• What is an ostomy?
  
• Types of ostomies
  
• Why ostomy is necessary
  
• Appearance and location
  
• Caring for an ostomy
  
• Ostomy appliances and supplies
  
• Cleaning the stoma and skin
  
• Skin barriers and seals
  
• Emptying the pouch
  
• Discarding waste
  
• Attaching or reattaching the pouch
  
• Odor
  
• Noises
  
• Other sensations
  
• Resuming activities
  

Not everyone who has surgery to remove colorectal cancer will need to have an ostomy. When it is possible to do so, your surgeon will remove all of your cancer and reconnect your remaining intestine to the rectum or anus so that you can continue to eliminate solid waste as you always have. Newer surgical techniques permit preservation of the anal sphincter, for instance, in rectal cancer patients who would have had to have an ostomy in the past.

At times, however, surgery for more extensive disease requires removal of rectal and anal tissue as well. This absence is remedied by a manmade opening in the abdomen through which solid waste can exit.

I fly a lot for my job. Traveling is a lot easier now than it was before when I was dealing with ulcerative colitis. I'd get on an airplane and something would happen, and they'd end up sitting on the runway for 45 minutes or an hour. The flight attendants didn't want anyone getting up and walking around, much less locking himself or herself in the bathroom, because they can get a call at any time to take off.

I flew down to a business convention in New Orleans about eight weeks after my surgery, though, with no problems. (Unfortunately, I didn't realize I'd be too tired to do much carousing.)

As far as how an ostomy under clothes looks to others, it looks--unless you know exactly what you're looking for--maybe just like somebody's shirt is bunched up wrong on one side. If someone is staring at your pants that much to start with, they've got other issues to deal with, so I wouldn't worry about it anyway!

When I went to a vacation spa, I questioned the nurse there about restrictions. She suggested the only thing I shouldn't do was the thing where they use a hose to squirt you from a distance, a water massage. She didn't think it would be a good idea to pound the stoma with water. She also suggested I skip the seaweed wrap, which might dehydrate me--dehydration can be a problem for ileostomates. I did it anyway, but they kept the seaweed away from the stoma. I did the algae whirlpool baths, too. I just left my appliance on, just like I do when I'm swimming.

There are people who are so hung up on body image and looking like supermodels--they can't deal with it. I knew somebody who was a nurse who died of colon cancer basically because she knew her husband--and therefore her life--couldn't deal with it if she had an ostomy.

What is an ostomy?

Ostomy is the surgical creation of an opening through the abdominal wall to allow feces or urine to exit. During colorectal cancer surgery, part or all of the colon or rectum is removed in order to remove the cancer. If there is not enough intestine or rectum left to reconnect the remaining tissue, or if the anus is removed, an ostomy will be created in the abdominal wall so that waste can exit. The surgeon will make an opening and attach the end of the intestine to that opening. See Figure 1 (click here).

A person who has had an ostomy is called an ostomist or ostomate.

Types of ostomies

Most ostomies involve surgical creation of an open stoma. Waste passes out of the open stoma and is collected in a pouch. However, in some cases a continent ostomy can be performed.

For colorectal cancer, ostomies are further divided into colostomies and ileostomies, depending on how much of the colon must be removed.

During a partial colectomy, only part of the colon is removed and the remaining colon is reattached to the ostomy. Because part of the colon remains to remove moisture from waste after it passes through the small intestine, the waste will be more or less solid.

Removal of the entire colon (total colectomy) necessitates an ileostomy. The ileum, the portion of the small intestine nearest the colon, is what remains to create the ostomy.

Because the colon is not present to remove water from feces, the waste that passes out of an ileostomy will be more liquid.

Temporary ostomy

Sometimes one's colon and rectum need to heal before they can safely process waste. Surgery for colorectal cancer has advanced beyond the point of performing colostomies or ileostomies on all colorectal cancer patients. Today, many alternatives exist, such as creation of internal ileorectal pouches, and stapling surgeries to reconnect the remainder of the intestine to the anus within the narrow bony space of the pelvis that rules out traditional suture surgeries.

For some surgical procedures, a temporary ostomy will be used. This might also be true, for instance, if pre- or postsurgical chemotherapy or radiation therapy is planned, as these treatments can slow healing, or if an obstruction or perforation was caused by the tumor.

If you receive a temporary ostomy, you might have two closely positioned stomas instead of just one:

• One from the top portion of the intestine, which will remain active in the digestion of food, and from which waste will exit.
• A second for the temporarily inactive lower portion of intestine, called the mucus fistula, from which only mucus will emerge. (A fistula is an abnormal tubelike body tissue that erroneously connects two organs, or one organ and skin, usually developing as the result of disease. In this instance, it is manmade.)

I still wear a colostomy bag. I tried to have the ostomy reversed back in November after wearing the bag for more than fourteen months. However, because of lack of muscles, the operation did not go as planned and I am still wearing a bag.

The surgeons were going to try to reverse it again, but due to CEA levels climbing from being off chemotherapy so long while recovering from surgery, my oncologist said that I have to wait.

J-pouch (ileoanal anastomosis with reservoir)

In this surgical procedure, the small intestine is folded back onto itself to form a J shape, then stitched together to create a wider reserve. The sphincter muscle and the anus are left intact. The end of the constructed pouch is connected to the anus.

Continent ileostomy

Certain patients who have had most or all colon tissue removed may be candidates for a type of ostomy called a continent ileostomy. This variation on ostomy surgery involves creation of an abdominal stoma implanted with a valve that remains closed until the patient opens it to drain the intestine.

The advantage of this implant is that no pouch is needed for collection--just a stoma cover, a sound awareness of body function, and reasonable manual dexterity. The disadvantage is that continent ileostomy works well only for ileostomy and the liquid waste that results--not for sigmoid colostomy's more solid waste.

Why ostomy is necessary

Most patients realize quickly that a colorectal tumor that's found very low in the colon, or in the rectum itself, might require surgery that entails removal of all rectal and anal tissue along with creation of an ostomy. It's sometimes difficult, though, to comprehend why a tumor that's farther up in the colon requires what seems like drastic surgical treatment, including an artificial opening. The answer depends on several factors:

• Healthy tissue must be removed along with diseased tissue to ensure that no microscopic cancer remains. If several tumors or a very large tumor that has invaded deeply are found, a great deal of healthy tissue, including many lymph nodes and blood vessels, must be removed. The relatively small portion of healthy intestine that remains after radical surgery might not heal or function if it were reconnected to the anus or rectum.
• Tumors that are associated with certain diseases, such as ulcerative colitis, or that occur in family members at risk for inherited colon cancer, often are best treated by removing all colon and rectal tissue to avoid recurrence of disease.
• Severely inflamed colon and rectal tissue, such as that crushed by a nearby tumor or affected by the body's inflammatory response to the tumor, will not heal if surgically cut and repaired. Thus, in some cases, a temporary ostomy is created to allow the intestine to heal, after which the remaining pieces of intestine are rejoined, and the opening in the abdomen is surgically reversed.

Appearance and location

The ostomy's exit through the skin of the abdomen is called the stoma, a Greek word meaning mouth. The most visible portion of the stoma is actually a portion of the inner lining of the intestine. When healthy, the stoma is pliant, painless, red, and moist. It has these characteristics because centuries of surgery and research--colostomies have been performed since ancient Egyptian times--have shown that the most workable, infection-free ostomies are made by pulling intestinal tissue through the abdominal opening and rolling it outward to form a ridge.

Although directly after surgery the stoma may appear large and swollen, in time the healthy stoma will shrink, protruding a bit past the skin of the abdomen and developing a puckered appearance. Ileostomies will protrude farther than colostomies, because ileostomy must accommodate more liquid waste than colostomy, as the removal of the entire colon changes the ability of the body to remove water from the stool. This liquid waste is more likely to "travel" and irritate nearby skin than solid waste; the protruding stoma is intended to be a larger barrier between waste and skin.

Where the ostomy is positioned on the abdomen is determined by several factors:

• The location of the tumor
• The extent of disease
• The kind of surgery performed--that is, how much of the colon is removed
• Certain physical characteristics of the patient, including weight, posture, and skin folding

The typical stoma location for an ileostomy is a little below and to the right of the navel. For a colostomy, there is more variety in location, but often it is on the lower left side of the abdomen.

If time permits before surgery, you should discuss with your surgeon any preferences or concerns you might have regarding the proposed position of the stoma, such as your desire to remain active in a certain sport, and the subsequent possibility that the position of the stoma might interfere with this activity. Most surgeons will do their best to accommodate their patients' concerns, but the overriding consideration must be the positioning of the stoma to facilitate proper functioning of the intestine after removal of all cancer.

Caring for an ostomy

While you are still in the hospital, the nurses, and especially a nurse trained as an enterostomal therapy (ET) nurse, will help you learn to care for your stoma, the skin around it, and the health of your altered digestive tract.

If your hospital does not have an ET nurse, contact your surgeon or medical oncologist for a referral, or contact one of the ostomy associations, such as the United Ostomy Associates, and ask a volunteer to visit you to discuss up-to-date tips and techniques. Often the regular nursing staff haven't time to keep abreast of new advances in ostomy appliances and care. You'll save time, money, and peace of mind by learning the best ideas as soon as possible.

Issues with which these professionals can help you include:

• How to clean and care for the skin around the stoma. The stoma itself is relatively tough tissue compared to the skin nearest it, which must be protected from intestinal enzymes, bacteria, and potentially irritating ostomy products.
• How to choose, empty, and clean appliances that attach to the stoma to collect waste.
• How to select clothing that will not injure the stoma or interfere with its emptying.
• How to eat to avoid constipation and diarrhea, and how to choose foods to cause bowels to move at your convenience.
• How to irrigate your bowel through the stoma, if you have a sigmoid colostomy and choose to irrigate instead of using a collection pouch. Irrigation, which is similar to an enema, is a means to remove waste from the remaining colon on a schedule that's convenient for you.

Before I was discharged, an ET nurse helped me learn to care for my stoma and showed me various ostomy appliances. I spoke with a few people about this and it still was a shock for a while. I haven't had too many problems caring for my new body part. I did do some shopping around and experimenting to find things that would work best for me. Finding the right combination of appliance skin preps is very important.

I heard an older couple, obviously retired, talking about how they take care of things. They irrigate every 48 hours, and spend four hours doing it. The first thing I thought of was, "Man, you are wasting a lot of time." They say "we" do it, so his wife has to be there to take care of him, so every two days ...

A young man in my Ostomy Association group was talking about his colostomy. He irrigates and still puts on a closed-end pouch in case it leaks. He irrigates every night and changes his bag every day, so that's one way to do it. One of the first things I thought of was that my equipment costs about five or six dollars every time I change it. I've gotten so mine lasts seven or eight days without skin irritation or problems. But if people are changing these things daily, even if they're two or three dollars a day, that mounts up pretty quick. To change it every day is expensive.

One of the things the Ostomy Association points out is that just because one guy says irrigation works for him and he's been doing it for five years doesn't mean that you should also start out doing irrigation if your system is working fine and things are moving through. You need to figure out what's best for you. Just because someone else does it doesn't mean you should switch your style to do it.

Ostomy appliances and supplies

An ostomy appliance consists of two parts: a collection pouch and a positioning plate that surrounds but does not touch or enter the stoma.

If you've had an ostomy for years, you may remember how few products used to be available in the past, and you may note happily how many are available now. The era of the leaky rubber pouch that smelled odd even when clean and didn't accommodate gas episodes is over. Today's options include:

• Disposable pouches.
• Reusable pouches that empty from the bottom, or from the top, while still attached. These are the most practical choice for ostomies that produce liquid waste.
• Pouches with filters to control odor.
• Pouches that hang sideways instead of down for use when jogging or playing tennis. This might be a more suitable option for sigmoid colostomates who will manage solid waste rather than other colostomates and ileostomates.
• Small patches similar to Band-Aids to cover and protect the stoma during swimming. These are suitable only for sigmoid colostomies or those with continent ileostomies. An ileostomate with a traditional stoma and many colostomates with liquid waste would have the patch pushed away from the body by the constant flow of diarrhea from the small intestine.
• Ornamental stoma covers for romantic interludes.
• Pouches that glue in place.
• Pouches that are held in place with a belt, for those who are allergic to some adhesives.
• Hypoallergenic gluing and skin-sealing products made from vegetable matter.
• Neoprene pouch belts for use during sports activities.
• Irrigation tubes (catheters) for those who prefer to empty the bowel by irrigation (enema) instead of collecting waste in a pouch. This applies only to sigmoid colostomates; many other colostomies as well as ileostomies produce continuous liquid waste.
• Catheters for opening and draining the continent ileostomy.
• Skin barrier creams to protect the skin nearest the stoma, which must be shielded from bacteria and digestive enzymes (to which the stoma itself is impervious).
• Appliances geared either to the continual liquid waste of ileostomy or the more solid and periodic waste of sigmoid colostomy.
• One-piece appliances, or two-piece appliances with a stoma-surrounding attachment that stays glued in place, but a bag that's detachable.
• Appliances in different sizes to accommodate individual stomas and more copious flow overnight or during travel.

Many of these products are preferred by some people, but disliked by others. Some people say, for instance, that certain pouches with built-in filters that are intended to allow gas to escape without odor don't work as advertised. The best way to find what works for you is to contact a local branch of one of the ostomy associations and talk to a volunteer (many of whom have ostomies), to join a support group for colon cancer survivors or ostomates, and to try various products. Products can be purchased by mail until you feel comfortable talking about your needs with your pharmacist.

It took me a while after both operations to find the correct bag that fit properly. The last operation left me with an open wound near the new stoma and that caused the bag to keep coming loose. I had problems for about a month with that, but eventually it cleared up and everything is fine now.

Cleaning the stoma and skin

The stoma will clean itself by producing and shedding intestinal mucus, but the skin near the stoma, called peristomal skin, must be kept gently and scrupulously clean. There are several reasons for this:

• Its juxtaposition to both feces and digestive enzymes makes it very likely to become infected, as digestive enzymes are capable of breaking down skin, which is then very likely to be infected by fecal bacteria. Fecal bacteria are common, abundant, and necessary for digestion, but not at all healthy for skin.
• The peristomal skin is more likely to be scratched or scraped owing to the amount of activity it sees in its new role: pouch attachment, cleaning, removing adhesives, and so on. These scratches and scrapes make it more likely to become infected or to develop allergic reactions.

Most people find it easiest to clean the stoma and its surrounding skin when the digestive tract is least active. For many, this is in the morning before breakfast.

The stoma can be rinsed with water and patted dry, if you wish, although it is not necessary to clean it: as mucus-shedding intestinal tissue, it will clean itself. Exposing the stoma to the spray from a shower will not hurt it. A stoma should never be scrubbed.

Peristomal skin should be cleaned gently with very mild soap and patted dry--never rubbed. If you use a skin barrier or a skin sealant, cleaning is done every few days to once a week, dictated by your own skin's tolerance for the barrier substance. If a bit of skin sealant or barrier remains after washing and rinsing, leave it until the next cleaning, provided the skin beneath looks healthy. Rubbing away residual barrier or sealant is more likely to harm your skin than leaving the residue in place.

If your stoma was placed amidst body hair, trim it regularly so that removing the pouch or adhesive will not pull hair, causing pain and opening the skin to infection.

Peristomal skin should look just like the skin anywhere else on your abdomen: not red, wrinkled, grey, or chapped. Changes in peristomal skin should be discussed with an ET nurse and reported to your oncologist.

Skin barriers and seals

A skin barrier or seal is a liquid, powder, paste, or membrane that rests between your skin and the stoma attachment in order to protect the skin from bacteria, moisture, and the irritants in adhesives. These are excellent products that truly save the skin; many varieties are available, and should be used no matter what model appliance you prefer. Each comes with its own instructions and precautions for use.

People normally gain weight after surgery, especially if they've had ulcerative colitis, because they feel better. They warn you not to gain too much weight because then the stoma can pull inside, it doesn't protrude like it's supposed to, and it makes life interesting. But they have appliances that will work around that. The barrier spray goes on to protect the skin from any irritation.

I had trouble with yeast infections under the wafer. I got little blisters and it was irritated all the time. I had to change the wafer every couple of days because it got itchy, and I had to spray cortisone on it. Basically once I got the rhythm down for the combination of products I use, I haven't had any trouble like that for a year or longer. How much you sweat and what kind of food you eat can also come into how well the appliance stays on.

Even if you've never had a skin allergy before, you should assume that these products might cause an allergic reaction because:

• Humans develop more allergies as they age.
• Skin that is repeatedly injured is more likely to develop sensitivity.
• Chemotherapy and radiation therapy are known to cause skin to become more sensitive to a variety of substances.

When trying a new product, it's wise always to do a patch test first on a part of the abdomen well away from the stoma. The instructions packaged with the barrier or seal will explain how to do a patch test.

Emptying the pouch

The pouch should be changed when it's about one-third full. Accumulating excessive material increases the pouch's weight and may cause it to pull away from the skin. Leakage, odor, and infection of nearby skin may result.

Many pouches are what is termed "drainable," or open ended. The "open" end hangs down. There is a plastic clip that folds the pouch end back and keeps it closed. The seal created by the clip is water/ liquid- and gas-proof. I couldn't change the appliance every time it starts to fill. It would cost a fortune and take a lot of time. Drainable pouches come in one- and two-piece models. Most appliances are designed to be left on for up to two weeks. I change mine about every seven days or earlier if it starts coming loose.

One man in our ostomy support group was using a two-piece system that had a drain. He was not told to leave it on and just open the bottom to let out the waste. He was very pleased to hear there was a faster, cleaner way to deal with the equipment.

At times, the pouch should be emptied before it's one-third full:

• If you're traveling and won't be able to empty it easily en route, it should be emptied first. Some ostomates report that air travel in particular may cause the pouch to expand as the cabin is unevenly pressurized during takeoff and landing.
• If you're having a spell of diarrhea.
• If you've prepped for a colonoscopy.
• If you're about to engage in sports or any physical activity.

Gently remove all pouch models, but especially the one-piece models, to avoid damaging the skin beneath the attachment plate.

As far as wearing the bag is concerned, it does get better. However, I find that I empty my bag still about eight times a day some days, and usually at least four or five times. However, after a while you learn to live with it and you are able to go out and do things.

Discarding waste

If you are using disposable pouches, you can empty the pouch into the toilet first, then wrap it and put it in the trash, or you can dispose of it, well wrapped, while it's still full. What you choose to do depends on how well you're feeling, what trash collection facilities are available, and the sensibilities of those you live with.

If you have a reusable pouch, you can empty it while sitting on or standing in front of the toilet. Put some toilet tissue into the toilet bowl first to act as a cushion for the material you're discarding--this helps prevent splashback. For emptying, some reusable pouches open from the top, some from the bottom. All come supplied with directions for emptying.

A reusable pouch must be carefully cleaned and deodorized. Fortunately, this is easy today, as many very good products are available for these purposes. A few points to remember are to avoid hot water, as this will cause the pouch material to expand and hold odors, and to dry the pouch thoroughly. Empty the pouch into the toilet (you might need to squeeze the outside of the pouch to get all material out); give it a good rinse; soak it for a spell; then scrub the inside gently with a bottle brush. Add a few drops of mineral oil to the bottom of the bottom-opening type to make the next emptying easier. It might be useful to purchase three reusable pouches at once: one for wearing, one for washing, and one for emergencies.

If you share a bathroom with others, take an extra minute to clean splashes and stow away supplies and trash.

Attaching or reattaching the pouch

How the pouch is attached or reattached depends on which model you're using. Most people find it easiest to reattach any pouch while seated.

For either the two-piece or one-piece pouch, you may need to adjust the stoma opening in the skin plate to match the size and shape of your stoma--they differ among people, and may change as age and weight change. Some appliances come with a template that you can match to your stoma to choose the correct size opening. The skin plate then can be cut carefully to match your needs.

Two-piece pouch

If you're using a two-piece pouch, you can simply continue to reattach fresh pouches to the skin plate for several days or a week until it's time to change the skin attachment.

Your own body will dictate the schedule for changing the skin plate, based on your skin's sensitivity. In general, the skin should be left undisturbed by plate changes for as long as possible in order to avoid irritation by too-frequent changes.

One-piece pouch or pouch plate

The skin plate of a one-part pouch that's glued in place must be changed whenever the pouch is changed. A skin barrier is a must in this instance; otherwise, skin layers are stripped away whenever the adhesive is removed, leaving exposed newer, more tender skin that's increasingly likely to become irritated or infected.

Most people find that placing the bottom of the skin plate under the stoma and "rolling" the plate upward provides a better fit around the stoma, because visibility is better using this method.

Odor

The improved pouches available today hardly ever emit odors. When odors exist, they are identical to the odor of gas and feces of those who have an intact colon.

There are steps you can take to be very certain that odors will not become a problem:

• Use deodorant tablets or liquids in the bottom of the pouch, as recommended by the manufacturer.
• Clean and dry reusable pouches carefully.
• Pretest pouches that contain charcoal filters to be sure they work as advertised.
• Ask a sensitive, helpful, honest person if he or she notices any odors.
• Eat yogurt, parsley, and other foods known to ameliorate odors in the gastrointestinal tract.
• Avoid foods such as cabbage that increase gas if you'll be with people who object to tummy rumbles and possibly an aroma.
• Ensure that the skin attachment fits well and is firmly attached. Most people don't have the ideal flat tummy that allows no gas to escape; firm attachment can remedy this.
• If your pouch has a "burp" valve, engage it in the bathroom or use a room deodorizer.

I've never had a problem with gas in my bag when on an airplane, as some ostomates report. It depends more on what you eat first: you'll only have gas in your bag if you've eaten something that causes gas to form ... and you can take care of releasing it from the bag in the bathroom.

Noises

Passage of waste material and gas through the stoma can create wheezes, sighs, rumbles, or gas-like noises. Do try to be gentle with yourself when assessing these: are they really any worse than the stomach noises your body made when you had an intact colon?

But suppose one of the "healthy unaware" notices and is rude enough to comment? You might explain that it's just your intestine, that your digestive tract has been noisy all your life, which is a true statement for many of us. As Miss Manners says, those who ask nosy questions deserve to be lied to.

If your stoma regularly makes noise as gas passes, you may be able to anticipate it. If the setting is less than ideal for such noise, you can suppress it temporarily by subtly moving your forearm over the stoma and holding it there.

Other sensations

You will undoubtedly have other observations or will note other sensations:

• You may see the pouch expand as material, especially gas, pass into it. It's unlikely anyone else will notice this unless you point it out to them.
• You may feel warmth against your skin as waste material collects in the pouch. At first, you may think this is a leak.
• Your remaining gastrointestinal tract will continue to behave as before, with sensations of movement or mild gas pains. Any pronounced pain should be reported at once to your oncologist, even if it's transient.

Resuming activities

Everything you enjoyed doing before surgery can continue to be done after ostomy. Sunbathing, swimming, dancing, sexual activity--all of these are still possible; all have appliances and techniques developed to allow the gastrointestinal tract to go about its healthy business while you have fun.

Shelly Weiler describes his way of dealing with his ostomy:

I carry an emergency kit with me, which includes a towel, a fresh bag, a new wafer, scissors, remover pads, skin prep pads, and a roll of paper towels. I am very open about my "emergency kit" and take it anytime I'm going anywhere that is too distant from my house to get back quickly. No need to worry about odor. The modern appliances are tighter than crazy glue and no odor escapes unless the wafer is broken.

I'm happy the surgeon didn't put the darn contraption on my forehead.

Of course I can't wait to have it reversed, it is a pain to have to think about it, clean it, and be prepared for that inevitable emergency.

For activities that require lots of skin to be bared, a sigmoid colostomate might consider a stoma plug and a patch that can be used. For ileostomates who have a continent ileostomy, this might also be an option; for other ileostomates and for colostomates with liquid waste, however, the constant flow of diarrhea from the small intestine would push the patch away from the body. For strenuous physical activities, pouches with special capacity and belts that wick away sweat have been developed.

I'm an RN who had ulcerative colitis for years and knew my risk for colon cancer increased with each year. I swore I would never have a colostomy. I even had it written into my living will at one point. But when it came to the point of having it done or dying with a bowel obstruction, I chose the baggie.

And it really isn't all that bad. It hasn't stopped me from doing anything I really want to do. I swim, hike, go to social functions, whatever. No one outside my immediate family and a few close friends even knows it's there.

For the best tips and news of advances in ostomy care, join a local support group. In addition to learning of new products, you'll likely find it an immense relief being able to share feelings with others who know exactly what you're going through.

After a few months I found out about and started going to monthly United Ostomy Association meetings, and I still do. The meetings range from presentations by doctors, presentations by appliance manufacturers, discussions about problems and solutions. We compare stories and share what we've learned about cleaning the skin, using different moisture barriers and glues, special appliances for sports, and the like. My local group also has an additional meeting to discuss quality-of-life issues. I've met a lot of good people, and also some people who aren't as lucky as I am: people who were much sicker, who had no partner and can't seem to find one now. Two women in the group from vastly different cultural backgrounds have had partners divorce them. In my case, my wife has been great throughout this ordeal. We've taken up ballroom dancing and are basically doing everything we did before, and more.