Resolve to Exercise!

 Me on a zip-line 

Once again, a new year is upon us. I have always loved ringing in a new year. A chance to start over. A chance to evaluate my life and make changes to make my life a little better. While I don’t necessarily make specific resolutions for the New Year, I do like to take the opportunity to set new goals to work toward. Like many other Americans, one area of my life I resolve to improve is that of fitness.  In the first week of January the gyms are packed! But often this massive influx of exercisers does not last very long. It’s difficult for many to keep up with exercising. Sitting on the couch is way easier! But regular physical activity has many benefits, including physical, mental, and emotional rewards. You don't need to join a gym to stay active. There are many activities to do outdoors that can keep you busy and keep you moving!

There are so many benefits to exercise. Knowing these will hopefully lead to helping others get started on a fitness program or to keep their exercise momentum going. Here are some of the many benefits:  

Exercise Prevents or Helps Manage Health Conditions and Diseases

Regular physical activity helps to prevent or manage certain health conditions. Exercise can help prevent or manage diseases such as stroke, Type 2 Diabetes, depression, certain types of cancer, osteoarthritis, osteoporosis, high blood pressure, and metabolic syndrome. It can have profound positive effects on the cardiovascular and pulmonary systems.  Additionally, exercise increases high-density lipoprotein (HDL), also known as the ‘good’ cholesterol, and helps to decrease low-density lipoproteins (LDL) (bad cholesterol) and triglycerides, which can clog arteries and lead to heart attack, heart disease, and stroke.

A sedentary lifestyle and lack of exercise has led to obesity and the Type 2 Diabetes epidemic that we are seeing here in the United States. Exercise is beneficial in preventing diabetes and has been shown to reduce the incidence of Type 2 Diabetes by about 50%. Research shows that physical activity can lower blood glucose levels and improve the body’s ability to use insulin. It can reduce visceral body fat, abdominal fat that plays a role in insulin resistance. Physical activity burns calories and helps prevent weight gain and can promote weight loss, which is an important part of preventing and managing Type 2 Diabetes.

Exercise makes muscles stronger. It stretches muscles and joints, which increases flexibility and helps prevent injuries. Weight-bearing exercises helps to strengthen bones and helps to prevent osteoporosis. Those with osteoarthritis may experience a decrease in pain with regular exercise. Migraine sufferers may find a reduction in migraines with regular physical activity.  Of course the person exercising needs to be sure they are exercising safely. Healthcare professionals, such as doctors and nurse practitioners, can help those with health conditions to find the right exercise routine to benefit the individual and help prevent injury.

 Oscar playing tennis

Exercise Improves Mood and Reduces Stress

Chemicals in the brain, such as endorphins, dopamine, serotonin, and norepinephrine are released during exercise and can help boost your mood and improve mental health. These brain chemicals can make you feel happy, more relaxed, and give you a sense of well-being. Research has shown that exercise can be as effective as antidepressant medications in alleviating depression. One study found that three sessions of yoga per week boosted GABA levels, a brain chemical that helps to improve mood and decrease anxiety.  Additionally, exercise may work at a cellular level to reverse the damage that stress takes on the aging process. Increased concentrations of norepinephrine can help moderate the brain’s response to stress.  We can literally walk off our stress and the damaging effects that stress causes!

Exercise Boosts the Immune System

Our immune system helps to fight off infections caused by viruses and bacteria. Exercise increases circulation of natural killer cells, antibodies, and white blood cells that help to fight off illnesses caused by pathogens, such as viruses and bacteria. This includes viral infections, such as the flu, common cold, and bacterial infections that may occur in the respiratory system. The positive effect on the immune system may help to prevent some forms of cancer, such as cancer of the breast.   

Exercise Benefits the Brain

Yes, the brain benefits from regular physical activity as well! Levels of growth factors, which help make new brain cells and establish new connections between brain cells to help us learn, are increased with exercise.  Activities, such as tennis and dance, have been shown to lead to the biggest brain boost. Exercise can help to maintain thinking skills or cognitive functioning as we age. It helps to keep the brain fit and active and can fend off memory loss. Research by the Alzheimer’s Research Center has shown exercise to be the best defense against the development of Alzheimer’s disease. It has been shown to reduce the risk of developing Alzheimer’s disease by about 40%. This appears to be due to the protective effect physical activity has on the hippocampus, a region of the brain that is often first affected by Alzheimer’s damage.  Alzheimer’s disease is a devastating illness. The simple task of regular physical activity may be able to prevent or prolong onset of this disease.

Exercise Improves Sleep Quality

Lack of sleep or poor sleep quality is a common complaint for people of all ages. Sleep is important for our productivity, mood, and overall health. Regular exercise has been shown to improve sleep quality. Research shows it helps people fall asleep faster. It helps to produce a deeper sleep, which can help you feel more rested in the morning. However, exercising too close to bedtime can have a negative effect on sleep, as the body is energized. So be sure to get your activity in earlier in the day.

Exercise and the Older Adult

Older adults may benefit from regular physical activity as much as their younger counterparts. Physical activity has been show to help improve functional ability and prevent falls and fractures. It can increase appetite, reduce constipation, and promote quality sleep, which are all issues many older adults face. Older adults who already carry a diagnosis of health conditions, such as cardiovascular disease, diabetes, and osteoarthritis can benefit from physical activity as well. The saying ‘use it or lose it’ rings true when it comes to physical activity. The older adult who lives a sedentary lifestyle can experience muscle atrophy and other issues related to muscle disuse. Simple, basic exercises can help prevent these issues.

Physical Activity

 Chris & Oscar kayaking

Okay, hopefully I have convinced you all on the importance of regular physical activity. The benefits are astounding and can help you to live a healthier, happier life. So get out there and run a marathon! Just kidding! You don’t need to run a marathon or be a gym rat to experience the health benefits of exercise.

 Nevia kayaking

Exercise can be broke down into three broad categories; light, moderate, and vigorous exercise. If you are just starting out on your exercise journey, you obviously would start with light intensity and work your way up. Again, it is very important to talk to your healthcare provider before embarking on your exercise journey. Always think safety first. Here are the categories and a few examples of types of exercises that fall into these categories.

Light Exercise

Light exercises includes activities such as walking, light housework, and stretching.

Moderate Exercise

Activities at a moderate intensity includes brisk walking, cycling moderately, or walking up a hill. Walking at a brisk pace has been shown to be as effective as running in reducing the risk for high blood pressure, high cholesterol, and diabetes. Other examples include yoga, hiking, roller skating, boxing, weight training, dancing, and swimming.

Vigorous Exercise

The more experienced or advanced exerciser may be able to participate in activities of vigorous intensity. This level of exercising includes running, fast cycling, heavy weight training, mountain climbing, rock climbing, high impact aerobic dancing, jumping jacks, and jumping rope.

Moderate and vigorous intensity exercises can lead to weight loss, because you are burning more calories.  You can determine the intensity level by the talk test or by monitoring your heart rate. For the talk test, for light intensity you should be able to sing while doing the activity. For a moderate intensity activity you should be able to talk, but not sing. For vigorous activities, you will not be able to say a few words without pausing for a breath.

To monitor your heart rate, or pulse, you should first figure out your maximum heart rate. To do this you subtract your age from 220. So if you are 40 your maximum heart rate would be 180. For a light intensity activity, your pulse would be less than 50% of your maximum heart rate, for moderate intensity your pulse would be 50-70% of your maximum heart rate, and for vigorous intensity, 70-85% of your maximum heart rate.

 Our family hiking in North Carolina

Finding activities that you enjoy makes the exercise process much easier. Also, exercising with a friend or family member can help keep you motivated.

No matter what physical activities you do you can reap the benefits I discussed above. So get moving & keep moving!

 Tubing in North Carolina

Dr. Donna M. Fife DNP, ARNP

Disclaimer: This blog is meant for informational purposes only and does not constitute medical advice. Be sure to talk to your healthcare provider prior to starting your exercise journey.  

Amendment 2: Medical Marijuana

Many of us Floridians may be feeling quite disappointed by the recent midterm election. A crook has another 4 years leading our state and the medical marijuana Amendment 2 fell short of passing by a mere 2%. Many of us shake our heads in disbelief over both of these results.

On the Amendment 2 issue, many Floridians sadly have rejected this amendment. What a shame. A non-toxic, natural medicinal option for pain relief (and other ailments) was voted against, so patients are forced to the option of synthetic drugs.  One of the primary options for pain relief in the United States are opioid pain pills. This class of synthetic drugs are derived from the opium poppy and includes hydrocodone (Vicodin), oxycodone (OxyContin, Percocet), fentanyl (Duragesic, Fentora), methadone, and codeine. Basically, opioid narcotics are pharmaceutical-grade heroin. Here is the chemical structure of oxycodone and heroin. Quite similar.

Opioid drugs have led to an epidemic of prescription painkiller abuse. Millions of prescriptions for opioids have been written. Many people obtain prescriptions when the medication really isn't needed or they obtain the medication on the street (or in their parent's medicine cabinet).  The abuse of these drugs leads to hundreds of thousands of emergency department visits each year. The abuse doesn't end with those who obtain a prescription when it is not needed. More than 12 million people reported using these drugs for nonmedical purposes or just to obtain the ‘high’ or euphoric feeling from the drugs. Opioids cause a physical dependence and can lead to addiction. After taking these drugs one may need to take a higher and higher dose until that euphoric feeling is achieved.  This can lead to a depressed function of the respiratory system, or slowed breathing, which can lead to death (overdose).  Interestingly, opioids have not even been proven to be effective for long-term, non-cancer pain management, yet are still so widely prescribed for this issue.

The death rates from prescription pain medication overdose are astounding.  The CDC reports that nearly 40 Americans die per day from overdose of painkillers, such as Vicodin and OxyContin. This equates to about 15,000 Americans each year. So where does Florida rank in these rates? Yep, you guessed it, Florida has one of the highest rates of pain medication prescriptions written and one of the highest death rates related to pain medication overdose.

So we’ve established that prescription drugs cause death by overdose in about 15,000 Americans each year, but how do recreational drugs measure up? The most common recreational drug, alcohol, kills around 50,000 people each year through alcohol poisoning. The second most common recreational drug, tobacco, is attributed to over 400,000 deaths annually. Comparatively, marijuana, the third most common recreational drug, is nontoxic and CANNOT cause death by overdose. In at least 10,000 years of marijuana use in humans, there have been ZERO documented deaths related to marijuana overdose.

Medical marijuana provides patients with a natural medicine that is much safer than the toxic, synthetic drugs discussed above. Yet, ending the prohibition against marijuana seems impossible in states such as Florida.

So what states have legalized the use of medical marijuana? Well, I researched this & found that it happens to be many more than I had initially realized! The following states all have laws allowing the use of marijuana for varying ailments. The year after the state name is when the law was passed.  Alaska (1998), Arizona (2011), California (1996), Colorado (2001), Connecticut (2012), District of Columbia (2010), Hawaii (2000), Maine (1999), Michigan (2008), Montana (2004), Nevada (2001),  New Jersey (2010), New Mexico (2007), Oregon (1998), Rhode Island (2006), Vermont (2004), Washington (1998). Some states had this passed into law in the late 1990’s and here in Florida we can’t get it passed in 2014? Wow. Florida is pretty far behind the curve.

These states had medical marijuana signed into law, but have not yet become operational: Delaware (2011), Illinois (2013), Maryland (2014), Massachusetts (2013), Minnesota (2014), New Hampshire (2013), New York (2014).

Cannabinoid (CBD) is the second major cannabinoid in marijuana, after tetrahydrocannabinol (THC). CBD specific medical marijuana has been found to have anti-inflammatory and pain-relieving properties, without the psychoactive effects. However, it has limited use and limited effectiveness has been reported with this type of therapy. Incidentally, CBD has shown great promise in inhibiting the growth of cancer cells in animals.  

States with CBD specific marijuana laws are: Florida, Iowa, Kentucky, Mississippi, Missouri, North Carolina, South Carolina, Tennessee, Utah, and Wisconsin.

So what types of ailments has marijuana been found, through research, to benefit? Marijuana is widely popular because of the effect of pain relief. In particular, neuropathic (nerve damage) pain is well controlled with marijuana use. Other ailments include nausea, glaucoma, movement disorders, seizures, Chron’s disease, and muscle spasms related to Multiple Sclerosis, paralysis, and other degenerative disorders. It is a powerful appetite stimulant (this is why people using it get the ‘munchies’) and patients with HIV, AIDS wasting syndrome, and dementia can all benefit from use of this drug. Can’t envision your dementia-suffering granny sitting around toking on a joint? Well, this is where edibles come in and where the trend in consumption has shifted over the years.

So while the obvious choice for safer medical treatment of chronic pain is medical marijuana, Floridians must continue to use synthetic heroin instead. Or they can suffer. I guess that’s another option.  Those with other medical ailments that would benefit from marijuana treatment must continue on with less effective, less safe alternative synthetic drugs. We can only hope that Floridians will get it someday and join the ranks of other states providing safer alternatives of drugs to treat chronic illness.

Dr. Donna Poma Fife DNP, ARNP

Disclaimer: This blog is meant for informational purposes only and does not constitute medical advice. If you or someone you know may be suffering with a chronic illness, your best bet to receive safe, natural treatment of your ailment may be to seek care outside of Florida.  For those in Florida who understand the benefit of medical marijuana, keep fighting.  We’ll get there someday. 

ADHD awareness week: Impulsivity

One of the most common symptoms for many kids with ADHD is impulsivity. This impulsive behavior leads kids to act before they think. We neurotypical (non-ADHD) people may evaluate a situation for social norm or potential danger and decide to not partake in an action that could be seen as socially unacceptable or dangerous. Those with ADHD who have impulsive characteristics will generally not self-regulate and decide against an unpleasant or potentially harmful situation. This impulsive behavior leads kids to spending extended amounts of time in trouble at home. They may end up in time-out or end up grounded. Of all the symptoms of ADHD, impulsivity is often the most difficult to control.

So what is impulsivity? This is described as behavior without adequate thought. The person with impulsive behavior may have a tendency to act with less forethought than others.  They may react to stimuli without regard to the consequences that could occur.

I recall a story a friend told me about her ADHD son. When he was about 7 or 8 years old and they were riding their bikes in their neighborhood. There was a vicious looking dog barking relentlessly at them from a backyard, behind a chain link fence. Her son got off of his bike and started walking towards the dog. The mom yelled “What are you doing?” In his innocent, sweet voice he said “I’m going to pet the dog.” My friend was in shock! She yelled to him to stop! “That dog might bite you! Get back here!” They had a discussion about the dangers of approaching a dog they don’t know. My friend said they had conversations like this many times in the past, as she always wanted to be sure he respected animals and their space. His impulsive behavior led him to nearly put himself in a potentially harmful situation.

Not only does impulsivity commonly occur in those with ADHD, but it is associated with other mental disorders, such as mania, substance abuse, and personality disorders as well.  The International Society for Research on Impulsivity (yes, there is actually a society dedicated to the research on this characteristic!) studies impulsive behavior that occurs with mental disorders, such as ADHD. This society has developed several rating scales as measurement tools to make research projects more meaningful.

One of the most commonly used tools is a questionnaire designed to assess the personality/behavioral construct of impulsiveness is the Barratt Impulsiveness Scale. There are 30 items on the scale that describe common impulsive and non-impulsive behaviors and preferences. These behaviors are rated as: Rarely/Never, Occasionally, Often, Almost Always/Always. This scale can be viewed at: http://www.impulsivity.org/pdf/BIS11English.pdf

Other scales include the Balloon Analogue Risk Task: http://www.impulsivity.org/measurement/BART

Cued Go No-Go Task: http://www.impulsivity.org/measurement/cued_Go_NoGo

Immediate and Delayed Memory Tasks: http://www.impulsivity.org/measurement/IMTDMT

Okay, enough about rating scales, as I’m sure that has bored many of you!

Impulsivity has for many years been linked to the neurotransmitter dopamine. Neurotransmitters are chemical substances that transmit nerve impulses across a synapse from one a neuron (nerve cell) to a “target” cell. They carry, boost, and modulate signals between neurons and other cells in the body. There have been over 100 neurotransmitters identified. Dopamine is a neurotransmitter that helps control the reward and pleasure centers of the brain. It allows us to see a reward and to take action to move towards the reward. Dopamine also plays a role in movement, sleep, mood, sustained attention, working memory, motivation, learning, and emotional responses.  

For years scientists have believed that one of the primary causes of ADHD is low dopamine levels, but recent research suggested that structural differences in the brain’s grey matter may play a significant role. Structural differences in the ADHD brain and non-ADHD brain include variations in the prefrontal cortex, the caudate nucleus and globus pallidus, and the cerebellum. Nerve pathways, in particular the basal-ganglia thalamocortical pathways have been found to have abnormalities in the ADHD brain. The research will likely continue on the link between chemical and structural differences in the ADHD brain. Regardless of the cause, the symptom of impulsivity can lead the ADHD person to take risky, dangerous actions.

So is impulsivity always considered bad or a negative characteristic? The answer is no. There are times when impulsive behavior is the right response to a particular situation. We may act of off a gut instinct in an impulsive manner. An impulsive action may lead us to seize a valuable opportunity. But high levels of impulsivity is where this characteristic can be maladaptive.

With proper treatment of medication and behavioral therapy, those with ADHD and this prominent symptom of impulsivity can find success in controlling some impulsive behaviors.

There may be those outliers with ADHD who don’t have symptoms such as impulsivity. They may have a little trouble focusing & managed to get doctor to put them on a stimulant medication so they can maintain a greater than 4.0 GPA in school.  I’ve heard colleagues speak of this issue in their practice. This information doesn’t really pertain to them. This pertains to the millions of individuals with ADHD who have presenting symptoms, such as impulsivity, that greatly affects their life on a daily basis. Hopefully, these individuals will receive the care they need to treat this symptom and the others associated with ADHD.  

Dr. Donna Poma Fife, DNP, ARNP

Disclaimer: This blog is meant for informational purposes only and does not constitute or substitute medical care. I speak of generalizations and do not speak to any particular individual with ADHD, so don't feel singled out if it does/doesn't apply to you!  If you think you or your child may have ADHD please see a healthcare provider, preferably a psychiatrist or a neurologist, as they are best equipped to make a proper diagnosis. 

ADHD Awareness: Getting the diagnosis

ADHD Awareness Month #ADHD #ADHDawareness #Seekahealthymind 

So my previous blog brought awareness to the symptoms of ADHD, but how does a person get diagnosed with the disorder? Well, I’m here to tell ya!

Making the diagnosis of ADD/ADHD:  

One of the most important steps in getting a proper diagnosis of ADHD is selection of a healthcare provider. Who can diagnose ADHD? Well, family doctors, pediatricians, psychiatrists, psychologists, and neurologists are all licensed to diagnose. However, when it comes to a neurodevelopmental disorder, such as ADHD, seeking evaluation by a psychiatrist and/or neurologist is often your best bet. These specialized healthcare providers are trained in diagnosing and treating this disorder, whereas many family doctors and pediatricians are not.

Diagnosing ADHD is done according to the criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders or DSM-V. This book provides diagnostic criteria for mental disorders.  The criteria for diagnosing according to the DSM is that the patient has to show six of nine symptoms of inattention and/or hyperactivity/impulsivity before the age of seven. I had listed those symptoms in my last blog, so refer back if you need to.  The symptoms should have persisted for at least 6 months, and must impair the person’s functioning in settings such as the home, school, and work.

 A clinical interview utilizing a standardized ADHD rating scale should be used in the diagnostic process. This scale rates the symptoms into classifications of inattention, impulsivity and hyperactivity.  The ADHD rating scale can be found at: http://www.fmpe.org/en/documents/appendix/appendix%201%20-%20adhd%20rating%20scale.pdf

There are common mistakes that occur in the diagnostic process. These mistakes may occur when seeking a diagnosis from a family or pediatric doctor. I’m not downing these types of providers, they are generally highly educated and experienced in general or pediatric practice. But many have limited knowledge in diagnosing and treating ADHD. Diagnosing is best accomplished by a neurologist or psychiatrist. Common mistakes include:

·         Length of time of an exam: A diagnosis of ADHD should not be done in a 15 minute office visit with a family/pediatric doctor. This is a complex disorder and a thorough evaluation is essential.

·         Diagnosing secondary symptoms as the primary problem. Many of those with ADHD have coexisting conditions of anxiety, depression, or other mood disorders. These may be secondary symptoms caused by the primary diagnosis of ADHD/ADD.

·         Academic success: Just because a person isn’t failing or doing poorly in school doesn’t mean they don’t have ADHD. Some kids with ADHD may do very well in school.

·         The child has a high IQ, therefore they can’t have ADHD. Many of those with ADHD have an average or higher than average IQ score.

Finding the right clinician is important. If I had listened to the first pediatrician who told me Nevia doesn’t have ADHD, we would have never received a proper diagnosis or treatment. This can really make a kid suffer unnecessarily. Of the three pediatricians Nevia has been to, none of them utilized the ADHD rating scale to evaluate for this diagnosis. She received a diagnosis of ADHD from doctor #2, and #3 carried on treatment after we switched providers for insurance purposes. While prescription of the medication to treat ADHD was not an issue, neither of the pediatricians referred us to a psychiatrist or psychologist for counseling or behavior therapy.

A friend of mine told me a story of a coworker who asked another coworker who has ADHD what symptoms she has with this disorder. She mentioned that she wants to get a prescription for ADHD because she heard it acts as an appetite suppressant. So this young lady went to her primary care doctor complaining of inattention & difficulty focusing. She even acted the part by staring out the window & losing her attention when the doctor was talking. After her 15 minute encounter with her primary care provider, she walked out of the office with a prescription for a Schedule II narcotic, Focalin. This medication is commonly prescribed to treat ADHD. It is a HIGHLY abused medication by those who don't actually have ADHD, but somehow managed to get diagnosed with it. A more socially acceptable form of drug abuse, I suppose.

Many of those with ADHD/ADD have coexisting learning disabilities, as well. While ADHD is not considered a learning disability, it is important to evaluate for learning disabilities in those diagnosed with ADHD. Some disabilities that may coexist include; dyslexia, dyscalculia, dysgraphia, dyspraxia, and executive functioning. By the way, I dislike the term ‘disability’. I really wish they would change the wording to Learning Differences. Those with learning disabilities have the capacity to learn. They just learn differently. Additionally, other screening tests may be conducted in those with ADHD to assess for coexisting conditions, such as anxiety, depression, and other mood disorders. This particular testing can take about 4 hours for a psychologist to complete. Yes, my daughter Nevia sat through FOUR hours of testing. Quite an accomplishment for an ADHDer!

So in some circumstances, getting a diagnosis of ADHD may be quite simple. However, it is a complex disorder with many variables and the potential for coexisting conditions. This is why a thorough evaluation by a licensed psychiatrist and/or psychologist is important.

Mental health does not receive the attention that it should. We have a tendency to undervalue the importance of a healthy mind. With ADHD Awareness Month, hopefully more focus will be shed on this mental disorder that over 15 million Americans have been diagnosed with and many others live with without a proper diagnosis.

Dr. Donna Poma Fife, DNP, ARNP

 Disclaimer: This blog is meant for informational purposes only and does not constitute or substitute medical care. If you think you or your child may have ADHD please see a healthcare provider, preferably a psychiatrist or a neurologist, as they are best equipped to make a proper diagnosis.

ADHD Awareness month

Welcome to October! At this time of the year, the kids are back in their routine of school, autumn is well under way, and we may be enjoying the cooler weather that is coming our way. In addition to the changing colors of leaves, shorter, cooler days, and pumpkin lattes, October also brings ADHD awareness month. Those individuals living with ADHD or living with a child with ADHD, are well aware of this disorder on a daily basis. But with a month dedicated to ADHD, hopefully many more will gain awareness of this disorder that affects more than 15 million Americans.

The terminology Attention Deficit Hyperactivity Disorder (ADHD) and Attention Deficit Disorder (ADD) are often used interchangeably. So you may see either of these recognized variations of the name and abbreviation being used. Either way, it is the same disorder, just with varying symptomatology.

ADHD is one of the most common neurodevelopmental disorders of childhood. The causes and risk factors for this disorder are unknown. Research points in the direction of genetics, brain injury, environmental exposure to toxins such as lead, alcohol/tobacco use during pregnancy, premature delivery, and low birth weight as possible causes/risk factors. But more research needs to be done.

A common misconception is that other factors, such as high intake of sugar, watching too much TV, poor parenting, and lower socioeconomic status contribute as causes to this disorder, but these factors have NOT been supported by research.  While they may not contribute to the diagnosis of ADHD, limiting sugar intake and TV time are good choices for everyone!

The CDC lists that as of 2011, approximately 11% of kids age 4-17 have been diagnosed with ADHD. This number continues to rise. Another common misconception is that ADHD occurs more commonly in boys than in girls. However, girls hold the same risk for the disorder, but are often not given the proper diagnosis like their male counterparts. The average age at diagnosis of ADHD is 7 years of age. However, many parents notice symptoms of the disorder well before the child’s 7^th birthday.

 This disorder affects adults as well. Many adults with ADD/ADHD have never received a proper diagnosis of the disorder. While ADD has been recognized in the medical community for many years, those with ADD in generations before the 1980s didn’t usually receive this diagnosis. They may have been labeled as bad kids, lacking discipline, unintelligent, lazy, or defiant. Imagine what these labels do to the self-esteem of a person. Think about how the self-esteem of the individual could have been supported, rather than diminished, if a proper diagnosis was made early on in life.  

Adults with ADD may have trouble with organization and remembering appointments and important events. They may have trouble completing the tasks to get out of the house in the morning, often making themselves and/or their kids late for work/school. They often have a history of difficulty in school during childhood & adolescence, and they may have a history of issues with employment and sustaining relationships.  Thankfully, healthcare providers are more aware of the disorder and the prevalence in adults, and with proper diagnosis and treatment, adults with ADD can find success and lead a productive, organized life.

So what are the symptoms of ADHD/ADD?

 Many may think that lack of focus and/or distractibility are what constitute a diagnosis. However, these symptoms are only the tip of the iceberg. Adults and children with ADHD/ADD generally have many of the following symptoms:

·         Trouble paying attention

·         Makes careless mistakes

·         Seems to not listen when being directly spoken to

·         Has trouble following instructions and finishing tasks

·         Trouble planning and organizing work/activities

·         Trouble completing and/or turning in homework

·         Avoid tasks, in particular those that require sustained mental effort

·         Loses things often

·         Becomes easily distracted, misses details, frequently switches from one activity to another

·         Forgetful, forgetful, forgetful

·         Fidgets and can’t seem to sit still

·         Gets up and moves around when they are expected to stay seated

·         Is often ‘on the go’ or acts as if ‘driven by a motor’

·         Talks too much or blurts out answers

·         Can’t wait his/her turn

·         Interrupts or intrudes on others’ conversations

Wow, that’s quite a list! Now some may read this and say “well I have trouble paying attention and am forgetful, perhaps I have ADD”. Well what human doesn’t fit some of these descriptors? Most all of us can think of times that we were sitting in class and started daydreaming or thinking of a plethora of other things we wish we were doing. I’m forgetful at times. I lose things at times. That doesn’t necessarily constitute an ADD diagnosis. Individuals with ADD/ADHD live with many of these symptoms, often to a VERY high degree, and deal with these on a daily basis.  While some individuals may outgrow the symptoms of ADHD, for many the symptoms are lifelong.

As a parent of a child with ADHD, I have a great passion for learning about this complex disorder.  In honor of ADHD awareness month, I hope to pass on some of the education that I have gained through my endless reading about this disorder and my life experiences gained with a child with ADHD!

Dr. Donna Poma Fife, DNP, ARNP

Disclaimer: This blog is meant for informational purposes only and does not constitute or substitute medical care. If you think you or your child may have ADHD please see a healthcare provider, preferably a psychiatrist or a neurologist, as they are best equipped to make a proper diagnosis. 

Giving thanks: Part 2

No, it's not Thanksgiving yet, I'm giving thanks as a part of the 'what are you thankful for?' challenge. This challenge encourages participants to post 3 things they are thankful for over 5 days. With so many things to be thankful for, I am having fun with this!

I am thankful for my mother-in-law, Peggy, also known as Mema. She is an energetic, kind, loving person who always puts others before herself. She has the biggest heart of anyone I know and she is always there to help others when needed. I couldn't ask for a better mother-in-law! Dank Dank was a wonderful father-in-law as well. They made a great team! Miss you Dank Dank!

I am thankful for my rescue mutts, Bella and Coco. They are my fur babies! They have filled our home with love, companionship, and lots and lots of dog hair! Our house would be so empty without them!

I am thankful for my career. Taking care of others is my purpose in life. I have had the pleasure of caring for many people in my 20+ years in the medical profession. Every patient I have cared for has been special in one way or another. I couldn't imagine doing anything else!

So, there you go, 3 more things that I am thankful for! 

Giving Thanks: part 1

So I was challenged by Valerie Morrow to list 3 things a day for 5 days of what I am thankful for. This should be easy, as I have a lot to be thankful for and think about this quite often! Saying it with words alone may not evoke the feeling and emotion that I have behind this, so I'll say it with pictures as well!

1. I am thankful for my husband and kids, who keep me laughing with their unending humor, keep me busy with their unending laundry, and keep my heart filled with all the love they give me.

2. I am thankful for my siblings. We may not all be geographically close, but it's great knowing I have them on my side! (not pictured, my sis Joann)

3. I am thankful for my 'framily', the friends who I call family. They are the people who have proved that you don't have to be blood related to be family. Life long friends are hard to find. Glad I found mine!

ALS Ice Bucket Challenge

                                              In Loving memory of Dank Dank 

ALS #IceBucketChallenge

With social media, it doesn’t take long for a video, trend, or challenge to go ‘viral’. One of the latest challenges to take on a viral status is the ALS Ice Bucket Challenge.

Many of you may be wondering what ALS even stands for. Our family knows all too well what these three letters mean. ALS or amyotrophic lateral sclerosis, more commonly known as Lou Gehrig’s disease, is diagnosed in about 5,600 Americans each year. My father-in-law, Thomas Fife (affectionately known as Dank Dank to the grandkids), was one of the victims of this disease. First diagnosed in a baseball player named Lou Gehrig in 1939, ALS is a progressive neurodegenerative disease that affects the nerve cells in the brain and spinal cord. This neurodegenerative process causes progressive loss of voluntary muscle control, leaving the person with the inability to eat, speak, walk, and eventually breathe. The individual eventually becomes totally paralyzed. There are no effective treatments for this disease. Those diagnosed with ALS live an average of only 2-5 years from the time of diagnosis. ALS is 100% fatal.  

So what is the ALS Ice Bucket Challenge? This challenge surfaced a few weeks ago, started by former Boston College baseball player Pete Frates. The challenge quickly spread across the country. Celebrities, politicians, athletes, and common men and women, have taken part in the challenge to have a bucket of ice water dumped over his/her head. When they complete the challenge, they are to challenge others to do the same or make a donation to fight ALS (or a charity of their choice) within 24 hours. Apparently, those individuals who completed the challenge end up making a donation as well. The ALS Association reports donations to various chapters of the organization totaling $4 million between July 29 & August 12 as a result of this challenge. Last year at the same time donations totaled about $1.12 million. Not only is the ALS association thanking the public for the monetary donations, but also for the visibility the disease has gained since the inception of this challenge.

It is great to live in a time when we can see something such as the Ice Bucket Challenge bring so much awareness to a disease and lead to so many generous donations to organizations committed to fighting ALS. Social media is a huge part of our life today. Those of us who peruse Facebook, Twitter, or Instagram view pictures of friends, kids, spiritual sayings, political bashing, recipes, and even pictures of what a friend had for lunch. We are uplifted, angered, or given new information to discuss with friends. We are given reminders of friend’s birthdays and flooded with well wishes when we post how sick we feel. We use social media for so much today. Some negative, some positive. I love to see when our use of social media can have such a profound positive force in our lives and in this world. The #IceBucketChallenge makes me appreciate it so much more.

To learn more about ALS and to make a donation, visit: http://www.alsa.org/ Go ahead. I #IceBucketChallenge you!

 Dr. Donna Poma Fife DNP, ARNP

Disclaimer: Author has no affiliation to the ALS association. It’s just an issue near and dear to my heart. 

Here is our ALS #IceBucketChallenge!  Nevia wasn't home to join in on the fun. It's hard to get us all in the same place at one time! In the video, you will see that our dog Coco thinks we are nuts!

https://www.youtube.com/watch?v=QwqtGPQley0&feature=youtu.be 

Suicide Prevention

As our social media newsfeeds are flooded with stories of the death of actor Robin Williams, I can’t help but feel that this sort of a tragedy will bring attention to suicide and mental health disorders in general. However, in reality, I understand the attention span of humans. After all, I’m human too. We will wake up in a few days and pictures of Robin Williams in his previous acting roles will no longer overwhelm our social media outlets. The issue of suicide, depression, and mental health disorders will likely be forgotten by most until the next famous person falls victim. Yet, day in and day out, millions of Americans suffer from depression and other mental health disorders and some may contemplate, attempt, or commit suicide.  

According to the most recent data provided by CDC.gov, in 2010 there were 38,364 suicides in the US. This averages to 105 precious lives lost each day. These are not famous people, but people who had others love them as if they were. The families and friends of these individuals feel pain, loss, and sorrow for years to come. A parent of a child who commits suicide will likely never get over their loss.

I remember when I was in high school a classmate committed suicide. I still remember his name. In fact, I’ll never forget his name. I never understood back then how anyone could take their own life. I don’t think anyone who has never felt that level of despair can understand this act.

In addition to the suicide statistic I listed above, the CDC reports that about 8.3 million adults reported having suicidal thoughts, 2.2 million reported having a suicide plan, and approximately 1 million had reported attempting suicide in the past year. For about every 25 suicide attempts, there is one person who completes the act.

The statistics regarding youths and suicidal thoughts and actions is equally upsetting. In high school students surveyed, about 12.8% reported making a suicide plan, 7.8% attempted suicide, and 2.4 reported an attempt that resulted in injury requiring medical attention, in the year prior to the survey.

Speaking of the young person, suicide is the third leading cause of death in youth age 10-24 years. A few years back, my daughter had a classmate in the 7^th grade who killed himself. 7^th grade. 12 years old. It is heartbreaking to think of the despair this child must have felt to have committed this act. Last year, a teenager in her high school committed suicide. A kid who seemed to have it all, ended it all with the pull of a trigger.

Discussing the topic of suicide is often uncomfortable. As a healthcare provider, when I worked with psych patients I had to approach the subject with my patients. Even for a healthcare provider this can be an uncomfortable situation. It’s as if dredging up emotions from a person’s deepest level of pain and despair. It’s discussing an incident from the darkest time in their life. But it is necessary in order to assess if there is a risk for future suicide attempts. Many people may be apprehensive to talk about their suicidal thoughts or attempts out of fear of being stigmatized. But if approached with the topic, you never know, the person may actually open up about it. It may be very therapeutic to talk about it. It may lead them in a direction of seeking mental health treatment. It may save a life.

Many people, I bet, are unaware of the risk factors for suicide. Here are some, as listed by the CDC.

*History of previous suicide attempts

*Family history of suicide

*History of depression or other mental illness

*Alcohol or drug abuse

*Stressful life event or loss

*Easy access to lethal methods

*Exposure to the suicidal behavior of others

*Incarceration

Mental health issues are often overlooked in our society. It’s important to open the conversations regarding depression, suicide, and other mental health issues. As a society, we need to move away from stigmatizing mental health disorders and instead look at ways to address these disorders. Health insurance reimbursement is often low or non-existent for mental health. This prevents a great deal of Americans from receiving counseling from a licensed mental health professional. Counseling that could lead to an improved state of mental health and even prevention of suicide.

Don’t be afraid to address the subject if you know someone who is going through a difficult time. Don’t hesitate to steer them in the direction of help.

National Suicide Prevention Lifeline: 1-800-273-8255.

To learn more about suicide and what you can do to help others, visit the American Association of Suicidology at http://www.suicidology.org/home

 Dr. Donna Poma Fife DNP, ARNP

Disclaimer: This blog is meant to be informative and does not constitute advice from a medical practitioner. Contact your healthcare provider for any medical issues you may be concerned about. 

Family & friends

This is a snapshot of my perspective of Lori's situation from Day 1-2. This is not an update on her current state. You may want to reread Part 1, The Arctic Sun. Sorry for the delay in posting, I've been busy!

Part 2:
I sat in the waiting room staring at the wall. My body and my mind were so numb. Staring was all I was capable of doing. Sometime later, I knew once again I would have to call my siblings and inform them of the new bad news that the attractive doctor with thick rimmed glasses delivered to us.   As technologically advanced as this hospital is, you would think they would find a way to have cell service available in the ICU waiting room, but they have not. So Chris & I walked to an area where I could make the dreaded phone calls.

After informing Joey & Joann about the current state of our sister, we walked the bare-walled hallways back to sit in the waiting room. As I sat staring at the wall again, I couldn't help but wonder how many other people have sat here staring at this same wall, numb from the news of their loved one's poor condition.

I knew I couldn't just sit & stare forever. I needed to deliver news of Lori to others. I knew I couldn't talk on the phone anymore. Not because of the ICU waiting room cell phone dead zone, but because I couldn't physically or mentally complete the task. Thankfully, I can text and get the message out. Not that I wanted to, but I felt I needed to. I couldn't text my best friend Cathy. She's usually the one I would text or call first. But she was at the airport on her way to Greece. I didn't want for her to worry about Lori when she was on vacation. I typed a text to Valerie, Cathy's little sister and another one of my best friends, & I stared at my phone for a minute or so deciding if I even wanted to send it. Not that I didn't want my friends to know what was going on, but I didn't feel that I even wanted to talk about the situation at this point. I just wanted to stare at the wall. It's much more peaceful when my mind is blank than when I'm talking and thinking about what is going on with Lori. My finger found its way to the send button on my phone. Within seconds Val texted me back (she knew she couldn't call me, she's well aware of this waiting room cell phone dead zone from when her mom was a patient here). She informed Paige and let me know they would be in the waiting room with us shortly. I asked her to please not tell anyone else right now. I couldn't handle a flood of calls or texts at this point.

People are our family by blood, by marriage, by adoption, and others are bound to us as family by mere friendship. It's not just the good times that turn friends into family, but it's through our most difficult times in life that we know when a friend is truly our family. I'm fortunate to have a few friends that I call my family. They have repeatedly and consistently been there for me through my darkest hours. And I've always done my best to reciprocate. Through their family connection with me, they also feel that Lori is one of theirs' as well. So the fact that my friends dropped everything to be there for us was no surprise to me.

The four of us sat in the otherwise empty ICU waiting room together. Sharing stories and feeling encouraged that we all agree that Lori is a strong person and will pull through this. Valerie and I went in to check on Lori. No changes. Nothing new going on. It's probably best we go home now. Get some rest. It's been a long, exhausting day.

My dream of going home and crawling into my cozy, comforting bed was short lived when I remembered Lori's dog was alone at her house. He had a crazy day as well. I needed to go check on Buster.

Talk about family stepping up to the plate in times of need, my mother-in-law, Mema, is another faithful family member ready to help on a moment's notice. Mema was there to pick up the kids for us and be at the house when their tutor was there. I wanted their day to stay as routine as possible. They're too young to understand the gravity of Auntie Lori's situation. Mema stayed with the kids while Chris and I drove out to Lori's house.

Buster was happy to see humans. Nervous, and unsure of us, but happy. We let him out to potty and made sure he had food and water. I knew I couldn't take him home with us tonight. I wasn't sure how he'd react to my kids and my dogs. I couldn't handle anything else tonight. He'll be fine home alone for the night & I'll get him on the morning.

The night was, as you might suspect, sleepless. I called the hospital in the middle of the night. "We are continuing to cool her body temperature down. She's stable. No changes" stated the night nurse. This was Lori's continued state throughout the night.

I had to continue on with my busy routine, my busy life.  Kids need to go to school, work needs to get done, the floors still need to get swept & mopped. Lori's world came to a halt, but mine could not. In addition to all my responsibilities, I needed to take on many of Lori's as well. She didn't need her little sister to sit around crying for her, she needed me to take care of her life while she couldn't. I've always taken my role as a patient advocate seriously in my professional life, and my personal life was no exception.

It takes time to learn a person's life. What bills need to be paid? What bank does she use? What bills are auto-drafted from her bank? Does her paycheck go thru as direct deposit? This list goes on & on & on. I think occupying my time in this process helped me deal with the situation the best I could.

So I went and picked up Buster, Lori's little fur baby, and brought him to our home. Bella, the alpha dog of our house, or I should say 'her' house, was quite curious who this short little fur ball was invading her space. Coco, afraid of anything that threatens her status as the most spoiled dog in the house, wouldn't even look in Buster's direction. But they managed to all deal with one another. Perhaps they all sensed that is what I needed them to do.

Once again, I was in the ICU to see Lori. She was still unresponsive. No eye opening. No voluntary movements. No attempts to say a word around the tube that occupied her throat. The only movement was her chest rhythmically rising and falling as the ventilator pumped air into her lungs. I became mesmerized watching this movement, looking for any breath that may be Lori's & not forced in by the ventilator.

The nurse came in and broke my concentration on Lori's ventilator breathing. She informed me they had reached the goal cooling temp of 32 degrees Celsius. She was now in a state of hypothermia. So now we just wait.

I have often heard that we spend a great deal of time in our life waiting. Waiting for a red light to change green, waiting for the cashier to ring up our purchase, waiting for our teenager to get home from a night out with friends. Sometimes it seems we are always waiting for something. Waiting for a loved one to regain consciousness is by far some of the worst waiting I have ever done. But there was nothing else I could do but wait.

Dr. Donna Poma Fife

The Arctic Sun

It was not the type of call that I was expecting. "This is EMS, Lori wants you to know she is having shortness of breath & EMS is taking her to the hospital." Working as a nurse practitioner, I felt it was important to clarify. "Are you talking about my sister Lori, or about a patient of mine?" "She said she's your sister ma'am." Oh. Okay. I took a second to process the information, walked to an area of the nursing home I was in where I could have some privacy and called Lori's cell phone. She answered. There was a distinct sound of panic in her voice. She said that she was having shortness of breath. I could hear the voice of whom I suspected was a paramedic in the background. I could barely get a word in before it sounded as if she fumbled the phone.  The line went dead. I stared at my phone and then put it up to my ear several times, checking for the sound of her voice. Any sound. But, there was no sound.

I was about 45 minutes away seeing patients at a nursing home when I received the call. I started on my way back to Lakeland. I made a few calls on my drive back.  Thank goodness for Bluetooth. I don't think I could have held a phone in my weak, shaky hands. I called my husband to let him know what was going on and my work so they could call the rest of the nursing homes on my schedule & let them know I wouldn't be there. Almost back to Lakeland now. So much traffic on Hwy 92. Get out of my way!

It took about 10 minutes to find a parking spot in the parking garage. A full parking garage is not a good place for an impatient woman. Finally, an open parking space! I pulled into the space & darted for the stairs, grateful I wore scrubs & sneakers to work today.  I ran down the stairs, because it had to be faster than the elevator and I'm too impatient to wait for an elevator anyhow. Once in the ER, I was directed to the visitor area. The kind lady opened the door for me with her badge and said "See that Exit sign at the end of the hall? Once you get there, she's in the third room to the right." As I walked through the bustling ER, I envisioned Lori sitting on the stretcher with tubing up her nose providing oxygen, talking on her phone. I thought, "As soon as I walk in the room she'll start telling me what I need to do in her big sisterly way."

Shaken from my day dream, a nurse in black scrubs darted out from what seemed to be nowhere and pulled the curtain closed in front of me. Wow, I know they are all about protecting patient’s privacy, but come on, she is my sister. "Who are you?" Asked the steady and firm nurse. I explained my relation & stated my name as if under interrogation. "What do you know about what happened?" asked the nurse. "Well, my sister was having shortness of breath & called 911" I said as I envisioned pushing the nurse out of my way.  "Aren't you taking HIPPA a little far here lady?" is all I could think. "A few things have happened since you talked to your sister". Oh no. My heart sank. All I could do was stare at her with saucer sized eyes & wait for the details. "When the paramedics got her into the ambulance, she went into cardiac arrest." Asystole. The worst heart rhythm possible. "They did CPR & after 5 minutes they revived her and she was in a-fib with rapid ventricular response. This is what her heart looks like now" she said as she held the EKG in front of my face. Wow. I haven't read heart rhythms in years, but that QRS wave looks an awful lot like a Bundle Branch Block, generally a sign of a more severe heart attack.  "She has a tube in her throat for an airway & she is unresponsive" the nurse continued to spew bad news at me. She opened the curtain and there my sister lay, lifeless on a stretcher. Yep, the nurse wasn't kidding, there's a tube in her throat. In fact, wires and tubing were plentiful. I started to feel chest pain myself. Is it possible to have a sympathy heart attack? Or was this merely a symptom of my own breaking heart?

 A few minutes seemed an eternity, but I knew it was time to call my siblings. The nurse gave me the okay to use my cell phone in the room, but afraid that Lori would hear me, I went to the other side of the room. Fighting back the tears, knowing I had to be strong for them, I called my brother and explained what was going on, the whole time my eyes were fixed on Lori's motionless body. Then I called Joann, who quickly became upset. As I was explaining things to Joann, a tall man with thinning red hair walked in. Dr. So & so (as if I'd remember a name right now) introduced himself & I hung up with Joann. "Your sister is in bad shape" he said with empathy clearly evident in his blue eyes. More chest pain for me. Good thing there is an empty stretcher in here, I may need it. "She's acidotic & has a glucose level over 600. It was over 800, but has come down some.  Her heart rhythm is abnormal and her blood pressure is very low. She has signs of congestive heart failure. I would expect to see all of this going on in an 80 year old, but not in a 55 year old." I know Dr. Red-hair had a lot more to say & ask, but the mind tends to go blank when overloaded with this kind of information. Again, my eyes stayed fixed on Lori's body, which has yet to so much as flinch. "We're going to transfer her to ICU in a few minutes" the nurse informed me. Feeling as though my knees would no longer allow me to stand, I sat back down in the chair across the room. I listened as the nurse gave report to the ICU nurse. Information I should clearly understand with my medical background made absolutely no sense to me.  It was as if she were speaking a foreign language. This happens to other people. Not to my family. I sat, frozen, my eyes fixed on Lori as my mind willed her body to move.

The nurse informed me that I would not be able to see Lori for at least 45 minutes as they assessed her in the ICU. I stumbled outside and walked aimlessly, trying to figure out what I needed to do next. You know in the movies when you see a person walking and they are unaware of what is going on around them, deafened to all sounds? That was me. I saw a bench in the parking garage and sat down, placing Lori's purse on the bench next to me. "I need to call her work", I thought. Damn, I don't even know the name of the company she works for. I looked through the 2 wallets in her purse 3 times each before I found a business card from her work, which was in the front slot of wallet #1. Not surprised that I missed it the first 3 times. I don't know if I could have found it if it jumped up & bit me. I called her work & informed her supervisor what was going on. Then I sat there, on the hard bench in the parking garage for 30 minutes, staring at the opening & closing doors leading into the hospital, wishing I never had to go back in, but knowing I had to.

Somehow I found my way to the ICU. Don't ask me how though. I floated there for all I know. I walked through the ICU doors after the sweet little lady volunteer waved her badge in front of the box on the wall.  An eerie feeling swept through me as I remembered the last time I was in this ICU, when my best friend's mom was a patient here. Overwhelming emotion flooded through me. Scanning the room numbers, I finally saw room 16. As I walked closer my chest began to hurt again. I walked in the room and approached Lori in her new bed. I touched her cold, pale skin and couldn't hold back the tears anymore. Still, she lay lifeless and I still believed I could will her body to move. No such luck. With once again weakened knees, I walked to the chair by the window and sat down. I couldn't take my eyes off of her. "Open your eyes dammit!" I shouted in my mind, apparently not loud enough for her to hear. Sometime later, Lori began to move. Not in the way I willed her to, but in jerking, seizure-like movements. This can't be good.

At some point the nurse directed me out to the waiting room. Thankfully, my husband Chris had made it here by now. We sat in the waiting room for a length of time I do not recall, waiting for the ICU doc to come out and talk to us. In walked a tall, thin woman who looked incredibly attractive with no makeup on. I stared into her eyes hidden behind thick, black framed glasses. "I'm Dr. So & so" she said, (really, who can remember a name at a time like this?).  I listened as she gave me another speech about what bad shape Lori is in.    As she painted the bleak state of affairs, I couldn't help but feel grateful that I don't have to deliver news like this to patients or families. I don't recall all she said. I can't remember a name right now, you think I can remember all the details here? I must paraphrase: "She was without proper oxygenation for a while, she is having seizure like activity, which is generally a bad sign, we don't know how well she will recover neurologically" the doctor empathetically informed me. "Do you know what her wishes are?", "If you have family to call, you may want to let them know in case they want to get here", "Is she religious? Do you want a priest to pray with her?" The attractive doctor with thick framed glasses was full of questions I was not fully prepared to answer. "We will do everything we can" she confidently stated. "There is a procedure called the Arctic Sun protocol that we do for patients in this situation. We will put her in a therapeutic hypothermia in hope of preserving brain and heart function. We cool her body down slowly over a few hours and keep her at the goal temp for 24 hours. Then we slowly rewarm her body temperature and wait to see if she wakes up neurologically. There are no guarantees, but this is her best shot at recovery." Envisioning Lori's lifeless body, I knew we had to do whatever we could. So a few hours later, when her body stabilized, the cooling began. And so did the waiting...

Published with permission of Lori Poma