MRSA Abscess and Septra Reaction

MRSA Abscess and Septra Reaction
A Personal Story and Home-Care Advice, Nick Yee, Main Draft Posted on June 12th 2007

I've recently struggled with a series of health issues that have severely impacted my life, both physically and psychologically. For me, documenting this is part of the healing process. It's a way for me to make sense of all that has happened. For those of you who know me, I felt it was important for you to understand how the past 5 weeks may have changed me forever, for better and worse. And finally, I also want to help others who may be suffering from abscesses by pointing out what worked and didn't work for me with regards to treatment, home care, and things to be very careful of.

Please know that I'm not a medical doctor, although I did recently get my doctorate in the social sciences. Where appropriate, I will provide links to journal articles, multimedia, and other web pages that substantiate some of the points I make. Illness is both a highly statistical and a highly personal thing. Many of the web sites you will find by googling "abscess" will show you the big picture and general trends. For those who are suffering from abscesses, I hope the following can give you a better sense of the day-to-day and personal side of the experience.

Brief Overview:

I was infected with a methicillin-resistant strain of staph (MRSA) which caused an abscess with about a 3-inch diameter on my leg where the thigh meets the buttock. After surgical incision and drainage, wound-packing began while I finished a course of antibiotics (Septra). I developed a mild skin rash from the Septra, but this occurred while I came down with the flu, so it was difficult to pinpoint the cause of the mild rash until the flu passed. I finished the antibiotics course and the rash continued. Four days after I last took Septra, I developed a severe allergic reaction that resulted in a rash that covered about 90% of my upper body and caused facial swelling. I was unable to sleep for 4 days.

Day	Date	Overview	My Story	Suggestions and Advice
Day 1	May 8th	Abscess begins	The abscess began like a zit-like bump on the back of my leg where the thigh meets the buttock. It felt exactly like a pimple that couldn't be popped.
Day 5	May 12th	First Clinic Visit	The bump had grown significantly larger, becoming more painful, more itchy, and more inflamed. By May 11th, it became moderately painful to walk and sit down. I made an appointment with the clinic and was diagnosed with an abscess. I was given a first-line antibiotic (Dicloxacillin) and told to do warm compresses as often as I could.	A dry compress (gel pack wrapped in cloth) feels significantly differently from a wet compress (microwaved wet towel). I found that wet compresses felt a lot better because of how it distributed the heat, although wet compresses cool down faster from the evaporation.
Day 8	May 15th	Dissertation Draft Due	The beginning of the last stage of the dissertation starts with distributing the draft to the reading committee. The defense was scheduled for two weeks later.
Day 9	May 16th	Clinic Follow-Up	I had been taking the antibiotics for 4 days but the abscess was getting bigger (about diameter of an orange). While there was a sore on the skin in the middle of the abscess, it didn't seem it would drain on its own. At the clinic, they opened up the sore a little with tweezers to get a culture and to see if it would get the abscess to drain. While they got some pus for the culture, the now open sore was only draining mildly. Worried that I may have a methicillin-resistant infection, they switched me to Septra (a different class of antibiotic) even though they wouldn't know for sure until the culture came back. One huge complication from this point on was that the open abscess was continually draining bloody pus and dressings had to be applied and changed every 4-6 hours.	For dressing sores that are draining bloody pus (i.e., more gel-like than liquid), you must use highly-absorbent loose cotton gauze as the first layer. If you use more solid first layer dressings, the pus will not be absorbed by the dressing and make a huge mess. I found that Kendall's Kerlix Bandage Roll worked best for this. Because you will be changing dressings frequently, use soft paper tape sparingly as the adhesive. If you use strong adhesives, the constant changings may cause a rash.
Day 12	May 19th	Culture Results In	The culture showed that I did indeed have a methicillin-resistant staph infection. The technical term for this is MRSA (Methicillin-resistant Staphylococcus aureus), pronounced "mersa". By this point, I had to take Advil constantly to manage the pain. And even with the Advil, sitting and walking were incredibly painful. This also meant it was difficult for me to drive a car.
Day 14	May 21st	Clinic Follow-Up	Even on the Septra, the abscess was not improving. The inflammation had gotten worse even with it draining bloody pus. At this point, the clinic (i.e., student health center) referred me to general surgery (at the hospital). The clinic was not equipped to perform surgical procedures. In other words, the clinic tried to exhaust all non-surgical treatment options before the referral. This can be dangerous because most skin abscesses need to be surgically drained before they can heal.	There is a general consensus that most skin abscesses larger than 5mm in diameter do not heal on their own without surgical incision and drainage (I&D). If you have a skin abscess that hasn't drained, ask your physician to perform a surgical incision and drainage as soon as possible. If the clinic cannot handle it locally, ask for a referral to general surgery as soon as possible. The longer you wait, the more the pus festers inside, and the bigger the abscess becomes.
Day 15	May 22nd	General Surgery	At general surgery, they performed an incision and drainage under local anesthesia. This allowed the majority of the pus to drain out. The "hole" in my leg left by the abscess now needed to heal from the inside out. If the incision were sutured, the abscess would fill again with pus and get reinfected. To do this, they "pack" the wound with gauze and repack it regularly until the wound heals. In other words, the surgical incision is kept open and draining until the abscess heals. Even under local anesthetic, the first packing was the most painful part of the process. I was under a great deal of pain right after the I&D, but the pain decreased dramatically over the rest of the day. It felt a lot better.	The following videos from YouTube show how a typical I&D goes. While extremely disturbing to watch, it helped me a great deal in psychologically preparing myself for the surgery. This particular video series is good because it shows the whole process: local anesthetic, surgical incision and drainage, and finally wound packing. What it doesn't quite show is the normal amount of pus drainage right after the incision. Video One Video Two Video Three
Day 16 - 19	May 23rd - 26th	Initial Clinic Packings	I had to go to the clinic to get the abscess repacked every day. Psychologically, having an open, draining wound on my body for weeks was very difficult for me, let alone having it repacked every day. They kept me on the Septra during the packing process. Because of the anxiety and pain involved with repacking the abscess, I was prescribed Vicodin and told to take it an hour before I went to the clinic. The Vicodin helped me a great deal in managing anxiety in the first few packings. At the clinic, they would remove the packing and then irrigate the wound with saline solution. They would then use a long cutip to probe the wound to figure out how deep the abscess wall was and where to pack the gauze. They then applied an anti-microbial gel (Silvasorb) before repacking the wound with a long strip of gauze. The main function of the gauze is for it to wick the drainage outside of the abscess. Thus, the tail of the gauze is left trailing through the incision point. After the 5 days of daily wound packing, I could begin going in every other day. This was such a relief.	Ask your doctor for Vicodin for the first few packings. This is for managing both the pain and the anxiety. You should only take it for the packing itself to minimize the chances of becoming dependent on it (it is a narcotic). Take Advil or Tylenol otherwise. There is a powder variation of the Silvasorb gel. While it is supposed to be more absorbent than the gel, it also stings a great deal for 10 minutes. If you have a choice, ask them to use the gel instead of the powder. For me, I would rather change the dressing once more than to have to deal with the stinging pain. While the very first unpacking hurt a great deal, subsequent gauze removal hurts a lot less than you would expect. The most painful part is when gauze is packed back in the wound. Hold on to the bed railing and take deep breaths. You need to try your best to not distract the nurse from the necessary packing. If you make too much noise, it may lead some nurses to not pack the wound as much as they should because they are worried about your comfort. There are now 2 complications to dressing the wound. The first is not getting the packing wet while showering. I found that the best bandaging for this was Nexcare's Absolute Waterproof Premium Adhesive Pad. It goes on hard-to-cover, non-flat surfaces, is comfortable, and very waterproof. Pricey but worth it. The second complication is not dragging the gauze strip out while changing the outside dressing. For this, I found that dabbing Neosporin on the dressing before putting it on the wound helped a great deal. When necessary, use a cutip to hold the gauze down while removing the dressing. With regards to antibiotic use after I&D, most studies have shown that the antibiotic doesn't really help much. I would suggest getting off Septra as soon as the I&D happens if you're on Septra.
Day 20	May 27th	Serum Sickness Onset	At this point, I came down with what I first thought was food poisoning. Both a friend and I developed similar symptoms at the same time and we both thought it was food poisoning at first because we both ate at a Japanese restaurant where there was some concern about food preparation.	Serum sickness is a delayed allergic reaction that begins with flu-like symptoms. While I used to think that the flu and the rash were separate things that just happened together, they were actually part of the same serum sickness.
Day 21	May 28th	Serum Sickness Onset	My friend began reporting acute food poisoning symptoms to me - chills, fevers, sweats, joint pains, and diarrhea. While I felt a little weak in general and began sweating profusely, I remained largely functional.
Day 22	May 29th	Dissertation Defense	I didn't tell anyone about the illness because the last thing I would have wanted was for my health to become special consideration during the final dissertation process. I didn't want to be treated any differently. And due to close deadlines, it would have been impossible to reschedule. I felt weak and was sweating profusely throughout the defense, but I worked through it. The defense went well. Revision of the dissertation was due at the registrar on June 7th along with an assortment of other forms and materials.
Day 22	May 29th	Serum Sickness Continuation	By the evening of May 29th, I began to develop serious flu-like symptoms, although at that point, I was still under the belief I had food poisoning like my friend but with a delayed onset. I started experiencing cyclical waves of chills, extreme fatigue, feverish sweats, and heat rash. My body temperature fluctuated between 98 and 102 degrees. This progressively got worse until I could not physically get out of bed for more than 2 hours every day for 3 days. I lost my entire appetite and began experiencing increased sensation to taste and smell. Then a bitter, metallic taste developed in my mouth that I could not get rid of. It was a persistent taste that was incredibly disturbing physically and psychologically. Never before had a taste in my mouth kept me from falling asleep. But because I wasn't experiencing diarrhea, I came to believe that I had the flu. For a long time, I just thought I was unlucky to catch the flu, but an email from a doctor months later alerted me to the high likelihood that the flu-like symptoms were the beginning of serum sickness, a delayed allergic reaction.	It is very important to stay hydrated and nourished, especially because most of the times, it may be physically impossible for you to get out of bed. Make sure you have water and granola bars by the bedside. Also keep a thermometer by the bedside. Keep monitoring your own temperature and seek immediate help if it exceeds 103 degrees.
Day 24	May 31st	Clinic Packings	I drove in to the clinic on the morning of the 31st between the waves of chills and fevers. The abscess was healing well. The nurse told me I could start coming in only twice a week for the packings.
Day 24	May 31st	Rash Onset	On the evening of May 31st, I experienced the first widespread itching sensation over my body during the "flu". The earlier heat rash was not itchy. The itching kept me up all night. Because I had gotten heat rash from the fever sweats, I attributed it to the "flu", but this was actually the ongoing allergic reaction to Septra. Not knowing this, I continued to finish the course of Septra (until June 3rd). In hindsight, one important clue that something was wrong was that my friend did not report rash/itching symptoms at all. Another confounding factor was that I have a chronic but mild allergic itch condition that I take an antihistamine (Zyrtec) regularly for. So at first I thought that the "flu" had magnified the underlying reaction. This also meant the Zyrtec masked the actual onset of the condition until it became more severe. Medically, a very important symptom and window of opportunity was missed due to the confluence of these factors.	If you are taking Septra and you experience any rash or itching, stop taking Septra and see your physician immediately. While skin reactions are actually typical for Septra, they also tend to be very mild. However, from time to time, the skin reaction can be severe. While Septra is a potent antibiotic, this common side-effect is one of the main reasons it is not used as a first-line antibiotic.
Day 27	June 3rd	Flu Ends / Septra Finished	I had largely recovered from the "flu" by June 3rd and that was also the last day of my Septra course. While the flu-like symptoms were now gone, I still had the itching all over my body intermittently throughout the day and night. I still thought this was just my chronic itching condition magnified.
Day 31	June 7th	Dissertation Due	On the morning of the 7th, I had developed a very mild rash over my arms and upper body, and the itching increased. I finished the revisions and my advisor signed off on the document. I turned in the dissertation copies and supporting material at the registar's office. I was officially done with the last requirement of my Ph.D. program.
Day 31	June 7th	Severe Rash Onset	I was in the clinic on the morning of the 7th for repacking. The nurse noticed my rash and immediately thought it was an allergic reaction to the Septra. She called the doctor who felt the same way. Because the rash still appeared mild, they told me to take Benedryl. The allergic reaction dramatically worsened throughout the day. By late afternoon, the rash had spread all over my arms and chest. It was also impossible to fall asleep now because the itching was constant. The Benedryl did not help at all.
Day 32	June 8th	Clinic Visit	On the morning of June 8th, after a night of no sleep, I woke up to discover my entire upper body was about 60% covered in a deep rash. My face had also swollen up so much that I could not recognize myself in the mirror. The facial swelling also made it difficult for me to fully open my eyes. I called the clinic and asked to be seen as soon as possible. They were now sure this was a Septra reaction as soon as they saw me. I was prescribed with a steroid (Prednisone) and an antihistamine (Atarax). The drugs made only a slight difference. My rash continued to spread and about 90% of my upper body was covered in rash. In most places, the rash had joined to create large swaths of red. The continuous and uncontrollable itching over my body was beyond words. It was also a horrifying physical reality to see in the mirror. There was nothing I could do and no amount of scratching that would help. It was also still impossible for me to fall asleep. I was in a painful, tortured delirium where I started having fleeting thoughts of suicide.	I was prescribed to take 3 Prednisone tablets each day. Because of a possible caffeine-high effect, the pharmacist had suggested I take all 3 pills before mid-afternoon. In hindsight, it would have been better to spread it throughout the day. Since I was not getting any sleep anyway, I would rather have minimized the itching as much as possible over the day. People react very differently to Prednisone though, so make sure you get a sense of its effects (and side effects) on you and consult your physician if you have trouble falling asleep etc.
Day 33 - 34	June 9th - 10th	Allergic Reaction Continues	The rash looked much worse and was now spreading down my legs where there was no rash before. This meant that almost every inch of my skin was itching uncontrollably. Warning: Very Graphic Images Image One Image Two Image Three I finally started to get temporary relief from the medication. For brief moments of time, the itching would be mild enough to bear for me to lie down and fall asleep for 30 minutes until it began again. The only true relief I found was in video games. I got two new games on the Nintendo DS and it was the games rather than the medication that provided the most relief by distracting me from the itching. I was still not getting any sleep, but at least I found a way to not scratch myself constantly and cause bleeding. Darkened patches started to appear on my face as the swelling subsided. The skin on my face began to become extremely dry. I had to lather lotion on my face to keep it from what felt like extensive peeling. Physically, it felt as if my face were about to fall off altogether.	If this happens to you, make sure you find something that can distract you from the itching. Because I couldn't stop the itching, I gave up on trying to sleep and concentrated on distracting myself from the itching. Do not just lie there and scratch yourself because you may cause your skin to bleed. If you are a gamer, pick up a new game. The portability of the Nintendo DS let me play in bed. Or consider renting and watching entire seasons of Lost or 24. If your face dries up, apply a strong fragrance-free moisturizer. For me, Cetaphil lotion worked best.
Day 35	June 11th	Clinic Visit	On June 11th, I was back at the clinic for repacking. The nurse who had seen the mild rash on June 8th was shocked to see how badly the rash had spread. There was good news though. The abscess had healed so much that packing was no longer needed. The irony was that being immobile in bed with a high fever produced the optimal conditions for abscess healing (i.e., constant warm compresses). They dabbed some Silvasorb on it and I was good to go. The medication was now helping moderately with the allergic reaction. The itching would intermittently change to what felt like cool spikes. Not comfortable, but much more bearable than the itching. It also became possible to fall asleep for 1-2 hour stretches at a time. But this temporary relief also made me breakdown psychologically. When I got home and opened the new bottle of 40 antihistamine pills, I realized how much I desperately wanted to swallow all of them. I began shaking violently and fell to the floor wailing uncontrollably. My mind finally had time to process what was happening to my body and it suddenly became too much to handle. Throughout the rest of the day, I would periodically collapse into tears and I would cry until I became too faint to cry. I was on the verge of a complete psychological breakdown.	I cannot stress how important a strong social network was for me during all of this. I don't think I would have been able to cope psychologically through it alone. While I didn't want anyone to see my in the physical state I was in, a very good friend convinced me that he just wanted to be there for me and didn't want me to be alone. That made all the difference.
Day 36	June 12th	Rash Begins to Subside	While I didn't get much sleep last night, the rash is beginning to subsibe and the medications provide relief now. The sloughing skin on my face has also stabilized. The itching is still there, but it is now bearable even though sleep is still difficult. My heightened sense of taste remains, probably a side-effect from one of the medications. But instead of giving everything a metallic taste, I am able to taste nuanced flavors in foods. When I took a sip of milk this morning, I tasted rich, creamy, nutty flavors that I have never before tasted in milk. For a moment, I was very confused, and had to check that I was indeed drinking milk. I held on to the glass for a moment realizing that this milk was the most wonderful thing I have ever tasted in my life.	If the heightend taste thing ever happens to you and milk tastes very good, go buy different brands of milk as fresh as you can. The differences between milk brands is amazing to experience. I had two brands of fresh milk in the fridge. One had a rich, creamy, almost primalistic taste to it (Foster Farms Vitamin D). The other was sweet, more refined, with a hazelnut aftertaste (Lucerne Vitamin D). Both were amazingly good in different ways. But they tasted as different to me as vanilla and strawberry.
Day 37	June 13th	Heat Wave	I had not been watching the weather forecast, but by 9am in my apartment I noticed the temperature rising rapidly. The weather forecast was going to be a high of 95. I looked at my body and noticed secondary rashes emerging. I panicked briefly until I realized I had splurged on a portable AC unit last summer during the unbearable heatwave. I quickly assembled the unit, hoping that it was still functional. Unfortunately, in my enthusiasm, I blew the surger as I absent-mindedly overloaded it with the AC and the computer. I realized I would have to completely require the power cables and surgers in my apartment to get the circuit loaded safely, and that I was missing components (i.e., 3-to-2 prong adapter and a working surger). I drove to the Long's around the corner and got the components, drove back, and rewired the apartment. By 10am, as the temperature outside spiked, I finally loaded the AC on the circuit and the unit began to maintain a room temperature of 79. I monitored the circuits to make sure nothing was over-heating. And then I collapsed on the couch, incredibly relieved. The secondary rashes began to fade. The weather forecast showed that the heat wave would be gone by Sunday (forecast 77 high), but it would still pose a significant health risk for me to wear the academic regalia (black cap, black gown, and hood) at the ceremony. I suggested an improvisation to my advisor because I wanted to maintain the visual symbolism of the hooding process (i.e., teacher transforms student). I have a chinese-style silk brocade jacket, fully-reversible, royal blue on one side, imperial gold on the other. I suggested to Jeremy that I walk on stage in blue, and that he would help me change into gold on stage. That is now the plan.	A good portable AC unit costs about $500. They are typically very heavy, but mobile and easy to move around once set up. This was the best investment I have ever made in an electronic equipment. 3-to-2 prong adaptors sometimes become impossible to find. Make sure you have spares around. Also make sure your electronic equipment is all surge-protected. I was very fortunate to have blown the surger and not the AC unit. Gorgeous, fully-reversible, silk brocade jackets in amazing hues sell for about USD15-20 in open markets in Shanghai, but bargaining is required. This isn't the brocade jacket I have, but the colors (blue and gold) most closely match the jacket I own and the style/cut is identical, except mine is fully-reversible.
Day 38	June 14th	Recovery and Counseling	The heat wave continues. I had to be on campus today and being in the sun was unbearable. I made sure to get into air-conditioned areas as quickly as I could. The forecast for Sunday's high had risen to 80. I am recovering well. The rash over my body has started to fade dramatically. I was in the clinic this afternoon, and everyone who had had seen me on Friday and Monday was relieved to see the dramatic improvement. The abscess has now become mainly a small incision wound. That means I only have to worry about scar management from this point on. I had my psychological counseling session today where I told the whole story to a counselor in one sitting. It was incredibly cathartic, and also reaffirmed that the healing process had begun for me psychologically. Throughout the day, I've received an amazing amount of support from my friends and colleagues over email. I feel incredibly blessed to know so many caring people in my life. Thank you Lisa, Tom, Dan, Aaron, and Liz.
Day 39	June 15th	Family Arrives	I was up early in the morning and I received probably the happiest email I have ever received in my life. In undecorated courier font were these understated words from the Registrar: "I am pleased to inform you that your application to graduate has been approved for the PHD in Communication for Spring Quarter 2006-07. You have satisfied all University and departmental requirements for this degree. Congratulations on your successful academic career at Stanford University." Incidentally, because we were allowed to get interim MA degrees on the way to the PhD and I was slow in that earlier filing, I also got this email at the same time: "I am pleased to inform you that your application to graduate has been approved for the MA in Communication for Spring Quarter 2006-07. You have satisfied all University and departmental requirements for this degree." So technically, I'm graduating with two degrees on Sunday. The forecast for Sunday's is now 84. It appears the heat wave may not break by Sunday. My parents are flying in today from Hong Kong. And my brother is driving up from LA. Around 1pm, my parents arrived at their hotel, across the street from my apartment. My immune system had to be partially shut down to fight the allergic reaction and so I am highly-susceptible to common germs right now. Because international flights are dangerously germ-filled, I've asked them to both shower, change all their clothing, and wait several hours before we meet (to let cold symptoms develop if they caught anything). My parents and brother brought me milk and gifts around 7pm. They were hesitant to enter the apartment so we exchanged words and gifts in the doorway. They are comforted that my appearance has improved dramatically. The facial sloughing actually dramatically improved my complexion. The heat wave has broken. The sun is no longer oppressive. It will be a beautiful Sunday ...
	June 16th	CNN Future Summit	One of the gifts my parents had brought was a DVD of the CNN Future Summit. I watched and loved the show, but was sad that it would never be broadcast in the US. It didn't occur to me till 5am that I knew exactly how to rip a DVD and edit digital video. So I hopped out of bed and started working on a shorter cut of the video focusing on the online gaming segments, and of course, with my responses. I had the 8-minute cut ready by 8am and then realized that the next natural thing was to put it on YouTube. And once it was on YouTube, I could blog about it on TerraNova, where I also discovered the beauty of directly-embedded videos. I did have one frightening moment in the early afternoon though. The area around the healing abscess itches very mildly once in a while (i.e., the healing itch), and I was scratching it a little while talking on the phone when suddenly I saw blood on my finger-tips. I rushed to the mirror and it turned out to be a blood-blister rash from the rubber adhesive bandages that I had been switch to (as opposed to just using paper tape to secure gauze). Let me tell you what kind of bandage I won't be using on the abscess area anymore ... It's almost shocking to me that the weather has become almost chilly. Today's high is supposed to be 81, but it's 1:30pm and the current tempeature is 69. Tomorrow's high is forecast to be 83. It's going to be a gorgeous, gorgeous Sunday ...
	June 17th	Graduation	I was able to truly fall asleep for the first time since May 31st. Either the rash or the Prednisone had kept me in a strange, lucid, woken state for 16 days. I woke up around 6am. I was heading to the kitchen for water when a ray of dawn flickered in my eye from the cracks of the blinds. I turned to catch the light in my hand. I saw the silhouette of my face against the white walls. Life is so precious. And every morning has become a gift to me. All the outward signs of the rash have disappeared. To others, I will look the same as I did before the illness, but I am forever changed. I am no longer the person I used to be. I tremble in the beauty of the day ...

This experience has changed me forever. I can't quite articulate what those changes are or will be, for better or worse, but I will never see life in the same way again. For those who know me, I ask for your patience in advance for any behavior that may seem erratic, selfish, irrational, or bizarre in the coming weeks. It will take some time for me to process all that has happened.

Thanks:

I'd like to thank all the medical staff who've helped to heal me over the past weeks. Carolyn, Megan, Dr. Kastellein, and Dr. Tepper were my physicians at Vaden Health Center managing the abscess. At Stanford Hospital, Dr. Spain and his resident performed the surgery. For the abscess repackings back at Vaden, nurses Dorothy, Yvonne, Merna, Meg, and Kelly helped to make the process as painless as possible. And pharmacists Elise and David provided genuine support during the many times I had to stop by their windows. For the Septra reaction, I'd like to thank nurse Kelly for spotting the rash and escalating it immediately to Dr. Dorman. For psychological counseling, I'd like to thank Amy for listening to the whole story in one session and offering valuable advice. Finally, I'd like to thank phone receptionist Suzanne for the incredible amount of assistance and warmth she offered during the several occasions when I needed desperately to make an urgent appointment at the clinic. I'd also like to thank nurse Kelly individually for her amazing balance of compassion, professionalism, and expertise.

I'd also like to thank all the people who've helped me emotionally during these past weeks. First of all, I'd like to thank my advisor Jeremy for the amount of concern, support, patience, and understanding he gave me as my health faltered during the dissertation process. I also deeply appreciate the understanding and patience my supervisers at PARC (Nic) and Sony Online Entertainment (David) have given me as I have been unable to contribute to active projects. I also want to sincerely thank Susie and Byron for letting me dump my condition on to them on the 11th as I struggled to cope psychologically. I'd also like to thank all the members of the dissertation committee - Byron, Cliff, Dan, Jeremy, and Benoit - for grilling me as they would have with any other graduate student. I didn't tell anyone about the flu because the last thing I would have wanted was for my health to become special consideration during the final dissertation process. And of course, I also want to thank my family for the support they offered despite us being separated by the Pacific.

I'd also like to thank the game developers who made Ouendan 2 and Pokemon Diamond/Pearl for the Nintendo DS. Both games were spectacular in different ways. One was more stimulating and rhythym-based, while the other was gradual grinding and growth-based. Alternating between the two helped me more with the itching than did the steroid and antihistamine during the worst parts of the Septra reaction.

But most of all, I'd like to thank Bruce for bringing me dinner, groceries, and medical supplies when I was unable to get out of bed, for calling and checking in on me to make sure I wasn't suffering alone, for having the courage to be with me during the most horrific night of the Septra reaction, for letting me breakdown and cry in front of him when it became too much to bear, and for giving me something I desperately wanted to live for. I'm not sure what I ever did to deserve someone like Bruce, but I'd like to thank him for helping me survive physically and psychologically over the past 5 weeks.