Sleep to Dream

Last weekend was spent visiting Aunt Ruth. I had wondered why the flight to Indianapolis was so pricey. As it turned out, it was the same weekend as the Indy 500. I perplexed more than a few race fans on the plane when I said I was planning on spending a nice, quiet weekend in a retirement home rather than watching the race.

Last fall, Aunt Ruth suffered a hip fracture from a nasty fall. She made it through surgery, and finally rehab, but she's definitely slowed down quite a bit from my visit two years ago. Since the fracture, she's had three more falls, but luckily hasn't broken any more bones. For me, the weekend was an opportunity to see her at her baseline. With my grandparents, there was always that expectation of an upcoming visit that was canceled abruptly by death. At least for me, visiting Aunt Ruth is somewhat awkward as in my head, I am always expecting it to be our last meeting. Happily, so far she's proved me wrong.

As it turned out, she had full-blown hip replacement last fall, which is kind of shocking given the high mortality rate (up to 35% in the first year following surgery) and her age (105 this past February!). I am sure that she made the decision as she would have hated to be bed-ridden, but it seems like most orthopedic surgeons wouldn't touch someone her age. Now she is clearly having balance issues and the long walk to the dining room now has to be interrupted by rest breaks.

Her remote memory is now being affected. She introduced me to a lot of other residents. Sometimes I was a doctor, sometimes I was a nurse. Sometimes I was from Washington, sometimes I was from Arizona, or Louisiana... it's a good thing we sat with different people at each meal, so nobody caught on!

Our days were full-- with meals at 8 am, 11 am, and 4 pm. In between there were 3 or 4 naps a day. It was a good visit and she reminisced often, sticking to the same memories that she felt comfortable talking about. We talked of Appersons and life on the farm.

Like my grandparents before her, Aunt Ruth is withdrawing from the world around her. The woman who used to read three newspapers a day still has a picture of Ronald Reagan at Camp David from 1984 on her desk.

Luckily, although she never had any children, one of my uncles checks on her several times a week. The staff at the assisted living center also seem to be pretty good about checking up on her several times a day. The day is soon coming when she will have to move to the nursing home wing, and she seems to be all too aware of that, but is putting it off for now.

I prefer to think that her mind works better when she drifts off to sleep, returning to a time of antiquated behaviors and expectations, a world where she makes decisions rather than having them be made more and more for her.

An Update, but Not Really

I have been neglectful about updating this thing as of late. Lately, I just seem to be content at doing nothing. Free time abounds, and instead I am content to waste it all. The running has continued, in spite of the "unseasonably" cold weather lately. My motivation has off and left once again. Tomorrow I am heading out to visit my Aunt Ruth, if I can get myself packed and on the plane! Let's hope I gain some inspiration from talks with a centenarian.

Puddle Jumping

Yesterday, I ran in a 5K race. I had participated in the same race last year, but this year I did much better, coming in over 3 minutes faster than last year's time. The first mile I ran in 8:34, which is flying for me (I am typically a 10 min+ distance runner)! For me, the highlight of the race was passing by this guy doing Beatles karaoke by himself dressed in a Sgt. Pepper-style costume, complete with mustache!


Today, I went for a 12-mile run. It was raining most of the time that I was out there. Unfortunately, I stepped in a puddle right around mile 6, so that changed my stride to step-splat-step-splat with rain dripping off the right side of the bill of my hat. The sprinkling finally stopped for the last 3 miles, and that was when the wind picked up. A rain/sweat-soaked fleece shirt does not make for good insulation. On the drive home, I was still sweating and shivering at the same time.

My legs are already telling me that tomorrow is going to be a day of rest. The good thing about getting the run done today is that was the longest run according to the training plan. The rest of the weeks before the half marathon taper off. It does make me nervous to be running 13 miles on race day when I haven't run that far in practice runs, but there seem to be two theories in training: either build up to 90% of the race distance and back off, or run 110% of the distance and back off. I guess the main thing is to not fall into my usual pattern of taking weeks off entirely and avoid injury.


I did finally pick out some new shoes, but I haven't worn them yet because I figured today was not the time to break them in.


Here's the old stand-by's:

They will probably be reserved for nasty weather until the end of softball season, when they'll make their debut in the ED. (Hospital shoes stay in the hospital, given the nasty things that can be found on our floors.)


And the new pair:

The fancy running store I went to measured me, analyzed my stride on a treadmill, and pored over the soles of my old shoes. I received a look of disapproval when I said I had been wearing my old shoes for over a year. Then an engineer-type dude sat down next to me with his 9 year-old Nikes! These ones have a lot more arch support, so we'll see if I still end up with sore feet. (Either way, I don't imagine I will stop taking advantage of Army Guy's foot massage skills.)

Into the Wild

One of the things that I have discovered that I like most about running is the ability to clear my head. After a certain point, it is just one foot in front of the other, with breaths rising and falling as part of the pattern. I think that I must be somewhat unbalanced, as after I get going, I inevitably develop an ache in one shin, which melts away as an ache in the opposite knee develops, which recedes in kind as a groin or butt muscle begins to whine. (How is it even possible for only one side of your butt to be sore?)

The other thing that I like is being outside. Now that Spring has finally arrived, there are all sorts of distractions... dandelion seedlings taking flight.

• The other day, my friend and I had to slow down to pass a group of geese and their downy goslings. As we approached, the mother started hissing, just like a cat, in our direction! Luckily, we were able to make a wide enough arc from her path that no sprints were necessary. I have a feeling I can't outrun an angered goose in flight!

• Earlier this week, as I rounded a corner, a beaver quickly scuttled into some reeds.

• Today, during my run, I was pretty much a blank slate, when suddenly a hawk swooped in for a quick attack on an unsuspecting small animal, soaring just feet from my face!

Currently, I am on an elective block, which lately has meant fluttering about from room to room in the ED looking for pathology on ultrasound. Basically, I pop in, introduce myself, and slop some cold gel on a stomach, leg or chest, and then disappear, leaving a slimy snail trail in my wake. It's been interesting to kind of be on observer status in our department. No dictations to do, only minimal paperwork. Sometimes there is an attending around to provide on-the-spot teaching, but often I am left to my own resources... which typically involves getting coffee and chatting with coworkers. Not bad at all.

April Showers Bring...

I was more than a little surprised when I opened the curtains today to look outside and found this guy staring back in at me! The storm window on that window is broken, so he had flown up and gotten caught in between the layers of glass.

Slow and Steady

On Sunday, I lined up behind the starting line with a bunch of serious runners. For 10 miles we ran up and down the streets of this city... through downtown, bad neighborhoods, exclusive neighborhoods, the university campus, and past "Hospital Row". I surprised myself, and was able to do the whole thing without walking! Granted I have been building up to this run for months, but up until now, my longest run had been 8 miles continuously on a treadmill, and just shy of 7 miles on the flat trails by the lake.

One of my friends decided the run sounded like fun, and signed up at the last minute. She hadn't trained at all, so I tried to discourage her from it, but she attempted anyway. For the first 5 miles, I plodded along with her at a 12-minute pace, but ultimately ended up parting ways when she needed to stop. I think she was a bit upset at me for not stopping to walk with her. I am glad I didn't though, because the race organizers were pretty serious about only keeping the streets in town shut down for as little as possible. I finished at 1:57. As I stood at the finish line waiting for my friend, they started re-opening the streets and rolling up the finish line at 2 hours and 15 minutes. As it turned out, my friend had her husband pick her up at mile 7. I'm pretty sure if I had gone at my own pace, I would have completed the race at least 10 minutes faster.

The race was a lot of fun though, and I saw several parts of the city that I had never seen before. One of the highlights was a small park with lots of small hills and twisting paths around a pond. Best of all, I beat my own distance record! There's a half-marathon (13.1 miles) that Army Guy and I are planning on running with another couple in about a month, so I think I am well on my way to being prepared for that. As for the new running shoes, I'm planning on going to a running store in a couple of days to get custom-fitted.

After the race, I felt pretty good, and worked a full shift that night. Yesterday, I just felt kind of tired, so I limited myself to walking the hills around my neighborhood. Today, my shins are kind of angry, but I am nowhere near as sore as I had expected to be. Perhaps that slow start was a good thing after all!

Mama's New Shoes

The other night, a couple of my friends and I went for a nice dinner at the local casino. Afterwards, we decided to hit the gambling floor. It made for some interesting people-watching. Despite being in the middle-of-nowhere, there were a few women who were dressed up in mini-skirts and heels. However, there were no well-dressed men to be found-- mostly biker-types, seniors, and scruffy-looking young adults with questionable hygeine. I don't know who or what these young women were expecting to find, but clearly there weren't many options.

Anyway, my friend and her husband proceeded to argue about exactly how much money he should be allowed to "throw away down the toilet." I had brought a set amount to mess around with, but as the situation was somewhat tense between the two of them, I settled for putting down $20 at the roulette table. After nearly losing it, I was up to $40. My friends were still bickering, so we walked around a bit. I was about ready to get out of there, but my friend's husband decided he was going to play some poker, no matter how much she scrunched up her face at him. (Isn't going out with married couples fun?)

I shrugged it off, and sat down next to him. I ended up getting dealt two jacks, and as I had paid for a "bonus", I was already sure to win something just off the deal. My friend's husband unfortuately didn't get much of anything, but I ended up with a full house and up $100. I decided there wasn't any way I could beat that, so after one hand of poker, I called it quits, having just won enough to buy a new pair of running shoes I had been trying to justify. It made for a short night, but I figured it was best to quit while I was ahead.

Amateur Transplants - YouTube Fun

One of my friends was sharing this clip the other day at work. (Beware of office-inappropriate language!)

My friends give me a hard time about not liking Billy Joel, but here's a more tolerable version of one of his songs:



And finally, I think this one's the funniest:

Treinta

Yesterday I turned the big 3-0. I think it is safe to say that a sure sign that one is getting on in years is the feeling of being younger than your actual age.

Sigh.

The morning I spent sleeping in (there were snow flurries!). Although I had the day off, I went in to work in the afternoon because we were having pig lab. Pig lab, like cadaver lab, involves performing as many surgical procedures as possible in order to help residents gain hands-on experience on rare procedures, so that in the event we do have to perform them on patients, we will at least have some exposure to the procedure rather than learning on a live patient.

The pigs are heavily anesthetized and then euthanized towards the end of the lab. We only do the lab a couple of times a year, and there are only a few animals available for the resident class to work on together, so it was too important of an opportunity to miss.

I am certain that some people would be horrified by this type of learning. However, doing a thoracotomy on a living animal is completely different than on a cadaver. There's no substitute for working with real blood vessels and beating hearts. At our program, we utilize mannequins and simulate different scenarios, but again, it's nothing like the visceral experience of a real patient.

Yesterday was our second session at the pig lab. As luck would have it, just a few days prior, a cricothyrotomy was performed in the department on a difficult airway patient. While I am sure that the situation was very stressful, I can't imagine the resident having had to perform it without having had the lab training first. And I am certain that the patient and their family are glad that they weren't on-the-job training! Although animal labs can certainly make you squeamish, I think that our program does a good job about being as humane as possible and maximizing the learning opportunities from each lab animal, while minimizing the number of deaths.

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After lab, I met Army Guy for a nice dinner. Throughout the day, I caught up with friends and family via email/phone. It was maybe not the most traditional of birthdays, but still a good one.

April Showers

Heavy spring rain showers pummeled the flowers outside. I love all of the color, but the sickeningly soapy-sweet smell of hibiscus is a little overwhelming when I open the door.

Checks and Balances

"So this was part of a check-off thing tonight, right?" he said, with the last word said with a hopeful lilt.

"Yeah, they've been wanting to meet you for several months now, and I had been blowing them off. But now it's done," I answered.

"Good."

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Army Guy and I were leaving from a dinner with some co-workers and friends. I am still really impressed with AG. He's willing to try new things, and puts up with meeting my friends and co-workers... even the annoying ones. And he shows a lot more restraint in annoying situations than I would if I had training in hand-to-hand combat!

I have told him that he doesn't have to hang out with my friends or even like them, but so far he's been really good in social situations. Even better, is that everyone seems to like him! Maybe I have just dated socially-inept people in the past, but typically I either couldn't even get ex-boyfriends to go out socially with my friends or the few encounters we had were always awkward.

While I pride myself on being pretty independent, it is nice having someone to do things with, talk to at the end of the day, and who pretty much instantly makes you happy just to be around them.

Bright, Sunshiney Days

Spring is definitely here...

-The daffodils Ru helped me plant last fall are blooming, with tulips on the way.

-Red-breasted robins chirp and flutter from one green branch to the next.

Bright-colored petals are competing for pollination, animals are competing for attention from the opposite sex, and local teens/young adults loiter outside-- ending stupid arguments with violence and gunfire.

Rooty Tooty Fresh N' Fruity

What does the name Emergency Department mean to you? A place to go for help when you are sick or injured? How about a place to go for breakfast? As it turns out, that's really all one of my recent patients was looking for.

She was a hand-off patient, meaning that another person initially saw her, and transfered her to me at shift change. The story was that she had just been discharged from the hospital the day before and was back with more pain. It was her typical sickle cell pain. No chest pain, no difficulty breathing, no fever. So the other resident treated her pain, gave her some IV fluids, etc. Sick sicklers we work up with labs and imaging, those with pain crises we treat and if we're unsuccessful at controlling their pain, they get admitted to the pain service for PCA pumps, and other meds we're not willing to administer willy-nilly in the ED.

So, I was a good little resident and immediately re-assessed the patient after signout. Her pain was a little better, but she said that she usually gets better pain relief when the morphine is pushed, rather than run in with fluids in a drip. Fine, second dose: IV push, followed by another liter of fluid.

In the meantime, the breakfast cart arrived in the department. Breakfast trays had been ordered for all of the overnight psych patients and nursing home guests that for whatever reason couldn't be moved out of the department overnight due to placement issues. Typically, we don't feed our patients as oftentimes they are not around for more than a few hours, are potential surgical candidates, or are in acute distress and can't actually swallow anything safely.

It is not "three hots and a cot", people.

So the sickler requests breakfast. Fine. Since the cafeteria was actually up and running by this point, a nice, hot breakfast arrived at her stretcher in less than 30 minutes. That's pretty damn good. During that 30 minutes, she pressed her call button no less than three times to demand fruit punch, more fruit punch WITH ICE, etc. from her poor nurse who was also managing an overdose-patient, a cardiac patient, and I think an asthmatic, all with multiple orders and monitoring tasks to keep up with.

Finally, the tray arrives. The call bell for Room 19 immediately starts beeping. Soon afterwards, the charge nurse comes up to me, and said that the patient was upset that there wasn't any meat on her breakfast tray.

She said, "This ain't no breakfast-- there's no meat in here! I've gotta have bacon or sausage, or I'm just going to go home."

That was the best news I had heard yet.

So, I go back to the room and tell the patient that I hear she's feeling better and ready to go home. She says "Yeah, my pain's all better, I just want to finish my breakfast." So we discuss follow-up plans with her hematologist to discuss chronic pain management.

The unsatisfactory breakfast? Steaming-hot cheese omlet, 2 pancakes with maple syrup, and hot coffee with cream and sugar. (I think I'd crammed a pre-smashed protein bar into my pie-hole that morning on the drive in, so I was seriously eyeballing her breakfast.)

Patients like this always frustrate me. I think her nurse should have set out a tip jar. They stroll in and out of the department frequently, and have been in so many times that they come with all sorts of crazy demands and expectations. Occasionally, they present really sick, but like the boy who cried, "Wolf", when you see someone multiple times every month it's hard to take their complaints seriously.

Often, it seems to be the patients who aren't paying for our services with co-pays or insurance premiums that try to glean as much out of the hospital as they can. I wonder how this works with countries with socialized medicine. Surely they still have the frequent-fliers, mainly drug-seekers, but do they have patients that are just as demanding, or do people abuse socialized medicine less?

The Stuff of Genius...

I never said I was smart. I was supposed to go for a long run after work today. However, things got crazy midway through the afternoon, and I never got a chance to eat anything for lunch. So, instead of just sticking it out, I decided to head home, wolf down some oatmeal cookies and gatorade and then go for a run. Apparently, nothing spells bricks in your tummy like oatmeal cookies. And that's how my 9-mile run went to 1 mile with 2 miles of walking. Argh.

Spring, Sprang, Sprung

On my way off to work on Sunday, I noticed the crocus were blooming in the front yard. I guess Spring this year isn't so far behind last year, it just has seemed like such a looonnng winter. It's been in the 60's for the past three days, a drastic change from the snowflakes that were still falling last week.

Yesterday, I went for a run out by the lake. The ice had finally all melted away, there weren't any boats out, but there were a few ducks testing the water. The bare trees looked funny in the bright light... naked and exposed, huddling next to each other.

Today I finally turned the heat off, and have several windows cracked open. It feels good to air out the house.

I had a few days off last week, and when I went back to work the other day, I was shocked to find out that a teenager I had admitted a few nights before had died suddenly on the floor. She'd had heart and lung problems her entire life and had been leading a relatively normal life when she started coughing up blood. When I saw her, she was completely stable, and she got admitted for more formal testing. Everything was done correctly-- specialists were called in early and responded quickly, and I don't think that there was anything that we could have done differently.

While death and bad outcomes aren't all that uncommon, I guess I just have high expectations for stable patients that get admitted. Emergency medicine is high-pressure, but generally you can lump patients into just a few categories: those that go home, those that get admitted and then go home, and those that you just can't fix. I think that I have been brooding about this case because we all thought that this child would do so well. I had to really push the parents to allow her to even stay to get evaluated.

I Wanna Be Sedated

I haven't updated for a while, although it has not been for lack of material. Things have been busy in the Peds ED. It seems like every shift is clogged up with sedations. Like I have said before, I like kids-- I just don't particularly like dealing with their parents.

The other day, I got called over the intercom to go into Room 7 for uncontrolled bleeding. I wasn't quite sure what to expect. When I walked into the room, I saw a relatively calm toddler seated on the bed with blood oozing through the dressing on his head. His mother was pacing back and forth uttering all sorts of obscenities while her "friend" sat in a rocking chair by the child's stretcher, shoveling Doritos into her mouth.

The situation? Rottweiler vs. Toddler

As I unwrapped his head, I couldn't get a good view of the oozing wound. He had a second laceration on the top of his head that went down to the skull, and there was an odd flat spot on his head. I notice an orange crumb fall on the sheet and and look up to realize Mom's friend is eating her chips over my patient's bleeding head. I am already annoyed.

I tightly wrap up my patient's head injury, fill out consent forms and personally take him to the CT scanner. He's only 4, and there's a good chance he won't hold still for the scan. Mom is still doing nothing to comfort her child (unless swearing is the equivalent of a lullaby at home), so I hold him in my arms, and place his turbaned head in the headrest of the CT scanner. One of our nurses gave him a stuffed dinosaur, and as we wrap him up burrito-style for the scan, I place the dino on his little chest so he has something to look at while the machine buzzes around his head.

Luckily, the scan's clean... no skull fractures. I pick boy and dino back up and back to room we go, where he gets hooked up to the monitor, and we start pushing the sedatives (midazolam, atropine, and ketamine in the Peds ED). His eyes spin and "Mom" laughs at the drunken expression on his face. She doesn't want to stay for the repair, and I kick Dorito-muncher out of the room.

His cuts are deep, extending through the galea down to the skull. The bleeding has finally stopped with the pressure dressing. My attending and I are deep into repairing the wounds when random Ortho resident walks in, and goes, "Wow, what layer are you guys at?"

"That would be skull," I answer, tapping the hard surface with my suture needle.

"Shouldn't ENT be doing this?" he asks. (Ear, Nose, and Throat Surgery is the substitute for plastics at my hospital.)

"Why would two strong, independent women need ENT?" I answer, gesturing at my attending. Who let this guy in here? He's about as helpful as Dorito-woman!

He says something about another patient to my attending and ducks out.

Several absorbable sutures and staples later, the wounds are all closed. Luckily for the kid, his injuries were all in the scalp area. Although he will have some huge scars, there's not a mark on his face. "Mom" finally returns a bit more calm. They don't exactly seem to be the most reliable at follow-up, so I go over wound care and antibiotic coverage three times with them. We also gave him IV antibiotics. "Mom" still has done nothing to comfort her son, and Dorito-woman interjects some helpful anecdote about something she saw on TV.

I was ready for my own chemical-induced nap by the time they left, and had to exchange white coats as mine now had blood all over the shoulder. I think that The Ramones said it best.

Internal Disaster

Granted I have not been at this game for very long, but there seems to be a general lack of common sense among many of our patients. The seasoned attendings swear it is just getting worse. A blight of stupidity.

If your child has a fever, and you take him to the Emergency Department and he/she gets given some Tylenol, which breaks the fever and you even go home with a prescription for Tylenol (which will be free to fill as the child is covered by Medicaid), why in the world would you not simply give the child the Tylenol as directed? Why would you return to the ED 12 hours later, have the child be doled out another dose of Tylenol by the triage nurse, sit through over a three-hour wait to even get seen by a physician, and then get mad at me when I give your runny-nosed, now afebrile toddler a popsicle, and discharge him home 10 minutes later? Sicker patients get a higher priority. And, I am not about to admit a well-hydrated tot with a cold to a hospital already short of beds because a parent can't follow simple instructions!

What more can I do? We can't physicially hand out medications because there's no way to stock supplies large enough to cover everything prescribed. At some point, parents have to have the responsibility to go to the pharmacy (several of which are open 24-hours) and get the prescription filled. (Or in this case, they could shell out the $5 for the medicine since it's over-the-counter, instead of spending their money on cigarettes and manicures.)

I know that I have ranted about this before, but the situation becomes all the more frustrating when the pipes in the dirty utility room start backing up and overflowing into the lobby. The whole waiting room had to be evacuated because of noxious fumes, so what we were left with was hallways of impatient (and mostly, non-sick) people corralled off and harassing nursing staff about the wait time. If I had a sore throat and was in a waiting room with dozens of people in front of me to see the doctor, and the room had to be cleared because of a hazardous exposure, I would just go home, or better yet, walk the block-and-a-half around the corner to the hospital next door, which is physicially attached to ours.

People, there wouldn't be any wait time if you only came in for emergencies.

The Name and Blame Game

If one was such a fan of great philosophers to go as far as to name their child after Socrates, shouldn't they at least spell it right?

The other day, I took care of a vomiting toddler named Socratiez, or Socks for short.

The all-time record for stupid names goes to my colleague, who saw a kid named Shithead. It was supposedly pronounced Shi-tay-ed. And no, they weren't recent immigrants. Some things should be illegal.

The Houseguest

My friends will tell you that vacationing with me can be exhausting. Sometimes I try to cram so many activities into such a short time period that you may just need a vacation from your vacation.

My friend, J, was on her Spring Break and flew in for a few days. Here's a brief summary:

Day 1:
- Pick up J at airport--they've actually lost her luggage!
- Give 5 minute tour of my house.
- Off to dinner!
- The Other Boleyn Girl - Confusing pentagon-shaped headgear.
- Ice cream sundae break!
- Watched "The Lake House" while waiting on J's luggage.
- Awakened at 1:30 am by airport van carrying lonely suitcase.

Day 2:

- Irish pub for breakfast (skipped the green beer since driving)

- Nearly got kicked by an Irish dancer.

- Oh Canada!

- Sampled some Canadian wine.

- Hit major city at rush hour, dined in the sky.

- Turned around and drove back.

Day 3:

- Unrelenting rain.

- J sleeps in and rests while I go to ACLS class .

- Show off my city.

- Drive up for dinner with Army Guy.

Today:

- Deposit J back at the airport .

J and I were college roommates, and although our lives have split in different directions from our pre-med days, it was good to catch up with her minus the kids an husband for a few days of just being old friends. For 72 hours, I was 20 again.

Home Again

I am back in the Pediatric Emergency Department. While things at the Veteran's hospital went smoothly (It is nice having computer access to records of primary care and specialist visits.), the patient volume was so much lower than it is at my hospital. While I miss the luxury of actually being able to leave on time with all of my charts dictated, time passes much more quickly when you are busy.

Over the past few shifts I have had some pretty sick children, mixed in with all of the usual fever and vomiting cases. The other morning started with a child hit by a car. She came in already intubated, so there wasn't too much to do, but the poor thing had fractured three out of four of her extremities. She'd been hit so hard that she had huge gashes across her chest, and her liver was lacerated. She's still in the ICU fighting for her life, but she came through surgery ok, and hopefully will come of the vent soon. Then there's been the gauntlet of medical stuff... asthma, sepsis, scarlet fever, meningitis exposure (!), appendicitis, etc.

And perhaps my favorite, the accident-prone: lacerations, shoulder dislocations, finger amputations, nailbed injuries to repair, all requiring lots of sedations. I have said this before, but I really like the straight-forward stuff: clean it, sew it, pop it back in place. As long as the rest of the department is settled down, it is really satisfying to have a quiet 20 minutes of irrigating, prepping and doing a quick suture job.

It's good to be back.