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Update on Ileostomy issues for my husband

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Posted 5/29/2012 5:45 PM (GMT 0)
Well last night the wafer/pouch lasted less than two hours and that was with a ring of stomahesive paste around the whole thing.  Leakage was on left side this time.  Bill did not let me change it because he was so sore and worn out.  We stuffed a clean washcloth under the edge where it was leaking and he slept through the night...got up and changed the washcloth every 3 hours.

Removed the whole thing this morning and he is lying on couch with nothing right now.  Cleaned him up gently with water.  Called home health and they are on their way with more supplies.  Nurse wants to see the area before we put on another bag.

APRIA cannot find the order for the supplies that were ordered Friday afternoon.  Two calles to the doctor whose assistant failed to itemize what we needed so order was never really placed.  I had to read out of the book on what to send.  i asked for the convex skin barriers, the bags, the stomahesive powder, the stomahesive paste, and sureseals based on what all of you have told me.  I explained that I didn't know and was surprised that the doctor's office didn't send a specific list.  The doctor's assistant said they ordered "ileostomy supplies" and figured that APRIA would know what to send.  What a bunch of imbeciles we are dealing with.

As far as specialized ostomy nurses, none have been offered to us and I am not sure how I would contact one or if it is covered by my insurance.  I know that routine home health care is covered. 

Thanks to all who have responded.  Once again we are sitting here waiting for supplies to get us through two days and hopefully APRIA will send us the right stuff this time.  We are not even sure which doctor we should be complaining to at this point: surgeon who did the ileostomy?  oncologist?  primary care physician who has not seen him since diagnosis of cancer?   We are lost in the process and things are looking pretty bleak.

Posted 5/29/2012 7:32 PM (GMT 0)
I have never heard of being denied the care of an ostomy nurse -- it would save the insurance company money if you didn't have to go through so many supplies! It's standard to see one...

One suggestion is to call the patient advocate at the hospital. S/he may be able to help you navigate and arrange for proper care. You are not getting good follow up.

The doctors don't know anything about caring for an ostomy. Your primary care doc may be able to advocate for you -- they are usually in charge of coordinating things. Your surgeon's office is very likely connected with stoma nurses so they may be able to set you up.

In the meantime, you also could try calling one of the ostomy supply companies. They have nurses on staff who really know their stuff (so I've heard on this list, no personal experience). Convatec's number is 1-800-422-8811.

But no harm in complaining to everyone..... you have major reasons to complain and this is an emergency!
Posted 5/29/2012 9:47 PM (GMT 0)
The drs office won't call in an actual order, just a rx that reads ostomy supplies. Its because everyone uses different things. You will be better off by calling hollister or convatec or one of the companies, or edgepark or your supplier for suggestions. And the ostomy nurse should also help you. I think it would be covered, not all hospitals have an ostomy nurse who goes out to peoples houses though. But you can take him back there.
Its times like this I wish one of us on the board who have been doing this forever could just pop on over and help! That would of him been very helpful to me right at first.
Keep asking questions, and call all the companies and get samples from everyone.
Posted 5/30/2012 12:55 AM (GMT 0)
You may need to call your insurance company to see who the preferred supplier is? I use Edgepark as well but I know there are others. I am so sorry this is going on, it does sound like you are not getting the services/support that you need.
Posted 5/30/2012 1:04 AM (GMT 0)
Well we saw doctor five hours after the home health nurse came and replaced the bag with Coloplast seal and it was leaking when we got to the doctor's office.  He had to send over to the hospital to get a bag and wafer to put on Bill.  Best part was he got to see what we had been dealing with.

Doctor will reverse his ileostomy in July if barium test in 3 weeks shows everything has healed.  HOORAY!

We can make decision on chemo after the reconnection.

Posted 5/30/2012 3:54 AM (GMT 0)
Assuming the barium test gives the results you need to get the reversal done in July will be a tremendous relief. Once the reversal is done I am sure your husband will need to be very careful for awhile with foods. Hopefully you will be given proper instructions at that time.

HOWEVER in the interim you have to get this under control. I can't believe you cannot get the services of an Ostomy nurse to intervene here. You can be given a ton of supplies but if you are not getting some good help to stop the leaking you both are at such a disadvantage. If you only have home health nursing services available then try and insist that they send you the most experienced person to help with ostomies and skin problems.

Of course you don't know this...but for a Dr's office to just say Ostomy supplies is crazy. Apria wouldn't know what to send out. We got a signed prescription type authorization from the Dr at Mayo Clinic ALONG WITH AN ADDITIONAL SHEET that the Ostomy nurse filled out indicating all the different supplies needed. Granted it was for Hollister New Image 2 piece convex system which is what the hospital started us on along with other items, paste, rings, powder, scissors, tape, skin barrier prep etc. As time went on and we went through the trial and error with different pouching systems we changed from one to another until finding the Coloplast Sensura system that works best for him.

We have had Edgepark from the beginning and they have been consistent and fine to deal with. There are other companies too. If Apria doesn't have all you need you may need to go to Edgepark, Byram or another. Hopefully Apria will be ok since you only need supplies for 4-6 weeks and it will be July before you know it. Can't come fast enough I'm sure.

Maybe some hospitals are better at the paperwork details and follow through when discharging a patient. Ours certainly was and it should certainly be that way for everyone. This is unknown territory, overwhelming and somewhat frightening in the beginning....everyone in this situation needs all the help they can get. I get so upset reading some of these threads and situations some are dealing with. Having received the proper kind of paperwork & instructions upon discharge, I feel there is no reason why this isn't the norm for everyone.

I hope in the next day or so things greatly improve. Stay strong...he really needs you right now.
Posted 5/30/2012 4:36 AM (GMT 0)
Donna,
I'm so sorry that you and your husband are having to navigate this with little help from his doctors. I would think the surgeon would be the one to get your husband set up with an ostomy nurse at home, but I would call all of them and complain.

In the meantime, he needs ostomy supplies, so I would look online for a medical supply store in your town. Call first and ask if they carry ostomy supplies, so you can get some asap.

Just as a heads-up, and you might already know this, but the Stomahesive paste is not an adhesive. It's just supposed to go around the hole in the wafer and turtleneck the stoma, so no waste gets on his skin. If you put too much paste on the wafer, it will cause it to not stick.

I hope you get an ostomy nurse and some supplies soon! Keep us posted.

Cecilia
Posted 5/30/2012 1:48 PM (GMT 0)
Cecilia is right...plus the paste helped my husband's crevice he had to the right and left of his stoma initially (3 and 9 o'clock position is the best way to describe)
Posted 5/30/2012 2:11 PM (GMT 0)
What can I say to all of you except THANK YOU and that is hardly enough.  I have received more help on this forum in just a few days than Bill and I have received from all of the "professionals".  God bless each and every one of you.

Surprisingly the doctor's quick "fix-it" without the lollipop skin barrier, without powder, without any easkin or stomahesive paste actually lasted through the night without leaking.  As of 7:00 a.m. (we are on Pacific time), he is not leaking and managed to sleep through the night.  Thanks to my sleeping pill, I did too.  He even managed a shower with the doctor's patch and it did not pull free.  We were promised overnight shipping by UPS from Apria so supplies should be here by 10:00 a.m.

I am hoping that with the new supplies and continued success against leaking (fingers crossed) that Bill might reconsider the post-op chemo.  I know there are no certainties in life....eleven years as a hospice volunteer certainly taught me that.  But I also want to have as many years with this loving gentle man as I can.  I have been so blessed to have him in my life.  So incredibly lucky that we made it through the ups and downs of marriage, raising children, my own health issues, loss of loved ones, loss of jobs, and found out so many years ago that we are each other's best friend. 

I don't know what our future holds...certainly one of us will precede the other in death.  We both agree it would be better if it was him...he is so helpless without a strong woman in his life....but my daughter is ready to take care of her Daddy if it is the other way around.  As for me I am feeling much more positive this morning...amazing what a good night's sleep and a cup of black coffee on a beautiful, peaceful summer morning can do for the soul.  God bless each and every one of you as you go through your day today.  Thank you for being there for me. 

Posted 5/30/2012 10:31 PM (GMT 0)
Wow, I have tears in my eyes reading your post -- I'm so happy that you got a good night's sleep and are feeling some hope. Really and truly, when it's not leaking, the bag is totally manageable, the inconvenience is nothing compared to being able to be with the ones you love and do the things you love.

More practically, sounds like he was using too many things -- not surprised, as the (regular) nurses sometimes push products, and most of them can contribute to the wafer not sticking (powder did me in at the beginning). I really hope you can get in to see a stoma nurse to figure out if you actually need any of these products.... Personally, I only use the eakin to prevent a burn under my stoma. Occasionally I use a dab of skin prep if I have an area that gets irritated.

And you're welcome for the help. Most of the folks here who offer help have been on the other end, desperately needing it themselves. This forum was a lifesaver to me too around my surgery, and now it feels good to actually know something that can sometimes help others (almost all of us start out clueless as we join this club we never wanted to be in..... but we catch on..... and for me, it's been a total surprise that there have been good things about having the ostomy, namely connecting w/so many different people who have one too (or are close to someone w/one))
Posted 5/30/2012 11:53 PM (GMT 0)
Oh my heart is bursting with joy for you two. I am so glad something has worked and you both got MUCH needed sleep! The way you describe your husband is how I feel about mine, only we haven't been married as long as you. Sometimes I wish I had met him earlier in my life but then I remember that God put him in it at the right time - a time that I needed.
Posted 5/31/2012 12:50 AM (GMT 0)
Blueglass said.....
Wow, I have tears in my eyes reading your post -- I'm so happy that you got a good night's sleep and are feeling some hope. Really and truly, when it's not leaking, the bag is totally manageable, the inconvenience is nothing compared to being able to be with the ones you love and do the things you love.

Ditto me too!!!!

I am thrilled and overjoyed to read a more upbeat post from you. AND YES less is usually better but you wouldn't know that. Once you can get this under control and managed and some kind of comfort factor with a bit of dependability you will both be able to focus and concentrate on other issues. I was talking with my husband about this today and I have him feeling so bad and angry as well that you both are going through this.

Once the skin can heal up and there is no itching or discomfort wearing the wafer it just becomes part of your day to day business. Believe it or not you are not spending every single minute of the day focused on it when you can get that comfort factor.

Please keep us aware and in the loop and use us for any and all the info or support you may need.

I met my husband just before I turned 18 and we have been together for 43 years soon to be 44 and I totally relate and understand every single thing you say, how you feel and how much you are suffering along with him. So happy to see some encouraging news from you and you both got some much needed sleep and rest. YAY!!!
Posted 5/31/2012 2:06 AM (GMT 0)

I am so happy to read that things are turning around for you and your hubby.   The folks here are so great with helping, as you already know.  I am a relative newby and am still learning and this place has been a Godsend to me in my journey.

You have been blessed with your relationship and I do hope he will be open to the chemo once he is healed and you can have many more years together. 

I was 16 when I met my hubby and we have been together for over 41 years.   My health was great for the first 50+ years of my life.  Hubby had weathered Testicular Cancer, heart attack in the widowmaker, and a couple of abdominal surgeries over the years.   I never fully understood what all he went through until I had my issues with Crohn's and had my 2 abdomnal surgeries which included my ileostomy.   Took a while for us to get to the "worse" part of the "for better or worse" but we also have made it through the trying times.  

Looking forward to more "thumbs up" posts with you and your hubby's journey.

Posted 5/31/2012 4:00 AM (GMT 0)
Well I guess I jinxed it.  The  bag started leaking again late morning.  Then we got the supplies and home health nurse stopped by to check on Bill.  Good thing she did, we opened the supplies to find they had sent the wrong sizes.  They sent convex wafers but only have 7/8" stoma opening and Bill's measures 1-1/4".  Then we tried to "snap-in ring" just to see how the new velcro pouches attach to the wafer and the pouches are a different size than the wafer ring.

I immediately called Apria and they are sending another shipment tomorrow.  They gave me a pickup number and I am sending  back the other supplies.  Nurse had TWO standard flat wafers with her....one she put on Bill and left me the other in case he leaks again overnight.  So I am setting the clock again to check every 3 hours to try and avoid leaking issue just by making him get up and empty every 3 hours no matter what is in the bag.

I honestly don't comprehend how anyone could go through this on a daily basis for the rest of their lives.  I am in awe that some of you do.  For Bill and I, we cannot wait for the reversal.  But we both fully intend to continue praying for everyone forced into this way of life.   You are all so brave to deal with this.

For me, I am just praying that when this is all over, it is really ALL OVER.  As a hospice volunteer for over eleven years, I know that cancer is not the worst way to end your life.  There are so many illnesses and diseases that steal away the person you know: stroke, Alzheimer's, Lou Gehrig's disease, mental illness, MS.  If all we have to deal with is cancer, we will be blessed because there is a great deal of pallitive care for cancer and it can be handled with compassion and loving care. 

Again, thank you all and I will keep you posted on how we are doing.   Hopefully tomorrow we will finally have the right fix for the problem and I can report that all is well!

 

Posted 5/31/2012 9:06 AM (GMT 0)
I wish you two luck.

I also hope your husbands decides to go for cancer treatment. I understand where he is emotionally right now and I have those moments of being so discouraged and upset about everything I've had to face this year too.

I'm new to these bags too so there isn't much I can offer you other than good thoughts, hope for improvement in your situation and prayers.

Jen
Posted 5/31/2012 12:17 PM (GMT 0)
Sorry this malfunctioned again BUT as you can see there is hope. Honestly once you find the right system and application method IT WORKS and works well for the greater majority of osomates. So.... they are not dealing with your anquish and malfunctions day in and day out. Some do have a much more difficult time than others I am sure but for the most part it is normal to get 4+ days of wear before needing to change. Fortunately your husband has a reversal to look forward to but the chemo is also a very important issue. My vote if it were my husband would be to get this darn problem conquered so you can get the dependability from the right appliance and be able to get on with living and having the ileostomy for an additional 6 months in order to get the chemo that seems to be important too. It is a tough thing to agree to when you are going through all of this which really is so so maddening 24/7.

Lets hope with the right supplies things will turn around again. It really is that simple when the right stuff is on hand which is the knowledge you need and you are so learning all this the hard way. Yes there is trial and error but you never even got the right foundation to start with which put you at such a disadvantage. Keep trying, keep a sense of humor somehow and just get whatever rest you can in between.

I know he will not want to eat or drink much to try to keep things less active but it is very important to stay hydrated...I can't stress this enough. You do not want him to become dehydrated as he would need IVs at the hospital as you just cannot do it yourself when you reach that point. Plus PROTEIN is very important...so if he doesn't want to eat too much food stuff then protein drinks/shakes are important for healing. That was also stressed after surgery to us. Hubby's appetite was very low initially and I made the chocolate protein shakes that had 15-20 grams of protein so at least he was getting some that way a few times a day.

Take care...sure wish we all had magic wands to make these situations better!
Posted 5/31/2012 12:32 PM (GMT 0)
Ugh, that's so annoying. It won't help since the bags don't fit the wafers, but if the opening is too small, you can cut it to make it bigger (if it's too big, you're out of luck....). My stoma is oval, so I don't get the pre cut wafers, I cut my own.

As UC wife said, we are not all dealing with the same thing you're dealing with.... I had a few leaks at the beginning, but nothing like what you're having (I suspect this is because I have a great stoma nurse who saw me before the surgery, in the hospital, and was always available for calls or emails). Now what I deal with is about ten or fifteen minutes every five days for a routine pouch change.

In some ways, it was emotionally easier for me to deal with the bag knowing that it's permanent. I knew I had to learn to live w/it, there was no reversal to pin my sights on.

Hang in..... hope things get better soon.
Posted 5/31/2012 3:31 PM (GMT 0)
Here's hoping today you will receive the right appliances!! It does give your life back.

Again, I was in a similar situation. When I had my colectomy, I was immediately connected, but it separated which led me to have my ileostomy. This trauma led to severe complications too. I was hospitalized for 6 weeks, the ostomy nurse wasn't helpful regarding my ostomy care because when my abdominal wound opened, that took precedent. I had reoccurring leaks, as did when I came home. After a week when I received my convex wafer, FINALLY I received my life back. I had a long recovery, but I didn't have to worry about my leaks. It was traumatizing and even couple months down the road, I remember telling my surgeon that I need to get my life completely back and need the reversal very soon. He wasn't receptive. Well, the more time that passed, the more grateful I became. The more I wanted to live peacefully then having to go back into surgery/recovery phase. In July will be 2 years and I'm still not ready for the reversal. What Blueglass has stated is correct in my case.....it's pinned my thoughts. Had the ileostomy been very unmanageable, than my take would be opposite. Here's wishing you can receive the same outcome so you can deal with the more important issues with his health, not these leaks as the determining factor.

Your personal sentiments regarding your husband and marriage brought me to tears. You have such an upbeat take on all this, your truly an inspiration as to life and love. My parents are both deceased, both had horrible health issues. Throughout their ordeals, they were there for each other. I took care of my father after my mother passed. We lived together and then both of us were diagnosed with issues within 2 months of each other...my severe reoccurring diverticulitis and him a form of leukemia along with his countless other illnesses. After 3 years, we both went downhill together, I had to wait until he passed in order to have my colectomy. My colectomy was nothing as expected and week later, I'm being told I might not make it, to call people before heading into surgery. My poor kids, they were only 6 & 7. I was hysterical. As I composed myself, it was ironic because I was actually at peace with my life, did the best I could and didn't have any regrets. Of course would've like to have done more...continued education, traveling, but was only 37 and never thought life would end. I then thought how unfair that I've never been in a loving relationship. Thoughts of marriages just like yours came to mind. You have truly been blessed and it's nice to hear how grateful your life has been having him in it. I feel humbled reading your posts, hence the tears in reading them.
Posted 5/31/2012 8:50 PM (GMT 0)
Well the saga continues.  Got the second overnight shipment from APRIA, the approved durable medical supply house for my insurance.  AND it was wrong again.  They back-ordered the wafers, sent the pouches with nothing to attach them to and sent 3 ostomy belts that don't work with the pouched they sent...AGHHH!

So I packed it all back up and called them again.  THEN I did what I probably should have done to start with: I called the manufacturer, CONVATEC directly.  I was able to speak to an ostomy specialist who told me to order product code #413183 for 1-1/4 inch stoma opening convex skin barrier wafers, product code #413312 velcro pouches to attach to those skin wafers, and product code #175507 ostomy belts to wear with the above two products. 

So then I called APRIA  back and ordered these three products.  Unfortunately the wafers come from California and the other two items from Arizona so delivery has to be special SATURDAY authorization.  So now I won't know what I am getting, whether it works, or have any supplies until Saturday.  Bill is wearing his last skin barrier which I put on last night and we have one pouch left. 

I did find one piece pouches at a local medical supply store...$8 each.  i bought two to get us through until Saturday (saying this with fingers and toes crossed).  Right now my eyes are crossed as well as I have a viral condition in  my eyes that flares up with stress....makes them all blurry.

Other than that it is a beautiful day in the neighborhood as Mr. Rogers used to say!   Time for my nap because we set the clock to get up every 3 hours last night to make sure we drained the bag in order to avoid leaks.  Sigh....good night all!

Posted 5/31/2012 11:04 PM (GMT 0)
If Apria can't get it right this time with the correct stock #s then maybe you need Edgepark or another supplier like them. This is nuts.

For the amount of wear time you are getting a one piece is probably the best. Hubby started with 2 piece units and switched to one piece which have been fine.

I know it is easier said than done....hang in there sweetie!!!!!
Posted 6/1/2012 4:07 AM (GMT 0)
trafficdonna
I agree with UC wife. Why are you fooling around with APRIA? I have been ordering from EDGEPARK since I started 11/7/2007. Never a problem. Always on time. Their nurses know what they are talking about. Phone number is 800 321 0591

Dan
Posted 6/1/2012 5:46 AM (GMT 0)
I called APRIA because that was the one my insurance company (Teamsters Local 14 of Southern Nevada) told me to use.  We are so new to this....didn't think to check if there were others that might take the insurance.  The hospital said we had to call the insurance and get pre-approval for durable medical supplies and then find out who to order from.  I just followed their instructions.  Definitely wish now that I hadn't.

So far the one I put on last night (our last one of the standard skin barrier and pouch) is still holding.  Of course we are making a huge point of making sure he drains every 3 hours so it doesn't get too heavy and pull away from the skin.   The lack of a full night's sleep is taking its toll....too lethargic to do much of anything else.  Bill is just so tired.  He is eating little and drinking even less because he doesn't want to fill the pouch at night and have it leak.  Today's entire menu was one scrambled egg, two Arby's junior roast beef, 2 small pieces of fish and 1/2 cup of white beans with 1/2 cup of sliced peaches for dessert.  I am trying to push protein as much as possible.  Liquid intake: one cup of coffee, one bottle of water, and one glass of cranberry juice.  Since surgery on May 9th, he has lost 19 pounds.

I don't honestly see how any of you manage "normal" lives if you have to worry about the pouch filling up every few hours, how it would not be conspicuous under clothing, or even how you could eat a normal meal to keep up your strength.  Bill has lost his appetite for almost everything and constantly worries about how it will process through the pouch.  To be honest, this has been far worse than my experience with gastric bypass ever was.  I go back to work on Monday and worry about what happens if he starts leaking while I am work.  He cannot see the stoma well enough to change patches himself...sometimes he doesn't even know he is leaking until it soaks through his clothing.  I guess I will just have to call and check on him at lunch every day and make the trip home if necessary...nothing else I can do.

Posted 6/1/2012 6:31 AM (GMT 0)
Donna,
I'm sorry he's having so many leaks and that the supply company keeps messing up your order! sad

For some reason, my stoma was much more active and the output was very liquidy in the beginning. Over time, the output thickens and slows down. Others on here have posted the same thing, so what he's experiencing is normal and will soon pass. Leaks are also normal in the beginning, and that will not happen once he gets the right wafer for him.

Are you shaving the hair off of his stomach, so the wafer can stick to his skin? Try putting the wafer on dry skin with no skin prep or any powders. That stuff makes my wafer not stick.

It might help for him to eat a BRAT diet (Bananas, Rice, Applesauce, Toast) along with Metamucil (fiber) and Imodium to help thicken and slow down the output. Baked chicken and mashed potatoes are good thickening foods, too.

The wafer I highly recommend is the Coloplast Assura Extended Wear #2833 with matching cloth covered velcro closure pouch #13986. I've been using that product for 6 years with a little bit of Stomahesive paste around the hole, and I get one week's wear time with no leaks, and that's with daily showers, exercise, and swimming in the pool! The wafer has a built-in skin barrier, so I just put it on dry skin, and it sticks really, really well.

I also purchase my products from Edgepark, and they have never made a mistake. In a pinch, you can purchase supplies on eBay. Their prices are much lower than the local medical supply store. I also use Hollister M9 drops for odor. Just have your hubby put a few drops in the pouch after each empty, and there's no odor! :-)

Praying that things improve and you get the right shipment of supplies soon!

Cecilia
Posted 6/1/2012 10:50 AM (GMT 0)
One thing to know about Edgepark is that they take care of all the insurance stuff for you. You give them your info and then they figure out what is covered and what isn't and how much you pay.

They did make a mistake with me at the beginning -- my insurance classifies ostomy supplies under medical, which means I pay the deductible and after they are covered 100%. Originally Edgepark classified as "durable medical goods," which my insurance would have me pay 30%. But it got fixed, and was fine. Never had a mistake in sending supplies; if I order M-R, I get the supplies the next day, and I always talk to the same guy who is really nice (he's the northeast rep, so wouldn't be the right person for you to talk to).

I was exhausted the first few months from the surgery and being sick. It is true that if you have a permanent ostomy, after a while your small intestine starts to learn to function more like a colon and absorb more liquid, so the output gets thicker and less frequent. Depending on what I eat, I empty about 5 times in the day, and once in the night. I eat just about anything I want, and the bag doesn't show very much..... but he's still recovering, that's a very different thing.... it's different at first for everyone.

I was concerned seeing white beans on the list of things your husband ate, and also roast beef. These are very fibrous for someone just out of abdominal surgery. I stuck to low residue foods for the first two months -- white fish, scrambled eggs, smooth peanut butter, cheese, pasta, etc.... also with lots of protein shakes to supplement. If his output is very thin, he should take lomotil or immodium to slow it down -- my surgeon gave me a prescription and said not to let myself get dehydrated. She also said that the first 1000 calories a day went to healing from the surgery .... important to get extra calories if you can.

Kind of appalled at the care you're getting (or not getting)..... hang in.
Posted 6/1/2012 1:54 PM (GMT 0)
I'm most worried about the lack of fluids - I ended up back in the hospital from dehydration. He has to has to has to drink, I know it isn't appealing but fluids are key. We can live weeks with no food, but must have hydration. I hope it all gets sorted out for you, I just feel awful that you are going through all of this.

As someone else said, the output the first few weeks after surgery is much different than what you will have months out from surgery - I am almost 6 months out and I know what to eat to thicken/thin my output, it's just become second nature.
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