Pages - Menu

Saturday, January 9, 2016

Wishbone, Leah, and the Return of Crowbarrens

Every shift, we introduce ourselves to our pts, explain how long we’ll be there today, and talk about our goals for the day. Some people have very simple goals: don’t die is popular, as are things like control pain and get out of bed. Some people will have procedures during the day, endoscopies or central line placements or dialysis.

Occasionally, the most important goals aren’t things we can cheerfully schedule with our pts: come to peace with impending death, or manage not to shit directly on anyone’s scrubs. In those cases, we find simpler goals: order breakfast and lunch early so they don’t have to wait, take a walk and get some sunlight, that kind of thing.

Then we do our assessments, because nothing helps your day get moving like peering at some guy’s butt and hoping that pink spot on his tailbone isn’t turning into a pressure ulcer.




Then, if we’re well-behaved and our minds haven’t already wandered off in search of 0800 meds and asphalt coffee, we’re supposed to write our names and our goals on the whiteboard. Each room has a whiteboard on the wall, conveniently located behind the computer monitor so that nobody can see it, too far from the bed for anything written there to be legible, with exactly one dried-up marker balanced on top. These can be valuable tools if you have a room full of panicky visitors who need something to fixate on, or if you need to keep a lot of information handy for transcribing later, or if you want to keep all the family’s phone numbers in one place.

I am notoriously terrible about updating the whiteboard. So is everybody else, because nobody remembers to replace the last nurse’s name when their morning is already thirty minutes behind. Which is why half the boards on the unit read “Shelley RN”—she’s a fucking overachiever who does everything right, and we are useless schlubs who will let seven shifts in a row go by without erasing her name. (I can’t be mad. Shelley may be the Joint Commission’s charting wet dream, but she’s also one hundred percent on every shift she works, and this makes her one of our best high-acuity nurses.)

So when I’m preparing to receive a pt, and I have enough time to fine-tune the room, I slap a few quick scribbles on the board before they arrive: Elise RN, control pain, oxygenate, stabilize. Then I don’t have to worry about it for a while—in fact, if I’m lucky and noc shift is as lazy as me, my name might still be on the board next morning when I come back to work.

This particular morning, I had spent the first four hours discharging telemetry pts at top speed, trying to clear my slate to receive a GI surgery pt by the name of Wieszczek* who had gone under the knife at around 0700 and was having one hell of a ride on the table downstairs. If I could get my pts out the door before he arrived from the OR, the charge nurse promised me I could land him one to one.

If not, my tele pts’ discharges would have to wait either until I could get around to them or until the flex nurse could wrap up my work for me. It wouldn’t be the end of the world, but it’s sloppy, and it’s hard for me to focus when I know I have other pts just sitting around waiting on me. And it’s kind of rude to them, because they want to get home to some decent food and a bed that doesn’t feel like a rubber bar mat, and the extra hour or two of hospital time just drags.

Fortunately, I have become very good at quick discharges. Mostly this just means I’ve learned to use our charting program at top speed, and am pretty good at explaining things to people in ways that they understand. Discharging requires a doctor’s order—not always a simple hurdle, since sometimes doctors wander off in the middle of the shift to take care of their other pressing responsibilities—and then a list of tasks for me to complete before they can leave.

Medications for discharge, and any home health care equipment, have to be finalized and called in to the pharmacy or medical supply agency. Drains and IVs need to be removed; clothing and belongings packed and double-checked (everyone seems to leave their cellphone chargers). I print out take-home instructions and a hospital summary, list all the medications they’ve taken and when, and the next time they’ll need to take them. I write notes about their care plans and education, and tick about six dozen little boxes to indicate that we actually took care of the pt while they were staying here.

Then I go in the room with a couple of pens and a ream of paperwork, pull up a chair, and start educating.

Every new medication and every dosage change requires some explanation. (I usually start the education process well in advance of discharge when I get the chance; if a pt is awake enough to understand that they’re taking a pill, or their family member is in the room while I’m giving the pill, somebody is getting educated about what I’m administering.) I tell them common side effects and what to do if they miss a dose, a little bit of pharmacology in layman’s terms, and a sheaf of paper to be read at home with a slightly more in-depth explanation.

We talk about what happened to them while they were in the hospital, why they came in, and what they can do to avoid coming back. We talk about smoking and why it’s crucial that they stop. We talk about warning signs that demand a doctor’s appointment, or an urgent care visit, or a call to 911. I make sure they have their last round of pain meds before they leave, and we sign the paperwork together, and then I call a volunteer to wheel them down to the lobby so they can leave.

You can see why this might take a while. And you can probably see why almost nobody gets discharged from the hospital before 1100. Thus, you can probably surmise that I was running around like my ass was on fire for the four hours before this pt arrived.

And I got both of my tele pts out the door.

Which turned out to be a really damn good thing, because Wieszczek’s case was a complete disaster from the moment the elevators opened. Somehow in transit all his lines and wires had become so entangled that by the time the door dinged, the bed couldn’t be moved without tipping over the IV pole and hauling on his arterial line. I managed to squeeze into the mess and help dislodge the offending snag—some metal chunk of the bed had snared itself in a coil of tubing—and we finally got him out into the hallway, still unconscious and intubated, the RT squeezing his breathing bag every few seconds to keep him ventilated.

When we reached his room, we got another surprise: somehow his twenty-something daughter had wandered into his room already instead of staying in the waiting room, and was having a complete breakdown in the corner. Eyes wide, tears streaming, gnawing on her fingers and sobbing aloud—this is not something you want happening in the room while you’re trying to land an unstable pt from the OR. I don’t think she saw much of her father in the bed, considering that the entire OR team was crawling all over him trying to manage lines and tubes, but she had definitely been working herself up to see (and react to) something horrible, and before we’d even realized she was there she started screaming and wailing.

I ushered her into the hallway and flagged down a coworker to guide her back to the waiting room. Then we set to work hooking him up to the ventilator, pumps, monitor, suction, and all the dings and whistles the hospital room had to offer. As we set everything up, I realized that his daughter had written on the whiteboard.

I mean, she had completely erased everything but my name, and markered in her own versions. The board introduced me to ‘Wishbone’, whose care plans included “Get better in a goddamn hurry” and “Eat a bowl of Tommy’s gumbo.” In the space where I usually write family phone numbers, she had written a quick scrawl about her father: “A hard-workin’, trombone-playin’, Cadillac-drivin’, SUPER DAD who never gives up, never stops smiling, never met a stranger, never put up with nothin’!”

She had written it in Sharpie instead of dry-erase marker. I made a mental note to get ‘Wishbone’ looking good before I let her back in the room.

Wishbone was here because his guts had done something terrible. He had a major allergy to dairy—not just an intolerance, but an allergy—and somebody had done that thing to him that people love to do when they hear someone has an allergy. Yeah, they had poisoned him. Some asshole had made some kind of dip at a party, and assured him that they’d made it entirely out of soy and almond milk when in fact it contained sour cream. Turned out, this self-righteous chef didn’t believe he was “really allergic” and wanted to prove him wrong.

For the next three days, Wishbone had suffered agonizing cramps, increasingly bloody diarrhea, and debilitating intestinal swelling. Finally, the morning after he’d checked himself into the hospital, his wrecked innards had become so swollen and damaged that they ruptured.

Just a little note here, for anyone reading this who might be tempted to test someone’s allergy status for themselves: DO NOT DO THIS THING. Nobody gives a quarter of a wet fart whether your coworker’s cousin is really gluten-intolerant or allergic to tomatoes, or just secretly trying to get attention. If you don’t want to cook something that accommodates an allergy, just cook whatever you want and label it appropriately. I promise you, they’ll get the message that you don’t like hearing about their allergies.

I really wonder what amateur allergy detectives think will happen when they make their big reveal: GASP, the salad had peanuts in it after all! Everyone will stand up and clap, and the malingering liar will slink away into the shadows, never to be seen again! I mean, what the fuck, best case scenario everyone will look away awkwardly and the faker will move the goalposts and insist that her allergy doesn’t show immediately but she’ll certainly have diarrhea for the next week. Worst case scenario, you get to watch somebody’s kid die.

Or, in this case, you get the satisfaction of putting a guy through abdominal surgery so surgeons can remove a length of his gut and wash out all the shit that spills from his broken bowels and open an ileostomy to divert everything away from his ravaged colon. You know, if you’re into that.

Wishbone was in for one hell of a ride. He was teetering on the edge of sepsis and needed tons of fluids to replenish what he was losing to the full-body swelling that comes with catastrophic infection. Pressors kept his blood pressure up and his toes cold and blue; the ventilator breathed for him, forcing air into lungs so stiff from swelling and pressors they could barely transfer oxygen into his blood. He was also on high-dose steroids.

No, we weren’t trying to get Wishbone swole. Steroids are actually quite common on the ICU, and their side effects can be simultaneously life-saving and devastating, because anabolic steroids—the muscle bulkers—are a relatively small subset of the huge steroid family of body chemicals. To give you some idea of the scope of this spectrum, both cholesterol and testosterone are steroids. (Thus the -ster- infix.)

The steroids we give in the ICU are typically glucocorticosteroids—that is, glucose-mediating steroids secreted by the adrenal cortex. Gluco-cortex-o-steroids. Naturally, they do a hell of a lot more than mediate glucose, but that’s one of the biggest effects they have on the body: raising your blood sugar in a hurry.

Why the fuck do you have some chunk of meat in your body, secreted by your adrenal glands, dedicated to skyrocketing your blood sugar? Let us explore this question by telling a story.

If you’re out camping and you see a bear and the bear sees you too, you’re going to need some things to happen in your body very quickly if you want to survive. Adrenaline and its buddy nor-adrenaline take care of this immediate response, jacking up your heart rate and blood pressure, signaling your body to make a lot of energy (glucose) ready for rapid use, and diverting blood flow from your gut (you can digest later) to your muscles (you can run now). You might also piss and/or shit yourself, because if you gotta sprint for the horizon, you don’t need the weight of a full bladder and gut. Adrenaline and noradrenaline are here to help you jettison the extras.

These chemicals are so potent and so fast-acting that we use them in the ICU as pressors.

Yes, adrenaline is also known as epinephrine. Your adrenal glands sit on top of your kidneys—thus, epi-nephrine, literally “on kidney.” And nor-adrenaline, the buddy chemical, also goes by norepinephrine, whose brand name in a bag is levophed. Yeah, the nasty pressor that makes your toes drop off. You can see why you don’t want this pouring into your system all the time.

But supposing that, in the process of running from the bear, you get completely turned around and lost and now you’re wandering through an entire forest full of bears. You’re gonna be here for days, eating nothing but granola bars from your pockets and thimbleberries from the riverbanks, sleeping for thirty minutes at a stretch when you can’t stay awake anymore, hiding from bears and jumping at every noise in the brush. You’re going to need quick energy at a moment’s notice; you’re going to need your resources diverted from useless shit like “making sperm” and “building dewy-fresh skin” to really crucial stuff like “grow monster quads” and “staying awake all night.”

You can’t afford to get sick here, in bear country. You can’t afford hay fever or asthma. You can’t spend a lot of effort on keeping your skin supple and healing all its little cuts. If you get a wound, you can just haphazardly scar it shut. If you have an infection, you can worry about mounting an immune response later, once you’ve escaped the bears. If your lungs are in danger of being damaged by cold air or weird pressure changes or irritating chemicals, or if your body just thinks it’s in danger and reacts by clamping your airway shut in a huge asthma attack, well… you can grow lung tissue back, later, if you survive the bears.

And you can’t just keep making deadly pressors to spur your current resources to the max. Eventually your body will give out. You’re gonna need to remodel your innards to respond to lower doses of adrenaline, and to stay primed for disaster. Your body is going into stress mode, and for that it needs a steroid.

These glucocorticosteroids are made in the adrenal glands themselves, right next to where adrenaline squirts out into the body. They aren’t nearly as powerful, but they do some of the same things, like keeping your airways open even when they feel threatened, diverting resources from your skin and stomach to your muscles, and shutting up your immune system when it gets mouthy. They do this indefinitely, changing your whole body in response to stress.

They are not good chemicals. Over time, elevated cortisol levels—that is, the primary stress steroid hormone—can really wreck your shit. Your skin thins and tears, inside and out; your blood vessels scar instead of healing, forming scabs and lumps that grab cholesterol and platelets and turn into huge plaques. Your guts struggle to process the protein and nutrients you need to keep yourself healthy. Fat deposits form in strange places, tossed into the corners of your body for fast access rather than stored in the proper places that look pretty good with some fat on them. Sure, your allergies stay under control, your immune system is too gobsmacked to mount a decent case of sepsis, and your asthma- or COPD-ridden lungs relax open. But the cost to your body is enormous.

And if you have wounds, like huge surgical wounds where half your guts were chopped out… your wounds don’t heal.

So here was Wishbone, packed to the gills with steroids to interrupt his sepsis and knock out his allergies, pinched all over with panic-hormone pressors, trying to get blood flow to his guts and seal the slash in his belly. I knew that first day it was going to take him quite a while.

It took us days to get him extubated; his pain was difficult to control, and he went into a panic spiral every time we dropped his sedation at all. His daughter clung to his bedside, increasingly pale and drawn, watching her father struggle to heal against the barrage of chemicals that kept him alive at tremendous cost. We tapered the steroids slowly, and slowly he gained ground, until we were able to pull out the breathing tube and let him wake up completely.

Typically, on the ICU, things either go quickly or they go badly. It’s not uncommon for the healing process to drag out over days and weeks, even months; but the longer you’re on the ICU, the more likely your body is to run out of reserves and pull something really bad on you. A clot, an infection, a fall, a complication of inactivity—with every day you spend in the hospital, your risk rises. And if you were super sick to begin with, you’re already starting from a place of high risk.

So every time Wishbone made a little progress without a major complication, it was a huge deal for all of us. He swung his legs over the side of the bed and, with our help, dangled his feet on the floor; he had his central line removed and a PICC line placed; he tolerated a few ice chips, had a CT come back clean for intestinal leaks, spent twenty-four hours in a row without any pressor support. His kidneys didn’t fail. His lungs resisted infection. His blood flowed without clotting.

Wishbone, against all odds, was escaping the bears.

Finally, after weeks of IV nutrition and bowel rest, the GI doctor put his stamp of approval on a solid diet for Wishbone. Nothing challenging, mind you—an egg salad sandwich on white bread, untoasted. We put in the order and I sat by his bed, running over the beginnings of discharge education, knowing that he and his daughter would be going home in a few days. We talked about his medications, and about his car; we talked about physical therapy, and his jazz band and his trombone. His daughter works at a sushi place, and he couldn’t wait to head back there for happy hour. I made his appointments for the next few months, and taught him to use his ostomy appliance.

The egg salad sandwich arrived, and I set up his tray: fork, juice, napkin, covered plate. As we talked, I did the automatic nurse thing and opened his sandwich for him, to slather mayonnaise inside, because an egg salad sandwich without mayo is like Yellowstone-flavored kindergarten paste.

From the egg salad sandwich rose the unmistakable smell of ranch dressing.

It took me a moment to realize what I was smelling and seeing. There was definitely, absolutely ranch dressing poured on the egg salad. I would never have expected it—ranch on egg salad sounds like some kind of obscene joke. But, you know, it’s a fucking hospital cafeteria, they make grosser dishes. (Do NOT eat the “autumn lentil stew.”)

And you know, for all my ranting earlier, something in my midsection wanted to say: I’m sure it’ll be fine, his chart says ‘dairy allergy’, I’m sure nobody in Dietary would put ranch dressing on an egg salad sandwich. Ranch dressing has buttermilk in it, isn’t that low in lactose? Nonsensical, bargaining, rationalizing thoughts.

I mean, here I was looking at a guy I’d spent almost a month trying to save, a guy who was only here because some person fed him dairy, and I didn’t want to believe anything would go wrong if I gave him ranch dressing. I had thirty other things to do. He was hungry, and it would be cruel to make him wait longer for solid food. It was just, you know, a little ranch dressing.

For a few moments, I saw some dark apathetic thing lurking inside me, something that didn’t want to believe in a food allergy because it was inconvenient, something that figured I could just give him antihistamines if it was such a big deal. It wasn’t a drug, something that I needed to scan because it could be dangerous. It was just a sandwich.

Then I took the sandwich away and told him what was wrong with it. I called Dietary and told them what had happened, and ordered him a new sandwich, absolutely dairy-free. I filled out an incident report sheet. I waited by the room for his meal to arrive, and I inspected it like I thought somebody might be smuggling drugs inside it.

Once it passed muster, I brought it to him, and he demolished it. I have never seen someone eat a sandwich with such shameless delight. He wasn’t nauseated at all, had no stomach pain, and after eating it he grinned ear to ear and declared it to be naptime.

I went out in the hallway and charted and took a few deep breaths, shaken by the near miss, and disappointed in myself for the few seconds’ temptation to let Wishbone be poisoned again.

But what the fuck, man. We’re all kind of apathetic, one way or another. The entire history of humanity, all our bright points have been places where we didn’t do the easy thing. The dark places haven’t been just the shadows of truly evil people—they’ve been long stretches of apathy, or of power maintained by exploiting that apathy. The vast majority of human suffering has resulted from people like me, people with a couple of discharges to get moving, people who smell ranch dressing and are tempted to let it slide just this once, even though we know.

Jeeze. I wonder, honestly, how many times I’ve fucked up and really hurt someone just by being a little lazy. Just a little. Shit like that keeps me on my toes.

Anyway, after that Wishbone was seriously motivated. His pain was still tremendous, and his body remained under heinous stress, but as we tapered off the steroids and his body started to recover, Wishbone found a new advantage.

It’s not easy to exercise, full stop. Like, I have no physical disabilities besides a mild case of nearsightedness and a vaguely bum knee, and the only exercise I get is lifting pts and performing CPR. Wishbone, however, despite debilitating pain and weakness, got his ass out of bed every chance he got, leaning on the cardiac walker (a tall padded walker you prop your elbows on), and walked as far as he could.

This is a big deal. I’ve talked about the importance of mobility before, but for Wishbone it was his secret weapon. He pushed his body so hard that his nurses had to remind him, over the next week, that exhaustion would be detrimental and he needed to leave himself some reserves. Each pain medication gave him enough time, pain-free, to stretch his legs or practice his deep breathing.

We gave him antibiotics, fluids, procedures, therapy—all the things he couldn’t do for himself. But Wishbone earned his way out of the hospital, and walked to the wheelchair that rolled him off the ICU for home.

He was a pretty rad dude. I’m glad he turned out okay. His ileostomy is due to be closed and his intestines re-attached sometime in the next few months. I hope things go well for him.

Meanwhile, I don’t remember if I told you guys about Crowbarrens, and I’m too lazy to re-read my own blog (and also self-conscious and I hate my own writing). He was out for a while, and we were all worried sick about him. Yes, worried about Crowbarrens.

Remember, the last time we saw him, his wife had threatened to kill him. Having him suddenly go missing for two months was genuinely not a good sign.

Then he came back. His wife claimed that he had been coughing up blood, earning him a spot in our negative-pressure isolation room for a day while we ruled out tuberculosis, which should have annoyed the crap out of him—he hates to even have the door to his room closed, because that keeps him from shouting at staff as they pass by.

He didn’t comment. He didn’t shout at all. We inflated the cuff on his trach, and he tolerated it just fine, asked to have it deflated for meals, let us brush his teeth and inflate it again afterward. He looked a little distant, distracted. He watched TV in silence and didn’t even complain during turns.

Needless today, we got him a CT scan stat. Something was wrong in there, even if the CT scan came back clean, and they took him down for an MRI later that day—mind you, not on any clinical findings, just on the fact that he wasn’t swinging punches at people.

While we waited for the results, Crowbarrens threw up a bellyful of blood. Turns out, he wasn’t coughing it up, he was vomiting it up. A quick EGD later, a biopsy sample sent to the lab, and we had our answer: Crowbarrens was being nice because he was really, really sick.

Crowbarrens has stomach cancer.

I mean, he’s been an asshole, this doesn’t change that. After a couple more visits and some medication and treatment, he was right back to screaming and demanding and verbally abusing his wife, although he hasn’t quite got back the gumption to swing at us. But man, when it comes to getting the short end of the stick, Crowbarrens not only has a terrible neurodegenerative disease, now he’s got fucking stomach cancer. It’s like life can’t help shitting on the dude. I wonder who he would have been, with his awesome name and his devoted wife, if things had gone a little differently with his body and his life.

Meanwhile, my coworker Leah recently went through an unexpected and thoroughly shitty breakup. I worried a lot about her—she had always seemed quiet and very conscious of others’ opinions—but since the split, the whole unit has seen her sort of… become a much louder, less apologetic version of the person she is. We’re all glad the asshole ex is gone, but we also kind of generally hoped that karma would kick in and provide us with some entertainment.

The ex got a new roommate, a laaaaaaaady roommate. A single lady roommate. A single lady roommate with… uh… a cat. And she left the cat there and went out of town. This is sounding less reboundish by the second, right?

It gets better. The cat was an impulse rescue. It has fleas. A week after its arrival and apparent abandonment by the single lady roommate, the cat has imbued the ex’s entire apartment with fleas.

The ex has fleas now. In his beard. He has beard fleas.

He has fleas that live IN HIS BEARD.


This is all I could have asked for, karma. Thank you. We’re even now.

115 comments:

  1. Holy shit Elise, you're amazing. From explaining why steroids are bad for you, to pointing out why it's called epinephrine, you teach so clearly and awesomely. We need a book, "Elise explains medical stuff in ways anyone can understand".

    ReplyDelete
  2. Thank you so much for your honest and important discussion of apathy affecting even the best of us. It's something we don't talk about and need to talk about more. I've been shocked at the ways I find myself getting complacent and apathetic the more I get used to nursing. Being honest and open about it probably helps to keep it in check; thank you for that!

    ReplyDelete
  3. Horrifying and fascinating story about the consequences of dairy allergy; I became allergic as an adult and had to work out what was going on myself through elimination due to disinterest from my GP when it turned out not to be lactose intolerance. I'm sick of arguing with people that I don't mean "lack toast" intolerant, and I just don't eat anything if I don't recognise what it is or can't read a label for ingredients. And I became sensitised to soy as well after trying to switch away from dairy milk. I wonder if this happened with Wishbone too and the poisoning was accidental. I sometimes have been testing new foods by just eating a little bit and seeing if it makes me shit blood but I am never going to risk that again knowing a bit more about how badly this can go wrong. Thanks Elise!

    ReplyDelete
  4. No worries, "Wishbone" is a nickname for Wiecziek the way his actual nickname was related to his actual last name (which was something totally different). Thus the asterisk after the first instance of his made-up last name!

    ReplyDelete
  5. Having had to spend time in the ICU of the hospital where I work because someone thought "I'm allergic to this thing" meant "I don't like this because I'm snooty", I want to go eviscerate the asshat who poisoned Wishbone. Preferably with something dull and rusty.

    Thank you for kicking ass, Elise. That weird moment of apathy? That's the monkey part of the brain that likes to see shit get flung against a wall. Good on you for squashing that fucker. Never doubt that you're a fabulous nurse, because you are. freaking. amazing.

    ReplyDelete
  6. This comment has been removed by the author.

    ReplyDelete
  7. Wow, you did great job writing such a big post. I'm not complaining, I love your writing style and I really love to read every single post you do. But you should rest more. Believe me, even if you try to up your rating of Freshessays.com, it doen't worth it.Just rest.

    ReplyDelete
  8. Really great post, Thank you for sharing This knowledge.Excellently written article, if only all bloggers offered the same level of content as you, the internet would be a much better place. Please keep it up!
    Click here:
    Microsoft azure training in btm
    Click here:
    Microsoft azure training in rajajinagar

    ReplyDelete
  9. I know you feel more happy when you get things done and best of all those things are your most precious treasure.
    Click here:
    angularjs training in chennai
    Click here:
    angularjs training in velarchery

    ReplyDelete
  10. Excellant post!!!. The strategy you have posted on this technology helped me to get into the next level and had lot of information in it.
    Blueprism training in tambaram

    Blueprism training in annanagar

    Blueprism training in velachery

    Blueprism training in marathahalli

    ReplyDelete
  11. Your good knowledge and kindness in playing with all the pieces were very useful. I don’t know what I would have done if I had not encountered such a step like this.
    Data Science training in Chennai | Data science training in bangalore
    Data science training in pune | Data science online training
    Data Science Interview questions and answers

    ReplyDelete
  12. It's very great post... Really you are... done a wonderful job Keep up the good work and continue sharing like this.
    Android Training in Chennai | Android Training in Kanchipuram

    ReplyDelete
  13. Whoa! I’m enjoying the template/theme of this website. It’s simple, yet effective. A lot of times it’s very hard to get that “perfect balance” between superb usability and visual appeal. I must say you’ve done a very good job with this.


    AWS Training in BTM Layout |Best AWS Training in BTM Layout

    AWS Training in Marathahalli | Best AWS Training in Marathahalli

    ReplyDelete
  14. Your Blog is really awesome with useful and helpful content for us.Thanks for sharing.... keep updating more information.
    Robotic Process Automation Training in Chennai | Robotic Process Automation Training in Taramani

    ReplyDelete
  15. I found this informative and interesting blog so i think so its very useful and knowledge able.I would like to thank you for the efforts you have made in writing this article.

    angularjs Training in marathahalli

    angularjs interview questions and answers

    angularjs Training in bangalore

    angularjs Training in bangalore

    angularjs Training in chennai

    ReplyDelete
  16. Nice Post! It is really interesting to read from the beginning and Keep up the good work and continue sharing like this.
    Microsoft Advanced Excel and VBA Macros Training in Chennai | Microsoft Advanced Excel and VBA Macros Training in Kanchipuram

    ReplyDelete
  17. Thanks for posting this useful content, Good to know about new things here,Keep updating your blog.
    iOS Training in Chennai | iOS Training in Tambaram

    ReplyDelete
  18. Nice blog.. Thanks for sharing informative blog.. its very useful to me..
    Python Training in Chennai | Python Training in Madipakkam

    ReplyDelete
  19. Awesome post. Really you are shared very informative concept... Thank you for sharing. Keep on updating...
    ISTQB Training in Chennai | ISTQB Training in Guindy

    ReplyDelete
  20. Very good and informative article. Thanks for sharing such nice article, keep on updating such good articles.
    Software Testing Training in Chennai | Software Testing Training in Saidapet

    ReplyDelete
  21. Good Post! Thank you so much for sharing this pretty post, it was so good to read and useful to improve my knowledge.
    Java Training in Chennai | Java Training in Chrompet

    ReplyDelete
  22. I have read your blog. It’s very informative and useful blog. You have done really great job. Keep update your blog.
    Graphic Designing Training in Chennai | Graphic Designing Training in Keelkattalai

    ReplyDelete
  23. The provided information’s are very useful to me.Thanks for sharing.Keep updating your blog...
    Ethical Hacking Training in Chennai | Ethical Hacking Training in Thiruvanmiyur

    ReplyDelete
  24. Your Blog is really awesome with useful and helpful content for us.Thanks for sharing ..keep updating more information.
    Android Training in Chennai | Android Training in Porur

    ReplyDelete
  25. Thanks its Great Article… I love to read your articles because your writing style is too good, its is very very helpful for all of us.
    Java Training in Chennai | Java Training in St.Thomas Mount

    ReplyDelete
  26. Have you been thinking about the power sources and the tiles whom use blocks I wanted to thank you for this great read!! I definitely enjoyed every little bit of it and I have you bookmarked to check out the new stuff you post
    Core Java interview questions and answers

    Java training in Chennai | Java training in Tambaram

    Java training in Chennai | Java training in Velachery

    Java training in Chennai | Java training in Omr

    ReplyDelete
  27. Very good and informative article. Thanks for sharing such nice article, keep on updating such good articles.
    Java Training in Chennai | Java Training in Meenambakkam

    ReplyDelete
  28. All the points you described so beautiful. Every time i read your blog content and i so surprised that how you can write so well.
    Software Testing Course in Chennai | Software Testing Course in Perungudi

    ReplyDelete
  29. Great post and informative blog.it was awesome to read, thanks for sharing this great content to my vision.
    Best Ethical Hacking Training Institute in Chennai | Best Ethical Hacking Training Institute in Velachery

    ReplyDelete
  30. This blog very easily understandable. Thanks for sharing such an informative post with us.This is a nice post in an interesting line of content.
    Robotic Process Automation Training course in Chennai | Robotic Process Automation Training course in T.Nagar

    ReplyDelete
  31. I am reading your post from the beginning, it was so interesting to read & I feel thanks to you for posting such a good blog, keep updates regularly.
    IOS Training Institute in Chennai | IOS Training Institute in Pallavaram

    ReplyDelete
  32. This is an awesome post.Really very informative and creative contents. These concept is a good way to enhance t
    angularjs Training in chennai

    angularjs Training in chennai

    angularjs-Training in tambaram

    angularjs-Training in sholinganallur

    angularjs-Training in velachery

    angularjs-Training in punehe knowledge.I like it and help me to development very well.Thank you for this brief explanation and very nice information.Well, got a good knowledge.

    ReplyDelete
  33. This is really too useful and have more ideas from yours. keep sharing many techniques and thanks for sharing the information.
    Best Java J2EE Training Institute in Chennai | Best Java J2EE Training Institute in Madipakkam

    ReplyDelete
  34. This is a nice post in an interesting line of content.Thanks for sharing this article.
    Advanced SoftwareTesting Course in Chennai | Advanced SoftwareTesting Course in Saidapet

    ReplyDelete
  35. Hi My Dearest Friends I am Puja Priya I am 21 Years Old and Young and Hot Ladies My Husband Divorced Me SO i am very unsatisfied are you single? So follow My Link

    |Escorts In Gurgaon|
    |Call Girls In Gurgaon|
    |Gurgaon Call Girls|

    |Gurgaon Escorts|
    |College Escorts In Gurgoan|

    ReplyDelete
  36. This comment has been removed by the author.

    ReplyDelete
  37. Very nice post here and thanks for it .I always like and such a super contents of these post.Excellent and very cool idea and great content of different kinds of the valuable information's.
    microsoft azure training in bangalore
    rpa training in bangalore
    best rpa training in bangalore
    rpa online training

    ReplyDelete

  38. Inspiring writings and I greatly admired what you have to say , I hope you continue to provide new ideas for us all and greetings success always for you.
    Keep update more information..


    Selenium training in bangalore
    Selenium training in Chennai
    Selenium training in Bangalore
    Selenium training in Pune
    Selenium Online training
    Selenium interview questions and answers

    ReplyDelete
  39. This is really too useful and have more ideas from yours. keep sharing many techniques and thanks for sharing the information.
    Web Designing and Development Training Institute in Chennai | Web Designing and Development Training Institute in Tambaram

    ReplyDelete
  40. This is really too useful and have more ideas from yours. keep sharing many techniques. eagerly waiting for your new blog and useful information. keep doing more.
    Best Java J2EE Training Institute in Chennai | Best Java J2EE Training Institute in Medavakkam

    ReplyDelete
  41. Good Post! Thank you so much for sharing this pretty post, it was so good to read and useful to improve my knowledge.
    Summer Course Training in Chennai | Summer Course Training in OMR

    ReplyDelete
  42. Nice Post! It is really interesting to read from the beginning and Keep up the good work and continue sharing like this.
    Vacation Course Training Institute in Chennai | Vacation Course Training Institute in Pallavaram

    ReplyDelete
  43. Really i enjoyed very much. And this may helpful for lot of peoples. So you are provided such a nice and great article within this.
    Vacation Training Course in Chennai | Vacation Training Course in Adyar

    ReplyDelete
  44. This is really too useful and have more ideas from yours. keep sharing many techniques and thanks for sharing the information.
    Summer Course in Chennai | Summer Course in Medavakkam

    ReplyDelete
  45. This comment has been removed by the author.

    ReplyDelete
  46. Really it's a good post.Your post give some idea to me. i gain more strength from Pure coconut oil in chennai.



    ReplyDelete
  47. Really i enjoyed very much. And this may helpful for lot of peoples. So you are provided such a nice and great article within this.
    Android Training Institute in Madipakkam

    ReplyDelete
  48. Good Post! Thank you so much for sharing this pretty post, it was so good to read and useful to improve my knowledge.
    Python Training Institute in Velachery

    ReplyDelete
  49. The standout among the most popular Pune escorts for the regular magnificence and business openings. A ton of tip-top men like you regularly visits this area for individual and expert work.
    Pune escorts

    ReplyDelete
  50. I have to search sites with relevant information on given topic and provi
    de them to teacher our opinion and the article.
    pmp certification malaysia

    ReplyDelete
  51. Really appreciate this wonderful post that you have provided for us.Great site and a great topic as well i really get amazed to read this. Its really good.
    date analytics certification training courses
    data science courses training
    data analytics certification courses in Bangalore
    ExcelR Data science courses in Bangalore

    ReplyDelete
  52. Great post i must say and thanks for the information. Education is definitely a sticky subject. However, is still among the leading topics of our time. I appreciate your post and look forward to more.
    www.technewworld.in
    How to Start A blog 2019

    ReplyDelete
  53. Excellent information with unique content and it is very useful to know about the information based on blogs...
    Graphic Designing Training in Chennai | Graphic Designing Training in Velachery

    ReplyDelete
  54. Informative and knowledgably for me but you can more improved its
    http://www.angelescort.in/ Jaipur escorts,
    http://www.angelescort.in/ Jaipur escort,
    http://www.angelescort.in/ Escorts in Jaipur,
    http://www.angelescort.in/ Escort in Jaipur,
    http://www.angelescort.in/ female escort jaipur,
    http://www.angelescort.in/ jaipur independent escort,
    http://www.angelescort.in/ Jaipur Escorts agency,
    http://www.angelescort.in/ Jaipur Escort Service,
    http://www.angelescort.in/ independent escort in jaipur,


    ReplyDelete
  55. Nice Post! It is really interesting to read from the beginning and Keep up the good work and continue sharing like this.
    Robotic Process Automation Training course in Chennai | Robotic Process Automation Training course in Porur

    ReplyDelete
  56. Pretty article! I found some useful information in your blog, it was awesome to read, thanks for sharing this great content to my vision, keep sharing.
    Tally Training Institute in Chennai | Tally Training Institute in Adyar

    ReplyDelete
  57. I have read your blog. It’s very informative and useful blog. You have done really great job. Keep update your blog.
    Best MCSE Training Institute in Chennai | Best MCSE Training Institute in Besant nagar

    ReplyDelete
  58. This is really too useful and have more ideas from yours. keep sharing many techniques. eagerly waiting for your new blog and useful information. keep doing more.
    JAVA and J2EE Training Institute in Chennai | JAVA and J2EE Training Institute in Velachery

    ReplyDelete
  59. very interesting topic.Helps to gain knowledge about lot of information. Thanks for posting information in this blog.
    IOS Training Institute in Chennai | IOS Training Institute in Guindy

    ReplyDelete
  60. wonderful thanks for sharing an amazing idea. keep it...

    Start your journey with In Software Training in Bangalore and get hands-on Experience with 100% Placement assistance from experts Trainers @eTechno Soft Solutions Located in BTM Layout Bangalore.

    ReplyDelete

  61. Also known to come with crucial offerings for its sensible, down-to-earth and important clients, Russian Call Girls in Dehradun really means in fulfilling their lives with cheerful moments to make love in concern to ensure them live their lives in a better way. Check our other Services...
    Hi Profile Escorts in Dehradun
    russian escorts in aerocity
    Call Girls in Surajkund
    Hi Profile Escorts in Rishikesh


    ReplyDelete
  62. Thank you very much, you wrote a very good post, you have written this post through your thoughts and this post is really beautiful, such a post has seen very little till date and I am thankful that you have posted this very well Written.
    Palam Vihar Escort Servcie
    Call Girls in Indirapuram
    Sushant Lok Escorts Girls

    ================================================================

    Escorts Service Sector 31
    call girls in noida
    Female Escorts in Gurugram
    Gurugram escorts
    call girls in manesar
    Bhiwadi Female Escort

    ReplyDelete
  63. very interesting topic.Helps to gain knowledge about lot of information. Thanks for posting information in this blog.

    Water Flosser

    ReplyDelete
  64. you have done a great job. I will definitely dig it and personally recommend it to my friends. I am confident they will be benefited from this site

    escort bangalore

    ReplyDelete
  65. This blog aware me about different programs which can become very useful for our friends and kids. Few websites provide combined courses and few of the are separately for single subject. Glad to get this information. Buy Real Driver's License Online

    ReplyDelete
  66. This blog aware me about different programs which can become very useful for our friends and kids. Few websites provide combined courses and few of the are separately for single subject. Glad to get this information. Buy Real Driver's License Online

    ReplyDelete
  67. Good Post! Thank you so much for sharing this pretty post, it was so good to read and useful to improve my knowledge as updated one, keep blogging.data science training in Hyderabad

    ReplyDelete
  68. The comment is good, there are some people in the world who do something. But the one who walks with everyone is a good person, really your post is very good and very unique thanx

    Call Girls Gurugram
    Call Girls Gurugram
    Gurugram Escorts Service
    Call Girls In Gurugram
    Call Girls Sector 1
    Call Girls In Noida
    Call Girls Sushant Lok
    Call Girls Palam Vihar
    CAll Girls Huda Metro
    Call Girls Phase 1

    ReplyDelete
  69. Really i enjoyed very much. And this may helpful for lot of peoples. So you are provided such a nice and great article within this.
    ISTQB Certification Course in Chennai | ISTQB Certification Course in Velachery

    ReplyDelete
  70. Good Post! , it was so good to read and useful to improve my knowledge as an updated one, keep blogging. After seeing your article I want to say that also a well-written article with some very good information which is very useful for the readers....thanks for sharing it and do share more posts like this.
    SAP Online Training

    ReplyDelete
  71. Before Data Science, we popularized the term Data Mining from an article published in 1996.This article referred to the overall process of discovering useful information from data. In 2001, William S. Cleveland wanted to take data mining to another level. data science course syllabus

    ReplyDelete
  72. Informative and knowledgably for me but you can more improved its
    jaipur escort | jaipur escorts | escorts in jaipur |

    indian escorts jaipur russian escorts jaipur housewife escorts jaipur college girls escorts jaipur high class escorts jaipur model escorts jaipur

    ReplyDelete
  73. The Massachusetts Bay Transportation Authority and others tap into real-time information to make accurate arrival-time predictions available to the public. data science course in india

    ReplyDelete
  74. Get huge discount on Home and Kitchen Appliances,Split and Window Air Conditioner, Mobiles & Laptops online , Television, Speakers & more electronics at best price.
    usha heater price

    ReplyDelete
  75. most people really want to be aware of.Thank you so much for sharing such an awesome blog
    AI Training in Bangalore

    AI Course in Bangalore

    ReplyDelete
  76. Thank you. I must appreciate you for providing such a valuable content for us. This is one amazing piece of article.
    AI Training in Bangalore

    AI Course in Bangalore

    ReplyDelete
  77. Great Blog to read, It gives more useful information. Thank lot.

    Big Data Hadoop Online Training

    ReplyDelete
  78. Very useful post. This is my first time i visit here. I found so many interesting stuff in your blog especially its discussion. Really its great article. Keep it up. Hemp Oil

    ReplyDelete
  79. https://cosmocratsoftwares.com/contact-us
    https://cosmocratsoftwares.com/

    ReplyDelete
  80. I was eager to find this page. I needed to thank you for ones time for this especially awesome read!! I certainly truly preferred all aspects of it and I likewise have you book-set apart to look at new data in your blog.

    contract of indemnity

    ReplyDelete
  81. A great website with interesting and unique material what else would you need.<a href="https://areteelsol.com/pce-industrial-plugs-and-sockets/>Weatherproof Plug & Socket</a>

    ReplyDelete
  82. The goal of sexual toys is to improve enjoyment and connection between lovers rather than to replace sexual interactions. Toys should be viewed as the cherry on top of the cake. Alone, they might make a decent cake, and you could always simply nibble on some cherries, but combined, they have incredible power. If you approach the introduction of sexual toys into your relationship with honesty, respect for one another, and an emphasis on intimacy and pleasure, it can be an exciting and gratifying adventure. Savor discovering new avenues and strengthening your bond with your significant other. <a href="https://www.cupidbaba.com/men-sex-toys/>Sex Toys for men</a>

    ReplyDelete
  83. This comment has been removed by the author.

    ReplyDelete