Journal: Prescribing portfolio ready for submission

Today I am finalising the prescribing portfolio, which is worth 10% of the marks for the topic.  
The finished document contains dated responses to questions posed by the writer of the course, and summaries of my learning and reflections through the course.

September and October were very busy months for me, with a full caseload.  I have not been able to devote all the time I would have liked to, to the course.  Babies have been born, and I have been privileged to accompany a small number of women in their birthing journeys.  In this brief time I have shared great joy, and great sorrow.

I started this course without much idea of how to navigate an online learning situation.  As I now prepare for the exam in a month's time, worth 50% of the mark, I am seeking to consolidate the new knowledge that I have accessed in the past few months.  I expect to do well in the exam, and I am satisfied that I will have met my personal learning objectives at the conclusion of the course.

Personal Learning objectives:

30 July 2012

• To critically review my knowledge of the medicines which I currently use as a midwife
• To develop a useful body of knowledge about the prescription of medicines which will become part of a midwife’s formulary
• To explore and reflect on published scientific work that is relevant to pregnancy, birth, and breastfeeding.
• To undertake the course of study that will meet my undertaking to the NMBA, to successfully complete "an accredited and approved program of study determined by the Board to develop midwives' skills and knowledge in prescribing"

These objectives are within the topic’s stated learning objectives

Some of the issues I have reflected upon and explored have already been mentioned in this blog.  In summary, here are a few highlights: 

Journal of a new student: I have learned a lot about working within an online learning site, and I can now work my way through MIMS online.  This is a big achievement.  I do not yet feel 'fluent' in a virtual library - I just get lost!

Writing prescriptions: I will need to continue to work on the knowledge and skill of prescribing.  The small number of medicines is OK.  I think there are many aspects of the various formularies that still need to be ironed out.  The Victorian law is in the process of being amended to allow midwives to prescribe.

The two Case Studies in which we explored the prescribing of Metoclopramide for nausea in pregnancy, and Benzylpenicillin for Group B Streptococcus (GBS) colonisation of the genital tract, provided good opportunities for learning and critical thinking.  Where I exceeded the word limit, and needed to remove some of what I wrote, I brought it across to this blog, such as in Case Study 2.  Blogs have no word limit!  

A significant piece of work that this study brought me to is the pharmacology of uterotonics.  I am not surprised that the study of pharmacology has confirmed my desire to work in harmony with wonderful natural processes in pregnancy, birth, and nurture of the infant. 

This study has given me information which confirms my commitment to protecting, promoting and supporting unmedicated, physiological birth, except in clinical situations where there is a valid reason to intervene.  The benefit of synthetic oxytocic treatment in preventing excessive blood loss after birth is undeniable.  My reluctance to use these drugs routinely rather than as indicated is related to the majority of women for whom the treatment is not required, and who are thereby exposed to unnecessary medication with attendant risks.

I am also concerned about the extent of possible adverse effects in newborn babies, particularly any sick babies who may need to receive drug treatments, and who may experience adverse drug reactions to syntometrine in mother's milk.  

A question on collaboration has given students the opportunity to engage in the maternity reform process that requires a collaborative arrangement as the starting point for women to receive Medicare rebate for a midwife's services.  It looks like this:
$$=carrot; collaboration=stick 

Collaboration is actually not onerous; it's basic to midwifery practice.  The problem with collaboration as the Australian government requires is that it's one-way collaboration, which is an oxymoron.  'co' + 'labor' requires at least 2 parties to participate.


As I look back on (most of) the pharmacology course, it's worth stepping into the assessor role, asking questions about how the course met my learning needs, and how it could be improved.

I am conscious of a great deal of new knowledge that is foundational to an understanding of pharmacology.  The course lacked systematic teaching of that basic body of knowledge.  I believe this could be corrected by offering weekly lectures for the first month or so, using the webinar function of the interactive online learning site.  Although the course is post graduate, most students have not studied undergraduate contemporary pharmacology courses, and even those who have would do well to refresh their minds. 

A further step is the application of that knowledge to effective midwifery practice.  This is a challenging topic, and could be used for debate between midwives working in various settings.  

Are midwives who have achieved the endorsement as 'prescribers' likely to take a liberal attitude towards medicines, and prescribe excessively, like a kid with a new toy? 



Thankyou for your comments

Journal: the pharmacology of uterotonics

Today I have reflected on bleeding after birth.


In preparation for this study I accessed MIMS online, to revise the pharmacology of the uterotonics that midwives and doctors use in the third stage of labour.  These drugs are Syntocinon, Syntometrine, and Misoprostol. A site linked to MIMS, with consumer information about medicines, is myDr.com.au . Readers may search for other information online, but I have linked each of these drugs to the myDr site to allow easy access to consumer information.

My study method when reading copious pages of information is to look for flashing red lights, which are anything that I didn't know, didn't expect, or am surprised about.  Today's study has provided me with a few flashing red lights.



Before revising the pharmacology of these drugs, I have reviewed the evidence around bleeding and the management of the third stage.  The unavoidable issue that arises for me is that I do not agree with national and international experts who recommend routine active management of third stage for all women.  My disagreement relates to women in my world: women who are well, and who intend to give birth within unmedicated normal physiological processes, and for whom there is a very low risk of morbidity as a result of post partum haemorrhage.  This is an informed position, which I have been studying since I began private midwifery practice in 1993, and realised that there is something unique and protective about protecting, promoting and supporting natural processes in birth and the nurture of the infant.  The principle I follow was set down by World Health Organisation:

"In normal birth there should be a valid reason to interfere with the natural process."

WHO (1996) Care in Normal Birth: A practical guide. 

When I attend a birth at home I carry an ampoule of Syntocinon®10 units, and an ampoule of Syntometrine®.  I use an intramuscular injection of one or both of these drugs if indicated.  A more recent development in preventing obstetric haemorrhage, developed for use particularly in resource-poor countries, is Misoprostol.  I have used this drug in hospital births, but do not carry it.

A few selected facts:

Syntocinon® is a synthetic oxytocin.  Oxytocin is that wonderful love hormone that causes the uterus to contract, and the breast to yield its milk in abundance. 

Pharmacodynamics:

... stimulates the smooth muscle of the uterus, producing rhythmic contractions, particularly towards the end of pregnancy, during labour, after delivery and in the puerperium, i.e. at times when the number of specific oxytocin receptors in the myometrium is increased.... being a polypeptide, is largely inactivated in the alimentary tract and therefore virtually ineffective when ingested. (MIMS)

Pharmacokinetics: 
Plasma levels and onset/ duration of effect. Intravenous injection and intramuscular injection. When administered by intravenous or intramuscular injection for prevention or treatment of postpartum haemorrhage, Syntocinon acts rapidly, with a latency period of less than one minute by intravenous injection and of two to four minutes by intramuscular injection. The oxytocic response lasts for 30 to 60 minutes after intramuscular administration and possibly less after intravenous injection. Distribution. Oxytocin distributes throughout the extracellular fluid, with minimal amounts reaching the fetus. ... Plasma protein binding is very low. Oxytocin may be found in small quantities in mothers' breast milk.
Biotransformation. A glycoprotein aminopeptidase, oxytocinase, is produced during pregnancy and appears in the plasma. It is capable of degrading oxytocin. Enzyme activity increases gradually until term approaches, at which time it rises steeply to high levels. Enzyme activity then declines after delivery. Enzyme activity in the placenta and in the uterine tissue is also high during this period. There is little or no degradation of oxytocin by plasma in men, nonpregnant women or cord blood.
Excretion. The relative ease with which the rate and force of uterine contractions can be regulated by the intravenous infusion of Syntocinon is due to the short half-life of oxytocin. Values reported by various investigators range from 3 to 20 minutes. Removal of oxytocin from plasma is accomplished mainly by the liver and the kidneys. The metabolic clearance rate amounts to about 20 mL/kg/minute in men as well as in pregnant women. Less than 1% of a given dose is excreted unchanged in the urine.(MIMS)

Precautions: ...
Third stage of labour and puerperium. When Syntocinon is used for prevention or treatment of uterine haemorrhage, rapid intravenous bolus injection of oxytocin at high doses should be avoided, as it may cause acute short lasting hypotension accompanied by flushing and reflex tachycardia. These rapid haemodynamic changes may result in myocardial ischemia, particularly in patients with pre-existing cardiovascular disease. Rapid i.v. bolus injection of oxytocin at doses amounting to several IU may also lead to QTc prolongation. When Syntocinon is used for the management of the third stage of labour, multiple pregnancy must be excluded before the drug is injected.(MIMS)

Use in pregnancy. (Category A) Use of oxytocin has contributed significantly to the safety of parturition. However, there have been instances of idiosyncratic sensitivity of the uterus resulting in fetal anoxia.(MIMS)

NOTE: I have asked a question in a tutorial about Syntocinon's inability to cross the blood-brain barrier, while endogenous oxytocin, from the posterior lobe of the pituitary, does.  This topic is not addressed in the MIMS information.  The tutor said she would check the specific pharmacokinetics of synthetic oxytocin.


Syntometrine® synthetic oxytocin/ergometrine maleate

... Syntometrine combines the rapid uterine action of oxytocin, a nonapeptide hormone released by the posterior lobe of the pituitary, with the sustained uterotonic effect of ergometrine [an ergot alkaloid].

Following intramuscular administration, the latent period for the occurrence of the uterine response is considerably shorter with Syntometrine (about 2 1/2 minutes) than with ergometrine given alone (about 7 minutes), whereas the uterotonic effect of Syntometrine lasts for several hours, compared with only 1/2 to 1 hour when oxytocin is given alone. These properties make Syntometrine intramuscular suitable for the active management of the third stage of labour (see Dosage and Administration) and for the prevention or treatment of postpartum haemorrhage, particularly in situations where for any reason the intravenous administration of a uterotonic agent is impracticable. ...

Indications: Active management of the third stage of labour. Prevention and treatment of postpartum haemorrhage associated with uterine atony.

Contraindications: Hypersensitivity to oxytocin, ergometrine or to any of the components in the formulation. Pregnancy, ... Severe hypertension, pre-eclampsia or eclampsia. Severe cardiac disorders. Severe hepatic or renal impairment. Occlusive vascular disease. Sepsis.

Syntometrine has the potential to cause serious adverse drug reactions in breastfed newborns/ infants. Postpartum women receiving Syntometrine should avoid breastfeeding for at least 12 hours after the administration. Milk secreted during this period should be expressed and discarded. (MIMS)

NOTE: I have highlighted this paragraph in red, because I need to follow up on it.  I have never heard this information before, despite many years of working and using it in hospitals, as well as private practice.

Misoprostol is a synthetic prostaglandin E₁ analogue.is used in tablet form, given either orally, PR or PV.  Its use has been promoted for use in resource-poor settings - see FIGO initiative. 
I will not go into the pharmacology of this drug here, as I do not use it.  As with Syntometrine above, it comes with a warning about breast feeding:

Use in lactation. Misoprostol is rapidly metabolised in the mother to misoprostol acid, which is biologically active and is excreted in breast milk. Misoprostol should not be administered to breastfeeding mothers because the excretion of misoprostol acid could cause undesirable effects such as diarrhoea in breastfeeding infants.  (MIMS)

COMMENT:
This study has given me information which confirms my commitment to protecting, promoting and supporting unmedicated, physiological birth, except in clinical situations where there is a valid reason to intervene.  The benefit of synthetic oxytocic treatment in preventing excessive blood loss after birth is undeniable.  My reluctance to use these drugs routinely rather than as indicated is related to the majority of women for whom the treatment is not required, and who are thereby exposed to unnecessary medication with attendant risks.

I am also concerned about the extent of possible adverse effects in newborn babies, particularly any sick babies who may need to receive drug treatments, and who may experience adverse drug reactions to syntometrine in mother's milk.  

Thankyou for your comments

What can we learn from a coroner's report

Readers may wonder why I would post comment on a coroner's report.

The publishing of this redacted report enables me to reflect on similar situations that I or other colleagues have experienced. Coroner Audrey Jamieson concluded "I hope the lessons learnt from the death of baby Oscar will prevent another such occurrence in the future."

 The report I am reflecting on today is of an investigation by the Victorian Coroner into the death of 'Baby Oscar'.

The Coroner concluded that baby Oscar's death was preventable, and that the midwifery care provide by a midwife who had been employed privately by the mother had contributed to the tragic outcome.  The Coroner noted that, in the opinion of a midwife who gave expert witness, neither the parents nor the midwife fully appreciated the potential risks in this case.


I need to make it very clear that I have no knowledge of the facts, apart from what has been made public in the report. In attempting to reflect and learn from this case, I question how I would act in a similar situation.

Suppose I palpated and advised a woman in my care that her baby was in a breech presentation ...
... that referral to the obstetric hospital had confirmed my palpation using ultrasound ...
... and that attempts to perform external cephalic version had been unsuccessful ...
... and that the hospital had told the woman that she should be booked in for an elective caesarean ...
... and that the woman had told me she did not want a caesarean; that she intended to arrive at hospital in advanced labour ...
... and that the woman had told me she was in labour ...
... and that when I went to her home she was already in advanced labour ...
[you can read a similar scenario in 'Baby Oscar']


Without knowing or trying to understand the conversations that transpired between this mother and her midwife, I do say without doubt that a midwife's duty in this sort of situation includes the difficult exploration of why the 'mainstream' obstetric recommendation is that a breech baby be born via caesarean surgery.  Yes, a competent woman has autonomous right of refusal in this and in any other situation where a medical procedure is offered.  But, it is not sufficient for a midwife to delegate responsibility for 'choice' to the mother.  Informed choice means much more than a preference for a particular mode or place of birth.

The midwife's primary concern must be the wellbeing of mother and child.  The midwife's professional advice may conflict with the mother's wishes.

A midwife who practises independently, and who is able to establish a partnership based on reciprocity and trust with each woman in her 'caseload' is in a privileged position when compared with the mainstream midwifery profession.  However this privilege does not excuse me from facing up to difficulties.


Since the paper by Hanna et al (2000) relating to the Term Breech Trial, the mainstream maternity community has accepted as 'evidence based' the interpretation that
"Planned caesarean section is better than planned vaginal birth for the term fetus in the breech presentation; serious maternal complications are similar between the groups."

This culture, I believe, has increased the likelihood of adverse outcomes for breech babies when either the mother does not want to undergo elective caesarean, or when the baby's breech presentation is undiagnosed.  The de-skilling of midwives and obstetricians in vaginal breech birth has led to tragic outcomes.

I consider that a major public maternity hospital has a duty to accept women who intend to labour and give birth to breech babies.  I wonder what would have been the outcome if, in this case, the hospital had responded positively to baby Oscar's mother.

What have I learnt from reflecting on the report into baby Oscar's death?

I am certain that there will be times when I need to challenge a mother's plans or choices.

I know that there will be times when women in my care are better cared for in hospital than at home.

I also know that there will be times when, despite the best care plans and preparations, I may need to provide professional care in a birth that is outside my usual scope of practice.  My decisions at the time may be challenged in professional and statutory settings.  Births are not always predictable.  That's why a midwife attends a birth.

Thankyou for your comments

Added 6/6/12
The SA Coroner's findings have been released today on a recent high profile case, involving the death of three babies born at home.

Prescribing

It was reported last week in the Australian that

Midwives still await PBS script training

by: Adam Cresswell, Health editor

From: The Australian April 20, 2012

MIDWIVES have not written a single prescription under the Pharmaceutical Benefits Scheme, nearly 18 months after they were supposed to begin, because no training courses exist to teach them safe prescribing.

Link


There are approximately 200 midwives nationally who have achieved eligibility for Medicare (MBS) and pharmaceutical benefits (PBS) - 'prescribing'.  Each of these midwives were required to sign an undertaking to the Nursing and Midwifery Board that we would
"undertake, and successfully complete, within 18 months of recognition as an eligible midwife:-

1. an accredited and approved program of study determined by the Board to develop midwives' skills and knowledge in prescribing; or
2. a program that is substantially equivalent ...  

A few midwives have completed university courses that have been accepted as 'substantially equivalent' to such an approved program of study as determined by the Board.  They have completed courses that have been accredited and approved for Nurse Practitioners, and submitted a comprehensive 'mapping' of the course against the standard set by the Board.

Many midwives, including yours truly, are waiting for (1) an 'accredited and approved program of study' before launching into this endeavour.  It is unlikely that midwives who have not commenced their course of study within 6 months of receiving notation as eligible for Medicare will be able to complete their courses within the required 18 months of recognition. 

protecting and enhancing the chance of a natural birth

Today I received a message from a midwife who has read some of my blog thoughts, who has asked me:

What do you think are the most important rules for protecting and enhancing the chance of a natural birth?

Where do I begin?

Perhaps there are no rules.

Rules tend to exclude some, and anyone who has been with woman will know that when a woman discovers her own strength, she seeks to organise her life so that she will not be denied that potential when she is at the peak of her labour. Perhaps the only 'rule' is an active decision making process that has the wellbeing of mother and baby at its centre.

There is no safer or more satisfying, fulfilling way for most women to give birth than to proceed as far as they reasonably can without medical or surgical assistance. Years ago, when I was experiencing my own intellectual awakening to the wonderful potential of our bodies in bearing, birthing, and nurturing our babies, I read some reports on birthing from the UK Health Department. One of the messages these reports promoted was that women want the 3C's: choice, control, and continuity.

Yes, I agreed!

So I worked hard to promote choice, control, and continuity in maternity care. But as I explored my own practice, and the midwifery literature, I have had to re-think each of the 3C's.

Choice is very limited. There is really only one choice: to promote health and intentionally work in harmony with the natural processes - this is what I call 'Plan A'. Any other notion of choice has little connection with reality.

Control must be relinquished. The only way most women can progress without medical assistance in the most demanding part of labour is when they surrender the neo-cortical thinking, relinquishing mind control to the powerful hormonally mediated intuitive processes within their bodies.

Continuity is an ideal that cannot be guaranteed. I mean real continuity of carer, with the midwife primary carer who is personally committed to the individual woman and who forms a partnership based on reciprocity and trust with that woman. This is the way I try to work, and with a very small caseload, I have been privileged to attend almost every birth that I have been booked for. But it is idealistic. I have been blessed with a robust body and good health. I won't labour this point. I recognise that mainstream publicly funded maternity services will need to trade off some of the idealism of continuity for the realism of sustainability.

So, dear reader, what rules are there to protect and enhance a woman's birthing potential?

The parallel of healthy natural birth and breastfeeding is obvious to me. In both, the midwife's role is to protect, promote and support the physiological processes, and when an intervention is made, to restore normality, restore to the mother her own body's health-affirming prerogative, as soon as possible. This requires education, skill, personal will power, intelligent action and much more. It's not a matter of sitting back and letting nature take its course, because we know that the natural course often leads to chaos. It's a matter of knowing and intentionally guiding at times. That's midwifery. It's a matter of the midwife-woman partnership having an intention to work with 'Plan A', and knowing when to move to 'Plan B'.


Thankyou for your comments

The Heart in the Womb

Book Review
The Heart in the Womb 
Amali Lokugamage, 2011

I have thoroughly enjoyed reading The Heart in the Womb, which the author, Amali Lokugamage kindly sent to me for review.

This is a wonderful title, 'The Heart in the Womb'.  Of course we know that the baby's heart is in the womb, but it seems that Amali Lokugamage has discovered another heart - her own centre of being - within her womb, as her baby developed.

The book has a compelling sub-title 'An exploration of the Roots of Human Love and Social Cohesion'.  I am fascinated by Amali's comments about her own development in loving, as her thinking mind surrendered to deeper, hormonally mediated processes.  As a midwife, I see evidence of 'roots' of 'human love and social cohesion' being put down in many lives at the time of childbirth.  I would love to see a sequel to this account in ?5, 10, and 20 years' time, continuing to explore human love and social cohesion, developing from the roots put down by Amali's son.

This is a very personal account, bringing a significant and seldom-heard perspective to the natural birth/homebirth debate; that of an obstetrician (and a very impressive much more!). "I was prompted to write about this very personal experience because, prior to my pregnancy, I was never fully able to understand why a woman would actively choose to give birth at home, outside of a hospital safety-net."

This is a complex account, weaving together knowledge and comment about Western, Eastern, and alternative maternity and health practices. As I followed Amali along her pregnancy-birthing journey, parts of the story were very familiar to me, and parts were from another place.

I have often pondered the fact that a person who has a great deal of skill in the field of obstetrics can be blind to the basics of physiological birthing.  This is a mass-blindness within maternity care providers, and it isn't limited to obstetricians.  Midwives who work in birth centres have told me that they couldn't possibly attend home birth because the woman might bleed!  That bright red emergency button on the wall represents security!  It can be pushed and every available midwife or doctor will rush to the room and provide assistance; the "hospital safety-net" that Amali refers to. 

I found the account of the multiple modalities of treatment and preparation that Amali selected very interesting.  Interesting because I am, quite openly, a non-believer in many popular alternative medicines that other maternity care providers have embraced, including homeopathy, kinesiology, reiki ...  I do not have confidence in acupuncture or acupressure. When I have experienced it, either personally or observing it in a woman, it has not seemed to 'work'!  If birth is not an illness, why, I ask, do we need so many treatments? 

I do not encourage women to learn meditation or other practices derived from various religions.  I encourage them to explore their own understanding of faith, love, and social connection within families.  I do not ask women to learn self-hypnosis, although I quickly acknowledge the 'hypnotic' altered state of consciousness that many women enter as they go deeply into their labours.   I do not encourage women to undertake childbirth education courses that seem to make them into mini-midwives, trying to understand the minutae of bodily and mind functions, particularly in labour.  I have personally come through the Grantly Dick-Read - Lamaze - Leboyer eras, talking about Pavlov's dogs and psychoprophylaxis, and now I don't teach those processes at all.  When someone asks me if they should learn patterns of breathing I ask them if they have studied breathing to assist when making love.  There's usually a puzzled look.  "So why should you learn how to breathe when you are giving birth?" 

Amali's account of her multiple advisors, care providers, and guides in her journey towards birth seems to have led her on an action research project.  It must have cost a lot! I felt exhausted just following along.

Dear Reader, please forgive me if I seem to have used this review to get on a soap box.  As I said, I have thoroughly enjoyed reading The Heart in the Womb, and I hope you do too.




Copies of this book can be accessed from:
Australia 1
Australia 2
Book Depository - UK but ships free world wide
Amazon  
E books
Kindle
Itune
Epub

Thankyou for your comments

Blogging

'Baby wrapped in a green blanket', by our Poppy

Today's brief comments come out of thoughts sparked by Sarah Stewart, who is a tech-savvy teacher-midwife based in New Zealand, and a compulsive blogger. Sarah is the person behind the Virtual International Day of the Midwife - a 24-hour webinar now in its fourth year, bringing together midwives and students literally around the globe.

Sarah has announced to her readers that "I am currently in the process of writing a paper about this blog and how I use it to reflect, and how the wonderful comments you leave enhances my learning. I plan to submit it to an academic journal for publication. ..."

I also use blogging to reflect and work through issues in midwifery. I love the fact that blogs are in the public domain, because I consider that anything I have to say as a professional midwife should be able to be said openly. In that sense I also welcome critique of anything I have written or said. 

When I first started writing blogs, the topics I chose were simply the topics I had discussed with women who came to see me, who wanted me to be their midwife. As I wrote I used the language and the discussion that I would bring to professional clinical discussions.   Since those early blogs I have commented on and explored my reflecting on many issues that come up in the life of a woman who is also a midwife, a mother, and a thinker.

My mother used to say, "If you always tell the truth, you don't have to remember what you said." That sort of truth-telling is what I am referring to in finding my voice on the www.

In June 2007 I wrote a brief post 'Natural birthing in Australia today'. A few days later I titled my post 'The culture of birthing'. I wrote:

I am asking for a total change in the culture of birthing, changing the focus of all the care from the provider to the woman. We seek a new culture that recognises the natural order in pregnancy, birth and nurture of the baby as superior to any artificially contrived system. ...

The culture of birth will change only when women reclaim their authority for their own bodies; only when the message that ‘birth is not an illness’ is heard. The role of maternity professionals will then change from being predominantly carers of sick people to agents of health promotion, working together to enable women to improve their health through pregnancy and birth, and to have strong, healthy and resilient families.

These words were true then, and I am happy to publish them again today, almost five years later.  I expect I will still say the same thing in five years' time! 

^^^^^^^^

I wonder if I am unusual in that I have not embraced other forms of social media to the degree that I am happy to use blogging?

Yes, I have a fb account, but the only people I have 'friended' are family and a few close folk who are something more than 'friends'.  I don't like the implications of a stock-standard 'friend' category that seems to me to be on offer there. It doesn't ring true to me.

Some years ago I decided to swallow my pride and have a go at twitter.  I lasted about 2 days! [that's probably an exaggeration - I'm sure it's all recorded somewhere!]  I felt that I was playing an inane game that was without direction.  I was offended by the word 'twitter'.   If I was going to write my thoughts they needed to be of more significance than the incoordinated noises coming from the canaries in a cage!  (I did name the canaries Tweet, Twitter 1, and Twitter 2)

That's all I'll say about today's social media.  My name appears on other systems too, but I haven't a clue how to make them worth while for me or anyone else.  Perhaps someone will tell me I am wrong - that there are wonders in store for those who find the key? 



Thankyou for your comments