HOOTER TALK: WITH JAIMERS AND ANDRICK

The EKG, female patients, and a male MA

Hey everybody,

In healthcare, there are, of course, procedures that are gender specific. That is, a woman will get a breast exam, while a male will get a prostate exam. For the most part, as patient comfort is paramount, a practitioner of the same gender as the patient will be assigned to the procedure. This is not always the case, and, in my experience, I have found that most patients, of either gender, as long as the procedure is not terribly invasive regarding sensitive areas, are perfectly okay with a practitioner of either gender carrying out the procedure or examination.

No one particularity likes going to the doctor, anyway, so many patients have ‘do what you have to do and get it over with’ kind of attitude. Fair enough. If practitioners are performing professionally, there is an air of confidence about them, of speed, that conveys to the patient that they have done this process countless times, and this is just another day at work to them.

Indeed, we’ve seen it all. Nothing shocks us. Nothing embarrasses us. It is extremely difficult to gross-out or disgust a healthcare practitioner. I helped an MD remove a cyst slightly larger than a golf ball from a patient’s leg once. She had the cyst out of the patient’s leg, grasping it tightly but delicately in a large pair of surgical grips, so that it would not burst. It was still connected to the patient by a thin strand of tissue, and she asked me to cut the connection just inside the abscess pocket in the patient’s leg. No problem. Kinda cool. Please don’t burst that cyst, doctor. These are new scrubs.

However, all of us in the industry are well aware (or damn well should be) that this is not just another day at the office for the patient. From day one, in whatever training you take, the abstract and highly important skills of empathy and compassion are drilled into your head. We may move confidently and business-like, but patient comfort, to the best the procedure allows, is always on our mind. We cannot sympathize, but we do, often heavily, empathize. There is a difference. We hate pain and suffering. We don’t show it, but it kills us when we see it in a child. That’s why I and thousands of others joined this industry. You may not be able to nauseate or embarrass a practitioner, but even the most seasoned MD can be emotionally moved by the site of suffering. But we carry on. The tears are for later, often alone.

But, back to the matter at hand. As I said, whatever procedure a patient is going through, it is often new to them, or, at best, they are somewhat familiar with it. However, an invasive, gender specific procedure can put a patient on edge if the person performing it is of the opposite gender. We are always aware of that potential.

Take, for instance, the common work a Medical Assistant will do. Give injections. Perform a lavage. Dress a wound. Take vitals. Draw blood. And: the EKG.

Allow to me to switch tracks for a moment. The human body is an amazing machine. Simply put, your body has two command systems that boss your other organs around: the endocrine system, which uses hormones to carry out instructions; and the central nervous system, which uses electricity. Both of these systems, frequently in concert with each other, tell the rest of your organs what to go do with themselves.

The tireless, all-important, paramount, primary organ known as the human heart receives it’s commands via electricity, from the CNS. This tireless, muscular organ is the centerpiece of human existence. It’s role is simple; it keeps your blood flowing through your vascular system. Sounds like an easy workload, but the movement of your blood, which, among many other things, carries needed oxygen throughout the body and removes things it does not need, gives us substance that we cannot do without. Your all-important brain can suffer severe trauma, one can become nearly brain-dead, really, and you might still live, most likely with the aid of machines. If your heart takes enough damage, and it is not tended to in time… well, head for the big light. We’ll see you in the whatever comes next.

As an embryo, the heart is the first functional organ to develop , and starts to pump blood in the developing human in about 3 weeks. However, the brain begins to slowly develop afterwards, around 7 weeks of pregnancy, so pain is not an issue, before anyone turns this fact into an abortion diatribe. That’s between a woman and her doctor.

As a human being, the heart is well protected, encased in the mediastinum, a chamber inside the thoracic cavity (upper torso), protected by the rib cage. Makes sense; it’s important, put it someplace well protected. Which is the opposite of the human brain, which is protected by a thin skull and sits, like an easy target, in the head, which sticks out prominently from the top of your body. Not the best spot for it. Just my opinion; I didn’t design the mess called the human body.

Anyhoo, the heart itself, receiving its constant instructions to contract and relax from the CNS, is about the size of an adult fist. It consists of 4 chambers, the upper atria and the lower ventricles. It will beat about 115,000 times a day, pumping roughly 2,000 gallons of blood everyday. This tireless, dedicated organ is truly the running back of the human body.

As I mentioned, the heart is controlled by electricity, from the CNS. It’s a fascinating combination: a grouping of muscular tissues, a collection of cells, really, that responds to a jolt of internal juice. Neato.

Let me run through this quickly: the vagus nerve, from the brain, carries electricity to the top of the right atrium, to a ‘node’ called the sinoatrial node (good Jeopardy fact, there), which then carries the spark through the rest of the heart, stopping briefly at other nodes to ensure that the chambers contract and relax. Contraction is known as systole. Relaxation is called diastole. So, when you get your blood pressure measured, the top number is the systolic, how hard the heart is contracting, and the bottom number is the diastolic, how well the chambers are relaxing. Now you know that.

Okie-dokie, let’s come back around to the EKG, one of the many procedures a Medical Assistant will perform. The electrocardiogram is a fascinating machine. It’s concept is simple; as the heart runs on electricity, the EKG measures this electrical process, allowing practitioners to ‘see’ how the old ticker is doing. Many of us have undergone this procedure.

That the body is manipulated by electricity was first proven in 1790 by Luigi Galvani, who made a dead frog’s legs dance by electrical stimulation. Physicians at the time were… shocked. It was an interesting trick, but Galvani was also obviously kind of warped, to conduct this experiment. Why is the poor frog always taking the brunt of medical research? Frogs are cool. Anyway.

In the mid 1880’s, two researchers named Ludwig and Waller developed their ‘capillary electrometer’ that showed the heart’s rhythmic electrical stimuli could be monitored from a patient’s skin. They were on to something, and they didn’t even have to slaughter a poor frog.

In 1901, Dr. Willem Einthoven, using magnetic poles and silver wire, and a whole lot of ‘let’s try this,’ finally invented what became known as the EKG. The device continued to develop, into the EKG that you will see in a clinic or hospital today.

Healthcare is very pompous and traditional. The device is called the electrocardiogram. However, as healthcare honors tradition more than major league baseball, Einthoven used the Greek ‘kardio’ as his invention was very, very important, and maybe now Dad might like him. Thus, the acronym ‘EKG’ is used.

Here’s a mind-bender for another time, that took me a while to figure out: the EKG uses 10 electrodes, placed across a patient’s upper body. These are the little sticky pads, connected to wires. The electricity is only measured; no current is carried to the patient. Many of us who have had the procedure often find electrodes later on in the shower that the practitioner forgot to remove. Be that as it may, these 10 little sticky electrodes give 12 ‘leads,’ or views, of the heart’s electrical activity. That’s 12 views from 10 electrodes. That explanation is for another time, but as a student, it took me a bit of time to wrap to my head around that one.

These 12 leads, interpreted by a computer, which render a wave-like display, can tell a great deal about how a patient’s heart is performing. Many, many problems with the heart can first be detected with the EKG. It is an invaluable diagnostic tool in healthcare.

There’s a little more to it, and some instruction in its use is needed. I was trained how to use the EKG when I spent a year in Medical Assistant school.

So, let’s bring it back around, to finish, with my opening: gender specific procedures. The EKG itself is not gender specific, but the procedure of using one can be.

The role of Medical Assistant is heavily female dominated. Only about 15% of Medical Assistants are male. Of our class of 9, I was the only male, other than our wise instructor, a patient, erudite veteran. To protect his anonymity, let’s use the name ‘Jaimers.’

We were trained in the EKG early on in our program. We were not quite yet a team, and the group-trust, while growing, was not there yet. As I mentioned, the EKG is not gender-specific. However, with a female patient, it does involve her removing much of her upper clothing, while lying on her back, putting her in a vulnerable and perhaps uncomfortable feeling state. Not every women getting an EKG feels this way, but I can see how one might.

Jaimers asked my fellow 8 female students if any of them would have an issue if I, the only male, practiced the EKG on them. Several of my classmates said they would. I took no offense. However, one particular classmate had absolutely no problem with this.

This classmate and I clicked early on in the program. She was intelligent, driven, and, like myself, determined to bury the program into the ground and come away with a cumulative 4.0 gpa. She has had quite an accomplished life, and I could see her determination. In school, always get a smart friend. Anyway, to protect her anonymity and dignity, let’s call her ‘Heidie.’ As an anecdote, had I been born a female, my name would have been the same, only my parents would have spelled it correctly. And even weirder, had I been born a male, my name would have been Tom. Inside joke!!!

Anyway, Heidie did not give a rat’s ass who worked on her; like me, she just wanted a 4.0. So, I had the honor. Even though she is older than I am, Heidie is quite beautiful, but that did not enter my mind at all when she was lying down on the exam table, her scrubs up, just exposing the bottom of her bra. Like I’ve mentioned, it’s just another day at the office for a practitioner.

But, I ran into trouble. The first two electrodes of the EKG go to just the right and left of the patient’s upper sternum. Heidie had decided to be Pamela Anderson that day. I hope you can see the logistical problem I was having. I needed my 4.0, but Heidie’s damn hooters were in my way. Heidie and I have gone on to be great friends, to this day, but at that moment, Dolly Parton there was annoying me. I needed to place the first two electrodes, but I did not want to molest my classmate. I was frustrated, trying to delicately place the first two electrodes at the sides of Heidie’s sternum, without touching her silicone work. Impossible.

Jaimers, our seasoned, knowledgeable instructor, noticed I was having trouble. He came over to assist me, and briefly instructed me on how to delicately and professionally, explaining what you are doing to the female patient, move her bazingas out of the way so that you can place the electrodes. His advice was spot-on, of course, but at that point, I was ready to just heave the annoying hooters out of the my way and use duct tape to hold them until I was finished. Jaimers and I got the electrodes hooked up, but, of course, Her Majesty happened to be wearing a bra with an underwire that day. This can cause AC interference in the EKG’s reading. I eventually had to move on to another willing female patient. This was the only time in our friendship that Heidie has annoyed me. Of course, she got the last laugh, when she performed an EKG on me. My family is mostly Swiss, with a fair amount of Sasquatch thrown in. That is to say, I am a hirsute man. I shed. It sucks. Whenever I have a girlfriend, the lights have to be off. So the process then, the humility reversed, is that the Medical Assistant has to shave, with a razor, the locations where the electrodes go. Actually, I probably disgusted Heidie. I hate being part Bigfoot.

After class, when everyone was leaving, Jaimers said his daily: “Andrick, may I talk to you for a moment?” I really got tired of hearing that. But that day we spent a good 20 minutes talking, staring out the window down onto Seattle’s downtown, a typical misty day. All we needed was some armchairs, soft jazz, and lower lights. He was quite informative that day. He imparted the (extremely useful) wisdom on how a male patient performs an EKG on a female. You explain what you are doing, politely and professionally, asking for permission, and use the back of your hand to briefly raise the female patient’s breast to place the electrode. It was an informative, bonding chat. So, please don’t miss the next episode of Hooter Talk, with Jaimers and Andrick, Sunday nights at 9:00 PM on your local PBS station. Won’t you donate now, to keep this quality program going? Hooter Talk with Jaimers and Andrick is brought to you by viewers like you, the Corporation for Public Silliness, and the National Endowment of Andrick Smarting Off Again.

All kidding aside, let me finish up this essay with my original opening: gender-specific procedures. I have indicated that the EKG is not gender-specific, but it can be to the patient. On my externship, my mentor tasked me with performing and EKG on a female patient. I asked her if we had checked with the patient to make sure that a male performing this procedure was comfortable with her. My mentor blew it off, saying that it shouldn’t matter. Oh well, I thought. She’s the boss. I grabbed the EKG kit, and entered the exam room.

I could tell there was a problem as soon as I entered the room. The woman looked scared and nervous. I used a soft voice, and politely introduced myself, telling her I was there to perform her EKG. She began to cry. I told her that it’s okay; what’s troubling you? She tearfully asked if a female could perform the procedure. I have no idea if I caused her concern, or something prior. Perhaps abuse, anxiety, or a troubling potential diagnosis. It did not matter. Empathy and compassion. I told her that that would be just fine, no trouble at all, and that I would find a female Medical Assistant. I excused myself.

I went back to my mentor and told her what happened. She seemed surprised. Whatever…

It can also work the opposite way. People are all unique individuals. I was working at a community clinic, and was asked to perform an EKG on a female patient. I entered the exam room and introduced myself. Bam! Off went her gown, off went her bra, she laid down flat, and said: “Okay!” Well! My kind of patient! Who gives a crap? Just do your thing, MA!

None of that EKG encounter with that patient bothered me. Her unabashed style made things quite easier. There is a little dead space in the EKG process, when the MA connects the electrodes, straightens the lines, and ensures that the computer is correctly connected. So she and I talked about Star Trek. It was quite the memorable EKG experience.

So, my final points. You never stop learning, even after school is over. When you practice on real patients, it’s a brand new world. The procedures we do in healthcare may all be similar, but each patient is unique. You never know the full story of what brought them to this place. Empathy and compassion. Most people are fighting a battle you know nothing about. The other thing I learned was: if you are a female patient, and going to the clinic or hospital, please don’t wear a bra with an underwire. We’d appreciate it.

Thanks for reading, everybody! Happy Thanksgiving!

A BAD ROLL OF THE DICE: THE MEDICAL DOUBLE-WHAMMY

Okay! I have a guest post today. It’s my brother Pedro (his name is Peter, I call him Pedro), and I asked him to share his experiences with a seriously bad roll of the medical dice. When he was about 11, in the 6th grade, he came down with a disease known as mononucleosis. He recovered, but six months later, he came down with another nasty disease known as meningitis. Dang! That’s some bad luck, big brother! So, he was kind enough to share his experiences of the ordeal(s). He was young, so many of his memories are hazy, but he clearly recalls the more painful moments during this time span of infections. Myself, I would have been about 6, so all I remember is that my big brother was home from school, not feeling well, and we had to have separate eating and drinking utensils for him. Then I probably played with my legos.

Both mononucleosis and meningitis are serious and potentially deadly diseases. During his narrative, I will jump in and do my best to explain what he may have been experiencing. Take it away, Pedro!

I left school one day, feeling kind of weak. By the time I got off the school bus, the weakness and fatigue had increased. I went to school the next day, but the teacher sent me to the nurses office, as it was obvious to her that I was feeling tired. I had also complained of a headache. By the time I got to the nurse’s office, I ended up barfing on her desk. Mom had to come pick me up.

It is widely known that younger adults, and specifically children, are more susceptible to disease. This is simply because their immune system has not been around long enough to develop antibodies to the various pathogens that love to call human beings home. Their defense mechanism is simply not yet developed, like the rest of their bodies. Most young children have 6 to 8 colds per year, according to John Hopkins Medicine.

Mom and Dad thought it might just be a cold or a flu, but I began to gradually feel weaker, I had a fever, no energy, and I had trouble keeping food down. I had a pretty bad sore throat. The weakness is what I remember the most. After a few days, Mom and Dad took me to the Doctor. My lymph nodes had begun to swell and actually felt like little rocks. I barfed in the Doctor’s office. Mom says I cried when they drew blood from me, but you ought to see my brother try and practice blood draws.

Shut up.

Later that day, the Doctor called to say that I had mononucleosis. I had no idea what that meant. Mom and Dad tried their best to explain it to me, but to me, it just felt like a really awful flu.

Unlike most diseases that infect children, mononucleosis typically effects young children in the early and mid puberty stages of life. Adults can definitely be infected with mononucleosis, but in those instances, the symptoms are usually mild to moderate. There is no vaccine against mononucleosis.

Yeah, like a bad flu. But it just wouldn’t go away. I started to feel better, but only gradually. I was out of school for almost two weeks. At the beginning of the second week, I started to feel a little better. My lymph nodes had returned to their normal state, I was no longer nauseaus, and my fever lowered back to an almost normal temperature. But I was seriously fatigued.

There is no specific treatment for mononucleosis. Like a flu, bedrest, OTC painkillers and a simple diet will do the trick. The disease itself is usually caused by the Epstein-Barr virus, one of the eleven or so types of herpes that can infect human beings (hey… it doesn’t have to be sex… my brother was 11…) In fact, about 90% of the world’s population is infected with the Epstein-Barr virus at some point in their lives, usually with no ill effects.

https://www.sciencedaily.com/releases/2010/12/101215121905.htm

The little virus is generally spread by contact with an infected person’s saliva, hence, it is often called the ‘kissing disease.’ My mother recalls the kids our age that lived in the house being sick just before my brother came down with mono, and if they were playing around, and shared a swig of soda pop, that might have done it. However, we all have to eat and drink, and we typically use utensils to do so, so Pedro could have caught it just about anywhere.

The virus usually attacks the epithelial (goop, mucous) that lines your alimentary canal (the passageway from your mouth to your pooper) in the pharynx, often causing a sore throat. Later, the virus goes to war and tried to replicate your B-cells (a lymphocyte, one of your system’s bodyguards). In most cases, your B-cells win this round, and develop antibodies, a sort of ‘memory’ of how to defeat this antigen (a substance, a pathogen, anything nasty that invades your body).

Viruses like human hosts. Viruses exist. Viruses can be easily transmitted. Some viruses are particularly nasty, aggressive, unpredictable, and opportunistic. Some of these viruses can kill over 600,000 Americans, even though there are precautions you can take to avoid them. If there is a vaccine against this virus, it would probably be a very good idea to get it. I don’t know what made me think of that. But I digress…

In the few days before I was supposed to go to school, my teachers started sending me stuff I had missed. I don’t know how people found out, but when I first got back to school, my friends were avoiding me like the plague. It didn’t last long, though, they could tell I wasn’t sick anymore, and I had a bunch of missed class stuff to catch up on.

Mononucleosis is not a reportable disease in Washington State, despite it’s prevalence to easily spread. It rarely causes serious problems, and it goes away with time. That’s not to say it’s an easy ordeal; like my brother said, it’s like a bad flu, only it last about two weeks.

I felt fine for a long time after that, with no lasting effects. But then, about 6 months later, I woke up Sunday, after going skiing on Saturday, with a sudden fever of 102 degrees. I felt cruddy and tired, worse than the mono.

Again, children and young adults have weaker immune systems. It was postulated, later on by his physician, that my brother’s mononucleosis, though he had recovered from it, was still doing lingering damage to his immune system as it rebuilt itself. The pathology is not well understood, but it has been estimated, by one study, that 1-18% of children who are infected with mononucleosis are susceptible to meningitis:

https://bmcinfectdis.biomedcentral.com/articles/10.1186/1471-2334-11-281

I was no better, in fact I was worse, Monday morning. My parents took me to Children’s Hospital. By that time, my fever had increased, my neck was terribly stiff, and I had trouble looking at bright lights. I had no idea what was going on.

Well, I’ve said it before. Seattle is a good place to get sick. Some of the best healthcare providers in the world are here. The sudden, rapid symptoms my brother was describing immediately cued the physician that this might be a case of meningitis. The definitive diagnostic to test for the presence of the disease is the performance of a lumbar puncture, better known as a spinal tap.

I remember laying on my right side. The doctor put anesthesia on my back, but it really didn’t do any good. Dad had to hold my legs down so that I wouldn’t buck and break the needle off in my spine. I really can’t describe the pain. Incredible pain. It was more like an electric shock. Thankfully, the needle was in my spine for only a few seconds.

A lumbar puncture is a medical procedure in which a needle is inserted into the spinal canal, most commonly to collect cerebrospinal fluid (CSF) for diagnostic testing. The main reason for a lumbar puncture is to help diagnose diseases of the central nervous system, including the brain and spine. In my brother’s case, meningitis. I love the movie Spinal Tap, but after hearing my brother’s story, the medical procedure is not something I’d look forward to.

There are protective layers covering the brain and spinal cord known as meninges. There are actually three layers of meninges: dura mater, the arachnoid mater, and the pia mater. I’ll take anatomy for $600, LeVar. The word meninges comes from the Greek ‘membrane.’ Then: ‘itis’ is the medical term for inflammation. Hence: meningitis. This puts enormous pressure on the brain and spinal cord, causing severe pain for the victim. The entire human body’s entire nervous system stems from this area, and the entire body will be in pain.

There are a few different types of meningitis. The most common are bacterial and viral. Either one, particularly bacterial, left untreated, can cause septicemia: the poisoning of the blood, frequently fatal.

I remember when the doctor pulled the needle out. There was an odd little kind of wet ‘pop’ sound. As the doctor took the specimen to the lab, a nurse brought me an orange popscicle. They offered one to Mom and Dad, but they passed. I was still in incredible, intense pain. Evidently, the testing procedure did not take long, as the doctor returned before I had finished my popscicle.

The ‘good’ news was that my brother had viral meningitis, as opposed to bacterial. There are vaccines against this virus, and my parents were good about keeping us up to date, but sometimes the little creature will find a way. Viral meningitis will generally go away on it’s own. Some virus do not.

It’s most likely that my brother, with his immune system still rebuilding itself after mononucleosis, caught the virus while he was on his ski trip. On the bus, in the lodge, who knows. Viruses are opportunistic pathogens, and can spread very easily. It’s too bad that my brother was not wearing his ski MASK. And staying safe while speeding down the slopes, practicing proper SOCIAL DISTANCING. Because viruses are REAL and can easily spread if you don’t take PRECAUTIONS.

Hey! Is this my story, or your rant about Covid again?

Sorry. Go on.

When we got home, and I tried to sleep, I couldn’t. The pain was incredible. It felt like a third-degree burn all over my body. Cold beverages didn’t help. Aspirin didn’t help. I was in misery. The folks called the hospital, and the doctor told them that I’d pretty much have to ride it out. It sucked.

Had my brother had bacterial meningitis, there is a good chance he would not be here today, or, at the very least, be severely crippled. Children that are fortunate enough to survive bacterial meningitis face a lifetime of medical problems: memory loss, cognitive difficulties, difficulty retaining information, motor-skill and coordination problems, headaches, hearing impairment, epilepsy and seizures, paralysis and spasms, speech problems, potential blindness; all or none to varying degrees. I understand now why my mother could never watch the Jerry Lewis Telethons. To see a child suffer is the worst image possible.

Unlike the mono I had, this one didn’t last as long. I gradually felt better in about a week. But those first few days were fucking awful. It’s impossible to describe the pain. You cannot comprehend it until you have been through it.

So, back to school I went, and once again, I was way behind on schoolwork, and my classmates steered clear of me. But, eventually, life returned to normal.

Meningitis is a reportable disease, as it is contagious. How myself and my parents, and anyone else at my brother’s school, managed to not catch it as well is… just a roll of the medical dice.

Thanks Pedro!

Medical Terminology (and the ancient Romans were kind of jerks)

Well, the third quarter is underway, and so far it’s going great! I’m taking 2 courses; one is Pharmacology and Medication Administration (this is what the chemical is, this is how I will inject you with it) and Administrative/Clinical review (this class is a lot of fun –  the instructor basically sets up exam rooms, and we practice on-boarding patients; the instructor, playing the MD, then gives us a procedure to carry out with the patient), which ties together everything I’ve learned so far. We are also studying medical terminology, and where it comes from. Not sure why that wasn’t covered in the first quarter; perhaps they just wanted us to get familiar with the jargon before we closely studied the etymology.

Everything in healthcare seems to have a needlessly fancy name, but there’s a good reason for that. Just about every bit of terminology a practitioner uses is either Greek or Latin in origin. There is also the occasional eponymous term, a word named after the person who discovered/invented it (Pap test, Alzheimer’s, Tommy John surgery). I’m oversimplifying the history a bit, but a long time ago, when Hippocrates and his colleagues figured out that illnesses and diseases were actually environmental and not divine punishment (although that unfortunate concept still exists today), and began to actually study the human body, the ‘English’ of the day was either Greek or Roman. Many people in the known world (which was much smaller then, than our own) spoke one of these two languages; much like a good portion of the known world speaks English today. This way, a physician in Rome could correspond with a physician in Roman occupied England, who perhaps spoke a local dialect, and they would know what they were talking about. The practice continues today.

The word ‘doctor’ comes from the Latin ‘docere,’ which means: to teach. It also shares its roots with the word ‘docile.’ The thinking here is that one cannot properly learn and absorb information if one’s mind is not calm and focused on the matter at hand.

But, as it turns out, the ancient Romans could be a little flippant. The word ‘hyster’ comes from the Latin ‘hystera,’ the word they used for uterus (think: hysterectomy). The Romans believed that women got moody and emotional because of their menstrual cycle; therefore, the word ”hystera’ shares a root with the word ‘hysteria.’ Well, that’s charming. Sure, some women do occasionally get a bit out of sorts on their menstrual cycle, but that is not a character flaw or an indication of a psychological or psychiatric disorder. A woman’s endocrine system is simply in overdrive, if you will, forcing an ovum into the uterus. So there you have it. The etymology of medical terminology is fascinating, but glib, dismissive opinions are nothing new.

Wash your hands!

3rd qtr so far