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Tuesday, December 27, 2016

Preventing Legionnaires’ Disease in Healthcare Facilities Part 2 How Our Legionella Experiences Shaped our Prevention Approaches Safe Healthcare Blogs CDC

Preventing Legionnaires’ Disease in Healthcare Facilities Part 2: How Our Legionella Experiences Shaped our Prevention Approaches | Safe Healthcare | Blogs | CDC

Preventing Legionnaires’ Disease in Healthcare Facilities Part 2: How Our Legionella Experiences Shaped our Prevention Approaches

June 16, 2016 by CDCs Safe Healthcare Blog

Guest Author: John Letson, Vice President Plant Operations, Memorial Sloan Kettering Cancer Center

Memorial Sloan Kettering Cancer Center (MSK) has a 470 inpatient bed hospital, outpatient clinics, and research facility headquartered on the upper east side of Manhattan, with additional outpatient treatment centers in Brooklyn; Long Island; Westchester County, New York; and New Jersey. The well-being of our patients is the primary concern of all doctors, nurses, and staff. The at-risk patients at MSK basically are in two groups. First, cancer patients receiving chemotherapy, including those with combinations of factors placing them at greatest risk, e.g. a patient who smokes and has respiratory issues in addition to having a cancer for which they are receiving chemotherapy. Second, bone marrow transplant patients. The majority of patients diagnosed at MSK with community acquired Legionella in the past have been bone marrow transplant patients. As cancer care continues to move to more outpatient treatment plans, all building owners need to be cognizant of the dangersLegionella poses. It is important to be proactive in preventing the bacteria from propagating in building water systems to preserve the health and safety of everyone.

For more information about MSK and background on our successful Legionella water management program, read my blog entry.

EXPERIENCE CHANGES THE APPROACH

One of the most feared environmental scenarios in healthcare, would be to have a Legionellaoutbreak. In addition it can be quite alarming when one encounters an “outbreak” of consistently positive environmental cultures. MSK has not experienced any Legionella “outbreaks” where tests show consistent levels of positive colony forming units at many multiple distal sites and buildings. But, MSK has had instances when we had a number of positive Legionella test culture results near locations where patients tested positive for Legionella. The resultant circumstances are the same whether wide spread in a general population or isolated in an at-risk population. The resources required during any outbreak scenario will vary. So here is a brief history of MSK’s experience with positive culture results and the ensuing changes that occurred in mitigation response activities, long term mitigation activities, and the evolution of testing and monitoring.

In 1999 MSK experienced a Legionella positive patient at the same interval as a positive environmental shower culture result and a timeline that suggested it was hospital-acquired. The patient was a bone marrow transplant patient and the Legionella types from the patient and shower were the same. At the time it could not be proven that the patient’s disease was hospital-acquired. Following this event, in 2000, MSK selected and implemented copper-silver ionization as a long term mitigation methodology on the potable hot water system in all in-patient areas. We also adopted a zero tolerance for anyLegionella in any water system. As a result of this long term mitigation strategy, positive cultures were eliminated for the next seven years until November 2007, when multiple environmental test culture results came back grossly contaminated for Legionella. This was strange because we went from no positive cultures to such a high level in a short period, so we sent samples to the same lab for retest; as well as to a second, different lab. The same lab (as the previous samples were sent to) report came back contaminated again, but the new lab report came back all negative. We performed mitigation anyway, retested (results negative again), and returned to service. MSK changed labs following this event. This experience validated the importance of using a lab knowledgeable in testing protocols for Legionella or one listed as being CDC ELITE certified.

MSK experienced another positive culture on September 2, 2010. We performed mitigation in this case sanitizing the affected potable water tanks, and retested which came back negative, and were returned to service. While we did not make the correlation at the time, this positive culture was attributable to heavy rain activity during the end of August 2010.

Another positive culture occurred almost one year later. There was one positive culture on September 7, 2011, and one positive case at the same time; both Legionella pneumophila serogroup one. We performed mitigation, retested which came back negative, and returned to service. On subsequent NYC Department of Health Pulsed Field Gel Electrophoresis (PFGE) the testing showed the serogroup in the environmental culture and patient culture were different, so the case was concluded as community-acquired. Similar to the previous event we noted increases in positive cultures in potable water tanks following heavy rain. This was observed at times following heavy thunderstorms or in this instance hurricane activity. This was thought due to the increased runoff and turbulence into open water reservoirs and settling ponds. The runoff which may have washed and disturbed bacteria and organic material from soil and Legionella from biofilms into the source water. Increased organics and pathogen content overwhelms oxidizing biocides and other water purification methods, permitting some bacteria to survive and enter the water system. The positive environmental cultures of September 7, 2011 were directly attributable to hurricane Irene which hit the New York area in late August. As a result, we now test potable water storage tanks a week to ten days after heavy rain events over two inches in order to provide proactive mitigation if required.

There are additional affects an institution could experience based on positive patient cases of Legionella; even if the case is community-acquired. So how does an event change views and practices around potable water safety? Patients and staff have a lack of confidence in the potable water source and utility. Mitigation and extended monitoring is required to reinforce that water is safe when others feel it may not be. Everyone feels at risk—not just the patient. Our experience is staff become highly sensitive and concerned about the level of risk from the water supply.

LONG TERM REMEDIATION

As stated earlier, in 2000 MSK adopted and maintained a zero tolerance policy for Legionella. We adopted the policy in conjunction with implementation of copper-silver ionization on the potable hot water in all in-patient areas. Any positive culture at minimum requires a retest and in some cases enhanced mitigations of hyper-chlorination and flushing, increased ionizer levels, and a second retest to confirm effectiveness. We accomplish and maintain this policy by continually performing:

Risk analysis is done in conjunction with the infectious disease department to identify potential sources of bacteria and outline monitoring and mitigation responses.
Regular mitigation and maintenance including potable tank cleaning, riser flushing, cooling tower cleaning and chemical water treatment. In the case of cooling tower water treatment, we maintain the zero tolerance due to our patient population instead of under the 1000CFU/liter OSHA standard.
Copper-silver units require regular cleaning, monitoring (testing), maintenance, and occasional repairs to be continually effective. We rebar our units every 18 to 24 months. The copper-silver units in our view are the closest thing to plug and play you can get.
Regular testing is key to the success or failure of any water treatment program. It qualifies the effectiveness of any mitigation and enables a proactive response to a positive culture.
Monitor and qualify new construction; new construction areas are a potential source of Legionella due to water being shut off for extended periods creating dead legs and any dirt or debris that may be left in the piping during construction activities. MSK’s process is to flush, sanitize, and test prior to placing new piping in service.

TESTING, TESTING, TESTING

Testing is key to success. We have always advocated testing of water systems including potable water tanks, random potable water distal sites, specifically hot water in showers, and cooling towers. Some states mandate testing dependent on patient population. State of NY requires quarterly water system testing where immune-compromised and transplant patient populations undergo treatment. In our experience in the past 16 years, testing has served to exonerate MSK when serogroup between patient case and cultured distal sites did not match.

Let your testing evolve to suit your conditions. MSK’s testing began and evolved as follows:

Potable water tanks were originally tested annually, which evolved to quarterly to be consistent with all other testing. Following two sequential years of a positive culture in 2010 and 2011, we now do weekly testing for a month following a rain event in excess of 2 inches or a hurricane as it was determined that there were elevated counts following major runoffs.
Random potable hot water at shower distal sites began and remains at quarterly intervals. Copper-silver ionization systems continue to provide outstanding results since installed in 2000. At that time, distal site random cultures previously consistently positive became negative in just two weeks and have remained that way since. We take both a bulk water sample and a swab at each site and send out 20 sites per quarter.
We do additional potable water samples for copper and silver levels once a month to ensure the levels are maintained within range.
Cooling towers began quarterly; we changed to monthly from June to September as we kept getting positive cultures in the 3rd quarter. Monthly testing during the cooling season allows mitigation to be more real-time and has eliminated most September positives.
All testing is completed at a 3rd party lab. We use one of the most well recognized labs on the east coast.

ASHRAE 188 defines a systematic approach similar to what has been done effectively at MSK for the past 16 years.

The CDC’s toolkit, Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings, reinforces and breaks down ASHRAE 188 into practical action based guide to help building and healthcare providers develop new policies and methodologies to proactively prevent this disease. Having gone through these steps years before, due to our patient population, MSK does not view the standard as added work or responsibility, only a reaffirmation that what we have done here for years is the right thing to do.

June 16, 2016 by CDCs Safe Healthcare Blog

Healthcare-associated infections

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Our first Levels class is a success and we visit Dr Neal!

Yesterday I taught my first Levels class at Canine Affair Center! Two people who had signed up didnt show so we might be able to bring a couple people in from the wait list. I used Hardy as a demo dog for clicker training and he was super! Then when I put him in a crate to wait, he yelled at me so after giving him a warning, he got "too badded" out to the crate in my van. After class, I worked with him a bit and he generally remembered everything. We are still working on loose leash walking with my chair really hard since what he learned with John walking doesnt just transfer to the chair (something I learned from training Laurel - the puppy has to learn both skills).
This afternoon, Laurel had an appointment with Dr. Neal. He checked her ruptured ligament and thought that it was healing nicely however, he wants her to rest for another two weeks. He doesnt think it is going to be a chronic injury and it shouldnt interfere with her ability to do her job or play dog sport games (like agility). Of course, the movement we want to avoid - having her pivot on that foot - is exactly what she does when she is playing with Hardy! However, she is being very good at self regulation and will put herself in her crate or lay on my bed instead of tearing around the house or yard with him. Dr. Neal looked at Hardys eyes which are still goopy at times (and Laurels are starting to be goopy some too) and gave us some antibiotic ointment to use with both. He also looked at an upper tooth behind one of Hardys adult teeth - it is a baby tooth that is resisting coming out. He suggested we just leave it until it comes out on its own. Hardy weighs 36.7 lbs now and seems to be growing nicely.

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Our Second Baby is a

GIRL!

Dont let the blue topper fool you! The inside was PINK!

Can you believe it? I still cant!

The whole story of finding out the gender was a tad dramatic.

On Thursday night, I confirmed how many cupcakes I needed with the baker and the various details of the transaction. We were set!

First thing Friday morning, she text me that she had a family emergency and wouldnt be able to bake them for me. I completely understood but at the same time I was panicked! I was supposed to host 30+ people at my house the following morning and who could I possibly get to bake an order on such late notice?

She ended up connecting me with her aunt, who lives in Tulare and is actually my uncles (on my moms side) sister! We made plans to meet up after my appointment in Visalia (pretty much halfway for both of us) and it was done! Whew. Crisis averted.

I work a normal day and at the right time I started drinking LOTS of water. If youve been pregnant and had an ultrasound you know how incredibly uncomfortable it is! There was already a lot of stress on the appointment because Bryan had a gig just past Fresno and hed have to leave early. I got to Hanford Imaging and they told me there would be a delay which meant Bryan was going to miss the entire appointment.

When that came to light, I was really upset. I couldnt believe that he would have to leave the appointment early let alone miss it entirely. He sat with me in the waiting room and I asked my sisters to come be with me. I was feeling fairly emotional about it all but was handling it fine. I went to grab my phone out of my purse (and I still had the large bottle of water that was almost finished) when I almost dropped the phone AND the water! I ended up doing this weird seizure-like move to catch them both but not before water from the open bottle splashed all over Bryan completely soaking his white shirt and leaving a large wet spot on his jeans.

That was the moment that I started to do the hysterical embarrassed laugh/cry thing in the completely packed waiting room. Maybe you arent familiar with it but unfortunately, I am.

Sigh.

By the time my sisters arrive, Ive pulled myself together and Bryan is ready to leave. He was already ten minutes past the time he was supposed to leave but he just knew that as soon as he walked out the door, they would call my name. Sure enough, it happened.

Youd think that the appointment/day couldnt get any worse but youd be wrong!

I get in the room and the technician apologizes for the wait and I played it off but said I was bummed that the delay made my husband miss the appointment. My sisters say they are going to take pictures and a little video to show him and the tech says she cant allow that due to HIPPA. This Ill never understand because I am the one consenting to the photo and video being done so I can show my husband. How is that a violation if Ive allowed it. Ugh! I gave my sisters a look and they nodded, totally prepared to take pictures for me. Yay for sisters!!

We start and I get to see the baby, but Im so upset by the whole ordeal that its hard to get into the appointment. Also, she doesnt move the screen so that I can even see anything which was frustrating Then she tells me that I wont get any print-outs of the baby because THEY ARE OUT OF FILM.

Uhhhhhhh.....what? I cant tell you what cuss words were flowing through my head but I can tell you there were many and they were colorful. Unless there is a reason, this is my ONE AND ONLY ultrasound and I have nothing except unlawful photos to show for it. Nice.

Then she says I am measuring smaller than my due date and she doesnt think shell be able to tell the gender. I track everything regarding my period and our sexy time (Hi Mom!) and I was like, but the dates dont match up. She said I was measuring a little over 16 weeks and the first day of my last period had me at over 18 weeks. According to my memory (and app) there is no way I could be that far behind because there wasnt a tell-tale dot on the calendar indicating.....ya know.

AT MOST, I could only be a week behind. I explained that Shepherd always measured small and even if I had had him at term, he would have been a small baby. Bryan and I are small in the stature sense so I think its all relative.

Anyways, I told her I hoped that it worked out because I was supposed to host a bunch of family the next day and she said she would definitely do her best. You could tell that she was flustered too so my sisters and I started trying to lighten the mood and laughing a bit, which worked wonders. She ended up letting us take a few clearer pictures that the sneaked ones to show Bryan. And obviously, she was able to see the gender. She stated (probably to cover herself) that she could see the gender but that "it seemed early, and its never 100%" so that didnt really help my confidence, but she confirmed with a tech-in-training who was there and they felt confident enough to write it down.

We end up leaving and I pick up Shepherd and my mom and we drive to Visalia to drop off the envelope. My Mom and Larry ended up being the stars of the show because they drove early the next morning to pick up the cupcakes, brought over their coffee pot and creamers and coffee and basically saved my life. My mom even ended up staying with me Friday night to help me clean up and set up for the next morning. Big, huge, wet kiss shout out to them for all their help.

Friday came to an end (good riddance) and the next morning, surrounded by our family and friends, we found out that we are having a precious girl... probably. ;)

It all worked out in the end, as things usually do. I am still in shock that the little girl I have dreamed of, my little Lauriana, could really be coming into the world! Its unreal! I am so excited and other than extreme exhaustion, have felt really good. My hair is falling out like crazy and Im dealing with acne for the first time ever, but all things considered, Im doing very well and the baby is healthy!

That is all that truly matters.

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Poopin on the Potty is a Big Deal in our House

Wait, what?

Oh yes. This guy:

This guy, pooped on the potty.

Over the past couple months, weve been trying to get Tyler used to the potty. Were not super consistent, but generally weve been getting him to sit on the potty at least once a day. Mostly just for familiarity purposes. We havent really expected him to actually go largely because when we sit him on the potty its typically during the process of changing an already soiled diaper.

Anyhow, this morning when changing him and getting him dressed, he told me he wanted to go sit on the potty. I was already running late and wasnt really in the mood for the potty this morning, but Im pretty sure theres a line in the parent handbook, in the potty training section, that says something like "Never deny your childs request to sit on the potty."

So off to the bathroom we go and I sit him on the potty and he proceeds to play with the potty seat and his boy parts and just generally having a good ol time sittin there grinning at me. Im getting impatient and keep asking him every 7 seconds if hes done. He keeps saying no. So I told him I needed to go finish getting ready for work and he could stay on the potty as long as he likes.

I go back to my bathroom and Im not in there 30 seconds before he hollers in his sing song voice, "I DOO-OOONE!" (When did he grow up???) So, with a big eye roll, I walk back to his bathroom and he says, "I poop." Whaaaaat?

I pick his little butt up off the toilet and sure enough, there is a gift staring back at me! (Youre welcome for not posting a picture of it.)

However, Im immediately skeptical cause its not usual for his sissy to forget to flush the toilet after shes done using it. I checked his butt for evidence, found some and commenced with the celebrating, high fiving, and fist bumping.

Then we had to call Daddy and tell him. And in all the excitement about pooping, I forgot to have the kids tell their Daddy happy birthday. My bad. But it was poop! In the proper location! Can you blame me for being distracted?

We did try to make it up to Daddy by having some cookies and creme pie for dessert tonight (Lily picked it out). We put 3 blue candles (dont ask me why 3...Lily said that was the right amount) and all sang Happy Birthday, which is to say, I sang it and Lily chimed in at the very end. Tyler just kept sticking his fingers in the pie, too anxious to wait until singing was over to eat some.

Happy Birthday Babe! So cool that you can share your birthday with such a monumental milestone in your sons life. Ha!

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Our Weekend

We have had a great weekend spending time with family and friends and enjoying this cool fall weather!

Brody absolutely LOVES getting his hair cut, loves it. Every time Timmy gets a hair cut Brody insists that he gets one too. On Friday evening we went for Timmy to get a hair cut and we were going to wait a little longer for Brody but he said, "Dad my hair looks ugly, I really need a hair cut." It was too funny and too cute so he got a hair cut too. He sits perfectly still and once they are done and turn him to the mirror he smiles and grins and is so proud!!!

After hair cuts on Friday we went to Buffalo Wild Wings to meet up for dinner with our friends Andrea, Tommy and Gage!

Hunting season is in so that means on the weekends Timmy is usually hunting, so that means girl time! Yesterday he went hunting with Ryan and Travis so the wivess went shopping of course! Me, Lacey, Morgan and Brody went shopping and had a great day! Brody loved getting to see the Chik-Fil-A Cow! After shopping we went out and met the guys at Ryan and Morgans and we cooked supper and played some games! I have to brga on Brody just a bit... he is doing a great job potty training and has had no accidents! He tells me when he needs to go and even being gone all day yesterday, he did awesome!!!!

Today we went to church and then went to Sakura to celebrate Titus Birthday (The fam all celebrated yesterday in Lexington, but we didnt go..) and now we resting and having a lazy afternoon!!

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We attend our first AKC STAR Puppy Class go out to dinner

Hardy, Brent and I attended our first AKC STAR Puppy Class at Fortunate Fido this morning. It takes about an hour to get there but at least we arent doing it during rush hour! The STAR program is kind of a pre-CGC (Canine Good Citizen) class developed for puppies in which you and your puppy not only have to pass a evaluation but you also have to attend all 6 classes run by the AKC evaluator. There is only one other puppy in the class, a lovely Border Collie one week younger than Hardy owned by someone I knew a long time ago (in my other life) in high school when we rode horses together. We have our instructor/evaluator, Anne and an assistant, so we have plenty of help! This week, we learned what the program would entail and worked on handling our dogs, "4 on the floor" greetings, and loose leash walking. Both puppies did a great job and we even had enough time to let them play a couple times. Although they are about the same height, Hardy definitely has the weight advantage on his side!
We dropped my power chair off at the medical equipment place on our way home so that it could get some repairs and maintenance done this coming week while my van is in the shop getting the body work done from when it got run into in Canada. That means that other than when Brent can take us places, Laurel, Hardy and I will be home together all week. Im thinking up things we can do that wont require Laurel to move too much while keeping Hardy busy.
Then, this evening we headed back to the west side to have dinner with some very good friends, Don and Alice at one of our favorite restaurants. We took Hardy with us because the weather was cool enough that he could stay in his crate in the van for part of the time. Before we went in, we took him to the grass and he quickly did his business! Don and Alice had gotten there early and when we went in, we found that our table was at the very back of the restaurant right in the major traffic pattern for all the servers carrying food out from the kitchen. I had my manual chair and we had to go through all the other tables which were very close together and filled with diners. Hardy had to go behind me - something we havent actually worked on but, he did it like a little pro. We had him go as far under the table as possible in front of Brent and he was very good; not perfect, but hes just 5 months old now. He stayed with us through our salad course and when our main dishes arrived, Brent took him out to rest in the van. We tend to take our time when we are out with our friends and I didnt want Hardy to have a bad experience. At his age and point in training, I want to make sure that when I have him out in public, the time is about him and how he is doing, not about eating dinner or running errands or spending time with friends.
To top off a great day with our little guy, when we got home and he finished greeting Laurel, he came over to me and started alerting to the rheumatoid in the chest wall. I asked him if I should take my meds based on his alert or whether I should wait for Laurel to confirm. Just then, she joined us with her own alert so I took my medications and snuggled in bed with my two amazing Labs! And sure enough, just as they both had known, the rheumatoid "struck" about 50 minutes later but the pain meds were already on board so it wasnt too bad.

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Shepherd Lincoln Our First Year

One night, a very, very long time ago, two young kids were sitting on the bench in front of house. There was a young boy who had walked over to hang out with a young girl and they decided it was nice enough outside to sit and talk.

As they were talking, the subject of children came up and the young girl said, "I want to name my first girl Lauriana. I always wish my parents had used my middle name as my first name, instead of Megan." The boy looked at the girl, smiled, and replied, "I like the name Megan. It suites you... Ive always thought my first son would be named Shepherd."

"Why?" Megan asked. " Bryan....Its not because you love German Shepherd dogs...right?"

"No!" Bryan laughed. "Because, I want my son to be a leader. To know others will look up to him and that its an important job. I want him to help others find their way. To be a light and a guide."

"Well, if we get married and have a son, well name him Shepherd."

"Sounds good. If we get married and have a daughter, well name her Lauriana."

--

Shepherd,

Before your father and I met, before we fell in love, before we dreamed about our future kids names, you were planned. You were always on the horizon and you were destined to be ours. Before Bryan and I got our lives together, before we married each other and bought our house, you were on our hearts. We knew you would come. You were foretold to us from the very beginning. God nestled you right in our hearts, He prepared us to have you, to hold you, to love you and raise you.

He knew the giggles we would share, He knew your first words. He knew the struggles we could face as mother and child. He saw the love and strength that would come from it. He knew how close our family of three would become.

I doubted for a long time, my boy. I was angry at God. How could He give me such a desire to have you and to have Lauriana and years went by with nothing. Finally, in the beginning of 2012, I gave up. I told God I couldnt bare the sadness. I couldnt hold onto any potential children anymore. I needed to let go.

On September 5, 2012 I found out I was pregnant. My immediate instinct was that it was a boy, that it was our Shepherd. It was a miracle. I was not supposed to be pregnant. It was not supposed to be possible... but there you were.

Week later it was confirmed in front of our family that you were a boy.

We were so happy. So blessed. And while the longing for Lauriana was still there, we were so happy to have our Shepherd boy.

We had a bit of a rocky start, you and I, but luckily, we made it through and you were born.

You have the best personality. Always happy, unless you are hungry. You love your daddy, you love your Papa, you moderately tolerate me.

The first year of your life has been full of the highest highs and the lowest lows for me. You have pushed me and stretched me more than anything else in my life. You have shown me my strength and a whole new level of love. Love I have never experienced. Love I dont know how to show you or give you properly. Im not equipped with the tools, because my childhood was different.

But I will do anything for you. I will learn any skill, read any book, right any wrong, fix my flaws, counsel with anyone I can to grow you into a smart, capable, wonderful young man. I will give up my dreams for yours to become reality. I will put you first. I will love you more than I was loved. I will give you more than I was given. I will teach you and learn from you all the days I have left.

You are the light of my beautiful life, kid. When things get hard. When I feel the clouds roll in, I hold you and things become clear. A weight lifts and I breathe again. You are my joy.

Your daddy and I, we adore you. You wont remember, but even now as we counsel you to make better decisions, to not bite, to not hit us with your beloved golf clubs, we giggle behind your back because you are so cute. So strong. So decisive. We pretend we arent, but we are putty in your hands, Bud. Hopefully you dont catch on....

But for your own sake we pretend so we can mold you into a good kid. A good man. A man of God.

I love you, Shepherd Lincoln. I pray that I do right by you every day.

Always,

Momma

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Our 6th Anniversary

Joel and I celebrated our 6th wedding anniversary the same day that I had my Farrells awards ceremony. Isnt he an awesome guy for enduring a 2 hour awards banquet with a bunch of people he doesnt know ON OUR ANNIVERSARY?

I feel kinda bad that I posted all about my Farrells results before I posted about our anniversary but I guess thats how it goes with blogging. Things arent always in chronological order or even prioritized with most important first.

My handsome partner in life. I really dont know what Id do without him. He makes me absolutely INSANE some times (as I do to him) but theres really no better man on the face of this planet that I would rather feel insane around.

We went out to dinner to Tre Bicchieri. It was amazing. Spicy vodka cream sauce - I love you. Joel scored us free cheesecake by mentioning our celebratory reason for dinner. I was so embarrassed when he told the waitress, but I totally got over it when she showed up with that cheesecake. It was bad word delicious. Thank goodness it was fun day.

This weekend, at the kids Easter program, a man came up to me afterwards and told me that I look great and was asking me about my weight loss and such. Then he said, "I have to be honest, when I first saw your husband today with his arm around you, I thought to myself, Oh no, hes here with another woman! But then, I realized its the same woman, she just looks a lot different!"

What a compliment!

However, I will say, after 6 years of marriage, 8 years of togetherness, Joel did get a different woman to put his arm around. One thats healthy and fit and that he can carry over the threshold without giving himself a hernia.

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Find Kardus

Tuesday, December 27, 2016