BELIEVE IT OR NOT

Today, I want to address the importance of believing what you hear. One of the most important diagnostic tools is a trained ear. Another important diagnostic tool is your brain!  Once a physician hears his patient’s story, he has the choice of believing it, even if it is illogical, or dismissing it in favor of a more conventional interpretation.

Yes, patients often tell you what’s wrong with them and, often, their diagnosis is highly unlikely or even impossible.  Thirty five years of practicing medicine has taught me that the “impossible” is possible and some of my best diagnoses have been made because I choose to believe what my patient told me!

In my second year of residency, I received a call from the floor nurse telling me that Patient Y was asking for Last Rights.  Patient Y was scheduled to go home in the next few days and had no reason to die.  I went to the floor and reviewed her records and then examined my patient.  Patient Y was resolute in her opinion that she would not see the sun rise despite my confident reassurance.  Patient Y died that night.  Her autopsy revealed a tiny cerebral aneurysm rupture as the cause of her death.  I never forgot how incredulous I was at Patient Y’s insistence that she was dying and how healthy she was at the time of her death.

Choosing to believe your patients when their concerns are unrealistic is not easy.  Yes, I’ve run a great deal of tests that turned out to be unnecessary in order to disprove my patients’ diagnoses; and the majority of time, my patients concerns turned out to be truly unfounded.  When my patients’ seemingly unfounded concerns turned out to be real, it reinforced my ability to believe in the impossible and often saved a life.

“Doc, there is something wrong in my head!  No, I don’t have a headache.  No, my memory and speech are ok.”   “No” was her answer to every question, yet she firmly stated there was something she could not describe that was in her head.  She was not crazy!  Choosing to believe her, I sent her for a CT.  She, too, had an aneurysm and it was successfully clipped.  Thirty-five years, later she is doing fine.  Believing what your patient tells you may be hard, but it is vital to good care.

In today’s cost-conscious world, believing is discouraged.  If the patient above walked into my office tomorrow morning, I would have had to convince an insurance clerk to authorize her CT and would probably have been refused authorization.  Trying to meet the requirements of a computer-driven algorithm in order to diagnose a disease process requires more than a belief.  And that, my friends, is the problem with today’s healthcare system.

Here’s today’s joke:

My wife asked, “Are you even listening to me?”

I thought that was a weird way for her to start a conversation.

FATIGUE

Just recently, I received a call from a loved one who as complaining of fatigue.  I hope this article helps.

March 17, 2015

Today, my first patient asked me my most dreaded question, “Doctor, why am I always tired?”  Tired, fatigued, exhausted and lacking energy are among the many dreaded symptoms I hear almost every day.  Why do I dread this complaint?  Fatigue is a symptom of almost every disease known to mankind!

In the article titled “Differential Diagnosis” (1/18/11), I reviewed how doctors formulate a list of possible causes for an illness, arrange those possible causes by probability of occurrence and potential for doing harm and methodically work through the list until an appropriate diagnosis is made.  The differential diagnosis for fatigue starts with “A” and ends with “Z”.  There are common causes of fatigue:  anemia; thyroid disease; sleep disorders including sleep apnea; depression; stress reaction; physical exhaustion; diabetes; hypertension; chronic fatigue syndrome; and COPD are but a few.

A typical office visit is divided into three parts: the interview, the exam and the planning stage.  The interview for the complaint of fatigue is often exhaustive.  The interview can also be frustrating as fatigue influences every part of a person’s life.   Doctors work with an interview tool called the “review of systems” (ROS).  The ROS is comprised of 14 organ systems with specific questions relating to each of those systems.  When dealing with a patient who suffers from fatigue, all 14 systems must be explored and most patients have complaints in the majority of systems.  The doctor is often left with the “Chicken vs. the Egg” conundrum.

Now, do you understand why I dread this question?  To make matters worse, the physical exam seldom provides an answer requiring laboratory and other diagnostic testing.  While I am a puzzle solver and very experienced at solving this puzzle, each patient’s puzzle is unique and requires a novel solution and treatment approach.

So, when you complain of fatigue, and most of us will during our lifetime, recognize that the “Why” may be difficult to find, requiring extensive searching through your history, your physical exam and extended testing.  Be prepared for some frustration.  Be opened-minded about the various possibilities.  Recognize that one of the differential diagnoses is psychological and do not get offended if your doctor suggests you see a psychologist for testing.  At least, the psychologist’s tests don’t involve needles and KY Jelly!

Before seeing your doctor, ask the why, what, how, when and where questions about your fatigue.  Go through your own ROS.  In doing so, you may solve your own puzzle.  The more you question yourself, the easier it will be for you to answer your doctor’s questions.  While I am trained to solve puzzles by myself, it is easier if I have help.  Bring your significant other; he or she often has insights that are helpful.

One last request, if you could have a run of the mill anemia or thyroid problem, it would make my life easier!  Now, the big question for today is why am I, your doc, so tired?

Here’s your joke of the day:

A beautiful college professor reminds her student of the big test tomorrow. She says “You cannot be absent unless you are wounded, seriously ill or you have a sudden death in the family.” One boy asks “But what about extreme fatigue from a hot night of sex?” When the class is done laughing the professor smiles and says
“In that case you can write with your other hand.”

PROFESSIONAL WORRIER

This article is just as germane to anxiety today as it was in 2012 when it was first published. As my health deteriorates, I’ve become a professional worrier. I hope you find this article helpful.

April 2012

It’s never too late to learn!  Yesterday, I saw Mr. X.  Mr. X has been seeing me for the past 20 years.  He is in his 70s and had been diagnosed and treated for a major anxiety disorder for as long as I have known him.  Despite the best my profession had to offer him, the best medicine, counseling and behavior modification techniques, Mr. X continued to be anxious and worry about everything.

“My knee hurts.  Do you think it could be cancer?”  Mr. X has seventy-some year-old knees and they are worn out.  “My shoulder hurts.  Do you think it’s a heart attack?”  Mr. X carried some heavy boxes from the garage to the attack over the weekend.  “I had a headache two days this week.  Am I going to have a stroke?”  Mr. X’s worries have gotten worse over the years.  In retrospect, the harder I try to alleviate his fears, the worse he gets!

It’s never too late to learn!  Yesterday, I had an epiphany.  Mr. X is a professional worrier.  He worries the way some people play golf, shoot pool or play bridge.  He is the Tiger Woods of worry.  Worry is woven into every facet of his life.  It is part of his social being.  In his younger years, he worried about work, paying the bills and his children.  His worries were less threatening.  As he aged and retired, his worries turn inward, focusing on his physical wellbeing.  His worries have become increasingly more threatening over time.  It’s one thing to worry that your painful knee is arthritis; it’s quite something else to worry that your knee pain is cancer.  

My mistake has been trying to take away his worries.  Doctors are trained to alleviate pain and suffering.  When a patient’s knee hurts, we are taught to diagnose the problem, treat it and provide for future care.  When a patient worries excessively, we do the same thing.  We try to remove the worry.  In the case of a professional worrier, when you say, “Don’t worry, it’s not arthritis.  It’s just your age.  It’s just  a minor sprain,” you take away a benign source of worry and open the door to a malignant worry.  “Could it be cancer?”

Live and learn!  I should have told Mr. X he has arthritis.  He would have been much less threatened by arthritis than by cancer.  I’m learning!  I talked to Mr. X about his worrying and his need to focus on less threatening worries.  I suggested that he buy a lottery ticket and worry about whether or not he would win.  I suggested that he should worry about what winning would do to his life.  I suggested other things he could worry about.

Not being a psychologist, I consulted with Dr. Lapporte, one of my colleagues.  Dr. Lapporte is one of the psychologists who has treated my patients for decades.  I wanted to make sure my new treatment approach was valid and safe.  He concurred, stating that “distraction” was a viable approach.  I think I will prescribe more “distraction” in the future.  It’s cheaper with far fewer side effects than medication.

For those of you who are professional worriers, find something harmless to worry about.  “Will it snow today,” is an excellent place to start.  As you become better at choosing less harmful things to worry about, work on developing healthy worries.  “Will I have time to exercise today?”  

Most of all, be happy and healthy!

Here’s today’s joke:

I actually had anxiety for so long I went to a psychiatrist. And I said to the guy, ‘I’m constantly anxious. What do I do?’

He told me I had obsessive-compulsive disorder.

I was shocked. I had to call him nine times to make sure he was certain.

AN AFFAIR

Is your loved one having an affair?  No, not a sexual affair with another human.  I’m referring to an affair with his job!  Yes, some people are bigamists, married to their jobs and their spouses.  Is your spouse married to his/her work?

A work affair can be worse than a physical entanglement with another human.  It can be harder to break up with work than with a human lover.  An affair with your job can be just as destructive to your marriage and can cost you your life.

Not long ago, I saw a leader of American industry whose job took precedence over all else.  Being responsible for a Fortune 500 company’s success is an awesome responsibility.  The company demands constant attention, nurturing and stroking the company’s growth. Responding to changing needs.  Being a successful corporate leader requires long hours, travel, business meals, and more, leaving no time for self and family.

As in any affair, denial plays a major role.  The unfaithful spouse will deny any impropriety, claiming that his/her long hours at work are spent on behalf of his family!  He/she claims that he/she works long hours in order to provide financial security for his/her family.   He/she claims that, one day, he/she will retire and enjoy his/her family and life.

As a patient, the office bigamist often neglects his health, skipping appointments, running out of medicine, and complaining that there is never time for exercise.  Certainly, business lunches and dinner are not amenable to proper eating habits.

Diets and Other Unnatural Acts was partially inspired by just such a corporate giant.  Being married to your business may provide for financial success and security, but money without health and family is worthless.  Carl was living proof.

Are you married to your work?  Is your work an abusive spouse?  Does it demand so much of you that there is no time to take care of yourself or others?  Or are you a stress junky?  A success junky?  

Sometimes business demands are not the problem.  Sometimes the personal need for success creates stresses that are self-imposed.  I’ve written about the two brothers, one whose has “everything” and the other who has “enough.”  Both brothers have identical assets, the difference is perspective.

Whether you are a work bigamist or a stress/success junky, it’s time to change your perspective!  Money without health is worthless.  Over the last 30 years, I have seen many patients sacrifice their health and family relationships in the name of making a living.  I have seen many spouses cheat on their loved ones by marrying their businesses.  In every case, the only thing the family ever wanted was time with their father/mother/spouse.

Success in your job is important.  Success as a spouse and family man/woman is more important.  They need not be exclusive of one another.  Make your health and your family your primary responsibility.  They will be with you long after your business is gone.  Don’t wait until your health fails or your family is irreversibly estranged.  Remember, the life you save may be your own and that life is important to others. 

Here’s a joke:

The Worst Way to Die

It got crowded in heaven, so, for one day it was decided only to accept people who had really had a bad day on the day they died. St. Peter was standing at the pearly gates and said to the first man, *”Tell me about the day you died.”*

The man said, *”Oh, it was awful. I was sure my wife was having an affair, so I came home early to catch her with him. I searched all over the apartment but couldn’t find him anywhere. So I went out onto the balcony, we live on the 25th floor, and found this man hanging over the edge by his fingertips. I went inside, got a hammer, and started hitting his hands. He fell, but landed in some bushes. So, I got the refrigerator and pushed it over the balcony and it crushed him. The strain of the act gave me a heart attack, and I died.”*

St. Peter couldn’t deny that this was a pretty bad day, and since it was a crime of passion, he let the man in.

He then asked the next man in line about the day he died. *”Well, sir, it was awful,”* said the second man. *”I was doing aerobics on the balcony of my 26th floor apartment when I twisted my ankle and slipped over the edge. I managed to grab the balcony of the apartment below, but some maniac came out and started pounding on my fingers with a hammer. Luckily I landed in some bushes. But, then the guy dropped a refrigerator on me!”*

St. Peter chuckled, let him into heaven and decided he could really start to enjoy this job.

*”Tell me about the day you died?”*, he said to the third man in line. *”OK, picture this, I’m naked, hiding inside a refrigerator….”*

SUDDEN DEATH

The phone call came last night. Damar Hamlin’s on-field cardiac arrest caused my patient to relive his own cardiac arrest, death, and rebirth. He called to thank me for bringing him back years ago.

Dying and being reborn doesn’t occur every day. Everything has to be just right. First, you need a witnessed event.   My patient arrested in front of his wife. Next, the witness needs to call 911 and start CPR. Done! From this point, you need God’s intervention.

When I got to the ER, the patient had already been diagnosed as brain dead. He was in a decerebrate posture consistent with the diagnosis. I had read about something called the Artic Blanket. The hospital had a brand-new one sitting on a shelf in its original box. While the ER had bought it, they had never used it.

With nothing to lose, we instituted the Artic Protocol and prayed. The next day, my patient woke up. From brain dead to fully functional was indeed a miracle. Ten years later, he’s still doing well. His call couldn’t have come at a better time. Parkinson’s and my assorted medical problems have caused me to question my faith. My patient’s call and “thank you” reminded me that I was present at his miracle.

Since his call, I have replayed other miracles I witnessed during my years as a physician. Thank you for taking me on a ride down memory lane. I want to invite all of my former patients to share their stories with me and my readers. Just as my reading about the Artic Blanket saved a life, your stories may help others in unimaginable ways.

Here’s a story I used countless times in practice:

A farmer is in Iowa during a flood. The river is overflowing. Water is surrounding the farmer’s home up to his front porch. As he is standing there, a boat comes up. The man in the boat says, “Jump in, and I’ll take you to safety.”

The farmer crosses his arms and says stubbornly, “Oh, no thanks, I put my trust in God.” The boat goes away. The water rises to the second story. Another boat comes up. The man says to the farmer, who is now at the second floor window, “Hurry, jump in. I’ll save you.”

The farmer again says, “Oh, no thanks, I put my trust in God.”

The boat goes away. Now the water is inching over the roof. As the farmer stands on the roof, a helicopter comes over, and drops a ladder. The pilot yells down to the farmer, “I’ll save you. Climb the ladder.”

The farmer yells back, “Oh, no thanks, I put my trust in God.”

The helicopter goes away. The water continues to rise and sweeps the farmer off the roof into the swiftly moving water. Unfortunately, he drowns.

The farmer goes to heaven. God sees him and says, “What are you doing here?”

The farmer says, “I put my trust in you, and you let me down.”

God says, “What do you mean, let you down? I sent you two boats and a helicopter!”

This time of year, I always repost the “BLESSING LIST\

Do you ever feel overwhelmed? Do you have too much on your plate? Your husband is out of work. You have a full-time job during the day and you are mom at night. Your parents are getting old. Your house needs work. You have too many bills and your children are needy, whiny and unappreciative. Dinner conversations are all about “needs,” that four-letter word. Life needs balance!

Often, we are so focused on our curses and problems that we can’t see our blessings. By adjusting your viewpoint, you can reduce your stresses and better address your problems. Try this exercise:

  1. Your husband is out of work; you are blessed to have a husband.
  2. You have too much on your plate; you have a table to put your plate on and food to put on that plate.
  3. You have a full-time job during the day and are a mom at night; you are lucky to have a job and blessed with children.
  4. Your parents are getting old; your parents are alive.
  5. Your house needs work; you have a roof over your head.
  6. You have too many bills; You can spend less and live with less as long as you have a roof over your head, food on the table to feed the children and a husband to love.
  7. My children are too needy; they will learn the difference between wants and needs and learn to be appreciative of what they have.
  8. Whiny kids are healthy enough to whine and they will grow up eventually.  

So, make a blessings list. Include everything you are lucky enough to have, everything that makes you smile. Place that list on your bathroom mirror and every morning and night, brush your teeth for two minutes. While you brush your teeth, count your blessings. If you start the day blessed and end the day blessed, whatever happens during the day won’t be too bad. By the way, count the fact that you have teeth to brush as a blessing!

Here’s a joke.

The doctor says, “Larry, everything looks great. How are you doing mentally and emotionally? Are you at peace with God?”

Larry replies, “God and I are tight. He knows I have poor eyesight, so He’s fixed it so when I get up in the middle of the night to go to the bathroom, poof! The light goes on. When I’m done, poof! The light goes off.”

“Wow, that’s incredible,” the doctor says.

A little later in the day, the doctor calls Larry’s wife.

“Bonnie,” he says, “Larry is doing fine! But I had to call you because I’m in awe of his relationship with God. Is it true that he gets up during the night, and poof, the light goes on in the bathroom, and when he’s done, poof, the light goes off?”

“Oh, no,” exclaims Bonnie. “He’s peeing in the refrigerator again!”

 

 

GO TO THE ER

“Doc, I was so sick over the weekend that I almost went to the emergency room,” is a statement I heard all too often.  The fact that the patient was in my office and telling me about it is the good news.  The bad news was that, sometimes by delaying going to the emergency room, my patient missed an opportunity to avoid disaster.  I know going to the emergency room is time consuming and expensive.  I’ve heard it all!

What amazes me is how casually people gamble with their health and their lives.  How sick do you have to be to go to the emergency room anyway?  Do you have to be on death’s doorstep?  I think not.  Yet many of my patients wait until they are knocking at death’s door to call 911.

How much pain do you have to be in before you seek help?  The guy with the ruptured appendix waited until the pain was a 12 on a scale of 0 to 10 with 10 being the worst pain he had ever felt.  Actually, he only decided to go when his temperature hit 104!

How long do you have to suffer before you seek help?  Would it amaze you if I told you that a patient seen recently waited a full week before coming in to be treated for his chest pain?  I understand not wanting to go to the ER.  So, if you don’t want to go to the ER, how about calling the on-call provider?  Every practice has an on-call service.  If you thought about going to the ER and weren’t sure what to do, don’t you think calling your doc would be a wise decision?

While I’m on the subject, another thing I hear way too often is straight from the spouse’s mouth.  “I told him I was calling the paramedics but he said if I did, he would never speak to me again!”  Wake up!  If he dies, he’s never going to speak to you again!

My advice is that if you think about going to the ER, go.  If you decide not to go, call your doc.  Then pack a bag because he’s probably going to send you to the ER.  What happens if you go to the ER and everything is ok?  I guess you get to live another day.  Sound better than dying or spending an extended amount of time in the ICU?  I think so!

HERE’S YOUR JOKE OF THE DAY:

A doctor is examining a woman in the Emergency Room.

The doctor takes the husband aside and says, “I don’t like the looks of your wife at all.”

“Me neither, Doc. But she’s a great cook and she is really good with the kids.”

PLEASE DON’T DRIVE

I first published this article on May 11, 2011.  It’s January 4th and I have a broken right index finger. My right hand is immobilized in a plastic orthotic.  Yesterday, I said, “I can drive.” I can’t!  I shouldn’t!  But I am a macho old man who needs to be reminded of his limitations. It’s a good time to re-post this article!

Having chest pain?  Please don’t drive.  Short of breath?  Please don’t drive.  Feeling faint?  Please don’t drive.  Is the room spinning?  Please don’t drive.  I am amazed at how many people get behind the wheel of a car when they are physically or emotionally impaired!

Once a week, we call the paramedics.  I guess I should be pleased that patients think enough of my care that they drive themselves to my office rather than calling the paramedics.  I’m not pleased.  It scares the crap out of me.  It’s one thing to underestimate how sick you are and die as the result of your own misjudgment.  It’s quite something else to arrive at the pearly gates with a stranger’s family in tow!

Pass out behind the wheel and the car drives off the road or into oncoming traffic.  What might well have been a treatable illness turns into a disaster of major magnitude.  Having such severe pain that you have to pull off on the shoulder leaves you all alone in your time of need.  I’m afraid that one day one of my most faithful patients is going to literally drive into my lobby.  Don’t let innocents get hurt because you don’t want to bother a friend or call the paramedics!

The paramedics are well trained professionals.  Their ambulance is a mobile intensive care unit.  Breathing is a funny thing.  My patients are always breathing until they are not.  They never know when they are going to stop breathing; it just happens.  It usually happens when they have a severe respiratory tract infection with cough and shortness of breath.  It happens when they are having the crushing chest pain of a heart attack.  The paramedics can breathe for you.  They can successfully start a heart that is no longer beating.  They save lives, yet many people are hesitant to call them.

Don’t be macho about driving.  This is one case where both men and women are alike.  Men can drive when they are half dead just because they are men.  Women are embarrassed to make a fuss by having the paramedics show up.  Dying needlessly is something to be truly embarrassed about.  Driving into a ditch or through a school yard is something to be embarrassed about.  Think about your family, neighbors, and friends.  Call them for help if you don’t think you need the paramedics.  Just don’t drive them off the road when you lose control of your car.

Treat illness like alcohol.  Don’t drive impaired.  Help is just a phone call away.  The life you save may not just be your own; it may well be the lives of the innocent!  

Here’s today’s joke:

I want to die peacefully in my sleep like my grandfather, but not like the other passengers in the car with him.

SMILE

“A smile is contagious. Be a carrier!”

Easier said than done! These days, everyone is worried! They’re worried about their insurance, jobs, parents, and everything other than the one thing they should be worried about. That one thing is their health!

You can and will deal with an insurance company. Sure, your doc may not be in your plan. Sure, the care you need may not be available to you based on your plan’s restrictive policies. You may have to suffer with an inferior medication or drive to a distant place for a needed procedure to be covered. But you will still be free to get the care you need and want by going outside your plan and paying for it! You haven’t lost your freedom of choice; getting what you need and want just got more expensive.

I know your finances are a mess. Your job sucks. Everything costs more. So, what do you do? One of my friends is a defense attorney. I once asked him how an incarcerated felon could afford to pay his legal fees. His answer was that the felon couldn’t afford to pay him. The felon’s family can’t afford to pay him either, but they do. They find the money; they mortgage their house, take out loans or whatever they need to do to try to protect their loved one. Sure, they could rely on the public defender’s office; but, when the stakes are high, they want the best and the best is expensive.

Do you want the best healthcare possible? If you do, I can tell you where to find it. It starts at home! It starts in your kitchen! What’s in your pantry and refrigerator? Is it healthy? If not, pitch it! Have you ever heard, “You are what you eat?” It’s true.

Good health starts in your bedroom. Do you sleep well? Is your bed comfortable? Is your room healthy, free from allergens, noise pollution, and other distractions? Do you or your spouse snore? Are you up all night worrying?

Good health starts in your neighborhood. Are you taking 30-minute walks daily? Are you taking long bike rides? Do you go to the local gym?

Good health starts with your family. Are you and your spouse getting along with each other? What about your children? Are you spending quality time with the ones you love?

The best healthcare is not dependent on your insurance policy; it is dependent on you caring for yourself and those you love. If you and your loved ones are healthy, then you will rarely need to access the healthcare system.

Invest in your self and remember, “A smile is contagious. Be a carrier!”

HERE’S YOUR SMILE OF THE DAY:
I was on a train and this woman opposite looked at me and said, “Everytime you smile, I feel like inviting you to my place….”
I asked, “Are you single?”
She replied, “No, I am a dentist.”

A BLEED, A READ, AND A REFILL

As I began to do the research necessary to write and publish my book, I started reading my old articles. 

Here is one from August 13, 2011. 

It’s a classic and still appropriate 12 years later:

THINGS PEOPLE SAY

Patient “X” came in the other day. He’s one of my favorites. Why? 

Patient “X” takes excellent care of himself. 

I never have to call him; he follows up on his own. He takes his medications as directed. He “works” on being healthy! Patient “X” has his own unique problems yet maintains an “attitude of gratitude”.

Why am I writing about Patient “X”? There are two reasons. The first and foremost is I like to tell success stories. I spend so much time writing about what people should do that it’s nice to write about those who do it right. The second reason is because Patient “X” made me smile!

“Good morning, “X”, how’s life?”  

“X” responded, “Pretty good most days. I still have some bad ones, but I’m coping.”  

“What can I do for you today?”

“I’m here for a bleed, a read, and a refill?”

“A bleed, a read, and a refill! I’ll have to write about that. It’s perfect.

So, today’s article is about “A bleed, a read, and a refill.” In other words, it’s about the importance of timely follow-up. In “Your Doctor, The Master Chef”, I talk about my medications as spices in my spice rack and your treatment protocol as a recipe. 

Patient “X” has simmered for the prescribed amount of time and returned to the office for a tasting.

A “bleed” allows me to monitor the effects of “X’s” medication chemically. I can check his cholesterol, kidneys, and an assortment of other bodily functions with a “bleed.”

A “read” allows me to check his blood pressure, heart, and lungs, as well as an assortment of other bodily functions.

A “refill” allows me to ensure he is on the appropiate medications and give him enough to get to his next scheduled follow-up.

“X” is one of my favorites. He labors hard to stay happy and healthy. Because “X” does his work, I don’t have to work as hard! Thank you “X”.

Here’s today’s joke:

True story: My patient needed an IV, and the nurse got ready to start it in his antecubital area as per her training. The patient asked the nurse why she didn’t start the IV in his hand to which she replied, in Polish-accented English, ”I don’t do hand jobs.” The entire staff cracked up! 

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