"I am about to kill my mother"

Sarah Lyall:

I am looking for a way to put this off as long as possible, and so I start watching one of the final episodes of the TV drama “The Americans.” Today, Keri Russell, playing a Russian agent, is spying on a State Department official by posing as a nurse for his terminally ill wife.
The agent is a stone-cold murderer, but she feels desperately sorry for the official, whose attempts to help his wife kill herself with morphine have left her in a gasping, not-dead limbo. So Keri Russell finishes the job by shoving a paintbrush down the woman’s throat and holding a plastic bag over her head.

This is not a good time to be watching this particular scene.

Right now my mother is in bed across the hall, in the endgame of Stage 4 lung cancer. She is nearly 83, she has had enough, and she is ready to die. More specifically, she is ready to have me help her die.

I can see her point.

An unsentimental, practical person, she has for many years been preparing for the moment when death would become more alluring than life. We have talked about it nonstop since she received her diagnosis about three months ago and, like Gloria Swanson going up in a blaze of grand pronouncements, declared that she intended to forgo chemotherapy... (continues)

Readers respond...

Vaccines and Immunity

BETWEEN HOPE AND FEAR 
A History of Vaccines and Human Immunity 
By Michael Kinch
334 pp. Pegasus Books. $27.95.

As Michael Kinch tells us in “Between Hope and Fear: A History of Vaccines and Human Immunity,” vaccinations have saved millions, possibly billions, of lives. Along with antisepsis and anesthesia, they rank as one of the greatest achievements of scientific medicine. It is therefore deeply disturbing that in recent decades a significant minority of people in the world’s wealthier countries has become opposed to them. This anti-vaccination movement has even been given the nod by Donald Trump. To be effective, a vaccine requires that at least 95 percent of a population receive it — a phenomenon known as “herd immunity.” If even a small number of parents decide not to have their child vaccinated because of an alleged (and usually spurious) risk from the vaccine, they are putting enormous numbers of children at risk of contracting the disease the vaccine protects against.

Until the 19th century, human life was dominated by infectious illness. Up to 50 percent of children died before the age of 5, almost all from infections. Long exposure over centuries to some of these pathogens yielded some resistance, but the devastating potential of infectious diseases was demonstrated when Europeans arrived in the so-called New World. In Cuba and its surrounding islands, it is estimated that one-third of the population was killed by smallpox beginning in 1518, and two-thirds of the survivors by measles in 1529.




(continues)

Natural solace

	Robert Macfarlane (@RobGMacfarlane)
9/9/18, 7:30 AM "In the hospice where I work, I am often struck by the intense solace some patients find in the natural world": take a few minutes to read ⁦‪@doctor_oxford‬⁩'s beautiful & moving essay the power of nature & living joyfully, right to the end of one's time. nytimes.com/2018/09/08/opi…

Uninsured and underinsured

	Atul Gawande (@Atul_Gawande)
8/20/18, 6:13 AM Nearly half of all Americans in fair or poor health — 46.4% — are uninsured or have affordability problems despite having coverage. ⁦‪@DrewAltman‬⁩ axios.com/not-just-unins…

“Dopesick: Dealers, Doctors, and the Drug Company That Addicted America”

Fewer than 50 pages into Beth Macy’s “Dopesick: Dealers, Doctors, and the Drug Company That Addicted America,” one of the many opioid users she talks to — this one a mother in Virginia — explains how her addiction started in the early 2000s, after routine gallbladder surgery. “The doctor didn’t force me to take them,” she said of OxyContin and Percocet, two powerful painkillers she was instructed to take concurrently. But her doctor, she assumed, was a “high-standard person, someone you’re supposed to trust and believe in.”

If you want a glimpse into how the opioid crisis began, the woman’s words are a good place to start. She was aware of her own choice in the matter, but her physician instructed her to double up on highly addictive narcotics. An expert, someone supposed to know better, had betrayed her trust.

Books like “Pain Killer,” by Barry Meier, a reporter for The New York Times, and “Dreamland,” by the journalist Sam Quinones, have covered the opioid crisis in detail, but they appeared before the 2016 election, when the places in the country most affected by the epidemic went for Drumpf. With “Dopesick,” her third book after “Factory Man” and “Truevine,”Macy has waded into a public health morass that has also become a political minefield. Commentators on the left have pointed out the gaping discrepancy between the sympathy extended to today’s opioid users, who are mainly white, and the brutal, racist handling of the war on crack.

“Dopesick” touches on these political developments, but its emphasis lies elsewhere. Macy’s strengths as a reporter are on full display when she talks to people, gaining the trust of chastened users, grieving families, exhausted medical workers and even a convicted heroin dealer, whose scheduled two-hour interview with the author ended up stretching to more than six hours. (continues)

How to Quantify a Nurse’s ‘Gut Feelings’

"I had a nagging sense that something was wrong, but I couldn’t articulate it."
By Theresa Brown (Ms. Brown is a hospice nurse.)

At the start of my shift, at 7 a.m., my patient, newly admitted a few days before for a blood cancer, was talking and acting normally. By the end of my shift, 12 hours later, she had grown confused and her speech was garbled. A CT scan revealed bleeding in her brain. She was sent to intensive care and died the next day.

This was years ago, but the case still haunts me. I believe that moving faster on her treatment might have prevented her sharp decline. But the medical team didn’t share my sense of urgency, and no obvious red flags signaled a coming emergency. Without a worrisome clinical value or test result to point to, my concern alone wasn’t persuasive.

Every nurse likely knows the feeling. The patient’s vital signs are just a little off, she seems not quite herself, her breathing is slightly more labored. But on paper she looks stable, so it’s hard to get a doctor to listen, much less act.

In such situations nurses invoke “gut feelings,” but they actually aren’t feelings at all — they are agglomerations of observations and experiences that over time have turned into finely tuned clinical judgment. The idea is that working at the bedside has honed nurses’ perceptions to be especially alert to brewing trouble. (continues)

Why Doctors Should Read Fiction

Last week, Sam Kean wrote about a new paper in Literature and Medicine. The paper, he explained, argues that “certain literary exercises can expand doctors’ worldviews and make them more attuned to the dilemmas real patients face.”

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As a physician who teaches both ethics and creative writing to medical students and house officers, I appreciate the value of using fiction and narrative to enhance the training of future physicians. These tools are certainly helpful in cultivating humanistic and compassionate doctors. However, medical school is rather late in the game to introduce these techniques. Ideally, admissions committees at medical schools should be looking for students who are imaginative and who are already reading literature, including literature about illness and physician-patient relationships. One might argue for altering medical school admissions requirements accordingly—for instance, replacing required courses in Newtonian physics with those that foster creativity and emotional understanding. As a physician, I am often asked to listen to my patients’ stories with empathy; in contrast, not once have I ever had to calculate the trajectory of a patient to be shot out of a cannon.

Jacob M. Appel, M.D., J.D., M.P.H.
Assistant Professor of Psychiatry and Medical Education
Director of Ethics Education in Psychiatry
Mount Sinai School of Medicine 
New York, N.Y.

==

	The Atlantic (@TheAtlantic)
8/5/18, 5:32 PM Letter: Literature should be a medical school admissions requirement on.theatln.tc/ooFciqp

The annals of literature are packed with writers who also practiced medicine: Anton Chekhov, Arthur Conan Doyle, William Carlos Williams, John Keats, William Somerset Maugham, and on and on. As doctors, they saw patients at their most vulnerable, and their medical training gave them a keen eye for observing people and what makes them tick.

But if studying medicine is good training for literature, could studying literature also be good training for medicine? A new paper in Literature and Medicine, “Showing That Medical Ethics Cases Can Miss the Point,” argues yes. In particular, it proposes that certain literary exercises, like rewriting short stories that involve ethical dilemmas, can expand doctors’ worldviews and make them more attuned to the dilemmas real patients face.

(continues)

The End

Installment 2 - Selwa Kanakrieh

Jehovah’s Witnesses Refusal to Accept Blood Transfusions.

The firm belief by the Jehovah's witnesses to entirely refuse to acknowledge blood transfusion; despite the seriousness of a particular situation including an emergency case, is because they are taught according to their teachings that transfusion of blood is sacred standpoint that is not up to negotiation and that if anyone has value and esteem that their life is a God-given gift they shall in no way accept blood transfusion in order to maintain their lives (Hoffman, 2016).

The Jehovah's witnesses stand with their Bible teachings which claim that blood incorporation, blood transfusions as well as blood donations and storing of their blood for transfusion at a later date, may it arise, is forbidden. This entire belief of the Jehovah’s witnesses is derived from a scripture that is different from other Christian values; thus reason as to why Jehovah's Witnesses are well known across the globe.

Jehovah’s witnesses further explain that the reason as to why they would instead not accept blood transfusions is because it is their way of showing great respect to God. This is elaborated by the fact that they are allowed to eat meat regardless of the fact that it may contain some blood. The Jehovah's witnesses, therefore, claim that the problem is not with the blood itself. Nonetheless, it is the respect and value they give to God that brought up there making this decision.  

 Organ Transplant and Judaism

At one moment opposed, Jewish practice and law on organ donation have altered dramatically, which some perceive as the beauty of Judaism as a living and evolving religion. Because organ transplantation is a very successful approach to save a life, the donation of organs has been perceived a compulsory act, a mitzvah chiyuvit, by every significant branch of Judaism. 

All the same, it is worth mentioning that some Orthodox leaders differ on the manner in which time of the death of a donor, and prefer a point later than the death of the brain. Death of the brain which results in some organs being deemed unusable but even in such an instance the kidneys, barring the disease of the kidney, remain transplantable after the demise of the donor. For that reason, not to bequeath at least a number of an individual's organs has become a sin of the mitzvah of pikuakh nefesh, i.e. saving a life.

Pikuakh nefesh which is ‘saving a life' in the English language, is a fundamental value of the Jews, and at any given time 40,000 individuals appear on the waiting list of The United network for the sharing of organs. As such, there is a question of whether to conduct a body organ while alive is a mitzvah (Messina, 2015). The answer is that as long as it beneficial and will not bring risk to an individual’s donor’s life, the removal of organs surgically and their subsequent donations such as kidneys or lungs through an alive donor is a mitzvah kiyumit, a mitzvah that should be deemed as praise-worthy but never in any way an obligatory mitzvah, because with all surgery there exists some great fear and some risk. 

In summary three verses from the Old Testament Torah (the first five books of the Bible) frame the idea of organ donation: “Thou shalt not stand by the blood of your neighbor” [Leviticus 19:16], ‘Thou shalt surely heal” [Exodus 21: 19] and “You shall restore” (an object that is lost, which is inclusive of someone’s health )[Exodus 23: 4]. The part of Judaism that refuses organ donation is against a live person donating an organ such as a kidney to another while they are both alive and is based on Leviticus 19:16. As such, there is no problem if the donor is dead.

Human Experimentation 2nd installment- Zach Nix

In my first installment , I posed several questions about human experimentation. However, I tried to stay fair to both sides of the argument. In installment 2 I will be stating my opinions and reasoning.

            Concerning the use of undeniably unethical research results I believe that it should be treated in a case by case manner. Much like any scientific paper the research should be reviewed for inaccuracies or bias. Simply because an individual is amoral does not mean that the results they produce are skewed, though it does warrant scrutiny. If data obtained by slaughter can save lives then it does indeed produce a “unique opportunity” that otherwise would never have occurred. As was discussed in class the use of such data can even be seen as a way to honor the dead. If the lives taken provided data that saved lives then perhaps their deaths meant more than just a war crime.

            Concerning informed consent, I agree for the most part with common practices. Although the way in which researchers attempt to convey information to subjects needs to increase to ensure that the subjects understand the study and risks more fully. Of more interest is the ethics of terminal subjects in research. If a person is desperate due to a terminal diagnosis then it is more likely they may participate in a type of test that may be more likely to end in death. Most trails on gene therapy have been targeted to genes that cause dearth early in life and many of the tests have cause the premature death of the subject. These tests understandably make one uneasy and need to be carefully monitored, but if the patient understands that they are risking a slightly longer life in return for furthering the research that may one day prevent their situation in the first place, then it is easy to see the appeal. Tests outside of the body can only tell us so much when concerning a system as complex as the human body, therefore, research such as cancer studies need willing cancer patients or the disease will never be cured. Tests such as these are the reason that any progress in medicine has been made. Small pocks or polio would never have been cured if it was not for the pioneers who risked their lives in a study or procedure that could have ended their lives.

            A more nuanced issue concerning consent is the ability of the cognitively impaired to give consent in the first place. In the case of children, it is obvious that they do not fully understand the concept of death, not to mention the difficulty explaining a procedure or test. While I generally advocate against the ability of parents to declare the desires, such as religion, of their child, children represent a huge demographic with unique traits that require their participation in tests that outweighs the issues inherent in allowing a parent to make life and death choices for a child. In the case of mentally impaired children and adults the ability to understand their own situation may not be easily determined. In these cases the specific impairment often has legal structures already in place for decision making of these individual that should be used. But if not I believe that the ethical action is to only allow for these individuals to be research subjects if, despite impairment, they are consenting when the nature of the research is explained to the best of the researchers ability and that the research requires the specific participation of the impaired demographic for proper results.

I commented on Jonathan and Joseph's 2nd installments.     

Medical Conscience (Installment 1) Katelyne Tatum

Medical Conscience

Medical conscience advocates that medical professionals can refuse to perform a service for a patient when it goes against their moral belief unless the patient’s life is at stake. Since, the Roe v. Wade verdict many conscience laws have been enacted. Starting with providing abortion-related exemptions to healthcare professionals if abortion or sterilization services go against their religious or moral beliefs. Some states have also enacted “right of refusal” laws for pharmacists allowing them to refuse to fill a prescription that goes against their religious or moral beliefs, such as, birth control or plan B. Many of the conscience laws deal with abortion, sterilization, and stem cell treatments, but with the ever-changing healthcare system and advancements in medicine these laws will continue to expand.

While a medical professional can refuse to participate in a procedure that goes against their religious or moral beliefs that professional still has a duty to ensure the care of the patient. Therefore, if a medical professional refuses to provide a service then they are obligated to allow that patient to seek medical care elsewhere without interference; refusing to give a referral, stepping between the patient and another doctor, or making a patient feel uncomfortable or ashamed goes against the patient’s right to care.

While healthcare workers should have the right to be exempted from services or procedures they do not believe in the right of the patient to have access to care also needs to be taken into consideration. Some laws, such as, “right of refusal” for pharmacist conflict with other laws; when a pharmacist refuses to fill birth control or emergency contraception it interferes with a person’s right to privacy because she is denied the right to decide to use contraception. It also can be seen as unequal treatment of men and women. Another consideration to be taken is access to care; for low-income or rural areas if a professional refuses to provide a service, let’s say an abortion, then that patient may have no other way to receive care in the area. Though a procedure may go against a healthcare workers morality, can that same person also say it is moral to leave a patient with no access to care?

               Medical conscience is good for healthcare professionals because it allows them to keep their morality while providing care to patients. But we also have to consider that there may be instances where these laws hinder a patient’s right to care. And those healthcare professionals may have to put aside their reservations for a procedure if there is no other way for a patient to receive care they need.

Surrogacy (Installment 2)

Surrogacy (Installment 2)

           

           As mentioned in the previous post, there are two main problems associated with surrogacy: the legality of whose child it is and commercial surrogacy. Today, commercial surrogacy will be discussed.

According to WebMD, pregnancy is an emotional rollercoaster. Many women have mood swings during their pregnancy and can experience ups and downs. Sometimes, the emotions are extended beyond pregnancy as a form of postpartum depression. Deborah Issokson, a licensed psychologist, stated, ”Motherhood is such a permanent transformation”. With that said, a surrogate mother is still a mother; she will have her emotions rampant during her nine months of having a human growing in her womb. The child that she is carrying in her womb has no relation to her in most cases. The emotional toll of pregnancy can be devastating to many mother.

A surrogate is someone will to carry a child for another, that being said, should do it out of the goodness of their hearts, a truly altruistic endeavor. The involvement of a payment for this  life-changing event, would degrade the significances of child birth to both parties. The surrogate will merely be doing a “service” for the couple. The couple would use her as a means to obtain a child. There is not an amount of money that can constitute the price of a human’s life. That being said there is no price worth the risks associated with pregnancy, the potential of complications and/or death are high, roughly 50,000 women die from complications associated with pregnancy in the United States every year. The surrogate mothers are usually socioeconomically disadvantaged, and are performing the surrogacy for monetary reward upon delivery of the child. They are usually taken advantage of by the system. The majority of the cost associated with have surrogate mother is taken by the IVF clinics that impregnate them.

           The legality of whose child it is and the downsides of commercial surrogacy is a very real thing. People are taken advantage across both parties. The complications associated with surrogacy shows how precious life is. It also show how emotional impactful give birth is. Becoming a surrogate mother is truly a rewarding feat, and should be regarded as upmost selfless acts, one that should be done for the happiness of others and not for compensation.

Sources used:

https://www.webmd.com/baby/features/pregnancy-emotional-roller-coaster#1

https://theconversation.com/not-for-profit-the-case-against-commercial-surrogacy-18512

                                                      

https://www.womenshealthmag.com/life/a19972147/high-risk-pregnancy/

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Posted on Zach's and Cameron's

Installment numner 2

Solitary Confinement

In my previous post I discussed the physiological, and psychological effects of solitary confinement. In class we also discussed what a doctor, with the circumstances handed to them, would for those these patients in solitary confinement. The answers that I received were excepted, but I don't think that our opinions were from a "Doctor" stand point. What I mean by this is that I don't think that we thought, with the mindset that we took oath and saving lives is a duty that we must take part in. The more research that I have done on this topic showed me that I was no longer allowed to think with my personal feelings. As a doctor I have to think with my brain and not my emotions, I have to want the best for my patient regardless of what crime he or she has committed. I have to understand that as a doctor no matter what my everyday goal is to do what is best for my patient. With that in my mind I can't help but to think about the many people that are in solitary confinement and the amount of damage that they are going through while being in solitary confinement.

If the world was perfect and had the tools to employ more doctors. In my mind  the motto would be "rehabilitation before incarceration". What that mean is that Judges would look at the cases that are presented and based on what the charge was and the history of crime that person committed. For example, if the judge gets a case and has seen that the person has been committed of prostitution, drugs, and things of that nature. Once the case was viewed, the judge instead of committing this person of a crime he or she would make it a mandatory for this person to attend rehab, if this person doesn't then they should be sentenced to jail or prison time. In prison this person committed of the crime should still get the services of rehabilitation so that this person will be a better person when released back into society.

Now I know other things factor into play such as tax dollars that the Americans will spend, having to fix the judicial system as a whole (basically rebuild it so that people of all colors are heard). BUT if these things did spontaneously occur, I think that the "rehabilitation before incarceration"  would be an outstanding thing to implement. 

                                       

I know you guys are saying "what about the psychopaths, murders, child molesters, and rapist?!" " I  don't think they can be cured". I don't think they can either honestly. I still don't think that it's ethically right that we should put them in a cages, and allow them to get worse ( I'm thinking with the mindset of a doctor here). Here again I feel as a doctor we took an oath that basically says" the patients health is the primary focus", with the knowledge that I have on solitary confinement it is my goal to fix this situation as a Doctor. Below I  have a provided a link that kind of the same perspective of me.

                                             http://jaapl.org/content/38/1/104

                             

Hostile Architecture (Part 2)

As much as I would like to make my second post about things that are being done to critique hostile architecture, there just isn’t much that can be done. There have been efforts. Artists put spiked benches in parks that you must pay to sit on, filmmakers make videos to increase our empathy, there are public campaigns and organizations set up to help these people. Some thoughtful citizens even have set up pillows on benches, or sawed off the arm rests in the middle of a bench.

The group Unpleasant Design had an interview with the design team of Factory Furniture, which often designs public spaces based on what their commissioner asks for. When asked about how they thought society should think of homeless people, Factory Furniture responded with “Homelessness should never be tolerated in any society and if we start designing in to accommodate homeless then we have totally failed as a society.” I find this to be very true (other than the “totally failed” part, that seems a little extreme). Even though design is an incredible tool, it cannot change some of the larger problems that create the environment design is being used to shape. For homelessness, I have no solutions, but many ideas on small ways to aid the problem here and there, and maybe that’s all we need instead of a massive societal overhaul.

What I think is the important takeaway from this is that we become aware of the decisions that design is making for us, and if we are ok with them. Many of these designs end up beneficial for some, yet harmful for others. Every object we see was made with the intent to manipulate behavior in some way, sometimes in incredibly minor ways. It is of the upmost importance that everyone is educated about how our world is made as society get more and more complex, and as businesses and cities move to our smartphones next in ways that are not even tangible.

Here is the interview I used as a source in the post:
http://unpleasant.pravi.me/interview-with-factory-furniture-design-team/#more-512

Jonathan Cannon Installment 2

           In my previous post, I stated that I am in favor of organ transplant research and that I personally believe that studies that are done in organ transplant research should not be considered human subject research. In response to the presentation, other students were supportive of transplant research with some constraints. Concern was directed to the efficacy of the studies being done and experimentation should only be performed when there is a reasonably high probability of success. This was mostly due to the fact that there is such a high demand for organs and it would be too much of a risk if there was a chance for adverse effects that could result in damage to the organ making it unsuitable for a transplant.
            In the article posted be Zach Nix for his first installment on human exportation the author states, “Even in cases of studying particular conditions, such as childhood diseases, research is usually only seen as ethically justified if it imposes no real risk of harm or is likely to have some direct therapeutic benefit.” I thought this was particularly applicable to the subject of organ transplant research because organ donors could be considered unable to protect their interest. It is important to remember that these studies are not entirely left to the discretion of the physician leading the project. The research still has to be approved by an IRB before the study can even begin. If the IRB is able to determine that there is no real risk to either the donor or the recipient of the transplant than there should not be an ethical issue with the research.
            I believe that the social taboo of this kind of research lies in the public’s perception of medical experimentation. There is the perception that when studies are not considered human subject research, the members participating in the studies no longer have an advocate to protect their best interests, leaving them exposed to the ambition of the physician leading the research.
           The first step that could be taken to remedy this would be educating people on the process that and circumstances that are required to get approval by an IRB.
Another aspect that is not fully understood by many people is what exactly is at stake for the people that are on the organ transplant list. Even individual is fortunate enough to receive an organ transplant, they are not out of the woods yet. The success rate is only between 80-90% with some procedures having more risk associated with them than others. Research that is done for the preservation of the during the transplant process is one way that the success rate for transplant recipients can be increased.
            For the majority of us in this class, our intended profession will require us to educate people. Transparency goes a long way and all of us should be able to explain how research is done and the safeguards and oversight that individuals leading studies must adhere to. It is normal for people to oppose something they don’t understand and that is not necessarily a negative thing. If the general public had a better understanding of things like the function of an IRB this would go a long way in changing public opinion and provide more open-mindedness to organ transplant research.







I commented on both Joseph's and Clorissa's posts

Medical Complications by Ana (Installment #2)

Thank you all for your participation in my presentation. The video displayed, as Dr. Oliver stated, was clearly disturbing and I agree. Here are many of your thoughts that were captured that day:

Livid

Negligent

AAAAHHH!!

Rotten

Shock

Afraid

Pissed

Anxious

Livid

Terrified

Disbelief

Passive

Un-respondent

Lawsuit

Unaware

Evil

Distrust worthy

Panic

Enabling

Unsettling

Unconscionable

My initial thought when I viewed the show on TV was ignorance, followed by anger, followed by fear. The thought of ignorance did not rise from the ignorance of the surgeon or staff during the operation, but of the producers of the show. In my opinion, they are the group that is bringing anger, fear, and potentially paranoia to viewers. Sure! It makes for great TV and fills their pockets and bellies, but this is when my thoughts turn from ignorance to anger.

As I travel a pre-med path, I understand how extremely complex this journey is. The years dedicated to virtually one-self to gain the knowledge and skills to help as many as possible is blatantly disregarded in this display of entertainment. It frustrates me that our society now feels the need to “shop” for a doctor due to a few bad apples. As a mother, I am guilty of “shopping” for a pediatrician for my children. So, what does this say about me? Yet, I do understand both points of view, but it is still frustrating that that trust is the quintessential factor that is being lost. This loss of trust also reminds me of the recent shift we have all felt in how police officers are viewed.

Finally, I was filled with fear. A fear that made me realize I will need to work even harder as a doctor. Not only will we all be faced with a variety of complications, hopefully, nothing like the surgeons in the video, but instead with an invisible complication. A battle in trying to restore the trust and prestige of a doctor that TV shows like my example are stripping away layer by layer.

How can this be accomplished? Perhaps by doing one of the most difficult acts of valor and selfless -- publicly admitting to a medical complication, no matter the cost. Can you do it? If you were the surgeon in the video and had the ability to manipulate your team, would you? Or would you admit to the truth? A question I believe, we can answer easily in this safe forum, but would it be as easy in a real-life situation?

Ana



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Posted comments on Kayla and Ilija's Installement #1's