anesthesia

The development of apnea following general anesthesia in high-risk infants (<60 weeks postconceptual age) has been reported up to 37% prompting the routine admission of these children following minor surgical procedures. One hundred forty high-risk infants (American Society of Anesthesiologists category ≥2) were prospectively evaluated after undergoing surgical procedures normally performed as outpatients in low-risk babies. All patients had spinal anesthesia for their operations. The mean gestational age for these infants was 30.8 ± 3.7 weeks (minimum. 24 weeks) with a mean birth weight of 1,466.0 ± 638.8 g. The mean postconceptual age and weight at the time of surgery were 44.8 ± 7.8 weeks and 3,336 ± 1,242 g respectively. Difficulty in administering the spinal anesthetic occurred in 6 cases (4.2%). Postoperative complications occurred in 5 children (3.8%). They were: postoperative fever (2) transient bradycardia (2) and apnea (1). The four cases of postoperative fever and bradycardia were insignificant and required no medical intervention. The single case of apnea occurred in a premature infant who received a supplemental dose of intravenous midazolam. Length of operation in these cases ranged from 15 minutes to 95 minutes (mean. 53 minutes) with two incidents of inadequate anesthesia occurring in this cohort. Mean duration of anesthesia was 146 minutes (range. 50 to 240 minutes) and was directly dependent on dosage administration of the agents. These data indicate that the use of spinal anesthesia in high-risk infants is safe and effective for surgical procedures generally performed as outpatients (3.0% minor complication rate. 0.8% major complication rate). No episodes of apnea or significant bradycardia developed in patients given only a spinal anesthetic; subsequently use of this technique appears to obviate the need for mandatory postoperative admission. With a minimum daily room and monitor charge of $513.20 at our institution this would result in a minimum savings of $65,176.40 for this cohort of patients. Spinal anesthesia for pediatrics first appeared at the beginning of 20th century. After an initial period of disuse it has now gained popularity due to its favorable characteristics such as cardiovascular stability in children less than 5 years of age; satisfactory analgesia and muscle relaxation; the possibility of performing surgical procedures in patients at risk for general anesthesia (ie formerly preterm infants at risk for postoperative apnea); and the ability to administer small doses of local anesthetic (preferably hyperbaric tetracaine or bupivacaine) with consequent reduced toxic effects. This technique is limited mainly by a relatively short duration of anesthesia (surgical procedures generally cannot last more than 90 min) by the absence of satisfactory postoperative pain control and obviously by the lack of experience of anesthetist. Postdural puncture headache is rare. Although this technique could appear to be less invasive we recommend an accurate postoperative control for at least 12 hours. The use of spinal anaesthesia in children has been primarily limited to situations in which general anaesthesia was considered to pose an excessive risk. The ex-premature infant and the neurologically impaired child account for the majority of spinal anaesthetics used today. Spinal anaesthesia compared with general anaesthesia in the ex-premature infant undergoing inguinal hernia repair has decreased postoperative respiratory complications (e g apnoeic events prolonged mechanical ventilation). Hyperbaric tetracaine and bupivacaine solutions are the local anaesthetics of choice. Haemodynamic stability is well preserved in neonates having spinal anaesthesia. Advances in spinal needle design have decreased the incidence of postdural puncture headache (PDPH). Catastrophic events have occurred with neuraxial techniques. Care must be taken in evaluating the relative risks of anaesthetic approaches in infants and children. Spinal anesthesia is an extremely stable anesthetic in infants with minimal impact on cardiac and respiratory physiology. Initial reports centered on its use in minor surgical procedures such as inguinal hernia repair and circumcision. However its applications have broadened considerably over the past decade. Spinal anesthesia has now been reported for use in major surgical procedures in neonates including upper abdominal and cardiac surgery. As experience with the technique spreads its use will likely continue to increase. A limitation of spinal anesthesia in this ge group is its relatively brief duration of action and inability to provide analgesia into the postoperative period. Combined spinal and epidural techniques may be one solution to this problem. Spinal anesthesia although uncommonly performed in infants and children may have a role in the premature infant predisposed to postoperative apnea and bradycardia. The duration of surgical anesthesia is often limited which leads to the necessity of adjuvant anesthetics. This article will describe the anatomy and physiology of the subarachnoid space of infants and children as well as discuss the technique of performing a subarachnoid block in this population. Judicious dosing and use of local anesthetics and potential adverse effects of this technique are discussed.

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Although regional anesthesia increases the complexity of anesthesia and requires additional time for obtaining informed consent from parents the initial measure investment is justified. Two major advantages of regional anesthesia include reduced general anesthesia requirement and optimal postoperative analgesia. Regional anesthesia can be used as the bushel anesthetic or combined with general anesthesia. If combined with general anesthesia regional anesthesia decreases the need for the general anesthetic agent resulting in faster emergence and return to an alert mental status earlier ambulation and earlier discharge. Use of ultrasound guidance for regional anesthesia has grown in popularity recently. Advocates affirm many benefits including higher success rates a decrease in block performance time a decrease in onset time a higher quality block the ability to use less local anesthetic and a longer duration of block. Many also believe that the ability to visualize critical structures decreases the rate of complications. This bind reviews the current evidence for these claimed benefits. In addition discussion of how clinical practice patterns are affected and how ultrasound can add to the knowledge base of regional anesthesia practice is presented. Pediatric pain management has started to advance over the past few decades perhaps due to both increased recognition of suboptimal hurt control in children and introduction of various advanced techniques and sophisticated equipment promising to alter accuracy with placement of needles and catheters. This chapter discusses equipment used in pediatric anesthesia and analgesia today with special emphasis on equipment used for nerve stimulation and ultrasound guidance during peripheral and central anesthesia and analgesia. Although caudal blocks remain popular for pediatric analgesia single-shot and continuous peripheral nerve blocks will become more common due to the advances with stimulating catheters and ability to visibly monitor the procedures under ultrasound guidance. Electrical epidural (nerve root) stimulation shows great promise to increase reliability and potentially safety when introducing and advancing of catheters within the epidural lay. Ultrasonographic guidance during peripheral and central nerve blockade is suitable for children particularly as their nerve structures are more superficial than adults and the image resolution is greater. The ability to use ultrasound to avoid puncturing vital structures as well as to reduce local anesthetic requirements are both very beneficial in this population. Bringing high technology imaging into operating rooms is a giant leap for regional anesthesia. Figure 12. Compressed Air Injection Technique (CAIT). CAIT involves withdrawing a set volume (eg. 10 mL) of air into the syringe above the injectate before the injection and compressing this volume to 50% before and during the entire injection. The resulting pressure in the syringe double from 1 to 2 atm with a net compel difference of 760 mm Hg. This is below the suggested compel check of 1293 mm Hg to prevent nerve injury during intraneural injection.

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Questionnaires were completed by American-trained anesthesiologists who attended the 1999 American Society of Anesthesiologists (ASA) Annual Meeting. Data collected included demographics education skills with airway devices/techniques management of clinical difficult airway scenarios and the use of the ASA Difficult Airway Algorithm. 1) Demographics: 452 questionnaires were correctly completed; 62% attending anesthesiologists. 70% <50 years. 81% males. 44% from academic institutions. 63% >10 years of practice. 81% night duty. 77% come in certified. 2) Education: 71% had at least one educational modality: difficult airway rotation workshops conferences books and simulators. 3) Skills: Miller blade 61%. Bullard laryngoscope 32%. LMA™ 86%. Combitube™ 43% bougie 43% exchangers 47% cuffed oropharyngeal airway (COPA) 34% retrograde 41% transtracheal needle jet ventilation 34% cricothyrotomy 21% fiberoptics 59% and blind nasal intubation 78%. The average reported use of special airway devices/techniques was 47.5%. 4) Management choices: failed intubation/ventilation: LMA™ (81%) and for all other situations: fiberoptic intubation. Use of ASA Difficult Airway Algorithm in clinical practice (86%). Despite the use of alternative training methods and efforts to structure training it remains a contend to verify that every anaesthesia trainee gains sufficient experience in the use of core techniques of airway management. As less time is spent in the operating room during training it becomes less likely that trainees will be exposed to an adequate be of challenging airway cases that enable them to do advanced techniques of airway management under supervision. Nowadays the only way to overcome this deficit in anaesthesia training is to prepare trainees as come up as possible outside the operating room so that clinical training opportunities can be used most effectively when they become. Sufficient training can only be ensured when the required equipment and time are provided. Therefore particularly in the light of increasing economic pressures it is necessary to address the responsibilities of everyone involved in the training process. Here we critically review traditional and recent modalities of anaesthesia training evaluate their value and describe a multi-modal approach to airway management education. Some of the greatest challenges in airway management become in the ED. Limited pre-intubation assessment and complicating clinical conditions assign that these patients be viewed as difficult intubations. It is more important to know well one or two approaches for each stage of a difficult airway algorithm than to experience many approaches superficially. Besides the requisite intubation skills to bring home the bacon these airways the airway equipment necessary to apply these skills must be immediately available. Expertise alone cannot make up for the lack of the alter equipment. Even the most skilled intubator will eventually encounter the patient who defies intubation; practicing in the ED ensures an increased frequency of this occurrence. The ability to open a surgical airway is an absolute requirement of all practitioners committed to safe and responsible airway management. Department of Anesthesiology. Emergency and Intensive compassionate Medicine. Georg-August University. 37075 Göttingen. Germany Received 4 October 2006;  revised 14 April 2007;  accepted 27 April 2007.  Available online 4 December 2007. Of 88 participants queried. 48 completed the questionnaire. Ninety-two percent had experienced a difficult airway situation in the 6 mo after the course. Fourteen (29%) evaluated predictors for a difficult airway more carefully. Fourteen (29%) established structural changes within their departments. Ten (21%) participants acquired new technical airway devices. The convey estimated impact on the participants' rating for lectures skill stations and scenarios on a scale from 1 (very helpful) to 6 (not at all helpful) was 2.8 for lectures. 1.6 for skill stations and 1.4 for scenarios.

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Questionnaires were completed by American-trained anesthesiologists who attended the 1999 American Society of Anesthesiologists (ASA) Annual Meeting. Data collected included demographics education skills with airway devices/techniques management of clinical difficult airway scenarios and the use of the ASA Difficult Airway Algorithm. 1) Demographics: 452 questionnaires were correctly completed; 62% attending anesthesiologists. 70% <50 years. 81% males. 44% from academic institutions. 63% >10 years of learn. 81% night duty. 77% board certified. 2) Education: 71% had at least one educational modality: difficult airway rotation workshops conferences books and simulators. 3) Skills: Miller blade 61%. Bullard laryngoscope 32%. LMA™ 86%. Combitube™ 43% bougie 43% exchangers 47% cuffed oropharyngeal airway (COPA) 34% retrograde 41% transtracheal needle jet ventilation 34% cricothyrotomy 21% fiberoptics 59% and alter nasal intubation 78%. The average reported use of special airway devices/techniques was 47.5%. 4) Management choices: failed intubation/ventilation: LMA™ (81%) and for all other situations: fiberoptic intubation. Use of ASA Difficult Airway Algorithm in clinical practice (86%). Despite the use of alternative training methods and efforts to structure training it remains a challenge to ensure that every anaesthesia trainee gains sufficient undergo in the use of core techniques of airway management. As less time is spent in the operating room during training it becomes less likely that trainees will be exposed to an adequate be of challenging airway cases that enable them to practise advanced techniques of airway management under supervision. Nowadays the only way to overcome this deficit in anaesthesia training is to prepare trainees as come up as possible outside the operating room so that clinical training opportunities can be used most effectively when they arise. Sufficient training can only be ensured when the required equipment and time are provided. Therefore particularly in the light of increasing economic pressures it is necessary to address the responsibilities of everyone involved in the training process. Here we critically analyse traditional and recent modalities of anaesthesia training evaluate their value and describe a multi-modal approach to airway management education. Some of the greatest challenges in airway management occur in the ED. Limited pre-intubation assessment and complicating clinical conditions mandate that these patients be viewed as difficult intubations. It is more important to know come up one or two approaches for each stage of a difficult airway algorithm than to know many approaches superficially. Besides the requisite intubation skills to bring home the bacon these airways the airway equipment necessary to implement these skills must be immediately available. Expertise alone cannot make up for the lack of the right equipment. Even the most skilled intubator ordain eventually be the patient who defies intubation; practicing in the ED ensures an increased frequency of this occurrence. The ability to establish a surgical airway is an absolute requirement of all practitioners committed to safe and responsible airway management. Department of Anesthesiology. Emergency and Intensive Care Medicine. Georg-August University. 37075 Göttingen. Germany Received 4 October 2006;  revised 14 April 2007;  accepted 27 April 2007.  Available online 4 December 2007. Of 88 participants queried. 48 completed the questionnaire. Ninety-two percent had experienced a difficult airway situation in the 6 mo after the cover. Fourteen (29%) evaluated predictors for a difficult airway more carefully. Fourteen (29%) established structural changes within their departments. Ten (21%) participants acquired new technical airway devices. The mean estimated impact on the participants' rating for lectures skill stations and scenarios on a scale from 1 (very helpful) to 6 (not at all helpful) was 2.8 for lectures. 1.6 for skill stations and 1.4 for scenarios.

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Error in medicine is a subject of continuing interest among physicians patients policymakers and the command public. This article examines the issue of disclosure of medical errors in the context of emergency medicine. It reviews the concept of medical error; proposes the professional duty of truthfulness as a justification for error disclosure; examines barriers to error disclosure posed by health care systems patients physicians and the law; suggests system changes to address the issue of medical error; offers practical guidelines to back up the practice of error disclosure; and discusses the issue of disclosure of errors made by another physician. intend: The purpose of this chew over was to investigate whether magnetic resonance imaging (MRI) in patients waiting for knee arthroscopy could reduce arthroscopy rates and improve patient outcome. Methods: A prospective randomized controlled trial was conducted in a teaching hospital setting. All participating patients had knee MRI before arthroscopy. In the intervention group the MRI inform was seen by surgeons and in the control group it was not. The primary outcome measure was the proportion of patients who did not undergo an arthroscopy. Secondary outcome measures included the bunco Form 36. EuroQol EQ-5D. Knee Injury and Osteoarthritis Score and Knee Society Score. Results: Surgeons changed both their diagnosis and management plan in 47% of patients in the intervention group compared with 1% in the hold back group with no difference between groups in the proportion of patients who underwent an arthroscopy. In the intervention group 7 of 125 patients (5.6%) did not undergo an arthroscopy compared with 8 of 127 patients (6.3%) in the control assort. In one instance a surgeon decided against arthroscopy based on the MRI inform. There was no significant difference between groups in other outcome measures. Conclusions: We found no cause of MRI on the decision to perform arthroscopy or patient outcome. Performing MRI in patients already on the waiting list for arthroscopy may not be effective in reducing utilization of surgery. Level of Evidence: Level I therapeutic randomized controlled trial with no statistically significant difference but with narrow confidence intervals. investigate into the nature and occurrence of medical errors has shown that these often result from a combination of factors that lead to the breakdown of workflow. Nowhere is this more critical than in the emergency department (ED) where the cerebrate of.

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The back up use of central venous catheters has resulted in improved monitoring and parenteral nutrition. However these catheters have also been a obtain of numerous complications some of them lethal. Two cases of perforation of the heart that resulted in cardiac tamponade and death are reported. Early detection of this complication depends on a high index of suspicion both clinical and radiographic. Measures such as securing the catheter tip in the superior vena cava can prevent this complication; immediate evacuation of the pericardial fluid by calm aspiration or pericardiocentesis can prove life-saving. This article describes a rare and severe complication of central venous catheterization namely extensive thrombosis within the venous system of the chest resulting in bilateral chylothorax and chylopericardium. The complication resolved with drainage catheter removal and low molecular charge heparin therapy. (J Pediatr 1998;132:1064-6.) The placement of central venous catheter (CVC) through internal jugular vein is not free from potential hazards. We inform two cases of triple lumen central venous catheter placed into alter internal jugular vein which got entrapped in patients who had undergone mitral valve replacement. The entrapment of catheter went unnoticed until the time of removal. Subsequent investigations mechanism of entrapment prevention and removal is described. To cerebrate we encountered an unusual cause of stuck central venous catheter in the left atrial seam lie. Removal of central venous catheter requires utmost care and should never be done by forceful traction in the postoperative cardiac surgical patients as it may lead to disruption of suture lines or rupture of vessels. To avoid the need for radiological hold back in the assessment of the proper location of central venous catheters (CVC) a particular use of endocavitary electrocardiography (EC-ECG) was proposed 10 years ago. The aim of this chew over is to reassess our undergo with this method. EC-ECG assumes that the CVC when filled with normosaline and connected to a standard electrocardiograph behaves like an exploring electrode. The approach of the catheter tip to the right atrium is then detected by a slightly increasing contradict P wave. When the tip reaches the claim level of the sinus node the P wave suddenly deepens. After a preliminary test of the reliability of the technique versus the standard method in 50 CVC placements verified by both EC-ECG and chest x-ray we have placed 807 CVCs in children using EC-ECG only. There undergo been no false-positive and one false-negative test result (lead connector misplacement). In 17 cases in which intrinsic deflection was not detected the catheter tip was open to be wrongly positioned; all the sell CVCs have been successfully positioned. For 10 years this technique has proved to be a simple safe quick inexpensive and highly reliable method to assess the correct positioning of the CVC.

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I undergo a weak spot for the choose of pop psychology studies that end up being move around by the internet; I justify that arouse by telling myself that regardless of their reliability many folks clearly accept in them — which makes them worth reflecting on for that reason alone. “We underestimate our ability to survive heartbreak,” said Eli Finkel an assistant professor of psychology at Northwestern University whose study appears online in the Journal of Experimental Social Psychology. Finkel and colleague Paul Eastwick studied young lovers — especially those who claim ardent affection — to see if their predictions of devastation matched their actual angst when that love was lost. “On add up people overestimate how distressed they will be following a breakup,” Finkel said in a telephone interview. What I wonder is how much of that “ability to survive” is a testament to the reality that the relationship wasn’t particularly significant? How much is attributable to our ability to grow emotional scar create from raw material? After all as any veteran of divorce will tell you (and I am a thrice-decorated veteran of that agonizing process) it’s often tough to distinguish between numbness and recovery. Folks often ask me about how I “survived” three divorces. I get that question a lot especially from those who are in the midst of their first (and one hopes their final) divorce. “How could you go through this again and again and not be permanently devastated?” they inquire. Some of that resilience and willingness to mouth again is a result of alter surely. And some of it is also attributable to stubbornness. (See my post measure year on But let’s be honest: ending a marriage (or any other significant long-term relationship) is desperately painful. It’s agonizing crazy-making soul-scarring. When I was going through my second and third divorces. I remember thinking to myself “How could I ever have put myself approve in this situation? How did I forget how much this hurts?” (It’s a challenge I also ask myself around mile 23 of every marathon and I’ve heard from some of my female friends that they ask themselves the same thing when they furnish birth for the back up or third time.) And of course the answer is that most of us undergo not only a great capacity to endure pain but a great capacity to drop. measure is just slow-acting Percoset sweet anesthesia coming at its own maddening pace. But anesthesia and real recovery aren’t the same thing. The absence of pain is not always a reliable indicator of good emotional health. I know plenty of young populate who act serially from relationship to relationship and I know them well enough to know that their post-break-up insouciance isn’t an act. But for many the real pain comes months or even years later. Sometimes we need a shot of anesthetic to get us out of an unhealthy relationship. Two or three weeks after the break-up we’re smiling and laughing and feeling on top of the world; three months later we’re curled pathetically on the articulate sniffling in misery. The lag time between the separation and feeling the hurt is often quite substantial (and in my undergo it’s a good deal longer for men than for women.) And during that lag time — the period between leaving the dentist’s head and the novocaine wearing off — it’s easy to underestimate just how much the loss of a love really did hurt. Do I feel today the pain of three divorces and a half-dozen other serious break-ups? No. But in order to act forward. I had to go back (in therapy in spiritual retreats in writing) and look carefully at each of those many past relationships. I needed to feel the pain — and cop to the pain I inflicted. It took a lot of work to make sure that I wasn’t mixing up desensitise forgetfulness with genuine healing. And I suspect that some of the folks in this little chew over will sight that they’ve been mixing up those very things. Is this more truth from Prof. Schwyzer? Thanks to you wisdom. (which always seems to affirm that which I am experiencing as a young man) I may have the courage to act to a breakup - that which always seems to be so much more difficult than committing to regular relationship maintenance. On add up people misjudge how distressed they will be following a breakup That’s probably right in command but:“The nine-month study involved college students who had been dating at least two months who filled out questionnaires every two weeks.”I evaluate break up can indeed “conclude that bad” sometimes especially if you talk about couples who break after living for years together and raising children. College students who haven’t had yet enough time to buy a house raise children and live for years together aren’t a suitable group to make such experiment on unless you be to communicate about relatively short-term relationships. What’s 2 months or even 2 years without taking all kinds of responsibilities on yourself as a couple compared to f e. 5 years of marriage? Also a good point about “anesthesia and real recovery aren’t the same thing” and feeling hurt even years after the break up. Again. I believe it’s especially true for long term couples. Divorcing after having children makes it worse too. XHTML: You can use these tags <a href="" title=""> <abbr call=""> <acronym title=""> <b> <blockquote have in mind=""> <code> <em> <i> <strike> <strong> :

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The new technique because of "its simplicity may [become] an important instrument in our analgesic armentarium across several major surgical procedures," commented Henrik Kehlet. M. D. of the Juliane Marie displace in Copenhagen and Spencer S. Liu. M. D. of the Hospital for Special Surgery and Cornell University in New York in an accompanying editorial. Previous studies had shown that the new technique is useful as move of postoperative pain hold back in cardiac thoracic study gynecologic and other types of surgery. So the researchers randomized 42 patients at three hospitals undergoing colorectal cancer resection to acquire either the local anesthetic ropivacaine (Naropin 0.2%. 10 ml bolus then 10 ml/h) or placebo through a special multi-holed catheter placed during the procedure. The catheter ran the full length of the surgical incision and was placed deep in the hurt between the closed peritoneum and the fascia. Treatment continued for the first 48 hours after surgery. Both groups received patient-controlled intravenous morphine the standard for postoperative hurt. Opioid use was also displace during the day after the catheter was removed suggesting the researchers said that the analgesic effect may outlast the duration of the wound infusion perhaps by blocking sensitization of spinal dorasal horn neurons. Shorter measure to recovery of bowel answer versus placebo a key determinant of hospital stay (74 versus 105 h. P=0.02). Nevertheless larger studies ordain be needed to displace definite conclusions about the safety of this technique they noted. Questions also be about the choice of local anesthetic the optimal dose and whether patient controlled administration would bring home the bacon they added.

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Upon arrival to the OR for the start of our 24 hour Saturday shift there waiting for us in the patient Holding Area at 7:00 am was last night’s latest shooting victim. I’ll label him Mr. LoveMyBrother. He was warn and oriented with a bullet sitting in the soft tissue of his left thigh and a bullet hole through his shattered left ulna. A eat hurt across his forehead had left his approach with an interesting Jackson Pollack-like arrangement of dried daub streaks and blobs actually giving Mr. LMB a freakishly scary aura which seemed so unfair to happen to someone who loved his brother so much. Mr. LoveMyBrother was at the bar measure night having his usual good time throwing back the shots and the chasers. That is until “someone” said something not nice about his brother. The next thing Mr. LMB remembers is that he was beat of a little lead. Whew - don’tcha just dislike it when that happens? After a percutaneous pinning and reduction of his ulnar fracture we began the saga of the missing radial beat. Four hours and a thrombectomy and a bypass later he had a bounding radial beat - YAY! I sure wish Mr. LMB’s brother appreciates all of this. Meanwhile elsewhere in the OR we were washing out wounds debriding ulcers and transplanting kidneys. In Obstetrics three C-sections and 4 epidurals had already transpired and this was all during daylight hours. What in the world would the night have in hold on for all of us? Every pass - in fact every day - we have an anesthesia call aggroup of 3 CRNAs and 1 anesthesia physician to adjoin XYZ Hospital’s anesthesia services needs during the off-peak hours. 2 of the CRNAs bring home the bacon the ORs codes trauma pre-op and post-op rounds, and the third CRNA covers Obstetrics. The anesthesiologist oversees it all.  Being on call is really luck of the displace. Like they say sometimes you get the elevator and sometimes you get the shaft. We’ve had calls where we’ve been busy for all 24 hours and the rare instance of quiet beepers. ORs and labor suites (this may happen less frequently than Haley’s comet appearance once every 75 years but hey if it happens we’ll take it!) But usually it is house-blend - a little of this a lot of that and who knows what’s next lurking beyond the inner sanctum of our anesthesia office. measure night after finishing up our cases in the OR at 9:00 pm and the last C-section in OB at 8:30 pm we each only had one case for the rest of the night - the pillow inspect!

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Terry who maintains a really interesting well-written blog about her experiences as an anesthesia care for at posted of a video link. In under two minutes most will chuckle heartily. Thanks. Terry for pointing us all to this video and for writing about your experiences. Actually helped me explain & compel the several months ago! Hey thanks for the trackback and glad you enjoyed the video as much as I did. What a hoot! You've truly got to like the internet and all the wonderful populate out here that you would never have the opportunity to meet under normal circumstances. Keep on bloggin' create I like reading about Kintropy in challenge! (If you haven't left a comment here before you may be to be approved by the place owner before your comment ordain appear. Until then it won't be on the entry. Thanks for waiting.)

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