Tag Archives: health

Questions

13 Friday Jul 2012

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One of the challenges I have faced over the past 16 months is quieting all the questions that frequently fill my head.   Questions most of which don’t have answers.

  • Why me?  Or what did I do to deserve this?
  • Did I do something to cause this?
  • Could I have done something to prevent this?
  • Will this happen again?

…Just to name a few

I have spent hours and hours reading medical journals and anything else I could find on HELLP Syndrome seeking answers.  There are tons of theories and even more statistics, but at the end of the day they all say the same thing.  Because there is no known cause; there is no known way to prevent HELLP and the only treatment is to deliver as soon as possible.  How can this be, with so many advances in modern medicine that so little is known about this deadly condition?  {Yet another question}

As I researched, the question that really got under my skin was: why had I never heard of this before?  I read baby books and spent countless hours on baby websites, not once had I heard of HELLP Syndrome.   I was very annoyed when I went to the March of Dimes website and there was no mention of HELLP under pregnancy complications.  There moto is “Working together for stronger, healthier babies”.  (I am glad to report that as of April of 2012, it is now listed.  Not sure if it was due to my emails as I never got a reply, but regardless, glad it is listed now)

At times, I have felt even some in the medical industry don’t really know much about HELLP.  I say that not because of my OBGYN or my primary care doctor, in fact I have been very pleased with the care I have gotten from both of them.  But, over the past year, I have had to see countless doctors.  The first doctor that shocked me was a neurologist; I suffer from migraines and have seen various neurologists for many years.  He told me on several occasions he had never met anyone that had a case like mine; he had only ever read about it.   Months later I had to see a cardiologist, as were talking he had a nurse taking notes.  She stopped the conversation to say, I don’t know how to code this.  I don’t see HELLP as a condition in our system and I don’t know what it is.  He told her to put it under either PreEclampsia or Eclampsia and note it was HELLP.  At least he knew what category it would fall into.

The irony is while I have had doctors tell me they aren’t exceptional familiar with HELLP, every labor and delivery nurse I come across seems to feel they are an expert on the topic.  I say they feel they are an expert because it takes very little time talking with them to realize they usually are not.  I had one go as far as to tell me I should sue my doctor for missing my PreEclampsia and letting it get all the way to HELLP.  When I told her I never had PreE she said, “No, that is impossible.”  Sorry to tell her, it is very possible. My blood pressure was good until the day it all went wrong and I was not swollen at all.  I had another nurse tell me “She sees HELLP all the time, and whoever told me it was rare was wrong”.  No comment on that one.

But, as I mentioned earlier my main doctors have been great.  When I first saw my primary care doctor and told her what had happened, she asked me for my OBGYN’s info.  She promptly called her to discussed my case and asked if she could send over all of my records. She has gone to great lengths to educate herself on HELLP Syndrome.  And, any test she runs she sends over to my OBGYN.  As the patient I really appreciate this, it is nice to have your doctors on the same page and it prevents any unnecessary double tests. 

As I approached the one year post HELLP mark, my primary care doctor wanted to do a complete physical to make sure my body had recovered fully.  This would also start the process of me (and the doctors) determining if we would try for another baby.   In addition to the normal physical tests, she tested for various types of Thrombophilia.  She explained that my insurance may not cover these tests, since I had not had multiple miscarriages, but they only costs a few hundred dollars if not covered.  They tested me for both  Leiden Factor 5  and MTHFR .   

A few days later I received a call from my doctor.  The test results were in.  I tested positive for 2 variants of MTHFR and they were running an additional test to see if my homocysteine levels were affected, which they were not.  She explained about 30% of the population, including her, has at least one of these genetic abnormalities.  And really, it just means extra folic acid and maybe blood thinners in a future pregnancy.

As I processed this news, I got angry.  You mean there was a simple blood test that could have been done?  And, while maybe it wouldn’t have made a difference, maybe it would have. But, it isn’t a standard pregnancy test because someone behind the desk at an insurance agency won’t cover it unless you have had multiple miscarriages or like in my case test positive.  I realized the link between MTHFR and HELLP is nothing more than one of the many theories, but still… I am a member of a HELLP survivor board and almost everyone on that board tested positive.   Maybe a coincidence or maybe something more, guess I will add this to my list of unanswerable questions.

Delivery Day

02 Monday Apr 2012

Posted by in Pregnancy, Stillbirth

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The time had come to deliver Ansley.  My contractions were almost constant.  In an instant, my hospital room transformed into a delivery room.   On one of my final pushes, I realized Chris was no longer by my side.  I looked around the dimly lit room, my eyes focusing through the tears, and see him in the far corner of the room facing the wall.  Within seconds he fell to his knees overcome with grief and although it didn’t seem possible, my heart broke even more.

A few minutes later Ansley was born.  She was so small; much smaller than anyone anticipated.  After all, it was just a month earlier that she was measuring big.  She was about the size a baby should be at 22 weeks.  Apparently, HELLP syndrome had been manifesting in my body for a few weeks.   Intrauterine Growth restriction (IUGR) is yet another complication caused by HELLP Syndrome.  Had we been able to have the c-section in time, based on Ansley’s size, her survival rate would have been less than 1%.

I asked the doctor why she died.  It was likely the perfect storm.  She was tangled up in her umbilical cord, although my doctor didn’t think that had much to do with it.   There was also a true knot in her cord; this combined with having a hard time getting blood, nutrients and oxygen from me was likely the reason.  She wasn’t going to order an autopsy.  At the end of the day, HELLP Syndrome was the cause of death.  She said they would send my placenta off for testing; that would provide more helpful information than an autopsy.

By the time the nurse had cleaned Ansley up and handed her to us, the sun had come up.  We studied our daughter memorizing every detail.  She had my lips, my nose, and the same little fold in her ear as I have.  But, she had her daddy’s long torso, and her face was the same shape as his.  She was a perfect blend of both of us.

As we looked at our daughter, I managed to convince myself that she was breathing.  And for just a minute I thought they were wrong that she wasn’t dead.  Chris assured me she was not breathing, but then I heard it again.  As it turns out, what I was hearing was the inflatable wraps they put on your feet and legs.   I had heard the wraps inflate and deflate for the last several days, but between all my medicines, the lack of sleep and the pure desire to have my daughter live I had forgotten all about them.

The nurse returned with the smallest little outfit I had ever seen.  We dressed Ansley and laid her in the bassinet.  She had many visitors waiting to meet her.   My parents were already in the waiting room and Chris’ parents were on their way.  Later that afternoon his grandparents and my friend Maren stopped by to meet Ansley.

Ansley spent the day in my hospital room.  It would be the only time Chris and I would have to spend with our daughter.  The hardest part of the day came that evening- when we were told we had to say goodbye.   I held my daughter for what would be the last time.

Just when I thought I was done for the day, emotionally, physically and mentally exhausted.  I was presented with paperwork.  The paperwork recorded Chris and I as her parents, her birth name and date and decisions like what funeral home she would be taken to and if we wanted her buried or cremated.  Decisions nobody should have to make on their child’s “birth” day.

Just a dream

26 Monday Mar 2012

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Saturday turned into Sunday. Time went from moving in slow motion to becoming a complete blur.  I had heard the words, Ansley had passed away. I saw everyone react, but for all I knew, this was just a very bad dream.

One minute the room was packed full of people, the next minute it was just family and a nurse.  I don’t remember seeing anyone leave, but they had all disappeared.  More evidence this must just be a dream, people don’t just disappear in real life.

I was told the course of my care would be changing.  The focus was now solely on me. There would not be a c-section it was too risky, instead they would be inducing labor.

I was given a blood transfusion of platelets as well as a few other medications.  It was the middle of the night.  I was mentally, physically and emotionally exhausted and not asking many questions.   My parents left as did Chris’s mom.  They suggested I get some sleep.  As exhausted as I was, there was no chance of me sleeping.

Sharon the night nurse pulled up a chair next to my bed where she would spend the rest of her shift, she turned the lights down and for the first time I cried.

I must have dosed off a time or two, but every time I did, I was awaken by alarms. My oxygen levels were dipping too low or my blood pressure was rising too high.  I was told to focus on slow deep breaths.

Soon they were hooking me up to oxygen. Pulmonary Edema (aka fluid in my lungs) was setting in.  This was yet another complication from HELLP Syndrome.

 

What is HELLP Syndrome???

25 Sunday Mar 2012

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The American Pregnancy Association has one of the best descriptions of HELLP Syndrome I have found.  They describe HELLP as:

HELLP Syndrome is a series of symptoms that make up a syndrome that can affect pregnant women. HELLP syndrome is thought to be a variant of preeclampsia, but it may be an entity all on its own. There are still many questions about the serious condition of HELLP syndrome. The cause is still unclear to many doctors and often HELLP syndrome is misdiagnosed. It is believed that HELLP syndrome affects about 0.2 to 0.6 percent of all pregnancies.

What is HELLP Syndrome?

The name HELLP stands for:

  • H- hemolysis ( breakdown of red blood cells)
  • EL- elevated liver enzymes (liver function)
  • LP- low platelets counts (platelets help the blood clot)

It is often assumed that HELLP Syndrome will always occur in connection with preeclampsia, but there are times when the symptoms of HELLP will occur without a diagnosis of preeclampsia being made. Unfortunately since the symptoms of HELLP syndrome may be the first sign of preeclampsia, this is what can often lead to a misdiagnoses.

What are the Symptoms of HELLP Syndrome?

The most common symptoms of HELLP syndrome include:

  • Headaches
  • Nausea and vomiting that continue to get worse (this may also feel like a serious case of the flu.)
  • Upper right abdominal pain or tenderness 
  • Fatigue or malaise

A woman with HELLP may experience other symptoms that often can be attributed to other things such as normal pregnancy concerns or other pregnancy conditions. These symptoms may include:

  • Visual disturbances
  • High blood pressure
  • Protein in urine
  • Edema (swelling)
  • Severe headaches
  • Bleeding

How is HELLP Syndrome Diagnosed?

Because the symptoms of HELLP can mimic many other conditions or complications, it is encouraged that physicians run a series of blood tests, including liver function, on any woman experiencing symptoms during the third trimester of pregnancy. HELLP syndrome may occur before the third trimester but it is rare. It also may occur within 48 hours of delivery, although symptoms may take up to 7 days to be evident.

Blood pressure measurements and urine tests to check for protein are often monitored when diagnosing HELLP syndrome. But the following tests and results are what help a physician to make an accurate diagnosis of HELLP Syndrome:

Hemolysis -Red blood bells

  • Abnormal peripheral smear
  • Lacatate dehydrogenase >600 U/L
  • Bilirubin > 1.2 mg/dl

Elevated liver Enzyme levels

  • Serum aspartate amniotransferase >70 U/L
  • Lacatate dehydrogenase >600 U/L

Low Platelets

  • Platelet count

How is HELLP Syndrome Treated?

The treatment of HELLP Syndrome is primarily based on the gestation of the pregnancy, but delivery of the baby is the best way to stop this condition from causing any serious complications for mom and baby. Most symptoms and side effects of HELLP will subside within 2-3 days of delivery.

If the pregnancy is less than 34 weeks gestation, doctors usually try to evaluate lung function of baby to see how well delivery would be handled.

Treatment’s that may be used to manage HELLP until baby is delivered include:

  • Bed rest and admission into a medical facility to be monitored closely
  • Corticosteroid ( to help babies lungs develop more rapidly)
  • Magnesium Sulfate ( to help prevent seizures)
  • Blood transfusion if platelet count gets too low
  • Blood pressure medication
  • Fetal monitoring and tests including biophysical tests, sonograms, non stress tests and fetal movement evaluation

If pregnancy is over 34 weeks gestation or the symptoms of HELLP begin to worsen, delivery is the recommended course of treatment.

In the past, Cesarean delivery was the most common way for delivery of babies whose moms were dealing with HELLP syndrome. But it is now recommended that women, who are at least 34 weeks gestation and have a favorable cervix, should be given a “trial of labor” (TOL). HELLP syndrome does not cause reason for an automatic cesarean and in some situations, operative surgery may cause more complications due to the possibility of blood clotting problems related to low platelet counts. 

What Causes HELLP Syndrome?

Doctors are still unclear on what exactly causes HELLP syndrome. Although it is more common in women who have preeclampsia or pregnancy induced hypertension, there are still a number of women who get it without previously showing signs of preeclampsia.

The following is a list of factors that are believed to increase the risk of a woman developing HELLP syndrome:

  • Previous pregnancy with HELLP Syndrome (19-27% chance of recurrence in each pregnancy)
  • Preeclampsia or pregnancy induced hypertension
  • Women over the age of 25
  • Caucasian
  • Multiparous (given birth two or more times)

What are the Risks and Complications of HELLP Syndrome?

If HELLP syndrome is undiagnosed or untreated, it can result in life threatening complications for both mother and baby. The most serious complications and risks of HELLP syndrome include:

  • Placental Abruption
  • Pulmonary Edema ( fluid buildup in the lungs)
  • Diseminated intravascular coagulation (DIC—blood clotting problems that result in hemorrhage)
  • Adult Respiratory distress syndrome (lung failure)
  • Ruptured liver hematoma
  • Acute renal failure
  • Intrauterine Growth restriction (IUGR)
  • Infant respiratory Distress syndrome (lung failure)
  • Blood transfusion

The maternal mortality rate is 1.1% with HELLP syndrome. The infant morbidity and mortality rate is anywhere from 10-60% depending on many factors such as gestation of pregnancy, severity of symptoms and the promptness of treatment.

How can HELLP Syndrome be Prevented?

Because there is not a known cause for HELLP syndrome, there is also no identified way to prevent it. Early identification and treatment is the best way to keep HELLP syndrome from getting serious.

For more information on HELLP Syndrome please see the AAFP’s – HELLP Syndrome: Recognition and Perinatal Management

The Moment- part 2

20 Tuesday Mar 2012

Posted by in Pregnancy

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We arrived at the Emergency Room at Emory John’s Creek Hospital.  They told us that since I was in my third trimester we needed to go straight to labor and delivery.  It was standard procedure.  Having not done our hospital tour yet, we were unsure where we were going.  A nice young lady escorted us upstairs where we were greeted by Nurse Linda.   Nurse Linda asked what brought me there.  I gave her my same list of seemingly minor issues: my back hurt, I just did feel great, and my blood pressure was up 160/89 at home and 220/212 at the urgent care.  She said well let’s get you in a room and check a few things.

She began to put me in one room and then changed her mind, one of the many things that only made sense in the days to come.   She had me change into a hospital gown, collected a few samples, checked my BP it was now 189/96; she hooked up a fetal baby monitor and advised that we make ourselves comfortable.

We debated calling family, but there was really nothing to tell. We were sure it wouldn’t be long before they would send us home.  Instead we watched a little TV, I believe the 6 o’clock news.  A quiet room with TV, defiantly a benefit of being in L&D rather than the ER.  It was neat to lay there listening to Ansley’s heartbeat on the fetal monitor.   I had heard it many times before in the doctor’s office, but only for a minute or two.  Ansley was way more active than usual.  I told Chris we must have a little gymnast because she is doing back hand-springs.

Hours passed and nobody was really telling us much.  Finally, Nurse Linda came back in and advised they would be coming to drawing more blood and may start and IV line, just incase the doctor wanted to use it.  She was very nonchalant.

A few minutes later the anesthesiologist came by.  He said, “I hear you have stubborn veins”.  Story of my life, nurses and lab techs always have a hard time finding my small deep veins.  He was not much older than Chris and I.  He hung out in the room for a while making small talk.  He explained it was a slow day at the hospital and he prides himself on getting a good vein every time on the first try.

He plunged the needle into my arm much like someone throwing a dart.  Before he could get the tube on, a volcano of blood erupted. It went everywhere, all over me, all over him, the bed, the floor, I am pretty sure even the ceiling.   It was a shocking sight, but he made a quick joke and laughed it off.

He said while he was there he was going to put and IV line in my hand in case they wanted to give me some fluids.  Then for good measure he added a line to my other hand as well.

I bit more time past before Nurse Linda reappeared, she wanted to introduce me to the night nurse, but explained she was going to hang around for a bit.  The doctor should be in soon to talk to me.

It was now after 9:00, Dr. Betty Anthony finally stopped by my room. She told me I was very, very ill.  I had a condition called HELLP Syndrome.  It was serious.  My platelet count had dropped to 30,000 and was continuing drop.

I may as well have been listening to Charley Brown’s teacher.  MAW, MAW, MAW, MAW.  What she said meant NOTHING to me.  I had never heard of HELLP syndrome and 30,000 sounded like a big number to me.  Not to mention, I didn’t feel ill, my only real complaint was my back hurt.

There was no questioning the next words out of her mouth.   They were prepping the OR for an emergency c-section; I was going to deliver Ansley that night.  They were waiting on the blood bank and the neonatologist would be in soon to speak with me.   In the mean time, they were giving me a corticosteroid injection-every little bit would help.

Moments later Chris and I were alone in the room again, both of our heads spinning trying to wrap around what just happened, or more what was about to happen.  It was time to call our families. Chris picked up the phone and called my parents.  My mom answered the phone.  I heard him tell her we were at that hospital, I was very sick, and I had to deliver Ansley that night.  I heard my usually soft-spoken mom scream “WHAT!!!” through the phone across the room.  She and my dad wold be right there.  He told her what hospital we were at and then proceeded to call his parents with the same news.

My parents and Chris’s mom arrived what seemed like moments later.  My parents live an hour away, but it couldn’t have been more than 30 minutes.  The doctor and nurses hadn’t been back in the room yet.  I tried to explain I had a condition called HELLP syndrome, but that was really all I knew.  I heard Nurse Linda say as she entered the room, “yes that is right. We are pretty worried about your liver”  This still didn’t add any clarity to the situation.   Chris had seen the name in his Google search the night before, but it was described as the most severe form of Preeclampsia and since I didn’t have Preeclampsia he didn’t click on it to read anymore.

Nurse Linda brought me an ice-cold towel and told me they were going to be starting a Mag drip.  The first push of medicine would make me hot.  Hot, that was an UNDERSTATEMENT.  As soon as the meds hit the IV my veins burned like crazy followed by insane sweating.  My mom pulled my hair up it was soaking wet instantly.  Nurse Linda explained the Mag would prevent me from having a seizure or stroke and while uncomfortable it was necessary. About this time my brothers showed up.

Nurse Linda assured me I was in good hands, and that she had been off for 3 hours now and really did need to leave.  She told me she was off the next day, but would call me to check on me.   As she left the room it was filling with other people.  A tech brought me the phone, my doctor was on the line. She told me that while she couldn’t be there tonight, she has been informed every step of the way and fully supported the decision that was made to deliver Ansley.  She told me I was in great hands with Dr. Anthony and she would be there first thing in the morning.  By this time the room was full.  The night nurse Sharon, who I soon learned would be my personal nurse for the night, two additional nurses, a tech, the anesthesiologist, the neonatologist and Dr. Anthony along with my parents, my brothers, Chris’s mom and of course Chris and I.

The neonatologist told me he was going to scrub up.  That at 24 weeks Ansley would have a less than 10% survival rate.  They were prepared and would do everything they could.  He told me that if it were up to him I would wait 24-48 hours get a few more corticosteroid injections and that would raise the survival rate immensely.  I was game, lets wait!  I was quickly told that was not an option and the choice was not up to me.

They began to prep me for surgery.  They removed the fetal monitor to wipe down my stomach.  The incision would not be a normal one it would be vertical because she was small and had not dropped yet. They put a surgical cap on my head and placed the fetal monitor back on my stomach but couldn’t find her heartbeat.  I panicked! “Oh there it is” a nurse said with relief in her voice, but then it was gone again. The second nurse took the monitor and was moving it all over my stomach.  It only took a second for the doctor to get frustrated.  She requested the print out of heartbeat and took over.  She dug the monitor deep into my stomach.  I wasn’t even breathing at this point.  And, I don’t think anyone else in the room was either. On several occasions they heard a beat or two, but then it was gone again. Her heartbeat was weak at best.  Dr. Anthony requested an ultrasound machine, this would be better anyway.  She could see exactly where she was.

Instantly the neonatologist appeared with the ultrasound machine.  There seemed to be even more people in the room now.  Dr. Anthony wasted no time getting it set up.  She stared at the screen for a while.  Sharon my night nurse shoved a thermometer in my mouth, still getting ready for surgery.  I could see Ansley out of the corner of my eye.  She wasn’t moving.

Dr. Anthony took a deep breath looked up at Chris and said.

I am so sorry, she is gone.

I heard the words, but I didn’t react at all.  I felt like I was an audience member simply watching a show.  I saw Chris drop his head into his hands, tears stream down my mom’s face, shocked looks by all in the room.  I even saw myself, the nurse was prying the thermometer out of my mouth telling me I had to stop clenching my teeth.  Time was moving in slow motion.  Chris’s mom told the doctor she was wrong.  The other nurse found the heartbeat why couldn’t she.  Dr. Antony left and returned with a second ultrasound machine, in so much disbelief herself, she thought perhaps the first machine was broken.  It wasn’t broken.  My daughter had died practically before our very eyes.

The Moment – part 1

19 Monday Mar 2012

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I woke up on Saturday feeling the best I had felt my entire pregnancy. I was full of energy and the timing couldn’t have been better; it was going to be a busy day. I had a hair appointment in the morning, a visit to my parents in the afternoon and couples baby shower that evening. The shower was not for me, but for friend who was just a few weeks ahead of me. Before I headed out the door, I did a quick check of my blood pressure, still paranoid from the night before. It was perfectly normal!

As I drove to the hair salon, I couldn’t help but admire the beautiful day, the cherry trees were blooming, tulips were popping up everywhere. Spring had arrived.

While Mark did my hair, I brought him and Brent (his partner in life and at the salon) up to speed on our baby name, what the nursery looked like and my very busy day. About half way through the appointment my back began bothering me yet again – soon after a wave of nausea came over me. Brent left his client and came to check on me.  Apparently, my eyes turned dull and all the color left my face. He joked they really should keep ginger ale on hand for all their pregnant clients, but a sprite would have to do.  It helped… the nausea was fleeting.

I got in the car and began to head towards my parent’s house, but as each moment passed I was feeling worse and worse.  It was as if someone were siphoning off every ounce of energy I had. I decided to head home and rest instead. I called my mom and told her about the back pain and that I wasn’t going to make it.

When I got home I headed straight for bed.  I typically would not lie on my freshly styled hair, but today I didn’t care.  I didn’t realize how long I had been in bed until Chris came flying in the door at 3:30 the same time were supposed to be leaving for the shower.  He was very surprised to find me in bed.

“Aren’t you getting ready?”

“I am ready” I said.

He could tell I wasn’t feeling well and asked if I had taken anything. I told him I had not.  The Tylenol was downstairs and I didn’t have the energy to go get it.

He left for a minute and soon returned with Tylenol, water and the blood pressure machine. My blood pressure was up again much like the night before. I assumed once the Tylenol kicked in it would go down again.

Chris took his shower and got himself ready. We talked about our options. He could go to the shower and I could stay home and rest, we could both go and only stay a brief time, or we could skip it altogether. I really wanted to go.  It was like a rehearsal for my own shower a few weeks later. I decided if my blood pressure had come back down we would both go, if it hadn’t, he could go and I would stay home.

None of our scenarios included what we would do if my blood pressure continuing to climb.  And unfortunately, that is exactly what had happened. 160/89. We just looked at each other unsure of what to do next. Chris decided to call my doctor.  Her message said push 1 for emergency.  But was this an emergency?  It didn’t feel like one.

I decided to call my friend Lindsay, she’s a physician assistant and could point me in the right direction.  I asked what is too high for a blood pressure to be when you’re pregnant.  She said by me asking that question it was probably wasn’t good. I told her what it was; she said home blood pressure machines aren’t always reliable.  I should go get it checked at the hospital by an actual person.

I relayed her message to Chris; we decided to go to the urgent care facility near our house rather than to the hospital. I loaded the baby shower gift into Chris’ truck still thinking we might make it by the end of the shower.

We sat nervously in the waiting room, but were quickly called back.  The nurse asked why I was there.  I told her my back hurt, I didn’t feel great,  my blood pressure was up around 160/89 and that I wanted to get it checked.  She asked why I was checking my blood pressure at home, did I have preelampsia? No I told her, it was a long story.  She checked my blood pressure, she didn’t say anything. She pulled the cuff off and placed it on my other arm and checked again.  220/112.  I told her that can’t be right.  She said she would be right back.  She was going to get the doctor.  Chris and I sat silently in the room. I know I was scared, I think we both were.

The next thing we heard were the most frightening words I had ever heard in my life up until this point.  Through the door I heard the doctor say, “Are you SURE”, “yes” the nurse replied.  “She needs to go straight to the hospital she will probably have to deliver the baby.”  I looked at Chris, and felt the tears start to stream down my cheeks, it was too soon.  He tried to reassure me, but he was scared too.

I did my best to pull myself together on the ride to the hospital.  After all what did that doctor know, he never even came into the room.

To be continued…