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Wednesday, July 16, 2008
Antibiotic Nazis
At this point my jugular vein started throbbing in my neck and my face turned a deep shade of Buckeye scarlett. Why was pharmacy unilaterally cancelling my antibiotic orders and making crucial decisions on the care of my patient?
Here's the deal. My hospital has now implemented a policy of limiting unncecessary use of antibiotics by giving the pharmacy the power to cancel antibiotic orders that extend 24 hours past a patient's surgery date. On the surface, it seems like a reasonable policy. Unnecessary courses of antibiotics have certainly contributed to the preponderance of such modern dilemmas as widespread MRSA infections and toxic megacolon from C Diff colitis. And surgeons who lazily/carelessly forget to cancel prophylactic peri-operative antibiotics are certainly much to blame. But there's a difference between antibiotics for prophylaxis versus antibiotics for the treatment of an infectious process. For perforated appendicitis, I'm not giving Zosyn to reduce my rate of superficial surgical site infections, but rather to actually treat an established, complicated infectious disease.
I spoke with the lead ID pharmacist and he was cool and apologetic about the misunderstanding. But the policy remains unchanged. It is now the surgeon's obligation to write in the post op orders "antibiotic to be continued post operatively for X-disease process (appendicitis, diverticulitis, peritonitis, etc)"
36 comments:
Can't they read the chart and see the words "perforated appendicitis" and acknowledge the need for further antibiotics? why is it always the burden of the physician to have to explain to every Tom, Dick, and Harry in the hospital the reasons for one's actions?
- July 16, 2008 at 1:22 PM
Let me get this straight- because some (not all) physicians fail to utilize antibiotics appropriately, a rule is passed that allows someone NOT responsible for the patient, to deem an antibiotic unwarranted and DC it without a conversation with the doc who prescribed the it? BTW if you have pharmacists (or nurses) who cannot (do not?) review the chart to try and understand why the ABX is being used-you need another rule-don't hire folks for clinical jobs if they are not going to do clinical assessment! Is Dilbert in the house??
- July 16, 2008 at 2:47 PM
- The Happy Hospitalist said...
Buckeye, it seems to me that an adequate solution to your problem would be for perioperative antibiotics be written as a one time instead of an ongoing order and letting continuous antibiotics be ordered at per it's normal regimen. For example. Ancef 1 gram pre op times one dose. A one time order falls off the nursing orders the following day automatically. Having a pharmacist cancel the antibiotic as a default opens your hospital up to a ton of liablility and is frankly irrational thinking. I'm surprised the pharmacist wants to take on that responsibility.
- July 16, 2008 at 5:40 PM
- Jeffrey Parks MD FACS said...
Good thought, but sometimes perioperative antibiotics are justified in being given over several doses. For instance, in colorectal surgery, there is good evidence to suggest that it is appropriate to give 24 hours of antibiotics after the procedure ends, ie Cefoxitin 2gm IV q 8hrs x 24 hrs.
I agree with you; it's strange that the pharmacists would be willing to involve themselves in sorting out when antibiotics are appropriate or not. Seems a better way would be to put the onus on surgeons; make it a QA issue to be evaluated quarterly.... - July 16, 2008 at 5:57 PM
They're going to get themselves in trouble like that. Maybe your young patient with appendicitis will do ok with missing a few doses, but the next elderly patient with fecal peritonitis won't take it so lightly. Then the pharmacists will be liable, and all the money saved will go down the drain.
- July 16, 2008 at 8:15 PM
- Resident Anesthesiologist Guy (RAG) said...
And yet again we see another novel idea that clearly says: "You can't trust your doctor to do right by you". Sad.
- July 17, 2008 at 8:04 AM
Perhaps a better solution would be for the policy to require the pharmacy to call the surgeon and ask if the antibiotics should be continued. A system that overrides a physician without notification is a broken system. Patient safety has to take priority over saving $$$.
- July 17, 2008 at 10:11 AM
I think Happy's on the right track here. Since the standard of care for prophylactic perioperative antibiotics is a 24-hour time frame post-operatively, the physician's order should reflect that (e.g., Ancef 1000 mg IV q8h x 3 doses).
This is made easier by more modern EMRs; our institution will be implementing post-operative order sets where the surgeon can select the antibiotic and indicate whether it is for prophylaxis (defaulting in a 24-hour limit) or therapy (defaulting in an open-ended order). - July 17, 2008 at 11:54 AM
I'm a hospital pharmacist in the UK and we have similar policies in many NHS hospitals. In the hands of experienced pharmacists, I would argue that they're a good backstop for preventing unnecessary antibiotic use (we have C. diff, MRSA and VRE like you wouldn't believe in my region...). The problem comes when policies like this are applied by someone inexperienced, from the pharmacy department, without considering the individual patient's need. I would personally never have stopped this script without at least lookin in the patient's notes to check what was going on and would argue that any pharmacist that did so was negligent.
I'm not sure what the solution is though: Jonathan Dee's suggestion re the pharmacist requesting the change each time would in my hospital result in the surgeon being bleeped constantly: not great use of his/her time and not great for the surgeon/pharmacist relationship! - July 18, 2008 at 12:01 PM
Responded to a Code in a hospital that had Pharmacy Residents in charge of the drug box(who knew there were Pharmacy residents?)Wasn't really a code, just a case of hypotension after C-section under spinal. I think the OBGYN asked for Ephedrine, patient got a milligram of Epinephrine IV, can you say ST elevation? We should call it "Adrenaline" like the limey's do.
- July 18, 2008 at 1:45 PM
- Bongi said...
the only person who should have the right to change the prescription chart, or anything to do with the care of the patient, should be the person who looks after the patient. if i were you i'd demand to know which pharmacist had clinically assessed my patient. if they did not i would report them to their board for misconduct.
- July 19, 2008 at 8:20 AM
- Hey, You said...
Does a pharmacist have a license to practice medicine? If not, if he cancels a medical order by a real M.D., does that constitute practicing medicine without a license?
I would think that state law in every state would make this hospital policy patently illegal. - July 19, 2008 at 1:18 PM
In my state, pharmacists can be given prescriptive authority based on the institutions policies. So, the guy could have had the 'power' to do so?
And would you freaking docs find a new cliche saying other than "do pharmacists have a license to practice medicine" or "stop playing doctor" -- They're both stupid and make you look like a pompous prick. You don't have a license to be a condescending jerk to everyone that doesn't have MD behind their name. - July 20, 2008 at 12:34 PM
- Jeffrey Parks MD FACS said...
Anon from 7/20:
The problem is, the order was not cancelled by an actual pharmacist; rather by some lackey pharmacist tech who was merely "following protocol". The pharmacist who rounds with the ID docs and was instrumental in intiaiting the policy was actually very cool about the whole thing and is actively looking in to ways to prevent this from happening again...
And if you're going to use perjorative words like "prick", at least have the cajones to do it with your real name, rather than anonymously.... - July 20, 2008 at 12:47 PM
- Hey, You said...
In my state, pharmacists can be given prescriptive authority based on the institutions policies. So, the guy could have had the 'power' to do so?
You mean that a pharmacist is empowered to prescribe medication? Are there limits to that authority that would not also apply to a medical doctor? That is interesting.
Does it makes sense to you, though, that a pharmacist could be changing medications based on someone else's notes rather than a clinical assessment of the patient?
How would you feel about the hospital assigning doctors on a rotating basis to wander through the wards reviewing patient medications and changing them based upon their own judgment? How would that be any different?
Is it conceivable that the surgeon might know something based on his full experience with the patient that the pharmacist doesn't know? This is actually not rhetorical; I'm wondering if that could be relevant.
And would you freaking docs find a new cliche saying other than "do pharmacists have a license to practice medicine" or "stop playing doctor" -- They're both stupid and make you look like a pompous prick. You don't have a license to be a condescending jerk to everyone that doesn't have MD behind their name.
Oops. I think you are referring to my previous comment. I meant to say license to prescribe medicine, not practice medicine.
But in any event, I'm not a medical doctor. Don't blame them. You seem to have some resentment towards those with an "MD" behind their names. I apologize to you for upsetting you and to all the real MD's out there who bore the brunt of your ire because of my comments. My bad. - July 20, 2008 at 9:46 PM
- Mark said...
Meh, it's just a mistake that probably some junior pharmacist made. Mistakes do happen and really there's no need to go hyper over it, people.
Can't we all just get along? - July 25, 2008 at 3:15 AM
- Pharmacy God said...
Rather than jump all over the pharmacy staff for d/cing the antibiotic order, why don't you see who implemented the policy? I'm pretty sure that the pharmacy department can't just adopt policies without some imput from the medical staff.
From my experience in a hospital setting, when the pharmacy wanted to do things a little bit different, we had a meeting that included the medical staff, nursing, respiratory, radiology, dietary, physical therapy, legal, and administration. Everybody had to be in agreement before new policies and procedures were implemented. So get off of pharmacy's back. - July 25, 2008 at 6:41 AM
- Pharmacy God said...
typing error......input
I don't want pharmacy to take the rap for my spelling error. - July 25, 2008 at 6:43 AM
"You mean that a pharmacist is empowered to prescribe medication? Are there limits to that authority that would not also apply to a medical doctor? That is interesting."
I am a pharmacist in a state that allows pharmacists to have prescriptive authority. Most states that allow this allow it only nder very specific circumstances, such as collaborative agreements and protocols that the doctors have also agreed to. The state board of pharmacy is also involved Sometimes, the medical board will also have to sign off on the protocol. So, no, we are not "practicing medicine". We are practicing pharmacy. - July 25, 2008 at 11:29 AM
I'm with Pharmacy God on this. No reason to get all hyper over anything. Investigate how the policy was implemented, then just write those simple little words on the post-op orders that will keep the desired antibiotics coming.
- July 25, 2008 at 2:58 PM
This is exactly why I am getting sick of almost every pharmacist I have to deal with. I had one completely change an order (I do experimental oncgological therapies) because he had "never seen them prescribed together before". He is now facing criminal charges, and I understand that he is an extreme example of the problem, but since when did pharmacists get the idea that they know more than physicians? I recently reemed out, probably somewhat unfairly, pharmacists in general on the angrypharmacist.com website and was called every name in the book for calling pharmacists on their arrogant bullshit. I am glad that this head pharmacist was cool about changing the order back, but as physicians we need to do something to reign in pharmacists and get them to stop practicing medicine. If they really want to, they should go to med school and go through the years of training we had to.
Sorry to expound, but I had to vent. Pharmacists are NOT M.D.s or D.O.s, and they need to realize it. - July 26, 2008 at 7:41 PM
- Willard Cupp, RN said...
Yeah, what do pharmacists know about medicine anyway? ......
No, j/k I see what you're saying. Where I work, I've seen MDs get all in a tizzy over clinical pharmacists ordering K riders adn they always say the same thing, "When did they ever go to medical school?". I see the point, but occasionally it seems borderline ad hom to me. - July 27, 2008 at 11:58 PM
Sounds like you need to take this up with your med committee. There wa obviously a reason this was implemented.
You should probably write the indication as well so the order is not d/ced.
Hospital Pharmacist - July 28, 2008 at 10:35 AM
Buckeye Surgeon, you said, 'It is now the surgeon's obligation to write in the post op orders "antibiotic to be continued post operatively for X-disease process (appendicitis, diverticulitis, peritonitis, etc)."' It is, in fact, the surgeon's responsibility- I am not placing a value judgement on that, I am simply speaking as someone who is well versed in regulatory policy.
Coming at this from both sides of the problem, first, let me say that there is a clear communication deficit in your institution. This policy was obviously put in place to mimic the national standards that every hospital has to abide by (which were put in place for good reason). However, the fact that it was adopted so stealthily that you were not aware is a problem.
For surgeons who were already doing the right thing, I can understand how the quality measures (and the process changes that result) can be infuriating. But there are a lot of caregivers who practice based on outdated evidence, or with less attention to their patients, and the measures were put in place to protect patients and hospitals from the sequelae of those doctors. - July 28, 2008 at 10:54 AM
- webhill said...
First of all, that totally sucks and would royally piss me off, too.
But I am curious about your comment that you can't lavage and drain the peritoneal cavity when doing an open appy. Why not? I'm a small animal vet. I have done ovariohysterectomy in emergent situations when a bitch has developed a pyometra which has ruptured prior to presentation, and you damn well better believe I irrigate the hell out of the peritoneal cavity before I close. Why can't you guys do the same thing? - July 30, 2008 at 9:17 PM
- JM said...
anonymous (MD) said"but as physicians we need to do something to reign in pharmacists and get them to stop practicing medicine. If they really want to, they should go to med school and go through the years of training we had to.
Sorry to expound, but I had to vent. Pharmacists are NOT M.D.s or D.O.s, and they need to realize it."
And MD need to realize that as clinical pharmacists, were looking out for the patients, too. And physicians are not PharmDs. They don't get every med order they write correct. As pharmacists we need to reign in physicians and get them to stop fucking up Pharmacy. I don't need to get reamed out by a general surgeon who prescribes Zosyn 4.5 g q6h for a 85 y.o. lady who's creatinine is 1.1 but is so tiny, her est CrCl is ~ 10mg/ml. She yells and say "her kidneys are fine" yeah, if she was 40 years younger and 140 pounds heavier, I'd agree.
I agree that the policy the Buckeye described is a little asinine, but someone from the medical staff committees, probably through P&T approved it. Pharmacy isn't taking the responsibility here, its the institution that put this policy into place.
the point really is, a sharp pharmacist is going to see that a ABX is for a post-op infection and call the surgeon to clarify, (if, he can actually reach him on the phone) and a sharp surgeon will appreciate a pharmacist who sees that the prescribed med may not be in the best interest of the patient and calls to follow up. The lackeys who graduate in the ass-end of pharmacy and medical school are the ones who have the problems with each other caring for their patients. And as pharmacists and physicians who are posting to this, we know who they are.
p.s. two jokes, equal opportunity
What do you call the guy/girl who graduates last in their class in medical school.........
What question does the guy/girl who graduates first in their class in pharmacy school, get asked most often...............
so , what CVS do you work at? - July 31, 2008 at 12:44 AM
I'm a pharmacist, and I worked in a hospital for a while. It is inconceivable to me that a pharmacist would change/cancel an order without at least discuss with the prescribing MD first. We have on occasion not entering a NEW order into the system pending the MD answering our page if the order does not conform to established hospital protocols (and yes these are set by MDs and in the case of my hospital, RNs).
In general, we do not page you guys to question if the use of Vanco is legit (although some will). We're just following protocols to cover our a**. - August 5, 2008 at 2:53 AM
I'd like to put in my $0.02...
first of all, we have all run into really STUPID doctors... Medical Doctors, Doctors of Pharmacy etc..
In regards to this particular incident, well, I am sure it went through med exec and P&T to make a policy. Instead of everyone reaming pharmacists (and yes, not only are there pharmacy residents, but they ASHP is trying to mandate residencies, right now it is optional) how about pushing your hospital to get a proper, GOOD, clinical pharmacist who has the sole job of working on the floors and following up on things like "this pt had surgery, was it complicated? uncomplicated? really need abx?" Etc.
At my hosptial our clinical pharmacists go on rounds, review charts make suggestions and do really GOOD work and I would say a good 98% of the physicians appreciate them... if they call down to the basement to the staff pharmacists, I can't say they get as good quality of people, but there are still some damned good (And bad) pharmacists in the basement.
Everyone seems so hell bent on reaming everyone else instead of seeing how we can improve and change things for the good. My thought is that if your hospital had this policy go through, there had to have been many surgeons that forgot to d/c postop abx.
Our hospital? post surgery orders must have a duration.. uncomplicated? they write ancef 1gm IV q8h x24...48h etc... Usually if zosyn is ordered, we use our brains to realize it isn ot just a postop uncomplicated order... and don't d/c it but after 24-48h the clinical pharmacist does a followup and chart check or write a 'dear doctor' not that does not become part of medical chart.
Personally, I would never change an onc order, i wouldn't just d/c orders, and i have no idea how a pharm TECH could d/c an order. We would fire him/her in a split second, as they have NO right to do that.
Get off the 'all pharmacists suck' because i also yelled at the pharmacists with 'all those surgeons... doctors etc.. suck'
There is good and bad everywhere. - August 7, 2008 at 4:52 PM
Scary. Anyone who has seen how fast an infection in a kid can go systemic would find that frightening. As it happens, I think that a good experienced clinical phamacist is very useful. I have worked with a couple that were worth there weight in the diamond studded precious metal of your choice. I think pretty much all our drug charts are reviewed at some point by one of our paediatric pharmacists. In neonatal intesive care, we speak to them all the time about interactions, compatibilities and concentrations. If any of our pharmacists spot a possible problem, I am more than happy for them to phone/bleep/grab me on the ward. Sometimes there is a factor they are not aware of, sometimes there is a very specific reason to do things differently in that patient, and sometimes they have spotted a real problem. If there is a problem I want to know about it, to sort it out. If one of my juniors has made an error, I want to know that there is a training need to address. If I have made an error I definitely want to know about it. But none of these excellent pharmacists I have worked with would ever have dreamed of unilaterally changing the prescription for a patient they don't know. Because they have more sense. Communication and teamwork is invaluable, blind adherence to protocol without consideration of individual factors is dangerous. For instance...the 4 year old on sildenafil/viagra: that wasn't a drug error, he wasn't on it for impotence, but rather it was instigated by one of the top respiratory consultants in the country to treat his pulmonary hypertension. You can see why pharmacy queried it. You can also see why I'd have gone ape if they'd just crossed it off!
- August 21, 2008 at 5:21 PM
- This comment has been removed by a blog administrator.
- September 3, 2008 at 11:53 AM
Well, the policy was probably implemented secondary to either a Medicare/Medicaid or a JCAHO requirement to stop all post-op antibiotics. I can't remember which organization it was that started the policy, but it was one of these. The policy will probably become standard at most institutions over the coming years.
As a clinical pharmacist, I have prescriptive authority in my state (with collaborative practice agreement with a physician) , and I am consulted on a daily basis by physicians to manage medication therapies. While I didn't go to medical school, I did spend a total of 7 years in graduate and post-graduate education to earn that right. I am ACLS certfied, PALS certified, and Board Certified as a Pharmacotherapy Specialist. Unlike the pharmacy residents mentioned earlier, I have actually run codes while the Intensivist was inserting a central line (and successfully I might add). I play a positive role in my patients' health.
While not all pharmacists are capable of this higher level of practice, I and many other clinical pharmacists are capable(at least a hell of a lot better than a NP or PA).
My suggestion: start paying attention to your institutions policies and quit complaining about a pharmacist that is just doing his job and following policy.
As I was told during my fellowship (yes we have those too!!!!), guns don't kill people....doctors do. - September 8, 2008 at 8:03 PM
I am surprised by the ignorance of so many physicians on this blog. Do you really think that all they teach in pharmacy school and residency training is how to count pills? That is ignorant.
I have saved many lives by intervening when physicians write deadly orders....you don't bitch when we intervene on those do you? - September 8, 2008 at 8:21 PM
sounds like the pharmacist was following hospital protocol.....maybe you should write a duration of therapy on your orders.
- September 11, 2008 at 2:11 PM
- Jeffrey Parks MD FACS said...
Allright guys, let's all cool off. In no part of my post do I imply that "pharmacists are bad". Th problem is one of communication, comprehension of treatment goals, and policy implementation. Perioperative antibiotics versus antibiotics for treatment of established infections are two entirely different animals. The length of antibiotic use for diverticulitis/appendicitis/peritonitis ought to be left up to the discretion of the MD's involved in the case, not subject to the limits of an algorithm that doesn't even apply to the situation at hand. If you disagree with that, you're being asinine and a threat to patient safety. Pharmacists have saved my ass plenty of times in terms of dosages and cross reactions; but in this case the policy is simply wrong.
And the "pharmacist" wasn't following protocol; it was a lackey tech who was mindlessly following some arbitrary dogma.
As long as pharmacists clearly elucidate the prophylaxis/treatment distinction in these protocols, there should never be a reason for the surgeon to "specify duration of therapy". - September 11, 2008 at 4:18 PM
As a clinical PharmD, I've been there. The infection control *nurse* and the medication use review subcommittee of the P&T established the protocol for post op abx orders. The two clinical PharmD's at our institution had nothing to do with it. It makes us cringe. The orders *automatically* fall off, with no alert upon order entry or alert to the clinical PharmD on duty. Even had I reviewed the chart of the patient you described, I would have had no way to tell that order was going to fall off unless I had remembered (like you should have since you know the policy), that the Zosyn will fall off without intervention. This entire process is oblivious to the nursing staff, who routinely report: "The pharmD killed that order", when the truth is, either the PharmD didn't review that chart because the patient hit the floor after our shift and we're not there on weekends to fix a flawed hospital policy, or the PharmD or physician forgot that orders like that automatically fall off. Truth likely is, this happened not because a PharmD was involved, but because there weren't enough PharmDs involved, and the clinical PharmDs have no voice at P&T. You're probably unaware of the significant number of interventions PharmDs make on your patients because your hospital doesn't record, track, and report them to you upon credentialing.
- February 1, 2009 at 12:18 PM
Good morning:)
Very Interesting Reading.
I practice both professions since 2002-so I can pay off my medical school loans. I see both points of view. Again, it is an institutional policy, discussed at the P&T and The Med Exec and at the Medical Staff meeting.
When it was discussed at my medical staff meeting-No one could response because of the 20 minute discussion on "why is it that the physicians who are oncall are not answering their calls?
My institution is going to CPOE next fall and this is to solve all the problems. Time is money with 2010 and the complete paperless system, COPE, and Joint Commissions mandates concerning safety and no "QD" just wait.
You can hire an LPN to sit at the CRT while you rush off to another sx-It will end up costing everyone Lots of Time and Money.
Perhaps if physicians would go to the source of the problem (the institution or Joint Commission) instead of always trashing, nurses, pharmacists, themselves (ortho saying cardiology not doing their job and cardiology blaming hospitalists for changing their orders)
The Tide of change is coming and we all have to pay attention.
Many years ago "Jako" wanted no standing orders-all individual orders-Now it is stream line protocol orders. Tides come in and they go out.
Oh to the physician who thinks pharmacists want and are practicing medicine-Go ahead and report them to the board for unlicense activity. Both my boards love it in Florida--Board costs are covered by either party regardless if you win or lose. Believe me you are going to lose with the board-especially if the institution made the pharmacists the watch dogs.
(Pairadocs) - April 19, 2009 at 5:46 AM


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This job posting is no longer active.
Location: Rockford, IL, United States - Cherryvale Mall 7200 E Harrison Ave
Job ID: 1103781
Store Hourly Positions
Job Type: Full-Time
Date Updated: Apr 28, 2023
General Description
As the Sales Floor Assistant, you are accountable for driving customer service to achieve profitable sales growth by leading and engaging associates, managing company merchandise standards and execution, training and developing associates and executing sales building programs.
Primary Responsibilities:
Core Competencies & Accomplishments:
To achieve success at JCPenney, a Merchandise Assistant will possess the following:
Results – Solve problems and make smart decisions that drive sales, profit or customer service; execute your work efficiently and effectively; inspire strong performance in yourself and others.
Ownership – Provide great customer service; cooperate and build positive, inclusive and respectful relationships; take accountability for your actions and outcomes.
Intensity – Proactively find ways to improve the customer experience; show the confidence and courage to do what's right; take action with energy and urgency.
About JCPenney:
At JCPenney, we share a passion for serving customers, supporting our communities and being the best retailer for all families. As a company founded on the Golden Rule, our success is rooted in the belief that we treat everyone the way we would want to be treated. At every touchpoint, customers discover stylish merchandise at incredible value from an extensive portfolio of private, exclusive and national brands. Reinforcing this shopping experience is the customer service and warrior spirit of associates across the globe, all driving toward the Company's mission to help customers find what they love for less time, money and effort.
Working at JCPenney means joining a dedicated team of associates who are encouraged to be uniquely themselves in a safe, caring and welcoming environment. It is a place where careers prosper, accomplishments are celebrated and diversity flourishes. It's a place that's meant for you.
If eligible, we offer a competitive benefits package including medical/dental/vision, term life insurance, paid vacation/holidays, and 401(k) with company match. All associates are eligible for an associate discount on JCPenney merchandise.
Job Title: Sales Floor Assistant - Cherryvale Mall
Location: Rockford, IL, United States - Cherryvale Mall 7200 E Harrison Ave
Job ID: 1103781
J.C. Penney Company Inc.
Plano, Texas


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A local Annie Oakley in the making?
An American sharpshooter in Mancos has future Olympian written all over her.
Shooting .22 rifle bullets through the center of quarters and dimes from 30-plus feet, is routine for Tia Imel.
Oh, and Tia Imel is 10.
The 4-foot-5 fourth-grader at Mancos Elementary School is already shooting with the best.
Tia competed and performed well at the Colorado State Junior Olympic Championships in the Olympic Training Center at Colorado Springs on Jan. 20. The on-target tike did so well shooting women's air rifle that Tia was invited back to the OTC.
The Mancos kid will take fire in the National Junior Olympic Championships on April 8-10, at the OTC in the (J3) 14-Under category.
Although Tia is returning to Colorado Springs, she's not completely satisfied.
"I want to beat the last score (of 343) I got up there," said the soft-spoken shooter.
Spoken like a true competitor - always striving to get better. Tia began shooting with her dad, Travis Imel, when she was 5 and has shot competitively for the past three years.
Tia's progression in the sport has been as fast as a speeding bullet.
"She started shooting with me and liked it so much, she just kept doing it," said Travis, who is a shooting instructor with the Four Corners Rifle & Pistol Club. "She even got me back into it, to where I became an instructor."
The Four Corners Rifle & Pistol Club's junior shooting program was instrumental in Tia's growth. Coaches Cody Lingo and Tim Hunter really set the foundation for her, while the gun club also provided specialized equipment for the youngster.
Tia is great shooting both rifles, but the air rifle is her favorite. She practices at her indoor range at home, shooting coin-size paper targets from 33 feet (10 meters), which is the competitive distance.
"It's pretty easy," Tia said, nonchalantly.
Like any sport, equipment costs money and rifles aren't exactly cheap.
Sponsors help out, but fundraising is important.
Those quarters and dimes Tia puts holes through aren't just for practice. They're for making jewelry.
The 10-year-old entrepreneur makes necklaces out of quarters and earrings out of dimes and sells them on Facebook.
The result?
Enough money raised for a new Walther air rifle, shooting jacket and pants.
Tia is also a part of the local 4-H shooting sports program. She's won and placed in various competitions at the regional and state level in both disciplines.
The ultimate goal is to one day get to the Olympics. Tia is coached via Skype video by former Venezuelan Olympian Gabby Franco.
Tia is already thinking college, hoping to earn a athletic scholarship to shoot rifles at the NCAA level. That's why she has shot air rifle with Kevyn Stinett, who is a member of the Air Force Academy women's rifle team in Colorado Springs.
Precision shooting takes extreme concentration. For a 10-year-old girl, it's still pretty simple.
"Think about happy things," said Tia, whose mother and younger brother are Tracey and Broc Imel. "Don't think about getting a bad shot when you're in position."
Those positions include standing, prone and kneeling.
It doesn't matter the level of competition or the amount of people shooting. Tia welcomes a challenge like a doughnut shop welcomes policemen.
"I used to could only shoot with a few people, now I can go to the outdoor range and shoot with 12 people," she said. "At (4-H) state in Pueblo, there were more than a 100 there."
Roughly 400 participants were in attendance, according to Travis.
Little Tia Imel has accomplished big things at 10 years young.
Ten years from now, Tia Imel won't be a little girl. The Mancos marksman may be practicing for the biggest sports stage: the Summer Olympic Games of 2024.
Whatever happens, she will give it her best shot.
[email protected].


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Salt in the Bible
There are over thirty references to salt [1][2] in English translations of the Bible. Probably the most familiar being the story of Lot's wife who turned into a pillar of salt when she looked back at the city of Sodom in Genesis 19:26 and the story of Jesus Christ refering to his followers as the "salt of the earth" in Matthew 5:13. In Scripture, salt is metaphorically used in different contexts to signify different meanings. [3]
Old Testament references
From the Books of the Law
- Genesis 14:3 "All these [Gr. agreed.] met with one consent at the salt valley; this is now the sea of salt." (Gr. θαλασσα των αλων [4]).
- Genesis 19:26 "And his wife looked back, and she became a pillar of salt."
- Leviticus 2:13 Every offering of your meal offering you shall season with salt; neither shall yo allow the salt of the covenant of God to be lacking from your meal offering. With all your offerings you shall offer salt.
- Numbers 18:19 Search for reference in progress
- Numbers 34:3 Search for reference in progress
- Numbers 34:12 Search for reference in progress
- Deuteronomy 3:17 Reference to a salt-sea - in progress
- Deuteronomy 29:23 "And that the whole land thereof is brimstone, and salt, and burning, that it is not sown, nor beareth, nor any grass groweth therein, like the overthrow of Sodom, and Gomorrah, Admah, and Zeboim, which the Lord overthrew in his anger, and in his wrath ..."
From the Historical Books
- Joshua (Jesus Navi) 3:16, 12:3, 15:2, 15:5, 15:62, 18:19 {OW Note: References to be checked against Septuagint}
- Judges 9:45 "And Abimelech fought against the city all that day; and he took the city, and slew the people that was therein, and beat down the city, and sowed it with salt."
- II Kingdoms (II Samuel) 8:13
- IV Kingdoms (II Kings) 2:20, 2:21
- I Paraleipomenon (I Chronicles) 18:12
- II Paraleipomenon (II Chronicles) 13:5, 25:11
- I Esdras (Ezra) There is a reference to salt in the context of the pay of the Persian king's servants. Search in Progress to find passage 4:14, 6:9, 7:22
The following books do not contain references to salt:
- Ruth and I Kingdoms (I Samuel), III Kingdoms (I Kings), Nehemiah, II Esdras, Tobit (Tobias), Judith, Esther, I Maccabees, II Maccabees, III Maccabees
From Books of Wisdom
- Psalm 59:17, 60:1, 107:34 ...
- Prayer of Manasseh
- Job 6:6 "Can that which is unsavoury be eaten without salt?"
- Job 30:4
- Job 39:6
- Proverbs
- Ecclesiastes
- Song of Solomon
- Wisdom of Solomon
- Wisdom of Sirach
From the Prophet Books
- Isaiah There is no reference to salt in the book of Isaiah.
- Jeremiah 17:6
- Ezekiel 16:4 "As for your nativity, on the day you were born your navel cord was not cut, nor were you washed in water to cleanse you; you were not rubbed with salt nor wrapped in swaddling cloths. (NKJV)
- Ezekiel 43:24
- Ezekiel 47:9
- Ezekiel 47:11 "But the miry places thereof and the marishes thereof shall not be healed; they shall be given to salt."
- Daniel and Hosea There are no references to salt in the Book of Daniel and Hosea.
- Joel 2:20 "But I will remove far off from you the northern army, and will drive him into a land barren and desolate, with his face toward the east sea, and his hinder part toward the utmost sea, and his stink shall come up, and his ill savour shall come up, because he hath done great things."[5]
- There are no references to salt in the following books:
Amos, Obadiah, Jonah, Micah, Nahum and Habakkuk
- Zephaniah 2:9
- There are no references to salt in the following books:
Haggai, Zechariah, Malachi
In the Old Testament, Mosaic law called for salt to be added to all burnt animal sacrifices (Lev. 2:13). The Book of Ezra (550 BC to 450 BC) associated accepting salt from a person with being in that person's service. In Ezra 4:14, the servants of Artaxerxes I of Persia explain their loyalty to the King. When translated, it is either stated literally as "because we have eaten the salt of the palace" or more figuratively as "because we have maintenance from the king."[6]
New Testament References
- Gospel of Matthew 5:13 Ye are the salt of the earth: but if the salt have lost his savour, wherewith shall it be salted? it is thenceforth good for nothing, but to be cast out, and to be trodden under foot of men.
- Gospel of Mark 9:49 For every one shall be salted with fire, and every sacrifice shall be salted with salt.
- Gospel of Mark 9:50 Salt [is] good: but if the salt have lost his saltness, wherewith will ye season it? Have salt in yourselves, and have peace one with another.
- Gospel of Luke 14:34 Salt [is] good: but if the salt have lost his savour, wherewith shall it be seasoned?
- Colossians 4:6 Let your speech [be] alway with grace, seasoned with salt, that ye may know how ye ought to answer every man.
- James 3:11 Doth a fountain send forth at the same place sweet [water] and bitter?
- James 3:12 Can the fig tree, my brethren, bear olive berries? either a vine, figs? so [can] no fountain both yield salt water and fresh.
In the New Testament, Matthew 5:13 Jesus said, "You are the salt of the earth." He added that if the salt loses its flavor, it is good for nothing but to be trampled. Jesus said this in order to show his disciples how valuable they were and this saying is commonly used today to describe someone who is of particular value to society. In addition, the preservative quality of salt is in view here to show how the disciples were called to preserve the society and the world around them from moral decay. On another occasion according to the Gospels, Jesus commanded his followers to "have salt within them"[7]
Characteristics of Salt
Knowledge of the characteristics of salt is one way to assist in the allegorical interpretations of the Scripture passages.
- Salt is a needed mineral: Salt is an essential element in the diet of not only humans but of animals and even of many plants. It is one of the most effective and most widely used of all food preservatives and has even been used to preserve Egyptian mummies. It's industrial, medical and other uses are almost without number.
- Salt is a taste enhancer:
- Salt is used as a symbol of wisdom and knowledge in many cultures: In many cultures, it is traditional etiquette to offer bread and salt to visitors.
- Salt was used as a currency in many cultures: Ezra 4:14: Salt has served as currency at various times and places in history and has been the cause of warfare between places. There are records outside of the Scriptures that place an importance on salt in commerce during the Medieval ages and earlier still in Nepal and the Sahara salt was used in trade. These records provide a glimpse into how salt would have been used even earlier still. During the 15th-century, in Russia, the monks from the Solovetsky Monastery would make salt that became the base for the monastery's economic power. The salt that they produced was black and was created by using ground grain and seaweed that when dried on stoves would turn black.
- Salt was used in sacrifices: Leviticus 2:13
Interpretations by Church fathers
What do the Church fathers have to say about the "salt" term in Scripture? List of articles discussing this:
- A reading from the homilies of St John Chrysostom on Mt 5. 13-16, non Orthodox based blog.
- ↑ Salt is the every day term for the chemical compound Sodium Chloride (NaCl); it occurs naturally in many parts of the world and is particularly prevalent in the area of the Dead Sea. Halite is the mineral form of sodium chloride.
- ↑ An interesting quality of salt is that when it is used it looses itself. Example, (1) when used in cooking the salt cannot be seen; it makes its contribution and is "gone". (2) In various chemical processes, salt "dissipates" after it has fulfilled its purpose.
- ↑ See the OW article on: Hermeneutics to understand how to approach reading and understanding Scripture from an Orthodox perspective.
- ↑ Text without diacritical marks
- ↑ The east sea, or the Sea of the Plain, is more commonly known as the Dead Sea! This sea is infact a large inland lake whose waters are extremely saline. In fact, it is five times more salty than the oceans, and marine life cannot live in it's waters. It is at the lowest point on earth and can be described as desolate.
- ↑ Source: Wikipedia: History of salt
- ↑ Source: Wikipedia: History of salt
External links
- Wikipedia: Salt in the Bible
- MRBLOCH SALT ARCHIVES: Salt made the World go round, website devoted to salt.


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Height 182cm(6ft) / Weight 72kg(158lbs) / Chest 102cm(40 inches) / Waist 78.5cm(30.9 inches)
Processing time before shipment takes approximately 1~2 business days and begins immediately after we receive confirmation of your payment.
If we don't have your item(s) in stock, it will usually take 1~3 business days to be restocked depending on the item.
1. Standard Shipping Service takes 7~42 business days depending on the country.
* We will split up your order into several packages if the items weighing over 2KG due to the weight limit of the standard shipping service.
2. EMS (Express Mail Service) takes approximately 3~8 business days depending on countries.
3. UPS (EMS Premium) takes approximately 2~6 business days depending on countries.
4. No shipping on weekends and Korean national holidays (KST).
5. Please note that we need 7~10 business days to produce handmade items.
- In all cases, the items must be in their original condition and will be inspected upon their return.
- The quickest way to make an exchange is to re-order the preferred size or color and to send the unwanted item(s) back to us for a refund.
- If you wish to exchange the item(s) for a completely different item or color, you need to place a new order for the desired item and return the other item(s) back for a refund.
- Please allow up to 3 business days from receipt of your return for us to process your exchange. If for any reasons, the item is out of stock, we will e-mail you.
- If you have any further questions, please contact us at firstname.lastname@example.com with your order information such as order ID, your name, registered email address, etc.
* 2% Points
- for registered member.
* Bonus Coupon
- $10 coupon for over $150 Purchases.
- $30 coupon for over $300 Purchases.
- $50 coupon for over $500 Purchases.


text:
Like all parts, batteries run their course. Most will last up to five years, depending on conditions and how often you drive. Signs of an aging battery include an audible slow crank when you attempt to start your engine, a lit check engine/battery light or the strange odor of rotten eggs.
If you have any concerns, Bickford Ford offers a complimentary computerized battery test. Plus, each Motorcraft® battery we install features the latest technologies in design and engineering. They provide dependable power to today's high‐technology vehicles across a wide range of conditions.
With over 47 million Ford cars, trucks and SUVs on the road today, it has never been more important to ensure your technician is familiar with your specific vehicle's battery needs. And no one knows your Ford better than Ford and the technicians at Bickford Ford.
Other benefits of Bickford Ford battery installation include:
The Ford Service Credit Card is a financing option that lets you pay for all service maintenance and repairs, including Batteries at Bickford Ford and other Ford Dealers across the U.S. It only takes a few minutes to apply and receive the decision.
Upon credit approval, you'll be provided with a credit line to assist you with all instore purchases, including:


text:
Chad Billingsley (4-8, 4.20) vs. Trevor Cahill (6-7, 3.63).
Tonight is part 1 in the Diamondbacks' Attack of the Trevors, with Cahill having hitched his waggons to the Snakes after three years of service with the A's (40-35, 1 All-Star appearance). Cahill has one career appearance against the Dodgers, going six innings without a decision.
As for Chad Billingsley? We need a win tonight, Bills, to ensure we'll remain in first place (irrespective of the Giants' fate). Can you Stave (off) Trevor? All the world is waiting for you, and the powers you possess.


text:
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Map record details
Map series | Regional Geochemical Atlas |
Sheet number | 53 |
Sheet title | Cerium in stream sediment - [text] |
Publication year | 2000 |
Additional information | Page from Regional geochemistry of Wales and part of west-central England: Stream sediment and soil. Keyworth, Nottingham : British Geological Survey, 2000 |
View map | View map | Buy direct from BGS Bookshop | Request a paper map or scanned copy |
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This map as displayed in this viewer is made available under the Open Government Licence, subject to the following acknowledgement accompanying any reproduced BGS materials: "Contains British Geological Survey materials © UKRI [year]".
Please be aware that separate terms will be supplied with digital or hard copy versions of the map purchased via the BGS Bookshop.


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To the editor:
Its always amazing how City Hall dupes motorists by raising its parking fees and how the gullible public falls for it believing the city has a right to earn a profit off its parking meters.
Recently, on July 29, 2010, two opinions from readers Hubbard (Citys parking policy encourages vehicle usage) and Hulfish (Was the parking meter rate increase a mistake?) talked about how the 75 percent increase in parking meter fees were revenue-raising. Well, they cant be and the citizen ought to do something about it instead of believing it to be so.
State law states that parking meter fees are traffic control devices and by that it is meant that cities and counties may regulate parking, not charge a tax for parking. It may not use these devices to raise revenue. Cities and counties can only charge what the cost of operation, i.e. installation and enforcement, bears. Otherwise, the city is engaging in illegal tax-gouging which is a violation of state law granting it no authority.
Any of these citizens can challenge this tax-raising event by the City of Alexandria by either defending a ticket issued on a meter right up to the appellate courts, because it was fined for the assessment of an illegal fee.
Or, go ahead and initiate a lawsuit on behalf of all motorists that the city has converted the parking meter user fee into a tax and have it enjoined and fees refunded by showing that the fees are unreasonable and not substantially related to the cost of servicing the meters. Just get their meter fee amounts raised from past years and this year with the 75 percent increase and match it against the cost to operate the meters if they are out of line by less than 2-to-1 you are going to create a bit of consternation among the City Councils profiteers.
You may even get the fees downsized to where they belong before tax mongers took over your streets. Why dont the citizens wake up instead of looking like a herd of sheep.
Dan Wemhoff