Case discussion

[Dr-Junior]

I want to open a discussion about a case I feel one of the challenging ones I've seen.

81 year old patient came 2 days ago to the ER with renal colic and a hydronephrosis on the right side and urosepsis was diagnosed. Pre-existing ilnesses: chr. renal failure stage 4, chr. heart failure NYHA 2, multiple heart valve insufficiency.
Antibiotics (Cefuroxim) was started after taking blood cultures which showed presence of E.coli.

Yesterday morning noradrenaline per pump with a rate of 0.5 μg/kg/min and a lactate of 7. PCT 70 and CRP 200. Then an emergency operation to relieve the obstruction on the right side, where pus was seen flowing out of the obstructed ureter.

Postoperative the patient was tachypnic, instable with a heart rate of 150/min. Due to bed issues in our critical care the patient was transferred to the intermediate care, where she had a CPAP mask and 0.7 μg/kg/min noradrenaline. Fluids were running on the rate of 200 ml/h. After noticing that urine output was nearly 0, 40 mg Lasix were administered, which didn't bring any benefit. Then 500 ml fluids over 20 min. were administered which afterwards the heart rate reduced to 120/min.

The patient didn't tolerate the CPAP mask despite morphin injection. The CPAP mask was removed and replaced by a normal mask with 3l/min O2. After 10 min., patient became unconscious and O2 Saturation decreased. At the same moment blood pressure reduced enormously despite high noradrenaline rate. Patient was intubated and CPR was carried on but was unsuccessful.

Was the 500 ml fluids postoperative the reason of the detoriaration of her condition? How can someone balance between giving fluids (to compensate intravascular volume in sepsis) and at the same time watching out not to aggravate the pre-existing heart failure?
What could have be done better in managing this case?

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[jdh71]

Why didn't urology deal with the obstructed ureter first thing? You had your diagnosis. Obstructed infected kidney is an emergency.

 

[chessknt]

Obviously we dont have the gestalt feel/look of the patient but aside from what JDH mentioned:

Antibiotic choice seemed a bit narrow for someone that sick--what if he had another organism or ESBL?
Fluid bolus or passive leg raise can help determine volume status, bedside TTE/cards help would have been good too; running continuous fluids at a rate too low to see any immediate impact and giving ineffective doses of lasix to someone with CKD4 may not be the optimal strategy to determine this.
Going from CPAP to 3L supplemental O2 in an unstable patient seems backwards, should have been intubated instead unless O2 sat was fine rbeathing 10/minute comfortably or something.

 

[deleted171991]

Lasix for obvious (worsening) septic shock. Will the person surrender her hospital privileges, please?

General anesthesia and surgery on a critical patient, in shock, when IR procedure should be enough, and when that patient is complicated even at baseline. Same.

Same for the person who increased the already high dose of norepinephrine postop, instead of adding a second pressor or fluids, or considering stress steroids. When 35 of levo don't work, the solution is usually not to go to 50.

Same for the hospital CEO who lets such jokers take care of critical patients.

You should really want this thread moved out of the public eye.

 

[tartesos]

It's easy to look back and find a lot of things that could be done differently, but it won't change anything so don't hurt yourself and take blame.
Btw who uses cefuroxime empirically anymore?


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[deleted171991]

It's easy to look back and find a lot of things that could be done differently, but it won't change anything so don't hurt yourself and take blame.
Btw who uses cefuroxime empirically anymore?


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Disagree. If patient on tons of levo, patient does not get Lasix (which is a direct venodilator). Same for morphine (histamine release, sympathetic antagonist, hello?!). Even an APRN would know that, or how to treat septic shock, or that urosepsis patients get much worse intraop and early postop.

A lot of malpractice material here.

 

[pulmoblast]

Trying to fix a restless agitated 81 year old on CPAP by giving them morphine and then giving nasal cannula after they fail CPAP...
????



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[deleted171991]

That morphine probably killed her, especially if some genius gave the full 2 mg to start with in a crashing patient with stage IV CKD, pulmonary edema or not. It cut off the sympathetic response that was keeping her barely alive.

The valvular disease is just the frosting on the cake. Where was the bedside focused echo with CO/VTI monitoring during all this time? Or at least a PAC? (Then OP would know what they did wrong.)

 

[SurfingDoctor]

81 year old patient came 2 days ago to the ER with renal colic and a hydronephrosis on the right side and urosepsis was diagnosed. Pre-existing ilnesses: chr. renal failure stage 4, chr. heart failure NYHA 2, multiple heart valve insufficiency.

Does he have an advanced directive?

 

[tartesos]

Disagree. If patient on tons of levo, patient does not get Lasix (which is a direct venodilator). Same for morphine (histamine release, sympathetic antagonist, hello?!). Even an APRN would know that, or how to treat septic shock, or that urosepsis patients get much worse intraop and early postop.

A lot of malpractice material here.

Just find the op and shoot him in the heart. Go for it.
Common sense is not that common anymore.... Smh


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[deleted171991]

Just find the op and shoot him in the heart. Go for it.
Common sense is not that common anymore.... Smh


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I have no issues with the OP who's a resident.

As much as I hate pointing fingers, it sounds that the attending dropped the ball in this case. Non-intensivist, I hope.

I haven't posted in a month, and don't enjoy doing it, but this story was too painful to read. Of course we don't have all the data and we are Monday morning QBs, but still... it walks like a duck and it quacks like a duck.

 

[Dr-Junior]

I'm a resident and what I did was after I talked to my seniors. Sir you are right she should have been intubated from the first moment she was instabile but what should I do as a resident after contacting and the refusal of our two critical care units to admit the patient?
I wanted to discuss what happened from a medical point of view not starting a fight.

This patient should have been operated once diagnosed but I'm responsible only for my part.

 

[deleted171991]

I'm a resident and what I did was after I talked to my seniors. Sir you are right she should have been intubated from the first moment she was instabile but what should I do as a resident after contacting and the refusal of our two critical care units to admit the patient?
I wanted to discuss what happened from a medical point of view not starting a fight.

This patient should have been operated once diagnosed but I'm responsible only for my part.

If the patient needs to be intubated, the patient should be intubated. The RT can stand there and bag her till they get a machine. You would be surprised how fast an ICU bed becomes available once that tube gets in. This is also where the attending comes into play.

Bad heart plus respiratory failure equal recipe for trouble, even without septic shock.

 

[jdh71]

I'm actually not that surprised when octogenarians with bad sepsis die. They live at the edges of their physiologic tolerances before they get sick. Factor in pre existing chronic illnesses.

This case was all source control and everything else is largely "details". It's like asking about a case where someone was pushed off a cliff into very deep rocky revive with a freezing cold water at the bottom. And trying to analyze if the person grabbed at the right roots and branches. Should have have remained limp or braced for impact? Whatever. The only exception here might have been the choice to intubate. Seems like this should have clearly been done sooner.

I doubt the Lasix killed the patient. Even if we allow for some venodilaton which arguably would have already been dilated in a bar distributive shock. The lack of UOP should have surprised no one though given the history.
The beans will get better or they won't. Initiate the crrt if or when needed and skip the Lasix. Ignore the UOP given the bigger clinical context. Occasionally you do need some diuretic with some pressor. But never in the middle of rip roaring distributive shock.

I even doubt the morphe killed the patient - at least from any vasodilator perspective. Though again. Septic shock failing NIPPV shouldn't be sedated for tolerance but rather intubated. Unless, obviously, the patient or decision makers didn't want intubation. Arguably the morphine may have worsened death from a resp standpoint.

A second pressor like Vaso seems reasonable with that kind of vasopressor need but I've never been convinced adding another alpha1 agent adds anything to a case that increasing the dose of the already present alpha1 agent doesn't. Assuming all you are interested in is the alpha1 effects. I have at times ran epi and norepi together when I'm looking to flog the heart a bit and the patient didn't tolerate dobutamine.

I also doubt all the echoes in the world or invasive monitoring in the world have saved the patient. None of our methods for trying to determine fluid responsiveness are completely accurate. I mean you need to pick one and try for some objective basis for a decision for or against further fluid hydration but you can do everything "right" for fluid resuscitation and still easily lose a bad distributive shock in an 81 year old patient which a bunch of stuff wrong at baseline.

It doesn't sound like "malpractice" to me but rather amateur. Sounds a bit like the resident(s) was thrown to the wolves. And someone who should have known better either didn't or wasn't being helpful enough.

 

[jdh71]

I'm a resident and what I did was after I talked to my seniors. Sir you are right she should have been intubated from the first moment she was instabile but what should I do as a resident after contacting and the refusal of our two critical care units to admit the patient?
I wanted to discuss what happened from a medical point of view not starting a fight.

This patient should have been operated once diagnosed but I'm responsible only for my part.

M and M's are tough. Which is kind of what you're asking for here. And I'm actually glad to see you trying to be self reflective in this case.

And I think you were let down.

With that said. I think my comments above are pretty good.

 

[deleted171991]

I'm actually not that surprised when octogenarians with bad sepsis die. They live at the edges of their physiologic tolerances before they get sick. Factor in pre existing chronic illnesses.

This case was all source control and everything else is largely "details". It's like asking about a case where someone was pushed off a cliff into very deep rocky revive with a freezing cold water at the bottom. And trying to analyze if the person grabbed at the right roots and branches. Should have have remained limp or braced for impact? Whatever. The only exception here might have been the choice to intubate. Seems like this should have clearly been done sooner.

I doubt the Lasix killed the patient. Even if we allow for some venodilaton which arguably would have already been dilated in a bar distributive shock. The lack of UOP should have surprised no one though given the history.
The beans will get better or they won't. Initiate the crrt if or when needed and skip the Lasix. Ignore the UOP given the bigger clinical context. Occasionally you do need some diuretic with some pressor. But never in the middle of rip roaring distributive shock.

I even doubt the morphe killed the patient - at least from any vasodilator perspective. Though again. Septic shock failing NIPPV shouldn't be sedated for tolerance but rather intubated. Unless, obviously, the patient or decision makers didn't want intubation. Arguably the morphine may have worsened death from a resp standpoint.

A second pressor like Vaso seems reasonable with that kind of vasopressor need but I've never been convinced adding another alpha1 agent adds anything to a case that increasing the dose of the already present alpha1 agent doesn't. Assuming all you are interested in is the alpha1 effects. I have at times ran epi and norepi together when I'm looking to flog the heart a bit and the patient didn't tolerate dobutamine.

I also doubt all the echoes in the world or invasive monitoring in the world have saved the patient. None of our methods for trying to determine fluid responsiveness are completely accurate. I mean you need to pick one and try for some objective basis for a decision for or against further fluid hydration but you can do everything "right" for fluid resuscitation and still easily lose a bad distributive shock in an 81 year old patient which a bunch of stuff wrong at baseline.

It doesn't sound like "malpractice" to me but rather amateur. Sounds a bit like the resident(s) was thrown to the wolves. And someone who should have known better either didn't or wasn't being helpful enough.

These are all excellent points, but there is a difference between falling from the edge of the cliff, and being "helped" by professional incompetence. We will never know if this patient would have died anyway. It's a very slippery slope to say that. It's the excuse I used to hear, in fellowship, from the lazy on-call attendings who wouldn't stay to help. And some of those patients did survive, despite all the bets on the contrary.

In this case:
1. The patient did not need surgery. The patient needed a nephrostomy tube. She was already too sick.
2. The patient needed well-titrated fluids and pressors. Meaning a continuous cycle of assess-treat-reassess-treat some more etc. We can debate how that assessment should be made, but this is not a diagnose-treat-walk away for 2 hours-patient. Or a 500 ml fluid bolus-patient. Or a non-intensivist-patient. She was so fragile that any mistake was magnified, like hand tremor on a telephoto lens.
3. The patient probably needed broad-spectrum antibiotics, regardless what that E. coli was sensitive to in vitro. This is septic shock, life or death.
4. The patient did not need furosemide or morphine, not even if this was pulmonary edema. They were both contraindicated at the time they were given.
5. The patient should have probably been intubated the moment they considered CPAP in a florid shock with a bad heart.
6. The fact that the patient crashed 10 minutes after the morphine suggests that morphine was the proverbial straw. Whether by sympatholysis, or sedation-related respiratory issues, who knows/cares. Everything up to that sounded subpar.
7. We should stop tolerating excuses, such as bad protoplasm in elderly, when the standard of care is not met. It's a human being, somebody's mother or grandmother, and they deserve better than here.
8. This patient needed a doctor. What kind of attending took care of her, and where was the attending all this time?
9. I hope the OP will learn from this. It's tough to prove malpractice in such a sick patient, but kudos to the OP for realizing something was really rotten in Denmark, and that the standard of care was probably not met.
10. Unsupervised trainees making mistakes should never be a valid excuse. There is always an attending of record, and the buck stops there. Team-care does not mean headless chicken anarchy, it means a benevolent dictatorship, where everybody gets only as much responsibility as their competence allows.

There were obviously gray areas here, that I painted in black and white. Of course hindsight is 20/20, and easy. Still, I see this scenario again and again, and I hope it will never happen to my family.

 

[jdh71]

These are all excellent points, but there is a difference between falling from the edge of the cliff, and being "helped" by professional incompetence. We will never know if this patient would have died anyway.

In this case:
1. The patient did not need surgery. The patient needed a nephrostomy tube. She was already too sick.
2. The patient needed well-titrated fluids and pressors. Meaning a continuous cycle of assess-treat-reassess-treat some more etc. We can debate how that assessment should be made, but this is not a diagnose-treat-walk away for 2 hours-patient. Or a 500 ml fluid bolus-patient. Or a non-intensivist-patient. She was so fragile that any mistake was magnified, like hand tremor on a telephoto lens.
3. The patient probably needed broad-spectrum antibiotics, regardless what that E. coli was sensitive to in vitro. This is septic shock, life or death.
4. The patient did not need furosemide or morphine, not even if this was pulmonary edema. They were both contraindicated at the time they were given.
5. The patient should have probably been intubated the moment they considered CPAP in a florid shock with a bad heart.
6. The fact that the patient crashed 10 minutes after the morphine suggests that morphine was the proverbial straw. Whether by sympatholysis, or sedation-related respiratory issues, who knows/cares. Everything up to that sounded subpar.
7. We should stop tolerating excuses, such as 81 year-old with bad protoplasm, when the standard of care is not met. It's a human being, somebody's mother or grandmother, and they deserve better than here.
8. This patient needed a doctor. What kind of attending took care of her, and where was the attending all this time?
9. I hope the OP will learn from this. It's tough to prove malpractice in such a sick patient, but kudos to the OP for realizing something was really rotten in Denmark, and that the standard of care was probably not met.
10. Unsupervised trainees making mistakes should never be a valid excuse. There is always an attending of record, and the buck stops there. Team-care does not mean headless chicken anarchy, it means a benevolent dictatorship, where everybody gets only as much responsibility as their competence allows.

There were obviously gray areas here, that I painted in black and white. Still, I see this scenario again and again, and I hope it will never happen to my family.

I think you make very good points as well. Though I'm not sure I can be quite as dogmatic and emphatic as you've been here. As I think often old folks with bad chronic disease isn't really an excuse but rather a reason things happen. Cases evolve and what seemed reasonable at the time with the luxury of the retrospectoscope now look definitely incorrect. Though this is a good reason to underline your fantastic point that patients this sick need very regular reassessment. I'm also cautious to throw around "standard of care" which is probably not really defined well enough in most critical situations to use outside of someone simply practicing obvious gross negligence. But reasonable people can reasonably disagree without being disagreeable on a few points.

I think we clearly agree about the source control, abx, Lasix, morphing, and intubation. Not to mention frequent reassessments and an objective rationale for fluid or no fluid. And for the rest I think I tend to side of the assumption of good intentions and motives and that folks were probably doing to the best they could to the extent of their abilities to know or do.

 

[deleted171991]

I am sure the people at bedside tried to do their best. That should also include recognizing when they are in over their heads, and asking for help early. If resident, call fellow. If fellow, call attending. If non-intensivist attending, call intensivist. If no ICU bed, call medical director. Etc. Always do the right thing for the patient, as if she were your mother, not somebody else's. Don't play with people's lives; mistakes in very sick patients can be costly.

The road to hell is paved with good intentions. That's what I want @Dr-Junior to walk away with.

Peace out.

 

[pulmoblast]

Yeah...
And...
Sometimes gomers die

And there ain't a thing anybody can do about it


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[leviathan]

You could argue the morphine should have been the first course of action in an 81 year old severely comorbid patient, along with a spiritual care consult.

If they want full care, then intubation should have been done up front. Severe vasopressor-refractory shock is an indication for intubation that is often forgotten.

 

[leviathan]

A second pressor like Vaso seems reasonable with that kind of vasopressor need but I've never been convinced adding another alpha1 agent adds anything to a case that increasing the dose of the already present alpha1 agent doesn't. Assuming all you are interested in is the alpha1 effects. I have at times ran epi and norepi together when I'm looking to flog the heart a bit and the patient didn't tolerate dobutamine.

Correct me if I'm wrong but vasopressin works by V1/V2 receptors and not by alpha receptors, which is the rationale behind adding it when someone's on escalating doses of norepi. Still no evidence it makes a lick of difference...

 

[jdh71]

Correct me if I'm wrong but vasopressin works by V1/V2 receptors and not by alpha receptors, which is the rationale behind adding it when someone's on escalating doses of norepi. Still no evidence it makes a lick of difference...

That was my point. The only reason Vaso makes any sense.

 

[deleted171991]

I wasn't talking about vaso necessarily. There are a number of patients who do better on epi than on levo, and that's the reason why epi is considered, in many places, the second pressor to add/try. Especially in a bad heart situation where there might be a component of heart failure. Yes,, I know that acute HF is not treated with inotropes, and I know the risks, but I have also seen patients with mixed cardiogenic and septic shock turn around after epi or dobutamine.

What I wanted to see is that somebody tried to do something, not just watched the patient worsen. If it works don't fix it, but if it doesn't... do at least a damn bedside echo, look at that heart.

 

[RuralMedicine]

If the patient needs to be intubated, the patient should be intubated. The RT can stand there and bag her till they get a machine. You would be surprised how fast an ICU bed becomes available once that tube gets in. This is also where the attending comes into play.

I had a huge "black cloud" as a resident and some of the worst calls (in retrospect, I'm probably a better attending for it now) but the reality is that sometimes you have to do what you have to do even if that is intubating on the floor at 3AM and then explaining to the less than thrilled nurses that there really are not any beds available in any of the ICUs in the hospital and the patient will have to physically stay in their room until a bed opens up. We did have an extra ventilator so that wasn't the issue and the ICU night nurse manager basically took the patient until 7AM shift change when they sent an ICU nurse down to the take over. It wasn't ideal but there really weren't any other options.

 

[deleted171991]

I used to fight with the hospital bed manager every few call nights, about making a patient ICU-status after "I had been told" that there were no ICU beds. I couldn't care less. If the patient really needed ICU (because of the gravity and/or poor quality of care), the patient was upgraded to ICU status, and the critical care team took over. Sometimes that decision saved a patient's life (e.g. the difference between drowning an elderly decompensated right ventricular failure in fluids for "hypotension", in intermediate-care, versus gently diuresing her for 2 days, while supporting the BP with phenylephrine, in the ICU). All some patients need is a competent and caring doctor.

Always do what's right for the patient, including comfort care. Find out what the patient would want, and use the golden rule.

 

[aspergilloma]

any ABGs?

(1) way too narrow of antibiotics, IMO. without looking at the H&P, I would assume that she was at risk for ESBLs based on her multiple sig comorbs. I prob would've had her on Zosyn and possibly even +levaquin depending on what her vitals did the night of admission
(2) prob should've gotten a perc neph placed before she even landed in the unit/IMC. Hydronephrosis + sepsis + horrible comorbs = make Uro tell you "no", then talk to IR. Did imaging reveal a stone (not that that would've chaned things dramatically)?
(3) (presumed) GNR sepsis in a frail old lady makes me think endotoxin shower/risk for ARDS. Can't imagine going the nasal cannula/morphine route when she fails CPAP. curious to see what the ABGs/CXRs were when she was failing the CPAP

 

[aspergilloma]

This case was all source control and everything else is largely "details".

*double like*

hours matter when you've got bugs pouring into their bloodstream. hot gallbladder, NSTI, whatever.

in this case: longer time to source control = more GNRs circulating = more endotoxin showers every time they get that beta-lactam dosed.

 

[Hernandez]

Yeah, sounds like very little finesse in management but at end of a day sick lady who very well could have died in the icu, the icu refusal is interesting and let's face it, I'm sure we all know some of us who are dinguses and are demeaning and not helpful when asking for help.

So yeah, sounds like a little slow on source control, improper level of care disposition, slow to recognize respiratory decline and intervene, contradictory medication approach in acutely ill pt (yes I'll diuresis some pts on pressors And give free water while diuresing) but the key is the acuity. And again, lack of finesse which is likely a function of training level/experience.

And for future reference, if you disagree with the icu about admission, you need to remain the patient advocate and call them again and ask for a in person evaluation or call your attending and make it their fight.

 

[jdh71]

Yeah, sounds like very little finesse in management but at end of a day sick lady who very well could have died in the icu, the icu refusal is interesting and let's face it, I'm sure we all know some of us who are dinguses and are demeaning and not helpful when asking for help.

So yeah, sounds like a little slow on source control, improper level of care disposition, slow to recognize respiratory decline and intervene, contradictory medication approach in acutely ill pt (yes I'll diuresis some pts on pressors And give free water while diuresing) but the key is the acuity. And again, lack of finesse which is likely a function of training level/experience.

And for future reference, if you disagree with the icu about admission, you need to remain the patient advocate and call them again and ask for a in person evaluation or call your attending and make it their fight.

Gotta admit the blocking of transfer to the unit is puzzling to me.

 

[tartesos]

Whenever I had that problem, I intubated him and then asked questions, and a bed and nurse suddenly became available in PACU or the unit.
It is not my problem if there are no nurses or beds, what needs to be done has to be done to keep the gomer alive( no matter how futile that may be).

 

[Hernandez]

Gotta admit the blocking of transfer to the unit is puzzling to me.

I can see it happening relatively easily, pt is Relatively stable resp, marginal bp and post op anesthesia buffing the chart to get out of pacu so they don't want a pt to take a bed that's going to wear off the voodoo the gas passers have given in an hour or two.

I've gone done and evaled many like this, but personally unless they come off pressors quickly, I always just took to unit because they can and do crump. And if I blocked I always had 1 in person f/u eval and another call to the nurse afterward to double check stability. It's a pia but if you make big boy decisions you have to have big boy follow through.

 

[tartesos]

I can see it happening relatively easily, pt is Relatively stable resp, marginal bp and post op anesthesia buffing the chart to get out of pacu so they don't want a pt to take a bed that's going to wear off the voodoo the gas passers have given in an hour or two.

I've gone done and evaled many like this, but personally unless they come off pressors quickly, I always just took to unit because they can and do crump. And if I blocked I always had 1 in person f/u eval and another call to the nurse afterward to double check stability. It's a pia but if you make big boy decisions you have to have big boy follow through.

That's so true.
I've never found pleasure in being a wall for unit transfers.
Most of the time even with stupid requests if they are asking for your help, you are obviously the best person to take care of that patient, and I just took them because it was the best for the patient.
Of course sometimes there a simple solutions that you can implement on the floor, and I've done that many times, but kept the patient on my list at least for a day to follow up.

As an attending I have not encountered that, as my Icu is open,whatever it is it just gets there and then they call me.


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[jdh71]

Whenever I had that problem, I intubated him and then asked questions, and a bed and nurse suddenly became available in PACU or the unit.
It is not my problem if there are no nurses or beds, what needs to be done has to be done to keep the gomer alive( no matter how futile that may be).

Best way to get someone into the unit!!

 

[tartesos]

Best way to get someone into the unit!!

Lol, nobody in their right mind can say no.


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[jdh71]

I can see it happening relatively easily, pt is Relatively stable resp, marginal bp and post op anesthesia buffing the chart to get out of pacu so they don't want a pt to take a bed that's going to wear off the voodoo the gas passers have given in an hour or two.

I've gone done and evaled many like this, but personally unless they come off pressors quickly, I always just took to unit because they can and do crump. And if I blocked I always had 1 in person f/u eval and another call to the nurse afterward to double check stability. It's a pia but if you make big boy decisions you have to have big boy follow through.

Maybe it's because everywhere I've been both training and work we didn't block unit transfers unless they were just so objectively stupid it was ridiculous.

 

[tartesos]

Maybe it's because everywhere I've been both training and work we didn't block unit transfers unless they were just so objectively stupid it was ridiculous.

I had 3 co fellows who loved being a wall( taking after 1 attending), and whomever came after them was always dealing with crap coming from the floor. It`s out there.

 

[Hernandez]

Lol, nobody in their right mind can say no.


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So you don't the guy who'd gladly extubate to some insane NPPV settings to punt?

 

[tartesos]

So you don't the guy who'd gladly extubate to some insane NPPV settings to punt?

Lol
Not in his right mind.... One of our former staff loved that, and my statement stays the same.


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