Yesterday Elaine and I attended the Lung Transplant Education Class at the UW Medical Center. This was presented by Kim Hoffman MN, RN and one of the Transplant Coordinators. Kim began with some statistics.
History of transplantation
• 1950 – First kidney transplant
• 1963 – First human lung transplant
• 1963-1983 only 40 lung transplants performed (still experimental)
• 1983 – First “successful” transplant
UWMC Lung Transplant Program
• Established in 1991
• First lung transplant Spring 1992
• Over 580 done to date
• Currently performing 50+ per year
What to expect in preparation
Tons of testing to look for contraindications (disqualifiers)
• Heart
o Echocardiogram
o Heart Catheterization
• Lungs
o Chest X-rays
o CT Scan
o VQ Scan (Ventilation (V) and blood flow (Perfusion/Q))
• Liver
o Blood tests
o CT scan
• Immune System
o Virus exposure
o Common childhood illnesses
If all goes well after all this, the wait begins. The selection committee, which includes the surgeons, pulmonologists, nurse, social workers, nutritionist and let’s not forget the finance team, reviews each patient applying for the program. Those that are deemed acceptable are then added to the waiting list and an individual plan is developed.
What will it cost?
The patient’s insurance coverage is updated as closely as the general health of the patient. We were advised that the procedure will cost $275,000 to $1,000,000 depending of patient specifics. Yikes!
UNOS
The centralized database of organ donors and recipients is the United Network for Organ Sharing or UNOS, ( www.unos.org). The active waiting list maintained here is over 105,000 people. That list breaks down like this:
• Kidney – 78,000
• Liver – 17,000
• Lung – 2183
• Heart – 2670
• Pancreas – 1644
The next obvious question becomes “How long must I wait?” In the early days of organ transplantation, the US median waiting time was 684 days. The good news is that has improved over time. In 2007 the waiting time at UWMC averaged out at 132 days after acceptance. Someone actually waited 0 days. The longest wait at UWMC was 678. So the clear challenge for me is to get on the list ASAP!
Along with UNOS, a new “lung allocation score” has been accepted nationally. This minimizes any hanky panky that could occur across UNOS regions. The score ranges from 0 – 100 and takes into consideration many factors. These include the general health of the patient, their age, body mass index (BMI), kidney function and tons of other factors. The average score across the 2183 lung candidate is between 30 – 40.
There are 13 UNOS regions. UWMC is the only transplant center in region 6 which includes Washington, Alaska, Montana, Idaho and parts of Oregon. A recipient can benefit from organ availability from any region. UWMC has a specialized team that is available on a moment’s notice to fly anywhere in the country to bring a matching organ for a patient in their program.
What happens when you get the call?
If all these factors fall into place, next I wait for the call. This occurs when a potential organ(s) are identified. I have to be able to appear at the hospital no longer than 3 hours after the call. They will prep me for surgery and wait for the organ to arrive.
One last hurdle must be cleared. When the organ arrives, it is tested one final time for “viability”. Did it arrive undamaged? Was the preliminary match data accurate? Is it within the ischemic time limits? (The time that an organ is outside the body and not supplied with O2)
When one or more of the negatives happen and the organ is unusable, it’s considered a “dry run”. You’re sent home to wait again. We were advised to expect at least 1 or 2 dry runs before the real deal can happen!
If everything is favorable, the operation begins. The technique the UWMC uses is called a “clam shell” incision (thoracotomy). If both lungs are being replaced, the surgeon literally cuts you in half, below the rib cage, across your middle. Ouch! The surgery generally lasts between 2 and 6 hours. Cardiopulmonary bypass is standing by should both lungs are being replaced. This keeps the blood saturated with oxygen and relieves pressure on the heart, reducing chances of damage.
Risks and Complications
All the factors and risks common with any major surgery apply in spades with lung transplantation. Infection, rejection, bleeding, side effects of general anesthesia, graft dysfunction (leaking stitching!) etc., must be controlled.
I will be in the intensive care unit for 3 – 4 days following surgery, on mechanical ventilation, tubes sticking out of every orifice, and the magic pain killer button in my hand! The total hospital stay averages 10 – 14 days. Some with complication can be in for months!
Care after transplant
One thing is for sure; Life will never be the same after the transplant. Constant monitoring of pulmonary function, watching for signs of infection or rejection becomes part of daily life. The infection and rejection symptoms are almost identical; fever, shortness of breath, cough, “flu-like” symptoms and drops in spirometry values (volume of air the new lungs can push out and draw in).
Extra care must be given to cleanliness. Washing hands, avoiding contact with sick people, no cat litter boxes and wearing of a N95 face mask when out in public, are all precautions that can't be ignored. We were advised that almost every patient experiences some mix of infection and rejection. If caught early enough, drug dosages can be adjusted to help the patient get past these episodes.
Medications
Large dosages of anti-immune system suppressants at the onslaught are normal (these taper down as healing continues), pain meds, antibiotics, statins (Lipitor), calcium, magnesium, vitamin D are just a hint of the regiment to expect. This becomes part of your daily life, for the rest of your life! What is the estimated annual cost of the medications? In today’s dollars, $36,000/year!
Survival: What can I expect?
The numbers continue to improve year over year as the procedure becomes more prevalent and new drugs and techniques are developed. UWMC’s number for the period from 2000 – 2008 are:
• 1 year survival – 85% (national average 73 – 94%)
• 3 year survival – 73%
• 5 year survival – 62%
This data is maintained at www.ustransplant.org. As time goes on the number are expected to continue improve.
Kim and her peers handled what could have been a very depressing class in a markedly upbeat and encouraging way. They gave us hope that we can survive, that systems, people and programs are in place to help us progress through the process. I'm very upbeat and positive that a good outcome will result if I follow their plan and pay attention to the details.
Let the testing begin!
Friday, January 21, 2011
Wednesday, January 19, 2011
The Prognosis #4
The Prognosis #4
On January 13, Elaine and I meet with Dr. Raghu at the UW Medical Center. Earlier in the day I had a high resolution CAT scan, pulmonary function testing, six minute walking tests where the technician monitors the oxygen saturation levels of my blood with and without oxygen supplementation and blood hemoglobin test. The news wasn’t good on any front or a surprise either for that matter.
The CAT scan showed progression of the disease. The pulmonary function testing showed that my lung function had dropped to ~30% of normal. The walking tests showed that while walking for six minutes without oxygen supplementation that the saturation level in my blood dropped to the high 70s or low 80s percent. (approaching the levels where you pass out) At rest it would hover in the low 90s percent. Normal is high 90s to 100% at rest and high 80s to low 90s percent under stress. Oxygen supplementation bumped the levels to safer range but still below normal.
All this suggested that everything went to “hell in a hand basket” as they say. Dr. Raghu stated the obvious. It was time to focus 100% of my time on my health. He told me that I was now qualified as 100% disabled, it was time to quit working, get into the UW transplant program and follow his instructions completely.
He promised that if I did what he told me, that my prognosis would improve. The survival rates of their transplantation program is greater than 80% after one year and greater than 50% after five. Last year they had 50 lung transplant patients with 60 lungs coming available. (some received one lung, other two) Because I am otherwise pretty healthy, I could expect to be in the high end of the survival numbers.
I was sent home with a ton of papers to read. He asked that I join a FDA sponsored study he was heading, (study to look at whether blood thinner Warfarin, had a positive effect on Idiopathic Pulmonary Fibrosis patients). The first step is to attend a 3 hours class on lung transplantation on January 20, (tomorrow).
I was sent home with hope that I can survive. I was also in shock that if I followed his instructions that I could not continue to work. Not working presents problems with insurance, income and all the other things we take for granted.
Ironically, my employer laid off 2/3 of their sales force, 717 people, on January 4, yours truly included. The severance includes keeping my insurance for 6 months at employee rates. After that, COBRA comes into play. The Catch-22 is how does one pay for COBRA when not working? That’s still unresolved.
So tomorrow’s class begins the official process of “applying” for the lung transplant program. Tons of tests will follow to identify whether I “qualify”. Ongoing blogs will document this process, the challenges I face on how to pay for this without a job, the application process for disability and supplemental social security insurance et. al. It’s going to be interesting and educational for sure. Wish me luck!
Bob
On January 13, Elaine and I meet with Dr. Raghu at the UW Medical Center. Earlier in the day I had a high resolution CAT scan, pulmonary function testing, six minute walking tests where the technician monitors the oxygen saturation levels of my blood with and without oxygen supplementation and blood hemoglobin test. The news wasn’t good on any front or a surprise either for that matter.
The CAT scan showed progression of the disease. The pulmonary function testing showed that my lung function had dropped to ~30% of normal. The walking tests showed that while walking for six minutes without oxygen supplementation that the saturation level in my blood dropped to the high 70s or low 80s percent. (approaching the levels where you pass out) At rest it would hover in the low 90s percent. Normal is high 90s to 100% at rest and high 80s to low 90s percent under stress. Oxygen supplementation bumped the levels to safer range but still below normal.
All this suggested that everything went to “hell in a hand basket” as they say. Dr. Raghu stated the obvious. It was time to focus 100% of my time on my health. He told me that I was now qualified as 100% disabled, it was time to quit working, get into the UW transplant program and follow his instructions completely.
He promised that if I did what he told me, that my prognosis would improve. The survival rates of their transplantation program is greater than 80% after one year and greater than 50% after five. Last year they had 50 lung transplant patients with 60 lungs coming available. (some received one lung, other two) Because I am otherwise pretty healthy, I could expect to be in the high end of the survival numbers.
I was sent home with a ton of papers to read. He asked that I join a FDA sponsored study he was heading, (study to look at whether blood thinner Warfarin, had a positive effect on Idiopathic Pulmonary Fibrosis patients). The first step is to attend a 3 hours class on lung transplantation on January 20, (tomorrow).
I was sent home with hope that I can survive. I was also in shock that if I followed his instructions that I could not continue to work. Not working presents problems with insurance, income and all the other things we take for granted.
Ironically, my employer laid off 2/3 of their sales force, 717 people, on January 4, yours truly included. The severance includes keeping my insurance for 6 months at employee rates. After that, COBRA comes into play. The Catch-22 is how does one pay for COBRA when not working? That’s still unresolved.
So tomorrow’s class begins the official process of “applying” for the lung transplant program. Tons of tests will follow to identify whether I “qualify”. Ongoing blogs will document this process, the challenges I face on how to pay for this without a job, the application process for disability and supplemental social security insurance et. al. It’s going to be interesting and educational for sure. Wish me luck!
Bob
How heartburn turns into lung transplants! #3
Yesterday's blog ended with a hint that GERD or better known as Acid Reflux Disease had a role in my dilemma. I will continue to build the history daily as this blog catches up with today’s events and goes forward.
Throughout my adult life, I had this phenomenon occurring that I didn't pay much attention to, since it was mostly annoying.
Regularly, I find myself inhaling fluid coming up from somewhere. It would make me cough violently and sometimes burn a little in my chest. I had no idea it was a problem and I frequently would tell myself to stop breathing and swallowing at the same time. As it turned out that I was refluxing stomach fluid and inhaling it. Little did I know that over the years each time this occurred, a tiny bit of damage to my lungs was occurring.
Fast forward to 2006:
While my diaphragm was paralyzed by the pinching of my phrenic nerves, the reflux worsened, since my weakened breathing mechanisms couldn't clear my lungs as well. The stomach acid accelerated the damage.
About 1.5 - 2 years after the paralysis of my diaphragm occurred, the nerves began to heal and slowly my diaphragm function began to return. However, I was still very short of breath and pretty confused. I thought that the extra 50 pounds I'd put on the last 10 years probably wasn't helping, so I decided to visit my primary care physician, Dr. Bayles to get checked out. I was determined to lose weight, begin exercising to regain my stamina and feel better.
Dr. Bayles ordered a calcium CAT scan, an experimental procedure to check your heart for deposits and blockages that could cause heart attacks. A cardiac CAT scan for coronary calcium is a non-invasive way of obtaining information about the presence, location and extent of calcified plaque in the coronary arteries—the vessels that supply oxygen-containing blood to the heart muscle. (http://www.radiologyinfo.org/en/info.cfm?pg=ct_calscoring)
There was good news and bad. My heart was in excellent shape. But even the low resolution images had picked up cloudiness in my lungs. Dr. Bayles referred me to the UW Medical Center, pulmonary specialties clinic to have it checked out. For some reason, that didn't click immediately and all I heard was my heart was great! It wasn't until I had made progress on losing weight but the lack of stamina persisted, that I revisited Dr. Bayles. He scolded me for not paying attention and told me to get to the UW ASAP. I listened this time.
Drs. Benditt and Raghu head up the Pulmonary Clinic at the UW Medical Center. Dr. Benditt ordered a test to confirm GERD. A transducer string was inserted in my nose and positioned all the way down into my stomach. The transducer had multiple acid sensors along its length and attached to a small data logger that I wore on my belt for 24 hours. This test confirmed I had GERD.
Simultaneously, a biopsy of one of the damaged lungs was taken and other testing led to the diagnosis of idiopathic pulmonary fibrosis. Pulmonary fibrosis is a serious disease that causes progressive scarring of your lung tissue. The current thinking is that pulmonary fibrosis begins with repeated injury to the tissue within and between the tiny air sacs (alveoli) in your lungs.
In my case the acid reflux was identified as the culprit. The prognosis was grim. In a typical case where the cause is unknown, the patient’s life expectancy was four to five years. (This was in 2008) If the cause is identified and corrected, the patients could live a semi-normal life. I chose to believe the second alternative. The alternative path is lung transplantation. More on that later. (http://www.bing.com/health/article/mayo-126601/Pulmonary-fibrosis?q=idiopathic+pulmonary+fibrosis&qpvt=Idiopathic+Pulmonary+Fibrosis)
I was placed on the generic version of Prilosec (Omeprazole). (http://en.wikipedia.org/wiki/Omeprazole) Over time, this reduced the PH level of my stomach acid but hasn’t fixed the physical problem of the stomach contents coming up and being inhaled. I continued my weight loss and dropped ~40 pounds. This combination provided marked improvement in how I felt for a couple of years.
This all changed about six months ago. The shortness of breath, fatigue and light-headedness returned. This occurred about the same time as the company I worked for began to feel the effects of the down economy.
It was time to head back to the UW Medical Center. Elaine and I met with Dr. Raghu on January 13, after a full workup of testing. The next segment will bring this blog up to present time. Stay tuned as the saga continues.
Your comments and thoughts are invited and appreciated.
Thanks
Bob
Throughout my adult life, I had this phenomenon occurring that I didn't pay much attention to, since it was mostly annoying.
Regularly, I find myself inhaling fluid coming up from somewhere. It would make me cough violently and sometimes burn a little in my chest. I had no idea it was a problem and I frequently would tell myself to stop breathing and swallowing at the same time. As it turned out that I was refluxing stomach fluid and inhaling it. Little did I know that over the years each time this occurred, a tiny bit of damage to my lungs was occurring.
Fast forward to 2006:
While my diaphragm was paralyzed by the pinching of my phrenic nerves, the reflux worsened, since my weakened breathing mechanisms couldn't clear my lungs as well. The stomach acid accelerated the damage.
About 1.5 - 2 years after the paralysis of my diaphragm occurred, the nerves began to heal and slowly my diaphragm function began to return. However, I was still very short of breath and pretty confused. I thought that the extra 50 pounds I'd put on the last 10 years probably wasn't helping, so I decided to visit my primary care physician, Dr. Bayles to get checked out. I was determined to lose weight, begin exercising to regain my stamina and feel better.
Dr. Bayles ordered a calcium CAT scan, an experimental procedure to check your heart for deposits and blockages that could cause heart attacks. A cardiac CAT scan for coronary calcium is a non-invasive way of obtaining information about the presence, location and extent of calcified plaque in the coronary arteries—the vessels that supply oxygen-containing blood to the heart muscle. (http://www.radiologyinfo.org/en/info.cfm?pg=ct_calscoring)
There was good news and bad. My heart was in excellent shape. But even the low resolution images had picked up cloudiness in my lungs. Dr. Bayles referred me to the UW Medical Center, pulmonary specialties clinic to have it checked out. For some reason, that didn't click immediately and all I heard was my heart was great! It wasn't until I had made progress on losing weight but the lack of stamina persisted, that I revisited Dr. Bayles. He scolded me for not paying attention and told me to get to the UW ASAP. I listened this time.
Drs. Benditt and Raghu head up the Pulmonary Clinic at the UW Medical Center. Dr. Benditt ordered a test to confirm GERD. A transducer string was inserted in my nose and positioned all the way down into my stomach. The transducer had multiple acid sensors along its length and attached to a small data logger that I wore on my belt for 24 hours. This test confirmed I had GERD.
Simultaneously, a biopsy of one of the damaged lungs was taken and other testing led to the diagnosis of idiopathic pulmonary fibrosis. Pulmonary fibrosis is a serious disease that causes progressive scarring of your lung tissue. The current thinking is that pulmonary fibrosis begins with repeated injury to the tissue within and between the tiny air sacs (alveoli) in your lungs.
In my case the acid reflux was identified as the culprit. The prognosis was grim. In a typical case where the cause is unknown, the patient’s life expectancy was four to five years. (This was in 2008) If the cause is identified and corrected, the patients could live a semi-normal life. I chose to believe the second alternative. The alternative path is lung transplantation. More on that later. (http://www.bing.com/health/article/mayo-126601/Pulmonary-fibrosis?q=idiopathic+pulmonary+fibrosis&qpvt=Idiopathic+Pulmonary+Fibrosis)
I was placed on the generic version of Prilosec (Omeprazole). (http://en.wikipedia.org/wiki/Omeprazole) Over time, this reduced the PH level of my stomach acid but hasn’t fixed the physical problem of the stomach contents coming up and being inhaled. I continued my weight loss and dropped ~40 pounds. This combination provided marked improvement in how I felt for a couple of years.
This all changed about six months ago. The shortness of breath, fatigue and light-headedness returned. This occurred about the same time as the company I worked for began to feel the effects of the down economy.
It was time to head back to the UW Medical Center. Elaine and I met with Dr. Raghu on January 13, after a full workup of testing. The next segment will bring this blog up to present time. Stay tuned as the saga continues.
Your comments and thoughts are invited and appreciated.
Thanks
Bob
Tuesday, January 18, 2011
How this began #2
This journey began in the fall of 2004 when we were moving my daughter, Jennifer, into her first off campus room at Western Washington University. It was a usual dark and dreary night. We had the Escape full of beds, books and clothes.
I parked the car and got out to go look for the address of a unlit house, when I turned and saw Jen and her friend driving up to tell us we were at the wrong house. I slipped on the wet concrete, twisted my ankle and fell across the bricks lining the sidewalk. As I tried to pick myself up, I realized something was broken. Both my ankle and leg were torn up.
I literally crawled back to the car and ask Robin to take me to the emergency room, then go unpack Jen and come back and get me.
I had broken my right tibia and my ankle had come apart as the ligaments tore. I was put into a boot and instructed to go see my physicians back in Redmond.
On Monday I was referred by my primary care physician to Orthopedic Department at Evergreen Hospital in Kirkland. The department head agreed to do the repair surgery ASAP, but later I was advised he was leaving the hospital and I was referred to another surgeon to go forward with the post surgery follow.
During the surgical recovery, the internal stitches didn't dissolve as expected, poked through the wound and became the super highway for staph germs. To treat the staph infection, the doctors installed a cardiac catheter to allow me to directly inject strong antibiotics into my heart. If I remember this was to improve the distribution of the antibiotics as well as protecting my heart from the staph. A visiting nurse came by weekly to check the catheter-body interface and to replenish my antibiotics. I would go see the "infection" doctor twice a week to check up the status of the infection. It had to be totally gone before they'd remove the catheter.
In parallel, I had a history of bulging discs in my neck that had been treated with a steroid injection directly into the discs. This had relieved the discomfort for a few years, but it resurfaced after my fall. I took a friend's advise and went to a Chiropractor for relief. I was very specific about avoiding twisting my neck and I only wanted massage to reduce the spasms in my neck and shoulders. She must of tuned me out and without warning cracked my neck. I knew immediately that something was wrong. That night I couldn't breath while lying down.
The next day I had the appointment with the infections doctor and told him about the breathing difficulty. He rushed me to the hospital for a CAT Scan. He was worried about a blood clot. When I tried to lie down on the CAT Scan table, my breathing stopped. They admitted me to the hospital again. This was around Christmas of 2004.
It became obvious that Evergreen's pulmonary department had no experience diagnosing an unfamiliar problem like this. They ordered a sleep apnea study, had me prop up the bed to rest and basically couldn't find their butt with both hands. I literally checked myself out and went home. Elaine insisted that I get myself to the University of Washington Medical Center ASAP.
I went to Dr. Josh Benditt the next week. Dr. Benditt immediately discovered my diaphragm was not working at all. The next day I went to a neurologist who pulled up a Boston Medical Journal article describing Phrenic nerve paralysis cause by Chiropractic manipulation. The neck cracking pinched both Phrenic nerves that control the diaphragm. This confirmed Dr. Benditt's diagnosis. (http://en.wikipedia.org/wiki/Phrenic_nerve)
The respiratory therapist at the UW, sent me home with a BiPAP machine. (www.wiseguy.com/what-is-bipap.htm) This is a super version of the machines that are used to treat sleep apnea and control acid reflex. I got the best night's sleep I had had in 60 days! It was a life changing event! The key word here is GERD or Acid Reflux Disease. This will be the topic for the next edition tomorrow... (https://health.google/health/ref/Gastroesophageal+reflux+disease)
I parked the car and got out to go look for the address of a unlit house, when I turned and saw Jen and her friend driving up to tell us we were at the wrong house. I slipped on the wet concrete, twisted my ankle and fell across the bricks lining the sidewalk. As I tried to pick myself up, I realized something was broken. Both my ankle and leg were torn up.
I literally crawled back to the car and ask Robin to take me to the emergency room, then go unpack Jen and come back and get me.
I had broken my right tibia and my ankle had come apart as the ligaments tore. I was put into a boot and instructed to go see my physicians back in Redmond.
On Monday I was referred by my primary care physician to Orthopedic Department at Evergreen Hospital in Kirkland. The department head agreed to do the repair surgery ASAP, but later I was advised he was leaving the hospital and I was referred to another surgeon to go forward with the post surgery follow.
During the surgical recovery, the internal stitches didn't dissolve as expected, poked through the wound and became the super highway for staph germs. To treat the staph infection, the doctors installed a cardiac catheter to allow me to directly inject strong antibiotics into my heart. If I remember this was to improve the distribution of the antibiotics as well as protecting my heart from the staph. A visiting nurse came by weekly to check the catheter-body interface and to replenish my antibiotics. I would go see the "infection" doctor twice a week to check up the status of the infection. It had to be totally gone before they'd remove the catheter.
In parallel, I had a history of bulging discs in my neck that had been treated with a steroid injection directly into the discs. This had relieved the discomfort for a few years, but it resurfaced after my fall. I took a friend's advise and went to a Chiropractor for relief. I was very specific about avoiding twisting my neck and I only wanted massage to reduce the spasms in my neck and shoulders. She must of tuned me out and without warning cracked my neck. I knew immediately that something was wrong. That night I couldn't breath while lying down.
The next day I had the appointment with the infections doctor and told him about the breathing difficulty. He rushed me to the hospital for a CAT Scan. He was worried about a blood clot. When I tried to lie down on the CAT Scan table, my breathing stopped. They admitted me to the hospital again. This was around Christmas of 2004.
It became obvious that Evergreen's pulmonary department had no experience diagnosing an unfamiliar problem like this. They ordered a sleep apnea study, had me prop up the bed to rest and basically couldn't find their butt with both hands. I literally checked myself out and went home. Elaine insisted that I get myself to the University of Washington Medical Center ASAP.
I went to Dr. Josh Benditt the next week. Dr. Benditt immediately discovered my diaphragm was not working at all. The next day I went to a neurologist who pulled up a Boston Medical Journal article describing Phrenic nerve paralysis cause by Chiropractic manipulation. The neck cracking pinched both Phrenic nerves that control the diaphragm. This confirmed Dr. Benditt's diagnosis. (http://en.wikipedia.org/wiki/Phrenic_nerve)
The respiratory therapist at the UW, sent me home with a BiPAP machine. (www.wiseguy.com/what-is-bipap.htm) This is a super version of the machines that are used to treat sleep apnea and control acid reflex. I got the best night's sleep I had had in 60 days! It was a life changing event! The key word here is GERD or Acid Reflux Disease. This will be the topic for the next edition tomorrow... (https://health.google/health/ref/Gastroesophageal+reflux+disease)
Introduction January 18, 2011 #1
Welcome to my first attempt at blogging. Special thanks to Google for making this easy and free!
The purpose of my blog is to review:
The purpose of my blog is to review:
- How this began
- What went wrong
- What I could have done better
- Where I am now
- What the short-term looks like
- What the long-term looks like
- What are my options for treatment
- What's my prognosis
- To document what occurs going forward
- To vent my frustration, rants and raves
- Keep my friends and family informed
- Capture ideas, advise and recommendations from everyone
I hope to keep this light hearted when possible, informative always and a source of hope and positivity for those who face their own personal challenges.
Thanks
Bob
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