married to the residency

I was recently discussing my use of fancy medical terms and how I always feel I need to justify it.  But only some.  For example, I have many years in a psych PhD program.  I therefore feel that this gives me “legitimate” claim to use the term “autonomic dysfunction” without getting into my life’s story.  But if I start throwing around terms like “NPO” and “orthostatic vitals” and the like, I feel as if I need to justify.  Otherwise, I figure docs and the like will assume I’m just some cooky broad who is obsessed with medical crap (and whose current health complaints are to be disregarded as a form of groupie-ism).  In the short version of the relevant history, I say “I was raised by nurses, I worked inpatient as a secretary for years, and I was married to a residency program”.  My (current) husband stopped me last night when I was reciting this and said “ha, you just said you were married to a residency program…not a resident.” I said “yeah…I was married to a residency program.  If you’re married to a resident, you’re married to a residency program.  It’s not the same as saying ‘I was married to a doctor’ because a doctor could be a 50 year old who has friends and interests outside of medicine.  A resident does not.  A resident has his or her residency.  All their friends are residents, fellows, and later, attendings.  All they do is hang out with each other.  And when they get together, all they talk about is medicine.”

My ex even stuck around for an extra year as chief resident, so I got the full residency treatment, right down to the fun and games of making rotation schedules.  Good times.

Sweating it out, part two

When I mentioned the night sweat thing at my appointment yesterday, the surgeon mentioned possible changes in the blood supply to ovaries after hysterectomy.  So like a mini-menopause? I asked – a minipause!  Although he is adorable, and although I’ve seen things approaching emotions on his face, I have to say that I’ve met few people who do stone-faced as well as my Nordic GYN surgeon.  Apparently “mini-pause” warrants stone faced.  And “it should pass.”  I knew if I pressed for scale of “passing”, I’d get evasion.  I don’t know, maybe it was something about him or just experiences with doctors in general.  Anyhow, I went home and looked it up after yet another sweaty (but not in the fun way) night.  An unscheduled hormone hop would also explain the HUGE migraine.  Hell, my body doesn’t even like the regularly scheduled ones, so you can imagine how it would feel about “minipause” ones.

    Ovarian changes after abdominal hysterectomy for benign conditions.
    Chan CC, Ng EH, Ho PC.
    Department of Obstetrics and Gynaecology, The University of Hong Kong, Queen Mary Hospital, Hong Kong, People’s Republic of China.AbstractOBJECTIVES: To investigate any change in the ovaries, including early follicular serum follicle-stimulating hormone (FSH) level, total ovarian volume, total antral follicle count, and ovarian stromal blood flow, in patients who had undergone abdominal hysterectomy for benign conditions. 

    METHODS: Fifteen women with abdominal hysterectomy and conservation of ovaries for benign conditions and who were between 29 and 44 years old were recruited to undergo three-dimensional ultrasound examination with power Doppler to assess total ovarian volume, total antral follicle count, and vascularization index (VI), flow index (FI), and vascularization flow index (VFI) of ovarian stromal blood flow. Serum FSH, estradiol, and progesterone levels were checked on the same day. The results of the assessments were considered taken during the early follicular phase if the estradiol and progesterone levels were basal. Fifteen age-matched healthy women underwent the same assessments on the second day of menstruation.

    RESULTS: Women with hysterectomy had significantly elevated serum FSH level and lower ovarian stromal blood flow indices, including VI, FI, and VFI, as compared with healthy women. The total antral follicle count and the total ovarian volume were similar between the two groups.

    CONCLUSION: These changes may suggest altered ovarian function after hysterectomy.


Big Bad Migraine

…from hell visited me last night.  Oh my god was it awful.  I haven’t had one like that in ages.  All squiggly sharp edged light creepers, this time in the right visual field.  My husband said “I figured this might happen with the weather changing so abruptly and you being ‘menstrual’, well hormonally.  Poor sweetie!”  “Unngh,” I said.  “That’s why I gave you the head’s up,” he added, rubbing my head.  “nnnnnrrrrrrrrr,” I said, then, “Thank you…I didn’t put it together,” and folded myself into as small a ball as I could with my head mashed into the ice pack covered pillow.

I do not consider this him rubbing it in (no pun intended).  He was right, 100% right.  And I’m an idiot for not taking a huge dose of migraine med when I first thought something was up with my vision.  “It’ll pass,” I thought blithely and continued acting as if nothing’s wrong.  Yeah, that’ll show me.


An unlikely favorite word, made so for the personal history with it.  And currently, I am.  Or more precisely, one of my incisions is.  There’s always one.  So off I go back to the surgeon (the fellow to be precise) at B.A.T.H. to have it “cleaned up” and probably to start an oral antibiotic.  Oh my poor intestine.


“That’s just a word for ‘fibroids’,” my neurologist said at my first appointment with him summer.  He had been reviewing my medical history.

    A bit of an excursionary side note here:  I always feel vaguely guilty when I list my medical conditions and/or recurring symptoms – like I have no valid right to claim to have them, like I am heaping it on, like I am writing out the invitations to a pity party.  Or at least, that I will be seen this way.  Why ever would a patient experience those feelings, one might ask.  I can tell you, they didn’t arise on their own.  These are iatrogenic, at least in large part.
    I used to try to keep it to only things I had a diagnosis for, a name for.  “Endometriosis, GERD, Migraines, IBS-D”  That’s a short list.  Again, because of the response of doctors.  “Who told you have …..” was a response I heard one too many times.  Interestingly, I’ve heard it for two things with confirmation – endometriosis and Lyme Disease.  “Who told you you had Lyme?!” one doctor said in an abrupt tone.  And this is when I thank my lucky stars I had the forethought to take a picture of my lyme rash.  The endo was questioned until I could firmly reply “It was confirmed by laparscopic surgery”.  But until I could say that, it was considered by some doctors a questionable diagnosis.
    So I know from those two test cases that there is a good chance I will be questioned, sometimes rather ham-handedly, about what I put down on that form.

The neurologist was not the first to question “adenomyosis”, a diagnosis I was given in 2007 after my last lap for

illustration of uterus with multiple fibroid tumors

Fibroids, from

endometriosis.  The first one was a GYN I tried out briefly.  “That diagnosis can only be made after hysterectomy” I was told by the stressfully thin looking impatient young doctor.  I told her that I was just reporting what my last GYN had said, that he had been the one doing the surgery, and that he had made the diagnosis based on imaging and his observations during the lap.  At this, she bristled with contradiction, as if I had personally insulted her.  Really, I greatly dislike this sort of doctor, well to boil it down -I dislike this sort of person but especially so when they are in a person-caring profession.  No one is as smart as me! seems to be their motto.  Needless to say, she did not remain my GYN long.  Moreover, her estimate for recovery time post-hysterectomy was an unqualified “2 weeks”.  No “every patient is different” or “it depends somewhat on what we’ll find and need to do when we’re in there”.  And this, ladies, is why I vowed never to go to another general purpose OB/GYN again.  Any OB/GYNs out there reading this who don’t suck, I apologize for painting you all with a broad, drippy brush but time and again in your offices, I’ve run into various versions of this soul scouring combo of ignorance, arrogance, and dismissiveness.  I’ve had it with the bad apples in your bunch who should just stick to pap smears, breast exams, handing out birth control, and perinatal whatnot.  I’ve had it with being a pinata for someone who decides to engage in a farce of diagnostic gynecology despite having a clear lack of preparation for that sort of thing.  It may come down to a flaw in the general OB/GYN training or it might have to do with a selection bias – too many of a certain kind of person who chooses to go into OB/GYN (babysniffers?).  Whatever the reason, the field is rife with men and women who do more harm than good with it comes to dealing with gynecological pathology in a general practice rather than referring the patient out to someone with more experience.

Illustration of a uterus with intramural endometrial infiltration, adenomyosis

Adenomyosis, from

Back to the neurologist’s comment.  It turns out that no, adenomyosis is NOT just another word for fibroids. They are distinct entities, with some significant implications if one if mistaken for the other.

And as for what I put on my medical history forms now – I still go back and forth.  If I’m feeling like this doctor needs to know everything, I list by name what has been confirmed with objective tests or impressions (and yes, that includes adenomyosis and migraine) and for the others, I write descriptive symptoms, e.g. “chronic joint pain” “chronic fatigue” “nausea”.  And mostly, these days I just try to avoid situations where I would feel uncomfortable doing anything else.

“stay outta the hot sun”

This is the greeting that awaits me at the local dunkin donuts most days. Well, most non work days which today is for reasons I’ll discuss below.  On nonworkdays, there’s a fellow there – who I found a bit creepy at first (I find all men who speak to me without solicitation creepy) but who’s grown on me – I think he rolls in between 9:00 and 10:00 and just hangs out all day alternating between indoors and out to smoke and scratch lotto tickets in the parking lot.  And whenever he sees me, he says “Heeeey!  Howya doin’!  Stayin’ outta the hot sun!?”  I always reply that indeed I am.  I think he says this to everyone but to me it has immediate relevance because indeed, I must stay out of the hot sun.  You see, I am delicate.  I wilt easily.  Sun, hot or not, has always done me in.

And now that I’m…uh….less young, have migraines and chronic fatigue (notice I didn’t say “syndrome” there folks), I especially like to stay outta the hot sun.

Never more so than this summer.  First off, it’s been hot.  Fucking hot.  I know, it’s summer, it’s supposed to be hot.  In the winter, she’ll be complaining about the cold, you’re thinking to yourself (and assume that’s the singular, personal “you” there since I think I have all of one reader of this blog).  But no.  I do tire of the winter but it’s on account of the limitations that ice, snow, and limited light impose.  Otherwise, I like it.  I much prefer cool to hot.  I always have.  I like Fall and winter fashions.  I like boots and heavy tights in neat colors or with cool patterns on them.  I like heavier fabrics even, not just the feel but the look and the drape.  I like hats – always putting them on my head as a kid.  Scarves and gloves are favorite accessories and I am positively giddy when I can bust them out.

Conversely, I fucking hate showing skin.  I don’t like tank tops, tube tops are right out.  I mean, they look ok on some folks.  They even might look ok on me if they are the just right cut, fabric, color, etc.  But I do not ever feel comfortable in summer clothes.  I feel like I’m in drag.  I feel like I’m putting on dad’s shoes and walking around the house in them.  Tee-hee, look at me in shorts!  (which you will never see in fact, not now that I can’t wear combat boots to offset the blocky sportiness or worse, sausage evoking tubularity of shorts – which I find fully offensive on my long boned, pale form).  Long lightweight skirts are what you’ll find wound around me in the summertime.

In addition to the several heat waves of July and my general dislike of the summer, this summer, I have been beset by a sensation I am perplexed by.  Most especially, by what to call it.  I’ve discussed it here.  Dizziness?  Nope.  Not really.  No spinning.  Vertigo?  Well, I described it to my primary care physician and he said (and wrote) “what you describe doesn’t sound like vertigo”.  The neurologist I saw last week said it sounded like “central vertigo”.  My therapist and I have been calling it “imbalance”, with tongues firmly in cheeks.  So I’ve been “imbalanced” all god damned summer.  I had a brief break in early/mid August.  I mean brief.  And now it’s back.  I could cry.  I have cried.  A lot.  Because on top of the fatigue, the joint pain, the headaches, the faintness, the daily diarrhea, the endometriosis and adenomyosis-fibroids-whatever-the-hell-you-call-big-fat-uterus-because-endometrial-tissue-is-growing-INTO-the-walls-of-it pain, on top of all that shit, I’m “imbalanced”.

Another trick my body has learned.

I do want to catch you (singular) up with the neuro appointment and stuff.  Here’s the speedy version:

Probably “transformed/evolved migraine”, god only knows why.  Why for anyone?  MRI with contrast, emphasis on orbits b/c I have lots of unilateral eye pain and visual symptoms.  EEG b/c I had this er, strange episode at the start of all this “imbalance” in early July.  Long story involving not being able to orient to a room – not because of spins/dizzies, just like my brain lost the instructions for how to look OVER THERE.  Very creepy.  EMG b/c I had diminished vibratory reflexes and have “proximal weakness” in my arms.  Had that for a while.  Figured it was just deconditioning.  Probably though I should be able to wash my hair without needing to take breaks.  And my least favorite of them all, a lumbar puncture.  To rule out MS I suppose.  This hasn’t been scheduled yet.  And I’m hoping it ends up not needing to happen.  Had one with the neuro lyme.  It leaked. It sucked.   In the meantime, for the probably transformed migraine that this probably is, I have been prescribed a fucking scary drug called Zonegran/Zonisamide.  It’s an anticonvulsant.  It’s got ugly psych side effects.  He didn’t tell me about those in his office and I did specifically ask “what is the worst not rare side effect it has?”  Oh he didn’t mention “A small number of adults and children 5 years of age and older (about 1 in 500 people) who took anticonvulsants such as zonisamide to treat various conditions during clinical studies became suicidal during their treatment. Some of these people developed suicidal thoughts and behavior as early as 1 week after they started taking the medication.” [1]  Nope.  I guess that’s what I get for saying “not rare”.  Also, the reference I quoted goes on to say “There is a risk that you may experience changes in your mental health if you take an anticonvulsants medication such as zonisamide, but there may also be a risk that you will experience changes in your mental health if your condition is not treated.”  which is 100% true.  The crying started before the Crazy Making Drug (new entry, CMD), and believe me when I say that my condition is fully affecting my mental health.

So.  I’ve been on the CMD since Saturday.  I’m supposed to increase the dose tonight.  I felt pretty darned good on Monday aside from a wee bit of anxiety (it’s rare for me so I really notice it when I have it.  I can count on one hand the number of times I’ve experienced actual physically felt anxiety with the whistles and bells).  Every other day but Monday, I felt like shit.  And yesterday, woooodoggy.  Yesterday was horrible.  Yesterday night was a big fat migraine.  A real doozy.  I’m just ending my period, the weather’s wonky, my neighbor’s apparently taken up step dancing or is auditioning for STOMP or something, since starting the CMD I’ve been waking up mighty early (like 3:30 AM early) so yeah, we had the migraine mix going in full swing.  Since I woke up this AM with a headache still (not a big ol’migraine level one but a headache nonetheless), I called in and used up the rest of my precious sick time.

My one foray out of the house was to dunkies and CVS.  Indeed I am staying out of the hot sun.  At least today.


“What’s going on?”

A friend recently asked this with regards to the health stuff.  She’s been a great friend through this.  She’s busy with her kids and her life several states away, but when we talk about my health problems, she listens and she asks questions and she expresses concern, support, and empathy.  I am so grateful for this.  Especially today, since it contrasts so sharply with some family of mine – specifically, my sister.

My sister knows I had my big follow up appointment on Thursday.  She called me Thursday and Friday, both times leaving a long voicemail message all about her.  Ok, whatever, she’s got her own stuff going on (looking for a new job to escape her PI who has modified the animal research protocols in her lab in bad, bad ways and who is truly an awful boss).  My sister and I talked today and we spent about 3 minutes out of the 45 minute phone call talking about my health stuff and then the rest was all about her.  And not anything new about her and her job search, but a replaying of the top ten greatest hits of what I call “fear and loathing in the biomedical research job hunt”.  She’s massively PTSD from all the family crap, and she has a tendency towards obsessive behaviors.  This was not a fun conversation.  Her transition from hearing about my medical news to the many minutes too long rehashing of the same old shit about her was quite abrupt:  “So, I don’t know if I told you but…” and then on to the thing she has told me nonstop for the last week.

Ugh.  Draining.  I’d understand if I was always unloading on her about my health problems, but truly I am not.  Part of why I blog so much on this shit is that aside from my husband, I don’t have anyone else in my day to day life that I do talk to about it.  Not honestly and unguardedly at least.  Privacy issues, stigma, and the emotional nature of dealing with chronic, disruptive health problems all keep me skimming the surface most of the time in my day to day.  I am very conscious of not wanting to “go on” about this stuff with people.  But I thought at least that my sister would give a shit about the outcome of all that testing.

Sometimes I’m such a blithering optimist.

So here’s what I wrote to my friend who asked “What’s going on?”  The topic started out because I asked if she had a suggestion on glucose meters (her husband’s got type 1 diabetes).  I figure this is a decent update for the blog too.

I got a new doctor who is doing an exceptionally thorough work up. So…had a glucose tolerance test and I’m hypoglycemic. I’ve been dizzy all damned week so he wants me to get a glucose meter to see if the dizzies go with blood sugar. I did a thing called a “tilt table test” a few weeks ago too. It’s meant to test autonomic function, which I guess in this case is really just about looking to see if your nervous system and your vascular system talk to each other right. And I failed it. They put you on a table and hook you up to a heart and BP monitor and you do all sorts of strange breathing exercises. Then they tip you upright to about 60 to 70 degrees so you’re basically “standing” without having gotten up and with most of your weight being borne by the table you’re strapped to. If you nervous system and your vascular system coordinate properly, you might get a little lightheaded but you don’t pass out. I passed out.

This wins me a cardiology consult and a nephrology consult (kidney). Cardio is to make sure it’s not an arrhythmia which has me feeling like shit all the time and which would account for the whole passing out/shittty vascular response I showed on the tilt table. Also, the doc heard a mitral valve murmur when I was in for my follow up (with dizzies).

Nephrology is because I guess I keep testing out as being dehydrated (that whole orthostatic hypotension thing, I stand up but my blood doesn’t) but having low sodium – that plus the feeling like shit plus the passing out on the tilt table might mean my body’s not balancing fluid properly. Apparently nephrologists check that.   Or this nephrologist checks that.  And hey, funny story – the nephrologist was a wee resident I and my sister worked with at the hospital wayyy back in the late 80s/early 90s.  Small world.

And then there’s an endocrine appointment. This is for the hypoglycemia and the feeling shitty.

I also have to pee in a jug for a day and do horrible things with poop and cups and vials and whatnot.

The common element in all of these appointments is the feeling shitty. The new primary care is being remarkably thorough about following the leads, which, while a bit of a pain in the ass to go through is good because I truly do feel fucking shitty and I’ve been dealing with this shit for years now. I’d like to know if there is something that can be identified and treated and he’s the first primary care I’ve had who seems to be interested in leaving no stone unturned before handing me the “well you’re just fucked, I have no answers, enjoy feeling shitty all the time, bye!” answer.

I signed myself up for this. After I discovered my boss was not going to be ok with me having surgery this summer and after I realized how much my (former) primary care largely was not good, I decided to (a) postpone surgery until winter break and (b) spend some time in the meantime finding a new primary care and hopefully getting a handle on some of this feeling shitty all the time shit.

So it’s finger sticks, cups, vials, and jugs for me for the next month or so.

That’s what’s up. And that’s also what happened to your care package that I said I was going to send you before the family road trip west. Once I saw this new primary in June, it was kind of like the staring pistol for a marathon….I had the tilt test and a round of cups and vials the week I was going to get stuff together for you. It ended up a bit of a mess. Sorry. I felt bad. Which is also why you haven’t heard much from me.

Abbreviations, etc.

As requested by the Queen.  There are terms I use sometimes that need some ‘splaining.

Some are medical terms, probably out of date by now – most of which I know because I had to learn them to decipher doctor scribble way back in the day (1990s) of handwritten everything (do they still handwrite and transcribe all orders?).  Also, my mother used the abbreviations as short hand in notes to us when we were growing up. I told you, they tried to make me one of them. Some are idiosyncratic terms coined by smaller groups, sometimes as small as one (me).

Here’s some guidance to them.

Idiosyncratic (and not) Terms and Abbreviations I use:

ABx = antibiotics.  I took a lot of them when I was being treated for Lyme Disease.

Babysniffer = a person (most often female) who is crazed for babies and all things baby related.  They obsess on it.  They seem to sniff out babies from miles away.  They are creepy in that they tend to say things like “Oooh, he’s so cute I just want to gobble him all up!”  See Dot from Raising Arizona.  Usage note:  A babysniffer is not the same as someone normal who wants to have kids or someone who expresses a non-pathological delight in a baby.

B.A.T.H. or “BATH” = Big Ass Teaching Hospital.
BI-BATH = Best Itty Big Ass Teaching Hospital. One of the orphans of the Big Northeastern City’s mega-BATH conglomerate, affiliated with Ye Olde New England University Across the River.

BBM = Big Bad Migraine.  The kind with all the trimmings – photosensitivity/photophobia, hyperacusis and phonophobia (I swear the sound of bubbles in an open soda can will send me over the edge when I have this), nausea, aura with a scintillating scotoma.

BCPs = birth control pills.

CMD = crazy making drug.  E.g. “My doctor put me on Zonisamide for my migraines, I looked it up and it says it can make people suicidal.  That’s one hell of a CMD.”

Dx = diagnosis.

F.A.S.T. = public health stroke awareness acronym for stroke assessment – Face, Arms, Speech, Time.

G.P. or GP = Gastroparesis. When your stomach (gastro) don’t move right (paresis). Leads to all sorts of feeling bad, malnutrition. All around sucky. There are several types based on presumed or actual cause, my favorite being “idiopathic”, which if observation is correct means “I, your doctor, am too much of an idiot to care why your gastro is paretic, so fuck it, let’s just say it’s idiopathic!”

‘HO = House officer (it may come up), but when said with that certain inflection, person who doesn’t answer his/her 80,000th page (this time it really is for something important, really).

Hx = history.

Judy = As always, with the caveat that I’m sure there are many people out there named Judy who are not like this.  However, I have encountered just one too many Judies in my lifetime – as either coworkers or office staff I need to interact with and who all strangely share a certain set of ungodly frustrating features which include

  • slow processing speed and limited verbal comprehension ability (which I can handle if the adult who has these traits is aware of them and has developed skills to compensate…I have a hard time with people whose apparent challenges are intrusive, pervasive, and yet exceptionally opaque to them).
  • very stereotypically feminine attitudes and manners including what I call “man pandering”.
  • a tendency to be easily overwhelmed by the mundane and routine tasks of their jobs, again in that oddly opaque way where they THINK they are doing a bang up job but their coworkers are ready to flog them for their ineptitude.

Manses = term for moody, dreary, and sometimes outright cranky phase of my husband’s mood cycle.

Minipause or mini-pause = Possible reason for my night sweats and BBM in the weeks after my hysterectomy.

PI = primary investigator or principal investigator.  MD/PhD or just plain ol’ PhD.  A very well educated but not usually well socialized person who has managed to get a grant to do something that they (probably used to) love.  This person’s job is to manage or oversee management of a research project.  When used in combination with B.A.T.H., this person could reasonably be called “research overlord” and possibly should be since it is likely how s/he thinks of her/himself.

Purulent = the adjectival form of puss.

PVCs (you can look them up below too) = premature ventricular contraction/complex.  It’s described as feeling like your heart “skipped a beat”.  The ones I had that wouldn’t go away, those felt more like my heart was going in reverse for a good three or four “beats”.  Like sucking instead of pumping.  Not painful (for me) but uncomfortable and makes you overly aware of your heartbeat.  Until they go away and you stop thinking about them totally.  Until they come back.

TBI = Traumatic Brain Injury

more as they come up….

General References:

Medical Abbreviations

Prescription Abbreviations

NIH Medical Dictionary

New word

It nearly rolls of the tongue, doesn’t it? At least it does when you compare it to “osteitis pubis” or “pubic symphysitis”. Here’s hoping mine doesn’t get worse than the current moderate, intermittent “pubalgia”. Got a shot in the hip today for the outer and posterior aspects of this whole pelvis/hip pain issue and while it wasn’t painful, it sure was not comfortable. I don’t even want to think about a shot in the pubic symphysis.

On the plus side, my ortho surgeon referred me for water PT this time. My town has a public pool with a heated therapy pool which you can only use if you have a documented need for it. I’m hoping the PT note will take care of that so I can finally get some damned regular exercise. I’m not accustomed to being so laid up. I used to walk all over the place, did two miles of strolling without batting an eye, occasionally worked out (cardio mostly although some ab work as well), and went dancing now and then. These days, taking a flight or two of stairs is like a damned olympic event for me.

Sound self pitying? It’s not. Just an accounting of the limitations, facts of life now. Water exercises will help in that I can maybe get some muscle tone back without worsening the joint pain in my ankles, knees, and hip. I’m approaching this with a hopeful attitude. Let’s see how it pans out.


As the in house linguistics major, I was sometimes called upon for word and language references when I worked as a unit secretary. My least favorite was the time a nurse asked me to use my extremely out of practice Italian to communicate with one of our frequent fliers who spoke nearly no English. “Hai dolore al petto?” I asked tentatively (and, I think, incorrectly), only to be rewarded with his barrage of fluent Italian, of which I caught about every fourth word. I felt totally unhelpful and we were none the wiser for the nurse’s having recruited me in her efforts to communicate with her patient.

But my all time favorite was puss – or more specifically – the adjectival form of that word. On more that one occasion I was fed the line which began “How do you spell…” And I would answer merrily “Exactly how you hope it isn’t spelled.”

I asked my mother about this one time. Without batting an eye, she rattled off “p-u-r-u-l-e-n-t”. Damned English major RNs.