LISA TODAY - 23 JULY 2006

How’s Lisa doing? July 19, 2006

I wish I could find the words to describe for you the skill, commitment and compassion of the “purple team” working to give Lisa the best chance to make the best recovery she can. While I’ve met with each of Lisa’s team members individually, and they meet each week to staff all their cases once a week, today, July 19, 2006, was the first time the whole gang gathered to discuss where we’ve been and where we’re going.

As I mentioned in my last, very wordy, update, by the last week in June, Lisa’s body and progress had been locked in the grip of Spasticity. Lisa’s ankles had turned almost completely over, her chin is thrust forward and upward and pulls to her left shoulder. She’d lost many of the hard-won gains she’d made including her ability to nod and blink answers to questions, shift her weight in the standing frame and move her arms and legs slightly but freely.

Lisa’s team, (each of the rehab teams is identified by color, Lisa’s is purple) beginning on Monday, June 26, launched a full-scale assault on this enemy. The attack has 4 elements: increase her Baclofin amounts, use Botox on her most vulnerable joints and with the gains made possible by the Baclofin/Botox, use a series of casts to get Lisa, literally, back on her feet. Aggressive range of motion exercises and stretching both protect her from crippling contractures of muscle and bone as well as measure and extend the progress Lisa is making as Baclofin slowly melts the icy grip of Spasticity.

Because nothing in Lisa’s recovery is simple, the efforts of her team have been hampered by a problem that has plagued Lisa most of her life: allergies, secretion-causing allergies. The secretions collect in the bottom of her throat, and Lisa, unable to clear her throat due to the Spasticity, must work harder to breath. Her team consults with respiratory therapists. They help with supplemental oxygen when Lisa needs it, breathing treatments and removing the secretions by suction. A pulmonologist, Dr. Wright “bonks” some of the secretions Lisa inhaled into her lung and than assures Dr. Kwasnica that none of this should interfere with the teams’ continued assault on Lisa’s Spasticity, indeed, the sooner Lisa can protect her airway, the better.

With this green light illuminating the team meeting, each of Lisa’s “purple” therapists, reports. All detail how Lisa is slowly regaining ground lost to her stiff muscle tone. Each says that Lisa is beginning to blink answers again, is becoming more responsive and is able to-for brief moments in therapy- more freely move her jaw, arms, neck, and legs. Still the key word is “slowly”. Lisa’s overall condition is tight, each movement of each and every muscle requires varying degrees of pressure and causes an equal amount of discomfort.

Dr. Kwasnica decides after speaking with dr. Wright, to cautiously press on with Baclofin increases up to 700 micrograms a day (mg/d) - a tiny amount if administered orally, but when contained within the intrathecal cavity containing Lisa’s spinal cord, a pretty healthy amount. Dr Kwasnica believes Lisa’s will require between 700-900 mg/d to control her Spasticity, so the idea will be to see how Lisa’s system responds to this amount before increasing it again. The goal? Loosen the grip of uncontrolled muscle stiffness without impairing Lisa’s ability to control when she wants to stiffen her muscles as when she wants to move her limbs.

Next, the team discusses new therapies and a decision is made to get Lisa back into an environment in which she thrives- the pool. Hydrotherapy is still classified as an “alternative” to traditional treatments, but one the team believes will benefit Lisa. There are logistics to be worked through but I’ve got her swimsuit ready and so, the following day Lisa’s back in the water. Freeing Lisa from the full effects of gravity makes it easier for her to move against her tight muscles. The session is declared a success and so will be the first of many.

Another alternative treatment- hyperbaric oxygen therapy (hbot)- is also kicked around. The idea is to place the patient into a pressure chamber filled with pure oxygen and increase the pressure anywhere from 1.5 to 2 atmospheres, about what you’d experience at 33 feet underwater. Treatments last an hour and are done a couple of times a day for as much as a month. HBOT is still considered experimental for Lisa’s type of injury but there are very promising results that have been obtained in individual cases. Dr Kwasnica, ever the optimistic skeptic, is reviewing the literature and consulting the handful of docs around the country doing what she does, to see if this is right for Lisa.

More about that last point: Christina Kwasnica, MD. is, officially speaking, a big dog. She doesn’t act like it (quick story- Michael and I stay with Lisa on the weekends. I try and feed him, take my shower and get dressed before the dayshift activities get started, usually by 6 am. The shower for our room is shared with the adjacent room so while you’re in there every sound carries. Michael will, especially when happy, make quite a bit of noise, so I’ve learned to try and shower while he’s sleeping off his first bottle to keep from waking the patient in the next room. One morning I turn off the water and hear Michael caterwauling in his crib. I panic but can’t go barging into “our” room without more on than I have at that instant. By the time I’ve dried and thrown clothes on, Michael’s quieted down. Relaxed myself now, I causally open the door to find… the program director for the world famous Barrow Neurological Rehabilitation Unit playing nanny to her patient’s son, rocking him in her arms back to sleep. Maybe this wasn’t a quick story still it’s illustrative of the point.) but she’s definitely a big dog within the fraternity (sorority?) of rehab docs. So, when dr. k say’s she’s consulting with her colleagues around the country about Lisa’s case it means we’re getting the best thoughts of the best minds in neuro-rehab in the country.

The next topic in the team meeting is Lisa’s morale. While possible problems with being aggressive with her treatment must be considered they must also be weighed against the certain problems of Lisa continuing to remain locked down by her Spasticity, chief among these is the certain frustration Lisa must feel. Keeping Lisa focused on her rehab requires constant and just as important, consistent confidence-maintaining support. The different sources of distraction and distress are discussed and strategies on how to avoid them are agreed upon.
Our goal is to establish a predictable routine, safe emotionally and physically, so that Lisa knows what to expect and what’s expected of her in her therapy sessions and is able to bring her full attention and efforts to bear on her rehab. The meeting ends with everyone on Lisa’s team clear on purpose, strategy and tactics.

It’s now Saturday, July 22, 2006. Lisa slept really well last night after secretions that had accumulated at the base of her throat were suctioned. She was so relaxed that she didn’t need the splints she normally wears at night to keep her arm straight or pain meds.

After working through all the more dire explanations for the secretions in Lisa’s throat, her docs are prepared to consider and treat her for post-nasal drip caused by her allergies. Medicines that we have at home, Claritin, Afrin and Flonase are ordered and with luck we’ll get her through this season with a minimum of discomfort.

I’ve got Lisa’s day splints on including her new ankle/foot splint for her right foot. The one for her left is still being tweaked by Sam the splint guy. Remember Reece the Zen serial caster from my last update? Sam must have gone to the same dojo the way he’s working over these custom-made splints to put just the right amount of pressure to protect the gains won with the casts without causing blisters or other skin breakdowns. Lisa’s physical therapist Tom wants Lisa wearing these 8 hours during the day and has walked me through how to put them on, check and remove them over the weekend. But for now I’ve just got one foot to splint and the other to stretch.

Lisa’s got therapy and a shower coming today than Mass at 5pm. Saturday evening mass here at St. Joseph's has been really special for us, and we’re looking forward for the time.

If you have questions about Lisa, I’m sure others have the same ones, so just pass them back to us and we’ll share the answers with everyone. Thank all of you again for your prayers, your support and your understanding. So many of you have sent or left messages, e-mails, cards and letters with the most wonderful thoughts and concluded by saying “ you don’t need to respond, you’ve got so much happening…” and I’ve taken you up on that too many times. So please know that while each of you deserves a thank you note for each of the many kind outreaches to us, I read everyone of these sentiments to Lisa. Our little family thanks God every day for each of you and prays for the time when Lisa can thank all of you personally. r

LISA TODAY – 14 JULY 2006

“So how’s Lisa doing?” July 9, 2006

My dad’s updates have been such a blessing to all of you and to me as well. They let us all stay pretty current so that folks who visit the website or get updates directly, can, when they bump into or call me, just hear the latest to be up to speed. But dad thought aL more comprehensive review of where we are, how we got here and what we believe the future holds from my point of view would be helpful. Also, I wanted to open a q and a dialogue for folks to ask follow-up questions without worrying about how many others have asked the same thing. Our goal is to keep those who care, are offering prayers and support and are reluctant to “be a bother” to be as informed about how Lisa’s doing as if they were here.

At this moment, 12:05 pm on Sunday July 9, 2006, Lisa’s down the hall getting a shower with Kesha and Andrew. Michael is hanging here with me deciding –ooops Lisa’s back.

Ok, it’s 1:22. We’ve gotten Lisa dried, lotion applied, her hair brushed and positioned her using pillows and weights to try and push back from her becoming the pretzel the injured parts of her brain are trying to make her into. The process was delayed by Michael insisting on attention, formula and finally, thankfully, sleeps, next to his mom who’s now watching me write this for you all.

This day started like most days for Michael and me visiting Lisa at the Barrow Neurological Rehab Wing. Lisa’s room is about 30’ by 20’ with a big window looking out over a large, lovely courtyard with big shading mesquites, grass yard, flowering shrubs, volley ball court (never used) benches and seating around the courtyard and a porch area with misters to make the phoenix summer bearable. Opposite of the porch area are some planting beds in raised boxes used by the occupational therapists. Some habanera peppers are clinging to life with the indifferent watering they are receiving.

The wall along side these windows hosts Michael’s crib and the pullout sleeper chair where Michael and I sleep (welcomed interruption here for calls from Lisa’s brother David sharing some really great stories from their childhood (I’m sworn to secrecy) along with an update on Lisa’s niece and another call from my mom) for the portion of the week we get to spend with Lisa, usually from Thursday night to Monday morning depending on my work schedule. The “family friendly” approach dr. Kwasnica and Barrow Neurological Institute (BNI) rehab take to rehab has really helped us start building the life together that was so catastrophically interrupted on February 23.

Speaking of interruptions, this one is of the welcome kind: one of our many new friends, Ricardo, a chaplain here at St. Joseph Medical Center, just stopped by for a prayer and blessing. Ricardo’s wife recently had a major surgery from which she’s recovering creating an even greater bond than his genuine compassion and kindness would have generated. I decline communion since Lisa and Michael and I were able to go to Mass together last night for the first time since I got back from Oklahoma. Father Bill greeted us warmly and Michael repaid him with several out of the blue screams during particularly inopportune times during the Mass. By the time I jumped up he immediately calmed down... just long enough for me to sit down again. Little wonder Father Bill came to us to administer communion, he probably wanted us out of there before any more disruption! Just kidding, Father Bill was just wonderful about it, I’d always told Lisa we wouldn’t have one of the crying kids in Mass that I’d walk him out before he’d disrupt a service, which just prompted one of Lisa’s patented, “we’ll see” laughs. Obviously, she and Michael conspired to come with a “scream and stop” strategy that has just been the most recent in a series of humbling fatherhood moments.

Where were we? Oh, yeah, interruptions. I’ve changed a couple of diapers, started a load of Lisa’s laundry, and we’re “good to go again.”

So our little family started our day after a pretty restful night. Lisa’s nurse, Joni turned Lisa every couple of hours, kept her clean and dry and made sure her arms and neck were positioned as well as can done. Her arms now have enough flex that I could position them last night so that Joni gave her blessing to letting Lisa go without the splints which I’m sure contributes to her sleeping better. Still she needs pain meds to get through the night.

Michael usually is the first up around 5:30, I buy a few more minutes by stuffing the pacifier back into his mouth, this lets me shake up his first bottle of the day, the first of 4 so far (it’s only 3:16). I shower with him in the bathroom to keep him from waking Lisa (or the dead, he’s that loud), dress and push Michael around the corner to the hospital’s Starbucks where Sonny fixes me up. We then dress Lisa, and all go outside to enjoy the morning before the heat becomes too much.

This is Sunday and the only day Lisa has “off.” Monday through Saturday are loaded with the intense 6 a day therapy sessions (Speech by Debbie, Physical by Tom and Occupational by Trent), two hours of range of motion exercises by our friend and ally from up at Select Specialty Care Hospital, Yolanda. Then, on the days Michael and I aren’t here, an hour or so visit from one of “Lisa’s Rangers” our local friends who got Lisa through the early stages of our nemesis Spasticity with their range of motion exercises and now continue to look out for her at Barrow Neurological Institute (BNI).

Lisa also has regular visits from Dr. Kwasnica and Suzanne, her nurse practitioner, assessing progress and increasing the dose of Baclofen, kind of our David against the goliath of Spasticity. This is done with a computer and kind of a remote control placed over the place in Lisa’s abdomen where the Baclofen pump is implanted.

Lisa also gets twice weekly visits from Reece, the king of serial castings. Reece is kind of a Zen craftsman, medicine man reclaiming Lisa’s ankles from the grip of spasticity, which had turned them completely over, preventing Lisa’s therapists from standing her up for fear of injuring her. Reece spends 2 hours to create a cast that firmly moves her stubbornly twisted ankles without blistering her skin only to cut that cast off in a couple of days and do it all over again, claiming the ground he’d gained in moving Lisa’s ankles back to a neutral position. For Lisa and her therapists though, the benefit was immediate: Lisa was able to get back on her feet in therapy.

Twice a week, Lisa is woken up with a massage from Erin. These started as a Mother’s Day treat, but Dr. Kwasnica believes they’re so important to Lisa’s recovery that she’s encouraged (unsuccessfully so far) blue cross to cover them. No matter, Erin, along with Yolanda, and Lisa’s Rangers are in for the long haul. I’m of course leaving out the nurses and aides who fill in the rest of Lisa’s time with medicines, feeding her through her PEG tube, protecting her from infection and bedsores by keeping her turned and cleaned until Lisa can do these things on her own.

With all the activity, you might think Lisa would get lost in the shuffle; far from it. BNI is a place where people get better. Lisa is surrounded by positive, confident, competent professionals and friends who have rallied to her cause with program director Christina Kwasnica, M.D. leading the way. But I get ahead of myself, how’d we get here?

On February 23, 2006, Lisa was finally feeling well. She’d had Michael a couple of weeks before and had been sore after two days of trying to deliver him naturally and finally accepting her obstetrician advice and delivering him by C-Section. By the 23^rd her incision was healing nicely, her physician advised just earlier that day. Breast feeding had been complicated with a common infection and tenderness but it was resolving and the pain had subsided.

My step-mom, Sherry had just flown in and Lisa was really looking forward to the help. Sherry’s a family nurse practitioner and has 4 young grandkids and is as steady a hand as you could hope to have in a family. Lisa and Sherry had really hit it off the first time they’d met and a great visit the previous thanksgiving in Sherry’s and dad’s home had solidified Lisa and Sherry’s plan for Sherry to take time off from work to come help the week following the 23^rd. The various post-birth difficulties that Lisa shared with sherry lead to a fateful and life-saving change of plans. Sherry moved her trip up to right after Lisa’s mom and step-dad left and thus was sitting next to Lisa when her heart stopped.

We still don’t know with absolute certainty what caused what happened but the best judgment of Lisa’s physician is “long Q-T Syndrome, a shockingly rare genetic condition that was present in Lisa in its rarest form. The syndrome claims most of its victims early in life. For Lisa, it appears that giving life, childbirth, awoke the killer in her DNA. In any event what did happen is that without any warning whatsoever, just after we’d finished eating pizza and were about to watch the Olympic ice skating finals, Lisa’s heart just stopped.

Sherry, sitting next to Lisa, first noticed something was terribly wrong and called me from the kitchen. Lisa’s eyes were wide open but fixed; she was drawing only gasping breaths and was completely limp. Sherry’s training and experience kicked in and she had us start CPR. I had to pull/drag Lisa onto the floor and only at sherry’s insistence did I do compressions hard enough to be effective. By hard enough, I mean I thought I was going to break ribs. Believe me; the CPR classes many of us have attended do nothing to prepare you for the event itself. If sherry hadn’t been there Lisa would have died that night. As it was, we did CPR until the EMT's arrived. Their efforts to shock Lisa’s heart into rhythm failed and so they continued CPR until we got to Emergency where her heart was restarted about 20 minutes after it stopped.

We now know more about all of this. The syndrome is also known as “sudden death syndrome” with good reason. The heart goes into ventricular fibrillation. Unlike a “regular” heart attack where the heart is still moving blood, just not very well, a “v-fib” doesn’t allow any blood and thus, life giving oxygen to move at all. The result is unconsciousness in 3-5 seconds and death in as many minutes without immediate intervention, of the type sherry started. CPR in a “regular” heart attack is effective even when not done well because the heart’s still pumping. CPR with a heart in v-fib is the only thing moving blood and oxygen through the body. For oxygen dependent organs, CPR simply isn’t enough. Of these none is more dependent than the brain, which stores neither oxygen nor sugar. Thus, the loss of oxygen damages the brain quickly and forever. Different parts of the brain use oxygen at different rates and therefore suffer injury at different levels.

As Sherry and I began to realize how horribly Lisa was injured we were convinced we had failed her when she needed us the most. It was months before we had any sign we done Lisa any good. That sign came when Lisa’s speech therapist up at Select Specialty Care Hospital, Maureen, and her occupational therapist, Connie helped Lisa begin to communicate through nods and head shakes. Dad’s updates detailed those interactions so I won’t repeat them other than to say they proved Lisa’s memory, values, sense of humor and steadfast determination to get home to us are intact.

Dr. Kwasnica provided the explanation: while the back portions of Lisa’s brain that control muscles, consciousness and coordination are big o2 users the front part of Lisa’s brain, where that which makes Lisa lives uses comparatively less o2. Thus, while we weren’t able to move enough o2 for the back portion of the brain we did protect her frontal lobes, liver and other vital organs.

Early tests showed that while Lisa suffered significant injury to parts of her brain her frontal lobes were intact. There is still a significant consequence though to the injury Lisa suffered: spasticity. Those injured portions of the brain that controlled Lisa’s muscles, still continue to send electronic messages down the spinal cord, only now the messages are malignantly simple: “clench”

We’d been told from the beginning about this condition, that it would, sooner or later, strike Lisa and that we wouldn’t know when or how severely but with her degree of injury it would be significant. So, like kids of my generation practicing for a nuclear attack by kneeling in the school hallways with our heads tucked between our knees (kissing our asses’ goodbye, we later joked), our family and friends moved Lisa’s limp arms and legs in the manner directed.

When the Spasticity hit, and muscle tone in Lisa’s arms, shoulders, neck, jaw, lips, ankles went from limp to stiff to rigid, Lisa lost precious ground she’d gained. Misguided efforts to “encourage” Lisa to speak had already caused her stop trying to coordinate the many different muscles necessary for the effort. Now, Lisa, fully aware of the progress she’d made, lost her ability to nod yes and no, to move her arms and torso. None of us can know the frustration she must feel. Even her ability to consistently blink “yes” answers has been overwhelmed by the discomfort and pain brought on by the tightening of her muscles and joints.

Slowly, despite the best efforts of Lisa’s Rangers and her therapists, her range of motion decreased, and muscles began to contract and shorten. Her wrists and ankles in particular rotated in toward the muscles that control them as they tense and hold. Seeing Lisa’s frustration rise as her abilities decreased, Dr. Kwasnica knew it was time to be decisive. It was time to get Lisa over to Neurological. Rehab, not to start rehabbing but to reclaim her ability to rehab at all, before Lisa’s frustration and the spasticity got beyond our reach.

And so, on father’s day weekend, Lisa made her move to BNI. After a week of assessments, evaluations and testing, her team developed an aggressive plan focused on breaking the grip spasticity has on their new patient.

The attack has three prongs: first, to use the recently-implanted Baclofen pump to bathe Lisa’s spinal cord with a steadily increasing amount of the powerful drug that blocks the errant signals from Lisa’s injured brain causing the problem - once enough is being administered. Second, Botox injections, aimed at using the neurotoxin to offer quicker, short-term relief for Lisa’s ankles and left wrist, shoulder and neck until the Baclofen can reach therapeutic levels. Third, a series of casts on Lisa’s ankles to immediately begin to move her ankles back to a neutral position and permit her therapists to get Lisa back on her feet, a necessary element of other efforts to break up the rigid muscle tone in other parts of her body.

The results so far are mixed but promising. Lisa’s ankles are dramatically better and are near their original position. This will allow the casts to come off and permit less bulky and invasive splints to protect her gains. Baclofen and Botox work more quickly at lower levels on lower limbs, so this is expected and welcomed. The success also confirms the longer term effects we can expect in her upper extremities where progress is slower.

In Lisa’s upper body, Spasticity, like some expanding glacier stubbornly resists the Botox and will only yield to greater amounts of Baclofen. The good news, according to Dr. Kwasnica, is that the Baclofen will at some point reach a level where it will, like a warming climate ending an ice age, melt the tone out of Lisa’s muscles. The fact the medicine is all kept within the cavity containing and surrounding her spinal cord means the levels can be increased without exposing the rest of her body to the medicine and any possible side effects. This is important because Lisa will need the Baclofen pump’s protection from spasticity the rest of her life.

So for now, we are in something of a stalemate, waiting for the Baclofen to reach a therapeutic level, while using advanced range of motion exercises to keep the positions the Spasticity pull Lisa’s muscles in from shortening them. Lisa’s therapists continue to use new splints, exercises and stretching to buy more time.

Once this battle is won, what’s the next struggle? More about that once me get Michael home. It’s Sunday night, about 7:30, Lisa’s resting comfortably and we’ve got a heavy docket in the morning.

Richard

LISA TODAY

LISA

TODAY
July 04, 20006

Barrow Neurological Institute

Phoenix, AZ

Introduction. The two paragraphs immediately below are made up from my imagination, also some of the events I describe never occurred… such as the “Sesame Street” episode I used to describe Michael’s vocalizations. My purpose is to draw you into Lisa’s story in a way that will enable you to relate and thereby become part of the story. My intent is not to minimize the seriousness of Lisa’s medical situation or of the struggle she is undergoing.

February, March, April, May, June and now July has arrived. I’m still laying here; the television is somehow on “Sesame S

treet,” and Big Bird… Big Bird screeching? Am I losing my mind? Is that Big Bird screeching? Whew, I wish I could laugh out loud. It’s Michael, making that funny-high pitched-screeching noise, and he’s charming Dr. Kwasnica, who is making her rounds with her nurse practitioner Suzanne and a resident, and they are all here in my room. I know he is successfully charming them because everyone is in good spirits and enjoying the moment. We’re all enjoying the moment.

I needed the break, I have really been thirsty, and from the extra fluid’s I was given I must of been dehydrated. An IV is a long way from a “cool one,” but it’ll do for now… until I can get out of here. Last night was restless for me, my breathing was audible, and it was decided I should have some precautionary tests. A chest x-ray, supplemental oxygen and a CT scan were ordered. All in a day’s work, you’d think, huh? The CT scan came at 2 AM, and me; having little else to do, took it all in stride. I was glad to hear the medics talking to Richard because they were saying my heart and respiration rates were spot on. You know I’ve always liked a normal heart rate, and that breathing thing, I like normal breathing too. I began to feel better soon after the IV fluids got into my system. The tests turned out okay, and unremarkable and I’m resting more comfortably now.

There is an

Isabel Bloom (Mother & Child) statue on a shelf overlooking my bed here at Barrow Neurological Institute (BNI). The day I was transferred to BNI, from Select Specialty Care Hospital, Mike a Nurse Assistant placed the statue on the shelf for me. Later that evening, Joe, a BNI Registered Nurse, got me squared away in my room. Joe noticed the Isabel Bloom right away, and asked about it. Sherry told him it came from Rock Island, Illinois. Joe became really excited because, as we learned, Joe was from Rock Island where the statue was made. He wanted to know all about it, and Sherry told him she received it as a gift from the Emergency Room Staff at St. Mary Medical Center. (Sherry is a 30-year employee of St. Mary’s.) Sherry told him she thought it would be fitting for me to have it. So there it stands and heartfelt greetings were shared all around.

Meet Heath

er (on the left below) a Nurse Assistant who works with Lisa. One can describe Heather as cheerful, willing, proficient and caring. It makes a day brighter when she cares for Lis

On the very serious side of matters, there is a war raging for Lisa’s body; it is being waged against Spasticity. After receiving applications of Botox and a bolus of Baclofen last week marginal improvement is seen in Lisa’s neck, shoulders, and waist. So in these three areas Spasticity has the high ground, so to speak. Lisa is, however, showing some improvement in her arms, legs and torso; it can be described as modest. Her dosage level of Baclofen is now at 450 micrograms. The drug is administered to Lisa 2 to 3 times a week, and on each occasion the amount receives is increased at the rate of 20 micrograms. It is expected she will reach a target, therapeutic level of 900 to 1000 micrograms in two weeks.

Dramatic improvement is seen in both Lisa’s ankles. She exhibits good range of motion. A week ago, had Lisa tried to stand she would have fallen because both of her ankles were turned. This is no longer the case as you can see below. The serial casts will prevent the reoccurrence of her ankles contracting.

On behalf of Lis

a, Richard and Michael, thank you most sincerely for the love and compassion you have shown them in this time, and for your continued interest in my narrative through “Lisa Today.”

Please send me your comments and suggestions, and especially questions that I may be leaving or have left unanswered.

To you and your family, we wish for you a very Happy and Safe Independence Day!

Until next time…

Michael

mlwintory@msn.com