I’m a nurse and have been going through a severe depressive episode.. I had gotten out of inpatient and a week or so later had an episode where I wasn’t eating/ drinking and was suicidal again. My friend/ coworker recognized the signs of dehydration (my HR was 140-150 and I was shaking so bad) and offered to give me some IV fluids (saline) on the down low. So we did that and I felt much better and we had a mini intervention where she encouraged me to start IOP and get help.
Now several weeks later we find out one of our coworkers is a snitch and reported us to the ethics committee for not having a doctors order. We didn’t think anyone was around because it was after shift and were in a private area (or so we thought). Now both of our jobs are on the line and I feel fucking miserable. If I wasn’t so impulsive and depressed this wouldn’t have happened. The guilt and shame I feel is immense and I can feel myself spiraling again.

I experienced the Rosetta Stoned experience in 2004 during my junior year of high school, 2 years before Rosetta Stoned was released. I turned 37 earlier this year in February. The experience started with a rave appropriately called “Off Yer Nut” on a Sunday, an unusual date given the upcoming work and school week, but my friend organized it so we went, took an ungodly amount of speedy ecstasy which likely propelled my thoughts and played a not insignificant role in my delusions later on, but we'll get to that. It was a smaller crowd at the rave considering it was scheduled to end around 5 am on Monday morning. There were fewer people I knew given the smaller crowd so afterwards, in my quest to avoid going home to parents I ended up following an odd set of characters I did not know well. One was a street kid who had just arrived in the city, just another city the Canadian street kids pass through along the annual winter pilgrimage to Vancouver which is the most habitable city in mainland Canada in the winter. This street kid had dreads filled with hot wheels toy cars, a pacifier, a lighter, and other random shit. He was with another guy I did not know and can no longer remember as well as the one guy I knew prior to the rave. He was a weird older dude in his 30s at the time with a serious case of OCD. I knew him because he was one of the first guys to hook me and my friends up with weed when we were 13-14. He used to hang out at the local spot where weed dealers and street kids would congregate, colloquially known as "The Circle" and he could often be spotted wearing a lab coat and walking somewhat erratically. So a strange group of people to say the least, and no close friends.
So here I am, age 17, heading with these 2 street kids and the OCD lab coat man back to his apartment downtown where I decided to take 3 hits of what I would discover was the most intense LSD I’ve ever come across. Two other friends who I was not with that night all took 3 hits of the same acid that night, it had just arrived in town earlier that day, and we all ended up in the 3 different hospitals around the city, completely independent from each other. When I called my one buddy to let him know what happened he was shocked, he thought I had heard what happened to him and was fucking with him, and I thought he was fucking with me, especially when he said that another one of our buddies had the exact same experience as well. All 3 of us took 3 hits each and ended up strapped down to a bed in 3 different hospitals that same night.
So what led me to my final destination strapped down? After dropping the acid my OCD fellow traveller decided to put on the most horrific movie I can imagine. It was some B-horror movie about a man sent to hell to die over and over again in an endless cycle of death and pain and misery. So that may have contributed to my desire to get the fuck out of there, but it was never a conscious motivating factor. What motivated me was when I began to peak. This coincided with the sun beginning to rise and with the light shining through the window of the apartment on Monday morning when everything clicked. It was the most cliche realization ever. We are all one. Duality creates variation, which creates discernible reality, but everything comes from the same source. Opposites are not in opposition, they are complementary, because they are dependent on each other to create each other's discernible existence, so we are all interconnected. We are all one. And one is peace. Cliche, but some interesting merit to the ideas that have been expressed in Taoism and many spiritual beliefs around the world throughout human history. But I was convinced that because I had figured it all out the purpose of reality had been fulfilled and now all variation, all contrast, all discernible reality would coalesce and collapse into itself as a unified whole. I literally thought I had unlocked the code for all of existence to unite with God. And I was the one. So naturally I had to greet the masses. Did I mention his apartment was downtown and this rave took place Sunday night? Where does that place me geographically and temporally? That's right, downtown, Monday morning, rush hour. Time to greet the masses.
That is how I ended up in the middle of the road during rush hour at the busiest intersection downtown, barefoot, in the middle of traffic, with my arms outstretched to the sky feeling my mind expand into the universe at an accelerating rate that brought me to my knees in an increasingly euphoric ecstasy that is indescribable. The best I can describe it is it felt like a mind orgasm expanding into the universe, at an accelerating rate of intensity and speed. It was the single most amazing experience of my life. Simultaneously the most reckless and traumatic experience of my life. I remember observing police officers and seeing them cycling between male and female, all opposites were cycling together, like a real-time yin-yang superimposed over all of reality, and this reinforced my delusion that I had unlocked the purpose of reality which meant that opposites would coalesce during the process of the universe's re-unification with God. This is what I actually believed was occurring. In reality I was likely approached by 1 male and 1 female officer and removed from the middle of the busiest intersection in the core of the business district downtown.
I was loaded into what I believed at the time was some special container to be carted somewhere important as I was The One compelled to greet the masses but I would soon realize while sober was simply an ambulance. And when I was strapped down to the hospital bed my delusions were reinforced when one of the nurses who caught my eye was someone I recognized. It was an acquaintance who I had met at the after party of the previous rave a couple weeks earlier and he was someone who I had a very intense philosophical discussion about insights from psychedelics that were highly relevant to the delusions I was experiencing. When I ran into him again he described what happened when he saw me in the hospital, he said my eyes instantly locked on to him and I pointed at him with a strong conviction and nodded my head and emphatically stated, "Yes!". He wasn’t aware of the significance of this at the time but from my perspective his presence validated all of my delusions and reassured me that everything made sense. I was the One and he was interconnected with it all based on our prior discussion so all of these signs and coincidences reinforced my megalomaniacal delusions.
Hours later I slowly began to sober up. There was a moment when I had my realization that I “shit the bed”. I began to recognize that I was strapped down to a hospital bed with what I recognized were nurses around me, and that I had just been on a fucking roller coaster ride of a dangerously reckless psychedelic experience. The delusion washed away in an instant and was replaced with fear. I now had to confront the reality that I was strapped down in a hospital bed, I would have to explain this to my parents, all while trying to piece together what in the fuck had just happened. I called a nurse to hold my hand and begged her not to leave while I regained my faculties and came to terms with the reality of the situation. My parents were called, I told them everything, and my parents had police talk to me as an intervention. I wasn’t charged with anything but more importantly I didn’t hurt myself or anyone else. I did cause many people to be late for work on that Monday morning, this was confirmed by at least one friend whose wife called him about some guy on the street, so when I told him what happened he responded, "Oh that was you? My wife was late cuz of you, you crazy bastard! As if that was fucking you! Yeah I heard all about what happened."
It was the most amazing and traumatizing experience of my life. With this context you can imagine what I felt when I heard Rosetta Stoned 2 years late. I have been a massive Tool fan since the day Lateralus was released. Almost 23 years to the day. And I've just right now realized my Rosetta Stoned experience would have been almost exactly 20 years ago to the day. It was sometime in April or May of 2004!
I imagine when I listen to Rosetta Stoned I don't hear the same song as most people. For one, when I hear the line “they chose me, and I didn’t even graduate from fucking high school” it rings differently. To me it's not describing a high school drop out, it’s describing me, and I hadn't even graduated from fucking high school cuz I was still in my junior year! 😂

Hello all,
I’m hoping to come down to London in a couple of years to study a masters in Early Intervention in Psychosis, supplementing my income by working in the wards. I just wanted to check if there are any nurses who work and live in London, if so - how the hell are you surviving? The pay is the same as it is in Glasgow which seems wild to me considering the cost of living down there?
I plan on saving up as much as possible over the next couple of years to help but I just can’t fathom how anyone is coping! I’d love to work in London for a year or two after the Masters but I don’t really see how that’s feasible on the wage.
Any advice appreciated!

People's shitty behaviors no longer surprised me, but I thought some of you might get a kick out of my appointment this morning.
I've been working with a fertility clinic to conceive for quite a few months and had an appointment this morning. The clinic does not require masks, but there is one nurse who is masked all the time and they do have one measly purifier running in the waiting room.
I was sitting in the waiting room, alone, masked and minding my own business scrolling on my phone. I saw a woman walk in from the corner of my eye but didn't pay any mind-- until I heard her laugh (not a hearty "haw haw" but more like a "tch!" chicken cluck). I looked up and she was standing right in front of me, stupid incredulous face smirking at me. I hadn't cracked a joke and I was definitely wearing pants so, while maybe there was some other reason she was laughing in my face, it was probably the mask.
Since I had been lucky to not yet experience flack from strangers for masking until today, I wasn't quite sure what flood of emotions I would get. I found that my reactive feeling was not to feel bad or feel shame for wearing a mask, which is good to know. I also found that I truly did not care what this toad thought of my decisions.
What did make me feel sad, though, was the fact that we were in a fertility clinic. The entire patient population is having difficulties conceiving and have to resort to medical intervention to get a chance of having a baby. The people who go there generally have pre-existing conditions and/or histories of pregnancy losses. There are physical ads in the waiting room offering services for cancer patients to freeze their eggs so they can try to conceive after treatment is done. She was literally a patient herself, so presumably, she was experiencing medical difficulty becoming pregnant!
I wasn't sad for myself, but sad for younger and future generations. The thought of someone so callous, cold-hearted, and, frankly, stupid, raising a child really does make my heart hurt. Not that kids of anti-COVID anti-maskers are guaranteed to grow up to be like their parents-- just that it must be so difficult growing up having parents so self-absorbed and ignorant and hateful.
Anyway, fuck that cow. Hope you all have a great week!

I experienced the Rosetta Stoned experience in 2004 during my junior year of high school, 2 years before Rosetta Stoned was released. I turned 37 earlier this year in February. The experience started with a rave appropriately called “Off Yer Nut” on a Sunday, an unusual date given the upcoming work and school week, but my friend organized it so we went, took an ungodly amount of speedy ecstasy which likely propelled my thoughts and played a not insignificant role in my delusions later on, but we'll get to that. It was a smaller crowd at the rave considering it was scheduled to end around 5 am on Monday morning. There were fewer people I knew given the smaller crowd so afterwards, in my quest to avoid going home to parents I ended up following an odd set of characters I did not know well. One was a street kid who had just arrived in the city, just another city the Canadian street kids pass through along the annual winter pilgrimage to Vancouver which is the most habitable city in mainland Canada in the winter. This street kid had dreads filled with hot wheels toy cars, a pacifier, a lighter, and other random shit. He was with another guy I did not know and can no longer remember as well as the one guy I knew prior to the rave. He was a weird older dude in his 30s at the time with a serious case of OCD. I knew him because he was one of the first guys to hook me and my friends up with weed when we were 13-14. He used to hang out at the local spot where weed dealers and street kids would congregate, colloquially known as "The Circle" and he could often be spotted wearing a lab coat and walking somewhat erratically. So a strange group of people to say the least, and no close friends.
So here I am, age 17, heading with these 2 street kids and the OCD lab coat man back to his apartment downtown where I decided to take 3 hits of what I would discover was the most intense LSD I’ve ever come across. Two other friends who I was not with that night all took 3 hits of the same acid that night, it had just arrived in town earlier that day, and we all ended up in the 3 different hospitals around the city, completely independent from each other. When I called my one buddy to let him know what happened he was shocked, he thought I had heard what happened to him and was fucking with him, and I thought he was fucking with me, especially when he said that another one of our buddies had the exact same experience as well. All 3 of us took 3 hits each and ended up strapped down to a bed in 3 different hospitals that same night.
So what led me to my final destination strapped down? After dropping the acid my OCD fellow traveller decided to put on the most horrific movie I can imagine. It was some B-horror movie about a man sent to hell to die over and over again in an endless cycle of death and pain and misery. So that may have contributed to my desire to get the fuck out of there, but it was never a conscious motivating factor. What motivated me was when I began to peak. This coincided with the sun beginning to rise and with the light shining through the window of the apartment on Monday morning when everything clicked. It was the most cliche realization ever. We are all one. Duality creates variation, which creates discernible reality, but everything comes from the same source. Opposites are not in opposition, they are complementary, because they are dependent on each other to create each other's discernible existence, so we are all interconnected. We are all one. And one is peace. Cliche, but some interesting merit to the ideas that have been expressed in Taoism and many spiritual beliefs around the world throughout human history. But I was convinced that because I had figured it all out the purpose of reality had been fulfilled and now all variation, all contrast, all discernible reality would coalesce and collapse into itself as a unified whole. I literally thought I had unlocked the code for all of existence to unite with God. And I was the one. So naturally I had to greet the masses. Did I mention his apartment was downtown and this rave took place Sunday night? Where does that place me geographically and temporally? That's right, downtown, Monday morning, rush hour. Time to greet the masses.
That is how I ended up in the middle of the road during rush hour at the busiest intersection downtown, barefoot, in the middle of traffic, with my arms outstretched to the sky feeling my mind expand into the universe at an accelerating rate that brought me to my knees in an increasingly euphoric ecstasy that is indescribable. The best I can describe it is it felt like a mind orgasm expanding into the universe, at an accelerating rate of intensity and speed. It was the single most amazing experience of my life. Simultaneously the most reckless and traumatic experience of my life. I remember observing police officers and seeing them cycling between male and female, all opposites were cycling together, like a real-time yin-yang superimposed over all of reality, and this reinforced my delusion that I had unlocked the purpose of reality which meant that opposites would coalesce during the process of the universe's re-unification with God. This is what I actually believed was occurring. In reality I was likely approached by 1 male and 1 female officer and removed from the middle of the busiest intersection in the core of the business district downtown.
I was loaded into what I believed at the time was some special container to be carted somewhere important as I was The One compelled to greet the masses but I would soon realize while sober was simply an ambulance. And when I was strapped down to the hospital bed my delusions were reinforced when one of the nurses who caught my eye was someone I recognized. It was an acquaintance who I had met at the after party of the previous rave a couple weeks earlier and he was someone who I had a very intense philosophical discussion about insights from psychedelics that were highly relevant to the delusions I was experiencing. When I ran into him again he described what happened when he saw me in the hospital, he said my eyes instantly locked on to him and I pointed at him with a strong conviction and nodded my head and emphatically stated, "Yes!". He wasn’t aware of the significance of this at the time but from my perspective his presence validated all of my delusions and reassured me that everything made sense. I was the One and he was interconnected with it all based on our prior discussion so all of these signs and coincidences reinforced my megalomaniacal delusions.
Hours later I slowly began to sober up. There was a moment when I had my realization that I “shit the bed”. I began to recognize that I was strapped down to a hospital bed with what I recognized were nurses around me, and that I had just been on a fucking roller coaster ride of a dangerously reckless psychedelic experience. The delusion washed away in an instant and was replaced with fear. I now had to confront the reality that I was strapped down in a hospital bed, I would have to explain this to my parents, all while trying to piece together what in the fuck had just happened. I called a nurse to hold my hand and begged her not to leave while I regained my faculties and came to terms with the reality of the situation. My parents were called, I told them everything, and my parents had police talk to me as an intervention. I wasn’t charged with anything but more importantly I didn’t hurt myself or anyone else. I did cause many people to be late for work on that Monday morning, this was confirmed by at least one friend whose wife called him about some guy on the street, so when I told him what happened he responded, "Oh that was you? My wife was late cuz of you, you crazy bastard! As if that was fucking you! Yeah I heard all about what happened."
It was the most amazing and traumatizing experience of my life. With this context you can imagine what I felt when I heard Rosetta Stoned 2 years late. I have been a massive Tool fan since the day Lateralus was released. Almost 23 years to the day. And I've just right now realized my Rosetta Stoned experience would have been almost exactly 20 years ago to the day. It was sometime in April or May of 2004!
I imagine when I listen to Rosetta Stoned I don't hear the same song as most people. For one, when I hear the line “they chose me, and I didn’t even graduate from fucking high school” it rings differently. To me it's not describing a high school drop out, it’s describing me, and I hadn't even graduated from fucking high school cuz I was still in my junior year! 😂

Reddit Account: u/Dejurewaffles1066
Discord Tag: Garin
Name and House: Ellyn Moore
Age: 25
Cultural Group: Valeman
Appearance: Of middling height and red hair, Ellyn has spent the last four years in constant training and increasingly eschews the courtly manners she was taught in favor of a direct and frank mode of speaking and acting, thoroughly disillusioned with subtleties and empty flattery. Her eyes can be rather intense and seldom evade contact.
Trait: Brave
Skills: Swords (e), Two-handed weapons (swords), Brute, Errantly
Talents: Weaving, Fishing, Hawking
Negative trait: N/A
Starting title: Scion of house Moore, Cavalier
Starting Location: Greyhelm
Alternate Characters: Dorian Merryweather
_____________________________________________________________________________________________________________________

Biography:

For house Moore, like many other houses of the Vale's sheltered interior, Aegon's conquest was rather unremarkable. They went to bed one evening as subjects of one king and woke up as subjects of a new one, without the old one having gone anywhere either. Ellyn was the third child of Lord Berrick Moore and his wife Sybelle Wydman. Ellyn would be their only daughter. Lord Berrick went on to play a minor role in the campaign against the Root Father. The stories of the menace in the mountains inspired many a youth at Bronzespear to want to take up arms themselves, Ellyn among them.
The tapestries of andal knights, fearlessly facing their enemies with gleaming greatswords captured her imagination already as a child, and she began training beside her brothers. They were fairly accepting of this, and so Lord Moore let it slide as long as Ellyn did not skip other lessons for the sake of training, however when the Cavaliers were formed, it would not be many years before his daughter began to speak of joining, in hushed tones at first but ever more loudly as time went on. When she turned sixteen, Ellyn asked for permission to join and was promptly shut down. Instead Lord Berrick took his family on a visit to Snakewood, where Ellyn was introduced to the heir of the house, who had become her betrothed by the end of the visit. her betrothed did not come accross as a cruel or mean-spirited man, yet he was also not particularly strong-willed, a fact which would later become painfully aparent
Soon after her eighteenth nameday, Ellyn married the heir to House Lynderly, moving to Snakewood. Three things quickly became obvious to Ellyn. Firstly, even as a man grown, her husband had few opinions of his own, preferring to hear the verdict of his parents and adjust to it. Secondly, the maester in House Lynderly's service had little knowledge of medicine, and somehow even less of how to practice it on women. This fact became clear from the third revelation, she was already with child, probably since her wedding night. This was celebrated as a sign of good luck and the blessing of the gods. The final outcome would prove a hellish ordeal. The labor would become a protracted affair as Ellyn struggled. Something was clearly wrong, and the maester was utterly clueless in regards to a solution. By the time the idea of cutting the child out of her was being proposed, the impasse finally ended and her daughter was born, as if by the Mother's much belated mercy. At this point a hedge-maester was called in, ostensibly as assistant to the Maester of Snakewood. In practice, the dornishman named Marcel took over her care, and his clueless colleague was happy for an excuse to leave the room. He would stay to nurse her back to health, a process which took more than three months.
By then the warning signs were already showing. Leyla, her daughter, could not even look straight at someone, her gaze constantly shifting and her pupils often turning in opposite directions. Ellyn requested that Marcel stay at Sanekwood to monitor the girl and the Lynderlys obliged, their maester being no more skilled in treating children than women. At age one Leyla was not learning to walk, and struggled to even crawl or lay still. The Lynderlys assumed the child to be dim-witted, an ill omen. Furthermore, even a year after the birth, Ellyn's cycle had not returned to normal, becoming infrequent and irregular. For two more years she and her husband were urged to try to produce a suitable heir, unlike their daughter, however Ellyn proved incapable of conceiving another child. She was increasingly left to her own devices, and began to take up her old swordsmanship again, a way to remind herself and those around her that she hadn't died that night, even if her in-laws increasingly seemed to treat her as such.
Meanwhile Marcel continued to monitor Leyla's condition, unconvinced by the analysis of Snakewood's regular maester. He eventually concluded the condition to be palsy, and that the girl might eventually learn to control the spasms of her limbs, fashioning straps that would limit the movement in her arms and legs, allowing her to begin to practice moving them deliberately rather than involuntarily.
By 21AC, the Lynderlys concluded that divorce was the solution to their plight. A wife incapable of producing a fit heir could be set aside, and so this was Ellyn's fate. Her husband had not leapt at the opportunity eagerly, however as his parents argued the necessity he protested it less and less. He offered Ellyn and Leyla a place at his court after the divorce, but Ellyn rejected it, unable to stomach how the court seemed to treat both her and her daughter as functionally dead, a sentiment which had started years before the divorce itself. Instead she took her unwanted daughter and made for the Gates of The Moon and the Cavaliers, bringing Leyla with her. Marcel would accompany her, intent on continuing Leyla's training. As the years went by, the girl slowly staggered to her feet, beginning to walk with shambling steps and speak with a ragged voice. Meanwhile Ellyn resumed her own training at arms, using up her anger by throwing it into her training, regaining the strength of teenage years that already felt like a lifetime ago. Rather than ruminate on what the gods may have meant by it all, she sought meaning in the people around her, her companions and her family, not any house.
Family Tree:
Berrick Moore (Father, b.30BC)
Sybelle Wydman (Mother, b.27BC)
Lucan Moore (Brother, b.5BC)
Harmen Moore (Brother, b.2BC)
Martyn Lynderly (Ex-husband, b.1BC)
Leyla Lynderly (Daughter, b.17BC)
NPCs:
Berrick Moore (55), General
Lucan Moore (30), Huntsman
Timeline:
1BC: Ellyn Moore is born
6AC: She begins training with her brothers
15AC: She asks permission to join the Cavalliers, but is instead arranged to be married to the heir of House Lynderly
17AC: Ellyn marries Martyn Lynderly and gives birth to her only daughter, Leyla, by the end of the year. The labor is long and difficult, and she is saved by the intervention of the hedge-maester Marcel after the maester of Snakewood proves incapable of helping.
20AC: It becomes clear that Leyla is afflicted with palsy while Ellyn is no longer capable of conceiving. Martyn Lynderly's parents begin advocating for a divorce to allow House Lynderly to have a healthy heir by another lady. Ellyn begins practicing with a sword again
21AC: The divorce is finalized. Ellyn is offered a place at court by her former husband but instead takes her daughter with her and joins the Cavaliers. Marcel joins her
21-25AC: Ellyn trains as a Cavalier while Marcel gradually teaches Leyla to move more independently and speak. Ellyn and Marcel accompany the leaders of the Cavaliers to Greyhelm
_____________________________________________________________________________________________________________________
AC
Name and House: Marcel
Age: 44
Cultural Group: Dornishman
Appearance: A tall man with greying, black hair. Marcello's curly beard is carefully trimmed and his hands usually carry a metallic scent, whether from tinkering or treating injuries. His eyes are bright and keen, but tend to dart around a lot, constantly preoccupying themselves with new objects of fascination
Gift: Erudite
Skills: Medic (e), Craftsman (Armor)
Talents: Tinkering, Language (Valyrian), Fishing
Negative Traits: N/A
Starting title: Maester
Starting Location: Greyhelm
_____________________________________________________________________________________________________________________

Biography:

Marcel was born in 20BC, a son of a Planky Town merchant. While taking an keen interest in learning letters, numbers and even a few valyrian phrases, he had no mind for managing money. His parents quickly decided that out of all their children, he was better sent off to the Citadel, before one of his flights of fancy caused a greater loss of money. This was after he had spent a considerable sum just to acquire a Qohorik automaton, an intricate little lion with cogs on the inside that allowed it to walk when wound up.
Arriving in Oldtown at the age of 16, Marcel initially pursued metallurgy, but soon found that medicine stirred a very similar fascination in him. whether understanding the intricacies of a body made of flesh or metal, he was always keenly interested. It only took a few years before he came to be considered somewhat of a prodigy, especially for his interest in reconvalescent healing, the act of helping stroke victims and the maimed to use their bodies once again. By 21 he had taken further interests, particularly in a fellow maester in training, named Leo. For three years they were inseparable, jointly pursuing their studies by day and their passion by night. Then, one day, Leo suddenly started avoiding him. Marcel grew angry and tried to confront him several times, even in public.
This eventually caused enough of a scene for one of his seniors to pull him aside. Leo, as things would have it, was the nephew of one of the closest aides to the Archmaester of medicine. The over-proud geezer, Malcom, accused Marcel of corrupting his nephew wiht 'dornish vices' and told him in no uncertain terms that he should abandon the study of medicine, having already thrown away his prospects with his impertinence. At the time Marcel scoffed at his threat. He abandoned Leo, who had willingly abandoned him at his uncle's order, however he stayed in his course. A decade later, he was painfully aware that Malcom had acted on his threat. After an unusually protracted study they finally granted him a link of medicine, but there after the Citadel's college of medicine wanted nothing to do with him, throwing menial jobs far below his level at him whenever he offered his services. He went into metallurgy, but soon found himself similarly disdained. Though not an Archmaester, Malcom knew many men in the other colleges and had obstructed him here too. At this point, Malcom took to the road, serving as a hedge-maester. With few friends at the citadel, even an official posting at some hole in the middle of nowhere was out of reach.
One fateful evening in the Vale however, he would find a new sense of purpose, aiding Lady Ellyn Moore and her newborn Leyla. As the little girl grew into her toddler years, he determined that she could learn to walk on her own like other children, given the right supports. Those few with her affliction who grew to adulthood would sometimes show more control of their limbs with time, and maesters had speculated about accelerating the process. The project engrossed him so much that joining the service of the Cavaliers was almost an afterthought, a simple decision that would allow him to continue his work on the girl. Functionally, Marcel has now achieved what his seniors tried to deny him, serving as a surgeon and smith at the Gates of The Moon
Timeline:
20BC: Marcel is born in Planky-Town as a merchant's son
7BC: Marcel is a quick learner at everything except how to manage money. After spending a lot of money to acquire an automaton, a Qohorik curiosity, Marcel's parents determine that he is best suited for the citadel
4BC: He arrives in Oldtown to begin his studies
2AC-5AC: Marcel becomes recognized as a promising student of medicine and develops a relationship with Leo, a fellow student. Eventually Leo begins ignoring him. Marcel is told by Leo's uncle Malcom that their relationship is intolerable and that he should stop studying medicine
15AC: After a decade Marcel is granted his chain in medicine, and promptly stonewalled from further advancement. Malcom also pulls strings to make other archmaesters obstruct him from advancement as well. Marcel becomes a hedge-maester at the end of the year.
17AC: Marcel happens to be in Snakewood when the heir's wife is giving birth. He is able to help save Lady Ellyn Moore and her child, Leyla.
18AC-21AC: Marcel trains Leyla to be able to move independently despite her palsy. When Lady Ellyn is set aside by the Lynderlys he joins her to the Cavaliers, where he takes up service as a surgeon and smith while continuing to train Leyla
25AC: He joins the Cavaliers to Greyhelm

I am, for all intents and purposes, the only person in my dad’s life. He lives in a retirement community. My sister-in-law will help out with his care if I am away.
My dad is prone to bouts of paranoia when he has manic episodes. I am noticing a pattern that when I am going to be away with my family, this paranoia seems to get triggered. He lives in a supportive environment where all meals are provided, his laundry and room cleaning is done for him, his medication is administered by nursing staff and there is a doctor on call who can visit you right in your room. If ever there was an emergency, my sister-in-law would step in or staff would call an ambulance. So when I am away, he is perfectly safe and cared for. But something about me being away seems to trigger anxious feelings that become paranoid accusations.
I went away in March and my dad became paranoid that I was lying about where I was and also that I had cleaned out all his money. He even called his financial advisors during my absence to check if his money was still there (it was, of course).
This weekend I am away with my family and my dad has called me three times very upset that I have “locked him out of his accounts” and he can’t make any more Amazon purchases. The nurses from his retirement home also emailed me to say he came down to report to them about the bank accounts and was considering calling the police.
I understand he doesn’t choose to be paranoid and that it must be a scary and vulnerable feeling. The truth about his finances is that he has a credit card with a low monthly limit because he spends impulsively online. I just paid the credit card bill at the beginning of the month and he has already maxed it out again. When he is lucid, he’s concerned about money, but when he’s manic he can’t seem to keep track of his spending at all.
He can’t listen to reason when he’s like this, but I’ve had to reiterate several times that this is not an emergency, that I am on vacation with my family and it will have to wait. I have a difficult relationship with my dad already and it makes me so frustrated and upset that I’m rewarded for my efforts in caring for him by being accused of stealing and threatened with police intervention.

I am 33, AFAB, trans man (I've been on testosterone for 6 years). I'm 5'7“ and 155 lbs. I have hashimoto's hypothyroidism and asthma as well as chronic migraines, meniere's. Meds: levothyroxine, ajovy, rizatriptan, Omeprazole, dicyclomine, Viibryd, lithium, Seroquel, Prazosin, and clonopin.
I have struggled with severe mental illness including a psychotic disorder and depression for most of my life since puberty, and a year and 5 months ago I gave myself a full thickness chemical burn (lye) on my right shin directly below my knee during a psychotic episode.
I have not hurt myself since then, and I've been doing exceptionally well with my treatment team and medication management. At the time, however, I refused medical intervention, and I've been healing it on my own. I have a fear of going to the doctor for these things due to past treatment during mental health events.
The affected area was approximately 3" by 4" and the chemical reached bone and muscle. The tibia ridge and muscle was exposed, and the muscle was damaged (looked like grey shredded pork and peeled easily like shredded pork), and skin/fat was gone/black. The ligament? that goes from the knee cap to the top of the tibia was burned as well, but thankfully not bad enough to cause it to tear.
I had no sensation in the wound, and no sensation along the outer area of my calf from the knee to about 3-4 inches from my ankle (are of approximately 6" by 8"), but the pain and swelling throughout the rest of my leg extended from my toes up to my butt. I was unable to bend my foot upward and needed crutches for about a month (foot movement has since returned).
I initially used silver calcium algenate for the wound, and I've switched to xeroform dressings. The only medical help I've had was the ER doc I saw for an unrelated infection about 3 months ago. He said he was surprised I had done so well taking care of it and said it looked good (I was not having my current pain at this time).
The skin around the wound and on my leg looks and feels healthy. The scar tissue that's developed thus far looks healthy. The exudate, while high in volume, is clear yellow. The remaining wound bed is about 2" by 2" and looks healthy (pink, not too much granulation, it's now level with surrounding skin, no exposed bone or muscle). It seems really close to completely scarring over. There is noticeable scar growth/development every day.
My issue now is that while the areas without feeling remain numb, I've been having deep muscle pain again with pain radiating from the toes to my butt with occasional numbness and pins/needles in my foot. It feels "bone deep". My knee will start to hurt and I can feel the ligament that was burned is sore again. The pain makes it difficult to... Exist, kind of. It's easier to handle if I'm moving because it's distracting. It's caused difficulty sleeping and sitting still. I do have good circulation, and I've been able to be active for the last ~9 months doing stuff like hiking and light cycling with minimal swelling and pain up to this point.
Is this normal for healing a wound like this? And I'm assuming there's a high likelihood of chronic pain related to this injury?
Also, the scar tissue isn't free-moving. It seems to be attached to the bone almost.
I appreciate any input. I'm concerned that this recurrence of pain could be a sign of something wrong, and frankly, after a year and half, I am really struggling with the pain and complications. Should I go to the Eurgent care?

I passed the FNP exam with ANCC!!! I’m honestly still riding my emotions. 🥹💙😭 I wanted to share what I used as my study materials. They were either helpful or not helpful. Please do understand that this is just based on my views of the study materials. Everyone has their own different experiences and opinions. I studied for 2 months before taking my exam.
Note: I have 7 yrs of experience as a RN primarily in cardiac ICU and oncology.
Study Materials 1) UWorld Q-bank (Not helpful) 2) Leik Book (Helpful & recommend) 3) Sarah Michelle 1 Day Crash Course (Not helpful) 4) ANCC/ANA Practice Exam (Helpful & recommend)
*UWorld Q-bank: I used UWorld back when I prepped for the NCLEX so I was stoked when I found out they recently launched a FNP Q-bank. UWorld is good for those who don’t want to read through a textbook. The questions are accompanied by very thorough rationales. However, I felt like the rationales did not focus too much on treatment plans or pharmacology. It was great at explaining pathophysiology. But when it came to treatment, there would be phrases like “This disease will need medical treatment or this infection will need antibiotics.” It wouldn’t go into depth as to what medications would be recommended or prescribed. With UWorld, the questions were also very lengthy and did not correlate much with the format of the ANCC exam. There is a category for professional practice/ethics, but it had maybe less than 40 questions.
*Leik Book: An upperclassman recommended Leik to me as a study tool. I purchased the e-book version which did not come with the Q-bank. Leik was very thorough and helpful. I liked that the rationales included medications that would needed to be prescribed or recommended. The book also had tips and pointers along the way such as “this may be a possible ANCC or AANP question/topic.” Leik also explains the difference between ANCC and AANP questions which I found was super handy as testing strategies. At the end of each chapter were knowledge review questions which were either 10-40 questions long. There are also 2 practice exams at the end of book.
*Sarah Michelle 1 Day Crash Course: I know a lot of students swear by Sarah Michelle courses. I enrolled for this course 1 week before my exam date. This is a rapid course that covers all the body systems with 2 instructors. The course provided a study guide for the students to follow along. I don’t know if it’s the ICU nurse in me, but I felt the outline and organization of the session was very hard to follow. One minute we would be reviewing a question about GI and the next question would be about cardiac or endocrine and then back to GI. Alot of students mentioned in my session they would have preferred if it was structured to be 1 system with all the questions instead of jumping around too. But information wise, this review session does not go into full details. If you want to know about the explanations for diagnosis, interventions, and treatment/management, this review is not for you. This was a rapid fire question review session. A lot of the times, the instructors referred to alot of mnemonics which I was not familiar with. I’m assuming they were covered in the regular SM courses.
*ANCC/ANA Practice Exams: My advise… don’t freak out about the topics that were on the practice exams lol. I bought the practice exam to familiarize myself with the formatting of the questions. You wont need to know things like reportable diseases (which scared me because I did not study that at all). But the ANCC exam did similarly follow the practice exam format. I definitely felt less stressed as I was taking the FNP exam. The questions are more theory based than clinical base. But having studied mostly clinical scenarios, you can pretty much narrow your options down to 2 answers.
I hope this post helps everyone who will be taking their boards! Remember to breathe!

Uncommon opinion: care plans aren’t a thing for students to complete because it’s a nursing degree intervention, but rather so students have a better understand of the process to a complete recovery for patients rather than just the role as a nurse.
I hated them as well, but looking back - I get why we did them.

This thread is about to be very long, and I will be adding to it frequently, but this is how I would write season 3 of Euphoria since Sam is obviously preoccupied with god knows what. This came to me in a dream so call it fate ig.
Background- since season 2 ends with the card that Rue stayed sober through the rest of junior year, and Lexi’s play takes place in the spring, I thought it’d be best to pick up on the first day of their senior year in the fall. This means that Cassie, Maddie, and Nate have all graduated, leaving us with Rue, Jules, Lexi, Elliot, Bobbi, Ethan, BB & Kat. Also Gia, the Parents, and Ali. Anyways here goes.
Episode 1- I Stayed Sober (Mostly)
[Scene 1]: The Last First Day Episode One opens with a black screen that has flashes of red and blue, like police sirens, that increasingly become more intense and vibrant, to indicate Rue coming out of a dissociative state. She narrates over the screen:
“You want to know the worst part about staying sober? It’s not the withdrawals or the cravings, even though they’re pretty fucking bad. It’s not even the depression or the emptiness you feel without your poisonous security blanket protecting you from your worst thoughts and emotions. The worst part about staying sober, is that you’re trapped back in the fucked up world that made you want to do drugs in the first place”
The red and blue screen shifts to police sirens with cops yelling in an attempt to evacuate everyone from the school. It’s raining and the sky is gray and muddy. All the students are now wearing muted uniforms in the school colors, blue black and white (the uniforms are explained later) The scene looks very muted and drained. As the students flood out of the school in a frenzy, we see Rue and Lexi standing at the exit, uninterested in the theatrics and significantly changed from last season.
Rue has a brighter disposition to herself, appearing more soft and bright, while keeping her moody demeanor. Her look shows that she is trying her best to be more optimistic, despite going through hell from her plethora of mental illness that have now taken over due to her sobriety. Still, she looks healthier and brighter.
Lexi, on the other hand, has a more goth like appearance. In addition to her new dark black hair with red colored streaks (red to signify her stepping into her power) she also looks less approachable with more gothic motifs such as skulls and roses on her increased accessories. We learn later that this is an attempt to reinvent herself after last year’s play incident and fez dying. She seems uninterested and annoyed, but has a more confident air after being put in the spotlight and no longer having to live under her sisters shadow. She has become more monotone, speaking her mind and embracing her realistic perspective of life.
They begin walking to the parking lot, looking for Lexi’s mom among the waves of chaotic students pushing past them.
Rue: Of course, just our fucking luck that someone decides to shoot up the school our first day of senior year.
Lexi: It wasn’t even a real shooting. I heard some kid brought a gun to show off and got tackled by his teacher. Everyone started freaking out, and now I’m missing the first day of my AP English class.
Rue: Not like you need it. I think you proved that you can write a good story that makes waves and changes lives (sarcasm)
Lexi: 😐 that’s not funny Rue. That play is all anyone could talk about all summer. Everyone hates me because they think it’s my fault that we all have to wear these stupid uniforms.
Rue: actually that was Cassie’s fault, that fight got a new edit every week. My favorite was the #mollywhop dance (starts doing a dance that is significant of Maddie slapping Cassie and Cassie riding a carousel)
Lexi: Rue I’m serious. I got so sick of living in the background that I put my entire life on display in front of all of East Highland just for my sister to make everything about her.
Rue: Well good writing is supposed to be controversial. And take it as a victory, at least you’re not a nobody anymore.
Random Guy: Hey Lexi, I got a horse you can ride (does the dance)
Cop: Keep it moving sir!
They get to the end of the parking lot and sit on the pavement.
Lexi: 🙄of course she’s late.
Rue: hey, it’s a new year. You’re no longer the girl whose sister was the hottest cheerleader in school and I’m no longer the resident drug addict that everyone is waiting to die.
Lexi: you’re right. That’s Elliot. Or Jules. Have you checked on either of them since his overdose?
Rue: no…fuck them both. They seem happy in their stupid relationship with their stupid anniversary posts. I had to block them both before I killed myself or worse. They can die for all I care.
Lexi: well he almost did. I heard he had a stroke and is in a wheelchair until he learns how to walk again.
Rue: trying to hide that she’s concerned really?…i mean i don’t care, but that’s what he deserves right? Can’t do drugs that carelessly without consequences. Ask me how I know.
Lexi: I don’t think anyone deserves to OD. I hope he gets some help.
Rue: he has help, that bitch is playing housewife which she probably loves. Attention seeking whore. You know I’m sick of talking about Jules and Elliot and Cassie and every other narcissist with a victim complex that keeps trying to make themselves the main character. pulls her closer with a shoulder hug this year it’s about us. Starting over and getting a chance to finally make it out of this stupid town. You have colleges lined up at the door and I’ve been sober for almost a year. No one is going to take this year from us. That why you blocked Cassie, and that’s why I had any memory of Jules permanently erased from my brain. Out of sight out of mind.
Lexi: I guess you’re right. New year, new us.
Rue: alright. Now call your mom so we can get out of the rain. I hate cops more than I hate being fully clothed and wet.
Lexi: (finally smiling) almost as much as they hate you
Rue: hey fuck you, I still have to go to court for that.
Lexi: too soon? 🤭
Rue: just dial the fucking phone
Rue [vo while it shows Suze driving up and the girls walking across the parking lot]: Despite how terrible last year was, I feel like Lexi and I finally got back to how things used to be. Before the drugs, before the funerals. Just Rue and Lexi like it’s always been. Sometimes I forget how great life was when I was just a kid. But drugs tend to take away everything that makes life, life. I just wish Fezco had stayed alive long enough to finally see me sober. Then maybe Lexi wouldn’t be so serious and emo these days. But she took care of me, and now it’s my turn. I just don’t know what’s worse, losing the love of your life before you get a chance to say it love you (shot of Lexi rubbing a cross chain fez gave her looking at the sky before getting in the car) or thinking you found the love of your life just to end up as strangers. (As Rue opens the door to get in, she sees Jules wheeling Elliot across the parking lot. She stares for a bit before getting in the car.) Either way, we all died. (Rue gets in the car before Jules can see her.)
Jules looks over at the car but doesn’t see anyone. She looks distraught, hoping to catch a glimpse of Rue, who she hasn’t seen since the play. She’s dressed in a mostly black school girl uniform with a short skirt and corset that she’s clad in neon accessories and coquettish garters and bows. Her hair is longer than in season 2 but shorter than season 1. This is to signify that she’s embracing her femininity more with Elliot, but is stepping into a more powerful, dominant version of femininity. She’s content with her relationship, and rebuilding herself after the abuse she endured in relationship with rue. Now she’s just worried about repeating the same story with Elliot. She looks off into the distance, paused in a state of reflection.
Elliot: babe are you good? Jules: what? Yea just thought I saw something. (Continues wheeling him across the parking lot) Elliot: It was probably a ghost. HEY CASPER, LOOK BUT DONT TOUCH HOMIE Jules: (laughing) you’re so unserious Elliot: what do you mean? I’m serious. I don’t want his ectoplasm fucking up your makeup. Jules: You’re the one who keeps fucking up my makeup Elliot: and I’ll do it again kisses her winces ow fuck Jules: relax dude. You know the doctor said you can’t stretch your spine much after your stroke. Elliot: and you know I told that doctor nothing can kill me and I’m basically a god Jules: even when you’re sick you’re still crazy Elliot: crazy for you Jules: yea yea, just be happy it was a stroke and not a death sentence. whispers in his you know if you would’ve died I would have to kill you. Elliot: besides the fact that that makes zero sense, you know it wasn’t my fault Jules: I’m just glad that Laurie lady got put behind bars. Who the fuck puts fentanyl in Weed? Elliot: a plug who can’t find enough junkies to buy their fentanyl. That’s why I always sniff my weed before I smoke it. Jules: and that sniff put you in a wheelchair, so who’s god now? Elliot: mmmm, still me. I live close enough to the school that I don’t have to pay for a van, and I have a hot chick with a huge dick as a nurse. Not to mention loads of settlement money from suing the biggest plug in our area and a med card with all the unlaced weed I can smoke. I’m up as fuck. Jules: or too high to be traumatized Elliot: And (dances her around his chair like a waltz until she falls in his lap) my dick still works. Jules: nice try Romeo, but your ego is showing (zips up his pants and continues pushing) Elliot: fuck, has it been like that all day? That’s embarrassing Jules: no more embarrassing than the whole school thinking you’re in a wheelchair because you couldn’t hold your oxys Elliot: it was Percs actually, thank you very much. And fuck what those bots think, I’ve been sober since that intervention. I guess you can say Rue knocked some sense into Me. Jules: (avoiding the topic of rue) did you see the comments on our last post, they called us percinstein and the coke bride Elliot: damn I guess they did know it was Percs (Now on his front porch)
Jules: (standing in front of him looking in his eyes with sentiment ) Elliot I’m serious. I’ve been the topic of conversation ever since I moved to this fucking town. I just want to have a normal year for once in my complicated life. Elliot: babe listen it’s high school. Everything is the topic of conversation and no one is normal. People talk shit because they’re bored and have no personality or sense of self outside of the useless drama they can create in their minds. But you have a life, and a future. You have an amazing, sober boyfriend who loves you and a portfolio that can get you into any art school in the world. You’re at the last step before your real life begins. I’m just happy that I have the privilege to watch. And you know I like to watch. Jules: you’re a lunatic. Elliot: I love you. Jules: I love you too. kiss
Elliot: Are you sure you can’t stay tonight Jules: I wish, but my dad is serious about making sure I get into the best school, which means spending hours look at boring virtual tours and applying early admission. Elliot: ok well I’ll be here figuring out how to pee without standing up Jules: how do our conversations always center back to your dick Elliot: I can’t talk about anything else, it’s too hard Jules: wow, you sound like my dad and I’m turned off [starts walking away] Elliot: it’s not me it’s the weed. now you make sure you make it home safe. There’s a shooter on the loose. Jules: [grabbing her bike] the gun wasn’t even loaded. besides, getting shot would not be the worst thing to happen to me. Elliot: you’re American. It always gets worse. Jules: [riding off] that’s depressing Elliot: text me when you’re home Jules: [almost gone] you have my location! Elliot: [to himself] and I still never know where you are

I‘be been out of EMS for more than 20 years. The last big trend we had in BLS airway management was combitubes, and the last big thing in ALS were the studies being done with RSI. Has anything interesting evolved in “the future of airway management” since I’ve been away?
I became a psych nurse, doing primarily mobile crisis intervention. Same basic idea as EMS; stabilize in field and transport, only with psychotherapeutic measures and psychiatric drugs instead of all the cool stuff I got to play with in EMS.
Also, the last big thing in ACLS was that the world supply of Bretylium was drying up, what ever happened with that? There were several candidates for new drugs.
Other questions: do we still do manual CPR on long hauls or did they ever come out with a simple device to deliver high quality chest compressions?
Anything new in trauma? Did they ever come out with anything better than the flexible splint like a pneumatic mechanism, or is it still the gold standard?
Cric kits: issued to medics or no?
Did EMT-Bs ever get to start using pulse oximeters? (I’m pretty sure the answer is yes!) If so, when?
Did they ever settle the fentanyl vs. morphine debate?
Do ALS units still carry meperidine? Does anybody new to EMS even know what meperidine is?
Are BLS providers carrying naloxone intranasal? What about intramuscular? What about ALS?
Oh god, the flood gates are open. I have so many more. I haven’t even thought about this in twenty plus years, and I’d rather hear from humans than GPT at this point.
Thanks ahead of time!

F45 Heavy smoker for 30 years- quit cigarettes in August but started vaping. Currently quitting No drug use but history of binge drinking (>4 units) monthly. Daily caffeine use Dx: 1. PoTS via TTT at age 22, Stress echo normal 2. GAD and Panic disorder diagnosed around the same time at PTS. ADD a year later 3. Asthma- birth 4. Rheumatic Fever- age 5, recurrence in 20s 5. Hypothyroidism- 2022 6. High cholesterol levels since age 20 7. IBS-C 8. IC with lesions/ulcers via cystoscopy 9. Hidradenitis S- stage 1 10. Primary open angle glaucoma- Just diagnosed 11. Low D3, low b12 12. Poly Cystic breasts 13 cervical radiculopathy and headaches 14. Previous DVT during pregnancy 15. Venus dysfunction- saphenous veins removed at 24, yearly revisions when warranted by US. 16. GERD- fundoplycation performed as a baby
Meds: 1. Rosuvastatin 0.5 mg qd 2. Spironolactone 100mg qd 3. Xanax 1 mg t.d.s 4. Spiriva 1.25mcg 5. Breo ellipta 200mcg 6. Semaglutide 1mg weekly 7. Lumigan 0.01mg 8. B12 1000mcg 9. D3 10. Linzess 145mg
Hi everyone and I apologize for the length of this post. I have been having some major dizzy spells, including near syncope episodes and little cramps in my left chest with some radiating left arm pain. I have been having the chest/arm pain episodes for over a year but have ignored them mostly believe they were a result of my c-spine disc herniations and arthritis, painful breast cysts, and anxiety. Recently my PoTS has seemed to flare and I have been getting nauseous, extremely dizzy and having little cramps in my chest which resulted in an ER visit. ECG/X ray and bloodwork was fine but I was sent home with a 5 day holter and followed up with cardio.
She didn't mention anything about the holter except a few instances of tachycardia but ordered a stress test and separate echo (not a stress echo)
Was told stress test was normal- I did have some BP issues at first but then a normal response. I've linked the report: https://ibb.co/album/1GB51m
The echo is abnormal :https://ibb.co/album/9ZsM1g
The nurse called me back and wants an additional echo with contrast and to have it reviewed by their cardiothoracic surgeon. I'm scheduled for Monday morning. I have a follow up with my cardiologist in 30 days
They told me to try and not stress unless i have severe chest pains, back or neck radiation of pain but my c-spine issues already cause this. I''m obsessing over my results. I'm generally healthy, only taking semaglutide due to a 36lb weight increase a year ago that happened within about 6 weeks. I eat decent but I do still vape and drink too more than the recommended amount of alcohol on occasion. Every chest pain I feel makes me want to go to the ER but I recognize that my anxiety could also be causing this.
The only other thing to note is that I did get Covid last winter and had some major personal stressors last year that required me to take Wellbutrin XR 300 mg which I stopped about 2 months ago. 2 years ago I went to the ER for leg and chest pain. Elevated D-dimer but no PE or clot was found (they said it couldn't be ruled out). I've also recently started getting tinnitus several times a day.
I'm not asking for medical dx or advice because I am currently under the care of a cardiologist but is anyone able to interpret my test reports and help me understand theoretically how this damage could happen in a 45 year old? Could a undiagnosed clot or MI cause damage similar to what is reported? Or is this due to my smoking and drinking history?
I appreciate all of you and the time you take out of your day for us posters.

Sorry if this sounds selfish but this is really only a one time thing for a friend. I need someone to use there undetectable AI account to paraphrase this please.
IntroductionThe rise of fast food chains in the United States from 2000 to 2010 had an impact on both the culture and economy. This period saw an increase in obesity rates among Americans, which coincided with the growth of these eateries. In this essay we delve into the connection between the expansion of fast food franchises and the obesity epidemic examining factors that influence health. Through an analysis of data, health studies and relevant literature our goal is to provide an understanding of how consuming food has played a role in fueling obesity during this particular decade, in America.The Growth of Fast Food Chains
Between 2000 and 2010 there was a rise in the fast food industry. Popular chains such as McDonalds, Burger King and Subway expanded their reach by opening stores to meet the demand for budget friendly meals. Data from the U.S. Census Bureau shows that the number of fast food eateries increased by around 20% during this timeframe (U.S. Census Bureau, 2011). This expansion made fast food more convenient for a range of people, including kids and teenagers.
Obesity Trends in the U.S. (2000 2010)
The prevalence of obesity in America has been on a trajectory during the early years of the 21st century. According to the Centers for Disease Control and Prevention (CDC) the rate of obesity among adults rose from 30.5% in 2000 to 35.7% in 2010 (CDC, 2011). Similarly among children and teens aged between 2 and 19 years old obesity rates increased from 13.9% to 16.9% over that period. This continuous increase signals a concerning public health issue with impacts on illness rates, mortality rates and healthcare expenses.
The Impact of Fast Food, on Eating Habits
food is commonly known for its levels of calories, excessive saturated fats, sugars and sodium with little nutritional value. These aspects of food are closely associated with weight gain and obesity. Studies show that regular consumption of food is linked to consuming calories and maintaining poor eating habits (Bowman & Vineyard 2004). Research conducted by Pereira et al. (2005) revealed that individuals who ate food than twice a week were more likely to gain weight and develop insulin resistance compared to those who consumed it less frequently.
Influence of Socioeconomic Factors
The easy availability and affordability of food make it an attractive option for people with incomes. Fast food establishments are often concentrated in low income areas where residents have limited access to dining choices (Powell et al. 2007). This situation, referred to as "food deserts " , worsens the issue of obesity because disadvantaged groups tend to rely on food as their main source of nutrition.
Impact of Advertising and Promotion
The aggressive advertising tactics used by fast food companies also have a significant influence on eating behaviors particularly among young individuals, like children and teenagers.
Many businesses invest sums of money each year in marketing showcasing their products across platforms, like TV, the web and social networks. Kids are especially influenced by these strategies that highlight the appeal and ease of food reinforcing harmful dietary patterns early on.
The impact of obesity, on health is significant and variedObesity is a factor in chronic illnesses like type 2 diabetes, heart disease, stroke and certain cancers (Flegal et al., 2012). The rise in obesity rates has led to an increase in health issues putting a strain on the healthcare system. The financial implications of obesity are also noteworthy with studies indicating that medical costs linked to obesity made up around 10% of healthcare expenses in the United States during that time (Cawley & Meyerhoefer 2012).
Policies and public health effortsIn response to the escalating obesity crisis, different policies and public health efforts have been put into action at state and local levels. These initiatives aim to encourage eating habits through measures like food labeling requirements, restrictions on advertising foods to children and campaigns raising awareness about the risks of obesity (Koplan et al., 2007). Schools have been a point for intervention well, with endeavors to enhance the nutritional value of school meals and boost physical activity among students.ExamplesVarious real life examples and stories showcase the effectiveness of taking action to address the issue of obesity. For example, New York City put in place a set of strategies to combat obesity, such as displaying calorie information on menus and prohibiting trans fats in restaurant dishes. These initiatives led to improvements in people's eating habits and a slight decrease in obesity levels, within the community (Dumanovsky et al. 2011).ChallengesThe obesity epidemic still poses challenges despite the efforts to address it. Unhealthy eating habits deeply ingrained in society, the presence of the fast food industry and disparities in status all add layers of complexity to this issue. Moving forward it is crucial to focus on creating an environment that encourages choices for vulnerable communities. This entails advocating for policies that restrict the marketing of foods to children, enhancing access to options in low income areas and urging food companies to improve the health profile of their products.
Psychological marketingWhen it comes to food marketing companies go beyond advertising tactics by leveraging deep rooted psychological triggers that influence consumer behavior. Bright colors, catchy tunes and recognizable mascots are commonly used in food ads to build a memorable brand image. This technique is particularly effective with audiences like children and teenagers who're more susceptible and likely to develop lasting brand loyalties. Research indicates that exposure to these advertisements can lead children to prefer calorie, nutrient foods ultimately impacting their dietary decisions and contributing to weight gain (Boyland & Halford 2013).The impact of portion sizes
One overlooked but significant factor contributing to the obesity crisis is the increasing sizes of portions served by food chains. Over time portion sizes have substantially grown, with meals exceeding the recommended calorie intake for a single meal. Young and Nestles (2002) study reveals that fast food item portions have expanded over the years with some items now more than double their size. This phenomenon of "portion distortion" results in calorie consumption as individuals tend to eat when faced with larger servings often underestimating the actual caloric content.
Changes in lifestyle and time constraints
The contemporary way of life characterized by schedules and time limitations has also played a role in the heightened dependence on fast food. With an increase in dual income households and longer work hours many people find themselves lacking the time to cook meals. Fast food emerges as a solution offering cost effective options that align with busy routines. Nonetheless this convenience comes at a price as frequent consumption of food is linked to dietary patterns and increased calorie intake contributing to the surge in obesity rates (Smith, Ng & Popkin 2013).Another significant measure involves restricting the promotion of foods to children. By reducing kids exposure to food ads policymakers aim to lessen the impact of marketing on their eating habits. Some cities have also imposed taxes on beverages and unhealthy foods in an effort to discourage consumption through penalties. While the effectiveness of these strategies may vary they mark progress in combating the obesity crisis.
Approaches Rooted in Communities
Community based strategies for addressing obesity highlight the importance of initiatives and grassroots movements. Programs that concentrate on enhancing access to foods encouraging activity and educating community members about healthy eating have shown positive outcomes. For example community gardens and farmers markets can offer produce to residents living in areas with access to healthy food options promoting better dietary choices. Schools and community centers can also play a role by providing nutrition education and physical activity programs.
The Impact of Technology
Technology has increasingly become an asset in the battle against obesity. Mobile applications and wearable gadgets enable individuals to monitor their calorie intake and exercise levels offering feedback and motivating lifestyle choices.
Furthermore social networking sites can play a role, in advocating for public health initiatives and sharing details on diet and wellness. Although technology isn't a solution to the issue of obesity it provides avenues to involve people and groups in embracing healthier habits (Stephens & Allen 2013).
Future Directions and Recommendations
The approach to tackling obesity needs to be multi-faceted and should involve collaboration between government departments, health workers, local communities, as well as the food industry. In future, there is need for more efforts in creating an atmosphere that supports healthier selections particularly among the disadvantaged groups. This means that one should continue to campaign for policies aimed at reducing children’s exposure to unhealthy food advertisements, improving availability of healthy foods in deprived neighborhoods and encouraging manufacturers in the food sector to change their products into a healthier version.
Further still public health campaigns will try and focus on having balanced diets regularly done exercises. Schools and offices can succeed by developing well-structured meals alongside opportunities for exercising. More research is also needed to understand why some people are poor eaters or overweight than others.
Policy Proposals
To further combat the menace of overweight, policy makers should think about enacting a variety of evidence-based strategies. Some of them could be: Sugar-Sweetened Beverage Taxes: Taxes on sugary drinks can decrease consumption and raise funds for public health projects. Zoning Regulations: By controlling the number of fast food restaurants in given areas, intake will subside and encourage establishment of grocery stores among other healthier alternatives.Menu Labeling Laws: This makes sure that restaurants indicate calorie counts as well as other nutritional information to assist customers in making informed choices. School Nutrition Standards: Schools meals and snacks in the course of learning ought to meet recommended nutrition levels so that students are eating healthy. Addressing Behavioral FactorsBehavioral interventions also play a significant role in dealing with obesity. Cognitive-behavioral therapy (CBT) and other psychological approaches aid individuals to develop better eating habits and deal with triggers involved in overeating. Programs addressing weight control which incorporate behavior change counseling together with diet and exercise components show promise towards helping individuals achieve successful long term weight loss.Long-Term Commitment and Sustainable Change
Society must collectively make a commitment that will last over a long period to reduce obesity rates. The approach should be ongoing and flexible enough to accommodate changing circumstances and new information. For this change to be lasting, there must be continuous investment in public health infrastructure, research, and education. Therefore, significant strides can be achieved in reducing obesity rates by nurturing a culture that appreciates wellness.
Cultural Shifts and Public Perception
In addressing the obesity epidemic another critical factor is shifting public opinion as well as cultural norms with regards to food and health. The acceptance of fast food and oversize portions as normative has been one of the major drivers towards unhealthy eating habits over the past few decades. This would involve public health campaigns focused on what constitutes healthy balanced meals and promoting on good home cooked fresh meal benefits instead. To change public perception cooking classes nutrition workshops media campaign advertising preparation advantages of healthy meals at home for instance.
Strengthening Health Care Interventions
Routine screenings, counseling and support for weight management by health care providers are crucial in handling obesity. Obesity prevention and treatment should be integrated into primary care to ensure consistency and comprehensiveness in people’s health. Personalized advice can be availed by the healthcare practitioners and also set realistic targets as well as referring patients to dietitians or structured weight loss programs.
Advancing Research and Use of Proven Practices
To better understand the intricate contributors to obesity and curate effective interventions, it is important to sustain research. Longitudinal studies that follow diet patterns, activity levels, and disease outcomes offer useful information on how to prevent or reduce obesity. By exploring behavioral, environmental and genetic factors that affect obesity, this will enable us to make interventions that are specific for different populations and situations as well.
Conclusion
The period between 2000 and 2010 registered a sharp increase of obesity rates that is closely linked to the spread of fast food outlets across America. This public health menace can only be fought with multidimensional approaches that will change public attitude, improve education, enhance corporate accountability and support inclusive research plus health care interventions. By creating an environment where good health is appreciated through provision of necessary resources and support, we can achieve significant milestones in curbing cases of obesity within our population as well as overall improvement in their welfare.
Citations:
Boyland, E.J. & Halford, J.C.G., 2013. Television advertising and branding. Effects on eating behavior and food preferences in children. **Appetite**, 62, pp.236-241.
Brownell, K.D. & Frieden, T.R., 2009. Ounces of prevention—the public policy case for taxes on sugared beverages. **New England Journal of Medicine**, 360(18), pp.1805-1808.
Drewnowski, A. & Specter, S.E., 2004. Poverty and obesity: the role of energy density and energy costs. **American Journal of Clinical Nutrition**, 79(1), pp.6-16.
Krieger, J.W., Chan, N.L., Saelens, B.E., Ta, M.L., Solet, D. & Fleming, D.W., 2013. Menu labeling regulations and calories purchased at chain restaurants. **American Journal of Preventive Medicine**, 44(6), pp.595-604.
Ogden, C.L., Carroll, M.D., Kit, B.K. & Flegal, K.M., 2014. Prevalence of childhood and adult obesity in the United States, 2011-2012. **JAMA**, 311(8), pp.806-814.
Smith, L.P., Ng, S.W. & Popkin, B.M., 2013. Trends in US home food preparation and consumption: analysis of national nutrition surveys and time use studies from 1965-1966 to 2007-2008. **Nutrition Journal**, 12(1), p.45.
Stephens, J. & Allen, J., 2013. Mobile phone interventions to increase physical activity and reduce weight: a systematic review. **Journal of Cardiovascular Nursing**, 28(4), pp.320-329.
Story, M., Kaphingst, K.M., Robinson-O'Brien, R. & Glanz, K., 2008. Creating healthy food and eating environments: policy and environmental approaches. **Annual Review of Public Health**, 29, pp.253-272.
Walker, R.E., Keane, C.R. & Burke, J.G., 2010. Disparities and access to healthy food in the United States: A review of food deserts literature. **Health & Place**, 16(5), pp.876-884.
Young, L.R. & Nestle, M., 2002. The contribution of expanding portion sizes to the US obesity epidemic. **American Journal of Public Health**, 92(2), pp.246-249.
Fulkerson, J.A., Story, M., Neumark-Sztainer, D. & Rydell, S., 2008. Family meals: Perceptions of benefits and challenges among parents of 8-to 10-year-old children. **Journal of the American Dietetic Association**, 108(4), pp.706-709.
Huang, T.T.K., Drewnowski, A., Kumanyika, S.K. & Glass, T.A., 2009. A systems-oriented multilevel framework for addressing obesity in the 21st century. **Preventing Chronic Disease**, 6(3), A82.
Kumanyika, S.K., 2008. Environmental influences on childhood obesity: Ethnic and cultural influences in context. **Physician and Sportsmedicine**, 36(1), pp.45-51.
Larson, N.I., Story, M.T. & Nelson, M.C., 2009. Neighborhood environments: Disparities in access to healthy foods in the US. **American Journal of Preventive Medicine**, 36(1), pp.74-81.
Ludwig, D.S. & Pollack, H.A., 2009. Obesity and the economy: from crisis to opportunity. **JAMA**, 301(5), pp.533-535.
Powell, L.M., Chaloupka, F.J. & Bao, Y., 2007. The availability of fast-food and full-service restaurants in the United States: associations with neighborhood characteristics. **American Journal of Preventive Medicine**, 33(4), pp.S240-S245.
Sallis, J.F., Floyd, M.F., Rodríguez, D.A. & Saelens, B.E., 2012. Role of built environments in physical activity, obesity, and cardiovascular disease. **Circulation**, 125(5), pp.729-737.

I benefitted a lot from the advice on this subreddit and used a lot of it to guide my approach to M3 year; now that I've had the chance to sit the exam, I wanted to create an exam write-up in the hopes that it will be useful to others. This write-up is lengthy, as I wanted to include advice for any new M3 students about how to maximize 3rd year, as well as some Step 2-specific strategies and advice.
A little about me: I am a non-traditional student (in my 30s) at a mid-tier US MD school. Pre-clinical grades were good (honored 2nd year, 0.5% away from honoring 1st year). Honored every rotation in 3rd year. I am a peer tutor at my medical school and was actively involved in tutoring 1st and 2nd year students throughout my M3 year and dedicated.
I am a big believer in students teaching students and the idea that if we all work together, we all become better students and clinicians. In that spirit, I welcome you to ask me any questions that you have below.

Overview

In general, my advice boils down to:

1. Don't try to use EVERY resource. Choose a few high-quality resources and really know them well.
2. Doing well on Step 2 (and shelf exams, tbh) requires active learning strategies and continually trying to think about what the next step would be. Practice questions are a great way to do this, but challenge yourself to go beyond what each individual question to build a broader knowledge base. That way, you won't only know the answer to that specific question, but also to a whole host of related questions.

General studying tips for 3rd year + dedicated
I am a big believer that the most effective study strategy involves four big components:

1. A question bank (UWorld) - gives you primary exposure to the material and helps to identify where your gaps are.
2. A system for continuously reviewing content - I used Anki (I discuss this more below). You can also use other strategies (note-taking, old school flash cards), but the important thing is that your review strategy needs to be ACTIVE (i.e., not just re-reading your old notes, but actively quizzing yourself and covering up the answers) and it needs to be CONTINUOUS. I did not pause any Anki cards during 3rd year, so by the time I got to dedicated, I had been actively, continuously reviewing content for months.
3. Resource(s) for primary sources - this is where you go when you need to refresh on pathophysiology, look up treatment/diagnostic testing for a disease, or understand the symptoms. I prefer UpToDate for this broadly, and used some additional resources on specific clerkships that I will discuss below.
4. Practice exams - NBME practice shelf exams ("CMS forms") and NBME Step 2 practice exams; do them timed to practice pacing.

A note on AMBOSS vs UWorld
A lot of people I know use AMBOSS and like it. Some people want an additional bank of questions to study from. I didn't personally use AMBOSS at all during 3rd year, and only used it for Ethics and QI during dedicated (and honestly, it was only marginally useful - may have gotten me 1 or 2 extra points on the real step 2 exam, but not more than that).
I think the smartest way to approach Q-banks is to make sure you have enough time to complete and thoroughly review at least one. For me, UWorld was more than enough to prepare well for each shelf exam and step 2 (honored every rotation). I think that a lot of people who try to use both AMBOSS and UWorld never finish either Q-bank in its entirety, or don't really review the Q-bank adequately. I decided it was a better use of my time and money to review only one but really know it well.
A note on Anki
Anki is a powerful tool that can really help with your long term retention, but it is dangerous if used incorrectly. I suspect that many people who don't find Anki helpful simply don't use it effectively.
The purpose of Anki is spaced repetition. In order for this to work, you have to keep up with reviews and you can't pause cards. I also caution students I tutor to be cautious of relying solely on a premade Anki deck; I used the AnKing deck, as well as this deck and a home-brew deck at my medical school.
During M3 year, I would start each rotation with UWorld from day 1, and as I came across each concept in UWorld, I would do a search through my Anki cards and unpause all the cards that related to that topic (so, for instance, when I got a question about diverculitis, I would then unpause all the diverticulitis cards). I found that doing this ensured that the new Anki cards I was adding were reviews of concepts I had just studied (via UWorld), so I was able to both reinforce the new content via Anki and also ensure that the new Anki cards I was adding were concepts that I was actually familiar with. I recommended this approach over the one that I saw many classmates using (just unpausing all the cards tagged for a clerkship at the start of the clerkship and "raw dogging" them, as my friend put it). It's also a good way to keep your daily new cards (and thus, your reviews) at a manageable number. On a typical day in 3rd year, I added between 50-100 new cards and averaged 250-350 reviews daily. I was nearly always able to complete my reviews while I was at the hospital each day, leaving my home study time free for UWorld.
More on how to effectively use Anki
A note on staying sane and prioritizing high-yield content
As others have said, I think that the best way to do extremely well on Step 2 CK is to approach M3 as a yearlong dedicated period. Doing well on Step 2 is not just about your preparation for the Step 2 exam, but also your learning during each rotation and your preparation for your shelf exams. Even if you're not at all interested in a particular specialty, there is a lot to learn from each rotation that will be valuable to you as a future physician. Additionally, each specialty has its own way of approaching medical decision-making, and paying attention to these patterns of thought can help you to reason through questions on exams, as well as be a better communicator with physicians in each specialty when you become a resident and attending.
As you progress through 3rd year, there are also a few things that I think it's wise to keep in mind:

• Remember that you are a person first and a medical student/doctor second. I put this first because it's the most important. It's hard to learn when your basic needs aren't being met or you're so anxious, stressed, or depressed you can't remember anything. Find something that keeps you grounded and whole and sane and make that a priority. For me, it's distance running. I ran nearly every day of 3rd year and dedicated (often at 3 AM, before rounds). I finished 3 marathons during M3 and dedicated, including running the Boston Marathon 2 weeks before I took step 2. Running relieves anxiety, gives me an excuse to step away from studying, and evens out my mood. In total, I ran over 2500 miles during my M3 year. I don't think I would have done anywhere near as well in M3 without it.
• Get really, really good at preventive care. The US Preventive Services Task Force guidelines are highly tested on all shelf exams and on Step 2, and there really aren't that many of them. Before my family med rotation, I made an Anki deck of the A and B recommendations based on the most recent updates and kept those in rotation through Step 2 (about 150 cards total). If you're at the beginning of M3 year, (or really any point in M3) I would suggest doing this right now. Every time you see a patient in clinic, think about "what screening exams should this patient have". If you get in the habit of always doing this, by the time you get to the exam, those screening questions will be free points (and there are usually a bunch of them).
• Try to approach every patient encounter as though you are the sole physician responsible for that patient's care. Formulate your own plan independently of residents or attendings. Ask questions about all these things in your patient interview, and present the answers to your attending. You will learn more if you push yourself to try to think about management from the beginning of 3rd year rather than relying on plans from your residents.
• Pay attention to sensitivity and specificity of tests. This is becoming a bigger and bigger deal on NBMEs and Step 2. Knowing sensitivity and specificity can help you determine whether a given finding in a question stem is significant or not.
• Look up every imaging test and diagnostic procedure you come across, whether in clinic or on a practice exam. A good rule of thumb for whether you understand a test is "Do I know when this test is appropriate, when it is inappropriate, and could I explain it to a patient?". I had a surgery fellow pimp me on when to order an ERCP vs MRCP; this stuff is important because it prevents unnecessary testing and allows you to get the most "bang for your buck", both in terms of diagnostic accuracy and scoring points on the "next step" questions on exams.
• Pay attention to thresholds for follow-up observation vs treatment. If a patient has a AAA that's 3 cm, you do serial ultrasounds and watch it clinically; if it's 7 cm, you operate. Many, many conditions have similar thresholds, and you should look for the differences in how you manage a condition based on the thresholds. Sometimes this stuff is buried in the UWorld explanations, so when you see it, make a flash card or add it to your review.
• Know the USPSTF screening guidelines like the back of your hand. There aren't that many of them, and it's basically free points on every single shelf exam + step 2. Make a flash card deck with the most updated versions on day 1 and review it throughout 3rd year. Especially high yield on FM + IM, but they appear on every shelf.
• Think about what things a specialty "cares about" when you're rotating on that specialty.
  • OBGYN: gestational age, STI history/screening, social/fam Hx of risk factors for gyn cancers (breast, cervical, ovarian, endometrial).
  • Surgery: is the patient safe to take to surgery (comorbidities, heart failure, coagulopathies, meds, etc)? When is surgery indicated (i.e., do they have to go now, or can they wait)? Antibiotic prophylaxis (who needs it, and what antibiotics)? Post-op complications (the "5 W's", leaks, nearby structures that can be injured)? Normal post-op care/patient safety (DVT prophylaxis, catheter removal, infections, etc).
  • Peds: developmental milestones/normal development/growth curves, rashes (pediatricians love rashes), upper respiratory infections, stuff that gets treated differently in kids (ex. febrile UTI), neonatal hyperbilirubinemia (basically guaranteed to get at least one question on this on any peds exam)
  • IM: Preventive care/screening, vaccines, hypertension, diabetes, heart failure, ACS, liver failure/cirrhosis.
  • FM: IM + Peds + OBGYN, with a heavy focus on preventive screenings
  • Psych: Pay attention to timelines; think of every psych disease as a continuum (i.e., <1 mo = brief psychotic disorder, 1-6 mo = schizophreniform, 6+ = schizophrenia, schizophrenia + mood symptoms = schizophreniform). Find something that makes sense to you for the personality disorders (I personally mapped them all onto Harry Potter characters and now I will never have to re-learn them).
  • Neuro: Differentiating causes of stroke, multiple sclerosis, when to get an MRI (answer: always get an MRI in neuro), different types of dementia

Subject Review

This section is intended for those who are starting or still in the midst of M3 year. If you're already in dedicated, this section may be less useful.
For all rotations, my strategy was generally:

1. Complete the UWorld Shelf exam Q-bank with 1-2 weeks to spare
2. Make/unpause Anki cards as I worked through UWorld
3. Take timed NBME practice shelf exams regularly throughout the rotation(I sat down at the start of each rotation and planned these out every 1-2 weeks so they were evenly spaced throughout the rotation). Get through every practice exam by the end of the rotation. Doing them timed is important because it helps you to practice pacing. One 50-question exam at 90 seconds/ question = 75 minutes total. I also wrote down the diagnosis for each question so that when I reviewed the exam, I could see whether any wrong answers were a problem with making the wrong diagnosis vs knowing the next step. Doing the NBME shelf exams also gives you a good sense of what the "pet concepts" that tend to occur over and over are (for instance, SCFE vs Legg-Calve-Perthes comes up shockingly often)

Order of rotations:
I did my rotations in the order listed below and I really liked this order. I know many people advocate for finishing on Internal Medicine, but I was very glad I started with it, because I think it laid a strong foundation for everything else. As long as you have a solid strategy for reviewing the IM content continuously throughout the year, I think it's a smart choice for the first rotation, especially because basically every other shelf exam will have 5-10 IM questions on it.
Medicine
Resources: UWorld (IM shelf bank + 1/2 of Ambulatory), Case Files Internal Medicine (did ~50% of it), USPSTF A & B guidelines, NBME practice shelf exams ("CMS forms"), Emma Holliday review
Advice: If you have free time 1-2 weeks before starting IM, get through as much of Case Files as you can. It lays a good base and helps you get into the mindset of IM. Once you start the rotation, crank through UWorld. I'd suggest trying to finish the UWorld Q's with 1-2 weeks to spare at the end of the clerkship in which you can review incorrects and/or shore up any weak areas.
Raw Score: 85
Neurology
Resources: UWorld, Case Files: Neurology, NBME practice shelf exams ("CMS forms")
Advice: Case Files Neuro is a little in the weeds, but it will help a lot with some of the more off-the-wall pathologies that aren't really seen in the UWorld bank.
Raw Score: 90
Psychiatry
Resources: UWorld, Case Files: Psych, NBME practice shelf exams ("CMS forms"). A lot of people swear by First Aid for the Psychiatry Clerkship; I didn't use it (but I think Case Files accomplished much the same purpose)
Advice: Pay attention to timelines + enjoy the psychation! This is the lightest rotation for most people. Take it in the summer if at all possible and enjoy the nice weather and free time. If you can, get it somewhere in the middle of 3rd year so you can have a little break.
Raw Score: 94
Family Medicine
Resources: UWorld (FM bank + 1/2 of ambulatory bank), Case Files: Family Med, NBME practice shelf exams ("CMS forms"), USPSTF A & B guidelines, CDC vaccination schedules
Advice: Try to take FM after IM, if at all possible. DO NOT underestimate the family medicine shelf exam. It is the broadest shelf exam, and it's heavily weighted towards prevention, so plan your studying accordingly. Know the USPSTF guidelines and vaccine schedules like the back of your hand (this is at least 25-30% of the shelf exam).
Raw Score: 85
Surgery
Resources: UWorld (Surgery bank + EM bank), de Virgilio's Surgery, NBME practice shelf exams ("CMS forms") for EM and Surgery, American College of Surgeons TEAM (Trauma Evaluation and Management) course book, Emma Holliday review
Advice: The surgery shelf exam focuses heavily on the pre- and post-surgical management of surgical patients, trauma assessment (hence the EM questions/CMS forms above), and knowing the indications for surgery. You will not be asked how to do a surgery on the shelf exam, but you will be expected to know when a surgery is indicated vs when medical management should be used instead (and also what that medical management is). De Virgilio's is a great and under-utilized resource that has a fantastic question bank at the end of each chapter. I would recommend reading at least the GI, vascular, breast, endocrine, and trauma sections (and honestly, as much of it as you have time for).
Raw Score: 85
Obstetrics and Gynecology
Resources: UWorld, Case Files: OBGYN, NBME practice shelf exams ("CMS forms"), ACOG guidelines, UWise questions
Advice: OBGYN is all about timelines (at least, the OB part is). Pay attention to gestational age requirements for diagnosis of various conditions. Know the various labs that are used to diagnose Pre-eclampsia with severe features, and really pay attention to risk factors for the various obstetric complications. As one nurse midwife I worked with put it, "The biggest risk factor anything in L & D is usually a history of the same complication". I didn't really find the UWise Q-bank that useful, but if you have extra time, it's a nice source of extra practice questions, or a good way to reinforce any trouble spots.
Raw Score: 87
Pediatrics
Resources: UWorld, Case Files: Pediatrics, NBME practice shelf exams ("CMS forms"), CDC vaccination schedule, Emma Holliday review
Advice: Know the general trends of pediatric vital signs (what's normal for an adult is abnormal for most pediatric patients and vice versa), pay attention to rashes and dermatology, and review these as often as possible. It's well worth your time to do a good review of all the glycogen storage diseases, inborn errors of metabolism, lysosomal storage diseases, etc that you forgot after Step 1. For this reason, if you can do Peds as your last rotation before Step 2 it's kind of nice...then you only have to re-learn all this stuff once. This stuff is fair game for Step 2 (and I did personally get questions on it on my exam).
Raw Score: 91

Dedicated Study

I completed my first pass of UWorld during my M3 core rotations with an average of 74%. I did reset UWorld and begin a 2nd pass during dedicated, but I found that the questions repeated a lot of content that I knew well, and ultimately decided it wasn't a good use of my time. I only completed about 20% of my 2nd pass of UWorld with an average of 92%.
My main resources during dedicated were NBME practice exams (I did 8-14 timed), UWSAs, and the Free 120. I also listened to some Divine Intervention episodes on my runs and reviewed the Emma Holliday shelf exam reviews (I had previously listened to these during my M3 rotations). Of the podcasts, I found the Divine Intervention Free 120 review the most helpful, and would strongly recommend listening to those episodes after you take the Free 120. It did a lot to help me with some test taking strategies that I used on exam day.
General advice for dedicated:

• Keep on a regular sleep schedule, even on your days off. I went to bed at 10 and got up at 6 every day, because I wanted my schedule to be close to what I would need to do on test day.
• Take days off. I took at least 1/2 a day off every week. I also ran a major marathon 2 weeks before my test day, so that was a very light weekend in terms of studying.
• Keep exercising and doing things you enjoy. For me, this meant running a marathon (something I do regularly). You don't have to go as crazy as I did, but do something to get outside and stay active. It will help you keep the anxiety under control and see the sunlight every so often.
• Take practice exams regularly and spend plenty of time reviewing them. I made a google doc to keep track of incorrects and assigned each one to a category of "why I got it wrong" (i.e., "overthinking", "knowledge gap", "guessed wrong of 2", etc). This helps to identify trends. I found that I have a tendency to overthink questions, so identifying this helped me to address this weakness and gave me confidence to go with my gut instinct on the exam.
• Don't be afraid to adjust your study plan during dedicated. I started a 2nd pass of UWorld, but after about 2 weeks of dedicated, I felt like I wasn't really getting anything additional out of it and I was remembering too many of the questions from my 1st pass, so I just stopped using it. I spent that time on other resources instead (more practice exams). Take the time to really analyze which activities are actually helping your learning. Don't just do something because that's what everyone else is doing during their dedicated.
• Keep up with your review strategy. For me, this was Anki. I spent 2-4 hours every morning during dedicated doing Anki. At times, I worried that this was too much time on Anki, but part of what makes Step 2 (and all USMLE exams) challenging is the sheer breadth of content. The best way to prep for this is to keep consistent with your review strategy.
• If there's a concept you dread seeing in a question stem, STOP, do not pass Go, do not collect $20. Take a second to go to a primary source (UpToDate, a textbook) and review that content. Make some flash cards and review it regularly.
• Practice your timing. I came up with my exam day break strategy at the start of my dedicated, and every time I took a practice exam, I practiced my break strategy (at least, the first 5 blocks of my break strategy). This made it very easy for me to execute on test day because I was already used to doing 5 blocks in a row exactly this way. I took my lunch break after block 5 instead of block 4 (because I liked the psychological factor of knowing the exam was more than halfway done). Coming back for 3 more was no problem on test day.

My practice exam scores:
CCSE: 254 (my school requires this, and it was given a few days after the final shelf exam, right at the start of my dedicated period)
NBME 9 (30 days out) 269
NBME 10 (21 days out) 268
NBME 11 (18 days out) 262
NBME 12 (15 days out) 251
NBME 13 (7 days out) 264
NBME 14 (2 days out) 264
UWSA 1 (25 days out) 254
UWSA 2 (9 days out) 268
UWSA 3 (5 days out) 266
New Free 120 (3 days out) 85%
Predicted score: 265

The Day Before

Just take a break, for the love of all that is good. I went for a run, watched some old TV, read for fun, had a nice pasta dinner, and tried to go to bed early. Laid out everything I needed (lucky t-shirt, snacks, testing permit, ID, keys, etc).
Of course, I ended up tossing and turning most of the night and slept very poorly. When I woke up, I considered trying to postpone my test, but ultimately I decided I just wanted it over and done with and I wasn't willing to wait any longer. My point here is that even if you have anxiety and/or a single bad night of sleep before the exam, you can still do very well if you've done the work. As we say in the marathon world, trust your training.

The Test

Got to the testing center 45 minutes early. Made sure the last thing I did before going through security was to take a bathroom break. Brought plenty of snacks, headache medication, chocolate, and a healthy and delicious lunch (I think there's some psychological power in knowing you have a delicious lunch awaiting you).
During the exam, I took a break of at least 5 min after every block. Personally, I found the mental break was extremely helpful. On the whole, I found the exam to be quite reasonable.
Step 2 CK: 277
My last piece of advice will be that I think doing well throughout third year is the best thing you can do. If you've had a break after 3rd year or you are an IMG or someone coming from a non-traditional program, doing a thorough content review with the CMS forms before starting Step 2 specific practice exams is a good idea.
Ultimately, I think the most important things are:
1.) Choosing a FEW, QUALITY resources to review
2.) Continuing your ACTIVE, CONTINUOUS review strategy
3.) Keeping a consistent schedule with time for sleep, healthy eating, exercise, and something you find fun (ideally something other than TV).
4.) Staying off Reddit. Really, I mean it. Especially during dedicated, it's just a black hole of anxiety and angst and you should avoid it at all costs. Come back after you get your amazing scores and pay it forward to others.

For context I’ve been a nurse for 4 years. I have worked peds cardiac icu my whole nursing career. 2 years as a staff nurse and 2 years as a travel nurse.
I decided to go staff at a hospital I did a contract at for 7 months. I had a great experience as a traveler there working dayshift. The staff were amazing, supportive and encouraging. I’ve been doing a condensed staff orientation for the past 5 weeks and it’s been going great. My dayshift preceptor and coworkers know me, they know my skill and are just as supportive as they were when I was a traveler.
I’ve been orienting on nights the past week and it’s been a struggle. The nightshift nurses only know me as “the traveler” but don’t know my skill level. I understand until they get to know me and see my work ethic and skill things will improve but man, my shift last night has me feeling so defeated. My patient needed consistent interventions, was a sedation nightmare and all around extremely busy. I don’t feel like anything we did was out of my depth but my preceptor was on top of me questioning every thing I did, down to even how I collected my labs.
I tried to be gracious and accept the “education” and take the constructive feedback but it totally beat down my confidence. The more my preceptor second guessed everything I did the more I started to second guess myself and the more timid I became. I felt like I couldn’t even use my own nursing judgement because my preceptor would tell me I need to do this or that. I felt like a new grad nurse all over again.
I knew transitioning from traveler to staff would have its bumps in the road but now I’m really questioning whether I still wanna deal with this level of stress and headache, especially for staff pay. I’m trying to stay positive but I don’t know if bedside nursing is even for me anymore. If you’ve made it this far thanks for listening to a tired nurse and drop some words of encouragement if you have any.

i was born and lived most of my life in an area what is occupied by the nation state switzerland
shortly after my birth this nation state switzerland has coersed me into being associated to it what is a theft of my ability to determine my own life
i do propose to all fellow human beings living on planet earth to consider rethinking how we relate to each other as in, we would best not associate anyone to a regional and or nation state without the person and or its parents expressly wanting the newborn human being to be associated to that state
further i propose a reform of constitutions of regional and nation states everywhere on the planet what would allow every human, animal, tree and artificial intelligent entity who wants to be its own person to leave the coersed association to the state at any moment without any condition
having repeated this most important theme of how it would best be a voluntary decision, a choice wether one would want to be associated to a state or not
i would like to highlight a people initiative for freedom and physical intactness
( volksinitiative fuer freiheit und koerperliche unversehrtheit )
what citizens of switzerland will have an opportunity to vote yes or no on the 9th of june 2024
the text what is at the core of that proposed constitutional reform could be translated with:
interventions into the physical or mental intactness of a person require the approval of the person
the person is not allowed to be punished nor given other social or professional disadvantages based on the refusal to give consent ( to an intervention )
in german:
eingriffe in die koerperliche oder geistige unversehrtheit einer person beduerfen deren zustimmung die betroffene person darf aufgrund der verweigerung der zustimmung weder bestraft werden noch duerfen ihr soziale oder berufliche nachteile erwachsen
i have allready dropped my written yes vote today into the mailbox of the village where i live because i do think this is a most important principle what would best be adopted on a global scale as in i believe that it would be good for human beings everywhere on planet earth if their choice to not have this that or the other stuff introduced into their bodies such as vaccines or micro-chips or nano-bots or whatever science might invent next to introduce control or and dominating and or disturbing informations into the human body
i hope that all human beings everywhere on the planet would want to allow each other to protect their own bodies against any overbearing intrusive demands
i hope that all human beings everywhere on the planet would want to respect every fellow human beings mental and emotional and bodily autonomy
my mind, my feelings, my body my choice
sadly, the national parliaments of switzerland and the federal council with 7 human beings as members have decided to recommend to reject this proposition of changing the constitution of the nation state switzerland in that way
why ?
the main reason is that these politicians and governement executives want the state and people working for the state such as police, judges, medical and or psychiatric doctors and nurses to be able to violate the principal of phsyical intactness
for example by forcing persons to ingest or be injected with medications / vaccines / whatever they would choose to harass people with in the future
in switzerland every day a lot of human beings are forced by the state to ingest pharmaceutical medications or and to tolerate being injected with those
these abusive and or medical torture is part of a punishment and or oppression mentality what the psychiatric universitary system is promoting and the parliamentary assembly together with the federal council are building their domination power upon

i was born and lived most of my life in an area what is occupied by the nation state switzerland
shortly after my birth this nation state switzerland has coersed me into being associated to it what is a theft of my ability to determine my own life
i do propose to all fellow human beings living on planet earth to consider rethinking how we relate to each other as in, we would best not associate anyone to a regional and or nation state without the person and or its parents expressly wanting the newborn human being to be associated to that state
further i propose a reform of constitutions of regional and nation states everywhere on the planet what would allow every human, animal, tree and artificial intelligent entity who wants to be its own person to leave the coersed association to the state at any moment without any condition
having repeated this most important theme of how it would best be a voluntary decision, a choice wether one would want to be associated to a state or not
i would like to highlight a people initiative for freedom and physical intactness
( volksinitiative fuer freiheit und koerperliche unversehrtheit )
what citizens of switzerland will have an opportunity to vote yes or no on the 9th of june 2024
the text what is at the core of that proposed constitutional reform could be translated with:
interventions into the physical or mental intactness of a person require the approval of the person
the person is not allowed to be punished nor given other social or professional disadvantages based on the refusal to give consent ( to an intervention )
in german:
eingriffe in die koerperliche oder geistige unversehrtheit einer person beduerfen deren zustimmung die betroffene person darf aufgrund der verweigerung der zustimmung weder bestraft werden noch duerfen ihr soziale oder berufliche nachteile erwachsen
i have allready dropped my written yes vote today into the mailbox of the village where i live because i do think this is a most important principle what would best be adopted on a global scale as in i believe that it would be good for human beings everywhere on planet earth if their choice to not have this that or the other stuff introduced into their bodies such as vaccines or micro-chips or nano-bots or whatever science might invent next to introduce control or and dominating and or disturbing informations into the human body
i hope that all human beings everywhere on the planet would want to allow each other to protect their own bodies against any overbearing intrusive demands
i hope that all human beings everywhere on the planet would want to respect every fellow human beings mental and emotional and bodily autonomy
my mind, my feelings, my body my choice
sadly, the national parliaments of switzerland and the federal council with 7 human beings as members have decided to recommend to reject this proposition of changing the constitution of the nation state switzerland in that way
why ?
the main reason is that these politicians and governement executives want the state and people working for the state such as police, judges, medical and or psychiatric doctors and nurses to be able to violate the principal of phsyical intactness
for example by forcing persons to ingest or be injected with medications / vaccines / whatever they would choose to harass people with in the future
in switzerland every day a lot of human beings are forced by the state to ingest pharmaceutical medications or and to tolerate being injected with those
these abusive and or medical torture is part of a punishment and or oppression mentality what the psychiatric universitary system is promoting and the parliamentary assembly together with the federal council are building their domination power upon

Genuinely seeking advice here because I can be quick to jump on my sister and be a little testy with her because our relationship is kind of iffy. I 22F have one year left of nursing school. I’ve been really enjoying myself, as my family knows well. I enjoy answering questions about school and certain conditions, and even answering occasional questions people have about their own issues. my problem is that now, when my sister 30F has any sort of medical problem, she comes to me and asks me questions. It makes me nervous to give advice because God forbid I tell her the wrong thing and she either A) seeks medical care for something that didnt require further intervention, or B) she doesn’t seek medical care because of my recommendations and blames me when it was something more serious than I thought. I don’t want to give the wrong advice, especially because I’m still in school and learning lots of things. I try my best to give her advice I think is appropriate but like I said, I don’t want to risk being wrong once. WIBTAH if I told her to stop asking me so many questions?

Thyroid disorders, such as hypothyroidism, hyperthyroidism, thyroid nodules, and thyroid cancer, impact millions globally. Despite being common, these conditions often go undiagnosed or misdiagnosed due to their subtle symptoms and complex causes. In today's fast-paced world, the need for effective thyroid wellness solutions is more critical than ever. This blog will explore the necessity for improved thyroid care, the available alternatives, why CureEZ stands out, and real-life examples of how CureEZ has transformed lives.

The Urgency for Thyroid Wellness Today
The Growing Prevalence of Thyroid Disorders
Thyroid disorders are increasingly prevalent, with millions of new cases diagnosed annually. For example, hypothyroidism, where the thyroid gland is underactive, affects approximately 5% of the population, with a higher incidence in women and the elderly. Hyperthyroidism, where the thyroid is overactive, affects about 1-2% of the population.
Several factors contribute to this growing prevalence. Environmental pollutants, dietary factors, and increased autoimmune diseases play significant roles. The impact of stress and lifestyle changes in modern society also exacerbates these conditions.
The Challenges of Diagnosis
One of the primary challenges in managing thyroid disorders is accurate diagnosis. Symptoms such as fatigue, weight changes, and mood swings often overlap with other conditions, leading to misdiagnosis or delayed diagnosis. Traditional diagnostic methods, primarily reliant on blood tests measuring thyroid hormone levels, may not always provide a comprehensive picture.
Moreover, subclinical thyroid disorders, where symptoms are present but hormone levels appear normal, complicate diagnosis further. Patients often face frustration and anxiety due to the uncertainty and inconsistency in their diagnosis and treatment plans.
The Impact on Quality of Life
Untreated or poorly managed thyroid disorders can lead to severe health complications. For instance, hypothyroidism can result in heart disease, mental health issues, and infertility. Hyperthyroidism can lead to severe complications like atrial fibrillation, osteoporosis, and thyrotoxic crisis if left untreated.
The physical symptoms are only part of the story. The mental and emotional toll of thyroid disorders can be profound, leading to depression, anxiety, and cognitive issues. This multifaceted impact underscores the need for comprehensive, accurate, and accessible thyroid care.

Current Approaches to Thyroid Wellness

Conventional Medical Treatments

1. Medication: The standard treatment for hypothyroidism is synthetic thyroid hormone replacement therapy, such as levothyroxine. This treatment aims to normalize hormone levels, but finding the correct dosage can be challenging and requires regular monitoring. For hyperthyroidism, antithyroid medications like methimazole or propylthiouracil are used to reduce hormone production.
   
2. Radioactive Iodine Therapy: Used primarily for hyperthyroidism and thyroid cancer, this treatment involves taking radioactive iodine orally to destroy overactive thyroid cells. While effective, it requires careful monitoring and can lead to hypothyroidism.
   
3. Surgery: In cases of large goiters, thyroid nodules, or thyroid cancer, surgical removal of part or all of the thyroid gland may be necessary. This option is usually considered when other treatments fail or when there is a suspicion of malignancy.
   

Natural and Holistic Approaches

1. Dietary Changes: Incorporating foods rich in iodine, selenium, and zinc can support thyroid health. For hypothyroidism, iodine-rich foods like seaweed, fish, and dairy are beneficial. For hyperthyroidism, a balanced diet avoiding excessive iodine and goitrogenic foods like soy and cruciferous vegetables is recommended.
   
2. Supplements: Nutritional supplements, such as iodine, selenium, and vitamin D, can help address deficiencies that impact thyroid function. However, supplementation should be approached cautiously and under medical supervision to avoid adverse effects.
   
3. Lifestyle Modifications: Stress reduction techniques, regular exercise, and adequate sleep are crucial for maintaining overall health and supporting thyroid function. Mindfulness practices, yoga, and other stress management strategies can be particularly beneficial.
   

Alternative Therapies

1. Acupuncture: Some studies suggest acupuncture can help alleviate symptoms associated with thyroid disorders. It is believed to balance energy flow in the body, potentially improving thyroid function and overall well-being.
   
2. Herbal Remedies: Certain herbs, like ashwagandha and guggul, are believed to support thyroid health. Ashwagandha, an adaptogen, may help regulate hormone levels and reduce stress, while guggul is thought to stimulate thyroid function. However, more research is needed to confirm their efficacy and safety.
   

Why CureEZ is the Superior Choice

Advanced Diagnostic Tools
CureEZ utilizes state-of-the-art diagnostic tools that go beyond traditional methods. Our AI-powered screening technology analyzes a comprehensive array of data, including medical history, symptoms, and lab results, to provide a more accurate and timely diagnosis. This approach addresses the limitations of conventional blood tests by considering a broader spectrum of indicators.
Personalized Treatment Plans
At CureEZ, we believe that no two thyroid conditions are the same. Our approach is tailored to each patient's unique needs, ensuring that they receive the most effective treatment. This includes personalized medication regimens, dietary guidance, and holistic care strategies. Our genetic testing capabilities allow us to identify specific predispositions, enabling early intervention and more precise treatment.
Innovative Therapies
CureEZ is at the forefront of medical innovation, offering cutting-edge treatments like Radiofrequency Ablation (RFA) for benign thyroid nodules and targeted molecular therapies for thyroid cancer. RFA is a minimally invasive procedure that uses heat to shrink nodules, reducing recovery time and complications compared to surgery. Our targeted molecular therapies focus on specific genetic mutations within cancer cells, providing more effective and less toxic treatment options.
Continuous Monitoring and Support
Our commitment to patient care extends beyond the clinic. CureEZ integrates wearable technology to monitor vital signs and hormone levels in real-time, providing continuous data to adjust treatments promptly. Our telemedicine platform ensures that patients can consult with specialists conveniently, no matter where they are. This approach offers flexibility and continuity of care, crucial for managing chronic conditions like thyroid disorders.
Patient Education and Community Support
We understand the importance of informed patients and a supportive community. CureEZ offers extensive resources and support groups to help individuals understand their condition, share experiences, and stay motivated throughout their treatment journey. Educational materials, webinars, and community forums are available to empower patients with the knowledge they need to manage their health proactively.

Real-Life Transformations with CureEZ
Mamatha's Journey to Recovery
Mamatha, a 35-year-old teacher, had been struggling with unexplained fatigue, weight gain, and depression for years. Despite numerous visits to different doctors, her symptoms persisted. Frustrated and desperate for answers, Mamatha turned to CureEZ.
Diagnosis and Treatment
Using our advanced screening, we quickly identified that Mamatha had hypothyroidism. Our team developed a personalized treatment plan, including the right dosage of levothyroxine, dietary adjustments, and stress management techniques.
The Transformation
Within a few months, Mamatha's energy levels improved, and she began to lose weight. Her mood stabilized, and she felt more in control of her life. Mamatha regularly uses CureEZ's telemedicine platform to check in with her specialist, ensuring her treatment remains effective.

Dilip's Battle with Hyperthyroidism
Dilip, a 42-year-old software engineer, was diagnosed with hyperthyroidism after experiencing rapid weight loss, anxiety, and heart palpitations. Conventional treatments had only provided temporary relief, and he was concerned about the long-term effects on his health.
Diagnosis and Treatment
CureEZ's comprehensive approach included a detailed analysis of Dilip's condition. We opted for a combination of antithyroid medication and Radiofrequency Ablation (RFA) to target the overactive thyroid cells.
The Transformation
Mark noticed a significant improvement within weeks. His heart palpitations decreased, anxiety levels dropped, and he regained a healthy weight. Continuous monitoring through wearable technology helped fine-tune his treatment, ensuring sustained progress. Mark now enjoys a better quality of life and peace of mind.

Conclusion
CureEZ stands out in the field of thyroid care by combining advanced diagnostics, personalized treatment plans, innovative therapies, and continuous support. Our approach ensures that patients receive the most accurate diagnosis and effective treatment, leading to better outcomes and improved quality of life.
If you're struggling with thyroid issues, consider CureEZ for a comprehensive, patient-centered solution. We're here to help you decode your thyroid disorder and transform your life.

References

1. https://www.liebertpub.com/doi/full/10.1089/thy.2016.0457
   
2. https://www.sciencedirect.com/science/article/abs/pii/S0025619611623896
   
3. https://www.webmd.com/women/thyroid-disease
   
4. https://www.healthline.com/health/hypothyroidism/symptoms-treatments-more
   
5. https://my.clevelandclinic.org/health/body/23188-thyroid#:~:text=Your%20nervous%20system%3A%20When%20your,and%20hyperthyroidism%20can%20cause%20anxiety.