Chapter 10

DIARY

Sunday 23rd September 2012 - I saw a liver specialist a couple of weeks ago regarding Portal Vein Thrombosis and he expressed his opinion that this, and the low platelet count, were possibly nothing to do with the Azathioprine (Imuran) that I had been taking for several years. We returned from a few days in the New Forest yesterday and found a copy of the follow-up letter that he sent to my gastroenterologist waiting for me.

But before I continue the story - no post is complete without at least one photo here's a three I took on Friday night at Christchurch Harbour. It's noted for the amazing sunsets.

About a month ago I decided to try and get hold of copies of all my medical records. When they arrived I was able to extract the dates and dosage levels for when I was on Azathioprine. I overlaid this information on my platelet graph and could see no obvious correlation.

When I saw the liver specialist one of his first questions was "When was your first surgery?" The answer was - 1979 when I was rushed into Croydon General Hospital with suspected appendicitis that turned out to be a perforated bowel that had leaked into my abdominal cavity. (Now that I have copies of all my medical records I have a copy of the discharge letter from July 1979 which details what the surgeon found and what actions he took). The liver specialist believes that the leak would have caused peritonitis resulting in my spleen becoming enlarged and then many years down the road started to drag my platelet count down.

The follow-up letter to my last appointment says "I suspect that ……the resultant splenomegaly has been the main cause of his low platelet count and certainly the cause of his oesophageal varices. I suspect that Azathioprine is blameless". He also went on to say "He is in the process of having his varices obliterated and had some quite juicy ones when endoscoped a week ago". I really like the way he puts things!

So this Thursday I've got some more "obliteration" to look forward to. It's off to St.Thomas' for another session of banding, where the doctor sticks a specially modified endoscope down my eosophagus, applies rubber bands around the varices, and then gives me a print-out with a couple of pictures showing what she has done. Then it's 24 hours of a purely liquid diet followed by three days of sloppy meals, otherwise it really hurts swallowing! The bands cause the varices to die off and the rubber bands drop away in about three days. I've then, potentially, got one more session before obliteration is complete. I will then go onto to an anticoagulant, probably Warfarin, to try and stop my blood clotting again.

Thursday 27th September 2012 - Variceal Banding 2. I've learnt my lesson from the last session - no driving home after this one so my sister picked us up and took us to the station. We arrived nice and early at St.Thomas' and knew exactly where to go to get booked in with endoscopy reception. Five minutes later I was called in by one of the nurses to go through "when was the last think you ate anything?","have you got an allergies?" routine. She then went off to find out how long I would be waiting before the procedure took place. She came back with the good news that there was only one patient in front of me so I could go and get my cannula fitted. I said goodbye to my wife and said I'd be ready for collection in a couple of hours.  It was certainly a lot quieter on a Thursday.

I was led to a small cubicle, took my shoes off and laid on the bed. At least with an endoscopy there's no need to get changed into a surgical gown. Another nurse then put a cannula into my right arm, checked my blood pressure and heart rate and I then waited to be seen by the doctor. In a while the doctor appeared and I recognised her as the one who had carried out the previous banding. She asked how I'd been feeling since the last one and if I had any questions. The one thing I did want to know is why you are only allowed liquids after the banding. I wanted to know if it was purely because it would hurt or if there was a medical reason. She explained that the rubber bands placed around the varices might become dislodged so it was liquids only for the first 24 hours and then 3 days of sloppy diet. I replied that this time I would keep to this advice to which she gave me an "old fashioned" look!

She explained that they would have a look and see how the previous banding had gone and then carry out any more that might be needed. She would book me in for a third session in another 3 weeks time. I was then wheeled into the procedure room and connected up to another blood pressure monitor and an oxygen supply. Then it was the xylocaine (burnt banana flavoured) spray that numbs the back of your throat, and finally a sort of gag is placed between you teeth and this helps to guide the endoscope. It's the gag that I really don't like so I was pleased that the doctor injected the sedative straight away with the words "you're going to feel a little drowsy".

The procedure started at 11:15 and the last image from the endoscopy report shows 11:29 so the whole thing took around 15 minutes. The next thing I was aware of was waking up in the recovery area and it was all over for another three weeks. I was given a copy of the printout from today's session and about one o'clock I was allowed to leave. Compared with last time I was in quite a bit more discomfort and was slightly wobbly on my feet. 

Here's today's endoscopy report. I haven't actually discussed the images with anyone but I think that Image 1 shows the varices down towards the stomach. Images 3 & 4 show the new bands in place.

Endoscopy Report - click on image for larger version

Before leaving the hospital I called into the Endoscopy Appointments room and asked if I could get a date for Obliteration 3. The doctor had already requested the appointment so I was able to choose a date for 3 weeks time. Given that today's clinic seemed very quiet I chose another Thursday and it has the added advantage of still being able to go to work for the first 3 days of the week and then spend a long weekend recovering.

We walked back along the South Bank of the River Thames on the way back to Waterloo. The London Eye was packed and there were a number of "living statue" of street artists there.

The Houses of Parliament looking back from the London Eye

The London Eye - How do they keep it so clean?

The Living Statue of Michael Jackson

That evening I was in quite a lot of discomfort and took a couple of doses of Paracetamol. It was certainly a lot more painful than before but I noticed that the report for this session actually says "May experience some mild chest discomfort" so I'll grin and bear it.

Friday 28th September 2012 - Have just finished writing up yesterday's events on this post. I'm finding each time I think about the burnt banana spray and the mouth gag I'm getting a slightly sick feeling in my stomach and at the back of my throat. I need to address this now so that I'm over it in time for the next banding. I surprise myself how laid back I am about hospitals, procedures and appointments so I don't want to spoil that for the next one.

I reckon I'm getting my money's worth out of the NHS. I have a further 4 appointments lined up for the next 6 weeks so I need to start noting down any questions that I want to ask at the latter two. I'm still not sure the likely outcome of the PVT/esophageal varices and the treatment I'm having. The very first page I read, having Googled varices and banding, said that 70% of those who have a variceal bleed will have it happen again and for a third of those it will be fatal. If I've got the maths right that's 70% x 33% = 23%, so for almost a quarter of patients suffering variceal bleeding it will be fatal. These don't sound like very good odds to me. What the page didn't explain was whether they related to patients that already had severe liver damage, which it looks like I don't! I suppose the Fibroscan will shed more light on this. The banding is supposed to obliterate the varices so I'd like to know what chance there is of them reforming. I seem to remember being told I will now need an upper GI endoscopy every 3 months so I'm guessing that is to check that they haven't regrown.

Sunday 14th October 2012 - I thought I should mark this significant anniversary in my Crohn's story with a post to the blog. It was on this Sunday two years ago that I was waiting on tenterhooks for the call from St.Thomas' Hospital to say that the bed was ready for my admission for Crohn's surgery. It was the most stressful time of the whole surgical experience.  I'd been told to wait for their call but by the time it got round to half past two I couldn't take the tension any more and rang them. I recorded the experience at the end of the chapter called "...Getting Ready for Admission".

I've noticed a real change in my attitude to Crohn's and life generally since this "event" and once I've got my thoughts clarified I'll put it down in words and post it. But in the meantime there are other things to think about.....

This coming Thursday I've got another endoscopy/variceal banding session up at St.Thomas'. I'm hoping that it will be the last one that I need and it's just possible that they will end up having a look down my oesophagus without needing to do the banding. The after effects of the last session were certainly a lot more painful than the first session so I'm not sure just what to expect. The restriction of a liquid only diet for 24 hours after the procedure followed by three days of "sloppy" food will screw up my digestive system which is currently behaving itself. It will then take a few days to get back on track. That's why I chose to have the procedure done on a Thursday as it then gives me 3 days recuperation before returning to work.

Monday 15th October 2012 - I've noticed that whenever I go onto YouTube I get adverts and clips which are specifically targeted at me. I suppose this is all part of Google's world domination plan. Tonight I was singled out for dating mature ladies and funerals. Do they know something I don't? I'm sure my wife would not be happy with me pursuing the former and I currently have no plans for the latter. Will watch with interest how their marketing campaign progresses. 

Tuesday 16th October 2012 - as part of the quest for getting hold of my old medical records I have ended up with the CT scan images from May 2009 and 2010. It was as a result of these scans that it was decided surgery was inevitable. The images arrived on a DVD from the health authority together with a viewer which only works on a PC. I've been trying to find a way of viewing the results on an iPad, not that I would know what I was looking at, but I'm hoping that they might show, to someone who is knowledgeable, if my spleen was enlarged that far back.

Tonight I finally cracked it. I copied all the images onto my hard drive and opened them in a brilliant piece of software by Lemkesoft - Graphic Convertor. This has the ability to take a folder full of images and convert them, in order, to a movie, all at a couple of clicks of the mouse.

Thursday 18th October 2012 - up to St.Thomas' endoscopy dept. again. Arrived early as you seem to get seen sooner. By 10:30am I had had my pre-procedure questionnaire filled in and was ready to go through to the next stage. Unlike my previous visit the clinic was busy and I didn't get called in to the preparation/recovery ward until 11:45am. There are two entrances into that area and I think there must have been a number of in-patients that were having endoscopies as the waiting room itself hadn't seemed any fuller than before.

Went through the usual drill - cannula in back of right hand; blood pressure and heart rate checked; visit from the doctor to discuss what he was planning to do and go through the risks; and then sign the consent form. It was a different doctor for the one I had seen previously so he asked a few background questions. I asked him if this was likely to be the last banding session today. He replied that it would depend on what he found and that once they were happy that the banding had been successful I would need yearly endoscopies to check everything was OK. (I thought they would be every 3 months so yearly sounds like good news)

Almost immediately I was wheeled into the endoscopy room and going through the next sequence - blood pressure monitor wrapped around arm; oxygen supply into nose; anaesthetic spray onto back of throat. (I'm beginning to find the taste of burnt bananas rather unpleasant). Finally it was time for the mouth gag which I asked to be fitted just at the point of going under. Of all the various tests I've been through it's the bit where the gag goes in which I dislike the most.

I was then asked to roll over onto my left side and made comfortable. The doctor injected the sedative and the gag went in. I woke up about 30 minutes later in recovery. The nurse came over to see how I was and give me a copy of the report. I asked her if any banding had been carried out. She replied that it had and that I would need a further endoscopy in 4 weeks time. Not what I really wanted to hear but I'm getting used to them now. Maybe I won't need the banding next time. Disappointingly the doctor hadn't taken any pictures this time so there wasn't much to take in from the report.

The good thing about this test is that you don't have to get undressed and put on a hospital gown. You stay in your usual clothes, just remove your shoes. So it wasn't long before I was taken down to the seated recovery area where my wife joined me and we set off to catch the train home. Overall I was actually out of the hospital earlier than the last time so whilst my wait in the general waiting area was longer as soon as I went through into the endoscopy suite the process was quicker.

My fingers are firmly crossed that the end of November session will be the last one for a year.

My next visits to St.Thomas'/Guys are to have a Fibroscan and then see the liver specialist and then two days later see the haematologist.

Saturday 20th October 2012 - I've recovered a lot quicker from this last banding session than I did on the previous occasion. Don't know why that should be but I'm thankful for it.

It's been pretty quiet since the last update on 20th October but I'm now about to embark on five appointments in the space of 11 days. I'm certainly getting my money's worth out of the NHS.

Monday 12th November 2012 - I don't particularly like using the Tube in the rush hour so decided to walk from where I work to St.Thomas' Hospital. It's about two miles and takes me past the Houses of Parliament and then over Westminster Bridge.

View from Westminster Bridge looking north

I arrived at the new Outpatient Centre at St.Thomas' to find the fire alarm sounding and everyone evacuated (not sure that sounds right). After a couple of minutes we were allowed in, with the alarms still screeching. I scanned the barcode on my appointment letter at the self check-in machine and then took my seat in the waiting area. There are large screens everywhere that display the name of the patient and which room you are to go to.

Appointment No.1 - 9:00 am - Fibroscan on my liver. This is the non-invasive alternative to a needle biopsy. To quote from the unit manufacturer's literature - "a mechanical pulse is generated at the skin surface, which is propagated through the liver. The velocity of the wave is measured by ultrasound. The velocity is directly correlate to the stiffness of the liver, which in turn reflects the degree of fibrosis – the stiffer the liver, the greater the degree of fibrosis."

For this procedure you lie on a bed with your right side exposed and right arm above your head. Some jelly is applied to the probe and then it is placed against your side and triggered to send a pulse. This is repeated 10 or so times.

The machine then aggregates the scores and gives you a value. My value came out as 7.2. The nurse said that up to 5 was normal and above 12 would cause concern therefore my value showed that there were some fibrosis.

Appointment No.2 - 9:20 am - the Hepatologist.  Unfortunately the very clever self check-in system can't cope with two appointments in one go so I had to go to the reception desk to get booked in for this second appointment. I don't know whether this caused a delay. I was quickly called in to get weighted - 91kg!!!! I've never been that heavy and I need to do something about that.

I then returned to the waiting area where the screens were displaying the message "All clinics are running within 30 minutes of appointment times". It didn't work for me as I finally got to see the consultant at 10:15. He does however take his time with each patient and I rather than and run late than feel I was being rushed.

It's only the second time I've seen him so it took a while for him to get up to speed with my notes.  He was trying to find a follow-up letter from my last haematology appointment back in August, but without success. This is the second time this has happened so I will ask the haematologist about it when I see her at Appointment No.3. In the meantime I have sent her an email explaining the problem and asking her to took into it.

Because the Fibroscan result showed some liver fibrosis he wants me to have a proper biopsy but as my platelets are low he can't risk the usual method which would involve inserting a needle between the ribs, directly into the liver to take a sample of tissue. The risk is that the procedure would cause bleeding and my low platelet count would prevent it from clotting properly. He is therefore booking me in for a transjugular liver biopsy and reckons I should get an appointment before Christmas. It involves feeding the biopsy needle down a vein from the shoulder area into the liver. If there is any bleeding it will be back into a vein. I'm not sure if I will be sedated completely or just have a local anaethetic.

Before my appointments I had run through, in my mind, what my expected outcome was. I thought that the Fibroscan was going to show that my liver was normal! So lots of new things to think about and questions to ask.

I was given a form to have a blood test but there's usually a long wait and I needed to get back to work so decided I might as well get it done on Wednesday, all in one go, at Haematology. As the day wore on I realised it would be better to have the test today so the results could be reviewed Wednesday. I therefore made my way home via St.Thomas' and didn't have to wait too long for the samples to be taken.

Wednesday 14th November 2012 - Appointment No.3 Haematology - Guy's Hospital

I arrived early for my appointment and checked in. The receptionist already had my name written down on a piece of paper and announced that the doctor was keen to see me. With that my consultant appeared and said "Come with me. We need to talk". A bit ominous.

She explained that I didn't need to be examined so instead of going into a consulting room we went into a small side room and sat down. She apologised for not having produced a follow-up letter from my previous appointment and explained the circumstances. I understood what had happened. It had not in anyway affected my ongoing treatment as I would not be put on any new medication until my eosophageal varices. So

We then had a fairly wide ranging discussion on Crohn's, spleens, liver fibrosis, blood clots, platelets, misleading information on the internet and Warfarin. I came away with a much better understanding of the relationships between the various conditions I am suffering with. As she pointed out the Crohn's currently seems to be under control so the emphasis, at present, should be on deciding when/whether I should start on Warfarin as a long term treatment to discourage further clotting and to help with this decision we need to know exactly what state my liver is in. The priority is therefore to prepare me for the transjugular liver biopsy.

One of the guidelines for carrying out this test is that the patient's platelet count must be at least 80. Mine was 72 (last Monday) although she did comment that we all tend to get hung up on numbers and in her opinion I would be fine as I am but the guideline has to be followed so some action is needed if the procedure is to go ahead. A 4 day course of steroids, with a long unpronounceable name, is given and this has the effect of boosting the platelets short term. Once I have the date for the procedure I need to contact Haematology and arrange for a blood test to see if I am still below 80. If I am still low I need to collect the prescription for the steroids and start taking them 5 days before the procedure. Three days after starting them I need a further blood test to ensure the platelets have risen. (I think I've got that right). Because the timing is key she asked me to contact her and her secretary directly so the process can be put in motion. She said I wouldn't normally ask a patient to contact me by email but I'm happy for you to as I don't want the procedure to be delayed.
 
I had my obligatory list of questions with me and most were answered in the course of our conversation but I did have two I needed to ask. The first one was did she have any other patients with my combination of conditions? "No". So looks like I'm on my own with that one.  The second question was - what is the long term prognosis for my health? I want to decide when I should retire from work and I need some guidance on what the future could hold. She replied that if she could tell me that she would be in another job. It's a question for my gastroenterologist next Tuesday. I'm not really expecting an answer but I would like to know what research has been done into the life expectancy of a patient with Crohn's and how other, parallel, medical conditions affect that. Roll on Tuesday.

What a difference in weather from Monday - a lovely autumnal day with a cloudless sky. With outside of the the "Shard" finished the emphasis is now fitting out the floors.

The Shard with Guy's Hospital Tower in the foreground

Thursday 15th November 2012 - I've now had a chance to look up what a transjugular biopsy involves. I suppose the clue was in the name. St.Thomas' Hospital have produced a leaflet about having  a liver biopsy. This is what it says :

"Trans-jugular biopsy is done under ultrasound and x-ray guidance. The right side of your neck will be cleaned with an antiseptic solution and draped with sterile towels. Local anaesthetic is injected. When your skin is numb a small catheter (tube) is introduced through a vein in your neck. The catheter is manoeuvred into the liver under x-ray guidance. When the radiologist is satisfied with the position, a small piece of tissue is taken from the liver. This is sent for microscopic examination. The wound site is cleaned and a dressing put over it.

The procedure itself takes about 30 minutes to an hour but you will need to stay in the recovery room for a few hours afterwards."
 

"After the biopsy you will stay in the recovery or day unit. You will be asked to lie on your right side or on your back for two to three hours to help the healing process. Your blood pressure, pulse and temperature will be checked at regular intervals to spot any problems.
You will need to stay in bed for four to five hours, or as instructed by the nurse. Your blood pressure and pulse will be checked at regular intervals and a clip on your finger will measure the oxygen level in your blood. This is not painful.

We will provide light refreshment, such as tea or coffee, a sandwich and some fruit. If you have any special dietary requirements, you may wish to bring some food and drink with you. The nurse will tell you when you can get up and move around.

If you had the biopsy as a day case patient, you will be able to go home. You will need a responsible adult to take you home by car or taxi. We do not recommend that you use public transport as it is unsafe if you feel unwell."

Another new experience! I'd like to get it over as soon as possible so I think an email to my hepatologist is in order to find out who I need to speak to about he procedure date. Not being able to use public transport could be a problem. I did find a document from another hospital saying that they don't recommend traveling for more than an hour in case of complications. I'll probably see if they can find me a bed for the night.

Saturday 17th November 2012 - we'd been down to the New Forest for a couple of days and waiting for me on my return were two letters from St.Thomas'. One for a follow-up Haematology appointment in January and secondly the biopsy appointment for 12th December. It was headed "Fluoroscopic Guided Biopsy" but that's not a term used in the "Having a Liver Biopsy" leaflet that is published by the hospital so I'm none the wiser as to whether it's a conventional biopsy or goes the transjugular route. Will have to wait until Monday to clear that up. There was also a blood test form enclosed but, unfortunately, it was for another patient. Something else to sort out on Monday.
 
Monday 19th November - I emailed my haematologist as she had asked me to let her know when my biopsy appointment was as soon as I received the letter.  I copied in my hepatologist as I wanted to know what type of biopsy was in prospect. I then rang the Interventional Radiology department to ask the same question and explain that I had been sent someone else's blood test form. We decided it would be best if I called in and spoke to one of the radiologists on Tuesday, since I will be at St.Thomas' anyway.

In the afternoon I received a return email from my hepatologist explaining that a normal biopsy would be carried out under ultrasonic guidance so it sounded like I would be having a transjugular one, but that could change if my blood test showed my platelets were still OK (above 80). I then received a couple of emails from my haematologist explaining that a blood test had been requested electronically and that I should have it on 3rd December. There was no mention of the short course of steroids to boost my platelets so will need to query that.
 

Tuesday 20th November 2012 - Appointment No.4 - Gastroenterology - St.Thomas' Hospital

First port of call was Interventional Radiology up on the first floor. I took my appointment letter in with me, returned the wrong blood sample envelope and said I had a couple of questions. The receptionist went off to find someone I could speak to and then took me to see one of the doctors. I explained about my borderline platelet count and asked him if the 80 was a hard and fast limit for deciding which type of biopsy I would undergo. He replied that they would decide on the day and make the judgement on my blood test results and an ultrasound scan.

I also told him that it would be difficult for me to be driven home from St.Thomas' as it would take a long time, probably 2 hours, to get through the South London traffic. I would prefer to take public transport. He reiterated the advice given in the biopsy leaflet said that they would not recommend using public transport in case there was a "problem". The "problem" is that the incision created by the biopsy needle could start bleeding, even though they keep you in the unit for up to 6 hours before letting you go home. I asked if it would be possible to stay in hospital overnight as that would mean my wife would not need to accompany me home. He replied that I would need to ask my doctor about that.

Then off to the new outpatients waiting area in Gassiot House for my gastroenterology appointment. Followed the usual drill - scan barcode from appointment letter into log in computer; take seat and watch large screen until name appears; go to room 15 and get weighed; return to seat and wit for name to appear again. 

I knew I would then have a long wait with it being a late afternoon appointment and I was right. The clinic was running one hour late. When my name finally appeared on the screen I started to make my way to the designated room and was met by one of the registrars. I told him that I really wanted to see my main consultant as this wasn't a routine appointment. The registrar asked me to return to the waiting area and then 15 minutes later my name appeared for a third time and I was in to see the main man.

I had my list of questions ready and the new diagram with which I have tried to make sense of the relationship between the various conditions I've ended up with. My main reason for asking for the appointment was to discuss the ache I've been getting in the area of my reversal operation and to ask whether I should be on a maintenance dose of Azathioprine. The last colonoscopy that I had was incomplete as the camera wouldn't go round the bend. We therefore decided I should have another one to find out exactly what was going on inside. I'll make the booking on Thursday when I'm in St.Thomas' yet again.

Thursday 22nd November 2012 - Endoscopy and variceal banding - St.Thomas' Hospital

Off to St.Thomas' yet again. Arrived at the Endoscopy Unit nice and early, booked in and took a seat in the waiting area. A couple of other patients turned up and were then taken into a sideroom to answer the pre-procedure questionnaire. I was starting to get a little worried that I had been forgotten so went back to the reception desk only to find I hadn't been checked in properly! Very frustrating.

I made sure I was the next to go into the sideroom to answer the questions and have my blood pressure measured. After that it was back to the waiting area but not for too long. My wife went off for a walk in St.James' Park to pass the time whilst the procedure was carried out. I was taken into the preparation area and a cannula fitted. The doctor came over to discuss the procedure. They have to go through the various potential risks before they get you to sign the consent form. He asked me if I usually felt the banding whilst it was being carried out. I replied that I was completely sedated so felt nothing. "Right, we'll give you the same dose of sedatives as before. Any more questions?". I was able to get his take on the likely sequence of events that had caused the PVT/esophageal varices.

Another few minutes and I was taken into the endoscopy room. The oxygen supply was placed up my nose, a blood pressure monitor round one arm and a heart rate/oxygen monitor on a finger. The gag was readied and I was then given the xylocaine throat numbing spray. I then rolled over onto my left side to face the endoscope. They were having a problem resetting the computer so the doctor asked if I had any further questions before he injected the sedative which gave me the opportunity to clarify a couple of points I was clear on. He then injected the sedative and I had the gag put in my mouth. (I had asked for this to be delayed until the very last minute as it's the bit I like least).

The next thing I remember was waking up in Recovery. On the previous occasions I could feel some pain in my esophagus but this time nothing. The nurse came over to see how I was and told me that I hadn't required any bands this time. Result! No liquid or sloppy diet for the next four days. Result! ....and no need for a repeat procedure for six or twelve months. My wife joined me in the waiting area and once I had been given a copy of the endoscopy report and had the cannula removed we were free to go.

Endoscopy Report

At my appointment on Tuesday we had decided that I needed to have another colonoscopy and was given the choice of getting it done this year or waiting until after Christmas. I had held off booking it in case I also needed to book another endoscopy. We made our way to the appointments office in outpatients and a suitable date was found this year - 22nd December. I then had to return to the Endoscopy Dept. to pick up the "prep" medicines and run through when to take them.

Friday 23rd November 2012 - That's the five appointments over with, now there's just one last thing that needs sorting out - the biopsy on 12th December. Yesterday afternoon I sent an email to my 3 consultants asking whether I should take the short course of steroids to boost my platelets and if I could use public transport to get home or if I needed to stay in overnight. I got the reply I needed from my hepatologist who set down the criteria for being able to come home on the train. Unless there are complications on the day then I can meet all the criteria so that's the last piece of the jigsaw in place. Time to take it easy for the rest of the day to get over yesterday's sedation.