Healthcare Acquired Infections in Long Term Care facilities:

Mobile (Portable) Diagnostic Imaging and C. diff. prevention

“Most nursing homes are not paying enough attention to the whole C. diff. issue.”

-Dr. Cliff McDonald, MD, Prevention and Response Branch Chief

CDC Division of Healthcare Quality Promotion

Clostridium difficile: Background and Statistics

Clostridium difficile, or C. diff., is a microorganism commonly found in the intestines of many healthy people as part of the normal intestinal flora.  In conditions often associated with long term care patients, C. diff can quickly multiply to dangerous levels.  In amplified amounts, the microorganism releases enough toxins, normally harmless, to successfully attack the intestinal lining and cause severe diarrhea.  Worse, when a person may have a compromised immune system, the infection can rapidly progress and cause toxic megacolon, sepsis and even death. 

According to the Centers for Disease Control (CDC), 94% of C. diff. infections are associated with receiving some sort of health care.  Of that 94%, the CDC reports that 75% of healthcare acquired C. diff. infections occur in patients discharged into a long-term care (LTC) facility or back into the home following hospitalization.  According to Dr. Cliff McDonald, MD, Prevention and Response Branch Chief, CDC Division of Healthcare Quality Promotion, “More than three-fourths of C. diff. infections in nursing homes occur within four weeks after a resident is discharged from an acute care hospital.” 

In the long-term care population, the number of C. diff. cases has risen to over 263,000 annually.  Although the annual C. diff. mortality count amongst the entire U.S. population is significantly less at 16,500, the percentage of these deaths occurring in people over age 65 has skyrocketed to 90%.  Considering these numbers only reflect reported cases of C. diff., we can estimate conservatively that between 4-6% of C. diff. patients in the LTC setting pass away prematurely from this preventable infection. 

Why focus on C. Diff?

C. diff. infections are a growing problem and of particular concern for the LTC community for a variety of reasons.  The clinical challenges and impending financial consequences, along with a target-rich patient population, should make C. diff. infections and infection control a top priority.  The idiosyncratic nature of C. diff., as opposed to other healthcare acquired infections (HAIs), also presents the necessity for a focused evaluation of infection control protocols.  Finally, while statistics demonstrate that as a whole, HAIs are trending downward as healthcare workers become more astute in prevention, containment and treatment; C. diff. has climbed to historic highs in recent years and remains a mystery to many seasoned and reputable caregivers.  The LTC community is beginning to realize that C. diff. is no longer a problem only in hospital settings and as the CDC recognizes, these infections are a patient safety concern everywhere medical care is provided. 

Clinical Challenges: Risk Factors for infection; Methods of transmission; and Prevention.

Richard Schwalberg, Administrator at Menorah Park, a large, multi-location, long term care network in Cleveland, Ohio, sums up the clinical challenges of preventing C. diff. simply and succinctly.  “Any healthcare worker who moves from room to room, such as nurses or housekeeping, has the potential to transmit the infection,” he begins, “The question is how much training are they getting in precautions and are they thinking about it on the job.” 

C. diff. is a bacteria that produces spores that can live for 30 days or more outside of the body and because the spores are resistant to traditional disinfectants, they can be readily spread throughout a LTC facility even while following standard infection control procedures.  Without proper precautions, the bacteria may be present on medical equipment and other surfaces long after a patient has recovered, moved to another room or even after discharge.  Researchers have reported C. diff. contamination on 10% to 50% of everything from bed sheets to electric thermometer and even on windowsills.  No surface in a room with a confirmed C. diff. patient is safe from the invasive spores. 

Once C. diff. spores are present, patients, caregivers, visitors, and even equipment moved in and out of the room become potential transmitters.  Under standard infection control procedures a quick wipe with an approved disinfectant, removing your gloves after an examination, or a dab of instant hand sanitizer may be enough to prevent further spread of most HAIs, but C. diff. lingers long after these precautions are implemented.  Alcohol, regular disinfectant solutions and hand sanitizers do not kill C. diff.  Chlorine-based agents with sporicidal action against the C. diff. spores have been approved to disinfect and prevent spread, but their caustic nature has prevented them from being universally embraced.  Recently, the EPA has approved a line of disinfectant products containing silver ions as an effective agent against C. diff.  The new product is non-corrosive and safe for use on delicate screens, probes and other medical equipment.  As mentioned before, while HAIs are being reduced largely in part to more effective standard infection control protocols, C. diff. containment requires a more target-specific approach to decontamination, so incidence of C. diff. infection and spread are increasing at an alarming and unacceptable rate.

Another increasingly evident factor in the struggle to prevent C. diff. is the lack of awareness the average healthcare worker has about the bacteria.  As Richard Schwalberg asked, “How much training are they getting in precautions and are they thinking about it on the job?”  Unless a facility deliberately trains staff on the differences between C. diff prevention and protocols versus standard HAI prevention and protocol, most LTC caregivers think traditional precautions are sufficient.  As we just demonstrated, these universally accepted standards fall short of what it takes to prevent C. diff.  In a recent study, 35 healthcare workers were tested for C. diff. after direct contact with an infected patient and 59% of them tested positive.  Two interesting lessons are learned from these results.  First, 59% of the healthcare workers failed at some point in preventing the spread of C. diff.  Second, with such a high percent of infected healthcare workers, why is the rate of C. diff. infection reported so low amongst them? 

A Target-Rich Population: LTC Patients and C. diff. infection

As mentioned above, C. diff. is often found in the normal intestinal flora of healthy individuals.  Our bodies keep the bacteria under control and we can go about our lives without incident.  For this reason, many healthcare workers that fail to take the necessary steps to guard against not only transmitting, but actually acquiring C. diff. are often non-symptomatic and are never reported as being infected.  However, the LTC population usually doesn’t get the same biological and beneficial hall pass. 

According to research, the major risk factors for developing C. diff. infection are:

     1.      Over age 65

     2.      Frail, elderly or otherwise not in perfect health

     3.      Compromised immune system

     4.      Recent history of antibiotics

Unfortunately, one or more of these factors may apply to most or all of an LTC population at any given moment.  To further complicate a risk assessment, in an LTC setting, the highest risk patients are those recently discharged from a hospital after a short-term rehabilitation or nursing stay.

Dr. Cliff McDonald assess the risk of the entire LTC population in terms of level of care, “In the 15,000 nursing homes in the United States we have a high percentage of patients who are sub-acute; and that’s the population most at risk for C. diff. because they have been primed with a lot of heavy duty antibiotics.”  Antibiotics kill the bacteria in the gut that normally prevent infection, leaving the path open for C. diff. to multiply. 

With a plethora of hosts that provide a rich environment for C. diff. to thrive and a lack of protocols to prevent it from spreading, the risk of an outbreak is looming for many LTC facilities. 

The cost of infection: C. diff. and bottom line impact

Although there have been many published reports of hospitals and LTC facilities implementing enhanced environmental cleaning and equipment decontamination in the past three years, many have yet to monitor and track the efficacy of the programs.  From a patient care perspective, implementing these and other infection control measures, even lacking a tracking element, is a win-win.  LTC facilities that successfully reduce HAI rates and provide an excellent patient experience gain a positive community reputation and gain the trust of local hospitals for referrals; both which are good for business and patients.  Until now, however, there hasn’t been a need to add the tracking element. 

In 2014 the Centers for Medicare and Medicaid Services (CMS) will require hospitals to report C. diff. infection rates and will partially weigh the annual payment update based on the results.  Currently, hospitals voluntarily submit data to avoid a 2% reduction in payment.  LTC experts believe the same financial carrot and stick will be implemented for LTC facilities.  Unacceptable C. diff. rates will eventually translate to reduced reimbursement.  The future success of LTC budgeting will be heavily influenced by C. diff. and other HAI rates and a proactive approach will include internal infection control strategy evaluation as well as HAI and C. diff. transmission protocols for contracted healthcare providers, such as mobile imaging, phlebotomy, and lab companies. 

Currently, even a C. diff. case that ends in recovery rather than fatality is a heavy financial burden on LTC facilities.  Reports estimate that each case may cost in the range of $5000 - $7000; adding up to $2.2 billion nationally.  By taking C. diff. prevention a step further, investing time and money now to bring the rate of incidence under control, an LTC facility could potentially save significant dollars all while adding to the strong community reputation and industry respect that ultimately drive the bottom line. 

Mobile Imaging Providers: Our role in C. diff. Prevention

A responsible imaging provider should be part of your solution to reduce C. diff. infections.  At Source Diagnostics, we are ahead of the pack for infection control, specifically C. diff. prevention and containment.  We have developed and implemented infection control protocols and all Source Diagnostics personnel are trained in our proprietary methods.  Our program is designed to protect your patients’ health and acknowledges the need for stronger awareness than standard infection control.  Our clients can expect that the Technologist or Sonographer entering their LTC facility is fully trained and compliant with our protocols.

As a leader in mobile imaging to the long term care industry, Source Diagnostics pushes the boundary of necessity and operates in the twilight of the rising sun.  We know what you need now, but we work to anticipate what is in store in the future.  For this reason, we are partnering with our clients as a resource for the multi-faceted approach necessary to comply with future CMS regulations. 

Easy as A, B, C. difficile

EMPLOYEES MUST WASH HANDS BEFORE RETURNING TO WORK.

I hardly notice the sign in our office anymore.   It reminds me each day to protect myself from thousands of unseen enemies lying in wait, growing in strength and numbers, and elated at the prospect of hostile takeover; still I largely ignore the importance of its message.  Like most people, I have trained myself to wash my hands as an afterthought, out of habit rather than horror.  It’s so simple and effective and it has become second nature. 

Also, like most direct care employees at nursing homes, the last thing I want is another reminder of the importance of washing hands.  Yet, here we are; in a time of instant hand sanitizer, bleach based cleaning products, and hundreds of policies and procedures on universal infection control; we endure a 4% - 20% rate of Clostridium difficile (C. difficile) colonization in nursing home residents.  Even worse, during an outbreak of the nasty little organism, up to 30% of residents might be infected.  If training, warning and flooding caregivers with reminders about infection control leaves us with such unacceptable numbers, what else can administrators, corporate ownership groups and clinical leaders do to prevent C. difficile from riding roughshod through their facilities? 

Unlike acute care hospitals, which generally have the atmosphere and staffing needed to successfully implement most universal precautions, nursing homes have several restrictions and even some fundamental operating policies that make it difficult to contain the spread of infections. 

Our customers’ facilities are social by nature.  Group activities are important to the residents and staff and isolating a patient with potential signs of C. difficile isn’t always harmonious with the goal of maximizing quality of life for the residents.  The vast majority (over 80%) of C. difficile reports are in adults age 65 or older in an institutionalized setting; and the typical case occurs just after antibiotic treatment.  If nursing homes were expected to be on high alert for these indicators, they may turn into a C. difficile ward, rather than a warm setting for loved ones to receive rehabilitation and end of life care. 

We don’t believe our customers should sacrifice their methods of caring for our grandmas and grandpas by caving in to the threat of an outbreak.  Although nursing homes may struggle with appropriate staffing, a lack of on-site diagnostic tools which could prevent the use of broad spectrum antibiotics, and the quantity and availability of preventative tools such as single use gowns or enough isolation areas like acute care hospitals; they shouldn’t struggle with a partner that inadvertently impacts the risk of outbreak. 

We take precautions above and beyond other vendors to make sure we work for you as part of the solution, not part of the problem.  We are conscious of the risk that portable equipment can be a vehicle for infections like C. difficile to move from room to room and we require that it is meticulously cleaned with products like Steriplex SD.  Our caregivers are always attentive to how our mere presence impacts the spread of infection because we train them rigorously on universal precautions and methods of cleaning that are specific to portable imaging.  At Source Diagnostics, we have made infection control as important as that little sign in the bathroom.  

Get a Clue: C. Diff, other HAI rates will impact reimbursement

Mrs. Peacock, in the Conservatory, with the knife.

The government agencies tasked with interpreting the Affordable Care Act of 2010 are making strides to transform the Act’s colorful plumage into measurable and enforceable metrics. Medicare and Medicaid reimbursements for Long Term Care Facilities and Home Health Agencies will be slashed in the near future; metrics and quality measures replacing the traditional blade. One of the main measurements used to determine cuts will be the frequency of healthcare acquired infections (HAI’s), specifically C. Difficile Infections (CDI’s). Preventing CDI’s is now increasingly important to a facility’s bottom line.

The scope and pervasiveness of HAI’s is also quickly becoming detrimentally transparent. Reporting requirements for acute care hospitals are already in place and they will start paying Medicare take-back penalties in 2015. The days are gone when a whistleblower had the power to bring down a facility for mismanaged infection control. Today, we all operate in glass houses, where a potential customer is only a mouse click away from changing his mind. Preventing CDI’s now impacts a facility’s reputation.

A toolkit for States to eliminate HAI’s and the National Plan to Prevent HAI’s have been published by the Centers for Disease Control and Prevention (CDC) and the Department of Health and Human Services (HHS), respectively. Each directive includes an element for Long Term Care facilities, our main customer base. Now, preventing CDI’s is our problem.

In an industry characterized by tight margins and the desire to provide care over the desire to earn a fortune, it’s understandable that the numbers don’t always add up for comprehensive prevention programs. We educate, provide tools and hope for the best, while risking the worst. The Mrs. Peacocks of the world are pushing for additional negative financial pressure in the form of reimbursement cuts, so the time is now to cinch the belt rather than lose the pants. Historically, reimbursement for CDI treatment often falls short of the actual cost, a good motivator for prevention on its own. Further, a CDI outbreak, or any preventable HAI that is allowed to thrive in your facility is a disappointment to the staff that genuinely wants to do the right thing for all the patients. Prevention programs and educating staff to the proper degree are the right steps to eliminating CDI’s in your facility, no matter the motivation.

If reimbursement cuts based on HAI’s, including and especially CDI’s, are a foregone conclusion just over the horizon; what can our customers do to prevent losing some percentage of their reimbursement payments? At Source Diagnostics, we promote a comprehensive prevention program which includes examining previously unnoticed transmission methods, including our presence at your facility. We are acutely aware that our staff and equipment are viable modes of transferring HAI’s between rooms. We take extra steps to prevent CDI’s from spreading. We work with our customers to develop prevention programs and play an important role in educating your staff as well as ours.

Whether Mrs. Peacock, the knife or the Conservatory motivate you; or, like Source Diagnostics, if you believe it’s the right thing for your patients, the time is now to get a clue and start preventing CDI’s in your facility. Please join us in the Parlor for upcoming posts about best practices for CDI and HAI prevention and bring your wrenches; we’re working on solutions!

ALL ABOARD!

Portable x-ray Providers for Railroad, Traditional and Medicare Advantage plans will be asked to show tickets in the near future.

As portable x-ray providers and Long Term Care (LTC) facilities boarded the “Party Train” with the release of the 2013 Medicare Physician Fee Schedule, which clarified that non-physician practitioners and others are now permitted to an order a portable x-ray, we almost overlooked the “gap” between the train and the platform.  With all the cost saving measures taking shape under the Affordable Care Act, we could have guessed this was coming. 

In May of this year, Palmetto GBA, as the Railroad Retirement Board’s Specialty Medicare Administrative Contractor, announced a “widespread review of radiology services.”  While Palmetto’s use of “widespread” may only be a harbinger of things to come, the first phase of this review is focused on claims submitted under CPT codes 71010 and 71020.  The Medical Review unit will call to question a sample group of claims from portable x-ray providers by sending out ADRs, or Additional Documentation Requests about the specific claim.  When a provider receives an ADR, they will be asked to reply within 45 days with the following information:

Support for billing the Technical Component (TC):

1.      Documentation to support the service was rendered. (Example: The diagnostic test report.)

2.      A signed order, or documentation that clearly reflects the ordering provider’s intent.

Further, if the provider is billing for the Professional Component (PC):

1.      A signed diagnostic test report.

2.      A signed order, or documentation that clearly reflects the ordering provider’s intent.

At Source Diagnostics, we work closely with our partners to ensure proper documentation of these requirements, whether a patient is covered by Palmetto’s Railroad Medicare or not and regardless of the CPT code.   We believe this “widespread” review will mature into an extensive cost saving investigation for all carriers, CPT codes and providers in the near future. 

If you are a client, you’re already aware that ALL orders we take contain 5 elements, which in conjunction with 42 CFR 486.106, provide the information needed for the signed order requirement of Palmetto’s ADRs.  

• The reason a portable x-ray is required;
• The area of the body to be exposed;
• The number of radiographs to be obtained;
• The views needed; and
• A statement concerning the condition of the patient which indicates why portable x-ray services are necessary.

As the healthcare environment becomes more adept at managing the massive amount of data required for these cost saving measures, Source Diagnostics remains ahead of the curve for our clients; to provide the most outstanding protection against the fear of slipping into the gap and missing out on the party train.  Anybody wanna take this ride?  

Thelma Ruth Zier McCostlin

“Where are the munchkins?” Johnny asked, neglecting to peek into the garage at Grandma’s ranch, where his four grandchildren greedily raided the outside freezer like thieving gypsies.

They marauded for the tasty sweetness Johnny usually doled out like Halloween candy; plastic cups filled with creamy vanilla ice cream.  The four cousins gobbled the treats with small wooden spoons every time Johnny made good on his pledges to hand them over.  They pitter-pattered through Grandma’s house regularly as youngsters.  The humble abode had one floor with three bedrooms at one end, an inviting kitchen inside the front door and a warm living room that stepped down into a large enclosed porch added to the house in the nineteen seventies. 

The delicious aroma of breakfast often wafted from Grandma’s kitchen, never more mouth-watering than when her homemade sausage gravy and biscuits spilled over the side of an old cast iron skillet.  Fresh ingredients for every meal imaginable, Miller High Life, and half-filled milk jugs with missing tops were crammed in the refrigerator.  The linoleum floor was worn from three young men hustling to and from football practice all through high school.  The legions of teammates stopping over to their home away from home also left an unmistakable path in the old kitchen floor.  The pattern was pure seventies, yellowing squares with a blurred floral pattern, the perfect size for a grandchild to traipse through without touching any lines and losing the game of balance he played in his head. 

The window over the kitchen sink looked out to a small suburban landscape accented with an enormous oak in the middle of the tree lawn, shadowing the yard and the street equally, littering helicopters that provided hours of adolescent entertainment.  The towering oak was a reminder of days gone by, of the stories Johnny told of cowboys and Indians, of hunting through the northeast Illinois wilderness long before Chicago became the megalopolis famous for meat packing, city fires and gang wars.  The tree was as much home as Grandma’s warm hug, it was our very own Giving Tree, made famous by Shel Silversteen and brought to life in Grandma’s front yard. 

Above the kitchen table, a giant bay window framed countless lightning shows, better entertainment than anything on television for the curious, scared, wide-eyed cousins.  Retreating into Grandma’s arms, learning to count between the lightning and thunder, one one-thousand, two one-thousand, three-one-thousand . . . JUMP! 

The attached garage, where Johnny kept his heavenly treats in the spare fridge, housed good quality American cars throughout the years.  The cousins often piled into a parked Oldsmobile and played on the cloth seats, making believe they were in faraway lands, jumping from front to back to elude dragons, bad guys and the occasional swipe of another’s hand.  The garage was littered with an aspiring carpenter’s tools, a lifetime of knick-knacks and even the eldest son’s family during desperate times. 

The family often gathered in the living room where the focus was on each other rather than the television.  During the coldest Chicago winters, a kerosene heater glowed in the middle of the room, radiating heat and keeping the room as warm as the hearts of those inside it. Grandma tapped the keys of a baby grand piano as Johnny sprawled out in front of the couch on a hodge-podge bed of old couch cushions.  He smiled at the intense gazes the cousins wore as we listened to Grandma’s slow music.  After the console TV died, her sons replaced it with a modest upgrade and perched it on corner mount hardware on the far wall.  The television usually came on when Grandma wanted to watch Wheel of Fortune, the cousins were ready to settle down and watch cartoons, or Johnny had an itch to see the last American Cowboy, John Wayne.  Johnny sat the cousins in front of that TV on many dreary nights to scare them with black and white Lon Cheney movies or a Bela Lugosi classic.  After the kids moved away, Grandma and Johnny would wait up in that living room to the wee hours of the morning, when the families would return home for the holidays after hours on the road.  The late night hugs, after driving all night through Midwest snowstorms, warmed us more than the kerosene heater ever could. 

Double doors opened off the living room and one step changed the warmth of the living room to the barren solitude of the back room.  Cold gushed from the door to the patio and seeped in through the sliding glass door.  Furniture was noticeably absent in the back room, save the youngest son’s king size waterbed.  It was difficult to move away from the comfort of that house, that home.  Each year, as if Jack had planted a bean in the shag carpeting, a Christmas tree magically grew in front of the sliding glass door.  Suddenly, the frigid room transformed into a glowing oasis of holiday spirit.  The room, dim and sullen most of the year, rivaled any carnival midway in sparkle and mysticism on Christmas morning.  The carefully decorated tree shrunk the room, as did the cousins’ growth spurts year after year. 

To the eager cousins, Christmas morning never came fast enough.  One after the other they stirred from sleep, only to be disappointed that the twilight on morning had not yet broken the snowy December night sky.  Every year the four cousins raced to the back room to discover what Santa brought the night before.  Without exception, they dove headfirst into a sea of presents, speckled with specially wrapped gifts in shiny department store window decorating paper, a staple of Christmas at Grandma’s house.  The paper was as constant as the company.  Johnny acquired it at one of the stores he cleaned at night; the roll was a thick as the old oak out front and always hid the best presents.  Twenty five years later, Christmas still isn’t exactly right without it. 

Outside the sliding glass door, a tall wooden slat fence guarded Grandma and Johnny’s stake in the world and protected the cousins as they played outside in the sacred, grassy yard.  Grandma’s garden was overgrown and peppered with lost matchbox cars and MIA G.I. Joe dolls.  The small concrete patio supported a worn out picnic table, weathered by years of sun and rain and topped with ashtrays and beer can tabs from long nights and early morning.  A rugged Weber grill stood stoically in the corner, chipped and grease laden from searing thousands of pounds of Chicago beef.  Two generations of kids played on the rusty swing set in the corner of the yard and occasionally the cousins camped out in a small tent, smack dab in the middle of their own Garden of Eden. 

Back inside, the family made the modest house a welcoming home.  Thelma, the matriarch of the small Midwest family was a strong willed mother and gentle grandmother with an infectious smile and a laugh reflective of her youthful personality.  She was quick to pucker up as soon as she saw the grandbabies, the wrinkles around her mouth showing her age even if the excitement in her voice contradicted them.  In contrast to the suburban life her grandchildren would know, Thelma was raised in the rural Midwest during a simpler time.  Her father tilled land until the day he died and Thelma exemplified his farmer’s values and simplicity.  The cousins learned to be honest and to enjoy the subtleties in life from Thelma, traits she picked up as she sat on her father’s lap on a faded green tractor.  Her oldest son would venture back to the farm with his new wife and baby boy while he searched for a starting point in life.  The cousins inherited the family work ethic and someday they would bubble with pride thinking of their country roots.  Years later, in the dairy aisle at the grocery store, one cousin would insist on buying only pure horseradish.  Look at the ingredients; horseradish root, salt, vinegar.  Anything more was unacceptable.  His affinity for the blend arose after seeing his father and Great-Grandfather emerging from the farmhouse basement, arms extending like zombies to keep the smell from further scalding their nostrils and crying like babies after a session of grinding the root for the morning’s breakfast. 

Harold Patrick Barry

The young Private first class used his handkerchief to wipe the sweat from his forehead.  The sweat rolled down his skin after performing several songs on the Mess Hall stage.  The makeshift lights were blazing hot and pointed straight toward him.  The packed room thumped and swelled from the body heat of five hundred enlisted men.  He loved singing for his comrades, but knew his stage career was grounded while he was still in the Army. 

His physical prowess was average at best.  A five feet, nine inches and barely one hundred and fifty pounds, his booming voice was obviously his most valuable characteristic.  He looked especially slim in his dress attire, neatly buttoned and tucked in tight for performances.  His prominent Irish features gave him a commanding presence despite his meager rank.  The soldiers loved his company during card games, over meals and at night, when he sang the barracks to sleep with sweet melodies that comforted the men and reminded them of the beautiful women desperately waiting to see their faces again.  His enormous smile and hearty laugh warmed the room, more so than the dry Texas heat.  Some of his closest friends on the base sensed a deep conflict within him that always brought a tear to his eye as he crooned sweet love songs late into the night. 

Two years earlier, the young man stumbled upon the one thing that held back his full commitment to the U.S. Army: love.  In a Chicago high school, notorious for student fights and touted as the toughest school in the city, the baby faced boy scowled through the halls, protecting himself from regular bullying because he appeared so frail and young.  Quick to throw a punch, he was known as a scrapper with a fiery temper.  Just a year before he found love, his previous high school kicked him out for punching a principal during a lunchtime melee.  His reputation preceded him to his new school and he was tested daily by anyone looking to make a name around the halls. 

On St. Patrick’s Day, 1937, the young man strolled past his high school to attend Catholic mass.  After confessing to Father McCleary, he wandered to school and slipped in the doors between classes.  He pushed open the cold metal doors and a small gang of kids confronted him, jealous of his carelessness toward the school’s attendance policy.  He emptied his lungs of the last puff of smoke from his non-filtered cigarette and a mixture of smoke and frigid March air clouded the dimly lit foyer.  He tried to ignore the collection of tough guys.  One determined, courageous youngster stuck a finger in his face and shouldered him as he walked through the glaring group.  He thought of confession; how uncomfortable he felt and how he promised to go this week without sin.  Then, he smiled as he remembered the disturbed look on the Priest’s face as he described his last fight.  The assailant looked confused when he smiled, but the inquisitive expression was quickly altered by a fist to his left cheek.  After a short scuffle, a passing teacher separated the boys.  Unscathed, he was led to the Principal’s office by his ear. 

He glanced around the familiar room as he waited to see the high school’s tsar.  A receptionist sat behind an oversized oak desk, pecking at an antiquated typing machine.  Over her left shoulder, the Principal’s door was closed.  A trophy case in the corner needed dusting and the administrator’s credentials yellowed under the glass frames on the wall.  Suddenly, an unfamiliar face strolled into the office.

“Anything else I can do for you Mrs. B?” she asked of the secretary as she brushed by his knees.

He touched his pants as if her long dress changed the gritty denim texture.  He stood quickly, as his father had taught him when a lady entered a room, but the secretary shot him a stern glance as he returned to the waiting chair.  He swore he saw the girl smile in the trophy case reflection.  Her sweet smell finally wafted his way and he faked a yawn to take in as much of her exciting scent as possible.  His inexplicable youthful confidence gave him the courage to look her straight in the eyes as she turned his way.  She was much shorter than he and he doubted she even reached five feet.  Her long curly hair flowed over her petite shoulders and mixed with her brown overcoat like a waterfall meeting the river below.  He gawked at her beauty and she noticed his stare, she turned away and blushed at his boyish flirtation. 

The Principal’s door slowly creaked open, but his eyes didn’t flinch from her rosy red cheeks. 

“Harold Patrick Barry!  Get in here!” demanded the angry totalitarian.

He stood again, this time drunk with puppy love and staggered by the young girl.  He slipped a hello her way as he approached the Principal’s office.  She finally smiled and he bumped into the door frame as the lecture began.

Harold Patrick walked out of the Principal’s lair feeling untouchable.  The lashes he endured were numbed by the tingle of love at first sight.  He smiled at the secretary, “Thanks Mrs. B.”  She was flabbergasted by his happiness after hearing the paddle’s crack behind the closed door.