Your Doctor’s Advise – Misunderstanding can lead to BAD Decisions

Good communication with your doctor
Let us help you avoid misunderstanding with your doctor.

Have you ever experienced misunderstanding with someone?  Did that lead you to make a bad decision?  If you had understood the original message, would you have made a different decision?

I have had two client examples this week.

Misunderstanding what the doctor said

In one instance, the doctor had said something about the pain medicine and the stomach acid medicine should not be taken together.  This person has had a long history of Barrett’s Esophagus – a severe inflammation of the esophagus cause by extreme gastroesophageal reflux disease (GERD).  To break that down, this person’s stomach acid was going back up the esophagus – the tube from the mouth to the stomach.  Normally there is a sphincter that closes to keep the acid safely in the stomach.  In many of us, that sphincter can become loose or have a condition that keeps it from completely closing.  When that happens, the acid can go back up the esophagus. Indigestion, burping, pain and/or burning in the mid chest area can result.  The acid inflames the esophagus lining.  When that inflammation becomes severe, the inflammation can lead to Barrett’s Esophagus.  So the stomach acid medicine was VERY important!

This person’s other issue was low back pain due to a herniated (bulging) disk and sciatic pain. Sciatic pain results in pain and burning from the lower back and spreading through the buttocks and the leg. It is caused by irritation of the sciatic nerve, common with lower back issues.

When this person heard the doctor say the stomach acid medicine and the pain medicine shouldn’t be taken together, the person decided to STOP the stomach acid medicine.  The sciatic pain was the ‘bigger issue’, so if both couldn’t be taken, the pain medicine took priority.  The doctor was not told.

The client heard ’these medicines shouldn’t be taken together’.  The more complete answer is, the pain medicine will make the stomach acid and esophagus irritation even worse.  There are safer pain medicine options that won’t make the Barrett’s Esophagus worse.  The person should DEFINITELY be on both a stomach acid medicine and a pain medicine. The pain medicine should just be changed to a safer option.

This was explained, and this person is now on a safer medication regimen for both conditions.

Another Misunderstanding Example

Another recent example was a man with severe vascular issues and lung cancer.

The lung and cancer doctors had together told him and his family there is no more they could do. They recommended hospice care. Hospice care was accepted.

The vascular issues caused very little blood flow to the feet.  As a result, one foot and lower leg had been amputated a few months ago. The second leg and foot are now very infected.  The foot infection is causing severe pain.  Hospice is treating the pain with morphine.  The morphine makes the patient’s stomach upset and dulls his thinking.

His wife understands that the hospice doctor is now his doctor rather than his specialists and primary doctor from before.  The hospice nurses visits regularly, but the doctor has not.  His wife is very upset that the doctor is doing nothing to heal the infection.  She also feels he is very overmedicated since his memory and decision making are slowed due to the morphine.

When we discussed goals – quality vs quantity of life – they each indicated the specialists who recommended hospice had asked that.  They chose quality.  However, they didn’t understand that this would mean a rather rapid decline with the untreated lung cancer and foot infection.  They thought he would be able to back to the things he loves like working on projects around the house and cooking.   They see a decline in quality of life rather than the expected increase.

Now they want to go back to the specialists and change their minds.  It has been six months of no curative treatment.  There is most likely no way to alter the pending outcome.

Essential Clear Communication

Healthcare visits can feel fast and pressured.  Any time there is bad news involved, it is hard to fully hear and process all that is being communicated.  These and other communication issues lead to misunderstanding of healthcare information. This is NOT an uncommon problem.

Another contributing factor is difficulty reaching the doctor after getting home to request clarification.  Most doctors are given schedules that make it difficult to squeeze in phone calls.  So, it is always best to receive, process, and fully understand the information while you have the doctor’s full attention during an appointment.

At Meds MASH and Retirement Wellness Strategies, we are your advocate.  You have guidance to prepare for medical visits by assuring you have your questions ready and the information your doctor needs organized and clear.  We also attend the visit with you by video when you want that.

After the visit, we can provide a wealth of information to further explain any new conditions or medications.  We can even contact your doctor(s) on your behalf to obtain any needed clarification.

Call today at 410-472-5078 and ask for Michelle Fritsch, Pharm.D.  Or e-mail at michelle@medsmash.com.   Check out more at www.medsmash.comor www.retirewellness.com.

BIBLICAL APPLICATION

Miscommunication and misunderstanding can lead to so many preventable problems.  I often ask this question of students in the health professions. ‘Tell me about a time miscommunication led to a bad outcome.’  Usually the answers involve people going to different restaurants or friends having an argument.  One time, while teaching active duty military healthcare providers, the example was of an international hunt for a notorious terrorist.  The terrorist had been found and surrounded, but a delay in the order to detain him resulted in his escape.  What an example!

The Bible has much instruction about good communication.

This Psalmist knows exactly how much trouble our words can cause:

Psalm 141:3 ESV

Set a guard, O Lord, over my mouth; keep watch over the door of my lips!

Our communication is instructed to build people up and turn them to Christ.

Ephesians 4:29 ESV

Let no corrupting talk come out of your mouths, but only such as is good for building up, as fits the occasion, that it may give grace to those who hear.

Colossians 4:6 ESV

Let your speech always be gracious, seasoned with salt, so that you may know how you ought to answer each person.

I know I have spoken in frustration and said words I regretted.  I know I have neglected to speak up when my support could have been very helpful to someone else.  I know I have said the wrong thing and caused more harm than good, usually out of complete ignorance or insensitivity.

Proverbs 15:2 ESV / 176 helpful votes

The tongue of the wise commends knowledge, but the mouths of fools pour out folly.

One of my frequent prayers in the morning is, ‘Lord please fill me up and pour me out today.’  I ask to be poured out with the Lord’s words and attitudes and sensitivities.

Psalm 19:14 ESV

Let the words of my mouth and the meditation of my heart be acceptable in your sight, O Lord, my rock and my redeemer.

I certainly can’t be trusted to do this on my own, but with the Lord’s guidance, excellent communication can make a huge positive difference in the lives we meet!

Blessings,

Michelle

Thanksgiving – Gratitude keeping you Healthy

 

On this Thanksgiving, praying you take the time to reflect on your many blessings.  What a day to remind us of how our areas of gratitude!

Gratitude, grateful, thankful, thanksgiving, appreciation

What do these words mean to you? What role do they play in your everyday life?

Wow, I am amazed how much information is available on this important link between gratitude and health. Just search for these two terms and see what all you will find.

What is gratitude?

This is being aware of all of the good things in your life. And it is being thankful for those things. Have you considered being grateful for:

  • A safe place to sleep
  • Food to eat
  • Clothes to cover yourself
  • Having a friend to call
  • Your job – current or past
  • A beautiful day

This simple awareness of and being thankful for these ‘little’ things can boost your health.

Note, it doesn’t have to be the biggest house or the softest bed or the tastiest food or the latest fashion clothing to be grateful. Gratitude focuses on what you have – all of the good things – rather than what you don’t have.

Expressing gratitude can:

  • Boost your spirits and sense of well-being
  • Boost your immune system making you less likely to get sick
  • Decrease your chances of heart disease
  • Improve your performance (grades, work productivity, concentration)
  • Bust your stress

There are many ways you can make gratitude part of your life. Here are a few recommended in a Harvard Mental Health newsletter:

  • Write a thank-you note
  • Go up and thank someone
  • Keep a gratitude journal
  • Pray
  • Meditate
  • Keep a list of your thanks = count your blessings

See your day and your health improve by focusing on the positive.

Even therapy for mood disorders and approaches to negative thinking know this truth. I am quoting this from Rick Warren, “When you change the way you think, it changes the way you feel. And when you change the way you feel, it changes the way you act.”

On this Independence Day weekend, as a country, we have much reason for gratitude!

For more information on gratitude and health, contact us at www.medsmash.com.

BIBLICAL APPLICATION

We have so many reasons to be grateful!

Have you ever been in a ‘funk’ having a bad day and then remembered to be grateful? I have done this so many times. When all looks dark and gloomy, make yourself think about all of the things that are good and right.

1 Thessalonians 5:18 ESV

Give thanks in all circumstances; for this is the will of God in Christ Jesus for you.

I’ll quickly admit I don’t always think to do this. I stay in that dark place far too long. Later, once I’m out I realize I had the ‘magic potion’ to leave that darkness behind. It was given to us by Christ when he died to erase our sins. It was given to us by God who maintained His love and focus on the good in the Jews through centuries of missteps (just as we live a series of missteps).

Lamentations 3:23 ESV

They are new every morning; great is your faithfulness.

I don’t even know where to begin selecting Bible verses to draw us closer to the benefits of gratitude. There are so many!!!

Psalm 118:24 ESV

This is the day that the Lord has made; let us rejoice and be glad in it.

Colossians 3:17 ESV

And whatever you do, in word or deed, do everything in the name of the Lord Jesus, giving thanks to God the Father through him.

Psalm 136:1 ESV

Give thanks to the Lord, for he is good, for his steadfast love endures forever.

Ephesians 1:16 ESV

I do not cease to give thanks for you, remembering you in my prayers,

James 1:17 ESV

Every good gift and every perfect gift is from above, coming down from the Father of lights with whom there is no variation or shadow due to change.

I feel energized, positive, and excited just reading these verses full of hope and promise! I am thankful for each person who takes the time to read this. May you be blessed by these assurances from God!

I pray you can stay focused on the many good things in your life this week and that can keep you out of the dark, gloomy places.

Blessings,

Michelle

 

Prevent post retirement suicide

Retirement and the Rising Rate of Suicide – plan to avoid this outcome

Prevent post retirement suicide
Know the risk factors, the warning signs, and the phone number.

You have had tremendous success in your career. Perhaps you started the company yourself. You at least had a major impact on its success.

For years you have been planning for retirement. Your financial portfolio is ready. Your succession plans are in place. Your family is excited to have more of your time.

Or, maybe retirement has come before you are ready. A buy-out or lay-off situation seemed to come out of nowhere.

Any of these situations can lead to the almost unthinkable outcome of suicide.

Rise in Suicide in the US

The Centers for Disease Control released new data in June 2018 about the rising rate of suicide in the United States. Over at least the last decade, the population with the most increase was men ages 45-59 followed closely by those over 60. All but one state has seen an increase in suicide from 1999 to 2016.

Note, during this time two key variables could be playing a role.

  • The Boomer generation has a different perspective on life and religion as compared to previous generations. This generation has explored a wider range of religions and a larger segment has moved away from traditional religion.
  • There was a recession that changed the economic portfolio for many people. Although age and health might indicate it is time to retire, the financial situation might have taken a hit from which it has not yet recovered.

Depression and Suicide in Retirement

Another factor for anyone who retires is the possibility of the post-retirement-blues. Those with hobbies and a broad social network seem to get through this the best. But, especially for those who spent most of their time working and had their social network primarily consist of work colleagues, retirement can feel like sudden isolation.   So much planning has gone into getting to retirement. Then, once there, the sudden stop of the normal routine and the uncertainty about what comes next can have a big effect. In some cases it is mild disillusionment and an impetus to start creating new routines exploring new opportunities.

In some cases, it leads to a loss of self. A deeper, darker depression can erode confidence, meaning, and a sense of relevance. For some, this downward spiral can lead to suicide.

  • If you ever have a desire to end your life, or know someone who may be contemplating suicide, please reach out to a resource such as the National Suicide Prevention Lifeline Phone Number 1-800-273-8255.

Planning for Retirement

Much effort often goes into planning for the financial component of retirement and the succession at work. But, what about preparing mentally, emotionally, spiritually, and physically for the personal transition of retirement? This is at least as important as the other planning.

At Retirement Wellness Strategies, we have a unique mapping tool to help you plan for this next chapter. Retirement should be meaningful, active, sustained (for a good long time), and healthy. That is where we come in. Don’t leave your transition to chance.

You can reach us at www.retirewellness.com, michelle@retirewellness.com, or by calling 410-472-5078.

BIBLICAL APPLICATION

Life can be so stressful. Even during the transition to retirement, life stressors can overtake you.

Retirement is meant to be a time of new possibilities, adventure, relaxation, and no more rigid time rules. It is a reward that is earned through years of hard work.

Yet, many people, especially men in positions of leadership and great responsibility, struggle with this transition. It impacts every aspect of their being. It is too easy to get lost in the separation from work life to retirement life.

We are assured throughout the Bible that we will encounter difficult times.

John 16:33  NIV

 “I have told you these things, so that in me you may have peace. In this world you will have trouble. But take heart! I have overcome the world.”

Romans 5:3-5  NIV

Not only so, but we also glory in our sufferings, because we know that suffering produces perseverance; perseverance, character; and character, hope.  And hope does not put us to shame, because God’s love has been poured out into our hearts through the Holy Spirit, who has been given to us.

We are also assured throughout the Bible that we will not be left alone during these struggles.

Proverbs 3:5-6 ESV

Trust in the Lord with all your heart, and do not lean on your own understanding. In all your ways acknowledge him, and he will make straight your paths.

Jeremiah 29:11 ESV

For I know the plans I have for you, declares the Lord, plans for welfare and not for evil, to give you a future and a hope.

Psalm 34:17-20 ESV

When the righteous cry for help, the Lord hears and delivers them out of all their troubles. The Lord is near to the brokenhearted and saves the crushed in spirit. Many are the afflictions of the righteous, but the Lord delivers him out of them all. He keeps all his bones; not one of them is broken.

I encourage all who read this to consider how they can help those who are giving up to see these promises of Christ! Even Christians and successful leaders can fall into despair.

I often wonder if someone who chooses suicide could have held on for just another couple of minutes, if the outcome could have been different. Our deepest valleys do eventually dissipate into a more hopeful scenario.

Philippians 4:6-7 ESV

Do not be anxious about anything, but in everything by prayer and supplication with thanksgiving let your requests be made known to God. And the peace of God, which surpasses all understanding, will guard your hearts and your minds in Christ Jesus.

2 Corinthians 4:8-9 ESV

We are afflicted in every way, but not crushed; perplexed, but not driven to despair; persecuted, but not forsaken; struck down, but not destroyed;

How can you help decrease this rise in suicide in our country?

Blessings,

Michelle

Why is DIVORCE during and after retirement on the rise?

Protect your marriage
Protect your marriage from the stresses of divorce

Divorce around retirement – You’ve seen it in pop culture, in famous people. And, you’ve likely seen it in your own community. It won’t be surprising if you are seeing this trend in your own family, even your own marriage.

The incidence of divorce over age 50 is experiencing a sharp rise. It has nearly TRIPLED since 1990. (Interestingly, the divorce rate among younger adults under age 40 is declining). So, why are the Boomer’s divorcing at an unprecedented rate?

The role of RETIREMENT in divorce

Retirement is one of the top 10 biggest life adjustments. It is a time of huge transition ranking right up there with marriage, having children, moving, and loss of a loved one.

Many people enter retirement unprepared. They often haven’t thought about the daily changes, the sudden loss of routine, and the sudden increase in togetherness time with their spouse.

In a perfect, romantic world, more time together is exactly what each couple wants. Nothing in life is perfect, at least not for long.

That’s not to say that marriages can’t thrive in retirement. They absolutely can. But that usually requires some communication, compromise, and adjusted expectations.

A healthy marriage in retirement

Both partners have a lot of change to navigate with retirement. Time spent together usually increases. Either partner might find that restrictive. The more we are together, the more complicated communication can be as well. (It is much easier to say the wrong thing when you’re talking more).

  1. The most important step to a healthy marriage in retirement is to talk about it before it happens, or at least before relations get very hurtful after retirement. Rarely do both partners have a clear picture of what retirement will really be like. But, both have some ideas of what they want it to be like. How much have you talked about this?
  2. Until it happens, sometimes people don’t even know what might annoy, frustrate, or stifle them in retirement. Agree to be open with one another as these stumbling blocks present themselves. Recognize that they will occur, and before they are personal or hurtful, calmly talk about them.
  3. Plan for how you will maintain some independent interests and activities. If you have had only a few hours in the evening and on the weekends together for decades, 24/7 togetherness can be overwhelming.
  4. Talk about expectations. What are common aspirations, plans, and desires? Unmet expectations are almost always at the center of a divorce. Often, one doesn’t know what the other was expecting until the relationship is too far-gone. Don’t let that happen.
    1. I’ve seen examples where one person wants to travel while the other wants to stay home.
    2. Sometimes one has always dreamed of taking couples dance lessons and the other would rather do anything but that.
    3. A big issue I’ve seen is one spouse wants a lot of togetherness going and doing things while the other wants to spend most time with the grandchildren.
  5. Include the more intimate parts of your relationship in your planning. This is an area of frequent mismatch in expectations. There is NO truth that sex ends at a particular age. It is very helpful when partners can open discuss these expectations and honor what motivates the other partner to share the same desires.

Planning is key

Don’t leave your marriage to chance after retirement. Recognize that retirement is a major life transition. Respect the wide range of emotions and adjustments each partner will make.

Retirement Wellness Strategies is here to help!   Let us help you preserve your health and strategically plan for all aspects of your retirement such that it is Meaningful, Active, Sustained, and Healthy!

Learn more at www.retirewellness.com, michelle@retirewellness.com, or call 410-472-5078.

BIBLICAL APPLICATION

Marriage is sacred. Marriage vows are committed in the presence of God and witnesses.

Yet, marriage can be very hard. Marriages go through good and bad times (as usually stated in the vows).

Today’s culture values feelings over commitment. Culture supports and sometimes even promotes greater focus on self than on a partner.

I know so many lovely people who have experienced the trauma of divorce. Know that you are deeply loved. God knows the details. Give the grief, disillusionment, and any other feelings over to him who can heal all wounds.

Where have you made mistakes in your marriage?

When have you put yourself above your spouse?

When have you been hurtful and unkind?

When have you taken your marriage for granted?

I believe all married people have done these things. We all have difficult days.

The commitment of marriage doesn’t mean sunshine and roses.

1 Corinthians 13:4-7 ESV

Love is patient and kind; love does not envy or boast; it is not arrogant or rude. It does not insist on its own way; it is not irritable or resentful; it does not rejoice at wrongdoing, but rejoices with the truth. Love bears all things, believes all things, hopes all things, endures all things.

There’s a reason these verses list all of the ways we mess up in marriage or any love relationship.

If you feel like you’ve done it all wrong, don’t give up hope. Love comes from God, and He can fill your love bucket at any time…just ask. Love is so much more than a mushy feeling.

Ephesians 5:33 ESV

However, let each one of you love his wife as himself, and let the wife see that she respects her husband.

1 John 4:7 ESV

Beloved, let us love one another, for love is from God, and whoever loves has been born of God and knows God.

I pray your love and marriage are resilient. If your marriage has officially ended, I pray you find healing, forgiveness, and hope for a bright new future. God is good!

Blessings,

Michelle

 

Retirement preparation

The best laid plans… When retirement is unnecessarily too short

Retirement preparation
Retirement should be meaningful, active, sustained, and healthy.

I am sad.

I am surprised.

I am mad.

So, I need to take action.

Retirement is often not the golden age of happiness that is dreamed.

Retirement is a MAJOR life transition – up there with marriage, having children, and moving.

I have been researching more and more about retirement. As a healthcare professional, I have seen TOO MANY people lying in a hospital bed with their future retirement plans dashed. And, TOO MANY times, this event that led to the hospital could have been prevented. If only things had gone differently hours, days, months, or years earlier, this hospital visit could have been avoided.

Role of Medication Use

Medication use plays a part in these avoidable events at least 80% of the time. There are many ways medication can be part of the problem:

  1. Not taking a medication that is prescribed.
  2. Taking too much of the medication.
  3. Taking too little of the medication.
  4. Taking a medication for one thing that makes another problem worse.
  5. Taking medications that are not safe together.
  6. Having a severe side effect from a medication.
  7. Not seeking medical care for a problem that should be treated with medication.
  8. Taking a medication when no medication is needed.

And then there are multiple variations of each of these issues.

Medications are not benign.

Medications are not all bad.

Medications can save lives.

Preparing for the future

Sometimes the preventable problem is related to lack of planning for retirement.

Most people think of MONEY when they think of retirement planning. There are many professionals who dedicate their career to helping people secure the finances for retirement. Others focus on insurance and protection of assets.

Few have made plans for the enormous lifestyle transition that is retirement. Those who especially struggle with the transition are:

  • people who are very busy at work with a lot of responsibility,
  • those who always have people lined up to talk with them,
  • those who are the decision makers, and
  • those who run the company.

Work Withdrawal

The withdrawal from the daily demands of work can be similar to any other withdrawal from an addiction. Symptoms the first few days can include:

  • sense of loss
  • restlessness
  • frustration
  • anger
  • palpitations
  • sense of loss

Later withdrawal symptoms can be:

  • depression
  • despondence
  • loneliness
  • feelings of inadequacy or irrelevance
  • anger
  • lack of concentration
  • irritability

Planning for Retirement

Finding the retirement years of your dreams takes planning. How will you prepare for the first day the phone no longer rings, people are no longer lined up outside your office, and the big decisions are made without your input?

We dream of retirement practically from the time we start working. The thought of a break from the pressure sounds wonderful. Then it happens…

I have talked to many men, most thinking they had planned well for retirement, who are then surprised and disappointed when the realities of the transition hit. Others plan to never retire to avoid going through this.

A successful transition to many happy years and a long delay of functional decline is possible!!!

Contact us today at www.retirewellness.com, or call 410-472-5078, or e-mail michelle@retirewellness.com.

BIBLICATION APPLICATION

Retirement is a Biblical concept. We are designed for a period of rest from work, but not from ministry.

Going back to the Levites –

Numbers 8:23-26 ESV

And the Lord spoke to Moses, saying, “This applies to the Levites: from twenty-five years old and upward they shall come to do duty in the service of the tent of meeting. And from the age of fifty years they shall withdraw from the duty of the service and serve no more. They minister to their brothers in the tent of meeting by keeping guard, but they shall do no service. Thus shall you do to the Levites in assigning their duties.

And how wonderful to have a phase of life where you keep doing the joyous parts and let the hard work go!

Acts 20:24 ESV

But I do not account my life of any value nor as precious to myself, if only I may finish my course and the ministry that I received from the Lord Jesus, to testify to the gospel of the grace of God.

It might feel frightening to let go of a decades-long career and enter the unknown of retirement. Then again, that is right where you should be, and God can use you in amazing ways!

Jeremiah 29:11 ESV

For I know the plans I have for you, declares the Lord, plans for welfare and not for evil, to give you a future and a hope.

Philippians 1:6 ESV / 67 helpful votes

And I am sure of this, that he who began a good work in you will bring it to completion at the day of Jesus Christ.

Psalm 71:17 MSG

You got me when I was an unformed youth,
    God, and taught me everything I know.
Now I’m telling the world your wonders;
    I’ll keep at it until I’m old and gray.

Consider how God wants to use you in retirement. What blessings are just around the corner, when you give the part of your life completely over to His guidance?

Blessings,

Michelle

 

 

 

 

Prevent falls; manage changes

Fall Changes, Falls, and Your Changes

Prevent falls; manage changes
Physical changes can increase risk of falls.

In Maryland, the leaves are turning beautiful fall colors. The air is crisp more often, and that fuzzy blanket feels good at night! The move from summer to autumn makes itself known in obvious and in subtle ways.

Throughout life, your body makes changes, too. Some are obvious. Some are subtle.

Many of these changes increase your risk for falls and/or injury with a fall.

Obvious changes

  • Joints get stiffer
  • Lung capacity gradually decreases – you might get short of breath easier
  • Skin gets drier as overall body water content decreases
  • Vision changes, especially your ability to see up close
  • Skin and tissues get looser

Subtle changes

These changes are usually caught when your doctor monitors your labs, your urine, or does a physical exam.

  • Kidneys slow down
  • Liver slows down
  • Bones get less dense (hard)
  • Reflexes aren’t as quick
  • Risk for urinary track infection goes up
  • Hormone production changes – for men and women

Association with falls

As we move slower, have more joint pain, lose some of our range of motion, and reflexes slow, the risk of falls goes up. As senses such as vision, hearing, touch, smell, and even taste change, these also increase the risk of falls.

The kidney and liver changes are especially important as we think about the impact on how our body handles medications. The liver is the key organ that breaks down medicines in our body. The kidney is one of the primary ways they are then removed. So, as our kidneys and liver slow down, for many medicines, we need lower doses. Sometimes, at some point in the decline of kidneys or liver, some medications should NOT be used at all.

Falls can lead to losing your ability to walk, run, climb stairs, and be as active as you would like to be.

Remember, with accumulated years we also grow in wisdom, in maturity, and learn to count the blessings in our lives! Graceful aging is a beautiful thing. I just don’t want you to fall!

Call us at Meds MASH for a thorough assessment of your current changes, your medications, and ways to decrease your risk of falls. This is one of our specialties! Michelle is one of the creators of a comprehensive falls risk assessment.

You can reach Michelle at michelle@medsmash.com; 410-472-5078; www.medsmash.com/contact.

BIBLICATION APPLICATION

Our bodies aren’t the only things that change with time. Our Christian walk is also a journey with twists and turns. Ideally it is an uphill climb to more maturity. But without practice and several bumps in the road, it can be a very flat journey.

Ephesians 4:14-15 ESV

So that we may no longer be children, tossed to and fro by the waves and carried about by every wind of doctrine, by human cunning, by craftiness in deceitful schemes. Rather, speaking the truth in love, we are to grow up in every way into him who is the head, into Christ,

Growing, learning, and changing take effort and dedication. Practice makes perfect. I don’t expect any of us will reach perfect until Heaven, but practice can certainly help us with improvement.

Hebrews 5:12-13 ESV

For though by this time you ought to be teachers, you need someone to teach you again the basic principles of the oracles of God. You need milk, not solid food, for everyone who lives on milk is unskilled in the word of righteousness, since he is a child.

To grow and change, we take risks, learn from our mistakes, and gain confidence as God sees us through each obstacle.

James 1:1-27 ESV

James, a servant of God and of the Lord Jesus Christ, To the twelve tribes in the Dispersion: Greetings. Count it all joy, my brothers, when you meet trials of various kinds, for you know that the testing of your faith produces steadfastness. And let steadfastness have its full effect, that you may be perfect and complete, lacking in nothing. If any of you lacks wisdom, let him ask God, who gives generously to all without reproach, and it will be given him. …

Romans 5:3-4 ESV

More than that, we rejoice in our sufferings, knowing that suffering produces endurance, and endurance produces character, and character produces hope,

Rather than avoid the changes that include hardship, know that God will get you through them, and you will grow and change in beautiful ways with each piece of the journey.

Blessings,

Michelle

board certified geriatric pharmacist

Why would you benefit from a board certified geriatric pharmacist?

board certified geriatric pharmacist
How Meds MASH promoted safe, healthy, active living

I started a company that I call Meds MASH in 2015. I am a board certified geriatric pharmacist. That means I specialize in medication use in people over the age of 60.

What Meds MASH doesn’t do for you:

  • Fill your prescription
    • Your local pharmacist will do this
  • Change any of your prescription medications
    • I will make suggestions to your doctors or help you discuss them with your doctor
  • Take over your healthcare
    • You will keep your doctors who will lead your healthcare

What Meds MASH will do for you:

  • Talk with you to find out what are your health and life goals
  • Review all of your medications
    • Prescribed
    • Over-the-counter
    • Vitamins
    • Supplements
    • Herbal remedies
    • Any other substances
  • Obtain your medication history
  • Review your labs to check for medication safety
    • Kidney function
    • Liver function
    • Medical condition control
    • Side effects
  • Review your medicines compared with your allergies
  • Evaluate in-depth for risks of falling
  • Review for some common issues that are often missed
  • Make sure you understand each of your medications and how to best take them
  • Take time and answer your questions
  • Provide you with detailed information you can review later and share with your doctor
  • Talk direct with your doctors at your request and authorization
  • Engage your family at your request and authorization

Does Meds MASH make a difference? On average in an initial review- 

  • We make 4.5 interventions
  • A recommendation is made to improve two medications
  • A recommendation is made to change a medication for 82% of clients
  • Over 98% of the time a significant suggestion about medication is made!

Questions frequently asked

Doesn’t my doctor already do this?

  • Rarely does your doctor know absolutely every medication you take and how you actually take it.
    • Meds MASH specializes in obtaining this before reviewing the medications.
  • Only a small percentage of people over 60 have a doctor board certified in geriatrics.
    • Meds MASH provides a board certified geriatric expert.
  • Most people have 7-15 minutes with their doctor.
    • Most Meds MASH initial visits are 45 minutes.
  • Rarely are people fully prepared for their doctor visit.
    • Part of a Meds MASH review includes specific strategies to get the most out of each medical visit with your doctors.

Doesn’t my pharmacist already review all of my medications?

  • Rarely does your pharmacist know all of the medications you take.
    • They know the prescriptions only, even if you only use one pharmacy.
      • You absolutely should use only one pharmacy!
    • Your pharmacist has a limited time to carefully review your medicines.
    • There are not many geriatric board certified pharmacists in the country.

Contact us today for a free consultation! Meds MASH 410-472-5078 or e-mail michelle@medsmash.com or on the website www.medsmash.com/contact.

BIBLICAL APPLICATION

There is a lot of talk about and emphasis on being ‘transparent’ today in our society. It has taken me months to clearly, succinctly state what we do at Meds MASH. I am still honing the message so that it really makes sense to people. We need to be able to put things in someone’s own perspective to help them really understand.

If an alien from Mars came to visit and talked to you about places, customs, and politics on Mars, it is unlikely you would understand very much of it. You would have no perspective of how things look or operate on that planet.

I had this same thought this week as I was reading the Psalms, especially the ones written by David. David was the king. He was responsible for all of the people. His perspectives were oriented around keeping people safe and alive.

He frequently talks about enemies and God’s protection in wars. I’m sure they were attacked, or at risk of being attacked, most of the time. God made it clear that when the people of Israel went into battle with God’s protection, then they would prevail.

Deuteronomy 28:7 ESV

“The Lord will cause your enemies who rise against you to be defeated before you. They shall come out against you one way and flee before you seven ways.

When they went into battle on their own, the outcomes were not so good.

Numbers 14:39-45 ESV

Israel Defeated in Battle

When Moses told these words to all the people of Israel, the people mourned greatly.  And they rose early in the morning and went up to the heights of the hill country, saying, “Here we are. We will go up to the place that the Lord has promised, for we have sinned.”  But Moses said, “Why now are you transgressing the command of the Lord, when that will not succeed?  Do not go up, for the Lord is not among you, lest you be struck down before your enemies.  For there the Amalekites and the Canaanites are facing you, and you shall fall by the sword. Because you have turned back from following the Lord, the Lord will not be with you.”  But they presumed to go up to the heights of the hill country, although neither the ark of the covenant of the Lord nor Moses departed out of the camp.  Then the Amalekites and the Canaanites who lived in that hill country came down and defeated them and pursued them, even to Hormah.

Our personal battles aren’t with swords, but they are still battles. And if God is for us and leading us, then our outcomes are infinitely better than when we do battle on our own without Him.

David also makes frequently reference to rain, crops, vineyards, and grain. We don’t tend to spend our days focused on those things. Our grocery stores and markets are filled with all we need.

But what are the daily struggles in your life that mean just as much to you as ability to grow crops meant in David’s time? Is it your finances, your job, career opportunities, relationships, finding your meaning in life? Our daily struggles are no less important that David’s. Our world and our perspectives are just different.

So, whatever your battles, lay them before the Lord. Honestly lay it all out there. Be completely transparent and clear in your requests before God. He already knows. He loves the trust you place in Him as you bring it all to Him.

Psalm 71:14-17 ESV

But I will hope continually

    and will praise you yet more and more.

My mouth will tell of your righteous acts,

    of your deeds of salvation all the day,

    for their number is past my knowledge.

With the mighty deeds of the Lord God I will come;

    I will remind them of your righteousness, yours alone.

O God, from my youth you have taught me,

    and I still proclaim your wondrous deeds.

If you’re ever at a loss for what to pray, consider the Psalms. They are the prayers and songs of praise of David. Put it in today’s perspective, and you’ll find they are completely relevant to your needs today.

Blessings,

Michelle

We need to be needed

We NEED to be NEEDED to maintain our HEALTH

We need to be needed
We all need to be needed even if it is to care for an African Violet

Have you ever thought about the link between being needed and health? As I’m thinking about it, that link could probably go both ways. I am wanting to tell you about the health benefits of being needed. But, I’m sure you could make a case that being overworked in constant demand can have negative health implications.

Think of a woman you know who went from caring for children and her husband to now being in an empty house with infrequent visits from children.

Think of a man or woman who worked in a very demanding job with a lot of responsibility who has now retired.

Often, we dream of the day everyone is raised and on their own. We dream of the day we reach the point of retirement.

Then, when that day comes you find yourself lonely. It is not as exciting as you expected. Reading books and relaxing can get boring.

Aging joints, accidents, and new medical conditions can create changes to retirement plans. Loss of a spouse can create changes to retirement plans. Children with jobs that take them away can create changes to retirement plans.

Social isolation

Social isolation is a real hazard to your health. Social isolation is when you don’t feel like your belong, don’t have much interaction with other people, don’t have people to call to get out and do something, and no/few close personal friends.

Social isolation can be bad for your health when it leads to drinking, being less active, or eating less healthy meals. It can increase your risk of heart disease, stroke, dementia, or depression.

We all Need to be Needed

A very innovative program was launched in the early 1990’s called Eden Alternative. They call their method, ‘person-directed care’. When I first heard about it in the 1990’s a very clear picture was left in my mind. A senior living facility had enhanced their environment by bringing in a cat, a dog, birds, a garden on the lawn, indoor plants, and a baby chick. There was a woman who wanted to spend all of her time in her wheelchair. The physical therapists were trying all they could think of to encourage her to walk and get stronger. She refused. Then she saw the baby chick. She did not want it to be eaten by the cat, so she put the chick in her wheelchair and pushed it. That chick, of course, became a chicken that continued to get first-class rides in the wheelchair.

Even people who were extremely incapacitated were given ‘jobs’. Even if it was caring for an African Violet. Some planted and worked in the garden. Some fed and cared for the birds. Some brushed the dog. Residents could sign up for the responsibilities that met their interests and abilities.

It was impressive how depression, anxiety, and pain were so much better with these changes. Since that time, the Eden Alternative has grown and spread and documented even more inspiring outcomes.

New Ideas to Decrease Isolation

I know many people who live in areas where they don’t feel safe getting out to walk. Some no long feel safe driving. Some don’t have the desire to get out and about without a partner.

So, some really smart minds have been working on ways to keep all of the health benefits of interacting with other people. Here are some of the creative options:

Virtual senior center. Using technology, you can take art classes, chat with others, participate in yoga or tai chi, and other activities. There are a lot of ways to keep in touch with family, read to someone, discuss topics, and support each other with technology.

Concierge driver options. Uber and other driving services are starting to offer unique options to take the stress out of getting out. There are groups working on strategies to provide more helpful driving service for people with walking aids, ways to coordinate outings such as restaurant or art gallery trips, and ways to make driving services more easy to coordinate.

This is only a very quick overview of the importance of interaction with other people, the dangers of isolation, and some of the many new ideas being developed. Stay tuned; I think we will all be amazed at what is to come.

For more information about the need to be needed and the dangers of isolation, or for updates on the amazing new advances we are hearing about, please contact us at www.medsmash.com or 410-472-5078. We’d love to tell you more!

BIBLICAL APPLICATION

We just discussed how our continued health needs us to stay active and engaged after retirement. Becoming alone is hazardous in many ways. We need each other. We never lose our need for purpose and fellowship.

And, we all have a purpose. We get so caught up in our daily details. We get so discouraged by our limitations, frailties, our weaknesses.

But, we are here for so much more! I’ve always heard this life is just a short, short preamble to a life of eternity in the presence of Christ! Can you even fathom that? I try then find it is so hard to begin to grasp!

We are assured of this truth numerous times in the Bible.

John 3:16 ESV

“For God so loved the world, that he gave his only Son, that whoever believes in him should not perish but have eternal life.”

John 5:24 ESV

Truly, truly, I say to you, whoever hears my word and believes him who sent me has eternal life. He does not come into judgment, but has passed from death to life.

Romans 10:13 ESV

For “everyone who calls on the name of the Lord will be saved.”

And while we are here in this life, we aren’t asked to sit around and twiddle our thumbs. We have a purpose!

Romans 8:28 ESV

And we know that for those who love God all things work together for good, for those who are called according to his purpose.

Jeremiah 29:11 ESV

For I know the plans I have for you, declares the Lord, plans for welfare and not for evil, to give you a future and a hope.

Sometimes we wonder what that purpose might be. In my experience to date, the purpose can even change over time. Things happen that seem strange and nonsensical, then suddenly, it turns into something only God could have planned.

I do my best to not make my own plans but rather stay open to what God has planned. That’s not meant to be pious. I have learned through a lot of changes, huge mistakes, and amazing teachers that my life is more fulfilling when I’m doing what God is calling me to do. It’s become a really wild ride, but I wouldn’t miss it. In the darkest times I need to remember that God can turn it all into his purpose and his plan.

Proverbs 16:9 ESV

The heart of man plans his way, but the Lord establishes his steps.

I’m praying you find comfort in the promise of eternal life when God is Lord of your life. And, I pray you are asking Him for your purpose and blindly trusting Him to lead you on your personal adventure until He calls you to eternal life!

Blessings,

Michelle

Use reflective statements to enhance communication and decrease conflict

Communicate Your Way to Better Health

Use reflective statements to enhance communication and decrease conflict
Communicate to decrease conflict and increase understanding using reflective statements

How do you handle conflict? For most of us the answer is, ‘not very well’. Conflict can raise your blood pressure, constrict your veins and arteries, and make your heart beat harder and faster.

Did you know that communication is NEARLY ALWAYS at the heart of conflict. As people, we miscommunicate on a regular basis. Part of what makes good communication so difficult is that it involves at least two people. Once is communicating and one is interpreting that communication. Let’s take a look at both important parts.

Communicate a consistent message

I was at a retreat this weekend where we played a game about consistent messaging. Think about a time when someone was talking with you and their message was not consistent. Their words said something that did not match their tone or their face or their body language. Imagine someone saying, ‘I love you’ with a grimace on their face and a mocking tone. Or picture someone saying, ‘So nice to meet you’ while glancing around the room looking for someone else. Has anyone ever tried to express anger with you then started laughing? It is hard to express anger while laughing. Someone was just telling me a story about a toddler rearranging a bunch of decorations and falling into a box headfirst with her feet sticking out of the top. The decoration was too heavy and pulled her over. This parent had to stifle giggles and get a picture before retrieving and correcting the toddler.

So, when you are communicating, carefully think about saying the same message with your words, your tone, your eye contact, your facial expression, and your body language. That will help avoid misinterpretation.

Check for understanding

When you are the one communicating, make sure the receiver actually understands what you are saying. It is ok to ask them to repeat it back. Or to ask what questions they have. If we assume the other person understood exactly what we were thinking and trying to communicate, we can often be disappointed. Think about the last time you thought someone understood and they did something completely different than what you asked.

If you are the listener, this is a critical step to assure you are understanding the message.

Reflective Statements

When you are the listener, one of the best techniques you can use is ‘reflective statements’. State back to the person communicating with you what you hear them saying. Put it in your own words. Here are some examples:

  • You are saying you are upset about _________ because _________.
  • You are asking me to _________________ and have it done by _________.
  • ___________ frustrates you when he/she ______________.
  • You want to ________________ before you agree to a hip surgery.
  • You heard that I ______________, and it has upset you.
  • Your son forgot to _______________, and not you don’t know what to do.

When you respond with a reflecting statement, you are making sure you understood the person’s message. It is a chance for them to clarify if you misunderstood. It is also a chance for them to feel heard and understood if you are correct.

Making sure you understand before taking any action, even before getting angry, and help avoid a lot of conflict.

If someone is upset or angry and respond also upset and angry, the situation escalates quickly. I have seen this happen where the two people don’t even realize they are saying the same thing. Neither is listening, they are just yelling. Now that will really get your blood pressure up!

I have found that FREQUENTLY, what I think I heard and what the person really intended were different. Especially when the topic is emotionally charged. It is our natural reaction to get defensive when someone comes at us angry. It is very hard to listen well in that state. So, a really deep breath and a calm reflecting statement can often help the situation calm back down. Sometimes when we are angry or frustrated we just want to vent. Once the venting is done, and the recipient reflects understanding, the situation doesn’t seem so bad.

Communicate with your Healthcare Team

These same techniques are very helpful when you communicate with your doctor. Sometimes the news we receive from our doctor can be upsetting. The words used in medicine are big and scary all by themselves. It can be hard to understand all of the technical information.

I highly encourage you to state back to your doctor what you just heard. Say it in your own words.   This will help the doctor know where to clarify. I have had many patients get upset by a medical term that was actually no big deal. It just sounded scary. My grandfather, after 40+ years of smoking, a heart attack, a stroke, and stomach ulcers quit smoking cold turkey. We had been trying to get him to quit for years. None of those scary medical issues made him quit. But, when he was diagnosed with hiatal hernia he quit on the spot. [Hiatal hernia is when the sphincter between the esophagus and the stomach can’t close all the way. This allows stomach acid to come back up giving you heartburn. For him, this was the mildest of his issues.] I ask him why. His answer, ‘That’s a really scary word.’ I was in pharmacy school at the time. I had all sorts of scary words I could have given him. Who knew that was all it would take to get him to quit.

So, I encourage use to be clear and consistent with your communication. And, ask clarifying questions and use reflective statements when you are receiving communication. Especially if it seems upsetting, make sure you really understand the message before you make any decisions. This could help you avoid a lot of conflict.

Your heart will thank you for managing conflict better and keeping your blood pressure down.

For more information about communication techniques for your health, please contact us at Meds MASH at 410-472-5078 or www.medsmash.com/contact.

BIBLICAL APPLICATION

When we react without first understanding, we often get ourselves into trouble. Throughout the Bible we see examples of people making bad assumptions followed by bad actions.

The people of Israel, after God had gotten them out of slavery and out of Egypt and led them through the desert supplying food and water and protection, still made bad assumptions. While Moses was on the mountain with God himself, they assumed he wasn’t coming back, so they made a golden calf to be their god.

Exodus 32:1 NIV

When the people saw that Moses was so long in coming down from the mountain, they gathered around Aaron and said, “Come, make us gods[a] who will go before us. As for this fellow Moses who brought us up out of Egypt, we don’t know what has happened to him.”

When Jesus was talking with his disciples about what was coming next for him, including his death, Peter jumped right in and disagreed.

Matthew 16:21-23 NIV

From that time on Jesus began to explain to his disciples that he must go to Jerusalem and suffer many things at the hands of the elders, the chief priests and the teachers of the law, and that he must be killed and on the third day be raised to life.

Peter took him aside and began to rebuke him. “Never, Lord!” he said. “This shall never happen to you!”

Jesus turned and said to Peter, “Get behind me, Satan! You are a stumbling block to me; you do not have in mind the concerns of God, but merely human concerns.”

In the bible we are also told to expect miscommunication in the future. There will be false prophets and all sorts of misinformation.

Matthew 7:15 ESV

“Beware of false prophets, who come to you in sheep’s clothing but inwardly are ravenous wolves.

1 John 4:1 ESV

Beloved, do not believe every spirit, but test the spirits to see whether they are from God, for many false prophets have gone out into the world.

We are called to be discerning. Ask questions. Get the full story. Make sure you understand and that what you hear matches the messages of the Bible.

I feel better when I read this passage. There will be no doubt when Jesus returns. Other people can claim what they want. I won’t believe it until it is this obvious:

Matthew 24:29-31 ESV

The Coming of the Son of Man

“Immediately after the tribulation of those days the sun will be darkened, and the moon will not give its light, and the stars will fall from heaven, and the powers of the heavens will be shaken. Then will appear in heaven the sign of the Son of Man, and then all the tribes of the earth will mourn, and they will see the Son of Man coming on the clouds of heaven with power and great glory. And he will send out his angels with a loud trumpet call, and they will gather his elect from the four winds, from one end of heaven to the other.

That doesn’t sound too subtle. So, until it is extremely obvious and visible to all of creation, let’s not fall for false messages.

Blessings,

Michelle

 

Falls – Steps you can take now to prevent them

fallenman
Be proactive to prevent falls that could change your future.

I have been talking with a lot of groups and individuals about ways to prevent falls. Falls come out of nowhere most of the time. You don’t even think about them until they happen.

According to data from the Centers for Disease Control, there are over 2.8 million older adults seen in the emergency department for falls every year! Yes, 2.8 million!!!   And these are not always the obvious people who can just look at and tell they could easily fall. Many would consider themselves health, active, and not at risk.

You CAN determine your risks and take action now to lower them.

So, how do you determine if you have this falls risk?

The Center for Disease Control tackled that question and developed the Stopping Elderly Accidents, Deaths, and Injuries. They created a toolkit with several resources. Some of the resources are for your doctor or other healthcare provider. Others are for YOU to help find and minimize your personal risks.

You can find access to these tools on our Meds MASH website. Or you can follow this link: https://www.cdc.gov/steadi/patient.html. You will find information about falls, how often they happen, and many of the risk factors. You will also find tools to help you assess yourself and your home.

I especially encourage you to complete the Check for Safety checklist. It has you walk room to room through your house looking for specific risk factors. It also has several tips to help you avoid falls.

Next, I encourage you to complete the Stay Independent checklist. This will ask you a series of 12 questions. You will answer each with a ‘Yes’ or a ‘No’. Then, take this list with you to your next doctor’s appointment. This will help you to have a very focused talk with your doctor about ways to minimize your falls risk.

Finally, read the What You Can Do to Prevent Falls brochure. This will give you even more tips to help you avoid a fall.

What can you do to lower your falls risk?

There are four different assessments in the toolkit that your doctor can use to better understand how to help you decrease your risks. One of these you can do yourself.

It is called a Chair Rise Exercise. It can help you gain strength in your thighs and buttocks. This will help you be more stable when you walk. Here are the instructions from the CDC STEADI guide:

How to do it: 

  1. Sit toward the front of a sturdy chair with your knees bent & feet flat on the floor, shoulder-width apart.
  2. Rest your hands lightly on the seat on either side of you, keeping your back & neck straight & chest slightly forward.
  3. Breathe in slowly. Lean forward & feel your weight on the front of your feet.
  4. Breathe out & slowly stand up, using your hands as little as possible.
  5. Pause for a full breath in & out.
  6. Breathe in as you slowly sit down. Do not let yourself collapse back down into the chair. Rather, control your lowering as much as possible.
  7. Breathe out.

What about medications?

There are so many medications that can increase your risk for falls. That’s one of our specialties at Meds MASH. We can take a thorough look at all of your prescribed medicines, your over-the-counter medicines, your vitamins, your herbal medicines, and any other substances. Even the doses you take, your kidney function, and your liver function will be assessed. We will also look at the timing of your medicines and your diet. All of these things work together to impact your falls risk.

For more information contact us at www.medsmash.com and 410-472-5078.

BIBLICAL APPLICATION

One of the best ways to avoid falls is to know your risks and take steps to minimize them. You need to do some work, and usually get some professional input, to fully analyze those risks. Then, it takes personal motivation to do the exercises, change the shoes, use the assistive device, or work with your healthcare team to make the medication changes to lower your risks.

What are your risks to fall off the path of Christ? I’m thinking of the parable of the seeds found in Matthew 13.

Matthew 13:8 NLT

Still other seeds fell on fertile soil, and they produced a crop that was thirty, sixty, and even a hundred times as much as had been planted!

How do we avoid the thorns, the rocks, the birds, the hot sun, and the shallow soil that kept the other seeds from growing?

Jesus explains the parable later in the chapter.

Matthew 13:23 NLT

The seed that fell on good soil represents those who truly hear and understand God’s word and produce a harvest of thirty, sixty, or even a hundred times as much as had been planted!

God’s Word and the value of our studying, understanding, and applying it are found throughout the Bible. It is throughout the Hebrew Bible, Proverbs, Psalms, and throughout the New Testament.

2 Timothy 3:16 ESV

All Scripture is breathed out by God and profitable for teaching, for reproof, for correction, and for training in righteousness,

Proverbs 4:20-22 ESV

My son, be attentive to my words; incline your ear to my sayings. Let them not escape from your sight; keep them within your heart. For they are life to those who find them, and healing to all their flesh.

Isaiah 40:8 ESV

The grass withers, the flower fades, but the word of our God will stand forever.

Psalm 119:105 ESV

Your word is a lamp to my feet and a light to my path.

John 14:21 MSG

“The person who knows my commandments and keeps them, that’s who loves me. And the person who loves me will be loved by my Father, and I will love him and make myself plain to him.”

What is your grasp of the Word of God? If that is the key to ‘letting our seed grow’, what is your growing potential? I know I have rocks and thorns and birds that try to snatch my seeds away in my life.

It takes motivation and discipline to stay in God’s Word on a regular basis. It takes discussion and study with others to really understand it from varying perspectives. And, it takes talking about it with other people to apply it.

People, instructors, pastors, mature Christians can help you gain the self-insight needed to really determine where your stumbling blocks are. Sharing and accountability help us stay focused and commit to the spiritual exercise, assistive devices, and work required to maintain ‘fertile soil.’

Psalm 1:1-3 ESV

Blessed is the man

    who walks not in the counsel of the wicked,

nor stands in the way of sinners,

    nor sits in the seat of scoffers; 

but his delight is in the law of the Lord,

    and on his law he meditates day and night.

He is like a tree

    planted by streams of water

that yields its fruit in its season,

    and its leaf does not wither.

In all that he does, he prospers.

Blessings,

Michelle

Image source: National Library of Medicine, National Institutes of Health, United States Department of Health and Human Services