.1 erectile dysfunction lineage in Manaus, Brazil. Science 2021 April 14 (Epub ahead women and viagra of print).5.

Wang P, Nair MS, Liu L, et al. Antibody resistance of women and viagra erectile dysfunction variants B.1.351 and B.1.1.7. Nature 2021;593:130-135.6. Madhi SA, women and viagra Baillie V, Cutland Cl, et al.

Safety and efficacy of the ChAdOx1 nCoV-19 (AZD1222) erectile dysfunction treatment against the B.1.351 variant in South Africa. February 12, women and viagra 2021 (https://www.medrxiv.org/content/10.1101/2021.02.10.21251247v1). Preprint.Google Scholar7 women and viagra. Food and Drug Administration.

FDA briefing women and viagra document. Janssen Ad26.COV2.S treatment for the prevention of erectile dysfunction treatment (table 22). treatments and women and viagra Related Biological Products Advisory Committee Meeting, February 26, 2021 (https://www.fda.gov/media/146217/download).Google Scholar8. Novavax erectile dysfunction treatment demonstrates 89.3% efficacy in UK phase 3 trial.

Press release of Novavax, Gaithersburg, MD, January 28, 2021 (https://ir.novavax.com/news-releases/news-release-details/novavax-erectile dysfunction treatment-treatment-demonstrates-893-efficacy-uk-phase-3#:~:text=In%20the%20South%20Africa%20Phase,population%20that%20was%20HIV%2Dnegative).Google women and viagra Scholar9. Dhar MS, Marwal women and viagra R, Radhakrishnan VS, et al. Genomic characterization and epidemiology of an emerging erectile dysfunction variant in Delhi, India. June 3, women and viagra 2021 (https://www.medrxiv.org/content/10.1101/2021.06.02.21258076v1).

Preprint.Google Scholar10. De Serres G, Skowronski DM, women and viagra Wu XW, Ambrose CS. The test-negative design. Validity, accuracy women and viagra and precision of treatment efficacy estimates compared to the gold standard of randomised placebo-controlled clinical trials.

Euro Surveill women and viagra 2013;18:20585-20585.11. Sterne JA, Hernán MA, Reeves BC, et al. ROBINS-I. A tool for assessing risk of bias in non-randomised studies of interventions.

BMJ 2016;355:i4919-i4919.12. Lewnard JA, Tedijanto C, Cowling BJ, Lipsitch M. Measurement of treatment direct effects under the test-negative design. Am J Epidemiol 2018;187:2686-2697.13.

Dean NE, Halloran ME, Longini IM Jr. Temporal confounding in the test-negative design. Am J Epidemiol 2020;189:1402-1407.14. Gilbert P, Self S, Rao M, Naficy A, Clemens J.

Sieve analysis. Methods for assessing from treatment trial data how treatment efficacy varies with genotypic and phenotypic pathogen variation. J Clin Epidemiol 2001;54:68-85.15. International Coalition of Medicines Regulatory Authorities.

ICMRA erectile dysfunction treatment viagra Variants Workshop, February 10, 2021 (http://icmra.info/drupal/en/erectile dysfunction treatment/10february2021).Google Scholar16. Muñoz-Fontela C, Dowling WE, Funnell SGP, et al. Animal models for erectile dysfunction treatment. Nature 2020;586:509-515.17.

Singh JA, Kochhar S, Wolff J, WHO ACT-Accelerator Ethics &. Governance Working Group. Placebo use and unblinding in erectile dysfunction treatment trials. Recommendations of a WHO Expert Working Group.

Nat Med 2021;27:569-570.18. World Health Organization. Emergency use designation of erectile dysfunction treatment candidate treatments. Ethical considerations for current and future erectile dysfunction treatment placebo-controlled treatment trials and trial unblinding.

Policy brief. December 18, 2020 (https://apps.who.int/iris/bitstream/handle/10665/337940/WHO-2019-nCoV-Policy_Brief-EUD_placebo-controlled_treatment_trials-2020.1-eng.pdf).Google Scholar19. Krause P, Fleming TR, Longini I, Henao-Restrepo AM, Peto R. erectile dysfunction treatment trials should seek worthwhile efficacy.

Lancet 2020;396:741-743.20. WHO Ad Hoc Expert Group on the Next Steps for erectile dysfunction treatment Evaluation. Placebo-controlled trials of erectile dysfunction treatments — why we still need them. N Engl J Med 2021;384(2):e2.21.

Collins R, Bowman L, Landray M, Peto R. The magic of randomization versus the myth of real-world evidence. N Engl J Med 2020;382:674-678.22. Fleming TR, Krause PR, Nason M, Longini IM, Henao-Restrepo A-MM.

erectile dysfunction treatment trials. The use of active controls and non-inferiority studies. Clin Trials 2021 February 3 (Epub ahead of print).23. Oxford JS, Sefton A, Jackson R, Innes W, Daniels RS, Johnson NPAS.

World War I may have allowed the emergence of “Spanish” influenza. Lancet Infect Dis 2002;2:111-114.24. Kemp SA, Collier DA, Datir RP, et al. erectile dysfunction evolution during treatment of chronic .

Nature 2021;592:277-282.25. Eaton L. erectile dysfunction treatment. WHO warns against “treatment nationalism” or face further viagra mutations.

BMJ 2021;372:n292-n292.26. Foege WH, Millar JD, Lane JM. Selective epidemiologic control in smallpox eradication. Am J Epidemiol 1971;94:311-315.27.

Henao-Restrepo AM, Longini IM, Egger M, et al. Efficacy and effectiveness of an rVSV-vectored treatment expressing Ebola surface glycoprotein. Interim results from the Guinea ring vaccination cluster-randomised trial. Lancet 2015;386:857-866.28.

Fenner F, Henderson DA, Arita I, Jezek Z, Ladnyi ID. Smallpox and its eradication. Geneva. World Health Organization, 1988 (http://whqlibdoc.who.int/smallpox/9241561106.pdf).Google Scholar29.

Macintyre CR, Costantino V, Trent M. Modelling of erectile dysfunction treatment vaccination strategies and herd immunity, in scenarios of limited and full treatment supply in NSW, Australia. treatment 2021 April 24 (https://doi.org/10.1016/j.treatment.2021.04.042) (Epub ahead of print).Google ScholarTo the Editor. Vaccination against severe acute respiratory syndrome erectile dysfunction 2 (erectile dysfunction) prevents and reduces the severity of erectile dysfunction disease 2019 (erectile dysfunction treatment) in vaccinated persons.1,2 We investigated whether vaccination would reduce transmission in the household setting in the context of postvaccination .

We analyzed data from the Household Transmission Evaluation Dataset (HOSTED), which has information on all laboratory-confirmed cases of erectile dysfunction treatment in England and in which data on all persons sharing the same address are linked.3 We then linked to individual-level data on all erectile dysfunction treatment vaccinations in England (see the Methods section in the Supplementary Appendix, available with the full text of this letter at NEJM.org). We compared the risk of secondary (defined as a positive erectile dysfunction test 2 to 14 days after the positive test for the index case) among unvaccinated household contacts of persons with erectile dysfunction who had received at least one dose of the ChAdOx1 nCoV-19 or BNT162b2 treatment 21 days or more before testing positive with the risk among unvaccinated household contacts of unvaccinated persons with . We fitted logistic-regression models with adjustment for the age and sex of the person with the index case of erectile dysfunction treatment (index patient) and the household contact, geographic region, calendar week of the index case, deprivation (a composite score of socioeconomic and other factors), and household type and size. We also considered the timing of effects among index patients who had been vaccinated at any time up to the date of the positive test.

Table 1. Table 1. Numbers of Household Contacts and Secondary Cases of erectile dysfunction treatment, According to Vaccination Status of Index Patient, and Adjusted Odds Ratios. Between January 4 and February 28, 2021, there were 960,765 household contacts of unvaccinated index patients, and there were 96,898 secondary cases of erectile dysfunction treatment (10.1%).

(Descriptive data regarding the index patients and their household contacts are provided in the Summary Results section.) The numbers of secondary cases according to the vaccination status of the index patient, and the results of logistic-regression models, are shown in Table 1. Overall, the likelihood of household transmission was approximately 40 to 50% lower in households of index patients who had been vaccinated 21 days or more before testing positive than in households of unvaccinated index patients. The findings were similar for the two treatments. Most of the vaccinated index patients in our data set (93%) had received only the first dose of treatment.

Assessment of risks among household contacts according to the timing of vaccination of the index patient showed protective effects when the treatment had been administered at least 14 days before the positive test (Figs. S1 and S2 in the Supplementary Appendix). HOSTED does not include data on symptoms or cycle-threshold values and has information only on diagnosed cases. Among index patients, those who had been vaccinated were likely to be less severely symptomatic2 and might have been less infectious than those who were unvaccinated.4 Studies that involved active follow-up of contacts and that used serologic testing have shown higher rates of household transmission than were observed in our study5.

Bias could occur if case ascertainment differed between household contacts of vaccinated persons and those of unvaccinated persons. Our findings with respect to the timing of vaccination of index patients are consistent with previous data regarding the timing of individual protection after vaccination1 and thus support the overall findings. There may have been misclassification of index and secondary cases, which are determined on the basis of testing dates. However, such misclassification would tend to attenuate the estimated protective effect of vaccination.

Data are needed to inform the reduction in transmissibility of the viagra after the receipt of two treatment doses. It will be important to consider these findings alongside other emerging evidence to inform the benefits of vaccination. Ross J. Harris, Ph.D.Public Health England, London, United Kingdom [email protected]Jennifer A.

Hall, Ph.D.University College London Institute for Women’s Health, London, United KingdomAsad Zaidi, M.Sc.Nick J. Andrews, Ph.D.J. Kevin Dunbar, M.B., Ch.B.Gavin Dabrera, M.B., B.S., F.F.P.H.Public Health England, London, United Kingdom Supported by Public Health England. Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org.

The Household Transmission Evaluation Dataset (HOSTED) surveillance system was reviewed and approved by the Public Health England Research Ethics Governance Group. The data were collected and linked by NHS Digital. The data were processed lawfully under General Data Protection Regulation Article 6(1)e and 9(2)i and shared under Regulation 3 of the Health Service (Control of Patient Information) Regulations 2002.This letter was published on June 23, 2021, at NEJM.org. Drs.

Dunbar and Dabrera contributed equally to this letter. 5 References1. Polack FP, Thomas SJ, Kitchin N, et al. Safety and efficacy of the BNT162b2 mRNA erectile dysfunction treatment.

N Engl J Med 2020;383:2603-2615.2. Bernal JL, Andrews N, Gower C, et al. Early effectiveness of erectile dysfunction treatment vaccination with BNT162b2 mRNA treatment and ChAdOx1 adenoviagra vector treatment on symptomatic disease, hospitalisations and mortality in older adults in England. March 2, 2021 (https://www.medrxiv.org/content/10.1101/2021.03.01.21252652v1).

Preprint.Google Scholar3. Hall JA, Harris RJ, Zaidi A, Woodhall SC, Dabrera G, Dunbar JK. HOSTED — England’s Household Transmission Evaluation Dataset. Preliminary findings from a novel passive surveillance system of erectile dysfunction treatment.

Int J Epidemiol 2021 April 9 (Epub ahead of print).4. Levine-Tiefenbrun M, Yelin I, Katz R, et al. Decreased erectile dysfunction viral load following vaccination. February 8, 2021 (http://medrxiv.org/content/early/2021/02/08/2021.02.06.21251283).

Preprint.Google Scholar5. Public Health England. SARS-CoV2 susceptibility and transmission risk in children. An overview of current evidence from PHE surveillance work, 19 August 2020.

2020 (https://www.gov.uk/government/publications/phe-sars-cov2-susceptibility-and-transmission-risk-in-children-an-overview-of-current-evidence-from-phe-surveillance-work-19-august-2020).Google Scholar10.1056/NEJMc2107717-t1Table 1. Numbers of Household Contacts and Secondary Cases of erectile dysfunction treatment, According to Vaccination Status of Index Patient, and Adjusted Odds Ratios.* Vaccination Status of Index PatientHousehold ContactsSecondary CasesAdjusted Odds Ratio(95% CI)no.no. (%)Not vaccinated before testing positive960,76596,898 (10.1)ReferenceVaccinated with ChAdOx1 nCoV-19 treatment ≥21 days before testing positive3,424196 (5.7)0.52 (0.43–0.62)Vaccinated with BNT162b2 treatment ≥21 days before testing positive5,939371 (6.2)0.54 (0.47–0.62).

V-safe Surveillance order viagra online. Local and Systemic Reactogenicity in Pregnant Persons order viagra online Table 1. Table 1. Characteristics of Persons Who Identified as Pregnant in the V-safe order viagra online Surveillance System and Received an mRNA erectile dysfunction treatment. Table 2.

Table 2 order viagra online. Frequency of Local and Systemic Reactions Reported on the Day after mRNA erectile dysfunction treatment Vaccination in Pregnant order viagra online Persons. From December 14, 2020, to February 28, 2021, a total of 35,691 v-safe participants identified as pregnant. Age distributions were similar among the participants who received the Pfizer–BioNTech treatment and those who received the Moderna treatment, with the majority of the participants being 25 to 34 years of age (61.9% and 60.6% order viagra online for each treatment, respectively) and non-Hispanic White (76.2% and 75.4%, respectively). Most participants (85.8% and 87.4%, respectively) reported being pregnant at the time of vaccination (Table 1).

Solicited reports of injection-site pain, fatigue, order viagra online headache, and myalgia were the most frequent local and systemic reactions after either dose for both treatments (Table 2) and were reported more frequently after dose 2 for both treatments. Participant-measured temperature at or above 38°C was reported by less than 1% of the participants on day 1 after dose 1 and by 8.0% after dose 2 for both treatments. Figure 1 order viagra online. Figure 1 order viagra online. Most Frequent Local and Systemic Reactions Reported in the V-safe Surveillance System on the Day after mRNA erectile dysfunction treatment Vaccination.

Shown are solicited reactions in pregnant persons and order viagra online nonpregnant women 16 to 54 years of age who received a messenger RNA (mRNA) erectile dysfunction disease 2019 (erectile dysfunction treatment) treatment — BNT162b2 (Pfizer–BioNTech) or mRNA-1273 (Moderna) — from December 14, 2020, to February 28, 2021. The percentage of respondents was calculated among those who completed a day 1 survey, with the top events shown of injection-site pain (pain), fatigue or tiredness (fatigue), headache, muscle or body aches (myalgia), chills, and fever or felt feverish (fever).These patterns of reporting, with respect to both most frequently reported solicited reactions and the higher reporting of reactogenicity after dose 2, were similar to patterns observed among nonpregnant women (Figure 1). Small differences in reporting frequency between pregnant persons and nonpregnant women were observed order viagra online for specific reactions (injection-site pain was reported more frequently among pregnant persons, and other systemic reactions were reported more frequently among nonpregnant women), but the overall reactogenicity profile was similar. Pregnant persons did not report having severe reactions more frequently than nonpregnant women, except for nausea and vomiting, which were reported slightly more frequently only after dose 2 (Table S3). V-safe Pregnancy Registry order viagra online.

Pregnancy Outcomes order viagra online and Neonatal Outcomes Table 3. Table 3. Characteristics of V-safe order viagra online Pregnancy Registry Participants. As of March 30, 2021, the v-safe pregnancy registry call center attempted to contact 5230 persons who were vaccinated through February 28, 2021, and who identified during a v-safe survey as pregnant at or shortly after erectile dysfunction treatment vaccination. Of these, 912 were unreachable, 86 declined to order viagra online participate, and 274 did not meet inclusion criteria (e.g., were never pregnant, were pregnant but received vaccination more than 30 days before the last menstrual period, or did not provide enough information to determine eligibility).

The registry enrolled 3958 participants with vaccination from December 14, 2020, to February 28, 2021, of whom 3719 (94.0%) identified as health care personnel. Among enrolled participants, most were 25 to 44 years of age (98.8%), non-Hispanic White (79.0%), and, at the time of interview, did not order viagra online report a erectile dysfunction treatment diagnosis during pregnancy (97.6%) (Table 3). Receipt of a first dose of treatment meeting registry-eligibility criteria was reported by 92 participants (2.3%) during the periconception period, by 1132 (28.6%) in the first trimester of pregnancy, by 1714 (43.3%) in the second trimester, and by order viagra online 1019 (25.7%) in the third trimester (1 participant was missing information to determine the timing of vaccination) (Table 3). Among 1040 participants (91.9%) who received a treatment in the first trimester and 1700 (99.2%) who received a treatment in the second trimester, initial data had been collected and follow-up scheduled at designated time points approximately 10 to 12 weeks apart. Limited follow-up calls had been made at order viagra online the time of this analysis.

Table 4. Table 4 order viagra online. Pregnancy Loss and Neonatal Outcomes in Published Studies and V-safe Pregnancy Registry Participants. Among 827 participants who had a completed pregnancy, the pregnancy resulted in a live birth in 712 (86.1%), in a spontaneous abortion in 104 (12.6%), in stillbirth in 1 (0.1%), and in other outcomes order viagra online (induced abortion and ectopic pregnancy) in 10 (1.2%). A total of 96 of 104 spontaneous abortions (92.3%) occurred before 13 weeks of gestation (Table 4), and 700 of 712 pregnancies that resulted in a live birth (98.3%) order viagra online were among persons who received their first eligible treatment dose in the third trimester.

Adverse outcomes among 724 live-born infants — including 12 sets of multiple gestation — were preterm birth (60 of 636 among those vaccinated before 37 weeks [9.4%]), small size for gestational age (23 of 724 [3.2%]), and major congenital anomalies (16 of 724 [2.2%]). No neonatal deaths were reported at the time of order viagra online interview. Among the participants with completed pregnancies who reported congenital anomalies, none had received erectile dysfunction treatment in the first trimester or periconception period, and no specific pattern of congenital anomalies was observed. Calculated proportions of pregnancy and neonatal outcomes appeared similar to incidences published in the order viagra online peer-reviewed literature (Table 4). Adverse-Event Findings on the VAERS During the analysis period, the VAERS received and processed 221 reports involving erectile dysfunction treatment vaccination among pregnant persons.

155 (70.1%) involved nonpregnancy-specific adverse events, and 66 (29.9%) order viagra online involved pregnancy- or neonatal-specific adverse events (Table S4). The most frequently reported pregnancy-related order viagra online adverse events were spontaneous abortion (46 cases. 37 in the first trimester, 2 in the second trimester, and 7 in which the trimester was unknown or not reported), followed by stillbirth, premature rupture of membranes, and vaginal bleeding, with 3 reports for each. No congenital anomalies were reported to the VAERS, order viagra online a requirement under the EUAs.1. Global Initiative on Sharing All Influenza Data (GISAID).

HCoV-19 tracking order viagra online of variants. 2021 (https://www.gisaid.org/).Google Scholar2. World Health Organization order viagra online. WHO erectile dysfunction order viagra online (erectile dysfunction treatment) dashboard. 2021 (https://erectile dysfunction treatment19.who.int/).Google Scholar3.

Volz E, order viagra online Mishra S, Chand M, et al. Assessing transmissibility of erectile dysfunction lineage B.1.1.7 in England. Nature 2021;593:266-269.4 order viagra online. Faria NR, Mellan TA, Whittaker C, et al. Genomics and order viagra online epidemiology of the P.1 erectile dysfunction lineage in Manaus, Brazil.

Science 2021 April 14 (Epub ahead of order viagra online print).5. Wang P, Nair MS, Liu L, et al. Antibody resistance of erectile dysfunction variants order viagra online B.1.351 and B.1.1.7. Nature 2021;593:130-135.6. Madhi SA, Baillie V, Cutland Cl, et al order viagra online.

Safety and efficacy of the ChAdOx1 nCoV-19 (AZD1222) erectile dysfunction treatment against the B.1.351 variant in South Africa. February 12, 2021 order viagra online (https://www.medrxiv.org/content/10.1101/2021.02.10.21251247v1). Preprint.Google Scholar7 order viagra online. Food and Drug Administration. FDA briefing document order viagra online.

Janssen Ad26.COV2.S treatment for the prevention of erectile dysfunction treatment (table 22). treatments and Related Biological Products Advisory Committee Meeting, February 26, 2021 (https://www.fda.gov/media/146217/download).Google Scholar8 order viagra online. Novavax erectile dysfunction treatment demonstrates 89.3% efficacy in UK phase 3 trial. Press release of Novavax, Gaithersburg, MD, January order viagra online 28, 2021 (https://ir.novavax.com/news-releases/news-release-details/novavax-erectile dysfunction treatment-treatment-demonstrates-893-efficacy-uk-phase-3#:~:text=In%20the%20South%20Africa%20Phase,population%20that%20was%20HIV%2Dnegative).Google Scholar9. Dhar MS, Marwal R, Radhakrishnan VS, et al order viagra online.

Genomic characterization and epidemiology of an emerging erectile dysfunction variant in Delhi, India. June 3, order viagra online 2021 (https://www.medrxiv.org/content/10.1101/2021.06.02.21258076v1). Preprint.Google Scholar10. De Serres G, Skowronski order viagra online DM, Wu XW, Ambrose CS. The test-negative design.

Validity, accuracy and precision of treatment efficacy estimates compared to the order viagra online gold standard of randomised placebo-controlled clinical trials. Euro Surveill order viagra online 2013;18:20585-20585.11. Sterne JA, Hernán MA, Reeves BC, et al. ROBINS-I. A tool for assessing risk of bias in non-randomised studies of interventions.

BMJ 2016;355:i4919-i4919.12. Lewnard JA, Tedijanto C, Cowling BJ, Lipsitch M. Measurement of treatment direct effects under the test-negative design. Am J Epidemiol 2018;187:2686-2697.13. Dean NE, Halloran ME, Longini IM Jr.

Temporal confounding in the test-negative design. Am J Epidemiol 2020;189:1402-1407.14. Gilbert P, Self S, Rao M, Naficy A, Clemens J. Sieve analysis. Methods for assessing from treatment trial data how treatment efficacy varies with genotypic and phenotypic pathogen variation.

J Clin Epidemiol 2001;54:68-85.15. International Coalition of Medicines Regulatory Authorities. ICMRA erectile dysfunction treatment viagra Variants Workshop, February 10, 2021 (http://icmra.info/drupal/en/erectile dysfunction treatment/10february2021).Google Scholar16. Muñoz-Fontela C, Dowling WE, Funnell SGP, et al. Animal models for erectile dysfunction treatment.

Nature 2020;586:509-515.17. Singh JA, Kochhar S, Wolff J, WHO ACT-Accelerator Ethics &. Governance Working Group. Placebo use and unblinding in erectile dysfunction treatment trials. Recommendations of a WHO Expert Working Group.

Nat Med 2021;27:569-570.18. World Health Organization. Emergency use designation of erectile dysfunction treatment candidate treatments. Ethical considerations for current and future erectile dysfunction treatment placebo-controlled treatment trials and trial unblinding. Policy brief.

December 18, 2020 (https://apps.who.int/iris/bitstream/handle/10665/337940/WHO-2019-nCoV-Policy_Brief-EUD_placebo-controlled_treatment_trials-2020.1-eng.pdf).Google Scholar19. Krause P, Fleming TR, Longini I, Henao-Restrepo AM, Peto R. erectile dysfunction treatment trials should seek worthwhile efficacy. Lancet 2020;396:741-743.20. WHO Ad Hoc Expert Group on the Next Steps for erectile dysfunction treatment Evaluation.

Placebo-controlled trials of erectile dysfunction treatments — why we still need them. N Engl J Med 2021;384(2):e2.21. Collins R, Bowman L, Landray M, Peto R. The magic of randomization versus the myth of real-world evidence. N Engl J Med 2020;382:674-678.22.

Fleming TR, Krause PR, Nason M, Longini IM, Henao-Restrepo A-MM. erectile dysfunction treatment trials. The use of active controls and non-inferiority studies. Clin Trials 2021 February 3 (Epub ahead of print).23. Oxford JS, Sefton A, Jackson R, Innes W, Daniels RS, Johnson NPAS.

World War I may have allowed the emergence of “Spanish” influenza. Lancet Infect Dis 2002;2:111-114.24. Kemp SA, Collier DA, Datir RP, et al. erectile dysfunction evolution during treatment of chronic . Nature 2021;592:277-282.25.

Eaton L. erectile dysfunction treatment. WHO warns against “treatment nationalism” or face further viagra mutations. BMJ 2021;372:n292-n292.26. Foege WH, Millar JD, Lane JM.

Selective epidemiologic control in smallpox eradication. Am J Epidemiol 1971;94:311-315.27. Henao-Restrepo AM, Longini IM, Egger M, et al. Efficacy and effectiveness of an rVSV-vectored treatment expressing Ebola surface glycoprotein. Interim results from the Guinea ring vaccination cluster-randomised trial.

Lancet 2015;386:857-866.28. Fenner F, Henderson DA, Arita I, Jezek Z, Ladnyi ID. Smallpox and its eradication. Geneva. World Health Organization, 1988 (http://whqlibdoc.who.int/smallpox/9241561106.pdf).Google Scholar29.

Macintyre CR, Costantino V, Trent M. Modelling of erectile dysfunction treatment vaccination strategies and herd immunity, in scenarios of limited and full treatment supply in NSW, Australia. treatment 2021 April 24 (https://doi.org/10.1016/j.treatment.2021.04.042) (Epub ahead of print).Google ScholarTo the Editor. Vaccination against severe acute respiratory syndrome erectile dysfunction 2 (erectile dysfunction) prevents and reduces the severity of erectile dysfunction disease 2019 (erectile dysfunction treatment) in vaccinated persons.1,2 We investigated whether vaccination would reduce transmission in the household setting in the context of postvaccination . We analyzed data from the Household Transmission Evaluation Dataset (HOSTED), which has information on all laboratory-confirmed cases of erectile dysfunction treatment in England and in which data on all persons sharing the same address are linked.3 We then linked to individual-level data on all erectile dysfunction treatment vaccinations in England (see the Methods section in the Supplementary Appendix, available with the full text of this letter at NEJM.org).

We compared the risk of secondary (defined as a positive erectile dysfunction test 2 to 14 days after the positive test for the index case) among unvaccinated household contacts of persons with erectile dysfunction who had received at least one dose of the ChAdOx1 nCoV-19 or BNT162b2 treatment 21 days or more before testing positive with the risk among unvaccinated household contacts of unvaccinated persons with . We fitted logistic-regression models with adjustment for the age and sex of the person with the index case of erectile dysfunction treatment (index patient) and the household contact, geographic region, calendar week of the index case, deprivation (a composite score of socioeconomic and other factors), and household type and size. We also considered the timing of effects among index patients who had been vaccinated at any time up to the date of the positive test. Table 1. Table 1.

Numbers of Household Contacts and Secondary Cases of erectile dysfunction treatment, According to Vaccination Status of Index Patient, and Adjusted Odds Ratios. Between January 4 and February 28, 2021, there were 960,765 household contacts of unvaccinated index patients, and there were 96,898 secondary cases of erectile dysfunction treatment (10.1%). (Descriptive data regarding the index patients and their household contacts are provided in the Summary Results section.) The numbers of secondary cases according to the vaccination status of the index patient, and the results of logistic-regression models, are shown in Table 1. Overall, the likelihood of household transmission was approximately 40 to 50% lower in households of index patients who had been vaccinated 21 days or more before testing positive than in households of unvaccinated index patients. The findings were similar for the two treatments.

Most of the vaccinated index patients in our data set (93%) had received only the first dose of treatment. Assessment of risks among household contacts according to the timing of vaccination of the index patient showed protective effects when the treatment had been administered at least 14 days before the positive test (Figs. S1 and S2 in the Supplementary Appendix). HOSTED does not include data on symptoms or cycle-threshold values and has information only on diagnosed cases. Among index patients, those who had been vaccinated were likely to be less severely symptomatic2 and might have been less infectious than those who were unvaccinated.4 Studies that involved active follow-up of contacts and that used serologic testing have shown higher rates of household transmission than were observed in our study5.

Bias could occur if case ascertainment differed between household contacts of vaccinated persons and those of unvaccinated persons. Our findings with respect to the timing of vaccination of index patients are consistent with previous data regarding the timing of individual protection after vaccination1 and thus support the overall findings. There may have been misclassification of index and secondary cases, which are determined on the basis of testing dates. However, such misclassification would tend to attenuate the estimated protective effect of vaccination. Data are needed to inform the reduction in transmissibility of the viagra after the receipt of two treatment doses.

It will be important to consider these findings alongside other emerging evidence to inform the benefits of vaccination. Ross J. Harris, Ph.D.Public Health England, London, United Kingdom [email protected]Jennifer A. Hall, Ph.D.University College London Institute for Women’s Health, London, United KingdomAsad Zaidi, M.Sc.Nick J. Andrews, Ph.D.J.

Kevin Dunbar, M.B., Ch.B.Gavin Dabrera, M.B., B.S., F.F.P.H.Public Health England, London, United Kingdom Supported by Public Health England. Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org. The Household Transmission Evaluation Dataset (HOSTED) surveillance system was reviewed and approved by the Public Health England Research Ethics Governance Group. The data were collected and linked by NHS Digital. The data were processed lawfully under General Data Protection Regulation Article 6(1)e and 9(2)i and shared under Regulation 3 of the Health Service (Control of Patient Information) Regulations 2002.This letter was published on June 23, 2021, at NEJM.org.

Drs. Dunbar and Dabrera contributed equally to this letter. 5 References1. Polack FP, Thomas SJ, Kitchin N, et al. Safety and efficacy of the BNT162b2 mRNA erectile dysfunction treatment.

N Engl J Med 2020;383:2603-2615.2. Bernal JL, Andrews N, Gower C, et al. Early effectiveness of erectile dysfunction treatment vaccination with BNT162b2 mRNA treatment and ChAdOx1 adenoviagra vector treatment on symptomatic disease, hospitalisations and mortality in older adults in England. March 2, 2021 (https://www.medrxiv.org/content/10.1101/2021.03.01.21252652v1). Preprint.Google Scholar3.

Hall JA, Harris RJ, Zaidi A, Woodhall SC, Dabrera G, Dunbar JK. HOSTED — England’s Household Transmission Evaluation Dataset. Preliminary findings from a novel passive surveillance system of erectile dysfunction treatment. Int J Epidemiol 2021 April 9 (Epub ahead of print).4. Levine-Tiefenbrun M, Yelin I, Katz R, et al.

Decreased erectile dysfunction viral load following vaccination. February 8, 2021 (http://medrxiv.org/content/early/2021/02/08/2021.02.06.21251283). Preprint.Google Scholar5. Public Health England. SARS-CoV2 susceptibility and transmission risk in children.

An overview of current evidence from PHE surveillance work, 19 August 2020. 2020 (https://www.gov.uk/government/publications/phe-sars-cov2-susceptibility-and-transmission-risk-in-children-an-overview-of-current-evidence-from-phe-surveillance-work-19-august-2020).Google Scholar10.1056/NEJMc2107717-t1Table 1. Numbers of Household Contacts and Secondary Cases of erectile dysfunction treatment, According to Vaccination Status of Index Patient, and Adjusted Odds Ratios.* Vaccination Status of Index PatientHousehold ContactsSecondary CasesAdjusted Odds Ratio(95% CI)no.no. (%)Not vaccinated before testing positive960,76596,898 (10.1)ReferenceVaccinated with ChAdOx1 nCoV-19 treatment ≥21 days before testing positive3,424196 (5.7)0.52 (0.43–0.62)Vaccinated with BNT162b2 treatment ≥21 days before testing positive5,939371 (6.2)0.54 (0.47–0.62).

Viagra gif

The emergency alarm went http://www.ec-saint-jean-strasbourg.ac-strasbourg.fr/wp/?p=4871 off just before sundown viagra gif. For the oil-field medics of Loving County, that sound means your world is about to get a shot of adrenaline. One minute you might be lounging on the couch with the guys on call, watching Lethal Weapon 4, nursing a post-brisket food baby, and the viagra gif next you’re in the back of an ambulance, watching a ribbon of West Texas highway unspool behind you, cursing yourself for not using the restroom before hustling out of the clinic. Which is exactly where I found myself one stormy Friday evening last July.An emergency medical technician named Justin Esthay was behind the wheel. Beside him, Anthony Luk, a paramedic trained for more-complex procedures, radioed to dispatch for directions.

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

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

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

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

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

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

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

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

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

The hard living, the time away from family, the macho culture, the insider lingo, the physicality of the job. Those who work in emergency medical services viagra gif are essentially the roughnecks of health care. Although their job requires a high level of skill and knowledge, compared with other health-care gigs it is undeniably blue-collar and often treated as less than. But at least roughnecks are paid well, with many banking at least $75,000 a year. The same can’t be said of EMS workers, who on average make less than half viagra gif that.

And yet here they were, EMTs and medics, proving their guts and grit in the heart of nowhere, their work known only to each other—and the people they save.The OHSI clinic in Loving County in July 2021.Photograph by Jeff WilsonI found OHSI by accident. Though I’d grown up in the oil patch, in viagra gif the small town of Andrews, about eighty miles northeast of Mentone, I’d never heard of an outpost of oil-field medics. Most folks haven’t. OHSI doesn’t advertise, and it’s not the kind of outfit EMS workers flock to.But in October 2020, I was reporting a story on the last county in the U.S. Without a single recorded erectile dysfunction treatment case, which happened to viagra gif be Loving.

A cashier at the Horseshoe, the only convenience store (or any kind of store) in the county, had mentioned a small clinic on the outskirts of Mentone where oil-field workers and locals could get tested for the viagra. When I drove out there, Cary Skelton, a fifty-year-old paramedic and viagra gif OHSI’s West Texas program manager, was outside. He had on his typical uniform. A T-shirt, ball cap, cargo pants, and square-toed cowboy boots. He was viagra gif chain-smoking Kool menthols next to a parked ambulance.

A gray cat named Tigger was curled up on the vehicle’s hood, and a shotgun named Bubba rested against the front bumper. Cary nodded at the gun. €œCoyotes been getting too close for ol’ Tigger here.”We talked as the sun went down—about the viagra, about how the viagra gif clinic had been erectile dysfunction treatment-testing scores of workers every day, about the region. Loving County, Cary told me, is a tough sell. The 677-square-mile county is best known for being the least populous in the entire United States viagra gif.

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

This part of West Texas is his home. As a boy, he worked cattle on ranches, including his grandfather’s, across the region. And today you’d be hard-pressed to find a more viagra gif entertaining source of regional history than Cary Skelton. When he tells stories, his posture shifts and his voice changes, depending on the character he’s enacting. He affects a lisp to imitate the late viagra gif Newt Keen, a droll cafe owner in Mentone who lost a few front teeth after he took a bullet to the face.

And Cary’s eyes narrow when he takes on the role of Sheriff Elgin “Punk” Jones, the top lawman in the county from his first term, in 1965, till he hung up the badge in 1992.Cary lights up when he talks about growing up out here. Like the time he was nine or ten, when he and a buddy decided to drive a go-kart the thirty miles from the Red Bluff Reservoir to Mentone in the dead of night. This was in the early eighties, some three decades before the shale boom brought viagra gif heavy traffic and thousands of itinerant workers to the area. The roads were mostly empty then, but they could still be dangerous. Mexican cartels used them as improvised runways on which to land small aircraft loaded with cocaine or other illicit drugs.

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

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

He strolled up viagra gif to the go-kart.“What are you boys doing?. € he asked. €œWell, we’re viagra gif driving around,” they told him. Punk shook his head. €œI don’t know if riding around on a go-kart in this part of the country is very safe.” He loaded the boys and their go-kart into his truck and drove them back to their homes.

Cary was viagra gif sure he’d get a whupping for the stunt, but Punk never said a word about their adventure, not even to Cary’s dad.There have been a few changes since Cary was a kid. Thanks in part to the same Punk Jones, who drilled some of the county’s first non-brackish wells, you can now turn on a tap anywhere in town and get drinkable water. Still, potable water isn’t much of a selling point in 2022, and besides the lack of modern conveniences, the OHSI staff also faces all the dangers and discomforts of the oil field. When they’re out on viagra gif a call, they might encounter poisonous gases, homicidal drivers, and high-pressure wells that sometimes blow up. There are also the long hours and weeks away from home.

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

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

We could lose someone.” Cary snubbed out his cigarette viagra gif. €œGive me another sweet,” he told one of the EMTs who’d joined us outside. Another Kool was produced. Cary lit it viagra gif. It was dark now.

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

€œEMS is the bastard stepchild of the planet,” Cary told me.Today, most of us take for granted that we can pick up the phone, dial 911, and someone will be at our side in minutes, capable of keeping us alive during the brief trip to a hospital awaiting with teams of doctors. But this convenience is a relatively viagra gif new development. Texas’s Department of State Health Services didn’t include an EMS division until 1973.In Texas and most other states, EMS, unlike police and fire departments, is not considered an “essential service.” Instead, EMS workers are dispatched through a haphazard patchwork of municipal and county operations, hospital-affiliated services, nonprofit and volunteer associations, and private enterprise. That’s where OHSI comes viagra gif in. Dustin Hoffpauir outside the OHSI clinic.Photograph by Jeff WilsonThe nutty idea of opening a for-profit clinic in the country’s least populated county was Dustin Hoffpauir’s.

I met Dustin during my first week at the clinic. He arrived from Houston in his King Ranch Ford bearing a load of boiled crawfish, a nod viagra gif to his Cajun roots. Dustin had come to EMS through the safety departments of several oil and gas companies. After graduating from the University of Louisiana at Lafayette in 1998, he worked as a fire watchman on offshore rigs in the Gulf of Mexico.He eventually migrated to dry land and a small Lafayette-based safety company, doing contract work for bigger oil and gas companies. One of those was Anadarko viagra gif Petroleum, which hired Dustin in 2005.

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

It took more than an hour and half, an eternity to Dustin. €œAnd that’s when I really started thinking about the challenges associated with providing medical care out here, and the lack of resources,” he said viagra gif. €œThe same thing kept on reoccurring. Delayed response. Unfortunately, some lives were viagra gif lost.”“The same thing kept on reoccurring.

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

€œMy God, people,” he said, his voice choked, “what have we come to!. €Dustin and his wife, Mandy Hoffpauir, a registered nurse, made a plan. Dustin recalled his time working in viagra gif the Gulf. The challenges of providing medical care on offshore oil rigs mirrored those in the Permian Basin. He figured viagra gif he could replicate the model he’d learned out there.First, he tackled the economics.

Most ambulance companies don’t get paid unless they transport a patient. Out in a rural area like Loving County, the relatively low volume of transports, compared with the number carried out by city services, can make it hard for a company to keep the lights on between calls. If a patient doesn’t have insurance and is deemed indigent, the viagra gif ambulance company often eats the bill. But Dustin knew that the oil and gas industry was desperate to find solutions to the problems it had brought to the region. The traffic accidents, the thousands of itinerant workers needing basic care for chronic conditions or medical emergencies, and the work-related incidents (well blowouts, rig injuries, flash fires, heat exhaustion, and so on) that are often more serious than those that occur in other viagra gif industries.

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

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

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

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

This is my granddad’s stomping grounds, and I cannot mess this viagra gif up.” Cary understood Loving County. €œOil-field workers and rodeo cowboys, they don’t go the doctor unless something is sticking out,” he said. €œPeople don’t even take their prescriptions out here because it’s seen as a sign of weakness.” Cary’s dad is like that viagra gif. He once showed up at the clinic with a busted head. He refused to get out of his truck, so one of the medics had to staple the wound through the window.

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

But for the EMTs and medics who make their living and spend more than half the year at the clinic, their viagra gif sacrifices add up. Dominic Sanchez, Steven Hutson, and Anthony Luk play poker in the clinic while waiting for a call.Photograph by Jeff WilsonMy first hitch, which would last two weeks, began in late June. On a Tuesday morning, I arrived at the clinic, a metal structure the same beige as desert camouflage. The clinic abuts a viagra gif rodeo arena just to the east. Otherwise there is little but sun-scorched pastures of mesquite and greasewood, the occasional pump jack, and a few rusted skeletons of old trucks and tractors.

As Cary and viagra gif I walked up the entrance ramp, Tigger and her kittens scattered from a heaping plate of food. In front of the door was a bloody rabbit’s foot. €œThat was probably Tigger,” Cary said, catching my stare as he swung open the door. €œNot the first time she’s viagra gif gotten a cottontail. And, hey, that’s good luck!.

€Touring the clinic didn’t take long. The building viagra gif is divided in half. One side includes an examination room, X-ray room, and dispatch office. The other side serves as the viagra gif living quarters for the staff. A cramped kitchen.

A common room with an overstuffed brown sofa, an easy chair, and a TV on the wall. A bathroom viagra gif. And two bedrooms, where the crew members sleep two to a room. There are plain white walls and scuffed linoleum floors viagra gif throughout. The vibe is a mix of college dorm and military medical outpost.

As the fresh crew trickled in, the EMTs and medics who’d been on duty headed home, to El Paso, Lubbock, and as far away as Louisiana. One by one, I met the guys I’d viagra gif be shadowing for the next two weeks. First was Steven Hutson, an EMT from the flyspeck of Kirvin, a town eighty miles southeast of Dallas. The youngest of the bunch at 25, he had a hefty frame and Bambi eyes that had earned him viagra gif the nickname Baby Huey. Next was Dominic Sanchez, a 26-year-old Albuquerque transplant with a boy-band smile and muscles on his earlobes.

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

The next, the team might be slammed from morning to night with workers dropping in for erectile dysfunction treatment screenings, for drug and alcohol tests, or with physical maladies. A welder came in with a metal viagra gif shaving lodged in his eye. Another patient arrived needing an X-ray after falling from a catwalk between two tall tanks. Several workers, their accents suggestive of places a long way from Texas, came in suffering from dehydration. And one evening a man hobbled in with severe viagra gif burns on his leg.

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

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

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

€œThese are perishable skills,” he explained. Because OHSI doesn’t run calls every day like city ambulance services do, “you have to be studying. You have to be practicing viagra gif. You have to be putting your hands on equipment.” But for all the grief he gives them, Cary is fiercely loyal to and proud of his crew. €œA lot of people viagra gif think that because we’re out here in Hickville, we’re going to deliver some type of substandard medicine.

No way. I would put my guys up with anybody out there.” When that emergency phone rings—and eventually it does—life-and-death situations await the OHSI crews. Their memories are full of the kind of gore that most viagra gif of us see only in horror films. A road-rage victim shot point blank in the belly, guts slopping out like uncooked sausage. An F-150 crushed like a Coke can under an eighteen-wheeler.

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

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

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

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

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

In EMS, picking up overtime is viagra gif where we make our money. It’s also a big reason why there’s a lot of burnouts.” The annual turnover rate for EMS workers is about 30 percent.“You’re constantly working,” Anthony continued. €œIt’s hard on marital life, social life, all life outside of work. Relationships are hard to sustain because, like, for us here, viagra gif you’re gone for two weeks. It’s terrible to say, but out of the guys who’ve had partners or were married, a good forty to fifty percent are no longer.”Anthony’s fiancé, William, is a composer in Lubbock.

I met him viagra gif briefly when he made the three-hour one-way trip to deliver a set of keys Anthony had accidentally left at their apartment. It was the only time William had ever set foot in the clinic where Anthony spends more than half the year.“When you go home, you don’t want to do anything,” Anthony said, speaking generally. €œYou just want to rest, and your partner doesn’t always understand. Plus, you viagra gif don’t want to tell them everything because you don’t want to relive it. Like, if you had a bad day at work where you had to do CPR on a kid who drowned.

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

Cary chalks this up in part to EMS culture, in which the ability to put on a tough front and “silently suffer” is highly valued. Others don’t seek counseling because they can’t afford it. (A couple of the OHSI workers I spoke with said they’d opted out of the company’s plan because they felt the premiums were too high.) This means EMS workers find other ways to deal with their trauma. €œI know a lot of EMS guys who have pretty bad vices,” Anthony said. €œThat’s the way that they wind down, whether it be a massive amount of alcohol or a massive amount of partying.”According to one study, EMTs and medics are about ten times more likely to have suicidal thoughts than workers in other professions.While the crews are on call at OHSI, they temper certain bad habits they might indulge at home.

A couple of them funneled their energy into working out at Mentone’s only gym, a tiny collection of weights set up inside a shipping container. Some dipped tobacco, smoked, and guzzled an endless stream of energy drinks to ward off stress, boredom, and weariness. But without exception, all the guys leaned heavily into a dark humor specific to their profession.That night in Culberson County, for instance, as we stood around waiting for the drone to finish its search for any lingering hot spots from the fire, Justin told a story from a few years back. He’d just finished an ambulance shift and was walking out to the parking lot to head home. €œThis car comes hauling ass in, pulls right up, and almost hits me.

The window rolls down, and the driver leans over. €˜This guy just OD’d on heroin.’ ” The man in the passenger seat was barely breathing. Justin got him out of the car. €œI start doing CPR on this dude. I’m dripping sweat, absolutely drenched because it’s so hot.” Justin managed to get the guy to the hospital alive.

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

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

A few bad wrecks and a fire that had burned a crew of three. Plus, a surge in erectile dysfunction treatment cases had forced the crews to work even longer hours, as they had to transfer patients to hospitals farther and farther away. There had been some personnel changes too. Dominic Sanchez had left OHSI for a medical gig nearer to his home in Killeen. And Steven Hutson had found work with an ambulance service close to his wife and family in Kirvin.

Anthony Luk is still at OHSI but has been preparing to apply to medical school. He hopes to start later this year. Cary hates to lose good workers, but he doesn’t blame anyone for leaving.Sometimes when we spoke on the phone, Cary sounded bone tired. Finding replacements hadn’t been easy, and the crews were stretched thin. At times he felt as if OHSI were barely hanging on.

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

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

On that cold Saturday morning, Cary had been on his way back to the clinic from Kermit when he received a panicked call from Punk’s family. €œHe’s not breathing well. He’s doing bad.”Cary and the family started making calls. They finally managed to find a hospital bed for Punk in Amarillo, about three hundred miles away. Cary sent an ambulance to Punk’s house and summoned a plane to Winkler County Airport, outside Kermit, to transport Punk the rest of the way.

Meanwhile, Cary had been speeding toward Punk’s place. He arrived just before the ambulance and went inside. Punk’s daughter, Mozelle Carr, was there with him. So was Mary Belle. She told Cary, “I want you to do everything you can.” “I will,” he promised.The ambulance dock at the OHSI clinic in Loving County in July 2021.Photograph by Jeff WilsonHe and the OHSI medics got Punk on the stretcher and into the ambulance.

They were flying down the road, hooking him up to monitors, starting an IV, when Punk squeezed Cary’s hand. He wagged a finger up at Cary. Then he pointed down. Punk Jones had made it clear. He wanted to die in Loving County.Cary knew Punk wouldn’t make it to Amarillo.

He told the EMT driving the ambulance to pull over in the parking lot of the county courthouse. There, Cary did as he promised. He and his fellow medics tried everything they could to save Punk. They intubated him and gave him fluids through an IV. When Punk’s heart stopped, Cary did compressions on his chest until it started thumping again.

Eight times he was able to get the heart rate monitor to register a rhythm.Cary phoned Punk’s family. The Jones clan trickled into the parking lot, congregating at the ambulance. Cary held Mozelle’s hand, and they cried together. Punk’s heart stopped again. This time, Cary could not bring him back.At OHSI, Cary and his crews fight every day to keep folks from dying in Loving County.

Of course, they can’t save everybody. And being able to provide dignity at death, to allow someone to die in the place they call home, can be just as important. It’s these moments, however weighted with tragedy, that keep Cary working overtime in Loving County, making plans to ensure that basic health care is here to stay—no matter what happens at OHSI or to the fortunes of the oil patch.A week later, Punk was laid to rest at his ranch. During the funeral, Cary offered his condolences to the Jones family. Tom, one of Punk’s sons, told him, “I’m glad you were with him, Cary.”Cary nodded.

€œIt was an honor.” This article originally appeared in the January 2022 issue of Texas Monthly with the headline “There Will Be Blood.” Subscribe today..

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

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

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

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

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

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

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

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

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

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

The hard living, the time away from family, the macho culture, the insider lingo, the physicality of the job. Those who work in emergency medical services order viagra online are essentially the roughnecks of health care. Although their job requires a high level of skill and knowledge, compared with other health-care gigs it is undeniably blue-collar and often treated as less than. But at least roughnecks are paid well, with many banking at least $75,000 a year. The same can’t be order viagra online said of EMS workers, who on average make less than half that.

And yet here they were, EMTs and medics, proving their guts and grit in the heart of nowhere, their work known only to each other—and the people they save.The OHSI clinic in Loving County in July 2021.Photograph by Jeff WilsonI found OHSI by accident. Though I’d grown order viagra online up in the oil patch, in the small town of Andrews, about eighty miles northeast of Mentone, I’d never heard of an outpost of oil-field medics. Most folks haven’t. OHSI doesn’t advertise, and it’s not the kind of outfit EMS workers flock to.But in October 2020, I was reporting a story on the last county in the U.S. Without a single recorded erectile dysfunction treatment case, which happened order viagra online to be Loving.

A cashier at the Horseshoe, the only convenience store (or any kind of store) in the county, had mentioned a small clinic on the outskirts of Mentone where oil-field workers and locals could get tested for the viagra. When I drove out there, Cary Skelton, a fifty-year-old paramedic and OHSI’s West Texas program manager, was order viagra online outside. He had on his typical uniform. A T-shirt, ball cap, cargo pants, and square-toed cowboy boots. He was chain-smoking Kool order viagra online menthols next to a parked ambulance.

A gray cat named Tigger was curled up on the vehicle’s hood, and a shotgun named Bubba rested against the front bumper. Cary nodded at the gun. €œCoyotes been order viagra online getting too close for ol’ Tigger here.”We talked as the sun went down—about the viagra, about how the clinic had been erectile dysfunction treatment-testing scores of workers every day, about the region. Loving County, Cary told me, is a tough sell. The 677-square-mile county is best order viagra online known for being the least populous in the entire United States.

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

This part of West Texas is his home. As a boy, he worked cattle on ranches, including his grandfather’s, across the region. And today order viagra online you’d be hard-pressed to find a more entertaining source of regional history than Cary Skelton. When he tells stories, his posture shifts and his voice changes, depending on the character he’s enacting. He affects a lisp to imitate the late Newt Keen, a droll cafe owner in Mentone who lost a few front teeth after he took a bullet to the face order viagra online.

And Cary’s eyes narrow when he takes on the role of Sheriff Elgin “Punk” Jones, the top lawman in the county from his first term, in 1965, till he hung up the badge in 1992.Cary lights up when he talks about growing up out here. Like the time he was nine or ten, when he and a buddy decided to drive a go-kart the thirty miles from the Red Bluff Reservoir to Mentone in the dead of night. This was in the early eighties, some three decades before the shale boom brought heavy traffic order viagra online and thousands of itinerant workers to the area. The roads were mostly empty then, but they could still be dangerous. Mexican cartels used them as improvised runways on which to land small aircraft loaded with cocaine or other illicit drugs.

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

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

He strolled up to the go-kart.“What are order viagra online you boys doing?. € he asked. €œWell, we’re driving around,” order viagra online they told him. Punk shook his head. €œI don’t know if riding around on a go-kart in this part of the country is very safe.” He loaded the boys and their go-kart into his truck and drove them back to their homes.

Cary was sure he’d get a whupping for the stunt, but Punk never said a word about their adventure, not order viagra online even to Cary’s dad.There have been a few changes since Cary was a kid. Thanks in part to the same Punk Jones, who drilled some of the county’s first non-brackish wells, you can now turn on a tap anywhere in town and get drinkable water. Still, potable water isn’t much of a selling point in 2022, and besides the lack of modern conveniences, the OHSI staff also faces all the dangers and discomforts of the oil field. When they’re out on a call, they might encounter poisonous gases, homicidal drivers, and high-pressure wells that sometimes order viagra online blow up. There are also the long hours and weeks away from home.

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

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

We could lose someone.” Cary order viagra online snubbed out his cigarette. €œGive me another sweet,” he told one of the EMTs who’d joined us outside. Another Kool was produced. Cary lit order viagra online it. It was dark now.

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

€œEMS is the bastard stepchild of the planet,” Cary told me.Today, most of us take for granted that we can pick up the phone, dial 911, and someone will be at our side in minutes, capable of keeping us alive during the brief trip to a hospital awaiting with teams of doctors. But this convenience order viagra online is a relatively new development. Texas’s Department of State Health Services didn’t include an EMS division until 1973.In Texas and most other states, EMS, unlike police and fire departments, is not considered an “essential service.” Instead, EMS workers are dispatched through a haphazard patchwork of municipal and county operations, hospital-affiliated services, nonprofit and volunteer associations, and private enterprise. That’s where order viagra online OHSI comes in. Dustin Hoffpauir outside the OHSI clinic.Photograph by Jeff WilsonThe nutty idea of opening a for-profit clinic in the country’s least populated county was Dustin Hoffpauir’s.

I met Dustin during my first week at the clinic. He arrived from Houston in his King Ranch order viagra online Ford bearing a load of boiled crawfish, a nod to his Cajun roots. Dustin had come to EMS through the safety departments of several oil and gas companies. After graduating from the University of Louisiana at Lafayette in 1998, he worked as a fire watchman on offshore rigs in the Gulf of Mexico.He eventually migrated to dry land and a small Lafayette-based safety company, doing contract work for bigger oil and gas companies. One of those was Anadarko Petroleum, which hired Dustin order viagra online in 2005.

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

It took more than an hour and half, an eternity to Dustin. €œAnd that’s when I really started thinking about the challenges associated with providing medical care out here, order viagra online and the lack of resources,” he said. €œThe same thing kept on reoccurring. Delayed response. Unfortunately, some order viagra online lives were lost.”“The same thing kept on reoccurring.

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

€œMy God, people,” he said, his voice choked, “what have we come to!. €Dustin and his wife, Mandy Hoffpauir, a registered nurse, made a plan. Dustin recalled his time working in order viagra online the Gulf. The challenges of providing medical care on offshore oil rigs mirrored those in the Permian Basin. He figured order viagra online he could replicate the model he’d learned out there.First, he tackled the economics.

Most ambulance companies don’t get paid unless they transport a patient. Out in a rural area like Loving County, the relatively low volume of transports, compared with the number carried out by city services, can make it hard for a company to keep the lights on between calls. If a order viagra online patient doesn’t have insurance and is deemed indigent, the ambulance company often eats the bill. But Dustin knew that the oil and gas industry was desperate to find solutions to the problems it had brought to the region. The traffic accidents, the thousands of itinerant workers needing basic care for chronic conditions or medical emergencies, and the order viagra online work-related incidents (well blowouts, rig injuries, flash fires, heat exhaustion, and so on) that are often more serious than those that occur in other industries.

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

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

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

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

This is my order viagra online granddad’s stomping grounds, and I cannot mess this up.” Cary understood Loving County. €œOil-field workers and rodeo cowboys, they don’t go the doctor unless something is sticking out,” he said. €œPeople don’t even take order viagra online their prescriptions out here because it’s seen as a sign of weakness.” Cary’s dad is like that. He once showed up at the clinic with a busted head. He refused to get out of his truck, so one of the medics had to staple the wound through the window.

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

But for the EMTs and medics who make their living and spend more order viagra online than half the year at the clinic, their sacrifices add up. Dominic Sanchez, Steven Hutson, and Anthony Luk play poker in the clinic while waiting for a call.Photograph by Jeff WilsonMy first hitch, which would last two weeks, began in late June. On a Tuesday morning, I arrived at the clinic, a metal structure the same beige as desert camouflage. The clinic abuts a rodeo order viagra online arena just to the east. Otherwise there is little but sun-scorched pastures of mesquite and greasewood, the occasional pump jack, and a few rusted skeletons of old trucks and tractors.

As Cary and I walked up the entrance ramp, Tigger and her order viagra online kittens scattered from a heaping plate of food. In front of the door was a bloody rabbit’s foot. €œThat was probably Tigger,” Cary said, catching my stare as he swung open the door. €œNot the order viagra online first time she’s gotten a cottontail. And, hey, that’s good luck!.

€Touring the clinic didn’t take long. The building is divided in order viagra online half. One side includes an examination room, X-ray room, and dispatch office. The other side serves order viagra online as the living quarters for the staff. A cramped kitchen.

A common room with an overstuffed brown sofa, an easy chair, and a TV on the wall. A bathroom order viagra online. And two bedrooms, where the crew members sleep two to a room. There are plain white walls and scuffed linoleum order viagra online floors throughout. The vibe is a mix of college dorm and military medical outpost.

As the fresh crew trickled in, the EMTs and medics who’d been on duty headed home, to El Paso, Lubbock, and as far away as Louisiana. One by one, order viagra online I met the guys I’d be shadowing for the next two weeks. First was Steven Hutson, an EMT from the flyspeck of Kirvin, a town eighty miles southeast of Dallas. The youngest of the bunch at order viagra online 25, he had a hefty frame and Bambi eyes that had earned him the nickname Baby Huey. Next was Dominic Sanchez, a 26-year-old Albuquerque transplant with a boy-band smile and muscles on his earlobes.

Dom was responsible for dispatching crews to calls for help, a duty he performed while wearing a pair of pearly white Crocs. And finally there was Anthony Luk, a 29-year-old paramedic who grew up far from West Texas, in the Asian grocery store his family managed in Houston order viagra online. These three, along with Cary, would be responsible for running the clinic 24 hours a day for the next fourteen days, as well as responding to emergency calls.Texas Highway 302, which leads into Mentone from the clinic.Photograph by Jeff WilsonDays at the clinic varied wildly. One might be mind-numbingly slow. Hardly anyone would show up for treatment, and the emergency order viagra online alarm stayed quiet.

The next, the team might be slammed from morning to night with workers dropping in for erectile dysfunction treatment screenings, for drug and alcohol tests, or with physical maladies. A welder came in with a metal shaving lodged in his order viagra online eye. Another patient arrived needing an X-ray after falling from a catwalk between two tall tanks. Several workers, their accents suggestive of places a long way from Texas, came in suffering from dehydration. And one order viagra online evening a man hobbled in with severe burns on his leg.

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

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

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

€œThese are perishable skills,” he explained. Because OHSI doesn’t run calls every day like city ambulance services do, “you have to be studying. You have order viagra online to be practicing. You have to be putting your hands on equipment.” But for all the grief he gives them, Cary is fiercely loyal to and proud of his crew. €œA lot of people think that because we’re out here in order viagra online Hickville, we’re going to deliver some type of substandard medicine.

No way. I would put my guys up with anybody out there.” When that emergency phone rings—and eventually it does—life-and-death situations await the OHSI crews. Their memories are full of the order viagra online kind of gore that most of us see only in horror films. A road-rage victim shot point blank in the belly, guts slopping out like uncooked sausage. An F-150 crushed like a Coke can under an eighteen-wheeler.

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

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

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

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

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

In EMS, picking up overtime is order viagra online where we make our money. It’s also a big reason why there’s a lot of burnouts.” The annual turnover rate for EMS workers is about 30 percent.“You’re constantly working,” Anthony continued. €œIt’s hard on marital life, social life, all life outside of work. Relationships are hard to sustain because, like, for us here, you’re order viagra online gone for two weeks. It’s terrible to say, but out of the guys who’ve had partners or were married, a good forty to fifty percent are no longer.”Anthony’s fiancé, William, is a composer in Lubbock.

I met him briefly when he made the three-hour one-way trip to deliver a set of keys Anthony had accidentally left at their order viagra online apartment. It was the only time William had ever set foot in the clinic where Anthony spends more than half the year.“When you go home, you don’t want to do anything,” Anthony said, speaking generally. €œYou just want to rest, and your partner doesn’t always understand. Plus, you don’t want to tell them everything because you don’t want to relive order viagra online it. Like, if you had a bad day at work where you had to do CPR on a kid who drowned.

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

Cary chalks this up in part to EMS culture, in which the ability to put on a tough front and “silently suffer” is highly valued. Others don’t seek counseling because they can’t afford it. (A couple of the OHSI workers I spoke with said they’d opted out of the company’s plan because they felt the premiums were too high.) This means EMS workers find other ways to deal with their trauma. €œI know a lot of EMS guys who have pretty bad vices,” Anthony said. €œThat’s the way that they wind down, whether it be a massive amount of alcohol or a massive amount of partying.”According to one study, EMTs and medics are about ten times more likely to have suicidal thoughts than workers in other professions.While the crews are on call at OHSI, they temper certain bad habits they might indulge at home.

A couple of them funneled their energy into working out at Mentone’s only gym, a tiny collection of weights set up inside a shipping container. Some dipped tobacco, smoked, and guzzled an endless stream of energy drinks to ward off stress, boredom, and weariness. But without exception, all the guys leaned heavily into a dark humor specific to their profession.That night in Culberson County, for instance, as we stood around waiting for the drone to finish its search for any lingering hot spots from the fire, Justin told a story from a few years back. He’d just finished an ambulance shift and was walking out to the parking lot to head home. €œThis car comes hauling ass in, pulls right up, and almost hits me.

The window rolls down, and the driver leans over. €˜This guy just OD’d on heroin.’ ” The man in the passenger seat was barely breathing. Justin got him out of the car. €œI start doing CPR on this dude. I’m dripping sweat, absolutely drenched because it’s so hot.” Justin managed to get the guy to the hospital alive.

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

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

A few bad wrecks and a fire that had burned a crew of three. Plus, a surge in erectile dysfunction treatment cases had forced the crews to work even longer hours, as they had to transfer patients to hospitals farther and farther away. There had been some personnel changes too. Dominic Sanchez had left OHSI for a medical gig nearer to his home in Killeen. And Steven Hutson had found work with an ambulance service close to his wife and family in Kirvin.

Anthony Luk is still at OHSI but has been preparing to apply to medical school. He hopes to start later this year. Cary hates to lose good workers, but he doesn’t blame anyone for leaving.Sometimes when we spoke on the phone, Cary sounded bone tired. Finding replacements hadn’t been easy, and the crews were stretched thin. At times he felt as if OHSI were barely hanging on.

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

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

On that cold Saturday morning, Cary had been on his way back to the clinic from Kermit when he received a panicked call from Punk’s family. €œHe’s not breathing well. He’s doing bad.”Cary and the family started making calls. They finally managed to find a hospital bed for Punk in Amarillo, about three hundred miles away. Cary sent an ambulance to Punk’s house and summoned a plane to Winkler County Airport, outside Kermit, to transport Punk the rest of the way.

Meanwhile, Cary had been speeding toward Punk’s place. He arrived just before the ambulance and went inside. Punk’s daughter, Mozelle Carr, was there with him. So was Mary Belle. She told Cary, “I want you to do everything you can.” “I will,” he promised.The ambulance dock at the OHSI clinic in Loving County in July 2021.Photograph by Jeff WilsonHe and the OHSI medics got Punk on the stretcher and into the ambulance.

They were flying down the road, hooking him up to monitors, starting an IV, when Punk squeezed Cary’s hand. He wagged a finger up at Cary. Then he pointed down. Punk Jones had made it clear. He wanted to die in Loving County.Cary knew Punk wouldn’t make it to Amarillo.

He told the EMT driving the ambulance to pull over in the parking lot of the county courthouse. There, Cary did as he promised. He and his fellow medics tried everything they could to save Punk. They intubated him and gave him fluids through an IV. When Punk’s heart stopped, Cary did compressions on his chest until it started thumping again.

Eight times he was able to get the heart rate monitor to register a rhythm.Cary phoned Punk’s family. The Jones clan trickled into the parking lot, congregating at the ambulance. Cary held Mozelle’s hand, and they cried together. Punk’s heart stopped again. This time, Cary could not bring him back.At OHSI, Cary and his crews fight every day to keep folks from dying in Loving County.

Of course, they can’t save everybody. And being able to provide dignity at death, to allow someone to die in the place they call home, can be just as important. It’s these moments, however weighted with tragedy, that keep Cary working overtime in Loving County, making plans to ensure that basic health care is here to stay—no matter what happens at OHSI or to the fortunes of the oil patch.A week later, Punk was laid to rest at his ranch. During the funeral, Cary offered his condolences to the Jones family. Tom, one of Punk’s sons, told him, “I’m glad you were with him, Cary.”Cary nodded.

€œIt was an honor.” This article originally appeared in the January 2022 issue of Texas Monthly with the headline “There Will Be Blood.” Subscribe today..

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