Monday, September 23, 2019

Notes From The Trauma Bay



Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.
Motorcycles are not your friend.

Unless you want to be deader than disco before you're 25 years old.

In which case, please make sure your driver's license says "organ donor".
Thousands of people needing transplants await your demise.

Every few years, when I start to think about getting a bike, someone comes in really jacked up from a motorcycle accident, and beats the idea out of me in about one head-to-toe assessment.

Or, sometimes, a head-to-thigh assessment, because that's all the paramedics could find to bring in.

Motorcycle?
Don't.

Tuesday, September 10, 2019

No, Really

















I have now officially spent more time in annual re-certs than the amount of time I originally spent in nursing school.

Sunday, July 7, 2019

Is It Just Me, Or...?




I really do love my job, and saving lives never gets old, except when you don't, but I was just wondering...

does anyone else ever get so tired from a shift that when they get home, they could fall asleep in the Porcelain-Clad Thinking Room?

Not that it ever happens to me or anything.

And does that mean "pooped" is etymologically a dual-meaning word?

Sunday, April 21, 2019

Assinus politicus - Assclown Of the Year



It has come as a rudely unpleasant shock to WA state senator and walking braindead jackhole Maureen  Moron Walsh [R - Retardia] that nurses do not, in fact, "play cards for a considerable amount of the day". Only someone who's never performed worthwhile labor in their adult life, and/or has a resting IQ in the low teens, somewhere just north of fungus, could managed to get both feet thusly inserted in their own gaping mouths, with their empty head simultaneously shoved so far up their own hindquarters so as to choke off the passage of light or oxygen. But it always cheers my heart when some elected functional moron's political turkey timer pops up to let us know they're done.

Someone on the Twaddleverse helpfully added her WA office number:
(360) 786-7630.
How cute. Have fun. Maybe you could invite Moron to a nice card game at your hospital shift.

I will personally pledge to contribute to every opponent she faces in her next primary, and every other party's candidate from opposing parties in the general election, the next time this sorry sack of sh*t is up for a vote. She needs to be kicked RTF out of the state house for being that egregiously stupid in public, and based on her speech, we're guessing this is one of her brighter and more coherent stupid utterances. The rest certainly have to sound like she's having a stroke, every time she squawks and squeals. If she has the good grace to quit now, quickly, I'll contribute a like amount to Alzheimer's research and money to care for actual retarded people.

Were I in WA state, I would be gathering signatures for her immediate recall, as being too stupid to suck air and a waste of skin has to be a disqualifying factor in holding office, even in a community like Walla Walla.

But in true form, the memes and Twittterlanche on her head have been properly brutal.
“Nurses … probably play cards for a considerable amount of the day” is in the running for most inane, indefensible, disgraceful thing said by a legislator this year (even though the competition is really fierce). — Ajai Dandekar (@ajai_dandekar) April 20, 2019
When world-class retards tell you you're retarded, YOU'RE REALLY RETARDED. - A.
















(And yes, I made that, but Kathy absolutely tweeted it.)

I'm also pretty sure Joy Behar ( "Why is she wearing a doctor's stethoscope?") could send along a few tips on coping with being the biggest jackass in America today to state senator Walsh.

More here.

I'll be dog-goned if I'm not piling on to this monumental level of stupidity.
















And a personal benediction to Sen. Moron Walsh:

Don't worry, Sh*t-For-Brains. No nurse would ever treat you like you just treated a few millions of us.
Or...would they?
Sleep tight. Take your vitamins.
And may God have mercy on you when (not if) you end up in a hospital needing care.
No one else will.
You might want to think about getting some gold-plated Costa Rican medical policy.
For the rest of your life.
And for pity's sake, do the world a favor: Change parties.
You're already overqualified to be a Democrat socialist, so by all means, run down and sign up today. You'll increase the IQ of both Republicans and Democrats in WA state the minute you do that.

But walk tall, sweetheart.
Earning Assclown of The Year honors in April has to be some sort of record, even for a politician who's overmatched by celery bunches at the grocery store in a contest of wits.

You might have thought someone who'd had a heart attack and gotten two cardiac stents a couple of years back would have been a wee bit more circumspect, but remember, this is a politician we're talking about, not someone with a functional brain, let alone one connected to their mouth.




















Jesus rose from the dead today. But, you, Bright Light, should invest in a shroud and a cemetery plot.
Hey...is that a fork sticking out of your back?
Yeah, you're done.

Tuesday, January 1, 2019

Year End/New Year's Ebola Update




















As multiple commenters elsewhere have observed, we've brought an M.D. exposed to Ebola in DRC, but asymptomatic and not contagious, back to Nebraska for observation.

Ok, fine, so far.

This is how it's supposed to work for everyone exposed, even TV spokeshole doctors and whiny Mimi Crybabypants "nurses" who think they should have the right to run hither and yon and hopefully not start infecting people when they pop a fever. Or not. Because they're special, and the sun shines out of their anuses, apparently. Contrary to quarantine policy and black-letter health laws going back 700 years.

Sending the guy to quarantine at Nebraska Medical Center is fine too, as it's home of one of the four BL-IV treatment centers with the 11 actual BL-IV beds extant in North America, should that become necessary, and their patient becomes symptomatic.

The gaping flaw in what they're doing is that they plan to observe Doctor Oopsie for two weeks - fourteen days.

But Ebola Virus Disease incubates for between 1 and 25+ days, NOT JUST 14 DAYS(!), and while 99% of cases appear in 25 days or less, 1% of cases don't show up until after 25 days.
(Another very small but non-zero percentage of persons exposed are asymptomatic, but may still carry the disease and be infectious without symptoms. Nobody is talking about that last part, either, because if you pretend it doesn't exist, you don't have to deal with it. Until you do.)

Geniuses in action, right there.













It will be cold comfort to anyone subsequently infected if they stop checking Dr. Oopsie on Day 15, and he doesn't become symptomatic, and thus infectious, until Day 18, or 23. Especially if he celebrates the end of his quarantine at the mall or movie theater, coughing out virus onto random passersby.

If you're going to half-ass a quarantine (and clearly, they ARE doing exactly that in this case), better to not do one at all, and just tell people to kiss their asses goodbye, because - EXACTLY LIKE IN 2014 - TPTB are playing roulette with the entire populace, because for them, that's more convenient.

Sleep tight.
And cross your fingers.

 
Oh, and that Congo outbreak itself?
 
As we warned, it's accelerating out of control, growing from 503 cases on 11/30 to 692 cases as of 12/21, a week ago. IOW, more new cases in the last 21 days than the total number of cases for the first ten weeks from August to mid-October.
The experimental vaccine is still, AFAIK, 100% effective, but the outbreak has blown through every containment ring like a brushfire in a gasoline-soaked forest.
 
Buckle up. 2019 is looking seriously fugly.
 
And that doctor is just the first case we're watching.
He won't be the last.

UPDATE:
And for those unwilling to follow this closely, bringing him here is not the problem.
Bringing back 12 or more symptomatic patients is the problem - because we don't have that 12th Ebola bed - as is cessation of his/their infection monitoring before the likelihood of infection gets to at least a 99% chance of safety.

And if you bring 100 exposed people back, that statistically guarantees that one of them will be the 1% long period incubation that you'll release into the wild here, and we're off to the races.

A quarantine has traditionally meant 40 days ("You could look it up." - Casey Stengel), and that standard should apply yet again, in this case. Six weeks' surveillance, not two.
Anything less is rolling the dice, and we're all the chips in that wager.

Friday, October 26, 2018

RN Staffing Ratios

h/t EDNurseasauras


























EDNurseasaurus had a post about MA and staffing ratios, and a very typical shift in any ER in the country.

I may have covered this on this blog before, but it bears repeating:

CA calling.

1) I started in the pre-ratio days.
On but one memorable night in Busiest ER On The Planet (no, really!), I was the third nurse in triage.
My assignment:
Everyone coming in on ambulances too weak/fragile/fall-prone to put in a chair.
Everyone seen, treated, admitted, but not needing a monitored bed, so pulled out so we could hot-stack new patients in their old rooms, and the pre-admitees moved to the hallways.
All the traumas downgraded from trauma monitoring, and in the back hallway.
The fresh chest pains who needed to be moved to the EKG tech booth, then back to the triaged-but-no-bed-open pit.
Move the admits to the floor after calling report, when beds become available: no tech. 18 floors.
Get food/water/urinals/bedpans/blankets/pain meds/barf basins for any and all of the above.
Discharge anyone seen, treated, and released in my flock.
Total body count tonight, just for me: 79.
Seventy. Nine.
I shit you not.

As I received report from day shift, thinking he was kidding me, and then finding out he was serious, I did some napkin math: at 5 minutes apiece for vitals, that's 12 an hour. 6 + hours to get from A to Z, and start with A again.
"Yeah, that sounds about right." he confirms.
He only tells me the highlights on the 10 sickest ones. The other 69 are either unknown, stable, or GOK: God Only Knows.
I look at his vital signs updates. In our 1-2 hour standard-of-care ER, they are listed every q6+ hours.
Spot-on.
In the pre-EMR world, I spend over an hour just finding the charts, locating the bodies that match the charts, and writing down a list of the names on everyone's favorite ER scratch paper, a brown paper hand towel. (*Bookmark this note.)

I locate a portable vital sign machine, and except for full-arrest traumas, it takes the entire staff, including Trauma and ER Chief Attendings, about 3 minutes to realize I have the right of way at all times, owing to my demeanor, size, and attitude, and they'd better GTFO of my path, or be run over like the extra in the chariot race in Ben Hur.


Vital signs - urinal - blanket - pain med - vital signs - jello - straw - blanket - vital signs - bedpan - water - report - transport - vital signs - accucheck - snack - vital signs.
Lather, rinse, repeat, 200X.

Come 7AM, I have six patients left. No one died, everyone got to the floor/a room/discharged/whatever.

Last year, going through my papers, I found the *paper towel, with all 79 names. It went home in my cargo pocket, and I was hoping JCAHO would stop and ask me about the place.

As if. They took one look at the place after 5PM, pronounced "Privacy issues must be challenging for you." and were never seen in the ER again.
2) A few years later, CA (i.e. nurses in CA) put nursing ratios on the ballot. It sailed passed voter acclaim, over the fear-mongering b.s. of penny-pinching corporate sh*tweasels.
For ER:
Normal: 4:1
Critical 2:1
Super-critical trainwreck 1:1
If I have one ICU player, I can have 2 normals as well, for 3 total
And obviously, if TSHTF, and there's a train wreck, plane crash, 7.0 earthquake, you're gonna get what you get, and suck it up.

It's still too much sometimes, but is one helluva lot better than nothing.

And any place busy, you're getting patients shoved up your butt as fast as you D/C the last one, with about 60 seconds to strip and flip the gurney, shpritz it with cootie-cide, and slap a fresh sheet on it.
I've taken up my ICU player, only to return to two fresh untouched normies or another ICU player before I even get back with the empty bed.

That's everywhere, all the time.

Ratios? Hell yeah!
Next stop: mandatory ancillary staff: EMTs/CNAs, etc.
If I and another nurse split a tech, that tech, for 1/4 to 1/3 of my hourly rate, doubles my output and productivity and, can do all the stupid but important stuff you don't need a license to do: vitals, blankets, water, code brown-yellow/ transport to x-ray/CT/U/S, the M/S floor, doing EKGs, D/C'ing IVs on patients for D/C, running samples to the lab, etc.

Paying me $40/hr to spend twenty minutes looking for a fricking tube system transport container to tube my samples to the lab is cost-ineffective b.s., and keeps me from doing patient care. And I spend three hours out of twelve a night doing that. So I point out regularly to manglement that they're paying me $120/shift to play hide-and-seek with $40 worth of plastic, while lawsuits are waiting because I couldn't care for $50K patients. (Whereupon, they look at me as if I've grown another head.)

We could have enough techs to speed throughput for a thirty-something bed ER, for the price of one additional nurse, and there'd only be 1200 ambulance company EMTs who'd leap at a chance for 12 hour shifts instead of 24, benefits, and a chance for tuition reimbursement to become RNs/PAs/MDs, so of course fully staffing techs is not a staffing priority, because they could fix it in about 5 seconds, forever, and have a 100-person float pool to ensure we'd never be short techs, even with 10 psychs needing sitters.

But they'd have to pay money for that, while simultaneously cutting wait times, admit times, and sending patient satisfaction scores to the moon, so, not a priority for the clipboard commandos and the Good Idea Fairies who haven't been at a bedside since the Johnson Administration. (I'm not sure whether it was Lyndon's or Andrew's.)

I feel ya, sister.
MA should vote "Yes". So should the other 48 states.

Thursday, October 25, 2018

Somewhere Else

















It's happily rarer than people imagine, even in knife-and-gun-club trauma centers, but Death visits the ER.

Nobody's death comes easy, even the gang-banger who brought a knife to a gun fight, as his mother sobs agonal soul-shaking cries to the heavens. It's not my job to pass judgment, nor torture the living with the final sins of the dead. They'll be able to do that themselves anyways, and for months, soon enough.

I hate death with a passion when early, or some unbidden surprise visitor, and only when the awardee has lived at least their threescore and ten can I see it as a transition, while for only those dying in terminal pain is it the truly welcome arrival of a long wished-for friend.

The sudden, random, unexpected variety is waste beyond explanation, and the recipient of my quiet rage. Like Captain Kirk, I don't believe in the Kobayashi Maru scenario, and the ones you couldn't pull back are the hardest to bear, and the ones you remember long after the others happily fade from memory.

In Gene Hackman's line in Uncommon Valor, some faces never leave your mind's eye, but you make friends with them. Not to do so would drive anyone mad.

This very morning I was happy to be working on a critical patient, because it kept me too busy to deal with the one right next door, dying with no help nor hindrance from me, despite the earnest efforts of 20 others, and I was glad to be able to let others focus on that problem while I got my guy - awake, alert, and very much alive - ready for the cath lab and then ICU. It could have just as easily been the other way around.

I understand and pity the doctors, because they always get to make the notification, generally face-to-face, and they try to keep it simple and as subtle as a scalpel slicing your throat: "Your xxxx is dead. We tried everything we could. I'm very sorry for your loss."
And then understandably try to get back to work on the living, because there are always more live patients to see.

Dealing with the new patients in the room, the next of kin, family, friends, coroner, mortuary, etc., and calling to tell those unknowing to come in, but safely, and without revealing news over the phone, falls back on the nurse responsible for the man or woman or child they'll eventually have to disrobe, clean up, make less fearsome, and remove pads and tape, while leaving tubes and IVs and such in place, in case the coroner takes the case. Covering the patient for modesty, removing blood and worse; and then, after all the sobs are finally spent, zipping them exactly as naked as the day they entered the world into their final sleeping bag for that trip to the Eternal Care Unit. Tag on the toe, tag on the zipper, hands crossed, and please God, in the couple of hours' grace before rigor mortis starts to stiffen limbs and make it impossible to put grandma or auntie or son Jack into the bag without difficulty, and no limbs extended to other points of the compass than due south.

I've bagged some dozens, of all ages. Some mine, some as a favor to an overwhelmed co-worker. Gently and respectfully, sometimes with help, sometimes alone.

Mindful of the fact that fluids accumulate, muscles relax, and fluids follow gravity. Bad enough to handle the dead without getting slimed by them after their departure. Worst of all, the traumas, some where they've cut them open to reach the heart and stimulate it by hand, often to find the offending missile has penetrated the bullseye, and rendered further efforts more than futile, and sometimes after the patient has been sawn virtually in half from each side, with only the spine maintaining the semblance of a whole person.

I don't know what others do, but I tell you freely and honestly, I talk to them as if they were still there as they're being prepped for that last gurney ride. Maybe they still are there, or nearby, in some way known but to God. I have no idea how soon the bus gets there afterwards, or how quick the departure occurs. They may even still be alive inside there, seeing and hearing, trapped inside the body for a minute or few as things fade away after everything fails. It's simple respect for them afterwards, and it helps me to deal with what I'm doing. Quietly, but sincerely, knowing this is as close as I'll ever be to the doorway they've just entered until it's my turn to be zipped into the bag. They get the same compassion they'd merit if they were still breathing, because they're not carcasses.
Not yet.

I'd happily never have done it, but if not me, who? At least I know it'll be done properly, and with what measure of dignity I can accord someone who probably woke that day with no idea it would be their last.

I have my own suspicions as to what happens to them afterwards, but no one truly knows, nor but seldom is in any great hurry to find out, the trip being always a one-way turnstile.

At this point in my life, I still agree with the man who, when asked where he wanted to be when died, answered quite sincerely, "Somewhere else."

Saturday, September 22, 2018

Qwitcherbitchin', Crybabies


























Burning Platform has some whiny rant (and coming from me, that's really saying something) about a guy billed $426 for an $8 can of OTC pain spray.

Well, gee, no shit, Sherlock, and if you'd seen the report from MIT on the topic, or drove by Homeless Depot any time since 1986, you might have noticed those 200 Julios standing outside their branch in Greater Aztlan Assland, which heritage Mexican homeland apparently stretches all the way to Anchorage AKand Bangor ME. (Who knew?) And unlike whom, you have actual insurance.

Oh, and back awhile, your congressweasel voted in EMTALA, mainly in response to anesthesiologists passing gas for docs doing C-sections on pregnant migras who were crowning, and getting sued by them afterwards, but never actually getting, y'know, paid for their twelve years of higher-education services or their $1M expertise. Those bastards!! Doctors should work for free, amIright??
Occupy!

Short story long, if you show up at the ER, yours, mine, anybody's, you get to play, but you don't have to pay. At least, not up front. Unlike, say, your doctor's office, Urgent Care, or - waitaminute - every other commercial establishment in the flipping country, including the DMV and the Post Office.
Well-played, Fucktard Minions of Stupidity.

So, by the by, exactly how long d'ya suppose Mickey D's or Burger King would be open as a business anywhere, if tomorrow Congress passed the WAAH! My Tummy's Rumbling Active Hunger And Deadbeat Wimpy Act of 2018, dictating that anyone who wanted a hamburger now could get it now, solely on the promise to pay for it next Tuesday?

And if you worked at a business similarly burdened, how long would you have a job when that enterprise subsequently went tits-up, in about a New York minute??

And if the pharmacy at Wal-Mart had to hand that spray out for free, how much d'ya figure they'd start charging for kettle corn bags and underpants to subsidize that largesse? Say, somewhere around $426 dollars, just mebbe?

Anyways, they go on to knee-jerk call the price of the pain spray to government regulation and socialism(!), rather than all y'all getting the system you pissed and moaned for, and now finding out you're getting it good and hard.




















Then, a couple of comments down, this nugget:
"Husbands bill was over $2000 to tell him his arm wasn’t broken.
Xrays were separate, about $50.
$256.00 for a tetanus shot.
For comparison, i can get a tetanus shot for a horse at tractor supply for $4.00
Tetanus boosters have been around for decades. Not like they’re rare or anything.
This is after sitting there for 4 hours among a couple dozen non English speaking persons."
Some people cannot put two and two together, and come up with the answer.
Let me help:

And that's why you're paying $256 for the shot.
You're paying for all the Julios and Marias and Wangs and Achmeds and Crazy Homeless Alcoholic Eddie guys with no insurance.

And of course they get a bill too (despite another idiot commenter suggesting we don't bill them).
Which we can't make them pay.
If they gave the right address.
If they gave the right name.

And also, because if your husband got an infection from poor injection technique, or they hit a nerve or blood vessel, or the sun was in your eyes, it was $256 to offset insurance premiums, because you'd then sue the hospital for a gazillion $$$. So you have a doctor ordering it, a pharmacist stocking it, and an RN giving it, rather than you grabbing a dose at Tractor Supply, and doing it yourself.

And of course, if he'd just gone to your doctor and gotten the booster himself, on time, months ago, it could have been had for maybe $20 co-pay, or even less than that, right?

Make your congressweasel pass tort reform, stop suing everybody for everything, build the frickin' Wall at the border, start throwing people back over it, get your annual checkups, and quit using the ER for drive-thru Urgent Care.  Now, how much of that is within the hospital or ER's control, and how much is within yours?

Otherwise, pony up. Walking in the door at any ER worth the name starts at about $1500.
If it was open, depending on day of the week/time of day, you could've gotten the same X-ray and treatment at any competent Urgent Care for a few hundred bucks.

People will price-shop for a ten dollar difference on a cell phone, but they won't use common sense about an ER bill of $2K vs. one at Urgent Care of $500.
Genius, right there.

(And if Urgent Care wasn't available for you, for any reason, then let's be reasonable. You had no choice about the ER, that injury hurt - a lot, and you wanted to know now. Fair enough. You want care now, you pay now.
We take cash, check, almost any insurance, and VISA/MC. Tell me they do things different at Burger King and Target when you want a Whopper or a pair of jeans.)

But don't bitch when you got the gold-plated care you demand, at prices your insurance company mostly pays, while you rarely see 10-20% of that cost.

This is the system you wanted, and now it's not so bitchin. I get that.
Now go fix it, as outlined.

I'd chat further, but I'm on duty at the ER tonight.
Where, if someone comes in with a heart attack, and we save their lives via the Cath Lab and first-world medicine that should be the envy of every Swinging Richard in human history since Adam, the only thing they'll remember afterwards, and go online to bitch about afterwards, is that the baby aspirins we gave them were billed at $20@.

So don't take this the wrong way, but as someone who couldn't have made two car payments in their life if they received $100 for every "thank you" heard from patients or families in 20 years of saving actual lives, if you complain about anything but gross negligence or egregious harmful malpractice, like having the wrong leg amputated, please, I beseech you most humbly and sincerely, go and fuck yourselves up the ass with a lit flamethrower, m'kay?

Because If I gave you that enema, I'd bill you for it at the price you deserve, and laugh while I did it.

Maybe when the shift is over, if I feel like it, I'll tell what you ought to be doing, and bitching about.
Knowing full well the odds of you taking such concentrated experiential wisdom is about as good as the odds of you listening to the discharge instructions you get.

Friday, September 14, 2018