Thursday, July 2, 2015

Traits of a Great Nurse: One Patient's Perspective

This post is dedicated to all the nurses at UWMC Labor and Delivery, especially Mary M, Lori, Ann, Anna, Tammy, Jane, Karen, Lila, Christine, Bekah, Nadine, Sharon, and Laurie.


One good way to understand what makes an effective and empathetic nurse is to rely on their care for multiple days. Without intending to conduct such a study, I recently had an opportunity to do just that. Due to a sudden onset of severe preeclampsia with HELLP syndrome, I was rushed to the University of Washington Medical Center's Labor and Delivery six and a half weeks before my due date. Thanks to the excellent care I received, my son was born safe and sound on Saturday, June 6 at 8:58am.

I am so thankful to each nurse that I met before, during and after delivery (one for day shift and one for night shift with few repeats). I was so impressed with their consistent positivity, skill and good humor that I kept a list of traits to remember. Becoming a mother has already made me more attentive to being the best version of myself possible, starting with the example of my caregivers.

In case you were curious, here's my take on what makes a great nurse.

Bedside Manner

As the days spent in the hospital before delivery added up, I felt increasingly like a helpless and possibly crazy person. The drugs I was given messed with my head, I couldn’t get to the bathroom without help and I needed food and water brought to me in bed. It was uncomfortable to be so needy. But I was treated with nothing but respect and dignity.

All my nurses acted as if it was normal to suddenly require help to use the toilet, not shower for days and have no control over my surroundings or my appearance. Their calm and collected demeanor normalized the whole situation for me. That was comforting. Those that related to me as if everything was in order (bantering, cracking jokes, laughing along with my interactions with Hubbins) were my favorites. It didn't seem impossible to imagine being friends in another context.


All my nurses were down to earth and very easy to talk to. None of them made me feel like an imposition. As far as I knew, I was the only patient in the entire hospital: every shift change, I was the primary focus. It helped me to understand what was going on when I overheard each nurse give their replacement a synopsis of the last 12 hours of my care.

By day two, I was overwhelmed by so many new faces (especially when shift assignments changed mid-day). A new nurse meant another personality to learn and communication style to adapt to. But as time went on I got to know so many fun women. It became a source of entertainment to meet the next nurse! I don't know if their confidence and joie de vivre came as easily as they made it seem, but both were effective methods for putting me at ease.


The nurses who tidied my room throughout their shift made me feel the most cared-for. They took unnecessary items out of the room (empty food containers, used linens, medical equipment that was no longer needed) and cleaned all surfaces of clutter. Then they focused on what I needed without distraction. 

“Can I bring your another cold pack?” Yes, please! 

“Refill your ice water?” Yes, please! 

“Do you need another pillow?” Yes, please!

There are several nurses in my life. I don't know why I didn't make this connection before, between close control of environment and professional necessity. Of COURSE nurses like clean work spaces and carefully monitored surroundings - they are assigned  new patients and rooms constantly, they perform medical procedures that require cleanliness, they are continually picking up where someone else left off and leaving something behind for another nurse (a patient, a room, or a report). I get it now. While extraneous fussing and fidgeting got on my nerves in the past, I can now see those behaviors in a brand new light: occupational efficiency. 

I have a whole new respect and admiration for nurses everywhere. Keep up the good work.

Birth Story: Part III

June 3 - 5
The next three days all run together in my memory. I remember nurses coming and going, ordering meals from Food Services when I wasn't hungry, throwing up all over myself in bed at least once, and calling for nurse's help every time I had to maneuver from bed to bathroom while pushing my IV bag on wheels. In the toilet, the nurses put a hat-shaped container to collect my pee and measure my output. They were keeping track of the fluids I was drinking and peeing. And there was lots of both. Magnesium made me feel hot - like I'd been in the sun too long and was nursing a bad sunburn. I chugged ice water and asked for new ice packs whenever the nurses checked on me. I knew hydration was important, but I was mostly concerned about my dry mouth and internal temperature.

My own personal heatwave

"Do you want apple juice, cranberry juice or Sprite?"
Since there wasn't a rush (yet) to deliver, I was given several methods to induce labor - the idea being that if my body could be coaxed into early labor, we could avoid a cesarean section and get baby away from that crappy placenta sooner rather than later. Here's what I remember about each (not for the squeamish. Feel free to skip this post, Dad).

Misoprostol - the doctors explained I would be given six doses orally every couple of hours, with the intention of getting my cervix to cooperate (words like "dilate, ripen, efface, thin" were all used to describe the desired outcome for my lady parts). The seventh dose was inserted vaginally (the doctor and nurse laughed because the same pill I had been swallowing was simply put into a suppository-shaped capsule. I failed to see the humor).

Cook's Catheter - this was, by far, the most uncomfortable part of the whole experience. The doctors, again, patiently explained the purpose: by inserting small balloons into both my cervix and vagina and inflating them with fluid, the added pressure would create space for baby to lower - in effect, forcing further dilation. I understood the concept, but couldn't picture how this was going to work.

To get my feet up into stirrups, the resident doctor (who looked like she was in her twenties), trainees (in their late teens? Sheesh!) and nurse walked me into a triage room. Hubbins opted to stay behind in the hospital room (for which I am eternally grateful). Had he been in the room, I would have tapped out simply from embarrassment.

The procedure couldn't have taken more than 10 or 15 minutes, but seemed like a torturous lifetime. Knowing it was necessary for the safe delivery of my baby was the only reason I didn't completely wimp out (or melt down in tears). I felt like a needle being threaded. I think it was the first moment I realized what it would take to be a mother: sacrifice I couldn't fathom until it was absolutely necessary. I closed my eyes and gripped my nurse's hand. She commiserated, "I think cervical pressure is the worst discomfort there is." My summary would have included more expletives than that.

When I was sure I couldn't bear another second, I squeaked (in a voice I didn't recognize as my own), "Any progress down there?"

The doctor chuckled sympathetically and said, "Just about done." Thank goodness. She patiently elaborated, "We're working in a curved environment with straight tools." No kidding. She added that my cervix was being "elusive." Add that to the list: Adjectives I hope I never hear used to describe my privates again.

In an attempt to lighten the mood, I said, "Hey, after this my next pap smear will be a breeze!" It was a forced attempt at solidarity. Graciously, my fellow women laughed. As they removed their surgical gloves and left the room, I heard myself say, "Thank you." Touche, Mom. You taught me well. My gratitude wasn't for the harrowing experience, but knowing their efforts were for my benefit and the benefit of my baby.

Pitocen - compared to the catheter, pitocen is hardly worth mentioning. It was added to my growing collection of IV medications and pumped in without me even feeling it. I thought of childbirth class and our discussion on voluntary induction, which is now discouraged in most cases. I was a far cry from laboring at home and waiting until six centimeters dilation before waltzing into Labor and Delivery. By contrast, the whole scene resembled an episode of Star Trek more than natural childbirth.

When a cyborg goes into labor does she get an epidural?
Epidural - Thankfully, I never had my heart set on a drug-free delivery. After three days on magnesium, I knew for sure I wouldn't have the strength to labor au naturale. When the resident anesthesiologist (who looked like Ethan Hawke, only younger and more handsome) visited for the second time to introduce himself and check in with me, I told him Yes, Please.

So, Friday afternoon, he and the MD got me hooked up. This was another procedure that, in real life experience, didn't match up with the textbook description. My childbirth book didn't tell me I would have to sit still and simultaneously arch my back to create space between vertebrae for the local anesthetic injection. It didn't describe the feeling, like an electric shock down one leg or the other, that could easily be felt during the placement of the small catheter in my lower back. It didn't warn me I might bleed, nor of the unnerving sensation of a warm trickle of my own blood down my tail bone.

I sat cross-legged on my hospital bed while the resident and MD anesthesiologists did their thing (thankfully, completely out of my view). Hubbins sat in a chair front of me, beside the bed, and held my hands (actually, he let me hold his hands with all my strength, as if my full body weight was hanging from his grip). I closed my eyes so I couldn't see his reaction as he watched the doctors work over my shoulder. I knew it would distract me to try to interpret what he was observing and the instructions I was hearing between teacher and student. They asked me multiple times how I was doing. I said, "Good" but what I wanted to say was, "This sucks. Are you done yet?"

As they finished, the MD asked, "Are you nervous?" I answered honestly that yes, I was. He quipped, "Don't be nervous, you've got all of us here to help you! You should be nervous about your son turning 16 and getting a drivers' license. 'Cause we won't be there to help you then!" At the time, this attempt at levity was appreciated and seemed appropriate. In retrospect, he's lucky I only responded with a courtesy laugh.

Once everything was in place, I lay back down in my hospital bed. The Ethan-Hawke-Look-Alike handed me a small wand with a single button. "Push this if you feel pain," he said. "It will automatically dispense the analgesic through the epidural." My hero.

When I pushed the button a few hours later, I heard the whirring of machinery behind me. The drugs were locked safely inside a small pain-relief vending machine. I felt a chill down my spine as the dose was released into my back.

Part medical equipment, part Autobot
Because I would lose all feeling in the lower half of my body thanks to the epidural, the nurses also inserted a regular Foley catheter, so I wouldn't have to get up to use the bathroom anymore. That evening, feeling particularly uncomfortable and unable to find a good position to lay in, I realized I was literally tethered to my bed (or at least to all my equipment):
  1. Epidural (line in my back)
  2. Cook's Catheter (connected to nothing, but I was supposed to tug on it periodically to keep the pressure building) 
  3. Foley catheter (pee bag)
  4. Heart rate monitors on my belly to keep tabs on baby
  5. Pulse oximeter on my toe
  6. IV with four bags: magnesium, Lactated Ringer's Solution (regular fluids), pitocin, and penicillin (since I tested positive for Group B strep - common in healthy women but risky for baby) 
On top of all that: tangled up in my hospital gown
Friday morning I was feeling contractions (hence the epidural). By the afternoon I was dilated to 4 centimeters, but baby still wasn't low enough and my cervix wasn't cooperating. An ultrasound technician wheeled her equipment into the room and checked on baby: still tolerating his environment. The nurses adjusted and re-adjusted the sensors on my belly. I asked them to turn the volume down - the racehorse sound of his heartbeat was reassuring, but the scratchy sound quality and highly sensitive mics drove me nuts.

No one had mentioned a C section yet; the waiting continued.

Wednesday, July 1, 2015

Birth Story: Part II

June 2, cont'd
A nurse from the local hospital rode with me in the ambulance to Seattle (bonus: I'd met her before! She is the mother-in-law of a good friend from work - I was so grateful for a familiar face). The driver and assistant were at least a decade younger than me (not the last time I would be startled by the age difference between me and my care givers), both very professional and efficient.

It was a new view of I-5: belted to a collapsible gurney at my ankles, knees and waist and tucked under a couple of lightweight blankets, I faced the rear of the ambulance and saw the familiar route south but in reverse. I wondered if the cars driving behind us could see me inside (if I was a civilian driver, I would be super curious to peer into the lit interior of an ambulance). I thought of my 2 1/2 year old nephew and texted my sister: Clive is going to be so jealous!

We made really good time to the University of Washington Medical Center (kudos to my driver). I was wheeled into Labor and Delivery a little after 9:00 pm. Hubbins was waiting for me at the nurses' station. I could tell he was in "act now, feel later" survival mode because he was joking with the nurses: "Oh here she is! Jeez, what took you guys so long?!" What a relief to see him. I wouldn't know how to direct him to find me if he wasn't there already.

In my hospital room, I got up from the ambulance gurney and into the hospital's bed (a little wobbly on my feet with a couple hours' worth of magnesium in my system plus the bumpy ambulance ride, but I was still mobile). The resident doctor came in to introduce herself (about my age, I'm guessing) and review the facts. "The thing with preeclampsia is that basically you've got a crappy placenta," she explained. She said that because both baby and I were stable, they would monitor us overnight and see if they could keep him in me for as long as possible. She ordered a blood sample around midnight and the lab staff continued to draw blood every six hours for the next four days.

Between the multiple pin pricks, taped cotton over the draw sites, and the constricting blood pressure cuff in the same vicinity, my arm bruised quite impressively. Eventually, I asked the phlebotomists to not use tape and just let me hold the cotton until the bleeding stopped. Still, by the end of the week my right arm looked like an impressionist painter's color palette.


That night, I didn't sleep well at all. Poor Hubbins was on a little bench-bed at my side, probably more uncomfortable than I was. The Magnesium made my mind race, like I was trying to accomplish a long list of things to do but couldn't remember any specific item from the list. My imagination ran wild - my thoughts all had a visual aid to go with them, but they were fleeting and I couldn't keep track of whatever my mind was listing. I got a stiff neck from my position on the hospital bed and dreamt that the light-fixture grid in the ceiling above me was actually my pillow. I felt like my head was inside a gerbil ball: my thinking was foggy and slow. When nurses and doctors talked to me, I tried my darndest to make eye contact, but couldn't focus. Everyone looked like they had four eyes.

The only way I could get any sleep was to specifically visualize a peaceful location or interaction. I thought of my mom. I didn't realize it until later, but I was following her example as a patient: keep in good spirits, give everyone the benefit of the doubt, be grateful (remember first names and say "thank you"), be empathetic to others. Mom lived in a nursing facility for two years. I had lots of material to draw on when I thought of her and the nurses who took care of her in the final stages of Alzheimer's. I wished she was with me then.

Tuesday, June 30, 2015

Birth Story: Part I

I'm trying to record all the details of baby's arrival while they're still semi-fresh in my memory. Here's the first installment, starting from the day my pregnancy went from no-risk, hunky-dory, smooth-sailing to "danger, danger Will Robinson."

Friday, May 29th  

During my routine monthly doctor's appointment Friday morning, my blood pressure was high. As in, I-should-at-least-get-credit-for-burning-calories-cause-this-is-like-aerobics high. Without trying to cause panic and raise my BP even higher, the doctor recommended I have more lab work done. Fair enough. I already felt like I was on a first name basis with the lab staff. I stopped by, left samples of various bodily fluids and then went back to work. 

While leaving my office for the day, I got a call from my OB/GYN. The lab results had come back already, showing impaired kidney function (protein was “leaking” into my urine). My RN made an appointment for the next morning, Saturday, to have more tests done at the hospital since the doctor's office would be closed for the weekend.

"Preeclampsia" was mentioned for the first time, with the caveat that it was most likely mild. I was told to buy a blood pressure cuff and monitor my rates at home that night. That evening, I read the pertinent sections of my pregnancy books to learn what eclampsia was (the onset of seizures in a woman with preeclampsia) and whether pre-eclampsia was any less serious (a disorder of pregnancy in which there is high blood pressure and either large amounts of protein in the urine or other organ dysfunction).

Saturday, May 30th

Saturday morning I met one of my doctors at the Labor and Delivery unit of the local hospital. Nurses conducted a "non-stress test" (meaning there were no simulated contractions: baby experienced no stress, though I was feeling plenty). The purpose was to see if baby's heart rate changed based on his movement. His heart was doing just what it should – good news!

"Intrauterine growth restriction" (IUGR) was mentioned for the first time: baby was smaller than he should be. My doctor ordered a biophysical profile ultrasound to check on baby's heart rate, muscle tone, movement, breathing, and the amount of amniotic fluid he had. He scored 8 out of 8 on the ultrasound assessment. However, his small size (combined with my lab results and still-high blood pressure) confirmed the preeclampsia diagnosis. The nurses warned me I probably wouldn’t make it to the 37 week-mark. That seemed crazy; as of 5/30, that was only five weeks away!

My doctor reassured me that preeclampsia was a vascular issue. It was nothing I caused or could have prevented. She consulted with doctors at the University of Washington Medical Center in Seattle – they advised giving me betamethasone (steroid) shots to help boost baby’s metabolism and help protect his still-forming lungs – which would most likely be breathing sooner than expected! My doctor told me encouragingly my baby is “small but mighty!” Her office would continue to monitor us both closely.

Sunday, May 31st

I went back to the hospital Sunday morning for a second non-stress test and another betamethasone injection. The plan at that point was to visit the OB/GYN office twice per week until delivery and to take it easy at work (bed rest recommended, though my doctor gave the OK to work half-days as I was able).

That evening I emailed my family a list of current concerns and the good news (no need to incite panic): 
  1. As long as everything holds stable for one more week, I'll be able to deliver in Bellingham. If things take a turn for the worse and they need to induce me before next Sat (the 34 week mark), we'll be sent to Seattle.
  2. I'm hoping to not require full bed rest yet (I don't want to use up maternity leave before he even arrives). I'll find out more tomorrow at my follow up appointment.
  3. Baby is small. Everything looks OK developmentally, but the longer he stays put the better (based on the ultrasound I saw yesterday, he's content to keep chilling. Not a care in the world based on his expression and body language). :) I got a series of baby-safe steroid injections as an added barrier of protection in case he does make an early appearance in the next week or two. This will give a little extra oomph to his metabolism and help the development of his lungs.
  4. Our stress levels. We want to be alert and agile for whatever baby needs, but not freak out. Serenity now.
Good news:
  1. We caught it early - still lots of options for treatment (in addition to the shots, I'm on a low-dose blood pressure pill to keep things in check. I got a blood pressure cuff so I can keep track at home).
  2. Medical professionals - I've loved every doctor and nurse I've met. We're in good hands.
  3. Baby seems un-phased (aside from being small which is common with preeclampsia) - he's active, has great cardiac response, good blood pressure, and all his parts. Pretty sure he tried to high-five the ultrasound technician mid-sonogram. I got to see him practice using his diaphragm muscles (which I didn't realize babies did in utero, getting ready for actual breathing!).
Monday, June 1st

I took Monday off work and rested at home. Couldn’t believe how many hours I slept - all appreciated by the cat. He provided excellent pre-natal care.

Ivan, M.D.
Tuesday, June 2nd

I had another follow-up at the OB/GYN, including another non-stress test: baby was still doing well, my blood pressure was still high, and the close monitoring continued. I visited the lab for another round of tests. With my doctor’s blessing, I worked a half-day that afternoon. I wrapped up a few loose ends and tried not to panic about the amount of work that was likely going to remain undone. I put my feet up on my break and mentioned preeclampsia to only a few co-workers. The waiting game continued.

As I was leaving work, I got another phone call. My RN explained that the lab work was now showing increased liver enzymes, indicating further stress on my organs. The on-call doctor was conferring with the UW, and my RN said he wanted to meet me at the local hospital. Since baby was displaying normal function on the non-stress test from that morning, medivac via helicopter wasn't necessary but an ambulance ride to Seattle was.

I called Hubbins and told him the change in plans. Instead of childbirth class that evening (discussing “The Birth Plan” ironically enough), we were escalating to immediate action. There were no more decisions for me to make, just instructions to follow. Thankfully, the parameters were set for me: 1) labor and delivery options in town were nil: the special care nursery wasn’t equipped for babies younger than 34 weeks, and 2) the medical team with specialists' training for higher risk deliveries were all in Seattle.

As soon as I got to the hospital, the nurses got me into triage and hooked me up to a magnesium sulfate IV drip. They explained this would protect me and baby from seizures and coma. But the on-call doctor warned me it would also make me feel crummy. He used a stronger word than crummy so I knew it was serious.

Hubbins met me at the hospital and after relaying the plan, I asked him to pack a few things from home and meet us in Seattle. He left to get a head start. The nurses offered to dim the lights in the small triage room. I waited in the dark and took a couple of pictures. 

Triage selfie

My chariot awaits - gurney for ambulance ride 

Magnesium IV

Signs You've Been in the Hospital Too Long

Here are a few indicators of Hospital Cabin Fever.

The ultimate expression of independence and self-care is a hot shower.

Iggy Azalea knows what I'm talking about: I'm So Fancy!

The gift shop has become your source for accessorizing.

"By adding this $12 scarf to my ensemble, my T shirt and yoga pants become a BRAND NEW OUTFIT!"

Caution: the nursing staff might not recognize you in civilian clothes. If the nighttime security guard asks the reason for your visit, offer a friendly reminder: I'm a real person AND a patient!

You've started collecting memorabilia for the hospital's own scrapbook page.
Too bad they don't have their own line of stickers.

You wear battle wounds as badges of honor.

With bruises like these, who needs tattoos?

You actually begin to memorize your pill-popping schedule.

This handy mnemonic device will help: 
Pain killers before blood pressure meds,
except after stool softeners, 
and when followed by multi-vitamins 
on days ending in y.

You start daydreaming about having your own really-quite-comfortable hospital gown at home.

You know, this can't be that hard to sew.

You assume the call button is included in the patient discharge kit.

What do you mean the nurses stay here when I go home?!

Saturday, May 9, 2015

Thoughts on Pregnancy

I started feeling baby move around 14 or 15 weeks. What an odd sensation. I've wondered how my child acquired a hamster wheel based on all the activity. At least one of us is exercising.

Less charming: playing hacky sack with my ovaries.

February 2015 - 16 weeks

My insurance company refers to the birth of a child as a "life event." Prior to that, pregnancy is defined as a protected disability by employers. It's nice to know my job won't be filled while I'm on maternity leave because this "disability" is temporary.

I couldn't help comparing first trimester symptoms (mild, by all accounts) to how I might react to the same symptoms sans baby: persistent, unresolved nausea; fatigue; breast pain; isolated mid-section growth. Good thing pregnancy tests are so readily available. Otherwise, I would have been panicked: Cancer! Tumors! Autoimmune failure!

Nope. None of the above. Just growing a person in there. Pay no attention to the alien life form squirming and stretching its limbs. Amazing.

February 2015 - 18 weeks

The hormonal/emotional journey since going off birth control last summer has been... interesting. I'm grateful I lived through adolescence (forgot how grueling it was to feel unhinged most of the time). I'd like to say that my coping skills have improved in the last two decades, but I'm not sure they have. Let's not ask Hubbins to confirm or deny. Tears and FEELINGS and introspection are exhausting.

March 2015 - 20 weeks

Our 20 week ultrasound was so special. I had been hoping for and assuming we were having a baby girl. But when the ultrasound technician said "its a boy," My reaction was all joy. I smiled so big lying there on the exam table; the tears that sprang up landed in my ears. I had this strange vision of all stages of boyhood, from infant baby boy, rough and tumble kiddo, to full grown young man with his arm around my shoulder. I reached for Hubbins' hand and we just grinned excitedly together for a while (even though it was dark in the room, I know that's what was happening).

As we left the doctors office, Hubbins turned to look at me and said wistfully, "I have a son." You know that saying that women become mothers as soon as they find out they're pregnant, but men don't become fathers until they hold their newborn? Not true for us. I'm so thankful I don't have to wait until the delivery room to see the transformation to "daddy." He's going to rock parenthood.

March 2015 - 24 weeks

Observation: social constructs change during pregnancy. I can’t think of another instance where it’s socially acceptable to openly comment on someone’s bodily protrusion (the exception, I suppose, would be when seeing a compound fracture – to which the appropriate response would be “AAAAAAAA! I’m taking you to the emergency room!”).

But during pregnancy, it’s perfectly normal to hear enthusiastic commentary on my changing anatomy. I find it a little embarrassing, having gained noticeable weight, to hear “Ooh! Look at your belly!” but it’s also nice to flaunt my growing mid-section. “Form fitting” clothing was taboo in adolescence, but now it’s acceptable and maternal. Curious, considering my new “form.”

Speaking of my new wardrobe, maternity pants for the win! Spandex from navel to armpits? Yes, PLEASE!

Easter 2015 - 25 weeks

Pregnancy seems the most passive form of parenting. Granted, my unborn child is biologically connected to me and we're contained in the same physical space. He relies on me for survival at this point. The ironic thing is that this total dependence is low-maintenance in comparison since it’s all happening automatically. Once we’re separate entities, care taking becomes manual.

In honor of this miracle and mystery, my silent sidekick and I are going to go take a nap.

Skagit Valley Tulip Festival - April 18, 2015

27 weeks

We're Pregnant! Christmas 2014

We shared some big news with our families at Christmas: we're expecting!

I wrapped some of my favorite picture books to give to my dad and siblings. The card said "Save for July and practice your read aloud voices!" with a little ultrasound picture inside.

Best reaction ever.

Wednesday, January 21, 2015

Winter thoughts: January 21, 2015

Today is Mom's birthday. How should one celebrate the birth of a lost loved one? At lunchtime today, I made a plan: I'll buy flowers after work and lay them on her gravestone tonight.

My work is now done for the day, but the sun has gone down. I don't want to visit a graveyard by myself in the dark. Other than Mom's name in writing, there is nothing about that location that makes me feel close to her.

So instead, I bought myself flowers and I'm writing her a birthday card. With lots of stickers. That's much cheerier, exactly like her.


I don't know which is worse: not being able share celebrations with Mom, or not being able to go to her for comfort when I'm sad. As a kid, I remember a framed proverb a friend wrote in calligraphy for us. It was displayed in our home for years:

Shared joy is twice the joy.
Shared sorrow is half the sorrow.
Recently, there have been many joys and a few heavy sorrows in my life - my instinct to share both accentuate Mom's absence.