Sound Advice

This was given to me this afternoon by one of my clinical instructors. Seeing as how he has been an RT almost 40 years and is one of the smartest people I know, I figured it was worth sharing. Here are his keys to success:

1. Be honest in money matters. Real success will never come to a dishonest person who has compromised himself.

2. Work harder than you are required to do. A successful leader will always do a little more work than he is paid to do. An underachiever will always do a little less. The difference in effort is small. The difference in success will be great.

3. Make up your mind to accomplish your goals. Determination is undoubtedly the most important characteristic of a successful person. Visual the successful end results of your efforts before you start. Write down specific goals. Don't take your eyes off of them.

4. Be positive -- not negative. Approach all things with enthusiasm. Being positive is an attitude. You can decide. It is a conscious state of mind.

5. Dress yourself a little better than the occasion calls for. You'll receive better attention, acceptance, and a response wherever you go. You'll be much more influential if people think you care about yourself and take yourself seriously. If in doubt, overdress.

6. Take special pride in your personal experience, home, and automobile. It's more important than ever to project a clean, organized image to others.

7. Make those who report to you feel successful and good about themselves. Be generous and compassionate with those individuals. You'll achieve tremendous success if you make those who report to you feel successful. It will also give you greater influence.

8. Keep on good terms with all business associates, neighbors, and family. It takes two uncommitted people to be enemies or adversaries. Don't participate. Life is too short. Keep the harmony. Do more than your part in your relationships.

9. Be eager to please your customers (patients), your employees, your co-workers, and your boss. You must be eager to please.

10. Don't burden yourself with debt. Do without.

11. Enjoy yourself. Get a hobby. Laugh some, especially at yourself.

Sometimes, if we are deficient in even one of these areas, we suffer as if we failed them all.

I may just be a student, but...

Dear ICU nurse,

You're right about one thing-- I am a student. You're wrong about the other-- this doesn't mean I don't know what I'm talking about when it comes to the respiratory care of a patient (I mean, there is a reason we're called RESPIRATORY therapists, respiratory therapy students).

When I told you that increasing the FIO2 on your long-time COPDer in bed 7 would knock out her drive to breathe, I'm sorry you weren't satisfied with my knowledge. I am just a student, but not only have I read about, I've seen it happen. 88% is, in fact, an acceptable to SpO2 for this patient, and as she wasn't in distress and her blood gases were within normal limits for the typical COPD patient, there was no reason for alarm.

But I'm just a student. You didn't buy what I had to say.

When I told you I didn't think it was a good idea, in my opinion, to increase her FIO2, you did it anyway. You were shocked when her sats dropped from 88% to 82% and her respiratory rate slowed severely. Again, calmly and professionally, I tried to explain this to you.

Finally, it reached a point where it was time to do something before your patient coded. You started screaming for BiPAP. I explained that since her respiratory drive was no longer stable, she wasn't a candidate for BiPAP, coupled with the fact that she had *severe* anxiety and was extremely claustrophobic.

I suggested we intubate your patient, instead, before matters became worse. You know, give her a break, allow her to resume a normal breathing pattern. I'm ALL for BiPAP to avoid intubation, but BiPAP wasn't indicated anymore.

Well, you went ahead and did it anyway. You called the hospitalist, instead of the pulmonary doctor, and got an order and placed the patient on BiPAP. She crashed harder. She damn near coded. A few minutes later, here comes the pulmonologist with the intubation kit.

Your patient is now intubated. Her gases are awful. I'm just a student, but she will have to be tubed for a lot longer than she would have if you could have had a little faith in me.

I don't try to piddle in nursing things. Don't piddle with respiratory.

Kthxbai.

Much Love,

TJ

Always Remember

The thing I love about respiratory therapy is that I'm always learning new things. A lot of these things are learned in the classroom, but a lot of them are things they just can't teach you in school. Some of them, hard lessons. Some of them, just things you pick up on. Just as important as it is to have textbook knowledge and common sense, it's also important to pay attention to these type of lessons, as well.

The most recent thing I've learned is that, in Respiratory Therapy, you have to find a balance. If you want to be good at what you do, and do it for a long time, remember that it isn't about saving lives. Remember that you aren't just there to make people better. Remember, above all, that your purpose is to make a difference, however you can do so. In the past week, I've:

• Watched three people die
• Saw one patient go from bad to worse
• Seen a brilliant classmate and good friend kicked out of the RT program due to illicit drug use (I had no idea...)
  
• Watched a patient improve significantly o--ver the course of a day, then fall back to critical condition even quicker
• Treated two MIs, three MVCs, and four people in respiratory arrest.

A difficult conclusion for me to come to, although it seems so obvious, is that working in healthcare isn't all about glory days. Real life is nothing like TV. You don't go home happy every day, and not every single one of your patients will walk out of the hospital. Some will go home, some to the nursing home, and some to Heaven.

At the same time, in the past week or so, I've:

• Witnessed my first "successful" code-- I didn't work it, but still.
• Weaned and extubated 3 patients who are now saturating just fine on room air
• Placed a patient on BiPAP, avoiding intubation (they were since weaned from BiPAP and doing fine on 2L NC)
• Received a few "thank yous" for the care I've given
• Terminally extubated a patient (sometimes called "pulling the plug"), at the wishes of the family/Power of Attorney, who ended up living following removal of the tube.

It's not all about the glory days, but hold on to them when they happen.

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Added to the Blogroll

A couple of recent editions to the Blogroll--

• Medic 7 For those of you that don't know Medic 7, he is actually a lot like my good friend Epijunky. M7 shares a passion for what he does that rivals most people. He's sharp, caring, and at times pretty witty. If you don't follow his blog, I'd definitely consider adding it to your "must read daily" list. I have.
• Fat Fireman JS is a good friend of mine. He's a firefighter and EMT from up north who has a lot good posts to read. From his bio, hobbies include shooting and SCUBA diving. What's cooler than that???
  

Stop by their blogs and give a shoutout when you have time.

A Heart-Warming Story

It took me way longer to write this post than it should have, but sometimes you just can't find the right words.

I love a good heart-warming story. A good, true heart-warming story.

Somewhere out there, a girl is living the dream. Her dream. And she's doing it because others see great things in her-- potential, passion, determination, and a commitment to helping others.

Epijunky is my best friend. One day this past January, we added each other on Twitter and started talking through IMs and phone calls. Right off the bat, from that first conversation we had, I found a friend-- a true friend...and we all know how true friends are hard to come by.

Seeing as Epi has always been there for me when I needed help with any number of things, when I got a phone call one day this past August saying she was throwing in the towel on attending Medic school due to financial issues, I decided it was time for me to step up and pay it forward. I made a phone call to Bernice, a fellow medblogger and EMT. We knew we needed to do something. Life really is all about paying it forward, yanno.

Between the two of us, we came up with the idea to set up a Paypal fund-- think, the medical blogosphere's largest tip jar. Later that night, Bernice wrote a post challenging everyone to three fives: "Give her five dollars, tell five friends, and take five minutes to stop by Epi's blog and give her some words of encouragement." Simple enough, right? Sometimes simple favors are the most appreciated.

In the past month, Epi has been absolutely rocking it in Medic school. In her time of need, everyone came together to help one of their own-- a girl with a passion for what she does that is clear in her writing. People started chiming in to help. People she knew, people she didn't. People who know her only through her blog.

We all know what it's like to be faced with challenges in life. We know how it is when life gets in the way of helping us do what we really want. Sometimes things are beyond our control, but sometimes all it takes is a little help from others.

Today, I'm giving you a challenge a lot like Bernice did. Help a girl out. Stop by Bernice's blog, give any amount you can, big or small, to help someone who wants to be a Paramedic more than anything. Then stop by Epi's blog, and send some kind words her way. In doing so, you'll know that you hold a permanent place in one EMT's heart. What can be more gratifying than this?

Go Forth and Ventilate: Initiation

Look at this thing. Pretty intimidating, right?

When it finally reached the point that we started covering ventilators in RT school, I was a mix of emotions. Excited, nervous, intimidated, and confident all at the same time. Okay, well maybe not confident. But I am now.

You see, when it comes to ventilators, you can't be intimidated. Yes, the machine is breathing for your patient, and yes, you are the one to apply the settings and make the changes to benefit the patient, but you have to take a deep breath. Don't let it scare you.

Some of the best advice I've heard about ventilators came from an RT student who recently graduated. "Don't fear the vent. You can always bag your patient. The vent changes don't take effect until you apply them."

Since we are covering initiation of mechanical ventilation in lab this week, I'd like to share with all of you some tips/tricks I've found to help make this a bit easier. For the purposes of this post, I'm going to describe setting up a vent in Volume Control, Assist/Control mode (VC/AC).

1. When setting the ventilator controls without prescribed settings from the physician, always remember the "rule of 10s":

Preliminary settings:
-Respiratory rate (f) of 10-12
-FIO₂ at 1.0 or 100% in emergency situations (cardiac arrest, etc.), or 40-50% for post-op/overdose. See? Intervals of 10.
-Tidal volume (V_T) at 10-12 mL/kg of the patient's ideal body weight (IBW)

IBW male= [(height in inches - 60) x 2.3)] + 50

IBW female= [(height in inches - 60 x2.3) +45.

Note: Once the IBW is determined, set the tidal volume in intervals of 50. Say your patient has an IBW of 66kg, so the V_T at 10 mL/kg, would be 660. Set it at 650 to make it easier.

-Peak Flow: Set at 40-60 L/min (again, intervals of 10) to achieve an appropriate inspiratory:expiratory ratio (I:E ratio), which is typically 1:2. (10/10=1. See?)
-Sensitivity: For patient-triggered sensitivity, set at 1.5-2. For flow-triggered sensitivity, set at 2-3. Okay, this has nothing to do with the rule of 10...but work with me here.
-PEEP of 5. (10/2=what?)

Preliminary alarms:

-Normal pressure limit (also called peak pressure, P_peak, peak inspiratory pressure, or PIP) at 50 cmH₂O
-Respiratory rate high limit at 10-15 bpm > set respiratory rate
-Low exhaled volume at 10-15% < set or targeted minute volume or 5 L/min (1/2 of 10 is 5. Remember that.)
-Low exhaled minute volume at 100 mL < set tidal volume. Again with the intervals of 10.
-Apnea alarm at 20 seconds (10 x 2=20. Woo!)

Still with me? Okay.

So you now have the ventilator set up and the patient arrives to the ICU. It's time to place them on the vent. (Don't forget your humidifier, if needed! Remember 30-35°C for the temp.) Next, it's time to adjust the alarms after connection to the patient so the blasted thing isn't screaming at you every two minutes for something that isn't important. This part is simple enough. As easy as A, B, and C. (Get it? Airway, breathing, and circulation?).

A. Determine the peak inspiratory pressure or PIP.
B. Set the low inspiratory pressure alarm at 5-15 cmH₂O < PIP. (Still with the rule of 10s? Just remember 5, 10, 15.)
C. Set the low PEEP alarm at 3-5 cmH₂O < set PEEP. This one still follows the rule of 10, because a good place to set the PEEP is 5 to begin with, so 5-3=2. 10/5=2. See? See?

Have you made it this far? Good. We're ALMOST done with initiating mechanical ventilation. (I swear!)

Next, assure the patient's airway. This is the simplest part, to me. 4 steps:
1. Note placement of the ET tube (it's easier if you document at the teeth). 23cm at the teeth, etc.)
2. Check the cuff pressure (18-27 is ideal, but you'll do okay if you still want to go with the rule of 10s and remember 20-30.)
3. Make sure there are no cuff leaks by auscultation. While you're at, auscultate to make sure you have good bilateral breath sounds.
4. Assess the patient for oral secretions and suction as needed. (Most of the time, it WILL be needed, so have that Yankeur ready at bedside). By the way, for an adult, you can use the rule of 10 to set the vacuum pressure. A good vacuum pressure is about 120 inHg (forgive me if I've got the wrong unit of measurement here, but just look for 120 on the dial). 10 x 12= 120. Yep.

Last step-- chart it. A few pieces of advice from fellow RTs, nurses, and others to remember when charting (I'm sure you've heard them all before):
If it wasn't documented, it was never done.
Always, always CYA (cover your ass).
Chart consistently so that if it comes back to you in the future, you'll remember doing it.

That being said, here are the things to chart, in no particular order:
1. Date/Time of initiation
2. Ventilator parameters
3. Airway placement/cuff pressure
4. Adequacy of ventilation (breath sounds)
5. Patient complaints
6. Anything else that you feel is pertinent.

Remember, chart in the same order every time. It doesn't matter how you fit all of this in your documentation, as long it is documented. Here's an example of how I always chart vent setup:

"09/05/09 mechanical vent initiated at 1310 with Draeger Evita 4, ETT at 23cm at teeth, cuff pressure 22cmH₂O, vent settings as prescribed on orders. BBS auscultated in all ant. lobes/bases. Ventilator/alarms functioning properly. Pt sedated with bil wrist restraints in place and no s/sx of distress noted. "

Well, ladies and gentlemen, there you have it.

Go forth and ventilate.

Finding the Balance

My friends, and humble readers, I'm having a problem.

What do you do when the ER goes from this...


...to this?

What do you do at the end of your shift, after you've spent the day doing nothing but working codes, treating chest pains, and applying oxygen to people who don't respond to it? When it's time to go home and relax and all you can do is thinking about treating patients and helping them get better?

I'm having a hard time dealing with something, and I'm not sure if the problem is separating work from home, or something simpler.

Recently, I've started following a lot of EMT blogs, and paying more attention to blogs of ER nurses, ER physicians, and the like. I'm starting to realize that a lot of us face common problems in this line of work, and that often we can help each other out. Just as we care about our patients, we care about each other...we're in this together.

So what do you do? Do you listen to hard rock music on the way home to keep the rush going a little longer? Do you mellow out, take deep breaths, and try to relax? Perhaps play a little classical music?

Do you do things on your day off to get your adrenaline going? Extreme sports? Or simply take pleasure in the simple things in order to find a balance between the stress of working in emergency medicine and trying to live a normal life outside of work?

I'm asking what works for you. I love trauma, I love emergency med, and I love nothing more than working a code (besides my family, friends, daughter, and significant other). Once the rush starts at the beginning of a shift/clinical, I never want it to end, but I know it always does.

Help me find a common ground. And thank you.

Warning: Graphic

You may think this isn't relevant to what we do for a living. I don't care.

This video is so real, and so tragic, that it holds a place in my heart. H/T Epijunky for putting this up on her blog.



If you text and drive, please stop. I don't want you to end up in the ER while I'm doing clinicals needing an artificial airway because of something you could have prevented. Be safe out there, guys.

The Number 1 Sign You're Burned Out on School

One classmate to another this afternoon during Mechanical Ventilation class,

"Umm. I'm so tired and so lost. What is he talking about now?"

"I don't know, I'm sure it has something to do with breathing. AGAIN."

Maybe I'm a bit hysterical myself, or maybe I've hit a bit of burn out, but I laughed so hard.

Share your quotes, if you have any.

Unexpected

Stacks of blue charts lined my desk. A vast amount of paperwork was scattered in every direction, joined by a few ink pens, highlighters, and a pencil. The phone was ringing constantly, in competition with the tones from the call light system to my left. A few visitors gathered in front of me, wanting to know what room their father was admitted to earlier this morning. While trying to direct them to the room, I was approached by nurses who had questions on orders I had checked off. The stack of charts wasn’t becoming any smaller, as completing one chart simply meant a new one was added to my stack.

Amidst all the chaos and calamity, behind that desk sat someone who appeared calm and collected. I’ve learned that even during the busiest moments, losing your cool will not help matters. I kept reminding myself that it was just another day at work. Not all days are like this. Eventually, things will slow down. Eventually.

In what seemed like an ordinary shift, in any ordinary hospital, the operator came over the PA system and spoke those words that no one ever wanted to hear:

“Your attention, please…”
Dear God, please let it be something else. A fire drill? Someone who left their lights on in the parking lot? Dr. Brown, please call extension 4394? If only its not--

“Code Blue, room 4-5-1. Code Blue, room 4-5-1. Code Blue, room 4-5-1.”

In the blink of an eye, everyone stopped what they were doing. I bolted for the Crash Cart as another co-worker grabbed the portable Oxygen tank. Someone lifted the dusty LifePak off the shelf, and we hauled ass to room 451.

In my mind, I’m recalling key points from school:
-Four minutes without oxygen before brain death.
-15:2, compressions to breaths
-Bag at 12 breaths per minute, or a breath about every five seconds. It is okay to count to yourself, no one will notice.

I push the Crash Cart into the room and step outside the door. I’ve been working in hospitals long enough to know that CNAs and Unit Clerks don’t’ have much of a role in a cardiac arrest situation.

As I’m standing outside the room, I can’t help but look inside. Expecting to see an 80-year-old man, someone with children and grandchildren, and his hysterical wife at the bedside, yelling at the staff to save her husband, I’m absolutely shocked at the scene before me. I shake my head a few times to make sure I’m not imagining things, then reality hits.

My stomach sinks. I feel a large lump begin to form in my throat. My palms become sweaty, and I hold back my tears. While staying completely focused on the situation, I try to imagine myself anywhere but here, anywhere but now.

Her long, blonde hair is brushed away from her face by the anesthesiologist who is preparing to intubate. A pulse oximeter was in place over her right index finger-- it didn’t match her other fingers, freshly manicured the night before surgery. I’m thinking over our census in my head. Since I wasn’t doing patient care on this particular day, I knew nothing about this patient. Just then, it hit me--

Jesus Christ. She arrived to our floor earlier this morning following a very simple and very common surgical procedure, a lap chole. A few hours ago, the nurse was working on her discharge papers. The patient decided they wanted to eat lunch before they went home. That is the only reason she was still in the hospital.

She was all of 25 years young, and a nursing student, a semester shy of graduation. Amy had a beautiful daughter who was but a year old, as I’d later learned.

Her father swooped their daughter up and carried her out of the room as more and more people entered to work on his wife.

I can’t imagine what it must have felt like to be in his position. His young wife was being coded, and he hurried down the hall and into the waiting room, placing all of his trust in the medical staff. I remember seeing the look on their daughter’s face. She was terrified and had no idea what was happening. As I stood there outside of her room, I couldn’t help but think of my own daughter, just a year older in a similar situation. It was horrifying and gut-wrenching.

I’ve found myself in this situation more times than I can count. I continued to stand outside the room, feeling completely helpless as nurses and doctors certified in ACLS did everything they could to save Amy’s life. Sure, I’m certified in Basic Life Support, but that was already being done. I remember this being one of the major reasons I wanted to go to school.

I wanted to do more. I wanted to help save a life. I wanted to try. I wanted it more than anything. I was kicking myself that I didn’t go sooner. I was kicking myself for being a first year and working in the capacity of a unit secretary that particular day. Not that I could I could do more than all the fine medical staff, but I still wanted to help.

After a while, I realized the situation was being handled in Amy’s room. I realized there were 3 or 4 other people standing by next to me if the doctor needed them to grab supplies or someone needed relief from chest compressions for a bit. And my thoughts instantly went back to their little girl.

I thought about it for a second longer, then I stopped thinking. Yes, there were patients calling on the call light because their infusion pumps were beeping. A patient next door to Amy wanted someone to give her a sip of water. This was my job during a code. But amongst all the commotion, all of the staff take on different roles…and I figured out what my role was this day.

I walked past the rooms, to the nurses’ station. I continued down the hall, passing the kitchen and the supply room. I walked, and kept walking, all the way to the waiting room. I made eye contact with Amy’s husband, trying to tell him anything without saying a word.

It’s going to be okay? No, that wasn’t appropriate. She’ll make it? No, I couldn’t’ say that either. And before I could think, I opened my mouth.

“Hey, baby girl, what’s your name?”

She didn’t answer. I wasn’t sure that she was talking yet. But I kept talking to her. I was a slight distraction at the most needed moment, as Amy’s husband was completely losing it…and I can’t even blame him. He walked over to the opposite side of the waiting room, looked me directly in the eyes, and whispered the softest “Thank you.”

All I could do was nod. I love kids, and I kept putting myself in his position. I knew I’d want some alone time to process what was happening, and I knew that he was in that waiting room with his little girl, trying to pretend like nothing was wrong. He was trying to distract his daughter, but he needed the distraction more than anyone.

As the baby and I sat there playing on the floor of the waiting room, I could see him praying in the background. He was whispering and I can’t even imagine what he was saying. Begging. Pleaing. Making ammends. Anything for Amy, I imagined him saying at one point.

Not a single code I’ve ever seen has ended well. I try not to think about that. I try to think that everything will be okay, and how much this little one needs her mother. I even caught myself praying silently at one point.

About 15 minutes later, an ICU nurse walked into the waiting room. She pulled Amy’s husband aside.

Oh, no… Oh, no… I can’t do this job. I quit. I can’t. I remember thinking this before she delivered the news. I could only imagine the worst. I could only assume that Amy didn’t make it.

And just then, on that day, something amazing happened. The husband of a 25 year old nursing student followed the charge nurse to the intensive care unit. For some reason, I went along with them. I can’t recall why now.

I stood for a second outside of Amy’s room in ICU. Just a second. Long enough to know that she was intubated. Long enough to know that she was in Sinus Tach. Long enough to know, that she was already breathing against the machine. She had spontaneous respirations.

Long enough to hear the doctor talk to Kevin, Amy’s husband.

“It’s always very rare that someone recovers fully after their heart stops beating and they stop breathing, and it’s still a waiting game at this point, but I anticipate that, if things keep going as they are now, she’ll be off of that breathing machine in anywhere up to a week. We’ll work with her. I think we may have made it there just in the knick of time.”

And with that, I made my way back to my unit. I shuffled around the papers on my desk and started to work through my charts again. This time, I had a smile on my face.
I know I didn’t save a life. I know it was a combination of a huge effort on behalf of every single person working in this hospital that responded to the page. I know that I’m just a CNA.

But I also know that Amy will be okay. And thank God for that.

As the 02 Flows...

At the end of the first year of RT school, I remember several things:



Some of these things, very basic, but very important:

-Never withold oxygen from a patient who needs it

-Bronchodilators are intended to treat bronchospasm/bronchoconstriction

-Normal respiratory rate is 12-20bpm, normal heart rate is 60-100, normal B/P is 95-145/50-80

-Always wash your hands

-Central cyanosis, hemo-/hydro-/pneumo- thorax, and pulmonary emboli are very serious and require immediate intervention



Some of these things, slightly humorous, but slightly irritating:

-Patients who tell you they know how to properly use their inhalers and nebulizers (you know, they have been doing them at home for years), in fact prove to you that they cannot demonstrate the proper way to do them

-Almost everyone who is admitted with a respiratory problem, such as pneumonia, will have bronchodilators scheduled, even if they have no indication for this therapy (they aren't "wheezing" and have no history of asthma or reactive airways)

-Doctors, especially residents, don't always know how or when to properly order a neb treatment, including frequency and dosage ("Albuterol 4mg per neb TID and q1h PRN SOB," anyone?)

-Patients do not know why they take their breathing treatments, they don't help, but they just do it and have never asked why

-Some of the therapists you work with in clinicals will tell you all the wrong ways to do things



Some of these things, don't just apply to respiratory therapy:

-Everything that can and will go wrong, usually does (a variation of Murphy's Law)
-If you've got time to sit, sit. (An EMS thang)
-People live against all odds, people die with no odds against them
-Sometimes, all you can do is hold their hand
-Experience matters, but not always
-You will say things that make you sound totally stupid, and sometimes you'll catch yourself, but sometimes you won't (I once came to the "conclusion" that Sp02 could *ALWAYS* be calculated by adding 30 to the Pa02 on a pt's blood gas [if their Pa02 is 85, then this would make their Sp02 115%.] Yeah, laugh it up.)
-Sometimes, you know more than you give yourself credit for knowing. Sometimes you will surprise yourself, and sometimes you'll feel like you don't know enough
-You will question what you're doing with your life at least once during the course of your formal education
-Some days, you will know that you have chosen the right career field, and other days, you will find yourself wondering if you've made the right choice
-It is, in fact, okay to not know the answer. It is, however, never okay to not ask or seek out the answer in another way
-Some people are there to help you, others will try to hurt you
-You can't fix everyone, but you can sure try like hell

They say that the first year of RT school is the toughest. You learn basic concepts, formulas, laws, and equations that you will carry with you for your entire career as a therapist. The second year just consists of building on these concepts.

I have a wide base of readers for my blog. Some of you are new grad RTs, some of you have been practicing a while. Some of you are potential students, and some of you are right where I'm at in school. Some of you are nurses, doctors, and other health professionals. Some of you, are members of the general public.

I just wanted to take the time to thank all of you for sticking by me through my bouts of writer's block, stress, many questions and sporadic posting. I started my second year three weeks ago, and I'm in the home stretch. I've met a lot of great people, and even my significant other, through blogging and reading other blogs.

You have all been most excellent, and there is something about each of you that I either see in myself or would like to be like. I have one more year, then I can rock the RRT to my fullest potential.

It is my ultimate hope that I have at least helped one of you as much as you have helped me. Life really is all about paying it forward.

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